Every finding on record at Arcadia Care Auburn

Based on record review and interview the facility failed to administer the correct medication to 1 of 3 residents (R12) reviewed for medication errors in the sample of 3. Findings include:1 R12's face sheet, undated documents a diagnosis in part of Vascular Dementia severe with Anxiety, Acute and chronic respiratory failure with hypoxia, Pleural Effusion in other condition classified elsewhere, Chronic Obstructive Pulmonary Disease (COPD), essential hypertensionR12's Minimum Data Set (MDS) dated [DATE] documents a Behavioral Interview of Mental Status (BIMS) of 13 (cognitively intact). R12's care plan dated 2/16/26 documents R12 is receiving anti-psychotic medication related to delirium due to known physiology control and takes anti-anxiety medication related to anxiety disorder. R12's Medication Error Report dated 2/12/2026 at 00:00 documents R12 was administered Ativan 1milligram (mg) instead of Hydrocodone-Acetaminophen 7.5-325mg q 8 hours as ordered by physician. R12's medication error report documents the error was discovered during narcotic count with the oncoming nurse. R12's medication error report documents failure to identify reason for error. R12's Medication Administration Record (MAR) dated 3/1/2026 documents Hydrocodone-Acetaminophen 7.5 milligrams (mg)-325mg; give one tab every 8 hours for moderate pain V7's facility corrective action form dated 2/27/26 documents termination. The corrective action form documents on February 12, 20025 V7 was the nurse on duty for North Hall resident in rooms 19-35. During this narcotic count conducted at shift change, a discrepancy was identified. Upon further investigation, V7 inadvertently administered the wrong medication to the resident in room [ROOM NUMBER] during the medication pass resulting in a medication error. Documents the error was initially reported by another nurse on shift. The policy documents V7 received training on the medication administration policy on 9/25/2025. The corrective action form documents V7 has previously received corrective action for incompetence, substandard productivity or unsatisfactory job performance due to the following actions: failing to document a residents change in condition, failure to document emergency service transfer to the hospital on two occasions, despite prior corrective action and policy training. V7's performance deficiency has progressed to a medicine administration error Medication errors pose severe risks to the health and safety of the residents and create significant legal and regulatory compliance issues for the company. On 4/2/2026 at 9:56A V23 Licensed Practical Nurse (LPN) stated to ensure residents receive correct medication make sure right resident,right medication and right dose. V23 stated Medication Administration Record (MAR) is also checked with medication card. The facility Medication Administration Policy dated revised 1/2025 documents Administration of Medications; medications must be administered in accordance with a physician's order (PO) the right resident, right medication, right dosage, right route, and right time.

Based on interview and record review, the facility failed to answer call lights and provide care in a timely manner for 2 (R1, R2) of 4 residents reviewed for resident rights in a sample of 4. 1.) R1's admission Record documents R1 was admitted to the facility on [DATE] and has a diagnosis of Epilepsy, Parkinson's Disease without Dyskinesia, Essential Tremor, Chronic Obstructive Pulmonary Disease, Fibromyalgia, Chronic Kidney Disease, Lack of Coordination, Generalized Anxiety Disorder, Hypothyroidism, and Major Depressive Disorder.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, is dependent on staff for toileting hygiene, showering/bating, and needs substantial/maximal assistance for personal hygiene.R1's Care Plan Date Initiated 6/27/2025 documents the resident has an Activities of Daily Living (ADL) self-care performance deficit related to epilepsy, tremors, Parkinson's, lack of coordination, muscle wasting and atrophy.On 11/19/2025 at 8:00 AM R1 stated she has had to wait over an hour or more for her call light to be answered for staff to help her to the restroom or provide care. R1 stated when her call light isn't answered in a timely fashion, she feels like she does not matter to staff and it takes away her dignity, self-respect, and self-worth. R1 stated staff rush to get any task done when they do answer her call light, including bathing and cleaning up her and that makes her feel dirty.2.) R2's admission Record documents R2 was originally admitted to the facility on [DATE] and has a diagnosis of Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Morbid (Severe) Obesity, Major Depressive Disorder, Generalized Anxiety Disorder, Lack of Coordination, Heart Failure, and Hypertension.R2's MDS dated [DATE] documents R2 is cognitively intact, needs supervision or touching assistance with toileting hygiene, partial/moderate assistance with showering/bathing and personal hygiene, and occasionally incontinent of bladder and bowel.R2's Care Plan Date Initiated 12/15/2023 documents the resident has an ADL self-care performance deficit related to obesity, pain, difficulty walking.On 11/19/2025 at 8:21 R2 stated she has waited over an hour to have her call light answered and care provided. R2 stated when she has had to wait a long time for her call light to be answered it makes her feel awful and like her needs don't matter. R2 stated the facility has trouble with answering call lights in a timely fashion and this issue has been brought up to the Administration with nothing done about it. On 11/19/2025 at 10:15 AM V10, Certified Nursing Assistant (CNA), stated he knows residents have waited an hour or more for their call lights to be answered and residents do not always receive timely care. On 11/19/2025 at 11:11 AM V3, Assistant Director of Nursing (ADON), V3 stated all staff answer call lights and if a housekeeper or other staff member answer the light and cannot help the resident, they will inform the proper staff member. V3 stated she excepts staff to answer call lights promptly, usually within 3 minutes unless staff are in another resident's room or providing care to a resident.The Facility's Resident Council Minutes dated 9/4/2025 documents Old Business (concerns) [NAME] call light response time is still slow. Nursing: Follow up from August: Residents discussed this again [NAME] call light response time is still slow and said they see some improvement again depending on who was working the hall. The Facility's Resident Council minutes dated 10/2/2025 documents Old Business (concerns) [NAME] call light response time is still slow.The Facility's Call Light Policy Last Revised 01/2022 documents Purpose: To respond to residents' requests and needs in a timely and courteous manner.

Based on observation, interview and record review the Facility failed to ensure room temperatures were within the heat index/apparent temperature guidelines inside the facility and did not exceed 81 degrees Fahrenheit (F), the Facility failed to follow their Heat Emergency Policy as residents were not moved out of their rooms when temperatures were reached over 81 degrees for 4 of 4 residents (R1, R2, R3 and R11) reviewed for room temperatures in the sample of 16. This failure resulted in residents being left in rooms with the heat index indicating extreme caution to the residents. On 8/27/2025 at 9:55 AM, the Immediate Jeopardy/IJ was called with V1, Administrator. V2, Director of Nursing. and V17, Regional Director Operations The Immediate Jeopardy began on 8/7/2025 when resident room temperatures were not within the heat index/apparent temperature guidelines inside the facility and exceeded 81 degrees Fahrenheit (F), the Facility failed to follow their Heat Emergency Policy. The first abatement plan dated 8/27/2025 at 10:03 AM, was not accepted. The second abatement plan dated 8/27/2025 at 12:32 PM, was accepted. The surveyor confirmed by observation, interview, and record that the Immediate Jeopardy was removed on 8/27/2025, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the facility's policies and procedures and in-service training.Findings include:On 8/12/2025 at 9:45 AM, V1, Administrator stated, the air conditioning (AC) broke last Thursday (8/7/2025), and we were waiting for a part. All the air temperatures are good now. The AC repair man is here, and he is fixing everything. We brought in fans and some small AC units to the 500 halls, and we are having staff pass out drinks for hydration. The AC unit on the 500 hall was affected. We are not having issues with the other halls, and we are installing a new unit on the 500-hall unit today. Our maintenance man has been taking temperatures and took temperatures this morning and everything is good.On 8/12/2025 at 10:02 AM, V25, Registered Nurse (RN) was putting an IV (intravenous therapy medication) on a metal pole and quickly pulled her hand back and yelled out. On 8/12/2025 at 10:03 AM, V25 stated, This pole has been in the storage unit, I just took it out and it is so hot in there that this metal pole is hot, I cannot even touch it. It was being stored on the storage unit that is on the North Hall, that one with the broken AC (air conditioning) and it is super-hot!On 8/12/2025 at 10:03 AM, the metal pole was touched and was very hot to the touch and the hand had to be removed immediately. On 8/12/2025 at 10:31 AM, V6, Maintenance Director stated the AC (air conditioning) got struck by lightning on the South/West Hall and we finally got it repaired and up and running and then on Thursday the AC unit went out on the 500 halls. The 500 halls have been without AC for the past six days. I have been taking temperatures in all the rooms, and I have been using a laser thermometer. I did not use a Humidity Meter Hygrometer I do not even know what that is and I did not know I needed to factor in the humidity. I took temperatures this morning before you got here.On 8/12/2025 at 10:41 AM, V31, Contractor for HVAC system stated, we were called on Friday (8/8/2025) by (the facility) telling us they were having problems with their AC unit. I am replacing the thermal expansion valve today. The North Hall unit was out. I needed the parts, which I had to order and am replacing everything today. Hopefully, this will take care of everything for that hall.1-R2's Physicians Order Sheet (POS) for August 2025 documents diagnoses of Morbid Severe Obesity, Heart Failure, diabetes mellitus 2, kidney Failure, hypertension; chronic pain syndrome; unspecified protein calorie malnutrition; acute kidney failure; shortness of breath; hypertension; and generalized anxiety.R2's Minimum Data Set/MDS dated [DATE] document R2 was cognitively intact for decision making of activities of daily living, uses a wheelchair, and is dependent on staff for most activities of daily living.R2's Care Plan with a start date of 7/29/2024 documents, the resident has an ADL (Activities of daily living) self-care performance deficit r/t (related to) respiratory failure, obesity, chronic pain, depression. The resident has diabetes mellitus start date 8/28/2024; Intervention: Avoid exposure to extreme heat or cold.On 8/13/2025 at 10:03 AM, R2's room was measured with a Humidity Meter Hygrometer and Indoor Digital Thermometer with Temperature Gauge and Humidity Gauge which was calibrated and documented R2's room was 86 degrees with 61 percent humidity = for 91-degree Fahrenheit (F) room (extreme caution). On 8/12/2025 at 12:08 PM, V5, Family of R2 stated, The nursing home has failed to repair the broken air conditioner. It broke on Thursday August 7th, the system stopped functioning in my mom's room. There is no Air conditioning on their wing at all. Nurses have opened the windows and are using what fans they can find. The temperature outside has been in the high 80's and 90's all 5 days the air conditioner has been down. There was a thermometer in her room and her room was 87 degrees inside. My mom was sweating and complaining of headaches and how she was having issues sleeping because the room was so hot. The temperature inside the building exceeds outside temperatures at times. We are worried for my mom's and others' safety. It is too hot, for too long. She is bedridden and cannot escape the heat. They don't have the staff to get her up and move her throughout the day. She has asked for ice water, but (Facility) is experiencing problems with their ice.On 8/12/2025 at 12:08 PM, V5, Family of R2 stated, The nursing home has failed to repair the broken air conditioner. On Thursday August 7th the system stopped functioning in my mom's room. There is no Air conditioning on this wing at all. Nurses have opened the windows and using what fans they can find. The temperature outside has been in the high 80's and 90's all 5 days the air conditioner has been down. The temperature inside the building exceeds outside temperatures at times. We are worried for her and others' safety. It is too hot, for too long. She is bedridden and cannot escape the heat. They don't have the staff to get her up and move her throughout the day. She has asked for ice water, but Arcadia is experiencing problems with their ice machine as well, so it is in short supply. I came to visit my mother and noticed there wasn't air in the room, and it was very hot. I asked staff why it was so hot, and they stated the air doesn't work. There had been a storm, and it knocked out the air conditioning unit (A/C). When I asked how long it had not been working, they said for over a week now. I sat up a fan for my mom. The facility had put a box fan at the bottom of her bed, and I was dripping in sweat. Her room was so hot. They were not passing out any liquids. I was there for about two hours and a half, and no liquids or ice water were being passed out. I moved the fan up off the floor so it would circulate better. I am not sure if it really does anything because the fans are blowing around hot air. I was not sure what else to do to cool her down. I gave her a washcloth, but it got hot fast. It was hot outside too, but it was even hotter in my mom's room.On 8/13/2025 at 12:08 PM, R2 stated, the a/c had been broken for over a week. It is finally better today. Last week was miserable, the whole week we were without air conditioning. I was having issues sleeping and I was having problems breathing and suffering from headaches and I was sick to my stomach. Sleeping was so difficult, because the room was so hot. The maintenance man brought in a thermometer, and I know it read it was 87 degrees inside this room at that time. I can't get up on my own. I was trapped in the heat, and it was horrible, it was just horrible. I was just laying here suffering. Thank goodness it is better today as I am not sure how much more I could have taken. I can now breathe better, and my headaches are gone, and my stomach feels better. It is amazing how that heat can wipe you out.R2's August 2025 vitals document here weight was documented on 8/3/2025, blood sugar 8/22/2025, oxygen and pain on 8/22/2025. No other documentation was present addressing vitals and or any resident assessment related to heat.2- R1's POS for August 2025 documents diagnoses of chronic kidney disease stage 4, severe sepsis with septic shock; acute respiratory failure with hypoxia, major depression, sleep apnea; chronic pain, major depressive disorder, heart failure, and type 2 diabetes mellitus with diabetic neuropathy.R1's MDS dated [DATE] document R1 was cognitively intact for decision making of activities of daily living. R1 has impairment on one side on her upper extremity, she uses a wheelchair, and needs some assistance with her ADL's, (Activities of Daily Living). R1's Care Plan with a revision date of 4/19/23 document she (R1) resident has an ADL self-care performance deficit r/t obesity, pain, difficulty walking.On 8/12/2025 at 9:58 AM, R1 is a large woman in a bariatric wheelchair. R1's forehead is covered with droplets of sweat. R1 is in the main room when entering the facility near a fish tank. R1 does not have any water and/or cup near her.On 8/12/2025 a 9:59 AM, R1 stated my room is a furnace. I had to go and order myself another fan because it is just too hot for me to stay in there, and I am a large woman and can't take the heat. The A/C has been broken since Thursday. It has been over a week. I just can't take it. I guess they had to order a part to get it fixed. They tinkered with it, but it is still broken and not working. It has been miserable trying to sleep in this heat. We have ice water passed out to us, but no popsicles or anything like that. I have had a headache since the heat started, which I think is due to the extreme heat.On 8/13/2025 at 10:02 AM, R1's room registered 86 degrees Fahrenheit with 62% humidity = 102 degrees F (extreme caution). R1's August 2025, Medical records were reviewed and does not document any vitals were taken except for pain on 8/9/2025 and 8/21/2025. No other vitals were documented for any other days. No other documentation was present addressing vitals and or any resident assessment related to heat.3- R3s POS August 2025 documents diagnoses of acute osteomyelitis, left ankle and foot, morbid (severe) obesity with alveolar hypoventilation, type 2 diabetes mellites without complications, acute respiratory failure, chronic systolic heart disease, and major depression. R3's MDS dated [DATE] document R3 was cognitively intact for decision making of activities of daily living.R3's Care Plan: The resident has an ADL self-care performance deficit r/t respiratory failure, obesity, weakness, lack of coordination, reduced mobility. The resident has Diabetes Mellitus; Avoid exposure to extreme heat or cold. (2/14/2025)On 8/12/2025 at 10:24 AM, R3 stated it was so hot, it was like living in a furnace. He was very uncomfortable, and the heat was out of control and the AC had been out for 8 days now. He had just gotten out of the hospital and was not sure that the room being so hot was good for him. He stated he has asked for multiple bed baths, and they give them to him, but he is still sweating really bad because of the heat.On 8/12/2025 at 10:22 AM, R3's room temperature was 86 degrees Fahrenheit with 60 degrees humidity = 91 degrees (extreme caution for heat index). R3's August Medical Records/Vital Signs only document the weight on 8/3/2025, blood sugar, 8/22/2025, oxygen 8/22/2025, and pain 8/22/2025. No other documentation was present addressing vitals and or any resident assessment related to heat.4- R11's POS for August 2025 documents, diagnoses of chronic obstructive pulmonary disease, acute kidney failure, type 2 diabetes without complications, shortness of breath and specified abnormal findings of blood chemistry. R11's MDS dated [DATE] document R2 was cognitively intact for decision making of activities of daily living.R11's Care Plan with a revision date of 1/13/2025, documents, Resident has an actual skin impairment of (specify type: pressure/skin tear/bruise/surgical incision/rash/venous/stasis ulcer/arterial/ischemic ulcer/cellulitis/diabetic ulcer/) to (location). *Do not list stage* diabetes, diuretics, edema, fragile skin, impaired mobility, incontinence. Avoid exposure to temperature extreme.On 8/13/2025 at 10:02 AM, R11's room registered 86 degrees Fahrenheit with 62% humidity = 102 degrees F (extreme caution). On 8/15/2025 at 1:11 PM, R11 stated, The AC did break, and it was so hot in here and I am so thankful it is fixed now. They brought in some fans for my room, but it was just blowing around hot air, and it was not pleasant. It was so uncomfortable, and I felt so tired.R11's August 2025 Vital Documents for breathing 8/12/2025, and 8/19/2025. No other documentation was present for the month of August. No other documentation was present addressing vitals and or any resident assessment related to heat.On 8/13/2025 at 2:32 PM, V16, Medical Director stated, I would expect the residents' room temperatures to follow the policy and standards for the temperature guidelines. I know the AC is up and working now. For this population extreme heat is not always good thing but sometimes there can be other things going on as well with the patient. I would expect fans to be placed in residents' rooms and attempts to lower the room temperatures made by the facility. The Heat Emergency Policy with a revision date of 11/1/2024 documents, The purpose of this guideline is to provide precautionary and preventative measures for our residents during the hot and humid summer months. Older adults are extremely vulnerable to heat related disorders. Heat Exhaustion: A disorder resulting from overexposure to heat or to the sun. Early symptoms are headache and a feeling of weakness and dizziness, usually accompanied by nausea and vomiting. There may also be cramps in the muscles of the arms, legs, or abdomen. The person turns pale and perspires profusely, skin is cool and moist, and pulse and breathing are rapid. Body temperature remains at a normal level or slightly below or above. The person may seem confused and may find it difficult to coordinate body movements. Heat Stroke: A profound disturbance of the body's heat-regulating mechanism, caused by prolonged exposure to excessive heat, particularly when there is little or no circulation of air. The first symptoms may be headache, dizziness and weakness. Later symptoms are an extremely high fever and absence of perspiration. Heat stroke may cause convulsions and sudden loss of consciousness. In extreme cases it may be fatal. If the heat in the building increases above state mandated guidelines evacuate if necessary and follow evacuation policy.The Facility Vital Signs Monitoring Policy with an effective date of 4/2025 documents, Definition includes temperatures, pulse, respirations, and blood pressure, May also include pain level and oxygen saturations. Blood pressure 90/60 mm Hg to 120/80 mm Hg. Breathing 12-18 breaths per minutes; Pulse 60-100 beats per minute. Temperature 98.8 F to 99.1 F (36.5 C to 37.3 C/ average 98.6 F (37.0). Vital signs may be obtained more frequently with change of condition. Abnormal vital signs will be reported to the physician.The Immediate Jeopardy and deficiency practice that began on 8/7/2025 when the air conditioning was no longer working and the IJ was corrected/removed on 8/27/2025 after the facility took the following actions to correct the noncompliance prior to the start of current survey: AC unit was immediately repaired. Facility purchased extra fans and portable AC unit. Facility initiated Heat Emergency Policy making hourly rounds, offering water, wet rags, offering to relocate residents. R1, R2, R3 and R11 have been accessed and documented for risk of heat induced illness. All staff was in-serviced on Heat Emergency Policy. All nursing staff were in-serviced on documenting and monitoring resident's vitals and identify signs and symptoms of head induced illness. Also offering to relocate residents while under a Heat Emergency. All residents were assessed, and a QA (Quality Assurance) meeting was held to ensure compliance with facility Heat Emergency Policy.

Based on observation, interview and record review the facility failed to administer medication as ordered for 1 of 3 residents (R2) reviewed for medication in the sample of 5. Findings include: On 5/27/2025 at 8:50AM medication cup on R2's bedside table with medication in it. A Trelegy Ellipta aerosol powder breath activated inhaler and Fluticasone Propionate Nasal spray also sitting on bedside table. R2 asleep in chair. R2's Medication Administration Record (MAR) dated 5/1/2025-5/31/2025 documents R2 prescribed medications as Cetirizine 10 mg in morning Duloxetine 30mg, in morning, Esomeprazole Magnesium capsule delayed release 40 mg in morning, Ferrous sulfated ER 45mg in morning, Furosemide 40mg, 1 tablet in morning, Magnesium Oxide 400mg in morning, Omeprazole 20mg daily, Trelegy Ellipta inhalation aerosol powder breath activated 1 puff orally in the morning, Apixaban 5mg every morning, Doxycycline Monohydrate 100mg two times a day, Eliquis 5mg every morning, Fluticasone allergy relief nasal suspension 50 mcg (microgram) a spray each nostril two times a day, Gabapentin 300mg in morning, Metformin HCL ER extended release 24 hour 500mg, Methocarbamol 500mg every morning, Hydrocodone-Acetaminophen 5/325mg every 8 hours for pain (signed out by V4, Registered Nurse (RN) 8:00AM). R2's MAR documents all above medications administered by V4, RN. R2's MAR does not document R2 is to have medications at bedside. R2's Physician Orders (PO) dated May 2025 does not document R2 to have medications at bedside or document R2 on a self-administering medication program. On 5/27/2025 at 11:47AM V4, Registered Nurse (RN) stated she did leave R2's medication at the bedside. V4 stated R2 keeps nasal spray and inhaler at her bedside too. V4 stated she does not leave anyone else's medication at the bedside. On 5/27/2025 at 2:34PM V2, Director of Nursing (DON) stated R2 does not have a program to self-administer medication. The facility policy Medication Administration Policy dated last revised 1/2015 documents licensed nurse (Registered Nurse (RN), Licensed Practical Nurse (LPN) may prepare, administer and record administration of medications.

Based on observation and interview the facility failed to provide comfortable temperatures in the dining room and visiting room. This failure has the potential to affect all 57 residents residing at the facility. Findings include: 1.R3's medical diagnosis sheet, print date of 5/9/25, documented R3 has diagnoses including type 2 diabetes mellitus, heart failure, fibromyalgia, dementia, and anemia. R3's Minimum Data Set (MDS), dated [DATE], documented R3 is moderately cognitively impaired although resident was alert and oriented at time of interview. On 5/9/25 at 9:24 AM R3 stated the facility was freezing the first day they shut the heat off, my room temperature is okay now, but the dining room is still cold. 2. R4's medical diagnosis sheet, print date of 5/9/25, documented R4 has diagnoses including chronic obstructive pulmonary disease, hypokalemia, atrial fibrillation, osteoarthritis, anxiety, hypertension, and morbid obesity. R4's MDS, dated [DATE], documented R4 is cognitively intact. On 5/9/25 at 9:33 AM R4 stated the dining room and lobby are always cold. Other residents and I have told maintenance about it being so cold. 3. R5's medical diagnosis sheet, print date of 5/9/25, documented R5 has diagnoses including heart failure, muscle weakness, asthma, chronic obstructive pulmonary disease, and myalgia. R5's MDS, dated [DATE], documented R5 is cognitively intact. On 5/9/25 at 9:42 AM R5 stated her room is a comfortable temperature but it is a little cold in the dining room. Resident was observed wearing a scarf over her head and had a hooded jacket on with the hood also covering her head while sitting in her wheelchair in the dining room. 4. R6's medical diagnosis sheet, print date of 5/9/25, documented R6 has diagnoses including morbid obesity, chronic kidney disease, heart failure, anxiety, hypothyroidism, and depression. R6's MDS, dated [DATE], documented R6 is cognitively intact. On 5/9/25 at 9:57 AM R6 stated her room temperature is okay, but it is usually cold in the dining room and makes it uncomfortable during meals and activities. On 5/9/25 at 9:40 AM V6 Certified Nurse Assistant, CNA, stated she has had some residents complain to her about the dining room being cold. On 5/9/25 at 9:45 AM V7 CNA stated she occasionally hears residents saying they are cold in the dining room, so she gets them a blanket. On 5/9/25 at 9:52 AM V3, Maintenance Director, stated the dining room thermostat is in the kitchen, the air conditioner is on, and they keep it set on 70. V3 stated it blows cool air out into the dining room and sitting area. On 5/9/25 at 10:02 AM V3 was observed checking the dining room temperatures with 2 different thermometers. The first thermometer read 68 degrees Fahrenheit (F) and his second thermometer read 67.3 F. Surveyor checked the temperature with third thermometer, and it read 67.8 F degrees. On 5/9/25 at 10:18 AM V9, Activity Assistant, stated she had one resident, R2, recently say she was cold in the dining room during lunch, so she bundled her up with blankets. On 5/9/25 at 10:25 AM V3, Maintenance Director, checked the visiting room temperature with 2 different thermometers. The facility's thermometer read 67.3 degrees F and surveyor's thermometer read 67.6 degrees F. On 5/9/25 at 10:54 AM V1, Administrator, stated the current facility census is 57 and all residents do come out of their rooms. On 5/9/25 at 11:52 AM, V1, provided surveyor with the facility disaster plan/policies and procedures. V1 stated the facility does not have any other policies for internal facility temperatures other than what is in the emergency plan in the event the facility loses power.

Based on observation, interview and record review, the facility failed to provide hot water for resident use for 21 of 21 residents (R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, R26) reviewed for safe/comfortable/homelike environment in a sample of 26. Findings include: 1. On 4/7/2025 at 10:30 AM, R1 stated that the hot water heater was still out on his hallway, and it's been a week since he got his last shower. R1 stated that he doesn't have hot water to wash his hands or face in the morning or after he uses the toilet. R1 also stated that was not provided nor offered a warm wet washcloth to clean his face or hands. On 4/7/2025 at 10:30 AM, R1's bathroom faucet was turned on and after a few minutes, the hot water was still cold. R1's Shower sheet, dated 3/23/2025, documented that there was cold water. R1's Minimum Data Set (MDS), dated [DATE] documented that his cognition was intact and that he required set up assistance for shower and bathing. R1's Care Plan, dated 1/13/2025 (revised), documented, I prefer a shower, (2) times per week. 2. On 4/7/2025 at 1:15 PM, R2 stated that they have to take her down to the other hallway to get a shower because the water heater on their hall has been out for the past 3 weeks. R2 stated she has been unable to wash her hands and face because there was no hot water and that she was not given a warm wet washcloth to wash her hands and face. On 4/7/2025 at 11:50 AM, R2's hot water from her bathroom faucet was cold to touch after running it several minutes. R2's MDS, dated [DATE], documented that her cognition was intact. It also documented that she was dependent upon staff for toileting but partial to maximal assist for dressing assistance. R2's Care Plan, dated 1/20/2025, documented, BATHING/SHOWERING: The resident requires assist of (1) staff member with bathing/showering. 3. On 4/8/2025 at 8:30 AM, R3 stated that it is frustrating that there has been no hot water on their hallway or in their rooms so she can wash her hands or her face in the morning and that she was not given or offered a warm wet washcloth to wash her hands and face. On 4/8/2025 at 8:30 AM, R3's hot water in her bathroom was cold to touch after running several minutes. R3's MDS, dated [DATE], documented that her cognition was intact, but bathing and showering was marked not applicable. R3's Care plan, undated, documented that she required an assist of 1 for bathing and showering. 4. On 4/8/2025 at 11:00 AM, R5 stated that she has hot water, but the other hall hasn't had any for a week or 2 and she would not want to be without hot water to wash her face and hands. R5's MDS, dated [DATE], documented that her cognition was intact and that she was dependent upon staff for bathing and showers. On 4/7/2025 at 10:20 AM, V1, Administrator stated that yes, the water heater went out on the south hallway and that the new on was ordered and it would have been put in last week, but the company sent them the wrong one because theirs is propane. On 4/7/2025 at 10:40 AM, the south hall's shower room hot water was cold to touch when ran for several minutes. On 4/9/2025 at 11:00 AM V7, Certified Nurse's Aide, CNA, stated that when the water heater was out no residents missed their showers because they were using the other shower room. She also stated that it was hard with making sure the residents had hot water to wash their hands and faces but they used the water basins. V7 stated that she used the bathroom up front to wash her hands. On 4/9/2025 at 11:05 AM, V8, CNA, stated that they brought the residents off that hall down to the other shower room when that one was out. V8 stated that she washed her hands in the kitchen or the bathroom up front and that she had a stack of rags in a plastic bin with hot water and she would hand them out. On 4/9/2025 at 11:10 AM, V9, CNA, stated that they brought the residents down to the other shower room to give them their showers. V9 stated that she would go and get warm water and wash cloths and pass them out to the residents who needed them in the morning. V9 stated that she used cold water to wash her hands. On 4/8/2025 at 3:40 PM, V1, Administrator, stated that she was unsure of the date as to when the hot water heater went out but did not think it was on 3/24/2025 when shown the work order. V1 stated that the pilot light kept going out of it and they thought they could replace the part but they ended up having to replace the whole thing and then they were sent the wrong water heater and that was why it took so long. V1 also stated that they thought about having a cooler with hot water and wash cloths in it to pass out to the residents but was told it was an infection control issue. On 4/9/2025, at 10:55 AM, V3, Maintenance Director, stated that around 3/24/25, was when the pilot light kept going out. He was having to light it every morning and it may have lasted a few days before having to re light it. V3 stated that they figured out they needed a whole new water heater. A new one was ordered, then they got it and realized it was propane and they needed the other one that was not. Resident council meeting minutes, dated 4/3/2025, documented, (V3, Maintenance Director) laundry, and housekeeping supervisor was at the meeting. He talked about the new hot water heater and discussed any maintenance and laundry questions Maintenance work order, dated 3/24/2025, documented, South has no hot water. Residents' Rights for People in Long-Term Care Facilities, dated 11/2018, documented, Your facility must be safe, clean, comfortable and homelike. The facility's room roster, dated 4/7/25, documented that there were 21 residents on the south wing which included the following residents: R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, and R26.

Based on observation, interview and record review, the facility failed to maintain a hot water heater to supply hot water to residents for 16 days for 21 of 21 resident (R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, R26) reviewed for Physical Environment in a sample of 26. Findings include: 1. On 4/7/2025 at 10:30 AM, R1 stated that the hot water heater was still out on his hallway, and it's been a week since he got his last shower. R1 stated that he doesn't have hot water to wash his hands or face in the morning or after he uses the toilet. R1 also stated that was not provided nor offered a warm wet washcloth to clean his face or hands. On 4/7/2025 at 10:30 AM, R1's bathroom faucet was turned on and after a few minutes, the hot water was still cold. 2. On 4/7/2025 at 11:50 AM, R2's hot water from her bathroom faucet was cold to touch after running it several minutes. On 4/7/2025 at 1:15 PM, R2 stated that they have to take her down to the other hallway to get a shower because the water heater on their hall has been out for the past 3 weeks. R2 stated she has been unable to wash her hands and face because there was no hot water and that she was not given a warm wet washcloth to wash her hands and face. 3. On 4/8/2025 at 8:30 AM, R3 stated that it is frustrating that there has been no hot water on their hallway or in their rooms so she can wash her hands or her face in the morning and that she was not given or offered a warm wet washcloth to wash her hands and face. On 4/8/2025 at 8:30 AM, R3's hot water in her bathroom was cold to touch after running several minutes. On 4/7/2025 at 10:20 AM, V1, Administrator stated that yes, the water heater went out on the south hallway and that the new on was ordered and it would have been put in last week, but the company sent them the wrong one because theirs is propane. On 4/7/2025 at 10:40 AM, the south hall's shower room hot water was cold to touch when ran for several minutes. On 4/9/2025 at 11:00 AM V7, CNA, stated that when the water heater was out. V7 stated that it was hard with making sure the residents had hot water to wash their hands and faces but they used the water basins. V7 stated that she used the bathroom up front to wash her hands. On 4/9/2025 at 11:05 AM, V8, CNA, stated that they brought the residents off that hall down to the other shower room when that one was out. V8 stated that she washed her hands in the kitchen or the bathroom up front and that she had a stack of rags in a plastic bin with hot water and she would hand them out. On 4/9/2025 at 11:10 AM, V9, CNA, stated that they brought the residents down to the other shower room to give them their showers. V9 stated that she would go and get warm water and wash cloths and pass them out to the residents who needed them in the morning. V9 stated that she used cold water to wash her hands. On 4/8/2025 at 3:40 PM, V1, Administrator, stated that she was unsure of the date as to when the hot water heater went out but did not think it was on 3/24/2025 when shown the work order. V1 stated that the pilot light kept going out of it and they thought they could replace the part but they ended up having to replace the whole thing and then they were sent the wrong water heater and that was why it took so long. V1 also stated that they thought about having a cooler with hot water and wash cloths in it to pass out to the residents but was told it was an infection control issue. On 4/9/2025, at 10:55 AM, V3, Maintenance Director, stated that around 3/24/25, was when the pilot light kept going out. He was having to light it every morning and it may have lasted a few days before having to re light it. V3 stated that they figured out they needed a whole new water heater. A new one was ordered, then they got it and realized it was propane and they needed the other one that was not. Maintenance work order, dated 3/24/2025, documented, South has no hot water. Electronic mail between V11, Director of Plant Operations, to V10, Purchasing Officer, dated 3/26/2025, V11 documented, We are indeed (sic) of a water to replace the current one that has a cracked tank . Electronic mail between V10, Purchasing Officer and V11, Director of Plant Operations, dated 3/27/2025, documented, (V11) we are quoting out and will keep you posted here. Electronic mail between V10, Purchasing Officer to V14, Regional Director of Operations, dated 3/28/2025, documented, (V14) can you please advise if this is approved: 74-gallon BT-80 75, 100 BTU Commercial Gas Water Heater (NG). Electronic mail between V14, Regional Director of Operations, and V10, Purchasing Officer, dated 3/31/2025, documented, Approved. Electronic mail between V10, Purchasing Officer and V12, Regional Maintenance Director, dated 3/31/2025 at 2:26 pm, documented, This has been ordered, looks like its back ordered, will keep an eye on the ETA, please let me know if would like us to make any changes: Arriving Thu, May 01- Tue, Jun 03. Electronic mail between V12, Regional Maintenance Director to V10, Purchasing Officer dated 3/31/2025 at 2:37 pm, documented, We'll need something prior to those dates. we currently have a shower room/laundry that has no hot water. Electronic mail between V10, Purchasing Officer to V12, Regional Maintenance Director and V11, Director of Plant Operations, dated 4/2/2025 at 7:40 AM, (V12 and V11) please confirm if this option will work for the facility. Electronic mail between V14, Regional Director of Operations to V10, Purchasing Officer, dated 4/2/2025 at 9:22 AM, documented, Approved. On 4/8/2025 at 1:45 PM, V3, Maintenance Director, stated that the new hot water heater is in, and they now have hot water for that hallway. The facility's room roster, dated 4/7/25, documented that there were 21 residents on the south wing which included R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, and R26. On 4/9/2025 at 3:25 PM, V1, Administrator, stated that EWSP, stands for emergency water supply process and since the facility did not lose water, they did not follow that process. V1 stated that she does not think the facility has a policy about when the hot water heater goes out. The facility's Emergency Operations Plan, undated, documented, The ESWP will vary from facility to facility, but with an ESWP will assist to ensure that patient and staff standard of care will be maintained during a water emergency.

Based on interview, observation, and record review the facility failed to act immediately after determining a resident was unresponsive, did not check for a pulse until prompted by the survey team and initiate CPR immediately to a resident in medical distress for 1 of 1 resident (R257) reviewed for CPR in the sample of 34. This failure resulted in an Immediate Jeopardy that began on [DATE] at 10:09AM, when R257 was identified to be unresponsive to verbal stimuli and staff failed to check for a pulse until prompted by the survey team and immediately initiate CPR (Cardiopulmonary Resuscitation). On [DATE] at 3:07PM V5, Regional Director of Operations and V18, Regional Director of Clinical Operations were notified of the Immediate Jeopardy. The survey team confirmed through observations, interview, and record review, that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and quality assurance. Findings Include: On [DATE] at 10:05 AM, R257 was lying on her back, in bed in flat and was unarousable to verbal stimuli. On [DATE] at 10:09 AM, V15, CNA (Certified Nursing Assistant) was observed walking into R257's room, V15 was asked if she could arouse R257. V15 tried to arouse R257 by calling out name and touching R257. V15 was unable to arouse R257 at this time. V3, ADON (Assistant Director of Nursing) was in the hallway and asked to come into R257's room by the survey team. V3 tried to arouse R257 by calling her name and shaking R257's chest. V3 stated, She is diabetic. I'm going to do an accucheck. She stated to the CNA, Get a set of vitals on her. V3 left the room to get a glucometer and V15 got an electronic vital signs machine and put the blood pressure cuff on the resident and hit the start button. The machine was not registering a pulse or blood pressure and I (surveyor) asked the, How do you usually check for a pulse? and she (V15) stated she (V15) usually checks for a pulse on a resident's wrist (radial) and surveyor asked her to please do that no one had stated, Call a code . additional staff came into the room at this point and V3 DON did walk up the hall with the crash cart On [DATE] at 10:11 AM. V15, CNA, came into R257's room with vitals machine and tried to obtain vitals. V15, CNA, was unable to obtain blood pressure reading. V15 was asked by the survey team if she could feel a pulse. V15 stated she was unable to feel a pulse. On [DATE] at 10:12 AM, V3, ADON tried to obtain vital signs on R257. V3 unable to obtain blood pressure reading. V3 stated R257 had shallow breathing with a pulse oximeter reading of 76%, and she could feel a faint pulse. V3 stated she did not count R257's pulse but could feel a faint one. V3 obtained a blood sugar reading of 139. On [DATE] at 10:13 AM, V2, DON (Director of Nursing) walked into R257's room and V3, ADON advised V2 that R257 needed oxygen. V2 left room and came back with the crash cart containing the oxygen and applied it to R257 per nasal cannula. On [DATE] at 10:15 AM, V16, RN (Registered Nurse) listened to R257. V16, RN, stated she could not hear any breath sounds but could feel a faint pulse. On [DATE] at 10:16 AM V16, RN, started chest compression and V3, ADON administered breath per resuscitation bag. On [DATE] at 10:17 AM, V7, SSD (Social Service Director) stated R257 is a full code and emergency services were already called by nursing staff. On [DATE] at 10:18 AM, V14, LPN/MDS (Licensed Practical Nurse/Minimum Data Set) took over chest compressions on R257. On [DATE] at 10:22 AM, First Responders arrived to the facility. On [DATE] at 10:24 AM, First Responders applied AED (Automated External Defibrillator) machine. No heartbeat noted on machine, first responders took over CPR from facility staff. On [DATE] at 10:47 AM, Emergency Medical Services declared R247's date/time of death. R257's Face Sheet, undated, documents R257's medical diagnoses includes Orthopedic Aftercare, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Hypothyroidism, Congestive Heart Failure and Chronic Kidney Disease. R257's POLST (Practitioner Order For Life-Sustaining Treatment) form, dated [DATE], documents R257 is a Full Code. Attempt cardiopulmonary resuscitation (CPR). Utilize all indicated modalities per standard medical protocol. On [DATE] at 11:44 AM V17, Medical Director stated CPR should have been started on R257 right away when staff noticed R257's condition. The Facility CPR Policy, dated ,d+[DATE], documents the facility will provide basic life support, including CPR, when a resident requires such as emergency care, prior to the arrival of emergency medical services, subject to the physician order and resident choice indicated in the resident's advanced directive. Abatement Plan [DATE] Description of occurrence:Cardio-pulmonary Resuscitation Action Taken Completion Date 1) Facility reviewed code blue procedure and emergency procedures with all staff. Initiated on [DATE] by V18, Regional Director of Clinical Operations. o Weekly random code blue mock drill to be completed by administrator or designee. o All staff educated to stay with unresponsive person and call for help. If qualified, staff to check for pulse, if pulseless initiate CPR immediately, if required by V14, LPN/MDS, on [DATE]. Any staff that are not in in the facility were notified via phone, if not reachable will be educated prior to taking shift by DON or designee. o Signage placed at time clock and nurses' station with the above education. o All nursing staff is being required to attend CPR refresher course. Courses starting [DATE]. Weekly audits to be completed by DON or designee. o Ad hoc QA (Quality Assurance) with IDT (Interdisciplinary Team) to review code blue policy by V18, Regional Director of Clinical Operations, on [DATE]. o Emergency code blue drill ran on [DATE] at 5:40 PM to ensure compliance by V5, Regional Director of Operations and V3, ADON. 2) Facility reviewed for POLST and advance directives polices with IDT. Initiated on [DATE] by V18, Regional Director of Clinical Operations. o Social services to audit twice a week to ensure POLST forms are in place for all residents. o Ad Hoc QA with IDT to review POLST/advance directives and educate if any changes to educate staff on [DATE] o Audit of all residents POLST and verification that code status is showing on EMR (Electronic Medical Record) home sheet to easily read- audited by V7, Social Services Director, on [DATE]. o Administrator and/or designee will audit all POLST and verification that code status is on (EMR) home sheet to easily read weekly beginning on [DATE].

