Every finding on record at Allure of Stockton

Based on interview and record review the facility failed to have a RN (Registered Nurse) on duty in the facility for eight hours a day. This applies to all residents in the facility.The findings include:The CMS 671 (Centers for Medicare and Medicaid Services) dated 7/28/26 shows there are 28 residents in the facility.On 7/28/26 at 1:10PM, V2 (Director of Nursing/DON) said the facility does their best to staff the facility with an RN. V2 said the facility has only one RN on staff besides her. V2 said it's been difficult to find RN's in this area.On 7/29/26 at 1:21 PM, V1 (Administrator) said, the DON schedule is fluid, and she is sometimes here on the weekends when we don't have RN coverage. V1 said V2 doesn't sign in and is not on the schedule. V1 said the facility is placing ads and offering a sign on bonus. V1 said the facility has had to limit referrals for new admits due to not having more RN coverage. V1 said it is necessary to have an RN in the building. The facility nursing schedule for 6/21/26 to 7/25/26 shows 4 days with no RN coverage. The days without an RN in the building are Saturday 6/27/26, Sunday 6/28/26, Friday 7/24/26 and Saturday 7/25/26.The facility assessment with a revised date of 6/18/26 shows this staffing plan is based on the facility assessment, along with facility based and community-based risk assessments to inform staffing decisions to ensure that there are a sufficient number of staff to care for the residents' needs. Overall staffing needs 1/day RN's providing direct care.

Based on observation, interview, and record review the facility failed to ensure the wound care physicians' recommendations were followed and preventative measures were in place for 2 of 5 residents (R25 & R1) reviewed for pressure in the sample of 22.The findings include: 1. On 7/28/26 at 1:18 PM, R25 was sitting up in a recliner in her room and stated she has been at the facility since June 2026; she came after being in the hospital. R25 stated she came into the facility with a sore on her bottom. On 7/29/26 at 11:30 AM, R25 was up in her wheelchair for lunch. At 12:20 PM, R25 continued to be up in her wheelchair. R25 went back to her room and was transferred to a recliner. At 1:25 PM, R25 was up in the recliner in her room. The Wound Care Physician's note dated 7/27/26 for R25 showed she has a stage 3 pressure wound to the coccyx. The recommendations were to limit sitting to 60 minutes; off-load wound(s), reposition per facility protocol, and turn side-to-side in bed. The Care Plan dated 6/20/26 for R25 showed she had an impairment in skin integrity of the coccyx. The interventions in place were reviewed and did not show the wound care physician recommendations. On 7/29/26 at 2:12 PM, V8 (Certified Nursing Assistant/CNA) stated R25 came to the facility with a sore on her bottom but no longer had one. V8 stated she was not aware of limiting R25's time sitting up to 60 minutes. On 7/29/26 V11 (Licensed Practical Nurse/LPN) stated the area to R25's bottom was still open and gets creams to the area but not a dressing. V11 stated R25 was agreeable to switching positions. V11 stated she was not aware of the wound doctor's recommendations, including limiting her time sitting to 60 minutes at a time. V11 stated V2 (Director of Nursing/DON) rounds with the wound doctor so she would be the one to take his recommendations and place an order. It would be care planned. If R25 refused to lay down, it would be documented in her notes. The Progress Notes from the date of R1's admission through 7/29/26 were reviewed and did not show any documentation of refusals to lay down. On 7/29/26 at 2:28 PM, V10 (Corporate Nurse) stated the wound doctor's notes should be made an order, care planned and any refusal documented. Staff should be aware of the recommendations so can be carried out. On 7/30/26 at 8:39 AM, V11 provided wound care for R15 and she had a small open wound to her coccyx. The Face Sheet dated 7/29/26 for R25 showed diagnoses including muscle wasting, urinary tract infection, pressure ulcer of the sacral region – stage 2, heart failure, acute kidney failure, hematuria, ileostomy, and need for assistance with personal care. The facility's Pressure Injury Prevention and Management policy (2026) showed the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. 2. R1's face sheet printed on 7/29/26 showed diagnoses including but not limited to Alzheimer's disease, diabetes mellitus, peripheral vascular disease, polyneuropathy, left sided hemiplegia, and cerebral infarction. R1's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed total staff dependence for transfers, dressing, hygiene, and bed rolling side to side. R1's pressure ulcer risk assessment dated [DATE] showed a high risk for pressure ulcer development. R1s care plan showed a focus area related to potential for alteration in skin integrity related to dementia, incontinence, and limited mobility. Interventions included staff to encourage resident to float heels while in bed. On 7/28/26 at 11:09 AM, R1 was laying in bed wearing striped socks. Blue heel protectors were across the room on top of the dresser. At 11:29 AM, R1 was in the same position and the heel protectors were on the dresser. On 7/29/26 at 9:50 AM, V4 (CNA) and V5 (CNA) were completing a transfer to the bed for R1. V5 performed pericare and placed a pillow under R1's calves. R1's heels remained lying directly against the mattress. The aides exited the room and the heel protectors remained on the dresser. At 12:57 PM, R1 was in bed and the heel protectors were on the dresser. On 7/29/26 at 1:56 PM, V1 (Administrator) stated R1 needs the heel boots on when in bed to stop pressure on the heels. She lays down a lot in between meals. It is important to float her heels at nap time too. It reduces pressure and prevents skin breakdown. The facility's undated Pressure Injury Prevention and Management policy states: c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present.

Based on observation, interview, and record review the facility failed to ensure a secure device was in place, catheter tubing wasn't touching the floor, the drainage bag wasn't touching the floor and was maintained below the level of the bladder for 2 of 4 residents (R16 & R30) reviewed for catheters in the sample of 22.The findings include: 1. On 7/28/26 at 10:21 AM, V8 (Certified Nursing Assistant/CNA) and V9 (CNA) provided peri care for R16. When they were finished, they transferred him using a mechanical lift. V9 held the drainage bag above the level of R16's bladder during the transfer while V8 moved the mechanical lift. V8 noticed V9 had the bag up and swatted V9's hand down for her to lower the bag. At 10:32 AM, V9 stated the drainage bag is to be kept below the level of the bladder and that's why V8 slapped her hand. V9 stated she knew better and that the bag was to be kept low so there isn't any backflow of urine. On 7/28/26 at 3:16 PM, R16 was sitting in his wheelchair out in the hallway waiting to go into his room. R16 stated V8 was in the room helping his roommate. The catheter drainage bag under his wheelchair was touching the floor. V8 was showed R16's drainage bag when she came out of the room. V8 stated the drainage bag shouldn't be touching the floor for infection control reasons. On 7/29/26 at 12:24 PM, R16 was sitting in his wheelchair with the drainage bag attached under his chair, propelling himself down the hall and the tubing was touching the ground. On 7/30/26 at 1:36 PM, V10 (Corporate Nurse) stated the catheter drainage bag should below the level of the bladder so there isn't any backflow into the line and body to decrease the risk for infection. Try to prevent urinary tract infections. V10 stated the drainage bad should not be touching the floor because it is dirty; it is for infection control. V10 stated the same applied to the tubing. The Face Sheet dated 7/29/26 for R16 showed diagnoses including obstructive and reflux uropathy, disorders of muscle, urinary tract infection, calculus of ureter, sepsis, acute respiratory failure with hypoxia, benign prostatic hyperplasia, hyperkalemia, neuromuscular dysfunction of bladder, epilepsy, bacteremia, acidosis, retention of urine, type 2 diabetes, absence of left and right lower leg below knee, hyperlipidemia, acute kidney failure, acute pyelonephritis, and hypertension. The Care Plan dated 7/22/26 for R16 showed he has a suprapubic catheter for neurogenic bladder with stent placed to his ureter on 7/22/26. The care plan did not state anything about keeping the drainage bag below the level of the bladder or off of the floor. The care plan did not state anything about not letting the tubing lay on the floor. The facility's Catheter Care policy (2026) showed it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. Ensure the drainage bag is located below the level of the bladder to discourage backflow of urine. 2. R30's face sheet printed on 7/29/26 showed diagnoses including but not limited to hydrocephalus, obstruction/reflux uropathy, and heart failure. R30's facility assessment dated [DATE] showed moderate cognitive impairment. R30's July 2026 physician order summary report showed the use of an indwelling urinary catheter dated 7/11/26. On 7/28/26 at 10:39 AM, R30 was lying in bed with a catheter bag hooked to the lower side of the bed. R30 stated he had just had a bowel movement and needed help to be changed. R30 pushed the call light. At 10:42 AM, V3 (Certified Nurse Aide) entered and put on personal protective equipment to assist R30. V3 rolled R30 to his side and began pulling down his pants. The catheter tubing was stretched taunt. R30 said it hurts his groin area when the tubing is pulled. V3 pulled the tubing upward and relieved the pressure. V3 removed R30's pants and brief. A stat lock device was on R30's right thigh but the catheter tubing was not connected to it. V3 completed incontinence care and put a new brief on. V3 did not connect the catheter tubing to the stat lock on R30's thigh. On 7/29/26 at 1:51 PM, V1 (Administrator) stated the stat locks are used to prevent the tubing from being pulled at the site of insertion. There is the potential for trauma, infection, and poor urine drainage if it is not connected to the device. The tubing should always be hooked to the stat lock, unless a resident requests it to be different. The facility's undated Catheter Care policy showed: 6. Leg bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension. The policy did not address the use of stat locks to reduce catheter tubing pressure.

Based on observation, interview, and record review the facility failed to ensure an opened vial of Tuberculin was labeled with an open date. This has the potential to affect all the residents residing in the facility. The findings include: The facility's CMS form 671 dated [DATE] showed there were 22 residents residing in the facility. On [DATE] at 10:40 AM, V6 (RN - Registered Nurse) used a key to open the black, medication refrigerator, in the facility's only medication room. On the top shelf of the refrigerator was a sealed, clear plastic bag with 3 unopened vials of Tuberculin inside. To the left of this bag was an opened vial of Tuberculin, with approximately ,d+[DATE] of the fluid remaining in the vial. This vial was not labeled with an open date. The surveyor asked V6 what this vial was used for. V6 stated, We use that to do the TB tests on all new admissions and then once a year for our long-term residents. That vial should have an open date on it. It's not labeled, so I will need to throw it away. V6 said the open dates are important, so the nurse knows when the medication had expired. V6 stated, I think those vials are only good for 30 days. V6 said she did not know when the vial had been opened. The facility's Labeling of Medication and Biologicals Policy reviewed [DATE] showed, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications . 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle punctured); b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. c. Unopened or accessed (needle-punctured) vials should be discarded according to the manufacturer's expiration date .

Based on observation, interview, and record review the facility failed to clean ceiling fans above the food service area and failed to clean and defrost a freezer. This applies to all residents in the facility. The findings include: The Centers for Medicare and Medicaid (CMS) 671 dated 6/4/24 shows there are 22 residents in the facility. On 6/4/24 at 9:21 AM, the freezer in the dry storage room was observed with large amounts of frost present throughout the entire freezer. The food within the freezer was covered with frost crystals. On 6/4/24 at 11:45 AM, the kitchen staff were observed preparing the lunch trays for the residents. Above the food service area were two working ceiling fans covered with a black substance. The cleaning schedule and procedures check list shows the freezers should be defrosted if ice build up is present. The list also shows to clean ceilings and light fixtures during non-food production hours, clean free from dust and debris. On 6/06/24 at 9:10 AM, (V3) (food service supervisor) said it's important to keep the work areas clean to prevent contamination of the food and the freezer should be defrosted to keep the freezer temperature maintained and to prevent the food from getting freezer burnt. The facility policy for sanitation inspection with a revision date of 2/1/22 shows it is the policy of this facility to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. 1.All food service areas shall be kept clean, sanitary 4. sanitation inspections will be conducted in the following manner: a) daily-food service staff shall inspect refrigerators. coolers, freezers, storage area temperatures and dishwasher temperatures daily. b) weekly the dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.

