Every finding on record at Arcadia Care Bloomington

Based on observation, interview, and record review, the facility failed to maintain the kitchen environment in a sanitary condition and failed to ensure identified environmental concerns affecting the food service area were addressed timely. This failure has the potential to affected all 92 residents resident in the facility. Findings:The Sanitation of Dining and Food Service Areas policy revised on 05/2027 documents the dining services staff will uphold sanitation of the dining areas according to a thorough, written schedule. This document also documents that task will be designated to specific departmental positions and all staff will be trained on the frequency of cleaning. On 8/19/2026, during observation of the kitchen, a floor drain was observed covered by a box. When V3, Dietary Manager, lifted the box, gnats were observed swarming from the drain. V3 stated the drains frequently became clogged.During the same observation, dirt and old food were observed on the kitchen walls. The kitchen ceiling was observed to be sagging, and cobwebs were present throughout portions of the kitchen.The kitchen bathroom was also observed to be dirty. Three empty toilet paper rolls were observed on the floor.On 8/19/26 at 9:00AM, V5 (Maintenance Director) confirmed the drain in the kitchen has been an ongoing concern and V5 had placed a rubber tote over the area. V5 stated housekeeping or dietary staff are to clean all aspects of the kitchen and any problems need to put into (Computer System Name) Maintenance Program. At 11:30 AM on 8/19/2026, V1(Administrator) stated, it's unacceptable for this dirtiness to be in the building. V1 confirmed all food comes out from the kitchen to be served to all residents residing in the facility. The Midnight Census dated 8/17/26 documents 92 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to maintain the facility in a clean, sanitary, functional, safe, and comfortable condition. This failure has the potential to affect all 92 residents residing in the facility. Findings Include:The facility's Maintenance Director Job Description, revised 5/26/26, documents the Maintenance Director is responsible for repairing facility and resident property as necessary; coordinating with outside vendors when repairs could not be completed internally; ensuring outside vendor services were properly completed and supervised; inspecting storage rooms, workrooms, utility and janitorial closets for upkeep and supply control; participating in facility inspections; developing plans of correction for maintenance deficiencies; recommending adjustments in maintenance services necessary to maintain a clean, safe, and comfortable environment; completing necessary maintenance records; and making periodic rounds to ensure equipment is available and functioning properly.The facility's Housekeeper Job Description, revised 5/26/26, documents that housekeeping staff are responsible for performing the day-to-day activities of the housekeeping department and ensuring the facility is maintained in a clean, safe, and comfortable manner. Responsibilities include cleaning and sanitizing fixtures and room heating/cooling units, cleaning and disinfecting floors, properly discarding waste, following safety precautions, and using appropriate cleaning techniques and disinfectants.The August 2026 Maintenance Log contained outstanding work orders for, Broken doors, missing and damaged ceiling tiles, nonfunctioning bathroom fan, broken lights, backed-up drain near the steam table, drywall damage and holes near air-conditioning units, scratched and damaged drywall, broken doors, electrical outlet coming out of the wall, exit door concerns, nonfunctioning call light, nonfunctioning toilet, broken bed, leaking laundry sink, flies, leaking toilet base, wall damage, clogged toilet, ceiling and wall damage, clogged kitchen sink and standing water in the kitchenOn 8/17/26 at 8:01 AM, room [ROOM NUMBER], which was unoccupied, was observed with dirt covering the floor, personal belongings on the floor, a sticky floor, and cobwebs on the windowsills, around the window, behind the bed, and along the corners of the room.On 8/17/26, the 400 Hall, 200 Hall, and 300 Hall were observed with gloves lying throughout the hallways. A linen cart containing towels, washcloths, and gowns was uncovered, with towels hanging down toward the floor and visible dirt nearby. Garbage cans in the hallway were observed without garbage bags.On 8/17/26 at 8:35 AM, R8's room was observed with visible fecal stains on the sheets, and the bed was not made. R8 stated that housekeeping never comes and cleans the room and reported that the sheets had not been changed for more than a month and that the bed was never made.On 8/17/26 at 8:41 AM, R9's room was observed with cobwebs present in the windowsills.On 8/17/26 at 8:45 AM, R10's room was cluttered, with a garbage can and towel located near the air-conditioning unit. Two-inch by two-inch holes surrounded the air-conditioning unit beneath the windowsill. Black material was present around the unit and the area was dusty. R10 stated housekeeping did not clean the room.On 8/17/26 at 9:46 AM, R11's room had approximately three-inch by two-inch holes surrounding the air-conditioning unit, black material around the unit, cobwebs in the ceiling corners and windowsill, and a sticky floor with visible dirt along the wall edges and throughout the floor. R11 stated, staff is shorthanded and never cleans.On 8/17/26 at 9:01 AM, V15 a visitor, reported that the facility was filthy when visiting R1. V15 reported seeing old blood on a railing, spider webs with small eggs, mold/mildew underneath an air-conditioning unit, a strong urine odor in the bathroom, garbage cans without bags, and an oxygen electrical socket hanging out of the wall. V15 stated, I want reporting concerns for the entire facility because residents should not have to live in those conditions. V15 further stated that only one housekeeper was working at a time and that staffing was consistently short.On 8/17/26 at 9:10 AM, V16 (Power of Attorney) reported filth, cobwebs, and floors that appeared not to have been swept for a long time. V16 stated that only one housekeeper was working that day and reported the concern to V2 Director of Nursing. V16 further stated that after R1 changed rooms, cobwebs remained. V16 also reported that the bathroom shared by residents did not function because the toilet was clogged and would not work, despite administration being asked to address the problem.On 8/17/26 at 9:18 AM, V17 (Power of Attorney) reported a strong urine odor in the dining room and observed a puddle underneath a resident. V17 stated that residents were also complaining about the odor and reported holes in the walls and an air-conditioning unit that had reportedly been repaired but remained nonfunctional.On 8/17/26 at 1:30 PM, R12's room had electrical outlets coming out of the wall and visible wires. R12's bed was connected to the outlet. A bath blanket was on the floor underneath a leaking air-conditioning unit.On 8/17/26 at 2:00 PM, the Activity/TV Room had exposed wood on the windowsill, cobwebs, sinking/crumbling drywall, warped/cracked wood, inconsistent caulking, and plastic taped over the windows. A ceiling tile was warped with a visible opening above it.On 8/17/26 at 2:05 PM, the 200 Hall near the exit door had a dirty windowsill, a poorly filled gap, and flooring that was peeling upward before the hallway entrance.On 8/17/26 at 2:35 PM, R4 and R13's room had clothing on top of a running air-conditioning unit, dirt and crumbs under the television stand, crushed chips and cobwebs under the dresser, and tissues/plastic beneath the bed. A hole near an electrical outlet exposed cords. The air-conditioning unit had heavy dust and sticky/damp dust around the controls. R4 and R13 stated, nobody comes in and cleans, and it's gross. The bathroom in R4 and R13's room had rippling walls, a cracked floor, a detached metal baseboard with an exposed nail, white powder on the floor, baby powder on the toilet, a cracked/rippling sink where it attached to the wall, and rust and sticky residue above the paper towel dispenser.On 8/17/26 at 2:50 PM, R3's toilet was nearly filled to the seat level with feces and toilet paper was present in a mound. There was no trash bin and no not in use signage. Empty toilet paper rolls were on the floor. Detached/peeling baseboards, a hole in the wall, a closet missing door handles, and torn drywall around an electrical outlet were also observed. A small refrigerator that was not in use was sitting in the hallway, and a ceiling tile in the shower room was bulging and falling.On 8/18/26 at 9:45 AM, R14 and R15's room had noticeable clutter, cobwebs, and food on the floor. The bed was covering the air-conditioning unit. R15 stated that the shower did not work because turning on the water caused the drain to clog and water to come into the room and bathroom. R14 and R15 stated that housekeeping had not been in their room to clean for a very long time.On 8/18/26 at 11:01 AM, R5's room had clutter and a sticky floor. A towel and an unlined garbage can containing water were located underneath the air-conditioning unit. A bedside table obstructed the air-conditioning unit, and a crack beside the unit allowed the outside to be visible. R5 stated that no housekeepers came to clean the room and stated, reporting it doesn't help as nothing gets completed.On 8/18/26 at 1:30 PM, R1's air-conditioning unit contained a cigarette.On 8/18/26 at 2:10 PM, V29, Laundry Aide, was observed working in the laundry room. Cigarette butts were observed on the ground in the clean laundry area near clean clothing. Four 44-gallon containers were full of clothes that were draping onto the floor, and two full racks of clothes were present. Bath towels and linens on the shelves were discolored and stained. V29 stated there was only one laundry aide, that V29 could not keep up with the laundry, and that the department was operating with only one washing machine and two dryers. V29 reported having six 44-gallon containers of dirty clothes awaiting washing. V29 also stated that a checklist was supposed to be completed for cleaning the laundry room but that there was not enough time to complete it. Dust was observed around the dryers and washing machines, and black material was hanging from ceiling tiles.On 8/17/26 at 10:00 AM, V4, Housekeeper, stated that the facility had only two housekeepers, with one housekeeper working during the day and one working at night. V4 stated that one person could not keep up with the workload and could not clean every room daily, in addition to frequent interruptions throughout the day. V4 stated, It's embarrassing, but I try my best, on what I have available to me.On 8/17/26 at 1:00 PM, V5, Maintenance Director, stated that an air-conditioning unit on the roof had been affected by a lightning strike during a storm the previous Thursday, resulting in a burning/hot odor throughout the building. V5 further stated that an HVAC company inspected the system on 8/17/26 and determined the system had changed from air conditioning to heat, causing the odor. V5 toured resident rooms and acknowledged that the in-room air-conditioning units had not been installed correctly. V5 confirmed that mold was present around the air-conditioning units and stated that housekeeping should be cleaning the vents and inside the air-conditioning units. V5 also acknowledged that the facility did not have adequate housekeeping staff and stated that the cleanliness of the facility was unacceptable.On 8/19/26 at 1:00 PM, V5 stated that V5 had no help and was the only person performing maintenance duties. V5 identified a running list of work orders from the previous month that remained to be addressed. V5 confirmed that this affects all residents residing in the facility. On 8/19/26 at 11:30 AM, V1 (Administrator) stated, it's unacceptable for this dirtiness to be in the building. V1 confirmed that the ceilings, roof, and air-conditioning units needed to be inspected by an outside source but stated that, due to the Illinois Department of Public Health being in the building frequently, V1 did not have time to follow up on all the reports. V1 also confirmed that this would affect all residents as all residents go up and down the hallways and use the dining room and activity room and each resident has an air conditioner unit in their rooms. V1 also confirmed that the dirt is throughout the facility. The Midnight Census dated 8/17/26 documents 92 residents reside in the facility.

Failures at this level required more that one deficient practice statment. A. Based on interview and record review, the facility failed to ensure a resident was promptly assessed for injury following a reported fall and failed to complete fall risk assessments according to facility policy for three (R5, R6, R11) of four residents reviewed for accidents and injury of unknown origin in the sample list of 17. B. Based on observation, interview and record review the facility failed to ensure portable oxygen tanks were properly stored. This failure has the potential to affect all residents residing in the facility.Findings Include: a.1) R6's Minimum Data Set, dated [DATE], documents R6 is rarely/never understood and requires supervision for ambulation. R6's Emergency Department after visit summary, dated 7/21/26, documents Reason for visit: arm pain. Diagnosis: Closed nondisplaced fracture of surgical neck of left humerus. On 7/21/26, Xray report of humerus left for R6, documents, Findings/Impression: there is a fracture of the humeral neck. R6's clinical record documents fall risk assessments were completed on 3/6/26 and 5/28/26. The facility's final abuse investigation report (Injury of Unknown Origin Investigation), dated 7/27/26 documents, Conclusion and Action Taken, 1b. Staff reported (R6) was observed getting (R6) up off the floor beside the bed by CNA (Certified Nurse Aide). No fall risk assessment was documented following the reported 7/20/26 fall. No assessment for injury was documented after R6 was observed getting up off the floor on 7/20/26. V12's (Licensed Practical Nurse) timecard, dated 7/17/26 to 7/20/26, documents V12 worked 5 hours and 45 minutes on the evening of 7/20/26. On 8/18/26 at 12:50pm, V18, Certified Nursing Assistant, (CNA), stated that on 7/20/26 at approximately 9pm, V18 witnessed R6 getting up from the floor in R6's room. V18 stated V18 assisted R6 to sit on the bed and then reported the observation to the nurse. V18 stated that R6 ambulates independently and requires minimal assistance with toileting and dressing. On 8/18/26 at 2:16pm, V20, CNA, stated that on 7/20/26 at approximately 9pm, V20 and V18 saw R6 on the floor in R6's room. V18 assisted R6 to sit on the bed and then reported the incident to the nurse. V20 confirmed that R6 ambulates independently and requires minimal assistance with toileting and dressing. On 8/19/26 at 9:53am, V24, Licensed Practical Nurse, (LPN), stated V24 arrived at the facility at 9:35pm on 7/20/26. V24 received report from V12, LPN, and stated there were no issues reported regarding R6. On 8/19/26 at 10:07am, V25, CNA, stated that the morning of 7/21/26, R6 had finished breakfast and was walking in the hallway dressed only in a robe. V25 walked with R6 back to R6's room to assist R6 in getting dressed. V25 stated R6's left arm was hanging close to R6's body and R6 was very protective of the arm and would not let V25 touch the arm. V25 stated V25 reported this behavior to V26, LPN. On 8/19/26 at 10:13am, V12, LPN, stated V12 probably wasn't here that night. V12 stated R6's arm injury was reported to V12 on 7/21/26 and denied assessing R6 following the reported fall. On 8/19/26 at 10:30am, V26, LPN, stated that on the morning of 7/21/26, two CNAs reported to V26 that R6 was unable to move R6's left arm. V26 assessed R6, notified the physician and guardian and transferred R6 to the emergency room for evaluation. On 8/19/26 at 11:52am, V30, R6's guardian, stated V30 was notified by V26 on 7/21/26 at 9:54am that R6 was being sent to the emergency room to have R6's left arm evaluated due to pain from a fall. On 8/20/26 at 12:58pm, V2, Director of Nursing, stated residents should be assessed by nursing after every fall. V2 confirmed R6 was not assessed after R6 was found getting up off the floor on 7/20/26. V2 confirmed fall risk assessments should be completed after each fall. R5's clinical record documents a fall risk assessment was completed on 2/5/26. The facility's incident log dated 5/21/26 – 8/18/26, documents R5 experienced a fall on 8/10/26. No fall risk assessment was documented following the 8/10/26 fall. R11's clinical record documents a fall risk assessment was completed on 4/14/26. The facility's incident log dated 5/21/26 – 8/18/26, documents R11 experienced falls on 6/6/26, 7/16/26, and 8/1/26. No fall risk assessment was documented following any of these falls. The facility's Fall Prevention and Management Education, undated, documents, What is a fall? Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Complete head to toe assessment of the resident, notify MD (physician) and POA (Power of Attorney), complete all required assessments. The facility's Fall Prevention Program, revised 5/2022, includes, A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. b. 1. On 8/17/26 at 9:40 AM, near rooms [ROOM NUMBERS], a portable oxygen tank was sitting on the floor with the nasal cannula and carrying strap hanging on the handrail. The nosepiece was attached and resting directly on the rail. On 8/18/26 at 10:38 AM, inside the 400 Hall near the exit used for residents to go outside to smoke, there was a portable oxygen tank on the floor with the nasal cannula and strap hanging from the handrail. The nasal prongs were touching the rail. At that time, V21 Registered Nurse confirmed the portable oxygen tank and cannula were not properly stored and should not have been on the floor or hung on a handrail. On 8/19/26 at 11:47 AM, V2 Director of Nursing stated portable oxygen tanks should not be placed on the floor and nasal cannulas should not be hung on handrails. V2 stated staff are expected to store portable oxygen tanks at the nurse's station and place cannulas in bags when not in use. On 8/20/26 at 1:15PM, V1 Administrator stated the facility does not have an oxygen storage policy. The Midnight Census dated 8/17/26 documents 92 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to protect the residents right to be free from verbal/mental abuse by a staff member for one of three residents (R4) reviewed for abuse in the sample list of 17. Findings Include:R4's admission Record, dated 8/19/26, documents R4 has multiple medical conditions including Osteomyelitis, Bacterial Infection, Chronic Kidney Disease, Diabetes, Anxiety Disorder, Hypothyroidism, Disorders Of Muscle, Lack Of Coordination, Malnutrition, Anemia, Obesity, Depression, Hypertension, Weakness, Bipolar Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, and Insomnia.R4's Care Plan, dated 8/03/26, documents R4 is at low risk for abuse/neglect and interventions include ensuring R4 feels safe and secure. R4's Care Plan dated 7/15/26 documents R4 has Activities of Daily Living (ADL) deficits related to osteomyelitis and requires assistance with bathing, bed mobility, hygiene, toileting, and transfers.R4's Minimum Data Set, dated [DATE], documents R4 is cognitively intact.R4's Point of Care (POC) Response History for Behavior Monitoring & Interventions, dated 8/19/26, documents no observations of behaviors from 7/21/26 through 8/18/26.R4's POC Response History for the Task: Is the resident short tempered and/or easily annoyed, dated 8/19/26 with a 30 day lookback period, documents no responses.R4's Skilled Medicare Charting dated 7/26/26, 7/27/26, 7/28/26, 7/30/26, 7/31/26, 8/3/26, 8/4/26, 8/8/26, 8/9/26, 8/12/26, 8/13/26, 8/15/26, and 8/17/26, documents R4 did not have any notable changes in mood or behavior. R4's Skilled Medicare Charting dated 8/18/26 documents R4 was irritable.On 8/18/26 at 8:40 AM, R4 was heard yelling for assistance, and R4's room and bathroom call lights were on. At 9:20 AM, R4 was in the room speaking with V3 Licensed Practical Nurse (LPN). V9 Certified Nursing Assistant (CNA) and V19 CNA were standing outside R4's door. V9 was yelling at V19, stating V19 should not have toileted R4 and left. V19 stated V19 had to speak with the doctor. V9 then walked into R4's doorway, looked at V19, and yelled, asking if V19 was going to stay and help with cares for R4. V9 and V19 then entered the room.On 8/18/26 at 9:25 AM, R4 reported being placed on the toilet around 8:20 AM by V19 CNA and being left there unattended. R4 reported that over 30 minutes later, V9 CNA assisted R4 off the toilet and was disrespectful. R4 stated that after V9 applied R4's brief, the brief was not placed correctly and was uncomfortable. When R4 attempted to inform V9, V9 yelled, I don't know what you want me to do about it! R4 reported being very upset. V9 then assisted R4 to R4's wheelchair and obtained V3 LPN, stating R4 was being rude. R4 stated R4 had not been rude and felt V9 was very rude. R4 reported feeling the interaction was elderly abuse and stated R4 did not deserve to be spoken to that way. R4 appeared visibly upset.An Abuse Allegation Interview: Alleged Victim - All Abuse Types, dated 8/18/26, documents R4 reporting R4 was left on the toilet for 30 minutes and CNAs ignored R4's call light. R4 reported the brief was not on correctly and was bunched up. V9 said, I can see it. R4 stated V9 yelled and left the room, and could be heard in the hallway saying, (V3 LPN) come down here, I'm not dealing with (R4).On 8/18/26 at 2:04 PM, V9 CNA stated V9 saw R4's call lights on and assisted R4. V9 stated that during peri care, R4 scoffed. V9 stated R4 reported the brief was not on correctly and yelled that the brief still wasn't right. V9 stated V9 could not see the right side of the brief due to positioning and instructed R4 to sit in R4's wheelchair so V9 could adjust the brief in R4's room. V9 stated R4 unlocked the wheelchair and wheeled R4's self back into R4's room. V9 walked out of the shared bathroom, and R4 yelled that R4 needed foot pedals applied. V9 stated V9 went to get V3 LPN because V9 did not want to be yelled at. V3 assisted R4, and V9 and V19 assisted with adjusting the brief. After exiting the room, V9 told V19 that R4 should be cares in pairs.An Abuse Allegation Interview: Alleged Perpetrator - Staff, dated 8/18/26, documents V9 stating R4 yelled about being left on the toilet. V9 stated V9 asked R4 questions because V9 had not assisted R4 before and was unaware of how R4 preferred briefs positioned. V9 stated V9 became louder so R4 could hear but denied yelling. V9 stated V9 asked V3 LPN for assistance, stating, Please help. I'm not dealing with (R4) yelling at (V9).On 8/18/26 at 9:55 AM, V19 CNA stated V19 put R4 on the toilet at 8:30 AM and left the floor at 8:50 AM for a doctor call. V19 stated R4 had said to come back later. V19 returned to find R4 in the wheelchair. V19 assisted V9 and V3 with adjusting the brief. V19 stated V19 did not hear V9 say anything inappropriate or rude.On 8/18/26 at 10:13 AM, V3 LPN stated R4 reported being left on the toilet for over 30 minutes and stated R4 could not stand V9 because V9 was rude.An Abuse Allegation Interview: Staff Interview, dated 8/18/26, documents V3 LPN heard R4 yelling because the call light had been on for a long time. V3 stated V9 said something like V9 is not dealing with this. V3 stated R4's call light had been on for 5-10 minutes.On 8/20/26 at 12:58 PM, V2 Director of Nursing stated staff should not place a resident on the toilet and leave the floor.On 8/19/26 at 11:30 AM, V1 Administrator stated V1 had spoken with V9 and believed there were customer service issues, but could not confirm abuse until the investigation was complete. V1 stated V9 yelled in the hallway for assistance regarding R4's care and stated this should not have occurred.The facility's Abuse Prevention and Reporting - Illinois policy, revised March 2026, states residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment, and the facility prohibits all such actions. The policy further states the facility will maintain a resident sensitive and secure environment to uphold these protections.

Based on observation, interview and record review, the facility failed to ensure complete and accurate skin assessments were conducted upon readmission from the hospital and failed to ensure timely identification and documentation of skin concerns for one (R16) out of five residents reviewed for abuse on a sample list of 16.Findings include:R16's admission Record, dated 8/19/26, documents R16 has diagnoses including Parkinson's disease, Protein-Calorie Malnutrition, Delusional Disorders, Alzheimer's Disease, and Dementia.R16's Minimum Data Set, dated [DATE] documents impairment in short term and long term memory, disorganized thinking, and inattention.On 8/19/26 at 12:05PM, R16 was lying in bed covered with a blanket. Two bruises approximately the size of a quarter were observed on either wrist, mostly yellow with a small, purple center. R16 denied pain and was unable to recall where the bruising originated.R16's Weekly Skin Observation Note, dated 8/19/26 at 08:33AM, documents a new skin concern consisting of bruising to bilateral wrists, redness/skin breakdown to the right iliac crest, and redness/skin breakdown to the left iliac crest. The note documents the physician and family were notified on 8/17/26. The record did not include earlier documentation of these concerns.On 8/19/26 at 12:20PM, V23 Certified Nursing Assistant recalled R16 having bruising on both wrists when R16 returned from the hospital. V23 recalled giving R16 a shower the day after R16's re-admission and reporting the bruising to a nurse, who stated it was likely from intravenous (IV) access during hospitalization.R16's Health Status Note, dated, 8/4/2026, documents R16 returned from the hospital at approximately 4:00PM. It does not document a skin assessment for R16.On 8/19/26 at 2:16PM, V26 Agency Licensed Practical Nurse recalled completing a skin assessment on R16 at re-admission on [DATE] but did not document the assessment. V26 stated being unsure of facility documentation expectations due to being an agency nurse. V26 stated making a short note because someone at the facility stated a brief note was sufficient for admissions, but V26 was unsure who provided that direction.R16's Shower Sheets dated 7/30/26, 8/5/26, and 8/11/26 do not document any skin issues. The shower sheet dated 8/17/26 documents bruising on the outer aspect of the bilateral forearms.R16's Skin Other Skin Condition Report V2, dated 8/8/26 and 8/15/26, document no skin concerns.On 8/20/26 at 10:01AM, V30 (R16's Guardian) recalled visiting R16 approximately 24 hours after R16 discharged from the hospital and observed R16's left wrist covered with gauze similar to aftercare for an intravenous (IV) catheter removal. V30 also observed R16's right wrist with similar aftercare. V30 stated R16 reported having IVs in both wrists during hospitalization. V30 stated the Director of Nursing (V2) contacted V30 on 8/17/26 reporting R16 had bruising to bilateral wrists. V30 visited again on 8/19/26 and observed small bruises on either forearm, believed to be related to recent IV access.On 8/20/26 at 12:58PM, V2 Director of Nursing stated skin assessments are to be completed on admission or readmission from the hospital.The facility's Pressure Injury and Skin Condition Assessment Policy, revised January 2018, documents a skin condition assessment will be completed at the time of admission or readmission.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secured area inaccessible to residents for three (R8, R9, R10) of three residents reviewed for medication administration in the sample list of ten. Findings Include:R8's Electronic Health Record (EHR) documents R8 was admitted to the facility on [DATE] and continues to reside at the facility. According to R8's EHR R8 has diagnoses including Type 2 Diabetes Mellitus, Cerebral Infarction, Essential (Primary) Hypertension, Mixed Hyperlipidemia, Rhabdomyolysis, Protein-Calorie Malnutrition, Anemia, and Insomnia.R8's Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 06. A score of 06 indicates R8 is moderately cognitively impaired.R9's Electronic Health Record (EHR) documents R9 was admitted to the facility on [DATE] and continues to reside at the facility. According to R9's EHR R9 has diagnoses including Malaise, Metabolic Encephalopathy, Alcohol Dependence with Withdrawal, Angina Pectoris, Chronic Embolism and Thrombosis Of Deep Veins Of Right Lower Extremity, Pulmonary Embolism, Mild Protein-Calorie Malnutrition, Venous Insufficiency, and Dementia, Severe, with Agitation. R9's Minimum Data Set completed on May 8, 2026, documents a Brief Interview for Mental Status (BIMS) score of 05. A score of 05 indicates R9 is moderately cognitively impaired.R10's Electronic Health Record (EHR) documents R10 was admitted to the facility on [DATE] and continues to reside at the facility. According to R10's EHR R10 has diagnoses including Epilepsy, Protein-Calorie Malnutrition, Unsteadiness on Feet, Obstructive and Reflux Uropathy, Cognitive Communication Deficit, Hypokalemia, Ocular Pain, Dementia, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Repeated Falls, Folate Deficiency Anemia, Hyperlipidemia, and Generalized Anxiety Disorder.R10's Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 99. A score of 99 indicates R10 is severely cognitively impaired.On 8/4/26 at 12:20PM the surveyor entered the 300 hall (secured hallway), through the closed and secured doors, noting there was an unlocked/unsecured medication cart in the middle of the hallway. On top of the medication cart was an open bottle of 81mg (milligrams) aspirin, an open bottle of 325mg Iron tablets, and an insulin pen. R8, R9 and R10 were noted to be in the area near the unsecured medication cart.V7, Certified Nurse's Assistant (CNA), came out from a resident room. The surveyor asked V7, CNA, where the nurse was located, V7 stated V8, RN (Registered Nurse), was located, at the nurse's station which was on the other side of the unit securement doors out of view of the unlocked medication cart.V7, CNA, stated R8, R9 and R10 are confused and would take unattended medications left out on top of the medication cart. V7 confirmed the medication cart observed in the middle of the hallway was unsecured, unlocked with open medication bottles and an insulin pen on top accessible to the residents.The unsecure medication cart remained under constant observation by the surveyor until V8, RN, returned to the hallway.On 8/4/26 at 12:35PM V8, RN, returned to the hallway through the secured unit doors.V8 confirmed V8 was not on the hallway and could not visually see the medication cart through the closed doors.V8 stated V8 was the nurse for two hallways and was assisting a resident on a different hallway.V8 confirmed at this time the medication cart was unsecured, unlocked with an open bottle of 81mg aspirin, an open bottle of 325mg Iron tablets, and an insulin pen on top.V8 stated V8 had the keys to the medication cart in V8's pocket.V8 stated there is an education binder at the nurse's station that contains education for agency nurses that is supposed to be reviewed before start of the shift.On 8/7/2026 at 11:55AM V2 Director of Nurses confirmed the medication cart should be locked at all times, no medications should be left unattended on top of the medication cart, and that the audits are being completed and agency nurses are the priority for the audits.The Medication Storage policy Dated 12/2025 documents:Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles.Guidelines: The facility should ensure that only authorized Facility staff, as defined by the Facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with Applicable Law.The facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on interview and record review the facility failed to ensure residents were free from significant medication errors for two (R2, R3) of three residents reviewed for medication administration in the sample list of ten. Findings Include:R2's Electronic Health Record (EHR) documents R2 was admitted to the facility on [DATE] and continues to reside at the facility. According to R2's EHR R2's diagnoses include Anxiety Disorder, Major Depressive Disorder, Mental Disorders Due To Known Physiological Condition, Cerebral Infarction, Age-Related Osteoporosis Without Current Pathological Fracture, and Brief Psychotic Disorder. R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired.On 8/4/26 at 10:00AM R2's Electronic Health Record (EHR) review documents R2 was transferred to the local hospital due to administration of insulin (on 7/31/26). R2's EHR does not contain a diagnosis of Diabetes Mellitus.R2's Electronic Health Record (EHR) documents R2 was transferred to the local hospital for treatment due to a non-diabetic resident (R2) receiving insulin administration by the nurse. Hospital Records document R2's Date of Service as 7/31/2026 at 10:45 AM for a chief complaint of accidental medication error. The Hospital Records document R2 was sent to the hospital after being given 34 units of long-acting insulin Lantus and 5 units of short acting insulin Aspart at 10:02 AM. Further review of hospital records documents R2 received treatment of intravenous 10% Dextrose in water.On 8/4/26 at 2:06PM V16, Agency Registered Nurse (RN), stated 7/31/26 was V16's first time working in the facility. V16 stated V16 reviewed the medication administration record, drew the insulin pen up and turned the dial and prepped to give the insulin. V16 stated V16 turned around and entered the wrong room and said good morning to the resident (R2) who responded to V16 and R2 lifted R2's shirt to take the shot and V16 Administered the medication. V16 stated V16 left the room and then realized V16 was in the wrong room and administered the insulin to the wrong resident. V16 stated V16 immediately reported to the Director of Nurses (V2) that V16 gave the insulin to R2 and began to help transfer R2 to the hospital for treatment. On 8/4/26 at 10:08AM V6, R2's Guardian stated V6 was informed that R2 received insulin without a physician order and was transferred to the hospital. V6 stated V6 received a phone call about five minutes after the insulin injection.On 8/4/26 at 11:08AM V2, Director of Nursing (DON), confirmed R2 is not diabetic, does not have an order for insulin and received insulin from the agency nurse. V2 stated R2 was sent to the local hospital for treatment immediately following the administration of the insulin.2. On 8/5/26 at 10:00AM R3's electronic health record (EHR) review documents R3 was transferred to the local hospital due to administration of twice the physician ordered dose of insulin.Hospital Records document R3's Date of Service as 7/30/2026 at 5:57pm for a chief complaint of accidental medication error. The Hospital Records document R3 was sent to the hospital after being given twice the physician ordered insulin. Further review of Hospital Records documents R3 received treatment of intravenous 5% Dextrose in Lactated Ringers.On 8/5/26 at 9:00AM R3 stated R3 was recently sent to the hospital due to receiving two doses of insulin from two different nurses.On 8/5/26 at 2:40PM V19, Agency RN stated V19 was working on 7/30/26 and did not know that another nurse was providing care for R3 and administered the insulin prior to V19 going into the room to administer the insulin. V19 stated R3 never indicated that another nurse had administered the insulin, so V19 administered the insulin. V19 was then talking to V18, LPN (Licensed Practical Nurse) who told V19 that V18 had administered the insulin previously. V18 and V19 informed V2, DON, that a medication error had occurred and sent R3 to the hospital for treatment. On 8/4/26 at 11:08AM V2, Director of Nursing, confirmed R3 is diabetic, and received two doses of insulin on 7/30/26. V2 stated R3 was not in her normally assigned room due to renovations, and two nurses thought they were assigned to the resident for medication administration, and both nurses administered the insulin.The Medication Administration Policy dated 01/2026 documents:Purpose:1. To safeguard the resident.2. To identify causes and prevent future errors.3. To provide guidelines for reporting and recordingThe Medication Administration Policy dated 01/2026 documents:POLICY: I. LEVEL OF RESPONSIBIUTY Licensed nurse (RN, LPN) may: a) prepare, b) administer, and c) record theadministration of medications (prescription ointments are considered medications). Medications shall aways be prepared, administered, and recorded by the same licensed nurse or CMA. Documentation of medication administration is recorded on the Medication Administration Record (MAR) or Treatment Record and includes the date, time, and initials of the licensed nurse or CMA who administered the medication. II. ADMINISTRATION OF MEDICATIONS Medications must be administered in accordance with a physician's order, e.g. (for example), the right resident, right medication, right dosage, right route, and right time.

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from abuse by failing to prevent resident-to-resident physical abuse for eight of nine residents (R5, R6, R7, R9, R10, R11, R26, R27) reviewed for abuse on a sample list of 27. Findings Include: The Facilities Abuse Policy revised on 2/27 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. To do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. 1.R5's Electronic Health Record (EHR) documents diagnoses including Dementia, COPD, Diabetes Mellitus, Congestive Heart Failure, Chronic Kidney Disease, Hypertension, and Major Depressive Disorder. R6's EHR documents diagnoses including Cerebral Infarction, Hemiplegia, Dysarthria, Diabetes Mellitus, Hypertension, and Major Depressive Disorder. On 7/5/26, the facility received an allegation of resident-to-resident physical abuse involving R5 and R6. The facility immediately separated the residents, completed skin and pain assessments, completed psychosocial assessments, initiated an investigation, and notified the physician, responsible parties, police, and Ombudsman. During interviews conducted as part of the investigation, R5 reported R6 struck him with a yardstick for no known reason. R6 reported R5 was repeatedly talking and bothering R6 and stated R6 swatted R5 on the arm with a backscratcher. Additional resident and staff interviews did not identify witnesses to the incident. The Final Abuse Investigation Report dated 7/10/26 concluded that R6 made physical contact with R5's arm with a backscratcher. 2. R9's Care Plan with an admission date of 3/27/26 documents R9 is at moderate risk for abuse related to Cognitive Impairment, Depressive Symptoms, and Frailty. R7's EHR documents diagnoses including Severe Dementia with Mood Disturbance, Major Depressive Disorder, and Alcohol Abuse. R7's care plan documents R7 could misinterpret accidental contact as intentional and become verbally or physically aggressive. Known triggers included crowded areas, personal space violations, and interactions with other residents. On 7/3/26 at 11:15 a.m., staff documented an allegation of a physical altercation between R7 and another resident. On 7/3/26 at 3:38 p.m., the facility documented the root cause as R7 misinterpreting accidental contact when another resident bumped R7's wheelchair while entering the dining room. Interventions were implemented for R7 to eat in the larger dining room and R9 to eat in the smaller dining room to prevent further conflict. On 7/3/26 at 3:43 p.m., Nursing Progress notes documented an intervention to avoid crowded areas because accidental contact triggered R7's agitation and aggression. On 7/6/26 at 11:54 a.m., Social Services documented R7 became verbally aggressive during lunch in the main dining room when the dining room was crowded. Staff de-escalated the situation and moved R7 to a quieter area. Despite identified triggers and interventions, on 7/21/26 at approximately 12:10 p.m., Social Services confirmed prior interventions remained in place following the July 3 incident. On 7/21/26 at 1:00 p.m., R9 stated that while entering the dining room R9's wheelchair accidentally bumped R7's wheelchair. R9 reported R7 made threatening statements and swung R7's arm, striking R9 on the right side of R9's face. No injury was identified. 3. R27's EHR documents diagnoses including Cerebral Infarction, Hemiplegia/Hemiparesis, Seizures, Major Depressive Disorder, and Alcohol Dependence. R27's care plan documents R27 could become verbally and physically aggressive toward others and includes interventions for redirection, separation from residents who escalated behaviors, evaluation of impulse control, and notification of behavioral health providers regarding changes in behavior. R26's EHR documents diagnoses including Paranoid Schizophrenia, Anxiety Disorder, Major Depressive Disorder, and Chronic Medical Conditions. R26's care plan documents a history of verbal and physical aggression and includes interventions to analyze triggers, redirect inappropriate behaviors, consult behavioral health providers when escalation occurred, and maintain the safety of the resident and others. On 7/22/26 at 8:05 a.m., R27 reported R27 became angry after R26 allegedly ran over R26's feet with R27's wheelchair and directed profanity toward R26. R26 admitted R26 removed a brush from R26's pocket and struck R27. On 7/22/26 at 8:08 a.m., V14 (Certified Nursing Assistant) reported there was an altercation in the dining room between R26 and R27 and that R26 removed a brush from R26's pants and struck R27. On 7/22/26 at 8:10 a.m., V12 (Registered Nurse) confirmed R26 and R27 were involved in a physical altercation and that R26 struck R27 with a brush. On 7/22/26 at 8:13 a.m., R26 confirmed R26 struck R27 with the brush after becoming angry. The facility separated the residents, notified the physician, responsible parties, police, and Ombudsman, and completed a preliminary 24-hour abuse investigation report that was submitted to the State Agency. No injuries were identified. On 7/21/26 at 2:35PM, V1 confirmed that all these resident-to-resident physical abuse took place. 4. R10's Minimum Data Set, dated [DATE], documents R10 is moderately cognitively impaired. R10's admission Record, dated 7/22/26, documents R10 has diagnoses including, but not limited to Dementia, Epilepsy, Major Depressive Disorder, Generalized Anxiety Disorder, and Disorientation. R10's Care Plan, dated 10/20/25, documents R10 has a history of criminal behavior and R10's Identified Offenders Program risk level is moderate, which means R10 requires more frequent observation for mental health and behavioral changes. It also documents R10 is at a high risk for abuse related to memory issues, past substance use, aggression, and agitation. An intervention for R10's risk for abuse is to provide a safe and secure environment. It further documents R10 can exhibit aggressive behaviors towards others due to R10's diagnosis of Dementia. R11's Minimum Data Set, dated [DATE], documents R11 is cognitively intact. R11's admission Record, dated 7/21/26, documents R11 has diagnoses including, but not limited to Metabolic Encephalopathy, Alcohol Use with Withdraw Delirium, Psychoactive Substance Abuse, and Bipolar Disorder, Current Episode Hypomanic. R11's Care Plan, dated 10/24/25, documents R11 is at a moderate risk for abuse/neglect due to substance abuse, depressive symptoms, and frailty. An intervention is for the facility to provide a safe and secure environment. R10's Incident Note, dated 7/10/26 at 9:30PM, documents that the nurse went to R10's room due to an argument and upon entering the room, had learned there was a physical altercation between R10 and R11. R10 and R11 were separated. R10 reported that R11 came over to R10's bedside table and took the television remote and an argument followed by a physical altercation had ensued. R10 reported R11 was pounding R11's fist on furniture and stating R11 was going to beat up R10. R10 stated there was pushing, shoving and punching. The nurse noted that the air conditioning unit had been broken and R11's shirt was torn. The nurse assessed R10 and R11 for injury and no injuries were noted. V1 Administrator was contacted and R11 was moved to a new room and the appropriate parties were notified. R11's Incident Note, dated 7/10/26 at 9:30PM, documents R11 stated R11 got the television remote from R10's table to turn off the television. R11 then became increasingly upset and did not wish to speak about it any further. No injuries were sustained from the altercation. On 7/22/26 at 8:43AM, R10 was lying in bed. R10 recalled the incident from 7/10/26 with R11 but R10 did not wish to speak about it. R10 stated, I've had enough with (R11). R10 appeared agitated while stating this and no longer wanted to speak. On 7/22/26 at 8:38AM, R11 was lying in R11's bed utilizing a laptop on R11's bedside table. R11 did not wish to speak about the incident with R10 on 7/10/26. R11 then pulled the blanket over R11's face and no longer wished to speak. On 7/22/26 at 10:42AM, V2 ADON stated that R10 and R11 had been roommates for a long time. V2 reports that R10 and R11 have always gotten along and have not had any issues. V2 recalled the incident between R10 and R11 on 7/10/26. V2 stated that R11 came up to the nurses' station without a shirt on and reported that R11 and R10 had gotten into a fight over the television. V2 stated when V2 went to R11 and R10's room, R10 was lying in R10's bed and would not speak to V2 or V13 LPN. V2 stated R10 ignored V2, V13 and R11. During V2's duration in the room, R11 attempted to lunge at R10. V2 and V13 separated R10 and R11. V2 moved R11 to another room. V2 reported this to V1 Administrator. On 7/21/26 at 2:43PM, V11 Social Services Director stated that R11 has been verbally aggressive and agitated in the past. V11 stated on the morning of 7/11/26, R11 was the most escalated V11 has ever seen him. R11 was able to be calmed down that day. V11 reports that R11 is somewhat difficult to find a roommate to pair with due to R11's agitation. V11 reports R11 has never been physically aggressive before the 7/10/26 incident with R10. V11 stated that R11 has never been aggressive with any of R11's prior roommates. V11 stated that R10 has made attempts to be physically aggressive before with other roommates and sometimes staff, but not recently. On 7/22/26 at 12:28PM, V1 Administrator stated that the investigation for R10 and R11's incident on 7/10/26 indicated R10 and R11 made physical contact with each other. V1 also stated the facility's Abuse Policy documents physical abuse would include hitting and kicking.