Based on interview and record review, the facility failed to have a system in place to monitor and track, infections in the facility for 5 of 5 (R3, R8, R47, R30, and R22) residents reviewed for antibiotic stewardship/ Infection control in a sample of 34. Findings include: 1. R3's Physician order sheet dated 8/19/2024 documents Fosfomycin Tromethamine Oral Packet 3 gram (GM). Give 3 gram by mouth one time only for Urinary Tract Infection (UTI) for one day. R3's Medication Administration Sheets (MARS) dated 8/1/2024 - 8/31/2024 documents Fosfomycin Tromethamine Oral Packet 3 GM. Give 3 gram by mouth one time only for Urinary Tract Infection for one day. Date of administration 8/19/2024. Facility's infection control log dated 8/19/2024 documents Fosfomycin, Urinary Tract Infection. No organism documented. R3's Nursing Notes dated 8/19/2024 at 1:40PM documents daughter called requesting R3 be placed on an antibiotic for UTI. Nurse Practitioner, NP, notified and ordered Fosfomycin 3 GM by mouth times one. Daughter called back and made aware. 2. R8's Physician order sheet dated 12/20/2024 documents Amoxicillin Oral Capsule 500 MG (Amoxicillin). Give one capsule by mouth in the morning for cellulitis for 30 Days. R8's Physician order sheet dated 1/25/2025 documents Amoxicillin Oral Capsule 500 MG (Amoxicillin). Give one capsule by mouth one time a day for preventative cellulitis. R8's Medication Administration Sheets (MARS) dated 12/1/2024-12/31/2024 documents Amoxicillin Oral Capsule 500 MG. Give one capsule by mouth in the morning for cellulitis for 30 Days Start Date-12/21/2024 at 6:00AM. Dose administered 12/21/2024-12-31-2024. R8's Medication Administration Sheets (MARS) dated 1/1/2025-1/31/2025 documents Amoxicillin Oral Capsule 500 MG. Give one capsule by mouth in the morning for cellulitis for 30 days. Start Date-12/21/2024 at 6:00AM. Dose administered 1/1/2025-1/19/2025. Facility's Infection Control Log dated 12/20/2024 documents for R8: Ceftriaxone, Bacterial, Cellulitis. Facility's Infection Control Log dated 1/27/2025 documents for R8: Amoxicillin. Infection unknown. R8's Nurse's Notes dated 12/21/2024 at 8:53PM document continue on intravenous Ceftriaxone and by mouth Amoxicillin for cellulitis to left lower extremity with no adverse reactions noted. Fluids encouraged and taken well. PICC line in place to right upper arm with no signs or symptoms of infection noted. No redness, edema, or warmth noted to left lower extremity. Voices no complaints of pain. R8's Nurse's Notes dated 1/25/2025 at 2:15PM documents Call received from Nurse Practitioner, NP at Infectious Disease. R8 is to start Amoxicillin 500 MG daily. Antibiotic will have no stop date. This is a preventative medication to help prevent cellulitis from returning. NP gave OK to start medication in the AM. 3. R47's Physician Order Sheet dated 1/25/2025 documents Cephalexin (Keflex) capsule. Give 500 MG by mouth two times a day for UTI for 5 days. R47's Medication Administration Sheets dated 1/25/2025 Cephalexin (Keflex) capsule. Give 500 mg by mouth two times a day for UTI for 5 Days. Start Date-01/25/2025 at 4:00PM. Doses administered 1/25/2025-1/30/2025. R47's Nursing Note dated 1/25/2025 at 3:45PM documents Physician here in building. Aware of urinalysis being obtained but lab being unable to pick urine up until Monday. R47's urine is cloudy and has sediment. Orders received to start Keflex 500 MG by mouth twice daily for 5 days for possible UTI. First dose obtained from back up for R47. Facility Infection Control log dated 1/24/2025 documents for R47: Acyclovir, Bacterial, UTI. 4. R22's order sheet dated 1/2/2025 documents Levofloxacin Oral Tablet 500 MG (Levofloxacin). Give one tablet by mouth one time a day for Cellulitis until 01/12/2025 11:59PM. R22's Medication Administration Sheets dated 1/1/2025-1/31/2025 documents Levofloxacin Oral Tablet 500 MG(Levofloxacin). Give one tablet by mouth one time a day for Cellulitis until 1/12/202523:59-Start Date 1/02/2025 4:00PM. Doses administered 1/2/2025-1/12/2025. R22's Nursing Notes dated 1/2/2025 at 5:40AM documents R22 has redness, slight swelling to left lower extremity, warmth noted, pain noted. Physician notified. New orders given for antibiotic. Will continue to monitor. Facility infection control log dated 1/2/2025 documents for R22: levofloxacin, bacterial skin infection. 5. R30's Physician Order Sheets dated 11/22/2024 documents Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim). Give one tablet by mouth every morning and at bedtime for prophylactic until 11/29/2024 11:59PM. R30's Medication Administration Sheets dated 11/1/2024-11/30/2024 documents Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give one tablet by mouth every morning and at bedtime for prophylactic until11/29/2024 at 11:59PM. Start Date 11/22/2024 at 8:00AM. Doses administered 11/22/2024-11/29/2024. R30's Nursing Notes dated 11/22/2024 at 12:45PM documents R30 returned via facility transport from OCI. New order received for Bactrim DS one tablet by mouth twice daily times seven days for prophylactic use. Soft care on left arm. May remove for hygiene. Complaints of pain to bilateral arms. Will continue to monitor. Facility infection control log dated 11/26/2024 documents for R30: Sulfamethoxazole. Bacterial cellulitis. On 2/6/2025 at 10:00AM V2, Director of Nursing, DON, stated We have a computer program that we track and trend with. If a resident comes into the facility on an antibiotic but no culture, we have to try to get it. Facility policy dated 2025 states The facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program help ensure that our residents get the right antibiotics at the right tie for the right duration and can improve individual patient outcomes prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections, and reduce healthcare costs.

Based on interview and record review, the facility failed to prevent resident to resident abuse for 3 of 5 residents (R24, R36, R109) reviewed for abuse in the sample of 34. Findings Include: R20's Face Sheet, undated, documents R20 has the following diagnoses: Anxiety Disorder, Depression and Unspecified Dementia with Behavioral Disturbance. R20's Minimum Data Set, MDS, dated [DATE], documents R20 has severe cognitive impairment and displays verbal, physical, and other behaviors. R20's Care Plan, dated 3/29/23, documents R20 has a behavior problem of becoming physically aggressive towards others, becoming aggressive when anxious becoming verbally aggressive and has a mood problem. R20's Progress Note, dated 7/16/24 at 4:40 PM, documents the following: R20 grabbed another resident (R109) by the right arm, shirt area. No signs of injury noted. The State Agency and local PD (Police Department) notified. The facility's Preliminary Report, dated 7/16/24, documents the following: R20 grabbed R109's shirt in the right arm area. Staff intervened and the residents were separated. R20's Progress Note, dated 7/26/24 at 11:14 AM, documents the following: Based on the results of the investigation the facility has found evidence to support the allegation. The facility's Final Report, dated 7/23/24, documents the following: Facts determined: R20 grabbed R109's shirt. Staff was interviewed and stated R20 came up and grabbed R109's right arm, it appeared that he only grabbed her shirt, no red marks were observed on R109. Based on the results of the investigation the facility has found evidence to support the allegation of physical abuse. SSD will follow up with R20 and R109 for any psychosocial needs that arise. Care plans were reviewed and updated accordingly. Staff were in-serviced on the Abuse policy. R20's Progress Note, dated 9/16/24 at 10:00 AM, documents the following: IDT (Interdisciplinary Team) met to discuss the alleged physical altercation between R20 and another resident (R24). Root cause - a resident (R24) was sweeping the dining room floor and R20 came into the dining room. Intervention R20 asked to leave the dining room during clean up after meals. The facility's Final Report, dated 9/19/24, documents the following: R24 was interviewed and voiced he was sweeping in the dining hall and R20 tried to take his broom and then came up behind him and put his arms around his head/ear. R24 reported he had an abrasion to the right ear from R20 putting his arms around him. V9, Licensed Practical Nurse, LPN, stated she came to the dining hall after being alerted of an alleged altercation between R20 and R24 and saw R20 with his hands and arms around R24's neck and face. V9 stated she separated the two residents and observed an abrasion to R24's right side of his face below his ear and provided first aid. Intervention: R24 enjoys sweeping and will sweep while staff are present. Staff will encourage R20 to leave the dining room during clean up. Care plans were reviewed and adjusted as needed. The facility's Final Report, dated 12/13/24, documents the following: V8, AD (Activity Director), stated she heard someone say stop and when she turned around, she saw spilled coffee and R24 put his arm up as if to block the coffee, then R20 hit R24 in the left forearm. V8 stated she separated the two residents. R24 stated he does not know why R20 did this, he did not do anything to R20. Intervention: R20 will be seen by psychiatry services on 12/24/24. Review and revise care plans accordingly. R20's Progress Note, dated 12/29/24 at 5:27 PM, documents the following: Writer observed resident (R20) ramming his wheelchair into the back of another resident's (R36) wheelchair in the dining area. R36 asked resident (R20) to stop, and resident (R20) became aggressive and grabbed her (R36) arm and attempted to yank/pull her arm away from her. Female resident (R36) began to scream in pain and yell at R20. At this time, writer came into the dining area and separated both residents. Writer assessed female resident (R36) and found no injuries. Offered analgesic, which she declined. Call placed to administrator to notify of incident. The facility's Final Report to the State Agency, dated 1/3/25, documents the following: V4, LPN (Licensed Practical Nurse), stated R36 said to R20 Grandpa, don't bump my chair. R20 then grabbed R36's arm. R36 stated she didn't know why R20 did this, he was bumping into her wheelchair, so she asked him to stop, when she said that, he grabbed her upper left arm and then staff came to help and took R20 out of the dining room. No injuries noted. Intervention: R20 was redirected by staff from the dining room after displaying behaviors, review, and update care plan accordingly. On 2/6/25 at 12:31 PM V7, Social Services Director, (SSD), stated R20 has agitation due to his Dementia. V7 stated R2 becomes agitated when it is louder than he would like, when someone bumps into him or his wheelchair or when he feels like he is being yelled at. V7 stated in response, he will intentionally bump into the other person or grab them, trying to get them. V7 stated as an intervention she will try to talk with R20 or if he is having a rough day, try and find out why and R20 likes hot chocolate so they will offer that to him. The Abuse Prevention and Reporting Policy, dated 11/2016, documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services or mistreatment.

Based on observation, interview, and record review the facility failed to provide surgical site care on 1 of 3 residents (R257), reviewed for quality of care in the sample of 34. Findings include: On 2/5/25 at 1:00 PM R257's left hip dressing, undated, was observed with the outer layer of the dressing torn away, exposing gray layer of dressing. R257's Face Sheet, undated, documents R257's medical diagnoses includes Orthopedic Aftercare, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Hypothyroidism, Congestive Heart Failure and Chronic Kidney Disease. R257's Care Plan, dated 1/24/25, documents R257 is at risk for skin impairment with interventions to monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to MD (Medical Doctor). R257's Admission Assessment, dated 1/24/25, documents R257 is cognitively intact, alert to person, place, time, and situation. Left trochanter (hip) Incision line well-approximated with 24 staples. No redness or drainage noted. Measures 18 cm in length. R257's Physician Order, dated 1/24/25, documents to schedule a follow up appointment with the Orthopedic Surgeon 2 weeks from surgery. R257's Hospital Discharge Plan, dated 1/24/25. documents discharge wound instructions: treatment: do not submerge incision in water. Do not apply ointments, creams, or lotions. R257's Wound Rounds Assessment History, dated 1/27/25, documents R257 has surgical site to left hip measuring 22 cm (centimeters) x 5 cm and unable to determine if infection is present. R257's Wound Rounds Assessment Details Report, dated 2/4/25, documents R257 has dressing to left hip surgical site with light amount of serosanguinous drainage present and unable to determine if signs of infection present, measuring 22 cm x 5 cm, unable to remove dressing at this time. R257's Nursing Note, dated 2/5/25 at 1:29 PM, documents the following Writer phoned (Orthopedic Surgeon) to inquire about when follow up appointment was scheduled for. It is scheduled for 02/06/2025 at 1400. Writer also inquired to the nursing staff re: dressing & drainage. Informed that dressing pad was almost completely saturated with exudate. Writer asked if MD would like for dressing to be changed before appointment or wait until tomorrow. Nurse stated that if dressing is leaking, staff may change the dressing before the appointment. On 02/05/25 at 1:00 PM R257 stated the facility has not done anything with her left hip dressing or surgical incision. On 2/5/25 at 11:10 AM V3, ADON (Assistant Director of Nurses) stated R257 has follow up appointment with the Orthopedic Surgeon on 2/6/25 at 2:00 PM On 2/5/25 at 11:34 AM V3, ADON stated R257's Orthopedic Doctor monitors R257's left hip surgical incision and bandage. On 2/5/25 at 1:32 PM V3, ADON stated she has not seen R257's left hip surgical incision and does not know what it looks like. When asked about physician orders for R257's left hip surgical incision, V3, ADON stated the facility has orders from R257's hospital discharge regarding the incision. V3, ADON stated it is normal standard practice not to remove a surgical dressing, when the resident has their follow up orthopedic appointment the dressing will be removed. On 2/5/25 at 1:58 PM V13, RN (Registered Nurse) at Orthopedic Doctor's Office stated the physician expects the facility to be checking the resident's surgical incision and site for any signs and symptoms of infection. V13 stated if a patient is discharged to a facility after surgery, the physician will have the facility check and take care of the patient's surgical wound and dressing. V13 stated R257's physician notes documents to have the surgical dressing remain clean, dry, and intact until follow up appointment and may reinforce and change as needed. V13 stated the facility should be checking R257's surgical dressing every shift, monitoring for any signs and symptoms of infection. V13 stated if R257's dressing is saturated and does not get changed, then the surgical site could get infected. V13, stated the facility contacted the physician's office on 2/5/25 reporting R257's dressing was saturated and soiled. V13 stated the facility was informed they can change R257's dressing due to it being saturated. V13 denied any other documented phone calls from the facility regarding R257's surgical incision and dressing. On 2/5/25 at 2:30 PM V3, ADON asked if she would be changing R257's left hip dressing and V3, ADON stated she would not be changing the hip dressing because it was not leaking. V3, ADON stated the physician's office stated the facility could change the dressing if it was saturated or leaking. On 2/5/25 at 1:28 PM V2, DON (Director of Nurses) stated when a resident is admitted to the facility following a surgery, she expects the resident to have orders documented regarding surgical incisions and care to be provided. The Facility's Skin Condition Assessment & Monitoring Non-Pressure Policy, revised 6/2018, document's purpose: to establish guidelines for assessing, monitoring and documenting the presence of non-pressure skin conditions and assuring interventions are implemented. Dressings which are applied to incisions shall include the date of the licensed who performed the procedure. Dressing will be checked daily for placement, cleanliness and signs and symptoms of infection. A licensed nurse shall observe condition of wound incision daily or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling or pain will be documented in the nurse's notes.

Based on interview and record review, the facility failed to administer anti-hypertensive/cardiac medications at safe intervals of time for 2 of 3 residents (R2, R3) reviewed for medications errors in the sample of 4. Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, stage 4 chronic kidney disease, congestive heart failure, and essential primary hypertension. R2's Physician Order dated 6/24/24 documents Carvedilol Oral Tablet, 25 milligram (mg) tablet, give one tablet by mouth two times daily for hypertension. R2's Medication Administration Audit Report for 11/4/24 documents R2 received 6:00 AM dose of Carvedilol at 11:32 AM and 4:00 PM dose at 3:52 PM. On 11/8/24 at 9:40 AM, V10, Licensed Practical Nurse (LPN), stated R2 did not get her medication until later in the day on 11/4/24 because she sleeps in late. V10 stated she did not communicate to the next nurse that it was given late. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including pulmonary heart disease, heart failure, and essential primary hypertension. R3's Physician Order dated 5/24/24 documents Carvedilol Oral Tablet, 25 mg tablet, give one tablet by mouth two times a day for hypertension. R3's Medication Administration Audit Report for 10/27/24 documents R3 received 6:00 AM dose of Carvedilol at 1:14 PM and 4:00 PM dose at 4:32 PM. On 11/8/24 at 9:40 AM, V10 stated she was unsure why R3's medication was given late on 10/27/24, but the Facility only has three nurse aids on morning shift and she often helps them out before passing medications. On 11/7/24 at 3:18 PM, V9, Medical Director, stated Carvedilol should not be given within three or four hours of each other, because it can cause hypotension (low blood pressure) and bradycardia (slow heart rate). On 11/8/24 at 8:50 AM, V2, Director of Nursing (DON), stated the Facility follows a Liberalized Medication Pass which allows nurses to pass morning medications between 6:00 AM and 11:00 AM. The Facility's Liberalized Medication Administration Policy revised 4/2022 documents medications should be administered to residents in a safe manner, but in a way that correlates with their daily activities and natural schedules. The Facility's Medication Administration Policy revised 1/2015 documents medications must be administered in accordance with a physician's order, e.g. the right resident, right medication, right dosage, right route, and right time.

Based on interviews and record review the facility failed to implement interventions, for R2 to prevent overdose of medication. Faculty was aware R2 had medications in her purse and previously had meds. R2 was being seen by a Psychiatry Nurse Practitioner. R2 had shown a decrease in Mental status and the Psychiatry Nurse Practitioner, nor the Physician was notified. Based on interviews and record review the facility failed to accurately assess, monitor, implement and provide services, for R2's Mental and Psychosocial wellbeing, due to R2 recently sustaining physical abuse, and having major depressive disorder and anxiety. This resulted in R2 overdosing on Xanax and Tylenol. Then being admitted to hospital and subsequently expiring. The Immediate Jeopardy began on 04/18/2024 when R2 was admitted to facility, with known history of spousal abuse, depression, and anxiety. V1, (Administrator), was notified of Immediate Jeopardy on 06/06/2024 at 8:16am. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 06/06/24, but noncompliance remains at Level Two, because additional time is needed to evaluate the implementation and effectiveness of the in-service training of staff. Findings include: R2 admitted to facility on 4/18/2024, with diagnoses of Parkinson's Disease, Encounter for Mental Health Services for Victim of Spousal or Partner abuse, Depression, unspecified, and Generalized Anxiety Disorder. Hospital discharge prior to admit to facility, dated 4/12/2024, documents, Chief Complaint R2 Reportedly being battered by her husband, states, she was struck in the head multiple times, she also fell and hit her right ribs. The patient presents after an altercation with her husband. He has been aggressive and has had history of abusing her physically in the past. She states that he became angry earlier today and threw several things at me. She was struck to the face, possibly with an ashtray. Patient sustained some lacerations and abrasions. R2's trauma informed care document, dated 4/22/2024 documents, physical assault-yes, how much are you bothered by the problem- extremely, comment section documents- husband has beaten her, [NAME] her neck with a case of soda and broke her leg with walker. R2's PHQ-9 assessment dated [DATE] documents, little interest, or pleasure in doing things-yes, 7-11 days, feeling down, depressed, or hopeless-yes, 12-14 days, trouble falling asleep-yes, 12-14 days, feeling tired-yes, 12-14 days, poor appetite-yes, 12-14 days, total score of 16 -moderately severe depression. R2's abuse/neglect screening dated 4/22/2024 documents, history of abuse-yes, diagnosis of depression-yes- total score of 3 indicating moderate risk. R2's behavior charting dated, 5/23/2024 documents, disruptive sounds, anxious, delusions, agitated hallucinations on dayshift and second shift. V11, Psychiatry Nurse Practitioner notes dated 5/14/2024 documents, Chief Complaint Psychiatric Evaluation, related to Depressive symptoms. R2 has a history of major Depressive Disorder and generalized Anxiety Disorder. Staff reports, R2 is anxious, restlessness, paranoid regarding her abusive husband finding her here. R2 denies feeling sad, depressed, or hopeless. R2 stated, her mood was alright. V11 (Nurse Practitioner), Progress Note dated 5/11/2024, documents, R2 has an order of protection against her husband. She is now discharged to skilled rehab facility. During exam patient is lying in bed, in no acute distress, Psych: cooperative, anxious during exam. R2's Progress Note dated 5/23/2024, at 9:02pm, documents, V6, (CNA), questioned R2 and R2 reported taking approximately 15 Alprazolam and 25 Tylenol. On 5/28/2024 at 2:05pm, V5, (LPN), stated, that on the evening of 5/23/2024, R2 had been yelling and hallucinating earlier in the evening and that V6, (CNA), came to her and said that she had found an empty bottle of prescription medication on R2's bed and that R2 stated, I should be gone by the end of the night. V5, (LPN), stated, the empty bottle was labeled Alprazolam with a fill date of 5/06/2024, and it said 60 tabs on it. V5 stated, that V6 also, found an empty bottle of Tylenol on the floor next to R2's bed. V5 stated, that both bottles were empty. V5 stated, that R2 stated, she had taken 15 tabs of the Alprazolam and 25 tabs of the Tylenol. V5 stated, that she was not aware, prior to this occurrence that R2 had any medications on her. V5 stated, that R2 did not have any signs of Depression. V5 stated, that V4 brought the medications into R2. V5 stated, that R2 did go several days without her Alprazolam, earlier in May, due to having difficulty getting a new a script. On 5/28/2024, at 2:35pm, V6, CNA stated, that a few days prior to this event, (5/23/2024), R2 had been Hallucinating and stated, that a black boy was stealing her stuff and she had dumped all her stuff from her purse on her lap. V6, CNA stated, that she reassured her that no one was stealing her stuff and that she saw prescription bottle of medication and Tylenol bottle in her lap and put these medications back into R2's purse. V6 stated, she did not tell anyone about the medications in R2's purse. V6 stated, that on the evening of 5/23/2024, R2 was yelling so much and so loud that other residents were complaining about R2's yelling. V6 stated, that R2 was making comments about wanting to be home with her husband and that she missed her family and that she didn't want to be here. V6 stated, that R2 was having hallucinations on 5/23/2024, that R2 was making comments, that people were beating her up. V6 stated, that she told V5 about it and V5 gave R2 her bedtime medications to calm her down. On 5/29/2024, at 9:00am, V3, (Social Service Director), stated, that R2 was her own decision maker, that R2 was completely with it when she first admitted to facility. V3 stated, that R2 was admitted after being in the Hospital for being beaten by her husband. V3 stated, R2 had an Order of Protection, against her husband and her husband was to not have any kind of communication with R2. V3 stated, on 5/02/2024 the Activity Aide delivered a letter, to R2 from her husband and R2 read the letter. V3 stated, that R2 started, to have Delusions and Hallucinations after receiving the letter from her husband. V3, SSD, stated, that R2 was feeling down and seemed sad, about not seeing her family/kids but, not to the extent of harming herself. V3 stated, that she did ask R2 if she felt like harming herself and R2 would say, NO. V3 stated, that Adult Protective Services, would call and check on R2. V3 stated, that R2 scored a 16 on her PHQ assessment and that is a Moderately Severe Depression score. V3 stated, that the facility does not provide any Psychosocial Programs, small groups, or any Counseling Services for any of the residents. V3 stated that they don't do anything different for the residents who score high or low. V3 stated, she believes that more services should be provided for residents with Psych needs and that she herself has requested more training on this. V3 stated, she was not aware of R2 having medications at her bedside, prior to R2's hospitalization and that it was not safe for any resident to have medication at the bedside. V3, SSD, stated, after this situation, she went room to room and collected any medications/ointments that residents had in their rooms. V3 stated, that R2 is currently on a Ventilator at the Hospital. On 5/29/2024, at 11:50am, V3, SSD, stated, that the staff attempt to redirect and divert a resident if they are having behaviors, but they do not have any Psychosocial Programs available or any community counselling services available for the residents. V3 stated, she has been trying for the last year to get some kind of counseling services for the residents but, there have been issues with getting one. On 5/29/2024, at 1:15pm, V8, CNA, stated, that at the end of R2's stay, R2 cried a lot, said she missed her husband, that she stopped eating and was more incontinent of urine, that R2 stopped calling for help to the bathroom and just wet on herself instead. V8 stated, that R2 made comments, about her husband hitting her with a case of pop in the back of the head and that was why R2 had pain in her neck and back. V8 stated, that R2 did not make comments, about taking her life, she just cried a lot. V8 stated, she had not seen any medications in R2's room. On 5/29/2024, at 1:45pm, V9 CNA, stated, that in the beginning of R2 would talk about her husband a lot, and at the end of her stay she was angry a lot, that she threw her tray one time, because she was mad at the phone. On 5/29/2024, at 1:50pm, V10, CNA, stated, that R2 was one assist with cares when R2 was first admitted but, then R2 started getting more confused and was seeing people in her closet. V10 stated, that R2 became more fearful during her stay, saying she was afraid her husband was coming back to get her, that R2 even began asking for the light to be left on and wanted V10 to check the closet and make sure no one was in the closet. V10 stated, that R2 was afraid and tearful a lot, before she went to the hospital. V10 stated, that R2 was tearful and scared about things in her past. V10 stated, that R2 stopped going to the dining room, for meals and isolated herself in her room. V10 stated, R2 was very quiet, when she was first admitted but, towards the end of her stay, R2 became very scared, just seemed very afraid. V10 stated, she was not aware of R2 having any meds in her room. On 5/29/2024, at 3:00pm, V11, Nurse Practitioner, stated, that she expected Psych evaluation, for R2 and that would provide recommendations to the facility, for R2's Psych needs. V11 stated, that the last time she saw R2, she was very Anxious and tearful but, V11 was not aware that R2 had received a letter from her husband. V11 also, stated, she was not aware that R2 had missed, 7 consecutive doses of her Xanax in the month of May. V11 stated, that R2 would benefit from Psychosocial Therapy if that was available. V11, Nurse Practitioner, stated, that she did not feel that it was safe for R2 to have medications at the bedside, and V11 did not trust, R2 to take it appropriately. On 5/29/2024, at 3:25pm, V12, Medical Director, stated, that R2 was admitted to facility for Physical Therapy, and that if the facility had Psych services, R2 could have used some but, the facility does not have those services. V11, Nurse Practitioner, stated, that V4 should not have brought in the medication, for R2 because, R2 had Psych issues. On 5/30/2024 at 11:30am V16, Certified Occupational Therapist Assistance, (COTA), stated, that R2 was Paranoid, that she stated, one time, R2 thought this place was safe, that she had visitors come in over the weekend but, no one came in to see her over the weekend. V16 stated, R2's cognition had gotten worse during her stay, that in the beginning, R2 was good but, near the end she didn't want to do much. On 5/30/2024, at 1:30pm, V15, Psych Nurse Practitioner, stated, that R2 was struggling with Intermittent Depression and Anxiety, on V15's visit on 5/14/2024, R2 was in a decent mindset, that spousal abuse is absolutely considered trauma/PTSD, that her services are available 24-hours a day but, V15 did not receive any update on R2's behaviors. V15, stated that R2 having behaviors of crying, angry, scared, tearful, afraid, missing her family and hallucinating are all clues of worsening depression and someone should have been talking/seeing R2, that someone should have called V15, and she could have come to see R2 more frequently or medications could have been adjusted. V15 stated, that with R2 exhibiting those behaviors the facility should have been monitoring/tracking her behaviors and checking on her more frequently as in every 15-30 minutes. V15 stated, that she is not involved in the Care Plan Process, that she rarely makes recommendations to a facility for interventions. V15 stated, she was not aware of R2 received a letter from her husband on 5/02/2024, but it was her understanding that R2's husband was not to have any contact. V15 stated, that this could have been prevented, if facility had made V15 aware of R2's behaviors. V15 stated, that she has a Clinical Team that is available and even have specially trained, Trauma Counseling Services, available if needed. V15 stated, I can't do anything if I am not aware of anything. Based on resident's Care Plan, dated 04/2024, the facility noted the following: Administer medications and observe for adverse side effects, if noted, document and report to MD (medical doctor). Contact Social Services, prn, (as needed). Discuss with resident ways to utilize present coping skills to deal with situations that arise. Encourage and allow open expression of feelings and reinforce appropriate expression of feelings. Encourage frequent contact with family and friends, per resident's request/approval. Ensure ADL, (Activities of Daily Living), needs are met. Investigate the need for psychological support. Observe for signs and symptoms of depression, document, if noted, and report to improvise emotional support. Report, assess and record any changes in mood. Report to MD changes in mood. However, the facility failed to provide any of the above-mentioned interventions or cares for R2 as nothing was identified within residents Care Plan or within the Nursing Notes provided by the facility. The surveyor confirmed by observation, record review and interviews that the Immediate Jeopardy was removed on 6/06/2024, but noncompliance remains at level two, because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The Immediate Jeopardy that began on 4/18/2024 was removed on 6/06/2024. When the facility took the following actions to remove the immediacy. Facility ensured all residents are safe and not at risk and Psychosocial needs are being met. Initiated on 5/24/2024 per V3. Evaluation of Risk for Suicide and Self Harm completed on the whole house by V3 on 6/4/2024. 3.) Trauma assessments completed by V3 on 6/6/2024. 4.) Assessment of Depression completed on the whole house by V3 6/6/2024. 5.) All trauma distress depression assessments are being completed on whole house to ensure appropriate services are in place on 6/6/2024 by V3 and V25. 6.) Directive has been posted at timeclock and Nurses' Station if any signs or symptoms of distress/depression to report to nurse. 7.) Staff educated if any signs or symptoms of depression/distress noted, facility will update Psychiatry for further orders. 8.) Staff education for signs and symptoms of depression completed on 5/24/2024 by V2. 9.) 6/6/2024 Staff education sheet posted by timeclock per V24. 10.) Residents that have exacerbation of depression, V2 and V3 followed up with Psychiatry for guidance, for 1:1, 15-minute checks or hospitalization . 11.) Reviewed behavior monitoring. 12.) All staff educated on monitoring behavior per standards of practice. 13.) Education completed on 5/24/2024 by V2 for medications at bedside and signs and symptoms of depression. 14.) 5/24/2024 rooms were swept for meds with resident consent and education to residents at that time by V1, V2 and V3. 15.) All residents on Psychoactive Medications are referred to Psychiatry upon admission by V2, this is ongoing. 16.) 6/5/2024 V26 has increased visits to every three weeks. 17.) Depression is assessed upon admission, quarterly, and with a significant change by V3. Residents that have exacerbation of depression, SS and DON followed up with Psychiatry and Medical Physician for guidance, for 1:1, 15-minute checks or hospitalization . 18.) Policy for suicide watch was reviewed and no changes necessary V27 6/6/2024. 19.) Behavior monitoring is documented per shift per CNA staff and reviewed by Interdisciplinary team daily in QA meeting which consist of nursing management, social services and administrator. 20.) All residents assessed to ensure resident based intervention care plan services are in place. 21.) Initiated and completed on 6/6/2024, reviewed all residents for individualized care plan interventions for behaviors - by V2, V3, V28 and V7. 22.) Education provided to staff on trauma/mental disorder. 23.) Initiated and completed on 6/6/2024 V1 with all staff educated prior to taking shift. 24.) Audits completed by V25 weekly. 25.) All charts audited for psychosocial assessment, trauma assessments, self-harm/suicide risk assessment and the patient healthcare assessment 6.6.2024 per V24 and V30 26.) Regional team V29 with complete weekly starting next week. 27.) QAPI meeting held to ensure compliance. 28.) Be reviewed and discussed daily in morning meeting with Interdisciplinary team. 29.) QAPI completed 6/6/2024 by V24 and V30 30.) For residents identified by the facility as requiring services for trauma/mental illness/depression facility will notify Psychiatry and Medical Physician for guidance for 1:1, 15-minute checks or hospitalization . Notifications will be made immediately by nursing or social services. This is ongoing.

Based on interviews and record review the facility failed to implement interventions, for R2 to prevent overdose of medication. Faculty was aware R2 had medication previously and that she had medications in her purse. R2 was being seen by a Psychiatry Nurse Practitioner. R2 had shown a decrease in Mental status and the Psychiatry Nurse Practitioner, nor the Physician was notified. This failure of not reporting or calling the Physician or Psychiatry Nurse Practitioner and R2 having meds in her purse, resulted in R2 overdosing, being sent to the Hospital and Expiring. R2 admitted to facility on 4/18/2024, with diagnoses of Parkinson's Disease, Encounter for Mental Health Services for Victim of Spousal or Partner abuse, Depression, unspecified, and Generalized Anxiety Disorder. R2's Hospital discharge prior to admit to facility, dated 4/12/2024, documents, Chief Complaint R2 Reportedly being battered by her husband, states, she was struck in the head multiple times, she also fell and hit her right ribs. The patient presents after an altercation with her husband. He has been aggressive and has had history of abusing her physically in the past. She states that he became angry earlier today and threw several things at me. She was struck to the face, possibly with an ashtray. Patient sustained some lacerations and abrasions. R2's trauma informed care document, dated 4/22/2024 documents, physical assault-yes, how much are you bothered by the problem- extremely, comment section documents- husband has beaten her, broke her neck with a case of soda and broke her leg with walker. R2's PHQ-9 assessment dated [DATE] documents, little interest, or pleasure in doing things-yes, 7-11 days, feeling down, depressed, or hopeless-yes, 12-14 days, trouble falling asleep-yes, 12-14 days, feeling tired-yes, 12-14 days, poor appetite-yes, 12-14 days, total score of 16 -moderately severe depression. R2's abuse/neglect screening dated 4/22/2024 documents, history of abuse-yes, diagnosis of depression-yes- total score of 3 indicating moderate risk. R2's behavior charting dated, 5/23/2024 documents, disruptive sounds, anxious, delusions, agitated hallucinations on dayshift and second shift. R2's Nurses Notes documents, on 5/05/2024, at 9:52pm, R2 reported that V4, (her sister), brought her pills from local Pharmacy today and that they were in her drawer. V5, (Licensed Practical Nurse), explained that medications would be put in nurses' cart, because it is a liability to keep medications for others to access in room. R2 was upset that medications could not be kept in her room. R2's Medication Administration Record, (MAR), dated 5/2204 documents, Xanax 0.5mg, twice a day with dates of 5/04/2024 at hs, (nighttime), dose not given, 5/05/2024 am, dose not given, 5/05/2024 hs dose not given, 5/06/2024 am, dose not given, 5/06/2024 hs, dose not given, 5/07/2024 am dose not given, 5/07/2024 hs, dose not given. V11, Psychiatry Nurse Practitioner notes dated 5/14/2024 documents, Chief Complaint Psychiatric Evaluation, related to Depressive symptoms. R2 has a history of major Depressive Disorder and generalized Anxiety Disorder. Staff reports, R2 is anxious, restless, paranoid regarding her abusive husband finding her here. R2 denies feeling sad, depressed, or hopeless. R2 stated, her mood was alright. V11 (Nurse Practitioner), Progress Note dated 5/11/2024, documents, R2 was treated for UTI and now has an order of protection against her husband. She is now discharged to skilled rehab facility. During exam patient is lying in bed, in no acute distress, Psych: cooperative, anxious during exam. R2's Progress Note dated 5/23/2024, at 8:52pm documents, V6, CNA, (Certified Nursing Assistant), came to V5, (LPN), with an empty bottle of Alprazolam, (Xanax), 0.25mg tab. The bottle showed it was filled on 5/06/24 and that there were 60 tablets in the bottle. V6 questioned R2 upon finding bottle and R2 stated, I took the rest of my medication, so I should be gone by the end of the night. V6, (CNA), notified V7, (ADON), (Assistant Director of Nursing). R2's Progress Note dated 5/23/2024, at 9:02pm, documents, V6, (CNA), questioned R2 and R2 reported taking approximately 15 Alprazolam and 25 Tylenol. Call was placed to 911 at this time unknow who placed it. On 5/28/2024, at 1:35pm, V4, (R2's sister), stated, that she brought medications in to R2 around the first week of May, because R2 had called, V4 and asked her to bring the medication to her. V4 stated, that the facility did not have her medications. V4 stated, that she brought two bottles of medications into R2 and put them in R2's drawer. V4 stated, it was a bottle of Ropinirole and something else. V4 stated, she picked these medications up from the Pharmacy. V4 stated, that she did not tell anyone, that she brought in the medications, but that R2 had called her later and stated, that one of the nurses had found the medications in her drawer and took them away from her. On 5/28/2024 at 2:05pm, V5, (LPN), stated, that on the evening of 5/23/2024, R2 had been yelling and hallucinating earlier in the evening and that V6, (CNA), came to her and said that she had found an empty bottle of prescription medication on R2's bed and that R2 stated, I should be gone by the end of the night. V5, (LPN), stated, the empty bottle was labeled Alprazolam with a fill date of 5/06/2024, and it said 60 tabs on it. V5 stated, that V6 also, found an empty bottle of Tylenol on the floor next to R2's bed. V5 stated, that both bottles were empty. V5 stated, that R2 stated, she had taken 15 tabs of the Alprazolam and 25 tabs of the Tylenol. V5 stated, that she was not aware, prior to this occurrence that R2 had any medications on her. V5 stated, that R2 did not have any signs of Depression. V5 stated, that V4 brought the medications into R2. V5 stated, that R2 did go several days without her Alprazolam, earlier in May, due to having difficulty getting a new a script. On 5/28/2024, at 2:50pm, V5, LPN stated, that on 5/05/2024, V5 had found two bottles of medications in R2's drawer and that she took the medications to the med room and educated R2, on not having medications in her room or her purse. V5 stated, she searched R2's room and R2 did not have any other meds in the room at this time. V5 stated, that the two bottles of medications were R2's Ropinirole, (requip), and Fluoxetine, (Prozac), and the fill date for these medications were 5/05/2024. On 5/28/2024, at 2:35pm, V6, CNA stated, that a few days prior to this event, (5/23/2024), R2 had been Hallucinating and stated, that a black boy was stealing her stuff and she had dumped all her stuff from her purse on her lap. V6, CNA stated, that she reassured her that no one was stealing her stuff and that she saw prescription bottle of medication and Tylenol bottle in her lap and put these medications back into R2's purse. V6 stated, she did not tell anyone about the medications in R2's purse. V6 stated, that on the evening of 5/23/2024, R2 was yelling so much and so loud that other residents were complaining about R2's yelling. V6 stated, that R2 was making comments about wanting to be home with her husband and that she missed her family and that she didn't want to be here. V6 stated, R2 had sons but, she didn't talk to them. V6 stated, that R2 was having Hallucinations on 5/23/2024, that R2 was making comments, that people were beating her up. V6 stated, that she told V5 about it and V5 gave R2 her bedtime medications to calm her down. V6 stated, around 8:45pm-9pm, she went to do bed check and R2 was talking very calmly and stated, you should be glad, I took all my meds. V6 stated, she told R2 that she was glad, she took her meds from the Nurse. V6 stated, that R2 then said, no I took more, I took about 15 Xanax, (alprazolam), and 25 Tylenol. V6 stated, she looked in R2's purse for the Prescription bottles, she had seen a few days earlier and she found it empty. V6 stated, she then saw the Tylenol bottle on the floor, and it was empty. V6 stated, took the prescription bottle to V5. Then told V5, what R2 had said about taking the pills. On 5/29/2024, at 9:00am, V3, (Social Service Director), stated, that R2 was her own decision maker, that R2 was completely with it when she first admitted to facility. V3 stated, that R2 was admitted after being in the Hospital for being beaten by her husband. V3 stated, R2 had an Order of Protection, against her husband and her husband was to not have any kind of communication with R2. V3 stated, on 5/02/2024 the Activity Aide delivered a letter, to R2 from her husband and R2 read the letter. V3 stated, that R2 started, to have Delusions and Hallucinations after receiving the letter from her husband. V3, SSD, stated, that R2 was feeling down and seemed sad, about not seeing her family/kids but, not to the extent of harming herself. V3 stated, that she did ask R2 if she felt like harming herself and R2 would say, NO. V3 stated, that Adult Protective Services, would call and check on R2. V3 stated, that R2 scored a 16 on her PHQ assessment and that is a Moderately Severe Depression score. V3 stated, that the facility does not provide any Psychosocial Programs, small groups, or any Counseling Services for any of the residents. V3 stated that they don't do anything different for the residents who score high or low. V3 stated, she believes that more services should be provided for residents with Psych needs and that she herself has requested more training on this. V3 stated, she was not aware of R2 having medications at her bedside, prior to R2's hospitalization and that it was not safe for any resident to have medication at the bedside. V3, SSD, stated, after this situation, she went room to room and collected any medications/ointments that residents had in their rooms. V3 stated, that R2 is currently on a Ventilator at the Hospital. On 5/29/2024, at 11:50am, V3, SSD, stated, that the staff attempt to redirect and divert a resident if they are having behaviors, but they do not have any Psychosocial Programs available or any community counselling services available for the residents. V3 stated, she has been trying for the last year to get some kind of counseling services for the residents but, there have been issues with getting one. On 5/29/2024, at 1:15pm, V8, CNA, stated, that at the end of R2's stay, R2 cried a lot, said she missed her husband, that she stopped eating and was more incontinent of urine, that R2 stopped calling for help to the bathroom and just wet on herself instead. V8 stated, that R2 made comments, about her husband hitting her with a case of pop in the back of the head and that was why R2 had pain in her neck and back. V8 stated, that R2 did not make comments, about taking her life, she just cried a lot. V8 stated, she had not seen any medications in R2's room. On 5/29/2024, at 1:45pm, V9 CNA, stated, that in the beginning of R2 would talk about her husband a lot, and at the end of her stay she was angry a lot, that she threw her tray one time, because she was mad at the phone. On 5/29/2024, at 1:50pm, V10, CNA, stated, that R2 was one assist with cares when R2 was first admitted but, then R2 started getting more confused and was seeing people in her closet. V10 stated, that R2 became more fearful during her stay, saying she was afraid her husband was coming back to get her, that R2 even began asking for the light to be left on and wanted V10 to check the closet and make sure no one was in the closet. V10 stated, that R2 was afraid and tearful a lot, before she went to the hospital. V10 stated, that R2 was tearful and scared about things in her past. V10 stated, that R2 stopped going to the dining room, for meals and isolated herself in her room. V10 stated, R2 was very quiet, when she was first admitted but, towards the end of her stay, R2 became very scared, just seemed very afraid. V10 stated, she was not aware of R2 having any meds in her room. On 5/29/2024, at 3:00pm, V11, Nurse Practitioner, stated, that she expected Psych evaluation, for R2 and that would provide recommendations to the facility, for R2's Psych needs. V11 stated, that the last time she saw R2, she was very Anxious and tearful but, V11 was not aware that R2 had received a letter from her husband. V11 also, stated, she was not aware that R2 had missed, 7 consecutive doses of her Xanax in the month of May. V11 stated, that R2 would benefit from Psychosocial Therapy if that was available. V11, Nurse Practitioner, stated, that she did not feel that it was safe for R2 to have medications at the bedside, and V11 did not trust, R2 to take it appropriately. On 5/29/2024, at 3:25pm, V12, Medical Director, stated, that R2 was admitted to facility for Physical Therapy, and that if the facility had Psych services, R2 could have used some but, the facility does not have those services. V11, Nurse Practitioner, stated, that V4 should not have brought in the medication, for R2 because, R2 had Psych issues. On 5/30/2024 at 11:30am V16, Certified Occupational Therapist Assistance, (COTA), stated, that R2 was Paranoid, that she stated, one time, R2 thought this place was safe, that she had visitors come in over the weekend but, no one came in to see her over the weekend. V16 stated, R2's cognition had gotten worse during her stay, that in the beginning, R2 was good but, near the end she didn't want to do much. On 5/30/2024, at 1:30pm, V15, Psych Nurse Practitioner, stated, that R2 was struggling with Intermittent Depression and Anxiety, on V15's visit on 5/14/2024, R2 was in a decent mindset, that spousal abuse is absolutely considered trauma/PTSD, that her services are available 24-hours a day but, V15 did not receive any update on R2's behaviors. V15, stated that R2 having behaviors of crying, angry, scared, tearful, afraid, missing her family and hallucinating are all clues of worsening depression and someone should have been talking/seeing R2, that someone should have called V15, and she could have come to see R2 more frequently or medications could have been adjusted. V15 stated, that with R2 exhibiting those behaviors the facility should have been monitoring/tracking her behaviors and checking on her more frequently as in every 15-30 minutes. V15 stated, that she is not involved in the Care Plan Process, that she rarely makes recommendations to a facility for interventions. V15 stated, she was not aware of R2 received a letter from her husband on 5/02/2024, but it was her understanding that R2's husband was not to have any contact. V15 stated, that this could have been prevented, if facility had made V15 aware of R2's behaviors. V15 stated, that she has a Clinical Team that is available and even have specially trained, Trauma Counseling Services, available if needed. V15 stated, I can't do anything if I am not aware of anything. On 5/30/2024, at 10:15am, V3, SSD, stated, that she was not aware of the incident on 5/05/2024, when a Nurse, removed medications from R2's room. V3 stated, that she was not aware that a staff member knew that R2 had prescription meds in her purse either. V3 stated, she would expect staff to remove the meds. V3 stated, that someone like her, with a history of abuse and depression, would be referred to Psych Nurse Practitioner. V3 stated, that Psych Nurse Practitioner, is the one who would decide if R2 needed any other services. V3 stated, that R2 had expressed, that she would like to transfer to a different facility and V3 was assisting with that. V3 stated, that she would have reached out to the Doctor, if she had known, of R2 having behaviors of crying, angry, scared, tearful, afraid, missing her family and hallucinating. On 5/30/2024, at 10:15am, V2, DON, stated, that she was not aware of R2 having meds in her room on 5/05/2024. V2, DON, stated, she doesn't know what she would have done if she knew about it. V2 stated, that she was not aware that a staff member knew, that R2 had prescription meds in her purse. V2 stated, she expected staff to remove the meds from her purse, if they knew that R2 had them or at the least notify someone of it. V2 stated, the facility does have an assessment, they can do, to let a resident have meds at the bedside, if they feel like the resident is safe to do so. V2 stated, they did not do an assessment for R2. V2 stated, she was not aware of R2 having behaviors of crying, angry, scared, tearful, afraid, missing her family and hallucinating. On 5/30/2024, at 10:25am, V1, Administrator, stated, that she was not aware of R2 having meds in her room, prior to the 5/23/2024 incident. V1 stated, that she was not aware of R2 having prescription meds in her purse. V1 stated, she would expect her staff to keep a better watch on R2, if she had known these things were going on. V1 Admin, stated, that they would have put interventions in place. V1 stated, that if she was aware of R2 having behaviors of crying, angry, scared, tearful, afraid, missing her family and hallucinating that the Doctor, would have been contacted and if it was bad enough, they would have sent R2 to the Hospital for an evaluation.

