Every finding on record at Arcadia Care Aledo

Based on observation, interview and record review, the facility failed to ensure opened refrigerated and frozen food items were labeled with expiration dates, a kitchen food storage freezer was free from spills and the required meal food temperatures were obtained and recorded. This failure has the potential to affect all 43 residents residing in the facility. The facility policy, Food and Supplies: Storage, dated 01/2026 directs staff that food services will maintain clean food storage area. This same policy documents that all foods will be covered, labeled and dated. The facility policy, Monitoring Food Temperatures For Meal Service, dated 05/2026 directs staff that prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. On 5/11/2026 at 9:13 A.M ., during an initial tour of the facility kitchen with V4/Dietary Manager (DM), an unlabeled, undated package of frozen precooked pork ribs was present in the facility freezer. This same freezer had a large green/yellow liquid food spill present on the bottom of the freezer. At that time, V4/DM confirmed the unlabeled, undated meat and the large spill. During the kitchen tour, the facility kitchen Food Temperature Logs for 5/8/26 and 5/9/26 documented no required food temperatures were obtained for the supper meal, on both dates. V4/DM also verified the missing food temperatures. The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 5/11/26 and signed by V3 (Corporate Regional Director of Operations) documents 43 residents reside within the facility.

Based on Observation, Interview and Record Review, the facility failed to ensure resident and employee infections were monitored and tracked, residents were placed in isolation precautions when required, personal protective equipment (PPE) was available in isolation rooms, employees wore PPE during direct contact resident care and ensure glove removal and hand hygiene was completed during a resident's incontinence care. This failure has the potential to affect all 43 residents residing in the facility.Findings include:The facility's Infection Precaution Guidelines Policy dated 01/26 documents, Guidelines: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. Transmission-Based Precautions will be employed for known or suspected infections for which the route of transmission/prevention is known. The transmission-based categories are the following: Airborne, Droplet, and Contact. Gather all equipment and supplies needed before going into the room. Only take needed supplies into the room. All personal protective equipment (disposable isolation gowns, masks, and gloves) should be used once and discarded in either the trash or linen receptacle before you leave the room. Precautions signs will be utilized to alert staff and visitors to see the nurse for instructions prior to entering the room. The facility's Enhanced Barrier Precautions policy, dated 12/2026, documents Enhanced Barrier Precautions (EBP): recommendations now include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Standard precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: dressing, bathing/showering, providing hygiene, changing linens, incontinence care, medical device care, wound care. The facility's Infection Prevention and Control Program policy, dated 7/2026, documents To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under contractual arrangement. This policy also documents The program provides for the recording of each suspected infection and surveillance activities as they relate to individual resident infections. A log is maintained of suspected and actual infections on a day-to-day basis. The facility shall assure that necessary training, equipment and supplies are maintained to carry out an effective Infection Control Program. The facility policy, Hand Hygiene/Handwashing, dated 01/2026 directs staff of when to perform hand hygiene: after glove removal. 1. R4's Care Plan, dated 1/30/26, documents R4 has an indwelling urinary catheter and is in enhanced barrier precautions. On 5/11/26 at 9:55 AM, R4's room contained a sign documenting R4 was in Enhanced Barrier Precautions (EBP). R4's room did not contain any gowns for staff to wear while providing cares. On 5/11/26 at 11:30 AM, V25 (Licensed Practical Nurse, LPN) confirmed she is the nurse working in the facility's locked dementia unit (where R4 resides). V25 stated she is not sure where the PPE (Personal Protective Equipment) is kept for someone in isolation and assumed it would be in his room. On 5/11/26 at 11:35 AM, V19 (LPN/ Infection Control Preventionist) stated R4 should have gowns and gloves for PPE in his room. At this time V19 entered R4's room and confirmed there was not any PPE available. V19 then toured the facility and confirmed that R47 is a new admission to the facility and has an intravenous line in his arm. V19 stated R47 should be in EBP isolation and verified there was not a sign or any PPE in R47's room. At this same time V19 confirmed that R18 has ongoing active wounds and pressure ulcers, is seen by wound physicians and is not in any isolation precautions. On 5/13/26 at 9:34 AM, V19 confirmed the facility is not tracking resident or employee infections to identify patterns or locations of the facility where resident infections occur or where ill employees may have worked. V19 stated We have a system in the computer that we can run reports of resident's illness before we have monthly meetings, but I am not keeping a record of them or plotting any tracking to show where infections are located in proximity to other resident rooms. I do not have employee illness tracking either. I know that if someone calls in they write down the reason and if it's something contagious or needs recorded it is supposed to be relayed to me. I don't have anything to show for employee illness though because I have not been tracking it. V19 again confirmed that R18 has wounds and is not in EBP isolation and stated (R18) was in contact isolation for MRSA (methicillin resistant staph-aureus) but that was treated and so he is not in isolation now. I have not been putting wounds in enhanced barrier precautions. I didn't realize it was required for wounds. 2. R40's admission Record documents R40 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Intraspinal Abscess and Granuloma, Paraplegia, Acute Osteomyelitis to Right Ankle and Foot, Respiratory Failure with Hypoxia, and Spinal Stenosis. R40's MDS (Minimum Data Set) assessment dated [DATE] documents R40 is cognitively intact. R40's current Physician's Orders document R40 has an indwelling urinary catheter and wounds to the right heel, right lateral foot, right outer calf, right ischium, scrotum, and the middle of the back. R40's current Care Plan documents R40 requires contact isolation due to Candida Auris (Multi-Drug Resistant fungus causing bloodstream, wound, and ear infections). On 5/11/26 at 9:40 AM R40 was lying in bed. R40's doorway had a sign posted indicating R40 was in contact isolation precautions. The Contact Precautions Sign posted on R40's doorway states, Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. V7 (CNA/Certified Nursing Assistant) and V8 (CNA) entered R40's room, washed their hands, and applied gloves. V7 and V8 did not apply a gown and continued to provide cares to R40. V7 and V8 gave R40 a bed bath and provided indwelling urinary catheter cares without wearing gowns. On 5/11/26 at 11:00 AM V8 (CNA/Certified Nursing Assistant) stated, I am not sure if we (V7 and V8) were supposed to wear gowns when providing cares to (R4). On 5/11/26 at 1:15 PM V7 (CNA) stated, I did not wear a gown while caring for (R40) as I did not see any gowns in his room. On 5/11/26 at 1:40 PM V2 (Director of Nursing) stated, (R40) is placed in contact isolation and staff should be wearing masks and gowns at all times when providing (R40) with personal cares. 3. R3's facility admission Record documents that R3 was admitted to the facility on [DATE] with the following diagnoses: Functional Quadriplegia, and Multiple Sclerosis. R3's most recent Minimum Data Set Assessment, date 04/15/2026 documents that R3 is dependent on staff for toileting (Section GG0130) and is always incontinent of urine (Section H0300 and 0400). On 5/11/26 at 12:38 P.M., V7 and V12/Certified Nursing Assistants (CNAs) prepared to provide incontinence care for R3. V7 and V12 donned gown and gloves, transferred R3 to bed via a mechanical transfer device and removed R3's urine saturated disposable brief. V12 wet a washcloth with soap and water and wiped the front of R3's peri region. V12 then assisted V7 in rolling R3 onto her right side, by pushing on R3's shoulder and hip with her soiled glove. V12 then wiped smeared stool from R3's buttocks, placed the soiled washcloth in a plastic bag, and assisted V12 in applying a clean disposable brief on R3. Without removing her soiled gloves, or performing hand hygiene, V12 applied a black wrist splint to R3's right wrist, positioned R3's call light in R3's reach, straightened R3's lines, repositioned R3's fan, handed R3 her bed controller, picked up R3's pink cup and placed the straw in R3's mouth, then repositioned R3's bedside table. At that time, V12 removed her soiled gloves and performed hand hygiene. V12 then confirmed she failed to remove her soiled gloves prior to touching R3 and R3's possessions. The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 5/11/26 and signed by V3 (Regional Director of Operations), documents 43 residents reside within the facility.

Based on Observation, Interview and Record review, the facility failed to ensure infection preventionist duties were implemented to provide infection surveillance and ensure that infection preventionist hours were adequate to oversee infection control and infection prevention policy and procedures. This failure has the potential to affect all 43 residents residing in the facility.Findings include:The facility's Infection Preventionist job description, dated 12/2026, documents The role of the Infection Preventionist is to oversee the infection prevention and control program for the surveillance, investigation, prevention, and control of healthcare-associated infections and other infectious diseases. Duties and responsibilities may include but not limited to: Infection prevention and control- tracking and trending of infections, infection control rounding and observations, regulatory compliance.The facility's Facility Assessment, dated 4/6/26, documents This facility maintains an infection prevention and control program administered by our Infection Preventionist in collaboration with the IDT (Interdisciplinary Team). Infections, antibiotic usage, and antibiotic monitoring are tracked by IP (Infection Preventionist) and IDT in IDT meetings.The facility's Infection Prevention and Control Program policy, dated 7/2026, documents To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under contractual arrangement. This policy also documents The program provides for the recording of each suspected infection and surveillance activities as they relate to individual resident infections. A log is maintained of suspected and actual infections on a day-to-day basis. The facility shall assure that necessary training, equipment and supplies are maintained to carry out an effective Infection Control Program.The facility's Infection Precaution Guidelines Policy dated 01/26 documents, Guidelines: It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. Transmission-Based Precautions will be employed for known or suspected infections for which the route of transmission/prevention is known. The transmission-based categories are the following: Airborne, Droplet, and Contact. Gather all equipment and supplies needed before going into the room. Only take needed supplies into the room. All personal protective equipment (disposable isolation gowns, masks, and gloves) should be used once and discarded in either the trash or linen receptacle before you leave the room. Precautions signs will be utilized to alert staff and visitors to see the nurse for instructions prior to entering the room.The facility's Enhanced Barrier Precautions policy, dated 12/2026, documents Enhanced Barrier Precautions (EBP): recommendations now include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Standard precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: dressing, bathing/showering, providing hygiene, changing linens, incontinence care, medical device care, wound care. The facility policy, Hand Hygiene/Handwashing, dated 01/2026 directs staff of when to perform hand hygiene: after glove removal.On 5/11/26 at 9:40 AM, R40's room contained a sign that documented R40 was in Contact isolation. At this time V7 and V8 (Certified Nursing Assistants) entered R40's room and without applying a gown, provided R40 with a bed bath and indwelling urinary catheter care.On 5/11/26 at 9:55 AM, R4's room was observed to contain an enhanced barrier precautions sign. R4's room did not have any gowns for staff to wear when caring for R4.On 5/11/26 at 12:38 PM, V7 and V12 (Certified Nursing Assistants) competed urinary incontinence care on R3. After cleaning R3's genitals and without removing gloves or performing hand hygiene, V12 continued touching R3's wrist and multiple items in R3's room with soiled gloves.On 5/11/26 at 11:30 AM, V25 (Licensed Practical Nurse, LPN) stated she is unsure where PPE is kept for residents in isolation. V25 also confirmed R18 has pressure wounds that receive treatments.On 5/11/26 at 11:33 AM, R18's room did not contain a sign or PPE to indicate any isolation or enhanced barrier precautions for R18.On 5/11/26 at 11:35 AM, V19 (LPN/ Infection Control Preventionist) entered R4's room and confirmed there was not any PPE available. V19 verified that R47 has an intravenous line, should be in EBP isolation and confirmed there is not a sign or any PPE in R47's room. The facility's infection control binders do not document any tracking logs, trending or monitoring with location tracing for resident and employee illness.On 5/13/26 at 9:34 AM, V19 confirmed the facility is not tracking resident or employee infections to identify patterns or locations of the facility where resident infections occur or where ill employees may have worked. V19 stated We have a system in the computer that we can run reports of resident's illness before we have monthly meetings, but I am not keeping a record of them or plotting any tracking to show where infections are located in proximity to other resident rooms. I do not have employee illness tracking either. I know that if someone calls in they write down the reason and if it's something contagious or needs recorded it is supposed to be relayed to me. I don't have anything to show for employee illness though because I have not been tracking it. V19 confirmed that R18 has wounds and is not in EBP isolation and stated (R18) was in contact isolation for MRSA (methicillin resistant staph-aureus) but that was treated and so he is not in isolation now. I have not been putting wounds in enhanced barrier precautions. I didn't realize it was required for wounds. I am ICP, wound nurse and I work on the floor. I am only able to devote about 12 hours a week to infection control and clearly, I need more training and time to do the work. V19 then stated Staff only have to wear PPE for enhanced barriers when they are messing with the invasive line or the catheter or changing them. Providing direct care to the site. They (staff) do not have to wear a gown with transferring or dressing a resident in EBP isolation, just gloves.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 5/11/26 and signed by V3 (Regional Director of Operations), documents 43 residents reside within the facility.

Based on observation, interview, and record review the facility failed to ensure a bedside table, toilet, bedspread, walls, baseboard trim, and window seals were kept clean and in good repair for three of 12 residents (R6, R23, and R40) reviewed for safe, clean, and homelike environment in the sample of 25.Findings include: The facility's Housekeeper Job Description Summary dated 05/26 documents, The primary purpose of the housekeeper is to perform the day-to-day activities of the housekeeping department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. Essential Duties and Responsibilities: Ensure that work/cleaning schedules are followed as closely as practical. The Facility Maintenance Director Job Description dated 5/26 documents, The primary purpose is to plan, organize, develop and direct overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing the facility and to assure that the facility is maintained in a safe and comfortable manner. Repair facility/resident property as necessary and in the event unable to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Assist in identifying, ensure that supplies and equipment are maintained to provide safe and comfortable environment and promptly report equipment or facility damage to the Administrator. Make weekly inspections of all maintenance functions to assure that quality control measures are maintained. The facility's Daily Housekeeping Cleaning Schedule, undated, documents all table trays and legs should be wiped down daily. 1.R40's MDS (Minimum Data Set) assessment dated [DATE] documents R40 is cognitively intact. On 5/11/26 at 9:40 AM R40 was lying in bed with one bedspread underneath R40 and one bedspread on top of R40. Both bedspreads were tattered, had multiple holes, and had frayed edges. The bottom half of R40's toilet bowl was covered in a thick brownish-blackish stain. The legs of R40's over the bed table were covered in thick dried food and dirt debris. R40 stated, Things are pretty dirty here. On 5/11/26 at 9:45 AM V7 (CNA/Certified Nursing Assistant) stated, (R40's) toilet bowl has been stained for years. Quite a few of the bedspreads here have holes and are old. On 5/11/26 at 9:50 AM V8 (CNA) stated, The legs of (R40's) bedside table is nasty. I think it is the housekeeper's job to clean the bedside tables. On 5/11/26 at 1:20 PM V13 (Housekeeper) stated, I have worked here for nine years and am aware of how bad (R40's) toilet is stained. I have asked multiple people over the years for a new toilet and have been told it is not in the budget to get a new toilet. On 5/11/26 at 1:25 PM V14 (Housekeeping Supervisor) stated, I am playing catch-up from the weekend. I do not believe (R40's) over the bed table was cleaned over the weekend. On 5/12/26 at 9:50 AM V15 (Maintenance Director) stated, I was told by staff that (R40's) toilet has been stained for years. The toilet will need replaced. 2. On 5/12/2026 at 1:00 PM, in R6's room there was three to four feet of rubber base board coming off the wall underneath the air unit. R6's window trim had several spots of paint chipping all around the window. On 5/12/2026 at 1:30 PM, V15 (Maintenance Director) stated he looked at the wall in R6's room and the window trim all around the window and confirmed the rubber trim was coming off the wall and that there was peeling around the window. 3. On 5/12/2026 at 1:10 PM, in R23's room there were two large holes in the wall behind R23's bed. R23's window also had paint peeling around the window. On 5/12/2026 at 1:30 PM, V15 (Maintenance Director) stated he saw the large holes underneath R23's bed on the wall and confirmed the paint peeling around the window trim as well.

Based on interview and record review, the facility failed to prevent physical abuse from happening between residents (R5, and R7), who were reviewed for Abuse in a sample of 25.Findings Include:The facility's Abuse Prevention and Reporting-Illinois policy dated 09/2024 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident-sensitive and resident-secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. Resident-to-Resident Abuse (any type): A resident-to-resident altercation should be reviewed as a potential situation of abuse. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish, or pain must be reported in accordance with regulations. Establishing a resident-sensitive environment; this facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive quality management approach.R5's Initial Preliminary 24-hour Abuse Investigation Report dated 4/21/2026 documents, At approx. 6:51 a.m., this administrator was notified of an altercation between two residents. Investigation initiated, all parties notified.R5's Final Abuse Investigation Report dated 4/27/2026 documents, Resident R7 on the dementia unit grabbed resident R5 also on the unit on the neck, leaving a small red mark on the neck. Interview with R7: R5 grabbed my shirt when I walked by. Interview with R5: R5 could not recall the incident. Interview with V24 (Licensed Practical Nurse): R5 was in her wheelchair in common area where hallways meet talking to herself, when R7 was ambulating by R5. R7 became angry yelling at R5 and turned quickly grabbing her by the neck with his left hand. Residents were immediately separated, and R5 was assessed. No other witnesses.R5's Progress Note dated 4/21/2026 documents, R5 was in her wheelchair in common area where hallways meet talking to self, when another resident was ambulating by her. R7 became angry yelling at R5 and turned quickly grabbing R5 by the neck with R7's left hand. This writer immediately ran to residents and stepped in between them and resident was released. After separating residents and getting them to separate areas, R5 was assessed and found to have red marks and small fingernail indentation. No skin breakage. R5 denied pain/discomfort and able to turn neck. Administrator notified immediately thereafter. Daughter/POA (Power of Attorney) notified.On 5/11/2026 at 11:15 AM, R5 was in the dining room, eating lunch. R5 was not interviewable. R5 was pleasant and showed no signs of fear, no visible marks on her skin, clothes were clean, hair brushed, and nails clean.R5's Care Plan dated 5/13/2026 documents R5 has a medical diagnosis of Dementia and Alzheimer's disease with late onset.R5's Care Plan dated 5/13/2026 also documents R5's potential for aggressive (verbal/physical) behavior related to dementia. Target behavior: hitting, grabbing, pushing others, cursing at others, unprovoked anger towards others, undressing in common area, wandering into other rooms and staff areas, rummaging, throwing food, agitation, anxiety, responding to internal stimuli, sleep disturbances, refusing care. R5 is at a high risk for abuse/neglect as noted from Abuse screening related to assessment score of 5. Ensure resident is redirected away from identified aggressive resident and high-risk areas during wandering to prevent contact and maintain safety.R5's MDS (Minimal Data Set) section C-Cognitive Patterns dated 2/13/2026 documents R5 has a BIMS (Brief Interview of Mental Status) score of 99, meaning unable to complete.R5's MDS section E-Behavior dated 2/13/2026 documents a score of 1 on all physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others, happening one to three days a week.On 5/11/2026 at 11:20 AM, R7 was in the dining room eating lunch. R7 was dressed and in a pleasant mood. R7 stated he did not recall this incident.R7's Care Plan dated 5/13/2026 documents R5 has a medical diagnosis of Dementia, Paranoid Personality Disorder, Schizoaffective Disorder, and bipolar disorder.R7's Care Plan dated 5/13/2026 documents, This resident is/has potential to be physically aggressive related to Dementia, history of harm to others related to poor impulse control, and invasion of personal area or taking his personal property.R7's MDS (Minimal Data Set) section C-Cognitive Patterns dated 3/20/2026 documents R7 has a BIMS (Brief Interview of Mental Status) score and was 10 meaning moderate impairment.R7's MDS section E-Behavior dated 2/13/2026 documents a score of 1 on verbal behavioral symptoms directed towards others, happening one to three days a week.On 5/13/2026 at 11:00 AM, attempted to call V24 (Licensed Practical Nurse), but could not contact.On 5/13/2026 at 10:00 AM, V22 (Licensed Practical Nurse) stated she was not here the day R7 grabbed R5 but was told about it in the report on the first shift after the incident happened. V22 stated she was instructed to watch R5 for signs and symptoms of pain and bruising. V22 was instructed to keep R5 and R7 separated at all times.On 5/13/2026 at 10:05 AM, V18 (Certified Nurse Assistant) stated she was instructed by management to watch R5 and make sure she does not wander into R7's room, and to always keep R5 and R7 separated.On 5/13/2026 at 10:10 AM, V23 (Certified Nurse Assistant) stated she is instructed by management to take R7 into his room when he is agitated and if R5 tries to wander into R7's room, she is to remove R5 from the area and keep R5 and R7 separated at all times. On 5/13/2026 at 10:15 AM, V2 (Director of Nursing) confirmed resident to resident abuse did happen between R5 and R7.

