Every finding on record at Arcadia Care Jacksonville

Based on interview and record review, the facility failed to follow the physician's order for a STAT x-ray and failed to notify the physician of inability to follow the physician's STAT order for one or three residents (R5) reviewed for post fall assessment and treatment in the sample list of 14. This failure resulted in a delay in diagnostic evaluation and treatment of a fracture causing undo pain. Findings Include:R5's face sheet documents an admission date of 07/25/2018 with diagnoses including: Schizophrenia Unspecified, Other Lack of Coordination, Vitamin D Deficiency and Cognitive Communication Deficit.R5's nursing progress note dated 3/20/2026 at 6:09PM written by V10 (Licensed Practical Nurse/LPN) documents that R5 sustained a fall on 3/20/2026 at 3:30pm and complained of pain at a 5 out of 10 with no new skin concerns. V10 further documents on 3/20/2026 at 7:09PM that R5 complained of right wrist pain post-fall with pain rated at 5 out of 10 with a new order from V18 (Medical Doctor) for a STAT (immediate) X-Ray to rule out fracture. STAT X-Ray order placed in R5's physician orders on 3/20/2026 at 5:35PM for right arm and wrist r/t (related to) pain and crepitus. On 3/20/2026 at 8:12PM V10's nursing note for R5 documents (X-ray company) reports no available X-Ray until Monday (3/22/2026). Nursing Note dated 3/21/2026 at 5:02 PM documents R5 had a bruised purple color noted to right elbow. R5's nursing progress notes do not document any contact with the physician regarding the delay in the ordered STAT x-ray. R5's Nursing Progress notes document R5 received Hydrocodone (opioid) and Tylenol for pain on 3/20/26, 3/21/26 and 3/22/26. On 3/22/2026 at 09:06AM, R5's nursing progress note documents that R5 continued to complain of elbow and wrist pain and that purple bruising to the area had increased along with swelling. R5 was then sent to the hospital for evaluation and treatment. Discharge notes from the hospital dated 3/22/2026 documents the following X-Ray findings for R5: acute mildly widened fracture of the lateral distal right humeral epicondyle with questionable intra-articular extension. R5 returned to the facility on 3/22/2026 with a diagnosis of Upper Extremity Fracture and a fiberglass cast on the right arm.On 7/6/2026 at 12:53 PM, R5 stated that after their fall occurred on 3/20/2026 R5 had a lot of pain and some bruising to the right arm. R5 confirmed that the facility did not have an X-Ray completed on 3/20/2026 and that the X-Ray was not completed until Sunday (3/22/2026) after requesting to go to the emergency room for increased pain, swelling and bruising. R5 stated that the hospital diagnosed R5 with an arm fracture, and R5 was placed in a cast and sling.On 7/7/2026 at 3:44PM, V1 (Administrator) stated that nursing staff are expected to notify the physician when a STAT order cannot be completed as ordered.On 7/8/2026 at 7:30 AM, V18 (Medical Doctor) stated that nursing staff are expected to obtain an alternative diagnostic service or additional instructions from the provider or his Nurse Practitioner if a STAT order is unable to be obtained.

Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident for three (R1, R2, R4) of three residents reviewed for abuse in the sample list of 14. Findings include: 1.) Final Abuse Investigation report dated 3/13/2026 documents on 3/7/2026 it was reported that R1 and R2 had an altercation. Both residents were separated by staff and assessed with no injuries noted. Notifications were made to family, local police, Ombudsman, and V18 (Medical Director). This report documents, on 3/7/2026 (R1) was interviewed and stated (R2) made contact with (R1) in the front foyer of building while waiting for resident smoke break. (R1) states (R1) then pulled (R2) to the ground and held (R2's) arms for safety. This report then documents, on 3/7/2026 V11 (Licensed Practical Nurse/LPN) stated (V11) heard yelling and observed (R1) holding (R2's) hands. (V11) immediately separated the residents and assessed both. (R2) refused vital signs. Notifications were made to (V1) Administrator, (V18) Medical Director, and (R1) and (R2's) families. Then this report documents, on 3/7/2026 (V12) Certified Nursing Assistant (CNA) stated (V12) heard yelling and observed (R1) holding (R2's) hands. On 7/6/2026 at 12:00pm V1 (Administrator) stated R1 has a history of verbal and physical altercations, difficulty adjusting to the facility, frequently refuses services, and requires frequent redirection. On 7/8/2026 at 2:30pm V12 (CNA) stated that R1 is problematic, always starting things with residents, verbally aggressive with staff, and requiring frequent redirection. R1's care plan dated 6/23/2026 included mood and behavior issues and identified R1 as having potential for verbal aggression. R1's BIMS (Brief Interview for Mental Status) score is 15/15 (cognitively intact). R2's MDS documented severe cognitive impairment and a diagnosis of dementia (care plan dated 6/4/2026), increasing R2's vulnerability to harm in resident to resident interactions. R2's BIMS score is 14/15 (cognitively intact). The facility's Abuse Policy dated March 2026 states the facility must establish an environment that promotes resident sensitivity and resident security. 2.) The facility's abuse investigation dated 6/9/26 at 5:30 p.m. documented a resident to resident altercation between R1 and R4 in the dining room. The investigation documented that R1 approached R4, spoke to R4, and then swung R1's arm, making contact with R4. This report also documents V7 (CNA) witnessed R1 hitting R4. R4's BIMS score is 6/15 (Moderate cognitive impairment). On 7/6/26 at 10:30 a.m., V1 (Administrator) stated V1 investigated the 6/9/26 incident and determined that a resident to resident altercation occurred and that the allegation of abuse was substantiated following interviews with R1, R4, and V7. On 7/6/26 at 12:08 p.m., V8 and V9 (Licensed Practical Nurses) stated that R1 is verbally abusive to other residents and staff daily. On 7/7/26 at 2:15 p.m., V7 (CNA) stated V7 observed R1 roll up to R4, exchange words, and then saw R1 land one punch to R4's cheek. V7 stated V7 separated the R1 and R4 and notified the nurse and the Administrator, confirming the resident to resident altercation.

Based on observation, interview, record review, the facility failed to ensure foods were properly stored, labeled, dated, and discarded when expired in accordance with sanitary food services practices. This failure has the potential to affect all 63 residents receiving meals prepared by the dietary department. Findings Include:On 3/1/26 at 8:15 AM, during the initial kitchen tour, the surveyor observed concerns related to improper food storage. Observation of the large double-door refrigerator revealed the following expired food items:A one (1) gallon container of salad dressing, approximately 1/4 full, with an expiration date of 2/2025.3 large bags of lettuce noted to be wilted with an expiration date of 2/26/26.A one (1) gallon container of sweet pickle relish, approximately 1/4 full, with an expiration date of 12/18/25.A one (1) gallon of open container of soy sauce, almost full, with an expiration date of 12/21/25.V30 Dietary Aide was present at the time of observation and confirmed all listed items were expired and should have been discarded. During the same tour, a pitcher approximately 3/4 full of a yellow liquid was observed on a food delivery cart. The pitcher lacked a label identifying the contents and did not contain preparation nor discard date. V31 [NAME] confirmed the liquid was chicken broth. On 3/3/26 at 10:12 AM, V1 Administrator stated she expects Dietary staff to promptly discard expired food items and ensure all food and beverages are labeled and dated when opened. The Facility's Food and Supplies Storage policy, dated 1/2026, documents food and supply storage areas shall be maintained in a clean, safe and sanitary manner. Procedure: 1. Food services will maintain clean food storage areas. It continues, 4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. 5. Food stored in refrigerators or freezers will be stored on shelves, racks, dollies, or other surfaces that facilitate cleaning. 6. All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product.The Facility's CMS (Centers for Medicare and Medicaid Services) Long-Term Care Facility Application for Medicare and Medicaid 671 form dated 3/1/26 documents there are 63 residents residing at the facility.

