Every finding on record at Allure Of The Quad Cities

Based on interview and record review, the facility failed to identify an area of pressure for a resident at risk of developing pressure injuries, failed to do a full assessment of the wound when it was identified, and failed to obtain a treatment order when it was first identified for 1 of 3 residents (R2) reviewed for pressure in the sample of 11. These failures caused the wound to further deteriorate and become necrotic (non-viable, dead skin tissue).The findings include:R2's admission Record, provided by the facility on 6/17/26, showed he had diagnoses including, but not limited to a fracture of lower end of right tibia, anemia, type II diabetes mellitus, hypertension, unspecified fracture of sacrum, unspecified protein-calorie malnutrition, non-pressure chronic ulcer of other part of right foot, pain in right leg, abnormal gait and mobility, unspecified fracture of unspecified lumbar vertebra, procedure and treatment not carried out because of patient's decision for unspecified reasons, and patient's noncompliance with other medical treatment and regimen due to unspecified reasons. The admission record showed R2 was admitted to the facility on [DATE], The admission record showed a diagnosis for an unstageable pressure ulcer to his right heel with an onset date of 4/2/25. R2's 3/13/25 facility assessment showed he was cognitively intact. The assessment showed R2 was dependent on staff for bed mobility and transfers. The assessment showed R2 did not have any pressure ulcers on admission, however, he was at risk for developing pressure injuries.R2's care plan initiated 3/7/25, showed he had an ADL (activities of daily living) self-care deficit related to physical limitations and was non-weight bearing for 3 months.R2's Care plan initiated 3/7/25 showed he was at risk for alteration in skin integrity related to diabetes and recent surgery. The care plan showed staff should encourage to reposition as needed, use assistive devices as needed, observe skin condition with ADL care daily, report abnormalities.R2's Care plan initiated 3/14/25, showed Resistive/noncompliant with treatment/care related to refusing evening medications. The care plan showed staff should allow for flexibility in ADL routine to accommodate mood, preferences, and customary routine.R2's notes from a local hospital, printed on 3/6/25 (the day he was admitted to the facility), did not identify any pressure wounds for R2 when he was discharged from the hospital to the facility.R2's Type: N ADV Clinical admission dated 3/6/25 showed he arrived at the facility via ambulance on a stretcher, was alert and oriented, pleasant with no unwanted behaviors. The assessment showed skin issues to his right dorsum second digit (second toe) and his right knee surgical incision. Effective Date: 03/09/2025 Type: Health Status Note showed Resident alert and cooperative with cares this shift. R2's progress notes from 3/6/25 through 3/31/25 were reviewed showing R2 refusing lab draws and some of his medications. No refusals of repositioning or offloading were documented in R2's progress notes from 3/6/25-3/31/25. The only place documentation regarding procedure and treatment not carried out because of patient's decision for unspecified reasons, or patient's noncompliance with other medical treatment and regimen due to unspecified reasons (other than some lab draws or some medications) from 3/6/25 through 3/31/25 progress notes was under V22 and V23's (Nurse Practitioners) progress notes under R2's past medical history notes, and in R2's diagnoses upon admission.R2's 3/27/2025 Type: N Adv - Lift/Transfer Evaluation showed resident is non-weight bearing, is cooperative with transfers, cooperative with repositioning and is partially able to assist with repositioning in bed and chair.On 6/16/26 at 10:35 AM, R2 said he went to the facility for therapy after he fractured his right femur. R2 said he would refuse some of the medications at the facility because he felt they had him on a lot of medications he did not need. R2 said he would not refuse any care, adding, That is what I was there for was to receive care and get better so I could go back home. R2 said while he was in the facility, he developed pressure sores. R2 said he could reposition himself some in bed, but he needed two staff to assist him with toileting and transfer needs.R2's 3/31/25 Type: N Adv - Skin Check showed a new skin issue: Right lateral foot. Heel pressure injury measuring 2.5 centimeters (cm)in length x 1.4 cm width, by 0 depth. No further description or characteristics of the wound bed were documented in the assessment.R2's 3/31/25 progress notes did not document a new skin issue/pressure injury to R2's right heel or document a full assessment.R2's Skin/Wound Note dated 4/2/25 showed Resident was seen on 3/26/25 by V15 (Wound Doctor contracted through facility). Please refer to wound notes. The note was written by V21 (previous Assistant Director of Nursing-ADON)V15's wound notes dated 3/12/25 showed Signing off on patient who remains in the facility. Sign off without visiting. In house.On 6/16/26 at 2:25 PM, V15 said on 3/12/25 she signed off on R2. V15 said she was told she did not need to see him. V15 said it would either be because he did not have any wounds, or he did not need to be seen by her. V15 said the facility did not refer R2 to her for the pressure wound to his right heel until 4/2/25. V15 said someone should have seen it before it became necrotic tissue. V15 said R2 had dark skin so staff may not have noticed it. V15 said R2 had limited mobility, and arthritis everywhere. V15 said she has followed R2 throughout several facilities. V15 said the 4/2/25 assessment was the initial presenting wound to R2's right heel. V15 said R2's capability for healing is very low. He has decreased blood flow, so he is already compromised. V15 said staff should be more vigilant with a patient like R2. R2's 4/2/25 wound assessment by V15 showed an unstageable pressure injury due to necrosis (dead, non-viable skin tissue) measuring 4.1 cm x 6.3 cm. The assessment showed the depth of the wound was not measurable due to presence of nonviable tissue and necrosis. The assessment showed the wound had 100% thick adherent black necrosis tissue (eschar). The treatment initiated was skin prep once daily and as needed for 30 days and recommendations to off-load wound.R2's Medication Review Report from 3/6/25 through 9/4/25 showed an order dated 4/2/25 that read as follows: Right second toe and Right Heel-Cleanse with normal saline, apply skin prep and leave open to air everyday shift.R2's March and April 2025 Medication Administration Records (MARS) and Treatment Administration Records (TARS) were reviewed. R2's March and April MARS and TARS showed the treatment for R2's right heel pressure ulcer was started on 4/3/25.R2's 9/2/25 Wound Evaluation by V15 showed a stage 4 full thickness pressure ulcer to his right heel with a duration of greater than 149 days. On 9/2/25 the wound measured 2.9 cm in length x 3.4 cm width x 0.3 cm in depth. The wound evaluation showed surgical excisional debridement procedure was performed to remove necrotic tissue and establish the margins of viable tissue. The evaluation showed that R2 had a previous surgical debridement procedure performed on 6/26/25.On 6/17/26 at 10:57 AM, V2 (Director of Nursing-DON) said she was looking through R2's progress notes and did not see any documentation of him refusing care, other than refusing some of his medications. At 11:10 AM, V2 (DON) said that with R2 being diabetic and having neuropathy, a pressure injury can be acquired quickly so I would expect staff to be vigilant. V2 said we would see those progressional changes and I would expect them to find it before it was an unstageable pressure injury with eschar.The facility's policy and procedure titled Pressure Injury Prevention and Management, copyright 2026 The Compliance Store, LLC, showed This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors ; monitoring the impact of the interventions; and modifying the interventions as appropriate.3.c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain tissue type in wound bed), and treatment and interventions implemented. D. Assessments of pressure injuries will be performed by a licensed nurse and documented on the (fill in blank for designated form). The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. E. Nursing assistants will inspect the skin during bath and will report any concerns to the resident's nurse immediately after the task.

Based on observation, interview, and record review the facility failed to store controlled substances behind a double lock allowing activity staff to enter an area with controlled substances. This applies to 2 of 3 residents (R3 and R4) reviewed for controlled substances in the sample of 11.The findings include:The facility's Final Incident Report (dated 4/30/26) showed, On 4/24/2026 [actual date of discrepancy was 4/23/26, incident was not reported until 4/24/26], during a routine controlled substance count, licensed nursing staff identified two bottles of [antianxiety medication, lorazepam] missing from the medication cart. The medications had documented discontinuation orders for both residents prior to discovery. No discrepancies were identified in medication administration records, and no doses were missed or inappropriately administered. The report identified that the medications had belonged to R3 and R4; however, the medications had been discontinued.The facility's investigation showed R3 and R4's bottles were identical bottles of liquid lorazepam concentrate of 2 milligrams per milliliter.R3's controlled substance count sheet for the missing lorazepam showed it had been delivered to the facility on 5/10/25 and 28.25 milliliters remained in the bottle.R3's physician orders showed the order for his liquid lorazepam had been discontinued on 10/2/25. (6 months prior to when the lorazepam was discovered missing.)R4's controlled substance count sheet for the missing lorazepam showed it had been delivered to the facility on 4/4/26 and 18.5 milliliters remained in the bottle.R4's physician orders showed the order for his liquid lorazepam had been discontinued on 4/14/26 (9 days prior to the medication being discovered missing.)On 6/16/26 at 11:57 AM, V7 Registered Nurse stated she was working on 4/23/26 and she was responsible for the controlled substance for R3 and R4. V7 stated she was scheduled to work from 2:00 PM to 10:00 PM on 4/23/26; however, the facility was short staffed, and she came in to work from 10:00 AM to 10:00 PM. V7 when she arrived at the facility .it was a mess. V7 said she could not get report, medications had not been administered, and there was no one to do a controlled substance count. V7 said the refrigerator lock which housed R3 and R4's lorazepam had been broken for weeks prior to 4/23/26. On 6/16/26 at 1:18 PM, V9 Human Resources stated she was tasked with reviewing security camera footage for the medication room containing R3 and R4's missing controlled substances. V9 stated, for the date of 4/23/26, the footage showed V8 Activity Aide entering the medication room without a key. V9 stated she could not see what V9 was doing in the room. V9 said no other unqualified staff entered the medication room during the time when R3 and R4's discontinued lorazepam was identified to have gone missing.On 6/16/26 at 10:40 AM, V20 Housekeeping Supervisor stated she observed V8 enter the medication room on 4/23/26. V20 stated V8 exited the room with a garbage bag with only a few items in the bag. V20 stated she confronted V8 and V8 stated she was cleaning up garbage. V20 said there was no nursing staff with V8. V20 said V8 then exited the building with the bag of garbage. V20 said only nurses are supposed to enter the medication room and she does not know how V8 gained entrance.On 6/16/26 at 1:04 PM, R5 stated he had witnessed an activity person entering the medication room. R5 stated he thought it was odd as he knew only nurses were supposed to go into the medication room. R5 stated the activity aide opened the fridge; however, he could not see if she removed anything.On 6/16/26 at 1:39 PM, the medication room for R3 and R4 was observed with V2 Director of Nursing. The door to the room was locked, the refrigerator had a pad lock, and there was a locked plexiglass box in the fridge containing controlled substances. V2 stated, when R3 and R4's lorazepam went missing, the lock on the fridge was not working and she believes the plexiglass box was not properly locked either. V2 stated only nurses should have access to the medication room. V2 said if housekeeping needs to clean the medication room, a nurse needs to open the door for them and stay in the room while they are in there. V2 said controlled substances, like lorazepam, need to be double locked and on 4/23/26 they were not. V2 said the purpose of the locks is to prevent drug diversion.The facility's controlled Substance Administration and Accountability policy (copyright 2025) showed, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Patient-specific controlled substances (e.g., narcotic/epidural infusions, tablets, etc.) are stored under double lock until administered to the patient . If any unauthorized person is seen lingering around a location where controlled substances are stored, call the Police.

Based on observation, interview, and record review, the facility failed to implement procedures regarding the reconciliation and management/disposal of controlled substances. This applies to 2 of 3 residents (R3 and R4) reviewed for controlled substances in the sample of 11.The findings include:The facility's Final Incident Report (dated 4/30/26) showed, On 4/24/2026 [actual date of discrepancy was 4/23/26, incident was not reported until 4/24/26], during a routine controlled substance count, licensed nursing staff identified two bottles of [antianxiety medication, lorazepam] missing from the medication cart. The medications had documented discontinuation orders for both residents prior to discovery. No discrepancies were identified in medication administration records, and no doses were missed or inappropriately administered. The report identified that the medications had belonged to R3 and R4; however, the medications had been discontinued.The facility's investigation showed R3 and R4's bottles were identical bottles of liquid lorazepam concentrate of 2 milligrams per milliliter.R3's controlled substance count sheet for the missing lorazepam showed it had been delivered to the facility on 5/10/25 and 28.25 milliliters remained in the bottle.R3's physician orders showed the order for his liquid lorazepam had been discontinued on 10/2/25. (6 months prior to when the lorazepam was discovered missing.)R4's controlled substance count sheet for the missing lorazepam showed it had been delivered to the facility on 4/4/26 and 18.5 milliliters remained in the bottle.R4's physician orders showed the order for his liquid lorazepam had been discontinued on 4/14/26 (9 days prior to the medication being discovered missing.)On 6/16/26 at 11:57 AM, V7 Registered Nurse stated she was working on 4/23/26 and she was responsible for the controlled substance for R3 and R4. V7 stated she was scheduled to work from 2:00 PM to 10:00 PM on 4/23/26; however, the facility was short staffed, and she came in to work from 10:00 AM to 10:00 PM. V7 said that when she arrived at the facility .it was a mess. V7 said she could not get report, medications had not been administered, and there was no one to do a controlled substance count. V7 stated a controlled substance count should be done when a nurse takes over a medication cart and it was not done when she took over R3 and R4's medication cart on 4/23/26 at 10:00 AM. V7 stated, a count was done at 10:00 PM that evening and R3 and R4's discontinued bottles of lorazepam were not in the medication refrigerator. On 6/16/26 at 1:39 PM, V2 Director of Nursing stated V7 should have completed a controlled substance count on 4/23/26 at 10:00 AM. V7 stated nursing staff should do a controlled substance count at shift change and/or whenever another nurse takes control of the medication cart. V2 stated R3 and R4's lorazepam should have been destroyed when the medications were discontinued. V2 said the purpose of controlled substance counts and destroying discontinued controlled substances is to minimize the risk of drug diversion.The facility's controlled Substance Administration and Accountability policy (copyright 2025) showed, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on interviews and record review, the facility failed to adequately supervise a known wandering resident (R1) who was evaluated to be at risk for elopement, failed to remain with an eloped resident (R1) once found out in the community, and failed to assure a secured door was locked preventing access to a wandering resident (R1). These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of unspecified dementia, eloping from the facility through the Maintenance Office exterior exit door, crossing a moderately busy road to a gas station and park approximately one block from the facility. These failures have the potential to affect all three (R2, R3, R4) Elopement Risk residents who reside off the secured floor in the facility.The Immediate Jeopardy began on April 14, 2026, when R1 eloped from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on June 5, 2026, at 9:52 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, as of April 15, 2026, prior to the start of the survey on June 2, 2026, and was therefore Past Noncompliance. This past non-compliance occurred from April 14, 2026 -April 15, 2026.Findings include:The facility's policy, Elopement and Wandering Residents, not dated, documents not in its entirety, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering'' is random or repetitive locomotion that may be goal-directed {e.g. the person appears to be searching for something such as an exit), or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines:1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team, b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan, c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff, d. Adequate supervision will be provided to help prevent accidents or elopements, e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly, f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff.The Final Abuse Investigation Report sent to (the State Agency) dated 4/15/26, documents, on 4/14/26, It was noted at approximately 3:42 pm that (R1) was at the park near the nursing home, eating some tacos and watching kids play ball. He was immediately brought back by staff. A head-to-toe assessment was completed upon return by the nurse (V5/Licensed Practical Nurse), and no injuries were noted. Staff verified his wander guard was in place and functioning properly. (R1) became agitated and attempted to remove his wander guard bracelet. (R1) was placed on a 1:1 (one-to-one) with our Activity Director. This is not normal behavior for him, so he was sent out for examination due to his behavior, to clarify if there was an acute medical condition to cause his behavior. While in the hospital his medications had some adjustment made. Upon review of the camera footage, you can see (R1) pacing outside the breakroom looking for a pop, when he noticed the open door and he was able leave the facility via the maintenance exit. The maintenance door did not fully close when staff exited the office and (R1) was able to enter their office and go out the exterior door from their office which is why the wander guard system did not alarm. Maintenance staff were immediately educated on keeping their door ALWAYS closed and locked for resident safety reasons. Upon further inspection, it was noted that the door closure was not functioning properly, Maintenance immediately brought a new closure for the door and installed it on 4/14/26, the door is now fully functioning, and it remains locked at all times. (R1) was moved to our locked memory care unit and the dashboard is updated for staff to offer the (R1) a pop if he is pacing or agitated, because that is typically what he is looking for.R1's admission record documents R1's date of admission to the facility was 5/14/25 and his diagnoses included but are not limited to: Other Seizures, Unspecified Dementia/Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, or Anxiety, Alcohol Abuse, Uncomplicated, Schizophrenia, Unspecified, and Anxiety Disorder, Unspecified.R1's Minimum Data Set (MDS) assessment, dated 4/1/26, documents R1 has a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment, documents R1 has non-Alzheimer's dementia and documents R1's ambulation for distances over 10 feet as supervision or touching assistance.R1's physician orders dated 4/16/26, documents R1 has an order for a Wander-guard to check placement and function every night shift for monitoring.R1's current care plan documents R1 is Exit seeking/elopement risk related to cognitive impairment/Dementia and (R1) may wander and look for soda-pop and staff will assist him to obtain.R1's elopement risk assessment dated [DATE], documents R1 is an elopement risk with a score of one (1), and elopement risk assessment dated [DATE] documents an elopement risk with a score of three (3).On 6/3/26 at 12:48pm V1 (Administrator) provided a screenshot picture of the facility's surveillance video which showed R1 leaving the building unsupervised through an open door at the back of the building. The picture of the video surveillance was timed stamped at 15:25 (3:25pm) on 4/14/26.On 6/2/26 at 9:15am, V4 (Regional Director of Operations) stated that on 4/14/26 video surveillance showed R1 opened the maintenance office door that was not securely locked and exited the building through an exterior door within the office.On 6/2/26 at 10:00am, V16 (Maintenance Director) stated, The door closure to the office (Maintenance) wasn't automatically closing like it should, it would stop which prevented the door from latching all the way and locking. I was told he (R1) came through the door and left the building through here by V4 (Regional Director of Operations) and was asked to come look at the door, so that's when I noticed it wasn't working. I called V17 (Maintenance Assistant), and he came in and helped me replace it that night.On 6/2/26 at 2:52pm, V5 (Licensed Practical Nurse/LPN) stated she was R1's nurse on 4/14/26 when he left the building and was found at the park. V5 stated R1 had been doing his normal walking like he always does and was not acting any different than normal. V5 stated she was unaware that R1 had left the building unsupervised until V6 (Certified Nursing Assistant/CNA) came back from her lunch and asked if V5 was aware that R1 was at the park. V5 stated that V6 did not stay at the park with R1.On 6/2/26 at 3:08pm, V6 (Certified Nursing Assistant/CNA) stated she was returning to work on 4/14/26 from break when she drove by the park and noticed a man who looked like (R1) walking with another person on the sidewalk next to the park. V6 looked back in her rearview mirror and verified that it was (R1) who was now alone. V2 immediately stopped her car and yelled his (R1) name and (R1) came over to V6. V6 attempted to get R1 to come back to the facility with her but he was getting agitated, so she backed off, called the facility, asked them if they knew (R1) was at the park and I was told that they were not aware. V6 got back into her car, leaving R1 alone at the park and drove back to the facility.On 6/3/26 at 8:44am, V7 (Certified Nursing Assistant/CNA) stated that she was working on 4/14/26 when R1 was found at the park. V7 stated that V6 (Certified Nursing Assistant/CNA) called her asking if she (V7) knew R1 was at the park and V7 stated she did not know. V7 stated she and V1 (Administrator) went to the park where R1 was alone and was able to bring him back to the facility. V7 also stated she had seen him (R1) earlier in the day sitting in the chair in his room and he had asked for a pop, I didn't know he had left his room.On 6/3/26 at 9:12am, V10 (Certified Nursing Assistant/CNA) stated that she was working on 4/14/26 when R1 got out of the building unsupervised. V10 stated that she and V17 (Speech Therapist) saw R1 walk toward the therapy gym and turn right into the small hallway that led to an exterior door. V17 walked down to see what R1 was doing and asked R1 what he was looking for and R1 told her he wanted a pop so V17 pointed down the hallway to show R1 where to go to get a pop. V10 stated she did not see R1 the rest of the day that she could recall.On 6/3/26 at 10:01am, V17 (Speech Therapist) stated she was working on 4/14/26 when R1 exited the building. V17 stated she watched R1 walk down the hallway toward the therapy gym and turn right into the hallway next to the therapy gym, so she asked if he needed anything and R1 told her he wanted a pop. V17 stated, I walked him up the hallway and pointed toward the breakroom and told him that is where he could get a pop. Within the next hour I think I heard he got out of the building.On 6/3/26 at 11:00am, R1 stated, I had a premonition that day and wanted to see my friends, I was upset because I felt like this place (facility) was a prison. R1 stated he does not recall how he left the building or how long he was gone but stated, I use to leave my sister's house and forget where I was or where I was going so, they put me here to keep me safe. I don't remember too good, and I hear and see things sometimes. They moved me to this room so I can be safe and I'm ok with that because I don't want them to worry about me.On 6/3/26 at 11:15am, V23 (Regional Nursing Consultant) stated that it is the expectation if staff find a resident that has eloped from the facility that the staff member remain with the resident for their safety if unable to get them to return to the facility until additional help can arrive to assist.Prior to the survey date of 6/2/2026, the facility had taken the following actions to correct the non-compliance:1. Immediate actions taken: R1 has an (electronic wander device) in place and is fully functioning on 4/14/26; R1 had a head-to-toe assessment, no concerns identified on 4/14/26; R1 was sent to the ER (Emergency Room) and admitted to the hospital on [DATE] and returned to the facility on 4/16/26 to avroom and was placed on 1:1 (one-to-one) supervision at that time; R1 was moved to the secure Memory Care Unit, on 4/17/26 and the 1:1 was discontinued at that time; Education with maintenance staff on keeping the office door locked was conducted on 4/14/26; Door closure has been replaced on 4/14/26, to ensure the automatic door closure/lock is fully functioning. All other doors were assessed and were fully functional.2. All residents have the potential to be affected; no others were identified at this time.3. Measures put into place/systems changed: An in-service was initiated by the RDO (Regional Director of Operations/V4) with maintenance staff on 4/14/26 that includes: 1) Keeping the maintenance door locked at all times. 2) the alleged deficiency; An in-service was initiated by the Administrator (V1) to all staff on 4/15/26 that includes: 1) Elopement Protocol. 2) Abuse, Neglect, and Exploitation Policies. 3) The alleged deficiency; Maintenance Director or designee will conduct a QA (Quality Assurance) study to determine 1) was the maintenance door locked and secured? The results of this tool will be reviewed during the facilities Quality Assurance Performance Improvement meetings. Any issues identified will be immediately corrected. This QA study will be performed 5 (five) times per week for a period of 2 (two) months. Administrator will monitor overall compliance; Administrator or designee will conduct an audit to determine if any elopements have occurred and if so, did staff follow policy. This QA (Quality Assurance) study will be performed once per week for a period of 90 days to ensure that all staff follow the elopement policy and procedure.