Based on Observation, Interview and Record review, the facility failed to document a diagnosis and behaviors to warrant the use of scheduled injectable Haldol (antipsychotic medication), complete a psychotropic medication assessment when initiating Haldol, provide rational past the 14 day usage of PRN (as needed) injectable Haldol, and ensure that duplicate psychotropic mediations were not being provided for the same symptom for one of four residents (R4) reviewed for psychotropic medications in the sample of 25.Findings include:The facility's Abuse Prevention and Reporting policy, dated 9/2025, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: assuring that physical restraints are used sparingly and properly, and that chemical restraints are not used.The facility's Psychotropic Medication- Gradual Dosage Reduction policy, dated 7/2026, documents To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. The plan to alternatives to psychotropic medication and/or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/problems, goals and approaches as it relates to the use of psychotropic drug use. This policy also documents PRN antipsychotic medications shall be limited to 14 days, the attending physician or prescribing practitioner will evaluate the resident and enter a new order for PRN administration as indicated, not to exceed 14 days.R4's Physician Order Summary, dated 5/12/26, documents R4 was admitted to the facility on [DATE] with diagnoses including Dementia, Parkinson's Disease, Agitation, and Anxiety. This same order summary documents R4 has orders for Depakote Sprinkles (mood stabilizing psychotropic medication) 125 milligrams (mg) four capsules (500 mg) by mouth two times a day for Dementia with Agitation start date 1/30/26, Haloperidol injection solution (antipsychotic medication) 5mg/ml (milliliter) inject 0.4 ml intramuscularly every four hours as needed for agitation/delirium related to Dementia with Agitation start date 2/9/26, Haloperidol injection solution 5mg/ml inject 2mg (0.4 ml) intramuscularly at bedtime for agitation start date 2/26/26, Trazadone (antidepressant psychotropic medication) 100 mg by mouth at bedtime for mood related to Dementia with Agitation start date 2/18/25, Xanax (antianxiety psychotropic medication) 0.25 mg by mouth six times a day related to Anxiety start date 8/15/25, and Xanax 0.5 mg by mouth at bedtime related to Anxiety and Restlessness and Agitation start date 8/15/25.R4's Depakote consent, dated 1/30/26, documents R4 is being prescribed Depakote for Agitation.R4's Haldol consent, dated 2/6/26, documents R4 is being prescribed injectable Haldol every 4 hours as needed for Screaming/ Not sleeping.R4's PASRR (Preadmission Screening and Resident Review) summary, dated 11/11/25, documents upon screening R4 was taking Xanax, Trazadone and Sertraline (antidepressant medication) and had diagnoses of Alzheimer's Disease, Anxiety disorder and Dementia with Agitation. This summary documents You do not have a severe mental health condition requiring evaluation through PASRR process.R4's Care Plan, dated 1/30/26, documents The resident uses psychotropic medications related to Dementia. Interventions: administer psychotropic medications as ordered by physician, monitor/record occurrence of target behaviors symptoms and document per facility protocol. This same care plan documents R4 has a self-care deficit related to Dementia and Impaired balance and is fully dependent on staff for all activities of daily living. R4's care plan does not address the use of the antipsychotic medication Haldol and does not document R4's specific target behaviors for the use of psychotropic medications.On 5/11/26 at 10:02 AM R4 was sitting in a high-back reclined wheelchair in the dining room of the facility's locked Dementia unit. Residents in the dining room were playing a game with activity staff. R4's feet were propped on recliner foot pedals with cushioned pressure relief boots. R4's hands were actively shaking with uncontrolled tremor-like movements. At this time R4 was mumbling incoherent and repetitive words in a low tone. R4 was not disruptive or displaying any behaviors.On 5/11/26 at 11:15 AM, R4 was sitting in a high-back reclined wheelchair at a table in the dining room awaiting lunch. R4 was not displaying any behaviors.On 5/11/26 at 1:12 PM, V26 (R4's family) stated she works at the facility part time as a CNA (Certified Nursing Assistant) and she is able to see R4 frequently. V26 stated (R4) doesn't have any behaviors anymore. He's wheelchair bound and that's been since maybe August or October 2025. He has Dementia. Prior to him declining he would cuss, had falls, would get loud and was an elopement risk because he was a wanderer. (R4) was never mean or anything and he could be re-directed and would joke around. I know they tried several medications for his behaviors.R4's current electronic medical record documents the last behavior note was documented on 4/7/2025 at 6:38 AM and documents (R4) continues to follow others very closely, he has spastic rapid speech with flight of ideas, often repeats self. No signs or symptoms of pain at this time.R4's Behavior Monitoring and Interventions reports dated 1/12/26- 5/12/26, document R4's behavior monitoring is canned text and a large array of potential behaviors that can be marked including but not limited to hitting, kicking, punching, cursing at others, agitated, anxious, wandering, picking at self. This behavior monitoring does not indicate any specific behaviors that are targeted for R4.R4's Nursing Progress note, dated 2/24/26 at 11:52 AM, documents Order received per Hospice to schedule Haloperidol 0.4 ml intramuscularly every evening for agitation, and continue PRN order as well. This same nursing note documents Resident increasingly groggy and calm today.R4's nursing Progress notes prior to 2/24/26 do not document behaviors for R4, a reason for the newly scheduled Haldol, or any justifications for the continued PRN Haldol.R4's Social Service Note, dated 2/27/26 at 11:38 AM, documents R4's cognition is severely impaired, has no indicators of psychosis and has not exhibited any behaviors. This note documents Behaviors: Physical behavioral symptoms directed towards others were not exhibited. Verbal behavioral symptoms directed towards others were not exhibited. Behaviors not directed towards others, did not occur during the 7-day lookback noted. Examples of behaviors include: no aggressive behaviors noted.R4's electronic medical record documents the first Psychotropic Medication Observation completed after R4's Haldol was started (2/9/26), was not until 3/20/26 and documents R4 has confused mental status, memory impairment, abnormal thinking, has behaviors of agitation, mood swings and outbursts, and is prescribed six psychotropic medications for diagnoses of Dementia, Agitation, Restlessness with Agitation and Anxiety.R4's Nursing Progress Note, dated 4/14/26 at 1:53 PM, documents Resident has been very quiet and sleepy today. Drank only a few sips of water and juice at breakfast.On 5/12/26 at 12:12 PM V20 (CNA) was in the facility's Dementia unit feeding R4 in the dining room. R4 did not make eye contact when spoken to and was staring forward. V20 confirmed that R4 required full assistance with eating. R4 was not displaying any behaviors. At this time V20 stated (R4's) only behavior is that he will yell out. I started working here in December 2025 and his behavior has decreased since then. (R4) doesn't have any other behaviors aside from yelling.On 5/12/26 at 12:18 PM, V18 (CNA) stated (R4) yells out, sometimes random or if like his foot gets bumped. Mostly he will yell after laying down and occasionally during showers. (R4) has been in a high-back wheelchair for a while. Before he had more of a decline, he was up and walking, he'd joke around and act like he was charging you. It was towards staff and not residents, but he was just joking. I can't think of any other behaviors, and I have worked here since before (R4) was admitted in 2024.On 5/13/26 at 10:03 AM V2 (Director of Nursing) confirmed R4 has a behavior of yelling. V2 stated (R4's) family wanted him on medication to control him yelling. That is his main behavior. V2 confirmed that the diagnosis for R4's Haldol use is Dementia with Agitation, R4 does have target behaviors that are being monitored and R4's nursing progress notes do not document or describe behaviors for R4 in the past year. V2 confirmed that Dementia and yelling are not psychotic in nature and verified that R4 has other duplicative psychotropic medications that are also prescribed for Dementia with Agitation. V2 stated The nurses and CNA's are not using the tasks the proper way to chart behaviors. That was just brought to my attention yesterday. Hospice and family all want us to do more and want (R4) medicated. V2 also confirmed that (R4's) PRN Haldol order exceeded 14 days in length without any justification to continue or a new order.

Based on observation, interview, and record review the facility failed to accurately assess a resident's limitations in range of motion and develop and implement a restorative range of motion program for two of two residents (R4 and R21) reviewed for limitations in range of motion in the sample of 25. The facility's Restorative Nursing Program dated 12/25 documents, Policy: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Identify residents who currently have splints/braces or previous range of motion programs or those that have actual or potential limitations with ROM and/or pain. Develop an individualized program based on the resident's restorative needs and include the restorative program on the care plan. 1.R21's admission Record documents R21 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side, Aphasia following a Cerebral Infarction, Major Depressive Disorder, and Hypertension. R21's MDS (Minimum Data Set) assessment dated [DATE] documents R21 is severely cognitively impaired, has impairments in range of motion to one side of the upper extremity and one side of the lower extremity, is dependent on staff for ADLs (Activities of Daily Living), does not receive skilled therapy, and does not receive a range of motion restorative program. On 5/11/26 at 10:15 AM R21 was lying in bed. R21's right arm and right leg were flaccid. On 5/11/26 at 1:15 PM V7 (CNA/Certified Nursing Assistant) stated, I have worked here for years. I am not aware of (R21) getting any therapy or range of motion exercises. On 5/12/26 at 11:50 AM V16 (Care Plan Coordinator) stated, (R21) does not have a restorative range of motion program. We (the facility) currently do not have a restorative nurse that could develop that. 2. On 5/11/26 at 10:00 AM, R4 was sitting in the facility's dining room during an activity. R4 was positioned in a high back reclined wheelchair with both hands on his abdomen noticeably shaking with uncontrolled tremor-like movements. R4's feet had cushioned heel to calf boots in place and were resting on reclined chair leg rest. On 5/12/26 at 12:12 PM, R4 was sitting in the dining room being fed by V20 (Certified Nursing Assistant). R4 did not respond to words or being spoken to. V20 stated R4 requires total assistance from staff with all meals as he is unable to follow commands. R4's Care Plan, dated 1/30/26, documents R4 admitted to the facility on [DATE] with diagnoses of Dementia, Parkinson's Disease, Transient Cerebral Ischemic Attack and Restlessness with Agitation. This same care plan documents R4 has a self-care deficit related to Dementia and Impaired balance and is fully dependent on staff for all activities of daily living. R4's Minnimum Data Set (MDS) assessment, dated 3/2/26, documents R4 has a lower extremity impairment on one side, is dependent for sitting, rolling, hygiene, dressing and transferring and does not walk due to his condition. R4's current electronic medical record does not document a program to address R4's limits in range of motion or a plan to prevent a decrease in range of motion and prevent contracture. On 5/12/26 at 1:15 PM, V2 (Director of Nursing) stated she does not have any range of motion programming (ROM) for R4. On 5/13/26 at 10:03 V2 confirmed that R4 used to be mobile and walked around the facility's dementia unit frequently. V2 stated (R4) has been non-ambulatory for a while now. I am not sure of exact date he became wheelchair bound. We don't have a specific range of motion program for him. At this same time, V16 (Licensed Practical Nurse/ Care Plan Coordinator) stated she has been doing the MDS assessments for about five months. V16 confirmed R4 has severely impaired cognition, does not move extremities regularly or understand commands to do so, does not ambulate and is dependent on staff for all activities of daily living. V16 stated When I assess someone like (R4) for impairments I usually just go by their diagnoses as to whether or not that have limits in range of motion.

Based on observation, interview and record review, the facility failed to ensure fall precaution interventions were in place for R29, a resident with a history of falls and failed to assess and implement interventions for a resident with exit seeking behaviors (R6), for two of five residents reviewed for safety, in a sample of 25. The facility policy, Fall Prevention Program, dated 01/2026 directs staff at the time of admission and in accordance with the plan of care, the resident will be oriented to the use of the call device, and the nurse call device will be placed within the resident's reach at all times. The facility's Code Pink-Missing Resident/Elopement policy dated 4/2023 documents, The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as an elopement risk, and institute measure for resident identification at the time of admission. A. Assessment, 1. The preadmission evaluation process includes a wandering and elopement history and whether the resident can be safely care for at the facility. 2. An Elopement Risk Assessment is completed on all residents at the time of admission, quarterly, and with any increase in exit-seeking or wandering behaviors. 1. R29's facility admission Record documents that R29 was admitted to the facility on [DATE] with the following diagnosis: Cerebral Infarction. R29's most recent Fall Assessment, dated 4/5/26 documents that R29 is at risk for falls. R29's most recent Minimum Data Set Assessment, dated 4/17/26 documents that R29 requires substantial/maximal assistance of staff for all transfers, is always incontinent of bowel and bladder and has a history of falls. R29's current Care Plan, dated 8/12/24 documents that R29 has a Focus Area of At Risk for Falls. This same care plan includes the following Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The facility Fall Investigation Reports, dated 4/5/26, 9/28/25, 8/19/25, 6/4/25, 5/24/25 and 5/14/25 document that R29 fell in his room. On 5/11/2026 at 10:29 A.M., R29 was sleeping in his room, in bed. R29's call light was out of reach, laying on the floor, unavailable. On 5/11/2026 at 1:13 P.M., R29 was in his room, sleeping in bed. R29's call light remained unavailable to R29, laying on the floor. At that time, V7/Certified Nursing Assistant (CNA) verified that R29 had a history of falls and R29's call light on the floor. 2. On 5/11/2026 at 11:15 AM, R6 was in the dining room eating lunch in her wheelchair, dressed. R6 was not interviewable but was pleasant and voiced no concerns. R6's MDS (Minimum Data Set) Section C- Cognitive Patterns BIMS (Brief Interview of Mental Status) score was 99, meaning unable to complete the interview. Cognitive skills for daily decision making were a score of two, moderately impaired; decisions were poor; cues/supervision were required. R6's MDS Section E- Behaviors showed a score of 1 for wandering, meaning this type of behavior occurred one to three days a week. R6's Care Plan dated 5/13/2026 documents R6 has a diagnosis of Dementia and Altered Mental Status. R6's Care Plan dated 5/13/2026 documents, I have a behavior problem: Wandering into other residents' rooms and personal spaces. R6 is an elopement risk/wanderer. R6 does not have any record of an Elopement/Wandering Risk Assessment in her chart. On 5/12/2026 at 9:51 AM, V2 (Director of Nursing) confirmed there are no Elopement/Wandering Risk Assessments done for R6.

Based on observation, interview, and record review the facility failed to assess and identify entrapment risks associated with the use of side rails, attempt alternatives prior to installing side rails, develop a plan of care to address side rail use along with the risks associated with side rail use, and obtain consent prior to the use of side rails for two of three residents (R21 and R40) reviewed for side rail use in a sample of 25.Findings include:The facility's Side Rails/Bed Rails Policy dated 12/25 documents, Purpose: To ensure the appropriate, safe, and correct installation, use, and maintenance of bed rails. Definitions: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sized ranging from full to one-half, one-quarter, or one-eight lengths. Guidelines: The facility shall ensure that prior to the installation of bed rails, the facility has attempted to use alternatives. After alternatives to bed rails have been attempted and determines that these alternatives do not meet the resident's needs, the facility shall assess the resident for the risks of entrapment and possible benefits of bed rails. In addition, the resident assessment should include an evaluation of the alternatives to the use of a bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. Informed Consent: The facility shall obtain informed consent from the resident or if applicable, the resident's representative for the use of bed rails. Plan of Care: The care plan shall be developed on an individual basis and may include but is not limited to the following related to use of bed rails: Identification of interventions to address any potential complications such as physical and/or psychosocial changes related to the use of the bed rails, such as increased incontinence, decline in ADLs (Activities of Daily Living) or ROM (Range of Motion) increased confusion, agitation, and depression.1. R21's admission Record documents R21 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side, Aphasia following a Cerebral Infarction, Major Depressive Disorder, and Hypertension.R21's MDS (Minimum Data Set) assessment dated [DATE] documents R21 is severely cognitively impaired.R21's Electronic Health Record dated 5/11/25 through 5/12/26 does not include a side rail assessment, alternatives tried prior to the installation of a side rail, a consent for the use of a side rail, or a care plan for the use of a side rail.On 5/11/26 at 10:15 AM R21 was lying in bed. R21's bed was positioned against the left side of the wall and R21 had a half side rail in the raised position to the left side of the bed. R21 was confused and R21's speech was mumbled.On 5/12/26 at 11:30 AM R21 was lying in bed. R21's bed was positioned against the left side of the wall and R21 had a half side rail in the raised position to the left side of the bed. On 5/12/26 at 11:50 AM V16 (Care Plan Coordinator) stated, (R21) has not had an entrapment risk assessment completed, alternatives tried prior to side rail use, a consent obtained, or a care plan developed for the use of a side rail.2. R40's admission Record documents R40 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Intraspinal Abscess and Granuloma, Paraplegia, Acute Osteomyelitis to Right Ankle and Foot, Respiratory Failure with Hypoxia, and Spinal Stenosis.R40's MDS assessment dated [DATE] documents R40 is cognitively intact and is dependent on staff for ADLs.R40's Siderail assessment dated [DATE] and signed by V16 (Care Plan Coordinator) documents, Risks identified for rail usage: Decline in function including activities of daily living, mobility, and bowel and bladder function. Final Recommendation: Side rails indicated to promote mobility and independence. R40's Electronic Health Record dated 3/5/26 (Admission) to 5/11/26 does not document alternatives tried prior to the installation of side rails.R40's current Care Plan documents, Date initiated 3/5/26: (R40) uses side rails to maximize independence with turning and repositioning in bed. This same Care Plan does not include a plan of care to address the risks associated with the use of R40's side rails.On 5/11/26 at 9:40 AM R40 was lying in bed. R40 had a half side rail in the raised position to the left side of the bed. There was a half side rail lying behind the head of R40's bed on the floor. R40 stated the side rail lying on the floor had broken off and no one has fixed it.On 5/12/26 at 9:50 AM V2 (Director of Nursing) stated R40 is supposed to have two half side rails for mobility and positioning. V2 stated R40 has had no alternatives tried prior to the implementation of R40's side rails and does not have a care plan with interventions to address the risks associated with the use of R40's side rails.

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for one of nine residents (R7), reviewed for medication administration, in a sample of 25.The facility policy, Medication Administration policy, dated 01/2026 directs staff medications must be administered in accordance with a physician's order, the right resident, right medication, right dosage, right route and right time. R7's facility admission Record documents that R7 was readmitted to the facility on [DATE] after a hospitalization for Metabolic Encephalopathy. R7's Nursing Progress Notes, dated 4/29/26 at 8:05 A.M. document that R7 was noted with left-sided weakness, altered mental status, unsteady gait and generalized weakness. R7 's physician was notified and R7 was sent to the local emergency room. R7's hospital discharge instructions, dated [DATE] includes the diagnosis for R7's hospitalization as Drug- induced Encephalopathy (Acute Metabolic Encephalopathy due to Valproic Acid Encephalopathy) and Hyperammonemia due to Valproic Acid. R7's discharge orders document, Please do not give (R7) Valproic Acid because it is the cause of his confusion. A review of R7's May 4- May 31, 2026 (Physician) Order Summary Report do not include a current physician order for R7 to receive Valproic Acid. On 5/12/2026 at 8:37 A.M., V17/Agency Nurse prepared to administer medications for R7. V17/Agency Nurse punched 2 tablets of Valproic Acid (anti convulsant) 500 MG (Milligrams) DR (Delayed release) into a plastic medication cup, along with nine other medications, walked to R7's room and handed R7 the medication cup and instructed R7 to take the medicines. R7 swallowed all the medications at one time with a 60 ML (Milliliter) cup of water. On 5/12/2026 at 9:40 A.M., V2/Director of Nurses (DON) confirmed that R7 did not have a current physician order for Valproic Acid and was not to receive Valproic Acid due to his recent metabolic encephalopathy brought on by Valproic Acid.

Based on observation, interview, and record review the facility failed to ensure multi-dose injectable insulin pens were labeled with the date when opened for three of 12 residents (R22, R29, and R35) reviewed for storage and labeling of medications in a sample of 25.Findings include:The facility's Medication Storage Policy dated 12/25 documents, Purpose: To ensure proper storage, labeling, and expiration dates of medication, biologicals, syringes, and needles. Facility staff should record the date opened on the medication container when the medication has shortened expiration dates once opened.On 5/11/26 at 9:30 AM V9 (LPN/Licensed Practical Nurse) was standing at the North and Short Hallway medication cart. V9 opened the top drawer of the medication cart where residents' multi-dose insulin injector pens were stored. This drawer contained R22's opened 1/3 full Lantus Insulin100 u/ml (units/milliliter) injector pen that was not labeled with the date when opened, R29's opened 1/4 full Lantus Insulin 100 u/ml injector pen that was not labeled with the date when opened, and R35's opened 1/3 full Lantus Insulin100 u/ml (units/milliliter) injector pen that was not labeled with the date when opened. V9 stated, I only work here as needed. I do not know why all of these insulin pens are not dated. All insulin pens should be labeled with the date of when they are opened.On 5/11/26 at 1:40 PM V2 (Director of Nursing) stated, All multi-dose insulin vials and pens should be labeled when opened and are only good for 28 to 30 days after opening.

Based on observation, interview, and record review failed to conduct regular maintenance inspections as part of a regular maintenance program to identify areas of possible entrapment for three of three residents (R21,R35, and R40) reviewed for side rail use in a sample of 25.The facility's Side Rails/Bed Rails Policy dated 12/25 documents, Purpose: To ensure the appropriate, safe, and correct installation, use, and maintenance of bed rails. Definitions: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sized ranging from full to one-half, one-quarter, or one-eight lengths. Guidelines: The facility should ensure the bed is appropriate for the resident and that bed rails are properly installed and maintained. Potential risks can be exacerbated by improper match of the bed rail to bed frame, improper installation and maintenance, and use with other devices or supports that remain when the bed rail is removed. Installation and Maintenance of Bed Rails: Assuring the correct installation and maintenance of bed rails is an essential component in reducing the risk of injury resulting from entrapment or falls. When installing and using bed rails, the facility should: Ensure the bed's dimensions are appropriate for the resident. Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed. Inspect and regularly check the mattress and bed rails for areas of possible entrapment. Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time.The Facility Maintenance Director Job Description dated 5/26 documents, The primary purpose is to plan, organize, develop and direct overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing the facility and to assure that the facility is maintained in a safe and comfortable manner. Repair facility/resident property as necessary and in the event unable to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Assist in identifying, ensure that supplies and equipment are maintained to provide safe and comfortable environment and promptly report equipment or facility damage to the Administrator. Make weekly inspections of all maintenance functions to assure that quality control measures are maintained.1.On 5/11/26 at 10:15 AM R21 was lying in bed. R21's bed was positioned against the left side of the wall and R21 had a half side rail in the raised position to the left side of the bed. R21 was confused and R21's speech was mumbled.R21's Electronic Health Record dated 5/11/25 through 5/12/26 does not include a maintenance assessment or evaluation of R21's side rails.2. On 5/12/26 at 2:00 PM R35 was lying in bed. R35's bed was positioned against the left side of the wall and R35 had a half side rail in the raised position to the left side of the bed. R35's Electronic Health Record dated 4/25/25 (R35's Admission) through 5/12/26 does not include a maintenance assessment or evaluation of R35's side rails.3. R40's Electronic Health Record dated 3/5/26 (Admission) to 5/11/26 does not include a maintenance assessment or evaluation of R40's side rails.On 5/11/26 at 9:40 AM R40 was lying in bed. R40 had a half side rail in the raised position to the left side of the bed. There was a half side rail laying behind the head of R40's bed on the floor. R40 stated the side rail laying on the floor had broken off and no one has fixed it.On 5/12/26 at 9:50 AM V15 (Maintenance Director) stated, I have not performed maintenance inspections or assessments for any of the residents' side rails. I cannot find any maintenance inspections or assessments of side rails that have been done within the last year. I have not been told that (R40's) side rail was broken off of his bed.