Based on interview and record review, the Facility failed to provide the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 63 residents living in the Facility. Findings include:The Facility's Daily Staffing Schedules were reviewed for 1/1/2026 through 2/28/2026. These schedules do not document a Registered Nurse (RN) worked for at least eight hours on 1/4/26, 1/10/26, 1/11/26, 1/17/26, 1/18/26, 1/24/26, 1/25/26, 1/31/26, 2/1/26, 2/7/26, 2/8/26, 2/14/26, 2/15/26, 2/21/26, 2/22/26 and 2/28/26. On 3/3/2026 at 9:40 AM V1, Administrator, stated that they didn't have a staffing policy. V1 stated that they follow state guidelines. V1 stated there are days without RN coverage in the building. V1 stated that they are currently advertising for RNs and actively hiring. The Facility's CMS (Centers for Medicare and Medicaid Services) Long-Term Care Facility Application for Medicare and Medicaid 671 form dated 3/1/26 documents there are 63 residents residing at the facility.

Based on observation, interview, and record review the facility failed to properly store medication and discard expired medication. This failure has the potential to affect all 63 residents residing in the facility.Findings include:On 3/1/ 2026 at 8:32 AM the 100-hall medication cart was inspected. The medication cart contained the following:1. R56's opened and partially used multidose Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Vial. No open date.2. R7's opened and partially used multidose Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Vial. No open date.On [DATE] at 9:33 AM V5, Licensed Practical Nurse (LPN), stated that R56's and R7's insulins were open and in use. V5 stated that on the first date the insulin is accessed and used that date is placed on the multidose vials and pens. V5 stated that the insulins have a shortened expiration date of 28 days. V5 stated that the open dates let them know when the new expiration or use by date is so the medication can be removed from use and destroyed.On [DATE] at 8:34 AM the facility's Medication Room was inspected. The unlocked refrigerator, with the lock open and hanging on the refrigerator, inside the medication room contained:3. An opened and partially used multidose vial of Tuberculin. No open date.4. R58's liquid multidose bottle of Lorazepam.5. R35's liquid multidose bottle of Lorazepam.On [DATE] at 8:35 AM V4, LPN, verified that the multidose Tuberculin Vial was open, in use, and no handwritten date on the vial. V4 stated that the medication should be disposed of and not in use. V4 stated that the multidose Tuberculin vial in the medication room is a stock medication. V4 stated that the medication can be used for all residents if they have an order and is not allergic. V4 stated that R58's and R35's Lorazepam should be under a double lock system. V4 stated that the double lock system is the locked medication room and the locked refrigerator. V4 stated that if the refrigerator is not locked then there isn't a double locked system in place.The facility's Medication Storage policy, dated 7/2019, documented that Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. 3. General Storage Procedures: Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 12. Controlled Substances Storage: 2. After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law) and double locked (i.e. locked narcotic drawer inside locked medication cart or locked box in locked medication room).The Facility's CMS (Centers for Medicare and Medicaid Services) Long-Term Care Facility Application for Medicare and Medicaid 671 form dated [DATE] documents there are 63 residents residing at the facility.