Based on interview and record review the facility failed to submit required payroll based journal (PBJ) data. This effects all residents in the facility. The findings include: The Centers for Medicare and Medicaid (CMS) 671 dated 6/4/24 shows there are 22 residents in the facility. The [NAME] Report 1705D for the fiscal year quarter 1 2024 shows the facility triggered for failed to have licensed nursing coverage 24 hours a day and one star staffing rating. The facility was able to produce time card records showing a nurse was on duty for all infraction dates of 10/1/23, 10/4/23, 10/5/23, 10/9/23, 10/10/23, 10/13/23, 10/14/23, 10/15/23, 10/19/23, 10/28/23, 10/29/23, 11/11/23, 11/15/23, 11/23/23, 11/24/23, 11/25/23, 12/9/23 and 12/23/23. On 6/05/24 at 11:38 AM, (V4) (Office Assistant) said she receives the spreadsheet from (V5) (Vice President of Operations) and she fills in all the staff hours of the social services, activities, dietary, management staff, and any outside agency staff and returns the spread sheet to V5. V4 said she does not understand why the information did not show up correctly in the PBJ data report. On 6/05/24 at 2:45 PM, V5 he does not understand why the PBJ data is not correct. V5 said he has numerous ways to track the data and have it input into the system.

Based on observation, interview, and record review the facility failed to ensure a resident was provided catheter care in a dignified manner for 1 of 1 residents (R1) reviewed for catheters in the sample of 13. The findings include: On 6/05/24 at 1:28 PM, V7 (CNA- Certified Nursing Aide) and V8 (Restorative Aide) entered R1's room to provide catheter care. R1's roommate was seated in her wheelchair, watching TV. V7 explained that she was going to provide catheter care to R1 and pulled the privacy curtain between R1's side of the room and the roommate's side. R1's room had 3 windows on the opposite side of her bed. Each window had it's own blind. The center window had the blinds closed, but the left and right window blinds were open. There was a clear view to the sidewalk, street, and diagonal street parking from R1's window. V7 and V8 removed R1's linens and exposed her perineum and lower body. V7 provided catheter care to R1. During this care, a white sedan pulled into the diagonal parking, facing R1's room. A male exited the car and walked down the sidewalk, passed R1's open blinds. R1's body was fully exposed from the waist down. V7 completed catheter care and R1 decided to get up for the afternoon activity. V7 and V8 turned R1 side to side placing an incontinence brief and dressing her. V7 and V8 used a total, mechanical lift to transfer R1 from the bed to her wheelchair. R1's left and right window blinds remained open throughout. R1 said she's used to the CNAs seeing her because she needs help, but wouldn't want anyone to be able to see her private parts. R1's Facesheet dated 6/5/24 showed diagnoses to include, but no limited to: morbid obesity, chronic ischemic heart disease, diabetes, acute on chronic respiratory failure, mild protein-calorie malnutrition, neuromuscular dysfunction of bladder, history of colon cancer, intervertebral disc degeneration (lumbar region), Barrett's Esophagus, cataracts, major depressive disorder, dyshidrosis, seborrheic dermatitis, peripheral vascular disease, psoriasis vulgaris, and gout. R1's facility assessment dated [DATE] showed she had severe cognitive impairment and required substantial/maximal assistance from staff for personal hygiene, toilet use, and rolling side to side in bed. On 6/6/24 at 8:21 AM, V9 (CNA) said it's important to close the privacy curtains and window blinds, during catheter care. V9 said it's for the resident's privacy and dignity. On 6/6/24 at 9:56 AM, V6 (RN - Registered Nurse) said R1 has had the catheter for a long time. V6 said the privacy curtain and blinds should be pulled during resident care, so no one can see inside. The facility's Catheter Car Policy reviewed 2/1/22 showed, It is the policy of this facility to ensure that resident's with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Compliance Guidelines: .3. Provide privacy by closing the door, closing the blinds/curtains, pulling the room dividing curtain, etc . The facility's Resident Rights Policy reviewed 2/1/22 showed, The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . 10. The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for it's residents . Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 4. Respect and dignity. The resident has a right to be treated with respect and dignity .

Based on observation, interview and record review the facility to complete assessments including wound measurements for a resident with a reoccurring wound. This applies to one of two residents (R6) reviewed for non-pressure wounds in the sample of 13. The findings include: The facility face sheet for R6 shows diagnoses to include heart disease, hemiplegia, obesity, chronic kidney disease and mild protein-calorie malnutrition. The facility assessment dated [DATE] for R6 shows him to be cognitively intact and is dependent on staff for all activities of daily living. The weekly skin assessments for R6 dated 5/14/24, 5/21/24 and 5/28/24 shows scar tissue open to left buttock. No measurements or other assessment of the wound observed in the record. On 6/5/24 at 9:56 AM, R6 was observed lying in bed receiving incontinence care by the staff. A small opening was observed on R6's left lower buttock near his leg. The area that was open was surrounded by a darker red color skin. No drainage was observed at the open area. On 6/5/24 at 1:41 PM, (V2) Assistant Director of Nursing said she is responsible for the weekly wound assessments. V2 said R6's wound to his left buttock has been opening often, but heals quickly. R6 was seen by the wound care physician before, but is currently not being seen. V2 said the area is the same area and the Physician determined it to be an area of trauma. V2 said the staff are trying to figure out why the area is re-opening so frequently. V2 said when a resident is seen by the wound care physician, the weekly measurements are documented with that assessment. V2 said the weekly wound assessments she uses does not have a place for wound measurements and she relies on the Certified Nursing Assistants to let her know if the wounds are getting bigger or smaller. V2 said it's important to monitor the wounds weekly for improvement and to see if the current wound treatment is working or needs to be changed. The facility policy with a revision date of 2/1/22 for wound treatment management shows 5. treatment decisions will be based on: b.) characteristics of the wound 2)size-including shape, depth, and presence of tunneling and/or undermining The effectiveness of treatments will be monitored through ongoing assessments of the wound .

Based on observation, interview, and record review the facility failed to ensure a resident had an anchoring device for an indwelling catheter for 1 of 1 residents (R1) reviewed for catheters in the sample of 13. The findings include: On 6/5/24 at 1:28 PM, V7 (CNA - Certified Nursing Aide) and V8 (Restorative Aide) entered R1's room to provide catheter care. V7 and V8 pulled R1's blankets down and moved her gown to expose R1's perineum and lower legs. R1 had a silicone, indwelling catheter in place. The catheter was not anchored to her leg. The catheter tubing ran along R1's right leg, curled on the bed, then extended to the catheter bag that was hooked on the bed-frame. R1's right and left thigh did not have any tape or evidence of a securing device being in place. R1's bedding did not contain a catheter anchoring device. V7 (CNA) provided catheter care, then R1 decided she wanted to get dressed for the day and participate in an activity. V7 and V8 rolled R1 side to side while applying an incontinence brief, dressing R1, and transferring R1 to the wheelchair with a mechanical, total lift. R1's catheter was not anchored to her leg. R1's Facesheet dated 6/5/24 showed diagnoses to include, but no limited to: morbid obesity, chronic ischemic heart disease, diabetes, acute on chronic respiratory failure, mild protein-calorie malnutrition, neuromuscular dysfunction of bladder, history of colon cancer, intervertebral disc degeneration (lumbar region), Barrett's Esophagus, cataracts, major depressive disorder, dyshidrosis, seborrheic dermatitis, peripheral vascular disease, psoriasis vulgaris, and gout. R1's facility assessment dated [DATE] showed she had severe cognitive impairment and required substantial/maximal assistance from staff for personal hygiene, toilet use, and rolling side to side in bed. R1's Progress Note dated 5/7/24 showed the CNA reported to the nurse that R1's indwelling catheter was out with the balloon intact. On 6/6/24 at 8:21 AM, V9 (CNA) said the facility has white adhesive dressing that hold the resident catheters in place. V9 stated, They are nice and they keep the catheter from pulling. I think they are supposed to be used when a resident has a catheter. On 6/6/24 at 9:56 AM, V6 (RN - Registered Nurse) said R1 has had the catheter for a long time. V6 said in May R1's catheter had dislodged, with the balloon intact. V6 said she wasn't sure why that happened. The surveyor asked why R1 didn't have a catheter anchoring device in place. V6 said R1's catheter should have an anchoring device to keep the catheter for dislodging. The facility's Catheter Car Policy reviewed 2/1/22 showed, It is the policy of this facility to ensure that resident's with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .

Based on observation, interview, and record review, the facility failed to label food items, failed to ensure a functional thermometer was utilized in two freezers, and failed to maintain a freezer to prevent ice buildup. These failures have the potential to affect all residents in the building. The findings include: The Resident Census and Condition Report, dated 5/2/23, showed 29 residents residing in the building. On 5/2/23 at 8:59AM, The facility's standing freezer located in the dry storage room had an unlabeled fast food cup full of a pink frozen substance and 2 packages of unlabeled food. The thermometer in the freezer was unable to measure an accurate temperature, due to the scale line being broken and tilted, giving an inaccurate temperature reading. The freezer shelves were all lined with thick blocks of ice and packed full of bags of frozen food items. There was no additional room in the freezer and bags were falling off shelves during observation. On 5/2/23 at 9:09AM, containers of brown sugar, butter, and peanut butter were placed in a cabinet underneath the food preparation area. All 3 containers had no label showing the contents or date on them. On 5/2/23 at 9:20AM, the facility's free-standing freezer had 2 packs of unlabeled meat with no date, 3 bags of breaded meat that were unlabeled, and 1 bag of hamburger patties that did not have a date on it and was opened. The thermometer for the freezer was buried under 4 packs of bread and covered in ice. V3 (Dietary Manager) dug the thermometer out of the freezer and chipped the ice off the outside of the thermometer. V3 stated the thermometers should be in working condition, and able to be easily read to ensure that the freezers are at the appropriate temperature. On 5/2/23 at 10:45AM, V3 stated the freezers should be free of ice buildup to allow adequate cooling and freezing in the freezer. V3 stated if too much ice builds up, then the freezer will shut down and the food will not be kept frozen. V3 stated all food items should be labeled with a received date and when they are opened; that date and a use by date should be put on the package or container. V3 stated all items should have a label with what the item is so all staff know what they are pulling form the refrigerator or freezer to cook, and it will help them know how to thaw and prepare the food. The facility's policy titled, Food Safety Requirements, dated 09/2021, showed, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety .c .Practices to maintain safe refrigerated/frozen storage include: i. Monitoring food temperatures and functioning of the equipment daily and at routine intervals during all hours of operation.

Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 27 opportunities with 9 errors, resulting in a 33.33% medication error rate. This applies to 4 of 4 residents (R7,R15,R28,R126) observed in the medication pass. The findings include: 1) R7's electronic face sheet printed on 5/3/23 showed R7 has diagnoses including but not limited to heart disease, major depressive disorder, hypertension, and venous insufficiency. R7's medication administration record (MAR) for May 2023 showed R7 receives Carvedilol 25mg and Sacubitril-Valsartan 97-103mg at 8AM and 5PM. On 5/2/23 at 9:35AM, V4 (Licensed Practical Nurse-LPN) administered R7's Carvedilol 25mg and Sacubitril-Valsartain 97-104mg. (1 hour and 35 minutes past the scheduled administration time) On 5/2/23 at 9:40AM, V4 stated, My whole screen is red and I'm late on all of my remaining medications. I was busy this morning doing skin checks and wound treatments so that is why I am late giving medications. I probably should have prioritized my time better but there's nothing I can do about it now. 2) R15's electronic face sheet, printed on 5/3/23, showed R15 has diagnoses including but not limited to altered mental status, major depressive disorder, schizoaffective disorder, disorder or psychological development, anxiety disorder, and dementia with agitation. R15's MAR for May 2023 showed R15 receives amantadine 100mg and oxcarbazepine 600mg at 8AM and 8PM, benztropine 0.5mg, lithium 150mg, and Haldol 1mg at 8AM and 5PM. On 5/2/23 at 10:14AM, V5 (Registered Nurse) administered R15's amatadine 100mg, benztropine 0.5mg, Haldol 1mg, lithium 150mg, and oxcarbazepine 600mg. (2 hours and 14 minutes past the scheduled administration time) 3) R28's electronic face sheet, printed on 5/3/23, showed R28 has diagnoses including but not limited to anxiety disorder, psychotic disorder, and major depressive disorder. R28's MAR for May 2023 showed R28 receives Dilantin 100mg at 8AM, 12PM, and 8PM. On 5/2/23 at 9:41AM, V4 administered R28's Dilantin 100mg. (1 hour and 41 minutes past the scheduled administration time) 4) R126's electronic face sheet, printed on 5/2/23, showed R126 has diagnoses including but not limited to hypertension, venous insufficiency, acute cystitis, and severe sepsis. R126's MAR for May 2023 showed R126 receives Potassium Chloride 10meq at 8AM and 5PM. On 5/2/23 at 10:03AM, V4 administered R126's Potassium Chloride 10meq. (2 hours and 3 minutes past the scheduled administration time) On 5/3/23 at 11:41AM, V2 (Director of Nursing) stated, Medications administered over 1 hour before or 1 hour after their scheduled time would be considered a medication error. (V4, LPN) did inform me of the late medications yesterday, but she notified the physician, so we thought that would be sufficient. I didn't realize she was that late on administering medications. She can always let us know so that a nursing supervisor can help her pass medications. The facility's policy titled, Medication Administration, dated 09/2021, showed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .11. Compare medication source with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician .

Based on observation, interview, and record review, the facility failed to provide wound care treatment as prescribed by the physician and in manner to promote resident comfort. This failure applies to 1 of 1 (R126) residents in the sample of 13. The findings include: R126's Transfer/Discharge Report (Face Sheet) showed an admitted [DATE], with diagnoses to include: venous insufficiency, obesity, right artificial hip joint. On 5/2/23 at 2:20 PM, R126 had a dressing to her right hip, left calf, and right calf. R126 was alert and oriented to person, place, time, and her condition. V4, Licensed Practical Nurse (LPN), entered R126's room to provide wound care. V4 provided wound care to R126's right hip and completed the care at 2:30 PM. V4 then proceeded to R126's right leg wound. Prior to removing the right leg dressing, R126 asked if V4 was going to soak the dressing prior to removal; V4 did not respond. After V4 removed R126's right leg dressing she applied an antimicrobial/petroleum based gauze dressing. V4 covered this dressing with an absorbent pad and gauze wrap. V4 completed the right leg dressing change at 2:48 PM. At 2:53 PM, prior to starting the left leg dressing change, R126 stated the left leg was her most painful leg, and she again asked V4 to soak the dressing prior to removal. V4 did not respond. R126 stated soaking the dressing with saline solution allows the dressing to come off more easily, and with less pain. V4 did not soak R126's left leg dressing and began removing the dressing. As V4 removed the antimicrobial/petroleum dressing, the dressing was adhered to an open area on R126's left outer shin area. As V4 reached this area R126 yelled Owww. R126 shut her eyes covered her face, and again asked V4 to soak the dressing. V4 soaked the area with wound cleanser and attempted to remove the dressing; R126 again yelled Owww. R126 stated other nurses soak it with water, let it soak for a time, then remove the dressing. At 3:12 PM, V4 returned to R126's room with saline solution, soaked the wound, and removed the dressing. V4 again applied a antimicrobial/petroleum based dressing; then absorbent pad; then covered with a gauze wrap. V4 completed the wound care at 3:30 PM. (An hour and 10 minutes later.) On 5/03/23 at 8:44 AM, R126 stated, I've never had a dressing change hurt like that before, at least not since I was in the hospital. I told her to soak the dressing. That makes the dressings come off so much easier. The other nurse that does the dressing change on nights will soak the dressing and they come right off and it doesn't hurt. If she had offered me a pain pill before the dressing change, I wouldn't have accepted it, because it never hurt like that before. All the nurses should know how to take care of my dressing. There was an agency nurse that did my dressing change, and she was even aware of soaking the dressing. I think she was aware of it because of how badly the dressing change went yesterday. Normally, they can change all three dressings in about 20 minutes; that took too long. Yes, all nurses should know how to do my dressing changes and they should know to soak both legs dressing to make it less painful. I did tell her many times to soak the dressings. Normally they soak them before they remove them, long before it gets to the point of it hurting. On 5/03/23 at 1:31 PM, V2, Director of Nursing, stated dressing changes can be painful because the wounds are sensitive and inflamed. V2 stated some techniques to minimize pain during dressing changes are to pre-medicate with pain medication; moisten the dressing; and to remove the dressing slowly and gently. V2 stated if a resident requested the dressing be soaked prior to removal. she would check for an order to do so. and if there was not order, she would obtain the order. V2 stated while reviewing R126's wound care orders, V4 should have applied the antimicrobial/petroleum dressing as well as a second petroleum only dressing. V4 stated the additional petroleum based dressing could aid in the dressing removal, and possibly be more comfortable for the resident. R126's Medication Review Report (Physician Order Sheet) showed an active order starting on 4/26/23 to apply a antimicrobial/petroleum based dressing as well as a petroleum only based dressing. The facility's Wound Treatment Management policy (Implemented 9/2021) showed, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . The policy showed, Treatment decisions will be based on .Goals and preferences of the resident .

Based on observation, interview, and record review, the facility failed administer the correct dose of an antipsychotic medication and failed to notice an antipsychotic medication on the floor of the facility. This applies to 1 resident (R15) outside the sample. The findings include: On 5/2/23 at 2:00 PM, a white and brown, oblong capsule was seen on the floor next to the medication cart parked by the dining area. The medication cart showed the only resident in the facility taking that medication was R15. The blister card listed that medication as Thiothixene 5 mg (milligrams) with 2 capsules in each blister. R15's Face Sheet showed her diagnoses includes, schizoaffective bipolar type, anxiety and dementia with agitation. R15's 5/2023 POS (Physician Order Sheet) shows, she (R15) is ordered Thiothixene 5 mg, 2 capsules, by mouth, every morning for schizoaffective disorder. On 5/4/23 at 10:20 AM, V1 (Administrator) said, (R15) is the only resident to get Thiothixene, and if a pill was found on the floor, it means she didn't get her full dose. V1 said it's important to administer medications as ordered by the Physician so the resident can get the full benefits from the medication. On 5/4/23 at 11:15 AM, V5, RN (Registered Nurse), said, The nurse should inspect the med cup before giving the cup to the resident to make sure all pills made it into the cup. The Nurse should inspect the med cart surface and the floor for accidental spills of medication and waste any dropped medication, so no other residents take medication not prescribed to them. The 9/2021 Medication Administration Policy and Procedure shows, the MAR (Medication Administration Record) should be reviewed to identify all medication to be administered, all medications should be administered 60 minutes prior or after scheduled time, and all medication should be administered as ordered by a Physician.

Based on observation, interview, and record review, the facility failed to provide incontinence care to prevent cross-contamination. This failure applies to 1 of 2 residents (R11) in the sample of 13. The findings include: R11's Transfer/discharge Report (Face Sheet) showed and original admitted [DATE], with diagnoses to include: Alzheimer's disease, diabetes, and overactive bladder. R11's 4/6/23 Minimum Data Set (MDS) showed she had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 12 out of 15. The MDS showed R11 required extensive assistance of two staff for toilet use to include cleaning herself after elimination. The MDS showed she was always incontinent of bowel and bladder. R11's Medication Review Report (Physician Orders Sheet) showed an active order for an antibiotic to prevent urinary tract infections (UTIs). On 5/02/23 at 1:13 PM, R11 stated, I have had many UTIs (urinary tract infections). I'm not sure the last time I had one. On 5/02/23 at 10:28 AM, V6 and V7 Certified Nursing Assistants (CNAs) provided incontinence care for R11. While providing incontinence care, V7 wiped a bowel movement (BM) from R11's buttocks with a washcloth. Without changing gloves, V7 then touched R11 as well as R11's clean brief with the same gloved hand used to wipe the bowel movement. On 5/03/23 at 1:31 PM, V2, Director of Nursing, stated, The purpose of glove use is to protect us (staff) and the resident from cross-contamination. I would agree that when gloves are grossly contaminated, removing gloves is an easy way to remove a lot of contamination and should be followed up with hand hygiene. During incontinence care, staff should change gloves after wiping a BM prior to touching any clean surface including the resident. This is to prevent contamination of those surfaces. The facility's Helping a Resident with Toileting Needs policy (implemented 9/2021) showed .If the resident needs help with wiping when finished, put on new gloves. Help with wiping .removed your gloves and dispose of them in the trash bag .