Based on interview and record review the Facility failed to provide a RN (Registered Nurse) 8 hours a day 7 days a week. This has the potential to affect all 59 residents of the facility. Findings include: The Facility's Nursing Schedule, dated 3/30/24, documented there was no RN on duty 3/30/24. The Facility's Nursing Schedule, dated 3/31/24, documented there was no RN on duty 3/31/24. On 4/23/24 at 9:00 AM V2 DON (Director of Nursing) stated the facility does not have a RN on duty 7 days a week. V2 stated she did not have a RN on duty on Saturday, March 30, 2024, nor on Sunday, March 31, 2024. On 4/23/24 at 10:20 AM V1 Administrator stated the facility does not have a staffing policy and the facility staffs according to census needs. The Facility's Resident Census Report and the CMS 671 form, dated 4/22/24, documented that there were 59 residents in the facility.

Based on interviews and record review the facility failed to notify family/Power of Attorney (POA) of a fall and fully discuss residents declining medical condition with POA for POA to make decisions on resident's medical treatment options for one of three residents (R2) reviewed for notification in the sample of 8. This failure resulted in no discussion of possible Hospice treatment to address R2's overall decline in health and ongoing pain. Findings include: R2's Face Sheet, dated [DATE] documents admitted [DATE] with diagnosis of end stage renal disease, malignant neoplasm of the kidney, peripheral vascular disease, acute and chronic respiratory failure. R2's Face Sheet documents R2 advance directives as CPR/ cardiopulmonary resuscitation. R2's Minimum Data Set, dated dated dated [DATE] documents that R2 is moderately cognitively impaired. R2's Hospital Record contain Power of Attorney (POA) document dated [DATE] naming V17, R2's family, as POA of health care. R2's Progress Note, dated [DATE] at 12:00 PM, written by V16, Registered Nurse/RN, documents R2 sustained a fall on [DATE] at 6:00 AM. The Note documented the incident occurred in the R2's room. The Note documented, R2 is alert and disoriented per usual baseline. The Note documented no changes in range of motion from normal baseline. The Note documented V10, Medical Director/R2's Physician, notified on [DATE] at 7:00 AM. On [DATE] at 10:00 AM, V16 stated she was present on [DATE] when R2 fell , and she did not notify the family. R2's Progress Note, dated [DATE] at 12:24 PM, written by V2, Director of Nursing, documents Interdisciplinary Team (IDT) met to discuss fall. The Note documents Care plan and interventions reviewed. The Progress Note documents probable root cause found to be R2 attempted transfer from bed unassisted and found sitting next to bed. The Note documented MD and POA notified. On [DATE] at 1:30 PM V2 stated on [DATE] at the time of the fall she had tried to call the daughter, but the daughter did not answer. V2 stated that R2's daughter was not notified of the fall on [DATE]. R2's Progress Note, dated [DATE] at 8:01 PM, written by V9, Nurse Practitioner, documented Called facility and spoke with nurse at 7:57 PM. Discussed CXR (chest Xray) results revealing moderate pleural effusion, nurse to notify POA and relay recommendation to send resident to hospital for evaluation. R2's Progress Note, dated [DATE] at 8:5PM documents ambulance here to transport R2 to emergency room (ER) for evaluation and treatment related to chest Xray results back with pleural effusion results. The Note documented R2 in agreeance to go. The Note documented call to V17 to inform of above and message left to call facility. R2's Progress Note, written by, V11, Podiatrist, dated [DATE], documents staff requests R2 be seen due to a very painful left foot. The Note documents R2 is to have vascular studies performed on her lower extremities and has wound care nurses taking care of the left foot, also painful are both feet. The Note documented R2 was seen for initial assessment at today's visit left dorsalis pedis nonpalpable, left posterior tibial nonpalpable, right dorsalis pedis nonpalpable, right posterior tibial nonpalpable. The Note documented R2's left foot was ice cold from the distal digits to the ankle, hair growth absent, bilaterally, cyanotic bilaterally. The entire hallux left foot was showing lines of demarcation for gangrenous changes. The note documented Discussed with nursing staff that patient is in the stages of dry gangrene of the lower extremities. The Note documented V11 requested a vascular consultation and staff replied that the order is already in. The Note documented that staff also stated that the wound care doctor was in yesterday and looked at her feet and didn't mention anything wrong with R2's feet. The Note documented The ABI's (ankle brachial index) ordered will confirm my diagnosis of vascular disease. R2's Physician's Progress Note, dated [DATE] from V10, R2's Physician/Medical Director, documents R2 has bilateral lower extremity swelling some discoloration of her toes in the right lower extremity. PVD (peripheral vascular disease) progressive worsening, R2 has significant pain in her lower extremity likely related to her PVD as well as due to her swelling, pain not controlled with her Norco ,d+[DATE]mg dose increase to ,d+[DATE]mg every 4 hours as needed. R2 has seen vascular surgery before refer R2 to vascular surgery for further evaluation however with her multiple comorbidities R2 will be high risk for any procedure. R2 and daughter not ready for hospice yet. R2's ABI results, dated [DATE], that documents pain to feet and toes, no pedal pulses present, right great toenail removed, heels mushy and toes are darkened. Findings are bilateral ABI's of 0.58 which lie within the claudication range. R2's Progress Note, dated [DATE] from V9 documents R2 has had continued progressive decline since admission both cognitively and physically. The Note documented evaluation of her feet reveal left great toe dark dry hard appears necrotic wound to left 2nd toes with ulcer draining edema. The Note documented right foot ,d+[DATE] toes dark, dry hard appear necrotic. The Note documented pitting edema recent ABI's show claudication. The Note documented R2 would benefit from referral to vascular surgery or referral to hospice to better control her pain. R2's Progress Note, dated [DATE] at 10:50 AM, from V16, Registered Nurse/RN, documents left great toe is mottled, black-necrotic, hard, cold, cannot find a cap refill. Right ,d+[DATE]th toes are mottled, black-necrotic, hard, and cold. +3 pitting edema in BLE (bilateral lower extremities). V9 notified and aware. R2's Progress Note dated [DATE] at 9:15 AM documents R2 is constantly screaming out in pain, unable to obtain SPO2 level with Oxygen therapy at 4L/Liters per NC/nasal cannula. Resident uncooperative with taking meds, not wanting to open mouth to swallow meds. R2's Progress Note dated [DATE] at 8:30 AM documents R2 has been screaming out, Lord help me. PRN/as needed pain medication given. Attempted to reposition pt/patient to get her to calm, this didn't help. R2 having difficulty swallowing her meds. R2's Progress Note, dated [DATE] at 3:07 PM documents Received new orders from (V10) to have resident's vascular Dr/doctor, see resident regarding bilateral toes. The Note documented transport aware and to make appt. R2's Progress Note, dated [DATE] at 1:25 PM documents Patient has been yelling out all day. Pain meds were given and still yelling out in pain. NP (Nurse Practitioner) aware. Wound Dr. aware. R2's Wound Evaluation & Management Summary, dated [DATE] from V8, Wound Physician, documents Discussed in detail with household staff patient insignificant pain should see vascular or made hospice for aggressive pain management - nurse informed they are already trying to talk regarding Hospice. The Summary documented Recommend Vascular Consult due to claudication range ABI or patient be made hospice with aggressive pain control - for claudication- will defer to primary physician. On [DATE] at 10:00 AM, V16, Registered Nurse, stated that she took care of R2 and that her legs hurt her really bad. V16 stated that R2's toes were black and necrotic and that on [DATE] she notified V9 of the toes being black and necrotic. V16 stated she felt as if R2 should have been sent to the hospital sooner. V16 stated she had discussed with V9 R2 being sent out but that someone else had decided that R2 needed to be hospice and R2 didn't need to go out. V16 was unsure of who had made that decision. V16 stated she did not notify the family of anything because she was told family was aware already. On[DATE] at 10:42 AM, V5, Social Service Director, stated that she had spoken with V17 on multiple occasions but her discussions with the V17 were about money and R2's discharge plans and that she did not discuss any medical conditions with the V17. On [DATE] at 11:00 AM V9 stated she did not have a conversation with the family about R2's care and prognosis and expected the facility to do that. On [DATE] at 1:00 PM V10, R2's Primary Care Physician/Medical Director, stated he did not speak with the family about the condition of R2 that he expected the facility to do that. On [DATE] at 1:30 PM, V2, Director of Nursing and V3, Nurse Consultant, stated they have no documentation that the family was notified or any discussion with the family of R2's condition. V2 stated R2 was a full code but should have been on hospice. Facility provided change of condition policy dated ,d+[DATE] documents that facility will consult with doctor and family for any changes in condition. Facility provided advance directive policy dated ,d+[DATE] documents that resident representatives will be informed concerning the right to accept or refuse medical or surgical treatment, and at the resident options to formulate advanced directives.

Based on interviews and record review the facility failed to provide vascular consult timely for one of three residents (R2) reviewed for quality of care in the sample of 8. This failure resulted in R2 experiencing a decrease in circulation to R2's lower extremities, increased pain, and discomfort in R2's lower extremities and hospitalization for septic shock related to decreased circulation and gangrene. Findings include: R2's face sheet, dated [DATE] documents admitted [DATE] with diagnosis of end stage renal disease, malignant neoplasm of the kidney, peripheral vascular disease, acute and chronic respiratory failure. R2's Minimum Data Set (MDS), dated [DATE] documents that R2 is moderately cognitively impaired and is dependent for transfers. R2's Admission Skin assessment dated [DATE] documents left great toenail missing with open wound present with no other skin issues noted to feet. On [DATE] at 10:00 AM, V7, Wound Nurse, stated that R2 was admitted on [DATE] after removal of right great toenail and R2's legs were very edematous but no other skin issues to feet upon admission. R2's Physician Initial Wound Evaluation & Management Summary, dated [DATE], from V8, Wound Physician, that documents left lower extremities foot cool, moderate edema, dark discoloration of toes. R2's right lower extremities foot cool, moderate edema, dark discoloration of toes, right great toenail bed dry. R2's pedal pulses left dorsalis pedis no palpable pulse or doppler signal detected, posterior tibial no palpable pulse or doppler signal detected. R2's pedal pulses right dorsalis pedis no palpable pulse or doppler signal detected, posterior tibial no palpable pulse or doppler signal detected, recommend vascular, end stage renal disease contributing. Complains of ,d+[DATE] pain in both feet/toes. Cool to touch. The Evaluation documents Recommend ABI (ankle brachial index- a diagnostic test used to determine severity of peripheral vascular disease) and vascular consult if considered appropriate by med (medical) director/primary. R2's [DATE] Physician's Order Sheet (POS), documents ABI (Ankle brachial index) to BLE (bilateral lower extremities) due to pain in feet/toes cool to touch, dated [DATE]. R2's Nursing Progress Note, written by V9, Nurse Practitioner, dated [DATE] documents that R2 was seen for evaluation after sustaining an unwitnessed fall this morning and no additional concerns at this time per nursing report. R2's Progress Note, written by V11, Podiatrist, dated [DATE] documents staff requests R2 be seen due to a very painful left foot. The Progress Note documented R2 is to have vascular studies performed on her lower extremities. The Progress Note documented R2 has wound care nurses taking care of the left foot, also painful are both feet. The Progress Note documented R2 also seen for initial assessment at today's visit left dorsalis pedis nonpalpable, left posterior tibial nonpalpable, right dorsalis pedis nonpalpable, right posterior tibial nonpalpable. The Progress Note documented the left foot is ice cold from the distal digits to the ankle, hair growth absent, bilaterally, cyanotic bilaterally. The Progress Note documented the entire hallux left foot is showing lines of demarcation for gangrenous changes. The Progress Note documented Discussed with nursing staff that the patient is in the stages of dry gangrene of the lower extremities. I requested a vascular consultation, and they replied that the order is already in. They also stated that the wound care doctor was in yesterday and looked at her feet and didn't mention anything wrong with (R2's) feet. The ABI's ordered will confirm my diagnosis of vascular disease. R2's Physician's Progress Note, dated [DATE] from V10, R2's Physician/Medical Director, documents R2 has bilateral lower extremity swelling some discoloration of her toes in the right lower extremity. PVD (peripheral vascular disease) progressive worsening, R2 has significant pain in her lower extremity likely related to her PVD as well as due to her swelling, pain not controlled with her Norco ,d+[DATE]mg dose increase to ,d+[DATE]mg every 4 hours as needed. R2 has seen vascular surgery before refer R2 to vascular surgery for further evaluation however with her multiple comorbidities R2 will be high risk for any procedure. R2 and daughter not ready for hospice yet. R2's ABI results, dated [DATE], documents pain to feet and toes, no pedal pulses present, right great toenail removed, heels mushy and toes are darkened. Findings are bilateral ABI's of 0.58 which lie within the claudication (symptom of PVD) range. R2's Progress Note, dated [DATE] from V9 documents R2 has had continued progressive decline since admission both cognitively and physically. The Note documented evaluation of her feet reveal left great toe dark dry hard appears necrotic wound to left 2nd toes with ulcer draining edema. The Note documented right foot ,d+[DATE] toes dark, dry hard appear necrotic. The Note documented pitting edema recent ABI's show claudication. The Note documented R2 would benefit from referral to vascular surgery or referral to hospice to better control her pain. R2's Progress Note, dated [DATE] at 10:50 AM, from V16, Registered Nurse/RN, documents Left Great toe is mottled, black-necrotic, hard, cold. Cannot find a cap refill. Right ,d+[DATE]th toes are mottled, black-necrotic, hard, and cold. +3 pitting edema in BLE (bilateral lower extremities). V9 Notified and Aware. R2's Progress Note, dated [DATE] at 9:15 AM documents R2 is constantly screaming out in pain, unable to obtain SPO2 (oxygen saturation) level with Oxygen therapy at 4L per NC. Resident uncooperative with taking meds, not wanting to open mouth to swallow meds. No documentation that V10 or V9 were notified of R2's constant pain. R2's Progress Note dated [DATE] at 8:30 AM documents R2 has been screaming out, Lord help me. PRN pain medication given. Attempted to reposition pt to get her to calm, this didn't help. R2 having difficulty swallowing her meds. R2's Progress Note, dated [DATE] at 3:07pm documents Received new orders from (V10) to have resident's vascular Dr, see resident regarding bilateral toes. The Note documented transport aware and to make appt. R2's Progress Note, dated [DATE] at 1:25pm documents Patient has been yelling out all day. Pain meds were given and still yelling out in pain. NP (Nurse Practitioner) aware. Wound Dr. aware. R2's Wound Evaluation & Management Summary, dated [DATE] from V8, documents Discussed in detail with household staff patient insignificant pain should see vascular or made hospice for aggressive pain management - nurse informed they are already trying to talk regarding Hospice. The Summary documented Recommend Vascular Consult due to Claudication range ABI or Patient be made hospice with aggressive pain control - for claudication- will defer to primary physician. R2's January POS, documents referral to see vascular r/t (related to) bilateral toes dated [DATE]. R2's progress note dated [DATE] from V9 documents R2 is being seen today per nursing request due to uncontrolled pain, R2 is moaning and yelling out Lord please help me and please help me. R2 has had a continued decline since admission, recent bilateral ABI are in the claudication range. Pedal pulses are not palpated. Nursing reports that R2 is having increased difficulty swallowing pills. Full code status, and multiple comorbidities. Refer to vascular. Plan discussed with nursing staff and R2. R2's Progress Note, dated [DATE] at 4:00pm by V2, Director of Nursing/DON, documented a call received from local emergency room . The Note documented R2 was sent to ER from dialysis center and ER was requesting med list be faxed and emergency contact number given. R2's Progress Note, dated [DATE] at 4:26 pm by V5, Social Service Director, documents they were notified that R2 was transferred from dialysis to ER. R2's Hospital emergency room notes dated [DATE] at 1:48pm titled Ambulance service record documents R2 yelling and screaming with no palpable radial pulses, unable to obtain blood pressure. R2's Hospital Emergency physician notes dated [DATE] at 3:34pm documents R2 with bilateral feet with necrotic/gangrenes toes. Skin is sloughing from both legs. R2's Hospital Emergency Physician Notes dated [DATE] at 5:17 PM, documents R2 presents with septic shock and bilateral lower extremity gangrene, right lower extremity wet gangrene will require emergent above knee amputation for source control. The Note documents R2 has a documented history of peripheral arterial disease although there are not clear records of any sort or revascularization procedure being performed in the past. The Note documented R2 is clearly in moderate distress in extreme pain. The Note documented I discussed with family that her legs are no longer salvageable and there are not revascularization options for her at this time. She would need bilateral lower extremity amputations. She is quite sick and unstable at this time. R2's Hospital Emergency physician notes dated [DATE] document R2 expired at 5:50pm. Death certificate unavailable at this time. On [DATE] at 9:00 AM, V5 stated that R2 was sent to the hospital from dialysis on [DATE] and that R2 passed away at the hospital on [DATE]. On [DATE] at 9:45am V2 stated that R2 did not have a POA on file and they were unable to reach V17, R2's family, on several occasions. V2 stated that she had taken care or R2 on the morning of [DATE] and had done her dressing change and her legs were not gangrenous. V2 stated they processed the order of vascular doctor on [DATE]. V2 states they faxed vascular doctor's office on [DATE] but have not obtained an appointment prior to R2 going to the hospital on [DATE]. On [DATE] at 10:00, AM V7, Wound Nurse, stated that R2 was admitted on [DATE] after removal of right great toenail and legs were very edematous but no other skin issues to feet upon admission. V8 saw R2 on [DATE] and [DATE]. V7 stated that V11 had seen R2 on [DATE] and said R2 had gangrene but V8 didn't mention that R2 had gangrene. On [DATE] at 3:04 PM V8 stated that she saw R2 on [DATE] and R2 did not have palpable pedal pulses and V8 ordered ABI and a vascular consult. V8 stated R2 had dry gangrene due to poor blood flow from her PVD. V8 stated ESRD often results in PVD and there really is no medical treatment for it. On [DATE] at 8:25 PM V12, Certified Nursing Assistant (CNA), stated he took care of R2 a lot and that R2 had gotten worse during her stay. V12 stated that R2 used to talk and get out of bed even on non-dialysis days. V12 states R2 would complain about pain in her feet. V12 stated that R2 had blisters on her lower legs and the right leg was wrapped. V12 states R2 was in pain and would moan and groan with movement. V12 stated R2 did not get up on non-dialysis days because she was in too much pain. V12 states he had to help her eat because she wasn't eating and drinking. V12 states R2 was a full body lift for transfers to the wheelchair and that he transferred her to the wheelchair on [DATE] for dialysis around 9:45am that morning. V12 stated R2 would yell out in pain any time we moved her. V12 states on the morning of [DATE] R2 continued to moan/groan even after she was in the wheelchair and was waiting in the lobby for transport to dialysis. V12 states he had told nurse about her pain and the nurses could hear her moaning while in the lobby also. On [DATE] at 8:50 AM V14, CNA, stated that she took care of R2 frequently. V14 stated that over the last month R2 had declined and was very sleepy. V14 stated that R2 would holler/moan/groan out all the time. V14 stated that R2 would say her feet hurt. V14 stated she helped V2 with the dressing change to her lower leg on the morning of [DATE] and that R2's toes were black and cold. V14 states she was told that R2 had gangrene and was supposed to see a vascular doctor. V14 stated that R2 screamed when she put her socks on her on the morning of [DATE]. V14 stated R2 would moan/groan with any movement, that R2 would yell out during transfers with the full body lift to the wheelchair. V14 stated that R2 was hollering the lobby as she waited for transport to dialysis on the morning of [DATE]. V14 stated she would tell the nurses that R2 was in pain and the nurses would give her something. V14 stated that R2 was not eating and had to be fed now but was eating when she first came in. V14 stated the night shift nursing staff would tell her that R2 had yelled all night. On [DATE] at 9:15 AM V15, CNA, stated that R2 would scream out in pain a lot and that she was very tired, that she would have to wake her up to eat. V15 stated R2 used to talk to me but didn't talk much now. V15 stated she had not seen any family visit R2. V15 stated that R2 would say she hurt but not tell her where her pain was at. V15 stated that R2 would moan anytime you moved her. V15 stated nurses could hear her yelling out in pain. On [DATE] at 10:00 AM, V16, Registered Nurse, stated that she took care of R2 and that her legs hurt her really bad. V16 stated that R2's toes were black and necrotic and that on [DATE] she notified V9 of the toes being black and necrotic. V16 stated she felt as if R2 should have been sent to the hospital sooner. V16 stated she had discussed with V9 R2 being sent out but that someone else had decided that R2 needed to be hospice and R2 didn't need to go out. V16 was unsure of who had made that decision. V16 stated she did not notify the family of anything because she was told family was aware already. On [DATE] at 11:00 AM V9, stated that R2 was supposed to see a vascular doctor and that R2 was already established with a vascular doctor. V9 stated she expected the vascular consult to be done timelier. V9 stated she did not have a conversation with the family about R2's care and prognosis and expected the facility to do that. V9 stated she has no idea what the treatment would have been for R2 if she had been sent to vascular/hospital sooner. V9 stated that R2 had a lot of comorbidities and that she felt like R2 should have been on hospice but understood from the facility that R2's family did not want R2 on hospice and wanted her a full code. On [DATE] at 1:00 PM V10 stated that R2 was to see vascular doctor as soon as possible. V10 stated that facility should have gotten R2 into see vascular doctor sooner. V10 stated that R2 had a lot of co-morbidities, and that surgery probably would not have been likely and that he didn't think the outcome would have been any different for R2. V10 stated he did not speak with the family about the condition of R2 that he expected the facility to do that. On [DATE] at 1:30 PM V2 and V3 (Nurse Consultant) stated they have no documentation that the family was notified or any discussion with the family of R2's condition. V2 stated R2 was a full code but should have been on hospice. On [DATE] at 10:42 AM V5 stated that she had spoken with V17 on multiple occasions but her discussions with the V17 were about money and R2's discharge plans and that she did not discuss any medical conditions with the V17. Facility provided change of condition policy dated ,d+[DATE] documents that facility will consult with doctor and family for any changes in condition.

Based on observation, interview and record review the facility failed to provide complete incontinent care for 1 of 4 residents (R1) reviewed for incontinent care in the sample of 35. Findings include: 1. On 1/8/2024 at 9:21AM during incontinent care R1 was lying on her back in her bed. V6, Certified Nursing Assistant (CNA) entered room washed hands with soap and water. V6 then donned gloves. V6 then placed 3 washcloths under faucet of running water in the bathroom, V6 then wrung wash cloths out., V6 did not put any soap on the wash clothes. V6 then placed washcloths on a plastic bag on bedside table. V6 unfastened R1's adult brief. R1 incontinent of liquid stool as visualized in front of R1's adult brief. V6 took washcloth and cleansed R1's left groin, then right groin, folded washcloth separated labia and went down labia visible stool on washcloth. V6 then does again with visible stool still showing on washcloth. V6 did not use peri wash or dry R1. V6 then removed adult diaper and rolled R1 to left side. V6 then took washcloth and cleansed rectal area and folds and cleansed area a second time. V6 did not cleanse inner thighs or buttock. V6 did not dry R1. V6 stated she did not use soap or peri wash when providing incontinent care to R1. R1's care plan dated 12/1/2023 documents R1 has bowel incontinence. R1's care plan documents the following interventions: provide peri care after each incontinent episode. On 1/11/2024 at 8:2AM V12, CNA stated when providing incontinent care, it is important to completely clean and dry the resident. V12 stated we can use wipes, but if resident had diarrhea, we would use soap and water for cleansing. V12 stated it is expected that the resident be cleansed and dried after care. The facility policy incontinence care dated , revised 04/2021 documents to soap one cloth at a time to wash genitalia using a clean part of the cloth for each swipe, in the female, separate labia wash with strokes from top downward, (with gloved hand), each side separately with a clean cloth or clean area of the cloth. Keep labia separated with one hand wash the labia first then groin areas., rinse with remaining cloth using clean surfaces for all three surfaces(female). cleanse/rinse inner/upper thigh areas to remove urine moisture. Gently pat dry with a towel from anterior to posterior. The incontinence care policy documents remove/wipe any fecal material first with toilet tissue as necessary.

Based on observation, interview and record review the facility failed to provide hand hygiene per current standards of practice during incontinent care for 2 of 3 residents, (R1, R4) reviewed for infection control practices during urinary and bowel incontinent care in the sample of 35. FINDINGS INCLUDE: 1. On 01/10/24 at 1:12PM, V11, Certified Nurse Aide, (CNA), entered R4's room, R4 was lying in bed, prior to cleansing hands placed on clean gloves, rolled R4 to her right side while in bed, removed R4's soiled incontinent brief which revealed a large amount of soft stools. V11 then used cleansing wipes to clean perianal area, removed soiled gloves, applied clean gloves, and continued to cleanse R4's perianal area. During R4's cleansing of her perianal area, 4 glove changes was observed from removing of soiled gloves with soiled bowel on the gloves, then to applying clean gloves without hand sanitizer or hand washing applied. R4 was then positioned to her left side while in bed, was cleansed and R4 was then positioned on to her back to cleanse the front of R4's, perineum, removed soiled gloves, applied clean gloves and placed a clean incontinent brief. On 1/10/24 at 1:25PM, V11 stated, Yes I should have washed my hands between glove changing, but I didn't. On 1/11/24 at 8:50AM, V2, Director of Nursing, (DON), stated, she would expect the nursing staff to sanitizer or wash their hands between glove changing. The facility's policy and procedure, entitled, hand hygiene/Handwashing, dated 3/2023, documented, hand hygiene means cleaning your hands by using either handwashing with soap and water, antiseptic hand wash or antiseptic hand alcohol-based hand sanitizer including foam or gel. When to perform hand hygiene, before glove placement, after glove removal and after body fluids. 32874 2. On 1/8/2024 at 9:21AM during incontinent care with R1 V6, CNA removed glove off of the right hand got another glove out of bathroom, and donned glove to right hand. V6 did not sanitize hand prior to donning glove. On 1/11/2024 at 8:2AM V12, CNA stated if gloves become soiled you need to change them and wash hands with soap and water prior to donning new gloves. The facility policy Infection Precaution guidelines dated 8/2023 documents under points to remember; handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment. Alcohol-based hand rub may be used if hands are not visibly soiled.

Based on interview, observation and record review, the facility failed to provide a physician prescribed narcotic to relieve pain for 1 of 5 residents (R8) reviewed for pain in the sample of 8. This failure left R8 without moderate pain medication from 11/17/23 - 11/20/23 while in the facility for rehabilitation from a broken hip. Findings include: R8's Admission Profile, print date of 11/21/23, documents R8 was admitted on [DATE] and discharged on [DATE] and had a diagnosis of Displaced Intertrochanteric Fracture of Right Femur. R8's Baseline Care plan, dated 11/17/23, documents that R8 does have pain related to a right hip fracture. R8's Physician Orders, dated November 2023, documents, Tylenol Extra Strength Oral Tablet 500 MG (milligram) (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for Mild-Moderate pain. Start date of 11/17/23. R8's Physician Orders, dated November 2023, documents, HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Moderate pain for 7 Days. Start date of 11/17/23. R3's Medication Administration Record (MAR), dated November 2023, documents that Tylenol 500 mg 2 tablets were given on 11/18/23 at 2:26 PM for a pain rating of 7, on 11/19/23 at 10:31 AM for a pain rating of 8 and on 11/20/23 at 2:06 AM a pain rating of 10. This MAR does not document any HYDROcodone-Acetaminophen Oral Tablet 5-325 MG for moderate pain was given. R3's Nurses Notes were reviewed on 11/21/23 at 9:20 AM and the nurses' notes fail to document any doctor notification that R3 did not have a written prescription for the Hydrocodone. R3's Admission Assessment, dated 11/17/23 at 7:20 PM, documents, Pain: Resident had frequently pain in the past 5 days. Pain frequently interferes with day-to-day activities. Resident rates pain as: Resident rates pain severe over the last 5 days. R8's E-RX (prescription) New Prescription documents that V18 sent in a prescription for R8 of Norco 5 mg - 325 mg oral tablet with directions of 1 tablet by mouth every 6 hours as needed. This document is dated and timed 11/18/23 at 7:55 pm. On 11/22/23 at 11:42 AM, R8 stated, I was in horrible pain the whole time I was there. They were giving me Tylenol but that was it. I would say my pain was a 10 the whole time I was there. I couldn't sleep at all while I was there. The nurses kept telling me they were leaving messages for the doctor, but he didn't call back yet and that I would have to wait until Monday to see the doctor. At the hospital I was getting morphine and the Vicodin. I get there and they can't give me anything but Tylenol because they can't get the Vicodin. What was I going to do? I didn't want to throw a fit, but I was in pain. On 11/21/23 at 8:50 AM V6, Licensed Practical Nurse (LPN), stated, She (R8) came from the hospital without a script (prescription) for her narcotic. She had it ordered but they did not send a script. She had not seen our doctor so we couldn't get a script for her. We were trying to get the doctor to give and order for Vicodin. We were giving her Tylenol 500 mg for pain she did have an order for that. On 11/21/23 at 12:38 PM, V19, Registered Nurse (RN), stated, I took care of her (R8) over the weekend on night shift. She had told me that she was leaving in the morning, and she had all her stuff packed at the end of the bed. She said she was not getting her pain medication the way that she should, but she was leaving because she could do all that we were doing for her at home. I gave her the Tylenol that I had access to. The day shift told me she had a stronger pain medication, but it was not available yet and there is nothing I can do about that on the night shift. On 11/21/23 at 12:45 PM, V17, LPN , stated that she had spoke to her (R8) for a short period of time on the night shift of Friday. She had asked for some pain medication, so I brought her the Tylenol. She was ok with that. Her pain medication was not here yet. I let her know that I could not get the higher pain medication out of the cubix because it requires 2 nurses to sign out and we only have 1 nurse on night shift. On 11/21/23 at 3:37 PM, V11, LPN, stated, I admitted (R8). I put in all her orders. She got here about 5:30 PM on Friday (11/17/23). We have to have a written script (prescription) written and signed by a doctor for narcotics. She did not have one. The hospital knows this, and they are suppose to send one. I attempted to get a hold of (V18, Doctor). I couldn't get a hold of him. I did put in standing orders in for Tylenol 500 milligrams 2 tablets so at least she would have something for pain. I passed it on in report for the night shift that we still need a written script for her. I was then off and I didn't come back until today so I don't know what happened. On 11/21/23 at 3:42 PM, V12, Certified Nurse Aide (CNA), stated, She (R8) had her light on often and she would say she was uncomfortable in her hip and that she wanted the nurse. On 11/22/23 at 9:37 AM, V14, CNA stated that, I did overhear her telling the nurse and someone she was talking to on the phone that she needed pain medication. On 11/22/23 at 2:19 PM, V3, MDS/ LPN, stated that the nurses were notifying her of R8 not having her narcotic. I reached out to the hospital and spoke with R8's hospital care coordinator and asked if they could get a prescription sent out for us. I was told they would check and call me back. I never heard from them, so I called V18 (Medical Director) and he had me send all of the information over to him and he was going to send in a electronic script to the pharmacy. Which he actually did. I am not sure when this happened and why the medication was not available to be given to her. On 11/22/23 at 2:33 PM, V2, Director of Nurses (DON), stated, If a resident comes without a script from the hospital, the nurses should notify the doctor and he will do what is necessary to get the needed medication. In this case, I think it was an error on the pharmacy side because the medication was never available to us even though (V18) had sent the script to pharmacy. The facility failed to provide a policy on receiving prescriptions for narcotics.