Based on observation, interview, and record review the facility failed to utilize appropriate personal protective equipment (PPE) when providing care for residents on Enhanced Barrier Precautions, failed to remove soiled PPE prior to exiting a resident's room, failed to prevent potential cross contamination during incontinence/face care, and failed to ensure soiled linens were not placed on the floor for three of three residents (R8, R13, and R15) reviewed for infection control in a sample of 18. On 6/12/26 at 11:53 a.m., V2 Assistant Director of Nursing/Wound Nurse/Infection Control, entered R8's room to perform wound care. A sign on R8's door documents R8 requires Enhance Barrier Precautions (EBP). V2 did not don a gown a before entering R8's room or during wound care. On 6/15/2026 at 8:02 a.m., V15 Certified Nurse Assistant (CNA) stated staff should wear gloves, a gown and a mask when providing care for residents on Enhance Barrier Precautions (EBP). On 6/12/26 at 11:45 a.m., V2 Assistant Director of Nursing/Wound Nurse/Infection Control stated she has been providing wound care/treatments since last week. V2 stated V2 does wound treatment for residents. V2 stated she has not received training for wound care or infection control. On 6/15/2026 at 7:57 a.m., V16 Licensed Practical Nurse (LPN) stated, staff should wear gloves, a gown and a mask when providing care for residents on Enhance Barrier Precautions. On 6/15/2026 at 9:14 a.m. V17 Director of Nursing (DON) stated Enhance Barrier Precautions (EBP) signs indicate staff should wear personal protective equipment such as a gown, gloves and a mask when providing care. V17 stated, I have been telling staff to wear the mask when going in Enhance Barrier Precautions rooms just to be safe with all the respiratory infections going around. R8's Care Plan dated initiated on 6/19/2025 documents R8 is on Enhanced Barrier Precautions related to a suprapubic catheter. The Care Plan also states to educate staff/resident/family on enhanced barrier precautions as needed and states to use gown and gloves during high contact resident care activities (such as dressing, bathing, showering, changing briefs, assisting with toileting, or wound care). R8's Minimum Data Set (MDS) dated [DATE] documents R8 is cognitively intact. R8's physician's order dated 6/15/25 documents R8 requires Enhanced Barrier Precautions related to Suprapubic Catheter every shift. 2. R13's Minimum Data Set (MDS) dated [DATE] documents R13 is cognitively intact. R13's physician's order dated 1/19/2026 documents to use Enhanced Barrier Precautions related to dialysis port. R13's Care Plan dated 1/19/2026 documents to use Enhanced Barrier Precautions (EBP) related to a central line needed for dialysis treatment. Interventions include gown and glove during high contact resident care activities (such as dressing, bathing, showering, changing briefs, assisting with toileting or wound care). On 6/13/26 at 11:00 a.m., V7 Certified Nurse's Assistant (CNA), provided incontinence care for R13. R13 has a sign on R13's door documenting R13 requires EBP. V7 did not wear a gown during cares. V7 removed R13's soiled incontinence brief and tossed the brief onto the floor. V7 cleansed R13's perineal area with a dampened washcloth and threw it on the floor also. V7 dampened a clean washcloth and wiped R13's face and threw it on the floor. V7 removed soiled linens from R13's room without placing the linens into a bag then V7 proceeded to walk down the hall with dirty gloves on and dirty linens in hand. V7 dropped the dirty linens onto the hall floor due to not having the dirty linen hamper available and V7 walked away. V7 did not change gloves between dirty to clean cares. On 6/13/26 at 11:15 a.m., V7 confirmed R13 had an EBP sign on the door and V7 stated she should have worn a gown when provided cares. V7 stated she should have put the dirty linens in a trash bag before taking it out of R13's room and placed it in a dirty linen hamper and not on the floor. V7 stated she should have changed gloves between dirty to clean areas. On 6/15/26 at 8:36 a.m., V11 Registered Nurse (RN) stated staff should wear gloves when providing care to the residents on EBP precautions. V11 stated dirty linens should be transported in a plastic bag and not to be placed on the floor. On 6/15/2026 at 9:14 a.m., V17 Director of Nursing (DON) stated an Enhanced Barrier Precautions (EBP) sign on the door means staff should wear Personal Protective Equipment (PPE) such as gown, gloves and mask. V17 stated, I have been telling staff to wear the mask when entering Enhance Barrier Precautions rooms just to be safe with all the respiratory infections going around. 3. On 6/13/26 at 1:45 p.m., V2 ADON/Wound Nurse/IP provided wound care for R15. After completing the wound care, V2 left R15's room with gown and gloves on and proceeded to walk down the 200 hall rolling a bedside table draped with a hand towel and used wound supplies on top of the table. V2 placed the bedside table in front of a resident room and walked down to the end of the 400-hall still wearing the dirty gown and gloves. V2 then removed the dirty gown and gloves on the 400-hall and then returned to medication cart. On 6/13/26 at 11:15 a.m., V2 stated she should have removed the Personal Protective Equipment (PPE) before leaving the resident's room. V2 stated staff should not wear used PPE in the hallway. V2 stated she was newly hired and has not been trained in infection control and wound care. On 6/15/2026 at 9:14 a.m., V17 Director of Nursing (DON) stated she would expect the staff to remove PPE prior to leaving the room and perform hang hygiene. On 6/15/26 at 2:30 p.m., V1 Administrator stated the facility provided in-services to staff regarding Enhanced Barrier Precaution (EBP). V1 stated there are signs on the door for residents that are on EBP, and staff are expected to wear complete PPE or follow the instructions written on what to wear. R15's Minimum Data Set (MDS) dated [DATE] documents R15 is cognitively intact. R15's physician's order dated 9/4/2025 documents Enhanced Barrier Precautions for Central Venous Catheter (CVC) port. R15's Care Plan dated 9/5/2025 documents Enhanced Barrier Precautions (EBP) related to CVC dialysis port. Interventions include gown and glove during high contact resident care activities (such as dressing, bathing, showering, changing briefs, assisting with toileting or wound care). The Facility's Policy for Enhanced Barrier Precautions dated 12/2025 documents Personal Protective Equipment: Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: dressing, bathing/showering, providing hygiene, changing linens, incontinence care, medical device care, wound care.

Based on interview and record review, the facility failed to perform weekly skin assessments for three of three residents (R2, R8, R15) reviewed for wound care management in a total sample of 18. Findings include: Findings include:R2's Care Plan initiated 5/8/2026 documents R2 was admitted to the facility 5/7/26 and has diagnoses of Congestive Heart Failure, Morbid (severe) Obesity Due to Excess Calories, Type 2 Diabetes Mellitus with Foot Ulcer, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Charcot Foot due to Diabetes Mellitus, Chronic Kidney Disease Stage 5, End Stage Renal Disease on Hemodialysis, Atherosclerosis of Native Artery of Both Lower Extremities with Intermittent Claudication. R2's Care Plan dated 5/12/2026 documents R2 is at risk for skin impairment related to decreased mobility. R2's physician's order dated 5/13/2026 documents an order for weekly skin assessment every night shift every Wednesday, notify doctor if new impairment. R2's skin-other-skin assessment dated [DATE] documents a skin assessment was completed on 5/11/26. R2's Medical Record does not document additional skin assessments completed during R2's stay at the facility. R2's Minimum Data Set (MDS) section C dated 5/12/2026 documents R2 is cognitively intact.R2's electronic medical records dated 5/30/26 document R2 was re-admitted to the hospital from the facility with a new deep tissue injury to the left foot upon arrival to emergency department.R2's hospital records dated 5/30/2026 included a Clinical Note documenting the following wounds 0304 (AM) right gluteal pressure injury, stage 2-wound thickness: partial, wound 05/30/26 0400 (AM) right lateral; plantar foot surgical, non-healing-wound thickness: partial, wound 05/30/26 0400 (AM) left dorsal toe, great pressure injury, deep tissue grade 1-wound thickness: partial, wound 05/30/26 0400 (AM) scrotum MASD (moisture associated skin damage)-wound thickness: partial, wound 05/30/26 0918 (AM) left plantar foot pressure injury, deep tissue-wound thickness: full, wound 05/30/26 1233 (PM) coccyx MASD (moisture associated skin damage)-wound thickness: partial, and wound 05/30/26 1233 (PM) left coccyx pressure injury, deep tissue-wound thickness: partial.On 6/12/2026 at 10:00 a.m., V3 Family Member confirmed seeing R2's new wound to the left foot upon arriving to the emergency room on 5/30/2026. On 6/12/2026 at 12:10 p.m., V16 Licensed Practical Nurse (LPN) stated R2 had a wound to the right foot during R2's stay at the facility but was unaware R2 had a wound to the left foot. On 6/12/2026 at 12:18 p.m. V19 CNA (Certified Nursing Assistant) stated V19 only remembers R2's wound to the right foot with wound vac.On 6/15/2026 at 12:05 p.m., V38 LPN stated weekly skin assessment should be performed and documented under the skin assessment tab after completing the assessment. On 6/15/2026 at 2:31 p.m. V16 LPN confirmed a weekly assessment was completed if a skin assessment was documentation under the assessment tab in the resident's electronic medical record. On 6/15/2026 at 9:14 a.m., V17 Director of Nursing (DON) stated being aware of R2's chronic wound to the right foot, however V17 was unaware of R2 having a wound to the left foot. V17 stated she expects the nurses to perform weekly skin assessments for residents with increased risk for skin impairment. High Risk weekly skin assessments and the assessments should be documented under the skin assessment tab on the resident's electronic medical records. On 6/15/2026 at 11:30 a.m., V37 Nurse Practitioner (NP) confirmed R2 had a chronic wound to the right foot, however V37 was unaware of a wound to the left foot. V37 stated she expects the nurses to perform more frequent skin assessments than weekly due to R2's comorbidities and already preexisting wounds. V37 stated she expects at least daily if not every shift skin assessments for R2. The Facility Wound Report dated 3/17/2026-6/14/2026 and the Wound Round Report pulled on 6/12/2026 at 11:10 a.m. documents R8 has active wounds to the Left lower leg classified as abrasions staged as superficial with a date identified as 3/20/2026 and R8 has an active wound to the right great plantar toe classified as a blister and staged as partial thickness with date identified as 7/28/2025.R8's record review documents skin assessment completed on 6/19/2025 and 11/25/2025 for the last 12 months. R15's physician order dated 8/27/2025 documents a physician order of weekly skin assessment every night shift on Wednesday.The Facility Wound Report dated 3/17/2026-6/14/2026 and the Wound Round Report pulled on 6/13/2026 at 1:00 p.m. document R15 has wounds to the left plantar foot since 8/26/2025 and the right lateral foot since 12/26/2025 that are vascular diabetic, and the right lower leg since 4/23/2026 that are abrasions. R15's record review documents skin assessment was completed 9/4/2025, 9/20/2025 and 11/3/2025 for the period of nine months.On 6/15/26 at 9:14 AM V17 DON stated V17 expects nurses to complete weekly assessment on all residents. The Facility's Skin Condition Assessment and Monitoring- Pressure and Non-Pressure Policy dated 12/2025 documents A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. Residents identified will have a weekly skin assessment by a licensed nurse. Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment.

Based on observation, interview and record review the facility failed to maintain a resident's privacy and dignity by failing to ensure shower rooms were protected from unauthorized entry during bathing and personal care for two (R84, R52) of two residents and failed to protect a resident's dignity and privacy by failing to cover an indwelling urinary collection bag for one (R39) of one resident reviewed for infection control in the sample list of 47. The facility's failure to protect residents from repeated privacy intrusions during bathing caused emotional distress, fear, embarrassment, and loss of personal privacy. These outcomes constitute actual harm as R84 and R52 experienced negative psychosocial consequences directly related to the facility's deficient practice. Findings Include: On 5/31/2026 at 11:05AM, V1 Administrator stated V1 submitted an initial report on 5/29/26 due to R84 reporting two males were trying to enter the shower room while R84 was taking a shower. V1 stated V1 has not completed a full investigation and submitted a final to the State Agency. On 5/31/2026 at 9:20 AM, R84 was in bed and reported concerns regarding privacy in the shower room. R84 stated that approximately two days earlier, while a resident was preparing to shower in the shower room, two male residents attempted to enter the shower room. Although Certified Nursing Assistants (CNAs) attempted to redirect the residents, R84 stated the situation made R84 feel unsafe and fearful. R84 expressed concern for R84's personal safety and concern that R84 could be sexually assaulted. On 5/31/2026 at 10:01 AM, R86 stated R86 routinely used the shower room as a restroom and was frequently present in the hallway area surrounding the shower room. On 6/1/2026 at 2:45 PM, R70 stated R70 used the shower rooms located on the 100 and 400 halls and reported that residents and staff frequently entered the shower room without knocking while R70 was showering. R70 stated the incidents made R70 feel embarrassed and reported that it occurred regularly. On 6/2/2026 at 9:22 AM, V28 Certified Nursing Assistant was providing a shower to R40 in the 100 Hall shower room when R61 entered the shower room without knocking. At this time, the occupancy indicator was positioned to occupied with a red sign displayed; however, the door remained unlocked. On 6/2/2026 at 9:45 AM, V28 Certified Nursing Assistant stated that residents and staff entered occupied shower rooms all the time without knocking despite the occupancy sign indicating the room was occupied. On 6/2/2026 at 10:15 AM, V14 Certified Nursing Assistant stated that residents and staff routinely entered shower rooms while staff were providing showers. V14 stated there should be a better method to prevent residents and staff from entering occupied shower rooms. On 6/2/2026 at 10:20 AM, R52 stated that residents frequently ignored the occupied/vacant sign and entered shower rooms while occupied. R52 reported that residents would bust through the shower room door, invading privacy. R52 further stated that male residents would sometimes wait outside the bathroom area and then enter the shower room. R52 stated these incidents made R52 feel awkward, nervous, scared, and embarrassed. On 6/2/2026 at 11:15 AM, V2 Director of Nursing stated that residents and staff should not enter a shower room when the occupancy indicator was red and displayed as occupied, but there needs to be a better system as there is no lock or keypad on the door. The facility's Dignity Policy, revised August/2026, documented that the facility shall promote care for residents in a manner and environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The policy further stated that resident privacy would be protected and valued, including requesting permission before entering private spaces and ensuring privacy during care 2. On 05/31/26 at 9:23 AM and 9:57 AM, R39 was sitting in the wheelchair in R39's room. R39's urine drainage collection bag did not have a dignity cover over it and the bag was laying directly on the floor under the wheelchair. On 05/31/26 2:27 PM R39 was sitting in R39's wheelchair in the dining/activity room. R39's indwelling urine drainage collection bag did not have a dignity cover of it and the collection bag was laying directly on the floor under the wheelchair. On 05/31/26 3:30 PM V2, (Director of Nursing) stated urinary drainage collection bags are to be covered for all residents.

Based on observation, interview, and record review, the facility failed to ensure expired medications were discarded and not available for use and failed to ensure medications were stored in a manner to prevent potential cross contamination. This failure has the potential to affect all 91 residents residing in the facility. Findings include: The facility's Medication Storage policy dated 10/2015 documents the facility should destroy or return all discontinued, outdate/expired, or deteriorated medications or biologicals. On 6/2/26 at 8:04 AM, V43 License Practical Nurse (LPN) was in the medication storage room. There were three bottles of Oyster Shell Calcium Plus Vitamin D (mineral supplement) 250 milligrams (mg) containing 100 tablets sitting on the shelf. An expiration date of 5/26 was printed on these three bottles of Oyster Shell Calcium Plus Vitamin D. There was also two bottles of Bisacodyl (laxative) 5 mg containing 200 tablets sitting on the shelf. An expiration date of 2/26 was printed on these two bottles of Bisacodyl. At this time there were five bottles of Jevity 1.2 CAL (calorie)- 50.7 Fluid Ounces of tube feeding formula sitting on the self. An expiration date of 5/26 was printed on these five bottles Jevity. Additionally, 50 prefilled 10 milliliters (mL) normal saline flush syringes with an expiration date of 7/25 and multiple Intravenous (IV) start kits with expiration date 4/25 were present in the medication room. On 6/2/26 at 8:20 AM, V2 Director of Nursing (DON) stated expired items are to be removed when found. On 6/2/26 at 8:25 AM, an open box of coffee pods were found in the IV (Intravenous) storage cart with IV tubing and other medical supplies. On 6/3/26 at 1:00 PM V2 DON stated all residents could potentially use the expired medications. The Long-Term Care Facility Application for Medicare and Medicaid dated 5/31/26 documents the facility has a census of 94 residents.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent and control the presence of insects within the facility for seven residents (R7, R14, R16, R70, R72, R84, and R94) reviewed for environmental concerns. This deficient practice had the potential to affect all 91 residents residing in the facility by exposing them to unsanitary environmental conditions and nuisance pests within resident living areas.Findings:The facility's Pest Control policy, effective December/2025, documents the purpose of the pest control program was to prevent or control insects and rodents from spreading disease. The policy further documents the pest control program would be conducted on a regular and as-needed basis, employees were instructed to promptly report observations of pests to their department heads, and the facility was to be maintained in a condition that prevented the harborage or feeding of insects and rodents. This document also states the department would be periodically inspected and serviced by a pest control company. The policy further documented a pest control log would be maintained, including the type of pest, location, and date observed, and that the contractor would document visits and actions taken.On 5/31/2026 at 8:45 AM, R7's room had food debris scattered throughout the room, ants present on the floor, and flies flying within the room.On 5/31/2026 at 9:20 AM, R84 was repeatedly swatting at flies while lying in bed. Flies were observed in the room that is shared by R84 and R94.On 5/31/2026 at 12:52 PM, R16 stated crawling black bugs and flies are an ongoing issue within the facility and further stated R16 had seen insects in R16's room and throughout the facility hallways. R16's Minimum Data Set (MDS) assessment dated [DATE] documented R16 was cognitively intact.On 5/31/2026 at 12:55 PM, R16's room had flying black insects present near a full trash receptacle located within R16's room.On 6/1/2026 at 9:15 AM, R14 stated R14 had experienced an ant issue the previous day and had several ants crawling on the floor near dropped food in R14's room. R14 stated facility staff entered the room and swept up the ants.On 6/1/2026 at 10:00 AM, R70 stated there have been ants and flying insects within the facility during the previous several weeks. R70's MDS assessment dated [DATE] documented R70 was cognitively intact.On 6/1/2026 at 10:30 AM, R72 stated flying insects, which R72 described as gnats, were present in the dining area during mealtimes. R72 stated the insects would fly around R72's face while eating and further stated R72 had observed other residents swatting insects away from their faces during meals. R72 also stated R72 had seen ants crawling on the dining room floor.On 6/1/2026 at 1:45 PM, V17, Certified Nursing Aide (CNA), stated V17 has known of the insect and bug issue within the facility for an extended period of time. V17 CNA stated V17 had seen ants in several resident rooms as well as common areas of the facility. V17 confirmed the black crawling insects actively crawling on the floor in a common area hallway were ants. V17 stated ants have been an ongoing issue within the facility during the previous several weeks.On 6/2/2026 at 11:42 AM, V19 Maintenance Director, stated V19 was unaware of a pest control log maintained by the facility. V19 also stated an outside pest control company had been at the facility within the previous few weeks but was unable to provide the exact date of service. V19 stated the pest control company recommended additional exterior treatment to better control ants around the facility.On 5/31/2026 at 2:46 PM, V1, Administrator, stated V1 had considered utilizing the facility's contracted pest control company to perform additional spraying due to ants being present within the facility.

Based on observation, interview, and record review the facility failed to protect residents' right to a functional, sanitary, and comfortable environment in the facility. This failure has the potential to affect all 91 residents residing in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid dated 5/31/26 documents a facility census of 91 residents. On 5/31/26 at 11:16 AM the facility had multiple areas with scraped paint on the walls and doors, ceiling tiles that show water damage and discoloration, floors that appear dirty and worn, broken tile, missing baseboards and trim throughout the facility, cloudy windows, dirty windowsills, and old discolored sanded wood handrails with no paint or stain. On 6/3/26 at 10:50 AM V1 Administrator confirmed the facility needed a lot of environmental work, both cometic and functional. On 05/31/2026 at 9:15 a.m., the wall behind R1's bed had a hole measuring approximately 10 inches by 12 inches. This hole was in line with R1's bed frame. On 5/31/2026 at 9:25 a.m., all resident doors on the 200 hallway had black scuff marks along the bottom half of the doors, the floors had dark black marks running up and down the hall, and the baseboards were pulled away from the walls. On 6/2/2026 at 11:38 a.m., V19 Maintenance Director stated V19 was not aware of any resident rooms containing holes in the walls. V19 stated V19 uses an (Operations and Building Management Platform) for communication with staff regarding items that need repaired. V19 stated there are no work orders regarding holes in the walls in any residents' rooms. V19 stated V19 would fix the holes in the walls if notified of the issues. On 5/31/26 all of the walls within the facility had paint chip marks and, on the ceiling, there are holes around the sprinkler system. On 05/31/2026 at 8:45 AM, R7's room had a hole measuring approximately 12 inches by 10 inches in the wall approximately one foot above mattress height. On 05/31/2026 at 9:20 AM, in R84 and R94's room there was a hole approximately 10 inches by 10 inches in the wall underneath the air conditioner located underneath the window. R84 stated holes and cleanliness throughout the building have always been a problem and management staff knows because it has been reported.

Based on interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours per day. This failure has the potential to affect all 91 residents residing in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid dated 5/31/26 documents a facility census of 91 residents. Facility Nursing Staff Daily Schedule Sheets document the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours on 5/4/26 and 5/22/26. On 6/3/26 at 10:14 AM, V2 Director of Nursing confirmed the facility did not have RN coverage on 5/4/26 and 5/22/26. The facility's Facility assessment dated [DATE] documents a Registered Nurse is needed every day in order to provide competent support and care for the facility's resident population.

Based on interview and record review, the facility failed to communicate regularly with the dialysis center to coordinate resident dialysis care. This failure affects one resident (R5) of one reviewed for dialysis on the sample list of 47.Findings include:The facility's Care Coordination Agreement (2/23/2024) between the facility and their contracted kidney dialysis provider documents For the purposes of care coordination, in advance of each Resident's dialysis treatment, Long Term Care Facility shall furnish all information and documentation necessary for Dialysis Facility to provide safe and appropriate care, including any and all information reasonably requested by Dialysis Facility.R5's Census Sheet (6/2/2026) documents R5 admitted to the facility on [DATE].R5's Medical Diagnosis sheet (6/2/2026) documents diagnoses including End Stage Renal Disease, Type 2 Diabetes Mellitus, Chronic Embolism And Thrombosis Of Deep Veins of Lower Extremity, Cellulitis, Peripheral Vascular Disease, and Osteomyelitis.R5's Physician Orders form (6/2/2026) documents an order starting on 8/7/2025 for R5 to receive hemodialysis outside of the facility three times per week on Mondays, Wednesdays, and Fridays. The same record documents an order for facility staff to obtain R5's vital signs prior to each dialysis treatment and to weigh R5 every Monday, Wednesday, and Friday morning before R5 receives dialysis. R5's Care Plan (6/2/2026) documents R5 needs kidney dialysis related to End State Renal Disease. The same record documents an intervention to coordinate care with outside providers regarding dialysis.On 6/1/2026 at 1:32PM, V2 (Director of Nursing) reported the facility uses communication forms that should be sent with R5 to the dialysis center three times per week to communicate recent changes in vital signs, weights, changes in condition, and any new labs or changes of orders. V2 reported the same form should be returned to the facility when R5 returns from dialysis and the form has a section for dialysis center staff to complete that documents resident vital signs and weight post-dialysis, changes or concerns with resident status, and any new orders, labs, or instructions for the resident. V2 reported the communication forms should be located in the R5's electronic medical record or in a three-ring binder located at the nurse's station. V2 reported the facility has had some difficultly getting the dialysis center to return the communication forms sent with R5 on treatment days.On 6/1/2026, R5's electronic medical record (undated) documented the presence of only two Dialysis Communication Forms for all of R5's 42 or more weeks of dialysis treatments since R5 began dialysis the week of 8/7/2025.On 6/1/2026 at 1:36PM, the above three-ring binder was located at the nurses station and only contained blank communication forms and no completed forms for R5. V35 (Registered Nurse) was present and reported completed forms for residents receiving dialysis treatment are supposed to be in the binder. On 6/2/2026 at 3:10PM, V2 reported if R5 does not have any more communication forms in R5's electronic medical record, then additional forms for R5 probably do not exist. V2 reported facility staff nurses should complete a dialysis communication form for R5 prior to sending R5 to the dialysis center and then facility staff hand off that sheet to the dialysis center staff and should retrieve the sheet when R5 is picked back up after dialysis. V2 reported the in-house facility nurses will complete the communication forms but the facility has had a lot of nurse turnover and agency nurses are filling in and they have not been completing the forms for residents who receive dialysis. V2 reported the nurse on shift should be calling the dialysis center if a resident returns without the form to ensure coordination of resident care.

Failures at this level required more than one deficient practice statement. Based on observation, interview, and record review the facility failed to protect residents' right to a clean, comfortable, and homelike environment in resident living and dining spaces. This failure affects 18 of 24 residents (R1, R2, R3, R7, R9, R10, R19, R21, R29, R45, R55, R65, R68, R71, R84, R85, R94, R99) reviewed for environment on the sample list of 47. Findings Include: The Illinois Long-Term Care Ombudsman Program: Resident Rights for People in Long-Term Care Facilities, last revised November 2018, documents all residents have the right to live in a facility that is safe, clean, comfortable, and homelike. On 5/31/2026 at 10:07 AM R85's room had very dirty floors, garbage under the bed, dirt build up around the edges where the floors meet the walls, marks on the walls, paint scraped off the walls, trash and debris outside of R85's window, the bedside table had built up gunk around all the edges of the table, the closet door was broken, there was base board missing in the bathroom, a strong urine smell in the bathroom, and used paper towels piled up on the sink due to there being no trash can in the room. On 5/31/26 at 10:31 AM R21's room had a bed frame with no mattress, holes and scrapes on the walls, clothes all over the floor, a very dirty floor, and a used urinal and bed pan with a dark substance in it on the floor by R21's bed. R21's bathroom had a dark substance all over the toilet seat and the seat itself was pealing, yellow stained towels were on the floor next to the toilet, a plunger with a towel around it was sitting by the toilet, a used bed pan was on the floor, the base of the walls were torn up with no base trim, and paint was peeling from the door frame and door itself. R21 stated R21 wishes the facility would keep R21's room and bathroom clean because it is disgusting to use the bathroom and makes R21 very uncomfortable. On 5/31/2026 at 10:43 AM R55 and R10's room had clutter everywhere on the floor, debris and trash, bags and boxes, food and drinks covered bedside tables, a trashcan with no liner had old food in it, and the closet doors were broken. On 5/31/2026 at 10:55 AM R2's room had paint scraped off of the walls, a broken closet door, a bed frame with no mattress, air conditioning unit coming off the wall and a bedside dresser cabinet door was broken. The bathroom had peeling paint and scraped up walls, three plungers sitting around the toilet, a toilet riser covered in a dark substance, a hole in the wall, a bed pan resting on the towel rack on the wall beside the sink, and a dirty incontinence brief in the trash can. R2 stated housekeepers do not come into R2's room very often or clean anything every day. R2 stated R2 takes out R2's own trash because it gets full and the housekeepers never come into her room. On 5/31/2026 at 11:01 AM R99's room had a broken closet door, one knob missing, very dirty floor, and peeling paint on the walls. On 5/31/26 at 11:05 AM R19's room had scraped paint peeling off the walls and the floors were messy. R19's bathroom had a bedpan resting on the towel bar on the wall and no trash can liner with paint peeling off the wall above the sink. R19 stated R19 doesn't remember the last time R19's sheets were changed and housekeeping hardly ever comes into R19's room. On 5/31/26 at 11:10 AM R65's bathroom had no trash can liner, an incontinence brief hanging on the towel bar, a dirty toilet seat with a brown substance on it, and the entire room's floor was dirty. On 6/3/26 at 10:50 AM V1 Administrator confirmed the facility needed a lot of environmental work and housekeeping staff needed to do a better job of cleaning up the facility. On 05/31/2026 at 8:45 AM, R7's room had food debris scattered throughout the room. R7's floor was sticky from some kind of liquid that had been spilled on the floor. R7 also had noticeable trash on the floor which included Styrofoam cups, wrappers and old food. R7 stated no housekeeping has been in to clean R7's room for over a week. On 05/31/2026 at 9:20 AM, R84 and R94 had noticeable food on the floor, the garbage was overflowing, the floor was sticky with visible corn on the floor. R84 stated that nobody ever cleans their room. R94 stated cleanliness throughout the building has always been a problem and management staff knows because it has been reported. On 6/1/2026 at 9:01AM, V2 Director of Nursing confirmed R7's room needed to be cleaned and stated there has been a staffing turnover with housekeeping. On 5/31/2026 at 9:15 a.m., R1's room had a sticky substance on the floor. On 5/31/2026 at 9:13 a.m., R3 and R29's (roommates) room had trash (cups, papers, food wrappers) on the floor between R3 and R29's beds and the floor had a sticky substance on it. On 6/1/2026 at 12:45 p.m., R1, R3, and R29's resident rooms had not been cleaned and appeared the same as they did on 5/31/2026. On 6/2/2026 at 11:28 a.m., R1's room was in disarray with food debris and a sticky substance on the floors. On 6/2/2026 at 11:25 a.m., V23 Housekeeper stated housekeepers are to clean rooms every day, including garbage, mopping and high touch service areas. On 6/2/2026 at 11:35 a.m., V24 Housekeeping Supervisor stated the facility has housekeepers every day of the week. V24 stated the expectation of housekeepers is to clean all rooms daily and each housekeeper is to deep clean one room a day until there is a monthly rotation in place. On 05/31/26 at 11:31 AM, the floor in the dining room was sticky making it difficult to walk. 2. On 05/31/26 at 11:31 AM, V8 Certified Nursing Assistant (CNA) and V10 CNA pulled more chairs away from the tables and placed them in the entrance of dining area to the left side. V8 CNA stated the dining area cannot accommodate all residents utilizing the dining room at the same time and because of this some residents choose to eat in their rooms. On 05/31/26 at 11:50 AM, V10 CNA assisted R9 and R71 with their meals. While assisting R9 and R71, V10 CNA stood up and was standing over them while going back and forth between the two. V10 CNA stated it was easier to stand as V10 had to help other residents often. 05/31/26 12:09 PM, V10 CNA squeezed behind another resident sitting at table and the wall to assist R71 with their meal. V10 CNA stood up while feeding R71. V10 CNA stated V10 must stand up because there isn't enough room to place another chair on that side. On 05/31/2026 at 12:18 PM, R45 and R68 attempted to get out of dining area, both were not able to get past the chairs along the wall and other resident wheelchairs. V8 CNA assisted R45 and R68 out of dining area.

Based on interview and record review the facility failed to develop a Dementia specific plan of care for one of three residents (R2) reviewed for Dementia Services on the sample list of 47. Findings Include: R2's Medical Diagnoses List dated June 2026 documents R2 is diagnosed with Unspecified Dementia Unspecified Severity with other Behavioral Disturbances. On 6/02/2026 at 11:50 AM V2 confirmed R2 did not have a plan of care related to R2's Dementia diagnosis and R2 should have one. V2 confirmed a Dementia care plan was added on 6/1/26 after surveyor notified the facility there was no Dementia plan of care in R2's medical record.

Based on observations, interviews and record review the facility failed to ensure an accident hazard-free environment and failed to provide safe assistive devices for one resident (R7) reviewed for accidents on a sample list of 47. Findings Include: R7's diagnoses included Complete Paraplegia, Stage Four Pressure Ulcers of the Left and Right Lower Back and Right Hip, Chronic Osteomyelitis, Protein-Calorie Malnutrition, Cellulitis, and an Unspecified Thoracic Spinal Cord Injury. The care plan documented that R7 had a history of bumping lower extremities on objects while repositioning in bed and required interventions to maintain skin integrity and prevent injury.Review of nursing documentation dated 4/19/2026 at 2:40 PM revealed R7 was found bleeding from the left leg with a large amount of blood present in the room and hallway. R7 stated R7 was attempting to lift R7's left leg with a grabber/reacher and did not realize R7 had cut R7's self. Nursing staff applied pressure, initiated emergency measures, and called 911. Additional nursing documentation indicated R7 became intermittently unconscious and was transferred by ambulance to the emergency department. Documentation dated 4/19/2026 at 4:58 PM indicated R7 was receiving blood for blood loss. Hospital return documentation dated 4/20/2026 noted an incision to the left lower leg with six stitches.On 5/31/2026 at 8:45 AM, R7 was in bed, with the reacher/grabber on the floor next to R7. R7 stated since R7 can't feel R7's legs, R7 must have hit the reacher/grabber on R7's left leg which required hospitalization. R7 stated it was a one and million accident and stated R7 has used the reacher/grabber for years. On 5/31/2026 at 8:28 AM, V2 Director of Nursing, removed the grabber/reacher from the room and informed R7 that a safer grabber/reacher would be obtained as V2 confirmed part of the reacher/grabber had sharp edges.

Based on interview, and record review, the facility failed to obtain informed consent prior to administering psychotropic medications for one (R77) of two residents reviewed for psychotropic medications in the sample list of 47.Findings include:The facility Behavioral Health Services Program, last approved on 03/2025, documents Obtain consent for any new psychotropic medications prior to administration.R77's clinical Physician Orders, printed 5/31/26, documents Olanzapine (antipsychotic) 2.5 milligrams (mg) by mouth one time daily ordered on 5/27/26, Fluoxetine (antidepressant) 10 mg to be given with Fluoxetine 20mg for a total of 30 mg daily ordered on 5/2/26, Trazodone (antidepressant)150 mg at bedtime ordered on 4/30/26, Clonazepam (benzodiazepine) 1 mg twice daily ordered 4/30/26, and Buspirone (antianxiety) 20 mg twice daily ordered on 4/30/26. R77's Medication Administration Record documents that R77 has received the medication as ordered in May of 2026.R77's medical record did not contain documentation of informed consent for Olanzapine 2.5 mg, Fluoxetine 30 mg, Trazodone 150 mg, Clonazepam 1 mg, or Buspirone 20 mg.On 6/1/26 at 4:47 PM, V25, R77's Power of Attorney, stated V25 had not signed consent forms or provided verbal consent for R77's psychotropic medications.On 6/1/26 at 1:27 PM, V2, Director of Nursing, confirmed the facility did not have informed consent documentation for R77's psychotropic medications.

Based on interview and record review, the facility failed to follow facility transportation policy resulting in transportation staff failing to properly secure a resident's wheelchair prior to driving, resulting in the wheelchair tipping backward and falling to the floor when the van accelerated from a traffic light due to being improperly secured in the wheelchair securement system. Additionally, staff failed to respond to a resident's request for medical attention and did not summon emergency medical services following the incident. These failures affect one of four residents (R12) reviewed for accidents in the sample list of 16. These failures resulted in R12 experiencing severe pain and sustaining a compression fracture requiring hospitalization after R12 fell to the van floor in the wheelchair. Findings include:The Immediate Jeopardy began on 3/30/26 when the facility failed to secure R12's wheelchair in the facility van before driving and R12 tipped backward in the wheelchair and fell to the floor. V1 Administrator was notified of the Immediate Jeopardy on 5/4/26 at 1:23 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 4/29/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and implementation of protocols. R12's Care Plan dated 4/16/2025 documents an admission date of 04/15/2025. The Care Plan documents R12's diagnoses as Fusion Of Spine, Thoracic Region, Type 2 Diabetes Mellitus Without Complications, Sleep Apnea, Migraine, Essential (Primary) Hypertension, Major Depressive Disorder, Recurrent, Anxiety Disorder, Anemia, Chronic Postprocedural Pain, Muscle Spasm, Thrombocytosis, Nicotine Dependence, Seasonal Allergic Rhinitis. The Care Plan further documents R12 has Weakness, and Impaired Mobility and R12 uses a wheelchair for mobility and requires one to two staff members assistance to complete Activities of Daily Living. The Minimum Data Set, dated [DATE] documents R12 as cognitively intact.On 4/26/26 at 09:00 AM V1, Administrator provided an Investigation Report dated 4/1/26 for R12's change of plane on 3/30/26. The Investigation Report documents R12 is alert and oriented, that R12 needs staff assistance with activities of daily living and transfers, that R12 is unable to ambulate, and R12's mode of locomotion is manual wheelchair.The same report documents this Summary of events/situation:- On 4/1/26, R12, [AGE] year old female was being transported to appointment by facility when resident had a change of plane. Resident was sent to ER for evaluation. Resident was admitted to hospital for further work up and pain management. Hospital records documented possible new compression fracture at T12 upon return to facility. Upon investigation which included clinical records, assessments, and interview of staff it was determined that the resident is an assist of two for transfers. The resident was being transported to an appointment via facility vehicle. Resident has a follow up with neurosurgeon scheduled 4/27/26. The resident returned to our care on 4/1/2026. Her pain is controlled with current interventions in place. Care plan has been reviewed and updated.Investigation findings were reviewed with MD. This serves as the final report.The same investigation dated 4/1/26 at 12:54pm documents R12's, witness statement dated 4/1/26 as Resident stated that while she was being transported to (City Name) for an appointment the wheelchair straps in the van became loose causing her to tip in the wheelchair.R12's Emergency Department (ED) physician notes dated 3/30/26 at 1:52pm document a Chief Complaint: Patient fell backwards out of wheelchair in transport van and hit head. Patient complained of pain to neck and back pain shooting down right leg. The same document stated R12 was tearful during exam.On 04/27/2026 at 2:00 PM, R12 stated that on 03/30/2026 she was waiting to be transported to an appointment with her neurologist in (City State). R12 reported that V4 (Transport Driver) was running late and appeared to be in a rush. R12 stated that V4 buckled her seatbelt but did not secure her wheelchair with the four required anchor straps. R12 reported she did not realize the wheelchair was not anchored because she was wearing the seatbelt and assumed the wheelchair had been properly secured. R12 stated that while traveling in (City), the transport vehicle stopped at a red light. When the light turned green, V4 accelerated, causing her unsecured wheelchair to tip backward onto the floor of the vehicle. R12 reported hitting her head and neck and experiencing extreme pain. She stated she was crying and repeatedly asked V4 to call 911. R12 reported that V4 told her they were close to the neurologist's office and asked her to please let me just take you to your appointment. R12 stated that V4 pulled her by the arm and the wheelchair back upright from the floor and then continued driving to the appointment. R12 reported that she immediately called V15 (Receptionist) and V3 (Assistant Director of Nursing) to report what had occurred. Upon arrival at the neurology office, R12 informed the receptionist of the incident, and her neurologist was notified. EMS (Emergency Medical Services) was dispatched, and R12 was placed in a neck brace and transported to Local Hospital Emergency Department. On 04/27/2026 at 2:00 PM, V4, Transport Driver, stated V4 was transporting R12 to a physician's appointment in (City) on 3/30/26. V4 stated V4 accelerated from a traffic control light and heard R12 yell out, V4 stated V4 looked in the rearview mirror and R12 was tipped over backwards in the wheelchair laying in the van floor. V4 stated V4 forgot to attach the wheelchair anchoring straps to the wheelchair when V4 loaded R12 into the van. V4 then stated V4 accelerated to the shoulder of the road from the center lane of the roadway, then pulled R12 up to a sitting position by one of R12's hand/arm while pushing the wheelchair back into the correct seated position with the other hand. V4 confirmed R12 was complaining of pain and requested emergency medical services. V4 stated the van was just blocks from the physician appointment/office, so V4 elected to drive the van to the appointment.On 04/27/2026 at 2:30 PM V1, Administrator, provided V4's employee file. V1 confirmed V4 had not attached the wheelchair securement device in the van to R12's wheelchair. V1 confirmed V4 should have contacted emergency medical services for R12 at R12's request.On 4/28/26 at 09:35 V15, receptionist, stated that R12 will not allow V4, driver, to transport R12 to appointments due to fear V4 will not secure R12 correctly in the van. V15 stated V15 contacts an outside company to take R12 to the physician appointments R12 may have. On 04/28/2026 at 10:00am V1, Administrator, stated on 3/30/26 that V4, Driver, did not follow the transportation policy. V1 stated V4 should have called emergency medical services upon the incident. V1 stated V4 should not have lifted R12 back up into the wheelchair.On 05/4/26 at 01:19pm V3, Assistant Director of Nursing, stated V4 was transporting R12 to a follow up physician appointment in (City) when R12's wheelchair tipped over in the back of the van. V3 stated V4 should have followed the policy and called emergency medical services right then as soon as the incident occurred. V3 stated R12 told staff V4 did not have the wheelchair secured in the van.On 05/5/2026 at 08:52am V16, Neurologist, stated (on 3/30/26) R12 came inside the office asking for help, telling the office receptionist about the incident in the transport van. V16 stated V16 was alerted to the incident and requested emergency medical services transport R12 to the local emergency room for evaluation. V16 stated R12 had recent cervical and thoracic laminectomy/surgery and that the driver (V4) should have called emergency services from the scene and not moved R12.On 4/28/26 at 11:01am V1, Admin stated the facility does have a transportation policy titled Transportation for Residents; dated 01/2026. The policy documents under the section titled Guidelines: Lines 10, 11 and 12 document the following:10. All transport personnel must be trained on securement procedures, le. safety belts, buckles, straps, wheelchair securement.11. In the event of an accident during transportation staff must Immediately contact the facility Administrator.12. In the event of an accident during transportation and a resident sustains major injuries staff will immediately call emergency services (911).On 4/28/26 at 8:51am V1 provided an undated Transportation driver Job Description that documents: Summary: The Transportation Driver will provide the transportation of patients to and from hospitals, medical offices, dialysis centers and private residences in a safe, secure, and professional manner.Essential Duties: Provides assistance to residents including but not limited to: Boarding and leaving the bus, Assistance with seat belts, Securing wheelchairs and walkers,Hospital emergency room Progress Notes dated 3/30/2026 at 6:14pm document R12 was treated in the emergency room with the following diagnoses-Impression and Plan Back pain- Fall - Intractable pain - Neck pain by V26, emergency room Physician before being admitted to the hospital for further care.Hospital Discharge Orders dated 4/1/26 document V24, Hospitalist/Physician, documented a discharge diagnosis of compression fracture T12 for R12. The same record documents a Progress Note dated 03/30/2026 at 5:49 pm authored by Neurosurgery Physician V25 which states: (R12's) wheelchair was not secured and she (R12) fell back. Neurosurgery has since gotten additional imaging it appears that patient does have an acute compression fracture. She was in pain on arrival. On 4/29/26 at 12:38pm V1, provided (Company Name) installation manual which included user instructions.On 4/29/26 at 1:00pm review of the (Company Name) Use and Care Manual-- Vehicle Anchorages & Accessories For 4-Point Wheelchair Securement Systems dated 2020: Documents on page four the following: Tie-Down Hooks must be attached to a solid wheelchair frame (no spokes, wheels or movable components) at an approximate 45-degree angle with floor. The manual further documents: The (Company Name) 4-Point Wheelchair Securement Systems should not be operated by anyone who does not have full comprehension of how the system works or if the system is not working properly. This (Company Name) 4-Point Wheelchair Securement System and its components MUST be regularly inspected, cleaned and maintained-reference the Maintenance and Care section in this manual. Page 21 documents: The following items should be inspected and serviced by an experienced and trained technician during the scheduled maintenance of the (Company Name) 4-Point Wheelchair Securement System. Always keep belts clean and off the floor by using a storage device such as a (Company Name) wall pouch. We recommend one storage device per wheelchair location. All systems and components MUST be regularly inspected, tightened, cleaned, and maintained.The facility presented an abatement plan to remove the immediacy on 5/4/26. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 5/5/26, and the survey team accepted the abatement plan on 5/6/26.The Immediate Jeopardy that began on 3/30/26 was removed on 4/29/26 when the facility took the following actions to remove the Immediacy.On 5/6/26 Surveyor was able to confirm onsite that the facility took the following measures to remove the immediacy:On 4/2826 V1, Administrator, conducted in-service education for the proper securing of resident wheelchairs in the transportation van, including the newly developed facility policy, for the three approved transportation drivers and the maintenance director.On 4/28/26 V1, Administrator, utilized (Company Name) training manual for the securement straps and seat belts in the transportation van for each of the three approved transportation drivers and the maintenance director.On 4/28/26 V1, Administrator, conducted return demonstrations for each of the three approved transportation drivers and the maintenance director.On 4/28/26 V1, Administrator, reviewed the facility policy for securement of wheelchairs in the transportation van with drivers.On 4/28/26 V1, Administrator, reviewed the job description for the transportation drivers with each driver.On 4/28/26 V1, Administrator, developed a list of approved transportation drivers.On 4/28/26 V1, Administrator, conducted an Ad-Hoc Quality Assurance Meeting to discuss the Immediate Jeopardy citation, needed training, proficiency checklist, list of approved drivers, review of transportation aide job description, development and corporate approval of facility policy, and abatement plan.On 4/29/26 V20, Maintenance Director, began conducting audits for three residents utilizing the facility van for transport to appointments, R102, R103, and R104.On 4/28/26 V1, Administrator, confirmed each of the three transportation drivers completed proper demonstration for securement technique of an occupied wheelchair into the facility transportation van.