Based on observation, interview, and record review, the facility failed to follow the facility's lunch menu on 4/19/22, and did not follow the recipe for pureed ham, provide pureed bread for residents, or measure the portion sizes for the ham. This applies to all 33 facility residents. The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) form 672 Resident Census and Condition of Residents, dated April 19, 2022, showed 33 residents reside in the facility. On 4/19/22 at 11:13 AM, V5 (Cook) took the ham out of the oven, cut off some pieces of ham and placed them into a food processor. V5 did not weigh the ham to see if the portion size was correct. V5 took a glass, put cold 2% milk in it and added it to the ham in the food processor to puree the ham. V5 turned on the food processor. V5 looked at the consistency of the ham, and it was still chunky. V5 grabbed more 2% milk and added it to the ham. V5 continued to use the food processor to puree the ham. V5 dumped the ham that was supposed to be pureed into a pan. The ham did not look completely pureed and milk was visible. On 4/19/22 at 11:34 AM, V5 took the ham out of the oven and carved the ham into random sized slices. V5 used tongs to place different sized pieces of ham on residents plates. V5 served ham, roasted potatoes, corn bread, peas and carrots for the regular consistency diets. V5 plated up the food for the three residents (R1, R14 & R25) on pureed diets, and they did not receive any pureed cornbread. On 4/19/22 at 11:53 AM, V5 stated It is an estimated guess when it comes to the meat as to how much the resident is going to get. V5 stated V5 forgot about making the pureed cornbread. On 4/19/22 at 1:05 PM, V3 (Dietary Manager) stated V3 should have used the ham juice and not milk to puree the ham. V3 stated V3 heard V5 did not make the pureed cornbread. V3 stated they should follow the menus. The Pureed Glazed Ham recipe (winter 2021-2022, day 24) showed, Dissolve pork base in water to make broth. Place prepared meat in a sanitized food processor. Gradually add broth; blend until smooth. The regular consistency Glazed Baked Ham recipe (winter 2021-2022, day 24) showed, Using a meat slicer, slice the ham into 3 ounce portions. Set the dial on #13-15; weigh slices randomly to maintain 3 ounce portion control. On 4/20/22 at 10:30 AM, during the group interview, the residents stated sometimes the portions of food that are served look skimpy. They stated the food trays do not have the same amount of food on them; one person may get more food than another person. The Diet Spreadsheet week 4 for the winter 2021-2022 menu showed on 4/19/22 residents on a regular diet should have received 3 ounces of baked ham. Residents on pureed diets should have received pureed cornbread. The facility's Puree Food Preparation policy (2/1/22) showed, Residents receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per the facility policy and procedure.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was cleaned on a regular basis. The facility failed to ensure the kitchen did not have grease on walls, cobwebs and thick dust to surfaces. The facility failed to ensure staff wear hair nets in the kitchen. This applies to all 33 facility residents. The findings include: The facility's CMS (Centers for Medicare & Medicaid Services) form 672 Resident Census and Condition of Residents, dated April 19, 2022, showed 33 residents reside in the facility. On 4/19/22 at 8:53 AM, the handwashing sink in the kitchen had a brown build up around the drain and the white sink had brown dried buildup all over it. The faucet on the handwashing sink had a white crusty substance on it. Thick dust and cobwebs were on the ceiling, walls, ceiling fans, and exposed pipes including pipes above the food preparation areas. There was crusty debris on stainless steel 3 compartment sink rubber mat where pans and other kitchen items dry. V5 (Cook) was standing at the 3-compartment sink washing, rinsing and sanitizing pans. On 4/19/22 at 9:05 AM, V3 (Dietary Manager) stated, My sink, all my pipes, ceiling fan, corners and ceiling need to be cleaned. It's on my list and I am working on it, but I am trying to get stuff done in here and still have other stuff to do out there. On 4/19/22 at 9:10 AM, V3 stated the facility just got the new chemical sanitizer system on 3/10/22, and they ran out of sanitizer on 4/14/22. V3 stated bleach was being used as a sanitizer right now in the 3-compartment sink. V3 used a test strip to check for levels of chlorine, dipped it into the sink with sanitizer, and it read 200 ppm (parts per million). V3 stated the water was cold, and the test strip should read 50 ppm for the bleach. V3 stated the temperature of the water in the sink should be 110 degrees Fahrenheit. V3 stated V3 needed to add more water to the sink with the sanitizer. A sign was posted above the 3-compartment sink that showed, Wash in water at, at least 110 degrees Farenheit with a good detergent; rinse thoroughly in clean hot water after washing to remove cleaners and abrasives; sanitize in warm water with sanitizer for one minute 110 degrees at least 50 ppm, air dry - sanitizer contact time is important. do not towel dry. V3 stated the sign was for the chlorine sanitizer and not the new sanitizer system. On 4/19/22 at 9:15 AM, there was grease and dust built up on the wall behind the oven/stove. On 4/19/22 at 9:20 AM, V4 (Dietary Aide) was not wearing a hair net when V4 walked in and out of the kitchen several times. V4 brought resident food trays in to clean them off and place them in the washing station directly across from the food prep station and oven/stove area. On 4/19/22 at 9:40 AM, V3 (Dietary Manager) tested the chemicals in the single rack, low temperature dishwasher. The test strip read at 25 ppm. V3 stated the reading should be at 50 ppm, and the dishwasher sanitizes using a chlorine-based product called sodium hypochlorite. V3 stated they have always used the chlorine test strips to test the sanitizer. V3 stated, The dishwasher doesn't keep its temperature. It will show 101 on the outside and is 4 degrees hotter. It has been doing this for the last 3-4 weeks. The sensor has been out in the dish machine, and it is not reading correctly. The dishwasher hasn't sanitized right in the last 2 years. I have worked here for [AGE] years in kitchen and recently took over as Dietary Manager. On 4/19/22 at 9:45 AM, the bucket with cleaning solution with a rag in it that was sitting in a kitchen sink was tested by V3 and read 200 ppm. V3 stated it was bleach that was used in the sanitizer bucket. V3 stated the rag in the bucket is used to wipe down tables, counters etc, and should be at 50 ppm. On 4/19/22 at 1:05 PM, V3 (Dietary Manager) stated the Daily/Weekly Cleaning Schedule, dated 4/7, showed it was documented the walls of the kitchen were cleaned. V3 stated that the walls were only cleaned on the bottom portion, but not the upper part of the walls. V3 stated there weren't any Daily/Weekly Cleaning Schedules for the facility prior to April 2022. V3 stated hair nets are to be worn in the kitchen so no hair gets in the food or on the surfaces. V3 stated the dishwasher was a single rack, low temperature machine that reads 105, but the temperature was 109 degrees Fahrenheit. V3 stated the dishwasher temperature should be 120 degrees Fahrenheit. V3 stated, During the day the temperature of the dishwasher won't maintain its temperature when I have to fight laundry for hot water. The temperatures are better in the evening than in the day; but they are still on the low side. The heating sensor element is out, and maintenance can't find a replacement part. I have talked to the different maintenance people we have had, and they can't either get the part and/or don't want to work on it. The facility's Sanitation Inspection policy (2/1/22) showed, It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. All food service area shall be clean, sanitary, free of litter, rubbish and protected from rodents, roaches, flies and other insects. The department shall establish a sanitation program for food services based on applicable state and federal requirements. The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation daily inspections. The facility's policy Manual Warewashing-3 Compartment Sink policy (2/1/22) showed, Third sink sanitizing - fill with hot water (171 degrees Fahrenheit) or use chemical sanitizer: . chlorine at 50-100 ppm. Confirm appropriate temperature or concentration prior to washing and record on sanitation control log. The sanitizing sink should be monitored for the proper temperature, if hot water sanitization is used and for proper chemical concentration if chemical sanitization is used. The facility's policy Dishwasher Temperature policy (2/1/22) showed, For low temperature dishwashers (chemical sanitization): The wash temperature shall be 120 degrees Fahrenheit. The sanitizing solution shall be 50 ppm hypochlorite (chlorine) on dish surface in final rinse. The facility's Sanitizing Buckets policy (4/2017) showed, Sanitizer concentration will be checked using a test kit. The following sanitizer concentrations are recommended and use of test strips to monitor accuracy of the sanitizer. Chlorine 50 - 100 ppm.

Based on interview and record review, the facility failed to offer and provide influenza vaccinations between October 1, 2021 and March 31, 2022. This applies to all 33 facility residents. The findings include: On 4/20/22 at 11:30 AM, five residents (R3, R6, R15, R28 & R32) were reviewed for the receipt or declination of the influenza vaccination. There was no documentation to show the residents were offered the influenza vaccination, consented, or declined receiving it. There was no documentation showing the residents received the administration of the influenza vaccine between October 1, 2021 through March 31, 2022. On 4/20/22 at 12:00 PM, V1 (Administrator) stated, We are looking for immunization information but I don't know where the previous DON (Director of Nursing) put it. On 4/20/22 at 12:20 PM, V2 (Assistant Administrator) stated, Some consents and/or refusals for vaccinations are scanned into the computer and some are not. We are looking for them. On 4/20/22 at 2:30 PM, V6 (Corporate Regional Nurse) stated, I know the DON was instructed to give residents the Influenza vaccine. On 4/21/22 at 10:05 AM, V7, RN (Registered Nurse), stated, They were looking for the consents for influenza last night. There were 7 residents that did not get the flu shot and it was given yesterday. The DON that was here said that she gave them. There is a 4 month window that they are to receive them. V10, LPN (Licensed Practical Nurse), gave the immunizations yesterday. They they should have been given earlier. On 4/21/22 at 10:18 AM, V10, LPN, stated, I was given this list yesterday and I was told to give the flu shot. The DON was in charge of the program. I don't know why it was not done. You would have to ask her and she isn't here anymore. I know (V1) and (V2) were working on getting the consents done yesterday. Normally we give it in October or November. Its supposed to be given between October and March every year. I know I have two more residents to give the flu shot to today. V10 gave a copy of the Flu Vaccine Temperature Log, dated 4/20/22, and it showed 20 residents had received the influenza vaccine on 4/20/22. On 4/21/22 at 10:21 AM, V1 (Administrator) stated, (V12, RN) the old DON supposedly got consents. I cant find them. I called pharmacy and they said she got the consents. I asked if they (influenza vaccination) were given and they said we have the vaccine but it was never given. I called the medical director and he said we could still give it until the end of May so we got consents and/or declinations yesterday. We started giving the flu vaccine yesterday. The DON did not implement and follow the influenza program. She was supposed to get a consent or refusal and give the immunization. V1 confirmed the facility's policy is to offer the influenza vaccination between October 1, 2021 and March 31, 2022. The facility's Influenza Vaccination policy (2/1/22) showed, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine.

Based on observation, interview, and record review, the facility failed to apply a hand and wrist splint to prevent contractures for 1 of 2 residents (R19) reviewed for positioning and mobility in the sample of 13. The findings include: R19's electronic face sheet, printed on 4/21/22, showed R19 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's care plan, dated 5/19/20, showed, Contracture of right hand secondary to [CONDITION(S)]. Palm protector to (R19's) right hand. Please wash and dry (R19's) right hand 2-3 times daily. If or when palm protector becomes soiled, please contact therapy and she will clean the protector and provide a clean one for (R19) to wear. Remove for skin care twice per day. R19's facility assessment, dated 2/3/22, showed R19 has severe cognitive impairment. R19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Please cleanse, wash, and dry (R19's) right hand 2-3 times daily. Hand carrot or rolled washcloth to right hand to reduce contractures. R19's certified nursing assistant task list for April 2022 showed, Carrot or rolled wash cloth to right hand. Please cleanse, wash, and dry (R19's) right hand 2-3 times daily. Remove for skin care twice daily. On 4/19/22 at 11:06AM, R19 was sitting up in R19's reclining wheelchair in R19's room with R19's hands in R19's lap. R19's right hand was slightly closed, and had no brace or splint on it. A brace was laying on the windowsill on R19's side of the room, and another brace was laying on R19's bedside table. On 4/20/22 at 8:14AM, both of R19's braces were laying on R19's bedside table while R19 was in the dining room eating breakfast. At 8:29AM, staff brought R19 back to R19's room, covered R19 with a blanket, and left the room. Both of R19's braces continued sitting on R19's bedside table. On 4/19/22 at 1:05PM, V8 (Certified Nursing Assistant) stated, (R19) has a splint for her hand that should be on at all times during the day. We are only supposed to take it off to clean it. There is no reason why she wouldn't have it on. On 4/20/22 at 1:16PM, V7 (Registered Nurse) stated, (R19) is supposed to have a palm protector to her right hand to prevent contractures. She wears the carrot in her hand at night but the palm protector should be on during the day. She does not have any history of refusing it or taking it off by herself. The facility's Splint Placement In-service, dated 3/8/22, showed, This is an example of proper splint placement for (R19). Please make sure that the strap on the top is not pulled too tight as this could cause skin breakdown. Attached to this document were photographs showing proper splint placement for R19.

Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were in place for 2 of 3 residents (R27,R6) reviewed for falls in the sample of 13. The findings include: 1. R27's electronic face sheet, printed on 4/21/22, showed R27 has diagnosis including but not limited to: COVID-19, [CONDITION(S)], repeated falls, sciatica, Alzheimer's disease, and major depressive disorder. R27's facility assessment, dated 2/20/22, showed R27 has no cognitive impairment and requires 1 person assistance for transfers. R27's care plan, dated 7/26/21, showed, (R27) has an activities of daily living self-care performance deficit related to disease processes: [CONDITION(S)], Alzheimer's dementia, gait instability, and history of falls. (R27) requires 1 assistance by staff to move between surfaces. Refuses assistance. R27's care plan, dated 4/19/22, showed, (R27) is a high risk for falls related to confusion, gait/balance problems, and history of falls. Resident appears to be intentionally falling at times related to behaviors. Resident states I want to fall 200 times before I die. I am at 113. Falls on 3/9/22 and 3/16/22 with no injury. Falls on 4/11/22 and 4/17/22. Keep wheelchair out of room, ensure bed is in low position, floor mats next to bed, follow fall protocol, large print signage in room, educate resident to use call light for staff to remove floor mat to get up. R27's certified nursing assistant daily tasks for April 2022 showed no documentation of R27's refusals for assistance with activities of daily living or poor safety awareness. R27's nursing progress notes, dated 4/18/22, showed, Fall was not witnessed. Fall occurred in the resident's room. Did injury occur as a result of the fall: Yes. Staples to back of resident's head. On 4/19/22 at 1:25PM, R27 stated, I had a fall over the weekend. I sat up and fell over and hit my head on the nightstand. The fall mat is supposed to be on the floor in case I fall out of bed. It is supposed to be put it down whenever I'm in bed. R27's fall mat was folded up and leaning against the wall opposite of R27's bed. R27 was lying in bed at this time. No large print signage was observed in R27's room. On 4/20/22at 8:16AM, R27 was lying in bed. R27's fall mat was folded up and leaning against the wall opposite of his bed. No large print signage was observed in R27's room. On 4/20/22 at 1:08PM, V7 (Registered Nurse) stated, (R27) is a fall risk and has had a recent fall with injury. Fall prevention measures for him are to ensure his call light is within reach, gripper socks when ambulating, education about safety reminders, walker, assistance with making his bed, removed shelf, large print signage in room, and floor mats are to be removed by staff when resident wants to get up. If the fall prevention measures are not present in his room then he could fall and get injured. The facility's policy titled, Fall Prevention Program, implemented 2/1/22, showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 2. R6's Admission Record (Face Sheet) showed an original admitted [DATE], with diagnoses to include: Alzheimer's, abnormalities of gait, weakness, impaired balance (ataxia), lack of coordination, and need for assistance with personal care. R6's 2/25/22 Post Fall Evaluation showed, Reason for fall; was trying to get something to drink .Conclusion: Need to make sure that fluids are available at bedside. On 4/19/22 at 9:03 AM, R6 was asleep and laying on R6's back in bed. R6 had a nutritive shake in R6's hand, which was open and had a straw in it. R6 had no bedside table, and R6's nightstand was a few feet outside of R6's reach. R6 had no cups of water in R6's room. (With the exception of R6's call light, R6 was in the same condition at 1:04 PM and 2:25 PM.) On 4/20/22 at 11:02 AM, R6 did not speak; however, when asked where R6's call light was located, R6 was able to point to it's location in R6's bed. R6 had no bedside table, the nightstand was as described previously, and R6 had no water or nutritive shake. On 4/20/22 at 12:41 PM, R6 was on the floor between R6's bed and R6's night stand antempting to crawl or roll to R6's nightstand. While R6 was on the floor, R6 had an out stretched arm attempting to reach something on R6's nightstand. R6 had no water in R6's room, no bedside table, and R6's nightstand was in the same location as before. While R6 was on the floor, no alarm was sounding, and there was no alarm in R6's bed. R6's Care Plan (as of 4/20/22 at 11:10 AM) showed R6 was a high risk for falls with interventions to include: .Be sure (R6's) call light is within reach .Bed pad alarm (alarm was entered twice in the care plan), .have cups available within reach .ensure bedside table is within reach . R6's updated care plan, provided on 4/21/22, showed the bedside table intervention was removed and replaced with nightstand. On 4/20/22 at 1:52 PM, V7, Registered Nurse, stated R6 does occasionally use R6's call light. R6 said it would be important for R6 to have R6's nightstand next to R6, water available to R6, and to have R6's call light within reach to prevent falls. On 4/20/22 at 12:56 PM, V13, Certified Nursing Assistant, stated R6 doesn't use the call light often, but R6 does use it occasionally. V13 said R6 did not have any cups of water in R6's room (V13 was the CNA who responded to R6 being on the floor at 12:41 PM), and having R6's nightstand with water near her is important to prevent falls. The facility's Fall Prevention Program (implemented 2/1/22) showed protocols to prevent falls include Call light and frequently used items are within reach .

Based on observation, interview, and record review, the facility failed to offer and provide incontinence care in a manner to prevent a urinary tract infection for 1 resident (R7) with a history of urinary tract infections. These failures apply to 1 of 1 residents reviewed for bowel and bladder incontinence in the sample of 13. The findings include: R7's electronic face sheet, printed on 4/21/22, showed R7 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's care plan, dated 6/30/21, showed, (R7) has mixed bladder incontinence: stress incontinence due to leakage and obesity, urge incontinence related to diabetes mellitus, and functional incontinence related to needing assistance with mobility and clothing management, [CONDITION(S)], and pain. (R7) has exhibited some stubborn behavior with bladder incontinence. When staff has offered to toilet her she stated, I'm 83 y/o and who gives a sh*t. Offer and encourage toileting upon rising, after meals, at bedtime, and as needed. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes and monitor for signs and symptoms of urinary tract infection. R7's facility assessment, dated 4/8/22, showed R7 has no cognitive impairment, requires 1 staff member assistance for hygiene, and is frequently incontinent of bowel & bladder. R7's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/22 at 2:08PM, V8 and V9 (Certified Nursing Assistants) were providing incontinence care for R7. R7 stated R7 has not receive incontinence care or been offered toileting assistance or incontinence care since R7 got out of bed this morning. R7 usually gets out of bed around 9-9:30AM. V8 and V9 stated they were unsure of when R7 last received incontinence care or offered toileting assistance. V9 then began providing perineal care to R7, and wiped 3 times down front of vaginal area with the same side of a soap filled washcloth. R7 was then turned over on R7's side and V9 wiped 3 times with the same side of the washcloth & over R7's vaginal area. V9 removed R7's shirt that was soiled with urine, and R7's urine saturated incontinence brief. V9 applied a clean incontinence brief and clean shirt to R7, with the same gloves V9 provided incontinence care with. V9 stated the staff offer and provide toileting and bathroom assistance every 2 hours or as needed for residents. V9 stated, (R7) does call when she is ready to lay down and get changed, but staff should be checking in on her too and offering toileting assistance. She has a history of skin breakdown so it's important to make sure she is being changed and getting out of her soiled clothing. Gloves should be changed when going from soiled to clean tasks due to the risk of infection. I should have flipped the washcloth and towel over to a new area before wiping because those are soiled areas once they have touched her. On 4/20/22 at 1:06PM, R7 stated, I was changed this morning around 9:30AM or so when I had my shower. They haven't offered to change me since then. I know I'm wet, but hopefully I get to lay down soon. R7's certified nursing assistant daily tasks for April 2022 showed no bowel and bladder elimination assistance or personal hygiene assistance were completed on 4/19/22. On 4/20/22, no documentation was present for either task until 9:30PM. The facility's policy titled, Incontinence, dated 2/1/22, showed, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

Based on observation, interview and record review the facility failed to safely transfer a resident to prevent a fall. This applies to one of three residents (R1) in the sample of 3. Staff utilized a pivot transfer instead of using a mechanical lift as care planned. The facility failure resulted in R1 sustaining a fracture to her left hip requiring surgical intervention. The findings include: The facility face sheet shows R1 has diagnosis of [CONDITION(S)] (paralysis) of the left side, obesity, lack of coordination and difficulty in walking. The facility assessment dated [DATE] shows R1 is cognitively intact and requires extensive assistance of two staff for transfers, and has impairment to one side of her body. The facility care plan dated 3/30/21 shows R1 required extensive assist of two staff and the mechanical stand lift for all transfers. The nursing progress note dated 3/30/21 shows R1 had fallen during a transfer. R1 was assessed after the fall and was showing verbal and non-verbal indicators of extreme pain and unsafe to transfer back to bed. An ambulance was called. A nursing note later that same day showed R1 had sustained a fracture to her left hip. On 4/2/21 at 9:00AM R1 was up in her wheelchair eating breakfast. R1 said I feel rough, it hurts. At 9:50AM R1 was taken to her room to be transferred back to bed. R1 was shaking and facial grimacing observed. R1 said she hurt a lot. When R1 was asked if one staff member transferred her alone the day she fell , R1 shook her head yes. At 12:30PM, V6 R1's POA was in the resident room. V6 said her mother (R1) was in a lot of pain and she was worried for her mother. At 1:30 PM, R1 continues to say she is in a lot of pain. V6 said the staff are calling the doctor to get more pain medications for her (R1). On 4/2/21 at 1:45 PM, V3 CNA (Certified Nursing Assistant) said she was the CNA doing the transfer the day R1 fell and broke her hip. V3 said she was transferring R1 from her bed to her wheelchair by herself and was not using a mechanical lift. V3 said she had no reason for why she did not use the mechanical lift as care planned. V3 said two staff usually transfer R1 to her chair. On 4/2/21 at 9:00 AM, R4 (R1's roommate) said she did not witness the fall but said there was only one CNA in the room and no mechanical lift was brought into the room. R4 said the mechanical lift is rarely used to transfer R1. On 4/2/21 at 1:25 PM, V5 RN (Registered Nurse) said CNA's are to follow the patient care summary document in each residents room to know how to care for the resident. V5 said the information on the patient care summary comes right off the care plan and it is the safest way to transfer each resident. On 4/2/21 at 9:50 AM, V4 CNA said R1 is to be transferred with two staff present and are to use the mechanical lift. On 4/2/21 at 11:25 AM, V1 DON (Director of Nurses) said she was the nurse working the day R1 fell . V1 said V3 came to get her to tell her R1 had fallen during the transfer. V1 said R1 fell because V3 did not lock the brakes on R1's wheelchair. V1 said she was not sure who was in the room when R1 fell or if the mechanical lift was in the room. V1 said R1 was in a lot of pain and she just wanted to get her transferred to the hospital. V1 then said R1 was transferred by one staff member and no mechanical lift was used. V1 said the care plan should always be followed and that this was a serious accident that could have been avoided. On 4/2/21 at 10:15 AM, V2 Rehabilitation Director said a resident is assessed by her when they are admitted to the facility or if the resident has a change in condition, to determine the safest way to transfer each resident. V2 said R1 has a flaccid left side, does not follow commands well and will not turn to her sides. V2 said the safest way to transfer R1 was with two staff and the mechanical stand lift. V2 said transferring R1 with one staff and no mechanical stand lift is very dangerous and should never be done that way. V1 said with R1's injury and previous deficits, she does not see R1's rehab going very well and is not sure if R1 will be able to get back to where she was before. The facility physical therapy note dated 12/22/20 shows R1 had been evaluated for transfer ability after a change in condition. The note shows R1 had potential for decline in functional transfers which would result in decreased safety and an increased need for assistance. The precautions listed on R1's therapy notes shows she is a fall risk and has left sided weakness and a left upper extremity contracture. The hospital records for R1 dated 4/1/21, showed a diagnosis of acute closed left hip fracture after a fall at the nursing home. Surgery was preformed on 3/31/21 to repair the hip. The undated facility policy for resident handling shows the resident handling policy exists to ensure a safe environment and transfers will be designated into categories for each residents safe transfer. This policy is to be followed at all times.