Based on interview and record review, the facility failed to report an allegation of abuse in 1 of 8 residents reviewed for abuse in the sample of 9. This failure resulted in the abuse of R2 due to the abuse on R1 not being reported, this subsequently allowed V2, Former Administrator to further abuse another resident. The Immediate Jeopardy began on 03/08/23 when R1 was swinging his cane and stating his was going to hit someone. V2 was asked by V11, Activity Director to assist with getting the cane from R1. V2 then twisted the cane out of R1's hands. V2 also placed his hands on R1's chest in an attempt to calm R1 while lying in his bed. V1 Administrator was notified of the Immediate Jeopardy on 05/02/2023 at 3:00 PM. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 05/04/2023, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. On 4/27/23 at 2:50 PM, V1, Director of Nurses (DON), stated she and V3, Minimum Data Set (MDS) Nurse, were standing at the nurse's station. V3 had just called V17, Regional Nurse Consultant, regarding an allegation of abuse with V2, Former Administrator and R2 that occurred on 3/9/23. V11, Activity Director, came to the nurse's station and stated yesterday (3/8/23) R1 was swinging his cane and V2 twisted the cane out of R1's hands. V1 stated she asked V11 why she did not report this on 3/8/23 and V11 stated because she didn't feel like it was abuse. V1 stated she notified V18 of the allegations of abuse. On 4/27/23 at 1:56 PM, V11, Activity Director, stated the incident with R1 and V2, Former Administrator, occurred on 3/8/23. V11 stated R1's roommate came to her and told her R1 was throwing things. V11 went to R1's room, there were things all over the place, clothes, the bed side table was out in the middle of the floor, the nightstand had been moved and R1 was swinging his cane. V11 stated she asked R1 why he was swinging his cane, and he stated he was mad at the nurses, the aids, just mad at everyone. V11 stated R1 stated he was going to hit someone with the cane but never did, he just threatened to do it. V11 stated she went to V2 and requested he go and help her to get the cane away from R1 and to help R1 calm down. V11 stated she and V2 went into R1's room, V2 asked R1 what he was going to do with the cane. V2 them stated to R1, you're not going to hit anybody. V2 then asked for the cane and R1 stated no, you're not going to get the cane. V2 then walked up to R1 and took the cane away from R1. V2 was holding onto R1's cane on both ends and R1 was holding the cane in the center. V2 then twisted the cane out of R1's hand. V11 stated she felt it was excessive but didn't see that it did any harm to R1. V11 stated R1 didn't act like it hurt. V11 stated R1 then picked up his cup and threw it at V2, grazing his left arm. V11 stated V2 stepped forward towards R1 and stated, you can't act like this, hit people or throw things at people. V11 stated R1 was lying down flat on his bed and flinging his arms in the air and V2 walked over to R1 and stated, what's wrong with you. V11 stated V2 then took his hands and placed them on R1's hands on R1's chest. V11 stated she felt V2 was trying to calm R1 down and no harm was being done. V11 stated she did not report the incident that day because she didn't feel it was abuse. V11 stated when she heard about the abuse between R2 and V2, she felt like she needed to report it to the DON. V11 stated she did not approve of how V2 dealt with R1, twisting the cane and putting his hands down on R1's hands. V11 stated V2 is [NAME] with R1 and V2's approaches were not the best. On 4/28/23 at 9:00 AM, V11, Activity Director, stated the day before the incident with V2 and R2, there was an incident with V2 and R1. V11 stated she did not report the incident with V2 and R1 because she didn't feel that it was abuse, she felt that it was inappropriate and excessive. On 4/28/23 at 2:10 PM, V1, DON, stated she assumed R1's abrasion occurred during the incident on 3/8/23 with V2. It was found during a skin assessment after the abuse allegation was reported on 3/9/23. R1 no longer resides in the facility. R1's Face Sheet, undated, documents R1 has a diagnosis of Post Traumatic Seizures, Altered Mental Status and Difficulty in Walking. R1's MDS, dated [DATE], documents R1 is cognitively intact. R1's Care Plan, dated 2/10/23, documents R1 has a behavior problem towards others and will throw things and swing his cane at staff when he gets upset and is at risk for abuse/neglect. R1's interventions include providing a safe and secure environment. R1's Progress Note, dated 3/9/2023 at 6:09 PM: At approximately 4:20 PM, staff reported an allegation of physical abuse. The alleged perpetrator immediately suspended pending the results of the investigation. Physician/Ombudsman/Local Police Department/Resident representative notified. Investigation initiated. R1's Skin Condition Report, dated 3/9/23, documents R1 has an abrasion/scratch to the right wrist measuring 2.3 centimeters (cm) x 1 cm and to monitor the area. The Abuse Investigation Final Report dated 3/16/23 by V18, President of Operations, documents on 3/9/23, an allegation of staff to resident physical abuse was reported. The alleged perpetrator was V2, Former Administrator. V11, Activity Director, was asked about an occurrence between V2 and R1. V11 stated R1's roommate asked for assistance with R1. V11 responded and observed R1 waving his cane around. V11 stated she attempted to calm R1 and asked him for the cane. V11 stated she asked V2 for help and he responded. V11 stated V2 asked R1 for the cane and R1 refused. V11 stated R1 had one hand on the middle of the cane swinging it. V11 stated V2 the twisted the cane, releasing the cane from R1's grasp. V11 stated R1 and V2 then had a conversation and R1 calmed down and apologized for his behavior. R1 was interviewed and stated he doesn't want to be at the facility anymore. R1 was asked if there was an occurrence with V2, and R1 stated he was trying to hit them with a cane because they aren't medical doctors and shouldn't be messing with the sores on his feet. In a subsequent interview, R1stated the bald guy did take his cane, but he got it back and the bald guy did get hit with the cane. V2, was asked if there was an occurrence between him and R1 regarding R1's cane. V2 stated R1 was attempting to sling his cane towards V11. V2 stated he sat down to talk with R1 and R1 was swinging his cane around. V2 stated he caught the cane and took it from R1. V2 denied twisting the cane to remove it from R1. V2 was again interviewed and asked if he twisted the cane from R1's, V2 stated he pulled the cane. V2 stated R1 had the cane with his right hand swinging it. V2 stated he grabbed the top and bottom of the cane and pulled it up because the weak spot is between the index finger and thumb. Conclusion and action taken: V2 utilized previous behavior management training (CPI) to remove the cane from R1's possession. V2 is no longer employed at the facility. The Abuse Allegation Interview with R1 by V13, Regional Nurse Consultant, dated 3/10/23, documents R1 stated he didn't hurt anyone with the cane, it ended with his shoulder getting sprained and it was with the guy that runs this place. On 4/28/23 at 10:20 AM, V19, Current Administrator, stated V11, Activity Director, should have reported the incident regarding V2 and R1 and they would have been the one to decide if it was or was not abuse. V19 stated she teaches the staff that even if they aren't sure, it's abuse, but it doesn't look right or feel right, they should report it. On 4/28/23 at 1 PM, V6, Medical Director, stated the incident that occurred with R1 and V2, Former Administrator, should have been reported on 3/8/23, when it occurred. V6 stated he had worked with V2 prior and wouldn't have expected this. V6 stated he wouldn't expect R1 to have been treated this way by V2. V6 stated he would expect the facility to protect its residents. V2, Former Administrator's, Corrective Action Form, dated 3/16/23, documents V2 was terminated on 3/16/23 for poor job performance, employee failed to meet expectations regarding resident behavior management. The Abuse Prevention and Reporting Policy, dated 11/2016, documents employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. The Immediate Jeopardy that began on 03/08/2023 was removed on 05/04/2023 when the facility took the following actions to remove the immediacy: A.) Identification of Residents Affected or Likely to be Affected: 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. 100% Completed by V19 Administrator, V13 Regional Nurse Consultant, V1 DON, V10 ADON, V3 MDS coordinator on 05/02/23 between 17:28 and 18:22. 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. 100% completed by V3 MDS, V1 DON, V10 ADON on 5/2/23 between 15:26 and 17:24. 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. 100% of phone calls to families/POAs completed by V11 Activity Director, V21 BOM, and V22 Dietary Director on 5/2/2023 between 15:26 and 17:37. 85% of these families answered the phone and were interviewed. A message to return the phone call has been completed with the remaining 15% of families. As of 5/3/2023 11:00am, Facility only has (3) families that has not returned calls. Facility Social Service Director V23 will make daily calls until 100% compliance is met. Administrator to monitor for compliance. B.) Actions to Prevent Occurrence/Recurrence: 1.) 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. 100% Completed by V23, SSD on 05/02/23 between 15:28 and 17:52. 2.) Regional VP Operations reviewed Abuse Prevention/Reporting - Illinois Policy. Completed by V18 VP of Operations on 05/02/23 at 16:35. 3.) Facility Administrator V1, 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. Initiated by V3 MDS and V10 ADON on 05/02/23 at 17:28. 4.) Abuse in-servicing for all staff. 99% Completed by V18 VP of Operations, V25 Regional Nurse Consultant, V3 MDS, V10 ADON, V1 DON on 05/02/23 between 15:26 and 18:18. 5.) Facility Administrator, V19, and V11 Activity Director were in-serviced on the facility abuse policy on 05/02/23 at 17:26 by V25, Regional Nurse Consultant. The remaining 1% will be educated prior to being able to next scheduled shift. Abuse Training will remain ongoing with all new hires. 6.) 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. 7.) AD HOC QA reviewing Abuse Prevention/Reporting - Illinois Policy and the components of F600, F609, F610 IJ. Completed on 5/2/23 at 16:40 with V24 VP of Clinical Services, V18 VP of Operations, V13 Regional Nurse Consultant, V25 Regional Nurse Consultant, V6 Dr., V3 MDS coordinator, V1 DON, V23 SSD, and V10 ADON. 8.) QA will meet May 5, 2023, and monthly, and as needed.

Based on interview and record review, the facility failed to investigate/prevent the abuse in 2 of 8 residents reviewed for abuse in the sample of 9. This failure resulted in R1 and R2 being abused by V2, Former Administrator. The Immediate Jeopardy began on 03/08/23 when the facility failed to prevent and protect the R1 and R2 from abuse and failed to report an allegation of abuse to prevent further abuse to the residents. V1 Administrator was notified of the Immediate Jeopardy on 05/02/2023 at 3:00 PM. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 05/04/2023, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. On 4/27/23 at 2:50 PM, V1, Director of Nurses (DON), stated she and V3, Minimum Data Set (MDS) Nurse, were standing at the nurse's station. V3 had just called V17, Regional Nurse Consultant, regarding an allegation of abuse with V2, Former Administrator and R2 that occurred on 3/9/23. V11, Activity Director, came to the nurse's station and stated yesterday (3/8/23) R1 was swinging his cane and V2 twisted the cane out of R1's hands. V1 stated she asked V11 why she did not report this on 3/8/23 and V11 stated because she didn't feel like it was abuse. V1 stated she notified V18, President of Operations of the allegations of abuse. On 4/27/23 at 1:56 PM, V11, Activity Director, stated the incident with R1 and V2, Former Administrator, occurred on 3/8/23. V11 stated R1's roommate came to her and told her R1 was throwing things. V11 went to R1's room, there were things all over the place, clothes, the bed side table was out in the middle of the floor, the nightstand had been moved and R1 was swinging his cane. V11 stated she asked R1 why he was swinging his cane, and he stated he was mad at the nurses, the aids, just mad at everyone. V11 stated R1 stated he was going to hit someone with the cane but never did, he just threatened to do it. V11 stated she went to V2 and requested he go and help her to get the cane away from R1 and to help R1 calm down. V11 stated she and V2 went into R1's room, V2 asked R1 what he was going to do with the cane? V2 then stated to R1, you're not going to hit anybody. V2 then asked for the cane and R1 stated no, you're not going to get the cane. V2 then walked up to R1 and took the cane away from R1. V2 was holding onto R1's cane on both ends and R1 was holding the cane in the center. V2 then twisted the cane out of R1's hand. V11 stated she felt it was excessive but didn't see that it did any harm to R1. V11 stated R1 didn't act like it hurt. V11 stated R1 then picked up his cup and threw it at V2, grazing his left arm. V11 stated V2 stepped forward towards R1 and stated, you can't act like this, hit people or throw things at people. V11 stated R1 was lying down flat on his bed and flinging his arms in the air and V2 walked over to R1 and stated, what's wrong with you. V11 stated V2 then took his hands and placed them on R1's hands on R1's chest. V11 stated she felt V2 was trying to calm R1 down and no harm was being done. V11 stated she did not report the incident that day because she didn't feel it was abuse. V11 stated when she heard about the abuse between R2 and V2, she felt like she needed to report it to the DON. V11 stated she did not approve of how V2 dealt with R1, twisting the cane, and putting his hands down on R1's hands. V11 stated V2 is [NAME] with R1 and V2's approaches were not the best. On 4/28/23 at 9:00 AM, V11, Activity Director, stated the day before the incident with V2 and R2, there was an incident with V2 and R1. V11 stated she did not report the incident with V2 and R1 because she didn't feel that it was abuse, she felt that it was inappropriate and excessive. On 4/28/23 at 2:10 PM, V1, DON, stated she assumed R1's abrasion occurred during the incident on 3/8/23 with V2. It was found during a skin assessment after the abuse allegation was reported on 3/9/23. R1 no longer resides in the facility. R1's Face Sheet, undated, documents R1 has a diagnosis of Post Traumatic Seizures, Altered Mental Status and Difficulty in Walking. R1's MDS, dated [DATE], documents R1 is cognitively intact. R1's Care Plan, dated 2/10/23, documents R1 has a behavior problem towards others and will throw things and swing his cane at staff when he gets upset and is at risk for abuse/neglect. R1's Care Plan Interventions include providing a safe and secure environment. R1's Progress Note, dated 3/9/2023 at 6:09 PM: At approximately 4:20 PM, staff reported an allegation of physical abuse. The alleged perpetrator immediately suspended pending the results of the investigation. Physician/Ombudsman/Local Police Department/Resident representative notified. Investigation initiated. R1's Skin Condition Report, dated 3/9/23, documents R1 has an abrasion/scratch to the right wrist measuring 2.3 centimeters (cm) x 1 cm and to monitor the area. The Abuse Investigation Final Report dated 3/16/23 by V18, President of Operations, documents on 3/9/23, an allegation of staff to resident physical abuse was reported. The alleged perpetrator was V2, Former Administrator. V11, Activity Director, was asked about an occurrence between V2 and R1. V11 stated R1's roommate asked for assistance with R1. V11 responded and noted R1 waving his cane around. V11 stated she attempted to calm R1 and asked him for the cane. V11 stated she asked V2 for help and he responded. V11 stated V2 asked R1 for the cane and R1 refused. V11 stated R1 had one hand on the middle of the cane swinging it. V11 stated V2 then twisted the cane, releasing the cane from R1's grasp. V11 stated R1 and V2 then had a conversation and R1 calmed down and apologized for his behavior. R1 was interviewed and stated he doesn't want to be at the facility anymore. R1 was asked if there was an occurrence with V2, and R1 stated he was trying to hit them with a cane because they aren't medical doctors and shouldn't be messing with the sores on his feet. In a subsequent interview, R1 stated the bald guy did take his cane, but he got it back and the bald guy did get hit with the cane. V2, was asked if there was an occurrence between him and R1 regarding R1's cane. V2 stated R1 was attempting to sling his cane towards V11. V2 stated he sat down to talk with R1 and R1 was swinging his cane around. V2 stated he caught the cane and took it from R1. V2 denied twisting the cane to remove it from R1. V2 was again interviewed and asked if he twisted the cane from R1's hands. V2 stated he pulled the cane. V2 stated R1 had the cane with his right hand swinging it. V2 stated he grabbed the top and bottom of the cane and pulled it up because the weak spot is between the index finger and thumb. Conclusion and action taken: V2 utilized previous behavior management training (CPI) to remove the cane from R1's possession. V2 is no longer employed at the facility. The Abuse Allegation Interview with R1 by V13, Regional Nurse Consultant, dated 3/10/23, documents R1 stated he didn't hurt anyone with the cane, it ended with his shoulder getting sprained and it was with the guy that runs this place. 2. On 4/26/23 at 10:24 PM, V9, Office Manager, stated R2 was going out the south door and V2, Former Administrator went after him. R2 made it to the sidewalk at the south door. The door alarm was sounding. V2 was telling R2 that he needed to come back inside and R2 was refusing. R2 was yelling, cussing, this place is f****** ridiculous, I will hit you with my wheelchair. R2 was stating this to V2. V2 then wrapped his left arm into R2's right arm. V9, stated V5, Agency LPN (Licensed Practical Nurse) stated to V2, what are you doing. V9 stated V2 did not respond to V5 and kept going, trying to get R2 inside. V2 was walking R2 back inside through the south door, as R2 was walking towards the doorway, he put his left arm on the building to keep from going back inside. When R2 and V2 got back inside the building, they were in the hallway near the south hall door, V2 put R2 against the wall for approximately a minute. As V2 was holding R2 against the wall, R2's face was sideways touching the wall and V2 had his hands on R2's back. R2 was able to move his arms, his hands, and head. V2 let R2 go because R2 wasn't yelling anymore and had calmed down. V9 stated R2 and V2 kept going back and forth talking about getting R2 to another facility that allows smoking. V9 stated V2 then went back to his office and R2 was sitting at the south door in his four-wheel Rollator Walker. On 4/26/23 at 11:12 AM, V10, Assistant Director of Nurses (ADON) stated on 3/9/23, she was in her office, heard the south door alarm going off, she looked down the hallway and saw a bunch of people at the south door. V10 stated she saw R2 and V2 coming in the door with their arms hooked together. V2 had a stern facial expression when he came through the door and started to walk closer to R2. As V2 and R2 made it through the door, they were saying something to each other, but she couldn't hear what was being said, they were both talking angrily. V10 stated she saw R2 against the wall but couldn't see if V2 was physically holding him, there were too many people standing in the way. V10 stated R2's face was against the wall. V10 stated V2 started walking towards his office and one of the CNAs got R2 situated and put him back in his Rollator [NAME] and began walking towards R2's room. V10 stated it wasn't right how V2 handled the situation. V10 stated that she and V3, MDS Nurse, called V13, Regional Nurse Consultant and V18, President of Operations and told them of the alleged abuse with V2. V10 stated she went to check on R2 and he was okay but mad, R2 was yelling at the CNA's (Certified Nurse Assistant) about the situation. V2 was in his office with his door shut. On 4/26/23 at 4:14 PM, V11, Activity Director, stated she heard the door alarm go off and saw a bunch of CNAs down at the south hall door and V2, was running down the hall. V11 states R2 would go outside with the alarm sounding, stating he wanted to go out and smoke. V11 stated R2 was not allowed to go out and smoke because it's a smoke free facility, but R2 was alert and oriented, after the incident R2 was allowed to go outside to the sidewalk, after he signed a paper to go outside and would smoke. On 4/26/23 at 4:38 PM, V8, CNA, stated she observed V2, grab R2's arm and R2 was holding onto the building and V2 was pulling R2 by the arm, V2 then grabbed R2's arms forcefully and pushed R2 up against the wall. R2 and V2 were yelling at each other in the hallway. V8 stated V2 then went to his office shut the door and then left the building. V8 stated V2 should not have gone out and grabbed R2. After the incident R2 showed her his arms and he had scratches on his arms. On 4/27/23 at 3:02 PM, V3, MDS Nurse, stated the door alarm went off, V3 turned down the hall and V2, had his arms locked with R2, coming back towards the building. R2 put his hand and wrists against the bricks wall by the south hall door and V2 was forcefully pulling R2's arm off the brick wall, it wasn't gentle. V2 did not ask R2 to take his arm off the brick wall. V2 and R2 came to the door and V2 took R2 and placed him up against the hallway next to the door while V2's arms were still locked with R2's arm. V2 then took his arm out of R2's arm. V3 stated she could see in V2's face, it was like a realization of handling the situation inappropriately. V3 stated she then notified V1, DON. V3, stated she was instructed by V13, Regional Nurse Consultant and V18, that V2 needed to leave the facility right now. V3 stated V2 stated he was calling V18 as she followed V2 to the door. On 4/27/23 at 3:33 PM, V3, MDS Nurse, stated things happened so quickly that they didn't have time to separate V2 and R2. V3 stated she was not aware that V2 had escorted R2 to his room. On 4/27/23 at 3:35 PM, V2, DON, stated that V2 had only been at the facility for about two weeks and had an authoritative demeanor, like he was an in-charge kind of person. He acted like military in general. In meetings he would say this is how it's going to be. V1 stated she was not aware and did not witness the incident with V2 and R2 until V3, MDS Nurse, reported it to her. On 4/27/23 at 4:25 PM, V20, CNA/Transportation Coordinator, stated the door alarm was going off and V2 was man handling R2 back into the door. V2 had both hands on R2 forcing R2 back in the building, he was using his body to shove R2 back in the building. V2 then put R2 up against the wall, face first with his arms wrapped around R2's arms so R2 couldn't move and R2's arm was twisted behind his back. V20 stated R2 kept repeating to V2 there's nothing to talk about. V2 was talking very harsh to R2. V20 stated she was in shock that (V2) could do this. On 4/28/23 at 9 AM, V3, MDS Nurse, stated she looked outside of her window in her office when she heard the door alarm sounding and saw V2, locked with R2. Once V2 and R2 were inside, V2 had R2 against the wall. V2 separated himself from R2 and walked down the hall. She thought V2 was walking to his office. V3 stated the whole incident occurred within 2-5 minutes and she is not sure how long it was between the incident with R2 occurred and when V2 exited the facility. V3 stated she did not see V2 go all the way to his office after the incident with R2. On 4/28/23 at 9 AM, V1, DON, stated V3, MDS Nurse, reported the incident with V2 and R2 to her (V1). She and V3 called V13, and V18, but V18 did not answer at first. V1 stated V18 called V3 and instructed her to walk V2 out. V1 is unsure of how long V2 was in the building between when the incident with R2 occurred and V2 actually left the building. V1 stated V16, CNA, had to separate R2 and V2. V1 stated R2 discharged to a sister facility. V1 stated R2 did not have any family and was homeless, R2 wanted to smoke and was angry that V2 was making him come back into the building. V1 stated R2 had his own cigarettes and tried to go smoke. V1 stated they tried to take R2's cigarettes but he hid them. V1 stated after a couple of weeks of R2 being in the facility, they got to know him and because of his cognition, it was determined that he was safe to sign himself out, and would walk to the tree, the same place where the incident with V2 started. V1 stated prior to the incident with V2 and R2, R2 didn't get far enough to smoke. R2 would stand at the door and yell for someone to let him out so he could go and smoke. R2 was allowed to go to the sidewalk off the property to smoke after the incident with V2. On 4/28/23 at 10:05 AM, V18, President of Operations, stated she completed the majority of the investigation involving R2 and V2, and R1 and V2. V18 stated she was notified the evening of 3/9/23 of the allegation between R2 and V2. V18 stated they don't substantiate or unsubstantiate allegations of abuse, they just list the facts at the conclusion of the investigation. V18 stated V2 was terminated because he didn't meet the expectations on how situations should be handled. V18 stated V2 had abuse training upon hire. V18 stated she would expect staff to report instances of abuse and ensure that the resident is safe and separate them. V18 stated if abuse involves staff, they are asked to leave the building or get out of the immediate area, and she would expect staff to have stayed with V2 until he left the building. V18 stated the incident between R1 and V2, it was her understanding that R1 was swinging his cane and V11, Activity Director, asked for assistance from V2 and V2 went with V11 to R1's room to help. R2's Face Sheet, documents R2 has a diagnosis of Atherosclerotic Heart Disease, Hypertension and Homelessness. R2's MDS, dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 2/28/23, documents R2 is at risk for abuse/neglect with an intervention to provide a safe and secure environment. R2's Progress Notes, document the following: On 3/9/2023 at 6:06 PM, at approximately 4:20 PM, staff reported an allegation of physical abuse. The alleged perpetrator immediately suspended pending the results of the investigation. Physician/Ombudsman/Local Police Department notified. Investigation initiated. On 3/9/2023 at 9:32 PM, Follow up assessment completed for alleged abuse. Resident is alert and oriented. R2 appears to have a sad, worried facial expression. R2 stated my pride is hurt worse than my arm. New injury noted on assessment. Abrasion to left forearm measurers 12.2 cm X 2.5 cm. Redness, inflammation noted at site. No bruising noted. No swelling noted. R2's Skin Condition Report, dated 3/9/23, documents R2 has an abrasion/scratch the left forearm measuring 12.2cm x 2.5cm. The Abuse Investigation Final Report dated 3/16/23 by V18, President of Operations, documents on 3/9/23 an allegation of staff to resident physical abuse was reported. The alleged perpetrator was V2, Former Administrator. R2 was assessed for physical and psychosocial distress. R2 was noted to have minor discoloration to his forearms. V3, MDS Nurse, was interviewed and stated she stepped out of her office, located on the south hall because she heard the south hall door alarming, and she observed V2 escorting R2 back into the facility. V3 stated V2 and R2 were locked at the elbows with V2 walking slightly in front of R2. V3 stated V5, Agency LPN (Licensed Practical Nurse), was behind V2 and R2. V3 stated that V2 appeared to be pulling R2. V3 stated once R2 and V2 were inside the door, R2 was against the wall and R2 and V2 were still locked at the elbows. V3 stated V2 then stepped away from R2. V3 stated she immediately reported the incident. R2 was interviewed and stated he wanted to go out to smoke, he understands the facility is a non-smoking facility, but stated he could walk around the block or off the property to smoke. R2 stated he went out the south hall door and grabbed his cigarette to smoke and V2 came out to bring him back in the building R2 stated V2 grabbed both of his arms to bring him back in the building. R2 stated both were talking loudly to each other. In a subsequent interview, R2 denied being resistive with staff but he was pulling in the opposite direction of V2. R2 denied being up against the wall when he returned to the building. V2 was interviewed and stated R2 had been having behaviors most of the day on 3/9/23. V2 stated R2 was cursing and exit seeking to go outside to smoke. V2 stated R2 walked out of the south hall door, and he escorted R2 back into the facility. V2 stated R2 was resistive as he attempted to get him back in the facility. V2 denied placing R2 against the wall upon re-entering the facility. Conclusion and action taken: R2 was exhibiting exit seeking behaviors related to wanting to smoke. R2 exited the facility out the south hall door to smoke. V2 and other staff members responded to return R2 to the facility. V2 utilized previous behavior management training (CPI) to assist R2 to return to the facility. V2 is no longer employed at the facility. The facility abuse investigation documents the following: Interview with V5, Agency LPN on 3/14/23 at 12:54 PM, with V13, Regional Nurse Consultant, V5 stated she was out back of the facility on break, V3, MDS Nurse, asked her (V5) to go around to the south hall exit door, a resident was attempting to leave. V5 stated when she rounded the facility, R2 was facing the road with his walker and V2 was behind him telling him to come inside, we're not going to do this. V5 stated she approached R2, and he turned towards V2, V2 then grabbed R2's right arm and started pulling him towards the door. V5 stated V16, CNA, V7, CNA and V9, Office Manager, was there V5 stated she said oh no we can't to R2. V5 stated R2 had one hand on the walker and let go of the walker. V5 stated she placed the walker behind R2 because it had a seat on it. V5 stated R2 and V2 got to the threshold of the door and R2 grabbed the brick wall and before she could make contact with R2's hand, R2 pulled his hand off the brick wall rubbing his hand/forearm on the bricks. V5 stated once they were inside, she placed the walker beside R2 as R2 was against the wall on his front side, V2 had R2's right arm with his right arm and V2's left arm was across R2's shoulders. V5 stated she reported this to V3. V5 stated R2 was cursing but not combative. V5 stated this was R2's second or third attempt to go outside to smoke. Interview with V27, CNA, on 3/10/23 with V13, Regional Nurse, documents R2 hasn't really been out of his room today, he's been sleeping more. On 3/9/23, V2, Former Administrator, was agitated with R2 because R2 wanted to smoke. Interview with V28, CNA, on 3/10/23 with V13, Regional Nurse, documents V28 didn't notice any changes with R2, he doesn't seem to be bothered by it, but she hasn't seen R2 out of his room today, he is usually up and in the hallways. An undated, written statement, signed by V29, CNA, documents V29 witnessed V2 forcibly grabbing R2 by the wrist causing him to scrape his arm on the brick wall and then once inside, V2 put R2 against the wall like he was arresting him. A written statement signed by V7, CNA, dated 3/9/23, documents she witnessed V2 grab a resident (does not name a resident) by the arm and forcibly walk him into the building. During the process V2 used force and the resident received scratches from the outer brick wall. Once inside the building, V2 forcibly escorted him (unnamed resident) to his room, where another employee split them apart. Interview with V2, Former Administrator, dated 3/9/23 at 5:44 PM, documents, V2 stated the staff had trouble with R2 all day. V2 stated R2 had been cursing at him because he would not let R2 go outside to smoke. V2 stated R2 walked out the south hall door and he (V2) had to escort R2 back into the facility. V2 stated R2 was resistive. V2 stated R2 raised his hands up and he (V2) had to put his hands up to defend himself. V2 stated this occurred inside R2's room. V2 stated V16, CNA, came in to R2's room during that time. V2 stated R2 kept sitting by the door, making comments that he was going to harm someone if he didn't get out. V2 stated the staff on south hall just stood there with saucer eyes. V2 stated R2 kept saying he was going to leave throughout the day. V2 stated once R2 was back in the facility, he doesn't know if he V2 was a little more excessive when trying to walk R2 back in but R2 was being resistive. V2 stated no other staff members were outside with him, R2 was only in the yard area and did not make it to the road from the south hall door. V2 denied placing R2's chest against the wall like he was being arrested. Interview with V2, dated 3/15/23 at 2:31 PM, with V13, Regional Nurse Consultant, documents V2's intent was to bring R2 back into the facility for his safety. V2 stated when R2 came back into the facility, he was belligerent, threatening staff and him. V2 stated R2 was stating I will kill a mother f**** if someone touches me, punch you in the face and throw my walker at you. V2 stated he attempted to re-assure R2 and calm him down but R2 continued to threaten. V2 stated he was not trying to push R2 against the wall, he had his left hand on the wall and R2's left shoulder against the wall. Interview with R2, dated 3/10/23 with V13, Regional Nurse Consultant, documents he wanted to go smoke, R2 knew it was a smoke free facility, but he can walk around the block or off the property and smoke a cigarette. I know what I'm doing with my life. I went out of the door, grabbed my cigarette and was starting to walk to smoke. The guy, the administrator guy, ran to get me and tried to forcefully get me back in the building. He grabbed both of my arms and was pulling and pushing me into the building. It didn't have to be like that. I was able to get my right arm out of his grip but he's a bigger guy than me, so he still had my left arm in his hand. We were both yelling. He tried to push me up against the wall, but I used self-defense. Interview with R2, dated 3/10/23 at 12:36 PM by V18, President of Operations, documents R2 stated he exited the south hall door because he wanted to smoke, he was not going to be around the facility. R2 stated he had his clothes and a coat on, he walked to the door and out it. R2 stated within 5 minutes V2 came rushing out and grabbed him by both arms. Writer asked R2 to re-enact how V2 had his arms, R2 held writer's forearms just above the wrists. R2 stated he was not being resistive or fighting. R2 stated he was pulling in the opposite direction of V2. R2 stated once they were back into the facility, he sat in his walker and told V2 he wasn't going to his room, V2 kept wanting him to go to his room while he (R2) was saying he was going back outside. R2 stated as they were coming back into the building, he grabbed the brick wall. R2 stated nobody overpowers him or has authority over him and V2 was strict. On 4/28/23 at 10:30 AM, the outside area just outside the south hall door was observed. The tree and sidewalk were approximately 40 feet from the building and approximately 45 feet from the road to the building. The road was not heavily traveled during the observation. On 4/28/23 at 10:20 AM, V19, Current Administrator, stated V11, Activity Director, should have reported the incident regarding V2 and R1 and they would have been the one to decide if it was or was not abuse. V19 stated she teaches the staff that even if they aren't sure if it's abuse, but it doesn't look right or feel right, they should report it. On 4/28/23 at 1 PM, V6, Medical Director, stated the incident that occurred with R1 and V2, Former Administrator, should have been reported on 3/8/23, when it occurred. V6 stated he had worked with V2 prior and wouldn't have expected this. V6 stated he wouldn't expect R1 or R2 to have been treated this way by V2. V6 stated R2 has Heart Disease, Diabetes, had been homeless but was harmless. V6 stated he would expect the facility to protect its residents. V2, Former Administrator's, Corrective Action Form, dated 3/16/23, documents V2 was terminated on 3/16/23 for poor job performance, employee failed to meet expectations regarding resident behavior management. The Abuse Prevention and Reporting policy, dated 11/2016, 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. The Immediate Jeopardy that began on 03/08/2023 was removed on 05/04/2023 when the facility took the following actions to remove the immediacy: A.) Identification of Residents Affected or Likely to be Affected: 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. 100% Completed by V19 Administrator, V13 Regional Nurse Consultant, V1 DON, V10 ADON, V3 MDS coordinator on 05/02/23 between 17:28 and 18:22. 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. 100% completed by V3 MDS, V1 DON, V10 ADON on 5/2/23 between 15:26 and 17:24. 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. 100% of phone calls to families/POAs completed by V11 Activity Director, V21 BOM, and V22 Dietary Director on 5/2/2023 between 15:26 and 17:37. 85% of these families answered the phone and were interviewed. A message to return the phone call has been completed with the remaining 15% of families. As of 5/3/2023 11:00am, Facility only has (3) families that has not returned calls. Facility Social Service Director V23 will make daily calls until 100% compliance is met. Administrator to monitor for compliance. B.) Actions to Prevent Occurrence/Recurrence: 1.) 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. 100% Completed by V23, SSD on 05/02/23 between 15:28 and 17:52. 2.) Regional VP Operations reviewed Abuse Prevention/Reporting - Illinois Policy. Completed by V18 VP of Operations on 05/02/23 at 16:35. 3.) Facility Administrator V1, 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. Initiated by V3 MDS and V10 ADON on 05/02/23 at 17:28. 4.) Abuse in-servicing for all staff. 99% Completed by V18 VP of Operations, V25 Regional Nurse Consultant, V3 MDS, V10 ADON, V1 DON on 05/02/23 between 15:26 and 18:18. 5.) Facility Administrator, V19, and V11 Activity Director were in-serviced on the facility abuse policy on 05/02/23 at 17:26 by V25, Regional Nurse Consultant. The remaining 1% will be educated prior to being able to next scheduled shift. Abuse Training will remain ongoing with all new hires. 6.) 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. 7.) AD HOC QA reviewing Abuse Prevention/Reporting - Illinois Policy and the components of F600, F609, F610 IJ. Completed on 5/2/23 at 16:40 with V24 VP of Clinical Services, V18 VP of Operations, V13 Regional Nurse Consultant, V25 Regional Nurse Consultant, V6 Dr., V3 MDS coordinator, V1 DON, V23 SSD, and V10 ADON. 8.) QA will meet May 5, 2023, and monthly, and as needed.