Based on interview and record review the facility failed to implement appropriate accident and fall prevention interventions to prevent accidental removal of a feeding tube and falls for one of three residents (R1) reviewed for accidents on the sample list of six. These failures resulted in R1 pulling R1's feeding tube out requiring hospital reinsertion of the feeding tube and R1 falling and suffering a laceration above the left eyebrow requiring three sutures. Findings Include: The facility's Fall Prevention Program dated October 2024 documents the program's purpose is to assure the safety of all residents in the facility and is to include measures which determine the individual needs of each resident by assessing the risk of falls, implementing appropriate interventions to provide necessary supervision, and using assistive devices as necessary. A Fall Risk Assessment should be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions should be implemented for each resident identified at risk. R1's Care Plan dated July 2025 documents R1 admitted to the facility on [DATE] and discharged on 8/3/25. The same care plan documents admission diagnoses of Cerebral Infarction, Encephalopathy, Diabetes Mellitus, Chronic Embolism and Thrombosis, Seizures, Alcohol Abuse, and Stimulant Abuse. R1's Hospital Patient Discharge Plan Dated 7/31/2025 at 10:25am documents R1 was prescribed anti-coagulant and anti-platelet medications at discharge to continue at the facility. R1's Hospital Patient Discharge Plan Dated 7/31/2025 at 10:25am uploaded to the medical record documents in handwriting report that R1 is oriented to person only, does not follow directions, has a bed alarm and sitter and gets up alone. R1's Hospital Patient Discharge Plan Dated 7/31/2025 at 10:25am documents a Progress Note from V12 Hospital Physician dated 7/30/25 at 7:29pm stating R1 is encephalopathic and cannot follow commands. The same Progress Note documents R1 is status post gastrostomy tube (g-tube) insertion on 07/16/25.R1's Fall Care Plan initiated 7/31/25 documents R1 is at risk for falls and documents the following interventions dated 7/31/25: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; Ensure the resident is wearing appropriate footwear; Physical Therapy evaluate and treat as ordered or as needed; and Review information on past falls and attempt to determine cause of falls. Alter/remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team as to causes as needed. R1's Care Plan dated 8/1/25 documents a Focus Area that R1 exhibits impulsive behaviors with resultant medical concerns (falls, removing medical equipment). The same Care Plan documents the interventions as administer medications as ordered, date initiated 8/01/2025 and Room by Nurse's station, date initiated 8/01/2025 with no other interventions noted. V13, Social Service Director, Progress Note dated 7/31/2025 at 8:14am documents that R1's behaviors result in medical concerns such as falls and pulling out medical equipment. The same note does not contain any documented interventions. V6's Licensed Practical Nurse (LPN) Progress Note dated 7/31/2025 at 5:32pm documents R1 admitted to the facility with in the last three hours. R1 has been restless pulling on tube feeding and urinary catheter and climbing out of bed nonstop. Hard to redirect. Alert with confusion. Unable to verbally communicate needs. Family at bedside at this time. R1 continues to attempt to climb out of the bed. The Note documents a call was placed to psychiatric services with a condition report. V6's Licensed Practical Nurse (LPN) Progress Note dated 7/31/2025 at 7:25pm documents R1 sustained a fall on 07/31/2025 at 7:25 PM. The Note documents the incident occurred in the resident's room. Resident is alert and disoriented per usual baseline. No changes in range of motion from normal baseline. No new intervention is documented in the note to prevent falls. V6's Licensed Practical Nurse (LPN) Progress Note dated 7/31/2025 at 7:25pm documents V6 went to check on R1 when it was observed that the gastronomy tube (g-tube) was displaced and hanging on the floor. R1 stated R1 doesn't know what happened. The same note continues V6 called Director of Nursing (DON) for assistance, stated to send R1 to the emergency room (ER) to replace tube. 911 was called for transport. No new intervention is documented in the note after this accident. V2's Director of Nursing (DON) Progress Note dated 8/1/2025 at 10:30am documents the Interdisciplinary Team (IDT) met to discuss incident. R1 had an unwitnessed fall in his bedroom. R1 has been restless and attempting to get up out of bed. Resident was noted sitting on the floor and had removed his g-tube. Resident was assessed by unit nurse no injury noted. Sent to ER to have g-tube replaced. Returned to the facility the same evening. Root cause - self transferred. The new intervention documented was to keep R1's bed in lowest position. V3's Assistant Director of Nursing (ADON) Progress Note dated 8/1/2025 at 4:32pm documents Writer and DON entered R1's room. R1 was found standing up, pulling his gastrostomy tube. DON assisted resident on one side, writer assisted resident on other side. Chair was provided for resident to sit, once bandage was removed, resident's g-tube fell into resident's lap. 911 called, resident being sent to local emergency department, face sheet, bed hold and medication list provided to Emergency Medical Service (EMS). No new intervention is documented after R1's g-tube was pulled out for the second time The Activity Note dated 8/1/2025 at 6:44pm documents R1 returned from local hospital after placement of new g-tube. R1 immediately became anxious and voiced he wanted to leave facility. V6's Licensed Practical Nurse (LPN) Progress Note dated 8/3/2025 at 8:00pm documents R1 observed sitting on floor mat next to bed with blood on his face. When cleaned up, he was noted to have a laceration above the left eyebrow. He also had a wound on the left side top of scalp. DON was on site and stated to send to the hospital due to blood thinners. V2's Director of Nursing Progress Note dated 8/4/2025 at 3:13pm documents IDT met to discuss incident. R1 had an unwitnessed fall in his bedroom. He was noted sitting on the floor in his room on a floor mat that was next to his bed. Resident caused a laceration to the left brow and top of forehead. Moderate amount of bleeding noted from these areas. First aid applied and EMS called to transport resident to ER for evaluation. Root cause - self transfer. The Final Incident Report submitted to the State Agency on 08/11/2025 documents the Director of Nursing was notified at 9:00 AM on 8/4/25 that R1's laceration above the left brow was closed with three sutures.On 10/14/25 at 08:59am V6 stated R1 was impulsive and had poor safety awareness and R1 had multiple falls and pulled out the gastrostomy feeding tube multiple times needing to go to the local hospital for replacement. V6 stated that on 8/3/25 V6 arrived for work and was getting started on the shift and R1 fell hitting R1's head on the feeding tube pole and received a laceration above the left eyebrow. V6 stated R1 had a one-to-one sitter and a personal alarm when R1 was in the hospital and needed a one-to-one sitter while a resident at the facility. V6 stated R1 did not have an alarm in the facility. V6 stated R1 was confused and would not have known to push the call light for assistance. On 10/14/25 at 09:09am V3 stated that R1 was not able to use the call light due to decreased mental capacity. V3 stated R1 was impulsive with getting up and pulling out the feeding tube and needed a one-to-one caregiver. V3 stated no one was in the room with R1 when R1 fell on 8/3/25. V3 stated V3 was the off going nurse that day, and that a CNA (Certified Nursing Assistant) hollered down the hallway that R1 had fallen and was bleeding.On 10/14/25 at 1:17pm V2 confirmed the admission paperwork documented R1 is oriented to person only, does not follow directions, has a bed alarm and sitter and gets up alone. V2 stated V2 was in the facility on 8/3/25 when R1 fell at the bedside and was injured needing to go to the emergency room. V2 stated R1 was severely cognitively impaired and would not have known to use his call light to call for help. V2 confirmed R1 did remove the feeding tube multiple times and was sent to the emergency room to have the feeding tube replaced. V2 confirmed R1 needed to have one to one care due to his impulsiveness and that R1 did not have one to one care at the facility. V2 confirmed R1 received three sutures to the laceration above the left eyebrow from the 8/3/25 fall.

Based on interview and record review the facility failed to apply a vehicle safety restraint during transportation in the facility van for one of three (R1) residents reviewed for falls on the sample list of three. This failure resulted in R1's wheelchair flipping backwards in the facility van during transport and R1 sustained a left side rib fracture. Findings Include: The Motor Vehicle Safety Program dated January 2025 documents seat belts and shoulder harnesses (occupant restraint systems) must be worn or used whenever the vehicle is in operation. The vehicle may not move until all passengers have fastened their restraints. R1's Fall Follow-up Note dated 5/15/25 documents R1 fell from his wheelchair while in the facility van. R1 was being transported back to the facility and his wheelchair was not properly secured. The root cause of the fall was determined to be the wheelchair was not properly secured. R1's Incident Note dated 5/12/25 documents R1 sustained a fall at 6:20 PM in the facility van. R1 is alert and orientated to person, place, time, and situation. R1 is rating new onset pain at a 5/10. R1's Progress Note dated 5/13/25 documents V5 Nurse Practitioner was called to evaluate R1 due to accident the day before. R1 was sitting at the nurses' station in his wheelchair complaining of pain in the neck and upper back radiating to the rib area. R1 stated the pain was not controlled by Acetaminophen. V5 requested R1 to be sent to the emergency room for evaluation. R1's Progress Notes document multiple requests for pain medication due to rib pain after the accident on 5/12/25. R1's Progress Note written by V5 Nurse Practitioner dated 5/13/25 documents V5 assessed R1 after a fall with a head strike. R1 complained of neck pain, headache, bilateral eye redness, and rib/chest wall pain. R1 was alert and orientated. R1 indicated when he fell backwards in the van in his wheelchair, he struck his head and blacked out. R1 reported having to deal with a headache and neck pain since the accident. R1 described the pain as bad and throbbing. V5 sent R1 to the emergency room. R1's emergency room documentation dated 5/13/25 documents R1 had a fall in his wheelchair which resulted in a closed head injury and closed left side rib fracture. On 5/12/25 R1 was loaded into the facility van in his wheelchair for transport. The facility driver did not strap in R1's wheelchair. When the driver hit the gas R1's wheelchair flipped backwards causing him to fall from his wheelchair. R1 woke up on 5/13/25 with continued chest wall pain and head and neck pain. The documented clinical assessment documents chest wall tenderness is present which correlates with the radiology report. R1's Radiology Report of the Chest dated 5/13/25 documents R1 sustained a possible non-displaced acute fracture of the left lateral rib number six and clinical correlation is advised. R1's Medical Diagnoses list dated May 2025 documents R1 is diagnosed with Dementia, Major Depression, and Obesity. R1's Minimum Data Set, dated [DATE] documents R1 is mildly cognitively impaired, requires supervision/touching assistance from staff to safely transfer from a seated position, and requires the use of a manual wheelchair for mobility. R1's Medication Administration Records for May 2025 documents prior to the accident on 5/12/25, R1 did not request any as needed pain medication. After R1's wheelchair flipped backwards in the van when being transported, R1 requested pain medication (Tylenol) daily. A new as needed pain medication (Tramadol 50 milligrams) was also added for R1's rib pain on 5/14/25 and then the frequency was increased from every six hours to every eight hours on 5/20/25. R1 has been taking pain medication regularly since the accident. On 5/24/25 at 12:55 PM R1 stated two staff members (V7 Certified Nurse's Assistant) and (V8 Licensed Practical Nurse) came to pick him up from the hospital. R1 stated V7 loaded him in his wheelchair into the facility van. R1 stated she did not provide him with a seatbelt or strap his wheelchair in with the van safety strap system. R1 stated they began to drive and stopped at a stop light. R1 stated as R1 took off from the red light, R1's wheelchair flipped backwards, and he fell back and hit his head. R1 stated the fall hurt his head, neck, and he felt it all through his body. R1 stated he has been having pain ever since the accident and for the first two days it was hard for him to get out of bed. R1 stated he has had chest wall pain on both sides, but it often hurts more on the right side. R1 stated he was sent to the emergency room the day after the accident, and they told him he had a fractured rib. R1 stated before the accident he rarely had pain but since the accident he has had pain every day mostly in his chest when he breaths more deeply. R1 stated he went from not taking any pain medication to taking pain medication every day. On 5/24/25 at 1:04 PM V8 Licensed Practical Nurse stated she went with V7 Certified Nurses Assistant (CNA) in the facility van to go pick up R1 from the hospital. V8 stated when V7 started driving after stopping at a red light, R1's wheelchair flipped backwards and R1 was on his back. V8 stated her and V7 helped get R1 back in his wheelchair in the van and they took him back to the facility. V8 stated R1 complained of a headache at the time. V8 stated she was never trained on how to properly secure a resident in the van for transport. On 5/24/25 at 1:31 PM V7 Certified Nurses Assistant (CNA) stated she was asked to pick up R1 from the hospital on 5/12/25. V7 stated she had transported residents before however V7 stated she had never been trained on how to properly secure residents in wheelchairs in the facility van. V7 stated as she drove back to the facility, R1's wheelchair flipped backwards, and he was on his back on the floor of the van. V7 stated she went back to check on R1 and he stated he felt like he was having a heart attack, his neck, head, and chest hurt. V8 helped get R1 back into the wheelchair and they returned to the facility. V7 stated the accident happened about 6:20 PM and R1 continued to complain of chest wall, head, and neck pain for the rest of her shift which ended at 10:00 PM. On 5/24/25 at 3:45 PM V2 Director of Nurses (DON) confirmed V7 and V8 failed to properly secure R1 in the wheelchair during transport in the facility van on 5/12/25. V2 confirmed this caused R1's wheelchair to flip backwards during transport. V2 confirmed R1 has had pain on his chest wall since the accident and the radiology scan completed on 5/13/25 documents R1 sustained a possibly acute left sixth rib fracture.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to promote residents' dignity by failing to care for and treat them with respect and in a manner that promotes their quality of life and individualized needs. This failure affects two of six residents (R8, R52) reviewed for dignity in the sample list of 39. This failure resulted in emotional distress and a significant increase in anxiety for one resident (R52). Findings Include: The facility policy titled 'Dignity' effective March 2024 documents the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his/her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Maintaining a resident's dignity should include promoting resident independence and dignity while dining, protecting resident's private space, including residents in conversations during activities or when care is provided and refraining from practices demeaning to residents. 1.) R52's Diagnoses List dated March 2024 documents R52 is diagnosed with Dependency on Renal Dialysis, Anxiety, Depression, Legal Blindness, Homelessness, and Bipolar Disorder. R52's Minimum Data Set (MDS) dated [DATE] documents R52 is cognitively intact. R52's Care Plan dated 12/27/23 documents R52 requires assistance bathing, transfers, mobility, and eating. R52 has issues with anxiety and depression and takes psychotropic medications. R52 has had episodes of suicidal ideations and suicidal attempts due to his current level of care and mental health diagnoses. R52 is at risk for abuse and neglect. R52 has impaired vision and is legally blind. R52 requires staff to verbalize things when they are taking care of him. Staff need to verbalize when they are approaching R52 and inform him of who they are and their role. Staff need to inform R52 of where they are places items he needs and and be consistent. On 3/24/24 at 10:30 AM R52 stated often staff enter his room without knocking or introducing themselves. R52 stated staff will wait until they are right beside his bed to say anything and because he is blind, this startles him and causes him anxiety. R52 stated staff also often bring in his food tray and set it on his bedside table without making sure he knows it is there. By the time he realizes it is there, the food is cold and he does not even know what food is on his tray. R52 states he feels staff should be telling him they are bringing his food tray and letting him know what is on the plate for him to eat and assisting him in setting up his meals if needed. On 3/25/24 at 1:45 PM R52 stated the Transportation Driver (V23) often comes up behind him and wraps his arm around R52 (upper chest, shoulder neck area) and startles him. R52 stated V23 also sneaks into his room and shake his bed and yells his name to startle him. R52 also stated V23 has tipped his wheelchair backward as if he was falling during times V23 has transported R52. R52 stated V23 has caused him a significant increase in anxiety and emotional stress which is something he struggles with already. R52 stated he has repeatedly asked V23 to stop and he just keeps on doing these things. R52 stated he has told other residents and some staff members about V23's behavior but it continues. R52 stated he is fed up with it and he doesn't want to be around V23 Transportation Driver. On 3/25/24 at 3:30 PM V20 Activity Aide confirmed R52 has mentioned V23 makes him uncomfortable with the way he treats him and the disregard for his (R52) vulnerabilities (blindness). On 3/25/24 at 3:00 PM V1 Administrator confirmed it would be inappropriate and unprofessional for any staff member to try to startle or scare R52 in any way, and staff need to be cognizant of R52's vulnerabilities (blindness) and individualize his care accordingly. V23 was away from the facility and unable to be reached during this time. On 3/25/24 at 4:08 PM V22 Certified Nurses Assistant stated R52 has complained to her on multiple occasions about staff not introducing themselves when they enter his room, about staff not telling him they are delivering his food tray or informing him what is on the tray, and about V23 Driver making R52 feel uncomfortable by purposefully scaring him and startling him even after R52 has asked him to stop. On 3/27/24 at 10:15 AM V2 Director of Nurses confirmed staff need to be sensitive to R52's medical conditions, specifically being blind. Staff need to knock upon entry to his room and announce who they are and what their role is. They need to tell him what they are going to be doing and if they deliver food, they need to make sure R52 knows what he has on his tray to eat. V2 stated V23 Driver should not be purposefully startling or scaring R52 and his actions are inappropriate and unprofessional. V2 confirmed if R52 had asked V23 to stop and he continued to startle and do things to scare R52, it is understandable that R52's anxiety would increase. 41970 2.) R8's undated Medical Diagnosis List documents R8's medical diagnoses of Dementia, Delusional Disorders and Heart Failure. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as severely cognitively impaired. This same MDS documents R8 requires maximum assistance with toileting, bathing, lower body dressing and moderate assistance with personal hygiene. R8's Care Plan interventions dated 8/17/23 document R8 requires one person assistance with personal hygiene, toileting, dressing and bathing. On 3/24/24 at 9:35 AM R8 was sitting in his wheelchair with bedside table in front of him. R8's breakfast plate, personal items and can of shaving cream was sitting on R8's bedside table. R8's hands, bedside table and breakfast plate were all covered with small mounds of smeared shaving cream. The lid to the can of shaving cream was sitting on the floor. R8's incontinence brief completely saturated hanging down exposing the front of R8's perineal area. R8 was not wearing pants. R8 stated 'I wanted to wear pants but they (staff) were too busy. I'm a mess and I am cold. Can you put those pants on me?'. On 3/24/24 at 9:40 AM V6 Licensed Practical Nurse (LPN) stated R8 should not be left with shaving cream. V13 stated (R8) always makes a mess with it. (R8) doesn't shave himself so he really doesn't need that shaving cream anyway. I will make sure he gets cleaned up before he eats any of it. B. Based on interview and record review the facility failed to maintain the dignity for three residents (R11, R33, R55) affected negatively by another resident's (R289) yelling and cussing outbursts. This failure affects four (R11, R33, R55, R289) residents out of six residents reviewed for dignity in a sample list of 39 residents. Findings include: 1.) R11's Minimum Data Set (MDS) dated [DATE] documents R11 as cognitively intact. R11's Care Plan intervention dated 9/14/22 instructs staff to provide a safe and secure environment for R11. On 3/24/24 at 1:05 PM R11 stated (R289) needs to move somewhere else. (R289) yells and hollers out all kinds of curse words right in front of me. I told (V1) about it last week but nothing gets done. (R289) was out of control last night (3/23/24) at supper. (R289) was yelling the 'f' (expletive) word and calling people names. I couldn't tell if (R289) was yelling at staff or residents but he was yelling loud enough everyone in the dining room could hear and the dining room was full. I was getting ready to call the cops on (R289) because he scared me because he was so out of control. The staff walked him (R289) to his room but then he came right back and started yelling again. I don't know why (R289) gets so mad but they ought to do something to control him before he hurts someone. (R289's) face gets so red and he yells so loud. You can tell (R289) is about to explode. That is why I wanted to call the cops. 2.) R33's Minimum Data Set (MDS) dated [DATE] documents R33 as cognitively intact. R33's Care Plan intervention dated 12/27/23 documents R33 as a moderate risk for abuse. On 3/24/24 at 1:10 PM R33 stated (R289) yells and cusses in front of everyone. (R289) was in the hallway this morning at 5:00 AM yelling at the staff to get their 'head out of their a** (expletive)'. I heard every word of it. The whole hall could hear (R289) yelling. I don't like it at all. I don't talk to people like that and I don't like it when people talk to me like that. 3.) R55's Minimum Data Set (MDS) dated [DATE] documents R55 as moderately cognitively impaired. R55's Care Plan initiated 1/7/24 documents R55 is at moderate risk of being abused. On 3/25/24 at 1:30 PM R55 stated (R289) yells and cusses all the time. (R289) screams out the 'f' (expletive) word and so much worse in the halls, the dining room during meal time, during the day, during the night. (R289) woke me up the other morning when he was screaming obscenities in the hall. I told the nurse to make him be quiet. I was afraid (R289) would come into my room. (R289's) room is not too far away. (R289) rolls around here (facility) scaring people and they (facility) won't do anything about him. (R289) is so intimidating because of his size and how he gets so angry when he yells. R289's undated Face Sheet documents R289 admitted to facility on 3/15/24. R289's Electronic Medical Record (EMR) documents R289's medical diagnoses as Developmental Delay, Bipolar Disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disorder (COPD) and Heart Failure. R289's Brief Interview for Mental Status (BIMS) dated 3/19/24 documents R289 as cognitively intact. R289's Care Plan does not include a focus area, goal nor interventions for behaviors. R289's Nurse Progress Note dated 3/19/24 at 4:59 PM documents Kitchen staff notified (V6) Licensed Practical Nurse (LPN) that (R289) was in the dining room yelling at other staff members and residents. (R289) has been noted to have this behavior continuously. (R289) was removed from dining room and escorted to his room to prevent any further altercations. On 3/24/24 at 12:55 PM V4 Cook stated (R289) acts up all the time in the dining room during mealtime. (R289) was yelling you are a f******* (expletive) b**** (expletive)' and 'get your f****** (expletive) a** (expletive) over here'. (R289) yells things like that all the time. (R289) was doing it last night during supper. There are a lot of other residents around. On 3/24/24 at 1:00 PM V5 Dietary Aide stated (R289) is out of control in the dining room. At lunch today (R289) was yelling at the staff 'you f****** (expletive) b**** (expletive)' and 'this food s**** (expletive)' and 'you f****** (expletive) stupid b**** (expletive)'. I went over to talk to (R289) and he just kept yelling so loud. (R289) does that about every meal. I don't know why they (facility) doesn't control that somehow. Other residents don't like it at all. On 3/25/24 at 11:50 AM R289 stated I get angry sometimes. I yell and scream at other residents when they say mean things to me. The other night one lady (unknown resident) told me to 'Shut up' and it made me mad so I yelled at her back. Yesterday (3/24/24) I yelled really loud in the dining room. There were a lot of people in there but I don't care. Somebody told me to shut up because I was mad at one of the kitchen staff so I yelled at all of them. They can't tell me what to do. Then they made me go to my room but I was so mad I went back to the dining room. On 3/26/24 at 8:00 AM V1 Administrator stated R289's careplan was entered on 3/24/24. V1 stated R289 did not have a behavioral careplan prior to 3/24/24. V1 Administrator stated R289 yells out in the dining room during mealtime all the time. V1 Administrator stated On 3/19/24 during supper time (R289) was yelling in the dining room. (R289) was yelling 'you f****** (expletive) b**** (expletive) ' and 'f****** (expletive) stupid b******* (expletive)' at the staff in front of a dining room full of people. V1 Administrator stated other residents are upset by (R289's) behaviors and outbursts. V1 stated We (facility) are working on a behavioral plan for (R289) to make it a better environment for everyone. The facility policy titled 'Dignity' effective March 2024 documents the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his/her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Maintaining a resident's dignity should include promoting resident independence and dignity while dining, protecting resident's private space, including residents in conversations during activities or when care is provided and refraining from practices demeaning to residents.

Based on observation, interview, and record review the facility failed to implement fall interventions, provide supervision to prevent a fall, provide safe transfer assistance, and thoroughly investigate falls to identify root cause and develop post fall interventions for three (R1, R2, R3) of three residents reviewed for falls in the sample list of nine. These failures resulted in R1 falling and sustaining a subdural hematoma and R3 falling and sustaining a scalp laceration that required sutures. Findings include: 1.) R1's Minimum Data Set (MDS) 10/16/23 documents R1 has moderate cognitive impairment, has upper/lower extremity range of motion impairment, and requires substantial/maximal assistance for chair/bed transfers. R1's Care Plan revised on 5/1/23 documents R1 transfers with extensive assistance of two staff. R1's Care Plan revised on 5/4/23 documents R1 has decreased ability to self transfer due to Parkinson's Disease and spastic movements/tremors. R1's Care Plan revised 11/28/23 documents R1 is at risk for falls and continues to self transfer even after being educated to call for assistance and includes an intervention dated 6/12/23 to offer to lay R1 down after meals. R1's November 2023 Medication Administration Record documents R1 receives Plavix (antiplatelet, blood thinning medication) 75 milligrams by mouth daily. The facility's Report to IDPH (Illinois Department of Public Health) Regional Office dated 11/29/23 documents R1 fell on [DATE] at 6:21 PM while attempting to self transfer from the wheelchair to the bed and R1's head hit the floor. R1 was found on the floor with a laceration and hematoma (bruising/swelling) to the right side of R1's head. R1 was transferred to the local emergency room and was diagnosed with a subdural hemorrhage (brain bleed). R1's Fall Investigation for 11/22/23 6:21 PM fall, provided by V2 Director of Nursing, documents V3 Licensed Practical Nurse's (LPN) incident description that R1 self propelled R1 to R1's room, attempted to self transfer into the low bed, and R1 fell to the floor hitting R1's head which caused a laceration and hematoma. V5 Certified Nursing Assistant (CNA) interview is the only documented interview as part of this investigation. V5's statement dated 11/22/23 documents V5 walked past R1's room and found R1 partway on the low bed and partway on the floor. R1's call light had not been activated, R1 was wearing nonskid socks, and R1's wheelchair lap cushion had been in place when V5 last saw R1 at 6:15 PM in the hallway. There is no documented interviews with staff to determine when staff last observed R1 prior to the fall, what R1 was doing at that time, if any staff had offered to lay R1 down after supper, or if R1 had requested to lay down prior to the fall. R1's Hospital Emergency Department Notes dated 11/22/23 at 6:58 PM, recorded by V6 Advanced Practice Registered Nurse, documents R1 presented to the emergency room for complaints of a fall and R1 hitting R1's head. This note documents R1 has a hematoma to the right scalp, R1 takes Plavix, and a head CT (computed tomography ) was ordered. R1's Head CT without Intravenous Contrast dated 11/22/23 at 7:17 PM documents the indication for this test was fall- on Plavix and there was a small left anterior frontal subdural hemorrhage with a depth of up to 7 millimeters. R1 was transferred to another hospital for further treatment. R1's Hospital Emergency Department Note dated 11/22/23 at 10:33 PM document R1 had an unwitnessed ground level fall with the following injuries - right frontal subdural hemorrhage, right scalp laceration, and hematoma. R1 was admitted with principal diagnoses of Trauma and Subdural Hemorrhage. On 12/11/23 at 10:37 AM R1 was next to the dining room sitting in a wheelchair. R1 had bruising to R1's right forehead. R1 stated R1 recalls falling recently and R1 was hurt bad. R1 was unable to recall any additional details of R1's fall. On 12/7/23 at 12:14 PM V7 LPN stated V7 was not assigned to R1's care the day R1 fell . V7 stated it was R1's norm to go back to R1's room and lie down after supper, R1 had not asked to lay down, and R1's call light was not on when R1 fell . V7 stated R1 doesn't always call for help and R1 is very impulsive with transfers. On 12/11/23 at 10:48 AM V3 LPN stated V3 last saw R1 in the dining room prior to R1's fall, R1 had finished eating and had made R1's way to R1's room. V3 stated that's (R1's) norm. V3 stated R1 did not mention that R1 wanted to lay down and V3 did not offer to lay R1 down after supper. V3 stated R1 does not have a routine bedtime. V3 stated R1 was found partway on the floor and partway on the bed with a bleeding head laceration. V3 stated V3 was unsure what R1 hit R1's head on as R1 has a lot of items in R1's room including totes and an overbed table. V3 stated R1 told V3 that R1 was trying to go to bed and attempted to self transfer from the wheelchair to the bed. V3 stated R1 usually tells staff when R1 wants to lay down. On 12/11/23 at 10:57 AM V5 CNA stated V5 was R1's assigned CNA on the evening of 11/22/23. V5 stated V5 did not witness R1's fall and V5 was walking past R1's room and found R1 with R1's upper body on the bed in low position and R1's legs on the floor. R1 had a bump and a bleeding cut to R1's right forehead. V5 stated V5 last saw R1 around 6:15 PM when V5 washed R1's face as R1 was leaving the dining room. V5 stated V5 did not recall if V5 offered to lay R1 down that day, after R1 was finished with supper. V5 stated R1 does not have a routine bed time and R1 attempts to self transfer at times. On 12/7/23 at 10:43 AM V2 Director of Nursing (DON) stated R1's fall investigation includes interviews that were conducted, and V3 LPN and V5 CNAs were the only staff interviewed as part of the investigation. On 12/11/23 at 12:17 PM V2 stated R1 doesn't like to stay put and we are unable to restrain R1. V2 stated V2 was told R1 removed R1's wheelchair lap cushion and attempted to self transfer for R1's fall on 11/22/23. V2 stated we try to keep R1 in the hallway to keep eyes on R1. V2 stated V1 Administrator, V2 and V8 Assistant DON conducted R1's fall investigation. V2 confirmed R1's head hematoma and laceration were injuries from R1's fall. V2 stated the root cause of the fall was R1's attempt to self transfer after removing the lap cushion. V2 stated V2 inquired with V1 for the post fall intervention, and was told the intervention was that R1 was sent to the emergency room . V2 confirmed staff interviews for R1's fall investigation do not document what R1 was last observed doing, if staff had offered to lay R1 down, or if R1 had requested to lay down prior to the fall. V2 stated V2 expects staff to follow the interventions listed on the resident's care plan. 2.) R3's MDS dated [DATE] documents R3 has short/long term memory loss and requires extensive assistance of two staff for transfers/ambulation. R3's cumulative diagnoses list documents R3 has Alzheimer's Disease and Severe Dementia with Agitation. R3 has impaired balance with standing/walking/transfers and requires staff assistance to stabilize balance. R3's Care Plan revised 9/21/23 documents R3 requires extensive assistance of two or more staff for transfers/walking. R3's Care Plan dated 10/14/22 documents R3 is at risk for falls related to gait/balance problems, history of falls, poor safety awareness, and wandering. This care plan includes interventions to follow up with hospice that R3 is still not resting during the night (11/28/23), review information on past falls to attempt to determine the cause and educate R3/family/caregivers/interdisciplinary team as to cause as needed. R3's Report to IDPH Regional Office dated 11/21/23 documents R3 was found lying on the floor of another unidentified resident room on 11/13/23. R3 had moderate bleeding from the back of R3's head, R3 was transferred to the emergency room and received staple closure of the laceration. This report documents R3's medications were reviewed by hospice and adjustments were made to ensure better sleep to avoid daytime exhaustion/weakness. R3's Fall Investigation, provided by V2, documents R3 had an unwitnessed fall on 11/13/23 at 10:15 AM. V10's (LPN) incident description documents a CNA (V11) reported that R3 was on the floor and V10 found R3 lying on the floor on R3's right side with a head laceration and blood noted on the floor near. R3 was not able to explain what happened. This investigation does not contain interviews with V11, V10, or any other staff to determine when R3 was last observed prior to the fall and what R3 was doing when R3 was last observed. R3's Hospital After Visit Summary dated 11/13/23 documents fall as R3's reason for hospital visit, R3 was diagnosed with a scalp laceration, and R3 required laceration repair. This summary documents to remove R3's staples in 7-10 days. R3's Nursing Note dated 11/13/2023 at 4:31 PM documents R3 returned from the emergency room with two staples to the back of R3's head. R3's Fall Investigation, provided by V2, documents R3 had an unwitnessed fall on 11/25/23 at 7:57 AM. V12 Registered Nurse (RN) incident description documents R3 was found lying on R3's right side in the common bathroom/shower room. R3 was unable to give a description of the fall. R3's Fall Follow Up Note dated 11/28/23 at 10:01 AM documents the interdisciplinary team reviewed R3's fall, R3 wandering the unit was the root cause, and a code lock for the shower room door was the intervention. There are no documented interviews conducted with staff in regards to this fall. This fall investigation does not identify the last time R3 was observed prior to R3's fall and what R3 was doing at that time. R3's Fall Investigation, provided by V2, documents R3 had an unwitnessed fall on 11/28/23 at 5:40 AM. V13 LPN incident description documents R3 was walking back and forth in the hallway, became unsteady, and fell . R3 was then assisted to R3's reclining geriatric chair. V14's (CNA) interview is the only documented interview in this investigation. V14's interview dated 11/28/23 documents V14 was assisting other residents with morning cares, R3 was wandering in the hallway, and many attempts were made to have R3 sit in a chair. This note documents R3 got R3's self up and began wandering the hallway, and as V14 left an unidentified resident room V14 found R3 lying on the floor. R3's Fall Follow up Note dated 11/28/23 at 10:17 AM documents the interdisciplinary team reviewed R3's fall, R3 was observed walking in the hallway after early morning medication pass, and R3 fell . This note documents the root cause as R3 fell in the hallway and the intervention was for hospice to review medications to ensure sleep at night and prevent drowsiness during the day. There is no documentation in R3's medical record that hospice reviewed R3's medications or that any new medication changes were made after R3's fall on 11/28/23. On 12/7/23 at 2:22 PM V11 CNA stated V11, V15, and V16 were the CNAs on R3's unit (on 11/21/23), V16 had went on break, leaving V11 and V15 on the unit. V11 stated V15 was in another resident's room. V11 stated V11 was in another resident's room when R9 came to report that R3 had fallen in R9's room. V11 stated V11 had just observed R3 walking in the hallway a few minutes prior to the fall, R3 was able to walk independently, staff did not have to provide walking assistance just monitor R3 and direct R3 out of other resident rooms. V11 stated V11 had to leave the hallway where R3 was walking, to assist another resident who was up by herself and was a high fall risk. On 12/11/23 at 10:19 AM V3 LPN stated R3 has not been a walker and one day R3 just got up and started walking. V3 stated R3 is very hard to re-direct when R3 is up walking so staff will walk with R3. On 12/11/23 at 12:17 PM V2 DON stated R3 ambulates/wanders constantly, R3 can get R3's self up, R3 needs staff assistance to safely transfer. V2 stated once R3 is up, R3 can ambulate on R3's own with visual supervision/monitoring of staff. V2 stated staff should redirect R3 out of other resident rooms. V2 stated R3 had an unwitnessed fall on 11/13/23, R3 was wandering, and R3 was found on the floor of another resident's room. V2 stated staff applied a towel to the back of R3's head to stop bleeding from the laceration that was believed to be caused by hitting the base of the bedside table. V2 stated V10 and V11 were interviewed, they were in the next room, and they heard R3 fall. V3 stated the root cause of the fall was R3's confusion and weakness due to lack of sleep. V2 confirmed the fall investigation does not document staff were interviewed to determined when R3 was last observed prior to the fall and what R3 was doing at that time. V2 stated R3 had an unwitnessed fall on 11/25/23 where R3 fell in the shower room and a code lock was then installed on the shower room door. V2 confirmed there are no documented staff interviews as part of this fall investigation to determine when R3 was last observed prior to the fall. V2 stated R3 had an unwitnessed fall in the hallway on 11/28/23. V2 stated V2 viewed video surveillance that showed the nurse V13 was administering medications while R3 was walking in the hallway, there were no other staff present in the hallway, V13 went into another resident room, and R3 just fell down. V2 confirmed the investigation documents the CNAs were in resident rooms providing care at the time of R3's fall. V2 stated R3 almost needs a buddy to walk with R3 at all times and during the mornings R3 just wants to walk. V2 stated the root cause of the fall was that R3 fell in the hallway and the intervention was a medication review by hospice requesting medication to help R3 sleep through the night. V2 stated Trazodone was ordered by hospice following R3's fall, and on 12/4/23 or 12/5/23 an unidentified hospice nurse reported the Trazodone order to V2. V2 stated hospice verbally gives orders to the floor nurses and V2 did not implement this order. V2 stated V2 thought hospice enters their own orders into the resident's electronic medical record. V2 confirmed R3's current orders do not include Trazodone. At 2:33 PM V2 stated V2 was unable to locate documentation of R3's Trazodone order and hospice visit note/medication review. V2 stated hospice provides a form after their visit that includes new orders, and V2 is awaiting a call back from hospice to request this documentation. 3.) R2's MDS dated [DATE] documents R2 is cognitively intact, R2 uses a walker and wheelchair, and R2 requires substantial/maximal assistance of staff for transfers. R2's Care Plan dated 10/25/22 documents an intervention with a revised date of 9/20/23 for extensive physical assistance of one staff person for transfers. R2's Fall Investigation, provided by V2, documents R2 fell on [DATE] at 12:00 PM while V9 CNA assisted R2 in transferring. R2 lost R2's balance and fell face first onto the floor. R2 stated R2 lost balance and fell forward. R2 had a small laceration under the left eye, bleeding bleeding skin tear to middle and fourth right finger knuckles, and bruising to the right middle finger. R2 was transferred to the emergency room for evaluation. This investigation documents interviews were conducted with V17 LPN and V9 CNA. V17's interview dated 11/29/23 documents V9 was transferring R2 and R2 was not wearing any footwear. V9's interview dated 11/29/23 documents V9 was transferring R2, R2 lost balance, R2 fell forward, and V9 was unable to stop R2 from falling. This interview does not document if R9 was wearing footwear. These interviews do not document whether a walker and gait belt were used for R2's transfer. The Fall Follow Up note dated 11/30/23 documents at 12:49 PM the interdisciplinary team reviewed R2's fall, R2 was not wearing appropriate footwear and the intervention was to apply nonskid socks for transfers. On 12/7/23 at 11:57 AM R2 was sitting in a wheelchair in R2's room. R2 had faded bruising below R2's left eye. R2 stated R2 fell about a week ago while V9 CNA transferred R2 from the wheelchair to the bed. R2 stated staff do not use a gait belt for R2's transfers and one was not used that day. R2 stated V9 applied nonskid socks prior to R2's transfer. R2 stated I think my leg just gave out and that has happened before. R2 stated R2 had hit R2's eye on the bottom of the overbed table during the fall and the whole right side of R2's head had turned purple/bruised. At 2:11 PM R2's wheeled walker was folded beside R2's dresser. On 12/7/23 at 12:06 PM V9 stated V9 had applied R2's gripper socks prior to R2's transfer on 11/29/23 and R2 got dizzy when R2 stood causing R2 to fall forward. V9 stated R2 tried to grab R2's incontinence brief during the fall, and a gait belt was not used during the transfer. V9 stated R2 hit R2's eye on either the overbed table or dresser, and R2 was transferred to the emergency room . V9 stated R2 had been in bed bad with COVID-19 for a few days prior to R2's fall. At 2:09 PM V9 stated a walker was not used during R2's transfer and R2 has never used a walker. On 12/7/23 at 2:01 PM V18 Physical Therapy Assistant stated R2 has been on therapy prior to R2's fall, R2 had COVID-19 about a week prior to R2's fall, and R2 transferred with a wheeled walker and standby/contact guard assist. V18 stated R2 has had balance issues. R2 has a history of R2's legs giving out, and R2 doesn't have good standing tolerance. V18 stated staff should be using a gait belt and R2's wheeled walker for R2's transfers. V18 stated the walker would have helped stabilize R2's upper body during the transfer. On 12/7/23 at 12:17 PM V2 DON stated R2 fell while transferring from the bed to wheelchair and R2 is a stand/pivot transfer. V2 stated V9 reported that R2 lost balance and fell forward during R2's transfer, the root cause was that R2 was not wearing nonskid socks during the transfer, and nonskid socks were provided as the intervention. V2 stated V2 just went by what the nurse had reported, that R2 did not have on nonskid socks. V2 confirmed V9's interview does not document if R2's footwear at the time of the fall and R2 was not interviewed about R2's footwear. V2 stated staff should use a gait belt for residents who require extensive assistance for transfers and ambulation. V2 stated V2 was not aware that a walker and gait belt was not used during R2's transfer. The facility's Fall Prevention Program revised May 2022 documents nursing personnel are responsible for ensuring the ongoing use of fall precautions, the interdisciplinary team reviews the falls to determine possible safety interventions, and the Director of Nursing/Designee is responsible for monitoring the Fall Prevention Program and providing further staff education. This policy documents fall interventions are documented on the resident's care plan, and fall interventions may include using assistive devices and transferring residents in accordance with their plan of care and monitor resident's gait for balance and fatigue. The facility's Transfers-Manual Gait Belt and Mechanical Lifts dated as revised August 2023 documents resident transfer needs are designated into categories including using a gait belt for a one person transfer that requires 25% or less assistance from the caregiver, and the use of a gait belt is mandatory in all physical assist transfers, and failure to comply with lifting guidelines may result in disciplinary action. This policy documents the resident's transfer needs are documented on the resident's care plan.

Based on interview and record review the facility failed to complete and document thorough investigations to determine root cause of falls and failed to maintain a wheelchair in safe condition for two of three residents (R1, R4) reviewed for falls on the sample of five. Failing to maintain R4's wheelchair resulted in R4 sustaining a puncture/laceration wound to the right thigh requiring six sutures when R4 fell on to an uncovered wheelchair hand break while attempting to self-transfer from the bed to the wheelchair. Findings include: The facility's Fall Prevention Program dated May 2022 documents the Fall Prevention Program includes methods to identify risk factors, methods to identify residents at risk for falls, assessment time frames, use and implementation of professional standards of practice, notification of physician, communication with direct care staff members, documentation requirements, care plan incorporates identification of fall risk, addresses each fall, and preventative measures. This policy documents a fall risk assessment will be performed on admission, quarterly and with each significant change in mental or functional status and after any fall incident. Accident/Incident reports involving falls will be reviewed by the Interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions. The facility's Incident and Accidents policy dated May 2022 documents an incident/accident report is to be completed by a licensed nurse and is to include the date and time of the incident/accident, a full written statement and possible cause of incident, physical assessment, injuries noted, treatment rendered and notification of appropriate parties. Documentation in nurses' notes is to include a description of the occurrence, the extent of injury (if any), assessment of the resident including vital signs, treatment rendered and parties notified. Mental and physical state, follow-up, tests, procedures, and findings are to be documented. 1. R4's Admission Record dated 3/23/23 documents R4's diagnoses including Laceration of muscle, Fascia and Tendon of the Posterior Muscle Group on Right Thigh, Repeated Falls, Cerebral Infarction, Alzheimer's Disease and Anxiety. R4's Minimum Data Set (MDS) dated [DATE] documents R4 requires extensive assistance of staff for bed mobility, transfers, dressing, and toilet use. This MDS documents R4 is not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface to surface transfer. R4's Care Plans with a revision date of 2/28/23 document R4 has alteration in urinary elimination as evidenced by urinary incontinence/stress incontinence. Interventions for this plan of care include toilet upon rising, before and after meals, in the evening and as needed. R4's Progress Notes dated as follows documents: 2/18/23 at 4:07am document R4 has a new skin concern of a puncture wound to the right rear thigh. This note documents R4 complains of pain from injury, the physician was notified and R4's care plan was reviewed. This note does not document how R4 got the laceration. 2/18/23 at 11:07am - attempt to notify emergency contact and unable to reach by phone. There is no documentation of reason for attempting to notify R4's emergency contact or who that contact is. 2/18/23 at 12:33pm - R4 continues on fall vitals. There is no documentation in R4's Progress Notes dated 2/1/23-2/18/23 documenting R4 had a recent fall. 2/18/23 at 4:56pm - R4 returned from the local hospital on 2/18/23 at 1:50pm. R4 has a laceration to the right inner thigh with 6 sutures measuring 7cm (centimeters) long. R4's dressing to the thigh was noted to have a moderate amount of bloody drainage and was changed as well as pressure applied to the wound. R4's hospital After Visit Summary (AVS) dated 2/18/23 documents R4's diagnoses including laceration of the right thigh and Hematoma. This AVS documents there are 6 sutures that were placed to the laceration and that there is a hematoma in the area of the wound. The facility's Final Report to the State Survey Agency dated 2/23/23 documents R4 was observed on the floor of R4's bedroom with a laceration to the right inner leg on 2/18/23 at 3:30am. This report documents R4 was seen in the emergency room and received 6 sutures to the right inner leg laceration. This report documents R4 returned to the facility on [DATE] from the hospital. The facility's investigation for R4's fall on 2/18/23 documents witness statements including V18 (Certified Nursing Assistant/CNA) stated V18 was on another hall when R4's call light came on. V18 stated V18 answered the call light and observed R4 and V19 (Licensed Practical Nurse/LPN) sitting on the ground with blood present, due to R4's leg being cut. This statement documents R4 said (R4) slipped and cut it on the brake. This typed statement documents there were no jagged edges to brake but does not document what time V18 responded to the call light being on. This investigation also documents V19's (LPN) statement. V19's typed statement documents R4 was last seen laying in R4's bed around 2:00am and R4 was wearing a pajama top and pull up brief. This statement documents V19 observed R4 on the floor laying on R4's back between the bed and the wheelchair with R4's knees up but does not document what time V19 observed/found R4. R4 stated R4 was trying to go to the bathroom and had forgotten to put R4's shoes on. R4 was not wearing shoes at the time of this fall. This investigation does not document when R4 was last toileted/offered toileting assistance. This investigation does not document how long R4's call light was sounding or the position of R4's wheelchair in relation to R4's position on the floor at the time of the fall. There is no documentation in this investigation if R4 had been incontinent at the time of the fall. On 3/23/23 at 1:34pm, V2 (Director of Nursing/DON) stated R4 fell on to R4's wheelchair and received a laceration to R4's right medial/posterior thigh. The facility reported the fall to V2 and told V2 that R4's wheelchair had gone into R4's leg, making a puncture wound. V2 stated V2 had the staff remove R4's wheelchair and replace R4's wheelchair with a different one after noticing R4's wheelchair brake did not have the silicone cover over the brake. V2 stated the facility looked at R4's wheelchair wheels and wheelchair brakes. R4's wheelchair was missing the handle cover for the brake that punctured R4's thigh. V2 stated R4 stated R4 was trying to go to the bathroom and fell . V2 stated V2 knows V19 (LPN) saw R4 last at 2:00am and R4 was asleep at that time. V2 was unsure of which CNA was assigned to care for R4 on 2/18/23 at the time of R4's fall. V2 stated V2 did not talk to anyone else/other staff regarding R4's fall or cares provided on 2/18/23 prior to R4's fall. V2 stated V2 did not ask staff about when R4 was last assisted with toileting. V2 stated R4 did not have shoes on and R4 stated R4 forgot to put them on. V2 stated V2 does not recall asking about where R4's shoes were at the time of R4's fall on 2/18/23. V2 stated the root cause of R4's fall on 2/18/23 was that R4 slipped trying to get out of bed to use the toilet because R4 did not have shoes on. V2 stated R4 tries to toilet (R4's) self frequently and has a history of falling due to that reason. 2. The facility's investigation documents R1 sustained an unwitnessed fall on 2/15/23 at 4:45am. This investigation documents a final report to the State Survey Agency. This final report documents a summary as follows: On 2/15/23 R1 was observed on the floor of R1's room per witness statement. R1 was assessed with no changes noted. Later assessment reveals increased signs and symptoms of pain and that V9 (R1's Physician) was notified with a new order received to get a STAT x-ray of the left hip and leg. Portable in-house x-ray revealed acute non-displaced left intertrochanteric femoral/hip fracture with mild varus angulation of the fracture site. This investigation does not document a statement from the Certified Nursing Assistant caring for R1 at the time of this fall. R1's Progress Notes dated as follows document: 2/15/23 at 4:48am - R1 has a new skin concern, a Hematoma, located to R1's rear Left Iliac Crest. Monitor R1's Hematoma to the left iliac crest and R1 complains of pain. There is no documentation of a description/details of circumstances of R1's Fall on 2/15/23 in R1's Progress Notes. R1's Incident Report dated 3/13/23 at 9:22am documents V10 (LPN) was called to R1's room where R1 was noted to be lying on the floor next to R1's bed. R1 had been using the trash can for a toilet and lost R1's balance and was on the floor. This report documents R1 did not have any injuries observed. R1 was sent to the local emergency department for evaluation. This report does not document R1's mental status at the time of this fall. There is no documentation in the investigation of fall prevention interventions that were in place at the time of this fall. Pre-disposing Physiological factors, decline in cognitive skills is marked, but no additional details documented. This report documents predisposing situation factors including behavior symptoms. This report documents no witnesses found. There is no documentation of interviews with staff who were responsible for R1's care/supervision on 3/13/23. On 3/23/23 at 1:34pm, V2 (DON) stated V2 could not remember who the CNA was taking care of R1 at the time of R1's fall on 2/15/23. V2 stated the only witness statement obtained was from V8 (CNA) although V8 was not working at the time of R1's fall on 2/15/23. V2 stated all interventions would have been in place at the time of R1's fall on 3/13/23, but V2 did not detail what the fall interventions were for R1. V2 stated family requested toileting after meals. V2 stated V2 did not interview the CNA responsible for caring for R1 on 3/13/23. V2 stated V2 reviews the nurses notes and counts that as the nurse's statement.