Based on interview and record review the facility failed to document the reason for a transfer to the hospital for 1 of 3 residents (R1) reviewed for hospitalization in the sample of 13.The findings include:R1s face sheet shows she was admitted to the facility on [DATE]. The same document shows she was discharged on 4/19/26. The nursing progress notes of 4/19/26 do not show the transfer/discharge, why she was discharged , where she was discharged to, and no bed hold issued.On 5/30/26 at 12:22 PM, V6 Registered nurse said when a resident is sent to the hospital, they are given paperwork including, the face sheet, any notes that would be relevant to the transfer, any interventions done prior to the transfer, and an assessment. A note would be put in the record showing who was notified and what was all done. It would be important so other staff can see the information of what took place.On 5/30/26 at 12:30 PM, V2 Director of Nursing stated when a resident is sent out to the hospital for any reason the paperwork sent with them should include the face sheet, POLST (Physician orders for Life-Sustaining Treatment), and a copy of the bed hold. There should be an order from the physician or Nurse Practitioner why they are being sent. There should be a progress note entered stating the condition of the resident and reason for the transfer, any interventions attempted at the facility and family notifications. V2 said R1s family came in were upset about her wound. They called 911 themselves and had her sent out. She believes the nurse gathered the paperwork to send with her to the hospital, but it should have been documented in the notes. She had received a call on 4/19/26 from V10 Licensed Practical Nurse LPN telling her about the situation. Upon review of R1s record, V2 said V10 did not make any progress notes regarding the transfer. V2 said she would expect documentation since the facility did not initiate the transfer.On 5/30/26, this surveyor attempted to contact V10 and was unable to leave any message.The facility's undated policy for Transfer and Discharge documents: 10. Emergency Transfers to Acute Care. A. The facility will obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. F. Document assessment findings and other relevant information regarding the transfer in the medical record. G. provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated.

Based on observation, interview and record review the facility failed to perform weekly assessments for a pressure injury, failed to have an ordered pressure injury treatment in place, and failed to have preventive interventions in place for 3 of 3 residents (R1, R3, R4) reviewed for pressure injuries in the sample of 13.The findings include: 1. R1s face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to Parkinson's disease, hypertension, and altered mental status. R1s progress note of 1/7/26 documents an open area noted to the sacrum measuring 1 cm by 1 cm (length by width in centimeters). The area cleansed with normal saline, applied xeroform and padded adhesive once daily and (as needed). The progress notes and assessments were reviewed and show no further assessment of the wound. No weekly assessments were noted. On 3/7/26, V5 (former Assistant Director of Nursing) documented she was notified R1 had an open area to her sacrum. The area measured 2 cm by 2 cm. The wound doctor was notified and placed on rounds for the wound nurse. R1s initial wound evaluation and management summary of 3/10/26 documents an unstageable pressure wound to the sacrum. The wound measured 2.2 cm by 3.2 cm with light drainage. On 5/30/26 at 12:22 PM, V6 Registered Nurse said when a new skin issue is identified the wound is cleaned and dressing put in place. The wound doctor needs to be notified and the family. The documentation would include what, where the wound was located, and should include measurement. The wound doctor does the weekly assessments. On 5/30/26 at 12:30 PM, V2 Director of Nursing said the nurses should be documenting measurements when an open area is identified. There should be a description of the wound, and orders put in place, and the wound nurse and physician notified. Once a wound is identified there should be weekly assessments to monitor the wound for any improvements, decline or signs of infection. V2 said she looked through the record and did not see where R1s wound had weekly wound assessments following the wound from 1/7/26. The facility undated policy for pressure injury prevention and management documents a pressure injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence. 3. Assessment of pressure injury risk c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements,(measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implements. 2. On 5/30/26 at 9:48 AM R3 was on her back in bed with her heels laying on the mattress not being offloaded. R3's heel boots were on the couch in her room. At 9:51 AM, V16 Assistant Director of Nursing went into R3's room with the surveyor for a skin check on her heels. R3 had a purple/burgundy area to her right and left heel. V16 stated the heel boots should be in place for R3 to prevent more injury to her heels. On 5/30/26 at 10:49 AM V3 Assistant Director of Nursing/Wound Nurse stated the wound to R3's heel was identified during wound rounds with the wound doctor last Wednesday. V3 stated R3 has a deep tissue injury. Skin prep and floating the heels were the preventative measure and treatment. V3 stated the offloading boots were provided. On 5/30/26 at10:57 AM, V3 went to R3's room with the surveyor to check her coccyx wound. There was dry dressing in place that was not dated. V3 removed the dressing and the large open wound to R3's coccyx did not have any packing inside. There was some serosanguinous drainage and mild odor present. V3 stated there should have been a medicated soaked gauze to the wound. V19 Certified Nursing Assistant was present and stated the hospice nurse was there and did the dressing that morning. On 5/30/26 at 1:28 PM, V17 Corporate Nurse stated they followed up with the hospice nurse who stated she just put a dry dressing over R3's coccyx wound. The hospice nurse did not put the correct dressing in place. The wound care provider's Wound Evaluation & Management Summary dated 5/27/26 for R3 showed end stage skin failure to the right and left heel. The approach that was recommended was off-loading and skin prep daily to the heels. End stage skin failure of the sacrum – full thickness; 13 cm x 24 cm x 0.9 cm with 5.6 cm of undermining at 10:00 o'clock. The dressing treatment plan: sodium hypochlorite solution, apply once daily as needed. Twenty -five percent solution to moisten 4.5-inch gauze roll daily. Moisten with the solution and then pack into the wound. Dry dressing as a secondary dressing daily. May 2026 Physician Orders for R3 showed apply heel boots at all times when in bed or float heel to relieve pressure if heel boots are not available. Pressure wound to sacrum: cleanse with normal saline, apply sodium hypochlorite solution-soaked gauze to wound bed, do not over pack, cover with dry dressing once daily and as needed if it becomes saturated, soiled or dislodged. The March 23, 2026 Minimum Data Set for R3 showed she was dependent for all activities of daily living. The Care Plan dated 3/27/26 for R3 showed she was admitted and returned from the hospital with a stage 4 sacral pressure ulcer. Treatments as ordered. The facility's Pressure Injury Prevention and management policy (2026) showed evidenced based interventions for prevention will be implemented for all residents who are assessed at risk or who have pressure injury present. Basic or routine interventions could include, but are not limited to redistribute pressure.offloading heels, etc. The facility's Wound Treatment Management policy (2025) showed, wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change. 3. On 5/30/26 at 9:59 AM, R4 was asleep in his chair next to his bed. R4 had grip socks on with athletic shoes on over the socks. R4 had a cast shoe sitting on the bed. V16 Assistant Director of Nursing was with the surveyor for a skin check of his right heel that she stated she thought was healed. V16 noted some swelling to R4's lower legs. V14 Registered Nurse came into the room and stated R4 has a deep tissue injury to his right heel that they are putting skin prep on. R4 was awake and stated he was told that the area was healed. V14 removed the sock and shoes to his right foot and there was black necrotic tissue present. V14 stated they put his shoes on when he goes to meals and then when he comes back to his room, they switch his right shoe to the cast shoe when he is sitting in the chair. V16 noted swelling to his feet and lower legs. V14 then re-applied R4's shoes and was having difficulty getting the shoes over his heels. R4 complained of pain to his feet and heels at that time. V16 told V14 that R4 should have the cast shoe on. V4 agreed to wear it and stated he had that at the hospital because of his right heel. On 5/30/26 at 10:49 AM V3 Assistant Director of Nursing/Wound Care Nurse stated R4 should have his heels floated when he is in bed or a heel boot in place. V3 stated staff should remind R4 to wear the walking shoe. The wound care provider's Initial Wound Evaluation & Management Summary for R4 dated 5/27/26 showed an unstageable due to necrosis, full thickness wound of his right heel. The wound was present upon admission. Skin prep to the heel and off loading of the wound was recommended. The Face Sheet dated 5/30/26 for R4 showed diagnoses including unstageable pressure ulcer of the right heel, sepsis, acute cystitis with hematuria, chronic kidney disease, muscle wasting and atrophy, protein-calorie malnutrition, and acute respiratory failure with hypoxia. The Care Plan dated 5/26/26 for R4 showed impairment of skin integrity to the heel. Keep the skin clean and dry. Weekly treatment documentation. There were no interventions for preventative measures that would include off-loading of the heel. The facility's Pressure Injury Prevention and management policy (2026) showed evidenced based interventions for prevention will be implemented for all residents who are assessed at risk or who have pressure injury present. Basic or routine interventions could include, but are not limited to redistribute pressure.offloading heels, etc.

Based on observation, interview, and record review, the facility failed to ensure medications were administered on time and medications were administered under the supervision of the nurse for 1 of 5 residents (R8) reviewed for medication administration in the sample of 9.The findings include: On 4/10/26 at 9:58 AM, V11, Licensed Practical Nurse (LPN), said she is giving R8 her 7:00 AM and 8:00 AM medications. V11 said it's not because she is late, it's because she has 13 (resident) blood sugars (glucose) to check.On 4/10/26 at 10:35 AM, R8 said she has not gotten her pills, her nasal spray, her eye drops, or her inhalers yet today.On 4/10/26 at 11:04 AM, V11 returned to R8's room with a med cup full of pills. R8 dumped the medications into her pudding and swallowed them, then her nasal spray was administered followed by her inhaler. No eye drops were observed being given.On 4/10/26 at 11:07 AM, a white patch dated 4/10 and initialed (indecipherable) with the backing still intact was on R8's overbed table. V11 said the pain patch is supposed to be put on in the morning at 6:00 AM.On 4/10/26 at 10:16 AM, R8 said she usually gets her medications late; somewhere between 10:30 AM and 11:30 AM.On 4/10/26 at 10:27 AM, R8 said she can get her morning medications anywhere from 6:30 AM and 10:30 AM. R9 said the nurse gives her a cup of her medications and she keeps them with her and takes them at 9:30 AM. R9 said the nurse does not watch as she takes them.R8's Medication Administration Record (MAR) for 4/1/26 to 4/30/26 shows an order for a pain-relieving external gel 3.5 percent (%) (Menthol topical analgesic) to be applied to the left arm twice a day as needed for pain. None of the patches are signed out as being administered for the month of April 2026 on R8's MAR. No other topical patches are on R1's MAR.On 4/10/26 at 11:58 AM, V13, Registered Nurse (RN), said medications are considered on time if they are given one hour before and one hour after they are scheduled.On 4/10/26 at 12:33 PM, V2, Director of Nursing (DON), said medications can be given an hour before and an hour after the scheduled time and still be considered on time.On 4/10/26 at 1:40 PM, V10, Regional Director of Operations, said the nurse should watch as the medication is taken and should apply any topical medications. Medications should not be left with the patient to take or apply by themself.R8's Medication Admin. Audit Report dated 4/10/26 shows R8 has orders to receive the following medications at 8:00 AM each morning: docusate sodium, lactobacillus, B-Complex with biotin and folic acid, fluticasone propionate nasal spray, budesonide-Formoterol fumarate inhaler, ezetimibe, black cohosh, calcium, cetirizine, cranberry, Lasix, Gabapentin, glucosamine, sertraline HCL, polyvinyl alcohol eye drops, magnesium oxide, artificial tears, gabapentin, spironolactone, potassium chloride ER, midodrine, multivitamin with minerals, topiramate, propranolol, cholecalciferol, and fiber. R8's Medication Admin Audit Report dated 4/10/26 shows V11 administered the above ordered medications anywhere between 9:30 AM and 1:56 PM on 4/10/26.The facility's Medication Administration Policy (not dated) shows the six rights of medication are followed: right resident, right drug, right dosage, right route, right time, right documentation. Administer within 60 minutes prior to or after scheduled time. Observe resident consumption of medication.

Based on observation, interview, and record review, the facility failed to administer insulin on time, failed to administer the correct insulin dose, and failed to administer a cardiac medication to 2 of 4 residents (R4 and R8) reviewed for medication administration in the sample of 9.The findings include:1.On 4/10/26 at 9:58 AM, V11, Licensed Practical Nurse (LPN) said she is giving R8 her 7:00 AM and 8:00 AM medications. V11 said it's not because she is late, it's because she has 13 (resident) blood sugars (glucose) to check. V11 said R8 has Humalog (a fast-acting insulin) per sliding scale and also has 70 units (of another insulin) scheduled. R8 was observed as she attempted to scan her glucose sensor with her phone. R8 said it didn't work. R8 said she already ate her breakfast. V11 said she will have to check R8's glucose with a finger stick and proceeded to do so. The result shows 326. V11 said she usually doesn't have to worry about checking R8's blood sugar with breakfast because she usually scans her sensor.On 4/10/26 at 10:14 AM, V11 returned to R8's room to give her insulin. V11 showed the medication, and it was a Tresiba pen (ultra long-acting insulin) set to 70 units. V11 administered 70 units of the Tresiba insulin subcutaneously to R8's abdomen. V11 said she saw that R8 already got 5 units scheduled before breakfast.On 4/10/26 at 10:20, V11 said she will be giving Humalog 38 units since her glucose was 365. V11 said if it's (the glucose) above 331, the order is for 38 units. V11 showed the Humalog pen which was dialed to 32 units. V11 said that's all that's left. V11 administered the Humalog 32 units to R8's abdomen, then she left to obtain a new pen for the necessary additional units.On 4/10/26 at 10:41 AM, V11 returned with the new Humalog Kwik pen which she dialed to 4 units for R8. After discussing the order parameters for the sliding scale insulin, V11 said she wrote down R8's glucose at 365. Per surveyor's observation, it was 326. V11 consulted R8's MAR (medication administration record) and no value was recorded. V11 said she didn't save it, then V11 said, thank you for stopping me.On 4/10/26 at 10:47 AM, V11 asked R8 if she wrote it (the glucose result) down. R8 said she didn't write it down, but it was three twenty something. V11 said if she gave the Humalog 4 units, that would have been a medication error. V11 said R8 already got the correct amount of Humalog if her glucose was 326. R8's Medication Admin Audit Report dated 4/10/26 showed an order for Humalog 100 units per milliliter (ml) 5 units to be injected subcutaneously before meals scheduled at 7:00 AM and Humalog KwikPen Subcutaneous solution pen injector 100 unit/ml inject subcutaneously per sliding scale at 7:00 AM before meals as follows: if glucose is 301-330 = 34 units, if greater than 331 give 38 units. R8's Medication Admin Audit Report dated 4/10/26 shows an order for Tresiba FlexTouch subcutaneous solution pen injector 200 unit/ml inject 56 units subcutaneously in the morning scheduled at 8:00 AM. R8's Medication Admin Audit Report dated 4/10/26 shows Humalog 5 units was administered on 4/10/26 at 10:56 AM and Tresiba 56 units (although it was witnessed as above to be 70 units) was administered at 11:16 AM on 4/10/26. R8's Medication Administration Record (MAR) for 4/1/26 through 4/30/26 shows V11 administered R8's Humalog 34 units (although it was witnessed as above to be 32 units) and R8's Medication Admin Audit Report dated 4/10/26 shows it was administered at 10:55 AM on 4/10/26.On 4/10/26 at 11:58 AM, V13, Registered Nurse (RN), said medications are considered on time if they are given one hour before and one hour after they are scheduled. V13 said sliding scale insulin needs to be given about one hour prior to meals.On 4/10/26 at 12:33 PM, V2, Director of Nursing (DON), said medications can be given an hour before and an hour after the scheduled time and still be considered on time. V2 said insulin, including sliding scale insulin, should be given 15 to 30 minutes prior to a meal, so the resident's blood sugar (glucose) doesn't drop.2.R4's MAR for 3/1/26 through 3/31/26 shows an order written on 3/17/26 at 11:00 PM for Dofetilide 50 micrograms (mcg) to be given by mouth twice a day (8:00 AM and 8:00 PM) for atrial fibrillation (an abnormal heart rhythm). The same MAR shows a 9 for the 8:00 AM dose on 3/18/26. The chart codes on the same MAR show a 9 means Other / See Progress Notes Effective. R4's Progress Notes dated 3/18/26 at 9:01 AM show dofetilide oral capsule 250 mcg give 250 mcg by mouth two times a day for atrial fibrillation is not available.On 4/10/26 at 12:26 PM, V2, Director of Nursing (DON), said, there should be a nursing note if family had been asked to bring medications for a resident from home. V2 said they do not have dofetilide available from their pharmacy, it is not on their formulary, and they do not keep it in their facility. On 4/10/26 at 12:33 PM, V2 said it is the facility's responsibility to make sure residents have their medications.On 4/10/26 at 2:55 PM, V1, Administrator, said if they don't have a medication available, they need to contact the doctor and inform them, and follow the doctor's orders. V1 said the nurse should not just document not available and not give it.The facility's Timely Administration of Insulin Policy (not dated) shows it is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. All insulin will be administered in accordance with physician's orders. Insulin administration will be coordinated with meal times. Before administering insulin, perform two nurse verification of correct resident, dose calculations, and correct route of administration. Administer insulin at appropriate times.The facility's Medication Administration Policy (not dated) shows the six rights of medication are followed: right resident, right drug, right dosage, right route, right time, right documentation. Administer within 60 minutes prior to or after scheduled time. Observe resident consumption of medication.