Based on observation, interview, and record review the facility failed to supervise a resident identified as high risk for falls. The facility failed to analyze risk factors contributing to falls. The facility failed to evaluate the effectiveness of fall prevention measures. The facility failed to revise and individualize fall prevention measures to prevent fall related injuries. These failures contributed to R1 falling and sustaining a right femur fracture and right humerus fracture, severe pain, and decline in function on August 21, 2015. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: R1 was admitted to the facility on [DATE] with a fractured pelvis from a fall at home. R1's Nursing Notes documented a pattern of R1 getting up to go to the bathroom on the night shift unassisted and increasing her risk for falls. 9/20/14 4:10 AM found resident up trying to go the the bathroom unassisted. 9/25/14 2:00 AM up looking for the bathroom. 9/28/14 5:05 AM attempted to get up unassisted three times. 10/4/14 5:00 AM attempting to toilet self unassisted. 10/20/14 2:55 AM, R1 was found on the toilet unassisted. 10/23/14 12:15 AM, found on the toilet unassisted. Said she forgets to get help. 10/25/14 1:30 AM, going to bathroom unassisted. 10/28/14 2:35 AM R1 up several times unassisted. The nursing note of October 17, 2014 at 12:10 AM shows R1 fell when attempting to go to the bathroom. Resident states, she doesn't understand the call light system, she is old and can't remember all of that. R1's Morse Fall Scale dated August 22, 2015 at 7:05 AM states R1 is high risk for falling R1's current Minimum Data Set (MDS) dated [DATE] shows R1's brief interview for mental status score is 2. (Severe cognitive impairment.) R1's incident report dated June 29, 2015 at 12:44 AM, states, Heard loud noise coming from resident's room. When entering noted Certified Nursing Assistant - E5 holding direct pressure to back of R1's head. The same report shows that prior to her fall, R1 was ambulating unassisted with an unsteady gait. She fell backwards into the dresser and struck her head and sustained a laceration. R1's care plan documented no additional or revised fall prevention measures following this fall with injury on 6/29/15. The care plan interventions at this time included to keep call light within reach and remind her to use it, encourage her to participate in activities, and ensure appropriate footwear. (No changes/additions were made to the prevention measures) From 6/29/15 until R1 fell and sustained fractures 8/20/15 no care plan modifications were made. The incident report of August 21, 2015 at 9:30 AM completed by E4 states, Patient's bed alarm sounded off, I ran down to patient's room immediately and noted patient sitting on her buttocks with both legs stretched out in front of her. I called for CNA back up and patient requested to use the bathroom, patient lifted by 2 staff without difficulty. Bed was in low position, bed alarm intact and functioning, call light was at reach. Patient is normally alert but can be forgetful and non compliant at times. The same report show that prior to her fall, R1 was ambulating , unassisted with an unsteady gait. R1 said Can you please just take me somewhere to die. R1 was starting to urinate and asked to be taken to the bathroom. Her call light had been within reach prior to this incident. The progress notes in the medical record, showed R1 fell on [DATE] at 4:40 AM. (Discrepancy in time of fall is noted from incident report). On August 26, 2015 at 8:02 AM Z1 (Paramedic) stated, When we first pulled up to the facility, I saw through a window, a staff member in a resident's room having difficulty managing the resident. (R3) I entered the facility and went to the room (where I saw the nurse) she directed me to R1's room and stated, The CNA (certified nursing assistant) is in R1's room, please send her down to help me. Z1 said she did not see any other staff members in the facility until she got to R1's room. Z1 said the CNA stated, I am the only CNA here. A written report by Z1 dated 8/20/15 documents that R1 fell on [DATE] and they responded to the facility call for help at 4:24 AM. Z1 documents the CNA reports after resident fell , she was walked to the bathroom, and she (CNA) noticed a change in R1's ability to walk. R1 complained of pain in her right leg, and later in her right arm. R1's X-ray report dated 8/20/2015 states, Comminuted oblique fracture distal femoral shaft and displaced fracture surgical neck right humerus. R1's Morse Fall Scale dated August 22, 2015 at 7:05 AM states R1 is high risk for falling. On August 25, 2015 R1 was observed laying in bed leaning towards her left side. R1 was heard screaming from the nurses station. At 2:30 PM, E2 (Director of Nursing-DON) stated, We have been trying to get a call back from the physician regarding a request for liquid Morphine and Ativan for better pain control. On August 25, 2015 at 5:15 AM, E3 (CNA) stated, I was with someone else that was a high fall risk at the time that R1 fell . At 12:58 PM, R1's alarm was sounding when she fell but I was with another resident. I'm pretty sure the fall could have been prevented if there was another CNA. On August 25, 2015 at 5:30 AM, E4 (Licensed Practical Nurse-LPN) stated, Staffing is not good here, there have been a lot of resident falls. R1 peed in her bed and took her legs off of the bed. When I found her, her legs were in front of her and she was sitting on her bottom on the floor. On August 25, 2015 at 6:45 AM, E5 (CNA) stated, On August 19, 2015 there were two CNAs until 2:00 AM, after 2:00 AM it was just E3. At 12:45 PM E5 said If I cannot get another CNA to come in and fill in for someone that calls in, I come in myself. On August 25, 2015 at 8:57 AM, E6 (CNA) stated, I am having a hard time taking care of residents because of the lack of help. Yesterday I had 20 residents to take care of myself. Sometimes resident cares are not met because of staffing. On August 25, 2015 at 9:20 AM E7 (CNA) stated, Sometimes we are unable to monitor residents that are a high risk for falls, due to lack of staff. On August 25, 2015 at 12:30 PM E9 (LPN) stated, Two weeks ago the CNA's were ready to cry. The administrator said they would have two CNAs on nights. There was only one CNA and one nurse the night R1 fell . On August 25, 2015 at 2:30 PM, E2 (DON) stated, R1's family is deciding on palliative care at this time. They decided against surgery. R1 required a one person assist and was able to use the bathroom prior to her fall and now requires a two person assist and she is on bed rest. There should be two CNAs on the night shift. If a CNA calls off on third shift, the PM CNA stays for an extra four hours. It is my expectation that E5 find a replacement CNA or come in herself to cover a shift if there is a call off. (E5 did not come in the night of 8/21/15 to cover in the absence of a CNA. On August 27, 2015 at 2:30 PM, Z2 (Medical Director) stated, I was not aware the facility had one nurse and one CNA to care for 32 residents. The ratio of one nurse and one CNA for 32 residents sounds low to me to safely monitor all the residents. The undated facility Fall and Fall Preventions Management Program policy states The floor nurse will be responsible for (a) ensuring interventions for fall prevention are being utilized and implemented by support staff. (b.) re-evaluating residents at risk for falls, change of conditions, and resident's with a recent fall. (d) evaluating a residents plan of care in relation to falls. I. (a). Fall assessment tool is to be completed upon admission, annual MDS review, with a significant change of condition .and within four days of a resident fall.

Based on observation, interview, and record review the facility failed to assess, monitor and provide treatment to prevent the development and worsening of pressure wounds on R1's buttocks and her right heel. These failures contributed to R1 developing a purple unstageable area to the right heel and a stage two pressure ulcer on her buttocks. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 3. The findings include: On June 10, 2015 at 8:00 AM, R1 was at a local hospital. There were two Duoderms (dressings) in place to the upper buttocks. The surrounding skin was reddened from the top of her buttocks down to 1/4th of her thighs. R1 had a darkened purple area on her right heel that measured 1 in x 0.5 in. R1 stated, I need help to turn in bed. My bottom is very raw and sore and I have a sore on my right heel. They wrapped my right heel with gauze after I got the sore. On June 10, 2015 at 9:05 AM, Z1 (Registered Nurse at local hospital) stated, R1 has a stage two pressure ulcer to her buttocks. The one wound measures 0.5cm x 0.5cm and the other wound measures 1 cm x 2 cm. The stage 2 wound on her buttock was documented on admission. On June 8, 2015 at 10:02 AM, Z4 (Case manager at a local hospital) stated, She has a pressure ulcer on her right heel. It is purple and unstageable. The nurse chart assessment from the local hospital dated June 3, 2015 at 9:00 AM, states, Open areas to coccyx and right medial heel ulcer that is not open, purple in color approximately quarter in size. The physician admission documentation from the local hospital dated June 3, 2015 at 10:36 AM, states, Skin: Positive for [MEDICAL CONDITION], ecchymosis, [DIAGNOSES REDACTED], rash, ulceration, warm to touch of the buttocks, right hip and right heel. at 10:45 AM, There is diffuse [DIAGNOSES REDACTED] and maceration and superficial ulceration over both buttocks and posterior proximal thighs as well as an early decubitus on the right heel. Disposition: Decubitus ulcer, pressure, (buttock)-bilateral, decubitus ulcer, pressure, (heel)-right. On June 9, 2015 at 11:10 AM, E2 (Director of Nursing-DON) stated, R1 has a stage 2 pressure ulcer on her bottom that we discovered on June 2nd. We just discovered it the day before she went to the hospital on June 3rd. at 3:15 PM, When a nurse finds a new wound I expect them to assess, measure, call medical doctor for orders, update the family, implement orders, and document the assessment. It was acquired here at the facility. The admit nurse completes a skin and admission assessment. On June 11, 2015 at 11:10 AM, The skin assessment policy is used as the prevention program. We also rely on nurses training and critical thinking skills to contact the medical doctor when more orders are needed. On June 9, 2015 at 11:50 AM, Z3 (Medical Doctor) stated, I first became aware of her wounds on June 2, 2015. I did not know the severity until I saw her. The facility's progress notes dated June 3, 2015 at 1:20 AM states, New orders were received. Wound center consult to be done for right heel and incision and [MEDICAL CONDITION]. Buttocks treated with antifungal cream and butt paste/barrier cream. The facility's nurse assistant notes for the AM, PM, and Night shift for May states,resident was cooperative and did not refuse assistance. On June 10, 2015 at 1:45 PM, E4 (CNA) stated, The nurses are supposed to do skin assessment. We keep an eye on resident's skin everyday. If we notice something out of the ordinary we report it to the charge nurse right away. When R1 came to the facility she had spots on her coccyx area. They were reddened and raw. They were not opened. I reported it to the nurse, I don't remember the nurse's name. We don't document the skin checks, the nurses document the skin checks and skin assessments. I thought the spots on her coccyx looked better when she left. We were applying skin protectent every incontinent episode. On June 10, 2015 at 2:27 PM, E6 (CNA) stated, We perform skin checks every time we do care. Her skin on her buttocks was slightly red on admission. I notified the nurse but do not remember which nurse. On June 2nd her bottom was opened and red, her right heel had a blister. Her buttocks was redder on her last day on June 3rd. I told the nurse but do not remember who. We repositioned her every two hours and float her heels. She sometimes refused repositioning. That would be documented on the CNA sheet each time she refused. On June 10, 2015 at 2:50 PM E5 (Certified Nursing Assistant-CNA) stated, I perform skin checks about every two hours. When R1 was first admitted her bottom was red and it started to look better and then it progressed to almost blister like. She refused to be repositioned. I charted that in the CNA charting and told the nurse that as well. She had a blister or pressure ulcer on her right heel. On June 10, 2015 at 3:30 PM, E7 (Licensed [MEDICATION NAME] Nurse-LPN) stated, I did a skin assessment when she first came in and on the third day because of loose stools. Her buttocks was excoriated on admission. The third day skin assessment was documented under progress notes. The excoriation to her buttocks remained the same and there was no other skin issues noted. The facility's nurse aides information sheet not dated states, Skin Care special: Hip incision and routine. Needs encouragement to get out of bed and reposition. The facility's nursing admission screening/history dated May 21, 2015, states, Skin: Note all skin issues: Right trochanter (hip) surgical incision 5.5cm X 1cm, Right trochanter (hip) surgical incision 8cm X 1cm. The facility's braden scale effective date May 22, 2015 at 1:02 PM states, Score:17, Category: At risk. The facility's use of pressure sore risk management (undated)states, Purpose is to identify resident at high risk for skin breakdown and ensure implementation of prevention program. Residents identified at risk, start program or if a significant change in residents condition. The facility's skin assessment policy (undated) states, Skin assessments will be done for all new admissions, quarterly review, and significant changes of condition. Residents will be determined to be at risk according to the Braden Scale. On June 11, 2015 at 11:10 AM, E1 (Administrator) stated, The prevention program for R1 included repositioning every 2 hours and as needed and pillows used as support. She was on a pressure relieving mattress upon admission. She needs encouragement to get out of bed and reposition.