Based on interview and record review, the facility failed to notify a physician of a change in condition, failed to implement physician's orders timely and failed to document a thorough assessment for multiple days after a resident's fall, for one of three residents (R1) reviewed for falls on the sample of five. These failures resulted in R1's left leg/hip pain progressively worsening with R1's range of motion declining to the left leg and R1's decline in bed mobility, transfers and ambulation. These failures also caused a delay in repair of R1's left femoral/hip fracture. Findings include: The fall investigation for R1's fall on 2/15/23 at 4:45 AM documents a final report to the State Survey Agency dated 2/23/23 with a summary as follows: On 2/15/23 R1 was observed on the floor of R1's room per witness statement. R1 was assessed with no changes noted. Later assessment reveals increased signs and symptoms of pain and that V9 (R1's Physician) was notified with a new order received to get a STAT x-ray of the left hip and leg. This report states the portable in-house x-ray documented an Acute Non-displaced Left Intertrochanteric Femoral/Hip Fracture with mild varus angulation of the fracture site. V9 (Physician) was made aware of the results and R1 was sent to the emergency room and admitted to the hospital for surgical intervention to the left hip. R1's Progress Notes dated as follows document: 2/15/23 at 4:48am - R1 has a new skin concern, a Hematoma, located to R1's rear Left Iliac Crest. Monitor R1's Hematoma to the left iliac crest and R1 complains of pain. There is no documentation of a description/details of circumstances of R1's Fall on 2/15/23 in R1's Progress Notes. 2/15/23 at 7:54am - R1's follow up assessment post-fall. This note documents R1 is alert and oriented. No changes in Range of Motion (ROM), No pain. 2/16/23 at 4:36pm - R1 is alert and oriented, intermittent confusion, with rating pain 4/10 to R1's left hip. This note documents swelling observed at site. Reddish-purple bruising noted. There is no documentation V9 (R1's Physician) was notified of these observations. 2/17/23 at 8:22am - Follow up assessment of Hematoma. R1 is alert and disoriented per usual baseline. R1 having pain at a 3/10 on the pain scale and not of new onset. This note documents no changes in range of motion and that R1 has swelling and deep purple bruising to the site. 2/17/23 at 1:03pm - Follow up assessment post-fall. Follow-up assessment of Hematoma. This note documents new injury noted on assessment, Hematoma on left hip with pain 3/10 on the pain scale and that V9 (R1's Physician) notified of new pain onset. This note documents R1 also has a new onset of limitation in ROM. There is no documentation of the location of limitation of ROM or that V9 was notified of R1's limitation in ROM. This note documents swelling was observed with deep purple bruising noted. There are no Progress Notes from 2/17/23 at 1:03pm until 2/19/23 at 7:03am documenting at 9:00pm (on 2/18/23), an unidentified Certified Nursing Assistant (CNA) reported change in condition advising that R1 has been in bed unable to walk or move for three days. This note documents on assessment, R1 unable to perform baseline ROM, with 2+ edema noted to the left distal ankle with grimacing noted. This note also documents, Per (V9), stat X-ray processed. There is no documentation of when the facility's Mobile X-ray company was notified of the STAT X-ray order for R1. R1's Medication Administration Record dated February 2023 documents R1's administration of Acetaminophen 650mg by mouth twice daily scheduled with a pain level as follows: 2/15/23 evening/dinnertime 4/10 2/16/23 day/breakfast and evening/dinner time 0 2/17/23 day/breakfast 0 and evening/dinner time 2/10 2/18/23 day/breakfast and evening/dinner time both 3/10 2/19/23 day/breakfast NA (not applicable) and evening/dinnertime 4/10. This record also documents R1's pain on 2/17/23 at 8:47pm as pain rating of 10/10 and on 2/18/23 at 8:08pm as pain rating of 5/10 with Acetaminophen (Analgesic) 650mg administered. R1's Progress Notes dated as follows document: 2/19/23 at 1:07pm the facility's Mobile Radiology company arrived at 12:00pm and completed X-ray to R1's hip, leg and ankle. 2/19/23 1:09pm, R1 with increased pain in the left hip, waiting on X-ray results, called V9 about stronger pain medication. There is no documentation of a response, orders received from V9 or a follow-up with V9 related to the request for stronger pain medication for R1's increased left hip pain. 2/19/23 at 2:34pm, R1 skin concern bruising to the left trochanter (hip) with swelling and slight bruising. R1 complains of pain, has facial grimacing with complaints of pain in left hip with difficulty with changing positions. 2/19/23 at 2:51pm documents V2 (Director of Nursing/DON) notified of R1's X-ray results of fractured hip. 2/19/23 at 3:55pm, R1 sent to the local emergency room for evaluation and treatment due to left hip fracture. R1's Radiology Results Report dated 2/19/23 documents R1's Left Hip and Pelvis X-ray was performed on 2/19/23 at 12:31pm and reported date of 2/19/23 at 1:58pm. This report documents R1 has an Acute Non-displaced Left Intertrochanteric Femoral/Hip Fracture with mild varus angulation of the fracture site. R1's hospital History and Physical (H&P) dated 2/19/23 documents R1 with likely memory difficulty/undiagnosed Dementia, presented to the local emergency room for left hip pain and reportedly suffered from a fall 3 days ago, had X-rays done, notable for left hip fracture and (R1) was subsequently sent to ED (Emergency Department). This H&P documents R1 has a history of Alcohol Abuse and Peripheral Vascular Disease (PVD) and that R1 has been taking Enteric Coated Aspirin 81mg (milligrams) (Antiplatelet Agent), one tablet by mouth daily and Clopidogrel (Antiplatelet Agent) 75 mg, one tablet by mouth daily. This H&P also documents R1's physical assessment at the hospital including R1 had tenderness (left hip/groin) with left leg externally rotated and shortened. R1's H&P documents R1's results of X-rays of the pelvis and left femur performed at the hospital as a Comminuted Displaced Left Intertrochanteric Fracture. On 3/20/23 at 1:57pm, V12 (Certified Nursing Assistant/CNA) stated on 2/18/23, R1 was in quite a bit of pain and V12 told V14 (Licensed Practical Nurse/LPN) because V14 had come to the unit to check in. V12 (CNA) stated V13 (CNA) and V12 told V14 that something was wrong/different with R1. V12 stated R1 had stayed in bed all day, which is not normal for R1. V12 stated R1 is usually independent for transferring, ambulation and toileting. V12 stated earlier in the day on 2/18/23, V12 mentioned to V15 (LPN) that something was going on with R1 and that R1 was not R1's self. V12 stated it wasn't until V14 was notified of R1's pain and not getting out of bed that the facility got orders for testing. V12 stated R1 just progressively worsened until R1 was sent out on 2/19/23 after receiving the results from R1's X-ray that R1 had a hip fracture. V12 stated after R1's fall, V12 noticed someone had given R1 a urinal and R1 was using that instead of independently ambulating to use the restroom. V12 stated R1 having a urinal threw (V12) off because R1 had never used one before. R1 did not get out of bed on 2/18/23 during V12's shift. V12 stated R1 was in a lot of pain, making sounds and grimacing in pain when staff would assist R1 with bed mobility/cares. On 3/22/23 at 11:45am, V11 (R1's family) stated V11 was notified of R1's fall on 2/15/23 but was told (R1) was okay. V11 stated the facility did not notify V11 of R1's hematoma/bruising to the left hip nor that R1 was having pain. V11 stated the facility should have never let R1 sit in pain and with the swelling and bruising of R1's left hip area for over three days before getting an order to x-ray the hip. V11 stated the facility told V11 that R1 had been assessed when they initially reported the fall and V11 was not notified of the additional details of injury nor that an x-ray to assess the hip had not been done. V11 stated V11 assumed an X-ray would have been done to assess to make sure there were no injuries after the fall or at least with the signs of the injury to the left hip. V11 stated the facility should have identified there were problems/potential internal injuries and if they would have assessed R1 thoroughly, the facility would have found the fracture sooner and R1 would not have had to lay in bed in pain and declining. V11 stated V11 came to the facility on [DATE] and R1 could not get out of bed and was complaining of pain to the left hip area. V11 stated R1 has a history of drug abuse and does not want narcotics so many times does not notify the facility of pain unless R1 is asked. In the morning of 2/19/23, the facility called V11 to notify V11 that R1 was not getting out of bed and was concerned for injury, so the facility was going to obtain x-rays. On 3/23/23 at 1:34pm, V2 (DON) stated on 2/15/23 at 4:45am when R1 fell , V2 was the nurse on hall. R1 was found sitting on R1's buttocks with R1's right side against the wall by R1's closet. V2 stated at that time, R1 was not complaining of pain. The facility assisted R1 back into bed. R1 had no facial grimacing or signs of pain. When asked about R1's range of motion (ROM), V2 stated R1 was asked to pick leg up and out and could but this is not documented in R1's progress notes. V2 stated R1's skin to R1's thigh area was raised but not discolored, and R1 stated R1's left hip/thigh hurts when it is pushed on and stated ouch, but nothing indicating severe pain. V2 stated V2 would not have expected the facility to notify V9 (R1's Physician) of the new bruising because there was already injury so bruising would be expected. V2 stated the facility was not measuring the raised area or bruising and there is no documentation of measurements of the raised area or size of the bruising. V2 stated V2 would have assumed V15 (LPN) would have told V9 R1 had new findings of limitation of range of motion. V2 stated V2 expects an X-ray ordered STAT should be completed within 4 hours. V2 stated if there is a delay, the facility should call the physician and follow up for further orders if X-ray cannot get here timely to complete testing as ordered. The facility's Physician-Family Notification-Change in Condition policy dated November 2018 documents the purpose of the policy is 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. This policy documents the facility will inform the resident, consult with the physician and if known, notify the residents legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention, a significant change in the resident's physical, mental or psychosocial status, or a need to alter a treatment significantly.

Based on observation, interview and record review the facility failed to prevent episodes of physical aggressive behaviors resulting in R1 kicking R2 and R2 subsequently hitting R1 in the face, R4 grabbing R1's arm, R9 shoving R11 and R6 pushing over a bedside table towards R5, hitting R5 in the face causing lacerations to R5's right side facial area, resulting in an emergency room visit due to right sided periorbital edema resulting in a closed fracture of the nasal bone. These failures affect seven of 14 residents (R1, R2, R4, R5, R6, R9 and R11) reviewed for abuse on the total sample list of 14. Findings include: The facility's Abuse policy, with a revision date of April 2022, documents, Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes: verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. On 1/24/23 at 11:55 AM, V8 (Licensed Practical Nurse/LPN) stated, On 1/9/23 I was down on another hallway with V23 (Certified Nursing Assistant/CNA). V23 thought she heard some yelling. We listened and saw R6 in the hallway, who was yelling 'you better get down here and get this (explicit language)' and R6 headed back to room. We headed down the hallway and heard shouting. I walked into the room and R5 and R6 were arguing over the TV (television) being on. R5 was lying in bed, R6 stood up and pushed the bedside table into R5's face. I took R5 to the nurses' station, applied compression to nose as it was bleeding and strips to lacerations. The nurse on the next shift sent R5 to be checked out, because eye was swelling. R5's medical record documents on 1/9/2023 at 3:29 AM Incident Note by V8 (LPN) reports V8 heard yelling and cursing coming from the Hall; upon further investigation as I was walking to room, I got to the doorway, and I noticed R6 was standing over R5, cursing at R5 telling R5 to shut the television off. R6 pushed bedside table into the R5 at which time I ran and got in between both residents to separate. R5 was noted to have blood coming from R5's face. R5's medical record documents on 1/9/2023, Resident has a new skin concern. Type of skin concern: Laceration. Located to Face - right side of face - Laceration, Other (specify) - Right eye lid - Laceration. Treatments include Cleansed lacerations and steri strips applied. Resident complains of pain, aching. R5's medical record documents, 1/9/2023 at 4:22 PM, Resident sent out to Emergency Department for evaluation and possible treatment. The facility's abuse investigation files note On 1/9/23 at 6:15 PM V22 (Licensed Practical Nurse) notified V1 (Administrator), (R5's) eye was almost completely swollen shut and needs to be assessed. V22 sent R5 to the emergency room for evaluation. R5's emergency room After Visit Summary dated 1/9/23 documents, Reason for visit: Facial Pain, Facial Swelling. Diagnosis: Closed fracture of nasal bone. CT of facial bones without contrast: Clinical Impression: Blunt Facial Trauma. Findings: there is soft tissue swelling in the infraorbital, perinasal and peri-maxillary regions. There is an acute appearing fracture at the base of the right nasal bone with slight depression. Nasal septum is deviated to the right inferiorly. Impression: 1- Acute Right Base Nasal Bone Fracture. On 1/24/23 at 2:00 PM, R5 had a maroon/dark purple discoloration to R5's right cheek bone area. There was mild edema to the bridge of R5's nose on the right side. R5 stated, I was watching TV that night in my bed. R6 woke up and told me I needed to turn the TV off. I didn't even have the volume on, it was on mute. We started having words about it and R6 shoved the table into my face. On 1/25/23 at 1:30 PM R6 stated, It was around 2 AM; I woke up to the sound of the television on. I told R5 to shut it off. I got up and turned off the television, laid back down in bed, and R5 turned it back on again. I told R5 again to turn it off. R5 said something smart to me, and I said something smart back. I turned on the light and went down the hallway yelling for someone to come down to the room. I laid back down and R5 turned it on again, but this time had it muted. I stood up out of the bed again to go towards the television and at the same time R5 must have been starting to sit up in bed. I pushed the over the bed table that was towards the end of the bed over towards R5's side of the room and it hit R5 in the face. On 1/25/23 at 2:15 PM, V1 (Administrator) stated, R5 and R6 had just got placed in same room on Friday (1-6-23). That night (1-9-23) R5 was watching tv on mute, woke R6 up, R6 asked R5 to turn off the tv, R5 had the remote and R6 kept turning it off at the television. They had a verbal exchange. R5 stayed in bed, continued going back and forth, then V8 (LPN) heard raised voices. V8 saw R6 in the hallway, then R6 went back into room. V8 saw R6 push the tray table towards the other side of the room (R5's area); it hit R5 in right cheek area. R5 had lacerations and bruising to the face. Next day later in the day, R5 was sent out to ER. R5 had a Nasal Bone Fracture. The Facility's Abuse Investigation File documents, Initial report: 1/9/23. Conclusion and Action taken: R5 and R6 shared a room, R5 and R6 had a disagreement regarding the television. R6 voices R6 was getting up to go to the nurse's station and pushed that tray table away from him, inadvertantly pushed the tray table hitting R5 in the face. R5 was sent to the emergency department for evaluation and returned with a diagnosis of closed fracture of the nasal bone. 2. R1's medical record documents, 12/31/2022 at 2:45 PM, V22 (LPN) reported an alleged physical altercation between R1 and another resident. R2's medical record documents, 12/31/2022 at 2:46 PM, V22 (LPN) reported an alleged physical altercation between R2 and another resident. The Facility's Abuse investigation file documents, Initial report: 12/31/22, Conclusion and Action taken: Based on the results of the investigation, the facility has determined R1 and R2 were involved in a physical altercation. On 1/24/23 at 2:10 PM V5 (CNA) stated, On 12/31/22 I was sitting on the hallway with another resident. R2 was walking towards the door to look out the window, because that is what R2 does. R1 was coming back down the hallway. R2 said something; I could not make it out to R1. R1 turned around and kicked R2 in the back of the leg, and R2 then smacked R1 in the face. On 1/25/23 at 2:15 PM V1 (Administrator) confirmed, On 12/31/22 R1 kicked R2 in the leg and then R2 smacked R1. 3. R4's medical record documents, 1/5/2023 Incident Note: V7 (Activities Director) reported an allegation of a physical altercation between R4 and another resident. R1's medical record documents, 1/5/2023 Incident Note: V7 (Activities Director) reported an allegation of a physical altercation between R1 and another resident. The Facility's Abuse Investigation file documents, Initial report: 1/5/23. Conclusion and Action taken: Staff report R1 took (R4's) soda and R4 held (R1's) arms to get the soda back. On 1/25/23 at 9:10 AM, V6 (CNA) stated, I was in the hallway, and I heard R4 say 'give that back you (explicit language).' R4 had a hold of R1's upper arm, trying to reach in and grab soda R1 had under R1's arm pit area. I got to them, and I told R4 I would get it. R4 stepped away. On 1/25/23 at 2:15 PM V1 (Administrator) stated, R1 went into R4's room and took R4's soda. R4 came out to hallway and tried to get soda back from R1. Staff didn't get to R1 soon enough and saw R4 reaching and grabbing R1's arm to get the soda back from R1. 4. R9's medical record documents, 1/17/23 Behavior, resident to resident altercation noted. R11's medical record documents, 1/17/23 V21 (LPN) reported an allegation of a physical altercation between R11 and another resident. The Facility's Abuse Investigation file documents, Initial Report: 1/17/23. Conclusion and Action taken: R9 and R14 share a room. R11 entered (R9 and R14's) room. R11 approached R14's bed and sat in R14's wheelchair. R9 called for assistance. R9 pushed R11 to the hall while R11 was sitting in R14's wheelchair. On 1/25/23 at 9:30 AM, V26 (CNA) stated, On 1/17/23 I had just came on shift, and I saw a call light on to R9's room. Then I heard yelling 'get this (explicit language) out of here.' I got down to the room. R11 was in R9's doorway. R9 tried to push R11 in the wheelchair out of the room and it didn't go out all the way. Then R9 pushed on R11's shoulders to get R11 and the wheelchair out of R9's room. On 1/25/23 at 2:15 PM, V1 (Administrator) stated, R11 had only been here a few days. R11 was a little more confused than when here for a prior stay. R9 and R14 were roommates. R14 said R11 had come in room. R11 had tried to sit on R14's bed. R14 told R11 that R11 wasn't supposed to be in there. R14 turned on the call light. R11sat in R14's wheelchair beside the bed. R14 yelled for help. R9 then went around to R14's side of the room and pushed R11 in R14's wheelchair out of the room. The CNA said she saw R9 push on R11's shoulders to get R11 out of the room.

Based on observation, interview and record review the facility failed to administer Lantus Insulin 85 units for one (R3) resident for a total of 25 days due to facility did not follow their own policy when reviewing a Physician order. This failure affects one (R3) of three residents reviewed for medication in the sample of 17. This failure caused R3 to experience a significant increase in R3's blood glucose levels resulting in R3 developing cellulitis requiring additional antibiotic therapy, with a potential for sustained elevated blood glucose levels resulting in diabetic coma and/or death. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R3 was initially not administered 85 units of Lantus Insulin. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:28 PM. The Immediate Jeopardy was removed on [DATE], but noncompliance remains at a severity level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3's Medical diagnoses include Type II Diabetes Mellitus Without Complications, Essential Hypertension, Respiratory Failure, Dementia with Behavioral Disturbances, Chronic Congestive Heart Failure, Venous Insufficiency, Difficulty in Walking and Chronic Obstructive Pulmonary Disease. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as moderately cognitively impaired. This same MDS documents R3 as requiring extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene and extensive assistance of two people for transfers. R3's Physician Order Sheet (POS) dated [DATE]-30,2022 documents a physician order for Lantus Insulin 85 units to be self-administered unsupervised daily in the morning from [DATE]-[DATE]. This same POS documents an increase in R3's Humalog insulin to be administered subcutaneously with each meal on [DATE] from 4 units to 6 units. R3's Medication Administration Record (MAR) dated [DATE]-30, 2022 documents R3's Lantus Insulin was signed out as unsupervised self-administration (U-SA) for [DATE]-[DATE]. This same MAR documents R3's blood glucose levels from [DATE]-[DATE] as ranging from mid 100's to high 200's and [DATE]-[DATE] as high 200's to high 300's with four entries in the low 400's. R3's POS dated [DATE]-31, 2022 documents a physician order for Lantus Insulin 85 units to be self-administered unsupervised daily in the morning from [DATE]-[DATE]. This same POS documents physician orders for Cephalexin 500 milligrams (mg) twice daily for Cellulitis starting [DATE] through [DATE]. R3's Medication Administration Record (MAR) dated [DATE]-31, 2022 documents R3's Lantus Insulin was signed out as unsupervised self-administration (U-SA) for [DATE]-[DATE]. This same MAR documents R3's blood glucose levels range from [DATE]-[DATE] as mid 200's to mid 300's and [DATE]-[DATE] as high 100's to mid 200's. On [DATE] at 11:15 AM Surveyor observed R3 did not have any Humalog Insulin on medication cart nor in nurses' storage refrigerator. On [DATE] at 11:20 AM V9 (Licensed Practical Nurse/LPN) confirmed R3 did not have any Humalog insulin in the medication cart nor nursing storage refrigerator. V9 (LPN) stated We (staff) have been using (R6's) Humalog since we are out. (R3) has been getting the insulin, just not from (R3's) own bottle. I will get it ordered today. On [DATE] at 2:00 PM V2 (Director of Nurses/DON) stated V2 was not aware that (R3's) Humalog Insulin was not in facility. V2 stated All residents should have their own medication. The nurses should never borrow one resident's medication to give to another resident. On [DATE] at 2:30 PM V2 (DON) stated The previous Nurse Practitioner (V8) ordered (R3's) Lantus Insulin 85 units every morning on [DATE]. (V8) entered (R3's) Lantus order incorrectly. (V8) entered an order that read (R3) would self-administer the Lantus unsupervised. This was a mistake on (V8's) part. (R3) cannot safely self-administer any medications. Because of that, (R3) never received that medication from [DATE]-[DATE]. V2 stated when the Electronic Medical Record (EMR) 'reads' that order, it is not digitally sent to the Medication Administration Record (MAR) that the nurse sees on their computer. So the nurses would never have seen that (R3) was supposed to be getting the 85 units of Lantus every morning. (V10) (LPN) reviewed and confirmed the order, but I am sure (V10) did not question the order since (V8) entered it. On [DATE] at 8:30 AM R3 stated I did not have to go to the hospital or anything, but I sure didn't feel good most of those days. On [DATE] at 9:55 AM V8 (previous NP) stated (R3) is a long time diabetic patient. I did enter an order for (R3's) Lantus 85 units daily to be administered in the morning on [DATE]-[DATE]. I wrote that order for one month due to R3 has had multiple changes in (R3's) Insulin regimen. I did enter the Lantus order to be self-administered unsupervised. (R3) is not cleared to self-administer medications due to poor cognition. The facility policy was for the nurses to review all physician orders. (V2) (DON) called me on [DATE] to report the error. I told (V2) then to complete a medication error report. The original error in entering the order was my fault, but if the facility would have followed the facility policy to review the orders, (R3) would have only missed possibly one dose, not a month's worth of insulin. For (R3), not getting the insulin that was prescribed more than likely caused (R3) to have to take antibiotics for bilateral lower leg cellulitis. (R3's) elevated blood sugars would have prevented healing. If (R3's) blood sugars had been better controlled with insulin, more than likely (R3) would not have been on those extra antibiotics. (R3) could have gone into a Diabetic coma due to dangerously elevated blood sugar levels. (R3) could have died . That is how serious this is. On [DATE] at 1:10 PM V20 (Medical Director) stated I was unaware of any medication error concerning (R3). (R3) is a chronic diabetic patient that requires a significant amount of insulin in order to maintain consistent blood sugars. It sounds like (V8) Nurse Practitioner entered the Lantus Insulin order incorrectly and the facility also did not review the order to ensure (R3) would have the insulin administered by a nurse. (R3) was previously getting 84 units of Lantus daily, so I don't understand why the facility did not recognize that (R3) was not getting (R3's) daily insulin. (R3) could have had severe consequences from not getting the Lantus for 25 days. The ill effects show in (R3's) elevated blood glucose levels and having to be prescribed antibiotics for the cellulitis. The facility policy titled 'Physician Orders-Entering and Processing' revised [DATE] documents the following: To provide general guidelines when receiving, entering and confirming physician or prescriber orders. (A prescriber is noted as Physician, Nurse Practitioner or Physician's Assistant). Following a physician visit, a licensed nurse will check for any orders that require confirmation. The orders will be confirmed by the nurse and the instructions for the order will be completed. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. The surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. V2 (DON) confirmed R3 was assessed on [DATE] with no new findings and R3's Physician and Power of Attorney (POA) were notified of medication error and assessment with no new findings. 2. V2 confirmed facility house wide medication self-administration report was completed on [DATE] with three (R11, R12, R13) residents noted to have self-administration of medication orders. 3. V2 confirmed R11, R12 and R13 were assessed for self-administration on [DATE]. V2 stated R12 and R13 were deemed to be inappropriate for self-administration of medications and orders were adjusted to reflect medications should be administered by clinician. 4. V2 confirmed that all nursing staff was inserviced on [DATE] on when and how to review orders. 5. V4 (Regional Clinical Nurse) confirmed that V2 was inserviced on [DATE] on when and how to review orders. 6.a. V2 confirmed all medication carts were audited by facility on [DATE]. 6.b. V23 (Consultant Pharmacist) confirmed all medication carts were audited by pharmacist on [DATE]. 7. V1 (Administrator) confirmed that ad-[NAME] QAPI meeting was held on [DATE] with all members in attendance and that pharmacy was notified of all concerns. 8. V1 confirmed next QAPI meeting will be held on [DATE] and will include discussion of all survey concerns, med errors, citations and trends. 9. V24 (Regional Clinical Informatics Nurse) confirmed request for unsupervised self-administration option was not offered at facility level. V24 stated PCC denied request but allowed V24 to complete an 'enhancement' which is a formal request. 10. V1 confirmed IDT (Interdisciplinary Team) began discussing deficiency concerns, medication errors and trends on [DATE]. V1 stated IDT met again on ,d+[DATE] and ,d+[DATE] to discuss same concerns. V1 stated no new concerns have been identified.

This deficiency requires two deficient practice statements. A. Based on interview and record review the facility failed to obtain physician ordered laboratory values, failed to report critical level laboratory values to Physician and failed to report a change in condition timely to Physician for one (R2) resident out of three residents reviewed for change of condition on the sample of 17. These failures resulted in R2 experiencing poor fluid intake, delayed medical testing, experiencing critical labs then subsequently being hospitalized with lower leg cellulitis and pneumonia. B. Based on observation, interview and record review the facility failed to provide timely pain medication for a resident by not maintaining supply of R4's prescribed narcotic pain medication. This failure affects one (R4) resident out of three residents reviewed for change of condition on the sample of 17. R4 experienced severe unrelieved pain causing R4 to call for emergency services. Findings include: A. R2's Medical diagnoses include Right Lower Extremity (RLE) Cellulitis, Aspiration Pneumonia, Right Lower Leg (RLL) Deep Vein Thrombosis (DVT), COVID-19, Acute Lower Respiratory Infection, Cognitive Communication Deficit, Down Syndrome, Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity due to excess calories, Dysphagia and Difficulty Walking. R2's Minimum Data Set (MDS) dated [DATE] documents R2 was moderately cognitively impaired. This same MDS documents R2 required extensive assistance of one person for bed mobility, dressing, eating, extensive assistance of two people for transfers and total assistance of one person for toileting and personal hygiene. R2's Physician Order Sheet (POS) dated November 1-30, 2022 documents a physician order dated 11/23/22 of Please monitor over next 24 hours and encourage oral fluids at meals. If no improvement in oral fluid intake or increase in urinary output, please send to emergency department (ED) for further evaluation/treatment. This same POS documents a physician order dated 11/22/22 to obtain Complete Blood Count (CBC) with Differential (diff), Comprehensive Metabolic Panel (CMP) or D-Dimer on 11/22/22. One time only. This same POS does not document a physician order for lab work on 11/29/22. R2's Documentation Survey Report dated November 1-30, 2022 documents intakes of: -11/23/22 R2 refused all food and fluids for breakfast, refused all food and drank 50 milliliters (ml) for lunch and refused all food and drank 480 ml for supper. -11/24/22 R2 refused all food and fluids for breakfast and lunch and refused all food for supper and drank 760 ml fluids. -11/25/22 R2 refused all food and fluids for breakfast and lunch and there were no entries documented for supper meal. -11/26/22 R2 refused all food and fluids for breakfast, there were no entries for lunch meal and refused all food and drank 120 ml for supper meal. R2's Electronic Medical Record (EMR) does not document notification to (V20) physician of intakes from 11/23/22-11/26/22. R2's Physician Order Sheet (POS) dated December 1-31, 2022 documents a physician order dated 12/2/22 of Please get labs as previously ordered stat. CBC with diff, CMP, D-dimer STAT. R2's EMR documents R2's weight as 148.5 pounds (lbs) on 11/2/22 and 139.0 lbs on 12/2/22. R2's Electronic Medical Record (EMR) does not document laboratory results for physician ordered Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) or D-Dimer for 11/22/22 or 11/29/22. R2's Electronic Medical Record (EMR) documents the same labs were ordered STAT (immediately) on 12/2/22. R2's laboratory requisition dated 12/2/22 documents can't get as results of labs not obtained. R2's Laboratory Report dated specimen was obtained on 12/5/22. This same report documents R2's Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and D-Dimer results as follows: White Blood Cell (WBC) count result of 25.56 (high) with reference range of 4.0-12.0 10(3) cubic milliliter (mcL) of blood. D-Dimer result as >=20.00 (high) with a reference range of 0.50 micrograms (mg)/milliliter (ml) Fibrinogen Equivalent Unit (FEU). Nurse Progress Notes document: -11/26/22 at 2:45 pm documents Impaired balance noted. Weakness noted. Decreased sensation noted. (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. -11/27/22 at 6:45 AM documents (R2) has evidence of an acute change in mental status from (R2's) baseline noted. Decreased sensation noted. -11/29/22 at 3:05 PM V8 (Nurse Practitioner/NP) documents NEXT LABS PENDING: Will reorder missing labs for 12/2/22 - CBC, CMP, D-dimer. -11/30/22 at 6:40 AM documents (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when sitting or at rest. Shortness of breath or difficulty breathing when lying flat. (R2's) Lung sounds diminished. -12/1/22 at 11:07 AM documents (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. -12/2/22 at 9:05 AM document (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. -12/3/22 at 9:05 AM documents (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. (R2) lung sounds diminished. -12/4/22 at 9:05 AM documents (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. (R2) lung sounds diminished R2's Hospital Laboratory Report documents R2's 12/5/22 D-Dimer results were called, results acknowledged and read back. R2's EMR does not document receipt of abnormal lab values on 12/5/22 or 12/6/22. R2's Nurse Progress Note dated 12/7/22 at 1:45 PM documents Resident noted to have a WBC of 25.56. (V8) NP ordered resident out to emergency room (ER) for evaluation. R2's Nurse Progress Note dated 12/7/22 at 2:04 PM (V8) NP documents New Right Leg redness, swelling, post COVID-19. Onset-acute, first noticed one to two days ago, location Right Lower Extremity (RLE). (R2's) EMR shows nine pound weight loss within one month. Right Lower Leg edematous, erythematous, non-tender. Assessment/Plan: RLE redness, swelling; Leukocytosis, abnormal weight loss, send to emergency room for further evaluation to rule out Deep Vein Thrombosis (DVT), Leukocytosis. R2's hospital records dated 12/7/22 document admitting diagnoses as Right Lower Extremity (RLE) Cellulitis and Aspiration Pneumonia. R2's Ultrasound Right Duplex Lower Extremity Veins Result dated 12/8/22 documents Impression: Deep Vein Thrombosis (DVT) in the visualized Common Femoral, Femoral, Popliteal, Posterior Tibial and Peroneal Veins. R2's Chest X-Ray Report dated 12/7/22 documents Impression: Patchy opacity suspected at Left Lung base. R2's Ambulance Report dated 12/7/22 documents Staff wanted (R2) evaluated in emergency room due to elevated White Blood Cell (WBC) count. Assessment revealed with vitals as documented with (R2) having redness in Right Lower Leg. On 1/5/23 at 10:35 AM V2 (Director of Nursing/DON) stated the laboratory levels were never drawn on 11/22/22 or on 11/29/22. V2 stated the physician should have been notified but was not. The laboratory technician did come to facility on 12/2/22 but was unable to get blood collected due to R2 was not compliant. V2 stated the labs were finally obtained on 12/5/22 and physician was notified of the results on 12/7/22. V2 stated R2 was sent to the hospital on 12/7/22 for a decline in condition. On 1/6/23 at 11:00 AM V8 (previous NP) stated (R2) had a productive cough with thick green mucous and generally did not look like he felt well. V8 stated (R2) was not eating or drinking very well so on 11/23/22 I ordered the staff to monitor (R2's) fluid intake for 24 hours and send to the emergency room if not any better. They (staff) did not notify me of any changes in (R2's) condition including poor fluid intake, or I would have sent (R2) into the emergency room that day (11/24/22). V8 stated attempted to review the labs that were ordered on 11/22/22 but the labs had not been completed. V8 stated No one could tell me why the labs I ordered on 11/22/22 were not completed, but I was told that they would be completed and I would be notified of any abnormal values. I ordered the D-Dimer to rule out a possible Deep Vein Thrombosis (DVT) due to many patients I have seen with COVID-19 end up with DVTs. I saw (R2) again on 11/29/22 and realized then that the labs had not yet been drawn. I re-ordered them on 11/29/22. On 12/2/22 I ordered the labs to be drawn STAT due to the facility still had not obtained the labs that originally ordered on 11/22/22. (R2) refused to have blood drawn on 12/2/22 so I reordered them again for 12/5/22. On 12/7/22 I was able to review the lab results and saw that (R2) had a D-Dimer over 20 which is a critical level, and also the highest I have ever seen. (R2's) White Blood Cell (WBC) count was also at a critical level so at that point I gave the order to send (R2) to the emergency room . No one from the facility notified me of (R2's) critical lab values. On 1/6/23 at 2:15 PM V21 (Laboratory (lab) Resolution Specialist) stated R2's CBC with Differential, CMP and D-Dimer were collected, received and processed on 12/5/22. V21 stated it is the policy of the laboratory to call the critical laboratory values to the facility as soon as they are realized by the lab. V21 stated We (lab staff) called the abnormal values, especially the critical lab values such as in (R2's) case as soon as possible on 12/5/22. We (lab staff) call the lab values directly to the facility and ask for the nurse in charge of that patient. From there, I do not know what happens, but we (lab) call the labs to the patient's nurse, not the Physician. On 1/6/23 at 1:00 PM V20 (Medical Director) stated resident laboratory values should be reported to Nurse Practitioner (NP) or Physician (MD) when they are received. V20 stated critical labs should always be reported immediately. V20 stated In this case (R2) was hospitalized for something we could have treated more aggressively in the facility initially or have sent (R2) to the emergency room if applicable, but because the lab work was not done and then not reported (R2) subsequently ended up in the hospital. V20 stated V20 was made aware of R2's abnormal lab values on 1/6/23. The facility policy titled 'Physician Notification of Laboratory/Radiology/Diagnostic Results' revised November 2019 documents the following: Purpose: To assure physician ordered diagnostic tests are performed, and to assure test results are reported to the physician, so that prompt appropriate action may be taken if indicated for the resident's care. A requisition is to be completed and lab to be drawn on the next scheduled lab day unless STAT is ordered. A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician or other practitioner who ordered them. All critical lab values unless other parameters are ordered by physician: White Blood Cell greater than 12000. The licensed nurse is responsible for documenting the results in the clinical record. B. R4's undated Face Sheet documents medical diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Dysphagia, Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypercapnia, Chronic Pain Syndrome, Dilated Cardiomyopathy, Congestive Heart Failure and Spondylosis Without Myopathy of Lumbar Region. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact. This same MDS documents R4 as requiring extensive assistance of two people for bed mobility, dressing, toileting, personal hygiene and total dependence of two people for transfers. R4's Physician Order Sheet (POS) dated January 1-31, 2023 documents a physician order for Hydrocodone-Acetaminophen (Norco) 10-325 mg one tablet every four hours as needed for pain starting 12/6/22 and Norco 5-325 mg two tablets every four hours as needed for back pain starting 1/2/23. R4's Medication Administration Record (MAR) dated January 1-31, 2023 documents Norco 10-325 mg was administered on 1/1/23 at 4:23 AM, 1/1/23 at 2:10 PM and 1/1/23 at 10:40 PM. This same MAR documents Norco 5-325 mg was administered on 1/2/23 at 2:31 PM. On 1/3/23 at 11:00 AM surveyor observed R4 laying in bed with tears in eyes. R4 stated They (facility) let me go hours without my pain medication. I had to just lay here in bed for hours in pain. I was crying it hurt so bad. I asked to go to the emergency room and was told I had to wait because they (staff) were trying to get my pain medication. I got tired of waiting in pain so I sent myself to the emergency room (1/2/23) for pain because they (facility) would not send me. The emergency room gave me some pain medication and a new prescription, but the facility still did not give me any until later that day (1/2/23). On 1/3/23 at 1:30 PM V2 (Director of Nurses/DON) stated R4 is an established patient at the local pain clinic. V2 stated R4 does have back pain and that is why R4 sees the pain clinic. V2 stated R4 can be 'very demanding' and have 'unreasonable expectations' of staff. V2 stated the pain clinic will send a prescription electronically (e-scribe) to the facility, the facility enters the order and then the pharmacy will send the new prescription. V2 stated In the case of (R4), the pain clinic never sent the prescription. We (facility) should have followed up with that but did not. That is when we (facility) called the pain clinic and were told that they (pain clinic) never sent the prescription to our facility. So, that is why the pharmacy never sent any more Norco for (R4). (R4) asked me if we (facility) could send (R4) to the emergency room and I told him 'you have the right to go to the emergency room but we (facility) are working on getting you more pain medication. You just have to be patient.' I did not call 911 for (R4). (R4) could not wait for us (staff) to get his pain medication figured out so he called 911 himself. The hospital gave (R4) some pain medication and a new prescription for Norco 5-325 mg two tablets every four hours as needed. (R4) may have went a total of 8 or 10 hours without any pain medication. I did not know until today that the pain clinic sent (R4's) Norco prescription to a local chain pharmacy. On 1/3/23 at 2:45 PM V12 (Pain Clinic Nurse Practitioner/NP) stated R4 is an established patient at local pain clinic. V12 stated R4 was given a computer tablet to enter any updated information on when R4 arrived at pain clinic appointment on 12/9/22. V12 stated R4 is alert and oriented and independently chose an outside pharmacy so that is where the Norco prescription was sent. V12 (NP) stated The facility got (R4) to the appointment and we (pain clinic) got (R4) the medication needed. The facility should have asked (R4) about any new orders or called the pain clinic to inquire. I personally tried to call the facility multiple times because I knew (R4) lived in a long-term care setting and most of those use their own pharmacies. I could not get anyone to respond so we (pain clinic) sent the prescription to the local chain pharmacy that was listed in (R4's) chart. On 1/4/23 at 10:05 AM V10 (Licensed Practical Nurse/LPN) stated January 2, 2023 was the day we realized (R4) did not have any more Hydrocodone-Acetaminophen 10-325 milligrams (mg). I began calling the pharmacy. When I called the pharmacy, they said the order had been discontinued and would not be filled until a new prescription was obtained. So, that is when I called the pain clinic. I could not get ahold of them right away so (R4) decided to send himself to the hospital to get a new prescription. (R4) did not want to wait on us (facility). The facility policy titled 'Physician Orders-Entering and Processing' revised January 2018 documents the following: Purpose: To provide general guidelines when receiving, entering and confirming physician or prescriber's orders (a prescriber is noted as a physician, nurse practitioner, and a physician's assistant). Following a physician visit, a licensed nurse will check for any orders that require confirmation. The orders will be confirmed by the nurse and the instructions for the order will be completed.