Based on interview and record review the facility failed to ensure residents were free from verbal abuse for 4 of 4 residents (R1-R4) reviewed for verbal abuse in the sample of 7.The findings include:The facilities Final Report dated 4/8/26 showed, at approximately 5:50 PM on 4/3/26 the administrator was notified of an allegation of verbal abuse between R1, and 3 other residents (R2-R4) in the dining room. Staff interviews: housekeeping: R1 entered dining room and made unclear statement as she walked by the 3 residents. Other residents started yelling back. All yelled curse words at each other. Nurse: heard residents yelling profanities at each other. Residents separated, R1 put on 1:1 supervision due to threatening behavior.Residents were interviewed on 4/3/26 and written statements were obtained by the facility. R5's statement showed R1 came into the dining room and started chewing everyone's butts. He believed R1 started it. R6's statement showed R1 was walking around the table behind R3 and R4. Something was said and everyone started yelling and screaming at each other. R1 got stopped by V7 housekeeper. V7's statement showed she heard all of it. R1 called R3 a bitch. R4 yelled back at R1.Staff were interviewed on 4/3/26 and written statements were obtained by the facility. V7 housekeeper's written statement showed R1 entered the dining room and made an unclear statement as she walked by 3 other residents. R3 yelled, Fuck you bitch. R1 yelled back, Fuck you, you ho. No one wants your man. I'll beat your ass. R2 and R4 started yelling. V7 stated R1 charged at R3 and she put her arm up to keep them separated. V6 Licensed Practical Nurse - LPN's statement showed she was walking by the dining room and heard yelling. V6 said she observed an altercation between R1, R3, and R4. All 3 residents were yelling loudly at each other using profane language. R1 was yelling nobody wants your man and stated she would beat R3's ass.On 4/19/26 at 9:23 AM, R2 stated the person behind what happened isn't here anymore. R2 identified R1 as the person that started the verbal incident in the dining room. R2 stated R1 always talked loudly and thought she had something to say when she really didn't. R1 yelled at people and threatened them all the time. R2 stated R1 needed to keep her mouth shut and stay away from him and there wouldn't be a problem.On 4/19/26 at 9:33 AM, R3 and R4 were in R3's room together. R4 stated R1 flipped out while they were sitting there minding their own business. R4 stated R1 went after R3, and two staff members had to stop her. R4 stated words were said back and forth and it got a little out of control. R3 stated R1 came into the dining room yelling and screaming and everyone told her to shut up. R3 stated R1 calmed down for a little bit and then came after her because she is R4's girlfriend. R1 has threatened to have R4 beat up and to shoot him. R3 stated she did not feel safe at all because R1 is in the room next to her and they share an adjoining bathroom. R3 stated she did not feel safe even though the facility had a babysitter in the hall. R3 and R4 stated what happened that day in the dining room was random and R1 gets angry quickly.On 4/19/26 at 1:08 PM, V6 LPN stated she was walking past the dining room when the incident occurred, heard the commotion and them screaming at each other. R1 was yelling at R3 that she didn't want her man. R1 was walking towards R3 so she stepped in front of her and told the other resident to stop yelling. V6 stated R1, walked in screaming at R3 and the R3 screamed back at her. R1 stated she would beat her ass. R1 stated R1 hit a nurse when she first came in. V6 stated verbal abuse is any cussing around or at other residents. V6 stated what happened was verbal abuse.On 4/19/26 at 1:28 PM, V8 LPN stated she came in at the later part of the incident after the residents were separated. V8 stated she talked to R3 and R4 to hear their concerns. They said R1 needed to be out of the facility. They felt like R1 attacked them. V8 stated R1 can get aggressive.On 4/19/26 at 2:50 PM, V1 Administrator stated Abuse is intentional whether it is physical, mental, verbal etc. Verbal abuse is when someone is threatening another person, telling them they are going to hurt them; verbally assaulting another person; yelling/cussing could be verbal abuse.The facility's Abuse Prevention and Reporting - Illinois (2026) showed verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend or disability. Examples of verbal abuse include , but are not limited to threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again

Based on observation, interview and record review, the facility failed to ensure a resident was supervised in the dementia unit and away from the doors. This failure resulted in R1 being hit by the door for a second time, causing her to fall and fracture her hip. The facility failed to ensure a resident was safely transferred after a fall for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.The findings include:R1s admission record documents she was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 12/12/25 incident report for R1 shows she was ambulating in hallway and was behind double doors, door bumped into R1 causing change of plane. Under injuries it was indicated R1 had discomfort to right side. The final report shows the 12/12/25 fall was witnessed. The 12/13/25 emergency room radiology report shows the right femur fracture and right hip dislocation.R1s care plan documents she has risk factors that require monitoring and intervention to reduce potential for self-injury. (devices, cognition, mood/behavior, safety awareness). Risk factors include Dementia, history of falls with right hip fracture. R1s care plan shows her to be a wanderer. Interventions include disguising exits, cover doorknobs and handles. Distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.On 2/6/26 at 3:15 PM, V4 (R1s son/power of attorney) said R1 had been in the facility for about 2 years. She was fine physically she was able to walk around the dementia unit without any cane or walker. He said in December, she was on the unit and was hit by the door into the unit and this was the 2nd time she had been hit by the door. V4 said back in October when she was hit the first time, she had no injury and they said they were going to do something different with the door, and nothing had been done.On 2/7/26 at 2:33 PM, V13 Dietary cook said she was taking the lunch cart into the unit. She put the code in and did not see R1 behind the door. She said R1 was right by the crack of the door and the wall and did not see her before pushing open the door. When she entered the unit with the door open, R1 fell. V13 said R1 had previously been hit by the door and that is why there are signs to look before entering the unit. She said R1 tended to stand behind the door. V13 said after R1 fell, she went to get V11 Certified Nursing Assistant (CNA). V13 said with V11, they picked R1 up without a gait belt or any assistive devices and stood R1 up and placed her in a wheelchair. She said R1 was able to bear weight on one leg. She then went to tell the nurse about the fall. V13 said it was not safe to transfer R1 without a gait belt and could have hurt her more. On 2/7/26 at 2:09 PM, V11 said when she arrived to R1 after the fall, V13 was standing by the double doors and R1 was sitting on the floor. She grabbed a wheelchair and stood R1 up and put her into the wheelchair. V11 said she realized her mistake after it happened and did not use a gait belt. And moving her before the nurse was able to assess her could make any injury worse. On 2/7/26 at 9:32 AM, V6 LPN Licensed Practical Nurse said R1 was able to ambulate around the unit on her own. She said this was the 2nd time R1 had been hit by the doors. That is why the signs are up on the door to look before entering the unit. On 2/7/26, each of the double doors to the dementia unit had a long narrow window and the common area of the unit was visible. When looking through the window the areas behind the door are visible. Signs on the door remind staff and visitors to look prior to opening the doors. On 2/7/26 at 11:11 AM, V2 Director of Nursing said this was the second time R1 had been bumped by the door. She had no injury from the first fall, and that is when the signs were put up to remind people to look before opening the door. On 2/9/26 at 8:47 AM, V2 said after the first incident staff were in-serviced about looking through the window to check for residents, and the signs were posted. After the fall, the staff should have used the mechanical lift to move R1 from the floor to a wheelchair.The facility's 12/2025 policy for transfers- manual gait belt and mechanical lifts documents Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted.

Based on interview and record review, the facility failed to ensure a resident was assessed for injury after a fall and prior to being transferred for 1 of 3 residents (R1) reviewed for post-fall assessments in the sample of 3.The findings include:R1s admission record documents she was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 12/12/25 incident report for R1 shows she was ambulating in hallway and was behind double doors, door bumped into R1 causing change of plane. Under injuries it was indicated R1 had discomfort to right side.On 2/7/26 at 2:33 PM, V13 Dietary cook said she was taking the lunch cart into the unit. She put the code in and did not see R1 behind the door. She said R1 was right by the crack of the door and the wall and did not see her before pushing open the door. When she entered the unit, R1 fell. V13 said after R1 fell, she went to get V11 Certified Nursing Assistant (CNA). V13 said with V11, they picked R1 up from the floor and stood R1 up and placed her in a wheelchair. She said R1 was able to bear weight on one leg. She then went to tell the nurse about the fall. V13 said it was not safe to transfer R1 without a gait belt and could have hurt her more, and she should not have moved her without the nurse assessing her first. On 2/7/26 at 2:09 PM, V11 said when she arrived to R1 after the fall, V13 was standing by the double doors and R1 was sitting on the floor. She grabbed a wheelchair and stood R1 up and put her into the wheelchair. V11 said she realized her mistake after it happened and did not use a gait belt. And moving her before the nurse was able to assess her could make any injury worse. On 2/7/26 at 9:32 AM, V6 LPN Licensed Practical Nurse said she was on break when R1 fell. When she arrived back on the unit, she found R1 sitting up in a wheelchair. She said the two aides got her up off the floor before she could be assessed. They should not have moved her prior to any assessment just in case she had a broken hip. V6 said she was not very happy about the situation. On 2/7/26 at 11:11 AM, V2 Director of Nursing said when a resident has a fall, the nurse should be performing an assessment first, including range of motion, check their pain level and vital signs. The resident should not be moved prior to this assessment. The point of range of motion is to assess for injury and if you move them prior, you could cause an injury or worsen any injury.The facility's 1/2026 policy for fall prevention program documents its purpose: To assure the safety of all residents in the facility, when possible. Transfer conveyances shall be used to transfer residents in accordance with the care plan. On 2/9/26, V2 said after a fall, the nurse initiates resident assessment and risk management on the electronic record which auto populates the assessment to be completed. There is no specific checklist for post fall.

Based on observation, interview and record review the facility failed to recognize an altercation between an employee and a resident as verbal abuse, failed to prevent access to all other facility residents by the same employee, resulting in this employee verbally abusing a second resident (R7) on a different occasion, failed to prevent resident to resident physical abuse for three of three residents (R2, R3 and R5) and failed to prevent employee to resident physical abuse (R8), for eight of eight residents reviewed for abuse, in a sample of 8.This failure has the potential to affect all 51 facility residents and resulted in R6 to feel fear, anxiety and shame.These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 9/19/25 when V6/Former Employee Registered Nurse entered R6's room and verbally assaulted her within the facility.V2 (Director of Nursing) and V12 (Regional Nurse) were notified of the Immediate Jeopardy on 11/26/25 at 2:45 PM.While the immediacy was removed on 11/12/25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.The facility Abuse Prevention and Reporting policy, dated 09/2024 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other that by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental and psychosocial well- being. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Verbal abuse includes the use of oral, written or gestured communication, or sounds, to residents within hearing distance. A resident-to-resident altercation should be reviewed as potential situation of abuse. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations.The facility Preliminary Abuse Investigation Report dated 9/19/25 documents, Verbal or Mental Abuse. On 09/19/2025 at approximately 9:15 P.M., (R6) reported alleged verbal altercation with an employee (V6/Registered Nurse). (V6/RN) suspended immediately. Appropriate notifications made. Investigation initiated. 5-day Final (Report) to come.The facility Final Abuse Investigation Report dated 9/24/25 documents, On 09/19/25 at approximately 9:30 P.M., V7/Licensed Practical Nurse (LPN) observed R6 visibly upset while she was doing (a) med (medication) pass. R6 reported to V7 that the previous shift nurse (V6/RN) would send a CNA (Certified Nursing Assistant) to put her on bedpan. Staff provided peri care to (R6). R6 was assessed for any psychosocial injuries. No psychosocial needs noted. Facility leadership reviewed the medical record of (R6). Employees who were knowledgeable of the allegation were interviewed by the Abuse Coordinator. Based on the results of the investigation the facility has found the following: IDT (Intradisciplinary Team) met to discuss the investigation. Also discussed appropriate interventions for (R6). Care plan reviewed and updated accordingly. SSD (Social Services Director) will follow up with resident for any psychosocial needs that arise.The facility form, Statement of (R6), dated 9/23/25 and signed by R6 documents, Friday (9/19/25) I was admitted in to (facility). I had fallen asleep and when I woke up it was 6:15 PM. I hit my call light, (I) was in need of using (the) bedpan. At 6:55 PM, Head Nurse (V6/RN) came in and advised me that they have 5 residents that require feeding assistance and once they are done, (V6) has to watch over the dining area while 5 assisted (residents) were taken care of. The (V6) stopped and asked if I had gotten my food yet. I replied no, but I desperately need to pee, (V6) said, 'Oh fuck, alright. I'll send someone down.' At approximately 7:35 P.M. I was finally brought my supper. At approximately 8:15 PM, I finagled myself to first reach the gray peanut looking bowl (emesis basin) and managed to get it underneath of myself enough to use it as a bed pan. Estimated around 9:12 PM. (V9 and V8/Certified Nursing Assistants) came to check on me. I told them to be cautious cause on my dinner tray was the container I used to pee in. They said, 'Hit your call light we will help you.' I informed them (V6/RN) had two hours prior said she would send someone in to assist me and they both informed me that to their knowledge, (V6/RN) never once said a word about me needing to use the restroom.The facility form, Staff Statement, dated 9/19/23 and signed by V9/CNA documents, We (myself and V8/CNA) went into (R6's) room around 9:15 P.M. to meet the new resident (R6). (R6) was very unhappy due to asking (V6/RN) around 6:15 P.M. to go to the restroom. (R6) said (V6) told her she would get someone. I was never informed and did not know we had a new resident (R6) until entering (R6's) room. (R6) wanted to call her family. We explained we had no cordless (phone). We did let (R6) use our (phone). We asked if (R6) needed anything else and apologized to (R6). (R6) did urinate in a mouth wash basin due to not being put on a bedpan when asked.The facility form, Staff Statement, dated 9/19/25 and signed by V8/CNA documents, After supper, (V9/CNA) and I went to answer call lights. We went down to (R6's) room to see what see wanted. We were informed that she had her call light on, to use the restroom from 6:15 PM to 7:30 PM. (R6) told us (V6/RN) was informed and that (V6) would come tell us. We never got informed and (R6) had to use a small basin so she didn't pee her pants. Later on (R6) was upset and wanted to call her mother. (R6) told us that (V6/RN) told her to stop turning on her light.The facility form, Staff Statement, dated 9/19/25 and signed by V7/Licensed Practical Nurse (LPN) documents, During med (medication) pass I overheard (R6) crying to (V8 and V9/CNAS). Upon entering (R6's) room, R6 stated she called her parents, and they were coming to get her, (R6) wasn't going to stay here (facility). (R6) was very upset and stated the nurse wearing a red shirt (V6/RN) answered her call light and told her not to put it on again, that the staff were busy, and she had already put it on three times, in an hour. (R6) stated (V6) was very rude and yelled at her. (R6) told (V6) she needed the bedpan. (V6) stated she will tell someone. (R6) waited two hours before someone came back to help her.The untitled facility form dated 9/25/25 and signed by V1/Administrator in Training) documents, On 9/24/25, myself, (V14/Corporate Human Resources Director) and V2/Director of Nurses spoke with (V6/RN) about the incident that was reported on 9/19/25. (V6/RN) stated she asked one of the CNAS (Certified Nursing Assistants) to put (R6) on the bedpan. When asked what VNA she asked, (V6) stated, 'I thought I told (V8). (V8) was asked if (V6) asked her to put (R6) on the bedpan, (V8) stated that ((V6) did not ask her. (V9), the second CNA working on the evening of 9/19/25, also stated that (V6) never asked her to put (R6) on the bedpan. When (V6) was asked if she were carrying out a task that would prevent her from assisting (R6), she stated the hospital reported that (R6) was a 2 (person) assist. Upon investigating, it was found that (R6) was not a 2 person assist for bed mobility.R6's facility admission Record documents that R6 was admitted to the facility on [DATE], from a local hospital with the following diagnoses Major Depressive Disorder, Acute Pain in Left Hip and Iron Deficiency Anemia.R6's facility admission assessment dated [DATE] documents that R6 is alert and oriented to person, place, time and situation.R6's Nursing Progress Notes, dated 9/19/25 documents that R6 was admitted to the facility on [DATE] at 4:05 P.M.On 11/23/25 at 9:38 A.M., V7/Licensed Practical Nurse (LPN) stated she was the nurse working the evening of 9/19/25. States she was doing the evening medication pass and she heard R6 crying. States when she entered R6's room, R6 was crying and very upset stating that earlier in the day, she had asked V6/RN to assist her on the bedpan as she had to urinate and V6 refused to assist her. States R6 said the incident occurred around 6 PM. States V6 told R6 all staff were busy assisting other residents. R6 states V6 swore at (R6) and told her she would get someone to help R6 when they could. V7 states that R6 told her a couple of hours later, no staff had responded to assist her on the bedpan and R6 was finally able to get herself closer to her bedside stand, grab an emesis basis, place it under herself and pee. V7 states R6 was very upset about having to use the emesis basin, that it hurt to use the emesis basin and not a bedpan and that R6 stated she was humiliated due to using the emesis basin to urinate in. At that time, V7 states R6 told her she did not want V6 to ever take care of her again.On 11/25/25 at 11:54 A.M., V2/Director of Nurses (DON) stated she would consider verbal abuse to include anything that an employee would say to a resident that would upset the resident or hurt their feelings, name calling or vulgar language. States she and the facility administrator (V1) were the ones that investigated the 9/19/25 occurrence between V6/Registered Nurse and R6. V2/DON states she would consider staff cursing at, or in front of a resident, as verbal abuse. States V6 was given a 3-day suspension after the 9/19/25 incident and reprimanded for 'Misconduct- Failure to Meet Resident Needs. States V6 returned to work on 10/1/25 and the delay was caused by a delay in investigating the 9/19/25 incident. V2 states she did not make the decision to call the incident misconduct, nor did she make the decision to recommend a 3-day suspension. V2 states V12/Regional Nurse Consultant, V13/Regional Director of Operations and V14/Corporate Human Resources Director made the decision. V2 states V6/RN then worked throughout the facility for the rest of September, all of October and into November 2025.On 11/25/25 at 1:05 P.M., V1/Administrator stated she would consider verbal abuse as derogatory comments directed towards a resident, cursing in front of, or at a resident, yelling, harassing, etc. States she and V2/DON investigated the 9/19/25 incident between V6/RN and R6. States R6 had just been admitted to the facility that afternoon. States R6 was alert and oriented and wrote her own statement to the incident. States R6 was upset about the incident and stated R6 told her V6 came into her room, cussed at her, refused to offer her toileting assistance and R6 was forced to urinate in an emesis basin, as a bed pan was not provided for her. V1 states after gathering a statement from R6 and V7/LPN and V8 and V9/CNAs, she contacted corporate staff (V12/Regional Nurse Consultant, V13/Regional Director of Operations and V14/Corporate Human Resources Director) and the decision was made to suspend V6 for 3 days and call the incident 'Misconduct.' V1 confirms R6 was informed of the decision and returned to work on 10/1/25. V1 confirms the facility Employee Handbook, which was reviewed and provided to V6 in December 2024 documents that, 'Engaging in abusive, discourteous, profane, indecent or unprofessional language or conduct while on duty or on (facility) property is grounds for immediate dismissal. A review of V6/Registered Nurse's facility Timecards documents that V6 continued to work at the facility from 9/19/25 through 11/12/25. 2. The facility form, Final Abuse Investigation Report, dated (initial) 11/13/25 and (final) 11/19/25 documents, Resident: (R7) and Staff: (V6/Registered Nurse-RN). Staff to resident verbal altercation. Facts determined: On 11/12/25 at approximately 7:40 A.M., R7 told V6/RN that he needed to use the restroom. V6/RN asked R7 if he could wait due to staff being busy and her having to stay in the dining room. R7 stated that he needed to go, and he was not waiting. V6/RN took R7 down the hallway where the CNAs (Certified Nursing Assistants) were assisting another resident. V6 returned to the dining room. No psychosocial needs noted. Proper notifications made. V6/RN suspended immediately. Abuse Coordinator immediately initiated investigation. Facility leadership reviewed the medical record of R7. Employees who were knowledgeable of the allegation were interviewed by the Abuse Coordinator. Based on the results of the investigation the facility has found the following: IDT (Intradisciplinary Team) met to discuss the investigation. Also discussed appropriate interventions for resident. Care plan reviewed and updated accordingly. SSD (Social Services Director) will follow up with resident for any psychosocial needs that arise.R7's Abuse Allegation Interview, dated as 11/12/25 and signed by V1/Administrator in Training documents, Can you tell me what happened? I needed to pee. so, I didn't wet myself. (V6/RN) yelled at me and pushed me in my wheelchair down the hall. What was said? (V6/RN) was cussing and saying I already went.The facility form, Staff Statement, dated 11/12/25 and signed by V8/Certified Nursing Assistant/CNA documents, I was in (another resident's room) with (V9/CNA). V6/RN was shouting at (R7) because he needed to use the bathroom. V6 then pushed R7 down the long hall and said, 'See all these call lights' and told R7 he needed to wait and let R7 down the hall. During V6's shouting, V6 mentioned the F word, saying,'Fuck this' and 'You need to fucking wait.'The facility form, Staff Statement, dated 11/12/25 and signed by V9/Certified Nursing Assistant/CNA documents, (V6/RN) brought (R7) to the end of the hallway and says, '(R7) needs to be taken to the fucking bathroom now.'R7's current Minimum Data Set Assessment, dated 11/13/25 documents R7's BIMS (Brief Interview for Mental Status) as 8:15 (moderate cognitive impairment) and his toileting assistance as frequently incontinent and dependent on staff for toileting.On 11/23/25 at 1:05 P.M., R7 was alert and sitting at the side of his bed. R7 was unable to recall V6's name but did recall an incident with a nurse that occurred recently where he requested to use the restroom, when he was sitting in the dining room waiting for his breakfast. R7 states he needed to pee, so he didn't wet himself. Stated the nurse told him all staff were busy, and he would have to wait. Stated the same nurse cussed at him, pushed his wheelchair out into the hall and left him sitting in the hallway. States he did not hear the nurse ask any staff to assist him and when the CNAs did assist him, he had urinated on himself. States he was humiliated by the situation and doesn't want (V6/RN) to come near him any longer.On 11/23/25 at 1:25 P.M., V9/Certified Nursing Assistant (CNA) stated she was working the day of the incident with V6/Registered Nurse (RN) and R7. V9/CNA states she was in another resident's room when she heard V6/RN yelling and swearing at R7. V9/CNA states V6/RN entered the resident room where she was assisting another resident and V6/RN yelled that R7 needed to be taken to the fucking bathroom. V9/Certified Nursing Assistant stated when she and V8/Certified Nursing Assistant (CNA) were able to take R7 to the bathroom, he had been incontinent in his pants and expressed he was humiliated by the situation.On 11/24/25 at 11:13 A.M., V8/Certified Nursing Assistant (CNA) stated she was working the day of the incident involving V6/Registered Nurse (RN) and R7. V8/CNA stated she and V9/Certified Nursing Assistant (CNA) were providing care to another resident when they heard V6/RN yelling and cussing at R7 because (R7) needed to use the bathroom, from the hallway. V8/CNA stated V6 was yelling at R7, 'See all these call lights (on), and yelling at (R7), 'you need to fucking wait to use the bathroom.' Then V6/RN left R7 sitting in the hallway, outside of the room where we were helping someone else. V8/CNA states when she and V9 were able to get to R7 he had urinated on himself and was very upset about it.On 11/25/25 at 11:54 A, M, V2/Director of Nurses stated the 11/12/25 incident between V6/RN and R7 was also investigated by herself and V1/Administrator. V2/DON states she would consider the incident to be verbal abuse as the resident and two different staff members overheard V6/RN cussing and yelling at R7 V2 states V12, V13 and V14 (Corporate Staff) made the decision to call the incident Misconduct: Unsatisfactory job performance and place V6 on a 'Final Warning.' V2 states when she and V1 called R6 to discuss the incident and advise her of the final warning and tell V6 to return to work on November 21, 2025, V6 stated she was terminating her employment with the facility. On 11/25/25 at 1:05 P.M., V1/Administrator in Training stated there was a second incident on 11/12/25 involving V6/Registered Nurse and R7 where V6 was overheard cussing and yelling at R7 when R7 requested to use the bathroom while in the facility dining room as he didn't want to urinate on himself. V1 states during her investigation it was determined that V6 refused to provide toileting assistance for R7, pushed R7's wheelchair out of the dining room and down the hall, opposite direction from his room and placed him outside of another resident's room where V8 and V9/CNAS were providing care to another resident. V1 stated the incident was discussed with corporate staff (V12, V13 and V14) and the decision was made, at the corporate level, to call the incident, 'Misconduct' and to place V6/RN on a final warning. When V6 was called on 11/20/25 and informed of the decision to place her on a final warning status and to inform V6 to return to work on 11/21/25, V6 chose to terminate her employment with the facility.3. The facility form, Final Abuse Investigation report, dated (initial) 9/1/25 and (final) 9/5/25 documents, Resident to resident physical abuse. On 9/1/25 at 12:35 P.M., R1 was propelling out of the dining room. R2 was in a wheelchair adjacent to dining room entrance. CNA (Certified Nursing Assistant/V3) heard yelling, went to investigate and observed R2 make physical contact with R1. CNA and Nurse immediately separated both residents. (V17/Licensed Practical Nurse) assessed both residents. proper notifications made. On 11/23/25 at 9:51 A.M., V3/Certified Nursing Assistant (CNA) stated she was working on 9/1/25 when she witnessed R1 propelling himself out of the locked unit dining room while R2 was entering the dining room. V3/CNA states R2 began yelling at R1 and cussing at R1 and when their wheelchairs came into contact, R2 stood up and hit R1 in the face. 4. The facility form, Final Abuse Investigation report, dated (initial) 9/18/25 and (final) 9/23/25 documents, Resident to resident physical abuse. On 9/28/25 at approximately 8:05 A.M., R3 discovered R4 in his room. R3 stated he threw his coffee at R4. R4 stated that the coffee did not hit him. V4/Licensed Practical Nurse heard yelling in the hallway. proper notifications made. Investigation initiated. R3 Nursing Progress Note dated 9/23/25 documents, (R3) in hallway yelling at (R4). (R3) upset for (R4) l being in (R3's) room taking things. (R3) kicked and punched (R4) in head. Residents separated and taken back to rooms. Also reported to this nurse right before this incident (R3) threw coffee at (R4) and hit (R4). No injuries noted. MD (Medical Doctor) notified, and message left for (Power of Attorney).On 11/23/25 at 10:30 A.M., R3 was alert, and up in his room. R3 was able to recall the incident of 9/18/25. States R4 came into to his room and had his wheelchair back to R3. States he yelled at R4 to leave his room, R4 didn't move, so he kicked the back of R4'd wheelchair and threw his coffee on R4. At the same time, he was yelling for a nurse, who responded and removed R4 from his room.5. The facility form, Final Abuse Investigation report, dated (initial) 9/19/25 and (final) 9/26/25 documents, Resident to resident physical abuse. On 9/20/25 at approximately 7:00 P.M., Certified Nursing Assistant (CNA) V5 was helping another resident when she heard yelling coming from (R5's) room. R1 was in R5's room. V5/CNA observed R5 strike R1 with an open hand in the back of the head. CNA separated residents immediately and re-directed R1 out of R5's room. Proper notifications made.R5's Nursing Progress Notes, dated 9/20/25 document, Notified by (facility) staff nurse that physical altercation between (R1 and R5) took place. Staff nurse states (R1) wandered into (R5's) room and while R1 was in room, R5 states he asked (R1) numerous times to get out. R5 states he struck R1 in the back of the head with an open hand. R5 states V5/CNA entered the room at the same time he hit R1.6. The facility form, Preliminary Abuse Investigation Report, dated 11/23/25 documents, Physical Abuse, employee to resident. On 11/23/25 at approximately 5;30 P.M., R8 reported that agency staff (V10/Certified Nursing Assistant/CNA) was rough with cares. V10/CNA immediately suspended. R8 assessed immediately. Appropriate notifications made.On 11/24/25 at 11:17 A.M., R8 was alert, oriented, and seated in an easy chair in her room, reading her bible. R8 was able to recall the incident of 11/23/25. R8 states the tall, black man that took care of me yesterday (11/23/25) was rough with me and hurt my wrist during cares. States she was sitting in her chair in her room, reading her bible when V10/Agency CNA entered the room, roughly took her bible out of her lap and grabbed her right wrist and pulled on it, telling her she was wet (incontinent) and needed to get up and go to the bathroom. R8 states she told V10 she would as soon as she finished the passage she was reading, but V10 was insistent and kept pulling on her wrist. R8 states she told V10 he hurt her and to leave her alone. R8 states her wrist feels okay now but was painful yesterday.The facility form, Staff Statement, dated 11/23/25 and signed by V11/Certified Nursing Assistant documents, While in the dining room passing medications this nurse overheard (R8) telling her table (mates) at supper that the male CNA hurt her wrist. As I approached (R8) she stated that she did not want that male CNA take care of her again, he hurt her wrist. (R8) states (V10) came in her room, grabbed her bible out of her hands and told her to get up and go to the bathroom and he grabbed her wrist and hurt it. No injuries noted. V2/Director of Nurses and V1/Administrator notified. On 12/1/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:1. All residents with a BIMS 12 and greater currently in-house had abuse interview completed to ensure no other residents had been harmed and they feel safe in the facility completed by V24/Dietary Manager by 11/26/25.2. All residents with a BIMS 11 and below and skin assessments completed to ensure no other residents had been harmed and they feel safe in the facility completed by V2/Director of Nurses and V17/Wound Nurse by 11/26/25.3. Family members/POAs of those residents with a BIMS of 11 and below currently in-house had abuse interviews completed to ensure no other residents had been harmed and they feel that their loved one is safe in the facility. Initiated by V22/Business Office Manager on 11.26.25. 38 of these families answered the phone and were interviewed. A message to return the phone call has been completed with the remaining 13 families. Facility will continue to make daily calls until 100% compliance. Administrator to monitor for compliance. 4. All residents currently in-house had an abuse/neglect screening completed with care plans updated to reflect level of at risk for abuse as indicated. Completed by V23/Social Services Director on 11/26/25.5. Abuse in-servicing for all staff. Completed by V1/Administrator in Training and V2/Director of Nursing, on 11.26.25. Abuse Training will remain ongoing with all new hires, all agency staff, and current staff. All staff in serviced before their next scheduled shift. 6. Facility Administrator or Designee will interview 5 residents per week for 12 weeks to ensure residents feel safe and have no concerns with abuse. Facility will utilize the abuse Allegation Interview questions for residents. Completed on 11/26/25 by V1/Administrator in Training.7. Facility Administrator or Designee will interview 5 staff members per week x 12 weeks to ensure staff know reporting requirements. Facility will utilize an audit tool related to Abuse/Abuse Reporting/Abuse investigation. Facility Administrator or designee will monitor for completion. Completed by V1/Administrator in Training on 11/26/25.8. Administrator In Training in-serviced on abuse by V12/Regional Nursing Consultant on 11/26/25.9. All residents have the potential to be affected by V6(RN) alleged abuse. V6 (RN) is no longer employed as of 11/12/25.10. R6 had the potential to be affected by V6 (RN) alleged abuse. R6 discharged on 10/8/25. Psych services are available to all residents by Psychiatric vendor. Completion date 11/26/25