Based on observation, interview, and record review the facility failed to ensure a resident room was sanitary for 1 of 4 residents (R4) reviewed for environment in the sample of 9.The findings include:On 4/10/26 at 12:07 PM, resident room [ROOM NUMBER] B had a wall mounted heating/cooling unit under the window. Underneath the unit, along the baseboard there was a section of the drywall that was bumpy and black in color. On 4/10/26 at 12:11 PM. V8 Maintenance, with this surveyor, observed the area in room [ROOM NUMBER] B. V8 said that it was not black mold but was a buildup of dirt and debris from the condensation gathering there from the heating/cooling unit. V8 said moisture sits there and erodes the drywall and the dirt and debris collects there. V8 said the drywall needs to be fixed in that area, it should not be black. R4's Census shows that R4 resided in room [ROOM NUMBER]B during her stay at the facility.The facility's Routine Cleaning and Disinfection Policy dated 2025 shows It is the policy of the facility to ensure the provision of routing cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.

Based on observation, interview, and record review, the facility failed to implement personalized fall prevention measures for a resident (R4) resulting in (R4) obtaining a laceration that required sutures, and the facility failed to prevent a resident (R1) at risk for elopement from exiting the building unsupervised. These failures apply to 2 of 3 residents reviewed for safety in the sample of 6.The findings include:1. R4's electronic face sheet printed on 3/28/26 showed R4 has diagnoses including but not limited to myasthenia gravis, disorientation, dementia without behaviors, and history of falls. R4's facility assessment dated [DATE] showed R4 has severe cognitive impairment. R4's nursing progress notes dated 2/18/26 showed, 6:30 AM Fall was not witnessed. Fall occurred in the Resident's room. Resident was attempting to self toilet at time of the fall. Reason for the fall was evident. Reason for fall: Resident stated that she tripped over fall mat located next to bed. Did an injury occur as a result of the fall: Yes. Injury details: Large unmeasurable laceration to center of forehead. L knee bruised/painful. R4's local hospital records dated 2/18/26 showed, .Presenting to the emergency department by ambulance after a fall. Patient comes from (facility) where she had a fall. Patient does not remember falling .Laceration to right forehead approximately 3cm (centimeters) .laceration repair with 9 sutures . R4's care plan dated 3/17/25 (revised 2/9/26) showed, Fall .pool noodle to left side of bed, 2/18/26 removed the floor mat from in front of her bed, and ensure her walker is within her reach at bedtime. On 3/28/26 at 2:21PM, V12 (Certified Nursing Assistant) stated, (R4's) fall prevention measures include having a mat on the floor, check on her frequently at least every 15 minutes, and offer toileting, She's had some falls, sometimes she picks the mat up and we have to put them back down again. She gets a mat to the far side of her bed by the window and another one on the other side of her bed between the bed and wall. Surveyor went to R4's room and V12 followed. V12 confirmed there was no pool noodle to the left side of R4's bed. V12 confirmed there was a fall mat on the right side of R4's bed between the bed and wall and V12 also placed a fall mat to the left side of R4's bed and placed her walker on top of the fall mat. On 3/28/26 at 2:52PM, V3 (Assistant Director of Nursing) stated, (R4's) fall prevention measures are a low bed, non-slip socks while in bed, remove fall mat in front of the bed, and keep walker within reach at bedtime. She can ambulate by herself to a point but I would rather have her have help. A fall mat would pose more of a fall risk for her because she can ambulate so we wouldn't put one on the left side of her bed. She should have never had a mat on that side of the bed. The facility's undated policy titled, Fall Prevention Program 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 .7. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 2. R1's face sheet showed he was admitted to the facility 5/13/25 with diagnoses to include seizures, muscle weakness, abnormalities of gait and mobility, dementia without behavioral disturbance, alcohol abuse, schizophrenia, acute kidney failure, visual disturbances, depression, and altered mental status. R1's facility assessment showed he has moderate cognitive impairment, experiences hallucinations and delusions, and ambulates with supervision or touching assistance. R1's current Physician Order Sheet showed an order started 6/19/25 for Wanderguard Left ankle – Check Placement and function. R1's Care Plan initiated 6/20/25 showed, Exit seeking/elopement risk related to cognitive impairment/Dementia. Will not leave center unattended. R1's 10/18/25 nursing note entered at 9:45 PM showed, Resident was walking quickly throughout the unit and slammed the Exit door at the nurse's station attempting to leave. Alarms were going off. I got up from the nurse's station and called out, [R1] is trying to leave. He then went to the Front door where there were 2 staff members standing there and he walked past them and eloped. I attempted to catch up to him outside but was unable to reach him. DON and another staff member got into her car and found him 6 blocks from the facility and brought him back. DON instructed me that the resident is now on 15-minute checks. I gave that instruction to the oncoming 3rd shift nurse. R1's Nurse Practitioner Follow Up note dated 10/21/25 showed, . Follow up for exit seeking, increased agitation. Patient was seen today for psychiatric evaluation. Resident reported he had episode of increased hallucinations of ghosts which were very disturbing causing patient to exit the building. Patient agreed to return to the facility and has been closely monitored by staff since the incident. On 3/28/26 at 9:55 AM, V4 RN (Registered Nurse) said, It was around 10 pm, I was waiting for 3rd shift, sitting at the desk. [R1] walked past, went to the exit across from the nurse's station, and he started banging on the doors with a lot of force. Trying to bang down the door. The alarm started going off, so he ran in another direction looking for another door. I ran down the hall with him and I screamed to another lady that [R1] was trying to escape, they just let him out the door. I don't remember how far he actually got. a staff member [V9- CNA (Certified Nursing Assistant] got in a car with someone else to try and find him. They did find him. I had gotten in my car and went in the opposite direction. He didn't say anything about where he wanted to go or what he was doing, he just came and banged on the doors. On 3/28/26 at 11:30 AM, V9 CNA (Certified Nursing Assistant) said, It was about 9:45 PM that day when [R1] left. Normally when [R1] leaves his room and goes for a walk around the building, we back off and leave him alone. He walks off his aggression. That night in particular, I was coming off the back hall and he stormed down the center hallway, toward the front door. He banged on the front door until it opened, and he went out the front door. The nurse on duty was [V4]. She went after him, and I went after him with the previous Director of Nursing (V10) driving me. There was another nurse coming in the building at the time and he got out of the building and by the time we were able to get in the car and go follow him, he was 3 blocks down, past the funeral home parking lot on the sidewalk. He wanted to go home. It was raining. I got out of the car, and I walked with him for a while, because the sidewalk was busted up and I didn't want him to trip and bust his head up on the cement. We got him into the car and brought him back. We got back to the building about 10:30 that night. He went out at about 9:45 PM. I saw him walking because I knew what he looked like, since I had worked with him before. He had done this before. He has periods of agitation, because of his psychiatric issues and he will get agitated and when he walks around the building, he is either agitated or bored. I normally back off and leave him alone. don't remember when he got out the first time, that was when they put the wander guard on him. he didn't have the mental capability of signing himself out. He was walking by himself when I saw him. He was wearing shorts, tennis shoes, and a gray hooded sweatshirt. On 3/28/26 at 3:01 PM, V1 Administrator said, I was not in the building when it happened. I got a call that he had been pacing around in the facility and that he had gone out through the front door. they did tell me they were able to stay with him and talk him into coming back in. I was then able to go in and view the camera footage and I was able to see that he did go to the front door. He pushed on the door, and it didn't open right away because of the wanderguard. He then went out the front door and was in the parking lot . it was not originally reported that way to me ever. (R1 leaving unsupervised, staff leaving in cars to find him, and being picked up by car.) . I watched him on camera footage. Staff was never not with him on camera. I don't have that footage. Our cameras only store footage for 7 days. The facility's undated policy and procedure showed, Elopements and Wandering Residents. Policy: This facility ensure that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: 'Elopement' occurs when a resident leaves the premises or a safe area without authorization. and/or any necessary supervision to do so. Adequate supervision will be provided to help prevent accidents or elopements.

Based on interview and record review the facility failed to ensure a resident was free from physical abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 getting punched in the face by R3 and sustaining an abrasion and swollen lip.The findings include: R2's face sheet showed he was admitted to the facility 9/29/25 with diagnoses to include primary generalized osteoarthritis, degenerative disease of nervous system, disorientation, toxic encephalopathy, metabolic encephalopathy, mood disorder, major depressive disorder, anxiety disorder, and legal blindness. R2's facility assessment dated [DATE] showed he is severely cognitively impaired and uses a wheelchair for mobility. R3's face sheet showed he was admitted to the facility 6/3/25 with diagnoses to include dementia with behavioral disturbance, muscle wasting and atrophy, dysphagia, lack of coordination, anxiety disorder, depression, alcohol dependence with alcohol-induced persisting dementia, encephalopathy, and muscle weakness. R3's facility assessment dated [DATE] showed he has severe cognitive impairment and uses a wheelchair for mobility.R2's 12/20/25 nursing note entered at 9:55 AM showed, Resident involved in altercation in dining room at breakfast. Resident has abrasion to lower lip. No other injuries noted at this time. R2's 12/20/25 nursing note entered at 9:36 AM showed, Resident has abrasion to lower lip. Area cleansed. R2's 12/21/25 nursing note entered at 2:16 AM showed, Resident monitored closely by staff due to recent altercation with another resident. Ice pack applied to mouth area due to injury. Resident would not leave in place for very long. Small amount of red drainage noted from mouth area.R2's December 2025 eTAR (electronic Treatment Administration Record) showed a 12/22/25 order started, Monitor lower lip abrasion until healed.R3's 12/20/25 nursing note entered at 9:57 AM showed, Residents involved in altercation with another male resident in the dining room this morning at breakfast. No injuries noted at this time.On 3/28/26 at 1:10 PM, V8 CNA (Certified Nursing Assistant) said, From what I caught, the moment I saw was [R2] was at the table and [R3] was wheeling himself in. [R3] must have gotten caught on [R2's] chair because there was not enough space for him to get through. That is when the altercation started. I saw both swinging, literally throwing punches. [R2] threw a punch and [R3] threw multiple punches. there was just one injury to [R2's] lip. It was swollen and bleeding.The facility's undated policy and procedure showed, Abuse, Neglect, and Exploitation. Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 'Physical Abuse' includes, but it not limited to hitting, slapping, punching, biting, and kicking.

Based on observation, interview, and record review, the facility failed to protect cognitively impaired residents (R7, R5, R6) from sexual abuse by another resident (R4) with a known pattern of sexually inappropriate behaviors. R4 was observed with her hand on R7's vaginal area. R4 was observed with her whole hand inside R5's pants in his penile area. R4 was observed with her hand in R6's groin moving towards his penile area in a tapping motion up and down. This failure applies to 4 of 13 residents (R4, R7, R5, R6) reviewed for abuse in the sample of 14 and resulted in immediate jeopardy.The Immediate Jeopardy began on 11/22/25 when R4 put a glove on that she took from the nurses' cart, placed her gloved hand onto R7's vaginal area. V16 (Regional Nurse Consultant) was notified of Immediate Jeopardy on 3/13/26 at 3:32 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 3/14/26 but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:R4's face sheet shows R4 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (stroke) dementia and congestive heart failure (CHF). R4 was on hospice services due to CHF. R4's facility assessment dated show 2/5/26 shows R4 has moderately impaired cognition. R4 uses a wheelchair to self-propel and requires maximum assistance from staff for her activities of daily living (ADL's). On 3/13/26 at 9:45 AM, R4 was sitting in her wheelchair alert and smiling. R4 was away from the male residents in the common area. When asked how she was doing, R4 said she was doing well. 1.R4's progress notes dated 11/22/25 by V5 (Registered Nurse-RN) shows, R4 was observed in hallway having expressions of sexual behaviors. R4 was observed wearing a vinyl glove from nurses' cart. R4 had approached another resident (R7) in same hallway and began to fondle resident's labia. R4 and R7 were separated.R7's face sheet shows R7 was admitted to the facility on [DATE] with diagnoses that include dementia and cancer of the bladder.R7's facility assessment dated [DATE] shows R7 has severe cognitive impairment. R7 is wheelchair bound and dependent on staff for ADLs.During the noon meal, R7 was eating lunch in the same dining room as R4. R7 was unable to answer questions.On 3/13/26 at 12:45 PM V5 (RN) said she was the Nurse on 11/22/25, this incident happened while R4 was in the B wing. On 11/22/25, R4 was sitting in her wheelchair in the B wing hallway. R7 was also sitting in her wheelchair in the B wing hallway. R4 was observed taking a glove from a cart, placed her gloved hand and fondled R7's vaginal area in the hallway. V5 said R4 was taken away from R7 immediately. V5 said she felt bad for R7 who has dementia and was not aware that she was touched inappropriately. When resident touches another resident in their private area, that is sexual abuse. R4 and R7 were now moved in the dementia unit.R4's care plan (undated) did not address this sexual behavior dated 11/22/25 towards R7 with no interventions put in place for R4's sexual abuse to prevent further occurrence of abuse.R7's care plan dated 9/22/25 documents R7 was low risk of abuse with diagnosis of dementia with depression and anxiety. R7's care plan had no updated interventions in place to protect R7 from sexual abuse.2. A Facility Reported Incident dated 2/23/26 as final (with the date of incident as 2/10/26) documents R4 was sitting by R5 and staff observed her with hand near his waist resident immediately separated. R5 was placed on 15-minute checks. R4 was placed on 1:1.R5's face sheet documents R5 was admitted to the facility last 5/9/25 with diagnoses that include dementia, depression and diabetes.R5's facility assessment dated [DATE] shows R5 was severely cognitively impaired. R5 needs assistance with his ADLs due to dementia.On 3/13/26 at 9:50 AM, R5 was sitting in his wheelchair watching TV quietly. R5 said he was fine.On 3/13/26 at 12 PM, V13 (RN) said she was the Nurse in the Dementia unit on 2/10/26. V13 said she was passing the 5PM medications when she looked up and saw R4 wheeling herself fast towards R5. R5 was sitting in his wheelchair. R4 put her whole hand inside R5's pants towards R5's penile area. V13 said she yelled take R4 away from R5 now! When R5 was wheeled away from R4, R4 was so upset yelling and screaming that she wanted to go back to R5. V5 said she notified V3 (Assistant Director of Nursing- ADON) immediately. R4 was placed on 1:1. V13 said R5 had no reaction to what had just happened to him due to dementia but that was sexual abuse. Residents are to be free and protected from any kind of abuse. Residents should be safe.On 3/13/26 at 11:30 AM, V4 (Activity Aide) said on 2/10/26 she heard the nurse screaming to move R4 away from R5. V4 said she saw R4's hand inside R5's pants inside his undergarments touching R5's penile area. V4 said she hurriedly moved R4 away from R5. R4 was upset and she wanted to return to R5. On 3/13/26 at 11:15 AM, V3 (ADON) said it was reported to her regarding R4 having behaviors of sexual aggressiveness when she put her hand inside R5's pants. This was reported to the Administrator (V1) exactly how it happened (R4 touching R5's penile area not just waist). V3 said she instructed staff to closely supervise R4, placing her 1:1 supervision to ensure R4 does not sexually abuse R5 again. V3 said Hospice was also notified.R4's care plan (undated) did not address this sexual behavior dated 2/10/26 towards R5 with no intervention put in place R4's sexual abuse to prevent further occurrence of abuse.R5's care plan dated 2/24/26 documents R5 was moderate risk for abuse related to poor cognition (dementia). R5's care plan had no interventions in place to address R5 being sexually abused last 2/10/26, no interventions in place to protect R5 from sexual abuse.3. The facility's Reported incident sent to the state agency as initial dated 3/11/26 show, there has been a resident-to-resident incident. Residents separated immediately. No injuries and no distress observed. Physician and both POA's notified. 5 days to follow.R6's progress notes dated 3/11/26 shows R4's hand was noticed in groin area outside of clothing on a male resident (R6). Staff immediately intervened and separated them. The other resident (R6) did not appear to be in any distress. She (R4) is now on 15 min checks and will be under increased supervision while in common area.R6's face sheet shows R6 has diagnoses that include Alzheimer's dementia, bipolar disorder and hypertension. R6's facility assessment dated [DATE] shows R6 is severely cognitively impaired.On 3/13/26 at 9:55 AM, R6 was sitting in his wheelchair alert, smiling and had no complaints. On 3/17/26 at 10:32 AM V12 (License Practical Nurse-LPN) said she was the Nurse on 3/11/26 PM shift. It was around 4:30 PM, V4 (Activity Aide) was wheeling R4 towards her. V12 (LPN) said R4 and R6 were both sitting in their wheelchairs side by side. R4 was observed to have placed her hand in R6's groin area towards his private area tapping her hand up and down. Both R4 and R6 were immediately separated. R4 was yelling and screaming while being wheeled away from R6, I want to f---- him! I want to f---k him! I'll do whatever I want to do repeatedly.On 3/13/26 at 11:30 AM, V4 (Activity Aide) said on 3/11/26 it was during activity in the common area, residents were watching TV. R4 and R6 were sitting by each other. R4 had her hand in R6's groin to R6's private area while moving her hand up and down. R6's eyes were wide open looking around as if looking for help. V4 said she immediately moved R4 away from R6 and wheeled R4 towards the Nurse (V12). R4 was so upset yelling repeatedly I want to f--k him, I want to f--k him! R4's care plan (undated) did not address this sexual behavior dated 3/11/26 towards R6 with no interventions put in place regarding R4's sexual abuse to prevent further occurrence of abuse.R6's care plan dated 1/26/26 documents R6 was at high risk for abuse related to diagnosis of dementia, increased vulnerability due to mental health diagnosis of bipolar and PTSD. R6's care plan had no interventions in place to address R6 being sexually abused on 3/11/26, no interventions in place to protect R6 from sexual abuse.On 3/13/26 at 12:30 PM, V6 (RN) said she was the regular Nurse in the dementia unit. R4 came from another hall (B wing), she was moved to the Dementia unit beginning of this year (2026). R4 has been hypersexual, touching other residents in their private areas. R4 was a hospice patient, wheelchair bound and is able to wheel self around. V6 said when R4 placed her whole hand inside R5's pants touching R5's private area on 2/10/26, she was placed on 1:1. R4's monitoring then became every 15 minutes. A few days ago, (3/11/26) R4 again touched another resident R6 in his private area even if she was supposed to be on 15 minutes check. R4 should just have been on 1:1. V6 said R4 has had no new interventions to her sexual behaviors on 2/10/26 or on 3/11/26 incidents. There have been no med changes to address R4's sexual behaviors. On 3/13/26 at 10 AM, V9 (Certified Nursing Assistant-CNA) said R4 was now being kept away from other residents. R4 had been touching other residents in their private areas. R4 has also been heard saying lick my p---y to other residents.On 3/17/26 at 10:08 AM, V14 (Dementia Director/Social Service) said when abuse occurs, a Trauma Assessment should have been done right away to immediately assess the emotional and psychological results of the abuse and help with supportive interventions. V14 said there was no trauma assessments done on R7 (incident on 11/22/25 in B wing), there was no trauma assessment done and R5 (incident on 2/10/26) and there was no trauma assessment done on R6 (incident on 3/11/26).On 3/13/26 at 11:20 AM, V2 (Director of Nursing-DON) said he became DON last 11/2025. V2 said all he knew was R4 has inappropriately touched residents in the dementia unit. On 3/17/26 at 12:04 PM, V1 (Administrator) said she was the Abuse Coordinator and reports all abuse occurrences to the state agency. V1 said she cannot recall the details of what she reported to the state agency regarding R4, R7, R5 and R6. V1 said she was not at the facility to review the reportable incidents she sent to the state agency. (V1 was not at the facility during these investigations.) V1 said sexual abuse was not tolerated at the facility.On 3/13/26 at 3:45 PM, V18 (Regional Director of Operations) said R4, R7. R5 and R6's care plans should have been updated when the incidents happened to ensure proper interventions were put into place. All residents should be safe and free from harm including sexual abuse. V18 said care plans will be updated today-3/13/26.On 3/17/26 at 11:07 AM, V15 Physician regarding R4, R7, R5 and R6, said he was made aware of the sexual abuse of R4 to R7, R5 and R6 last 3/13/26. V15 said he expects the facility to have close supervision of residents to prevent abuse from happening.The facility policy on Abuse, Neglect and Exploitation (undated) documents, it is the policy of this facility to provide protection for the health, welfare and the right of each resident by developing and implementing policies and procedures that prohibit and prevent abuse neglect exploitation and misappropriation of residence property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish which can include staff to resident abuse and certain resident to resident altercation. Instances of abuse of all residents irrespective of any mental or physical condition cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated for a neighbor through the use of technology. Sexual abuse-Is a non-consensual sexual contact of any type with a resident. The Immediate Jeopardy that began on 11/22/26 was removed on 3/14/26 when the facility took the following actions to remove the immediacy:R4 was immediately separated from other residents and placed under continuous 1:1 supervision to prevent further inappropriate contact until discharge from facility or her condition warrants immobility.R5, R6 and R7 were immediately assessed by nursing staff for physical injury and psychosocial distress. No physical injuries or psychosocial distress were identified.SSD/Memory Care Director verified all memory care residents have had a risk for abuse assessment completed per policy.The physicians and parties responsible for all residents involved were notified.R4, R5, R6 and R7 had an Abuse/Neglect/Trauma assessment.R5, R6, and R7 had the Trauma Informed Care Assessment completed on 3/13/26.Abuse policies were reviewed on 3/13/26 and no revisions were required.DON and ADON educated all staff on facility Abuse, Neglect and Exploitation policy with an emphasis on identifying abuse, reporting abuse, appropriate interventions, following resident care plans, and monitoring of residents with a history of aggressive or sexual behaviors, on 3/13/26. Any staff who did not receive education will be educated prior to next shift.The DON or designee reviewed facility abuse policies and procedures with any agency staff prior to their shift.Regional Nurse Director in-serviced Administrator and DON on identifying abuse (including sexual abuse), and reporting abuse.Regional Nurse Director in-serviced Administrator and DON on process to relay information to staff regarding the resident's care plans or changes to a resident's care plans pertaining to interventions/strategies to redirect resident when exhibiting either aggressive or sexual behaviors.Emergency QAPI was held with Medical Director on 3/13/26 to discuss citation and develop interventions to ensure safety of other residents.Root Cause Analysis was completed on 3/13/26.R5, R6, and R7 had their care plan updated with safety interventions to protect from abuse.R4's care plan has been updated to reflect interventions put in place to safeguard other residents on the unit, including but not limited to: One to One supervision, providing residents with sensory items to help keep residents occupied, and hands busy.Administrator will audit weekly for 6 weeks and then monthly for 3 months to monitor residents with history of sexual behaviors, resident abuse, and if appropriate interventions are in place, and care plan updated accordingly.All Abuse findings will be reviewed by the QAPI team to ensure appropriate measures have been put in place.