Based on interview and record review, the facility failed to protect a resident by failing to prevent further abuse for one of three residents (R3) reviewed for abuse allegations on the sample of seven. The facility failed to remove staff who were observed physically restraining a resident by the hands/arms to prevent the resident from stopping staff from performing COVID testing which R3 had refused. This failure resulted in the staff continuing to work at the facility for the rest of their shift, coming in to contact with R3 a second time, causing a reaction by R3 with aggressive physical behaviors toward the staff resulting in R3 sustaining a laceration to R3's right hand forefinger. Findings include: The facility's Final Abuse Investigation Report dated 11/30/22 documents R3's diagnoses including Hemiplegia, Hemiparesis, Cognitive Communication Deficit and Vascular Dementia. On 11/22/22 at 7:55am, R3 reported V4, V5 and V6, CNA's and V7, Activity Director for physical abuse. R3 was assessed and noted to have an alteration in skin integrity to the right finger. R3 reported V4 and V5, CNA's were physically aggressive when performing COVID testing. R3 reported staff held R3's arms and tested R3. R3 also reported later that night, V4, CNA came in and took R3's white board from R3. When R3 took the whiteboard back it resulted in an alteration in skin integrity to R3's right finger. The investigation report documents V7 stated R3 refused testing and later approached R3 again with V5, CNA. V7 stated R3 was attempting to throw the remote control at staff, jerking/tossing R3's communication board and pushing the intravenous pole toward staff. V7 stated V7 and V5 attempted to hold R3's hands to keep him from hitting staff. The investigation documents R3 reported V4, V5 and V7 held R3's arms and made R3 take the COVID test. There is no documentation of the staff participating in/observing the physical restraint of R3 being immediately suspended. The Time Card Reports for the following staff document these staff involved in the physical restraint of R3 were not immediately suspended and allowed to work until the end of their shift on 11/21/22: V4, CNA worked from 1:58pm to 10:23pm V5, CNA worked from 2:03pm to 10:24pm V6, CNA worked from 1:51pm to 10:19pm On 12/19/22 at 2:00pm, V1, Administrator stated V4, V5 and V6 should have been sent home and would have if V1 was aware. V1 stated V4, V5, and V6 did not recognize the incidents as abuse so V1 was not notified and V4, V5 and V6 were not sent home/suspended until 11/22/22 after V1 spoke with R3. The facility's Abuse Policy dated April 2022 documents the resident has the right to be free from abuse including physical restraint.

Based on interview and record review, the facility failed to complete post fall investigations to determine a root cause and failed to implement post fall interventions to prevent further falls. These failures affect three of three residents (R2, R5, R6) reviewed for falls on the sample of seven. These failures contributed to R5 going without a post-seizure/post fall neurology follow-up appointment for a month. R5 was found on the floor again exhibiting seizure like activity and sustaining a second head injury with laceration requiring sutures and being hospitalized and started on Anti-seizure medication. Findings include: 1. R5's Progress Notes dated as follows document: 10/8/22 at 2:59am, Certified Nursing Assistant (CNA) (unidentified) called for assistance to R5's room. 1st responding nurse (unidentified) observed R5 lying face down. R5 was placed on R5's side noted snoring with jerking movements. There was evidence of bleeding noted on the floor but unable to observe where it was coming from. R5 was transferred out to the local emergency room for evaluation. 10/8/22 at 12:42pm, R5 returned from the hospital via ambulance at 1240pm. No new medication orders. Discharge instructions say to follow-up with primary Dr. and Neurologist. There is no documentation of a follow-up appointment with V22, Neurologist. R5's emergency room After Visit Summary (AVS) dated 10/8/22 documents R5 was seen for Seizures and an unwitnessed fall. This AVS documents R5 is to follow up with V22, Neurologist in 2 days. There is no documentation R5 was scheduled for the neurologist follow-up or that R5 followed up with V22 as per physician's orders upon discharge from the emergency roiagnom on [DATE]. The facility's October 2022 Fall Log does not document R5's fall on 10/8/22. The facility did not provide a fall investigation for R5's fall on 10/8/22. R5's Progress Notes dated as follows document: 10/10/22 at 7:15pm, R5 was seen on 10/8/22 after being found on floor lying face down and making jerking movements. R5's work-up was negative for acute pathology. R5's diagnosis was Seizure. (R5) is to follow-up with Neurologist. ASSESSMENT/PLAN: Seizure, ground level fall- Neurology consult. Continue facility fall precautions. R5's Fall Investigation documents an initial report documenting on 11/10/22 at 3:15pm, R5 was observed on the floor of R5's room displaying seizure like activity. R5 was found to have a laceration to the forehead and was sent to the emergency room . This sheet documents R5's hospital diagnosis of soft tissue contusion of the right forehead with a superficial laceration of the supra orbital ridge requiring sutures. This fall investigation is incomplete. There is no documentation of which Certified Nursing Assistant (CNA) was assigned to care for R5 at the time of the fall or when or where R5 was last observed. R5's Progress Notes dated as below document: 11/9/22 9:20am, History of fall with seizure. R5 was seen at the local hospital on 10/8/22 after being found on floor lying face down and making jerking movements. R5 is to follow-up with Neurologist. To date (R5) has not yet been seen by neurology. R5 has had no additional falls or suspected seizure activity. ASSESSMENT/PLAN: Seizures -New onset -Neurology consult pending. 11/10/22 at 3:15pm, R5 found lying on R5's right side on the floor in R5's room next to R5's bed. R5's head was towards the bathroom and legs towards wall. An unidentified nurse stated R5 was exhibiting seizure activity. Laceration was noted to R5's right eyebrow and pressure was applied to stop the bleeding. Resident was initially not responding to unidentified nurse. R5 was sent to the emergency room . 11/10/22 at 6:21pm, Call placed to the hospital and was notified sutures were placed to R5's laceration. R5 is being admitted to hospital due to seizure like activity and is to see neurology. 11/11/22 at 1:32pm, R5 readmitted to the facility from the hospital. 11/15/22 at 2:22pm, R5 was hospitalized [DATE]-[DATE], for seizure (convulsive epilepsy), initially presenting after fall with head injury while at the facility. Hospital stay complications include lactic acidosis 2/2 seizure, right eyebrow laceration from falling . R5 was started on Keppra (Anti-seizure) 500 mg (milligrams) twice daily. ASSESSMENT/PLAN: Seizures -Chronic. Apparently, R5 has had convulsive epilepsy since 5/18/2011 per hospital records, now on Levetiracetam which facility will continue. Will have nursing make follow-up appointment with Neurology that R5 seen in hospital (V22). Ground Level Fall with head injury, 2/2 convulsions and eyebrow laceration with sutures. There is no documentation in R5's medical records of attempts to make an appointment for R5 to see V22, Neurologist for a week until 11/17/22. 11/17/22 at 8:49am, Facility has reached out to V22's Neurology Doctors office multiple times, and sent a referral for a new (unidentified) doctor to look at. Waiting for a response from R5's doctor's office. 11/18/22 9:13pm, Followed up with V22's office today, 11/18/2022 and they've asked to re-fax it to another fax machine due to it having lines through the fax they received and not being able to read it due to a receiving issue on their end. There is no documentation of facility follow up or appointment after 11/18/22 at 9:13pm in R5's Progress Notes until 12/6/22 at 1:32pm. On 12/19/22 at 2:00pm, V2, Director of Nursing (DON) stated V2 thinks R5 was admitted for the seizure like activity not the fall or laceration on 11/10/22. V2 stated V2 would have been made aware of a fall for R5 if there would have been one on 10/8/22. V2 stated V2 was aware of R5's seizure on 10/8/22 but was not aware R5 was found on the floor and that a fall investigation was not completed for 10/8/22. V2 stated V2 believed the facility attempted to schedule an appointment with Neurology for R5 October 8th or later, but V2 does not make the appointments so V2 was unsure. V2 stated attempts to make an appointment and appointments that are scheduled would be documented in the progress notes. V2 stated V2 did not see documentation of an attempt to schedule an appointment or that an appointment had been scheduled for R5 with a Neurologist between 10/8/22 and 11/17/22. V2 was unsure of which staff were taking care of R5 on 11/10/22 at 3:15pm. R5 usually walks up and down halls all hours of the day so staff may not have known where R5 was just before the fall. 2. The facility's Fall Investigation documents a report dated 11/12/22 at 4:10pm documenting a 2nd shift CNA (unidentified) reported R2 was on the floor to V19, Licensed Practical Nurse (LPN). R2 was sitting up against the side of R2's bed. R2 told V19 that R2 was trying to get up to use the bathroom. R2 had a hematoma with blood to the back of R2's head. R2 was sent to the hospital for a head injury. R2 was educated on the use of R2's call light to transfer with assistance. This investigation does not document a completed/final investigation report. There is no documentation of interviews with additional staff who were working at the time of R2's fall. This investigation does not document when R2 had last been observed, what R2 was observed doing prior to R2's fall or when R2 had last been offered assistance with toileting. This investigation also documents R2 has a gait imbalance, depression, forgets to use call light and needed to go to the bathroom. This investigation is incomplete and does not document when and where R2 was last observed or when R2 had last been toileted. There is no documentation of interviews with additional staff working with R2 at the facility during this fall. There is no documentation of a root cause of R2's fall on 11/12/22 in this investigation. R2's Progress Notes document: R2's Fall Investigation report dated 11/13/22 documents V19, LPN was informed by an unidentified CNA that R2 had fallen from R2's bed to the floor on R2's knees trying to transfer R2's self in to R2's wheelchair on 11/13/22 at 10:00am. This report documents R2 stated R2 tried to get up. This report documents R2 was not having pain and non-skid socks were placed on R2 and put her on 1:1 for the day to prevent any future falls/injuries. This report documents fracture before fall and predisposing factors including recent change in cognition, improper footwear and increased agitation. This report documents R2 is non-compliant with using the call light/asking for help when transferring. There is no documentation of a witness statement from the CNA (unidentified) who found R2. There is no documentation of when R2 was last offered to be toileted or seen or where R2 was last observed. There is no documentation as to if R2's call light was within reach. There is no documentation of a root cause of this fall. R2's Progress Notes document: 11/14/2022 11:59am Fall Follow Up, IDT note: IDT team met regarding recent falls. On 11/12 resident fell transferring herself to the bathroom but does not document when R2 was last toileted or last observed. Intervention will be to re-educate to use the call light for assistance to the bathroom. On 11/13/22, R2 fell again transferring from the bed to the wheelchair. There is no documentation of why R2 was trying to get up when R2 transferred R2's self on 11/13/22. 11/14/22 at 5:05pm, R2's Knee immobilizer to the right lower extremity with weight bearing as tolerated for closed fracture of right fibula. R2 reports some continued discomfort in right leg starting from the knee down. R2 is currently in wheelchair and is weight bearing as tolerated (WBAT). R2's Fall investigation report documents R2 had a fall on 11/15/22 at 1:20pm. This report documents V13, LPN was called to R2's room by an unidentified CNA stating R2 had fallen. R2 was observed laying on R2's right side near the dresser/closet. R2 stated R2 hit R2's head. R2's immobilizer to the right lower extremity was in place. R2's wheelchair was near the window. R2 stated R2 was leaning over the chair and fell , hitting R2's head on the dresser. R2 then stated R2 hit R2's head on the floor. There is no documentation as to why R2 was leaning over the chair. This report documents sutures intact to laceration on posterior head from previous incident. Floor mat placed next to R2's bed. Re-educated to use call light for staff assistance. This report documents R2 has poor safety awareness and exhibits balance and impulsive behavior impairments. This report documents R2 forgets to use the call light and fracture before the fall and R2 requires frequent reminders to sit upright in the wheelchair. This report documents V23, CNA stated V23 had been in R2's room a few minutes prior to the fall but does not document why V23 was in R2's room nor when R2 was last offered/provided with toileting. V23 stated V23 was alerted by another resident (unidentified) that R2 was on the floor. There is no documentation of a root cause of R2's fall on 11/15/22. R2's Progress Notes document: 11/17/2022 11:28 Fall Follow Up: It was discussed with R2, R2's disbelief in requesting assistance of staff for transfers. R2 stated R2 wishes to continue as much independence as possible. R2 was informed that there were high risks to this decision including severe head trauma, increased risk for another fracture, and possible death. R2 verbalized understanding and continues to state R2's wishes. This note documents R2 is cognitively intact. There is no documentation of the facility's attempts to provide preventative oversight to check on R2 regarding toileting, etc. 12/6/2022 11:10am Appointment note, Facility has tried to schedule hospital follow up, will continue to call and try and schedule. There is no documentation of previous attempts to attempt to schedule hospital follow-up or with which physician this progress note refers to. On 12/19/22 at 2:00pm, V2 stated V2 is unsure of the unidentified staff for R2's fall investigations. V2 stated V2 was unsure of why R2 was leaning over R2's chair. V2 stated V2 was unsure of toileting offering for R2. 3. R6's Fall Investigation Report documents R6 had a fall on 11/22/22 at 9:00pm. This report documents R6 was found lying on the floor on R6's left side. At this time R6 stated R6 slipped out of R6's bed on to the floor because R6 was trying to get up. This investigation does not document R6's use of narcotic, anticoagulation, antihypertensive, Antipsychotic, antidepressant or diuretic medication use. This fall investigation report does not document a thorough investigation as to why R6 was attempting to get up, if call light was within reach or if the call light had been activated. There is not a statement from staff as to when R6 was last observed, was last provided with incontinence care or a root cause of R6's fall. R6's Progress Notes do not document R6's details on R6's fall on 11/22/22 at 9:00pm. R6's Progress Notes document: 11/23/2022 at 9:58am, the Interdisciplinary Team met to discuss recent fall. R6 has an acute infection, COVID 19, and has increased weakness. New intervention is to apply bolsters. Will reevaluate with resident returns to baseline strength. 11/23/22 at 4:02pm, Recent fall (2 days ago), no injury. Trying to get a cat. No cat in room according to staff. R6 does not recall this. R6 remembers climbing out of bed but denies seeing cat. Second bed placed up against R6's bed per staff to prevent falling out of bed. There is no documentation of an investigation with intervention of a second bed being placed or a fall with documentation of hallucinations. On 12/13/22 at 2:57pm, R6 stated R6 had a fall recently (unable to recall date/time) in the facility due to R6's bed being slippery. R6 stated R6 doesn't remember exactly what was happening, but R6 slipped off R6's bed on to the floor. R6 said if R6 wears pants/clothes in R6's bed, R6 slides all over because the mattress is slippery. R6 stated R6 was not hurt when the fall happened. On 12/19/22 at 2:00pm, V2 stated V2 did not complete the fall investigation for R6's fall on 11/22/22. V2 stated V2 did not see a root cause documented in the investigation for V2's fall on 11/22/22. On 12/19/22 at 3:00pm, the facility's policies and procedures regarding Falls/Fall Investigations/Prevention of Falls was requested from V2, Director of Nursing (DON). As of 12/19/22 at 5:52pm, this policy had not been provided by V2 or the facility.

Based on observation, interview, and record review, the facility failed to implement fall prevention interventions according to resident's care plans, and failed to maintain wheelchair equipment in a safe and functional manner to prevent falls. These failures affects two residents (R12 and R14) out of three reviewed for falls on the sample list of 20, and resulted in R12 experiencing a fracture of the right femur that required surgical repair and a compression fracture of the 12th Thoracic vertebrae. Findings include: 1) The facility's Final Report to Illinois Department of Public Health documents R12 experienced an incident sliding out of the wheelchair, began to show signs and symptoms of increased pain, was sent to the emergency room for evaluation and diagnosed with an impacted, angulated fracture of the right femoral neck (type of hip fracture), and a compression fracture of the 12th Thoracic vertebrae (bone in the spine collapses). R12's Medical Diagnoses List documents, Fracture of Neck of Right Femur added 7/25/22, and Fracture of T11 - T12 vertebrae added 7/23/22. This same Medical Diagnoses List documents historical Diagnoses for R12 including [CONDITION(S)] Disorder, Dementia with Behavioral Disturbance, and [CONDITION(S)] Disorder. R12's current Census Detail (8/2/22) documents R12 was in the hospital from 7/19/22 through 7/23/22, returning to the facility 7/23/22. R12's Hospital Notes dated 7/20/22, 7/21/22, and 7/22/22, document R12 was seen in the emergency room due to a fall at the nursing home, evaluated for injuries utilizing included reports from radiology (x-ray) and computer tomography (CT) scans to determine R12 had experienced an impacted, angulated fracture of the right femoral neck, and a compression fracture of the 12th thoracic vertebrae. These same Hospital Notes document R12 received surgical repair of the femoral fracture, and a back brace to be worn when R12 is up in a chair. R12's Minimum Data Set, dated dated dated [DATE] documents R12 received a score of 3 on a Brief Interview for Mental Status, rating R12 with severe cognitive impairment. On 8/2/22 at 11:58 am, V17, Certified Nursing Assistant, stated, The therapist (V18) said to me that I needed to come because she (R12) is about to fall. I went to the room and (R12) was about half in and half out of the wheelchair on her back with her leg on the bed frame. V17 continued, (R12's) wheelchair brake on the left side was loose so that when the brake was in the locked position (R12) could still move the chair. At 1:06 pm, V17 clarified, The brake on (R12's) wheelchair was loose before the fall, like I said, when the brake was locked (R12) could still move the chair. I never did report it to anyone until they (V1 Administrator and V2 Director of Nursing) came down to investigate after the fall and I pointed it out to them. I have been working here for [AGE] years. On 8/2/22 at 2:07 pm, V18, Physical Therapist, stated, When I went to (R12's) room to do a therapy session, (R12) was on the floor, supine, flat on her back. (V17) and I got (R12) up to the bed and (V17) changed her clothes because they were wet. V18 continued, I then did try to do the therapy but (R12) would not stand up from the wheelchair and said her back was hurting. On 8/2/22 at 3:36 pm, V16, Maintenance Director, stated, I did put the anti-rollback device on (R12's) wheelchair. At that time the left side brake handle was kind of wiggly, but when I had it in my office, it was holding the chair. No one had reported the loose brake to me until after the fall. On 8/3/22 at 10:15 am, V19, Certified Nursing Assistant, stated, I worked with (R12) in the days and weeks before she fell . I had noticed her wheelchair brake was loose and wiggly and she could move the wheelchair even when it was locked. I didn't report it to maintenance because I never put the wheelchairs in the locked position. V19 continued, I know there is a board over there to put in maintenance orders. 2) R14's current Care Plan (8/3/22) documents fall prevention interventions for anti-rollback bar to be placed on (R14's) wheelchair, initiated 10/17/19. This same Care Plan documents for (R14) to have non-skid strips placed on the floor beside the bed, initiated 4/14/20. On 8/3/22 at 10:00 am, R14 was seated on the edge of the bed dressing her lower half with pants. R14 at the time, was wearing only regular cotton socks on her feet and had tennis shoes by her feet which R14 had not yet placed on her feet. R14 had to rise to a standing position in order to place her pants on. There were no non-skid strips on the floor by the bed. R14's wheelchair was directly next to R14 at the bedside. This wheelchair did not have the anti-rollback device installed. On 8/3/22 at 10:10 am, R14 was in the aforementioned wheelchair rolling independently into the hallway. At this time, V2, Director of Nursing, accompanied (surveyor) into R14's room and confirmed there were no non-skid strips on the floor by stating, No, I don't see them, I think (R14) had a room change. V2 then confirmed there was not an anti-rollback device on R14's wheelchair, stating, That is not even (R14's) wheelchair. The wheelchair did have a label on it with a name that was not R14's name. V2 then clarified, That resident doesn't even live here anymore. On 8/3/22 at 10:15 am, a general tour of the locked dementia care unit where R14 resides determined there was only one wheelchair on the unit with the anti-rollback device installed and that wheelchair belonged to R12 who had the anti-rollback device installed between 7/19/22 and 7/23/22. On 8/3/22 at 11:20 am, V1, Administrator, stated, Regardless if (R14) had a room change or not, we didn't we didn't move the (non-skid) strips with her, and that isn't her wheelchair but there isn't an anti-rollback device on it.

Based on observation, interview and record review, the facility failed to ensure residents were free from physical, verbal, and mental abuse. These failures affect four of eight residents (R1, R2, R9, R10) reviewed for abuse in the sample of 13. This failure resulted in R9 being verbally and mentally abused by R10, resulting in R9 withdrawing from activities and isolating R9's self in R9's room. Findings include: The facility's Abuse Prevention and Reporting policy dated 12/17/21 documents the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, regardless of mental or physical condition, cause physical harm, pain or mental anguish. This policy documents abuse includes verbal, sexual, physical and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. R9's Face Sheet dated 1/6/22 documents R9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Abuse/Neglect Screening dated 8/27/21 documents R9 is at a moderate risk for abuse/neglect. R9's Care Plans dated 9/17/21 document R9 is a social person and enjoys people with interests including art and socializing with peers and staff. R9 will continue pattern of life by maintaining level of socialization to enhance the quality of life. These Care Plans do not document a Care Plan for R9's risk for abuse. R9's Minimum Data Set (MDS) dated [DATE] documents R9 is cognitively intact with no behaviors, no hallucinations and no delusions. On 1/4/22 at 3:10pm, R9 was tearful and stated, sometime before Christmas, R10 called R9 racial slurs including w****** and s*** and R12 a resident who no longer resides at the facility overheard R10 call R9 those racial slurs. R9 stated V11, Activity Assistant came in while R9 and R10 were getting in to it because of the statements that had just been made toward R9. R9 stated, it hurt me when R10 called me those racial slurs. R9 stated R9 is having a difficult time coping with being referred to as derogative/racist names and has stopped participating in activities and misses them (activities) so much. R9 stated R9 was always helping and attending activities, but not anymore. R9 stated R9 no longer participates in group activities since R10 called R9 those racial slurs and stayed away from the Christmas party because of R10 and not wanting to be around R10 due to R9 did not want R10 calling R9 that again. R9 stated R10 had made additional racist comments including asking R9 for R9's green card. R9 stated R9 tries to stay away from R10 and leave the area if R10 comes to the same area. R9 stated V11 was aware of R10 being verbally abusive to R9 and notified V10, Activity Director but R9 stated R10 continued to try to approach R9. R9 stated V1, Administrator talked to R9 regarding R10's behaviors toward R9 but V1 only asked a couple questions, nothing else was done. On 1/6/22 at 10:20am, V10, Activity Director stated V11, Activity Aide called V10 sometime around the end of November and reported R10 had called R9 some names, racial slurs and R9 and R10 had a verbal altercation. V11 stated R10 called R9 a couple racial slurs. V10 remembered one of the racial slurs of s*** which V10 described as offensive and that the racial slurs were very offensive to R9. V10 stated this verbal/mental abuse allegation occurred sometime toward the end of November. V10 stated R9 typically has been very involved with activities and after R10 did that to R9, R9 became very withdrawn and withdrew from the activities group which was not like R9. V10 stated R9 would help with many activities including R9 helped with all of the Halloween activities. V10 stated R10 has a history of saying derogatory things and had frequently made negative comments to others. 2. The facility's abuse investigation for an alleged physical abuse altercation between R1 and R2 documents R2 was observed swinging at R1 in the living room by the television by V6, Activity Aide on 12/19/21. V6, Activity Aide's Abuse Allegation Interview form documents on 12/21/21, V6 reported R1 was in the living room with family and V6 observed R2 swing at R1 but could not see if contact was made from (V6's) angle. V6 removed R2 from the living room and reported to V1, Administrator. R2's Abuse Allegation Interview form dated 12/21/21 documents R1 and some guy were going through R2's stuff and R2 asked them to get out and they left. R2 went to the living room and asked them why they were going through R2's stuff and the i**** (R1) asked R2 if R2 wanted to take it outside so (R2) went to hit (R1) but family was standing there. R1's Abuse Allegation Interview form dated 12/21/21 documents R2 and R1 got into it. We (R1 and R2) were going to take it outside. (R1) could kick (R2's) a**. On 1/4/22 at 3:03pm, R2 stated (R2) had a big problem, my roommate (R1) was going through R2's stuff. R2 stated R1 and R2 did not get along anyway. R2 stated R2 told R1 to get out and R2 was p***** off. R2 stated R2 went and found R1 and hit R1 because R2 was tired of R1. The Final Abuse Investigation Report Resident to Resident documents a Physical Abuse Allegation with initial report date of 12/19/21 and Final Report date of 12/24/21. This report documents R1 and R2 were both interviewed twice and both R1 and R2 gave conflicting stories about events related to allegation although there is no documentation of multiple interviews for R1 and R2 This report documents V7, R1's Family was interviewed about the alleged physical allegation as V7 was visiting R1 at the time and stated physical contact was made between R1 and R2. On 1/6/22 at 3:27pm, V1, Administrator stated V1 felt the physical abuse altercation between R1 and R2 was not physical abuse because both R1 and R2 were both agitated and wanted to fight each other. V1 stated V7, R1's Family and R1 were in the room R1 and R2 shared going through R1's clothes and R2 came in thinking they were going through R2's things. V7 stated V7 and R1 were standing talking in the front lounge area and R2 came up confronting V7 and R1 again and R1 said let's take this outside and R2 hit R1. V1 stated V1 could see contact was made when reviewing the facility camera footage and when R2 hit R1, R1's glasses moved.

Based on observation, interview and record review, the facility failed to administer a physician ordered narcotic pain medication and failed to implement interventions to manage pain for a resident with a [DIAGNOSES REDACTED]. These failures resulted in R2 experiencing an exacerbation of extreme pain on two different occasions and seeking emergency medical care for pain management on one occasion. Findings include: The facility's Pain Management Program policy dated 7/6/18, documents Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. Guidelines: It is the goal of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program. Definition: The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. This policy also documents 13. Interventions to be considered to supplement not replace drug therapy to manage pain may include the following: a. Repositioning, b. Ambulation, c. Mild exercise, d. Therapeutic massage, back rub, e. Diversion techniques, i.e., television, video viewing or reading, f. Therapeutic communication, g. Spiritual counseling, h. Visitation from family and significant others, i. Relaxation breathing exercises. R2's Minimum Data Set (MDS) assessment, dated 6/3/19, documents R2 has a Brief Interview for Mental Status score of 15, indicating that R2 is cognitively intact. R2's Current care plan, dated 6/4/19, documents I (R2) have acute and chronic pain, related to chronic back pain. This same care plan documents pain interventions to Administer [MEDICATION NAME] as per orders. Give a half an hour before treatments or care. Evaluate effectiveness of pain, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact cognition. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. R2's current physician order [REDACTED]. This same order sheet documents R2 has an order for [REDACTED]. R2's Medication Administration Record [REDACTED]. R2's only nursing progress note dated 6/2/19 documents at 2:01 PM (R2) did not want to wait for an updated script for [MEDICATION NAME] tablet 20 milligram. Called 911 to be transported to (local emergency room ). Seek medication. R2's emergency room note, dated 6/2/19, documents at 12:30 PM (R2) resides in (facility). He is here because of chronic pain, back issues. (R2) has had nine surgeries in the past couple of years. The reason for coming today is that his [MEDICATION NAME] 20 milligram prescription has run out at the nursing home. They (the facility) were not able to get a prescription filled from (the facility). He is having increasing back pain as it's time for his next dose. R2's MAR, dated 7/1/19-7/31/19, documents on 7/4/19 R2's pain level was a five out of ten for first shift and an eight out of ten for second shift. This same MAR indicated [REDACTED]. R2's Medical Record and Progress notes do not include any other pain relieving measures utilized to try and control R2's pain on 7-4-19. R2's nursing progress note, dated 7/4/19 at 11:05 AM, documents (R2) is currently upset about [MEDICATION NAME] being out, received his last dose at 4:00 AM. Nurse called out to on call for (V13/R2's physician's) office. On 7/9/19 at 10:20 AM, R2 was sitting in his room in bed. R2 got up to look for items in his room and used a walking cane for ambulation. R2 stated I've had about six surgeries and I am narcotic dependent for pain control. I went to the emergency room in early (MONTH) because (the facility) ran out of my [MEDICATION NAME]. I was getting sick and in a lot of pain as well. It hurts bad and I have extreme constant pain in my back when I don't take my medicine. I take [MEDICATION NAME] 20 milligrams and they (facility nurses) wouldn't take it out of the emergency box. So it took 24 hours to get the medication. I missed several doses and was hurting very bad. It makes it hard to function when you have that much pain. The emergency room doctor did not give me any medicine in the emergency room , but he gave me a prescription to last a few doses and get me thru until the full script could be filled. In addition to having vomiting, sweating, and feeling bad, I had extremely terrible back pain. They ran out of my medication on 7/4/19 also. I missed a couple doses and started experiencing pain and discomfort until they could get my prescription refilled. I don't understand why they keep running out of the [MEDICATION NAME]. No one ever tries to help me relieve pain with other intervention like breathing and relaxing exercises. I don't know if they would work or not but it's never been tried. On 7/10/19 at 12:30 PM, V17 (Assistant Vice President) stated Zero on the pain scale rating indicates the resident has no pain and a ten on the pain scale indicates a resident is experiencing the worst pain of their life. On 7/9/19 at 2:00 PM, V2 (Director of Nursing) stated (R2) did not have [MEDICATION NAME] for two doses on the fourth of July, 2019. (R2) had excruciating pain to the back and was very upset. When the dose ran out at the facility our nurses did not get it ordered through (R2's) physician timely to ensure (R2) got his doses as scheduled. (R2) got very verbal and agitated with staff when (R2) ran out of the [MEDICATION NAME] and was blaming staff for not having the [MEDICATION NAME]. (R2) had missed the 8:00 AM and 12:00 PM doses. On 7/10/19 at 2:05 PM, V13 (R2's Physician) stated The facility never let me know a reason as to why it ([MEDICATION NAME]) ran out. With a couple missed doses (R2) could also begin to have pain and the pain could potentially be worse since it is failed to be controlled. Being without the [MEDICATION NAME] could cause him transient worsening of pain.

Based on observation, interview and record review, the facility failed to provide physician-ordered scheduled pain medication on two separate occasions for one of three residents (R2) reviewed for medication availability in the sample of twelve. This failure resulted in R2 experiencing uncontrolled pain, nervousness, agitation, and opioid withdrawal symptoms which required treatment at the emergency department. Finding include: The facility's Medication Administration Policy, dated 1/1/15, documents Medications must be administered in accordance with a physician's orders [REDACTED]., the right resident, right medication, right dose, right route, and right time. Medication/Treatment errors: If a medication and/or treatment error occurs, the licensed nurse will: a. Immediately notify the attending physician, b. Describe the error and the resident's response in the Nurse's notes, c. Complete an Incident Report, d. Identify the error on the 24 hour report and e. Monitor the resident's status. This policy also documents Any discrepancy must be reported immediately to the Director of Nursing or his/her designee. The facility's (undated) Emergency Drug Kit policy documents Purpose: To provide medication in emergencies and when drugs are not available in the individual resident containers. An emergency drug kit medication list, provided by V1 (Administrator), documents the emergency box contains six [MEDICATION NAME] five milligram tablets. R2's current physician order [REDACTED]. This same order sheet documents R2 has an order for [REDACTED]. R2's Medication Administration Record [REDACTED]. R2's only nursing progress note dated 6/2/19 documents at 2:01 PM (R2) did not want to wait for an updated script for [MEDICATION NAME] Tablet 20 milligram. Called 911 to be transported to (local emergency room ). Seek medication. R2's emergency room note, dated 6/2/19, documents at 12:30 PM (R2) resides in (facility). He is here because of chronic pain, back issues. (R2) has had nine surgeries in the past couple of years. The reason for coming today is that his [MEDICATION NAME] 20 milligram prescription has run out at the nursing home. They (the facility) were not able to get a prescription filled from (the facility). He is having increasing back pain as it's time for his next dose. R2's MAR, dated 7/1/19-7/31/19, documents on 7/4/19 at 8:00 AM and 12:00 PM, R2's [MEDICATION NAME] 20 milligrams was not given and see progress notes. R2's nursing progress note, dated 7/4/19 at 11:05 AM, documents (R2) is currently upset about [MEDICATION NAME] being out, received his last dose at 4:00 AM. Nurse called out to on call for (V13/R2's physician's) office. This same note documents (R2) stated that if his medications were not here by 2:00 PM, he would be checking out and going to (local clinic) for detox. On 7/9/19 at 2:35 PM, V14 (Licensed Practical Nurse) stated One day we were out of (R2's) [MEDICATION NAME] medication and he called 911 on his own. (R2) was pacing the hall and stated he was going to be sick. (R2) takes 20 mg of [MEDICATION NAME], and the emergency box does contain enough for at least one dose. I'm not sure why the nurse taking care of him wouldn't have used the emergency box. On 7/9/19 at 10:20 AM, R2 was sitting in his room in bed. R2 got up to look for items in his room and used a walking cane for ambulation. R2 stated I've had about 6 surgeries and I am narcotic dependent for pain control. I went to the emergency room in early (MONTH) because (the facility) ran out of my [MEDICATION NAME]. I was getting sick and in a lot of pain as well. It hurts bad and I have extreme constant pain in my back when I don't take my medicine. I take [MEDICATION NAME] 20 milligrams and they (facility nurses) wouldn't take it out of the emergency box. So it took 24 hours to get the medication. I missed several doses and was hurting very bad. It makes it hard to function when you have that much pain. The emergency room doctor did not give me any medicine in the emergency room , but he gave me a prescription to last a few doses and get me thru until the full script could be filled. In addition to having vomiting, sweating, and feeling bad, I had extremely terrible back pain. They ran out of my medication on 7/4/19 also. I missed a couple doses and started experiencing pain and discomfort until they could get my prescription refilled. I don't understand why they keep running out of the [MEDICATION NAME] On 7/11/19 at 11:43 AM, V12 (Registered Nurse) stated I didn't pull (R2's) [MEDICATION NAME] from the emergency box when I realized he was out. I don't think anyone has ever pulled from the emergency box for (R2). I don't know why they haven't or why I didn't pull from it to get him a dose of [MEDICATION NAME]. On 7/9/19 at 2:00 PM, V2 (Director of Nursing) stated (R2) did not have [MEDICATION NAME] for two doses on the fourth of July, 2019. (R2) had excruciating pain to the back and was very upset. When the dose ran out at the facility our nurses did not get it ordered through (R2's) physician timely to ensure (R2) got his doses as scheduled. (R2) got very verbal and agitated with staff when (R2) ran out of the [MEDICATION NAME] and was blaming staff for not having the [MEDICATION NAME]. (R2) was complaining of having withdrawal symptoms. (R2) had missed the 8:00 AM and 12:00 PM doses. The nurses should have got a prior authorization before (R2) ran out of medicine and before the holiday. (V13/R2's Physician) was upset because we were dealing with this on the holiday and did not get it taken care of before (R2) ran out. On 7/10/19 at 2:45 PM, V2 stated The nurses use the emergency box when they get permission from the pharmacy. (R2) could essentially get one dose of [MEDICATION NAME] from the emergency box. He should not ever be running out of that medication ([MEDICATION NAME]) since he takes it every day scheduled and clearly needs it. On 7/10/19 at 2:05 PM, V13 (R2's Physician) stated The facility never let me know a reason as to why it ([MEDICATION NAME]) ran out. Theoretically someone who is on high doses of narcotics like (R2) is for an extended period of time could begin having opioid withdrawal symptoms when a dose or two are missed. With a couple missed doses he could also begin to have pain and the pain could potentially be worse since it is failed to be controlled. Being without the [MEDICATION NAME] could cause him transient worsening of pain or uncomfortable withdrawal symptoms. They (the facility) should have contacted me prior to the [MEDICATION NAME] running out. It would be ideal if his medication was not running out. It is a medication error due to the fact that it could cause him transient worsening of pain or uncomfortable withdrawal symptoms. On 7/11/19 at 1:40 PM, V1 (Administrator) stated they do not have any incident report investigations, as directed by the facility policy, for R2's missed doses of [MEDICATION NAME] on 6/2/19 and 7/4/19.

Based on observation, interview, and record review, the facility failed to respond to an exit exterior door alarm. As a result, R1, assessed as having poor safety awareness and being severely cognitively impaired, exited through an alarmed door, leaving the facility and grounds (alone and undetected) to a residential property located approximately one eighth mile away. R1 is one of three residents reviewed for supervision and elopement in the sample of three. This failure resulted in R1 leaving the facility undetected at night, being subjected to cold outdoor conditions, and finally being returned from the hospital, hours later by family. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 3/29/19, the facility remains out of compliance at a severity level two. The facility is in the process of evaluating staff re-education on the facility elopement protocol, front door alarms and staff response to activated alarms. Findings include: The facility Face Sheet (current) documents R1 being admitted to the facility from a sister facility on 3/21/19 (same day as elopement) and includes the following Diagnoses: [REDACTED]. There is no Care Plan or Minimum Data Set at this time. A facility Incident Report undated for R1 documents an Elopement on 3/21/19 as follows: (R1) missing by staff around 7:15 pm. (R1) had been sleeping in bed. Staff initiated Code Pink within the facility. Unable to locate (R1) in facility, staff canvassed outside grounds. Received call from Fire Department stating they found resident and will transport to (hospital) per protocol. This incident report was not available until 3/26/19. R1's Progress Notes dated 3/21/19 at 6:30 pm document R1 is resting quietly in bed and at 6:50 pm R1 is documented as missing. R1's Progress Notes also dated 3/21/19 documents R1 returning to the facility at 9:50 pm from the hospital with family. The Progress Notes are electronically signed by V3, Registered Nurse (RN). R1's Hospital Records dated 3/21/19 at 8:09 pm, document the following: Patient (R1) is a [AGE] year old female with history of [MEDICAL CONDITIONS](Hypertension), and dementia presenting to ER (emergency room ) via EMS (Emergency Response System) after (R1) was found wandering around the streets. Per report, (R1) lives at a nursing home (facility) and somehow got out. The police were called and (R1) was brought to ER. (R1's) only complaint is that (R1's) feet hurt because they were cold while walking around in stockings. Pulse 118, Blood Pressure 143/94 and temperature 98.6. A facility assessment for R1, titled Elopement Risk assessment dated [DATE] at 11:50 pm documents R1 with a history of elopement prior to the current admission on 3/21/19. This same assessment documents R1 is at risk to elope and should be placed on the elopement risk protocol and a care plan for elopement is indicated. R1's Fall Risk assessment dated [DATE] documents R1 as being a fall risk. A facility report titled Behavior Safety Checks (every) 15 min's (minutes) dated 3/22/19 was provided on 3/22/19 at 12:30 pm by V2, Director of Nursing. This report documents 15 minute checks starting on 3/22/19 at 9:49 am through 10:02 am, then beginning again at 12:22 pm. V2 stated these are the 15 minute checks that I have at this time. V2 acknowledged there is no documentation prior to 3/22/19 for 15 minute checks. On 3/22/19 at 1:30 pm, R1 was reclining in a geriatric chair at the nurse's desk. R1 was alert but non-communicative and unable to answer questions. On 3/22/19 at 2:00 pm, V2 stated R1's safety awareness is poor and R1 is not safe to navigate independently outside the facility. V2 acknowledged that R1 is severely cognitively impaired. On 3/22/19 at 2:05 pm, V12 Regional Director stated the facility did not have a policy on monitoring the door alarms and was not aware of what the elopement risk protocol is referring to per R1's Elopement Risk assessment dated [DATE] (as above). V12 stated expectations are that staff would go to the alarm panel at the nurse's desk and check which door is alarming and respond accordingly by checking that door. V12 also stated the facility did not have an overhead announcing system. V1, Administrator also present at this time, confirmed the above statement made by V12. On 3/22/19 at 2:10 pm, V3 RN (Registered Nurse) stated the documentation in R1's chart on 3/21/19 was based on estimated times and was unsure what the actual times were when R1 was last seen and noticed as missing on 3/21/19. V3 stated V3 did not remember the alarm going off on 200 exit door and denies turning the alarm off and resetting it. V3 stated the alarm goes off every time the smokers (residents who smoke) go out to smoke on 400 hall. V3 stated the residents have a smoke break at 7:00 pm and the alarm constantly rings during this time. V3 stated V3 has reported to V1 about the alarm continually ringing during resident smoke breaks and the potential hazard. V3 stated V1 was notified of R1's elopement and V3 was instructed to place R1 on 15 minute checks. V3 acknowledged the 15 minute checks had not been documented when R1 returned and V3 had not completed an Incident Report on R1's eleopement from the facility. On 3/22/19, the facility alarm panel is located centrally at the nursing station which faces the 200 hall. The alarm is a visual and audible system. The alarm panel is labeled with the facility exterior exit door numbers and each door is alarmed separately. The panel will light indicating which door alarm has been activated. On 3/22/19 at 2:25 pm, the alarm sounded for the exterior emergency exit door on 200 hall at the above panel. There is no differentiating alarm sound for the doors. R1's room is located at the end of the 200 hall next to the emergency exterior exit door. The alarm is manually turned off and reset by staff, only at the panel located at the nurse's station. On 3/22/19 at 3:40 pm, V1 stated staff probably heard the alarm and thought it was the smokers going out to smoke and just ignored it. V1 acknowledged staff are to respond to all alarms by going to the alarm panel at the nurses station to identify which door is alarming. V1 stated once the alarming door is identified, staff should respond by checking outside that exit door for any resident that might have exited the facility. On 3/22/19 at 2:45 pm, V5 Son/Healthcare Power of Attorney of R1 stated V5 arrived at the facility at 7:20 pm and went to R1's room and R1 was not there. V5 stated V5 spoke to V3 and asked where V5's mother (R1) was. V5 stated it was at this time as V5 recalls that V3 stated they were going to look outside for R1. V5 was unsure of what time the search started inside the facility but felt the facility didn't even know she was missing until V5 arrived. V5 stated R1 was found down the street at someone's house and 911 was called and R1 was taken to the hospital. V5 stated R1 did not have a coat or shoes on. V5 stated V5 recalled telling the facility that R1 did have a history of leaving the previous facility R1 had resided in. V5 also stated the facility was aware that R1 could walk. On 3/26/19 at 10:55 am V4, Paramedic/First Responder stated on 3/21/19, R1 was located at a residential house (approximately one eighth of a mile from the facility) on a street that has a very high traffic volume and a nearby bridge going over railroad tracks. V4 stated the homeowners called 911 at approximately 7:19 pm after R1 walked into their home acting very confused. V4 stated R1 did not have any shoes or coat on when V4 arrived on the scene. V4 stated R1 was very confused and V4 assumed R1 was probably from the facility. V4 stated R1 was taken to the local emergency room per protocol and the facility was informed. On 3/26/19 at 11:15 am, the facility's 200 exterior exit door leads to a grassy area and is located around the side of the building from the front entrance. When exiting the 200 exterior exit door, it is necessary to ambulate around the building in the grassy area to reach an egress to the sidewalk. These sidewalks are uneven and end in gravel. On the opposite side of the facility the sidewalks are uneven and continue around the corner to the high traffic volume street where R1 was located on 3/21/19. On 3/26/19 at 1:50 pm, V7 Certified Nursing Assistant stated V7 was on duty 3/21/19 and was assigned to the 200 hall and helped R1 lay down, but does not recall the time. V7 stated R1 was seen earlier walking with assistance and when V7 went back to check and change R1, R1 was not in R1's room. V7 stated V7 began looking for R1 in the bathroom and then in other rooms on 200 hall. V7 stated V3, (RN) was then notified that R1 was not on 200 hall and they began to look on other halls (100, 300 and 400). V7 stated V7 does not recall the alarm going off on the 200 emergency exit door and denies turning the alarm off at the nursing station. A statement dated 3/22/19 by V6, Certified Nursing Assistant (CNA) and assigned to 200 hall on the evening of 3/21/19, documents that around 7:30 pm, V6 was bringing in the smokers (residents who smoke) and was told by V7 that R1 was missing. V6 documents that a search was started in every room and closet. V6 went outside and walked around the building. V6 documents that another staff member (V8 CNA) reported to V6 that V8 saw R1 in a police car as they were driving by. V6 documents that this is when the fire department called and talked with V3 RN. Then the police came and talked with V3 (end of statement). On 3/26/19 at 3:30 pm, the facility video monitoring system was reviewed with V1. The video camera captures R1 dressed in pants and a shirt exiting the facility's 200 emergency exit door unattended at 7:06 pm on 3/21/19. The video captures V7 coming out of a room and looking toward the 200 hall and up toward the nurse's desk at approximately 7:14 pm (8 minutes after the 200 door was opened). V7 then goes back into the same room. At approximately 7:15 pm V7 goes to R1's room. V7 exits R1's room and starts going from room to room and passes the nurse (V3) who is standing at a medication cart. V7 continues to go from room to room and repeats the process until V7 again comes to V3 in the hall at approximately 7:20 pm and converses with V3. Then V7 and V3, both go in and out of rooms. At this time R1's son (V5) enters the hallway and V3 is speaking to V5. It is 7:30 pm (24 minutes after R1 has exited the facility) before V7 and V3 leave the hall, moving toward the nursing station. V3 and V7 do not go out the 200 door to check for R1 during this time review of the video. On 3/27/19 a facility binder titled Elopement Risk Residents dated 3/25/19, identifies eight residents being at risk for elopement. R1 is not documented among the eight pictured residents in the above binder. A web-based weather history application for the nearest reporting station documents the temperature in the area on 03/21/19 at 6:56 as being 41 degrees Fahrenheit, winds at 13 miles per hour, and relative humidity at 73%. The Immediate Jeopardy was identified on 3/28/19 at 11:48 am. The Immediate Jeopardy began on 3/21/19 at 7:06 pm when the facility failed to respond to an alarming exit door which R1 had gone through unnoticed. V1 Administrator was notified of the Immediate Jeopardy on 3/28/19 at 11:48 am. The Immediate Jeopardy was removed on 3/29/19. The surveyor confirmed through observation, interview, and record review on 3/29/19, that the facility took the following actions to remove the Immediate Jeopardy: - In-services included guidance on missing residents protocol (code pink) and appropriate staff response when a door alarm is activated (identification of which door is alarming at the alarm panel and going to that door to verify who exited). Per record review, in-services were completed by the following department heads: V1, Administrator, V18, Business Office Manager, V2, Director of Nursing, V19 LPN/Wound Nurse and V20, Human Recourse Director and signed by all employees attending. In-services were verified by staff interviews on 3/29/19. - On 3/29/19 the facility Elopement Risk Book identifying High Risk Elopement residents, included R1's name and picture. - As of 3/22/19 R1 is documented with 15 minute checks. - On 3/29 all alarms were in working order. On 3/29/19 at 1:45 pm the facility's 200 door alarm was activated and staff responded appropriately. - On 3/29/19 electronic wrist devices for elopement prevention were in place as an added security measure on identified residents, including R1.