Based on interview and record review, the facility failed to maintain a resident's right to be treated with dignity for (R6), one of eight residents reviewed for resident rights, in a sample of 8. This failure resulted in R6 to suffer shame and embarrassment. The (State) Long-Term Care Ombudsman Program Residents' Rights for People In Long-Term care Facilities, provided to all new residents upon admission to the facility documents, As an individual living in a long-term care facility, you retain the same rights as every citizen of (State) and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities. Your rights to dignity and respect* Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.The facility Dignity policy, dated (effective) 03/2024 directs staff, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Refrain from practices demeaning to residents such as refusing to comply with a resident's request for bathroom assistance during meal times.The facility Final Abuse Investigation Report dated Initial Report 9/19/25 and Final Report 9/24/25 documents, Staff (V6/Registered Nurse) to resident (R6) verbal altercation. On 9/19/2025 at approximately 9:30 P.M., V7/Licensed Practical Nurse observed R6 visibly upset, while V7 was doing medication pass. R6 reported to the nurse on shift (V7) that the previous shift nurse (V6/RN) would send a CNA (Certified Nursing Assistant) to put her on the bedpan. V6/RN immediately suspended. Investigation began.R6's (facility) handwritten statement, dated 9/23/2025 documents, Friday I was admitted in to (facility). I had fallen asleep and when I woke up it was 6:12 P.M., I hit my call light, (I) was in need of using 9the) bed pan. At 6:55 P.M., Head Nurse (V6/RN) came in and advised me that they had 5 residents that require(d) feeding assistance and once they are done, she has to over watch the dining area while 5 assisted (residents) are taken care of. Then she stopped and asked if I had gotten my food yet. I replied, 'no, but I desperately need to pee.' She (V6/RN) said, 'Oh fXXX, alright I'll send someone down.' At approximately 7:35 P.M. I was finally brought my supper. At approximately 8:15 P.M., I finagled myself to first reach (the) gray peanut looking bowl and managed to get it underneath of myself enough to use it as a bedpan. Estimated at 9:12 P.M., (V8 and V9/CNAs) came to check on me. I told them to be cautious cause on my dinner tray was the container I used to pee in and they said, hit your call light and we will help you. I informed them that (V6/RN) had 2 hours prior said she would send someone in to assist me and they both informed me that to their knowledge, (V6/RN) never once said a word to anyone about me needing to use the restroom.On 11/23/25 at 9:38 A.M., V7/Licensed Practical Nurse (LPN) stated she was the nurse working the evening of 9/19/25. V7/LPN states she was doing the evening medication pass and she heard R6 crying. V7 states when she entered R6's room, R6 was crying and very upset stating that earlier in the day, she had asked V6/Registered Nurse (RN) to assist her on the bedpan as she had to urinate. States V6/RN told R6 all staff were busy assisting other residents. R6 states V6 swore at R6 and told her she would get someone to help R6 when they could. V7/LPN states that R6 told her a couple of hours later, no staff had responded to assist her on the bedpan and R6 was finally able to get herself closer to her bedside stand, grab an emesis basis, place it under herself and pee. V7 states R6 was very upset about having to use the emesis basin, that it hurt to use the emesis basin and not a bedpan and that R6 stated she was humiliated due to using the emesis basin to urinate in. At that time, V7/LPN states R6 told her she did not want V6/RN to ever take care of her again.On 11/25/25 at 1:05 P.M., V1/Administrator In Training stated V6/Registered Nurse should have assisted R6 to the toilet when she requested, and she considers R6 being forced to urinate in an emesis basin as unacceptable and a violation of R6's resident's rights.

Based on interview and record review, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, including identification of abuse, failed in the protection of residents during investigations, and failed taking corrective actions for allegations of abuse, for two of eight residents reviewed for abuse (R6 and R7), in a sample of 8. These failures resulted in this same employee verbally abusing a second resident (R8) on a different occasion. The facility Abuse Prevention and Reporting policy, dated 09/2024 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by Identifying occurrences and patterns of potential mistreatment; Immediately protecting residents involved in identified reports of possible abuse; and making necessary changes to prevent future occurrences.The facility Preliminary Abuse Investigation Report, dated 9/19/25 documents, Verbal or Mental Abuse. On 09/19/2025 at approximately 9:15 P.M., (R6) reported alleged verbal altercation with an employee (V6/Registered Nurse). (V6/RN) suspended immediately. Appropriate notifications made. Investigation initiated. 5 day Final (Report) to come.On 9:38 A.M., V7/Licensed Practical Nurse stated she was the nurse working the evening of 9/19/25. States she was doing the evening medication pass and she heard R6 crying. States when she entered R6's room, R6 was very upset stating that earlier in the day, she had asked V6/Registered Nurse (RN) to assist her on the bedpan as she had to urinate. States V6 told R6 all staff were busy assisting other residents. R6 states V6 swore (cussed) at R6 and told her she would get someone to help R6 when they could. At that time, V7 states R6 told her she did not want V6 to ever take care of her again.On 11/25/25 at 11:54 A.M., V2/Director of Nurses (DON) stated she and the facility administrator (V1) were the ones that investigated the 9/19/25 occurrence between V6/Registered Nurse and R6. V2/DON states she would consider staff cursing at, or in front of a resident, as verbal abuse. States V6 was given a 3-day suspension after the 9/19/25 incident and reprimanded for 'Misconduct- Failure to Meet Resident Needs. States V6 returned to work on 10/1/25 and the delay was caused by a delay in investigating the 9/19/25 incident. V2 states she did not make the decision to call the incident misconduct, nor did she make the decision to recommend a 3-day suspension. V2 states V12/Regional Nurse Consultant, V13/Regional Director of Operations and V14/Corporate Human Resources Director made the decision. V2 states V6/RN then worked throughout the facility for the rest of September, all of October and into November 2025.On 11/25/25 at 1:05 P.M., V1/Administrator stated she and V2/Director Of Nurses investigated the 9/19/25 incident between V6/Registered Nurse and R6. States R6 was upset about the incident and stated R6 told her (V6/Registered Nurse) came into her room, cussed at her, refused to offer her toileting assistance and R6 was forced to urinate in an emesis basin, as a bed pan was not provided for her. V1 states after gathering a statement from R6 and V7/LPN and V8 and V9/CNAs, she contacted corporate staff (V12/Regional Nurse Consultant, V13/Regional Director of Operations and V14/Corporate Human Resources Director) and the decision was made to suspend V6 for 3 days and call the incident 'Misconduct.' V1 confirms R6 was informed of the decision and returned to work on 10/1/25. V1 confirms the facility Employee Handbook, which was reviewed and provided to V6 in December 2024 documents that, 'Engaging in abusive, discourteous, profane, indecent or unprofessional language or conduct while on duty or on (facility) property is grounds for immediate dismissal. V1/Administrator also stated she would consider the incident to be verbal abuse, that V6/RN continued to work throughout the facility for the next two months and no changes were made to prevent future occurrences of abuse.A review of V6/Registered Nurse's facility Time Cards documents that V6 continued to work at the facility from 9/19/25 through 11/12/25. 2. The facility form, Final Abuse Investigation Report, dated (initial) 11/13/25 and (final) 11/19/25 documents, Resident: (R7) and Staff: (V6/Registered Nurse-RN). Staff to resident verbal altercation. Facts determined: On 11/12/25 at approximately 7:40 A.M., R7 told V6/RN that he needed to use the restroom. V6/RN asked R7 if he could wait due to staff being busy and her having to stay in the dining room. R7 stated that he needed to go and he was not waiting. V6/RN took R7 down the hallway where the CNAs (Certified Nursing Assistants) were assisting another resident. V6 returned to the dining room. No psychosocial needs noted. Proper notifications made. V6/RN suspended immediately. Abuse Coordinator immediately initiated investigation. Facility leadership reviewed the medical record of R7. Employees who were knowledgeable of the allegation were interviewed by the Abuse Coordinator. Based on the results of the investigation the facility has found the following: IDT (Intradisciplinary Team) met to discuss the investigation. Also discussed appropriate interventions for resident. Care plan reviewed and updated accordingly. SSD (Social Services Director) will follow up with resident for any psychosocial needs that arise.R7's Abuse Allegation Interview, dated as 11/12/25 and signed by V1/Administrator In Training documents, Can you tell me what happened? I needed to pee. so I didn't wet myself. (V6/RN) yelled at me and pushed me in my wheelchair down the hall. What was said? (V6/RN) was cussing and saying I already went.The facility form, Staff Statement, dated 11/12/25 and signed by V8/Certified Nursing Assistant/CNA documents, I was in (another resident's room) with (V9/CNA). V6/RN was shouting at (R7) because he needed to use the bathroom. V6 then pushed R7 down the long hall and said, 'See all these call lights' and told R7 he needed to wait and let R7 down the hall. During V6's shouting, V6 mentioned the F word, saying, 'FXXX this' and 'You need to FXXX wait.'On 11/25/25 at 11:54 A,M, V2/Director of Nurses stated the 11/12/25 incident between V6/RN and R7 was also investigated by herself and V1/Administrator. V2/DON states she would consider the incident to be verbal abuse as the resident and two different staff members over heard V6/RN cussing and yelling at R7 V2 states V12, V13 and V14 (Corporate Staff) made the decision to call the incident Misconduct: Unsatisfactory job performance and place V6 on a 'Final Warning.' V2 states when she and V1 called R6 to discuss the incident and advise her of the final warning and tell V6 to return to work on November 21, 2025, V6 stated she was terminating her employment with the facility. On 11/25/25 at 1:05 P.M., V1/Administrator In Training stated there was a second incident on 11/12/25 involving V6/Registered Nurse and R7 where V6 was overheard cussing and yelling at R7 when R7 requested to use the bathroom while in the facility dining room as he didn't want to urinate on himself. V1 states during her investigation it was determined that V6 refused to provide toileting assistance for R7, pushed R7's wheelchair out of the dining room and down the hall, opposite direction from his room and placed him outside of another resident's room where V8 and V9/CNAS were providing care to another resident. V1 stated the incident was discussed with corporate staff (V12, V13 and V14) and the decision was made, at the Corporate level, to call the incident, 'Misconduct' and to place V6/RN on a final warning. When V6 was called on 11/20/25 and informed of the decision to place her on a final warning status and to inform V6 to return to work on 11/21/25, V6 chose to terminate her employment with the facility. V1/Administrator also stated she would consider the incident to be verbal abuse, and no changes were made to prevent future occurrences of abuse.

Based on interview and record review, facility staff refused to provide toileting assistance to two of two residents (R6 and R7), reviewed for Activities of Daily Living assistance, in a sample of 8. R6's Assessment Progress Note, dated 9/19/25 documents, 9/19/25 admitted from local hospital with diagnoses of Major Depressive Disorder and Acute Pain. R6's Nursing admission Assessment, dated 9/19/25, documents R6 as, Alert, oriented to person, place, time. Toileting assistance as requiring substantial/maximal assistance.R6's (facility) handwritten statement, dated 9/23/2025 documents, Friday I was admitted in to (facility). I had fallen asleep and when I woke up it was 6:12 P.M., I hit my call light, (I) was in need of using (the) bed pan. At 6:55 P.M., Head Nurse (V6/RN) came in and advised me that they had 5 residents that require(d) feeding assistance and once they are done, she has to over watch the dining area while 5 assisted (residents) are taken care of. Then she stopped and asked if I had gotten my food yet. I replied, 'no, but I desperately need to pee.' She (V6/RN) said, 'Oh fXXX, alright I'll send someone down.' At approximately 7:35 P.M. I was finally brought my supper. At approximately 8:15 P.M., I finagled myself to first reach (the) gray peanut looking bowl and managed to get it underneath of myself enough to use it as a bedpan. Estimated at 9:12 P.M., (V8 and V9/CNAs) came to check on me. I told them to be cautious cause on my dinner tray was the container I used to pee in and they said, hit your call light and we will help you. I informed them that (V6/RN) had 2 hours prior said she would send someone in to assist me and they both informed me that to their knowledge, (V6/RN) never once said a word to anyone about me needing to use the restroom.On 11/23/25 at 9:38 A.M., V7/Licensed Practical Nurse (LPN) stated she was the nurse working the evening of 9/19/25. V7/LPN states she was doing the evening medication pass and she heard R6 crying. V7 states when she entered R6's room, R6 was crying and very upset stating that earlier in the day, she had asked V6/Registered Nurse (RN) to assist her on the bedpan as she had to urinate. States V6/RN told R6 all staff were busy assisting other residents. R6 states V6 swore at R6 and told her she would get someone to help R6 when they could. V7/LPN states that R6 told her a couple of hours later, no staff had responded to assist her on the bedpan.On 11/25/25 at 1:05 P.M., V1/Administrator In Training confirmed V6/Registered Nurse should have assisted R6 to the toilet when she requested. 2. R7's facility admission Record documents that R7 was admitted to the facility on [DATE] with the following diagnoses Cerebral Ischemia, Type 2 Diabetes Mellitus and Fractured Femur (10/31/25).R7's most recent Minimum Data Set Assessment, dated 11/23/25 documents R7's Cognitive Status as 8:15 (moderately impaired) and his Toileting Assistance Needed as frequently incontinent and dependent on staff for assistance.R7's current Care Plan includes the following Focus Area: (R7) has an ADL (Activities of Daily Living) performance deficit. Also included are the following Interventions: Toilet Use- (R7) is dependent upon staff for toileting. The facility form, Final Abuse Investigation Report, dated (final) 11/19/25 documents, On 11/12/25 at approximately 7:40 A.M., R7 told V6/Registered Nurse (RN) that he needed to use the restroom. V6/RN asked R7 if he could wait due to staff being busy and her having to stay in the dining room. R7 stated that he needed to go and he was not waiting. V6/RN took R7 down the hallway where the CNAs (Certified Nursing Assistants) were assisting another resident. V6 returned to the dining room.On 11/23/25 at 1:05 P.M., R7 was alert and sitting at the side of his bed. R7 was unable to recall V6's name but did recall an incident with a nurse that occurred recently where he requested to use the restroom, when he was sitting in the dining room waiting for his breakfast. R7 states he needed to pee, so he didn't wet himself. Stated the nurse told him all staff were busy, and he would have to wait. Stated the same nurse cussed at him, pushed his wheelchair out into the hall and left him sitting in the hallway. States he did not hear the nurse ask any staff to assist him and when the CNAs did assist him, he had urinated on himself. States he was humiliated by the situation and doesn't want (V6/RN) to come near him any longer.On 11/25/25 at 1:05 P.M., V1/Administrator In Training stated there was a second incident on 11/12/25 involving V6/Registered Nurse and R7 when R7 requested to use the bathroom while in the facility dining room as he didn't want to urinate on himself. V1 states during her investigation it was determined that V6 refused to provide toileting assistance for R7, pushed R7's wheelchair out of the dining room and down the hall, opposite direction from his room and placed him outside of another resident's room where V8 and V9/CNAS were providing care to another resident. At that time, V1 verified that V6/RN should have assisted R7 with his toileting needs.

Based on record review and interview the facility failed to assess one resident (R1) of three reviewed for fall risk.R1 was admitted to the facility 12/28/23 with diagnoses to include, but not limited to: Major Depressive Disorder, Benign Prostatic Hyperplasia, Hypertension, Diabetes, and Cerebral Ischemia.R1 fell 10/28/25 at 5:05 AM resulting in R1 sustaining a right hip fracture.The facility's Fall Prevention Program policy dated 05/2025 documents, The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident.R1's medical record does not document a fall risk assessment completed November 2024 through August 2025.On 11/7/25 at 1:28 PM, V1 (Director of Nursing) verified R1 did not have a fall risk assessment completed quarterly November 2024 through August 2025.On 11/12/25 at 12:32 PM V11 (Regional Registered Nurse) verified the facility policy documents a resident is to have a fall risk assessment completed on admission and quarterly and that R1 did not have a fall risk assessment completed November 2024 through August 2025.