Based on interview and record review, the facility failed to prevent the abuse of 2 of 8 residents reviewed for abuse in the sample of 9. This failure resulted in R1 and R2 being abused by V2, Former Administrator. The Immediate Jeopardy began on 03/09/23 when R2 left the facility without staff knowledge to smoke a cigarette. R2 was grabbed by V2 and pulled back into the facility. V2 then placed R2 up against the wall as if R2 was being arrested. R2 was taken to his room in which V2 began verbally abusing R2. V1 Administrator was notified of the Immediate Jeopardy on 05/02/2023 at 3:00 PM. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 05/04/2023, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. On 4/27/23 at 2:50 PM, V1, Director of Nurses (DON), stated she and V3, Minimum Data Set (MDS) Nurse, were standing at the nurse's station. V3 had just called V17, Regional Nurse Consultant, regarding an allegation of abuse with V2, Former Administrator and R2 that occurred on 3/9/23. V11, Activity Director, came to the nurse's station and stated yesterday (3/8/23) R1 was swinging his cane and V2 twisted the cane out of R1's hands. V1 stated she asked V11 why she did not report this on 3/8/23 and V11 stated because she didn't feel like it was abuse. V1 stated she notified V18, President of Operations of the allegations of abuse. On 4/27/23 at 1:56 PM, V11, Activity Director, stated the incident with R1 and V2, Former Administrator, occurred on 3/8/23. V11 stated R1's roommate came to her and told her R1 was throwing things. V11 went to R1's room, there were things all over the place, clothes, the bed side table was out in the middle of the floor, the nightstand had been moved and R1 was swinging his cane. V11 stated she asked R1 why he was swinging his cane, and he stated he was mad at the nurses, the aids, just mad at everyone. V11 stated R1 stated he was going to hit someone with the cane but never did, he just threatened to do it. V11 stated she went to V2 and requested he go and help her to get the cane away from R1 and to help R1 calm down. V11 stated she and V2 went into R1's room, V2 asked R1 what he was going to do with the cane? V2 then stated to R1, you're not going to hit anybody. V2 then asked for the cane and R1 stated no, you're not going to get the cane. V2 then walked up to R1 and took the cane away from R1. V2 was holding onto R1's cane on both ends and R1 was holding the cane in the center. V2 then twisted the cane out of R1's hand. V11 stated she felt it was excessive but didn't see that it did any harm to R1. V11 stated R1 didn't act like it hurt. V11 stated R1 then picked up his cup and threw it at V2, grazing his left arm. V11 stated V2 stepped forward towards R1 and stated, you can't act like this, hit people or throw things at people. V11 stated R1 was lying down flat on his bed and flinging his arms in the air and V2 walked over to R1 and stated, what's wrong with you. V11 stated V2 then took his hands and placed them on R1's hands on R1's chest. V11 stated she felt V2 was trying to calm R1 down and no harm was being done. V11 stated she did not report the incident that day because she didn't feel it was abuse. V11 stated when she heard about the abuse between R2 and V2, she felt like she needed to report it to the DON. V11 stated she did not approve of how V2 dealt with R1, twisting the cane, and putting his hands down on R1's hands. V11 stated V2 is [NAME] with R1 and V2's approaches were not the best. On 4/28/23 at 9:00 AM, V11, Activity Director, stated the day before the incident with V2 and R2, there was an incident with V2 and R1. V11 stated she did not report the incident with V2 and R1 because she didn't feel that it was abuse, she felt that it was inappropriate and excessive. On 4/28/23 at 2:10 PM, V1, DON, stated she assumed R1's abrasion occurred during the incident on 3/8/23 with V2. It was found during a skin assessment after the abuse allegation was reported on 3/9/23. R1 no longer resides in the facility. R1's Face Sheet, undated, documents R1 has a diagnosis of Post Traumatic Seizures, Altered Mental Status and Difficulty in Walking. R1's MDS, dated [DATE], documents R1 is cognitively intact. R1's Care Plan, dated 2/10/23, documents R1 has a behavior problem towards others and will throw things and swing his cane at staff when he gets upset and is at risk for abuse/neglect. R1's Care Plan Interventions include providing a safe and secure environment. R1's Progress Note, dated 3/9/2023 at 6:09 PM: At approximately 4:20 PM, staff reported an allegation of physical abuse. The alleged perpetrator immediately suspended pending the results of the investigation. Physician/Ombudsman/Local Police Department/Resident representative notified. Investigation initiated. R1's Skin Condition Report, dated 3/9/23, documents R1 has an abrasion/scratch to the right wrist measuring 2.3 centimeters (cm) x 1 cm and to monitor the area. The Abuse Investigation Final Report dated 3/16/23 by V18, President of Operations, documents on 3/9/23, an allegation of staff to resident physical abuse was reported. The alleged perpetrator was V2, Former Administrator. V11, Activity Director, was asked about an occurrence between V2 and R1. V11 stated R1's roommate asked for assistance with R1. V11 responded and noted R1 waving his cane around. V11 stated she attempted to calm R1 and asked him for the cane. V11 stated she asked V2 for help and he responded. V11 stated V2 asked R1 for the cane and R1 refused. V11 stated R1 had one hand on the middle of the cane swinging it. V11 stated V2 then twisted the cane, releasing the cane from R1's grasp. V11 stated R1 and V2 then had a conversation and R1 calmed down and apologized for his behavior. R1 was interviewed and stated he doesn't want to be at the facility anymore. R1 was asked if there was an occurrence with V2, and R1 stated he was trying to hit them with a cane because they aren't medical doctors and shouldn't be messing with the sores on his feet. In a subsequent interview, R1 stated the bald guy did take his cane, but he got it back and the bald guy did get hit with the cane. V2, was asked if there was an occurrence between him and R1 regarding R1's cane. V2 stated R1 was attempting to sling his cane towards V11. V2 stated he sat down to talk with R1 and R1 was swinging his cane around. V2 stated he caught the cane and took it from R1. V2 denied twisting the cane to remove it from R1. V2 was again interviewed and asked if he twisted the cane from R1's hands. V2 stated he pulled the cane. V2 stated R1 had the cane with his right hand swinging it. V2 stated he grabbed the top and bottom of the cane and pulled it up because the weak spot is between the index finger and thumb. Conclusion and action taken: V2 utilized previous behavior management training (CPI) to remove the cane from R1's possession. V2 is no longer employed at the facility. The Abuse Allegation Interview with R1 by V13, Regional Nurse Consultant, dated 3/10/23, documents R1 stated he didn't hurt anyone with the cane, it ended with his shoulder getting sprained and it was with the guy that runs this place. 2. On 4/26/23 at 10:24 PM, V9, Office Manager, stated R2 was going out the south door and V2, Former Administrator went after him. R2 made it to the sidewalk at the south door. The door alarm was sounding. V2 was telling R2 that he needed to come back inside and R2 was refusing. R2 was yelling, cussing, this place is f****** ridiculous, I will hit you with my wheelchair. R2 was stating this to V2. V2 then wrapped his left arm into R2's right arm. V9, stated V5, Agency LPN (Licensed Practical Nurse) stated to V2, what are you doing. V9 stated V2 did not respond to V5 and kept going, trying to get R2 inside. V2 was walking R2 back inside through the south door, as R2 was walking towards the doorway, he put his left arm on the building to keep from going back inside. When R2 and V2 got back inside the building, they were in the hallway near the south hall door, V2 put R2 against the wall for approximately a minute. As V2 was holding R2 against the wall, R2's face was sideways touching the wall and V2 had his hands on R2's back. R2 was able to move his arms, his hands, and head. V2 let R2 go because R2 wasn't yelling anymore and had calmed down. V9 stated R2 and V2 kept going back and forth talking about getting R2 to another facility that allows smoking. V9 stated V2 then went back to his office and R2 was sitting at the south door in his four-wheel Rollator Walker. On 4/26/23 at 11:12 AM, V10, Assistant Director of Nurses (ADON) stated on 3/9/23, she was in her office, heard the south door alarm going off, she looked down the hallway and saw a bunch of people at the south door. V10 stated she saw R2 and V2 coming in the door with their arms hooked together. V2 had a stern facial expression when he came through the door and started to walk closer to R2. As V2 and R2 made it through the door, they were saying something to each other, but she couldn't hear what was being said, they were both talking angrily. V10 stated she saw R2 against the wall but couldn't see if V2 was physically holding him, there were too many people standing in the way. V10 stated R2's face was against the wall. V10 stated V2 started walking towards his office and one of the CNAs got R2 situated and put him back in his Rollator [NAME] and began walking towards R2's room. V10 stated it wasn't right how V2 handled the situation. V10 stated that she and V3, MDS Nurse, called V13, Regional Nurse Consultant and V18, President of Operations and told them of the alleged abuse with V2. V10 stated she went to check on R2 and he was okay but mad, R2 was yelling at the CNA's (Certified Nurse Assistant) about the situation. V2 was in his office with his door shut. On 4/26/23 at 1:49 PM, V16, CNA, stated on 3/9/23 the door alarm was sounding. Upon entering the south hall, V2, Former Administrator, was observed pulling/tugging R2 through the door. R2 had his left hand on the bricks outside of the south door. V2 was taking R2 in the door and V2 was trying to get R2's hands off the bricks. Once inside, V2 yanked R2's left arm and twisted his (R2) arm around R2's back, putting R2's face and body against the wall. V16 stated R2 couldn't move at all and R2 stated to V2 to keep your hands off of me. V2 then pushed R2 to his room. V16, went to check on R2 approximately 15 minutes later and V2 was in R2's room and they were nose to nose V16 stated R2 stated to V2 if he touched him again, he was going to grab something and hit him on the side of the head. R2 was mad. V16 stated she told V2 he needed to go and told R2 he needed to calm down. V16 stated V2 walked out of R2's room and later told V16, thanks for stepping in. V16 stated V2 was still in the building for an hour and a half after the incident. V16 stated the incident happened around 4:00 PM and management was still in the facility, and no one intervened except V16. V16 stated R2 had a red mark on his right middle forearm. V16 stated R2 was crying and stated to her that he was embarrassed, and his pride was hurt. On 4/26/23 at 4:14 PM, V11, Activity Director, stated she heard the door alarm go off and saw a bunch of CNAs down at the south hall door and V2, was running down the hall. V11 states R2 would go outside with the alarm sounding, stating he wanted to go out and smoke. V11 stated R2 was not allowed to go out and smoke because it's a smoke free facility, but R2 was alert and oriented, after the incident R2 was allowed to go outside to the sidewalk, after he signed a paper to go outside and would smoke. On 4/26/23 at 4:38 PM, V8, CNA, stated she observed V2, grab R2's arm and R2 was holding onto the building and V2 was pulling R2 by the arm, V2 then grabbed R2's arms forcefully and pushed R2 up against the wall. R2 and V2 were yelling at each other in the hallway. V8 stated V2 then went to his office shut the door and then left the building. V8 stated V2 should not have gone out and grabbed R2. After the incident R2 showed her his arms and he had scratches on his arms. On 4/27/23 at 3:02 PM, V3, MDS Nurse, stated the door alarm went off, V3 turned down the hall and V2, had his arms locked with R2, coming back towards the building. R2 put his hand and wrists against the bricks wall by the south hall door and V2 was forcefully pulling R2's arm off the brick wall, it wasn't gentle. V2 did not ask R2 to take his arm off the brick wall. V2 and R2 came to the door and V2 took R2 and placed him up against the hallway next to the door while V2's arms were still locked with R2's arm. V2 then took his arm out of R2's arm. V3 stated she could see in V2's face, it was like a realization of handling the situation inappropriately. V3 stated she then notified V1, DON. V3, stated she was instructed by V13, Regional Nurse Consultant and V18, that V2 needed to leave the facility right now. V3 stated V2 stated he was calling V18 as she followed V2 to the door. On 4/27/23 at 3:33 PM, V3, MDS Nurse, stated things happened so quickly that they didn't have time to separate V2 and R2. V3 stated she was not aware that V2 had escorted R2 to his room. On 4/27/23 at 3:35 PM, V2, DON, stated that V2 had only been at the facility for about two weeks and had an authoritative demeanor, like he was an in-charge kind of person. He acted like military in general. In meetings he would say this is how it's going to be. V1 stated she was not aware and did not witness the incident with V2 and R2 until V3, MDS Nurse, reported it to her. On 4/27/23 at 4:25 PM, V20, CNA/Transportation Coordinator, stated the door alarm was going off and V2 was man handling R2 back into the door. V2 had both hands on R2 forcing R2 back in the building, he was using his body to shove R2 back in the building. V2 then put R2 up against the wall, face first with his arms wrapped around R2's arms so R2 couldn't move and R2's arm was twisted behind his back. V20 stated R2 kept repeating to V2 there's nothing to talk about. V2 was talking very harsh to R2. V20 stated she was in shock that (V2) could do this. On 4/28/23 at 9 AM, V3, MDS Nurse, stated she looked outside of her window in her office when she heard the door alarm sounding and saw V2, locked with R2. Once V2 and R2 were inside, V2 had R2 against the wall. V2 separated himself from R2 and walked down the hall. She thought V2 was walking to his office. V3 stated the whole incident occurred within 2-5 minutes and she is not sure how long it was between the incident with R2 occurred and when V2 exited the facility. V3 stated she did not see V2 go all the way to his office after the incident with R2. On 4/28/23 at 9 AM, V1, DON, stated V3, MDS Nurse, reported the incident with V2 and R2 to her (V1). She and V3 called V13, and V18, but V18 did not answer at first. V1 stated V18 called V3 and instructed her to walk V2 out. V1 is unsure of how long V2 was in the building between when the incident with R2 occurred and V2 actually left the building. V1 stated V16, CNA, had to separate R2 and V2. V1 stated R2 discharged to a sister facility. V1 stated R2 did not have any family and was homeless, R2 wanted to smoke and was angry that V2 was making him come back into the building. V1 stated R2 had his own cigarettes and tried to go smoke. V1 stated they tried to take R2's cigarettes but he hid them. V1 stated after a couple of weeks of R2 being in the facility, they got to know him and because of his cognition, it was determined that he was safe to sign himself out, and would walk to the tree, the same place where the incident with V2 started. V1 stated prior to the incident with V2 and R2, R2 didn't get far enough to smoke. R2 would stand at the door and yell for someone to let him out so he could go and smoke. R2 was allowed to go to the sidewalk off the property to smoke after the incident with V2. On 4/28/23 at 10:05 AM, V18, President of Operations, stated she completed the majority of the investigation involving R2 and V2, and R1 and V2. V18 stated she was notified the evening of 3/9/23 of the allegation between R2 and V2. V18 stated they don't substantiate or unsubstantiate allegations of abuse, they just list the facts at the conclusion of the investigation. V18 stated V2 was terminated because he didn't meet the expectations on how situations should be handled. V18 stated V2 had abuse training upon hire. V18 stated she would expect staff to report instances of abuse and ensure that the resident is safe and separate them. V18 stated if abuse involves staff, they are asked to leave the building or get out of the immediate area, and she would expect staff to have stayed with V2 until he left the building. V18 stated the incident between R1 and V2, it was her understanding that R1 was swinging his cane and V11, Activity Director, asked for assistance from V2 and V2 went with V11 to R1's room to help. R2's Face Sheet, documents R2 has a diagnosis of Atherosclerotic Heart Disease, Hypertension and Homelessness. R2's MDS, dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 2/28/23, documents R2 is at risk for abuse/neglect with an intervention to provide a safe and secure environment. R2's Progress Notes, document the following: On 3/9/2023 at 6:06 PM, at approximately 4:20 PM, staff reported an allegation of physical abuse. The alleged perpetrator immediately suspended pending the results of the investigation. Physician/Ombudsman/Local Police Department notified. Investigation initiated. On 3/9/2023 at 9:32 PM, Follow up assessment completed for alleged abuse. Resident is alert and oriented. R2 appears to have a sad, worried facial expression. R2 stated my pride is hurt worse than my arm. New injury noted on assessment. Abrasion to left forearm measurers 12.2 cm X 2.5 cm. Redness, inflammation noted at site. No bruising noted. No swelling noted. R2's Skin Condition Report, dated 3/9/23, documents R2 has an abrasion/scratch the left forearm measuring 12.2cm x 2.5cm. The Abuse Investigation Final Report dated 3/16/23 by V18, President of Operations, documents on 3/9/23 an allegation of staff to resident physical abuse was reported. The alleged perpetrator was V2, Former Administrator. R2 was assessed for physical and psychosocial distress. R2 was noted to have minor discoloration to his forearms. V3, MDS Nurse, was interviewed and stated she stepped out of her office, located on the south hall because she heard the south hall door alarming, and she observed V2 escorting R2 back into the facility. V3 stated V2 and R2 were locked at the elbows with V2 walking slightly in front of R2. V3 stated V5, Agency LPN (Licensed Practical Nurse), was behind V2 and R2. V3 stated that V2 appeared to be pulling R2. V3 stated once R2 and V2 were inside the door, R2 was against the wall and R2 and V2 were still locked at the elbows. V3 stated V2 then stepped away from R2. V3 stated she immediately reported the incident. R2 was interviewed and stated he wanted to go out to smoke, he understands the facility is a non-smoking facility, but stated he could walk around the block or off the property to smoke. R2 stated he went out the south hall door and grabbed his cigarette to smoke and V2 came out to bring him back in the building R2 stated V2 grabbed both of his arms to bring him back in the building. R2 stated both were talking loudly to each other. In a subsequent interview, R2 denied being resistive with staff but he was pulling in the opposite direction of V2. R2 denied being up against the wall when he returned to the building. V2 was interviewed and stated R2 had been having behaviors most of the day on 3/9/23. V2 stated R2 was cursing and exit seeking to go outside to smoke. V2 stated R2 walked out of the south hall door, and he escorted R2 back into the facility. V2 stated R2 was resistive as he attempted to get him back in the facility. V2 denied placing R2 against the wall upon re-entering the facility. Conclusion and action taken: R2 was exhibiting exit seeking behaviors related to wanting to smoke. R2 exited the facility out the south hall door to smoke. V2 and other staff members responded to return R2 to the facility. V2 utilized previous behavior management training (CPI) to assist R2 to return to the facility. V2 is no longer employed at the facility. The facility abuse investigation documents the following: Interview with V5, Agency LPN on 3/14/23 at 12:54 PM, with V13, Regional Nurse Consultant, V5 stated she was out back of the facility on break, V3, MDS Nurse, asked her (V5) to go around to the south hall exit door, a resident was attempting to leave. V5 stated when she rounded the facility, R2 was facing the road with his walker and V2 was behind him telling him to come inside, we're not going to do this. V5 stated she approached R2, and he turned towards V2, V2 then grabbed R2's right arm and started pulling him towards the door. V5 stated V16, CNA, V7, CNA and V9, Office Manager, was there V5 stated she said oh no we can't to R2. V5 stated R2 had one hand on the walker and let go of the walker. V5 stated she placed the walker behind R2 because it had a seat on it. V5 stated R2 and V2 got to the threshold of the door and R2 grabbed the brick wall and before she could make contact with R2's hand, R2 pulled his hand off the brick wall rubbing his hand/forearm on the bricks. V5 stated once they were inside, she placed the walker beside R2 as R2 was against the wall on his front side, V2 had R2's right arm with his right arm and V2's left arm was across R2's shoulders. V5 stated she reported this to V3. V5 stated R2 was cursing but not combative. V5 stated this was R2's second or third attempt to go outside to smoke. Interview with V27, CNA, on 3/10/23 with V13, Regional Nurse, documents R2 hasn't really been out of his room today, he's been sleeping more. On 3/9/23, V2, Former Administrator, was agitated with R2 because R2 wanted to smoke. Interview with V28, CNA, on 3/10/23 with V13, Regional Nurse, documents V28 didn't notice any changes with R2, he doesn't seem to be bothered by it, but she hasn't seen R2 out of his room today, he is usually up and in the hallways. An undated, written statement, signed by V29, CNA, documents V29 witnessed V2 forcibly grabbing R2 by the wrist causing him to scrape his arm on the brick wall and then once inside, V2 put R2 against the wall like he was arresting him. A written statement signed by V7, CNA, dated 3/9/23, documents she witnessed V2 grab a resident (does not name a resident) by the arm and forcibly walk him into the building. During the process V2 used force and the resident received scratches from the outer brick wall. Once inside the building, V2 forcibly escorted him (unnamed resident) to his room, where another employee split them apart. Interview with V2, Former Administrator, dated 3/9/23 at 5:44 PM, documents, V2 stated the staff had trouble with R2 all day. V2 stated R2 had been cursing at him because he would not let R2 go outside to smoke. V2 stated R2 walked out the south hall door and he (V2) had to escort R2 back into the facility. V2 stated R2 was resistive. V2 stated R2 raised his hands up and he (V2) had to put his hands up to defend himself. V2 stated this occurred inside R2's room. V2 stated V16, CNA, came in to R2's room during that time. V2 stated R2 kept sitting by the door, making comments that he was going to harm someone if he didn't get out. V2 stated the staff on south hall just stood there with saucer eyes. V2 stated R2 kept saying he was going to leave throughout the day. V2 stated once R2 was back in the facility, he doesn't know if he V2 was a little more excessive when trying to walk R2 back in but R2 was being resistive. V2 stated no other staff members were outside with him, R2 was only in the yard area and did not make it to the road from the south hall door. V2 denied placing R2's chest against the wall like he was being arrested. Interview with V2, dated 3/15/23 at 2:31 PM, with V13, Regional Nurse Consultant, documents V2's intent was to bring R2 back into the facility for his safety. V2 stated when R2 came back into the facility, he was belligerent, threatening staff and him. V2 stated R2 was stating I will kill a mother f**** if someone touches me, punch you in the face and throw my walker at you. V2 stated he attempted to re-assure R2 and calm him down but R2 continued to threaten. V2 stated he was not trying to push R2 against the wall, he had his left hand on the wall and R2's left shoulder against the wall. Interview with R2, dated 3/10/23 with V13, Regional Nurse Consultant, documents he wanted to go smoke, R2 knew it was a smoke free facility, but he can walk around the block or off the property and smoke a cigarette. I know what I'm doing with my life. I went out of the door, grabbed my cigarette and was starting to walk to smoke. The guy, the administrator guy, ran to get me and tried to forcefully get me back in the building. He grabbed both of my arms and was pulling and pushing me into the building. It didn't have to be like that. I was able to get my right arm out of his grip but he's a bigger guy than me, so he still had my left arm in his hand. We were both yelling. He tried to push me up against the wall, but I used self-defense. Interview with R2, dated 3/10/23 at 12:36 PM by V18, President of Operations, documents R2 stated he exited the south hall door because he wanted to smoke, he was not going to be around the facility. R2 stated he had his clothes and a coat on, he walked to the door and out it. R2 stated within 5 minutes V2 came rushing out and grabbed him by both arms. Writer asked R2 to re-enact how V2 had his arms, R2 held writer's forearms just above the wrists. R2 stated he was not being resistive or fighting. R2 stated he was pulling in the opposite direction of V2. R2 stated once they were back into the facility, he sat in his walker and told V2 he wasn't going to his room, V2 kept wanting him to go to his room while he (R2) was saying he was going back outside. R2 stated as they were coming back into the building, he grabbed the brick wall. R2 stated nobody overpowers him or has authority over him and V2 was strict. On 4/28/23 at 10:30 AM, the outside area just outside the south hall door was observed. The tree and sidewalk were approximately 40 feet from the building and approximately 45 feet from the road to the building. The road was not heavily traveled during the observation. On 4/28/23 at 10:20 AM, V19, Current Administrator, stated V11, Activity Director, should have reported the incident regarding V2 and R1 and they would have been the one to decide if it was or was not abuse. V19 stated she teaches the staff that even if they aren't sure if it's abuse, but it doesn't look right or feel right, they should report it. On 4/28/23 at 1 PM, V6, Medical Director, stated the incident that occurred with R1 and V2, Former Administrator, should have been reported on 3/8/23, when it occurred. V6 stated he had worked with V2 prior and wouldn't have expected this. V6 stated he wouldn't expect R1 or R2 to have been treated this way by V2. V6 stated R2 has Heart Disease, Diabetes, had been homeless but was harmless. V6 stated he would expect the facility to protect its residents. V2, Former Administrator's, Corrective Action Form, dated 3/16/23, documents V2 was terminated on 3/16/23 for poor job performance, employee failed to meet expectations regarding resident behavior management. The Abuse Prevention and Reporting policy, dated 11/2016, 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. The Immediate Jeopardy that began on 03/09/2023 was removed on 05/04/2023 when the facility took the following actions to remove the immediacy: A.) Identification of Residents Affected or Likely to be Affected: 1. All residents with a Brief Interview for Mental Status (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. 100% Completed by V19 Administrator, V13 Regional Nurse Consultant, V1 DON, V10 ADON, V3 MDS coordinator on 05/02/23 between 17:28 and 18:22. 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. 100% completed by V3 MDS, V1 DON, V10 ADON on 5/2/23 between 15:26 and 17:24. 3. Family members/POAs of those residents with a Brief Interview for Mental Status (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. 100% of phone calls to families/POAs completed by V11 Activity Director, V21 Business of Manager (BOM), and V22 Dietary Director on 5/2/2023 between 15:26 and 17:37. 85% of these families answered the phone and were interviewed. A message to return the phone call has been completed with the remaining 15% of families. As of 5/3/2023 11:00am, Facility only has (3) families that have not returned calls. Facility Social Service Director V23 will make daily calls until 100% compliance is met. Administrator to monitor for compliance. B.) Actions to Prevent Occurrence/Recurrence: 1.) 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. 100% Completed by V23, SSD on 05/02/23 between 15:28 and 17:52. 2.) Regional VP Operations reviewed Abuse Prevention/Reporting - Illinois Policy. Completed by V18 VP of Operations on 05/02/23 at 16:35. 3.) Facility Administrator V1, 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. Initiated by V3 MDS and V10 ADON on 05/02/23 at 17:28. 4.) Abuse in-servicing for all staff. 99% Completed by V18 VP of Operations, V25 Regional Nurse Consultant, V3 MDS, V10 ADON, V1 DON on 05/02/23 between 15:26 and 18:18. 5.) Facility Administrator, V19, and V11 Activity Director were in-serviced on the facility abuse policy on 05/02/23 at 17:26 by V25, Regional Nurse Consultant. The remaining 1% will be educated prior to being able to next scheduled shift. Abuse Training will remain ongoing with all new hires. 6.) 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. 7.) AD HOC QA reviewing Abuse Prevention/Reporting - Illinois Policy and the components of F600, F609, F610 IJ. Completed on 5/2/23 at 16:40 with V24 VP of Clinical Services, V18 VP of Operations, V13 Regional Nurse Consultant, V25 Regional Nurse Consultant, V6 Dr., V3 MDS coordinator, V1 DON, V23 SSD, and V10 ADON. 8.) QA will meet May 5, 2023, and monthly, and as needed.

Based on observation, interview and record review, the facility failed to provide care to promote healing and the prevent deterioration of Moisture Associated [CONDITION(S)] for 2 of 16 residents (R5, R26) reviewed for quality of care in the sample of 37. This failure resulted in the worsening of R26's Moisture [CONDITION(S)]. Findings include: 1.R26's Admission Record, dated 10/31/22, documents, that R26 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Minimum Data Set (MDS), dated [DATE], documents that R26 is severely cognitively impaired, requires extensive assistance of one staff member for bed mobility, transfer, toileting, and personal hygiene. This MDS also documents R26 is always incontinent of bowel and bladder. R26's Care Plan, dated 9/2/22, documents, I am risk for a skin impairment r/t (related to) aging / disease process, decreased mobility. Intervention: Keep skin clean and dry. Use lotion on dry skin. R26's Care Plan, dated 10/20/22, documents, (R26) has an actual skin impairment of MASD to right and left buttock. Intervention: Treatment as ordered. Wound doctor to assess and treat as needed. R26's Care Plan, undated, documents, I have alteration in urinary elimination: Urinary incontinence r/t (related to) Impaired mobility, Lack of sensation. Intervention: Incontinence management program prn (as needed). Monitor for incontinence and change as needed. R26's Specialty Physician Wound Notes, dated 10/20/22, documents Site 1 Non-Pressure wound of the right buttocks full thickness. Etiology: Moisture Associated Skin Damage. Duration: greater than 7 days. Wound Size: 1.0 x (by) 0.5 x 0.1 cm (centimeters) with odor. It also documents, Additional Wound Detail PT (patient) has developed new buttock wounds due to moisture. Chemical Cauterization of hypergranulation tissue performed on Buttock wound with topical anesthetic to facilitate healing. This Note also documents Site 2 Non-Pressure wound of the left buttocks full thickness. Etiology: Moisture Associated Skin Damage. Duration: greater than 7 days. Wound Size: 4.5 x 2.5 x 0.1 cm. On 10/26/22 at 3:37 PM, V18, Certified Nurse's Aide (CNA), entered R26's room. R26 was sitting in his recliner wearing light gray sweatpants. V18 stated that he was not aware of R26 being wet and that he just was assigned to this hall. The front of R26's pants were visibly wet. V18 stood R26 up and transferred him to bed. R26's back of sweatpants were visibly wet from his waistband to the middle of his thigh. V18 removed R26's urine and feces soiled incontinent brief. R26's buttocks, scrotum and groin were fire engine red. R26's buttocks had dry sticky feces on it. R26 has 2 moisture associated wounds on the upper left and right sacrum the approximate size of a dime. The wound beds were red. V18 stated that R26's skin is usually not red and that the areas to his sacrum are not new. R26's Specialty Physician Wound Notes, dated 10/27/22, documents Site 1 Non-Pressure wound of the right buttocks full thickness. Etiology: Moisture Associated Skin Damage. Duration: greater than 14 days. Wound Size: 1.5 x 1.5 x 0.1 cm. Wound Progress: Deteriorated. It also documents, Additional Wound Detail Since the last visit he has developed another small ulcerative area in the region. This Note also documents Site 2 Non-Pressure wound of the left buttocks full thickness. Etiology: Moisture Associated Skin Damage. Duration: greater than 14 days. Wound Size: 0.5 x 0.7 x 0.1 cm with scab. Wound Progress: Improved. On 10/27/22 at 10:45 AM, V9, Assistant Director of Nurses (ADON)/Wound Nurse, stated that R26 should not be saturated in urine at any time and that it is not good for his wound healing. V9 stated, This really makes me mad to hear. 2. R5's Order Summary Report, dated 10/26/22, documents R5 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS, dated [DATE], documents that R5 is severely cognitively impaired and requires extensive assistance of 2 staff members for bed mobility, totally dependent on 2 staff members for transfers and extensive assistance of 1 staff member for toileting and personal hygiene. This MDS also documents R5 has an indwelling catheter and is always incontinent of stool. R5's Care Plan, undated, documents, Resident has an actual skin impairment of MASD (moisture associated skin [CONDITION(S)]). Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Minimize pressure over boney prominences. Treatment as ordered. R5's Order Summary Report, dated 10/26/22, documents, [MEDICATION(S)] Powder. Apply to sacrum and right buttock every day shift Mon (Monday), Wed (Wednesday), Fri (Friday) for Skin. Cleanse area apply collagen powder and [MEDICATION(S)] (a dressing). On 10/26/22 at 3:16 PM, V19, Licensed Practical Nurse (LPN), stated, I am going to put (R5's) treatment on his bottom. V19 entered R5's room's, uncovered R5 and rolled R5 onto his side. V19 unfastened R5's incontinent brief. R5's brief was soiled with a large amount of stool. V19 refastened the incontinent brief and stated, He needs to be cleaned up. I will let my aide know. V19 left the room. On 10/26/22 from 3:16 PM until 4:35 PM, R5 was continually observed. No staff entered R5's room to provide R5 with incontinent care leaving R5's skin exposed to the feces. On 10/26/22 at 4:35 PM, V18 was questioned if V19 had told him R5 was soiled and needed to be cleaned up, V18 stated, (V19) did not tell me a thing. I didn't know. On 10/26/22 at 4:40 PM, V18 entered R5's room. V18 removed R5's incontinent brief. R5's has a suprapubic urinary catheter. R5's incontinent brief was soiled with a large amount of stool. R5's bedding, gown and bed pad was wet. V18 using a washcloth had to make multiple wipes with the cloths to remove the dried-on stool from R5's buttocks. R5 also had dried stool on his scrotum and V18 needed to use multiple wipes with a washcloth to remove it. R5's buttocks and scrotum were red. R5 had 2 non - pressure wounds, both wounds did not have a dressing on them. The sacrum wound was a small area. The wound bed had granulation tissue. The right upper buttocks had a small area with slough and granulation tissue. V18 completed care for R5. When asked why R5's bedding and gown were wet on the back, V18 stated, (R5's) catheter leaks. R5's Specialty Physician Wound Evaluation, dated 10/27/22, documents Site 2 Non-pressure wound Sacrum Full Thickness. Etiology: Moisture Associated Skin Damage. Duration: greater than 15 days. Wound Size: 1.0 x 3 x 0.2 cm (centimeters). Wound Progress: Deteriorated. This evaluation also documents, Site 3 Non-pressure wound of the Right, Upper, Medial Buttock Full Thickness. Etiology: Moisture Associated Skin Damage. Duration: greater than 15 days. Wound Size: 0.3 x 0.1 x 0.1 cm. with 10% slough. Wound Progress: Improved. Surgical excisional debridement was performed on Site 3. On 11/1/22 at 12:00 PM, V1, Administrator, stated that the facility did not have a Moisture Associated [CONDITION(S)] policy.

Based on observation, interview and record review, the facility failed to provide timely and complete incontinence and catheter care for 5 of 5 residents (R5, R8, R16, R26, R206) reviewed for incontinent care in the sample of 37. This failure resulted in R206 feeling demeaned and experiencing pain during incontinent care. Findings include: 1. R206's Care Plan, dated 10/19/2022, documents, The resident has an ADL (activities of daily living) self-care performance deficit It continues, TOILET USE: The resident requires (1) assist with toileting. Resident is incontinent of B&B (bowel & bladder) and wears briefs It also documents, I am at risk for a skin impairment r/t (related to) incontinence It continues, Keep skin clean and dry. Use lotion on dry skin. R206's Minimum Data Set (MDS), dated [DATE], documents that R206 is cognitively intact. It also documents that R206 is occasionally incontinent and of urine, frequently incontinent of bowel and requires extensive assistance of 1 staff with toileting. On 10/25/2022 at 10:10 AM, V14, Physical Therapist, notified V9, Assistant Director of Nursing (ADON), and V10, Certified Nursing Assistant (CNA), of R206 have soiled pants and requiring assistance. On 10/25/ at 11:30 AM, R206 stated that he would like to get cleaned up. R206 stated that he does not like sitting in his own feces. R206 stated that he doesn't like it and it's demeaning. R206 stated that he is a man, and this is not right. R206 then lowered his head and would not make eye contact. On 10/25/2022 at 12:24 PM, V14 stated that when she entered R206's room at 12:15 PM she noticed that R206 was sitting in the same position she left him and R206 had not been changed. V14 stated that she notified the ADON. Based on 15-minute observation intervals, R206 remained sitting in the wheelchair in the same soiled pants without benefit of incontinent care on 10/25/2022 from 10:10 AM to 1:00 PM. On 10/25/2022 at 1:00 PM V10, CNA, and V11, CNA, assisted R206 with incontinent care. V10 and V11 assisted R206 into a standing position. R206 pants were soiled with bowel. V10 and V11 assisted R206 into the bathroom and pulled R206 pants down. V11 attempted to remove R206's incontinent brief. The incontinent brief was stuck to R206's buttocks. V11 pulled the incontinent brief off and R206 yelled Ouch. V10 then, using a washcloth and soap, cleansed the dried bowel from R206's buttocks. R206 observed with facial grimacing and asked, What are you doing back there? V10 continued to cleanse the buttocks and anal area. V10 and V11 then applied an undergarment and pants and assisted R206 into his wheelchair. V10 did not cleanse R206's penis and scrotum. On 10/25/2022 at 1:20 PM, when asked if he have any pain when cleaned by the CNAs, R206 stated, Yeah. It didn't feel good. On 10/26/2022 at 3:02 PM, V11, Corporate RN (Registered Nurse), stated that she would expect the staff to clean all areas of incontinence including the penis and scrotum. V11 stated that she expects the staff to perform catheter care when performing incontinent care. V11 stated that she expects staff to perform care in a timely manner. V11 stated that sitting in feces for waiting for 3 hours is not timely. On 10/26/2022 at 3:30 PM, V9, Assistant Director of Nursing (ADON), stated that she did not hear therapy say that R206 was dirty. V9 stated that there is no excuse. 2. R8's Care Plan, dated 10/18/2022, documents that (R8) has an indwelling Catheter r/t [CONDITION(S)] bladder and self-catheterization in the community. (R8) was retaining urine in the hospital and a Foley was placed. He failed voiding trials. Refuses Secure device for foley It continues Catheter care every shift and PRN (as needed) R8's MDS, dated [DATE], documents that R8 is cognitively intact, frequently incontinent of bowel and requires extensive assist for toileting. R8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/2022 at 10:07 AM, observed V9, ADON, and V10, CNA, perform incontinent care. R8 was incontinent of bowel. V9 and V10 pulled down R8's pants to his ankles. V9 and V10 then turned R8 onto his right side and V10 cleansed R8's anus and left buttock. V9 and V10 then turned R8 onto his right side and V10 cleansed R8's left buttock. V9 and V10 then turned R8 onto her back and cleansed R8's left and right groin. V9 and V10 then applied R8's undergarment. V10 did not cleanse R8's scrotum, penis and did not perform catheter care. 3. On 10/27/2022 at 09:05 AM, V11, CNA, cleansed R16's abdominal fold with a wet washcloth with peri wash on it, flipped washcloth over cleansed from abdominal fold down into left groin area. Then she took another wet washcloth with peri wash on it and cleansed the right groin area. V11 did not cleanse R16's labia or perineal area nor did she rinse off the peri wash or dry R16's abdominal fold or bilateral groin areas. V11 doffed her gloves and donned another pair without benefit of hand hygiene and assisted V10, CNA, with rolling R16 onto her left side. V11 removed urine-soaked incontinent brief, with gloved hands, took a wet washcloth, cleansed her right hip and rectal area, with a wet washcloth that had peri wash on it. There was peri wash on R16's right hip and V11 did not rinse off or dry the right hip. R16's Care Plan, dated 08/04/2020 documented Provide peri care after each incontinent episode R16's MDS, dated [DATE], documented R16's cognition was moderately impaired, that she requires extensive assist of 2 staff for toileting and that she was frequently incontinent of urine and occasionally incontinent of her bowels. The facility's policy, Incontinence Care, dated 10/2022, documented, a. Wash the labia first then groin areas. 4. R5's Order Summary Report, dated 10/26/22, documents R5 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS, dated [DATE], documents that R5 is severely cognitively impaired and requires extensive assistance of 2 staff members for bed mobility, totally dependent on 2 staff members for transfers and extensive assistance of 1 staff member for toileting and personal hygiene. This MDS also documents R5 has an indwelling catheter and is always incontinent of stool. On 10/26/22 at 3:16 PM, V19, Licensed Practical Nurse (LPN), stated, I am going to put (R5's) treatment on his bottom. V19 entered R5's room's, uncovered R5 and rolled R5 onto his side. V19 unfastened R5's incontinent brief. R5's brief was soiled with a large amount of stool. V19 refastened the incontinent brief and stated, He needs to be cleaned up. I will let my aide know. V19 left the room. On 10/26/22 from 3:16 PM until 4:35 PM R5 was continually observed. No staff entered R5's room to provide R5 with incontinent care. On 10/26/22 at 4:35 PM, when asked if V19 had told him R5 was soiled and needed to be cleaned up, V18 stated, (V19) did not tell me a thing. I didn't know. On 10/26/22 at 4:40 PM, V18 entered R5's room. V18 removed R5's incontinent brief. R5 had a suprapubic urinary catheter. R5's incontinent brief was soiled with a large amount of stool. R5's bedding, gown and bed pad was wet. V18 using a washcloth had to make multiple wipes with the cloths to remove the dried-on stool from R5's buttocks. R5 also had dried stool on his scrotum and V18 needed to use multiple wipes with a washcloth to remove it. R5's buttocks and scrotum were red. V18 completed care for R5. When asked why R5's bedding and gown were wet on the back, V18 stated, (R5's) catheter leaks. 5. R26's Admission Record, dated 10/31/22, documents, that R26 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's MDS, dated [DATE], documents that R26 is severely cognitively impaired, requires extensive assistance of one staff member for bed mobility, transfer, toileting and personal hygiene. This MDS also documents R26 is always incontinent of bowel and bladder. R26's Care Plan, undated, documents, I have alteration in urinary elimination: Urinary incontinence r/t Impaired mobility, Lack of sensation. Intervention: Incontinence management program prn (as needed). Monitor for incontinence and change as needed. On 10/26/22 at 3:37 PM, V18, CNA, entered R26's room. R26 was sitting in his recliner wearing light gray sweatpants. V18 stated that he was not aware of R26 being wet and that he just was assigned to this hall. The front of R26's pants were visibly wet. V18 stood R26 up and transferred him to bed. R26's back of sweatpants were visibly wet from his waistband to the middle of his thigh. V18 removed R26's urine and feces soiled incontinent brief. R26's buttocks, scrotum and groin were fire engine red. R26's buttocks had dry sticky feces on it. On 10/27/22 at 10:45 AM, V9, ADON / Wound Nurse, stated that R26 should not be saturated in urine at any time and that it is not good for his wound healing. V9 stated, This really makes me mad to hear. On 11/1/22 at 2:00 PM, V12, Regional Nurse Consultant, stated, Staff should be checking on residents every 2 hours more if needed for incontinence. All areas that were soiled should be cleansed. The facility policy, dated 10/2022, documents, Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every 2 hours and provided perineal and genital care after each episode. 4. Soap one cloth at a time to wash genitalia using a clean part of the cloth for each swipe. A. Wash the labia first then groin areas. B. Rinse with remaining cloth using clean surfaces for all three surface areas (female). Do not place soiled soapy cloths back in clean water basin until procedure completed. May drape soiled cloths over the side of the wash basin, or place directly in soiled linen plastic bag. In the male resident, wash penis first, turn the resident to the side, then wash perineal area. C. Clean/ rinse inner / upper thigh areas to remove urine moisture. 5. Observe for redness, irritation and discharge. 6. Gently pat area dry with a towel from anterior to posterior. 7. Assist resident to turn to side away from you. 8. Using the final rinse cloth, from front washing, wash and rinse the peri-anal area. Pat dry. 9. Change gloves and perform hand hygiene.

Based on observation, interview and record review, the facility failed to safely transfer residents for 3 of 3 residents (R2, R6, R7) reviewed for falls in a sample of 12. This failure resulted in R2 falling and sustaining lacerations and fractures to both legs. Findings include: 1. R2's Admission Record dated 9/28/22, documented, R2 was admitted on [DATE] with medical diagnoses of Spinal Stenosis, weakness, pain in hip, muscle weakness, chronic pain, Hirsutism, unsteadiness on feet and pathological fracture in other disease, unspecified tibia and fibula. R2's Minimum Data Set (MDS), dated [DATE], documented R2 requires two support assistance by staff with transfers and toileting with a mode of transportation of a wheelchair. The MDS documents R2 does not have a mental impaired cognition and is alert to person, place, and time. R2's previous Care Plan, with an initiated date of 11/16/20, documented R2 requires, one stand by assist by staff or as needed and R2 is at risk for falls, gait/balance problems initiated on 3/5/21 with multiple interventions as documented; call light in reach, initiate physical therapy to evaluate, lock brakes on wheelchair and review information on past falls and attempt to determine cause of falls. R2's, Care Plan, with an initiated date of 5/16/22, documented R2 requires one staff to assist with all transfers. R2's Skilled Medicare Charting, dated 5/11/22, 5/12/22, 5/13/22 all documented, R2 requires two staff support to assist with transfers and toileting and use of a wheelchair for mode of transportation. R2's Physical Therapy progress note dated 5/3/22, prior to R2's fall documented The patient will ambulate 20 feet on level surfaces with front wheeled walker and moderate assistance x(times) 2 (26-75% with 2 people) and mod (moderate) tactile and verbal instruction/cues to improve mobility on the unit with staff. The patient is unable to ambulate on level surfaces with front wheeled walker at this time. R2's Progress note dated 5/14/2022 11:25 AM, documented, ambulance here to transport resident to hospital, no documentation prior to 5/14/22 Progress note, for reason of transport. The facility's documentation regarding R2, entitled, Report to IDPH (Illinois Department of Public Health) Region Office, Initial Report, dated 5/14/22 with date of incident 5/14/22 at 10:56 AM, documented resident fell during transfer, pain to left and right legs, laceration to lower left leg, was sent to ER (emergency room ) for evaluation. The facility Final IDPH Regional office Report, dated 5/19/22 documented, R2 sustained a fall on 5/14/22 in her room. The report documented After a thorough review of the medical record, hospital records, and interviews, the following has been determined. Resident had a recent hospitalization for CHF (Congested Heart Failure), which required continuous oxygen upon return to facility as well as IV (intravenous) antibiotics for BLE (bilateral lower extremities) cellulites. Resident was standing at bedside and using wheeled walker for support. CNA (Certified Nurse Aide) went to assist (R2) as she lost her balance. CNA was unable to stop resident from fall. R2's, Regional Hospital Trauma Surgical Critical Care, dated 5/18/22 at 10:17 AM, for Physical Therapy Initial Evaluation, documents, PT (patient), who presented to the ED (Emergency Department) on 5/14/22 of a fall while attempt to transfer with assist and 2ww (two wheeled walker), PT with obvious LE (lower extremity) open fractures with large lacerations bilat (bilateral) tibial areas (low right and left legs). PT was admitted with bilateral comminuted fractures, laceration to bilateral lower legs. Foot X-ray shows right first phalanx (toe) and metatarsal (top of foot) possible fracture and left first met (top of foot) possible fracture. The same document, dated 5/18/22, documented, PT (patient) had stated she required assist of two staff for bed mobility and stand-pivot transfers bed/chair with 2 wheeled walker, continues to document that R2 stated of having chronic foot drop to both lower legs and reports one fall on day of admission due to loss of balance while transferring. R2's Progress note dated 6/21/22, documented, Resident arrived to facility per transport service on a stretcher on 5L (liters) of 02 (oxygen) per NC (nasal cannula), Alert and oriented x3 (person, place, time). Anxious and SOB (short of breath), bilateral lower extremities wrapped G-tube (enteral stomach feedings) in place NPO (nothing by mouth), non- weight bearing to BLE (bilateral lower extremities). On 10/10/22 at 10:50 AM, V15, Director of Rehabilitation, (COTA) stated, she was not employed during R2's stay; however, therapy progress and evaluation documentation reflects R2 required assistance of two staff, due to R2 was not able to stabilize on her feet prior to fall and not a candidate for standby assist of a two wheeled walker. The facility's policy's and procedure's, dated 5/2022, entitled, Fall Prevention Program, documented, To assure the safety of all residents in the facility, when possible. 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 and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Residents at risk of falling will be assisted with toileting needs as identified during the assessment process and as addressed on the plan of care. 2. R6's Care Plan, dated 2/25/21, as revision date, documented R6 ambulates with limited assist of one caregiver, wheeled walker and gait belt to and from bathroom. R6's MDS, dated [DATE], documented R6 requires two persons assist with transfers and with toileting, not steady with balance, only able to stabilize with staff assistance with walking, moving from seated to standing position, moving on and off toilet and surface to surface transfers with a mobility device of walker and wheelchair. R6's, Fall Risk Assessment, dated 8/10/22, documented at risk for falls due to balance problems standing and walking. On 9/29/22 at 11:20 AM, V17, Certified Nurse Aide, (CNA), entered R6's room, transferred R6 from her recliner with hand over hand on R6's walker to assist to the toilet, no support gait belt utilized during this transfer. On 10/13/22 at 9:15 AM, V17, stated she did not have or use a gait belt for transferring R6 and apologized, as the gait belt is in her car. R6's Fall Occurrence Note, dated 9/29/22 at 7:40 PM, documents, Resident was being assisted to toilet when she became unsteady and was lowered to the floor by a CNA. There were no new interventions listed on this Note to address this fall. R6's Progress note dated 9/29/2022 at 7:40 PM, documented, Writer was called to this resident's room where R6 was observed on the floor of her bathroom sitting on her buttocks. CNA in attendance, who was assisting her. Resident stated she slid and per CNA was lowered to the floor, head was not hit. After assessment, resident's gait belt applied and lifted per staff. R6's, Progress Note, dated 10/1/22 at 12:21 PM, V6, Licensed Practical Nurse, documents Witness fall incident without injuries or hitting head. has no complaints of discomfort vitals stable alert per resident norm. able to make needs known. CNA made aware per writer (V6) this AM (morning) to please put on non -skid socks and to use a gait belt when walking resident to and from the toilet or transferring. will continue to monitor. The facility's policy and procedure, dated 5/2022, entitled, Transfers-Manual Gait Belt and Mechanical Lift, documented, In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use Mechanical lifting devices for lifting and movement of residents and use of gait belt for all physical assist transfers is mandatory for a 1-person transfer. 3. R7's Skilled Medicare Charting, dated 9/28/22, documented R7 is alert to person, does not bear weight and transfers with assistance of two staff. R7's MDS, dated [DATE] documented R7 had dementia. R7's Care Plan dated 8/23/22, documented, R7 requires two person staff assistance with transfers between surfaces due to fatigue, does not document a specific equipment to use. On 9/28/22 at 11:10 AM, V3, Assistant Director of Nursing and V10, CNA both entered R7's room, placed mechanical lift under the wheelchair with support bars opened and locked where R7 was sitting. V3 and V10 then applied mechanical lift support loops to the lifts hooks, did not check the security of the lifting loops, then activated the remote to lift, closed the legs of the lift Neither V3 nor V10 provided stand by support to R7's body, when transferred to her bed. The mechanical lift leg bars were then spread apart under the bed but not locked. As R7 was being lowered down into her bed by V10, the mechanical lift started to roll away from under the bed. V10, then states to V3, This happens when not locked, lock the legs and let's try this again. On 10/10/22 at 10:45 AM, V1, Administrator stated, she would expect the CNAs to be aware of a resident's transfer needs, if unsure, inform either the nurse on schedule or the nurse manager. The facility user for the mechanical lift used to lift R7, dated 1/25/19, documented, Do not move the patient if the sling is not properly connected to the hooks of the hanger bar, check to make sure that the sling is properly connected to the hooks of the hanger bar prior to moving and lock the lift legs prior to lowering with transfer.