Based on observation, record review, and interview the facility failed to rapidly cool, hot potentially hazardous (TCS - Time/temperature controlled for safety), food to a safe internal temperature of 41 degrees Fahrenheit (F) or below within the maximum permitted six hours to prevent food borne illness. This failure resulted in the facility preparing to serve unsafe food without recognizing the potential for food borne illness to all 72 residents. This failure resulted in an Immediate Jeopardy. This situation of improperly cooled pork roast was observed being prepared for meal service. While the immediacy was removed on 9-28-18, the facility remains out of compliance at a severity level 2, while the facility is in the process of training and retraining staff on the facility's policy and procedure for rapidly cooling potentially hazardous foods after preparation. Findings include: According to the menu for the noon meal on 9-26-18, Tender Pork Roast was the planned protein source for all residents. On 9-26-18 at 9:20 A.M., V6, Day Cook was preparing roast pork, by pulling the pork apart, for the noon meal. V6 stated that the pork was cooked on 9-25-18. V6 stated V6 prepared two,10 to 12 pound boneless pork loin roasts on 9-25-18. V6 stated that the pork roasts were placed into the oven around 9:00 AM on 9-25-18. V6 was off duty at 1:30 P.M. on 9-25-18. V6 stated that the Evening Cook or V5, Dietary Manager removed the roasts at 1:30 PM from the oven. At 9:20 A.M. over 14 hours later the internal temperature of one of the pork roasts was 41 to 42 degrees Fahrenheit (F). The temperature was taken with the facility's thermometer and the thermometer's ice point test was 32 degrees F. that indicates that the facility thermometer was accurate. V6 stated that he did not see any documented evidence that the pork roasts were monitored to ensure that the roasts were rapidly cooled. V6 stated on 9-26-18 at 9:55 AM V6 removed the two pork roasts from the walk in refrigerator at 8:55 A.M. and began pulling the meat apart for the noon meal. V6 stated that the roasts were in the steam table pan it was cooked in. The pan was covered with a metal lid and the about two inches of broth around the roasts. On 9-26-18 at 9:55 A.M., V5, Dietary Manager stated that V5 did take temperatures of the roasts and recorded them. On 9-26-18 V5 provided a sheet of notebook paper dated 9/25/18 labeled Cool down on Pork listing the temperatures: 165 degrees F at 1:00 P.M., 140 degrees F. at 3:00 P.M., and 112 degrees F. at 5:00 P.M. V5 stated that V5 left the facility at 5:00 P.M. and V5 did not instruct any one to continue to monitor or record cooling temperatures of the roasts. V5 stated that roasts were in the walk in refrigerator when V5 had taken the temperatures. V5 confirmed that, the pork roast would have been served to residents. On 9-27-18 at 9:50 AM V5 stated that V5 did not assign anyone to monitor the cool down temperatures of the pork roast. V5 confirmed it should have been done. V5 stated that V5 was aware of the requirement for the pork roast to be cooled to 41 degrees F. or below within 4 hours of being cooked. V5 also stated that it has been at least 5 years since V5 has had any further training or in-services on cooling of potentially hazardous foods. According to V5 and V6 on 9-26-18 at 9:20 AM and 9:55 AM, it is unknown how long this potentially hazardous (TCS) food remained above 41 degrees F. while it was stored in the walk in refrigerator - from 5:00 PM (9-25) through 8:55 AM (9-26-18), a period of nearly 14 hours without the benefit of rapid cooling. The facility's undated policy Food Handling: Cooking, Cooling, and Holding of Raw Animal Foods Potentially hazardous cooked foods shall be cooled within two (2) hours from one hundred forty degrees (140 degrees) F. to seventy (70 degrees) F. and within four (4) hours to forty-one (41 degrees) F. or less. If prepared with ingredients at ambient temperatures, such as reconstituted foods and canned tuna, the food item shall be cooled within four (4) hours to forty - one (41 degrees) F. The policy further offers methods and procedures to facilitate rapid cooling including place in a freezer in a shallow pan with a loose fitting cover or uncovered if protected from overhead contamination. Cut or divide the food item into smaller or thinner portions. Place in shallow pans in refrigerator. Use chiller equipment. Stir the food item in a container placed in an ice water bath. Use containers that facilitate heat transfer. use of shallow pans, separating food into smaller portions, placing the container in an ice water bath, stirring food periodically, using ice paddles, and adding ice. The Resident Census and Conditions of Residents form completed 9-25-18 specifies that 72 residents reside in the facility. This also documents residents with pressure ulcers, receiving hospice care, on [MEDICAL TREATMENT], and receiving respiratory treatments. An Immediate Jeopardy was identified. The Immediate Jeopardy began on 9-25-18 when the facility dietary staff failed to recognize the need for rapid cooling of hot potentially hazardous foods intended for later service to residents. Such food was permitted to remain under conditions favorable for bacterial growth and potentially food born illness if consumed by residents. On 9-27-18 at 12:50 P.M., V1, Administrator was notified of the Immediate Jeopardy situation. The surveyor confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The pork roasts were discarded. No residents were served food that had not been properly cooled down. Completed 9-26-18 2. All Dietary Staff included the Dietary Manager were inserviced the Cooling of Cooked Potentially Hazardous Food policy and procedure by the facility's Registered Dietician (RD) on 9-28-18. 3. All Dietary Staff were given copies the material used by the RD for the inservice. Completed 9-28-18. 4. A monitoring log posted in the Dietary Department for logging temperatures of potentially hazardous foods that are prepared in advance in place. Completed 9-28-18. 5. Proper cooling logs will be audited by the Administrator, the Dietary Manager or designee daily for two weeks and then two times a week for three months related to the cool down process. Findings will be submitted the QA Committee for review and will provide additional recommendations for corrective action as needed. Initialed 9-28-18.

This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to provide treatment and services to prevent new pressure ulcers in one resident (R1) of three residents reviewed for pressure ulcers in a sample of three. This failure caused the development of multiple avoidable pressure ulcers for R1. Findings include: R1's physician's orders [REDACTED]. This document states that R1 was admitted [DATE]. R1's progress note dated 10/10/17 at 2:33AM by V4, Licensed Practical Nurse (LPN) states R1 has sacral decubitus ulcer currently being treated. [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) in wound. Currently on IV (intravenous) antibiotics until 11/15. Resident has catheter to manage incontinence during wound healing. This progress also states Resident is bed bound. R1's progress note dated 10/15/17 at 5:24AM by V11, Licensed Practical Nurse (LPN) states (R1) noted not receiving antibiotic therapy yesterday morning due to not have an RN (Registered Nurse) on staff and on the RN schedule. R1's Treatment Administration Record (TAR) for October 2017 documents the first treatment administered to R1's Stage IV pressure ulcer on R1's coccyx was done on 10/15/17. Treatments are not documented as done on day shift 10/20/17 or on evening shift 10/17/17 and 10/20/17. The treatment initiated 10/15/17 is documented per the TAR to be completed BID (twice daily). R1's physician's assessment by V2, Medical Doctor, Wound Care Physician dated 10/26/17 documents The wound measures 10 centimeters (cm) in length by 3 cm in width by 6.7 cm in depth. There is bone muscle tendon and fat exposed. There is a large amount of serosanguinous drainage. This assessment documents an order for [REDACTED]. DC Dakins Solution. [MEDICATION NAME] Border. Dressing change 3 times day. Prevalon offloading boot in bed recliner or couch. Mattress overlay. Keep heels off bed. R1's physician's assessment by V2, Medical Doctor, Wound Care Physician dated 11/9/17 documents New deep tissue injury to left heel. R1's MAR (Medication Administration Record) for November 2017 documents that no treatment was provided to this new area until 11/14/17, when the facility initiated skin prep to left heel daily. R1's physician's assessment by V2, Medical Doctor, Wound Care Physician dated 11/16/17 documents Now a new wound to right ischium. Pt. has intact blisters to both heels. Patient states (R1) is not using blue boots to protect heels. This document also states The wound is located on the midline coccyx. The wound measures 13cm length by 4cm width by 6.2cm depth. There is a large amount of purulent drainage noted. This document also states The wound is located on the right ischael tuberosity. The wound measures 3cm in length 4cm in width and 0.1cm in depth. On 11/27/17 at 5:52PM V7, Licensed Practical Nurse (LPN) wound nurse document in a progress note (R1) face was red and complaining of feeling warm. Temp taken and was 100.1. Call placed to on-call (physician) and received order notify Medical Doctor if temperature continues and if resident starts to show signs and symptoms of infections. On 11/30/17 at 11:56AM V3, Licensed Practical Nurse (LPN) documented in a progress note. Resident unable to arouse sternal rub done still unable to arouse, call to in home medical group, gave order to send (R1) out to hospital. On 11/30/17 at 12:19PM V12, emergency room Physician documented (R1) has bilateral heel ulcerations with eschar bilaterally. On 12/6/17/at 3:15PM V1, Licensed Practical Nurse (LPN) Wound Nurse stated R1 has no movement voluntarily from the waist down. I was unaware of the wounds on (R1's) heels until 11/14/17 when we started the skin prep. On 12/6/17 at 2:00PM V2, Medical Doctor, Wound Care Physician statd (R1) is unable to move from the waist down. (R1) requires staff assist and a (sling type mechanical lift) for transfer. (R1) is a diabetic and was admitted to (the facility) with a stage IV pressure ulcer to the sacral area involving bone and muscle. (R1) also can't control (R1's) bowels. I have personally spoken with the primary physician at the facility on two occasions to suggest (R1) will die from this wound situation unless (R1) goes to a plastic surgeon so that the wound on R1's sacrum can be cleaned and skin grafted. Even though (R1) is diabetic, the wounds on R1's heels and ischeum are caused by pressure and are not unavoidable. (R1) has trouble understanding the serious nature of her condition. The facility's policy Pressure Ulcer and Skin Condition Assessment Policy last revised 1/1/15 states the initial observation of wound or skin breakdown will also be described in the nursing progress notes. This policy also states physician's orders [REDACTED].

Based on observation, record review and interview, the facility failed to provide care and management of indwelling urinary catheters to prevent trauma and infection for two of three residents (R17, R16) reviewed for catheters in the sample of 39. This failure resulted in R17's acquired penile wound, ulceration with necrosis. Findings include: 1. According to the electronic admission record and the current Physician Order Sheet (POS) for 9/2017, R17 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R17 was admitted with multiple pressure ulcers and an indwelling urinary catheter. R17 was assessed on 8/14/17 as cognitively intact and required extensive to total assistance for activities of daily living (ADLS). R17's Skin/Wound Note Weekly Status Report by E27 (Wound Nurse) dated 7/6/17 identifies the first observation of right penis trauma wound 2.0cm (centimeters) x (by) 1.2mc x 0.1cm with moderate amount of serous drainage. Prior daily Skilled Charting from admission and then following that date noted the catheter and that is was draining but nothing on the condition of the penis. The Wound Care Specialist Evaluation report dated 7/6/17 by Z8 (Wound Doctor) documents assessment of the penis as trauma related to {urinary} catheter, and ordered House Barrier Cream to be applied every shift and as needed. The Wound evaluation dated 7/13/17 orders a Urology referral. The Wound evaluation dated 8/3/17 documents the wound on the right penis, Deteriorated due to trauma from {urinary catheter}. Z8 recommended on this date to schedule follow-up with urology for catheter associated penile ulceration. On 8/10/17 Z8's states that the penis is improved due to decreased surface area, but recommended Secure {urinary} catheter to thigh. On 8/17/17, Z8 again documents Secure {urinary} catheter to thigh. On 8/24/17, Z8 documents the condition of the penis wound as unchanged, and changes the treatment to Mupirocin (antibacterial) ointment, twice daily and as needed. On 9/7/17, Z8 documents the condition of the penis wound as deteriorated with 50% necrotic tissue and states Has urology appointment next week. At this point, ulceration unlikely to heal without {catheter} removal which would likely required sp (suprapubic) catheter. On 9/12/17, R17 went out to the Wound Clinic. Notes from that visit document measurements for the penis wound as 0.8 x 3 x 0.1cm. On 9/21/17, Z8 documents sending R17 to the hospital for evaluation of pressure ulcers. On that date measurements of the penis wound were 1.5 x 1 x 0.1cm. According to hospital laboratory report dated 9/21/17, R17 had a urinary tract infection [MEDICAL CONDITION] of greater than 100,000 Proteus Mirabilis. The only report in R17's record from the Urology consult is dated 7/18/17 by Z10 (Urology Nurse Practitioner). These notes document the excoriated/reddened area on 12:00 position of foreskin when retracted. Z10 documented to use {urinary catheter}leg strap and to consider a cystoscopy. R17 has a Physician's order dated 7/18/17 was Use {urinary catheter}leg strap with {indwelling} catheter and bag was entered as a Physician's order on 7/18/17. Neither the TAR nor the Task list includes an entry for the use of the leg strap for the catheter. The careplan dated 7/13/17 and reviewed 9/10/17, does not address securing the catheter, either under the focus of the open area on the penis or the indwelling catheter. On 9/26/17 at 8:45am, R17 was in the hospital, alert and oriented. When asked about handling of the catheter at the facility, R17 stated, They were pretty rough with it. R17 stated he had strap securing the catheter for a while, then it disappeared. On 9/26/17 at 11:30pm E2 (Director of Nursing) stated that everyone should have a leg strap, and that the physician's order for the leg strap should have at least been on the task list. E2 stated she thought R17's catheter was secured at one time. On 9/26/17 at 1:49pm, E27 confirmed the Wound notes documented on 7/6/17. E27 also stated R17's catheter was not secured at the time of that observation. E27 stated that E2 got a catheter strap at that time and applied it. E27 stated on most weekly visits, R17 did not have the catheter secured. On 9/2717 at 12:05, Z10 confirmed he saw R17 on 7/18/17 but had no caregiver or family with him and no records, and R17 did not know the why he was at the Urology office. Z10 confirmed the area of excoriation on the penis. Z10 stated he does not recall that R17's catheter was secured at the time of the visit and that the recommendation to use the leg strap was due to not being secured. Z10 also stated the excoriated area may have been due to tension on the catheter from not being secured, and that the leg strap is the preferred method of securing the catheter. Z10 stated that securing the catheter to the leg is necessary to prevent trauma and irritation to the meatus. The facility policy for Urinary Catheter Care dated 1/17/17 states that Indwelling catheters may be secured to prevent trauma and tension. 2. According to the current POS for 9/2017, R16 was admitted to the facility on [DATE] following hospitalization for a number of procedures. This POS, and the ones for 7/17 and 8/17, have no physician's orders for the catheter or care of the catheter. On 9/11/17 at 4:30pm, E3(Registered Nurse) administered medications and a treatment to R16. At that time, R16's entire catheter drainage bag, full of dark amber urine without a privacy bag, was resting on the floor. In providing the treatment of [REDACTED]. R16's catheter was not secured to her thigh, placing tension on the catheter. E3 stood to each side of the bed, having to step over the catheter bag that was resting on the floor. E3 did not pick up the catheter bag off the floor. On 9/12/17 at 8:30am, and 9/14/17 at 9:15am, R16's catheter bag was hanging on the bed frame, but was still resting on the floor. According to Nurses Notes and hospital records, R16 was treated with antibiotics for UTI on 8/12 - 8/20/17. On 9/20/17 at 11:20am, E4 (Licensed Practical Nurse) stated she was not aware that R16 had no physician's orders for the catheter. E4 stated she was going to get an order to get the catheter discontinued anyway. The facility policy for Urinary Catheter Care dated 1/17/17 states that Indwelling catheters may be secured to prevent trauma and tension. The policy also states Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor.

Based on observation, record review and interview, the facility failed to provide treatment for [REDACTED]. This failure resulted in R17's hospitalization for treatment of [REDACTED]. Findings include: According to the electronic physician's orders [REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE] and Treatment Administration Record (TAR) for 6/2017 documents R17 was admitted with multiple Stage 2, Stage 3, Stage 4 and unstageable pressure ulcers on the heel, right foot, ischium, thigh and buttocks, with treatments to be done daily and some twice daily. The MDS documents R17 as cognitively intact, requiring extensive and total assistance for all activities of daily living, and admitted with an indwelling urinary catheter. R17's 9/2017 POS lists the following orders for pressure ulcer treatments, which include cleansing with normal saline: Right ischium - Dakin's solution wet to moist BID (twice daily), day and evening shift and PRN (as needed) dated 7/20/17; Right lateral foot/ankle/heel - [MEDICATION NAME] ointment and dry dressing daily and PRN dated 9/7/17; Right penis - cleanse with soap and water, Muprocin ointment BID and PRN dated 7/8 and 8/24/17 respectively; Right posterior hip apply foam three times weekly on Tuesday, Thursday Saturday and PRN dated 9/7/17; Right distal lateral foot - dry dressing daily and PRN. R17 also had an order dated 9/7/17 for Bactrim DS (antibiotic) 800-160mg BID for 14 days for wound infection. Review of discontinued orders from admission to the current POS showed treatment orders changed and adjusted over the length of R17's stay. R17's care plan for each open area initiated 6/20/17 and revised 9/10/17 instructs staff to do treatments as ordered and monitor effectiveness. The Nurses Notes dated 9/21/17 state to send R17 to the Emergency Department (ED) in regards to wound infection. The Skin/Wound Note of that date describes the right penis trauma wound 1.5cm (centimeters) x (by) 1.0cm x 0.1cm with 100% (percent) granulation and is improved with decreased surface area and decreased necrosis. This note also describes the first observation on the right anterior thigh open area - 1.0 x 1.0 x 0.1cm - as a newly reopened area. R17's Skin - Pressure Wound Report dated 9/21/17 by E27 (Wound Nurse) describes the following: Wound #1 - right ischium Stage 4 measuring 3.0cm x 3.0cm x 2.7cm, unchanged with tunneling, and 100% granulation; Wound #2 - right lateral ankle Stage 4 measuring 3.2cm x 2.8cm x0.2cm, worsening with 20% devitalized necrotic tissue, 50% granulation tissue, 30% tendon; Wound #3 - right lateral heel Stage 4 measuring 2.9 x 2.8 x 0.3cm after debridement; worsening with 70% devitalized necrotic tissue and 30% granulation tissue; Wound #4 - right lateral foot measuring 3.0 x 2.8 x0.4cm, worsening with 85% devitalized necrotic tissue and 15% granulation tissue; Wound #5 - right posterior hip Stage 2 measuring 2.0 x 2.0 x 0.1cm, improving with 100% pink moist wound bed; Wound #6 - right distal lateral foot unstageable measuring 1.5 x 1.2 x. 0.1cm, unchanged with 100% eschar. The Wound Care Specialist Evaluation sheets completed by Z8 (Wound Physician) dated 9/21/17 confirms the above measurements and conditions of R17's wounds. All wounds were identified as pressure under etiology. Z8's notes document the right lateral ankle as deteriorated, and the surgical excision of devitalized and necrotic periosteum and friable bone, taking a sample for pathologic examination. Z8's note states that the dressing on the area that was removed was dated 9/18/17. This note also recommends that R17 be sent to ED for osteo (osteo[DIAGNOSES REDACTED]-infection) evaluation. Z8's notes also document the right lateral heel and the right lateral foot as deteriorated, and describes debridement procedures done at the facility. Z8 describes the right penis and right posterior hip as improved, the right distal lateral foot as unchanged, and notes the new areas are at the right anterior thigh. Under the Assessment and Plan of Care for this evaluation, Z8 notes the areas of deterioration due to general decline of patient. R17's Wound Care Specialist Evaluations dated 8/10/17 documents all areas to be improved or no change. The condition/measurements of wounds on this date as compared to 9/21/17 are as follows: Right lateral ankle - surface area 2.40cm {squared} 100% granulation tissue; on 9/21/17 - surface area 8.96cm 50% granulation with tendon; Right lateral heel - surface area 3.27cm; on 9/21/17 surface area 8.12cm; Right lateral foot - surface area 0.70cm; on 9/21/17 surface area 8.40cm with increased drainage. The 9/21/17 report also lists areas not on the 8/10/17 report of Right posterior hip, Right distal lateral Foot, and Right anterior Thigh. The hospital History and Physical (H & P) dated 9/21/17 states R17 had a history of [REDACTED]. The H & P also states that R17 and family were concerned regarding proper care and dressing changes. R17 was admitted and started on IV (intravenous) antibiotics as well as wound and various consultations. Hospital laboratory results dated [DATE] show low RBC (red blood cell) count, and low hematocrit and hemoglobin. Wound cultures taken on 9/21/17 show varying amount of Proteus Mirabilis and states this is a multi-drug resistant organism (MDRO). Place patient in isolation, and also Streptococcus(bacteria). The urine culture taken on 9/21/17 also shows greater than 100,000 colonies of Proteus Mirabilis(bacteria). On 9/26/17 at 8:45am, R17 was in the hospital in contact isolation for (MDRO) according to Z9 (hospital charge nurse). R17 was alert and oriented and stated he was admitted to the facility with several sores on this right side. R17 stated his sores needed to be cleaned and have new bandages every day. R17 stated the treatments often were not done daily, that sometimes they went two to three days before being cleaned and changed. R17's TARs for 8/2017 and 9/2017 show incomplete documentation that pressure ulcer treatments were completed. The TAR for 8/2017 has no documentation for, some or all treatments as ordered, on 16 of the 31 days or 43 individual treatment opportunities. The TAR for 9/2017 has no documentation for, some or all treatments as ordered, for 13 out of 20 days reviewed or 37 individual treatment opportunities. On 9/26/17 at 10:30am, E2 (Director of Nursing) started that sometime in July, R17's family member had expressed concern that R17's treatments were not being done as ordered. After that, E2 stated she monitored R17's dressings according to the dates on the dressing. E2 stated that if she found that a treatment had not been done on days that the evening shift nurse was instructed to do it. When asked about the BID treatments, E2 stated she was not aware of or monitoring the BID treatments, that E2 was concentrating on the foot. E2 stated she was aware that the TAR documentation was incomplete, but thought that nurses were doing the treatments, just not documenting. On 9/26/17 at 10:45am, E27 Wound Nurse confirmed documentation in the record and Skin Reports regarding the condition/measurements of R17's pressure ulcers. E27 confirmed the date on the dressings, at the 9/21/17 examination along with Z8, was 9/18/17. E27 stated that dressings were frequently not dated as done, that were to be completed daily or twice daily as ordered. E27 stated that R17 often did not have the correct off-loading(pressure relief) boots on when examined. On 9/26/17 at 3:35pm, Z8 confirmed information as documented in R17's Wound Care notes and stated that the wound dressings were often dated inappropriately as to the intervals the treatments were to be done. Z8 stated he always would note the date on the dressing because that explained why we weren't making any progress. Z8 stated that the inappropriate intervals and not doing the treatments as ordered certainly contributed to deterioration of the areas. Z8 stated he was concerned with possible recurrent [DIAGNOSES REDACTED], and that is why R17 was sent to the hospital. Z8 stated that at one point, R17's areas were looking wonderful, but then started to decline. The facility's Pressure Ulcer and Skin Condition Assessment Policy dated 1/1/2015 states that dressings applied to pressure ulcers and shall include the date and initials of the licensed nurse who performed the procedure, and that the dressing will be checked daily for placement, cleanliness, and signs/symptoms of infection. The policy also states that the Physician-ordered treatments shall be initialed by the staff on the TAR after each administration.

Failures at this level required more than one deficient practice statement: A. Based on observation, interview and record review the facility failed to ensure resident's anxiety and pain medication were available to be administered for pain management as ordered by the Physician. This failure of extended unavailability of pain and anxiety medication resulted in R11 experiencing excruciating pain which affected R11's activities of daily living and ability to ambulate. This failure resulted in R16 experiencing unnecessary pain during treatment and activities of daily living. This failure affected 3 residents (R11, R16, R5) of eleven residents reviewed for pain/anxiety management and treatments, in the sample of 39. B. Based on interview and record review the facility failed to do treatments for ulcers and surgical wounds as ordered by the Physician. This failure affected four residents (R9, R10, R16, R5, ) of eleven residents reviewed for pain/anxiety management and treatments, in the sample of 39. Findings include: a.) 1.) R11's physician progress notes [REDACTED]. The note documents hip tenderness along the posterior joint line and gluteal area, with minimal tenderness along the low back. R11's note documents [DIAGNOSES REDACTED]. R11's Minimum Data Set ((MDS) dated [DATE] documents no problems with cognition, no behaviors, and supervision of one for ambulation. R11's MDS also documents pain; with the worst identified as a seven (on a scale of 1 to 10 with 10 being the worst pain) in the last 5 days. R11's Care Plan dated 8/2/17 documents chronic pain with interventions as follows: Anticipate need for pain relief and respond immediately to any complaint of pain. Administer [MEDICATION NAME] per orders. Evaluate the effectiveness of pain interventions every shift and as needed. Review for alleviation of symptoms, dosing schedules and R11's satisfaction with results, impact on functional ability and cognition. R11's Physician order [REDACTED]. 4/26/17-[MEDICATION NAME] (anti-anxiety) 0.5mg one tablet three times a day. On 9/12/17 at 8:25am R11 was standing by the medication cart, leaning on the walker. R11's face was drawn as she asked for pain medication.At this time, R11 asked for her pain medication. On 9/12/17 at 8:25am E5, LPN (Licensed Practical Nurse) told R11 there is no [MEDICATION NAME]. E5 stated if the [MEDICATION NAME] has been ordered, then I can't pull it from the E-box (emergency box). On 9/12/17 at 8:35am R11 stated they were out of the [MEDICATION NAME] and [MEDICATION NAME] all day yesterday (9/11/17) and she had to stay in bed all day yesterday-in so much pain-I can't walk due to the pain. R11 stated she got a pain pill ([MEDICATION NAME]) at 12:00am (9/12) and was able to sleep through the night. R 11 stated her pain is all over her back, pelvis and hips. When asked to rate her pain with 0 being no pain and 10 being the worst pain imaginable, R11 stated her pain at this time was a 9 and all over her back, pelvis and hips. I get real anxious and not having the [MEDICATION NAME] when in pain-(I'm) a nervous wreck with pain. It ([MEDICATION NAME]) needs to build up, I take it every 4 hours and pain is a 5 then R11's Electronic Medication Administration Record [REDACTED] 9/11/17 at 8:00am-[MEDICATION NAME] 10-325mg one tablet as being given, with a pain level of 6 documented. 9/11/17 at 12:00pm- [MEDICATION NAME] 10-325mg one tablet, not being given, with no pain level documented. 9/11/17 at 12:00pm-[MEDICATION NAME] 0.5mg one tablet, not being given. 9/11/17 at 4:00pm-[MEDICATION NAME] 10-325mg one tablet, not being given, with a pain level of 7 documented. 9/11/17 at 8:00pm-[MEDICATION NAME] 10-325mg one tablet as not being given, with no pain level documented. 9/11/17 at 8:00pm-[MEDICATION NAME] 0.5mg one tablet as not being given. 9/12/17 at 12:28am-[MEDICATION NAME] 10-325mg as being given 9/12/17 at 12:28am from emergency box with a pain level of 8. 9/12/17 at 8:00am-[MEDICATION NAME] 10-325mg as not being given, with a pain level of 8. 9/12/17 at 8:00am-[MEDICATION NAME] 0.5mg as not being given. R11's Electronic Progress Note dated 9/11/17 at 11:32am documents script (prescription) sent. The note dated 9/11/17 at 3:59pm documents awaiting delivery. The note dated 9/11/17 at 7:42pm documents med (medication) on order. The note dated 9/11/17 at 9:13pm documents the Physician was notified of R11 being out of her [MEDICATION NAME], asking to have someone call the pharmacy for an authorization code and being told they were not able to call in for authorizations any longer, with E2, DON being notified. On 9/12/17 at 8:40am E2, DON (Director of Nursing) stated R11's [MEDICATION NAME] and [MEDICATION NAME] came last night and should already be in the drawer. E2 stated, I spoke with pharmacy-they don't seem to know where it's ([MEDICATION NAME]) at-it was a stat (now) order and to be brought last night. They (pharmacy) dispensed the [MEDICATION NAME] last night and gave it to a delivery driver. The pharmacy doesn't know where it's at. a.) 2.) According to the electronic admission record and [DIAGNOSES REDACTED]. R16 was assessed on 8/5/17 as cognitively intact and requiring extensive to total assistance for ADLs (activities of daily living), and experiences frequent moderate pain. R16's physician's orders [REDACTED]. The prior order dated 7/28/17 was for liquid [MEDICATION NAME](narcotic [MEDICATION NAME]) 7.5/325mg per ml (mililiters), give 10mls every 4 - 6 hours as needed. R16's care plan dated 8/4/17 includes the focus of Chronic Pain with the intervention to administer [MEDICATION NAME] as per orders, and to Anticipate resident's need for pain relief and respond immediately to complaint of pain. On 9/11/17 at 4:20pm, E3 (Registered Nurse) entered R16's room for medication pass. R16 was in bed crying and asking for pain medication. E3 looked in the drawer of the medication cart and found no [MEDICATION NAME] for R16. E3 stated they had not come in yet from pharmacy. E3 informed R16 but did not offer an alternative. R16 continued to cry/moan as E3 turned R16 from side to side to administer the [MEDICATION NAME] treatment as ordered. E3 stated the [MEDICATION NAME] should arrive with the evening medication delivery. On 9/13/17 at 10:00am, R16 was in bed and again crying, stating she needed something for pain. R16 said sometimes they have it and sometimes they don't. R16's Medication Administration Record [REDACTED]. The liquid [MEDICATION NAME] was also signed out on R16's Controlled Drug Receipt/Record form on 9/4, 9/5 and 9/6/17. R16's MAR further documents [MEDICATION NAME] tablets administered on 9/10 and 9/11/17 at 1:35am and 4:11am respectively, however these dates are not found on R16's Controlled Drug sheets. R16's Controlled Drug Receipt Record starts use of 1 or 2 tablets at a time as ordered with a quantity of 24 on 9/14/17 at 8:00am. On 9/14/17 at 10:00am, E4 (Licensed Practical Nurse) stated they had just received the [MEDICATION NAME] for R16. a.) 3.) According to the electronic admission record and the current POS for 9/2017, R5 was admitted to the facility 8/25/17 with multiple [DIAGNOSES REDACTED]. The MDS dated [DATE] assesses R5 as cognitively intact, requiring limited to extensive assistance for ADLs, and having frequent pain at a 7 out of 10 level. R5 has physician's orders [REDACTED]. On 9/11/17 at 4:40pm, E2 approached the medication cart with R5, who was crying, and asked E3 if R5 had any pain medication - [MEDICATION NAME] - in the cart. E3 checked the medication cart and locked drawer and stated R5 had no pain medication in the drawer. On 9/12/17 at 9:30am, E2 stated she got an order to give R5 an extra [MEDICATION NAME] until the [MEDICATION NAME] came in. Progress notes by Z4 (Nurse Practitioner) dated 9/5/17 state {R5} is having some issues with getting her PRN pain meds in the evenings. She is requesting the PRN be made {every} 4 hours instead of every 6 hours so then if she has to wait an hour or so she is still in the 6 hour window. On 9/20/17 at 10:00am, R5 stated that the facility frequently was out of her [MEDICATION NAME], and said she has gone a day and half sometimes before they had the [MEDICATION NAME] to give. R5 stated they tell her it was ordered from the pharmacy and didn't come in when expected. b.) 1.) R9's Wound Clinic Physician order [REDACTED]. R9's Medication Review Report dated 9/20/17 documents the following Physician Orders: 2/24/17- daily dressing change. ; 2/27/17-Check Juxtalight one time on evening shift for proper fit. Apply Juxtalight (compression device) in am shift, check for proper fit in evening and remove at bedtime.; 2/27/17-Follow treatment orders for wounds then apply Juxtalight to both legs in am shift sometime before noon, per resident request daily.; 4/24/17- Clean wound with normal saline-may also use Remedy with Olivamine wound cleanser and lotion. Antifungal cream around wound to both feet, also keep callus on both feet filed down twice a week once a day (am) Monday and Thursday. Alginate-cut to fit size of wound bed, cover with gauze, coban and conformant wound veil; leave veil in place. R9's August and September 2017 E-TAR (Electronic Treatment Administration Record) documents the following Treatments Orders: 4/27/17-Clean wound with normal saline-may also use Remedy with Olivamine wound cleanser and lotion. Antifungal cream around wound to both feet also keep callus on both feet filed down twice a week once a day (am) Monday and Thursday. Alginate-cut to fit size of wound bed, cover with gauze, coban and conformant wound veil; leave veil in place in the morning every Monday, Thursday for wound treatment. The August and September E-TAR documents a treatments not being done on Monday-8/7, 9/11/17 and Thursday-8/7, 8/17 and 8/24/17. 2/27/17 : Follow treatment orders for wounds then apply Juxtalight to both legs in am shift sometime before noon daily. The August and September 2017 E-TAR documents the treatment wasn't done on 8/2, 8/7, 8/16, 8/17, 8/19, 8/24, 8/30, 9/3, 9/8, 9/11, 9/13, 9/19 and 9/20/17. 2/27/17-Check Juxtalite one time on evening shift for proper fit every evening shift. Juxtalight applied in the am and checked for proper fit in the evening, removed at bedtime. The August and September 2017 E-TAR documents the treatment wasn't done on 8/3, 8/8, 8/9, 8/17, 8/22, 8/26, 8/29, 9/7,9/9, 9/18 and 9/20/17. The Wound Clinic Physician order [REDACTED]. Also keep callus on both feet filed down twice a week once a day (am) Monday and Thursday; Left Lateral Lower Leg: Enluxtra-t apply over wound. Dressing to cover1 inch perimeter of intact skin around ulcer. Do not place another dressing under enluxtra.-kerlix roll gauze and secure with paper tape; [MEDICAL CONDITION] Control: Coban 2 layer Standard to Left Lower Extremity; Juxtalight-right leg and re-adjust EACH shift. Please check at second shift. PLEASE PUT ON BEFORE NOON AND REMOVE AT BEDTIME on the right . Left has 2 Layer; Dressing frequency- Three times a week. On 9/21/17 at 9:25am Z6, Wound Clinic Program Coordinator stated that R9's right leg which has no wound is to be cleaned with remedy wound cleanser/lotion daily and the Juxtalight is to be applied (am) and removed at bedtime. Z6 stated the left wound dressing is being done at the Wound Clinic on Monday-Wednesday and Friday every week. On 9/20/17 at 3:45am E2, DON confirmed R9's treatments aren't being done as ordered. On 9/21/17 at 10:00am E2 verified R9's treatment orders are inaccurate on the E-TAR and should have been clarified earlier. b.) 2.) R10's Physician order [REDACTED]. R10's Skin Venous Wound Report dated 9/14/17 documents a diabetic ulcer on the right medial foot measuring 2.2 cm (centimeters) by 2.4cm by 0,2cm depth. which is improving. The wound has undermining of 1.5cm at 6 o'clock with 95% granulation tissue, 5% necrosis and a moderate amount of serous drainage. R10's E-TAR dated September 2017 documents to Cleanse the right medial foot with normal saline and apply [MEDICATION NAME] and dry dressing daily. The treatment is not documented as being done on 9/4, 9/5, 9/9, 9/12, 9/13, 9/14, 9/15, 9/19 and 9/20/17. On 9/21/17 at 12:30pm E2, DON confirmed that R10's treatment to the right medial foot is not being done consistently. b.) 3.) R16 has a physician's orders [REDACTED]. E4 did the treatment and applied new dressing on 9/20/17. The old dressing that was removed was dated 9/19/17. However R16 stated at that time that it doesn't always get changed every day. R16's Treatment Administration Record (TAR) for 9/2017 for the treatment to be implemented 9/8/17 had only 9/10, 9/13, 9/17 and 9/20/17 marked as completed. These dates were carried over to the progress notes. R16's care plan dated 8/26/17 includes the focus of the surgical wound to the abdomen, with the intervention to cleanse and apply Collagen and dry dress daily per order, and to monitor site for infection. On 9/21/17 at 3:15pm, R16 stated that the abdominal treatment was not done every day, maybe every other day or couple of days. On 9/26/17 at 10:00pm, treatment records were reviewed with E2 (Director of Nursing). E2 stated I have no defense for that. Treatments should be completed every day as ordered. b.) 4.) R5 treatment order dated 9/3/17 for the left shin, left calf and left medial thigh to cleanse with normal saline and apply [MEDICATION NAME] and dry dressing daily and PRN for infection/drainage. R5 also has an order dated 9/1/17 for Strict adherence to dressing change to left foot. On 9/21/17 at 3:00pm, R5 stated treatments do not get done every day, but has better last couple of days. R5 stated that over the weekend it went four days without getting changed. R5 stated when if finally got changed it really stunk. On 9/26/17 at 10:45am, E27 (wound nurse) stated that dressings are often found to not be changed every day as ordered. The TAR for 9/2017 through 9/17/17 documents treatments completed to the left shin and calf only on 9/5, 9/6, 9/7, 9/10, 9/12, 9/13 and 9/17/17. R5's careplan dated 8/30/17 has focus areas of chronic pain and [MEDICAL CONDITION], with interventions to administer medications and provide treatments per physician's orders [REDACTED]. On 9/26/17 at 10:00pm, treatment records were reviewed with E2 (Director of Nursing). E2 stated I have no defense for that. Treatments should be completed every day as ordered.