Based on interview and record review, the facility failed to implement interventions to prevent a resident from developing Stage 4 pressure wounds, failed to assess the wounds in a timely manner, and failed to implement treatment interventions of the wounds for 1 of 3 residents (R1) reviewed for pressure wounds in the sample of 14. These failures resulted in R1 developing wound infections leading to sepsis.The findings include:R1's Face Sheet dated 3/17/26 shows R1 was admitted to the facility on [DATE]. R1's diagnoses include, but are not limited to, atherosclerotic heart disease, pressure ulcer of left heel, Stage 4, edema, polyneuropathy, pain in right foot, pain in left foot, hypertensive heart and chronic kidney disease, heart failure, acute kidney failure, chronic kidney disease, pressure ulcer of the right heel, Stage 4, anorexia, and abnormal weight loss.R1's care plan provided by the facility initiated on 11/3/25 shows he is at risk for impaired skin integrity due to fragile skin, bilateral lower extremity edema, reduced mobility, and the presence of an indwelling urinary catheter.R1's N Adv-Skin Check dated 11/5/25 at 2:39 PM shows he has a new, in-house acquired wound/blister of his left heel and a new, in-house acquired wound/blister of his right heel. R1's nurse practitioner (NP) documented on 11/6/25 at 1:31 AM that R1 was found to have a stage 4 right heel pressure ulcer and a stage 2 left heel ulcer in the facility. A NP note dated 11/7/25 at 12:00 AM shows R1 was being seen for bilateral foot pains and with numbness with tingling. The note shows R1 has chronic bilateral foot pains and chronic neuropathy (nerve damage causing numbness, tingling, weakness, or burning pain, often starting in the hands and feet) of his feet.R1's Wound-Weekly Observation Tools both dated 11/11/25 at 6:12 PM documented by V3, (Assistant Director of Nursing & Wound Care Nurse), show R1's right heel, stage 4 pressure ulcer was acquired on 11/11/25 and the assessment is her first observation of the wound and R1's left heel stage 2 pressure ulcer was acquired on 11/11/25 and is also her first observation of the wound. R1's Health Status Note dated 11/10/25 at 1:04 PM shows the following: Family alerted this RN (Registered Nurse) regarding wound on right heel and informing this RN family would like foam boots applied. Foam boots applied to help facilitate pressure off bilateral heels. Float heels in bed: to help facilitate pressure off bilateral heels. Wound nurse notified.R1's Physician Orders show orders written on 11/10/25 to float heels while in bed and to apply foam boots while in bed to help prevent pressure off heels. These two orders were never included in R1's care plan provided by the facility and initiated on 11/3/25.V20's (Wound Care Physician) Initial Wound Evaluation & Management Summary dated 11/11/25 of R1's wounds shows R1 has a Stage 4 pressure wound of the right heel which has been present more than one day and a Stage 2 pressure wound of the left heel which has been present more than one day. V20 removed necrotic tissue (a procedure called debridement) of the right heel wound to reveal the underlying deep tissue at the muscle/fascia level. V20's treatment plan for the right heel wound is Leptospermum honey to be applied once daily and as needed with a gauze island border dressing. R1's Physician Orders shows an order with a start date of 11/11/25 for his right heel to be cleansed with normal saline or wound wash, followed by xeroform gauze to the wound bed and covered with bordered gauze. This same wound treatment was on R1's Medication Administration Record (MAR) for November of 2025 from the dates of 11/12/15 through 11/19/25. The treatment order provided by V20 on 11/11/25 as referenced above was not placed in R1's physician orders on 11/11/25 and was not on R1's MAR or TAR (Treatment Administration Record) for November 2025.R1's Specialty Physician Wound Evaluation & Management Summary dated 11/27/25 shows his left heel wound is now unstageable necrosis. R1's Specialty Physician Wound Evaluation & Management Summary dated 1/6/26 shows R1's left heel wound is debrided and has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis previously. The wound has now revealed itself to be a Stage 4 pressure injury. R1's right heel wound is also a stage 4 pressure wound.On 3/17/26 at 1:12 PM, V20 said her recommendations for wound care treatment should be followed. V20 said if a Stage 2 pressure wound starts as a blister, the natural progression is that it hardens and becomes unstageable necrosis as it dries up. One cannot see if there is further injury underneath. V20 said she believes R1's Stage 2 left heel pressure wound was always a Stage 4 pressure wound, but she could not tell because of the overlying blister and necrosis.On 3/13/26 at 1:21 PM, V3 said she does wound rounds with V20 on Tuesday mornings and V20 will tell her of any wound treatment changes. V3 said the physician's wound notes are uploaded right into the resident's chart and she enters any new orders into the electronic medical record. V3 said new wound treatment orders should be implemented the same day they are ordered. V3 said it is obviously her fault the orders did not get put in for the right heel wound treatment as per V20's recommendations. V3 said staff inform her about any new skin alterations and she goes and does an assessment that day or the following day which includes measuring the wound, noting if there is drainage, if it is wet, and what the wound and area around the wound look like. V3 said R1 had in-house acquired pressure wounds to his right and left heels which were first identified on 11/8/25 by the floor nurse. V3 said R1's heel wounds were caused by pressure against the foot board of his bed; it was not long enough for him, and his heels were pressing against it. V3 said R1 was at risk for pressure wounds. V3 said her first formal assessment of R1's heel wounds was done on 11/11/25; it should have been done the day after they were found. V3 said after R1 acquired the pressure wounds to his heels they implemented interventions including padded booties and she thinks they put an extender on his bed.R1's Health Status Note dated 1/10/26 at 12:14 PM shows R1's family came to get the nurse because R1 did not look OK. The nurse went to assess R1 and he was jerking and responded to his name being called, but could not answer simple questions. R1's vital signs were as follows: oxygen saturation 80 percent on oxygen at 2 liters, blood pressure 130/80, temperature 103, respiratory rate 25. R1 transferred to hospital via emergency medical services.R1's After Visit Summary dated 1/22/26 from his hospital medical records printed 3/16/26 show R1 was admitted to the hospital 1/10/26 with a primary diagnosis of sepsis and discharged [DATE]. These medical records show a cardiologist consult dated 1/14/26 stating R1 presented to the ED (emergency department) 1/10/26 due to shortness of breath, confusion, fever, and rigors. R1 was admitted with sepsis secondary to urinary tract infection and wound infection. After undergoing imaging studies, R1's ulcerations to R1's right and left heels are concerning for osteomyelitis. R1's blood cultures are positive for ESBL Klebsiella (bacteria). R1 is post excisional debridement of his right and left heels down to and including muscle and bone. The podiatrist note dated 1/12/26 at 7:35 PM shows R1 has necrotic bilateral posterior plantar heel ulcers covered in necrotic, nonviable tissue which was eventually found to be the source of his sepsis. The hospitalist note dated 1/21/26 at 10:45 AM shows R1's intraoperative wound cultures from his right heel is growing vancomycin resistant Enterococcus faecalis and Proteus.The facility's Wound Treatment Management Policy (undated) shows wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.

Based on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of resident property for two of seven residents (R9, R3) reviewed for Abuse/Misappropriation in the sample of 14. The findings include:1.R9's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including encephalopathy, cellulitis of right and left lower limbs, congestive heart failure, contracture of right and left lower extremity, restlessness and agitation, other chronic pain, low back pain, depression, and localized edema.R9's Order Summary Report dated March 16, 2026, shows an order for Oxycodone (an opioid pain medication) 5 mg (milligrams) one tablet by mouth every six hours as needed for pain, oxycodone 5 mg one tablet by mouth two times a day for pain, and oxycodone 5 mg give two tablets by mouth every six hours as needed for pain.R9's Minimum Data Set, dated [DATE], shows R9 is cognitively intact.On March 17, 2026, at 11:22 AM, R9 said he always has pain in his feet and in his buttocks. R9 said he receives pain medication. The pain medication does not get rid of the pain but does help the intensity. R9 said his pain medication was misplaced in the past.The facility's Final Report dated March 10, 2026, shows, On March 6, 2026, noted that a card containing 43 tablets oxycodone 5 mg was missing from the medication cart. The narcotic count sheet was also missing. Police notified.Following the initial report the building and all medication carts and narcotic drawers were searched, the medication was not located, no other missing items identified. Multiple attempts were made to reach the agency nurse [V19 Registered Nurse (RN)] for verbal and written statement.Video surveillance was watched by administrator. [V19 (RN)] is seen on camera remove(sic) the card from the narcotic drawer, then take the card in folded paper, place it into her personal bag, she then walks off the floor with the bag. She is seen exiting the building with her bag, placed her bag in her vehicle and return into the facility without her bag. Police department updated and video surveillance provided.On March 17, 2026, at 10:58 AM, V16 (Regional Nurse) said she was called the morning of March 6, 2026, by V2 (Director of Nursing) to report there was a card of narcotics missing. V16 said the facility tried to get a hold of V19 (RN) but could not get a hold of her. The police were called and a report was filed. V16 said that V1 (Administrator) reviewed the camera footage and saw where the theft occurred with V19. On March 17, 2026, at 12:17 PM, V1 (Administrator) said V21 (Licensed Practical Nurse) worked the morning of March 6, 2026. V1 said V21 also worked March 5, 2026. When V21 worked the morning of March 6, 2026, she noticed there was no oxycodone to give to R9. V1 said that R9 should have had another card with 48 tablets in it. V1 said that the surveillance cameras were watched and saw that V19 (RN) took the narcotic card out of the drawer and put it on top of the medication cart. V1 said V19 then turned her back to the cameras. V1 said she could see that V19 placed the card in between papers and then proceeded to place the items into her personal bag. V19 then took her bag outside of the building and put it in V19's car and then come back into the building without her bag. V1 said numerous attempts have been made to reach V19 but V19 is not returning the facility's call. V1 said the detective reached out to V19. V1 said this case will be sent to the state's attorney. The facility's Controlled Substance Administration and Accountability policy dated 2025 shows, The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure.2. R3's Face Sheet dated March 16, 2026, shows she was admitted to the facility on [DATE], with diagnoses including lack of coordination, anxiety disorder, urinary tract infection, history of falling, heart failure, and muscle weakness.R3's Minimum Data Set, dated [DATE], shows R3 is cognitively intact. The facility's Final Report dated February 23, 2026, shows, On February 10, 2026, [R3] reported to the business office manager that she only had $.17 remaining in her bank account. Bank records reflected multiple debit transactions that the resident stated she did not make. An internal investigation was conducted, including interviews with multiple staff members who provide care or services to the resident. Staff were asked if they had observed the resident's debit edit card in her room and whether they maintained accounts with services such as door dash (food delivery), uber (offers rides and free delivery on food), or Lyft (transportation company).On March 13, 2026, at 11:30 AM, R3 said she did not know anything was wrong until she got her bank statement and it showed she had no money. R3 said she looked everywhere for her debit card. R3 said she talked with V1 (Administrator). R3 said there were purchases over almost $200. R3 said she believed that someone from the facility took her debit card. R3 said the police came to the facility and took a report, but R3 said she has not received any updates from the facility. R3 said her debit card was in a little coin purse that was kept in her drawer. R3 said she was upset when she saw she had no money. R3 said the facility staff would take her to the store when she needed something. R3 also said she has never given anyone her card to use without her being present. R3 said her old debit card is now shut off and she has a new debit card. The facility has now given her a lock box. On March 17, 2026, at 12:17 PM, V1 (Administrator) said R3 went to the business office manager and asked her to contact the bank to find out why she did not have money in her checking out. V1 said there were several charges with door dash, uber, and Lyft. V1 said R3 did not make those charges and the police were notified. V1 said that R3 never used door dash, uber, or Lyft. V1 said the charges were all at places that were local to the facility. V1 said the local police are trying to find the address that the charges were delivered to.R3's Bank Statement shows on January 14, 2026, there were two charges for door dash from a local grocery store totaling $94.16. On January 16, 2026, there was a $7.92 charge from uber and an $.11 charge to Lyft. On January 18, 2026, there was a $7.91 charge to Lyft and a charge to door dash for $18.82 from a local restaurant. On February 6, 2026, there was a door dash charge from a local Arby's that totaled $29.71 and on February 8, 2026, a $27.72 charge for door dash from another local restaurant. These charges totaled $186.35.The facility's Abuse, Neglect, and Exploitation policy dated 2025 shows, It is the policy of this facility to provide protection for the health, welfare and right of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of Resident Property mean the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.