Based on record review and interview, the facility failed to provide supervision to prevent a fall for 1 of 4 residents (R26) reviewed for falls in the sample of 38. This failure resulted in R26 falling and sustaining a fracture of her left femoral neck. Findings include: R26's Admission Record, printed on 01/18/2022, documents R26 was admitted on [DATE] with diagnoses of [CONDITION(S)], fractured left clavicle, unsteadiness on feet, personal history of mental and behavioral disorders, and repeated falls. R26's Health Status Note, dated 09/15/2021, documents R26 was attempting to ambulate, and her foot became caught on her call light cord resulting in a fall. R26's Health Status Note, dated 09/15/2021, documents R26 was admitted to the hospital with a right hip fracture related to the fall. R26's Minimum Data Set, dated dated [DATE], documents she requires supervision of one-person physical assist with walking in her room. R26's MDS documents she requires extensive assistance (resident involved in activity, staff provide weight-bearing support) of one-person physical assistance for bed mobility and transfers. R26's MDS documents she is not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and surface to surface transfers. R26's Fall Report, dated 12/12/2021, documented R26 was observed on the floor near bathroom, during dinner by CNA (Certified Nursing Assistant). The report documented Resident was leaning against bathroom door, no injuries. The report documented Resident says she was walking around room and lost her balance. Stated she was not hurt, but she needed to get off her elbow. The Sections on the report for Predisposing Physiological Factors and Situation Factors documented R26 was confused, had gait imbalance and was ambulating without assist. R26's Fall risk assessment, dated 12/14/2021 documents that she was at risk for falls. R26's Unwitnessed Fall report, dated 12/14/2021, documented R26 was observed by CNA partially sitting up at bedside on left side in R26's room. The Report documented she had her shoes on. The report documented I slid down slowly, I was going to get up and get dressed without bothering anybody. The Immediate Action Taken section on the report documented Reminded to always use call light for assistance and reassured that assisting her is what we are here for. The Sections on the report for Predisposing Physiological Factors and Situation Factors documented that R26 was confused, had gait imbalance, impaired memory and was ambulating without assist. R26's Care Plan, initiated date of 07/14/2021, documents (R26) is a risk for falls, confusion, deconditioning, gait/balance problems, incontinence. R26's Care plan Interventions and initiation dates are as follows: 07/14/21 Assistive devices will be within reach of (R26) while they are in the recliner/lift chair; 07/14/2021 be sure (R26's) call light is within reach and encourage her to use it for assistance as needed; 11/20/2021 (R26) is to be in high traffic area when up in wheelchair; 12/12/2021 (R26) is to be up in dining room for all meals-on hold as of 01/05/2022 due to COVID Isolation; and 12/14/2021 room move. R26's Nurse's note, dated 01/06/2022 at 6:38 PM, documented, Certified Nurse Assistant (CNA), V24 CNA, observed resident lying on her left side facing the underside of her bed. (V24, CNA) called Registered Nurse, (staff member), to room to assess resident staff member (Licensed Practical Nurse), arrived as well, and assessed resident. range of motion within normal limits with complaint of left hip pain upon passive range of motions. Resident stated, 'I was going to stand up to pick up my cup that I knocked over. I'll never stand on my own again.' Resident also stated that she hit her head when she fell and complaint of dizziness. V2, Director of Nurses (DON), arrived after CNA, (V24, CNA), and nurse, (staff member), transferred resident to her recliner. Nurse (staff member) requested order from R26's medical doctor to send resident to Regional hospital-order granted. Writer called Emergency Medical Transportation and requested transport to Regional Hospital. Writer contacted (Power of Attorney (POA) to make her aware of situation. POA stated, 'I better get a phone call when she returns from the emergency room .' Writer called in report to (staff member at Regional Hospital). Resident's initial Neurochecks fluctuating-see neuros. R26's History of Present illness from the Regional hospital, dated 01/06/2022, documented, The patient presents following fall. The onset was just prior to arrival. The occurrence was single episode, lost balance. The locations where the incident occurred was at a nursing home. Per nursing home records and patient, she stood up to try to walk and fell landing on her left side. She complains of pain at her left hip and left proximal leg. R26's Radiography report, dated 01/06/2022, documented, Technique: AP (anteroposterior) view of the pelvis with 2 views of the femur. History: Patient fell and has left hip pain. It continues, Findings: There is a right hip arthroplasty. Pelvic rings are intact. No hip dislocation is seen. There is a displaced transcervical fracture of the proximal left femur. No destructive osseous lesion. No soft tissue abnormality. Impression: Displaced left femoral neck fracture. On 01/18/2022 at 03:08 PM, V24, CNA, stated that on 01/06/2022 she was taking another resident to the dining room, when she saw R26 sitting on the side of her bed, V24 stated that she told R26 to wait for her to come back to help her off of bed. V24 stated that when she returned to R26's room after taking the other resident to the dining room, R26 was on the floor, on her left side facing her bed. V24 stated that R26 told her that she was trying to pick up the cup she knocked off of her table. She continued to state that she called for the nurse, and they came immediately and that R26's oxygen level was reading low, so they placed oxygen on her, but it was not the cause of the fall. On 01/19/2022 at 9:30 AM, V2, Director of Nurses stated that she would have expected V24 or another CNA to stay with R26 or assist R26 when she was sitting on the side of the bed. The facility's policy, Fall Prevention Program, dated 11/21/2017, documents, The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based on interview and record review, the facility failed assess residents' weights, monitor and implement timely interventions to address weight loss for 2 of 5 residents (R35, R46) reviewed for weight loss in the sample of 38. This failure resulted in R35 having a significant weight loss of 26 pounds in 6 months. Findings include: 1. R35's Face Sheet, print date of 1/19/22, documents R35 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R35's Weight Summary, with print date of 1/19/22, documents, R35's weight on 6/1/2021 was 145.2 pounds. The facility had no documentation R35's weight was taken in July and August 2021. R35's Weight Summary, with print date of 1/19/22, documents on 9/7/21 was 145.2 pounds. There was no documentation R35's weight was taken/recorded in September or October 2021. R35's Dietary Note, dated 10/26/2021, documents, RD (Registered Dietician) weight note: resident weighed today 10/26/21 and found to be 124.2 pounds. She is down 21 pounds (14.5%) times one month, significant. However, nursing questioning weight change. RD will recommend a reweigh to confirm weight change at this time. There was no documentation, assessments or person-centered interventions implemented to identify/assess or monitor R35's weight loss prior to Dietician assessing R35 on 10/26/21. R35's Weight Summary, with print date of 1/19/22, documented R35's weight on 11/18/21, 23 days after the dietician requested a reweigh, was 124 pounds. This was a 21.2-pound weight loss from September 2021. R35's Dietary Note, dated 11/23/2021, documents, Nutrition Review weights: Noted significant weight loss times 2 months possibly r/t (related to) increased needs and poor appetite. CBW (current body weight)124-pound, diet: General, regular, thin liquids, cut food into small bites SKIN: PU (pressure ulcer) unstageable to Lt (left) hip, review receives RD referral for supplements. Reviewed medications, appetite is poor, PO (oral intake) intake >50% of meals. R35's Weight Summary Report, with print date of 1/19/22, documented R35's weight was 119.2 pounds on 12/3/21 and 111.8 pounds on 1/17/21, indicating a 17.91% weight loss for 6 months. On 1/18/22 at 3:30 PM, V2, Director of Nurses (DON), stated that if the Dietician requests a reweigh the staff should do that in a few days not wait weeks. On 1/19/22 at 2:45 PM, V2 stated that weight should be done monthly. On 1/19/22 at 11:34 AM, V22 Dietician, stated that she was not the dietician at this time but upon review she does see in the progress notes that R35 did have wounds and had a poor appetite. V22 stated that she has started her on supplements and that now that R35 is hospice so there is no plan for weight gain just comfort care. The facility policy Weight, dated 10/17/19, documents, 1. Each resident shall be weighed on admission and at least monthly thereafter, or in accordance with Physician orders or plan of care. 2. Residents identified at nutritional risk may be weighed weekly or biweekly as per physician order or Interdisciplinary Team recommendation. 3. Re-weight should be obtained if there is a difference of 5# or greater (loss or gain) since previous recorded weight. 4. Re-weigh should be taken as soon as possible after unanticipated weight change is noted and prior to calling the physician. 5. Efforts should be made to obtain all weights and re-weights by the 10th of each month. 6. Undesired or unanticipated weight gain/ loss of 5% in 30 days, 7.5% in three months, or 10% in six months shall be reported to the physician, Dietician and/or Dietary Manager as appropriate. Surveyor: [NAME], [NAME] 2. R46's Physician's Order (PO), dated 10/15/2021 documents REGULAR diet, Regular texture, REGULAR consistency. It continues on that on 12/20/2021 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's Dietician Assessment, dated 10/26/2021, documents, Recommend giving 60 (milliliters) Med Pass (twice a day) to help prevent further weight loss. Refer to Registered Dietician as needed. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] R46's Weight and Vital Summary, print date of 01/18/2022, documented R46's weight on 07/27/2021 as 173.6 pounds. It continued to document R46's weight on 08/19/2021 as 169.2 pounds for a 6.2% weight loss in one month. R46's Weight and Vital Summary, dated 01/18/2022, documented R46's weight on 07/27/2021 as 173.6 pounds. It continued to document R46's weight on 11/18/2021 as 156.4 pounds for a 7.8% weight loss in 3 months. R46's Weight and Vital Summary, dated 01/18/2022, documented R46's weight on 07/27/2021 as 173.6 pounds. It continued to document R46's weight on 12/08/2021 as 146.6 pounds for a 18.28% weight loss in 6 months. R46's Care plan, dated 11/5/2021, documents, EATING: the resident requires cueing and assistance to eat. On 01/19/2022 at 11:20 AM, V12, Regional Nurse, stated that she was unable to find the order for the Med Pass or if anything was done with it. On 01/12/2022 at 12:27 PM, R46 was lying in bed with head of bed elevated. V13, Certified Nurse Assistant was feeding R46. After meal was done, R46 only consumed approximately 25% of meal. On 01/19/2022 at 11:40 AM, V22, Dietician, stated that when she is assessing a resident who may have had weight loss, she would look at the resident's meal intake and recommend supplements from the get-go.

Based on observation, interview and record review the facility failed to assess for fall risks, provide supervision and implement progressive interventions to prevent falls for 3 of 3 residents (R1, R2, R3) reviewed for falls in the sample of 11. This failure resulted in R1 falling and sustaining a Femur (long leg) fracture requiring surgical repair, R2 sustaining a laceration to the head requiring 4 staples to close, and R3 sustaining a 1.5-centimeter laceration to head requiring 3 staples. Findings includes: 1. R1's Hospital History and Physical (H&P) report, dated [DATE] prior to facility admission, documented, R1 presented to Emergency Department for change in mental status, excessive falls at R1's residency which resulted in a fractured collarbone. The Hospital H&P documented R1 was unsteady on feet and confused, hallucinating and wandering, to include, a Modified [NAME] Scale, documented moderately severe disability, unable to attend to own bodily needs without assistance and unable to walk unassisted. The H&P documented per R1's family, R1 was falling a lot at home, was unsteady on her feet, confused and hallucinating regarding her deceased husband and son. R1's Facility's Admission Record, printed [DATE], documented R1 was admitted to the facility on [DATE] to South hall, with the following diagnoses: left clavicle fracture from home, admitted for Skilled Therapy, [CONDITION(S)], altered mental status, fracture of unspecified part of Left Clavicle, hallucinations, wandering, and repeated falls. The facility had no Fall Risk Assessment in R1's medical record at R1's which was completed at the time of R1's admission to the facility on [DATE]. On [DATE] at 9:57 AM, V1, Administrator, stated there was not a Fall Risk Assessment completed for R1's admission of [DATE]. V1 stated that due to the facility being bought and under new ownership, she was unable to find fall assessments and (Minimum Data Set) MDS prior to [DATE] when the new ownership took over. R1's Care Plan, initiated on [DATE], documents R1 had impaired cognitive function related to impaired thought processes and Neurological symptoms secondary to [CONDITION(S)]. The Care Plan documented R1 was at risk for falls related to confusion, deconditioning, gait/balance problems and incontinence. The Care Plan Interventions to address falls were as follows: assess clothing for proper fit; assess for [CONDITION(S)] (Urinary Tract Infection) using McGeer's criteria; assistive devices will be within reach of (R1) while in recliner /lift chair; Bathe prior to sleep; Be sure (R1's) call light is within reach and encourage her to use it for assistance as needed; and check labs. The Care Plan did not address if R1 required increased supervision due to her history of falls. R1's, [NAME]-Fall Risk Data Collection form, dated [DATE], documented R1 had a witnessed fall. The form documented it was a witnessed fall. The form did not document the time R1's fall occurred or where it occurred. The form documented R1 had no history of falls and was oriented to person, place, time and situation. This form did not document if R1 sustained any injury. This form did not document any interventions that were to be put into place to prevent future falls. R1's Hospital Record, dated [DATE], documents R1 was present to Emergency Department due to a fall at the facility on [DATE] at 10:49 AM, with an impacted, partially displaced Femoral Neck Fracture of the Right Hip, an immediate surgical candidate for surgery. The hospital record documented She has a history of [CONDITION(S)] and repeated falls. The Hospital Record documented R1 had a Right Hip Hemiarthroplasty to repair the fracture. R1's Care Plan Intervention, dated [DATE], documented Educate (R1) to ensure her feet are not tangled in her call light cord prior to getting up and ambulating. R1's Care Plan Focus, initiated [DATE], documented The resident has limited physical mobility. The Care Plan Interventions, initiated on [DATE], documents (R1) is totally dependent upon staff for ambulation/locomotion. The Care Plan did not address R1's increased need for supervision due to her high risk for fall, cognitive impairment, and recent hip fracture. R1's Minimum Data Set (MDS), dated [DATE], documented, moderate impaired cognition, extensive assistance of two staff for transfers, bed mobility and toilet use. This was the only MDS in R1's medical record for review. R1's, Incident Audit Report, documented R1 fell on [DATE] at 8:32 AM. The Report documented R1 had an unwitnessed fall and was found on the floor at the end of her bed sitting on her buttock by a commode. The Report documented R1 was ambulatory with assistance, and she was confused today. The Report documented R1 had no injury, but an order was obtained to send out to local hospital for evaluation and treatment due to a recent Right Hip Surgery. 2. R2's Admission Record, documented R2 was admitted on [DATE], with the following diagnoses: [CONDITION(S)] Disease, lack of coordination, abnormal posture and seizures. R2's Fall Risk Data Collection, completed while the facility was under different ownership, dated [DATE], documented that R2 was at high risk for falls due to inability to stand without assistance, loss of balance and jerky movements while standing. R2's Care Plan, initiated on [DATE], documents (R2) is at risk for falls. The Care Plan documented the following interventions implemented on [DATE]: Anti-tippers on back of wheelchair; Be sure (R2's) call light is within reach and encourage (R2) to use it for assistance as needed. R2's Progress Notes, documented R2 fell on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. The Notes documented all of these falls were unwitnessed and were due to R2 sliding out of her recliner. R2's Care Plan Interventions related to falls, initiated on [DATE], were as follows: Educate (R2) to call for assistance with transfers; and ensure personal items are within reach. There is no documentation on R2's Care Plan or in R2's Medical record that the facility implemented interventions after R2's falls on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. R2's Progress Note, dated [DATE] documents Call into resident's room by staff CNA (Certified Nurse's Aide) states that when walking past resident's room, they saw resident adjusting herself in her recliner and then slid out of her recliner. The Note documents Will attempt to find a piece of (non-slip pad) to put into recliner to prevent sliding out of chair again. There was no documentation in R2's medical record that a piece of (non-slip pad) was placed in R2's recliner to prevent her from sliding out of her recliner. R2's Progress Note dated [DATE] documents Resident was lowered from recliner footrest to floor due to not following instructions to stand on 2 feet, was holding 1 leg out straight. R2's Care Plan Intervention, dated [DATE] documents Gripper strips on floor in front of recliner to reduce sliding. The Care Plan did not address R2's inability to follow instructions from staff during transfers. R2's Progress Note, dated [DATE], at 10:35 AM documents resident was observed by CNA (name of CNA), on duty, sliding out of Recliner and landing on buttocks on floor. The Note documented resident did not hit her head per CNA who witnessed resident slide out of recliner. The Note documented that staff would continue to monitor. There is no documentation that the facility implemented any progressive intervention to address R2 from sliding out of her recliner after this fall occurred. R2's Progress Note, dated [DATE] documented as a late entry that R2's Physician and family were notified that R2 fell and had injuries/4 staples to head. The Note did not document at what time R2 fell or the circumstances regarding how R2 fell . R2's Hospital Discharge Summary, dated [DATE], documented treatment of 4 staples to a laceration to forehead. R2's Care Plan Interventions, initiated [DATE], documented ensure (R2) has appropriate fitting grip socks when up in wheelchair and recliner. R2's Progress Notes, dated [DATE], documented she was in her room sitting on her buttocks in front of her recliner and stated she slid out of her recliner. R2's Progress Note, dated [DATE] stated she slid out of her recliner and was found on the floor. R2's Progress Note, date [DATE] documented Family to bring in new recliner. R2's Progress Notes dated [DATE] and [DATE] all noted she fell . R2's Care Plan Intervention, dated [DATE] documented Therapy to evaluate for position in new recliner. R2's Care plan Intervention, dated [DATE] documented Place (non-slip pad) in recliner for position aid. This Intervention was implemented almost four months after R2 had an initial fall due to slipping out of her recliner. R2's Interdisciplinary Care Conference, last documentation dated [DATE]. R2's, Fall Risk Assessment, (New facility ownership), dated [DATE], documented R2, At Risk for Falls, was developed for a fall that occurred [DATE], with transport from Emergency Medical System for a laceration to the forehead. A Fall Risk Assessment, dated [DATE], completed for fall [DATE], documented At Risk for Falls. 3. R3's Admission Record documented R3 was admitted on [DATE]. R3's Admission Record documented the following diagnoses: Zygomatic fracture of left side (cheek bone), multiple fractures of ribs on right side, fracture of shaft of right tibia and right fibula, (whole leg), Dementia, [CONDITION(S)] (loss of ability to understand or express speech), abnormal posture, lack of coordination. R3's Care Plan focus, initiated, [DATE], documents (R3) is a risk for fall r/t (related to) in the community with fracture, hx (history) of fall, cognitive decline, unable to bear weight. R3's Care Plan intervention, initiated [DATE], documents Be sure (R3's) call light is within reach and encourage the resident to use it for assistance as needed. If note to be wandering with facial grimacing, lay down elevate, ensuring bed is low and fall mat is in place. R3's Care Plan Intervention, dated [DATE], documents Call Don't Fall sign. R3's Incident Audit Reports, completed at the time of R3's fall occurrence, documented the following R3 fell on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. The facility failed to present Incident Reports for dates of [DATE] and [DATE]. These fall occurrences are un-witnessed with a main location of incident occurring in her room. R3's Incident Audit Report, dated [DATE] documented at 8:35 AM, R3 was found lying on her left side. The Report documented she was found in front of her wheelchair which was in front of her bed and R3 was off the fall mat. R3's Fall Assessment, dated [DATE] documents she has 3 or more falls in the past three months, The Assessment documented that she has balance problems while standing and walking and decreased muscular coordination. The facility failed to implement new interventions to address R3's fall on [DATE] to prevent her future falls. R3's Care Plan was not revised after this fall with new interventions. R3's Minimum Data Set, (MDS) dated [DATE], documented, severely impaired cognition, extensive assistance of two staff, for transfers and toilet use for continuous incontinence of bowel and bladder. R3's Incident Audit Report, dated [DATE], documents on [DATE] at 2:00 PM, R3 was observed by staff attempting to self-transfer from her wheelchair and fell and hit her head on the nightstand in her room. The Report documented R3 sustained a laceration to the back of her head and was transferred by local Emergency Medical System (EMS) to local hospital. R3's emergency room report, dated [DATE] at 5:44PM, documented, R3 was transferred for evaluation and treatment due to a fall with a laceration to the head. R3's laceration was 1.5 centimeters in length requiring 3 staples to the occipital area (scalp). R3's assessment upon entry to emergency room documented a witnessed fall at facility and assisted to floor by staff. R3's Incident Audit Report, dated [DATE], documented an un-witnessed fall on the floor in front of her bed without injuries. There was no documentation in R3's medical record that the facility implemented progressive interventions after R3 fell on [DATE]. R3's Incident Audit Report, dated [DATE], documented, an observed fall in the facility hallway, R3 fell on her left side of face, left shoulder and left hip and hitting her head hard. R3 was transferred by local emergency medical system to hospital for evaluation and treatment with results of a contusion (bump) on left side of head. On [DATE] at 8:00 AM and through 4:00 PM, R3 was observed in her tilt back wheelchair, constantly self-propelling herself throughout the three hallways and foyer areas. R3 was observed to not be in her bed asleep at any time throughout this [DATE] and [DATE] investigation. On [DATE], at 4:30 AM, R3 was propelling self by front entrance door without staff identified to be in their viewing. On [DATE], V1, stated she understands that a Fall Risk Assessment needs to be completed with each fall incident and for each fall, new interventions documented on the Care Plan. V1 stated, she would expect her staff to monitor resident more frequently that are a high risk for falls and requiring assistance from staff. The facility's policy and procedure, entitled, Fall Prevention Program, dated [DATE], documented, To assure the safety of all residents in the facility, including measures which determine the individual needs of each resident by assessing the risk of a fall and implementation of appropriate interventions to provide necessary supervision. To include methods to identify risk factors and Care Plan to addresses each fall and interventions with each fall.

Based on observation, interview and record review, the facility failed to provide adequate wound treatment, timely updates to physician of wound deterioration, and failed to administer antibiotics as ordered by the physician for one of 3 residents (R7) reviewed for wounds in the sample of 13. This resulted in R7's surgical incision becoming infected with [CONDITION(S)] ([CONDITION(S)]) and dehiscing, requiring R7 to undergo surgical debridement of the wound. Findings include: On 11/19/21 at 9:17 AM, V18 (Certified Nursing Assistant/CNA) gave R7 a shower and washed R7's hair. V18 then notified V5 (Licensed Practical Nurse/LPN) that R7 was ready for V5 to change R7's dressing to her right hip. V5 entered the shower room and washed her hands and put on gloves. V5 removed the old dressing that was dated with yesterday's date from the incision. The old dressing had a half dollar sized area of dark red drainage on it. V5 washed her hands and applied a new dressing over the drainage without cleansing the wound first. V5 stated, The order states to put on a dry dressing, so that is what I did. R7's Face Sheet documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Minimum Data Set (MDS) dated [DATE] documents R7 is alert and oriented, and requires extensive assist with bed mobility, transfers and toileting. R7's Care Plan dated 11/11/21 documents R7 is on isolation related to [CONDITION(S)] found in surgical wound on her right hip. Under interventions, it includes, Provide medications as ordered and report any signs and symptoms of adverse reactions to the MD (Medical Doctor) as needed. R7's Hospital Discharge Instructions dated 9/24/21, following hospitalization for fractured hip, document, Comments: Take medications as prescribed and return for worsening symptoms. The Follow-up instructions include: Contact Physician for the following problems: *Notify surgeon with signs and symptoms of infection: temperature greater than 101F, redness, warmth or tenderness around your incision, increased swelling around your incision, drainage or odor from your incision. Under Wound Care, Drain Care or Dressing Instructions, it documents: Discharge Wound Care Instructions: Treatment: Keep splint/dressing dry and intact; Keep [MEDICATION(S)] in place. Okay to shower with [MEDICATION(S)] in place. R7's Treatment Administration Record (TAR) dated 9/1/21 - 9/30/21 documents the order, Surgical incision to right hip - Monitor for s/s (signs and symptoms) of infection every shift until healed. The start date of this order was 9/29/21 even though R7 was readmitted on [DATE]. There was no order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's TAR dated 10/1/21 - 10/31/21 documents the same order to monitor R7's surgical incision for s/s of infection every shift. R7's TAR dated 11/1/21 - 11/30/21 documents a new order on 11/1/21: Cleanse surgical site to right hip with normal saline. Pat dry. Apply [MEDICATION(S)] to wound bed. Cover with dry dressing TID (three times a day) and prn (as needed). According to this TAR, this treatment was not done as ordered on 11/2/21 (missed on night shift), 11/4/21 (only done once), 11/5/21 (not done on that date), 11/6/21 (only done on night shift), 11/7/21 (not done on that date), 11/8/21 (only done once on that date) and 11/9/21 (not done on that date). A new order documented on the TAR with start date of 11/12/21 documents: Surgical Incision to right hip - Monitor for s/s infection. Apply dry dressing daily and prn until healed. R7's Progress Note dated 10/13/21 at 1:02 AM documents, Surgical incision slightly red by area of eschar. Continue to monitor. R7's Progress Note dated 10/13/21 at 3:43 PM documents, Writer called to therapy room to assess surgical site to right hip. Part of scar tissue with scab showing redness/inflammation with area noted to have yellow colored drainage. MD (Medical Doctor) made aware as well as (surgeon's) office. Awaiting further orders at this time. According to R7's TAR there was no treatment being done to R7's surgical incision at this time. There was no documentation of a physician response to the notification of incision showing s/s of infection or further interventions by staff until 6 days later when R7's Progress Note dated 10/19/21 at 9:15 AM documents, Called (primary care physician) and spoke with (staff) and informed them of her right hip incision. It has black scab on the upper half of the incision. The peri-wound is red and warm scant amount of greenish drainage reported by agency night nurse. R7's Progress Note dated 10/19/21 at 2:57 PM documents, Writer called ortho doctor to inform him of resident's incision assessment and to get an antibiotic order. Waiting on a call back. R7's Progress Note dated 10/20/21 at 11:30 AM documents, Writer called ortho doctor again and was sent to a voice mailbox. Writer once again left a message requesting an antibiotic. R7's Progress Note dated 10/21/21 at 3:18 PM documents, Received order to start resident on antibiotic, [MEDICATION(S)] 250 milligrams (mg) by mouth every 6 hours for 5 days for infection in her right hip at surgical site. Order put in and medication pulled from the stat med safe. This order was received 8 days after R7's incision started showing s/s of infection. There were no treatment orders for wound treatment even though it was documented that the wound was draining. R7's Progress Note dated 10/27/21 at 3:07 AM documents, Antibiotic completed for infection to surgical incision without adverse reactions. Site continues to be reddened and slightly warm and has scant pale yellow drainage from center where scab is located. Area cleansed with normal saline and patted dry. R7's Progress Note dated 10/27/21 at 12:02 PM documents, Writer phoned (surgeon's) office related to wound dehiscence (the separation of the edges of a surgical wound) to right hip. Voice mail left. Area showing signs and symptoms of infection. (R7) recently completed round of antibiotics for this reason. Awaiting return call at this time to recommend oral antibiotic/culture and appointment to be seen in office. R7's Progress Note dated 10/28/21 at 2:08 PM documents, Resident's ortho surgeon still has not responded about infection to incision site. (Primary care physician) gave orders to send to the ER (emergency room ). R7's Progress Note dated 11/1/21 at 8:17 PM documents, Writer spoke with daughter again this evening and informed her we are changing treatment to TID (three times a day) due to drainage. MD aware. Daughter happy with this at this time. Also made her aware of us sending referral to wound clinic to set up appointment with wound doctor. R7's Progress Note dated 11/2/21 at 6:44 PM documents, Treatment completed to right hip. 100% yellow slough noted with minimal drainage. Wound measures 2.3 by 1.2. No redness, no warmth, no odor noted. Resident has no nonverbal signs and symptoms of pain and reports no pain at this time. Tolerated procedure well. Update on condition of wound given verbally to resident's daughter and she voiced understanding. Education provided and reinforced regarding hand hygiene and infection control practices. Will continue to monitor. R7's Progress Notes dated 11/2/21 at 7:34 PM documents, Culture results faxed to MD today. R7's Wound Culture Report dated 11/1/21 (collected 10/27/21) documents, under organism, [CONDITION(S)] ([CONDITION(S)]) (Heavy Growth). There was yellow drainage first noted in the incision on 10/13/21 according to R7's Progress Note on that date, but this was the first culture done of the drainage, two weeks after drainage first noted. R7's Progress Note dated 11/9/21 at 9:01 AM documents, Resident out of facility at 8:00 AM appointment with (surgeon) to debride/cleanse incision site to right hip. R7's Progress Note dated 11/9/21 at 4:30 PM documents, Resident back in facility from appointment today with (surgeon). Wound vac in place and suctioning properly. Not to be removed until Wednesday. R7's Order Summary Report dated 11/19/21 with order date range of 10/1/21 to 11/19/21 documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order had the start date as 11/8/21 and no end date listed. R7's printed prescription from her surgeon, dated 11/5/21 documents the order: [MEDICATION(S)]-Pot Clavulanate 500-125 mg (**14**Tablet) Take one Tablet every 12 hours for 7 days, then 1 Tablet daily for 14 days. The paper with this prescription on it had a handwritten note on lower right side that documented, Faxed Noted 11/8/21 indicating this medication was ordered on 11/5/21 but not started until 11/8/21. R7's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This indicated R7 missed 7 doses of her antibiotic in first week it was ordered. Corresponding progress notes dated 11/12/21, 11/13/21, 11/14/21, and 11/15/21 document her antibiotic was not available on those dates. The facility's pharmacy manifest documents R7's [MEDICATION(S)]-Pot Clavulanate 500-125 mg was not delivered until 11/16/21. On 11/23/21 at 2:10 PM, V2 (Director of Nursing/DON) stated any time a nurse is doing a dressing change, they should cleanse the wound before they put on a new dressing over an uncleaned surface. V2 stated that is standards of practice. V2 stated if there is not a specific type of cleanser documented as part of the dressing change the nurse should notify the doctor and get an order. V2 stated she does not know why R7's prescription for her antibiotic was not noted and sent to pharmacy until 11/8/21. V2 stated she does not know why the antibiotic was missed or not available, but they were having some difficulties with pharmacy when the facility first changed ownership on 11/1/21. The facility's policy, Dressing Change - (Clean/Non-Sterile) revised 1/9/18 documents, 14. Clean area/wound with solution specified in order. The facility's policy, Physician-Family Notification-Change in Condition revised 11/13/18, documents: Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as a Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (B) A significant change in the resident's physical, mental or psychological status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.

Based on observation, interview and record review, the facility failed to initiate progressive interventions to prevent additional falls for two of three residents (R10, R11) reviewed for falls in the sample of 13. Findings include: 1. R10's Care Plan dated 9/18/21 documents diagnoses to include: Multiple Fractures of Ribs, Right Side, Unspecified Fracture of the Shaft of Right Tibia, Unspecified Fracture of the Shaft of the Right Fibula, Encounter for Other Aftercare Zygomatic Fracture, Dementia, Other Lack of Coordination, and Unsteadiness on Feet. On 11/12/21 at 9:30 AM, R10 was continuously propelling herself in her wheelchair (w/c) in the halls with one foot, while holding her other leg up. R10 smiles when spoken to and repeats words back when spoken to but does not give appropriate answers. R10's Minimum Data Set (MDS) dated [DATE] documents R10 is moderately cognitively impaired, requires extensive assist with bed mobility, transfers, and eating, and is frequently incontinent of bladder and occasionally incontinent of bowel. It documents R10 has had multiple falls but none with major injury. The MDS documents the wheelchair is R10's primary mode of mobility. R10's Fall Occurrence Reports document R10 has had three falls: #1: 8/14/21 at 3:06 PM: Writer called to resident's room to observe resident on buttocks scooting self to door. Upon investigation, resident was laid down in bed with bed in lowest position and locked. Resident crawled out of bed to her door. Writer asked resident what happened? Resident stated, I want up. Neuro checks initiated immediately and WNL (Within Normal Limits). ROM (Range of Motion) to all BUE (Bilateral Upper Extremities) and BLE (Bilateral Lower Extremities) WNL. No c/o (complaint of) of pain or discomfort noted. Skin assessment completed and skin CDI (clean, dry and intact) with no abnormal findings. Slipper socks noted to be on resident and in good shape. New intervention listed on Fall Occurrence report as: Staff to provide more frequent checks when resident is in bed. MD (Medical Doctor) and POA (Power of Attorney) aware. #2: 11/12/21 at 9:09 AM: Writer was called to resident's room approximately 8:35 AM by staff member. Resident was lying on her left side with her head resting on her left arm. Resident was in front of her w/c which was in front of her bed, but resident was off the fall mat. Resident unable to give a description. No injuries observed. Writer visually assessed resident, obtained vitals, which were stable, did a physical head to toe, with no trauma to head or body noted. Writer laid resident down in bed and performed therapeutic relaxation and massage techniques until resident was asleep. Writer informed all proper parties. R10's Skin - Other Condition Report dated 11/12/21 at 9:09 AM documents: No injuries with fall. No change to care plan. R10's Fall Risk assessment dated [DATE] documents a score of 17, which indicates she is at risk for falls. #3: 11/17/21 at 2:00 PM: Writer called to resident's room to observe resident on the floor on buttocks. According to CNA (Certified Nursing Assistant) she was coming up hallway and looked into resident's room. CNA saw her hit her head on the nightstand. Writer immediately assessed resident with laceration note to back of head. FVS (full vital signs) and neurochecks initiated immediately. Pupils equal and reactive. ROM to all extremities WNL for this resident. 911 and POA called. MD notified. Vital signs as follows: 110/78, 86, 16, 95. Unable to get temp d/t (due to) Ambulance here to transfer resident to (local hospital). Hospital Discharge Report dated 11/17/21 documents R10 had a scalp bruise and laceration that required staples. R10's Care Plan dated 9/18/21 documents: (R10) is at risk for falls related to falls in the community with a fracture. R10's falls on 11/12/21 and 11/17/21 (which required staples to a laceration on the back of R10's head) were not listed on her care plan and there were no progressive interventions after these falls. On 11/23/21 at 9:50 AM, V3 (Care Plan/MDS Coordinator) stated the nurses should update the resident's care plan after they experience a fall, and if they don't, he (V3) should go in and update the care plan. V3 stated he has talked to R10's husband about finding her a more appropriate place to live, but V3 did not initiate any progressive interventions to prevent further falls for R10. 2. R11's Care Plan dated 8/9/21 lists diagnoses as: [CONDITION(S)], Seizures, Major Depressive Disorder, Other Lack of Coordination, and Laceration Without Foreign Body of Other Part of Head. MDS dated [DATE] documents: R11 is severely cognitively impaired. MDS does not document assessment of assist R11 requires for bed mobility, transfers, toileting or eating or bathing. R11's Progress Notes dated 8/4/21 to 11/5/21 document she had falls on the following dates: 8/4/21 found on floor in front of recliner 8/5/21 found on floor - got up to get in w/c 8/12/21 found on floor 9/3/21 slid out of w/c 9/4/21 slid out of bed 9/12/21 lowered to floor 9/17/21 lowered to the floor 9/25/21 on floor 10/2/21 slid out of recliner 10/8/21 lowered to floor 10/21/21 slid out of chair 11/5/21 fell in room; progress note: Resident was in her room standing up to find her phone book. She became unbalanced and fell headfirst onto the floor. CNA was in the room and witnessed the fall. CNA came and got the nurse and resident was assessed. Resident was alert and oriented, denied any pain, good range of motion, her forehead had a laceration that was actively bleeding. Bleeding was controlled by applying pressure. EMS (Emergency Medical Services) called for resident to be taken to ER (emergency room ) for evaluation of laceration. Resident remained alert and oriented, denied pain and had good ROM. Neuro checks were intact and resident was transferred to (local) ER for evaluation and treatment of head laceration. R11's Care Plan dated 7/23/21 documents the Focus: (R11) is at risk for falls. The last time R11's Care Plan was updated with progressive interventions after a fall was 8/9/21. R11 had 10 additional falls after her Fall Care Plan was updated, including her fall on 11/5/21 when she fell and hit her head, requiring an emergency room visit where she received staples to treat a laceration on her forehead. R11's Fall Risk assessment dated [DATE] documents a score of 10 indicating R11 is at risk of falls. R11's Emergency Department Discharge Patient Summary dated 11/5/21 documents, We repaired your scalp laceration with 4 staples. Please follow up with your primary care doctor in 7-10 days to have the staples removed. Please refer to the attached instructions for wound care. Please keep area dry and clean. It is okay to use soap and water, however avoid placing a wound in direct stream of water. The facility's policy, Fall Prevention Program revised on 11/21/17 documents, Purpose: to assure the safety of all residents in the facility, when possible. 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 and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: Care Plan incorporates: Identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, and preventative measures.