Based on interview and record review, the facility failed to implement interventions to reduce a resident's risk of a fall (R2) and failed to provide adequate supervision to prevent falls (R1 and R2), for two of three residents reviewed for falls, in a sample of 3. These failures resulted in R1 sustaining a fall with a hematoma and R2 sustaining a fall with a right hip fracture, pubic rami fracture and a T12 compression fracture. FINDINGS INCLUDE: The facility policy, Fall Prevention dated (revised) 11/10/18 directs staff, To provide for resident safety and to minimize injuries related to falls. All staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned, or assistance must be provided to the resident. Appropriate interventions will be implemented for residents determined to be at high risk for falls. 1. R1's New Admission Information form documents that R1 was admitted to the facility on [DATE]. R1's facility Cumulative Diagnosis Log documents R1's diagnoses: Dementia Disorder, Severe Dementia with Agitation, Legally Deaf, Anxiety. R1's Fall Risk Assessment, dated 3/5/24 documents that R1 is a High Risk for Falls, score 14 (10 points or more equals high risk for falls). R1's Care Plan, dated 3/22/24 includes the following Focus Area: (R1) does not understand mobility limits due to cognitive limitations. Also included are the following Interventions: Assist to recliner if restless in bed; Attempt to anticipate needs, Encourage and assist placement of proper non-skid footwear throughout the night and while in bed; Encourage resident to sit in areas well supervised by staff; Monitor in common areas while awake. R1's facility Investigation Report for Falls, dated 3/17/24 documents, 3/17/24 fell in room, unattended while making bed, due to vertigo. No injury. Intervention: Medication review. First (resident) up (in morning). Lab (laboratory) work. R1's facility Investigation Report for Falls, dated 3/18/24 at 3:00 A.M. documents, Got up from bed unassisted. Laceration to back of head, sent to ER (emergency room ) for staples. Intervention: Prefers to sleep in recliner in main area, at times. R1's facility Investigation Report for Falls, dated 6/15/24 at 4:40 P.M. documents, Sitting in (high back padded reclining) chair in dining room, unattended. Stood from chair and fell while not wearing non-skid footwear. Intervention: Remind staff to apply non-skid footwear at all times. R1's facility Investigation Report for Falls, dated 6/24/24 at 8:00 P.M. documents, fell in kitchenette area from wheelchair, unattended. Hematoma to left eyebrow. Intervention: Hospice to provide a peddle reclining wheelchair. R1's facility Investigation Report for Falls, dated 7/1/24 documents, Slid from wheelchair, next to nurse. No injuries. On 7/8/24 at 2:18 P.M., V4/Agency Registered Nurse stated, I was the nurse on duty the evening of June fifteenth when (R1) fell in the dining room. It was only me and two CNAs (Certified Nursing Assistants) working at the time. (V7/CNA-former employee) had left the dining room with a resident and (R1) stood from (R1's) wheelchair and fell to the ground. Another resident yelled for help and (V7) returned to the dining room and found (R1). I was down the hall, and the other CNA was down the hallway too. (R1) only had socks on, they weren't non-skid. I wasn't aware that R1 was supposed to be under direct line of vision of staff at all times when (R1) was out of bed and I didn't know (R1) was supposed to have non-skid footwear on, also. On 7/8/24 at 2:31 P.M., V8/Agency Licensed Practical Nurse stated, (R1) was out of (R1's) Alprazolam on June twenty-ninth and July first when I worked. I was under the impression it had been ordered by the hospice nurse and was going to be delivered. I had nothing to give (R1) for her anxiety. I have never seen (R1) so agitated and anxious. (R1) even fell , when I was standing near (R1) because (R1) couldn't sit still. On 7/9/24 at 7:00 A.M., V6/Registered Nurse confirmed that R1 fell in the kitchenette area of the locked unit on 6/24/24 at 8 PM, while unattended by staff. 2. R2's Facility Profile Sheet documents that R2 was admitted to the facility on [DATE] at 10:45 A.M. with a diagnosis of Weakness, Major Depressive Disorder, (recent) Fracture of Left Radius and Left Femur. R2's Progress Notes dated 5/3/24 at 2:20 P.M. document, (R2) had an unwitnessed fall in room. (R2) came out of room and was seen by nurse while (R2) was holding onto the rail and stated she fell . (R2) assessed and sent to emergency room . R2's Baseline Care Plan, dated 5/3/24 documents, high Fall Risk Assessment, Fall History, Gait/Balance Problems, Weakness. R2's emergency room Report, dated 5/3/24 documents, (R2) lost balance and fell at (facility). 2.5 CM (Centimeter) laceration to scalp. 4 staples placed. R2's facility Investigation Report for Falls, dated 5/3/24 documents, fell in room. Interventions: Frequent observation with nursing and CNAs (Certified Nursing Assistants). R2's facility Investigation Report for Falls, dated 6/29/24 at 8:20 A.M., (R2) fell in dining room when no staff were present to supervise. R2 sustained a Fractured Right Hip, Pelvis and T12 Compression Fracture. On 7/9/24 at 11:30 A.M., V8/Agency Licensed practical Nurse stated, I was the nurse the morning (R2) fell in the dining room. It was only me and two CNAs. They both had left the dining room to assist other residents and I was down the hall passing medications. (R2) is very impulsive and needs to be watched all the time. On 7/9/24 at 1:45 P.M., V2/Director of Nursing verified that R2 had been left alone in the facility locked unit dining room and fell and sustained multiple fractures while standing unassisted. At that time V2/DON stated, We have been discussing what to do about this situation. One staff member is supposed to stay with the residents at all times so things like this don't happen.

Based on observation, interview and record review, the facility failed to provide adequate supervision for one of three residents (R8), reviewed for accidents/incidents, in a sample of 13. This failure resulted in R8 sustaining a second degree burn from unattended hot coffee. FINDINGS INCLUDE: The manufacture guidelines for the facility hot beverage machine (BUNN U3/SRU) documents, Carefully read and follow all notices on the brewer. They were written for your protection. Brewer to be installed at a location where it can be overseen by trained personnel. Warning. Hot liquid. Use with care. The facility Incident Report dated 2/1/24 documents, Incident date: 1/26/24. On 1/26/24 at 10:30 A.M., (V13/Activity Assistant) asked (R8) if she wanted to go outside for some fresh air. V13/AA noticed (R8) was changing her pants, which is a little out of the ordinary for (R8). When (R8) returned to the unit, she was limping. The nurse (V12/Registered Nurse) noted a red raised area to the right upper thigh. (R8) did not voice how the incident occurred however, (V12/RN) noticed coffee spilled on the resident tray and the floor. The physician was notified. New orders were received to refer the resident to the Burn Clinic and to cleanse the wound with sterile water or normal saline solution, apply triple antibiotic and protective bandage twice daily and as needed. R12/Registered Nurse completed the wound treatment per order, administered pain medications with relief noted and cleaned up the spill. Upon interviewing staff, (it was determined) that (R8) approached the drink cart around 7:00 (A.M.) or 7:30 A.M. for her coffee and (V12/RN) advised (R8) she would assist her momentarily. (V12/RN) proceeded to assist with cares and upon returning to the area, (R8) had gone back to her room. (V1/Administrator in training) and (V9/Food Service Supervisor) interviewed (R8) regarding the incident. (R8) states she got her coffee and went back to her room. (R8) set her coffee on her tray next to her bed, sat down, moved the tray (with coffee) closer to her causing the cup to fall over, lid pop off and spill on her right thigh. When asked why she didn't notify the nurse, she stated she didn't think it was that bad. Conclusion: (R8) poured a cup of coffee and accidentally spilled it on her right thigh causing a burn from upper thigh to top of knee area. New intervention: Hot beverages are to be locked in the nurse's station while staff are performing cares. Staff educated to add 3-4 ice cubes to warm beverages. (R8) referred to the Burn Clinic on 2/5/24 and is being followed by the contracted wound vendor. R8's current Physician Order Sheet, dated February 2024 includes the following diagnoses: Altered Mental Status, HX (History) Seizures, Acute Encephalopathy, HX Head Injury, Aphasia. R8's AIM (Assess, Intercommunicate, Manage) form, dated 1/26/24 and signed by V12/Registered Nurse documents, Burn to right thigh. Physician and Family notified. Orders received from wound center. R8's Physician Order, dated 1/26/24 documents, Cleanse wound on right upper thigh with sterile water or normal saline solution. Apply TAO (Triple Antibiotic Ointment) and protective bandage twice daily and as needed. R8's Nurses Notes, dated 1/26/24 at (1:45 P.M.) document, Initial order received form physician for Silvadene cream and protective dressing. Pharmacy was consulted due to resident's mild sulfa allergy. Because the severity of allergy cannot be determined, Physician and Pharmacy concluded that TAO (Triple Antibiotic Ointment) and protective dressing would be the safest treatment order at this time. This RN (registered Nurse) changed bandage; moderate amount of serous drainage and one small blister containing fluid (0.5 CM X 0.5 CM). Peri wound is blanchable, bright red and painful to touch. Protective dressing applied as ordered. Tylenol given for pain. R8's (facility) Wound Management note, dated 2/1/24 documents, (R8) seen today for reports of a burn to her right thigh after (R8) dropped hot coffee on herself. Etiology: Burn; Wound size: 9 X 7 X 0.1 CM (centimeters). Exudate amount: Scant; Exudate Type: Sero-sanguineous; Tissue Type: 100 % granulation. Treatment Plans: Apply (Mesh, occlusive) Sterile Gauze- every 3 days. Notes: Treatment orders updated 2/1/24. (R8) presents with second degree burns with 2% TBSA (Total Body Surface Area). Discussed with (R8) and nursing staff that I do not think (R8) needs Wound Clinic appointment at this time. Nutritional consult recommended if not already completed in the presence of a new burn wound. On 2/28/24 at 8:30 A.M., (R8) was in bed. A healing burn was present to (R8's) right, anterior thigh, extending from (R8's) upper thigh to the top of (R8's) knee. The area was pink and measured 9 CM (centimeters) X 7 CM (centimeters). (R8) stated the area was very painful, is better, but is still tender. On 2/28/24 at 9:10 A.M., an observation of the (facility) kitchen coffee machine with V9/Food Services Supervisor (FSS). A temperature test of coffee coming from the machine registered 182.7 degrees Fahrenheit. At that time, V9/FSS stated, Hot water and coffee that comes from our machine is very hot. It is poured into a white carafe and placed on a food cart and taken to (locked) unit and placed outside of the unit dining room for the CNAs (Certified Nursing Assistants) to pour. On 2/28/24 at 10:17 A.M., V12/Registered Nurse (RN) stated, I was the nurse working the day that (R8) was burned by the hot coffee. When the food cart and beverage cart come from dietary, the dietary staff place it outside of the dining room and left the unit. The nurse and the assigned CNA (Certified Nursing Assistant) are responsible for serving the food and drinks. The coffee is always very hot, so is the hot water for tea. You have to be very careful with it. (R8) and (R13) like to help themselves to coffee. We always tell them not to, but they do anyway. On that day, I was helping (V10/Certified Nursing Assistant) with another resident, that required both of us. The coffee cart was outside of the dining room and (R8) had been told to wait until I got back. I left to go help (V10). Later that morning, we noticed (R8) was walking funny and she complained of pain to her leg. We undressed her and found a reddened area that was approximately 9 CM (Centimeters) X 7 CM. (R8) said it was very painful. There was no blistering at the that time. I called her doctor and got an order for a treatment, and I tried to call her sister. Her sister is not her POA (Power of Attorney) but will take updates on her condition. I honestly can't remember if I ever got hold of her. On 2/28/24 at 10:17 A.M., V10/Certified Nursing Assistant (CNA) stated, I was working the morning that (R8) was burned by the coffee. It was breakfast time and I needed (V12's) (V12/Registered Nurse) help getting another resident up. The food cart and beverage cart were outside of the dining room. Later that day, we noticed that (R8) was walking funny and when we took her pants off, we noticed the red area on her leg. It was pretty big, and she was complaining of a lot of pain. Her and (R13) always try to help themselves to coffee and we tell them to leave it alone. Now, after R8 was burned, when the kitchen staff bring out the coffee, they lock it up in the nurse's station until we can pour it.

Based on observation, interview and record review the facility failed to ensure a ureteral stent was removed for one resident (R2) of three residents reviewed for urinary catheters. This failure resulted in the ureteral stent becoming infected requiring removal after being transferred to the Emergency Department. Findings include: Hospital Records dated 10/26/23 at 3:21pm indicates R2 had bilateral hydroureteronephrosis (urinary obstruction of urine), chronic indwelling (urinary) catheter with recent stent placement by urology service. Hospital Care Timeline indicates: On 10/18/23 R2 was admitted from ED (Emergency Department) at 8:01pm On 10/20/23 R2 had a Cystoscopy with right stone extraction via laser lithotripsy On 10/25/23 R2 had Cystoscopy and right ureteral stent placement discharged on [DATE] at 6:12pm Hospital Discharge Follow-Up dated 10/26/23 indicates to go to a Urology appointment on 11/9/23 at 11:00am. Hospital ID (Infectious Disease) and Pulmonary Consult/Brief Hospital Course dated 12/23/23 at 11:18am indicates R2 is a [AGE] year-old with history of Autism, Seizure Disorder, Subdural Hematoma who recently had a right ureteral stent placement on 10/25/23 due to Nephrolithiasis and could not make it to the follow-up appointment on 12/8/23 for removal. Consult indicates R2 presented to the ED from the nursing home with hypoxia and fever (on 12/14/23). Consult indicates in the ED R2 was found to have an acute indwelling urinary catheter induced UTI (Urinary Tract Infection) and Septic Shock resolved. Hospital Radiology Exam dated 12/14/23 indicates There is a ureteral stent present on the right. There is calcification near the distal portion of the stent which may be within the urinary bladder. Hospital Clinical Impression: Ureteral stent retained. Differential Diagnoses: Sepsis, pneumonia, CHF (Congestive Heart Failure), UTI, cellulitis. Consideration of Admission: This patient was critically ill and required constant attention, providing direct management of acute potentially life-threatening situations involving acute impairment or failure of one or more vital organ systems, and/or high likelihood of imminent or rapid deterioration. Hospital Care Time indicates: admitted from ED on 12/15/23 at 12:11pm, Cystoscopy with irrigation of Pus, right ureteral stent removal. discharged on [DATE] at 5:02pm. Transportation Calendar indicates R2 had a scheduled appointment at a physician's office on 11/9/23 at 11am. Transportation Trip Log indicates R2 was transported to a follow-up appointment (from hospital discharge instructions) on 11/8/23 - not 11/9/23. December 2023 Calendar did not include an appointment on 12/8/23 (date stent was to be removed). Trip Log does not have an entry indicating R2 was transported to an appointment on 12/8/23 for stent removal. Progress Notes did not contain documentation of R2 being transported to a medical appointment on 11/8/23, 11/9/23 or 12/8/23. On 1/11/24 at 2:45pm V1, Administrator stated that she may have been the transport driver on 11/8/23 but does not recall the actual transport of R2. V1 could not explain how the stent removal appointment on 12/8/23 was missed. On various dates/times between 1/9/23 and 1/11/23 discussions with V1, Administrator requesting documentation of R2's medical appointments, no documentation of any medical appointments from 11/8/23, 11/9/23 or 12/8/23 were found or presented. No facility documentation was found or presented to indicate R2 had a ureteral stent placed on 10/25/23.

Based on observation, interview and record review the facility failed to assess, document and obtain treatment for sacral/buttock wounds, and failed to develop/revise a pressure ulcer wound care plan including initiating interventions for one of four residents (R2) reviewed for pressure ulcers in a sample of eight. This failure resulting in multiple pressure wounds across R2's buttocks and sacrum. Findings include: Facility Policy/Decubitus Care/Pressure Areas dated 1/18 documents: It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Upon notification of skin breakdown, the QA (Quality Assurance) form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses. The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Document Record. Complete all areas of the Treatment Administration Record (TAR) or Wound Documentation Record. Documentation of the pressure area must occur upon identification and at least once each week on the TAR or Wound Documentation Form. When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers. Assessment Scale For Predicting Pressure Ulcer Risk indicates on 10/16/23, 10/26/23 and 12/23/23 R2 was identified as high risk for pressure ulcer development. Nursing Admission assessment dated [DATE] indicates R2 had a Stage 3 cluster sacral wound on that date. TAR dated 12/23/23 indicates to cleanse R2 sacral wound with normal saline solution or wound cleanser, apply silver alginate and cover with silicone dressing every other day. TAR dated 1/4/24 indicates to apply in-house barrier cream to R2's sacrum every shift. and indicates the treatment was discontinued on 1/11/24. Infectious Disease Progress Note dated 12/28/23 indicates R2 had current assessment diagnosis of right buttock/sacral region wound, unstageable. Physiican Progress Note dated 12/29/23 indicates R2 was seen status post sepsis secondary to right hip decubitus ulcer wound infection. Facility Weekly Wound Tracking dated 12/2023 and 1/2024 indicate wound assessments for left medial heel, left lateral hip, left lateral foot, right lateral heel and right lateral hip for R2. No assessments were documented for R2's sacral/buttock wounds. On 1/5/24 R2 was observed on multiple times throughout the day positioned on his left side. On 1/5/24 at 2:15pm two staff assisted R2 to turn onto his right side. R2 was verbally resistant and at times attempted to push staff hands away from his body. R2's body- from mid back to under R2's buttocks- was laying on top of multiple thick cloth layers of linen that had been folded in half. R2 was noted with dressings to both hips. No dressing was in place across the multiple open areas across R2's upper buttocks and sacrum. The open areas were weeping a bloody drainage which was also noted on the incontinent brief that had covered the open areas. At that time, V11, CNA (Certified Nurse Assistant) attempted to place a small rolled pillow under R2's left side prior to R2 being returned to his left side. R2 rolled completely over the pillow which did not keep R2 positioned off of his left side. At that time V11 stated that R2 only likes to be on his left side and the pillows really weren't effective to keep him positioned off of that side. On 1/10/24 at 11:35am R2 was positioned on his left side in bed on top of multiple layers of thick cloth linens. R2 had a dressing over right hip with the bottom portion of the dressing saturated with bloody drainage and seeping out the bottom of the dressing. R2 also had a dressing over left hip. R2's upper buttocks/sacrum and coccyx had multiple scattered open areas, some with slough in the wound beds. No dressing was in place over any of the open areas and there was visible wound drainage on the incontinent brief. V2, DON (Director of Nursing)/Treatment Nurse was present during R2's assessment and stated that she was not aware R2's wounds across sacrum had become this bad. At that time, V2 stated she did not know why R2 did not have an air mattress and wasn't sure what the facility policy was on obtaining air mattresses for residents. On 1/11/24 at 9:30am V2, DON/Treatment Nurse stated that she has only been the wound care nurse for two months and had not written any notes on the observation of R2's sacral wounds from yesterday. V2 stated I started (R2) on a turn schedule today. I hadn't seen that area (sacral) in awhile. I didn't know it had become so bad. Those are definitely are not superficial wounds. I haven't notified (R2's) physician yet. On 1/11/24 at 9:40am V3, Infection Preventionist Nurse stated All of our mattresses are pressure relieving mattresses, we don't have air mattresses. At that time V1, Administrator stated We can rent an air mattress if it's recommended or ordered. On 1/11/24 at 12:30pm V10, Wound NP (Nurse Practitioner) assessed and measured R2's wounds. The following are wound sites, measurements and wound descriptors: Right hip: 6cm (centimeters) X 4.5cm X 3.5cm (depth) with tunneling at three different areas of the wound with the greatest tunnel at 8cm. The wound had thick greenish gray fibrous slough within the wound bed that was malodorous. Right buttock: 3cm X 5cm X 0.1 depth Left buttock: 8cm X 6cm X 0.1cm (depth) Coccyx: 2.5cm X 1cm X 0.2cm Right/left buttock and coccyx wound beds covered with slough weeping bloody drainage. Right heel: 4cm X 4cm (no depth) Right lateral plantar: 0.5cm X 1cm X 0.2 (depth) Left mid plantar: 2cm X 1.5cm X (no depth) Left hip: 5cm X 5cm X (no depth), entire wound covered with black thick eschar directly over hip bone. Left inferior hip: 3cm X 2cm X 0.1cm, wound bed pink with scattered slough. During assessments of R2's wounds V10 noted the multiple layers of thick linens (folded mattress pads and bath blankets under R2) and stated the padding is negating any benefits of the pressure relieving mattress. V10 stated that she will be recommending an air mattress for R2's bed An (air mattress) is a standard of practice for anyone with pressure wounds. V10 also noted bilateral sheepskin boots R2 was wearing and stated there is no benefit or pressure relief of R2's wounds with that style of boot. V10 stated that due to the bogginess of the skin and tissue across R2's buttocks and sacrum, the three wounds will likely become one large wound across entire buttock/sacral area. V2, DON/Treatment Nurse was present during the assessment of R2's wounds by V10, NP. V2 stated that R2 did not have a cushion for his reclining chair which R2 had been sitting in earlier that day. The chair was in R2's room and was an older model reclining chair covered with a stiff vinyl fabric. R2's Current Wound Care Plan indicates that R2 is at High Risk for Pressure Ulcers Start Date 8/18/22 Care Plan does not include any of R2's current pressure ulcer sites or individualized interventions for those sites. Generic interventions identified in the care plan were all dated 8/18/22.