Noncompliance resulted in multiple deficient practice statements. A. Based on observation, interview, and record review the facility failed to assess pain, provide pain relieving interventions, and control pain for one of three residents (R4) reviewed for pain in the sample of ten. These failures resulted in R4 experiencing an acute exacerbation of unrelieved chronic pain resulting in hospitalization for the exacerbation of pain, which also resulted in an elevated blood pressure. B. Based on record review and interview the facility failed to provide R8 with accucheck's and medications to treat Diabetes Mellitus Type II and Osteomylitis, provide nutritional interventions and a fluid restriction per the plan of care for Diabetes Mellitus Type II and End Stage [MEDICAL CONDITIONS], and provide a nutritional and nursing assessment for one of three residents (R8) reviewed for Acute Changes in Condition in the sample of ten. These failures resulted in R8 having a change in level of consciousness, falling, and requiring hospitalization for confusion, [MEDICAL CONDITION], fluid overload, [DIAGNOSES REDACTED], chronic Osteomylitis of the right foot, and hypothermia. Findings include: A. The facility's Pain Management Program policy dated 1-1-2014 documents, It is the policy of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity, and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program. The pain management program with include performing assessments,accurate and complete documentation of pain assessments and monitoring, and a schedule of frequent assessments. A pain assessment protocol will be initiated when the Minimum Data Set triggers an indication of pain, receives routine pain medication and the pain is not controlled, and a change in pain occurs. Documentation of assessments and the resident's response to the pain management plan will be made with each assessment. Pain control will be assessed with [REDACTED]. R4's current physician's orders [REDACTED]. This same POS documents R4 receives [MEDICATION NAME] HCL ([MEDICATION NAME]) 10 mg (milligrams) two tablets three times daily for pain, and [MEDICATION NAME] IR (Immediate Release) HCL (Narcotic Pain Reliever) 5 mg one to two capsules as needed every four hours for moderate to severe pain. R4's Minimum Data Set (MDS) Section J Pain Management dated 7-3-2017, documents R4's Pain is almost constant, makes it hard for R4 to sleep at night, and limits R4's day to day activities. This section also indicates R4's pain is a 10 on a 0-10 scale with a 10 meaning it is the worse pain R4 can imagine. R4's Pain Screen assessment dated [DATE], documents R4 has moderate pain and a pain score of five. This same assessment documents that a score of five or greater indicates a comprehensive assessment is needed. R4's Medical Record does not include a comprehensive pain assessment after 7-12-17. R4's Transcription Note dated 7-25-17 and signed by Z4 (Nurse Practitioner) documents R4 is having more pain, R4's left leg and lower back are getting worse, and R4 feels like she needs more pain medications. This same note documents a order referral to Z5 (Pain Specialist) has been filled out. R4's current Chronic Pai[DIAGNOSES REDACTED] Care Plan documents R4 will be free of any discomfort and interventions for pain control include the following: Administer [MEDICATION NAME] medication as ordered by a physician. Review every shift for pain medication efficacy by assessing whether pain intensity is acceptable to R4. Anticipate R4's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions every shift and as needed for compliance. Review for alleviation of symptoms, dosing schedules and resident satisfaction with results, and impact on functional ability and cognition. R4's Medication Administration Record (MAR) dated 8-1-17 to 8-14-17, documents R4 receives [MEDICATION NAME] two tablets on five occasions within this time frame. This same MAR documents the [MEDICATION NAME] was ineffective on 8-5-17 and 8-12-17. R4's Controlled Drug Record documents R4 received [MEDICATION NAME] 5 mg two tablets on 8-12-17 at 3 p.m. and 9 p.m., and on 8-13-17 at 1:15 a.m. R4's MAR and Nursing Progress Notes dated 8-12-17 and 8-13-17 do not include documentation of R4 receiving these doses of [MEDICATION NAME], the severity of R4's pain, the location of R4's pain, or the effectiveness of the [MEDICATION NAME]. R4's Nursing Progress Notes dated 8-13-17, document Z1 (R4's Family Member) called the facility and requested R4 be sent to the emergency room for pain control. This same note documents R4 was sent to the emergency room . R4's emergency room Note dated 8-13-17 and signed by Z6 (Emergency Department Physician), documents R4 presents to the ED (Emergency Department) from the nursing home with complaints of increased pain in the left leg which has been chronic for sometime, and an elevated blood pressure of 223/123 with complaints of pain to the right leg. This same note documents R4 will be admitted for hospital services for intractable pain and high blood pressure related to the pain with a plan to obtain a doppler ultrasound, start [MEDICATION NAME] one mg IV (Intravenously) every hour (in addition to the [MEDICATION NAME] as needed and [MEDICATION NAME] three times daily), and start blood pressure regimen medications. R4's Consultation dated 8-13-17 and signed by Z7 (Medical Doctor/Pain Specialist), documents R4 is admitted to the hospital for uncontrolled pain that is a continuously sharp pain to the left leg and right leg. This same consult documents R4's Plan for the chronic pain is to continue [MEDICATION NAME] 20 mg three times daily, continue [MEDICATION NAME] five to ten mg every four hours as needed, and add IV [MEDICATION NAME] one to two mg every two hours for severe pain. On 8-15-17 at 12:45 p.m. R4 was sitting on the side of the bed in the hospital. R4 had an I.V. of Dilauded running. R4 stated, My entire left leg hurt at the nursing home. When I left the nursing home my pain was at a level ten and was constant. Everytime I would ask the staff for a pain pill they would tell be to walk up to the nurse's desk and ask for it myself. Sometimes I would get a pain pill, but the staff would never check on me to see if it helped with the pain. I was never asked how bad my pain was. The staff never did anything to help my pain. I was always moaning and screaming in pain. I had to call my son to get sent to the hospital. The hospital has helped my pain. I finally have gotten some relief. On 8-15-17 at 2:00 p.m. Z3 (Hospital Social Service Worker) stated, The emergency room physician was concerned that (R4) was not getting her [MEDICATION NAME] as needed while at the nursing home. (R4) came to the emergency room with an extremely elevated blood pressure and severe pain. (R4) said she had to call her son at home to get help for the pain. On 8-16-17 at 9:15 a.m., E16 (Certified Nursing Assistant/CNA) stated, (R4) always complained of pain. (R4's) pain was never relieved. On 8-16-17 at 9:25 a.m., E15 (CNA) stated, (R4) would complain a lot of pain to her legs. (R4) was constantly moaning in pain. (R4) always complained of pain. (R4's) pain was never relieved. (R4) had chronic pain all of the time. I think the nurses just got use to her moaning and being in pain. On 8-16-17 at 10:10 a.m., E12 (R4's Physician) stated, I was not aware (R4's) [MEDICATION NAME] was ineffective. I suggested the facility send (R4) to a pain clinic for (R4's) worsening pain. On 8-16-17 at 1:30 p.m., E9 (Licensed Practical Nurse) stated, I gave (R4) [MEDICATION NAME] at 3:00 p.m. and 9:00 p.m. on 8-12-17 for back pain. (R4) has had back surgeries and would be in a lot of pain. I did not document on the PRN (As Needed) MAR (Medication Administration Record) sheet or the progress notes that I gave the [MEDICATION NAME] and did not document a pain scale. I was suppose to document on the MAR the pain scale and whether the pain pill was effective or not, but I did not. On 8-16-17 at 12:20 p.m. E10 (Charge Nurse) stated, I spoke with Z5's (Pain Specialist) office on 7-28-17 about (R4's) pain referral. I have not followed up since then. I would normally follow up daily, but I have been working the floor too much and have had no time to call. (R4) was having chronic pain to the left side and left leg. (R4's) chronic pain is never relieved. On 8-16-17 at 1:20 p.m., E8 (Licensed Practical Nurse) stated, (R4) complained of pain consistently to the left leg and sometimes to the back. I gave (R4) [MEDICATION NAME] on the 8-5-17 at 7:05 p.m. The pain pill was ineffective, but there is no documentation that the physician was notified that (R4's) pain was ineffective. On 8-16-17 at 11:45 a.m. E2 (Director Of Nursing) stated, Whenever (R4's) pain pill is given it should be documented on the PRN (as needed) sheet and the narcotic sheet. The nurses should go back to the resident and see if the pain pill was effective or not. If the pain pill was ineffective then the nurses need to look at getting a change in medication. The nurses are not documenting whether (R4's) pain pill is effective or not, and should be. The nurses have not been tracking (R4's) pain and should have been. (R4's) pain assessment should have been done every shift according to (R4's) care plan. (R4's) pain assessment has not been done every shift. (R4's) pain assessment score on 7-12-17 was a five and a comprehensive pain assessment should have been done, but was not. (R4's) pain started to worsen on 7-25-17 and no further pain assessments were done after the pain worsened. No one knew (R4) had a pain clinic order, so no one followed up to ensure the appointment was made. On 8-17-17 at 2:00 p.m. E2 (Director Of Nursing) stated, The nurses should have been assessing (R4) to figure out her pain. (R4's) [MEDICATION NAME] should have been given more frequently to control her pain and to prevent her hospitalization for chronic pain. B. The facility's undated Diabetes Mellitus Routine Care policy documents, Objective of policy is to provide care that will enable the person to achieve and or maintain control of diabetes and to function safely in his natural environment. A focused assessment is performed by a licensed nurse within 24 hours or admission which includes skin, sensory, extremities, appetite, thirst, urination, condition of feet, and other common problems. A registered dietician is to conduct an assessment and education once the [DIAGNOSES REDACTED]. Goal of the person with diabetes is to consume a therapeutic diet. Residents with diabetes maybe on replacement and bedtime snacks. The facility's undated Fluid Restriction policy documents, The nursing department and the dietary department will ensure that the resident receives the prescribed amount of fluid. All water pitchers will be removed from the bedside to ensure compliance from the resident, family, and facility staff during the fluid restriction. R8's physician's orders [REDACTED]. These same admitting orders document the following orders: [MEDICAL TREATMENT] every Tuesday, Thursday, and Saturday for the treatment of [REDACTED]. Controlled Hi Protein Renal Diet. Fluid Restriction of 800 ml (milliliters) every shift for [MEDICAL CONDITION]. Weight Daily. Accucheck's and Insulin [MEDICATION NAME] 100 units per ml inject per sliding scale subcutaneous before meals and at bedtime (Blood Sugar 201-250=2 units, 251-300=3 units, 301-350=4 units, [PHONE NUMBER]= 6 units). Insulin [MEDICATION NAME] 100 units per ml inject as per sliding scale at bedtime (Blood sugar 0-150 =0 units, 151-200=12 units, [PHONE NUMBER] =25 units). [MEDICATION NAME] 500-125 mg daily for Wound on the right foot due to Osteomylitis. R8's Medication Administration Records from 8-14-17 to 8-18-17, indicate R8's blood sugars were not obtained along with sliding scale insulin as ordered on 8-15-17 at 11:00 a.m., 8-16-17 at 7:30 a.m. and 11:00 a.m., and 8-17-17 at 11:00 a.m. These same records indicate R8 never received the scheduled [MEDICATION NAME] for Osteomylitis. R8's Nutritional Intake Report dated 8-14-17 to 8-18-17 does not include R8's intake for breakfast on any of these days. The facility's Bedtime snack list does not include R8. R8's Weight Record and Electronic Medical Record dated 8-14-17 to 8-18-17, does not include monitoring of R8's daily weight or fluid intake. R8's Medical Record from 8-14-17 to 8-18-17 does not include a nursing assessment of R8's condition or a nutritional assessment. R8's Hospital History and Physical dated 8-18-17 documents, (R8) is suppose to be receiving [MEDICATION NAME] for Osteomylitis, but it seems he wasn't receiving it at the nursing home according to the medication list. (R8) temperature upon arrival 96 degrees Fahrenheit. Admitting problem [DIAGNOSES REDACTED]. On 8-23-17 at 9:15 a.m., E25 (Dietary Manager) confirmed that R8 did not receive breakfast on [MEDICAL TREATMENT] days, did not receive a fluid restriction as ordered, did not receive a renal high protein diet as ordered, and did not receive bedtime snacks. On 8-23-17 at 10:55 a.m., E27 (Certified Nursing Assistant) stated, (R8) did not get a breakfast tray on the days he had [MEDICAL TREATMENT]. E27 also confirmed that R8 would get big pitchers of water and that the staff was unaware of R8 being on a fluid restriction. On 8-23-17 at 2:00 p.m., E29 (Cook) stated, I never received a diet order for (R8). I always gave (R8) a regular diet. (R8) had already left for [MEDICAL TREATMENT] and did not get a breakfast tray on those days. I was not aware that (R8) needed a renal diet. On 8-23-17 at 2:30 p.m., E28 (Dietary Aide) stated, I prepare the bedtime snacks for residents who only have physician's orders [REDACTED]. On 8-23-17 at 2:10 p.m., E11 (Registered Nurse) stated, The morning of 8-18-17 (E27/Certified Nursing Assistant) reported to be around 6:00 a.m. that (R8) was aggressive and spitting everywhere. I went down to (R8's) room and he was pushing me, spitting at me, and trying to crawl under the bed. I called 911 and send (R8) to the ED. The paramedics checked (R8's) blood sugar and it was only 23. I did not do an assessment progress note or a risk management assessment. I forgot. On 8-23-17 at 11:10 a.m., R8 stated, I never got my morning or noon medications, including my insulin, while I was at the facility. I never got breakfast when I would go to [MEDICAL TREATMENT]. The night before I went to the hospital I went to bed and next thing I know I woke up in the hospital. My sugar count was 23. My body temperature was low. I could feel my blood sugars dropping and was hungry from missing breakfast, and sometimes lunch. My blood sugars were never checked on the days I had [MEDICAL TREATMENT]. I did not get my antibiotic for my foot infection. The nurses never checked on me or assessed me. I will never go back. On 8-24-17 at 9:30 a.m., E2 (Director Of Nursing) stated, We (the facility) do not serve snacks at bedtime. Diabetic residents should always have a bedtime snack. (R8) did not receive a bedtime snack. On Thursday (8-17-17) (R8) was suppose to get a breakfast tray before [MEDICAL TREATMENT], but did not. I did not know until yesterday that (R8) was on a fluid restriction and neither did the dietary manager. (R8) should have been monitored closely here since he was diabetic. (R8) did not get his scheduled blood sugars with sliding scale insulin on 8-15-17 at 11:00 a.m., 8-16-17 at 7:30 a.m. or 11:00 a.m., or 8-17-17 at 11:00 a.m. That could have prevented (R8's) hospitalization , [DIAGNOSES REDACTED], change in mental status, and fluid overload. (R8's) daily weights were not done, either. E2 also verified that R8 did not have a nursing assessment or nutritional assessment done since admitted and should have. On 8-24-17 at 11:25 a.m., Z4 (Nurse Practitioner) stated, If (R8) was on [MEDICATION NAME]then (R8) should get a bedtime snack. The facility should have been getting (R8's) blood sugars four times daily with the sliding scale insulin. (R8) should receive breakfast daily. They (the facility) should monitor (R8's) fluid restriction as ordered and document. They should have obtained daily weights due to (R8) having [MEDICAL CONDITION] and [MEDICAL TREATMENT]. If (R8) was not getting bedtime snacks and blood sugars monitored, that could have contributed to the [DIAGNOSES REDACTED]. If they were not monitoring for fluid intake and daily weights that would have caused fluid overload. (R8) should have been receiving the [MEDICATION NAME] for chronic Osteomylitis as ordered.

Noncompliance resulted in multiple deficient practice statements. A. Based on record review and interview the facility neglected to provide services that aligned with physician's orders [REDACTED]. R8 was not given breakfast daily prior to [MEDICAL TREATMENT], not given bedtime snacks, not given insulin as ordered, not given a renal diet as ordered, did not have blood glucose monitored as ordered, and not given a fluid restriction with daily weights as ordered by the physician. These failures resulted in R8 being hospitalized for [REDACTED]. B. Based on interview and record review, the facility failed to prevent misappropriation of a resident's medications resulting in missing narcotic medications for one of three residents (R4) reviewed for misappropriation of narcotic medications in the sample of 10. Findings include: A. The facility's Abuse Prevention Program dated 2012 documents, Neglect is the failure to provide necessary and adequate medical, personal, or psychological care. Neglect is the failure to care for a person in a manner which would avoid harm and pain, or the failure to react to a situation which may be harmful. The facility must make a commitment to prevent abusive and/or neglectful actions towards residents. R8's physician's orders [REDACTED]. These same admitting orders document the following orders: [MEDICAL TREATMENT] every Tuesday, Thursday, and Saturday for the treatment of [REDACTED]. Controlled Hi Protein Renal Diet. Fluid Restriction of 800 ml (milliliters) every shift for [MEDICAL CONDITION]. Weight Daily. Accucheck's and Insulin [MEDICATION NAME] 100 units per ml inject per sliding scale subcutaneous before meals and at bedtime (Blood Sugar 201-250=2 units, 251-300=3 units, 301-350=4 units, [PHONE NUMBER]= 6 units). Insulin [MEDICATION NAME] 100 units per ml inject as per sliding scale at bedtime (Blood sugar 0-150 =0 units, 151-200=12 units, [PHONE NUMBER] =25 units). R8's Medication Administration Records from 8-14-17 to 8-18-17, indicate R8's blood sugars were not obtained along with sliding scale insulin as ordered on 8-15-17 at 11:00 a.m., 8-16-17 at 7:30 a.m. and 11:00 a.m., and 8-17-17 at 11:00 a.m. R8's Nutritional Intake Report dated 8-14-17 to 8-18-17 does not include R8's intake for breakfast on any of these days. The facility's Bedtime snack list does not include R8. R8's Weight Record and Electronic Medical Record dated 8-14-17 to 8-18-17, does not include monitoring of R8's daily weight or fluid intake. R8's Hospital History and Physical dated 8-18-17 documents, (R8) presented to the ER (Emergency Department) today with complaints of confusion that started earlier today. (R8's) blood sugar was very low. Since arriving to the ER, (R8) has been very tired and sleeping much of the time. (R8) temperature upon arrival 96 degrees Fahrenheit. Admitting problem [DIAGNOSES REDACTED]. R8's Nursing Home Progress Notes and Assessments do not include any documentation of R8 being discharged from the facility or R8 being sent to the ED for a condition change. On 8-23-17 at 9:15 a.m., E25 (Dietary Manager) stated, The cook gets to the facility at 5:30 a.m. The cook would send a tray to (R8) around 6:00 a.m., but it would always come back to the kitchen untouched. According to the intake logs, (R8) would already be gone to [MEDICAL TREATMENT] before receiving his breakfast. It would be too difficult to get (R8) a hot breakfast that early in the morning. We (the facility) could have sent a cold sack breakfast had we known that (R8) was leaving early for [MEDICAL TREATMENT]. Diabetic residents need breakfast to prevent low blood sugars, which could result in [MEDICAL CONDITION] or even a coma. I was not aware that (R8) was on a fluid restriction. On 8-23-17 at 10:10 a.m., Z15 ([MEDICAL TREATMENT] Clinic Nurse Manager) stated, (R8) did not have breakfast or any snacks on the days (8-15-17 and 8-17-17) he came to [MEDICAL TREATMENT]. Breakfast is very important for diabetics to prevent blood sugars from dropping. On 8-23-17 at 10:55 a.m., E27 (Certified Nursing Assistant) stated, (R8) did not get a breakfast tray on the days he had [MEDICAL TREATMENT]. E27 also confirmed that R8 would get big pitchers of water. On 8-23-17 at 2:00 p.m., E29 (Cook) stated, I never received a diet order for (R8). I always gave (R8) a regular diet. I never packed (R8) a lunch on the days of [MEDICAL TREATMENT]. I gave the nursing staff a breakfast tray on Thursday (8-17-17), but the tray was returned 15 minutes later untouched. (R8) had already left for [MEDICAL TREATMENT] and did not get a breakfast tray. Bedtime snacks are only offered to residents with physician's orders [REDACTED]. I could not provide (R8) with a hot breakfast because I am not here soon enough to cook it. On 8-23-17 at 2:30 p.m., E28 (Dietary Aide) stated, I prepare the bedtime snacks for residents who only have physician's orders [REDACTED]. On 8-23-17 at 2:10 p.m., E11 (Registered Nurse) stated, The morning of 8-18-17 (E27/Certified Nursing Assistant) reported to be around 6:00 a.m. that (R8) was aggressive and spitting everywhere. I went down to (R8's) room and he was pushing me, spitting at me, and trying to crawl under the bed. I called 911 and send (R8) to the ED. The paramedics checked (R8's) blood sugar and it was only 23. I did not do an assessment progress note or a risk management assessment. I forgot. On 8-23-17 at 11:10 a.m., R8 stated, I never got my morning or noon medications, including my insulin, while I was at the facility. I never got breakfast when I would go to [MEDICAL TREATMENT]. The night before I went to the hospital I went to bed and next thing I know I woke up in the hospital. My sugar count was 23. My body temperature was low. I could feel my blood sugars dropping and was hungry from missing breakfast, and sometimes lunch. My blood sugars were never checked on the days I had [MEDICAL TREATMENT]. That facility is very neglectful. I will never go back. On 8-24-17 at 9:30 a.m., E2 (Director Of Nursing) stated, We (the facility) do not serve snacks at bedtime. Diabetic residents should always have a bedtime snack. (R8) did not receive a bedtime snack. On Thursday (8-17-17) (R8) was suppose to get a breakfast tray before [MEDICAL TREATMENT], but did not. I did not know until yesterday that (R8) was on a fluid restriction and neither did the dietary manager. (R8) should have been monitored closely here since he was diabetic. (R8) did not get his scheduled blood sugars with sliding scale insulin on 8-15-17 at 11:00 a.m., 8-16-17 at 7:30 a.m. or 11:00 a.m., or 8-17-17 at 11:00 a.m. That could have prevented (R8's)hospitalization , [DIAGNOSES REDACTED], change in mental status, and fluid overload. (R8's) daily weights were not done, either. On 8-24-17 at 11:25 a.m., Z4 (Nurse Practitioner) stated, If (R8) was on [MEDICATION NAME]then (R8) should get a bedtime snack. The facility should have been getting (R8's) blood sugars four times daily with the sliding scale insulin. (R8) should receive breakfast daily. They (the facility) should monitor (R8's) fluid restriction as ordered and document. They should have obtained daily weights due to (R8) having [MEDICAL CONDITION] and [MEDICAL TREATMENT]. If (R8) was not getting bedtime snacks and blood sugars monitored, that could have contributed to the [DIAGNOSES REDACTED]. If they were not monitoring for fluid intake and daily weights that would have caused fluid overload. These failures and poor follow through were neglectful. B. The facility's Abuse Prevention Policy dated 6-11-2008 documents, Financial abuse is the deliberate misappropriation, exploitation, or other wise taking of a resident's money or property. Example: theft. R4's current physician's orders [REDACTED]. This same POS documents R4 receives [MEDICATION NAME] IR (Immediate Release) HCL (Narcotic Pain Reliever/Opiate) 5 mg one to two capsules as needed every four hours for moderate to severe pain. R4's Controlled Drug Receipt/Record/Disposition Form dated 8-1-17, documents 60 [MEDICATION NAME] 5 mg (milligram) tablets (two cards of 30 each card) were delivered to the facility on [DATE]. On 8-15-17 at 9:30 a.m., card one of two (30 tablets) was not in the medication room or the medication cart, along with the Controlled Drug Receipt/Report/Disposition for card one of two [MEDICATION NAME] 5 mg 30 tablets. R4's Controlled Drug Receipt/Record/Disposition Form dated 7-6-17, documents 60 [MEDICATION NAME] 5 mg (milligram) tablets (two cards of 30 each card) were delivered to the facility on [DATE]. R4's Medical Record does not include card one of two's (30 tablets) Controlled Drug Receipt/Report/Disposition for [MEDICATION NAME] 5 mg 30 tablets. On 8-15-17 at 9:30 a.m., R4's card one of two of [MEDICATION NAME] 5 mg 30 tablets was not in the medication room or the medication cart. R4's Controlled Drug Receipt/Record/Disposition dated 8-12-17 to 8-13-17, documents R4 received two [MEDICATION NAME] (Opiate Drug) IR (Immediate Release) 5 mg tablets on 8-12-17 at 3:00 p.m. and 9:00 p.m. by E3 (Licensed Practical Nurse/LPN), and two [MEDICATION NAME] 5 mg tablets on 8-13-17 at 1:15 a.m. by E11 (LPN) R4's Toxicology Urine Screen dated 8-13-17 at 10:39 a.m., documents R4 is negative for urine opiates. R4's emergency room Note dated 8-13-17 and signed by Z6 (Emergency Department Physician), documents R4 presents to the ED (Emergency Department) from the nursing home with complaints of increased pain in the left leg which has been chronic for sometime, and an elevated blood pressure of 223/123 with complaints of pain to the right leg. This same note documents R4 will be admitted for hospital services for intractable pain and high blood pressure related to the pain with a plan to obtain a doppler ultrasound, start [MEDICATION NAME] one mg IV (Intravenously) every hour (in addition to the [MEDICATION NAME] as needed and [MEDICATION NAME] three times daily), and start blood pressure regimen medications. R4's Hospital Progress Note dated 8-13-17 and signed by Z3 (Hospital Social Service) and Z5 (emergency room Physician), documents Z11 (Registered Nurse) and Z5 (emergency room Physician) are concerned that there is no indication that R4 was receiving R4's pain medication of [MEDICATION NAME] due to R4's negative urine opiate screen. This same note documents Z1 (R4's Family Member) is concerned that nursing home staff is stealing R4's pain medication. R4's Minimum Date Set dated 7-3-17 documents R4's BIMS (Brief Interview of Mental Status) score is an 11 indicating R4 is interviewable. On 8-15-17 at 12:45 p.m., R4 stated, I never got a pain pill in the middle of the night on 8-13-17. On 8-16-17 at 11:45 a.m., E2 (Director Of Nursing) stated, (R4's) [MEDICATION NAME] Controlled Record sheet is missing for card one of two for dates 7-6-17 and 8-1-17 along with (R4's) [MEDICATION NAME] 30 tablets for each card (60 tablets total). On 8-21-17 at 12:15 p.m. Z10 (Pharmacist) stated, (R4's) urine opiates screen should have most definitely tested positive for [MEDICATION NAME] 5 mg IR (Immediate Release) at least for 24 hours, if not longer. If (R4) was given a dose of [MEDICATION NAME] at 1:15 a.m., then the urine drug screen should have tested positive for opiates. It should have definitely tested positive if (R4) was given three doses within the 24 hours before the urine test. On 8-22-17 at 10:30 a.m., E2 (Director of Nursing) stated, 60 tablets of (R4's) [MEDICATION NAME] is missing and we (the facility) are concerned that the medication had been misappropriated. We have had concerns in the last month of nurses taking narcotic medication for personal use. (R4's) 60 tablets would have had to be taken by someone because they were definitely delivered to the facility.

Based on observation, interview and record review, the facility failed to use a mechanical lift while transferring one of three residents (R1) and failed to utilize two staff assistance with a gait belt while transferring one of three residents (R3) reviewed for safe transfer/falls in a sample of three. This failure resulted in a left arm fracture and increased pain for R1. Findings include: The facility's undated policy Transfers and Lifts, documents Know the Resident's Needs: The resident's care plan should be very explicit on exactly how the resident is to be transferred and or lifted. If you think changes need to be made to the way the resident is lifted, discuss this with the charge nurse. (Mechanical) Lift: For residents who are totally dependent or partial or non-weight bearing. 1. The Resident Care Plan for R1, dated 6-20-15, documents (R1) is a potential risk for falls related to.gait/balance problems.and (mechanical lift) transfer. Intervention: Use (mechanical lift) for all transfers. R1's Minimum Data Set (MDS), dated [DATE], documents R1's [DIAGNOSES REDACTED]. R1's MDS documents that R1's Functional Limitation in Range of motion is a bilateral impairment of upper and lower extremities. On 6-24-15 at 1:55 pm, E3 (Certified Nursing Assistant/CNA), stated After (R1's) shower (E4/CNA) and I transferred (R1) back into the wheelchair without the (mechanical) lift. (R1) then complained of left arm pain so I told the nurse right away. (R1) is supposed to be transferred by a (mechanical) lift, but it was easier (to get R1 dressed) not using the (mechanical) lift and to get (R1) from the shower chair to the wheelchair. On 6-24-5 at 2:03 pm, E4 (CNA), stated After (R1's ) shower, (E3) and I used a gait belt and transferred (R1) from the shower chair to (R1's) wheelchair. (R1) is supposed to be transferred by a (mechanical) lift. (R1) wasn't back far enough in her chair so we boosted her under her arms. (R1) was able to put a little weight on her good leg to stand and pivot. The facility's Incident/Accident Report for R1, dated 6-20-15 and signed by E6, (Licensed Practical Nurse/LPN), documents that at 1:00 pm (R1) said she received a shower and when the aids were done went to transfer her and slippers slipped and aids caught her from falling but c/o (complained of) left shoulder pain. The facility's undated policy Falls, Post-Fall Protocol, documents Definitions: An intercepted fall is still a fall. An episode where a resident lost his/her balance and would have fallen, were it not for staff intervention, is a fall. On 6-24-15 at 2:08 pm, E6 (LPN), stated (R1) is supposed to be transferred using the (mechanical) lift. I've never heard of a reason as to why they can't use the (mechanical) lift with a shower chair. It can be done, but it is time consuming. On 6-25-15 at 9:20 am, E2 (Director of Nursing/DON), stated (R1) is a (mechanical) lift transfer. They should have transferred (R1) using the (mechanical) lift. On 6-25-15 at 11:45 am, E8 (LPN), stated (R1) has been asking for more pain medication for that shoulder lately since the incident with the shower. On 6-25-15 at 1:30 pm, R1 stated There were only two CNAs (Certified Nursing Assistants) who dropped me. My knee was on the floor. My slippers are slippery; they tried to get me to stand, but I can't stand up. I told them to get the lift, but they didn't listen. Now my arm hurts all the time. An X-ray report, dated 6-27-15, of R1's left clavicle, scapula, shoulder, humerus, elbow, forearm, wrist, and hand, documents Acute left greater tuberosity fracture with mild lateral displacement. 2. On 6-27-15 at 11:00 am, E9 (Certified Nursing Assistant/CNA), transferred R3 from the toilet to R3's wheelchair without utilizing a gait belt. R3's Minimum Data Set (MDS), dated [DATE], documents R3's [DIAGNOSES REDACTED]. R3's MDS also documents R3 as needing extensive assistance with two person physical assist for transfers and toilet use. R3's MDS documents that R3's Functional Limitation in Range of motion is a bilateral impairment of upper and lower extremities. R3's Resident Care Plan, revised on 5-11-15, documents (R3) has an ADL (Activities of Daily Living) self-care performance deficit related to pain (back), Alzheimer's and Impaired balance. Intervention: Explain task. Apply gait belt. Decrease amount of assistance needed as able. On 6-27-15 at 11:05 am, E9 (CNA), stated I didn't use a gait belt because he was trying to get up on his own. I don't have a gait belt on me. On 6-27-15 at 11:53 am, E2 (Director of Nursing/DON), stated (R3) should have a gait belt on when being transferred.

Based on observation, interviews and record reviews the facility failed to administer a pain medication for one of five sampled residents. (R1) This failure resulted in R1 not receiving pain medication for 12 hours, crying in pain and calling 911 on own to be sent back to the hospital by ambulance due to pain. Findings include: Admission records for R1 document date of birth as 04/08/1969. Same admission records document admission [DIAGNOSES REDACTED]. On 3/26/15 at 10:15 A.M. R1 was sitting in room. This [AGE] year old resident was cognitively alert. Medical records from admission and R1's nurses notes document resident alert and oriented. R1 stated that on 3/11/15 R1 was admitted to the facility after she had fallen at home and fractured her right ankle with dislocation. R1 stated that she has been in a great deal of pain and is only relieved by the pain medication, [MEDICATION NAME] she is to receive every four hours. R1 stated that on 3/15/15 R1 had received a dose of [MEDICATION NAME] at 8:00 A.M. but when she asked for it again at 12:00 P.M., E5 (Licensed Practical Nurse) told R1 they were out of the medication and waiting for pharmacy to deliver it. R1 said that E4 (Registered Nurse) came on second shift and told R1 that the [MEDICATION NAME] was still not there and they were still waiting. R1 stated that she was in so much pain by 8:00 P.M. that she called 911 and went to the hospital per ambulance. R1 stated that the hospital was able to give her pain medications to relieve her pain and send her back to the facility. On 3/26/15 at 2:20 P.M. E4 stated that when she came in to work on 3/15/15 at 2:30 P.M., E5 had told her that they were out of R1's [MEDICATION NAME] and they were waiting for the pharmacy to deliver it. E4 stated that at about 5:00 P.M. R1 was noted to be crying in pain so she gave her [MEDICATION NAME] which did not help. E4 stated that around 8:00 P.M. E4 remembered that the facility had a convenience box with [MEDICATION NAME] in it. E4 stated just at that same time the ambulance staff had come into the facility to take R1 to the hospital. E4 said that E4 should have immediately went to the convenience box at 2:30 P.M. to get the [MEDICATION NAME] but did not remember it was in there. The facility's Controlled Drug Record form notes that R1 received a dose of [MEDICATION NAME] at 8:00 A.M. on 3/15/15 and then did not receive another dose of [MEDICATION NAME] until 8:00 A.M. on 3/16/15. R1's physician's orders [REDACTED].

Based on observation, interview and record review the facility failed to implement post fall interventions for two of three residents (R82, R106) reviewed for falls in a sample of fourteen. Findings include: 1.) The Admission Record, 5/1/14, documents R106 with [DIAGNOSES REDACTED]. The Care Plan, 7/25/14, documents R106 at risk for falls related to being unaware of safety needs, psychoactive drug use, gait and balance problems and a history of falls (4/3/14, 4/25/14, 5/15/14, 5/21/14, 6/10/14, and 7/10/14). The Care Plan documents interventions to include use of a chair alarm, push the chair with armrests up to the table for safety and a medication review. The Fall Risk Assessment, 7/9/14, documents R106 at risk for falls. On 7/29/14 at 12:15pm and 2:00pm R106 was sitting in the activity room in a reclining wheelchair without a chair alarm. On 7/30/14 at 9:30am R106 was in the activity room in a reclining wheelchair without a chair alarm present sitting with the table to the left side of R106, not pushed up to the table. R106 remained sitting with the table at the left side until R106 was removed from the activity room by E7 (Nursing Assistant) at 9:47am. On 7/30/14 at 12:10pm, R106 was transferred from bed into the reclining wheelchair; the chair alarm was not present on the wheelchair when E8 (Nursing Assistant) wheeled R106 into the activity room. On 7/30/14 at 12:15pm E7 stated R106 does not utilize a chair alarm but is to be pushed up to the table when in the activity room because R106 rocks forward in the chair. On 7/30/14 at 12:30pm, E2 (Acting Director of Nursing) stated the interventions in R106's care plan are added by E9 (Care Plan Coordinator) and should be the current interventions. On 7/30/14 at 12:35pm, E9 stated R106's care plan is up to date with interventions staff should be implementing to prevent falls. The Incident/Accident Report, 7/10/14, documents R106 incurred a fall. A step taken to prevent recurrence documents a medication review. On 7/30/14/14 at 12:30pm, E2 stated the medication review may be documented in the progress notes but was not able to indicate the facility process for documenting a medication review. E2 was unable to provide documentation of the medication review being completed after R106's fall on 7/10/14. The Progress Notes, 7/10/14 to 7/30/14, does not document a medication review. The Fall Prevention Policy, undated, documents the facility has a falls management program to prevent falls with residents who are at risk for falls. The policy documents the facility is to document post-fall care plans as needed. 2.) Per document titled Physician order [REDACTED]. According to the Fall Risk Evaluation, dated 5/20/14, R82 is documented as a high risk for falls and has a chair alarm in place. The facility Incident/Accident Reports, dated 7/21/14 and 7/28/14, documents R82 incurred a fall on each of these dates. Per Care Plan, dated 5/10/14, R82 is high risk for falls, unaware of safety needs, has gait/balance problems, has a history of falls, and is non-compliant with assistance. Some of the Interventions listed to prevent R82 from falling include chair alarm, and for staff not to leave her in her room alone when she is in her wheelchair. On 7/30/14, at 12:10 PM, R82 was sitting in her wheelchair, in her room with no staff present or in the immediate vicinity. At this time there was no wheelchair alarm on R82's wheelchair. On 7/30/14, at 12:15 PM, E10 (Nursing Assistant) stated that R82 was not supposed to be in her room in the wheelchair without staff, however she did not think that R82 was supposed to have a chair alarm on her wheelchair.

A. Based on interview and record review, the facility failed to ensure direct supervision while dressing, failed to maintain the functioning of safety alarms, and failed to implement post fall interventions for one (R19) of eight residents reviewed for falls in the sample of 22. These failures resulted in R19 falling on two separate incidents, sustaining a fractured right hip and a subarachnoid hemorrhage respectfully. Findings include: The Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R19 as cognitively impaired, poor decision making, needing cueing and supervision with decision making tasks. The same MDS documents R19 as not steady and only able to stabilize with staff assistance while walking, turning around, moving from seated to standing position, moving on and off toilet seat and surface to surface transfers. The MDS documents that R19 needs assistance of one when dressing. R19's Interim Plan of Care dated 1/31/14 documents R19 needing the assistance of staff while dressing, during ambulation and transfers. A facility document titled "Fall Risk Evaluation" and dated 1/31/14, 2/12/14 and 5/5/14 assesses R19 as being high risk for falls. R19's Nursing Notes dated 2/2/14 document that R19 has behaviors and when agitated is known to tear off her safety alarms. The facility's Accident and Incident log documents R19 falling on the following dates: 2/10/14, 2/24/14, 3/6/14, 3/20/14 and 4/20/14. A Fall Investigation Report dated 2/10/14 (no documented time) documents that E5, Certified Nursing Assistant left R19 sitting on the edge of her bed putting socks on. E5 then heard R19 yelling for help. E5 went back to R19's room and found R19 lying on the floor. The Investigation Report states R19's bed safety alarm was not sounding. The same report documents R19 being sent to the emergency room at 9:30 am due to a shortened and rotated right leg. The investigation report states R19 was admitted to the hospital for surgical repair of a fractured right hip per the same fall investigation. The facility's Fall Investigation Report dated 2/24/14 at 5:45 pm documents R19 was found sitting on the floor by her bed. The investigation documents that R19 often tries to transfer herself and is frequently confused. The same report documents to continue all interventions. There were no post fall interventions documented on the investigation report. The Care Plan dated 2/24/14 for R19 documents a fall on 2/24/14 and directs staff to continue all previous interventions. The facility's Fall Investigation Report dated 3/6/14 for R19 documents at 12:19 pm that R19 was found lying on the floor by her door with a large hematoma to the right side of her head. The report documents that R19's bed alarm failed to sound. The same report documents that R19 was transported to the emergency room via ambulance at 12:30 pm for evaluation. A facility report to the State Agency dated 3/6/14 documents that R19 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. On 5/14/14 at 10:20 am E2, Director of Nursing stated the facility had no Policy or Procedure concerning safety alarms. E2 stated there was no system in place for checking the working status of alarms. E2 acknowledged that anytime an alarm fails staff should be finding out why and correcting the problem. E2 stated that to her knowledge this had not been done on R19's falls of 2/10/14 and 3/6/14. E2 stated "I guess we find out after a resident gets up or falls if the alarm is working, staff will usually come and ask for new batteries." E2 acknowledged that R19 had a history of [REDACTED]. B. Based on record review and interview, the facility failed to ensure that an effective assistance device was implemented. The facility failed to provide a safe wheelchair for one (R20) of eight residents reviewed for falls in the sample of 22. Findings include: The Physician order [REDACTED]. R20's Minimum Data Set (MDS) dated [DATE] documents R20 with severe cognitive impairment. R20 is unable to stabilize without staff assistance during walking, turning around, and during transfers. The same MDS documents R20 at 73 inches tall (6 foot one inch). A facility report titled "Incident and Accident Report" documents that R20 fell backward in his wheelchair on 6/18/13 at 6:30 pm. The report documents that R20 received a small hematoma to the back of his head. The investigation tool for this incident also dated 6/18/13 documents that R20 was in the wrong wheelchair. On 5/14/14 at 3:05 pm E2, Director of Nursing stated R20 was in a different wheelchair because his regular one was broke. E2 stated the temporary wheelchair that R20 was placed in did not have anti-tippers on it. E2 stated R20 tipped back in his wheelchair and fell , striking his head and receiving a small hematoma to the back of his head. On 5/21/14 at 11:05 am E12, Care Plan Coordinator stated that R20 has had anti-tippers on his wheelchair since she started employment a year ago at the facility. E12 stated "(R 20) becomes agitated and has behaviors and needs the anti-tippers because (R20) tries to stand pushing back on his wheelchair." C. Based on observation, interview, and record review, the facility failed to ensure that R32 was provided with supervision measures to ensure safety. The facility failed to ensure that 30 minute checks were completed and documented for one of one residents (R32) reviewed for exit seeking behavior in the sample of 22. Findings include: R32's Physician order [REDACTED]. R32's Elopement Risk assessment dated [DATE] documents that R32 is at high risk for elopement. On 5/14/14 at 8:27am, R32 exited the 100 Hall door. On 5/15/14 at 8:20am and 1:25pm, R32 exited the building. R32's Nurse's Notes dated 3/24/14, 3/31/14, 4/6/14, 4/8/14, 4/19/14, 4/23/14, 4/24/14, 4/25/14, 4/26/14, 4/27/14, 4/28/14, and 5/2/14 document R32's exit seeking behavior. R32's physician progress notes [REDACTED]. She (R32) is also exit seeking." R32's Elopement Care Plan dated 3/23/14 documents that staff must "Every 30 minutes check on resident location and chart on elopement sheet." On 5/20/14 at 8:55am, E16, Licensed Practical Nurse, stated that the facility has no residents currently receiving 30 minute checks. On 5/20/14 at 9:02am, E30, Certified Nursing Assistant (CNA), stated that they are not using the 30 minute check elopement sheets. On 5/20/14 at 9:50am, E2, Director of Nursing, stated that 30 minute checks are not being done or documented because R32 rarely stays in one place for 30 minutes. D. Based on observation and interview, the facility failed to ensure that one resident toilet did not leak and that nonskid strips were intact for one of 22 residents (R24) reviewed during resident room review in the sample of 22. Findings include: R24's Minimum (MDS) data set [DATE] documents that R24 is totally dependent on staff for transfers and toileting. R24's Care Plan dated 4/22/14 documents that R24 requires a mechanical lift to transfer to the toilet. R24's Fall Risk assessment dated [DATE] documents that R24 is at high risk for falls. On 5/12/14 at 7:15am and 2:00pm, and 5/13/14 at 8:00am R24's resident toilet flush mechanism permitted a constant flow of water and a large puddle of water surrounded the toilet. The water extended from the toilet to both walls, approximately eight inches on each side and 12 inches in front of the toilet. Nonskid strips were peeling up from the floor in front of the toilet. On 5/13/14 at 12:15pm, E29, Assistant Maintenance Supervisor, stated that he had not been notified of R24's leaking toilet. E29 stated that he had to rebuild the tank mechanism in order to stop the leak. E29 stated that staff are supposed to complete a work order when repairs are needed.

Based on observation, record review, and interview, the facility failed to use the full mechanical lift instead of the sit to stand lift for one of ten residents (R15) reviewed for accidents in a sample of 17. This failure resulted in R15 sustaining significant bruising across the upper chest, bilateral breasts, right axilla, and right upper arm down to just below the right elbow, and significant swelling to the right upper chest extending into the axilla. Findings include: A physician's orders [REDACTED]. The Plan of Care, dated 1/10/12, indicates R15 requires the use of a full mechanical lift to transfer. Nursing Notes, dated 3/10/12, document R15 had bruising the entire length of the right arm. On 3/12/12, Nursing Notes indicate R15 developed swelling to the right side of the chest and the physician ordered an x-ray. An Incident/Accident Report, dated 3/10/12, documents R15 was noted to have a bruise on the entire length her right bicep. The Incident/Accident Report further documents E2 (Director of Nursing) interviewed staff to determine the cause of the bruising and "believed bruising to be caused by harness of stand lift." An Inservice Program Sheet, dated 3/12/12, documents all staff were educated that R15 requires a full mechanical lift to transfer and has required this since 1/10/12. The Inservice Program Sheet further educated staff to not use a stand lift when transferring R15. On 3/21/12, at 11:02 a.m., E16 (Licensed Practical Nurse) stated R15 is "confined to her wheelchair and does not try to get up on her own." On 3/21/12, at 11:30 a.m., E22 (Certified Nursing Assistant) stated R15 is unable to stand on her own and has required the use of a (mechanical) lift for some time." On 3/21/12, E2 (Director of Nursing) stated R15 is unable to stand and bear weight independently. E2 stated, based on her investigation, it is believed that staff used a stand lift instead of a full mechanical lift to transfer R15. E2 further stated that, since R15 is unable to bear weight, she would have hung in the harness/straps of the stand lift and that would have caused the bruising in the area she was injured. On 3/21/12, at 11:33 a.m., R15 had extensive purple and yellow bruising across her upper chest, dark purple bruising across the right and left lower breast, dark purple bruising and significant swelling (approximately two inches in diameter) in the right axilla, and purple and yellow bruising on the upper right arm extending down below the elbow (approximately three inches wide). R15 was unable to respond when asked how the injury occurred.