Based on Interview and Record Review the facility failed to ensure residents are free from sexual abuse. This failure resulted in residents experiencing harm when subjected to sexual abuse. This applies to 2 of 3 residents (R2 & R3) reviewed for sexual abuse in the sample of three. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/31/14. On 8/27/14, E1 (Administrator) was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 8/27/14. While the immediacy was removed the facility remains out of compliance at a level two due to the need to monitor staff compliance with the facility's abuse policy with an emphasis on what is considered abuse. The finding includes: On 8/27/14 at 8:20am, E7 (Certified Nursing Assistant - CNA) stated, "On 8/24/14 I heard a noise and went to R1 & R3's room. I turned the light on and asked if I could help. R3 was on her back in her bed and R1 had his penis in her mouth. R3 was gagging and trying to fight R1 off. R3 was upset. R1 stood up, zipped up his pants and sat in a chair. R1 acted like he knew what he was doing that morning. I told E9 (Licensed Practical Nurse - LPN) and she said to redirect R1 away from R3." On 8/26/14 at 3:50pm, E4 (CNA) stated, "R1 was up walking around all night (8/25/14). R1 kept taking his penis out of his pants and we were redirecting him to cover up. It was around 3:00am, and he was by the A hall nurses station with his pants down and penis about 3 inches from R2's mouth. R1 was saying, "Come on." R1 does this to his wife (R3) all of the time. I don't think she likes it. E7 told me she heard choking noises one morning and went into R1 & R3's room. R1 had his penis in R3's mouth. E8 (CNA) saw R1 with his wife and had to stop it; he was making her do it, have oral sex. R1 is pushy with R3. When R3 is at dinner with other ladies, she smiles and talks. When R1 is around, R3 looks sad and just sits there." The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/14 for R3 shows impairment of short term memory, long term memory and cognition. On 8/26/14 at 11:50am, E1 (Administrator) stated, "This took place between 2:30am and 3:00am this morning (8/26/14). I did not receive any phone calls last night. I am the Abuse Coordinator and I should have been notified. I got a call after E3 (Social Service Director - SSD) was informed after 7:00am today. R1 reportedly had been standing in front of R2 with his penis in her face. R2 was sitting in a wheelchair. It is not unusual for R3 to be up in the middle of the night. This was witnessed by E4 (CNA). E4 reported it to E5 (LPN) who did not think it was abuse. R1 has walked down the hall one time without his clothes on. R1's wife (R3) is a resident here and she is very confused. R1 and R3 are in the same room together." On 8/26/14 at 12:30pm, E3 (Social Service Director - SSD) stated, "I walked in today and me and E6 (Registered Nurse - RN) were discussing R1 and R3's behavior, if staff are verbally redirecting R1, Incident Reports not being filled out, sexual acts in a common area that happened last night too. E7 (CNA) came up and said that E4 told her this morning that R1 put his penis in R2's mouth. R1's daughter said R1 liked to strip his clothes when we did his admission (to the facility)." The Incident Reports for R1 dated 7/31/14 showed, "At 2:20pm - R1 walked into hallway with only socks and shoes on. I walked him back to his room and told him we don't walk around like this. R1 stated, "Don't you like what you see?" I told him we don't do this, let's get dressed. As I was dressing R1 he was fondling my breast. I was fixing his pants bent over and R1 started feeling my butt. I told him we don't touch workers or anyone. I was fixing R1' s shirts and he started to masturbate. R1 said, "Don't you want to help me?" I told him we don't act like this."; at 3:30pm - R1 was naked in the hallway and I took him to a room to get dressed and he stated he can touch my breasts. R1 licked his lips groaning at me saying, "That looks nice." while staring at my chest. " The Incident Reports for R1 dated 8/5/14 showed, "3:00pm - R1 was walking down the hall heading towards the desk with his genitals out so others could see his genitals; 3:15pm R1 was standing by A1 (R2's room) where visitors were and his private parts were hanging outside of his pants." The Incident Reports for R1 showed, "8/6/14 - R1 was standing at the door of his room pulling out his penis. After supper R1 was being very mean to R3; 8/8/14 - R1 was standing in the hallway with his genitals out. I told R1 to zip his clothes. I told R1 that he can't expose himself. R1 repeated it three times. R1 waved me off with his hand when I asked him if he understood. He then zipped his clothes and returned into his room; 8/9/14 -R3 was sitting next to R1, after breakfast, in the living room. R1 told R3, "Oh just be quiet. Go, get out of here. Go get up, I dare you. I hope you fall down."; 8/25/14 - R1 was making R3 play with him in the living room and putting his penis in her mouth." The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/14 for R1 showed a Brief Interview for Mental Status (BIMS) score of 11/15 (Moderate Cognitive Impairment). On 8/27/14 at 4:55pm, Z1 (R3's Power of Attorney - POA) stated, "I have been to the nursing home three times today. They moved R3 and placed her with another resident. R3 will be safe now. I don't want R3 back in a room with R1. The facility told me R1 was getting more aggressive with his sexual behaviors. About 10 months to 1 year ago R3's dementia got worse so I hired caregivers to care for her 8 hours a day. I felt R1 was declining too but he said he didn't need any help and it's not my decision to make. R1's daughter is his POA. R1 and R3 have been married for [AGE] years. R1 was never controlling until R3's dementia got worse. R1 started with this behavior over the last 10 -12 months since R3 got worse. R1 was pulling his pants down and exposing himself to the caregivers. When R1's behaviors increased I made the decision to have R3 moved here. R1's daughter agreed to have him moved here. R3's dementia is so bad that she doesn't even know who R1 is anymore. I didn't know R1 was having physical contact with R3 or gagging her." R1's Care Plan dated 7/21/14 showed, "R1 exposes himself in public places; Goal - Lessen public exposure; Interventions - Verbal redirection; Educate on sexual exposure; Invite resident to activities to help limit down time; Provide room for him and his spouse to be intimate." Through Observation, Interview and Record Review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation. A. On August 27, 2014 the Administrator in-serviced staff on the facility's Abuse Policy with emphasis on the following: What constitutes abuse, the different types of abuse, what to do if abuse is suspected and/or witnessed, when to report abuse (immediately) and who to report abuse to. B. All staff will be in-serviced by the Abuse Coordinator on the facility abuse policy before they are allowed to work.

Based on Interview and Record Review the facility failed to follow its policies and procedures that direct staff to immediately report allegations of abuse and investigate allegations of abuse. The facility staff witnessed R1 gagging R3 with his penis on 8/24/14 but did not report it to the Abuse Coordinator. Facility staff witnessed R1 making R3 play with his penis and putting his penis in her mouth on 8/25/14 and did not report it to the Abuse Coordinator. The facility staff witnessed R1 putting his penis in another resident's face on 8/26/14 which was not immediately reported to the Abuse Coordinator. These failures resulted in two female residents being subjected to sexual abuse. This applies to 2 of 3 residents (R2 & R3) reviewed for sexual abuse in the sample of three. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/31/14. On 8/27/14, E1 (Administrator) was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 8/27/14. While the immediacy was removed the facility remains out of compliance at a level two due to the need to monitor staff compliance with the facility's Abuse Policies and Procedures. The finding includes: On 8/27/14 at 8:20am, E7 (CNA) stated, "On 8/24/14 I heard a noise and went to R1 & R3's room. I turned the light on and asked if I could help. R3 was on her back in her bed and R1 had his penis in her mouth. R3 was gagging and trying to fight R1 off. R3 was upset. R1 stood up, zipped up his pants and sat in a chair. R1 acted like he knew what he was doing that morning. I told E9 (LPN) and she said to redirect R1 away from R3." On 8/27/14 at 4:20pm, E1 (Administrator) stated, "We did not know that R1 had put his penis in R3's mouth. The CNA and nurse did not tell me or E2 (Director of Nursing - DON). That is unacceptable. I didn't know anything about it until E4 (CNA) said something yesterday when I was getting her statement." The facility's Abuse Policy and Procedure (8/2011) showed, "Definition of Abuse: Sexual assault, or raping a resident or forcing a resident to engage in other sexual acts; Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault; During orientation of new employees as well as at least annually, the facility conducts training on sensitivity to residents needs, including the definition of abuse, neglect and misappropriation of resident property, as well as abuse reporting and investigation obligations." The Incident Report dated 8/25/14 for R1 showed, "R1 was making R3 play with him in the living room and putting his penis in her mouth." The Nurses Notes dated 8/26/14 for R1 showed, "1:00am - R1 was leaning over his spouse's head of bed exposing himself to her; 3:00am - R1 came out into the hallway, exposing himself in front of another female resident, not his spouse. R1 was redirected." The facility's Reporting on Abuse Allegation "(7/2014) showed, "Any allegation of abuse, neglect or theft from a resident will result in the following: The one who witnesses or has any knowledge of an act or suspected act of abuse shall notify the Administrator, Illinois Department of Public Health (IDPH), resident's family, and physician, if applicable, will be informed immediately; All reported acts or suspected acts of abuse shall be immediately and thoroughly investigated. The one who suspects a crime occurring that involves serious bodily injury must report that suspicion to the police and IDPH immediately." On 8/26/14 at 3:50pm, E4 (CNA) stated, "R1 was up walking around all night. R1 kept taking his penis out of his pants and we were redirecting him to cover up. It was around 3:00am, and he was by the A hall nurses station with his pants down and penis about 3 inches from R2 ' s mouth. R1 was saying, "Come on." R1 does this to his wife (R3) all of the time. I don't think she likes it. E7 told me she heard choking noises one morning and went into R1 & R3's room. R1 had his penis in R3's mouth. E8 (CNA) saw R1 with his wife and had to stop it; he was making her do it, have oral sex. R1 is pushy with R3. When R3 is at dinner with other ladies, she smiles and talks. When R1 is around, R3 looks sad and just sits there." On 8/26/14 at 11:50am, E1 (Administrator) stated, "This took place between 2:30am and 3:00am this morning (8/26/14). I did not receive any phone calls last night. I am the Abuse Coordinator and I should have been notified. I got a call, after E3 (Social Service Director - SSD) was informed, after 7:00am today. R1 reportedly had been standing in front of R2 with his penis in her face. R2 was sitting in a wheelchair. It is not unusual for R3 to be up in the middle of the night. This was witnessed by E4 (Certified Nursing Assistant - CNA). E4 reported it to E5 (Licensed Practical Nurse - LPN) who did not think it was abuse." On 8/26/14 at 12:30pm, E3 (Social Service Director - SSD) stated, "I walked in today and me and E6 (Registered Nurse - RN) were discussing R1 and R3's behavior. E7 (CNA) came up and said that E4 told her this morning that R1 put his penis in R2's mouth. I asked E7 if anyone else was notified and she said she didn't know. E6 and I decided to contact E2 (Director of nursing - DON) who said she didn't know anything about it. I hung up and said I was contacting the state (Illinois Department of Public Health - IDPH). I called the hotline. E5 said it did not happen and that she didn't see it so that is why she did not call anyone." On 8/26/14 at 12:49pm, E2 (Director of Nursing - DON) stated, "I was called at 7:20am today. E4 said R1 stuck his penis in R2's mouth. I came in to the facility. E1 was already here when I got here. E5 (LPN) should have notified us when this happened. She knows she is to contact us." The facility's "Procedure on Abuse Allegation" dated 7/2007 showed, "The one who witnesses or has any knowledge of an act or suspected act of abuse shall notify the administrator, Illinois Department of Public health, resident's family and physician, If applicable, will be informed immediately. All reported acts or suspected acts of abuse shall be immediately and thoroughly investigated." Based on Observation, Interview and Record Review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation. A. On August 27,2014 the Administrator in-serviced all staff on duty regarding the facility's Abuse Policy and Procedure and were given a copy of the Abuse Policy and Procedure. B. All staff will receive 1:1 in-servicing regarding the facility's Abuse Policy and Procedure prior to returning to work. C. All staff will receive training upon hire and quarterly regarding the facility's Abuse Policy and Procedure.