Based on observation, interview, and record review, the facility failed to adequately supervise a resident (R2) with a known history of wandering to prevent them from attempting to enter a resident's room for one of four abuse allegations reviewed. This failure resulted in R2 being pushed by R1 when R2 attempted to enter R1's room. R2 fell and obtained a comminuted mildly displaced fractures of the left superior and inferior pubic rami. Findings include: The facility assessment, dated 1/10/23, documents, The IDT (Interdisciplinary) will meet and identify any new needs or resources needed to provide care and support for the person (resident). The assessment also documents, The facility provided various services for the residents we care for. The residents' care is based on their individual needs and preferences and are reflected in the individuals care plan. General care: Mental Health and Behavior. Specific Care or Practices: Manage the medical conditions and medication-related issues related to dementia and those causing psychiatric symptoms and behavior, identify and implement, interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. 1. On 8/14/23 at 10:55 a.m., R2 was self propelling herself down the hallway aimlessly with no staff present. R2's Behavior Care plan, dated 7/21/22, documents, R2 known to wander may seek to leave home. Related diagnosis include memory loss. R2 has periods of forgetting where she is causing her to want to leave the facility. R2 can be easily redirectable from staff cues. R2's Psychosocial Assessment, dated 7/21/23, documents that R2 exit seeks, wanders, paces, and enters bedrooms uninvited four to six times in a seven day timespan. R2's Elopement Evaluation, dated 7/22/23, documents that R2's has an inability to identify safety needs, has altered perception of awareness leading to seeking exit/escape, her level of agitation has required supervision, and she wanders in the vicinity of exit doors. R2's ED Physician notes, dated 7/27/23, document, R2 brought in by paramedics after she was reportedly pushed by another resident of the nursing home and sustained ground level fall with subsequent left hip pain. R2's Pelvis and Lateral Hip left Final Report, dated 7/27/23, documents, Indication: Ground Level fall with left hip pain. Impression: Comminuted mildly displaced fractures of the left superior and inferior pubic rami. R2's Hospital Discharge Instructions, dated 7/27/23, document, Your diagnoses from this visit: Closed pelvic fracture, hip pain-swelling, Unspecified dementia severe with agitation, Urinary tract infection. The facility's Final Report to the State Agency, dated 8/1/23, documents, R2 has a history of wandering into other rooms. V1 (Administrator in Training) was notified by V3 (Care plan coordinator) that R1 shoved R2 causing R2 to land on her left hip and left arm. R2 was complaining of left hip pain. R2 was sent to the emergency room for evaluation and treatment. After further investigation it was determined that R1 was walking out of his room while R2 was walking in. R1 lightly shoved R2 with his left hand in the shoulder area causing R2 to lose her balance and land on her left side and left arm. R1 stated that he did not mean for her to fall and that he was moving her out of his way so he could leave his room, because he was going out and she was going in. R2 returned to the facility with a pelvic fracture. V4's (Occupational Therapy Assistant) written statement, dated 7/27/23 at 3:45 p.m., documents, I was walking out of the bridges unit on west side of building when I noticed (R2) walk up to (R1's) door. (R1) was standing at his doorway at that time. He shoved (R2) with his left hand on her right shoulder area. (R2) landed on her left hip and left arm. I asked (R1) why he pushed her. He said because she was coming in and I was going out. On 8/10/23 at 9:45 am, V7 (CNA-Certified Nursing Assistant) stated, She was an independent ambulator who would wander in the hallways. Since the incident, she's now in a wheelchair, and self propels wandering throughout the halls. On 8/10/23 at 10:15 am, V6 (Dementia Unit Coordinator) stated, I was here that day and heard (R2) screaming. I was in the dining room and when I went out she was sitting outside of (R1's) room. He had pushed her and she fell . She would wander and enter rooms at times especially if she was looking for a bathroom. On 8/14/23 at 10:00 a.m. V4 stated, That day I was leaving the unit after treating a patient. (R1) was standing in his doorway. R2 was wandering in the hallway, like she always does, in the direction of his room. When she got to the area around his room, she turned left and started walking towards him. She started to enter his room and his personal space, and he put his left hand out and pushed her. She isn't very steady as it is. So when he pushed her she fell to the floor onto her left side. On 8/14/23 at 12:40 p.m., V5 (Social Services Director) stated, (R2) is a wanderer. We try to keep in common areas and redirect her if she is wandering. On 8/14/23 at 1:30 p.m., V11 (CNA) stated, (R2) wanders constantly and goes into other resident's rooms. Some of them get pretty upset with her when she goes into their rooms.

Based on interview and record review, the facility failed to administer a Physician ordered pain medication and implement interventions to reduce pain for one of three residents (R1) reviewed for medication in the sample of four. This failure led to R1 experiencing untreated moderate to severe pain for two days and then being transferred and admitted to the hospital for severe pain. Findings include: The facility's Pain Prevention and Treatment policy, dated 12/7/17, documents, It is the facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (Activities of Daily Living) functioning and enhance quality of life. Pain- an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms of such damage. Pain is subjective and should be documented as perceived by the resident. Pain Management- the assessment of pain and if appropriate, treatment in order to assure the needs of residents who experience problems with pain are met. Pain Modalities- an intervention implemented to reduce pain which may include the use of medication, medical devices or treatments that may include, but are not limited to heat or cold, massages, transcutaneous electrical nerve stimulation (TENS), acupuncture, and neurolytic techniques such as radiofrequency coagulation and cryotherapy. Pain Treatment Plan- a plan based on information gathered during a resident pain assessment that identifies the resident's needs and specifies appropriate interventions to alleviate pain to the extent feasible and medically appropriate. Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. R1's Hospital Discharge Summary, dated 3/12/22, documents R1 was discharged from the hospital with orders to admit to the facility on [DATE]. This summary documents R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Nurses Notes, dated 3/12/22 at 6:30 PM, documents that R1 was admitted to the facility. R1's Skilled Progress note, dated 3/12/22 evening shift (unknown time), documents R1 had a pain rating of six out of ten and described as moderate pain. This same record does not document a night shift pain assessment. R1's Nurses Notes, dated 3/13/22 at 4:00 AM, documents R1 does have pain when moving, needs assist with ADLs due to pain. R1's Nurses Notes, dated 3/13/22 at 9:00 PM, documents R1 alert and oriented times three. Resident continues to complain of pain in right groin. Needs minimal assist with ADLs. R1's Skilled Progress note, dated 3/13/22 (unknown time), documents R1 rated pain a five to six out of ten, moderate pain on day shift and rated pain a seven out of ten, moderate pain on evening shift. This same record does not document a night shift pain assessment. R1's Skilled Progress Notes, dated 3/14/22 at 1:00 PM, documents R1 alert and oriented. Appetite poor. Waiting for pharmacy to deliver medications. R1's Skilled Progress Notes, dated 3/14/22 at 5:25 PM, documents R1 was given (as needed) [MEDICATION(S)] at 4:30 PM for abdominal pain. At this time, resident is screaming in pain due to her lower right abdomen area. R1 and V10 (R1's Power of Attorney) requesting that R1 goes to the emergency room . (Emergency number) called at this time. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's medical record does not document that any non-pharmaceutical pain interventions were attempted to control R1's pain. On 3/18/22, at 2:30 PM, V2 (Director of Nursing) confirmed R1 was admitted on [DATE] and did not receive any pain medication until 3/14/22 right before she was sent to the hospital. V2 stated, We wanted R1 admitted on a Monday, (admitting hospital) pushed us to take her on Saturday (3/12/22) instead. At this same time, V1 (Administrator) confirmed that it is the facility's responsibility to ensure medications are obtained and resident's pain is addressed. V1 stated, R1's pain medication had to have a script and the (admitting hospital) wouldn't send it. We accepted her so we took responsibility in saying we had the medication and resources to care for her. R1's hospital Gastrointestinal Inpatient Consult form, dated 3/16/22, documents R1 was transferred from the (local hospital) on 3/15/22 and admitted to a higher acuity hospital primarily due to right abdominal flank pain.

Based on observation, interview and record review, the facility failed to ensure facility exit door alarms were activated, failed to increase supervision/monitoring after recognizing an alert and oriented resident's change in mental status and failed to follow its policy for elopement prevention and door alarms for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in R1 exiting from the facility on 1/15/22 around 6:45 P.M. after sunset, in freezing temperatures and snow covered grounds for approximately 45 minutes. R1 was found laying in the snow at the bottom of a hill in a residential yard approximately 30-40 feet from the facility. R1 required emergency medical transportation to an area hospital emergency room approximately 29 miles from the facility, warmed intravenous fluids and a forced air warming blanket to bring R1's core body temperature back to normal range. R1 subsequently acquired fluid filled blisters to R1's fingertips on R1's left and right hands consistent with frostbite injury. These failures resulted in an Immediate Jeopardy. While the Immediacy was removed on 1/28/22 the facility remains out of compliance at a severity level II as the facility continues to conduct audits of the facility Emergency exit alarms and evaluate and update the plan of care for residents identified as high risk for elopement. Findings include: The facility's Emergency Care policy, reviewed 1/22/18, documents, Elopement: It is the policy of (facility company name) to provide for a secure environment in which residents incapable of responsibility for self are protected from wandering outside of the facility unattended. This is achieved primarily through door alarms and individual triggering devices. 3. A thorough search should be made of the facility, including under beds, in closets, bathrooms, storage areas and maintenance and laundry areas. Search of grounds should include any outside buildings and in cars. The facility's Elopement Prevention Policy, revised 10/06, documents It is the policy of (facility company name) to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. This policy continues with Procedure: 2. A licensed nurse will complete the Elopement Risk Assessment upon and/or within eight hours of admission to the facility. 3. A facility staff member will take a photograph of the resident upon or within 8 hours of admission. The photograph will be placed in the Medication Administration Record. Any resident assessed to be at high risk for elopement will have their photograph and basic identifying information placed in a special folder or binder to be maintained at the nurse's station. The facility's Door Alarm Policy, revised 10/06, documents, It is the policy of (facility company name) to ensure resident safety and security through the use of door alarms. Facility Procedure: All doors leading to the outside must meet these requirements: 1. The alarm must only be disengaged at the door itself, either by push button code or key. No alarm may be disengaged from the nurse's station or any other location without physical evidence gathered by a staff member of reason for trigger reported directly to the person silencing the alarm. 2. The alarm must ring continuously until physically disengaging through key or code. 3. Immediate response requires any employee to physically go to the door that has an alarm sounding to establish why the alarm was triggered. 4. Disengaging the alarm is not allowed until the reason for activation is determined. Steps to be taken: Go directly to the door where the alarm is sounding. Go completely outside the door to view the environment. Initiate a search of the immediate area if no resident or visitor is visualized. Instruct visitors or vendors how to properly disengage the alarm before leaving the facility should they be the source of activation. Conduct an immediate count of all residents. Initiate the Missing Resident Policy when unable to account for all residents. 5. Testing (including actual activation) and documentation of testing will be completed weekly. Any malfunctions are to be reported to the Administrator and repaired as quickly as possible. The facility's Missing Resident Policy, revised 10/06, documents, It is the policy of (facility company name) that reasonable precautions are taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to: door alarms, personal door alarm activation devices, staff intervention, staff education regarding response to door alarms, and individual resident intervention. It is the policy of (facility company) to demand immediate response to elopement attempts, door alarm activation and participation in search attempts in the event that a resident is deemed missing. Definitions: A resident shall be defined as missing: When initial reasonable search of the facility interior and immediate grounds has not rendered physical evidence of the resident's person; there exists no evidence of the resident's whereabouts upon examination of documents including but not limited to the medical record, calendar of events and sign out books/sheets; AND after questioning of facility staff and residents evidence of whereabouts remains uncertain. DON (Director of Nursing) Responsibility: 1. Conduct a thorough investigation using the Investigative Report of Missing Resident and report the findings of the investigation to the Quality Assurance Committee with a timeline of occurrences, interventions, and responses. Prepare a summary of staff performance and policy/procedure strengths and weaknesses. 2. Report as required by State and Federal regulation to appropriate regulatory agencies. The Resident Monitoring policy, revised 10/06, states, It is the policy of (facility company name) to initiate monitoring of residents as a nursing measure upon the clinical decision of the Charge Nurse and/or Interdisciplinary Team to assist in providing safety to residents that are identified to be a potential threat to self or others or an elopement risk. Procedure: 1. Assess the resident and document the need and rationale for monitoring. 2. Initiate resident monitoring and document date, time, resident location, and as deemed necessary, behavior and response to monitoring. 3. Initiate monitoring as indicated by need, 15 minute, 30 minute, 1 hour increments, or one on one monitoring if deemed necessary. 4. Depending on established need, behavior or response, increasing or decreasing of time frame may be necessary. Document reason for change and frequency of monitoring in the resident's medical record. 6. Notify Physician, legal Power of Attorney/Guardian, DON (Director of Nursing) and Administrator when the need for monitoring is indicated due to potential threat to self or others. 7. Continue monitoring the resident until the Interdisciplinary Team can determine the status of the resident and develop other appropriate measures for intervention determined by resident need. 8. Document all assessments, needs, interventions, and resident responses in the resident's medical record. 1. R1's Facesheet documents R1 was admitted to the facility on [DATE]. R1's Cognitive Assessment signed and dated by V10 (Social Service Director) on 1/10/22 documents R1's Brief Interview for Mental Status (BIMS) as a score of 15 out of 15; indicating R1 is cognitively intact with no memory impairments. R1's Cumulative Diagnosis Log documents R1 with diagnoses to include but not limited to: [CONDITION(S)] Affective Disorder, Depressive Disorder, [CONDITION(S)], [CONDITION(S)], and Altered Mental Status. R1's hospital records document additional diagnoses of: Dementia and legally blind (left eye). R1's Physician Order Sheet, dated 1/10/22, documents R1 is taking [MEDICATION(S)] and [MEDICATION(S)] for Depression, [MEDICATION(S)] for [CONDITION(S)], [MEDICATION(S)] for anxiety, [MEDICATION(S)] and [MEDICATION(S)] for [CONDITION(S)], and [MEDICATION(S)] for [CONDITION(S)]. R1's Elopement Assessment is documented as being completed on 1/13/22. R1's Elopement Assessment completed on 1/16/22 documents R1 as being a high risk for elopement. On 1/19/22 at 4:29 P.M., V10 (Social Service Director) verified elopement assessments should be completed on a resident's admission and that the elopement binder is being updated. R1's A.I.M. (Assess, Intercommunicate, Manage) for Wellness form, signed and dated by V5 (Registered Nurse) on 1/16/22 at 12:00 A.M., states, (R1) noted to have exit seeking behavior, exit through North hall-East doorway where he ambulated per self Eastwards outside. (R1) was transferred to ER (emergency room ) for eval (evaluation) and treatment. Staff had attempted to transfer (R1) to ER for last fall at 3:15 A.M. (on 1/15/22) but he refused to go. (R1) was noted to have pain in the left hip. R1's Nursing Note on 1/15/22 states, (R1) sent to (area hospital) for poss. (possible) hypothermia to tx (treat) and eval. (evaluate). Temp (temperature) = 95 (degrees Fahrenheit). R1's Investigative Report of Missing Resident, signed and dated by V1 (Administrator) on 1/15/22, documents R1 with a diagnosis of hallucinations. This same form documents on 1/15/22, R1 was last seen at 6:30 P.M. and declared missing at 6:55 P.M. by V5 (Registered Nurse). This form also documents R1 was found across the street and the (facility exit) door alarms were disengaged. R1's Emergency Medical Services/EMS Report, dated 1/15/22, states EMS was dispatched at 7:22 P.M. for a man down. This report also documents, responding immediately to (address of location) for a male found on the side of the road in a snow bank. (R1) was found by a person driving by. (R1) was found in the street with bystanders and (local police department) with him. (R1) was wearing a T-shirt, sweat pants, a stocking hat and slipper socks. The bystander states that she was driving by and spotted (R1) lying on the side of the road in a snow bank. She stopped to help him. She helped (R1) up and out of the snow but (R1) could not walk to her car. He just sat down in the road on his knees. She then states she called 911 for help. (R1) states that he was at (name of skilled nursing facility) for (sic) weakness treatments. (R1) then states (R1) was out at a restaurant and got lost. (R1) states that he can't feel his feet or hands. (R1) states he has trouble with circulation on his feet and legs normally. (R1) states he has pain in his left hip. He has abrasions on his toes, legs, knees, arms, and fingers. He has bruising on his legs, left hip, back, arms, and stomach. (R1) states that he falls a lot. (R1) states that he was at (an area hospital) a couple of days ago for a fall and that he just got to the nursing home. (R1) states that he is blind in his left eye and only has 10% (percent) sight in his right eye. (R1) knows his name, date of birth, the days date, his home address and why he is at the nursing home. (R1) does make states (statements) about being at a restaurant and walking around a store while being at the nursing home. (R1's) skin is pale, cold, and wet. His lips, fingers, and toes are cyanotic in color. (R1's) clothes were taken off of him and he was dried off with towels. (R1) was then covered by dry blankets. (R1's) temperature was taken orally and axillary but the thermometer did not register a temp (temperature). (R1) was transported emergent to (area hospital emergency room ). R1's local police department report #2022- 7, dated 1/15/22 and timed 7:26 P.M., documents, I (V7/Local Police Officer) got dispatched to a 911 ambulance call on a report of a male subject laying on the side of the road in the snow in the (specific address block) across from (name of skilled nursing facility). Upon my arrival, I observed (R1) laying in the snow on the east side of the roadway in the yard of (neighboring address). The 911 caller, was trying to help (R1) to get him our of the snow and help warm him up. (R1) was wearing a green T-shirt, gray sweat pants, slippers, and had a jacket over him. It is unknown if the jacket and slippers belonged to (R1) or had been given to him by a passerby. I asked (R1) if he could tell me his name. He (answered appropriately). He told me he had been outside for 45 minutes to an hour. (R1) told me he was trying to find a nursing home. It was hard to understand what nursing home he was referring to. (R1) was covered in melting snow and was shaking from being cold. Although (R1) could not walk to a vehicle to warm himself, he was covered with a blanket to help until EMTs (Emergency Medical Technicians) arrived. I had dispatch call (name of skilled nursing facility) to check if (R1) is a patient. Dispatch informed me (R1) is a patient at that facility. A few minutes later, (name of EMS company) arrived on the scene. I informed the EMTs that (R1) told me he had been laying in the snow for about 45 minutes to an hour. I told them (R1) is a patient at (name of skilled nursing facility). The EMTs informed me that (R1) would need to be transported to (specific name of an area hospital located 29 miles from facility) due to that facility having better equipment to treat (R1). (R1) agreed with EMTs that is where he wanted to go. I went to (name and address of skilled nursing facility) and spoke with (V9/Licensed Practical Nurse), an employee at the facility. (V9) told me that around 20 minutes until 7:00 P.M. she was in her vehicle that was parked in the northwest parking lot. She told me that she saw a kid or a person walking around the hill near the east side of the facility, but did not think of the person as being one of their (facility's) patients. (V3/Licensed Practical Nurse) was mentioned to me by (V9) who said that (V3) said she last saw (R1) around 5:45 P.M. before the end of her shift. While investigating the incident, (V1/Administrator) called the facility to speak with me. I talked to (V1) who informed me she found out the alarm to the east door that (R1) had exited from had malfunctioned and an electrician will be working on it. (V1) said she would have someone posted at the door at all times until the alarm was fixed. I told (V1) that EMTs did an emergent transfer to (area hospital) due to (R1's) condition and (name of hospital) having better equipment. It should be noted that the outside temperature at the time of the incident was approximately 10-15 degrees Fahrenheit. A website weather.com documents the high temperature on 1/15/22 as 26 degrees Fahrenheit and a low temperature of 7 degrees Fahrenheit. This website also documents sunset as 4:56 P.M. R1's Hospital Records from R1's 1/15/22 emergency room visit documents R1 arrived to the emergency room at 8:23 P.M. These records document that on 1/15/22 at 8:38 P.M., R1's rectal body temperature was documented as 95.8 degrees Fahrenheit. R1's chief complaint was documented as cold exposure and altered mental status. V21's (emergency room Nurse Practitioner) emergency room note and assessment stated, (R1) is a [AGE] year old male with a chief complaint of cold exposure. (R1) is from a nursing home. (R1) reportedly snuck outside and was found laying in a snow bank. (R1) has baseline Dementia. (R1) states, 'I left the nursing home and it was really cold outside. I was waiting for them to finish the railroad project.' R1's skin assessment was documented as bilateral upper and lower extremities were cold to the touch and all fingers were bright red. R1's neurological status was documented as alert to place and person and disoriented to time and events. R1's Nursing Notes document R1 was treated with warmed intravenous fluids and a forced air warming blanket. R1's report to the local State Agency on 1/19/22 documents R1 to have redness to fingertips with intact fluid filled blisters on R1's right and left hands status post R1 exiting the building on 1/15/22. On 1/19/22 at 10:33 A.M., R1 was noted to be laying in bed with eyes open, wearing a T-shirt, gray sweat pants, nonskid socks. R1 was noted to have obvious red/maroon discolored finger tips and blisters to R1's left and right hands. R1's left and right elbow were noted to have open abrasions covering the entire elbow. The right elbow abrasion was draining a serous fluid. Multiple red scabbed areas/scratches were noted to R1's forearm. R1's entire right lateral pinky (5th digit) finger was noted to have reddish purple/maroon discoloration. At this time, R1 stated discoloration to fingertips and side of pinky finger was frostbite. R1 stated, They told me they found me in a ditch. When asked about the 1/15/22 elopement, R1 stated, I don't remember leaving at all. I don't remember wanting to leave. I'm back here now (secured Dementia unit) because I need to be protected from myself. I lived at home alone before here. I don't want to leave here until I'm done with rehab and it's safe. R1 denied remembering being at the hospital. The last thing I remember was coming into this room (R1 motions his hands to mean the room he currently resided in). R1 stated R1 is happy here and states, I want to be here. On 1/19/22 at 10:47 A.M., a head to toe skin assessment was performed by V3 (Licensed Practical Nurse/LPN) and the above skin impairments were noted. On 1/19/22 at 10:20 A.M. V8 (LPN) stated, I was not here the night (R1) left. I was here Friday, Saturday, and Sunday (1/14/22-1/16/22) 6:00 A.M.-2:00 P.M. On Saturday (1/15/22), the day (R1) left, (R1) had intermittent confusion. He kept fixating that he wanted to go to the pharmacy. (R1) kept saying, I gotta (got to) get my meds. I would remind him that he was in the nursing home and that I had his meds. I remember one time, he was standing outside his room near the rail, and he was again saying that he needed to go to the pharmacy. I escorted him back to his room and he laid down on the bed. At this time, V8 verified that all exit doors should be alarmed at all times. On 1/19/22 at 12:26 P.M., V1 (Administrator) stated, I was at home (on 1/15/22). I received a call from the nurse on duty (V5/Registered Nurse) that (R1) was missing. On Sunday (1/16/22), I talked to (R1). He said he was tired. I believe I asked him where he was trying to go (when R1 left on 1/15/22). I think he might have stated, 'I don't remember.' R1 exited out the short hall, east exit door. I was not notified that the alarms were sounding. We increased to daily checks on the alarms after this. The alarms should have gone off. All doors were tested immediately. We did not report this to (the local state agency) because we didn't feel it was elopement and he was dressed properly and the doctor agreed he has abilities to community access. The resident had fallen that morning and refused to go to hospital. I don't believe he told anyone he wanted to go. No exit seeking or wandering behavior was noted prior. We were told he was wearing a dark coat, sweat pants and some type of footwear (shoe or slipper). I think it was close to 20 degrees (Fahrenheit) that evening around 7:00 PM on Saturday 1/15/22. At this time, V1 again verified the facility exit door alarms were not sounding and they should have been. V1 verified the facility exit door alarms should always be on. On 1/19/22 at 2:15 P.M., V15 (Certified Nursing Assistant/CNA) stated, I was his CNA that day he left. I worked from 2:00-10:00 pm. (R1) was really talking off his head. I was surprised to hear that he was alert and oriented. His behaviors seemed odd. He was talking to himself and talking to people that weren't there. I just kept watching him, kept a close eye on him because he didn't seem right. He did not have a roommate. He was in his room, mostly on the bed. I last saw him right before 5:00 PM. I did rounds before supper to make sure everyone was ready. I got busy picking up trays and answering call lights. Two others were helping passing trays, The nurse (V5, Registered Nurse) had asked us where (R1) was. I looked out the door and saw cop lights and I thought 'Oh no, this isn't happening'. I just had a gut feeling it was him. I did not go outside at all to check-I saw the cops were there. I did have visual eye contact on him. I saw him sitting on the ground. He was covered with a blanket. When I saw him last he was wearing a yellow shirt, gray sweat pants and I didn't pay attention to his feet. He had gone out the side door outside his room. He was down the hill. The alarm did not sound. I asked (V5) 'why didn't we hear the alarm go off?' and (V5) said he didn't know. (V17/Maintenance Director) was there and came and checked the alarms. (V17) verified the alarm wasn't going off. The alarm wasn't working and it should have gone off immediately so we could have been there (outside) immediately. I don't remember the temperature outside but it was cold. (R1) went straight to the hospital. On 1/19/22 at 2:35 P.M., V13 (CNA) stated, The first time I saw (R1) (on 1/15/22) he was asleep. Then later he asked me for eye drops, I went to tell the nurse. I was floating in between the two units. I gave him his dinner tray and he said he was going to take it home with him. I didn't think much of it. I helped him get set up with tray and then left. I last saw him around 6:30 P.M., he was laying down in bed. I was just finishing up picking up trays and then I'm being told he was gone (by V5). Me, (V5) and (V15) asked 'How did he get out?' No alarms were ever going off. We opened the door to try and set the alarm off again and it didn't go off. It was disengaged. (V17) was in the building and said that they disengaged (the alarms) doing the checks and then forgot to turn it back on. (R1) was different this day (1/15/22). He was talking to his wall. I was told he had a mental illness history. I saw him before this day and he seemed alert and oriented, he knew his meds, the day, and why he was there. He seemed different, laying on his side talking to the wall. (R1) was also reaching out and trying to grab things that weren't there. I told (V5) and he said, 'Ok that makes sense because of his mental history.' The last I saw (R1) he was wearing a short sleeve yellow shirt and gray sweat pants. I didn't see his feet. The neighbors ended up finding (R1), and the cops were called. He was taken by ambulance to (nearby city), I think. We are doing 15 minute checks on the unit for him now. It was a cold day the night he got out. He had some falls and it seemed his personality switched after the fall. On 1/19/22 at 3:05 P.M., V7 (Local Police Officer) stated, I was dispatched on 1/15/22 around 7:30 P.M. for a male subject (R1) laying in the snow across from the nursing home. (R1) was laying on the east side of the roadway. When I arrived, bystanders were helping him up. The bystander stated she was driving home and saw something laying in the snow. Paramedics arrived and he was agreeable to go to the hospital. He told me he had been outside for 45 minutes to one hour. I wanted to talk to staff, dispatch called to confirm (R1's) residence. (R1) went to (farther away hospital) for better accommodations. It was reported to me that the East alarm door was not working and did not sound when (R1) exited. (R1) was confused, knew his name and knew he was outside but couldn't say the name of the skilled nursing facility. (R1) kept asking if we were at a restaurant. None of the staff came out to help (once R1 was found). (R1) had a cut on his left elbow and he was bleeding. It was cold outside, I was wearing hat and gloves, it was pretty chilly. It was maybe 10-15 degrees. (R1) was stating that he was cold. (R1) was found in another person's yard. (R1) had exited the East doors, where there is a steep hill. I followed his tracks and could tell he fell down the hill. He must have gotten up, crossed the roadway. (The road) was cleared, so I lost his tracks for a second, but there is another hill. You could see that he fell down that hill as well and it looked like there was a struggle for him to get up and he couldn't get up, so (R1) just stayed laying there until he was found. On 1/31/22 at 10:50 A.M. V17 (Maintenance Director) stated, I was here in the building on another call when (R1) got out (on 1/15/22). I came over right away to check the door alarm. The only thing I can think of (regarding why the alarm did not sound when R1 exited the building on 1/15/22) is the gear on the inside didn't trigger the cell. (At this time, V17 had removed the door alarm from its case and opened the back of it to expose the gears and triggering mechanism inside. V17 was pointing to the gears that he thought could possibly not have activated on the alarm.) V17 continued to say, It (why the alarms didn't sound) could also have been from the cold outside. The alarm box inside had frost build up on it, so maybe that had something to do with it. I don't really know for sure what happened. V17 verified V17 did not hear the alarms sound (on 1/15/22 when R1 eloped). V17 stated, Once the (facility) exit door alarms are activated you have to use the key to disarm it. It's how you shut it off. V17 verified V17 did not deactivate any alarms after R1 eloped on 1/15/22. On 1/19/22 at 3:26 P.M., V9 (LPN) stated, I was here the night (R1) eloped on 1/15/22. It was a quiet evening, I was doing (medication) pass with (V5). I was in training that night. I went outside on break 20 min until 7:00 P.M. I was sitting in my truck and I could see movement by the trees from my headlights. It wasn't enough to alert me but whatever that shape was that went behind the tree by the East door. I came in from my break at 7:05 P.M. Shortly after that the police had alerted us that (R1) was found. I wasn't sure where (R1) was found. No alarms were going off. It was cold that night. I was back here Sunday night and he refused his meds. On 1/19/22 at 4:19 P.M., V12 (Unit Assistant) stated, The first time I helped with (R1), he was mostly normal. The 2nd time, he was really out of it. This was the Friday night (1/14/22) before (R1) left. He kept talking about feces under the other bed in his room. I checked with a flashlight and nothing was under there. He kept apologizing for the mess he made and we kept reassuring him that nothing was there. He was really adamant that he had had a bowel movement under the other bed in his room. We notified (V6/LPN) and he went to check on (R1). On 1/19/22 at 4:29 P.M., V10 (Social Service Director) stated, I was here the night before (R1) got out. (R1) had an episode. He was saying he wanted to go home, he kept trying to get out of bed. This was all the same morning of the day he got out. It was around 3:00 A.M. (R1) fell to the ground and was rolling around. The EMTs came and had him on the gurney. Once they said where they were taking him to the hospital, he just kind of freaked out. I came down and was asking him the questions and he could answer everything appropriately. EMTs stayed for about 20 minutes trying to get him to go get checked out. He kept refusing, so they said he was of sound mind and got him back into bed. He was normal and pleasant prior to all this. On 1/19/22 at 4:34 P.M., V11 (LPN) stated, I would notify the doctor immediately if a resident had a change in behaviors different from their normal. V11 verified the exit door alarms should always be on. On 1/19/22 at 4:41 P.M., V14 (CNA) stated, I was here the night (R1) got out. I worked 2:00-10:00 P.M. No alarms were going off after the east door was opened. When (R1) first got here he was alert and oriented, then he started seeming more confused. (R1) had thought he had defecated under the other bed in his room. Nothing was there. We reported to V6 (LPN) and V19 (LPN) Friday night (1/14/22) about (R1's) confused behavior. V14 verified the exit door alarms should always be on. On 1/19/22 at 4:45 P.M., V16 (CNA) stated, (R1) seemed ok every once in a while and then he would seem a little confused. He was sweet, pleasant and cooperative. He tried to eat the remote once and use the urinal as a phone. I wasn't here the night he left the building. The nurses knew he was confused. V16 verified the exit door alarms should always be on. On 1/19/22 at 7:24 P.M., V5 (RN) stated, I started my shift (on 1/15/22) at 6:00 P.M., I was done with report around 6:30 P.M. I went to (R1's) room around 6:50 P.M. I noticed (R1) wasn't in his room. The bed was empty. I checked the bathroom and he wasn't in there. I checked with the CNAs and they didn't know where he was either. We started looking in the dining room and the blue room. We weren't finding him in the building, so we said he was missing and needed do a search. It was around that same time the phone rang and it was the (local police department) asking if we had a resident by (R1's name) and I told them we did. (R1) got out the east exit door adjacent to his room. If you go out his room, it's to the left a couple feet. He was a fairly new resident and I didn't know a lot about him. He seemed confused and forgetful at times. He had [CONDITION(S)] so he said he had vision problems. I was told he had a coat on but I'm not sure whose it was. In the nurses' notes, you can see (R1) had fallen two times before this. They tried to get him to go to the hospital because they suspected injury and he refused. EMTs came and also tried to get him to go. I know (V19/LPN) was upset (R1) wouldn't go. The alarms were not sounding after he went out that door. We would have searched outside immediately if the alarms were going off. (V17/Maintenance Director) was in the building and he checked (the alarms). He said the east exit door alarm was off. We went and checked all the other alarms and they were working correctly. Sometimes when the batteries are dying, it will make a chirp noise or flash a light. It wasn't doing any of that. The door is normally alarmed at all times. (R1) was acting confused before he left. It seemed like he was talking to someone that wasn't there. He was hallucinating and thinking he was somewhere else he wasn't. We should report a change in condition to the Physician right away-we would just call the doctor. We did a full head count to make sure the rest of the residents were accounted for as well. (R1) was admitted with altered mental status. CNAs reported his confused behavior but I had handed over my keys to (V19) already so I was going to let her handle it. On 1/20/22 at 8:32 A.M., V19 (LPN) stated, The man (R1) is confused. (R1) was on the floor for me (Regarding the 1/15/22 fall). He was complaining of left hip pain and hitting his head. I called the ambulance. Two paramedics came and loaded him on the gurney. When they told (R1) they were taking him to the hospital, he refused to go. They tried talking to (R1) for about 25 minutes going back and forth. He was able to say the month, year, and that he had been at the nursing home for 5-6 days, so they said he was of sound mind. He's been odd since he's been there. I met him Thursday (1/13/22) when I came back. He was very polite and thanked me. Friday (1/14/22) when I came back, he was a little off. I introduced myself and he didn't remember me from the night before. He used the urinal and then tried to drink out of it. He was just a little odd. (R1) could answer questions appropriately, but then after he fell , I asked him why he got up and he said because he thought he heard his ex-wife in the hallway. I did not talk to the doctor after (R1) was on the floor and acting odd. If I had a resident who was acting different from baseline, I would get a full set of vitals, check neuros (neurological status), call the doctor and if don't hear back (from the doctor), I'm sending (the resident) right out. We have to check the alarm doors each shift now. At this time, V19 again verified V19 did not notify V4 (R1's Physician) of R1's change in behaviors and that the exit doors should always be alarmed. On 1/20/22 at 11:55 A.M., V6 (LPN) stated, (R1) kind of went south. They (facility staff) said (R1) was rolling around on the floor (regarding the 1/15/22 fall). (V19) reported to me that (R1) was seeing things that weren't there. At this time, V6 verified nursing should notify the doct[TRUNCATED]