Based on observation, interview and record review, the facility failed to have current policies and procedures regarding Pressure Sore Prevention and Treatment that provided staff with a working knowledge of how to properly assess and monitor pressure ulcers once they develop. Staff were not provided ongoing continuing education related to pressure sore prevention and treatment, resulting in a delay in the treatment of [REDACTED]. R8 developed a Stage III pressure ulcer on the Left Buttock after admission, which required debridement. The facility failed to ensure policies and procedures were in place to ensure residents who experienced a significant weight loss, received necessary services to improve their nutritional status, for one of three (R8) residents reviewed for weight loss. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level II as the facility continues to provide staff training and monitor the effectiveness of such training regarding pressure sore prevention and monitoring. Findings include: An Admission and Discharge Summary dated [DATE], documents R8 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Nursing Progress notes, dated [DATE], indicate R8's skin was free of pressure ulcers upon admission. R8's Braden Scale (for predicting pressure ulcer risk) of [DATE] identified R8 as being at moderate risk (score of 14) for pressure ulcer development. R8's Minimum (MDS) data set [DATE], indicates R8 required limited assistance of one staff person for bed mobility and transfers, extensive assistance upon staff for personal hygiene, at risk for pressure ulcer development, occasionally incontinent of urine and continent of bowel. R8's [DATE] Plan of Care does not identify the potential for skin breakdown as an area of concern for R8. A Telephone Order on [DATE], indicates R8 was put into a wheelchair with a soft waist restraint and on [DATE] changed to a highback reclining chair with a lap tray. R8's Minimum (MDS) data set [DATE], indicates R8 required an increase to extensive assistance of one staff person for bed mobility and transfers, remained at risk for pressure ulcer development, and had become frequently incontinent of urine and occasionally incontinent of bowel. R8's [DATE] Plan of Care does not identify the potential for skin breakdown as an area of concern for R8. On [DATE], E6 (Care Plan Coordinator) completed a follow-up Braden Scale (for predicting pressure ulcer development) on R8, and scored R8 at a "mild risk (score of 15)" for pressure ulcer development, despite R8's physical decline and increasing need of staff assistance for bed mobility and transfers. This score of 15 on the Braden Scale of [DATE], was an upgrade from the score of 14 on [DATE], from Moderate Risk to Mild Risk. On [DATE] at 1:35 p.m., E6 (Care Plan Coordinator) stated she determines a resident's need for Care Planning of Pressure Ulcer Prevention by the resident's Braden Score, clinical assessment, and if the Minimum Data Set identifies a resident as being at risk for pressure ulcers. E6 stated R8's admitting Minimum Data Set did identify R8 as being at risk for the development of pressure ulcers and that she should have proceeded to Care Planning to decrease R8's risk of pressure ulcer development. E8 stated R8 did not have any pressure ulcer prevention interventions in place, upon admission and through [DATE]. A Body Check Form dated [DATE] at 9:40 a.m., by E8 (Certified Nursing Assistant), documents R8 had an open area on his buttock. The nurse, E4 (Licensed Practical Nurse) signed the Body Check Form which documented R8's newly found open area. On [DATE] at 10:40 a.m., E8 (Certified Nursing Assistant) stated she noticed a "nickel sized" open pink area on his lower buttock. E8 stated she told E4 (Licensed Practical Nurse) about the open area on [DATE], after she noticed it. On [DATE] at 1:10 p.m., E4 (Licensed Practical Nurse) confirmed E8 (Certified Nursing Assistant) did inform him of a new open area on R8's buttock on [DATE]. However, Nursing Notes and a physician's orders [REDACTED]. E4 confirmed that he did notify Z2 (Physician) of R8's newly developed buttock wound, but not until [DATE], two days after the wound developed. On [DATE] at 2:43 p.m., E3 stated her role as the Wound Nurse, includes monitoring and measuring wounds, looking at dietary concerns, cushions and supplements. E3 (Wound Nurse) stated that E4 (Licensed Practical Nurse) did notify her, on [DATE], that R8 had developed a pressure area on his buttock. E3 did not have any documentation related to the wound size or appearance and indicated she only "looked at the wound" and did not measure it. E3 described R8's left buttock pressure ulcer as approximately nickel sized and pink, on [DATE]. E3 confirmed that the only pressure ulcer intervention implemented for R8,on [DATE], was a [MEDICATION NAME] Alginate Dressing over the wound. E3 stated she did not evaluate R8's bed mattress or wheelchair cushion at that time and "should have implemented additional measures, like a gel cushion for the wheelchair and air mattress." E3 stated R8 never received the gel cushion or air mattress that Z1 ordered, as they did not arrive before R8 expired on [DATE]. E3 stated she was abruptly put in the position of wound nurse "several months ago" and has not had any special training on pressure ulcer prevention and wound management. On [DATE] at 12:25 p.m., E2 (Director of Nursing) stated the facility was not following any specific policy on wound treatment/management. A Wound Care Specialist Note, dated [DATE], by Z1 (Wound Consultant/Physician) documents R8 as having a "pressure" wound, "unstageable (due to necrosis) of the left buttock of unknown days duration." The Wound Care Specialist Note describes the wound as being 3.5 centimeters by 3.5 centimeters and requiring "surgical excisional debridement of subcutaneous tissue." The Wound Care Specialist Note further indicates, "Length of visit more than 35 minutes of which greater than 50% spent in counseling and/or coordination of care. Reason: Patient's wounds required extensive discussion with PCP (Primary Care Physician) and/or nursing staff regarding prognosis." On [DATE] at 4:00 p.m., Z1 (Wound Consultant/Physician) stated R8's left buttock wound was pressure related and was dry, hard, dead tissue with granulation around the edges, when he first assessed it on [DATE]. Z1 stated R8's pressure ulcer was a Stage III or "could have been a" Stage IV. Z1 stated he would not expect a wound to quickly decline from pink and nickel sized on [DATE] to the condition the wound was in on [DATE], unless the wound "wasn't addressed by the staff" at the facility. Z1 stated, when R8's health started to decline, "putting (R8) on a low air loss mattress could have possibly prevented the development of a pressure sore." Z1 further stated R8's Braden Score was not accurately assessed in [DATE] and that an accurate Braden Assessment would have triggered an increased risk in pressure ulcer development and "ideally" new pressure ulcer prevention interventions would be created, such as a change in the resident's mattress. On [DATE] at 1:00 p.m., E2 (Director of Nursing) provided requested policies and procedures regarding pressure ulcer prevention and treatment. E2 provided an undated policy with pressure ulcer prevention methods that are not up to date with the current standards of practice, some of which were simply crossed out. The Prevention and treatment of [REDACTED]. On [DATE] at 11:40 a.m., E2 (Director of Nursing and Previous Wound Nurse) stated she was not certain what the assessment tools identified in the Prevention and treatment of [REDACTED]. E2 stated it is the protocol of the facility to measure and document the details of a pressure ulcer, on the day it is identified. E2 confirmed R8's wounds were not measured until, Z1 (Wound Consultant/Physician) evaluated the resident on [DATE], seven days after the onset of the pressure ulcer. E2 stated she took the Director of Nursing position in [DATE] and she has not coordinated an inservice for staff on pressure ulcer prevention and wound treatment since taking that position. E2 was unable to determine when the last training was for herself, or nursing staff, on pressure ulcer prevention and wound treatment. On [DATE] at 11:42 a.m., E6 (Care Plan Coordinator) stated the two assessment tools identified in the Prevention and treatment of [REDACTED]. A [DATE] Admission Resident-Data Collection documents R8 was 5 feet 5 inches tall and 160 pounds. A Plan of Care dated [DATE], documents R8 had the potential for impaired nutritional status and weight loss due to dementia and depression. The Weight Log lists R8's weight at 155 pounds for [DATE].9 pounds for [DATE] and 147 pounds for [DATE]. Weekly weights initiated in [DATE] lists R8's weight at 167.75 pounds for week one, 147 pounds for week two, 141.5 pounds for week three (a 11.5% decrease from the admission weight), and 154.25 pounds for week four. The Weight Log lists R8's [DATE] weight as 142 pounds and January weight at 129.5 pounds (a 10% decrease). From R8's admission on [DATE] to [DATE], R8 lost 30.5 pounds (a 24% decrease). A physician's orders [REDACTED]. A Dietitian Recommendation dated [DATE], indicates there was correspondence with Z2 regarding a significant weight change and concerns over inadequate fluid intake. The Dietitian Recommendation documents that on [DATE], Z2 agreed with the recommendation to add one Healthshake twice per day between meals. This was the only documented nutritional intervention made for R8. On [DATE], at 2:45 p.m., E2 (Director of Nursing) confirmed that the only notification made to the physician regarding R8's weight loss was on [DATE], and the 11.5% weight loss in [DATE] was not reported to the physician. On [DATE] at 10:56 a.m., Z8 (Registered Dietitian) stated that any big discrepancy in weights, such as the 167.75 pound weight and 154.25 pound weight in November, should have prompted the staff to do a re-weight to determine accuracy. Z8 stated any significant weight change needs to be reported to the physician and dietitian. Z8 stated R8's weight of 141.5 during the third week of [DATE], was a significant decrease and should have been reported to her and the physician. Z8 stated, had she been aware of R8's weight loss to 141.5 pounds in November, she would have started R8 on a dietary supplement at that time, rather than in December. The interventions/approaches identified on the [DATE] Plan of Care include Multivitamin daily and to monitor/record weight weekly for four weeks. There is no documentation to support R8 was provided a Multivitamin. On [DATE] at 2:10 p.m., E2 (Director of Nursing) stated the Physician should be notified of any significant weight loss. E2 stated the prior Dietary Supervisor, who was recently terminated, was responsible for monitoring weights and reporting them to the Physician. E2 stated, after the Dietary Supervisors termination, they determined weight changes were not being reported to the Physician as they should have been. On [DATE] at 1:35 p.m., E6 (Care Plan Coordinator) stated all dietary/nutritional concerns were to be given to the Dietary Supervisor, who in turn, forwarded them to the Registered Dietitian. E6 stated she has "noted some concerns" about weight issues not being reported as they should. On [DATE] at 1:00 p.m., E2 (Director of Nursing) provided requested policies and procedures regarding weight loss and nutrition. E2 provided policies on Monthly Weights, Weight Loss Interventions, Nutrition Intervention Program, Food Fortification and Supplementation and Dietary Supplements, which were faxed on [DATE] at 12:17 p.m., from another facility in their corporation, as they did not have any policies available in the facility. On [DATE] an Immediate Jeopardy was identified to have begun on [DATE] when staff failed to promptly notify the physician of R8's pressure ulcer, assess the wound, implement measures to prevent R8's wound from progressing to a Stage III pressure ulcer, and failed to develop systematic measures for the identification, monitoring, ongoing management of pressure ulcers. E1, Administrator, was informed of the Immediate Jeopardy on [DATE] at 10:05 a.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediacy Jeopardy: 1. On [DATE] E2, Director of Nursing, educated licensed nurses regarding regarding how to accurately complete a Braden Scale Assessment, wound interventions, physician notification of pressure ulcer development, and documentation of pressure ulcer. This training will be required before staff return to work. 2. On [DATE], all residents received a body/skin assessment and documented new Braden Scale. 3. On [DATE], E2 (Director of Nursing) and E6 (Care Plan Coordinator) reviewed all Care Plans of residents identified as being at risk for pressure ulcer development and made necessary revisions to reflect new interventions implemented. 4. On [DATE], facility Policy and Procedures for Pressure Ulcers and Physician Notification of Change were reviewed and revised. 5. On [DATE], staff inservices for all policy revisions was conducted. For those staff not in attendance, the inservice will be required before staff return to work. 6. On [DATE], Z1 (Wound Consultant/Physician) conducted an inservice for E3 (Wound Nurse) regarding wound management. 7. E3 is scheduled to attend a continuing education course on pressure ulcer prevention and treatment, on [DATE].

A. Based on observation, interview and record review, the facility failed to identify resident risk factors for the development of pressure ulcers, failed to develop and implement wound prevention interventions in a timely manner, and failed to accurately assess a resident for risk of pressure ulcer development, for one of two residents (R8) reviewed for pressure ulcers, in a sample of 11. The facility identified a nickle size, pink Stage II pressure ulcer on 12/28/11, however, did not notify the physician or implement new interventions to prevent the wound from progressing, until 12/30/11. By 1/03/12, R8 developed a 3.5 centimeter by 3.5 centimeter Stage III pressure ulcer on the Left Buttock after admission, which required debridement. Findings include: An Admission and Discharge Summary dated 9/16/11, documents R8 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Nursing Progress notes, dated 9/09/11, indicate R8's skin was free of pressure ulcers upon admission. R8's Braden Scale (for predicting pressure ulcer risk) of 9/09/11 identified R8 as being at moderate risk (score of 14) for pressure ulcer development. R8's Minimum (MDS) data set [DATE], indicates R8 required limited assistance of one staff person for bed mobility and transfers, extensive assistance upon staff for personal hygiene, at risk for pressure ulcer development, occasionally incontinent of urine and continent of bowel. R8's 9/19/11 Plan of Care failed to identify the potential for skin breakdown as an area of concern for R8. A Telephone Order on 9/21/11, indicates R8 was put into a wheelchair with a soft waist restraint and on 9/30/11 changed to a highback reclining chair with a lap tray. R8's Minimum (MDS) data set [DATE], indicates R8 required an increase to extensive assistance of one staff person for bed mobility and transfers, remained at risk for pressure ulcer development, and had become frequently incontinent of urine and occasionally incontinent of bowel. R8's 12/15/11 Plan of Care continued to not identify the potential for skin breakdown as an area of concern for R8. A Plan of Care dated 9/13/11, documents R8 had the potential for impaired nurtitional status and weight loss due to dementia and depression. The interventions/approaches identified on the 9/13/11 Plan of Care include Multivitamin daily and to monitor/record weight weekly for four weeks. There is no documentation to support R8 was ever provided a Multivitamin. A 9/09/11 Admission Resident-Data Collection documents R8 was 5 feet 5 inches tall and 160 pounds. The Weight Log lists R8's weight at 155 pounds for September 2011, 156.9 pounds for October 2011 and 147 pounds for November 2011. Weekly weights initiated in November 2011 lists R8's weight at 167.75 pounds for week one, 147 pounds for week two, 141.5 pounds for week three (an 11.5% decrease from the admission weight), and 154.25 pounds for week four. The Weight Log lists R8's December 2011 weight as 142 pounds and January weight at 129.5 pounds (a 10% decrease). From R8's admission on 9/09/11 to January 2012, R8 lost 30.5 pounds (a 24% decrease). A Dietitian Recommendation dated 12/23/11, indicates there was correspondence with Z2 (Physician) regarding a significant weight change and concerns over inadequate fluid intake. The Dietitian Recommendation on 12/30/11, indicates Z2 agreed with the recommendation to add one Healthshake twice per day between meals. This was the only documented nutritional intervention made for R8. On 2/01/12 at 10:56 a.m., Z8 (Registered Dietitian) stated R8's weight of 141.5 during the third week of November 2011, was a significant decrease and should have been reported to her and the physician. Z8 stated, had she been aware of R8's weight loss to 141.5 pounds in November, she would have started R8 on a dietary supplement at that time, rather than in December. Z8 stated a significant weight loss would have put R8 at greater risk of pressure ulcer development. On 1/26/12, at 2:45 p.m., E2 (Director of Nursing) confirmed that the only notification made to the physician regarding R8's weight loss was on 12/23/11, and that the 11.5% weight loss in November 2011 was not reported to the physician. On 1/24/12 at 10:40 a.m., E8 (Certified Nursing Assistant) stated she routinely cared for R8. E8 stated R8 was able to ambulate to meals, with assistance of staff, when he was admitted . E8 stated R8 began declining in "mid October" and became more confined to his highback wheelchair and would lay down after all meals. E8 stated R8 became incontinent of bowel and bladder and wore adult briefs. E8 stated R8's weight loss was evident, and "you could see he was losing weight." On 12/07/11, E6 (Care Plan Coordinator) completed a follow-up Braden Scale (for predicting pressure ulcer development) on R8, and scored R8 at a "mild risk (score of 15)" for pressure ulcer development, despite R8's physical decline and increasing need of staff assistance for bed mobility and transfers. This score of 15 on the Braden Scale of 12/07/11, was an upgrade from the score of 14 on 9/09/11, from Moderate Risk to Mild Risk. On 1/23/11 at 1:35 p.m., E6 (Care Plan Coordinator) stated she determines a resident's need for Care Planning of Pressure Ulcer Prevention by the resident's Braden Score, clinical assessment, and if the Minimum Data Set identifies a resident as being at risk for pressure ulcers. E6 stated R8's admitting Minimum Data Set did identify R8 as being at risk for the development of pressure ulcers and that she should have proceeded to Care Planning to decrease R8's risk of pressure ulcer development. E6 was uncertain as to why she scored E8's 12/07/11 Braden Scale as a 15 (Mild Risk) when the resident had experienced such a significant decline in November 2011. E8 stated R8 did not have any pressure ulcer prevention interventions in place, upon admission and through December 2011. A Body Check Form dated 12/28/11 at 9:40 a.m., by E8 (Certified Nursing Assistant), documents R8 had an open area on his buttock. The nurse, E4 (Licensed Practical Nurse) signed the Body Check Form which documented R8's the newly found open area. On 1/24/12 at 10:40 a.m., E8 (Certified Nursing Assistant) stated she noticed a "nickel sized" open pink area on his lower buttock. E8 stated she told E4 (Licensed Practical Nurse) about the open area on 12/28/11, after she noticed it. On 1/23/12 at 1:10 p.m., E4 (Licensed Practical Nurse) confirmed E8 (Certified Nursing Assistant) did inform him of a new open area on R8's buttock on 12/28/11. However, Nursing Notes and a physician's orders [REDACTED]. E4 confirmed that he did notify Z2 (Physician) of R8's newly developed buttock wound, but not until 12/30/11, two days after the wound developed. On 1/23/11 at 2:43 p.m., E3 stated her role as the Wound Nurse, includes monitoring and measuring wounds, looking at dietary concerns, cushions and supplements. E3 (Wound Nurse) stated that E4 (Licensed Practical Nurse) did notify her, on 12/30/11, that R8 had developed a pressure area on his buttock. E3 did not have any documentation related to the wound size or appearance and indicated she only "looked at the wound" and did not measure it. E3 described R8's left buttock pressure ulcer as approximately nickel sized and pink, on 12/30/11. E3 confirmed that the only pressure ulcer intervention implemented for R8,on 12/30/11, was a [MEDICATION NAME] Alginate Dressing over the wound. E3 stated she did not evaluate R8's bed mattress or wheelchair cushion at that time. A Wound Care Specialist Note, dated 1/03/12, by Z1 (Wound Consultant/Physician) documents R8 as having a "pressure" wound, "unstageable (due to necrosis) of the left buttock of unknown days duration." The Wound Care Specialist Note describes the wound as being 3.5 centimeters by 3.5 centimeters and requiring "surgical excisional debridement of subcutaneous tissue." The Wound Care Specialist Note further indicates, "Length of visit more than 35 minutes of which greater than 50% spent in counseling and/or coordination of care. Reason: Patient's wounds required extensive discussion with PCP (Primary Care Physician) and/or nursing staff regarding prognosis." On 1/24/12 at 4:00 p.m., Z1 (Wound Consultant/Physician) stated R8's left buttock wound was pressure related and was dry, hard, dead tissue with granulation around the edges, when he first assessed it on 1/03/12. Z1 stated R8's pressure ulcer was a Stage III or "could have been a" Stage IV. Z1 stated he would not expect a wound to quickly decline from pink and nickel sized on 12/28/11 to the condition the wound was in on 1/03/12, unless the wound "wasn't addressed by the staff" at the facility. Z1 stated, when R8's health started to decline, "putting (R8) on a low air loss mattress could have possibly prevented the development of a pressure sore." Z1 further stated R8's Braden Score was not accurately assessed in December 2011 and that an accurate Braden Assessment would have triggered an increased risk in pressure ulcer development and "ideally" new pressure ulcer prevention interventions would be created, such as a change in the resident's mattress. A 9/09/11 Admission Resident-Data Collection documents R8 was 5 feet 5 inches tall and 160 pounds. A Plan of Care dated 9/19/11, documents R8 had the potential for impaired nutritional status and weight loss due to dementia and depression. The Weight Log lists R8's weight at 155 pounds for September 2011, 156.9 pounds for October 2011 and 147 pounds for November 2011. Weekly weights initiated in November 2011 lists R8's weight at 167.75 pounds for week one, 147 pounds for week two, 141.5 pounds for week three (a 11.5% decrease from the admission weight), and 154.25 pounds for week four. The Weight Log lists R8's December 2011 weight as 142 pounds and January weight at 129.5 pounds (a 10% decrease). From R8's admission on 9/09/11 to January 2012, R8 lost 30.5 pounds (a 24% decrease). A physician's orders [REDACTED]. A Dietitian Recommendation dated 10/18/11, indicates there was correspondence with Z2 (Physician) to clarify the no added salt and mechanical soft diet and to recommend weekly weights for four weeks. Another Dietitian Recommendation dated 12/23/11, indicates there was correspondence with Z2 regarding a significant weight change and concerns over inadequate fluid intake. The Dietitian Recommendation documents that on 12/30/11, Z2 agreed with the recommendation to add one Healthshake twice per day between meals. This was the only documented nutritional intervention made for R8. On 1/26/12, at 2:45 p.m., E2 (Director of Nursing) confirmed that the only notification made to the physician regarding R8's weight loss was on 12/23/11, and the 11.5% weight loss in November 2011 was not reported to the physician. On 2/01/12 at 10:56 a.m., Z8 (Registered Dietitian) stated that any big discrepancy in weights, such as the 167.75 pound weight and 154.25 pound weight in November, should have prompted the staff to do a re-weight to determine accuracy. Z8 stated any significant weight change needs to be reported to the physician and dietitian. Z8 stated R8's weight of 141.5 during the third week of November 2011, was a significant decrease and should have been reported to her and the physician. Z8 stated, had she been aware of R8's weight loss to 141.5 pounds in November, she would have started R8 on a dietary supplement at that time, rather than in December. The interventions/approaches identified on the 9/13/11 Plan of Care include Multivitamin daily and to monitor/record weight weekly for four weeks. There is no documentation to support R8 was provided a Multivitamin. On 1/24/12 at 10:40 a.m., E8 (Certified Nursing Assistant) stated R8's weight loss was evident, and "you could see he was losing weight." On 1/23/12 at 2:10p.m., E2 (Director of Nursing) stated the Physician should be notified of any significant weight loss. E2 stated the prior Dietary Supervisor, who was recently terminated, was responsible for monitoring weights and reporting them to the Physician. E2 stated, after the Dietary Supervisors termination, they determined weight changes were not being reported to the Physician as they should have been. On 1/23/12 at 1:35 p.m., E6 (Care Plan Coordinator) stated all dietary/nutritional concerns were to be given to the Dietary Supervisor, who in turn, forwarded them to the Registered Dietitian. E6 stated she has "noted some concerns" about weight issues not being reported as they should. The facility policy and procedure, titled "Monthly Weights", states "(4.) Residents with a significant weight change, 5% in one month, 7.5% in three months, and 10% in six months, will be re-weighed by the ____th of the month." The facility policy and procedure, titled "Weight Loss Interventions", states "(1.) The Physician, Dietitian and appropriate family member will be notified of a resident's significant weight loss." B. Based on observation, record review and interview, the facility failed to provide pressure ulcer treatment and dressing, as ordered by the physician, for one of two residents (R10) reviewed with a pressure ulcer, in a sample of 11. Findings include: Nursing Notes dated 1/20/12, document R10 has a unstageable coccyx pressure ulcer, measuring 4 centimeters by 0.5 centimeters, and a right heel pressure ulcer, measuring 3.5 centimeters by 3.5 centimeters. Wound Care Specialist documentation indicate R10's coccyx wound required surgical debridement on 1/03/12. A physician's orders [REDACTED]. On 1/25/12 at 10:02 a.m., E5 (Licensed Practical Nurse) was going to change R10's coccyx and right heel dressing. Both of R10's pressure ulcers were not dressed and were open to air, upon entering the room. E5 stated she did not remove any old dressings that morning and did not know why R10's pressure ulcers were not dressed, as ordered by the physician. On 1/25/12 at 10:50 a.m., E11 (Restorative Aide) and E12 (Restorative Aide) stated they got R10 up from bed at approximately 7:30 a.m., on 1/25/12 and noted R10's coccyx and right heel wounds did not have dressings on them. The Treatment Administration Sheet documented E5 completed R10's wound treatments on 1/24/12. On 1/25/12 at 10:30 a.m., E5 stated she did not complete R10's wound treatment on 1/24/12, but just "signed it as being completed" because the "hospice nurse told me he'd do the dressing change." On 1/25/12 at 11:12 a.m., Z5 (Hospice Nurse) stated he did not change R10's dressing on 1/24/12, as E5 told him she would perform the wound treatment that day.

Based on observation, record review and interview, the facility failed to provided adequate personal hygiene to two of five residents reviewed (R14, R17) which required staff assistance for bathing and incontinence care, in a sample of 19. This failure resulted in R14 developing a yeast infection of the penis and experiencing pain when being cleansed. Findings include: 1. An Admission Summary dated 3/07/11, indicates R14 has the [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE], documents R14 requires the total assistance of staff for bathing/hygiene and is incontinent of bowel and bladder. A Plan of Care dated 1/24/12, indicates staff are to keep R14's skin clean and dry and that R14 requires assistance with Activities of Daily Living, such as dressing/grooming. Nursing Notes dated 1/29/12, indicate R14 was sent to the emergency room for agitation and increased thirst. Hospital emergency room documentation, dated 1/29/12, indicates R14 arrived with an elevated blood sugar reading. emergency room documentation also indicates, "Penis is uncircumcised, scrotum red...painful to pull back the skin to place (catheter)." An emergency room note, by Z11 (Physician) states, "(R14) did have some yeast in the (urine) specimen but he also is uncircumcised and he had quite a bit of yeast-like material under the foreskin." On 2/06/12 at 1:15 p.m., Z9 (emergency room Registered Nurse) stated R14 presented to the Hospital (on 1/29/12) with an altered level of consciousness and an elevated blood sugar reading. Z9 stated, when R14's adult incontinence brief was removed, the scrotum was red and irritated where the penis had been laying and when the foreskin was retracted, there was a large amount of white, dried crust under the foreskin. Z9 stated R14's penis had to be cleansed prior to inserting the indwelling urinary catheter, as they were unable to insert it otherwise. Z9 indicated R14 did verbalized pain, when his penis was being cleansed. Z9 stated R14's socks were "literally stuck to his feet" and they "obviously had not been changed" in some time. On 2/06/12 at 3:15 p.m., Z11 (emergency room Physician) stated when R14 arrived to the emergency roiagnom on [DATE], R14 had "lots of yeast on the shaft of his penis, which would have been related to having poor hygiene." Z11 stated R14's socks appeared to have been on his feet "for several days." On 2/07/12 at 8:30 a.m., Z10 (Family) stated she observed emergency room staff, on 1/29/12, cut R14's socks off of his feet because they were "stuck" to him. Z10 stated R14's penis had "crust" and "white film" on it. Z10 stated she observed R14 "crying in pain" when the emergency room staff had to cleanse the penis in order to insert an indwelling urinary catheter. Z10 stated, after residing at the facility for seven years, she would not allow R14 to return and had R14 transferred to another facility. 2. A physician's orders [REDACTED]. A Minimum (MDS) data set [DATE], indicates R17 requires extensive assistance of staff for bathing/hygiene and incontinence care. A Plan of Care dated 1/10/12, directs staff to provide "peri care with soap and water and dry thoroughly every shift", "assess skin daily during cares and notify nurse of any new issues (related to) skin", and "peri care to include: cleanse urinary opening with soap and water at least __ x daily." On 2/06/12 at 10:50 a.m., E14 (Certified Nursing Assistant) retracted R17's foreskin to observe for cleanliness. The underside of R17's foreskin was stuck to the tip of the penis when retracted and R17 cried out "it hurts." Directly below the head of R17's penis, the skin was red and excoriated. E14 stated she observed the excoriation on R17's penis earlier that morning, however, indicated she had not informed the nurse caring for R17 that day.

Based on record review and interview, the facility failed to utilize assessments, which idenitfied pressure ulcer development as a potential area of concern, to develop a comprehensive plan of care for pressure ulcer prevention, for one of two (R8) residents reviewed for pressure ulcers, in a sample of 11. This failure resulted in R8 developing a Stage III pressure ulcer on the buttocks, which required surgical debridement. Findings include: An Admission and Discharge Summary dated 9/16/11, documents R8 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Nursing Progress notes, dated 9/09/11, indicate R8's skin was free of pressure ulcers upon admission. R8's Braden Scale (for predicting pressure ulcer risk) of 9/09/11 identified R8 as being at moderate risk (score of 14) for pressure ulcer development. R8's Minimum (MDS) data set [DATE], indicates R8 required limited assistance of one staff person for bed mobility and transfers, extensive assistance upon staff for personal hygiene, at risk for pressure ulcer development, occasionally incontinent of urine and continent of bowel. R8's 9/19/11 Plan of Care does not identify the potential for skin breakdown as an area of concern for R8. A Telephone Order on 9/21/11, indicates R8 was put into a wheelchair with a soft wait restraint and on 9/30/11 changed to a highback reclining chair with a lap tray. A 9/09/11 Admission Resident-Data Collection documents R8 was 5 feet 5 inches tall and 160 pounds. The November 2011 Weight Log lists R8's weight of 147 pounds and by December 2011 R8's weight was 142 pounds. R8's Minimum (MDS) data set [DATE], indicates R8 required an increase to extensive assistance of one staff person for bed mobility and transfers, remained at risk for pressure ulcer development, and had become frequently incontinent of urine and occasionally incontinent of bowel. R8's 12/15/11 Plan of Care does not identify the potential for skin breakdown as an area of concern for R8. On 1/24/12 at 10:40 a.m., E8 (Certified Nursing Assistant) stated she routinely cared for R8. E8 stated R8 was able to ambulate to meals, with assistance of staff, when he was admitted . E8 stated R8 began declining in "mid October" and became more confined to his highback wheelchair and would lay down after all meals. E8 stated R8 became incontinent of bowel and bladder and wore adult briefs. A Wound Care Specialist Note, dated 1/03/12, by Z1 (Wound Consultant/Physician) documents R8 as having developed a "pressure" wound, "unstageable (due to necrosis) of the left buttock of unknown days duration." On 1/24/12 at 4:00 p.m., Z1 (Wound Consultant/Physician) stated R8's left buttock wound was pressure related and was a Stage III or "could have been a" Stage IV. On 1/23/11 at 1:35 p.m., E6 (Care Plan Coordinator) stated she determines a resident's need for Care Planning of Pressure Ulcer Prevention by the resident's Braden Score, clinical assessment, and if the Minimum Data Set identifies a resident as being at risk for pressure ulcers. E6 stated R8's admitting Minimum Data Set did identify R8 as being at risk for the development of pressure ulcers and that she should have proceeded to Care Planning to decrease R8's risk of pressure ulcer development. E8 stated R8 did not have any pressure ulcer prevention interventions in place, upon admission and through December 2011. E6 stated she was aware of R8's physical decline and significant weight loss in the two months prior to the development of the pressure ulcer.

Based on observation, record review, and interview, the facility failed to reposition and failed to provide the necessary care and treatment to prevent the development of a new pressure sore for one of three residents (R7) identified with pressure sores in the sample of seventeen. Findings include: R7's [DIAGNOSES REDACTED]. R7's care plan dated 02/23/11 documents R7 requires extensive assist of cares. R7 requires two staff and a mechanical lift for transferring from bed to recliner, for positioning, requires incontinence care, assist with bathing, and assist with feeding when needed. R7's Minimum (MDS) data set [DATE] documents that R7 is alert and oriented to person, place and time. On 05/09/11 at 9:55 a.m., R7 was sitting in his recliner/chair while receiving [MEDICAL TREATMENT] at the facility. At 11:45 a.m., R7 was wheeled from [MEDICAL TREATMENT] to the nurses station in R7's recliner. At 12:00 p.m., R7 was wheeled from the nurses station to the dining room for lunch. At 12:55 p.m., R7 was taken to his room and remained in his recliner chair. At 1:55 p.m., R7 stated that he wanted to go to bed but did not have his call light. Surveyor informed a staff person in the hall outside of R7's room, and E8 and E9 (Certified Nursing Aides) entered R7's room at 2:00 p.m. and transferred R7 from his recliner to his bed. R7 was incontinent of stool and urine and had an open sore below the coccyx area, an extremely excoriated buttocks, perineum area, scrotum and penis. R7 was positioned on his back before E8 and E9 had left the room. On 05/10/11 at 8:35 a.m., R7 was sitting in his recliner while in the dining room eating his breakfast. At 9:30 a.m., R7 was transferred to his room and remained in the recliner. At 10:15 a.m., E6 and E7 (Certified Nursing Aides) transferred R7 from his recliner to his bed. R7 had been incontinent of bowel and urine. R7's buttocks, peri area, scrotrum and penis were excoriated and on R7's thigh ( back of upper right leg) there was a small, open area that was not observed on 05/09/11. E5 (Licensed Practical Nurse) entered the room on 05/10/11 at 10:20 a.m., E5 identified two, new, open areas; one at the coccyx and one on the back of the right, upper, thigh area. E5 stated that E8 and E9 did not report to E5 on 05/09/11 the open area on the coccyx, or E5 would have notified the physician and would have started a treatment to the open area. E5 measured the open area at the coccyx as, 0.9 centimeters (cm) x 0.3 cm x 0.1 cm. The open area on the back of the upper, right thigh area measured 0.3 centimeters x 0.7 centimeters. On 05/10/11 at 10:00, R7 stated that he is usually up in the recliner all morning until after lunch and then he is lifted with a mechanical lift back to bed. R7 stated that he gets "very tired and very uncomfortable; especially on [MEDICAL TREATMENT] days." R7 stated he was not toileted or checked for incontinence before lunch on 05/09/11 and 05/10/11. On 05/10/11 at 11:20 a.m., E6 stated that R7 was already up today (05/10/11) when E6 arrived to work at 6:30 a.m.. E6 and E7 both stated that third shift gets R7 up in the morning and that R7 is up in his recliner when they arrive to work at 6:30 a.m.. Both E6 and E7 verified that R7 was not laid down or been checked for incontinence today (05/10/11) until R7 was transferred to bed at 10:15 a.m.. On 05/11/11 at 1:20 p.m., E19 (Certified Nursing Aide) stated R7 had been up since 6:30 and was not put back to bed until 1:20 p.m. on 05/11/11. E19 stated that R7 had been up for breakfast, then went to [MEDICAL TREATMENT], then to lunch, so was not able to check him for incontinence or transfer him from out of the chair. E19 stated on 05/11/11 at 1:20 that R7 was incontinent of bowel when she transferred him back to bed at 1:20 p.m.. R7's care plan documents to reposition R7 at least every two hours, provide toileting and incontinence care. Wound Nurse's notes dated 04/15/11 document R7 has pressure sores on the right, Ischial area, at the coccyx, and the left thigh. E5 stated on 05/10/11 at 10:20 a.m., that R7's coccyx area and an area on R7's left thigh was recently healed. E5 stated R7 frequently develops open areas and is recommended to the wound clinic. On 05/10/11 Treatment Record, a new order was received to apply barrier cream to the coccyx and dry gauze to right thigh daily until R7 is seen at the wound clinic.

Based on observation, record review, and interview, the facility failed to ensure that restraints were identified, assessed and re-evaluated for treatment of [REDACTED]. This failure resulted in R4 being found on the floor mat next to her bed with her head between the side rail and frame of the bed and discoloration around the right eye, on 12/23/10. Findings include: The Facility Policy, titled "Side Rails," documents: "1.) Prior to the use of side rails the nursing staff will: A. Assess the resident's individual needs through observation, discussion with resident/family and the Interdisciplinary Team and review of the resident's customary routine; B. Attempt interventions and document results ... ...2. ) A side rail assessment will be completed by the Interdisciplinary Team. Staff will weigh the probable effect of the use of side rails versus the effects of other interventions. If after a thorough assessment and use of interventions, it is determined that use of side rails is indicated the following will occur: A. A signed consent will be obtained from the resident or responsibility party. The consent form will state the reason the side rails are indicated and the expected benefits and/or side effects of their use. B. A physician's orders [REDACTED]. 3.) The resident's response to the use of side rails will be documented as appropriate, but no less than quarterly. 1. A physician's orders [REDACTED]. The Minimum Data Set, dated dated [DATE], indicates R4 has memory loss and cognitive impairment. The Minimum Data Set Restraint Section, dated 3/02/11, indicates R4 has a chair that prevents her from rising and a bed rail. On 5/09/11 at 9:55am and 5/11/11 at 10:39am, R4 was lying in a low bed with a floor mat on the right side of the bed and the left side of the bed up against the air conditioning unit. R4's bed had two full side rails in the upright position. An Incident/Accident Report, dated 12/23/10, documents: "Res (resident) observed laying on blue mat (with) head between rail (and) frame of low bed, noted discoloration surrounding (right) eye, (no) other (signs/symptoms) of injury neuro (neurological checks) initiated." The Incident/Accident Report documents that a "restraint" of two side rails was in use at the time of the fall and it "looks like res (resident) hit eye on SR (side rail) when rolling off of bed." The nurses note, dated 12/23/10, documents: "observed res (resident) lying on (right) side of blue mat (with) head wedged between frame of bed and half side rail. Noted (right) eye discoloration surrounding it." The Incident/Accident Report indicates a bed alarm was put in place. The Fall Management Tool For Care Plan, dated 12/23/11, documents that the resident was provided an "air canoe" mattress and that "rails x 4" were added as a fall intervention. On 5/11/11, at 10:00am, E2 (Director of Nursing) stated the facility does not do a written quarterly restraint assessment, as it is addressed in the quarterly Care Plan meeting and then charted in the nursing notes. On 5/11/11, at 11:41 am, E2 stated that the use of two full side rails was initiated as a fall prevention intervention (after R4's fall of 12/23/10) and that R4 is capable of rolling and moving around in her bed. R4's medical record did not contain a signed consent for use of the side rail by the resident's responsible party or a physician's orders [REDACTED]. R4's medical record did not contain documentation that the side rails were assessed on a quarterly basis and the use of side rails as a restraint was not addressed in R4's Care Plan. A Side Rail Assessment, dated 3/1/11, documents R4 is unable to express a desire to have side rails while in bed. The Side Rail Assessment further documents that R4's side rails are indicated to help her "feel secure." 2. A physician's orders [REDACTED]. A Side Rail Assessment, dated 7/31/01, documents R5 is unable to use the side rail for positioning or support. However, on 3/15/10, the Side Rail Assessment documents half rails being initiated for positioning. An Incident/Accident Report, dated 3/15/10, indicates R5 "climbed out of bottom half of bed," while half rails were in the upright position, and "scrapped her posterior torso." A Fall Management Tool for Care Plans, dated 3/15/10, indicates half side rails were continued as a fall prevention intervention, after R4 fell out of her bed. An Incident/Accident Report, dated 3/16/11, documents "notified by C.N.A. (Certified Nursing Assistant) that resident rolled out of bed. Resident was on knees next to bed with front shoulders leaning against the side rails." The Fall Management Tool for Care Plans, dated 3/16/11, documents half rails as a continued fall prevention intervention. On 5/11/11, 11:25 am, R5 was lying in a low bed with the right side of the bed up against the wall, a floor mat on the left side of the bed, and two half side rails in the upright position. During multiple observations, on 5/09/11 and 5/11/11, R5 did not utilize her side rails for repositioning when in bed. On 5/11/11, at 10:59 am, E15 (Certified Nursing Assistant) stated R5 is unable to reposition herself and staff do all of her repositioning. E15 stated R5 does not have the cognitive ability to use the side rail when they are turning her. On 5/12/11, at 11:42 am, E2 (Director of Nursing) stated that she did not consider eliminating R5's ? side rails after the 3/15/10 or 3/16/11 fall from the bed. E2 stated R5 is known to try and get up out of the bed and is capable of doing so. R5's medical record did not contain a signed consent for use of the side rail by the resident's responsible party or a physician's orders [REDACTED]. R5's medical record did not contain documentation that the side rails were assessed on a quarterly basis and the use of side rails as a restraint was not addressed in R5's Care Plan. 3. R3's physician order [REDACTED]. 1/2 (half) rails indicated at this point for positioning and safety." R3 stated on 5/11/11 at 11:00 am that R3 felt he did not need the bed rails at this time. At this time, the resident's bed had padded half rails in place.

Based on interview and record review the facility failed to provide adequate supervision and a lap tray for the reclining chair for 1 of 3 residents sampled with falls(R6). These failures resulted in R6 falling forward out of the reclining chair, hitting her face and receiving a nasal fracture, nasal and forehead lacerations requiring sutures. Findings include: The History and Physical dated 8/10/10 states R6 has [DIAGNOSES REDACTED]. The assessment states R6 used a chair which "prevented rising" daily and had no problem with sitting balance. The Occupational Therapy Evaluation dated 7/13/10 states R6 had "poor" sitting balance. The Physical Therapy Progress Note dated 7/26/10 states R6 had fair sitting balance with support and had poor sitting balance without support. E8, Physical Therapy Aide stated on 10/8/10 that R6 needed a lot of help for sitting balance with and without support. E8 stated R6 would lean from side to side. The facility fall assessment dated [DATE] states R6 is not at risk for falls. The Care Plan dated 8/19/10 states that R6 is at risk for injuries with interventions identified. The intervention dated 8/20/10 states, "(reclining chair) to have tray on it." The Care Plan dated as reviewed 1/4/10 and 7/26/10 do not address the use of a lap tray with the reclining chair or that R6 leaned forward and would try to pick things up off the floor. E3, Care Plan/MDS Coordinator stated on 10/7/10 at 1:55pm there was not a more current fall assessment for R6. E3 stated that R6 had a care plan addressing the potential for a fall prior to R6's fall on 8/19/10, but she was unable to find it. The facility "Incident/Accident Report" dated 8/19/10 at 4:30pm states R6 was "being prepared to go to the dining room, was sat up in (reclining chair) by aides(E6,E7), they left to check alarm down the hallway, when they went back in a few minutes later, the aide found (R6) on the floor with her face in a pool of blood..." The report documents R6 was transferred to the hospital. The hospital Radiology report states R6 had a nasal laceration, left forehead laceration and "Acute nasal bone fractures." The Physician Orders dated 8/19/10 state under diagnosis "Fall, non displaced nasal fx(fracture)......Normopressure [DIAGNOSES REDACTED], Facial contusion." The order states R6 had suture repair to the forehead and nasal laceration. The written statement dated 8/19/10 written by E7, CNA(Certified Nurse Aide) states they got R6 up to the "new chair" with a mechanical lift. "There was no tray with the new chair.....We made sure (R6) was properly positioned in the chair with her bottom completely back. We tilted the chair approximately 15 (degrees) and put her(R6) foot rest up...." E7, CNA, stated on 10/7/10 at 2:35pm that she and E6, CNA, got R6 up in a new reclining chair and leaned the chair back so R6 would not fall. E6 stated she did not recline the chair all the way back, because of R6's respiratory status, E7 stated she reclined the chair about 15-25 degrees back and put her feet down. E7 stated they hadn't been getting R6 up for a couple of days because R6 had pneumonia. E7 stated after getting R6 up they left R6 alone in her room to answer another resident's personal alarm. E7 stated before R6 got the new reclining chair, she "always had a chair with a tray." E7 stated R6 "always had a tray in front because she(R6) would lean forward. She would hallucinate and would reach." When asked what she thought happened, E7 stated, "(I'm) thinking she(R6) leaned forward and toppled out of the chair." E6, CNA, stated on 10/7/10 at 2:45pm she and E7 got R6 up in the reclining chair and reclined the chair back a "little." E6 stated, "We were in the habit of using a tray with (geriatric) chair, but the new (reclining) chair did not have a tray." E6 stated when R6 went back on hospice, R6 did not get a tray for the new reclining chair. E6 stated "Ever since I've worked here she(R6) has had a chair with a tray because (R6) leans forward and picks at things." When asked what she thought happened, E6 stated, "I think she leaned and fell face forward out of chair." The "Fall Investigation Tool" dated 8/19/10 states R6 was repositioned prior to the fall and a chair alarm was used. There is no mention of R6 having a history of using a lap tray for positioning or having poor sitting balance. The facility report dated 8/20/10 states, "Plan to continue with low bed with canoe mattress and bed alarm/mat on floor/padded 1/2 rails, (reclining) chair for positioning with alarm. Plan: order tray for the (reclining) chair for positioning DX(diagnosis) poor safety awareness." E2, DON(Director of Nurses) stated on 10/7/10 at 3:25pm in the past R6 had a reclining chair with a tray because she leaned forward and would grab her feet. E2 stated R6 got better and was taken off hospice for awhile, but then went to the hospital with pneumonia and went back on hospice. E2 stated that R6 had a lap tray on her chair until she went to the hospital with pneumonia. E2 stated when R6 came back from the hospital she was "dying" and was hospice. E2 stated hospice ordered a reclining chair for R6, but did not order a lap tray for the chair. Z2, Hospice Nurse, stated on 10/7/10 at 4:00pm that he gave R6 a reclining chair, oxygen concentrator and air mattress but did not give her a lap tray for the chair. When asked why he did not give R6 a lap tray, Z2 stated "We have to have an order for [REDACTED]." Z2 verified that he thought he was told after the fall that R6 used a lap tray with the chair. Z2 stated between himself and the facility "we would decide" what equipment was needed. Z2 stated R6 was alert but not verbal and he had not seen her leaning forward. There was no Physician's Order for a lap tray to be used with the chair in R6's record prior to R6's fall. There is an order dated 8/20/10 for a reclining chair with a lap tray. E2, DON, stated on 10/8/10 at 8:35am that she was unable to find an order for [REDACTED]. E2 stated R6 used a "lap tray for a long time when up in chair for leaning." E2 stated R6's status changed when in the hospital for pneumonia. E2 stated she assessed R6 and "did not feel (R6) needed a lap tray, she was dying." E6 stated hospice saw R6 and also did not think she needed a lap tray. E2 stated R6 was not moving when she came back from the hospital. Z3, R6's husband stated on 10/8/10 at 9:00am that R6 had a "bad fall" from the chair. Z3 stated, "(R6) was left by herself in the chair without a tray to keep her from falling out. (R6) fell face first out of the chair." Z3 stated, "(R6) should never have been left alone in the chair without the tray on it." Z3 stated when R6 came back from the hospital with pneumonia she did not respond(verbally), but this was not new. Z3 stated R6 continued to "squirm" in the bed, chair and grab his hand" after she returned from the hospital. Z3 stated R6 had just been put on hospice and she "got this chair and there was no tray for this one."