Based on observation, interview and record review the Facility failed to perform hand hygiene and follow Physician treatment orders for one of four Residents (R12) and follow Physician treatment orders, prevent a worsening pressure ulcer and prevent a newly acquired pressure ulcer for one of four Residents (R3) reviewed for pressure ulcers in a sample size of 46. This failure resulted in R3 developing a new in-house pressure ulcer to the left Ischium, a new in-house stage 4 pressure ulcer to right Ischium and increasing in size in stage 4 pressure ulcers to right and left heels.Findings include: The Facility Wound Treatment Management Policy, dated 2025, documents: to promote healing of various types of wounds, it is the policy of the Facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing; dressings will be applied in accordance with manufacturers recommendations; treatments will be based on etiology of wound, characteristics of wound, location of wound and goals/preferences of resident/representative, guidelines for dressing selection; treatments will be documented on the Treatment Administration Record; and effectiveness of treatments will be monitored through ongoing assessment of the wound and lack of progression towards healing, changing characteristics and goals/preferences. 1.R3's Physician Order Sheet/POS, dated 11/20/25, documents R3 admitted to the facility on [DATE] and diagnoses including Hypertension, Osteoarthritis, Type Two Diabetes with Foot Ulcer, Anemia, Polyneuropathy, Peripheral Vascular Disease, Venous Insufficiency, Pressure Ulcer of the Left Heel and Pressure Ulcer of the Right Heel. R3's 11/20/25 POS documents: follow-up with wound clinic (10/14/25); supplement for wound healing (11/11/25); send to Emergency Department for evaluation of Altered Mental Status (11/19/25); Left Heel and Right Heel cleanse (Normal Saline) and medicated dressing (Calcium Alginate with Silver) daily (11/4/25); and Left Ischium and Right Ischium cleanse (Normal Saline) and medicated dressing (Calcium Alginate with Silver) daily (11/4/25). R3's POS dated 11/20/25, does not document pressure ulcer interventions. R3's current Care Plan documents: pressure ulcers to the Left Heel, Right Heel, Left Ischium and Right Ischium; Venous Ulcers of the Left Dorsal Foot, Right Leg and Right Second Toe; liquid protein supplement (11/5/25); monitor/document location, size and treatment of skin injury and report abnormalities, failure to heal and signs and symptoms of infection to the doctor; apply stock moisture barrier cream as needed; use pressure relieving devices as appropriate; dietary supplements as ordered and dietician consult as needed to address skin issues; administer treatments as ordered; wound physician (VOHRA) to assess and treat weekly; and weekly treatment documentation to include measurement of each area of skin breakdown. On 6/26/25 R3's Wound Evaluation and Management Summary documents: Pressure Ulcer of the Left Heel [(Site Two), duration 30 days] measuring 1.5 cm by 3.6 cm by 0.4 cm with moderate serous drainage; Pressure Ulcer of the Right Heel [(Site Four), duration 45 days] measuring 4.7 cm by 13 by 0.4 cm; and surgical debridement of the Right Heel. On 11/18/25 R3's Wound Evaluation and Management Summary documents increased wound size: Stage Four Pressure Ulcer of the Left Heel [(Site Two), duration 175 days] measuring 2.9 by 3.5 cm by 0.3 cm with heavy serous drainage; Stage Four Pressure Ulcer of the Right Heel [(Site Four), duration 190 days] measuring 12.0 cm by 16.0 by 0.4 cm; and Stage Four Pressure Ulcer of the Right Ischium [(Site 14), duration 30 days] measuring 2.3 cm by 2.1 cm by 0.1 cm. The Wound Evaluation and Management Summary documents to elevate legs and off-load wounds and does not document any additional interventions. R3's Skin Documentation Log, dated 10/1/25 through 11/4/25, documents increased wound size: Right Heel Pressure Ulcer (Site Four), duration 148 days, measuring 6.0 centimeters/cm by 6.5 cm by 0.4 cm (10/7/25); 5.0 cm by 6.5 cm by 0.4 cm (10/24/25); 6.0 c by 6.5 cm by 0.4 cm (10/21/25); 7.0 cm by 6.0 cm by 0.40 cm (10/28/25); and 10.0 cm by 8.0 cm by 0.4 cm (11/4/25). R3's Skin Documentation Log, dated 10/2/25 through 11/4/25, documents increased wound size: Left Heel Pressure Ulcer [(Site Two), duration 133 days] measuring 2.6 cm by 3.2 cm by 0.4 cm (10/7/25); 2.0 cm by 2.6 cm by 0.4 cm (10/14/25); 3.0 cm by 3.0 cm by 0.4 cm (10/21/25); 3.0 cm by 3.0 cm by 0.4 cm (10/28/25) and 3.0 cm by 3.0 cm by .04 cm (11/4/25). R3's Skin Documentation Log, dated 10/2/25 through 11/4/25, documents: a new Left Ischium Pressure Ulcer [(Site 12), duration 8 days] measuring 2.0 cm by 2.0 cm by 0.1 cm (10/14/25); measuring 1.8 cm by 1.8 cm by 0.1 cm (10/21/25); 2.70 cm by 1.2 cm by 0.1 cm (10/28/25); and 1.90 cm by 1.0 cm by 0.1 cm (11/4/25). R3's Skin Documentation Log, dated 10/2/25 through 11/4/25, documents: a new Right Ischium Pressure Ulcer [(Site 13), duration 12 days] measuring 4.0 cm by 2.3 cm by 0.1 cm (10/14/25); measuring 1.4 cm by 0.9 cm by 0.1 cm (10/21/25); 1.2 cm by 0.7 cm by 0.1 cm (10/28/25); and 0.9 cm by 0.7 cm by 0.1 cm (11/4/25). R3's Treatment Administration Record/TAR, dated 10/1/25 through 11/19/25, does not document treatment administration on 10/1/25 through 10/14/25 (Left Ischium and Right Ischium); does not document 10/16/25 and 10/27/25 treatment (Left Heel, Right Heel and Right Ischium); does not document treatment administration on 10/27/25 (Left Ischium); does not document treatment administration on 10/10/25 and 10/13/25 (Left Heel, Right Heel, Right Ischium and Left Ischium); and does not document pressure ulcer interventions. On 11/18/25 at 1:52 pm, R3 did not have pressure reducing devices on the bed or chair. On 11/19/25 at 12:15 pm, R3 was unavailable for interview. V1 (Administrator) stated, (R3) got sent out to the hospital and got admitted . On 11/20/25 at 12:45 pm, V4 (Wound Nurse/Assistant Director of Nursing) stated, (R3) was high risk for skin breakdown upon admission because (R3) had other diabetic and venous ulcers. (R3) did acquire some of these pressure ulcers after admission. V4 verified that pressure ulcer preventions were not documented in the medical record and the Treatment Administration Record does not document the entirety of completion of all pressure ulcer treatments for the time period of 10/1/25 through 11/20/25. 2. R12's current Physician Order Sheet, documents to cleanse wound to the left medial foot with normal saline, then apply medi-honey (medicated ointment) to the wound bed, then cover with a dry dressing daily and as needed. This form also documents to cleanse R12's right lateral foot with normal saline, apply a collagen sheet (medicated sheet), and cover with a bordered foam daily and as needed. On 11/19/25 at 11:45am, V8, Registered Nurse, used hand sanitizer and applied gloves. V8 applied a medicated pad to R12's right heel. V8 did no cleanse R12's wound before applying the medicated pad. V8 left the room to gather supplies for R12 wound on her right lateral foot. V8 used hand sanitizer then applied gloves. V8 lifted the dressing to look at R12's wound. V8 then attempted to reapply the dressing to the wound. V8 then removed the dressing and applied a clean dry dressing. V8 stated that she did not cleanse R12's wounds nor did she apply any medications. V8 also stated that R12 did not have a wound on her left foot. V8 verified that she did not change her gloves or perform hand hygiene during wound care. V8 also stated that R12's left foot wound care was not done at all and her right foot wound care was not done as ordered. On 11/19/25 at 2:20pm, V4, Assistant Director of Nursing/Treatment Nurse, stated that V8 needed to redo R12's treatment as ordered, not just cover it up with a dry dressing. V4 also stated that R12's wound should have been done as ordered.

Based on observation, interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a fractured right ankle. This past non-compliance occurred from 8/21/25 to 8/29/25.The findings include:R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness. The 9/4/25 quarterly facility assessment shows R1 to have severe cognitive impairment. The same assessment showed impaired functional abilities to both lower extremities and requires a wheelchair for mobility. She was dependent on 2 or more staff for transfers to and from the chair/bed. The assessment defines dependent as the helper does all of the effort. The resident does none of the effort to complete the activity.R1's progress notes of 8/22/25 at 1:29 PM, documents the nurse was notified of the resident's right ankle being swollen and bruised. The notes show hospice was notified on 8/21/25 and was prescribed an antibiotic for cellulitis due to ankle being warm to touch and red. Upon assessing resident ankle, it had localized swelling and bruising to the right foot/ankle. Hospice notified again and stated they would order an x-ray.The 8/24/25 x-ray report documents a fracture involving the lateral and medial malleoli with mild displacement. The joint alignment is maintained. There is associated soft tissue swelling. The conclusion of the report shows acute ankle fractures.On 9/19/25 at 12:45 PM, V5 Certified Nursing Assistant (CNA) said R1 requires a mechanical lift, she cannot stand. She said there is always 2 staff when using the lift, one is needed to help guide the resident, or just in case anything goes wrong. And the other person operates the lift. V5 said R1 cannot get up on her own. Sometimes she will get a little anxious and move around in her bed, but that is all.On 9/19/25 at 9:17 AM, R1 was sitting up in a geriatric chair. Her right foot was wrapped with an elastic bandage and a support boot. Her eyes were closed and had no sign of discomfort.On 9/19/25 at 1:40 PM, V1 Administrator in training stated it was reported to her R1 had an acute ankle fracture of unknown origin. She stated there had been no fall or incident reported related to R1 to explain the fracture. V1 stated during her investigation she discovered V6 CNA was working on 8/20/25 on R1's hallway and already had been suspended due to an inappropriate transfer using the stand lift. She said while V6 was on suspension, this incident arose, and she called V6 to question her about R1 and her transfers. V1 said R1 should be transferred with 2 staff using the mechanical lift, and V6 reported she transferred R1 by standing her up by herself and attempted to pivot her into bed. V1 said that is when she concluded V6 had caused the fracture to R1s ankle. V1 said V6 reported to her she did not ask anyone for assistance; she took it upon herself to transfer the resident independently. She should have used the mechanical lift and asked for help. V1 said she interviewed the staff on duty with V6 and none assisted her with any transfers, and she had not asked for help. V1 said V6 was immediately terminated.The facility's undated policy for safe resident handling/transfers documents it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. 3. Mechanical lifting equipment or other approved transferring aids will be used based on the residents needs to prevent manual lifting except in medical emergencies. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Prior to the survey date of 9/19/25, the facility had taken the following actions to correct the noncompliance:1. Corrective action for residents identified in the deficiency. A. The CNA that transferred the resident improperly is no longer a certified nurse's assistant at the facility. B. Hospice ordered a portable x-ray on 8/22/25, it was done the same day. The results were shared on 8/24/25 and showed a fracture of the right lateral and medial malleoli with mild displacement. Her ankle was immobilized and elevated per orders and medications given per orders. 2. Identifying other residents with potential for being affected and corrective action. Any resident that needs transfer assistance have the potential to be affected, but no others were identified at the time. 3. Systemic changes to reasonably assure deficiency does not recur. A. In-service was conducted by the administrator with nursing staff on 8/28/25 which included the facilities policy and procedure for safe resident handling/transfer. 4. The DON or designee will conduct QA (Quality Assurance) study to determine 1) does the resident need assistance with transferring, and 2) was the resident transferred safely and per the care plan. The QA study will be completed 5 days a week for 2 weeks, twice weekly for 2 months and weekly for 1 month. Audit results will be forwarded to the facility quarterly QAPI committee for review.

Based on observation, interview and record review the facility failed to ensure a resident's medication was available for 1 of 3 residents (R2) reviewed for medication administration in the sample of 3.The findings include:R2 September Treatment Administration Record (TAR) shows he was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus without complications, non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, and cellulitis.The TAR shows an order for triamcinolone Acetonide external cream 0.1%, apply to RLE (right lower extremity) open area topically every day shift for wound care.On 9/19/25 at 11:00 AM, V9 Registered Nurse was asked to provide the triamcinolone cream applied to R2's legs. She began searching the medication cart, and the treatment cart and said there was none in stock. She said she applied the antifungal cream instead. She could not recall when she had used the triamcinolone. V9 said it should be in the medication cart and applied every day to his right leg for cellulitis. V9 looked in the pharmacy orders and said the last time the cream was ordered was May 2025. She said the triamcinolone cream was being used to prevent infection and the derma fungal cream she was using was not the same thing. On 9/19/25 at 11:10 AM, V9 presented a tube of cream labeled Derma Fungal, Miconazole Nitrate 2%, and was used to treat athletes' foot, jock itch and ring worm. On 9/19/25 at 11:23 AM, V3 Director of Nursing (DON) said the triamcinolone cream comes from the pharmacy and is a steroid cream. The nurses should be re-ordering though the computer. She said the anti-fungal cream would not be effective for R2's wound care. The nurses should not have been documenting the cream as applied if it was not available. The antifungal cream is not an appropriate substitution for triamcinolone cream. They should have contacted pharmacy and if they could not get it, they should have let us know. and not just use something random.The order summary for R2s triamcinolone cream shows the last re-order date was 6/17/25.The facility's undated policy for medication administration policy documents: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 10. Ensure that the six rights of medication administration are followed: b. Right drug. 11. Review medication administration record (MAR) to identify medication to be administered. 12. Compare medication source with MAR to verify resident name, medication name, form, dose, rout, and time.

Based on observation, interview, and record review the facility failed to ensure blood pressure monitoring was performed after a change in condition for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3. The findings include: R1's face sheet printed on 7/31/25 showed diagnoses including but not limited to left side hemiplegia and hemiparesis, psychophysiologic insomnia, epileptic syndrome, and cognitive social or emotional deficit following cerebrovascular disease. R1's facility assessment dated [DATE] showed no severe cognitive impairment. The same assessment showed R1 is capable of self-propelling her wheelchair with only supervision or touch assistance from staff. On 7/31/25 at 10:25 AM, R1 was seated in a wheelchair and easily wheeling herself down the hallway using the handrail. R1 was talkative and stated she did recall an incident about a week ago (7/24/25) when she was sitting outside. R1 said the exact details are fuzzy but she remembered staff taking her blood pressure when she was outside. R1 could not recall the temperature or weather that day. R1 said the aide was supervising her and other residents. R1 stated the aide told R1 her blood pressure was low. That was when the activity started. Staff pushed R1 back inside and laid her down in bed. Staff gave R1 fluids and checked her blood pressure again. R1 could not recall who the aide was, any other residents seated outside, or the time of day the incident occurred. On 7/31/25 at 11:20 AM, V3 RN (Registered Nurse) stated she was working on 7/24 on the afternoon shift. V3 said a CNA (Certified Nurse Aide) reported to her sometime around 6:30 PM, that R1 was acting different and seemed altered mentally. V3 said she ran vital signs, and the blood pressure was around 66/40. V3 said R1 was restless, slurred speech, and not herself. V3 stated she called the physician and R1's son. V3 stated R1's son wanted her to stay at the facility. The physician was notified and stated to continue monitoring the resident and to send out if any further declines were noted. V3 said she took R1's blood pressure 4 or 5 more times because it was so low. V3 said she did not know if R1 had been sitting outside in the hot sun earlier or what was going on. V3 said the blood pressure came up a little after laying her down and pushing fluids. V3 said she relayed the situation to the oncoming nurse and left around 11:00 PM. V3 said the oncoming nurse should have continued blood pressure checks and monitoring. V3 said considering R1's history of stroke, vital signs and offering fluids should be done every 30 minutes. That would be a safe and appropriate timeline for monitoring R1. The 7/24/25 oncoming night shift nurse (V5) was attempted to be reached during the survey but did not return any phone call messages. On 7/31/25 at 1:33 PM, V8 LPN (Licensed Practical Nurse) stated residents with a change in condition should be assessed right away, including a full set of vital signs. The physician is notified, and new orders should be carried out. Monitoring a resident includes checking and charting all vital signs and outward physical changes. Residents with a low blood pressure should be offered fluids, repositioned and have the blood pressure rechecked every 30 minutes to one hour. Nurses should be documenting under the vital sign tab or in progress notes of the medical record. No documentation means it was not done. On 7/31/25 at 1:40 PM, V2 (Director of Nurses) stated any resident with a change in condition should be monitored at least every four hours until stable. V2 said R1 did have a low blood pressure on 7/24 which was documented in a progress note at 66/40. The same progress note charted a second blood pressure at 87/46. V2 stated vital signs should have been taken and documented until R1 was stable. V2 said the time and vital sign levels should be recorded. There is no way of knowing if a resident is getting better or declining if it is not done. R1's progress note dated 7/24/25 at 6:51 PM, stated R1 was having altered mental status and speech was slurred. The note showed vital signs were taken and the blood pressure was 66/40. The note showed a second blood pressure was taken of 87/46 (no time documented). The same note showed report given to oncoming nurse to monitor pressure and contact physician of any further changes in condition. The note was authored by V3 (RN). R1's progress note dated 7/24/25 at 7:17 PM, stated resident remained in house and to monitor blood pressure. There was no blood pressure levels or times recorded. The note was authored by V3 (RN). R1's progress note dated 7/25/25 at 4:58 AM, stated will continue to monitor R1. There was no blood pressure levels or times recorded. The note was authored by V5 (LPN). R1's vital signs were reviewed under the electronic charting tab. The most recent blood pressure reading was from May of 2025. On 7/31/25 at 1:14 PM, V1 (Vice President of Operations) stated the only vital signs and blood pressure monitoring for R1 over the last 30 days are those that are in the progress notes. There are none other than those. The facility's Change in a Resident's Condition or Status policy revision dated May 2020 states: 6. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on record review and interview the facility failed to ensure one resident (R2) was free from sexual abuse and failed to ensure two residents (R3,R4) were free of physical, resident-to-resident abuse of five residents reviewed for abuse in a total sample of five.The Facility's undated Abuse, Neglect and Exploitation policy documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. R1's Medical Record documents that he was admitted on [DATE] with diagnosis to include but not limited to Dementia, Insomnia and repeated falls. R1's MDS (Minimum Data Set) dated 6/3/25 documents his BIMS (Brief Interview Mental Status) score of 9/15, indicating severe cognitive impairment. R2's Medical Record documents that she was admitted to the facility on [DATE] with diagnosis to include but not limited to Dementia, Muscular Dystrophy and falls. R2's MDS (Minimum Data Set) dated 4/21/25 documents her BIMS (Brief Interview for Mental Status) score of 7/15 indicating severe cognitive impairment. On 7/18/25 at 10:00 AM V1 (Administrator) confirmed that R1 and R2 both reside in the closed Alzheimer's Unit at the facility. The Facility's Final Report dated 6/28/25 documents that R1 was observed with his hand at her (R2)'s front, near the waistband of her pants. R2's Nurse's Note dated 6/20/25 at 9:54 AM documents While waiting for breakfast in the dining room this morning it was noted that a male resident was manipulating resident's genital area over her clothing. Throughout the survey neither R1 nor R2 were able to answer questions appropriately. On 7/20/25 at 9:30 AM V1 (Administrator) confirmed that the facility recognized this instance as sexual abuse of R2 perpetuated by R1. R3's medical record includes the diagnoses as follows: Alzheimer's Disease; Other Symptoms and Signs involving Cognitive Functions and Awareness and Depression. R3's current Care Plan documents the following under Behaviors: I display behavioral symptoms r/t (related to) dementia and difficulty adjusting to life in long-term facility. Behaviors manifested by wandering and pacing. 7/16/25 Involved in resident-to-resident altercation. R4's medical record includes the following diagnoses: End Stage Kidney Disease (with Hemodialysis) and Dementia. R4's current Care Plan includes the following Abuse/Neglect care plan focus: I am at low risk for abuse/neglect r/t poor cognition. The Goal for this focus is as follows: I will be cared for in a safe manner and verbalize/communicate to staff any incidences of possible abuse. Interventions include: Report any verbalization of abuse/neglect/exploitation to Administrator immediately. An incident report dated 7/16/25 at 10:20pm, by V11 LPN documents: Nurse heard resident wife yelling; went to investigate; Found another resident (R3) in his (R4's) room standing at the head of bed unable to figure out how to leave. (R4) noted rubbing neck. Red marks noted around (R4's) neck. The Resident Description given by R4 states: There was a fight. An additional Incident Report dated 7/16/25 at 10:20pm by V4 LPN/Licensed Practical Nurse, documents the following: Nurse heard yelling, went down hall to investigate. (R3) found in another resident's room standing by head of bed unable to figure out how to get out. (R3) escorted back to his room; sm (small) cut noted to upper lip, scratch noted to left cheek stated, He clocked me good. R3's medical record includes a Progress Note dated 7/16/17 at 11:03pm, by V11 LPN/Licensed Practical Nurse documents the following: 10:20pm, heard a resident yelling Nurse, went to investigate; Found this resident in another resident (R4) room standing at head of bed unable to figure out how to get out; Resident was escorted from room; CNAs (Certified Nursing Assistants) came to assist; Noted other resident (R4) rubbing neck; red marks noted around neck; Cut noted to this resident (R3) upper lip and scratch to left cheek Stated, He clocked me good DON (Director of Nursing) notified; Dr. notified; Messaged left for both (family members/Powers of Attorney) no answer from either; Sitter placed with resident for 1:1. On 7/18/25 at approximately 10:00am V2 DON/Director of Nursing verified R3 and R4 were residents in the facility's secure Memory Care Unit and the incident which occurred in R4's room, on the late evening of 7/16/25, when R3 attempted to choke R4 and R4 struck R3 in the face was resident-to-resident abuse. R3's Incident Investigation folder contained a report, faxed to the state agency on dated 7/17/25, titled Initial Report signed by V1 Administrator/Abuse Coordinator documenting under the heading The Original Allegation: (R3) entered another resident room (R4) last night, staff intervened, and both residents had minor injuries not requiring medical intervention. Both families' notifications were made. Investigation initiated, final five day to follow. On 7/18/25 at approximately 10:20am, V7 CNA/Certified Nursing Assistant stated she was on duty the night R3 assaulted R4. V7 stated she witnessed the altercation. She stated she heard R4's spouse/roommate yelling from their room, entered the room and saw R3 standing over R4. R3 was assisted out of R4's room and noted facial scratches on R3 as well as a bloody lip. R3 was separated from R4, moved to a different room, on another hall, and a one-to-one observation immediately went into effect. V7 stated it was a little later in the evening when staff noted R4 had abrasions and red marks around his neck and realized R3 had been choking R4 when R3 was in R4's room.