Based on observation, interview and record review, the facility failed to notify a resident's Physician after a resident's fall, notify the Physician after the resident's refusal to be sent to the hospital for evaluation following the fall with injuries and notify the Physician after a resident's change in mental status for one of three residents (R1) reviewed for accidents and supervision in the sample of three. These failures resulted in R1 displaying an altered mental status and exiting from the facility on 1/15/22 around 6:45 P.M. after sunset, in freezing temperatures and snow covered grounds for approximately 45 minutes subsequently requiring transport to the hospital and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The facility's Notification for Change in Resident Condition or Status policy, revised 12/7/17, states, Policy: The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON (Director of Nursing), Physician, Guardian, HCPOA (Health Care Power of Attorney, etc) of changes in the resident's medical/mental condition and/or status. Procedure: 1. The nurse supervisor/charge nurse will notify the resident's attending Physician or on-call physician when there has been: a. Any symptom, sign or apparent discomfort that is: 1. Sudden in onset 2. A marked change (i.e. more severe) in relation to usual signs or symptoms 3. Unrelieved by measures already prescribed; b. An accident or incident involving the resident; e. A significant change in the resident's physical/emotional/mental condition. g. Refusal of treatment or medications h. A need to transfer the resident to a hospital/treatment center; 2. The nurse supervisor/charge nurse will notify the DON, Physician, and unless otherwise instructed by the resident, the resident's next of kin or representative when the resident has any of the afore mentioned situations or: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychological status. e. It is necessary to transfer the resident to a hospital/treatment center. 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 1. R1's A.I.M. (Assess, Intercommunicate, Manage) for Wellness Form, signed and dated by V19 (Licensed Practical Nurse) on 1/15/22 states, This change in condition, symptoms, or signs observed and evaluated are: Fall resulting in Lt (left) hip pain; scrape to Lt (left) forehead;confusion at times. Other relevant information: 911-ambulance called to send to ER (emergency room ) for eval (evaluate) and tx (treat), (R1) refused to go. 1. Functional Status Evaluation: Falls-two. Other-Lt (left) hip pain. 2. Behavioral Evaluation: Other behavioral changes-increased agitation, increased confusion. Physician Recommendations and/or nursing interventions: (R1) assessed for injuries-c/o (complains of) Lt (left) hip pain, Lt (left) extremity appeared shorter in length. Also noted scrape Lt (left) side forehead, Ambulance (with) two attendants arrived to transport, assisted (R1) from floor to gurney, (R1) refused to go to hosp (hospital) for eval and tx (after) 25 min (minutes) of nursing home staff and two EMTs (Emergency Medical Technicians questioning resident, (R1) still refused. EMTs refused to transport d/t (due to) (R1) is his own POA (Power of Attorney). (R1) has the right to refuse. R1's Nurses Notes on 1/15/22 at 3:15 A.M., signed by V19, documents, (R1) found on floor, voices c/o Lt (left) hip pain and hitting head. Upon assessment Lt (left) extremity appears short in length. (R1) also states his head hurts. Noted scrape 0.3 cm (centimeter) x 0.3 cm Lt (left) forehead. R1's Nurses Notes on 1/15/22 at 3:25 A.M., signed by V19, documents, 911 called. Ambulance arrived (with) two EMTs, assessment done, (R1) placed on gurney, EMTs told (R1) they were taking him to a hospital here in (name of city). (R1) refused, stated, 'You can't make me.' EMTs spoke with (R1) for 25 mins (minutes). (R1) knew month, year, where he was at, (R1) then would ask where his ex-wife went to. Since (R1) is able to make his own decisions and refused medical tx (treatment) (at) hospital, EMT assisted (R1) back into his bed. R1's Nurses Notes on 1/15/22 at 4:45 A.M., signed by V19, documents, Message left for (V4/R1's Physician), awaiting callback. R1's medical record does not contain further information that V4 was further notified of R1's 1/15/22 fall or R1's refusal to seek medical treatment after a fall with injury. 2. R1's Investigative Report of Missing Resident, signed and dated by V1 (Administrator) on 1/15/22, documents R1 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and declared missing at 6:55 P.M. by V5 (Registered Nurse). This form also documents R1 was found across the street and the (facility exit) door alarms were disengaged. R1's report to the local State Agency on 1/19/22 documents R1 to have redness to fingertips with intact fluid filled blisters on R1's right and left hands status post [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/19/22 at 10:20 A.M. V8 (LPN) stated, I was not here the night (R1) left. I was here Friday, Saturday, and Sunday (1/14/22-1/16/22) 6:00 AM-2:00 P.M. On Saturday (1/15/22), the day (R1) left, (R1) had intermittent confusion. He kept fixating that he wanted to go to the pharmacy. (R1) kept saying, I gotta (got to) get my meds. I would remind him that he was in the nursing home and that I had his meds. I remember one time, he was standing outside his room near the rail and he was again saying that he needed to go to the pharmacy. I escorted him back to his room and he laid down on the bed. At this time, V8 verified that V8 did not speak with the Physician regarding R1's confusion. On 1/19/22 at 2:15 P.M., V15 (Certified Nursing Assistant/CNA) stated, I was (R1's) CNA that day he left. I worked from 2:00-10:00 P.M. (R1) was really talking off his head. I was surprised to hear that (R1) was alert and oriented. His behaviors seemed odd. He was talking to himself and talking to people that weren't there. I just kept watching him, kept a close eye on him because he didn't seem right. On 1/19/22 at 7:24 P.M., V5 (RN) stated R1 seemed Confused and forgetful at times. V5 stated, In the nurses notes, you can see (R1) had fallen two times before this. They tried to get him to go to the hospital because they suspected injury and he refused. EMTs came and also tried to get him to go. I know (V19/LPN) was upset because(R1) wouldn't go. (R1) was acting confused before he left. It seemed like he was talking to someone that wasn't there. He was hallucinating and thinking he was somewhere else he wasn't. We should report a change in condition to the Physician right away-we would just call the doctor. On 1/19/22 at 4:34 P.M., V11 (LPN) stated, I would notify the doctor immediately if a resident had a change in behaviors different from their normal. On 1/19/22 at 4:41 P.M., V14 (CNA) stated, I was here the night (R1) got out. I worked 2:00-10:00 P.M. When (R1) first got here he was alert and oriented, then he started seeming more confused. (R1) had thought he had defecated under the other bed in his room. Nothing was there. We reported to V6 (LPN) and V19 (LPN) Friday night (1/14/22) about (R1's) confused behavior. V14 verified the exit door alarms should always be on. On 1/20/22 at 11:55 A.M., V6 (LPN) stated, (R1) kind of went south. They (facility staff) said (R1) was rolling around on the floor (regarding the 1/15/22 fall). (V19) reported to me that (R1) was seeing things that weren't there. At this time, V6 verified nursing should notify the doctor if a resident has a change in condition. V6 denied notifying a doctor of any changes (with R1). V6 stated, CNAs normally chart on behavior tracking logs and nurses can add to (the behavior logs) if they need. You should chart when the behavior occurs. The CNAs reported (R1's) confused behavior but I had handed over my keys to (V19) already so I was going to let (V19) handle it. On 1/19/22 at 10:33 A.M., R1 was noted to be laying in bed with eyes open, wearing a T-shirt, gray sweat pants, and nonskid socks. R1 was noted to have obvious red/maroon discolored finger tips and blisters to R1's left and right hands. R1's left and right elbow were noted to have open abrasions covering the entire elbow. The right elbow abrasion was draining a serous fluid. Multiple red scabbed areas/scratches were noted to R1's forearm. R1's entire right lateral pinky (5th digit) was noted to have reddish purple/maroon discoloration. On 1/19/22 at 10:47 A.M., a head to toe skin assessment was performed by V3 (Licensed Practical Nurse/LPN) and the above skin impairments were noted. In addition, R1 was noted to have scattered ecchymotic areas to R1's abdomen, back, flank, and posterior upper arms in various ranges of coloring from purple to yellowish/green. R1 stated, I fall a lot. On 1/20/22 at 8:32 A.M., V19 stated, The man (R1) is confused. He was on the floor for me (regarding the 1/15/22 fall). (R1) was complaining of left hip pain and hitting his head. I called the ambulance. Two paramedics came and loaded him on the gurney. When they (paramedics) told him they were taking him to the hospital, he refused to go. They tried talking to (R1) for about 25 minutes going back and forth. He was able to say the month, year, and that he had been at the nursing home for 5-6 days, so they said he was of sound mind. He's (R1) been odd since he's been there (the skilled nursing facility). I met him Thursday (1/13/22) when I came back. He was very polite and thanked me. Friday (1/14/22) when I came back, he was a little off. I introduced myself and he didn't remember me from the night before. He used the urinal and then tried to drink out of it. He was just a little odd. (R1) could answer questions appropriately, but then after he fell , I asked him why he got up and he said because he thought he heard his ex-wife in the hallway. I did not talk to the doctor after (R1) was on the floor and acting odd. If I had a resident who was acting different from baseline, I would get a full set of vitals, check neuros, call the doctor and if don't hear back (from the doctor), I'm sending (the resident) right out. At this time, V19 again verified V19 did not notify V4 (R1's Physician) of R1's change in behaviors or R1's fall. V19 stated, (V4) never calls me back. On 1/20/22 at 2:18 P.M. V18 (V4's Nurse) stated, The only fall that was reported to us (for R1) was (R1's) fall on 1/13/22. I do not have a fax for any falls on 1/15/22. (V4) said that he knew about (R1's) elopement but he didn't know anything about (R1) falling, EMS (Emergency Medical Service) coming, or (R1) refusing to go to the hospital on 1/15/22. No notifications about his increased confusion or change in behaviors were given directly to (V4) or received via fax. The facility would usually just fax the sheets over. (V4) would expect the facility to follow their policy on notifications.

Based on interview and record review, the facility failed to provide supervision to prevent a fall for a resident at high risk for falls, for one of three residents (R2) reviewed for falls in a total sample of three. This failure resulted in R2 sustaining a nasal fracture, cervical 5 & 6 fracture, and an elbow chip fracture. Findings include: Facility policy, entitled Fall Prevention, revised 11/10/18, documents, All staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. R2's Fall Risk Assessment, dated 7/20/21, document R2's fall risk as 18; and 10 Points or More=High Risk Score. R2's Care Plan, under Category: 011 FALLS, dated 1/29/20, documents, [R2] has risk factors that require monitoring and intervention to reduce potential for self injury with the intervention Observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed. R2's A.I.M [Assess, Intercommunicate, and Manage] for Wellness document, dated 7/27/21, documents, [R2] fell to the floor with excessive amounts of blood coming from face; sent to e.r. [emergency room ] for further evaluation. R2's local hospital radiological reports, dated 7/27/21, document, Left Elbow Chip fracture at the posterior aspect of the olecranon process; comminuted and displaced bilateral nasal bone fracture with hematoma anterior to the left-sided nasal bones. Mildly comminuted and displaced fracture of the vomer/nasal septum. Small amount of hemorrhage in the bilateral maxillary sinuses and the left sphenoid sinus; and Nondisplaced fractures at anterior inferior corner of C5. Nondisplaced fracture of C5 spinous process noted as well. There is also a nondisplaced fracture noted at bilateral lamina of C6. On 7/30/21, at 9:41 a.m., V3/Certified Nursing Assistant confirmed R2's fall, on 7/27/21, was not observed as V3 was serving meals in the dining room. In addition, V3 confirmed V3 and V4/Unit Aide were the only two staff members present on the locked unit where R2 fell . On 7/30/21, at 10:20 a.m., V4 confirmed R2's fall, on 7/27/21, was unwitnessed.