Based on interview and record review the facility failed to provide adequate supervision and implement progressive interventions to prevent unsafe ambulation and falls for 1 of 3 residents (R2) reviewed for falls in a sample of 7. This failure resulted in R2 flipping over her (enclosed ambulation device/walker) while ambulating. R2 sustained a laceration to chin, left maxillary sinus fracture, right subdural hematoma, left periorbital hematoma, and left inferior orbital wall fracture requiring hospitalization in the intensive care unit (ICU). Findings include: R2's Quarterly Minimum Data Set ((MDS) dated [DATE], documents R2 was admitted on [DATE], has severely impaired decision making skills - never/rarely made decisions, requires extensive assistance of one to transfer, supervision with one person physical assist to walk in room, supervision with set up help to walk in corridor/ locomotion on unit, and uses a walker and wheelchair for mobility devices. R2's current face sheet documents R2 was admitted on [DATE] and has the following Diagnoses: [REDACTED]. R2's Care Plan with focused problem of falls was initiated on 5/23/2015. R2's Care Plan documents (R2) is risk for falls r/t (related to) Gait/balance problems. History of falls. Alzheimer Disease. Dementia in other Disease Classified, Elsewhere with Behavior Disturbance. Other Abnormalities of Gait and Mobility [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION] Type. R2's Care Plan Intervention, initiated on 9/1/2016 documents (R2) to use (enclosed ambulating device/walker) when ambulating if needed. R2's Care Plan, initiated on 1/17/2017, documents (R2) uses an (enclosed ambulating device/walker) to enhance her mobility in a safe environment. Restraint released tasked for CNAs q (every) 2 h (hours). R2's Care Plan Intervention, initiated 6/23/2017, documents (R2) needs to be in high traffic areas while up in (enclosed ambulating device/walker), d/t (due to) unaware of safety needs. Re-educate caregivers. R2's Care Plan, initiated date 10/3/17, documents When (R2) is restless in bed, place resident up next to nurse's station. R2's Care Plan intervention, initiated on 4/30/2018 documented Staff educated to monitor resident to make sure she is not going into other resident rooms. R2's Progress notes, dated 9/28/2020 at 3:30 PM, document, Health Status Note: Resident was in the tv room and moving around with (R2's) (enclosed ambulating device/walker) when a wheel became tangled in the cord from the blinds. (R2) and (R2's) (enclosed ambulating device/walker) both fell over. No injuries noted at this time. ROM (range of motion) WNL (within normal limits). Resident did c/o (complain of) L (left) hip and L thumb pain. Rcvd (received) order from (physician) to obtain a STAT x-ray of the L hip and thumb. R2's Care Plan Interventions, initiated 9/28/20, documented Ensure window blind cords are not touch floor r/t getting caught in wheels resulting tipping (enclosed ambulation device/walker). On 2/17/21 at 2:34 PM, V2, Director of Nurse's/DON, stated she witnessed R2 fall on 9/28/20. V2 stated R2 was in the TV room. V2 stated there are two entries into the area and V2 was actually just going around to one of the entry ways, when she looked over and saw R2 get caught up in the curtain cord. V2 stated the blinds were up for visitors to see loved ones, so the cord was longer. V2 stated the cord wrapped around the wheel and locked the wheels up. V2 stated R2 went forward and the chair didn't. V2 stated, I immediately ran to (R2) and assessed (R2) and got orders for x-rays. They came back negative. (R2) just ended up with redness and bruising. Facility occurrence report for R2's fall of 1/11/2021 documents Facility was evacuated due to gas odor in hallway. While outside in designated area to meet for evacuation, (R2) became tearful, anxious, restless and attempted to ambulate in (R2's) (enclosed ambulating device/walker) without anyone assisting (R2) to assure (R2) didn't tip over her (enclosed ambulating device/walker) since it was uneven ground. On 2/16/2021 at 2:45 PM, V2 stated on 1/11/2021 they had to evacuate the facility due to strong gas smell. V2 stated there was staff assigned to R2 and this staff person was V10, Social Services. V2 stated somebody else needed V10. V2 stated V10 turned for just a second and R2 tried to get up with walker and flipped the walker on the uneven ground. V2 stated, (V10) was right next to (R2) and just turned (V10's) head for a second. (V10) was doing one on one, but just turned for a second to help somebody else. I told everybody they don't ever leave (R2) unattended, so I was shocked when happened. On 2/17/21 at 2:28 PM, V10, Social Services, stated that on 1/11/2021 the day the facility was evacuated for smell of gas, V10's job was to assist south hall during the evacuation. V10 stated in emergencies situations her assignment is always to assist south hall. V10 stated the day of 1/11/2021 V10 was handing out blankets because it was cold and V10 went to check on R2 and gave R2 a blanket. V10 stated, I gave the blanket to (R2), then I turned and walked a couple steps to another resident. I heard one of the residents say (R2's) name and when I turned around, (R2) was already over in the (enclosed ambulating device/walker) on the ground. V10 stated, I was not assigned to be 1 on 1 with (R2). To be honest not sure who was assigned, there was no staff around (R2) when I was giving (R2) the blanket. (R2) lived on west hall then, they may have gotten (R2) out then went back for more, but I don't want to speak for anybody else. I turned away and only took couple steps, I assume (R2) went off edge in (R2's) specialized walker. I went right to (R2), covered (R2) with a blanket and then nurses were coming out and I yelled for one of them. On 2/17/2021 at 4:00 PM, V1, Administrator, and V2, were asked if staff were assigned to R2 to assure R2 would not get injured outside in the specialized walker in emergency situations such as the evacuation on 1/11/2021. V1 stated, I will be honest with you, no, we didn't have in our emergency plan to assign somebody to (R2). That is something we can look at and see if we need to do for other residents in the future. V1 and V2 were notified that during V10's interview V10 stated she was not assigned to provide one-to-one for R2 during the evacuation. V2 stated, I was told (V10) was the one with (R2) and right next to (R2) when (R2) fell . I was told (V10) had just turned around for a second to help another resident. I was in the building and didn't see what happened. V2 stated when this fall was reviewed our intervention was to assign one staff to R2 from now on if outside. R2's Care Plan was reviewed and there was no revision to R2's care plan after she fell on [DATE] to ensure staff would monitor and provide supervision to R2 if outside. There was no further documentation the facility reassessed R2's (enclosed ambulating device/walker) to ensure she was safe to use. R2's Progress Notes, dated 1/23/2021 at 5:50 PM, document, Health Status Note: Resident fell while in (R2's) (enclosed ambulating device/walker) chair at approx. (approximately 5:30 PM). Resident was hung-up on a doorway and standing sideways in (R2's) chair and it tipped over causing a gash under her chin, bruising, and swelling to L(left) orbital, and a bloody nose. Resident was sent to (the local hospital) as a precaution. POA (power of attorney), D.O.N (Director of Nursing) notified via phone, PCP (Primary Care Physician) notified via fax. All needed documentation sent with. R2's Progress notes, dated 1/23/2021 at 7:16 PM, document a Situation, Background, Assessment, Recommendation (SBAR) The resident is experiencing a change in condition. See SBAR assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is Resident fell on to L (left ) side while in (specialized)-chair. Sustained injuries and sent to (local hospital) ER (emergency room ) for evaluation. Resident has been more restless, wandering, and anxious since being moved to North hall for Isolation precautions r/t (related to) recent hospitalization . Attempts to reassure and redirect have been ineffective today. R2's Hospital Records, dated 1/23/2021, documents, Patient was admitted to (this local hospital) as a category 2 trauma following a fall from wheelchair nursing home. At that time show large periorbital hematoma without loss of consciousness. Workup revealed subdural hematoma. The Hospital History and Physical documented Right subdural hematoma, Left periorbital hematoma, Left maxillary sinus fracture, Left inferior orbital wall fracture. On 2/10/2021 at 9:52 AM, V4, R2's son, stated that V5, Licensed Practical Nurse/LPN, contacted him regarding R2's fall and notified him she would be going to the hospital for evaluation. V4 stated My brother went to the hospital the next day to see (R2) and sent me pictures and texts. My brother said it was horrific how bad (R2) looked and sent me pictures. When I saw the pictures, it was horrific, it looked like (R2) had been in the ring with (a professional boxer). Both eyes were bruised and swollen closed, the bruises were a deep purple, (R2) had 2 fractures of the left eye and a brain bleed. (R2)'s face was a deep purple bruise all over. (R2) spent a couple days in the ICU. V4 stated that R2 had a laceration on chin that had butterfly bandages on it and a bruise that ran from across chin to around mouth to top of mouth and ran to above top of mouth across upper lip. V4 stated R2 had bruises on R2's neck and shoulders. V4 stated that R2's left wrist was swollen badly but x-rays were negative for the wrist. V4 stated he received conflicting information from V2 and V5 if R2's fall had been witnessed. On 2/11/2021 at 4:13 PM, V5 stated that she was the nurse for R2 on January 23, 2021 when R2 fell . V5 stated that one of the residents witnessed R2 fall. V5 stated that she did not see R2 fall. V5 stated that R2 had gone in another resident's room and when turned around to leave room R2's walker got caught in the door and R2 flipped her walker. V5 stated R4 had yelled for staff to help R2. V5 stated that R2 was not located in a high traffic area when she fell . V5 stated R2 was not receiving one-to-one supervision when she fell but staff were aware of R2's whereabouts. V5 stated at the time of the fall, staff was busy with meal trays and feeding other patients and would have been impossible to do 1:1 with R2, staff was too busy going in and out of other patient's rooms. V5 stated that R2 had been wandering, anxious and agitated that night and had to be re-directed several times. V5 stated redirection was not working so they tried to lay R2 down to rest. V5 stated R2's roommate yelled to us R2 was trying to get up, so we got R2 back up. V5 stated that management was aware of R2's increased agitation, increased behaviors and being hard to redirect. V5 stated they had all talked and thought it was due to R2 being in a different hall due to being on quarantine. V5 stated they thought R2 was agitated more due to wanting off of the hall to wander again to R2's old area. V5 stated that V2, DON, was checking with corporate the next day to see if R2 could be moved early from quarantine, but R2 fell before V2 got the answer. On 2/16/21 at 10:27 AM, V6, Certified Nurse's Aide/CNA, stated V6 had worked the night R2 flipped over her (enclosed ambulating device/walker) on 1/23/2021. V6 stated they had put R2 to bed because they thought R2 was hurting and got R2 back up for dinner. V6 stated they thought R2 was more anxious/agitated because R2 was restricted to the hall because R2 was on quarantine. V6 stated she did not witness R2's fall, but it looked like R2 had tried to turn around in R4's room and got stuck in doorway. V6 stated that it depended on R2's level of agitation, if it was too bad, they would try to sit with R2 and calm R2 down, if R2 was just agitated because R2 couldn't go somewhere, they would just redirect. V6 stated, (R2) was just on the main hall. I wouldn't say that is a high traffic area, because everyone is staying in their rooms with COVID and we are in with other residents a lot. V6 stated the only rules when R2 is in the (enclosed ambulation device/walker) is to keep an eye on R2, not one on one though. On 2/16/21 at 10:59 AM, V7, CNA, that R2 had been agitated and anxious the evening of the fall. V7 stated they tried to put R2 in bed before dinner, but R2 wasn't going for it. V7 stated they tried several things to redirect R2. V7 stated, I tried toileting, but nothing worked, (R2) wants what (R2) wants, and that's the way it is. V7 stated (R2) was roaming all over, that is why (R2) has the (enclosed ambulation device/walker). We had done everything. We thought (R2) was going to wear down and calm down. The business of dinner was making (R2) more agitated. I thought once that calmed down, I figured I could toilet (R2) again and (R2) would calm down. When asked if R2 was supposed to be in high traffic area when up in the specialized walker, V7 stated, I don't know what that meant for sure, I don't know what it means in nursing home, staff are in the halls sometimes, so I guess that is high traffic. V7 stated, One of the cognitive residents was able to tell me what happened. They said (R2) was in the door frame of their room, where it is hinged, (R2's) (enclosed ambulation device/walker) got caught in that area. (R2) is like bull in china shop and will just keep shoving the walker and flipped it. I didn't hear (R2) as if in trouble, I just heard the walker flip. On 2/16/2021 at 3:15 PM, R4 stated, (R2) came in the room and wandered around their room. (R2) then turned around to leave and (R2) got the walker all cockeyed trying to get out the door. (R2) got the walker hung up on the door and just kept rocking it really hard, trying to get it to go. Before I could get up to help (R2), (R2) rocked it right over. R4 stated: (R2) would come in our room a lot, (R2) would try to stay in here, but we would just tell (R2) it was a guy's room and (R2) couldn't stay in here and (R2) would eventually leave. On 2/16/2021 at 2:45 PM, V2 stated, The (enclosed ambulation device/walker) is a rectangular walker that goes around resident that we ordered for (R2). V2 stated There is no special rules or expectations for the staff when (R2) is up. Staff know when they see (R2) is lost, or in an area (R2) didn't fit, staff is to redirect (R2). V2 stated Yes, we keep (R2) in high traffic area when up in (enclosed ambulation device/walker), always in hallways, and there is staff always in hallways. V2 stated Well the plan for that time is for the nurse to be in the hall doing med pass at that time when staff is in rooms feeding. The nurse must have been in a room with a resident at the time (R2) fell and in that short time period, (R2) fell . V2 stated they didn't have to keep their eyes on R2 at all times, because the (enclosed ambulation device/walker) allowed R2 to be able to get up and walk all over safely. On 2/16/2021 at 3:14 PM, V2 was asked how staff intervene to ensure R2 is not going into other resident's rooms. V2 stated It is like I said before on high traffic area, the hall usually has staff in it, even if staff are feeding. We have the nurse in the hall working on passing medications. This time was just a fluke that nobody was in the hall at that time. The Facility's Fall Prevention (S.A.F.E.) policy and procedure documents, DEFINITION: The S.A.F.E. program promotes Safety, Awareness, Fall, prevention and Education of both staff and residents. It continues, 3. Residents found to be at high risk for falls are placed on the S.A.F.E. program, and specific Interventions are implemented to meet individual need. Facility policy titled Care Planning - Interdisciplinary Team, dated 1/2017, documents Purpose: 1) To assess each residents strengths, weaknesses, and care needs. 2) To use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and well-being as possible.

[NAME] Based on interview and record review the facility failed to implement effective interventions and provide supervision to prevent falls for 2 of 4 residents (R39, R304) reviewed for falls in the sample of 27. This failure resulted in R39 falling twice and obtaining rib fractures, a pneumothorax, and laceration to her forehead and R304 falling and obtaining a right [MEDICAL CONDITION]. Findings include: 1. R39's Medical Record documents diagnosis, Alzheimer's, [MEDICAL CONDITION], Cerebral Infarction, Cognitive Communication Deficit, Major [MEDICAL CONDITION], Dementia, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION] Type. R39's Minimum Data Set ((MDS) dated [DATE], documents R39 has a severe cognitive impairment. Functional Status Needs extensive assist of 2 persons for transfers. R39's Care Plan documents Focus: Resident is at risk for falls related to Gait/Balance problems. History of falls. Interventions-Anticipate and meet (R39's) needs (initiated 5/23/15). Be sure (R39's) call light is within reach and encourage the resident to use it for assistance as needed (initiated 5/23/19). (R39) needs to be in high traffic areas while up in merry walker, due to unaware of safety needs. Re-educated caregivers (initiated 6/23/17). (R39) is to be at a table where Certified Nurse Aide (CNA) is assisting others to monitor while in dining room chair (initiated 10/19/19). (R39) uses a merry walker to enhance her ability in a safe environment. Restraint release tasked for CNA's every 2 hours (initiated 1/17/17). (R39) will eat all meals in her merry walker at a supervised table (initiated 11/21/19). Eliminate potential hazards such as uneven surfaces, debris or clutter, spills or water on floor (initiated 3/14/16). Ensure (R39) has on appropriate shoes for ambulation and that they are in good condition. To wear soft soled, diabetic, non-skid slipper. (MONTH) replace if worn per family (initiated 8/23/16). When (R39) is in dining room chair, continuous supervision is needed (initiated 1/04/18). When toileting (R39), staff must remain in the bathroom with her (initiated 7/07/18). R39's Fall Investigation/Intervention Final Report dated 10/24/19 for fall on 10/19/19 documents, On 10/19/19 resident was sitting at dining room table during dinner. She stood up and attempted to ambulate without assistance, lost her balance and fell backwards hitting the radiator. Nurse assessed resident and noted complaints of pain on the right side. Medical Doctor (MD) notified and obtained order to send to ER (emergency room ) for evaluation and treatment. X-rays done in ER revealed right rib fractures and small pneumothorax, (collapsed lung), Resident admitted for pain control. R39's Fall Investigation/Intervention Final Report dated 11/27/19 for fall on 11/21/19 documents Resident has [DIAGNOSES REDACTED]. She was seated in dining room chair eating lunch. Once she finished eating, she stood and started to ambulate away from the table. She lost her balance and bumped her forehead on the table. Resident was taken to ER for evaluation and treatment. She received 5 sutures to her right forehead. R39's Hospital records dated 10/19/19, document, Computerized [NAME]ography (CT) scan dated 10/19/19 documents CT of abdomen and pelvis with intravenous (IV) contrast. Findings: There are moderately displaced fractures identified involving the lateral aspect of the ninth and tenth ribs. There are mildly displaced fractures involving the lateral aspect of the right seventh and eighth ribs. There is associated focal pleural thickening involving the inferior and lateral aspect of the right hemithorax adjacent to the fractures. There is a tiny right basilar pneumothorax. On 12/17/19 at 4:14 PM, V10 Certified Nurse Aide (CNA) stated, I don't remember the name of the housekeeper, maybe it was (V11). On 10/19/19, I heard her tell (R39) to sit down and then I heard a loud smack sound and turned around and (R39) was on the floor. I wasn't sitting next to (R39) in the dining room, I was maybe 3 or 4 tables away from her. On 2/18/19 at 10:00 AM, V11 Housekeeper stated, On 10/19/19, (R39) was at the dining room table near the kitchen door, she got up and lost her balance and fell . No staff were sitting with her, they were in the back of the room feeding other residents. On 12/18/19 at 1:45 PM, R14 (R39's roommate) stated, On 11/21/19, I saw (R39) get up by herself and fall, no staff were with her. On, 12/18/19 at 3:27 PM, V2 Director of Nurses, (DON), stated, Staff should have been supervising (R39) in the dining room. The facility Policy and Procedure for Fall Prevention dated 2001, revised (MONTH) 2014, documents in part DEFINITION: The S.[NAME]F.E. program promotes Safety Assessment, Fall prevention and Education of both staff and residents. Program: #3. Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be reported will be reported and potential causal factors identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's plan of care. The staff will review the resident's Fall Risk Data Collection. An update or change to the data collection form would be made only if the resident the resident had previously been identified as low risk. 4. All Occurrences Reports are reviewed at the daily QA (quality assurance) meeting to ensure that an intervention was immediately implemented, added to the plan of care and that the current intervention is appropriate. #5. Occurrences will also be reviewed weekly at the facility Care Management Meeting to ensure, the occurrence report is completely finished and closed, that interventions were implemented timely and to evaluate the outcome of the interventions. Revisions to the plan of care will be done if indicated. Patterns and trends will also be reviewed at that time to enhance the success of the program. 2. R304's Progress Note, dated 12/4/19 04:10, Behavior Note Text: Resident was assisted to bed early last eve, approximately 2100, was found out of bed and sitting on the edge of her recliner at start of this shift. Later was found standing in the middle of her room and assisted to recliner. Resident laughs at staff and says no at each attempt to get her to lie down tonight. Was given crackers, peanut butter, a banana, and a slice of cinnamon raisin bread, as she was able to communicate that she wanted dinner. After eating, still refused bed. The progress note does not document any attempts to toilet R304. R304's Progress Note, dated 12/5/19 at 1:07 AM, documents R304 was in recliner with feet up, sitting on the feet of the recliner, sideways, facing her bed. Found by writer, walking by her room. Assisted resident to bed. Refused [MEDICAL CONDITION] (continuous positive airway pressure, eventually allowed NC (nasal cannula) to stay on. Now, sleeping quietly. The progress note does not document any attempts to toilet R304. R304's Progress Notes, dated 12/5/19 at 5:15 AM, documents the resident is experiencing a change in condition. The change in condition the resident is currently experiencing is Resident found sitting upright, leaned against the wall in front of her toilet. R304's Progress Notes, dated 12/5/19, documents Resident complained of right hip pain and decreased ambulation. New order for hip x-ray. X-ray results showed partially impacted, intertrochanteric fracture. R304 was transferred to the hospital and admitted with [DIAGNOSES REDACTED]. R304's Emergency report information dated 12/05/2019 at 3:58 PM documents admission reason right [MEDICAL CONDITION]. Chief Complaint Patient arrives by emergency medical service from Facility. Patient had a fall around 5:00 AM, had right hip X-ray with [DIAGNOSES REDACTED]. On 12/18/19 at 1:15 PM, V22, R304's son, stated, I had spoken with them about interventions when she first came here. She was at home with us forever. She never used a call light. She would yell out Hey and we would come and help her. I told them with the language barrier and her not understanding how to use the call was there anything else that could be done, an alarm, something. They said they don't have those. She had a blood transfusion that morning and she had energy. On 12/18/19 at 2:00 PM V22 stated My mom told me what happened. She says she got up and needed help to go to the bathroom. The staff came in and couldn't understand her and put her to bed. She then took herself and when she stood from the toilet she lost her balance and fell to the floor and laid there for about 2 hours before the staff came and found her. On 12/18/19 at 3:15 PM, V2 stated, when she first came here she never tried to get up. She had a blood transfusion and I guess decided to get up and get moving. I know she can't really understand us. She has a low cognitive because she doesn't understand the words. Maybe if we used words she understands then it (score) would be better. R304's Care Plan, date 11/09/19, documents (R304) is at risk for falls gait/balance problems, unaware of safety needs. Interventions to anticipate and meet (R304's) needs. Be sure (R304's) call light is within reach and encourage her to use it for assistance as needed. Requires (2) staff participation with transfers. R304's MDS, dated [DATE], documents resident is rarely/never understood with short and long-term memory problems and some difficulty in new situations. Totally dependent on 2 staff for transfers. R304's Fall Risk Data Collection, dated 11/08/19, documents high risk for falls. Fall in the last 90 days. Unable to independently come to a standing position. Decrease in muscle coordination. Confined to a chair and disoriented. R304's Fall Risk Data Collection, dated 12/05/19, documents high risk for falls. Exhibits loss of balance while standing. Strays off the straight path of walking. Requires hands-on assistance to move from place to place. Uses short discontinuous steps and/or shuffling steps. Uses an assistive device, cane, walker, et cetera. B. Based on observation, interview and record review the facility failed to safely transfer residents using a full and partial mechanical lift for 3 of 5 residents (R33, R49, R26) reviewed for transfers in the sample of 27. Findings include: 1. On 12/18/19 at 11:25 AM, V12 Certified Nurse's Aide (CNA) and V13 CNA transferred R26 from her bed to her wheelchair. V12 and V13 attached the sling to the partial mechanical lift, raised her up off the bed and over to the wheelchair and lowered her down into the wheelchair. R39's wheelchair was not locked. On 12/18/19 at 3:35 PM, V2 Director of Nurses (DON) stated, I expect the wheelchair to be locked during a mechanical lift transfer. The User Manual for Stand-Up Patient Lift (not dated) documents in part, Section 1- General Guidelines, Using the Sling, If the patient is in a wheelchair, secure the wheel locks in place to prevent the chair from moving forwards or backwards. Transferring to a Wheelchair WARNING DO NOT place the patient in the wheelchair if the locks are not engaged. The wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport, otherwise injury may result. 2. R33's Care Plan, dated 11/10/19, documents (R33) is at risk for falls. [MEDICAL CONDITION], Unaware of safety needs. R33 has an ADL Self Care Performance Deficit. (R33) to transfer with assist of 2 from bed to wheelchair and wheelchair to bed. R33's MDS, dated [DATE], documents (R33) requires extensive physical assist of 2 staff for transfers. On 12/17/19 at 3:30 PM V16, CNA and V17 CNA, assisted R33 into the bed from the wheelchair. V16 and V17 applied the sling traps to the full body mechanical lift. V16, was operating the controls and started lifting R33 into the air. Once R33 was in the air V17 maneuvered the wheelchair, to the opposite side of the room, leaving R33 unattended and free swinging from the chair to the bed. V16 and V17 did not inspect the mechanical lift equipment to ensure it is working properly and the lift sling for any wear and tear. Mechanical Lift User Instruction manual, dated 2014, documents Warning: recommend that slings be checked regularly and particularly before use for signs of fraying or damage. Do not use slings that are worn or damaged. Warning: important safety information for hazards that might cause serious injury. 3. R49's Care Plan dated 11/19/19 documents (R49) is risk for falls related to medication, arthritis, cognition and immobility. History of falls. R49 requires 2 caregiver assist and the mechanical lift for all transfers. R49's MDS dated [DATE] documents require extensive assist of 2 for transfers. On 12/17/19 at 11:26 AM R49 was incontinent of urine. V8, CNA, transferred R49 from the wheelchair to the toilet with the mechanical lift. V8 and V9, CNA, applied the sling to R49 and placed the straps onto the lift. R49 grabbed a hold of the lift and V8, operating the lift, and V9, standing behind the wheelchair, raised R49 into a standing position. The sling belt loosened, falling and lying loosely on R49's abdomen. V8 transferred R49 from her room to the toilet with V9 remaining in R49's room behind the wheelchair. V8 and V9 did not adjust the belt to assure a snug but comfortable fit on R49. After completion of toileting. V8 applied the sling to R49 and the mechanical lift. V8, operating the machine, assisted R49 into the standing position. The sling belt loosened, falling and lying loosely on R49's abdomen. V8 transferred R49 into her room and lowered into the wheelchair. V8 did not adjust the belt to assure a snug but comfortable fit on R49. On 12/17/19 at 1137 AM, V8 stated, (R49) used to stand and hold on to the rail. She went out to the hospital and she hasn't been able to since return. We use the lift. She does good in the morning but by the evening she can barely stand. On 12/17/19 at 3:15 PM V2, Director of Nursing, stated, I expect them to follow the care plan when transferring residents. I expect both staff to assist in the transfer if the care plan says 2 person transfer. On 12/19/19 at 10:40 AM, V20, CNA, stated, When transferring with 2 people and mechanical lift, 1 staff works the lift and the other guides, directs and physically supports the resident. On 12/19/19 at 10:44 AM V8 stated, One staff maneuvers the lift the other helps guide the resident back to the toilet, chair, bed, where ever they are going. The User Manual for the Standup Patient Lift, (not dated), documents Stand Assist Slings: the belt must be snug, but comfortable on the patient, otherwise the patient can slide out of the sling during transfer, possibly causing injury.

Based on interview and record review, the facility failed to identify, assess, monitor and treat a significant decline in overall condition including mobility, continence and continuing bloody stools for 1 of 3 residents (R4) reviewed for significant change in a sample of 8. This failure resulted in delay in treatment and hospitalization for lower [MEDICAL CONDITION] requiring blood [MEDICAL CONDITION] Findings include: The Electronic Health Record Profile section documented R4 as being a [AGE] year old male admitted to the facility following hospitalization on [DATE]. [DIAGNOSES REDACTED]. The 30 day Minimum Data Set ((MDS) dated [DATE] documents R4 to be cognitively intact with a Brief interview of Mental Status (BIMS) score of 13. The MDS documents R4 to require extensive assist of one person for bed mobility, extensive assist of 2 persons for transfers and ambulation in room/off unit. The MDS also documents R4 to be frequently incontinent of bowel and bladder. The Electronic Health Record (EHR) Progress Notes dated 6/30/18 at 3:22 AM, entered by V11, Licensed Practical Nurse (LPN) documents Upon preparation for bed this shift and performing resident ADL (activities of daily living) was noted that resident was very incontinent and had been this way for some period of time noting that his clothes were very well soiled as well as the pad in his chair. Resident was noted that upon him pulling down his pant that there was a very large amount of blood noted in his underwear with clots, resident inquired about the scheduling of his colonoscopy and writer noted to resident that she was unsure of place or time or if was in fact scheduled due to that last was aware that he had refused to have such treatment. Will continue to monitor and pass on to the next shift as to be sure that new facility is aware prior to move. There is no documentation V18, R4's Physician, or V14, R4's Power of Attorney (POA), was notified of R4's bloody stool. The next entry into the progress note was dated 7/3/18 at 1:38 PM, written by V19 Social Service, and documents Writer attempted to call POA of healthcare concerning how R4 was doing upon d/c (discontinue). Writer will attempt another call in a day or two. There record shows no discharge information. Discharge Logs dated 7/12/18 document R4 was discharged to an Assisted Living facility on 6/30/18. On 7/11/18 at 1:40 PM, V12 Certified Nurse Aide (CNA) stated he was very familiar with R4 and had taken care of him on his first admission. V12 stated R4 was alert and needed assistance with most of his ADL's adding that he was mostly continent during the day asking to go to the bathroom and/or use the urinal when he first arrived but that declined in the prior weeks before discharge. V12 stated R4 usually had his bowel movements on the toilet. V12 stated R4 would let staff know when he'd had an accident of bowel and/or bladder. V12 stated R4 was did not have any energy the last two weeks he was here and had a decline in his ability to ambulate. V12 stated R4 did not want to walk and/or go out of his room. V12 couldn't recall if R4 had any open areas on his coccyx or not but did know he had some redness they put barrier cream on. On 7/11/18 at 2:41 PM, V13 Director of Nurses at the Assisted Living where R4 was discharge to stated they received R4 on 6/30/18 at approximately10:30 AM. V13 stated R4 was almost a different person that he was when they originally assessed him for admission around the first of June, (YEAR). V13 stated he was very pale/ashen and was much weaker than previously noted. V13 stated she received no information from the long term care facility (LTC) on R4 except that he'd been recently treated for [REDACTED]. V13 stated at 2:30 PM, staff reported that R4 had been incontinent of bowel and urine with a large soft stool with blood in it. V13 stated she had not been told he'd had one the early morning of 6/30/18 and would not have admitted him if she had. V13 stated The stool had a large clot, almost the size of my fist in it along with other large clots and mucus. V13 stated the DON, V2, at the facility told her he had been having bloody stools throughout his stay but nothing that was consistent when she called to inquire about R4's condition upon discharge. V13 stated R4 was much lower functioning on admission than what he had been when they initially assessed him. V13 stated home health care was in the building at the time R4 had the bowel movement and they assessed him as well. V13 stated R4 had an area measuring approximately 7cm (centimeters) x (by) 7cm on his coccyx/buttocks that was excoriated with diffuse small open areas present that she was also unaware of. V13 stated they notified R4's physician and sent him to the emergency room for evaluation. V13 stated R4 had since been released to another long term care facility for rehabilitation services. On 7/11/18 at 4:00 PM, R4 stated he had bloody stools throughout his stay at the facility and the nurses were aware. R4 stated he had been told in the past that it was the result of a polyp removal which continued to bleed. R4 stated he told both the nurses and the CNA's when he had bloody stools but nobody seemed to care. R4 stated the last couple of weeks at the facility he could hardly move and he felt weaker the prior two weeks doing nothing but sitting in his chair in his room. V4 stated he did have sores on his bottom which were very sore which the nurses were also aware of but did not treat. On 7/12/18 at 10:00 AM, V11 LPN stated she knew R4 had bloody stools sporadically since the first time he was there and that she had monitored it but determined it was not a consistent thing so she didn't notify the physician. V11 stated R4 had a large decline in the weeks prior to his discharge and was almost totally incontinent and went from stand by assist to transfer to almost needing a partial mechanical lift adding that he required maximum assist of two to move. V11 stated R4 used to be able to get out of bed on his own but no longer could in the couple weeks before his transfer. V11 stated R4 had developed sores which were not opened on his coccyx with excoriation before he left. V11 stated she did pass on the bloody stool information to V6 LPN so she could let the Assisted Living facility know upon transfer. On 7/12/18 at 10:15 AM, V6 LPN stated V11 informed her of the bloody stools describing it as large with clots but that R4 had it before with the physician ordering a colonoscopy only to have R4 refuse to have it done. V6 stated she did not notify R4's physician and/or POA about the bloody stool. V6 stated they thought it could be bleeding from hemorrhoids too. V6 stated she did not inform the Assisted Living of the bloody stools nor was the information included in any discharge papers she sent. V6 stated R4 had a definite overall decline in mobility the few weeks prior to discharge but added that he had also been treated with antibiotics on 6/25/18 for a cough/chest congestion. V6 also confirmed that she failed to document his discharge. V6 stated she could not recall documenting any information on bloody stools. On 7/12/18 at 2:05 PM, V20 Physical Therapist stated she recalled assisting R4 to the bathroom and seeing a very large bloody stool in the toilet with bright red blood noted when she wiped him. V20 stated R4 told her he had hemorrhoids when she asked him about it. V20 stated R4 had declined and required much more care the last few weeks than what assisted living was able to provide wondering why he would be going there since he was bleeding profusely from his bottom. V20 stated she called the day shift nurse into the bathroom and showed her the stool but couldn't remember exactly which day shift nurse it was. V20 did recall having conversations with V6 about R4's rectal bleeding and also stated she discussed it with R4's POA. Progress Notes from admission on 4/23/18 through R4's discharge were reviewed and found to have only one reference to bloody stools and rectal bleeding which was on 6/30/18 at 3:34 AM. Hospital Records dated 6/30/18 document R4 was admitted to the hospital with [REDACTED]. The facility's Significant Condition Change & Notification Policy and Procedure, undated, documents its purpose as To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below: 'bleeding' and 'mobility changes' in part. The policy continues to document When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. Prior to calling the medical practitioner the nurse will complete the SBAR (Situation, background, assessment, recommendation) assessment. The policy continues to document that all significant changes will be recorded on the Communication board and in the resident record with charting including an assessment of the resident's current status as it relates to the change in condition.

Based on interview and record review the facility failed to maintain safe positioning for one of 4 residents (R12) reviewed for accidents in the sample of 16. This failure resulted in R12 sustaining a laceration to her forehead, bilateral nasal bone fractures, bilateral anterior maxillary process fractures, and nasal septal fractures. Findings include: The Facility's Report of Alleged Abuse, dated 10/4/17 at 5:40 AM regarding R12's incident, documents, in part, CNA (Certified Nurses Aide) providing morning care, rolled resident onto back, noted to have a cut to forehead. Resident sent to ER (emergency room ) for evaluation immediately suspended. Investigation to follow. On 10/4/17 at 11:32 AM, Z3, Social Worker from local hospital, faxed R12's emergency room report and x-ray reports from R12's 10/4/17 evaluation. The Trauma Admission H&P (History and Physical) (from local hospital), dated 10/4/17 at 7:25 AM, documents, in part, R12 sustained laceration to her forehead, nasal bone fracture, nasal septum fracture, and anterior maxillary process fracture. A CAT (Computerized Axial Tomography) scan report included with the medical records, dated 10/4/17 at 7:37 AM, confirmed R12 sustained bilateral nasal bone, bilateral maxillary process, and nasal septal fractures. On 10/4/17 at 4:50 PM, E8, CNA, stated that during incontinence care for R12 on 10/4/17 at 5:30 AM, he rolled R12 onto her right side, facing towards him, then rolled two soiled pads under her, then placed two clean pads, a mechanical lift sling, and an adult diaper under the soiled pads. E8 stated he then used one hand to pull soiled pads from under R12, while holding onto the sling with his other hand. E8 stated R12 rolled away from him as he was pulling the wet pads from underneath her, rolling away from him, and hitting her head on the wall. E8 stated that he could not say if he pulled too hard on soiled pads or used too much velocity when turning R12, causing her to roll into the wall. E8 stated he did not have any hand on R12 to keep her centered in the bed. E8 stated that it never takes two staff during bed check to provide care to R12 because R12 only requires one person to turn and position her. R12's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score as 3, indicating severe cognitive impairment. R12's MDS also documents that R12 is totally dependent on two persons' physical assist for bed mobility, which includes how R12 moves to and from lying position, turns side to side, and positions body while in bed. R12's Care Plan documents an intervention, dated 8/16/16, that R12 uses a wing mattress for safety. R12's Care Plan, dated 9/30/15, also documents R12 requires limited to extensive staff participation to reposition and turn in bed. On 10/5/17 at 3:10 PM, E2, Director of Nursing (DON), stated she would expect staff to tuck and roll dirty linens under the resident and then tuck clean linens under the rolled up dirty linens so as dirty linens were removed, the clean linens would be under the resident. E2 stated there should only be one clean pad used if the mechanical lift sling is also being placed under the resident, or the lump of linens would be too large for the resident to roll over. E2 stated the resident should be rolled over the linens completely to avoid being rolled as the linens were removed, and also to avoid shearing injuries. E2 stated staff should make sure the resident is centered in the bed when starting care, and staff should be aware of where resident is at all times when rolling them side to side to prevent resident from rolling too far and hitting their head on the wall. On 10/10/17 at 12:15 PM, Z4, R12's Medical Doctor, stated R12's injuries seemed excessive for what was reported to have happened. Z4 stated he would think, with common sense, a staff would take more care when turning a resident. On 10/5/17 at 1:00 PM, E1, Administrator, stated the facility does not have a specific policy for turning and positioning residents, but provided a policy, Pressure Ulcer Prevention and Healing revised 01/2017, which documents proper positioning and repositioning should be done by utilizing a 30 degree turning rule, using positioning devices such as wedges, as needed. E1 stated this is what they expect staff to follow when turning and repositioning a resident.

Based on observation, interview and record review, the facility failed to monitor, identify, assess and treat for pressure ulcers and failed to turn and reposition timely for 6 of 7 residents (R4, R3, R10, R1, R6, R8) reviewed for pressure ulcers in the sample of 15. This failure resulted in R4 developing multiple avoidable unstageable pressure ulcers from a pressure relieving boot. Findings include: 1) R4's Physician order [REDACTED]. R4's Care Plan dated 12/10/15, documents that R4 has pressure ulcer to left lower leg related to immobility and incontinence. R4's Care Plan documents that interventions are to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing. Measure length, width and depth where possible. R4's Care Plan Intervention, initiation date of 12/16/15, documents Float heels while in bed as tolerated. R4's Care Plan, dated 12/22/15 documents R4 has Diabetes Mellitus with intervention Inspect feet daily for open areas, sores, pressure areas, blisters, [MEDICAL CONDITION] or redness. R4's Care Plans did not address the use of a pressure releiving boot. R4's physician's orders [REDACTED]. The only Braden Scale in R4's medical record documenting pressure ulcer risk dated 12/31/15, documents a score of 12. (10-12 is moderate risk). The facility's Weekly Pressure Ulcer Report dated 1/11/16, documnents that R4 was admitted with a pressure sore on 12/9/15 to the left outer leg stage 2, measuring 3.0 centimeters (cm) X (by) 2.0 cm X 0.3 cm. On 1/20/2016, at 10:35 AM, R4 was at the end of the hall near the nurse's station in her geriatic chair. She was wearing a plastic type boot on her left foot/leg. At 11:35 AM, she was in the dining room and continued to wear the hard plastic boot. At 11:45 AM, she continued to wear the boot. The facility's Skin Check Weekly & PRN form, effective date 1/21/16 at 12:00 PM, documents No new changes this week. The form documented there were no new areas of skin impairment. This form was signed by E19, Registered Nurse (RN). On 1/21/16 at 1:35 P.M., R4 was lying in bed. R4 was wearing the boot on her left leg and her heels were not floated off the mattress. E19, Registered Nurse (RN) took boot off R4's left leg. The boot was made of hard plastic and had straps which extended around th bottom of the foot. E2, Director of Nursing (DON) and E3 Assistant Director of Nursing (ADON) were present. E19 removed dressing from R4's left leg. E19 stated that she had not seen R4's pressure areas. R4 had an area to the top of left foot that had not been identified the top layer of skin was gone, but scabbed over, E19 stated she would stage the pressure ulcer at a stage 1, there was 2 areas on the bottom of R4's foot that were black with echar. E3 stated that she was not aware that R4 had the areas and stated they looked necrotic. E3 stated that should would expect nursing staff to identify on the weekly skin assessment. The facility Weekly Pressure Ulcer Report dated 1/21/16 documents that R4 has a pressure sore left outer leg 2.8 cm X 2.1 cm X 0.3 cm that R4 was admitted with on 12/9/16. The report documented a newly acquired pressure ulcer to R4's left inner foot meauring 1.0 cm X 0.4 cm unstagable with 100% eschar, a newly acquired unstageable pressure ulcer to her left top of foot measuring 2.5 cm X 1.0 cm with 50% eschar, a newly acquired unstageable pressure ulcer to R4's middle toe measuring 1.5 cm X 1.0 cm with 100% eschar, a newly acquired unstageable pressure ulcer on R4's left outer foot back measuring 2.0 cm X 3.0 cm with 100 % eschar and a newly acquired Stage II on R4's Left middle outer area of the foot measuring 2.5 cm X 0.8 cm X 0.1 cm. The facility progress notes 1/10/16-1/21/16 did not document any assessment for R4's pressure areas. The facility's Monthly 100% Skin Audit dated January 2016 documents no new areas. The facility Skin Check Weekly and PRN dated 1/10/16, and 1/17/16 documents no new areas. On 1/22/16 at 9:15 A.M. Z1, R4's Physician, was interviewed per telephone. Z1 stated that she would expect nursing staff to identify any new pressure areas on R4 when they are to be doing dressing changes daily. Z1 stated that she had not been made aware of any additonal pressure areas on R4 until her office had recieved a fax on her day off on 1/21/16 reporting 4 new pressure areas. Z1 stated she was not provided any measurements of the areas. Z1 stated she was not aware R4 was wearing any type of boot on her left leg/foot. On 1/22/16 at 9:15 A.M. E2 stated that she would expect nursing staff to have identified any new pressure areas on R4's left foot when doing scheduled daily dressing changes. E2 stated that she was aware that R4's heels were not floated on 1/21/16 during observation of skin check. E2 stated that the R4 has a pressure ulcer on R great toe that is a stage 1, A stage 1 pressure ulcer on the top of R foot, A stage 2 pressure ulcer on the top of Left foot. E1 DON stated they were not refuting that R4 had black necrotic areas on the bottom of her Left foot. E2 stated that the facility had identified that the necrotic areas on the left foot were caused from the boot, because the areas were at the area of the straps and from the boot straps being too tight. E2 stated the boot had been removed. On 1/22/16 at 12:35 P.M., E3 ADON stated that she does a monthly head to toe assessment facility wide. E3 stated that she would have done the January asssessment on 1/10/16. The facility's Policy Pressure Ulcers/Skin Breakdown-Clinical Protocol dated February 2014, documents the the nursing staff and attending physician will assess and document and individual's significant risk factors for developing pressure sores: for example, immobility, recent weight loss and a history of pressure ulcers. The policy documents the nurse shall describe and document/report a full assessment of pressure sore including location, stage, width and depth, pressence of exudates or necrotic tissue, pain assessment, resident's mobility status, current treatment, including support surfaces. The facility's Policy Pressure Ulcer Prevention revised August 2015, documents that a standardized pressure ulcer risk assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcers. This assessment will be completed upon admission, weekly X 4 weeks, quarterly and when a significant change in the residents conditon is noted. The policy documents interventions for the prevention of pressure ulcers will be individualized to meet the specific needs of the resident. Interventions will consider the assessment of risk and skin condition of the resident. The policy documents that for residents identified as moderate risk; individualized turning and repositioning , toileting, incontinent vare and hydration per individual resident needs, restorative mobility programming as needed, protect heel, float if possible, manage nutrition, RD to assess as needed for additional interventions, monitor weight and food consumption, manage friction and shear, by utilizing positioning and repositioning. The policy documents that assessment and documentation includes weekly skin checks for all residents, monthly skin checks during the 100% Monthly Skin Audit for all residents, daily observation of skin and identification during routine care given by CNA's, any findings will by documented in Point of Care by the CNA which generates an alert for the Licensed Nurse for assessment and further follow up. 2. The MDS dated [DATE] documents R10 as requiring extensive assist of one staff for bed mobility and transfers. The MDS documents R10 is frequently incontinent of bladder and occasionally incontinent of bowel. R10's Care Plan dated 10/6/15 documents him to be at risk for skin breakdown with directions to follow facility policy on skin breakdown prevention in part. On 1/20/16 at 2:00 PM, R10 transferred to bed by E6, CNA. He was left laying crooked on his back. R10 was observed at 15-20 minute intervals to remain in that same position until 4:20 PM when the observation ended. He was still laying crooked in bed on his back. 3. R3's POS, dated 01/01/16, documented R3 had the following diagnoses, in part as, [MEDICAL CONDITION] with Left Sided [MEDICAL CONDITION] and Pressure Ulcer of the Sacral area Stage IV. R3's POS, dated 8/24/15 documented No laying flat. Turn every two hours on sides. R3's PO, dated 12/29/15 documented R3's pressure ulcer treatment was to Cleanse wound to coccyx with wound cleanser. Hydrogel/Foam dressing every three days on night shift and as needed. On 01/19/16, R3 remained in her high back wheelchair without benefit of repositioning from 11:00 AM to 1:10 PM, based on 15 to 30 minutes or less observation intervals. At 1:00 PM, R3 was sitting in her wheelchair in her room crying. R3 stated that she wanted to go to bed because her back and bottom hurt. At 1:10 PM, E15 and E16, CNAs, transferred R3 from her wheelchair and provided R3 incontinent care. When R3 was rolled to the side to remove the mechanical lift sling, R3's buttocks were deeply creased and reddened with areas of macerated skin near the crease of the buttocks. Her dressing near the sacral area was hanging off the left side, dated 01/17/16. E15 stated that R3 had been up since before breakfast (7:00 AM) in the wheelchair and had not been toileted or removed for repositioning. R3's Treatment Administration Record (TAR), dated January, 2016 documented R3's coccyx dressing was not changed until the nightshift on 01/19/16. The Care Plan, dated 01/01/16, documented R3 was identified to have a Stage IV Pressure Ulcer on the coccyx upon admission to the facility. The Care Plan documented that staff were to monitor dressing every shift to ensure it is intact and adhering and to report loose dressing to treatment nurse. It also documents that R3 is to be turned and repositioned at least every two hours or more often as needed or requested. The MDS, dated [DATE], documented R3 moderately cognitively impaired and required total assistance of at least two staff for bed mobility, transfers, toileting, hygiene and bathing. 4. On 1/19/16, from 9:15 AM until11:50 AM, R1 was on lying on her left side in bed with both heels laying directly on a pillow, without the benefit of turning and repositioning, based on 15 minute or less observation intervals. At 11:50 AM, E17 CNA, turned R1 onto R1's back. R1's Minimum Date Set ((MDS) dated [DATE] documents that R1 requires total assistance for bed mobility. R1's Care plan dated 10/24/15 documents that R1 is to be turned and repositioned every 1 hour and as needed. R1's Weekly Pressure Ulcer Report dated 1/4/16, documents that R1 has stage three pressure ulcers on; left great toe (facility acquired on 11/11/15), left outer foot (facility acquired on 12/7/15), and right outer foot (facility acquired on 11/11/15) and receives daily dressing changes. The facility's policy titled Pressure Ulcer Prevention (revised August 2015) documents that, Positioning the resident on an existing pressure ulcer should be avoided .For residents with a Stage one or above pressure ulcer, an every two hour repositioning schedule is inadequate .Resident whom are in bed should be on a at least every two hour reposition schedule On 1/20/16 at 3:00 PM, E2 stated that all residents who require assistance with turning and repositioning should be turned and repositioned at least every 2 hours. 5. On 1/19/16 from 9:15 AM until 11:45 AM, R6 was on lying on R6's left side in bed, without the benefit of turning and repositioning, based on 15 minute or less observation intervals. R6's MDS dated [DATE] documents that R6 requires total assistance for bed mobility and is at risk for pressure ulcers. R6's Care plan dated 11/19/15 documents that R6 is to be turned and repositioned every 2 hours and as needed and has a history of pressure ulcers. 6. On 1/19/16 from 9:15 AM until11:45 AM, R8 was in bed lying on R8's back, without the benefit of turning and repositioning, based on 15 minute or less observation intervals. R8's MDS dated [DATE] documents that R8 is totally dependant for bed mobility and is at risk for pressure ulcers. R8's Care Plan dated 1/5/16 documents that R8 is to be turned and repositioned with extensive assist and is at risk for pressure ulcers.