Based on observation and interview the facility failed to have documented behaviors to warrant the use of antipsychotic and other psychotropic medications and the facility failed to attempt nonpharmacological interventions prior to using antipsychotic and other psychotropic medications for three residents (R1, R3 and R5) of three residents whose psychotropic medications were reviewed in a total sample of five. The Facility's undated Use of Psychotropic Medication(s) documents It is the intent of this policy to ensure that residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. The policy defines Adequate indications for use as refers to the identified, documented clinical rational for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indications for use means that the medication administered is consistent with the manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals. The Facility's undated Restraint free environment policy documents it is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints. The policy defines chemical restraint as refers to any drug used for discipline or that makes it more convenient for staff to care for a resident, and not required to treat medical symptoms This include instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated, because they are less dangerous to a resident's health and safety. The Facility's undated Restraint free environment policy documents Behavioral interventions should be used and exhausted prior to the application of a physical restraint or administration of mediations that could be perceived as a chemical restraint, A physician's order alone is not sufficient to warrant the use of a physical restraint or a medication that could be construed as a chemical restraint. If a medication was initially administered for a medical symptom and continues to be administered in the absence of such symptoms, the facility should re-evaluate the need for such medication to ensure that it does not sedate the resident or make it easier for the staff to care for the resident, causing it to be deemed a chemical restraint. 1.R1's Medical Record documents he was admitted on [DATE] with diagnosis to include but not limited to Unspecified Dementia, severe, without behavioral disturbances, Anxiety, Insomnia and repeated falls. R1's MDS (Minimum Data Set) dated 6/3/25 documents a BIMS (Brief Interview for Mental Status) score of 3 out of possible 15, indicating severe cognitive impairment. R1's Nurse Practitioner Note dated 6/9/25 documents that resident was being seen because he was readmitted to this facility from the hospital after acute pneumonia. The facility staff have reported increase anxiety and agitation for this resident. R1 is reported as stating he is fine and doesn't need to be seen and that he was upset because he couldn't hear because someone stole his hearing aides and his glasses were lost at the hospital. R1's Physician Order sheet dated June 2025 documents a physician order for Hydroxyzine 25 mg (milligrams) every 8 hours as needed for anxiety/agitation for 14 days. [NAME] Drug Guide for Nurses defines Hydroxyzine as an antihistamine drug that's uses include to help control anxiety caused by dental nervous, and emotional conditions. Other uses: Sedation: can be used to induce sleep before and after surgery. R1's Medication Administration Record dated June 2025 documents that R1 received the 25 mg of Hydroxyzine on 6/12/25 at 9:37 AM. R1's medical record does not contain any documentation related to why R1 received the medication and/or what nonpharmacologic interventions were used prior to the use of a PRN (As Needed) psychotropic medication. R1's Nurse's Note dated 6/22/25 at 11:34 AM documents R1 was physically aggressive and increased agitation and was sent to the Emergency Room. R1 returned from the emergency room with physician orders for hydroxyzine 50 mg (milligrams) three times a day for dementia, and Halodol 5 mg IM (Intramuscular) every 6 hours as needed for agitation for 14 days. R1's Medication Administration Record dated June 2025 documents that R1 received Halodol 5mg IM on 6/29/25 at 7:47 PM. R1's Nurse's Notes dated 6/29/25 at 7:47 PM document that R1 was having vivid hallucination, getting in employees and resident's faces and raising his voice in the main TV area. R1's Medical Record did not document if R1 was redirectable or any nonpharmacologic interventions used prior to the injection of an antipsychotic medication. R1's Physician Order Sheet dated July 2025 documents a new physician order dated 7/6/26 Haloperidol Powder apply 1 mg (milligram) transdermally every 6 hours as needed for unspecified dementia until 7/17/25. R1's Medical Record does not document why this order was obtained on this date. R1's Medication Administration Record for July 2025 documents that R1 received Haloperidol Powder 1 mg transdermally on 7/13/25. R1's medical record did not document what behavior R1 was displaying, if R1 was redirectable or any nonpharmacologic interventions attempted prior to the administration of an antipsychotic medication. R1's current care plan last updated 6/20/25 documents R1 displays verbal/physical aggression towards staff. R1's Intervention/Task for this concern area is Notify (V14/Psychiatric Doctor). Send to ER (Emergency Room) for evaluation. R1's current care plan last updated 6/20/25 documents R1 is resistive/noncompliant with treatment/care (specify) related to: refused medication. R2's Intervention/Task for this concern area is Provide education about risks of not complying with therapeutic regimen. On 7/20/25 at 10:00 AM V2 (Director of Nursing) confirmed that R1 is severely cognitively impaired and that education would not be an effective intervention for him. V2 confirmed that R1 had no documented nonpharmacolgic interventions on his care plan. 2. R3's medical record includes the following diagnoses: Alzheimer's Disease; Other Symptoms and Signs involving Cognitive Functions and Awareness and Depression. R3's POS/Physicians Order Sheet documents R3 is receiving the following psychotropic medication: Donepezil HCl Oral Tablet 10mg (milligrams): 1 tablet by mouth at bedtime for dementia This order identifies this medication as a Psychotherapeutic/Neurological Agent. R3's current Care Plan dated 7/1/25 documents the following under Behaviors: I display behavioral symptoms r/t (related to) dementia and difficulty adjusting to life in long-term facility. Behaviors manifested by wandering and pacing. And 7/16/25 Involved in resident -to-resident altercation. The following intervention is documented under Interventions/Tasks: Record behavior symptoms and side effects. R3's current Care Plan dated documents, under Behaviors: I display behavioral symptoms r/t (related to) dementia and difficulty adjusting to life in long-term facility. Behaviors manifested by wandering and pacing. 7/16/25 Involved in resident -to-resident altercation. R3's Care Plan includes the following task associated with R3's Behavior Care Plan, documented under Interventions/Tasks: Record behavior symptoms and side effects. On 7/20/25 at approximately 10:45am, V11 CNO/Corporate Nursing Officer stated there was no behavior monitoring documented for R3. R5's medical record documents R5's diagnoses as follows: Bipolar Disorder; Anxiety Disorder and Paranoid Schizophrenia. R5's POS includes orders for the following antipsychotic and psychotropic medications: Zyprexa 7.5 mg (milligrams) one tablet by mouth daily and Seroquel 150 mg orally three times daily Antipsychotics/Antimanic Agents, and Buspirone HCl 15 MG one tablet by mouth three times a day related to Anxiety Disorder. R5's Physicians Orders Sheet also documents an order for staff to observe for and documents the following orders: Monitor for the following behaviors (specify): agitation, delusions, hallucinations, complaints, foul language, psychosis, aggression, refusal of care and Target behaviors: reports or observations of feeling anxious, self-isolating, hallucinations, paranoia, delusions every shift. R5's medical record does not include any behavior monitoring as ordered by R5's Psychiatrist and Primary Physician. On 7/20/25 at approximately 10:45am V11 CNO/Corporate Nursing Officer stated there was no Behavior Monitoring documentation for R5.

Based on observation, interview and record review, the facility failed to provide ordered pain medication timely, for one of three residents (R2) reviewed for pain control, in a sample of three. This failure resulted in R2 experiencing intermittent excruciating pain from 12/12/24 until 12/16/24. FINDINGS INCLUDE: The (undated) facility policy, Pain Management, directs staff to, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Pain Management and Treatment: Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. Opioids will be prescribed and dosed in accordance with professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences. R2 was admitted to the facility on [DATE] at 1:00 P.M. from a local hospital after a Total Right Knee Replacement on 12/9/2024. At the time of discharge, V10/Orthopedic Surgeon prescribed Acetaminophen/Hydrocodone 325 MG(Milligrams) /5 MG one tablet every 6 hours as needed for pain. R2's Nursing Admission Progress Note documents, 12/13/24 2:25 P.M. (R2) arrived at the facility at 1:30 P.M. (R2) diagnosis (includes) total (right) knee arthroplasty. (R2) is alert and oriented. (R2) has pain rated as a 9 out of 10. (R2) is a general diet. (R2) has an ice machine for RLE (Right Lower Extremity). (R2) oriented to room and call light. Therapy to evaluate and treat. R2's Nursing Progress Notes document on 12/13/24 at 10:02 P.M., (R2) given standing order of Tylenol 325 MG two tablets for pain. (R2) stated pain was a 9:10. (R2) reassessed at 2200 (10:00 P.M.) and stated pills were not effective. Current (medication) orders on order. No further assessment of R2's pain was documented until 12/16/24 at 10:30 A.M., when R2's pain was documented as a 10:10. On 12/14/24 at 8:58 P.M., R2's Nursing Progress Notes document, Call placed to (V11/Medical Doctor) to call (R2's) pain medication into Pharmacy due to the fact (R2) wasn't sent to the facility with hard prescriptions to receive from Pharmacy. (V2/Director of Nurses) notified of medication absence. On 12/15/24 at 9:05 P.M., R2's Nursing Progress Notes document, Call placed again to Pharmacy to check the status of pain medication and they informed this nurse that they had not received call from (V11/MD) for the medication. This nurse notified (V2/DON) and fax sent to (V11's) office in regard to situation. On 12/16/24 at 9:43 A.M., R2 was up in a wheelchair in her room, at the bedside, crying and moaning, clutching her right knee. R2 stated her right knee hurts, and the pain is excruciating R2 rated the pain as a 10:10. R2 stated she was admitted to the facility on [DATE] at 1:00 PM and was supposed to receive Norco as needed for pain, but facility staff have told her they don't have her Norco. R2 stated she has only received Tylenol for the pain one time, and it doesn't help at all. R2 stated she has been in pain since she arrived at facility, and no one is doing anything about it. R2 also states she is supposed to have the ice machine on her knee to help with pain, but staff never fill up the machine with ice. Ice machine observed and only contains water. R2 states she unable to sleep due to pain and is unable to eat, also. R2 requesting help with getting pain medication addressed immediately. On 12/16/24 at 9:51 A.M., V3/Registered Nurse states resident told her she was in excruciating pain and as soon as she finished her medication pass, she was going to call the doctor and pharmacy. On 12/16/24 at 4:00 P.M., V8/Licensed Practical Nurse stated, (R2) was my patient this past weekend. I worked second shift both Saturday and Sunday night. R2 was having pain and I noticed she still didn't have her (narcotic) pain meds (medications). I called (V2/Director of Nurses) and she instructed me to call (V11/Physician) and let him know. When I came in the next night, (R2) still didn't have her pain medications, so I called the Pharmacy and asked them if (V11/Physician) had called in the script and they said he hadn't. I called (V2/DON) again that night and she told me to fax the information to (V11's) office, which I did. On 12/17/24 at 9:45 A.M., V7/Nurse Practitioner stated, I work in the facility Monday through Friday. I usually arrive around 7:00 A.M., I didn't work last Friday (12/14/24) and didn't see (R2) for the first time, until yesterday morning. When I assessed her, (R2) told me she had been having excruciating pain since admission and (facility) staff kept telling her they didn't have her pain medication in. Also, she didn't receive the polar ice to her knee. Polar ice provides continuous ice therapy for a patient that has undergone knee replacement surgery. It helps significantly with pain and swelling and allows a patient to move around to take care of themselves and participate in therapy. On 12/17/24 at 10:10 A.M., V2/Director of Nurses stated, (V8/Licensed Practical Nurse) called me on (12/14/24 and 12/15/24) to let me know that R2 had not received her pain medication, as it wasn't in the facility. (V8) said that (R2) was admitted and she didn't have a (hard) prescription for the narcotics, so Pharmacy couldn't fill it. I told her to call (R2's) doctor and to tell him to call the Pharmacy and he could send an E-Prescription (electronic prescription) to the pharmacy, and they could immediately take the pain medication from our facility convenience box. I thought that's what (V8/LPN) did. When she called me back on (12/15/24) and said that (R2) still didn't have her pain medication, I told her to call the doctor back and to send a fax to his office. On 12/17/24 at 10:15 A.M., V9/Pharmacist verified he was the Pharmacist for the facility. V9 stated when a resident is admitted to the facility with a narcotic medication, the facility faxes over the order and the order gets processed. V9 states once the pharmacy receives a copy of the prescription, they will release a code to the nurse, who then can withdraw the medication from the facility convenience box, which is located in the medication room. At this time, V9/Pharmacist confirmed the pharmacy did not receive a prescription for R2's pain medication until 12/16/24 at approximately 10:30 A.M. On 12/17/24 at 10:35 A.M., R2 was in bed, watching television. The polar ice machine to R2's right knee was on and functioning. R2 was calm and relaxed. At that time R2 stated she had been receiving her (narcotic) pain medication every six hours and staff were applying the polar ice machine to her right knee as ordered by the physician. R2 stated she felt so much better and was able to concentrate on therapy and getting stronger so she could return home.

Based on observation, interview, and record review, the facility failed to ensure physician ordered pain medications were available at time of admission for a resident experiencing pain for one of one resident (R145) reviewed for pain in the sample of 48. R145 was admitted to the facility on [DATE] with a fractured sacrum, and remained in constant, severe pain for nearly 40 hours before the first dose of her pain medication was administered on 12/03/23. Findings include: On 12/06/23, V2 (Director of Nursing) provided a copy of (contracted pharmacy's) undated policy titled 'New Admission Policy & Procedure' and stated this policy is utilized by the facility in collaboration with (contracted pharmacy). This same policy documents the following: Process to provide medications prior to the next scheduled delivery: Review contents of the aforementioned boxes (E box or C box) that are on-site at the facility and with the nurse, confirm needed medications are available. If not, medications will either be: sent STAT (immediately) from the pharmacy or called into a local pharmacy and a courier scheduled by pharmacy will pick up the medication and deliver to the facility. If there is a control necessary and we do not have the medication or we cannot for legal reasons transfer the control medication, the pharmacist will contact the facility nurse to ask the prescriber to change the order to a medication or strength of medication that is available. Facility staff is notified to contact pharmacy if/when sending an admission after the facility 'cut-off' time to assure the medications will be sent in a timely manner. R145's current electronic medical record documents that R145 was admitted to the facility on the evening of 12/01/23 with the following diagnoses: Fracture of Sacrum; Anxiety Disorder; Arthritis; Sciatica; Age-related Osteoporosis; Spinal Stenosis. R145's Physician's Order Sheet, (dated 12/01/23-12/31/23), documents the following medication order (date of order 12/01/23): Codeine Sulfate Oral Tablet 30 milligrams give 0.5 tablet by mouth every 6 hours as needed for moderate to severe pain. R145's Grievance Form (dated 12/04/23) documents, (R145) admitted [DATE] at 06:00 PM. PRN (as needed) pain medication not available, not provided until Sunday (12/03/23) morning. On 12/04/23 at 01:50 PM, R145 was lying supine in bed with V9, (R145's daughter) at her bedside. R145 remained still in bed and explained her pain isn't as severe if she doesn't move around too much. R145 stated she was just admitted to the facility late in the day on 12/01/23, I arrived around dinner time. V9 then stated she was waiting to speak with management staff about some concerns regarding her mother's recent admission. R145 stated she currently has a fractured sacrum after a recent fall and came to the facility to receive therapy and pain control. R145 then stated, When I arrived here, I didn't get any pain medicine for a long time. I believe it was two days, and my pain was constant and unbearable. I couldn't sleep. I couldn't get comfortable. I wasn't hungry. It was horrible. I have never experienced pain like this. V9 then stated, My mom didn't get her pain medication for nearly two days. This medication was ordered for her at the hospital before she arrived here. She could barely function. It was upsetting to sit here and see her as miserable as she was. No one should have to go that long without anything to help with the pain. R145's Progress Note, dated 12/1/23 at 06:46 PM, documents the following: Resident arrived to the facility via wheelchair van accompanied by driver and family members. She is alert and orientated at this time, and it is reported that she gets increased confusion at night and has a tendency to want to wonder at night. She had a fall at home and fractured her lower back to the sacral area. She rates her back pain at a level 8 at the highest and level 3 at the lowest with analgesia. R145's Progress Note, (dated 12/02/23 and timed 10:31 AM), documents the following: Per pharmacy 15 milligram codeine tablets are not in stock and will not be until Monday 12/04/23. The pharmacy does have 30 milligram tablets in stock. Communication with (V10, R145's Physician) resulted in new order for codeine sulfate 30 mg tablets, 1/2 tablet by mouth every 6 hours PRN (as needed) for moderate to severe pain (5-10). Script faxed to (V10) for completion and signature. Communicated new order with pharmacy and expected delivery of signed prescription from (V10) later today which will be forwarded to them upon receipt. R145's Progress Note, (dated 12/02/23 and timed 11:07 AM), documents the following: Received signed script from (V10, R145's Physician) and faxed to (contracted pharmacy). R145's Progress Note, (dated 12/02/23 and timed 01:32 PM), documents the following: Contacted (contracted pharmacy) to verify their receipt of resident's prescription. Representative verified receipt and stated that medication would be dispense from the pharmacy and delivered with tonight shipment. Undated statement written by V11 (contracted pharmacy Chief Operating Officer) documents the following regarding R1's admission, The medication prescribed on 12/01/23 was OOS (out of stock), we called and informed nurse that we needed a new order for either a different pain med or to change to 30 milligram (take 1/2 tab), which came in on 12/02/23 late morning, and the med went out on the evening run (12/02/23). R145's Medication Administration Record, (dated 12/01/23 - 12/31/23), documents R145's first dose of Codeine was not administered until 12/03/23 at 08:51 AM. This same record documents R145 reported a pain level as high as 9 (severe pain) on a 1-10 pain scale. R145's Clinical Admission Evaluation Form, (dated 12/01/23), documents the following: R145 had vocal complaints of, throbbing pain to lower back, and was rating the pain 8/10 on 12/01/23 at 07:43 PM. R145's Skilled Evaluation, (dated 12/02/23), documents the following: On 12/02/23 at 01:12 PM, R145 was verbalizing constant pain in her sacral area rating 7/10. On 12/06/23 at 11:00 AM, V1 (Administrator in Training) confirmed that R145 was admitted to the facility on the evening of 12/01/23 and did not receive the first dose of the Codeine pain medication that was ordered for nearly 40 hours after arriving to the facility. V1 stated, (R145) should not have gone that long without her pain medication, especially with a fracture in her sacrum. I am sure that has to be very painful. We do not keep Codeine in the emergency backup medication box, so (V10 R145's Physician) should have been notified as soon as (R145) arrived. We can do better than this. What if something like this occurred with one of my family members? I would never want my grandmother sitting in pain for nearly two days.