Based on Interview and Record review the facility failed to provide supervision for R1 when he started demonstarting sexual behaviors to ensure the safety of female residents in the facility. These failures resulted in 2 female residents being sexually abused. This applies to 1 of 3 residents (R1) reviewed for behaviors in the sample of 3. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/31/14. On 8/27/14, E1 (Administrator) was informed of the Immediate Jeopardy. While the immediacy was removed the facility remains out of compliance at a level two due to the need to evaluate the implementation of the safety and supervison training provided to staff. The finding includes: The Nurses Notes dated 7/31/14 for R1 showed, "7/31/14 at 4:00am - R1 has been walking through the facility without clothes approximately 5 times this shift; 3:30pm - R1 found ambulating naked in the hallway again with his walker. Certified Nursing Assistants (CNA) intervened and covered R1 with a blanket and asked him what he is doing? R1 stated, "Don't you like what you see?"; 3:45pm - R1 again took all of his clothes off and was found wandering the hallway naked. CNA took him back to his room and he began making inappropriate comments and sexual advances towards CNA. CNA told R1 that he needs to put his clothes back on and he stated, "Let's make a deal." The CNA stated, "The deal is you need to put your clothes back on." R1 stated, "I will do that if I get to touch your breast." R1 then growled at CNA in a sexual manner. CNA also now reports that R1 was found in this same resident's room with one of her knick - nacks in his hand. I spoke with R1 about his inappropriate behavior but he laughs and seems to think this is funny. All behaviors reported to SSD and will continue to have staff continue to write incident reports for behaviors." The Nurses Notes dated 8/2/14 for R1 showed, "3:15pm - R1 found naked near his doorway in his room. CNA asked R1 if she could help him get dressed and R1 stated, "No, I want to expose myself to all of you girls." CNA told R1 that his behavior is not appropriate and he stated, "Don't you want to look at my nice prick?" CNA left room to get another CNA to return to room with her. They then told R1 that this behavior was not appropriate and he cannot be talking like that to staff. R1 stated, "Well don't you want to look at it?" On 8/26/14 at 1:45pm E2 (Director of Nurses - DON) read the Nurses Notes dated 7/31/14 and 8/2/14 for R1 and stated, "They are supposed to be filling out an Incident report with each incident. I didn't know about this incident (8/2/14)." E2 stated she did not know about R1 masturbating in front of another resident's doorway (7/31/14). The Incident Reports for R1 dated showed, "On 8/5/14 at 3:00pm - R1 was walking down the hall heading towards the desk with his genitals out so others could see his genitals; at 3:15pm R1 was standing by (R2's room) where visitors were and his private parts were hanging outside of his pants; On 8/6/14 - R1 was standing at the door of his room pulling out his penis. After supper R1 was being very mean to R3; On 8/8/14 - R1 was standing in the hallway with his genitals out. I told R1 to zip his clothes. I told R1 that he can't expose himself. R1 repeated it three times. R1 waved me off with his hand when I asked him if he understood. He then zipped his clothes and returned into his room; 8/9/14 -R3 was sitting next to R1, after breakfast, in the living room. R1 told R3, "Oh just be quiet. Go, get out of here. Go get up, I dare you. I hope you fall down"; 8/25/14 - R1 was making R3 play with him in the living room and putting his penis in her mouth." On 8/27/14 at 8:20am, E7 (CNA) stated, "On 8/24/14 I heard a noise and went to R1 & R3's room. I turned the light on and asked if I could help. R3 was on her back in her bed and R1 had his penis in her mouth. R3 was gagging and trying to fight R1 off. R3 was upset. R1 stood up, zipped up his pants and sat in a chair. R1 acted like he knew what he was doing that morning. I told E9 (LPN) and she said to redirect R1 away from R3." On 8/26/14 at 3:50pm, E4 (CNA) stated, "R1 was up walking around all night. R1 kept taking his penis out of his pants and we were redirecting him to cover up. It was around 3:00am, and he was by the A hall nurses station with his pants down and penis about 3 inches from R2's mouth. R1 was saying, "Come on." R1 does this to his wife (R3) all of the time. I don't think she likes it. E7 told me she heard choking noises one morning and went into R1 & R3's room. R1 had his penis in R3's mouth. E8 (CNA) saw R1 with his wife and had to stop it; he was making her do it, have oral sex. R1 is pushy with R3 and I don't think they should be together. When R3 is at dinner with other ladies, she smiles and talks. When R1 is around, R3 looks sad and just sits there." On 8/26/14 at 12:30pm, E3 (Social Service Director - SSD) stated, "I walked in today and me and E6 (Registered Nurse - RN) were discussing R1 and R3's behavior, if staff are verbally redirecting R1, Incident Reports not being filled out, Sexual acts in a common area that happened last night too. E7 (CNA) came up and said that E4 told her this morning that R1 put his penis in R2's mouth. I asked E7 if anyone else was notified and she said she didn't know. R1's daughter said R1 liked to strip his clothes when we did his admission (to the facility)." On 8/27/14 at 1:55pm, E10 (Registered Nurse - RN) stated, "R1 was upset today because R3 was moved out of their room. Last night R1 was agitated and angry because R3 was moved. Today R1 went up to R3 and told her she needs to say she needs to be back in with him. R3 has dementia and doesn't remember what he said to her. R3's daughter was here today and doesn't want R1 and R3 back in a room together. Today R1 had the door wide open and was masturbating in front of a mirror." On 8/27/14 at 2:25pm, E13 (CNA) stated, "I was told about it Sunday 8/24/14 when getting report from E7 (CNA). E7 said she heard R3 choking, went in to the room and turned the light on. E7 saw R1's penis in R3's mouth. E7 pulled the curtain, shut the door and left. It's not an appropriate response. E7 should have stopped it especially if R3 was choking on R1's penis. That could be a hazard. R3 isn't in her right mind so that is a problem." On 8/27/14 at 2:36pm, E12 (Activity Director) stated, "R1 is controlling with his wife and very sexual. R1 exposes himself to whomever. Other girls have walked in on R1 and R3 doing things. A lot of times it is her giving him oral sex or a hand job. R3 is confused and doesn't seem to know what is happening. R3 will come to activities. R1 is happy at activities, has fun and talks. When she sees R1 she will immediately stop, just sit there and go to the room with R1. R3 is happier when R1 is not around. She is more out of her shell, talks more, participates more and smiles. At R1's care plan meeting, his daughter asked if R1 had been taking off his clothes yet. R1's daughter knew his behaviors. It was a few days later that R1's behaviors started." R1's Care Plan dated 7/21/14 showed, "R1 exposes himself in public places; Goal - Lessen public exposure; Interventions - Verbal redirection; Educate on sexual exposure; Invite resident to activities to help limit down time; Provide room for him and his spouse (R3) to be intimate." The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/14 for R1 shows a Brief Interview for Mental Status score of 11/15 (Moderate Cognitive Impairment). On 8/27/14 at 4:20pm, E1 (Administrator) stated, "We did not know that R1 had put his penis in R3's mouth. The CNA and nurse did not tell me or E2 (Director of Nursing - DON). That is unacceptable. I didn't know anything about it until E4 (CNA) said something yesterday when I was getting her statement." On 8/27/14 at 4:55pm, Z1 (R3's Power of Attorney - POA) stated, "I have been to the nursing home three times today. They moved R3 and placed her with another resident. R3 will be safe now. I don't want R3 back in a room with R1. The facility told me R1 was getting more aggressive with his sexual behaviors. About 10 months to 1 year ago R3's dementia got worse so I hired caregivers to care for her 8 hours a day. I felt R1 was declining too but he said he didn't need any help and it's not my decision to make. R1's daughter is his POA. R1 and R3 have been married for [AGE] years. R1 was never controlling until R3's dementia got worse. R1 started with this behavior over the last 10 -12 months since R3 got worse. R1 was pulling his pants down and exposing himself to the caregivers. When R1's behaviors increased I made the decision to have R3 moved here. R1's daughter agreed to have him moved here. R3's dementia is so bad that she doesn't even know who R1 is anymore." The MDS with an ARD of 7/7/14 for R3 shows impairment of short term memory, long term memory and cognition. Through Observation, Interview and Record Review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: A. On August 27, 2014 all staff were in-service by the Administrator and Director of Nursing regarding the supervision of residents to include the following: Safety rounds to ensure that all residents are safe, accounted for and in appropriate areas of the facility for the resident's needs. B. Starting on August 27, 2014 the facility will coordinate a 1:1 sitter for R1 until a psychiatric evaluation can be completed. C. Beginning on August 27, 2014, all interaction between R1 and all other residents will be monitored by staff and/or the 1:1 sitter for R1. D. On August 27, 2014, R1 was sent to the hospital for a Psychiatric Evaluation. E. All in-services will be completed before any staff member is allowed to work beginning 8/27/14. F. Efforts will be ongoing by the facility staff to seek other living arrangements for R1 that are appropriate for R1's needs and ensures the safety of the other individuals that reside at the facility as of 8/27/14.