Based on record review and interview, the facility failed to use safe transfer techniques to prevent falls for 1 of 8 residents (R6) reviewed for falls in a sample of 15. This failure resulted R6 falling and sustaining a left leg fracture and laceration. The findings include: R6's Minimum Data Sets ((MDS) dated [DATE] documents that R6 is totally dependent for transfers with assist of 2 staff members. R6's Care Plan dated 12/31/15 documents that R6 is at risk for falls and is to be transferred per mechanical lift. The Facility's Occurrence Report, dated 1/25/15, documents that E12 Certified Nurse's Aide (CNA) attempted to perform a mechanical lift transfer without assistance on R6 on 1/25/15 at 1:36 PM. The report documents that the mechanical lift tipped over, E12 lowered R6 to the floor hitting R6's leg on a wheelchair. Report documents that E12 reported the mechanical lift may have caught on the floor mat. Subsequently R6 obtained a left leg laceration and complained of left leg pain due to the fall. R6 was sent to an emergency department and subsequently was diagnosed with [REDACTED]. Emergency Department report dated 1/26/15 documents that Patient (R6) presents from nursing home via EMS (Emergency Medical Services) after a fall, patient (R6) has severe skin tear below the knee level (left)-bleeding controlled .Patient has left femoral neck fracture .Since (R6) is non-ambulatory, (R6) will not require surgical interventions .sutured laceration .pain control .discharge back to extended care facility. The facility's policy titled (Mechanical) Lift (8/10/01) documents that Clear your path of obstacle or hazards before you move the resident. On 1/21/16 at 9:30 AM E3, Assistant Director of Nursing, stated, (R6's) fall was due to human error. (E12) attempted a mechanical transfer without assistance. Two staff members are to do mechanical transfers. On 1/22/16 at 9:30 AM, E18, CNA stated, We are required to do a mechanical lift with two staff members.

Based on record review and interview the facility failed to notify the Physician of developing pressure ulcers in a timely manner and of discontinuing an extension brace for 1 of 7 residents (R2) reviewed for pressure ulcers and braces in a sample of 15. This failure resulted in no timely treatment of [REDACTED]. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R2 as a [AGE] year old male originally admitted to the facility on [DATE] with bilateral hip contractures, Muscle Weakness and [MEDICAL CONDITION] among others. The MDS identifies no cognitive impairment. According to a Hospital History and Physical Report dated 7/29/13, R2 was admitted to the hospital on [DATE] for a left total hip arthroplasty and bilateral hamstring adductor release and returned to the facility on [DATE]. Discharge instructions from the hospital included orders among others for Hinged knee braces locked in a comfortable amount of extension, wear according to included instruction sheet. According to Admission Notes dated 7/29/13, R2 had a pressure ulcer on his heel on admission but no other open areas identified except the suture lines. On 8/6/13 at 12:24pm, a Physical Therapy (PT) note identifies R2 to have pressure ulcers and documents "Nursing notified of open areas on patient beneath brace and notified of sutures behind B (bilateral) knees and groin." On 8/7/13 at 12:25pm, PT again documents "Discussed with nursing staff pressure areas from braces." On 8/8/13 at 12:27pm, PT documents "two additional pressure noted on this session from previous session. Director of Nurses (DON - E29) at that time was notified and observed areas of concern." Progress Notes dated from 8/6/13 through 8/8/13 fail to document the pressure ulcers or any Physician notification. A Weekly Pressure Ulcer assessment dated [DATE] completed by E24, DON at that time identified right shin ulcers acquired in house measuring 3.5cm long x 1.5 cm wide with no depth, SDTI (suspected deep tissue injury) with small amount of exudate and 100% [MEDICATION NAME] tissue. No physician notification occurred of this area until the first treatment was ordered on [DATE]. Weekly Pressure Ulcers assessment done on this area three days later on 8/26/13 by E3, Assistant Director of Nursing (ADON) and current wound nurse identifies a decline with a much larger area measuring 9.5cm x 3 stage III, color red, small amount of exudate bloody, clear, no odor and no undermining. Telephone orders (TO) dated 8/23/13 read "Apply [MEDICATION NAME], ABD, wrap with Kerlix to bilateral shins dly (daily) every night shift for open areas from bilateral braces." Treatment Administration Record (TAR) for August confirm no treatments were documented as done until 8/23/13. On 9/4/13, R2's skin was assessed as stage II with eschar and on 9/11/13, the wound report completed by E3 documents the shin area at stage III increasing to 9.0 x 3.0 with 60% necrotic tissue. A TO dated 8/26/13 written by E3 attributes the bilateral shin pressure ulcers to the extension braces. On 8/13/13 at 2:43am, the nurse documents "Assisted in refastening braces, noted large fluid filled blister on left outer leg above the ankle, while tightening the straps. Blister measures 3.7 x 2.6 and red area around blister measures 6.4 x 2.6. [MEDICATION NAME] dressing applied to cushion blister. Resident advised to leave braces alone. Note left for physical therapy notifying them of the need to check the braces in morning." There is no documentation in the Progress notes that the Physician was notified of this area until 8/27/13 when a TO was written for "Cleanse with wound cleanser, dry, skin prep to wound edges and apply [MEDICATION NAME] to wound beds" by E6, Licensed Practical Nurse (LPN). Weekly Pressure Ulcer Assessment sheets dated 8/26/13 completed by E3 for this area on R2's left lower leg is documented as "Unknown". Measurements completed on 8/29/13 by E3 identify this area with eschar at 5.5cm x 2cm. According to a TO dated 8/20/13, R2's brace wear time was reduced from "at all times" on 7/31/13 to "four hours twice a day for a total of eight hours, may have braces off the rest of the time every day and evening shift for Post-Op therapy to BLE (Bilateral Lower Extremities." Treatment records for August and September show day and night shift initialing the 4 hours schedule until 9/20/13. Documentation prior to 9/20/12 documents that R2 did not always wear his braces for at least 4 hours twice daily as on 9/12/13 at 11:30am, R2 was documented by E7 as complaining of increase spasms to his right side and that he had to sit and hold his body with tension braces. On 9/14/13 at 13:19 (1:19pm), E27 LPN documents that R2 "removed leg braces himself after only wearing for a little over 3 hours." On 9/15/13 at 13:30 (1:30pm), R2 was documented by E27 again as only wearing his braces for 1 hour and 45 minutes on day shift. There is no indication the nurses notified the Physician of R2's refusal to wear the braces for 4 hour periods of time twice a day during this time. On 9/18/13 at 11:09am, E7, LPN, documents "talked with therapy today and they stated that the right brace is still causing some skin issues to the calf/shin area, wanted to know if it is still necessay for resident to wear it on the right leg, called and left message wtih Z1's office, waiting a call back." Treatment records for September show R2 no longer wearing the braces after 9/20/13. physician's orders [REDACTED].. On 11/15/13 at 4:43pm, Z3, Nurse of Z1 (Orthopedic Physician) stated that Z1 was unaware that R2 was no longer wearing his braces and had a call from E3 the day before requesting a back dated "DC" (discontinue) order for R2's extension braces ASAP (As soon as possible.) Z3 stated the office had given an order to decrease use but never to discontinue the braces as his mobility would decline. Z3 stated R2 was suppose to have his other hip done and that no further surgery was planned for his knees but with the discontinuation of the braces, it is unclear what surgery will be appropriate in the future. Z3 stated R2 had plans of walking again and returning home. Interview with E9, Corporate Nurse, on 11/19/13 at 11:43am, R2's extension braces were discontinued due to his multiple pressure ulcers and lack of healing. E9 stated she came in a saw the ulcer and determined that they would not heal unless the braces were discontinued and gave instructions to the nurses not to use them until the pressure ulcers healed. E9 stated she assumed the DON (Director of Nurses), E29, at the time, wrote an order or informed the Physician but stated she did not check to make sure. No order was provided by the facility. On 11/19/13 at 11:15am, R2 confirmed E9's discontinuing order of his braces and stated in interview that the "Head nurse came down and looked at the sores and said "that's it, no more." and he hasn't worn the braces since. On 11/15/13 at 8:50am, E28 Physical Therapist (PT) and E30 Certified Occupational Therapy Assistant (COTA) confirmed that the braces were discontinued due to pressure ulcers developing under the braces and that both therapies were discontinued in October when he developed a [MEDICAL CONDITION]. E28 stated he will not be able to walk if the braces are not used. E28 stated when R2 first came into therapy following his surgery, he was ambulating 5-10 feet, was highly motivated and cooperative.

Based on interviews and record review, the facility neglected to prevent/assess and treat avoidable pressure ulcers from developing under extension braces for 1 of 1 resident (R2) reviewed for extension braces in the sample of 15. This failure resulted in R2 developing multiple avoidable pressure ulcers that went untreated for [REDACTED]. The pressure ulcer decline resulted in R2's discontinuation of leg braces which resulted in a major decline in ambulation. Findings include: The Minimum Data Set ((MDS) dated [DATE] identifies R2 as a [AGE] year old male originally admitted to the facility on [DATE] with bilateral hip contractures, Muscle Weakness and [MEDICAL CONDITION] among others. The MDS identifies no cognitive impairment. According to a Hospital History and Physical Report dated 7/29/13, R2 was admitted to the hospital on [DATE] for a left total hip arthroplasty and bilateral hamstring adductor release and returned to the facility on [DATE]. Discharge instructions from the hospital include orders Hinged knee braces locked in a comfortable amount of extension and wear according to included instruction sheet among others According to Admission Notes, R2 had a pressure ulcer on his heel on admission but no other open areas identified except the suture lines. On 8/6/13 at 12:24pm, a Physical Therapy (PT) note identifies R2 to have pressure ulcers and documents "Nursing notified of open areas on patient beneath brace and notified of sutures behind B (bilateral) knees and groin." On 8/7/13 at 12:25pm, PT again documents "Discussed with nursing staff pressure areas from braces." On 8/8/13 at 12:27pm, PT documents "two additional pressure noted on this session from previous session. E29 Former Director of Nurses (DON) at that time was notified and observed areas of concern." Progress Notes dated from 8/6/13 through 8/8/13 do not reflect the pressure ulcers or any Physician notification. A Weekly Pressure Ulcer assessment dated [DATE] completed by E24, DON at that time identified right shin ulcers acquired in house measuring 3.5cm long x 1.5 cm wide with no depth, SDTI (suspected deep tissue injury) with small amount of exudate and 100% [MEDICATION NAME] tissue. No physician notification occurred of this area until a treatment was ordered on [DATE]. Weekly Pressure Ulcers assessment done on this area three days later on 8/26/13 by E3, Assistant Director of Nursing (ADON) and current wound nurse identifies a decline with a much larger area measuring 9.5cm x 3 stage III, color red, small amount of exudate bloody, clear, no odor and no undermining. Telephone orders (TO) dated 8/23/13 read "Apply [MEDICATION NAME], ABD, wrap with Kerlix to bilateral shins dly (daily) every night shift for open areas from bilateral braces." Treatment Administration Record (TAR) for August confirm no treatments were documented as done until 8/23/13. On 9/4/13, R2's skin was assessed as stage II with eschar and on 9/11/13, the wound report completed by E3 documents the shin area at stage III increasing to 9.0 x 3.0 with 60% necrotic tissue. A TO dated 8/26/13 written by E3 attributes the bilateral shin pressure ulcers to the extension braces. On 8/13/13 at 2:43am, the nurse documents "Assisted in refastening braces, noted large fluid filled blister on left outer leg above the ankle, while tightening the straps. Blister measures 3.7 x 2.6 and red area around blister measures 6.4 x 2.6. [MEDICATION NAME] dressing applied to cushion blister. Resident advised to leave braces alone. Note left for physical therapy notifying them of the need to check the braces in morning." There is no Physician notification and/or treaetment order in the Progress Notes for this area until 8/27/13 when a TO was written for "Cleanse with wound cleanser, dry, skin prep to wound edges and apply [MEDICATION NAME] to wound beds. Weekly Pressure Ulcer Assessment sheets dated 8/26/13 completed by E3 for this area on R2's left lower leg is documented as "Unknown". Measurements completed on 8/29/13 by E3 identify this area with eschar at 5.5cm x 2cm. Attached to the Hospital's discharge orders were instructions for the extension braces entitled "Orthopedic Dysfunction, Treatment and Use" for the brace. The "Initial Treatment: 1 to 14 days" documents "For best results, it is important to PRECONDITION THE JOINT with the orthoses by applying Untraflex stress therapy gradually. Please utilize the following procedure. It continues with the initial fitting instructions which occurred at the hospital prior to R2's discharge to the facility. It continues with "1st Day - tension set at "2" and wear for 2 hours. Instructions continue with 2nd day - tension set at "2" and wear for 4 hours, 3rd day - tension set at "2" and wear for 8 hours then "Continue tension setting "2" for 8 hours/day cannot be attained, for tolerance reasons, back tension by "one" setting and "If ROM (Range of Motion) plateaus, progress "one" tension setting and repeat steps 2 thru 5." Progress Notes dated 7/29/13 at 20:53 by E10 Licensed Practical Nurse (LPN) documents R2's readmission from the hospital and that he had Hinged Knee braces in place at the time. There is no documentation either in the progress notes and/or the TAR that R2's braces were applied per schedule and no order either with the discharge orders or physician's orders [REDACTED]. On 7/31/13, a TO was obtained for R2 to "wear braces at all times." On 8/20/13, R2's brace schedule was reduced from "at all times" to "four hours twice a day for a total of eight hours, may have braces off the rest of the time every day and evening shift for Post-Op therapy to BLE (Bilateral Lower Extremities." On 9/18/13 at 11:09am, E7, RN, documents "talked with therapy today and they stated that the right brace is still causing some skin issues to the calf/shin area, wanted to know if it is still necessay for resident to wear it on the right leg, called and left message wtih Z1's office, waiting a call back." Treatment records for September 2013 document R2 no longer was wearing the braces after 9/20/13. physician's orders [REDACTED]. On 11/20/13 at 2:25pm, E10, Admitting Nurse, confirmed she did receive the discharge orders with brace schedule from the hospital when R2 returned but that he had an order for [REDACTED]. On 11/15/13 at 4:43pm, Z3, Nurse of Z1 (Orthopedic Physician) stated that Z1 was unaware that R2 was no longer wearing his braces and had a call from E3 the day before requesting a back dated "DC" (discontinue) order for R2's extension braces ASAP (As soon as possible.) Z3 stated the office had given an order to decrease use but never to discontinue the braces as his mobility would decline. Z3 stated R2 was suppose to have his other hip done and that no further surgery was planned for his knees but with the discontinuation of the braces, it is unclear what surgery will be appropriate in the future. Z3 stated R2 had plans of walking again and returning home. According to interview with E9, Corporate Nurse on 11/19/13 at 11:43am, R2's extension braces were discontinued due to his multiple pressure ulcers and lack of healing. E9 stated she came in a saw the ulcer and determined that they would not heal unless the braces were discontinued and gave instructions to the nurses not to use them until the pressure ulcers healed. E9 stated she assumed that E29 Former Director of Nurses, at the time, wrote an order or informed the Physician but stated she did not check to make sure. No order was provided by the facility. On 11/19/13 at 11:15am, R2 confirmed E9's discontinuing order of his braces and stated in interview that the "Head nurse came down and looked at the sores and said "that's it, no more." and he hasn't worn the braces since. On 11/15/13 at 8:50am, E28, Physical Therapist (PT) and E30, Certified Occupational Therapy Assistant (COTA) confirmed that the braces were discontinued due to pressure ulcers developing under the braces and that both therapies were discontinued in October when he developed a [MEDICAL CONDITION]. E28 stated he will not be able to walk if the braces are not used. E28 stated when R2 first came into therapy following his surgery, he was ambulating 5-10 feet, was highly motivated and cooperative. On 11/19/13 at 1:15pm, Z4, Clinic Staff, stated he originally fitted R2 with the braces in the hospital and that the hospital failed to follow his instructions in having the nursing home call him after discharge to set up an appointment to come out and provide training. Z4 stated R2's braces were never intended to be used 24 hours a day as those particular braces are very aggressive. Z4 stated he doesn't understand why Z1 would order them to be on at all times and that the schedule sent back to the facility from the hospital clearly included that schedule. Z4 confirmed that he did come to the facility on [DATE] and provide training and inservice to the therapist but couldn't recall if any nurses were present. Z4 stated that the day he came to the facility, was the day the therapist "found the instructions and the tool." Z4 also stated that the manufacturers instructions for that brace would call for the first day post fitting to be only 2 hours. On 11/20/13 at 9:05am, E32, Director of Therapy, stated E28 and E30 were not provided the brace schedule on R2's readmission to the facility and that the first day they had the instructions and the tool were the day Z4 visited. E32 confirmed that the only orders both therapist saw was the order to wear at all times. On 11/20/13 at 1:20pm, E32 stated R2 had refused to wear his braces but thought most of his behaviors such as that was related to pain. As of 11/20/13 at 4:15pm, the facility was unable to provide an order for [REDACTED].

Based on interview, observation and record review, the facility failed to prevent/identify/treat pressure ulcers in a timely manner and failed to turn/reposition timely for 3 of 7 residents (R2, R7, R9) reviewed for pressure ulcers in a sample of 15, and one resident (R16) in the supplemental sample. This failure resulted in R2 developing multiple avoidable pressure ulcers to the bilateral lower extremeties including an unstageable pressure sore under new braces that went untreated for [REDACTED]. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R2 as a [AGE] year old male oringinally admitted to the facility on [DATE] with bilateral hip contractures, Muscle Weakness and [MEDICAL CONDITION] among others. The MDS indicates he has no cognitive impairment. According to a Hospital History and Physical Report dated 7/29/13, R2 was admitted to the hospital on [DATE] for a left total hip arthroplasty and bilateral hamstring adductor release and returned to the facility on [DATE]. Discharge instructions from the hospital include orders for Hinged knee braces locked in a comfortable amount of extension and wear according to included instruction sheet among others. Readmission Progress notes written by E10, Licensed Practical Nurse, LPN, dated 7/29/13 at 20:53 documents R2's return to the facility with Hinged Knee braces in place and a dressing over the surgical site on left hip and stitches in both sides of groin area. The Admission record also identifies R2 to have an eschar area on right heel with the dressing reapplied. There is no orders for the braces except those on the discharge instruction sheet that includes a increasing wearing time schedule starting with 2 hours on the first day and increasing to the maximum of 8 hours a day by the 3rd day following readmission. Progress Notes by E7, Registered Nurse, RN, on 7/30/13 at 14:51 (2:51pm) documents "tension braces to BLE, resident asked to remove them several times, advised him that we cannot remove them until the doctor gives permission" with the entry reflecting the groin areas and hip but includes no documentation on the condition of skin under the extension braces with Z1 (Orthopedic Physician) being called to clarify the brace use. There is no order on admission for the braces to be worn at all times and no indication that the nurses were checking his skin under the braces for pressure points and breakdown. On 7/31/13, Progress Notes written by E26, LPN, at 3:40am reflect the braces on R2's BLE (bilateral lower extremities) but also fail to reflect any skin checks done for pressure points during that shift. At 16:08pm, the Progress Notes by E7, RN, "resident alert and oriented, experiencing a large amount of pain to BLE and hips, PRN (as needed) given but not as frequent as needed". Again, there is no indication the nurse assessed R2's skin under the braces for redness and/or pressure points with his complaints of pain. Progress Notes of 8/1/13 at 3:01am and 7:23am document R2 complaining of pain with no evidence the nurses were monitoring R2's skin under the extension braces for redness and/or pressure points. At 12:54pm, the Progress Notes again record R2 complaining of pain BLE at a 10. This notes also documents R2 being seen by E28, Physical Therapist (PT) and E30.Occupational Therapy (OT). At 19:29pm, Progress Notes indicate R2 "does have a large amount of pain still and can barely stand for his legs to be touched", called Z2, Medical Doctor to see about scheduled pain medication. Progress Notes between 8/1/13 and 8/5/13 fail to include any documentation of R2's skin condition under the bilateral extension braces but refer to R2 wearing his braces continuously. On 8/5/13 at 14:10pm, the Progress Notes document R2 going to see Z1, Orthopedic Doctor. A note documented at 23:02pm indicates R2 has "no new areas noted besides surgical sites." Treatment Administration Records (TAR) reviewed from 7/29/13 - 8/5/13 fail to reflect any skin checks done on R2's legs. On 8/6/13 at 12:24pm, a PT documents "Nursing notified of open areas on patient beneath brace and notified of sutures behind B (bilateral) knees and groin." Progress Notes for 8/6/13 do not include this information. On 8/7/13 at 12:25pm, PT again documents "Discussed with nursing staff pressure areas from braces." Again, no documentation present in the Progress Notes of these pressure ulcers identified by PT and no evidence that nursing was monitoring R2's skin under the braces. On 8/8/13 at 12:27pm, PT documents "two additional pressure noted on this session from previous session.E29 Former Director of Nurses (DON) was notified and observed areas of concern." Progress Notes dated 8/8/13 again fail to include this information. There is no documentation in the Progress Notes from 8/8/13 thru 8/13/13 regarding R2's pressure ulcers identified by PT. On 8/13/13 at 2:43am, the nurse documents ""Resident taking apart leg braces, when asked what he was doing he replied "I don't know, what am I doing?" Assisted in refastening braces, noted large fluid filled blister on left outer leg above the ankle, while tightening the straps. Blister measures 3.7 x 2.6 and red area around blister measures 6.4 x 2.6. [MEDICATION NAME] dressing applied to cushion blister. Resident advised to leave braces alone. Note left for Physical Therapy notifying them of the need to check the braces in morning." There is no Physician notification or treatment orders obtained or documented following this entry. On 8/14/13 at 14:39, E7, RN, documents in the Progress notes that Z1's office was called "to see if resident can remove braces for a few hours a day because he is starting to have blisters and other skin issues caused from the braces, waiting on a call back." E7 did not seek a treatment or ensure that R2's pressure ulcers were being treated at that time even though she would have been responsible for the daily dressing changes. On 8/15/13 at 11:29am, the Progress Notes written by E7 include nothing regarding the pressure ulcers on his legs under the extension braces but document additional pressure ulcers on his coccyx. The note reads "skin assessment during peri care and three small open areas found to coccyx. 0.9cm (centimeter) x 1.6cm, .5 x 0.8 cm, and 0.4 x 0.4 cm. Wound bed pink, no drainage at this time. Cleansed area and applied [MEDICATION NAME], called Dr. Z2 office to request a TX (treatment order) for [MEDICATION NAME] to coccyx, change every three days and PRN til healed. Waiting on call back" No treatment documented on any of the other previously identified pressure ulcers was obtained. On 8/16/13 at 11:08am, E7 documents new treatment received for coccyx and at 10:54am, still no call back from Z2's office is documented regarding reducing the brace time. No orders for treatments on either leg was obtained. On 8/20/13 at 13:52 (1:52pm), E7 documented in the Daily notes that Z2's office called and gave order to wear the braces to BLE 4 hours twice a day. No treatment order is obtained for the shin areas until 8/23/13, 17 days after it was initially identified. A Telephone Order (TO) dated 8/23/13 at 16:34 (4:34pm) for "Apply [MEDICATION NAME], ABD, wrap with kerlix to bilateral shins dly (daily) every night shift for open areas from bilateral braces." is received and written by E3, Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN). Another TO dated 8/26/13 at 12:322 by E3 documents "Cleanse with wound cleanser. Apply [MEDICATION NAME], cover with ABD, wrap with Kerlix to bilateral shins dly (daily), every night shift for open areas from bilateral braces." On 8/27/13, an order for [REDACTED]. Cover with ABD and wrap with Kerlix every night shift." And on 8/29/13, the treatment for [REDACTED]." These are the first orders for treatments since the wounds were identified on 8/6-8/8, 8/13 and 8/15. A Weekly Pressure Ulcer assessment dated [DATE] completed by E24, Former DON, identified right shin ulcers acquired in house measuring 3.5cm long x 1.5 cm wide with no depth, SDTI (suspected deep tissue injury) with small amount of exudate and 100% [MEDICATION NAME] tissue. The next report dated 8/22/13 by E24 reflects the same exact information, but on 8/26/13, the ADON/wound nurse documents a much larger area measuring 9.5cm x 3 stage III, color red, small amount of exudate bloody, clear, no odor and no undermining. TAR's reviewed document no treatments until 8/23/13 even though the shin pressure ulcers were identified on 8/8/13. On 9/4/13, E3, ADON, documented the wound as having eschar, stage III measuring 7.2 c 0.7 x 0.1 depth. On 9/11/13, the wound report documents the area at stage III increasing to 9.0 x 3.0 with 60% necrotic tissue. Weekly Pressure Ulcer Assessment sheets dated 8/26/13 identify the left lower leg wound as "Unknown" with measurements completed on 8/29/13 identifying it as an eschar, 5.5cm x 2cm. Again, this wound identified on 8/13/13 had no treatment until 8/26/13, 13 days after it was identified by nursing. The facility was unable to provide any assessments for August 2013 of the left shin pressure ulcers but document them as being first treated on 8/23/13. Laboratory tests dated 7/16/13 and 10/17/13 document R2's total protein (Normal 6-8.3) and [MEDICATION NAME] (Normal 3.5-5.5) were within normal limits both dates. Treatment records reviewed for September and October 2013 document weekly measurements being documented with treatment changes obtained with wound decline. On 9/18/13 at 11:09am, E7 documented in the Progress Notes that she talked with therapy and they stated that the right brace is still causing some skin issues to the calf/shin area, wanted to know if it is still necessary for resident to wear it on the right leg, called and left message with Z1's office, waiting on a call back." TAR's reviewed for August 2013 documented R2 to not wear the braces at all after 9/20/13 but no order is evident. E3 stated she started at the facility as wound nurse the end of August 2013, and that she thought R2 wore his braces 24 hours a day "at all times" when he first came in. E3 stated he developed pressure ulcers from the braces and no longer wears them due to the pressure ulcers. E3 stated R2's ulcers have majorly improved since sending him to the wound clinic a few weeks ago. E3 stated dressings are now being done every other day with him going to the wound clinic on a weekly basis. At 10:32am on 11/14/13, E28, Physical Therapist (PT) confirmed that PT first found the pressure wounds under R2's brace on 8/6/13 and that the nurses were informed at that time. E28 stated that when they were noted to be without dressings with R2 developing additional wounds in the days following. E28 stated she again notified nurses and had E29, Former Director of Nurses, come down and look at them. She assumed they would get orders but confirmed that R2 continued to come to therapy with open sores on his legs from the braces. E28 stated that the order on admission was to wear the braces at all times and that she would assume the nurses would loosen them to check his skin for pressure sores. On 11/15/13 at 8:50am in interview, E28 stated R2 was walking 5-10 feet when he first returned from the hospital but as time passed and the pressure ulcers developed, his pain was tremendous at times and caused them to decrease the time using the braces. E28 said R2 also developed a deep tissue [MEDICAL CONDITION] and was discontinued from therapy but that he hadn't been wearing his braces according prior to that. E28 stated he no longer walks and the braces were discontinued due to the sores. Without the braces, E28 stated R2 would not walk. At 8:50am on 11/15/13, E30, Certified Occupational Therapy Assistant (COTA) confirmed that E29 was made aware of the pressure sores on R2's legs from braces when they first found them. E30 stated they had tried to pad the brace themselves but R2 continued to breakdown. E30 stated she did not think the nurses were loosening the braces to do skin checks since therapy found the wounds before the nurses did. E30 stated she thought none of the nurses removed the braces to check his skin as they should have. E30 also agreed that R2 has had the braces discontinued along with both PT and OT. On 11/20/13 at 9:35am, R7 confirmed that she did not monitor R2's skin under the braces for pressure uclers as the order was for them to remain on at all times. E7 stated she was told by E29 not to do anything with the braces. E7 stated she was aware that R2 had pressure ulcers but that she assumed E29 was taking care of them even though she admitted that she would be responsible for doing daily dressing changes. On 11/20/13 at 2:15pm, E10, LPN, confirmed that she did not monitor R2's skin under the braces because he was not to have his braces removed and she was unsure as how to to do anything with the braces. Interview with E9, Corporate Nurse on 11/19 at 11:43am confirms that E29, and E31 Former ADON, are no longer employed at the facility. E9 stated she was aware of skin issues with R2 and had told the nurses to discontinue the braces when the ulcers weren't improving as it wasn't going to do R2 any good to have straight legs if they "had to amputate due to pressure sores." E9 stated she did not look at the paper work closely but had identified the wound program as a problem in the months prior and had given the DON time to correct it which she did not do. E9 also stated that E31 just "walked" and didn't give a notice so E29 had to start doing the weekly wound assessments which weren't being done. E9 also stated that E7 would have been doing the daily dressing changes and didn't know why orders were not obtained when R2's wound were first found. R2's pressure ulcers are now being treated by a Wound Clinic and have improved dramatically. Measurements documented by the Wound Clinic on 11/12/13 are as follows: Left Lateral Leg - stage III, 3.1cm x 1.5cm x 0.2cm, Right Superior Anterior Shin, - stage II, 1.0cm x 0.6cm x .01cm, Right Inferior Anterior Shin - stage II, 1.3cm x .7cm x .01cm, Right heel - Stage II, 1cm x 1.2cm x .1. Dressing changes are done every two days and were noted to be in place and dry/intact. On 11/19/13 at 11:43am, R2 recalled developing the pressure ulcers from the braces and confirmed that his braces were left on continuously for quite a while. R2 stated the nurses did not "mess with the braces, they didn't know how" to do anything with them. R2 stated he no longer wears his braces due to the pressure sores and that he hasn't worn them for at least a couple months. R2 confirmed that he does't ambulate anymore although he is still wanting to so he can go back home. The Pressure Ulcer Prevention and Healing Program poilicy dated 8/27/13 was provided on 11/19/13 by E2, DON. The policy indicates skin audits will be used to identify pressure ulcers, in addtion to the identification during routine care giving and "Upon identification of a pressure ulcer, the pressure ulcer Assessmetn and Intervention Worksheet will be completed" It continued that treatment and healing of pressure ulcers will be based on the facility's pressure ulcer treatment protocols. physician's orders [REDACTED]. Reevaluation on a weekly basis will be done to determine the effectiveness and appropriateness of the treatment. 2. R9's MDS of 8/20/13 documents R9 is not at risk for pressure ulcers. R9's Care Plan of 10/21/13 documents R9 is at very high risk for the development of pressure ulcer due to current pressure ulcer. Care Plan interventions include, in part; Changed to assist x 2 with transfers for safety, Encourage good nutrition and hydration in order to promote healthier skin, Pressure redistributing mattress to bed and cushion to her wheel chair, Treatment to buttocks as ordered per MD (Medical Doctor). R9's Physician order [REDACTED]. R9's WEEKLY PRESSURE ULCER ASSESSMENT of 11/13/13 documents R9 has an acquired in house stage 2 pressure sore to her left buttock measuring 1.0 x 1.5 cm x 0.1 cm and has pain with dressing change. R9 was observed on 11/12/13 at 10:55AM to be sitting in a wheel chair at a feeding table in the Dining Room. R9 was observed at least every 10 to 15 minutes and remained in the Dining Room at the table in the same position. R9 ate less than 50% of food served and was only given a glass of lemonade at her meal. At 1:20PM R9 was taken to the hallway by the door of her room. At 1:25PM, E14, Social Service Director, took R9 into her room. R9 remained in her wheel chair in her room until 1:57PM when E15 and E16, CNA's transferred her from the wheel chair to her bed. R9 had been sitting on a wheel chair cushion and a folded bed pad that was wrinkled and creased. R9 had 2 bed pads on her bed, one on top of the other. R9's disposable incontinent brief was saturated with urine. R9 did not have a foam dressing on her left buttock, nor was there a dressing in her incontinent brief, or in and around her bed. R9 had a blood tinged area on her incontinent brief from the pressure ulcer and her buttocks and back of thighs were red and deep creased. E16 was observed to do incontinent care but failed to wash R9's buttocks, abdomen and back of thighs that were soiled with urine. 3. R16's Care Plan of 9/23/13 documents she has moderate potential for pressure ulcer development related to fragile skin. Care Plan intervention includes, in part; R16 needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. R16 was observed on 11/12/13 at 10:55AM to be sitting in a wheel chair at a feeding table in the Dining Room. R16 remained in the Dining Room in her wheel chair until 1:05PM when she was taken to her room and left in her wheel chair. At 2PM, E19 and E23, CNA's, transferred R16 to bed. R16 had a strong urine odor and her incontinent brief was saturated with urine. E23 was observed to give incontinent care and failed to wash R16's perineal area or buttocks that had been soiled with urine. R16 had been sitting on a bed pad that was folded into quarters, R16's buttocks and back of her thighs were deep creased and were white and deep red that remained that way when the observation ended at 1:21PM. 4. R7's current Care Plan documents R7 has a potential for pressure ulcers. R7's care plan documents that R7 is to be turned and repositioned every two hours, more often if needed. On 11/12/13 at 9:12am, R7 was sitting up in wheelchair in room. At 11:38 am, R7 was still sitting up in wheelchair in room visiting with family and at 12:22pm R7 was sitting in wheelchair in dining room eating lunch. No repositioning and/or off setting of pressure was noted to occur during this observation time. On 11/12/13 at 1:00 pm R7 was taken to her room from the dining room and left at bedside in her wheelchair. At 1:37 pm E19 CNA and E23 CNA placed R7 on the commode, R7's attends was wet and R7 was incontinent of stool. R7's inner thighs were red and buttocks were red with creasing.

Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent a shearing injury wound for 1 resident (R2), and failed to assess and monitor incision sites, and failed to obtain follow-up for removal of sutures for 1 resident ( R3) reviewed for skin concerns in the sample of three. This failure resulted in deterioration and infection in a heel wound for R2. Findings include: 1. On 7/12/11 at 10:20 AM, R2 was in bed on her back. Both feet had foam heel protectors in place. There were gauze dressings in place on R2's left ankle and right foot and ankle. E4, Registered Nurse, RN, stated she had already changed the dressing. E4 stated R2 had a "healed" area on her left ankle, "from a brace she used to wear." The gauze dressing on R2's right foot was removed. There was a deep wound noted to R2's right heel, with black eschar covering the wound bed. The Nursing Notes dated 4/28/11 at 05:30 AM documented, "Found blood stain on foot of res. (resident's) bed. Inspected res. feet & found 4.5 cm x 3 cm x .2 cm skin shear on bottom of right heel". The facility's Skin Condition Record for non-pressure ulcer skin conditions documented basically the same measurements weekly, with wound bed described as red or pink until 5/18/11, when the wound bed is described as "scabbed over" and surrounding tissue is "dark scabbed with white edges." On 6/21/11, the measurement was basically unchanged, but there was light green drainage noted, with surrounding skin color described as "ruby." The culture and sensitivity test report of the drainage was received by the facility on 6/23/11. The report documented a heavy growth of two organisms, [MEDICATION NAME] Cloacae, and [MEDICATION NAME] Faecalis VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]). The Nursing Notes dated 6/23/11 document, "Results obtained - VRE of wound. Prior to results, res (resident) increased temp - urine thick - physician made aware of res. status - Admit to (hospital)" R2's Care Plan does identify "5/6/11 - Stage II Pressure Ulcer to left ankle..Skin issue to right heel potentially related to her limited mobility and potentially related to DMII (Diabetes Mellitus)...." Care Plan interventions dated 6/21/11 documented the following: "Dressing order to Right heel - (change) as ordered - culture R. heel wound." Intervention dated 6/23/11 - "Send to ER for evaluation and treatment". The laboratory culture and sensitivity results dated 6/23/11 documented growth of [MEDICATION NAME]- Resistant [MEDICATION NAME] (VRE) from right heel drainage. R2 was admitted to the hospital, and treated with intravenous antibiotics. R2's Skin Condition Record dated 7/1/11 for re-admit documented the area as, "R - under outer heel - readmit - total 6 cm wide x 2 cm high. Inner necrosis 4.5 cm wide x 1.5 cm x .25 deep." The wound is described as "shear friction". On 7/12/11 at 1:30 PM, E3, Interim Director of Nursing, stated she does not consider R2's right heel to be a pressure ulcer. E3 stated R2 has "behaviors of rubbing heels, even when up in a chair", that caused the wound to develop. E3 stated when the area was first noted on 4/28/11, "we called it shearing, don't call it pressure ulcer." E3 stated that it does "present (appear) as a pressure ulcer now, but initially was caused by shearing." On 7/13/11 at 1:45 PM, R3, Interim Director of Nursing, stated that R2's wound was due to her behavior of rubbing her foot on the mattress. R3 stated the wound has deteriorated since first noted on 4/28/11. R2 stated the wound did become infected prior to R2's recent hospitalization . 2. R3's record was reviewed as a closed record. R3 was initially admitted to the facility on [DATE]. Admission Nursing assessment dated [DATE] documented R3's skin condition, "[DEVICE], Right upper arm PICC line - [MEDICATION NAME] Pump - rt. lower quadrant, red & inflamed, RUA,(right upper arm), R. forearm, left bicep bruise." 3/16/11 Hospital Discharge Instructions listed Follow-up Appointment: Dr. (Z2) to remove [MEDICATION NAME] pump next week. Z3, Physician, will follow up in 2 weeks or prn/sooner. Z2's office states they will call (facility) with day/time." R3 returned to the hospital on [DATE] for removal of the infected pump. physician's orders [REDACTED]. Incision Sites to RT (right) lower abdomen & R. lower back, change daily and PRN. Monitor for S/S (signs/symptoms)infection daily. 2. TX: Around J-tube clean and apply drain sponge daily and PRN. 3. Open Area Rt. lower abdomen, keep clean, dry dressing daily and PRN (monitor suture site).". There is no documentation or orders obtained from the surgeon for follow up appointments or suture removal. On 7/12/11, at 1:30 PM, E3 stated, "I know he (R3) had sutures and staples. I can't remember if we removed them or if they were removed at the doctor's office or during one of his hospital visits." When asked where the documentation of his incision sites, open areas, drains were in R3's chart, E3 stated, "I know he had sutures and a drain when he was admitted on ,[DATE]. I think the drain and sutures were removed when he had the [MEDICATION NAME] pump removed on 3/24." E3 stated she was "having trouble finding documentation" describing R3's areas in his chart. R3's Discharge Summary dated 5/9/11 does not identify sutures remaining in R3's incisions. The nursing services assessment does not identify any skin issues, or need for follow up services. On 5/9/11, R3 returned to the facility where he was living prior to his hospitalization and surgery on 3/24/11. The 5/9/11 Nursing Notes documented at 11:30 AM (in part), R3's "coccyx, buttocks area is dark reddish, purple.....visable [MEDICATION NAME] on lumbar region of lower back with 5 stitches present.....LRQ (lower right quadrant) dressing saturated with light brown, odorous drainage, penrose drain left in place with stitches present.......Will be seen in HCC (Health Care Center) tomorrow ...." On 5/10/11 at 10:00 AM, R3 was examined by Z6, Physician - Health Services. Z6 noted in his physical exam that he removed sutures from R3's lumbar incision, removed the drain and sutures from R3's RLQ area, and documented a Stage I pressure ulcer. R3 was referred to Z3, Surgeon, for evaluation of his wounds.