Based on observation, interview and record review the facility failed to maintain a resident's bed in a low position and failed to supervise a dependent resident while toileting for two of three residents (R1, R2) reviewed for falls in the sample of three. This failure resulted in R1 falling from a higher level of plane, sustaining a subdural hematoma, a laceration to the right forehead and requiring emergency medical treatment. Findings include: 1. The facility's Falls Practice Guide dated 12/2011 documents, Fall interventions are clear, specific, and individualized for a patient's needs. Regardless of the interventions that are put in place, a key factor to success is the timely review of the interventions as the patient's conditions and needs change. Environmental risk factors which may be associated with falls may need to be reviewed and considered as ongoing fall prevention strategies. These factors may include the bed height. Some risk factor management interventions that can be reviewed and considered as ongoing potential fall prevention strategies include but are not limited to management of co-morbidities and disease symptoms, to the extent possible (example: low blood pressure when standing, stroke, dementia). R1's Admission Record Report documents R1 was admitted to the facility on [DATE]. R1's Fall document, dated 9/11/22, documents R1 has the following fall risk factors: Difficulty maintaining standing position, impaired balance during transitions, take antidepressant and cardiovascular medications, decline in functional status, incontinence, chronic or acute condition resulting in instability, muscle weakness, fatigue, and dehydration. R1's current care plan, dated 9/12/22, documents R1 is At risk for falls due to impaired balance/ poor coordination, unsteady gait, weakness, [CONDITION(S)], [CONDITION(S)], arthritis. R1's Five Day follow up investigation, dated 9/21/22, documents on 9/16/22 at 11:00 PM, R1 was given incontinence care by V3 (Certified Nursing Assistant, CNA). When V3 left the room to get the nurse (V4, Registered Nurse), staff heard R1 fall from bed. R1 was found on the floor of her room bleeding from a laceration on the forehead. R1's emergency room records, dated 9/17/22 at 3:01 AM, document R1 had a small, acute parietal subdural hemorrhage (blood pooling between the skull and the brain), and mild right frontal scalp swelling and laceration. This same record documents R1's laceration was sutured upon admission to the emergency room . On 9/27/22 at 11:35 AM, R1 was in her room, in bed with her eyes closed. R1's forehead contained a thin dark purple laceration with sutures. R1 did not wake up with conversation or noise. At this time V5 (R1's family member) was sitting at R1's bedside and stated (R1) has completely given up. She's done. (R1) no longer interacts or wakes up very often. She is on Hospice (Comfort care) since her fall from bed. I don't think (R1) would recall what happened if able to be asked. She doesn't talk about it or say anything at all. Somehow, she rolled out of bed, I don't know how that could've happened. But since being back to the facility, she sleeps all the time. (R1) was alert and talkative before. (R1's) body has given up, but her brain was still there. On 9/27/22 at 1:15 PM, V4 (Registered Nurse) confirmed being the nurse to send R1 to the hospital on 9/16/22. V4 stated It was the end of the shift. The CNA (V3) came up and said, I'm changing (R1) and she's ready for her treatment (to her buttocks). I heard a thump and went in there and (R1) was on the floor, alert and said, She told me to turn this way. She had a gash on her head and blood pooled on the floor. The CNA (V3) had came to get me, so no one was in the room when (R1) fell , we entered the room at the same time. (R1's) bed was up in the air, raised high when we came back in. The bed was over my waist height, and I am almost five feet and five inches, it was not in a low position at a safe level. On 9/27/22 at 6:30 PM, V3 (CNA) confirmed being the last one to care for R1 before she fell from bed on 9/16/22. V3 stated It was the end of my shift, and I went in to clean (R1) up. She had a bandage on her bottom that needed to be reapplied after cares. I went to get the nurse (V4), before I left, I told (R1) to lay back. I was only out of the room for a minute and when we were walking back towards her room, we heard a thump, and I knew then that (R1) fell out of the bed. (R1) was about 3 doors down from the nurse's station where I had to get the nurse. (R1's) bed had been raised for cares and was about waist height when I left the room. When I had cleaned (R1) up she was rolling on her own with minimal assistance so it is possible she could roll on her own. (R1) was kind of groggy when I left her also, like she wasn't all the way awake. On 9/27/22 at 1:35 PM, V2 (Director of Nursing) stated I think it was okay that (V3) left the bed up when she left the room. It wasn't going to matter if (R1) fell whether the bed was up or down. She'd never had anything like this happen before to cause (V3) to be worried. It was really quick; I mean I wouldn't want the bed left up in the air for a long period of time but yes in this situation it was not a problem in my eyes. V2 then confirmed that (R1) has only been residing at the facility for a couple of weeks when this incident occurred and that the bed being higher in the air, while not causing the fall, could've made (R1's) injury worse. 2. On 9/27/22 at 11:50 AM R2 was in his room, sleeping in bed. R2 did not wake with conversation or noise. At this time, V6 (Certified Nursing Assistant for home care agency) was in R2's room. V6 stated she comes in often to help care for R2 and get him cleaned, help him to use the restroom, take him to meals and ensure he eats, etcetera. V6 stated R2 requires assistance with most activities of daily living. V6 stated (R2) did recently have a fall. No one from the home care company was here at that time. Not sure of the details. R2's current care plan, dated 11/17/21, documents R2 is At risk for falls due to history of falls, weakness, [CONDITION(S)]. R2's Fall document, dated 6/12/22, documents R2 has the following risk factors for falling: Difficulty maintaining a sitting balance, difficulty maintaining a standing position, impaired balance during transitions, gait problem, musculoskeletal problem, cardiovascular medications, narcotic analgesics, cardiac [CONDITION(S)], visual impairment, decline in functional status, incontinence, cognitive impairment, muscle weakness, low levels of physical activity and pain. R2's Minimum Data Set (MDS) assessment, dated 8/1/22, documents R2 has a BIMS (Brief Interview for Mental Status) score of six which indicates R2 has severe cognitive impairment. This same MDS documents R2 requires extensive physical assistance of one person for toileting and that R2 is not steady and only able to stabilize with staff assistance for: moving on and off the toilet, moving from seated to standing position, walking and surface to surface transfers. R2 Nursing Progress Notes dated 9/9/22 at 10:58 AM and signed by V7 (Licensed Practical Nurse) documents This nurse helped (R2) to the restroom, asked him to use his call light when he is done. Three minutes later, we heard a noise, run to his room, and found (R2) on the floor by the entrance of the main door, naked, pants halfway down on his right side. (R2) has couple skin tears to the right shin. On 9/28/22 at 1:20 PM, V7 (Licensed Practical Nurse) confirmed being the nurse who took R2 to the bathroom on 9/9/22. V7 stated I was the nurse working. I went in and assisted (R2) to the bathroom and I told him to hit the call light when he finished. I went back out to the medication cart at the nurse's station to count medications and less than five minutes passed. I can't remember if we heard (R2) fall or heard him yell but myself and other staff went down there quickly. (R2) was in the doorway to his room with his pants around his ankles. Sometimes (R2) gets confused. He is supposed to be assisted to the bathroom and not do it on his own. Often when a resident is a toilet assist, we just stay in the room until they're done, it just depends on their cognition. Sometimes (R2) gets himself up and back to bed and does fine, but he's not supposed to. I do think he's getting weaker lately.

Based on interview and record review, the facility failed to provide CPR (Cardiopulmonary Resuscitation) upon identification of absence of breathing and pulse to one resident (R99) identified as having Full Code Advance Directives of three residents reviewed for discharge in the sample of 62. This failure resulted in R99 not receiving Cardiopulmonary Resuscitation when found without a pulse and not breathing and placed 40 current residents (R1, R5, R6, R10, R17, R20, R26, R37, R38, R41, R42, R45, R47, R48, R50, R53, R57, R59, R64, R65, R72, R76, R79, R80, R81, R82, R83, R84, R88, R89, R93, R95, R149, R150, R200, R201, R202, R203, R204, R299) identified as having Advanced Directives indicating Full Code status at risk of not receiving life sustaining treatment. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level II as the facility continues to monitor the effectiveness and training related to Advance Directives, Code Status and initiation of CPR. The facility also continues to evaluate and discuss Code Status with resident/resident representative upon admission/readmission and review Code Status upon change of condition, readmission and quarterly. The facility also is continuing Mock CPR drills with Nursing staff that will be done monthly and reviewed by the QA&A (Quality Assurance) committee. Findings include: Facility Policy/Cardiopulmonary Resuscitation (CPR): Adult dated ,d+[DATE] documents: Purpose: To attempt to restore cardiopulmonary circulation to a patient without a pulse or respirations. CPR is initiated unless one of the three following conditions is present: 1) a valid DNR (Do Not Resuscitate) order is in place. 2) initiating CPR could cause injury or peril to the rescuer; or 3) in the presence of obvious clinical death (e.g., rigor mortis, decapitation, transection, or decomposition). Suggested Documentation: Condition of patient, interventions provided, date/time CPR initiated, staff involved witnessing the event and patient response. Record time EMS (Emergency Management Services) physician, family, or resident representative called as well as time patient left center or expired and pronounced dead. CPR/Adult [CONDITION(S)] Algorithm instructs to: Verify scene safety If victim is unresponsive, shout for nearby help. Activate emergency response system via mobile device (if appropriate). Get AED (Automated External Defibrillator) and emergency equipment (or send someone to do so). Look for no breathing or only gasping and check pulse (simultaneously) - if no breathing or only gasping and no pulse: Initiate CPR and use AED as soon as possible - continue both until ALS (Advanced Life Support) providers take over or victim starts to move. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R99's POLST (Practitioner Order For Life- Sustaining Treatment) dated [DATE] indicates, Attempt Resuscitation/CPR if patient has no pulse and is not breathing. Nurse progress Note dated [DATE] at 1:34pm indicates R99's vital signs were within normal limits; however, oxygen saturation level is documented as 89% on Room Air. Nurse Progress Note dated [DATE] at 8:14am indicates (V8, LPN/Licensed Practical Nurse) went into R99's room and found R99 not breathing and cold to the touch at 6:38am on [DATE]; confirmed by (V7, RN/Registered Nurse/Unit Manager). This note indicates family was notified at 7:00am, coroner was notified at 8:36am. Note on [DATE] at 9:57am indicates, Funeral home notified to pick up body and coroner also notified. R99's Medical record contained no documentation, and no documentation was presented for R99 between [DATE] at 1:34pm and [DATE] at 8:14am when documentation indicates R99 was found not breathing and cold to the touch. On [DATE] at 8:00am V8, LPN (Licensed Practical Nurse) stated that she saw R99 at the beginning of the night (on [DATE])and at some point, during the night, A new CNA (Certified Nurse Assistant) came and told me (R99) was breathing funny. V8 stated that R99 always had breathing problems - was a mouth breather - so V8 told the CNA to put the head of R99's bed up. V8 stated that she later went back and checked to be sure R99's head was up and R99 had normal breathing for him. V8 stated that she did not do any assessment or vital signs because she didn't feel she needed to and there was nothing out of the ordinary. V8 stated that when they went to do the next rounds R99 was gone. V8 stated that rounds are supposed to be done at 1:00am, 3:00am and 5:00am and that, We found (R99) about 6:00am. V8 stated that she was then going to call the other nurse in the building, found out V7, RN (Registered Nurse)/Unit Manager was in the building, so she called V7 to come to R99's room. V8 stated that R99 was cold and gray - not blue and (R99) had no pulse and was not breathing. V8 stated that she found out R99 was a full code after he was found with no pulse and not breathing and stated, I didn't really know what to do. V8 stated that she notified the coroner, R99's family and later the funeral home. V8 stated that she did not recall notifying R99's Physician. On [DATE] at 8:25am V7, RN/Unit Manager stated that she went in to assess R99 (on [DATE]) and R99 was not breathing and cold to touch. V7 stated that she did not notify the Physician or call for paramedics because she thought R99 was too far gone. V7 stated that she told V8, LPN to call R99's Physician, family, the coroner and funeral home. On [DATE] at 11:30am V7 stated, When I first saw (R99) - I asked (V8) how long has he (R99) been this way? and V8 didn't know. V7 stated, I picked up (R99's) arm - it was kind of stiff and then set it back down on his chest. I agree with (V8), (R99) was grayish - not blue but his lips were somewhat bluish, and his mouth and eyes were open. V7 stated, I don't usually chart, the nurse does - but I should have charted my assessment and notified the Physician. V7 stated there should have been documentation of R99's condition before, during and after being found unresponsive by both the nurse (V8) and the CNA. On [DATE] at 1:20pm V13, Medical Director stated, If resident is a Full Code, staff need to initiate CPR. The nurse can't just assume death. V13 stated that staff should be notifying the Physician at the same time to get orders on how to proceed while continuing CPR until given direction to stop. V13 stated, Always initiate CPR if the Advance Directives are Full Code. The Immediate Jeopardy was identified on [DATE] at 11:09am. The Immediate Jeopardy began on [DATE] at 6:38am when the facility failed to provide CPR to R99 when R99 was found without a pulse and not breathing - who previously chose Full Code status on signed Advance Directives. V1, Administrator of the facility was notified of the Immediate Jeopardy on [DATE] at 2:33pm. On [DATE], the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. All resident charts have been audited to confirm code status based upon resident/POA (Power of Attorney) wishes. Audits were completed by Unit Managers and Social Services on [DATE]. 2. Licensed staff were in-serviced by V2, DON (Director of Nursing) on [DATE] to ensure CPR is initiated for residents identified as a Full Code. The in-service included review of the facility CPR policy and Emergency Management Guidelines. Additional education was given regarding documentation and physician notification. 3. Facility Medical Director was notified [DATE] at 1:26pm. 4. Mock CPR Drills conducted on each shift every shift through Monday [DATE]. 5 An Ad-Hoc QAPI meeting was held on [DATE] to review findings and action plan.

Based on interview and record review, the facility failed to keep a resident residing on a locked Dementia unit safe from physical abuse for one of three residents (R78) reviewed for abuse in the sample of 62. This resulted in V4/Certified Nursing Assistant being witnessed, by other staff members, physically abusing R78 by slapping R78 several times including slapping R78's face. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 3/18/2022 , the facility remains out of compliance at a severity level II as: 1) The facility will provide weekly in-services for 4-weeks on the facility staff regarding Patient Protection policy ensuring allegations of abuse are reported immediately to the abuse coordinator; 2) The Facility will develop a plan to ensure the abuse policy is implemented); and 3) The facility will provide ongoing current and updated Dementia care training on types of Dementia/stages of Dementia/interpreting and managing behaviors/communication. V2 or designee will conduct weekly interviews of staff regarding abuse, neglect, mistreatment and misappropriation, who to report to, when to report and how to report abuse weekly for four weeks Findings include: Facility policy entitled, Patient Protection Abuse, Neglect, Mistreatment and Misappropriation Prevention, dated 10/2021, documents, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. (a) The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility's State Reportable Incident form (dated 3/10/22) documents the following incident occurred on 3/6/22: (At) approximately 5:00 PM, (V6/Certified Nursing Assistant) and (V5/Activities Assistant) observed (R78) strike (V4/Certified Nursing Assistant) and then observed (V4) strike (R78). (At) Approximately 5:00 PM, (R78) was seated in her wheelchair blocking entry into the kitchen area in the dining room. (V4) was asked by (V5) to assist a resident who was rummaging in the kitchen area. (R78) was seated in the doorway of the kitchen. (V4) told (R78) she was going to move her out of the doorway. (V4) was pulling (R78) out of the doorway, (R78) reached behind with her right hand and slapped (V4) across her face and dislodged (V4's) glasses (breaking the nose piece). (V4) then reached around and slapped (R78) in the face from behind. (V4) attempted to pass by (R78) to get to kitchen to assist another resident in kitchen area when (R78) hit (V4) on the right arm. (V4) reached back and slapped (R78) on the left shoulder. (R78) again hit (V4) on the right arm and again (V4) reached back and slapped (R78) on the left shoulder. (V4) then left the unit immediately. R78's Quarterly Minimum Data Set Assessment, dated 2/24/22, document R78's Brief Interview for Mental Status as 5 out of 15 which indicates R78 has little cognitive understanding. R78's EMR documents R78's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R78's Care Plan, dated 2/25/22 documents, At risk for behavior symptoms r/t (related to) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She becomes verbally aggressive by swearing, calling staff names, being argumentative, and raising her voice. Also makes accusations toward others that aren't true. Has taken other residents' wheelchairs to use for herself, refuses to be changed at times, refuses vitals sometimes V4's employee file was reviewed for documentation of previous instances of resident abuse. V4, an employee of the facility, had no documented instances of resident abuse. On 3/16/22, at 9:10 a.m., R78 confirmed not being slapped by staff and stated, If I was, I would hit them back. On 3/16/22, at 9:50 a.m., V2/Director of Nursing confirmed, through V2's investigation, that V4/Certified Nursing Assistant struck R78 on 3/6/22 which resulted in V4 being terminated and reported to the State Registry. V2 confirmed after R78's assessment, R78 was noted to have no injury. On 3/16/22, at 10:05 a.m., V5/Activities Assistant confirmed the typed interview [dated 3/7/22 at 12 p.m.,] provided to V2 regarding V4 physically abusing R78. V5's typed statement documents, Sunday March 6th at around 4:50pm. I asked [V4/CNA] to move [R78] out of the doorway. [V4] started pulling [R78's] wheelchair out of the doorway and [V4] was getting aggravated with [R78]. [R78] reached behind her and hit [V4] with an open hand in the face. [V4] slapped [R78] in the face from behind. [V4] continued to pull the wheelchair into the hallway and [R78] slapped [V4] in the body area as [V4] walked past her. [V4] hit her back. This happened three times-back and forth hitting. On 3/16/22, at 11:08 a.m., V6/Certified Nursing Assistant confirmed witnessing V4 strike the third time in the left side of R78's face. V6 confirmed no red marks were observed on R78's face after being slapped. On 3/18/22, at 2:04 p.m., V11/R78's Husband stated, regarding V78 being slapped, If under normal circumstances, that would have never happened. She grew up in [NAME] and could take care of herself. The Immediate Jeopardy was identified on 3/17/2022 at 8:30 a.m. The Immediate Jeopardy began on 3/6/2022 at 4:50 p.m. when V4/Certified Nursing Assistant was witnessed, by other staff members, physically abusing R78 by slapping R78 several times including slapping R78's face. On 3/18/2022 at 1:57 p.m.,V1 (Administrator) and V2(Director of Nursing), were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1) V4 was suspended 3/6/22 at 9:00 p.m. As a result, of V2's incident investigation, V4's employment was terminated, and the incident reported to the State Registry. 2) Physician, Medical Director, and family notifications were completed 3/6/22. The local police department was notified 3/7/22 Police Report 22-2666. 3) The facility filed an initial and 5-day report to the State Agency. 4) On 3/7/22, V2 (Director of Nursing) conducted a unit skin sweep, for physical signs of abuse, on each resident. 5) On 3/6/22 at 9:00 p.m., V3/Registered Nurse was educated by V2 regarding timely reporting of abuse. On 3/7/22, V3 was provided a final written warning-Failure to Report Abuse in a Timely Manner. 6) On 3/9/22 and 3/15/22, Social Services conducted interviews with interviewable residents regarding staff treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 7.) Education of staff members related to Abuse prevention and timely reporting of allegations of abuse was conducted by V2 (Director of Nursing) on 3/7/22 and 3/8/22. 8.) Dementia training was initiated by V2 (Director of Nursing) on 3/18/22. This includes current and updated Dementia care training on types of Dementia, stages of Dementia, interpreting and managing behaviors and communication.