Based on observation, interview and record review, the facility failed to assess a resident's skin condition, failed to administer a physician ordered skin treatment, and failed to monitor a resident's skin condition for 2 of 2 residents (R31, R23) reviewed for pressure ulcers in a sample of 34. These failures resulted in R31 developing an avoidable unstageable pressure wound to the right heel. FINDINGS INCLUDE: The facility policy, Pressure Sore Prevention Guidelines, dated 11/12 directs staff, To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as high or moderate risk for skin breakdown. The following guidelines will be implemented for any resident assessed as moderate or high risk: Incontinence care to include lotions and barrier creams; daily skin checks with documentation and weekly skin assessment of the resident's skin. The facility policy, Decubitus Care/Pressure Areas, dated (revised) 1/18 directs staff, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Upon notification of skin breakdown, the QA (Quality Assurance) form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses. The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record. Document size, stage, site, depth, drainage, color, odor and treatment (upon obtaining from the physician). Document the stages of the pressure ulcer. Document the color. Notify the physician for treatment orders. The physician's orders [REDACTED]. The order must have specific frequencies. Initiate physician order [REDACTED]. The assessment must include: Characteristic (size, shape, depth, color, presence of granulation tissue, necrotic tissue), Treatment and response to treatment. When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers. The facility's Preventative Skin Care policy (Revised 1/18) documents the following: All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly for four weeks then will be reassessed at least quarterly and/or as needed. 1. R31's facility Profile Face Sheet documents that R31 was admitted to the facility on [DATE] and readmitted on [DATE], with the following Diagnoses: [REDACTED]. R31's Nursing Admission Assessment form, dated 10/22/2020 documents, Skin Inspection: Vascular Ulcers right LE (lower extremity). No size, stage, site, depth, drainage, color or odor were documented on the wounds. R31's Braden Scale for Predicting Pressure Ulcer Risk form, dated 10/22/2020 documents R31 as a moderate risk for skin breakdown. R31's Care Plan, dated 10/22/2020 includes the following Problem/Need: Moderate Risk for Pressure Ulcer per Braden Risk Assessment. This same Care Plan includes the following Approaches/Intervention: Braden Scale weekly for 4 weeks upon admission; Weekly skin checks with documentation; Check skin, if opened or bruised areas noted, report to MD (Medical Doctor); Daily sponge bath, weekly shower, Skin check daily during cares and during bath/shower; Nurse to measure and monitor wound status progression or deterioration every week and notify MD and family of changes; Treatment as ordered (cleansing, application of medication, packing and/or dressing changes with wound status and progress). R31's facility Weekly Wound Tracking for October 2020 includes the following entry, 10/30/2020 Area 1: Post-surgical right shin, Unstageable, 20 CM (centimeters) X 15 CM X 0.2 CM depth, moderate drainage, no odor. No further documentation for October 2020 is noted. R31's facility Weekly Wound Tracking for November 2020 has no documentation for R31's wound. R31's facility Weekly Wound Tracking for December 2020 includes the following entry, 12/23/20 8 cm X 8.5 cm No stage, site, depth, drainage, color or odor were documented on the wound. No further weekly documentation for December 2020 was available. R31's facility Weekly Wound Tracking for January 2021 includes the following entry,Right heel 01/13/21 DTI (deep tissue injury). No measurements, depth, drainage, color or odor were documented on the pressure wound. Also, no documentation of the physician or family notification is documented. R31's facility Nursing Progress Notes for January 13, 2021 include no documentation of R31's new pressure wound to the right heel. R31's Physician order [REDACTED]. R31's Treatment Administration Record for November and December 2020, and January and February 2021 include no documentation of weekly skin monitoring for any additional skin concerns. R31's Primary Care Provider notes from V13/Wound Doctor, dated 2/17/21 document, Right proximal anterior leg ulcer 3.5 CM X 4.0 cm X 0.1 cm; Right distal anterior leg ulcer 0.8 CM X 1.0 CM X 0.1 cm; Right proximal lateral leg ulcer 2.5 CM X 1.8 CM X 0.1 cm; Right distal lateral leg ulcer 2.7 cm X 1.0 cm X 0.1 cm; and Deep tissue injury, right heel, 4.0 cm X 7.0 cm X UTI (unidentified traumatic injury). Wounds cleansed with wound cleanser. Applied [MEDICATION NAME] violet to periwound. Applied isosorb to wound bed. Covered with dry gauze and cast webbing. Secured with a two layer compression system. R31's Physician Orders, dated 2/17/21 and signed by V13/Doctor of Podiatry Medicine document, Continue with venous wound care. To pressure ulceration granular base apply Calcium Alginate at wound change schedule. On 2/23/21 at 12:30 P.M., V5/Licensed Practical Nurse (LPN) prepared to perform wound care for R31. V5/LPN removed bandage scissors from her uniform pocket and without cleansing them, placed them on the prepared clean field. V5/LPN used the bandage scissors to cut through the length of the heavily soiled bandage to R31's leg that was present from R31's leg from the knee to the toes. V5/LPN then placed the soiled scissors on the clean field and continued the dressing change to the right posterior shin. V5/LPN did not perform wound care to R31's right heel. V5/LPN applied a dressing to R31's posterior shin, and wrapped R31's leg from below the right knee and around R31's toes, leaving R31's wound to the right heel open. At that time, V5/LPN stated, All we do for the wound to (R31's) right heel is off-load (the pressure) to that area. (R31) doesn't have a treatment to that area. At the conclusion of the dressing change, V5/LPN picked up the bandage scissors and without cleansing them, placed them in her uniform pocket. At that time, V5/LPN confirmed she had not cleansed the scissors prior to placing them on the clean field, or after using them to remove a soiled dressing from R31's right leg. On 2/23/21 at 2:30 P.M., V2/Director of Nurses (DON) stated that the facility had no weekly wound tracking for R31's wounds for November or December 2020 and no weekly skin checks for R31's skin for October, November, December 2020 January and February 2021. V2/DON was unable to state the date the right heel wound began or provide an assessment of the right heel wound. V2/Director of Nurses stated, (R31's) Nursing Admission Assessment (10/22/20) should have included measurements of (R31's) right lower leg ulcers. V2/DON also confirmed V13/Wound Doctor had given a treatment order for R31's right heel pressure wound on 2/17/21. On 2/24/21 at 10:50 A.M., V13/Wound Doctor stated,The unstageable wound to (R31's) right heel was found by me at the appointment on 2/17/21. It was a black, unstageable wound measuring 4 CM` X 7 CM. On 2/17/21, I removed the eschar (black tissue) and ordered the facility to begin Alginate to the area. 2. R23's current physician's orders [REDACTED]. On 02/23/21 at 09:45 AM, V7 and V8 (Hospice Nurses) performed wound care and a dressing change to R23's coccyx pressure ulcer. V7 removed R23's coccyx dressing, and large circular wound measuring approximately 6 centimeters by 6 centimeters by 2 centimeters was present on R23's coccyx, with a large amount of eschar (black/brown) tissue present. R23's most recent Braden Scale Pressure Ulcer Risk Assessment (dated 8/12/20) documents a score of 14, indicating R23 is a high risk for pressure ulcer development. R23's current care plan does not include a care plan addressing R23's Stage IV coccyx pressure ulcer. R23's medical record does not contain any documentation of skin checks conducted on R23. On 02/25/21 at 10:58 AM, V2 (Director of Nursing) confirmed the following: R23's Braden Scale Pressure Ulcer Risk Assessment was last completed on 08/12/20. V2 stated it should have been conducted more frequently as indicated in the facility's Pressure Ulcer policy; V2 stated the facility has not documented weekly progress and measurements of R23's coccyx pressure ulcer from 8/12/20 until the facility began documenting Weekly Wound Tracking on 1/20/21. V2 stated V6 (local wound doctor) and the local hospice company documented about R23's wound from 8/12/20 - 1/20/21, but the facility did not maintain their own documentation during this time and should have been documenting weekly about the progress of R23's coccyx wound; V2 cannot provide documentation of any skin checks conducted on R23 since R23's admission to the facility. V2 stated that R23's Braden Scale Pressure Ulcer Assessment is high risk and R23 should have been receiving daily skin checks. V2 confirmed the facility has no documentation of any skin checks conducted on R23 since 8/12/20; V2 confirmed that R23's current care plan did not contain a care plan with interventions in place addressing R23's coccyx pressure ulcer.

Based on observation, interview, and record review, the facility failed to ensure a resident's wheel chair was free from sharp objects and supervise a resident at risk for ingesting potentially dangerous, non-edible items for 2 of 6 residents (R17, R21) reviewed for accidents in the sample of 34. These failures resulted in R17 receiving a laceration requiring 11 sutures and R21 attempting to ingest R21's face mask. Findings include: The facility's Dementia Specific Unit Training Requirements policy, undated, documents, Training of all unit staff who works on the unit: Methods of identifying and minimizing safety risks to residents with [MEDICAL CONDITION] and other dementia. 1. R17's Care plan, dated 2/18/21, documents, R17 has risk factors that require monitoring and intervention to reduce potential for self injury. Related diagnosis/condition/history includes dementia. R17's emergency room notes, dated 1/25/21, document chief complaint laceration leg/skin tear. R17's State Agency notification form, dated 1/25/21, documents R17 noted to have a skin tear on left lower outer leg. R17 sent to emergency room for treatment. R17 returned with 11 sutures. R17 does not use foot pedals on wheel chair as she typically propels herself. It was noted that the area where foot pedals would connect to wheel chair protruded out and caused injury. On 2/25/21 at 11:00 AM, V1 (Administrator) confirmed that R17's laceration was caused by R17's wheel chair. V1 stated, (R17) doesn't use foot pedals and there is a piece of her wheel chair that protrudes where the foot pedal would go. Maintenance and CNAs (Certified Nursing Assistants) should be checking the wheel chairs for things like this. 2. R21's Physician order [REDACTED]. R21's MDS/Minimum Data Set assessment dated [DATE], documents R21 is cognitively severely impaired. R21's Impaired Cognition plan of care documents on 12/20/20, (R21) tries to eat his face mask when placed on his face. Unable to wear mask due to safety concerns. On 2/22/21 at 12:57 pm, R21 was in his room sitting in his recliner with a face mask. After entering the room R21 quickly put the entire face mask into his mouth and began chewing on it. No staff were present at this time. V3 (LPN/Licensed Practical Nurse) was alerted and came in the room to try to remove the mask from R21's mouth. V3 stated, (R21) bites so (I) cannot stick my fingers in his mouth. V3 repeatedly asked R21 to spit the mask out into her hand, and after several attempts R21 stuck the face mask out far enough for V3 to grab and remove it. On 2/22/21 at 1:15 pm, V3 stated, (I )do not know if (R21) should have had a face mask on because (R21) eats everything including his shirts, silverware or anything he can put in his mouth. On 2/22/21 at 1:18 pm, V4 (LPN/Licensed Practical Nurse) stated, R21 should not have had a face mask on because (R21) puts everything in his mouth and tries to eat it.

Based on record review and interview, the facility failed to promptly identify a change in condition and notify the Physician for one of three residents (R3) reviewed for change of condition in a sample of eight. This failure resulted in a delay of R3 being sent to the local hospital and a delay in treatment for [REDACTED]. Findings include: R3's Profile Face Sheet, undated, documents that R3 admitted to the facility on [DATE]. Facility Oxygen Policy, Revised ,[DATE], documents that, Oxygen therapy may be used provided there is a written order by the Physician. The order must state liter flow per minute, mask or cannula, time frame. On an emergency basis, oxygen may be administered until the Physician is notified. Facility Notification of Change in Resident Condition or Status Policy, Revised [DATE], documents that: The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing/DON, Physician, Guardian, Health Care Power of Attorney, etc.) of changes in the resident's medical/mental condition and/or status; The nurse supervisor/charge nurse will notify the resident's attending Physician or on-call Physician when there has been any symptom, sign or apparent discomfort that is sudden, a marked change or unrelieved, a significant change in the resident's physical/emotional conditions, a need to alter the resident's medical treatment significantly or instructions to notify the Physician of changes in the resident's condition; The nurse supervisor/charge nurse will notify the DON or Physician, unless instructed by the resident representative, when the resident has any of the aforementioned situations; And the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. R3's Nursing Note, dated [DATE] at 10:00 am, documents that oxygen was started at one liter per nasal cannula for a low oxygen saturation (88 percent). R3's Nursing Note, dated [DATE], at 6:18 pm, documents that R3 was on two liters of oxygen and had an oxygen saturation of 90 percent, heart rate of 100 to 130, blood pressure of ,[DATE] and respirations of 36. It also documents that R3 had faint, muffled heart sounds, severe shortness of breath and that R3 was sent via ambulance to the local hospital. R3's Physician Orders, dated [DATE] through [DATE], do not document an order for [REDACTED]. R3's Medication Administration Record/MAR, dated [DATE], does not document Oxygen administration, flow rate, mask or cannula or time frame or as needed medication for anxiety. On [DATE], at 9:59 am, V15/LPN stated, (R3) asked me to call her Granddaughter because (R3) felt anxious and was having trouble breathing. (R3's) Granddaughter arrived at the facility around 10:00 am. (R3's) Oxygen saturations were low so I started her on Oxygen. She had anxiety sometimes and only had low oxygen saturations, so I did not think she was unstable enough that she needed to go to the hospital. I gave her Anxiety medication and put the oxygen on her and her oxygen saturation level came up. (V16/Nurse) sent her (R3) out just as I was leaving my shift. I did not fax or call the Doctor to notify him that I started her on oxygen or her change of condition. On [DATE], at 9:00 am, V15 stated, I did not give her (R3) any anxiety medication, I must have given her only scheduled medication. I did not do anything for anxiety. On [DATE], at 10:20 am, (V16/Nurse) stated, I came onto shift at 6:00 pm and (R3's) Granddaughter caught me, first thing, coming down the hallway and asked me to come assess (R3). (R3) had a very high heart rate and labored breathing. Her condition warranted me to call the Doctor and he said to send (R3) out to the Emergency Department. I had to convince her to go out, she did not want to go. She was not having any pain, just her vital signs and breathing were bad. R3's A.I.M. for Wellness, dated [DATE] at 6:30 pm, documents that R3's Physician was notified, via electronic facsimile, that R3 had pain in chest, started on oxygen and very short of breath this a.m. (morning), and very short of breath now. R3's Nursing Note, dated [DATE] at 9:00 pm, documents that R3 was admitted to the hospital with [REDACTED]. R3's Medical Record documents on [DATE] at 2:38 am, the facility received a phone call from the hospital that R3 had expired. On [DATE], at 10:33 am, V14 (R3's Family/POA) stated, They called me around 10:00 am and told me that (R3) had a bad spell around 5:00 am. Her oxygen was low (88 percent), her pulse was high and she was struggling to breathe and that she was continuing to struggle to breathe. She wanted me to come and see her, so I went and she told me she was dying. I was there all day until (V16/Nurse) came onto shift around 6:00 pm and immediately sent her by ambulance to the hospital. I kept telling the day shift nurse (V15/Licensed Practical Nurse/LPN) that (R3) needed to go to the hospital but she said it was just anxiety and that the hospital probably would not let me in anyway, due to COVID, so we did not go. (V16) called the hospital and they said I could go with her, so we went. The emergency room Doctor asked me why they waited so long to send her in and told me it was too late, that she had had a bad [MEDICAL CONDITION]. I did not see (V15) give any anxiety medication or any medication, for that matter, to help my Grandma. She was already on oxygen when I got there. On [DATE] at 8:15 am, V18 (R3's Physician) stated, I did not know that (R3) was having issues on [DATE] and I was not notified of her condition. I am finding that more facilities are overriding sending out the residents to the hospitals, they are just saying that it is anxiety and not looking at the worst outcome. If I would have been notified earlier in the day of her vitals, difficulty breathing and need for oxygen, I would have sent her to the hospital and it may have changed her outcome.

Based on interview and record review, the facility failed to follow the advance directives regarding cardio-pulmonary resuscitation for one of 17 residents (R53) reviewed for advance directives in a sample of 18. This failure resulted in facility staff not performing cardio-pulmonary resuscitation on R53, contrary to R53's advance directive to be resuscitated as documented in the resident's medical record. R53 expired in the facility. This failure has the potential to affect five other residents (R6, R20, R21, R33, and R302) whose medical record contains discrepancies regarding POLST (Physician order [REDACTED]. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE] at 2:00 p.m., the facility remains out of compliance at a Severity Level II as the facility audits all of the current residents advance directives related to Code status and POLST forms. The facility also continues to inservice staff regarding residents' advance directives, POLST form, completion of the POLST form, and the location of the POLST forms. Findings include: The facility's Do Not Resuscitate Policy, dated [DATE], documents, It is the policy of the facility that cardiopulmonary resuscitation and other emergency procedures will be initiated in all circumstances of a resident cardiac or [MEDICAL CONDITION] arrest unless a valid Do Not Attempt Resuscitate (DNR) order is written in the resident's record. When a valid DNR-Comfort order from the resident's physician is in the clinical record, CPR will not be initiated (or if initiated will be discontinued) in the event of cardio or [MEDICAL CONDITION] arrest. The policy also documents, The DNR-Comfort order will be entered, signed and dated by the physician in two places: Uniform Do Not Resuscitate (DNR) Advance Directive Form (POLST) as approved by the state agency; and the physician's orders [REDACTED]. 1. R53's POLST (Physician order [REDACTED].>R53's physician's orders [REDACTED]. R53's Care plan, dated [DATE], has no documentation of a comprehensive care plan addressing R53's code status. R53's Nurse's notes, dated [DATE] at 10:26 a.m., document, Gait belt applied to transfer (R53) from the toilet to his wheel chair. When staff went to transfer (R53) went limp and two Certified Nursing Assistants and (V4) (Licensed Practical Nurse) transferred (R53) to his bed. (R53's) blood pressure ,[DATE], pulse 53, and respirations 12 per minute with three second episodes of apnea. (R53) assisted to bed and took a large breath and stopped breathing. Chest rub done on (R53) without success. No pulse, femoral, pedal, cephalic, brachial or carotid. No respirations. No blood pressure. 10:35 a.m.: Director of Nursing notified (and) arriving in room to assess (R53). No blood pressure, pulse, or respirations noted. Physician notified, and new order to release (R53's) body to the funeral home. On [DATE] at 09:54 AM, V4 stated, If a resident codes I look for the POLST form. (R53) was sitting on the toilet yelling like he normally does. We were standing with him with a gait belt when he went limp. We transferred him to bed. I came to the desk to get stuff to check his vitals, and I checked his chart to see his code status. His code status was a DNR. I went back down to check his vitals raised the head of his bed. Initially, (R53) had vitals. Then, he stopped breathing. I did a chest rub. The DON had came down by that time to assess too. He had expired very quickly. I notified (R53's Physician) and he just gave me an order to release the body. I attempted to call the family and they finally called me back. (R53's daughter) was shocked. V4 confirmed that R53's POLST form states Full code, and stated, I saw the area of comfort measures only and was in a hurry. I didn't see the DNR marked. We should have performed CPR on (R53). On [DATE] at 10:03 AM, V1 (Administrator) stated, Advanced directives are determined by red colored POLST which is a DNR and a green colored POLST form is a full code. If a resident codes they should immediately go to the chart and check for the advanced directives. If they have the red form they should stop and not proceed with CPR, and if they have a green form they should proceed with CPR. V1 confirmed that R53's POLST form was colored red, however it documented that R53 was a full code. V1 stated, When R53's heart stopped beating and he stopped breathing according to his red colored POLST they should have done CPR even though it was red it was marked Full Code. On [DATE] at 01:54 PM, V9 (Licensed Practical Nurse) stated, I didn't know the POLST forms were different colors. I just assumed they were all red. On [DATE] at 02:07 PM, V13 (Licensed Practical Nurse) stated, a green POLST form means that a resident is a full code, and a red POLST form means that the resident is a DNR. On [DATE] at 12:00 PM, V6 (R53's Physician) stated, If a resident has a signed POLST form to be a full code, then CPR should have been performed. The accuracy of these forms is important. 2. R21's physician's orders [REDACTED]. R21's POLST copied on red paper, dated [DATE], documents that R21 is a DNR. R21's Care plan, dated [DATE], documents that R21 is a Full code. On [DATE] 12:56 PM, V9 (Licensed Practical Nurse) stated that R21 is a DNR, but her physician's orders [REDACTED]. On [DATE] at 01:08 PM, V1 (Administrator) stated that all residents POLST advance directives forms and physician's orders [REDACTED]. V1 confirmed that R21's POLST did not match R21's physician's orders [REDACTED]. 3. R20's POLST form copied on white paper, dated [DATE], documents R20 is a DNR (Do Not Resuscitate). On [DATE] at 11:30 AM, V1 (Administrator) stated his expectation is that if a resident is a DNR it's to be on a Red POLST form and Green if a full code. V1 verified R20's POLST form is white and should be red. 4. R302's Physician order [REDACTED]. R302's physician's orders [REDACTED]. On [DATE] at 11:30 AM, V4 (Licensed Practical Nurse/LPN) verified that there is a discrepancy with R302's code status on R302's physician's orders [REDACTED]. V4 stated that R302's physician's orders [REDACTED]. 5. R33's Admission Physician order [REDACTED]. R33's Social Services Progress Note, dated [DATE] documents, (R33) is a DNR (Do Not Resuscitate). R33's Care Plan Summary Record, dated [DATE] documents R33's code status as a Full Code. On [DATE] at 1:00 P.M., R33's Medical Record did not contain a POLST form indicating R33's code status, in the event of an emergency. On [DATE] at 10:34 AM V2/Director of Nurses verified R33's chart did not contain a POLST form. V2/DON stated, A resident's Code Status is kept in the front of the chart.(R33) does not have a Code status form in his chart. 6. R6's POLST form copied on white paper, dated [DATE], documents that R6 is a DNR. R6's physician's orders [REDACTED]. On [DATE] at 11:31 AM, V1/Administrator confirmed (R6's) Medical Record did not contain the red or green colored POLST form as expected. The Immediate Jeopardy was identified on [DATE] at 9:25 a.m., and began on [DATE] when R53 became unresponsive and was not resuscitated by facility staff despite R53's completed full code advance directive present in R53's medical record. V1 (Administrator), V2 (Director of Nursing), V3 (Social Services Director), and V5 (Care Plan Coordinator) were notified of the Immediate Jeopardy on [DATE] at 9:40 a.m. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. A facility audit of residents' medical records for current status of advance directives related to Code status and POLST completed on [DATE] by V3 (Social Services Director). 2. All POLST forms, with discrepancies identified during the audit, were completed on [DATE] by V3. 3. All staff were inserviced on [DATE] by V5 (Care Plan Coordinator) and V1 (Administrator) regarding POLST forms or Identifiers of code status, and the location of forms in the residents' chart. 4. All staff were inserviced on [DATE] by V5 and V1 explaining Advance Directives indicate resident wishes regarding Code Status, and that POLST forms must be read to determine Code Status. 5. V3 was inserviced on [DATE] by V1 regarding the completion of Advance Directives on admission. 6. V20 (Regional Director), V1, V2 (Director of Nursing), and V19 (Assistant Director of Nursing) clarified with all staff during the inservice on [DATE] that identification of residents' code status is located in each residents' medical record in the front of the chart on the POLST form or identifier of code status. 7. Advance directives will be sought on admission. Nursing management will audit Advance Directive status reflected correctly on physician's orders [REDACTED].