Based on interview and record review, the facility failed to safely complete cares for one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 rolling off of the bed during perineal care onto the floor and hitting R1's head. R1 was transferred to the local area emergency room and sustained a hematoma above R1's left eye. Findings include: The facility's Bed Positioning policy, updated 2/2019, states, Verify transfer assist needed per Kardex. Obtain additional assistance and needed equipment as indicated. Turn from back to side lying: Move the person to the edge of the bed on the side farthest from you so that when they are turned, they are in the middle of the bed. The facility's Incontinence Care policy, revised 8/2014, states, 6. Position on back with knees flexed and feet flat on the bed. If patient is unable to maintain this position, assist to side lying position by turning towards care giver, unless more than one caregiver present. After turning patient toward the caregiver, assure patient is positioned in the center of the bed before moving to the opposite side of the bed to provide care. If more than one caregiver present, one caregiver provides support of the patient to maintain side lying position while the other caregiver completes the procedure. R1's Facesheet documents R1 was admitted to the facility on [DATE]. R1's Diagnosis Report documents R1 with diagnoses to include but not limited to: Muscle Wasting and Atrophy Multiple Sites; Sciatica; Morbid (severe) Obesity; [CONDITION(S)]; and Other Signs and Symptoms Involving the Musculoskeletal System. R1's Weights and Vitals Summary documents R1's weight on 1/1/22 and 1/2/22 as 300 pounds. R1's Current Care Plan at the time of R1's admission states, Alteration in Musculoskeletal Status r/t (related to) BLE (Bilateral Lower Extremity) Weakness and Impaired Mobility; Functional Mobility deficits evidenced by weakness, balance deficits, low endurance, and increase need of assistance and increased risk of falls due to [CONDITION(S)] (Urinary Tract Infection), ADL (Activities of Daily Living) self care deficit as evidenced by max A (assist) related to pain, weakness, ROM (Range of Motion) limitations, impaired balance and unable to walk; Requires assistance/potential to restore function for transferring from one position to another as evidenced by needing total assist with all transfers related to weakness impaired mobility. Intervention: transfer with mechanical lift; At risk for falls due to Weakness, Impaired mobility, Gout, Sciatica, Pain, Morbid Obesity, OA ([CONDITION(S)]); At risk for complications due to Musculoskeletal problems r/t (related to) arthritis, gout, obesity, sciatic pain, and impaired mobility. Interventions: Assist with bed mobility; provide assist to transfer and reposition in bed.; Pain related to Weakness, Arthritis, Morbid Obesity, Sciatic Pain, Gout, [CONDITION(S)]. R1's Admission Minimum Data Set/MDS assessment, dated 12/11/21, documents R1 is alert and oriented with no cognitive impairments and that R1 requires extensive assistant of two plus person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and requires extensive assistant of two plus person physical assist for toilet use (how resident uses the toilet room, commode, bedpan, or urinal; cleanses self after elimination; changes pad). This same MDS assessment documents R1's admission performance of toileting hygiene (the ability to maintain perineal hygiene) and rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed) as dependent-helper does ALL of the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required to complete the activity. R1's Medical Practitioner Comprehensive note on 12/8/21 documents R1 with acute general muscle weakness. R1's Care Plan Progress Note on 12/22/21, documents, Nursing stated (R1) requires a lot of assistance with cares. Staff utilize a (mechanical lift), two people to transfer (R1). Therapy stated (R1) is dependent for bed mobility and transfers. R1's Physical Therapy Discharge Summary, dated 12/29/21, documents R1 was discharged from Physical Therapy due to achieving the highest practicable level. This same form documents R1 as being dependent on staff for bed mobility. R1's admission Fall Assessment on 12/5/21 documents R1 with physical performance limitations of: gait problem, Musculoskeletal problem; difficulty maintaining standing position; and impaired balance during transfers. This same assessment documents R1 with disease and conditions of: Decline in functional status; muscle weakness; arthritis; fatigue/weakness; pain; infection; cardiac [CONDITION(S)] and hypo/[CONDITION(S)]. R1's Fall Assessment, dated 1/13/22, documents, (R1) rolled out of bed and hit his head. Hematoma noted above left eye. Sent to ED (Emergency Department) to eval (evaluate) and treat. admitted to (local area hospital) with fall, [CONDITION(S)], [CONDITION(S)] (Urinary Tract Infection) and vomiting. R1's Incident Report on 1/2/22 documents on 1/2/22 at 3:15 A.M., R1 rolled out of bed and sustained a hematoma above R1's left eye and that 911 was called due to injury to R1's head. R1's Hospital After Visit Summary on 1/2/22 documents R1's reason for visit as Fall and diagnoses as Fall, initial encounter; facial hematoma, initial encounter and acute pain of right shoulder. R1's Final Incident Report to the local state agency on 1/5/22 documents, At 3:30 A.M. (On 1/2/22) (R1) was receiving pericare after using the bedpan. (V5/Certified Nursing Assistant) was holding (R1) on left side using (V5) left hand on (R1's) hip while wiping with (V5) right hand. (R1) was holding self in position with his right hand pressing on the nightstand. (R1) lost grip or let go of nightstand and fell to the floor. Attempted to ask (R1) about letting go of nightstand (R1) was unable to explain. (R1) just kept yelling. Upon initial assessment (R1) had a hematoma on his scalp. (R1) demanded that 911 be called. 911 was called and (R1) was transferred to hospital for eval. (evaluation). No other injuries. (R1) returned to the facility with no new orders. On 1/27/22 at 2:12 P.M., V7 (Therapy Director) stated that R1 had very poor trunk control and was dependent on staff to roll side to side in the bed. On 1/26/22 at 9:48 A.M., V8 (R1's Family Member) stated, (R1) called me around 3:30 in the morning right after he fell (on 1/2/22). He told me that they only used one CNA to clean him up, and he fell out of bed. I don't know why they only used one, he said they normally always use two. On 1/27/22 at 2:36 P.M. V5 stated that V5 was only using one CNA to provide cares to R1 on 1/2/22 because no other staff were available at the time to assist V5 with R1. V5 stated R1 was not positioned in the center of the bed, but closer to the edge, so R1 could reach the nightstand. V5 stated, With his size and everything, he just started to go (off of the bed onto the floor) and he just went. There was nothing I could do from where I was standing to stop it. There is nothing in (R1's) Care Plan or Kardex that tells us how many staff members to use during cares. At this time, V5 verified that had a second staff member been in the room assisting V5, R1's fall was more likely to not have occurred.

Based on observation, interview, and record review, the facility failed to provide thickened liquids as ordered by a physician for one of five residents (R63) reviewed for nutrition in the sample of 40. This failure resulted in R63 being admitted to the hospital with aspiration pneumonia. Findings include: R63's care plan, dated 5/12/21, documents, Problem: Eating and Swallowing. Goal: Will improve eating and swallowing as evidenced by safely consuming the least restrictive diet possible with minimal to no signs and symptoms of aspiration. Interventions: Bedside Swallow Evaluation; Swallowing Treatment. R63's Order Audit Report, dated 6/9/21, documents that R 63 received an order to receive Mildly Thick (nectar) consistency liquids on 6/3/21. 63's Speech Therapy Treatment Encounter Note, dated 6/3/21, documents, Skilled interventions addressing Swallow Dysfunction included Diet texture analysis to increase safe oral intake. Liquid swallows to increase safe oral intake, techniques to improve safe and efficient nutrition/hydration and therapeutic trial feedings to increase safety. Response to session interventions: R 63 displayed a consistent delayed, weak cough after drinking thin ice water per cup. Trials of mildly thick liquids were consumed without signs/symptoms of aspiration initially. 63's speech became slurred during session and nursing was alerted. Nursing assessed patient and speech improved during that time. R 63 was given additional trials of mildly thick liquids and displayed a delayed cough after presentations. Trials of moderately thick juice and yogurt were tolerated without signs/symptoms of aspiration. Recommend downgrade to puree with moderately thick liquids at this time. On 06/07/21 at 12:29 PM, R 63 was alert sitting up in his wheelchair in his room. R 63 had a bedside table in front of him with his lunch of pureed beef stew, pureed green beans, pudding, and a 7-ounce glass of a clear thin liquid. R 63 stated, I just don't' want to eat. I'm fine with just this cold glass of water, pointing to the water cup that was half empty. On 06/07/21 at 12:35 PM, V 9 (Registered Nurse) stated that R 63 is on thickened liquids, and that there shouldn't be any on his table. V 9 entered 63's room and confirmed the half drank glass of water was not thickened. 63's Respiratory Note dated 6/8/2021 13:12, documents, Presence of cough: Yes. Lung sounds; Right Upper Lobe Diminished, Right Lower Lobe Crackles, Left Upper Lobe Diminished, Left Lower Lobe Crackles. 63's Nurses' note, dated 6/8/2021 at 16:01, Spoke to wife about 63's change in condition. R 63 is ashen in color and unable to concentrate on conversations. Appears agitated and uncomfortable. Wife stated she would like R 63 to be sent out to be evaluated and treated at the ED (Emergency Department). 63's Nurses' note dated 6/8/2021 at 18:06, document, R 63 Temperature 101.4 degrees Fahrenheit, cold towels applied to head and back of neck. Moaning skin hot and dry, color poor, lungs upper diminished, lower crackles, coughing moist sounding. Pulse oximetry 79% room air, oxygen started at 1 1/2 liters. Called for ambulance. 63's temperature 99.9. Still not responding to verbal stimuli, finger cool unable to get pulse oximetry reading. Ambulance here with team to take at 5:25 PM out of facility. 63's Emergency Department (ED) Chief Complaint and History of Present Illness, dated 6/8/21, documents, R 63 is a [AGE] year old male presenting the ED by ambulance for fever. Also, documents, Physical Exam: Pulmonary: Effort: Achy (rapid respirations) and respiratory distress present. Comments: Coarse breath sounds bilaterally. The Chief Complaint and History of Present Illness documents, Progress notes: Spoke with wife, son, and daughter. I discussed code status with spouse and family. I explained that R 63 is critically ill with [CONDITION(S)] and probably aspiration pneumonia. Prognosis is extremely poor. Wife and family indicated that R 63 would not want any form of invasive life support. I discussed with them at length the treatment options. Wife and family request comfort measures only and DNR (Do Not Resuscitate) status. On 06/09/21 at 10:53 AM V 5, RN (Registered Nurse) stated, I cared for (R 63) yesterday, he had a moist crackled cough and had crackles in his bilateral lower lobes. The cough would come and go at times, but the crackles were new. (R 63) has difficulty swallowing and was just downgraded to thickened liquids a few days ago. On 06/09/21 at 11:22 AM, V 10 (Speech Therapist) stated, I was working with (R 63) for cognitive deficit and dysphasia (difficulty swallowing). (R 63) seemed more confused that day (6/3/21) I saw him. He had a consistent delayed weak cough with thin liquids. The delayed cough is a sign that liquids are penetrating the wrong area or aspiration. He would take a drink and a few seconds later he would have a weak cough. I knew something was going on. I tried the mildly thick liquids (nectar) and he did well. Then all of a sudden, his speech was slurred. I immediately notified staff and during their assessment he started to come back around. So I tried the mildly thick liquids again, and he started the delayed cough again. So I tried moderately thick liquids (honey) and he did much better. So I ordered for him to have pureed and moderately thicken liquids. He should be monitored for lung sounds changing, temperature, and intake. These would be signs of him not tolerating the diet and aspiration. If he was drinking thin water on his own it could develop into pneumonia over time.

Based on observation, interview, and record review, facility personnel failed to supervise the transfer (from the seated position to standing position) of one resident (R1) of two residents, reviewed for falls, in a sample of four residents. This failure resulted in R1 falling and sustaining a valgus impacted left subcapital fracture (left hip fracture), which required surgical intervention - specifically, a closed reduction, percutaneous screw fixation. Findings include: Facility, online, medical documentation, lists R1's [DIAGNOSES REDACTED]. R1's Minimum Data Set, dated dated [DATE], documents R1's Brief Interview for Mental Status as 13. R1's Care Plan, initiated 11/30/2015, documents R1 is At risk for falls due to impaired balance/poor coordination, unsteady gait, Parkinson's Disease ., with interventions to include: Educate resident that (R1) needs to call for assist and not get up unassisted .ALL High observation when awake and unsupervised. R1's Progress Notes, dated 2/18/2016, document: at 11:45 a.m., (R1) fell in room with therapy, therapist (E3/Physical Therapist Assistant) turned (E3's) back to get something and (R1) attempted to transfer self to chair. (R1) fell on left side, skin tear x 2 to left elbow. Areas cleaned and dressed, Left hip assessed (by E4/Registered Nurse), ROM (range of motion) good; at 3:53 p.m., (R1) complained of left hip pain. Order obtained to get x-ray of left hip; at 7:07 p.m., (R1's) x-ray result positive acute femoral neck fracture .Order to send (R1) to ER (emergency room ); and at 7:34 p.m., Report called to ER, (R1) sent out. The local hospital document entitled, Procedure Report, dated 2/19/2016, document, R1's orthopedic surgical intervention included a closed reduction, percutaneous screw fixation, of the valgus impacted left subcapital fracture. R1's facility Progress Notes, dated 2/23/2016, at 11:30 a.m., document R1 returned to the nursing home facility (from the local hospital). On 3/8/2016, at 1:10 p.m., E5/Licensed Practical Nurse approached R1 to look at R1's left hip. As R1 attempted to stand up, E5 asked R1 to remain seated, in R1's wheel chair, until E5 could put on a pair of gloves and provide R1 with standing assistance. R1 sat back down and as soon as E5 started to put on E5's gloves, R1 stood up without assistance. R1 's balance was weak as R1 stood up against E5's recommendation. On 3/8/2016, at 2:20 p.m., E3 stated the following, in regards to the incident on 2-18-16 in R1's room: E3 assisted R1 from the laying position to seated position on the edge of R1's bed; E3 advised R1 to sit still for a while; E3 turned E3's back to R1, in order to grab R1's wheeled walker; R1 then fell to the floor, on R1's left side; E3 stated, it happened fast and R1 is impulsive and R1 had no complaints of pain when assessed by E4, or during R1's therapy that followed R1's fall. On 3/9/2016, 8:30 a.m., E4 stated, after hearing R1 fall, E4 assessed R1; R1 had no complaints of pain; ROM was completed to R1's lower extremities with no complaints of pain from R1. R1 is very impulsive and wants to stand on (R1's) own; and R1 is a fall risk.

Based on interview and record review, the facility failed to implement and monitor interventions to prevent the development of pressure sores for one of one resident (R1) reviewed for pressure sores in a sample of three. This failure resulted in R1 developing five pressure sores during R1's admission to the nursing facility, including one necrotic pressure sore on R1's heel that is a suspected Stage 3 or greater. Findings include: The Admission Record Report dated 3/26/15 for R1 documents a current admission date of [DATE]. The Patient Admission/Readmission Screen (Electronic Medical Record) dated 3/26/15 for R1 documents only the following wounds: left buttock-wound, buttocks a little red and right buttock-wound. The Progressive Home Wound Care Progress Note dated 3/26/15 for R1 documents, "(R1) presents traumatic wounds to right and left buttock from shearing and friction injury...(R1) is at high risk for wound development to heel related to surgical fixation device..." The Progressive Home Wound Care Flow Sheet dated 3/26/15 for R1 documents, "Right buttock-2.7 cm (centimeters) length x 1.2 cm width x 0.1 cm depth and left buttock-5.9 cm length x 6.9 cm width x 0.1 cm depth." The Progress Notes dated 3/31/15 for R1 documents, "Right heel red and boggy, left heel a little red mark under. Will continue to monitor." On 4/18/15 at 12:15 PM, E2/DON (Director of Nursing) verified that neither the Wound Care Nurse or Physician were notified of findings for R1 on 3-31-15. E2/DON also verified there is no documentation indicating new interventions were implemented or any monitoring of the right heel took place until 4/6/15. The Progress Notes dated 4/6/15 for R1 documents, "Noted ulcer on (R1)'s right heel. Will have Wound Nurse see in the morning." The Progressive Home Wound Care Flow Sheet dated 4/6/15 for R1 documents, "Right heel-7.0 cm length x 10.0 cm width x 0 depth." The Progress Notes dated 4/9/15 for R1 document, "Removed RLE (right lower extremity) immobilizer due to drainage on brace. Found large blisters, some which ruptured causing drainage. Right heel now black eschar." The Progress Notes dated 4/10/15 for R1 documents, "(R1)'s HR (heart rate) 144. Blood pressure 100/70, resp(irations) 25, temperature 97.4. Lung sounds are diminished, distant and absent in bases. (R1) complaining of increased pain in back. Orders received from (Physician) to send (R1) to emergency room ." Local Hospital History and Physical dated 4/11/15 for R1 documents a [DIAGNOSES REDACTED]. The Physical Examination documents, "Extremities-Right lower extremity is [MEDICAL CONDITION]. There is marked [DIAGNOSES REDACTED] extending below his patella all the way to distal foot. There are patchy necrotic areas. Scattered areas of eschar." On 4/17/15 at 11:10 AM, Z2/Physician stated, "When (R1) was admitted to the hospital, (R1)'s leg was grossly ischemic. There were multiple open areas over right leg and a necrotic area on (R1)'s heel. I wondered if anyone had even looked at (R1)'s leg." The Wound Assessment Flowsheet dated 4/13/15 for R1 documents, "Wound location left buttocks-3 cm length x 2.5 cm width x 0.3 cm depth-Stage 3. Wound location leg, right, posterior, superior-5.5 cm length x 2 cm width x 0.2 cm depth-partial, thickness. Wound location heel right dorsal plantar-9 cm length x 10 cm width x 0 cm depth-suspected Stage 3 or greater, 100% eschar, unable to stage due to necrosis, wound location ankle, right dorsal-11 cm length x 12 cm width x 0 cm depth-partial thickness. Wound location leg, right mid calf-11 cm length x 15 cm width x 0.3 cm depth-full thickness. Wound location knee, right-2 cm length x 2.5 cm width x 0 cm depth-intact scab." On 4/17/14 at 11:10 AM, Z4/Wound Nurse stated, "(R1) had a wound on his leg that was almost from (R1)'s toes to (R1)'s knee. (R1) looked like he had a deep tissue injury on (R1)'s right heel. This was a significant wound."