Based on observation, interview and record review the facility failed to label oxygen tubing for 4 of 6 residents (R29, R56, R57, and R58) reviewed for oxygen therapy in the sample of 38.Findings include: 1 On 3/01/2026 at 8:28AM R29 in bed with head of bed elevated. Breakfast tray on over bed table. R29's oxygen on per nasal cannula. R29's oxygen tubing undated, and humidification bottle less than 1/4 water left in bottle and bottle unlabeled. R29's face sheet dated 3/3/3026 documents a diagnosis, in part Chronic Obstructive Pulmonary Disease (COPD)and chronic respiratory failure with hypoxia. R29's Physician Orders (POS) dated 1/21/2026 documents change Oxygen (O2) tubing weekly and as needed every night shift every Wednesday. R29's POS dated 2/18/2026 documents Oxygen at 2 Liters (L) per nasal cannula -may increase to 4L if needed. R29's care plan dated 8/9/2025 documents R29 has altered respiratory status/difficulty breathing, COPD. 2. On 3/01/2026 8:34AM R58's oxygen concentrator at the head of R58's bed. R58 in bed with his head at the foot of the bed. R58's oxygen tubing on the floor, undated. R58's humidification bottle on concentrator half full and undated. R58's face sheet, dated 3/6/2026 documents a diagnosis, in part COPD R58's care plan, dated 1/28/2025 documents resident has oxygen therapy related to COPD. R58's care plan documents intervention Oxygen Setting: O2 via nasal cannula at 2L prn. R58's POS dated 1/21/2026 documents change O2 tubing every night shift Wednesday 3. R57's admission Record, not dated, documents Chronic Obstructive Pulmonary Disease. R57's Care Plan, dated 3/27/24, documents that the resident has oxygen therapy r/t (related to) Ineffective gas exchange. It also documents Oxygen settings: O2 continuous at 2L via nasal cannula. R57's Physician Order Sheet, dated 4/20/24, documents Oxygen at 2 LPM (Liters per minute) via nasal cannula continuous R/T (related to) COPD (Chronic Obstructive Pulmonary Disease) every shift. 1/20/26 Change 02 and Nebulizer Tubing weekly and prn (as needed) every Wednesday night shift. On 3/1/2026 at approximately 8:08 AM observed R57 sitting in bed with oxygen next to her. Oxygen tubing on floor. Humidifier empty. No date on the tubing or humidifier. On 3/1/2026 at approximately 8:08 AM R57 stated that she is supposed to always wear her oxygen. R57 stated that the tubing fell, and she was not able to reach it to put it back on. 4. R56's admission Record, not dated, documents Chronic Obstructive Pulmonary Disease. R56's Care Plan, dated 3/27/24, documents the resident has COPD. R56's Physician Order Sheet, dated 6/30/2024, Oxygen at 2 liters Bi nasal cannula continuously to keep oxygen saturation above 92%. On 3/1/2026 at approximately 8:10 AM observed R56 sitting in bed with oxygen on her face. Oxygen Humidifier empty. No date on the tubing or humidifier. On 3/1/2026 at approximately 8:10 AM R57 stated that she is not sure if or when her oxygen was changed. On 3/1/2026 at approximately 8:15 AM V5, LPN, verified that R56's and R57's oxygen was not in place, not labeled and empty. V5 stated that the oxygen should be in place and labeled. V5 stated that she was going down to correct this immediately. The facility's Oxygen & Respiratory Equipment- Changing / Cleaning, dated 12/2025, Guidelines: Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Proceed 2. Nasal Cannula. a. Nasal cannulas are to be changed once a week and PRN. b. Whenever possible, residents using a portable oxygen tank, will be switched to a room oxygen concentrator while in their room. c. A clean plastic bag with a zip loc or draw string, etc. will be provided to store the cannula when it is not in use. It will be dated with the date the tubing was changed 3. Oxygen Room Concentrators. a. Concentrators in the resident room will be unobstructed by equipment/curtains, etc. b. The outside of the machine will be wiped down with facility disinfectant, following the manufacturer's instructions when switching users. c. The filter on the side of the concentrator will be removed and cleaned when switching users. 4. Oxygen Humidifiers. a. Oxygen humidifiers should be changed weekly or as needed and will be dated when changed.

Based on observation, interview and record review the facility failed to answer call lights timely and sit down beside residents when providing assistance with eating for 5 of 6 residents (R19, R24, R20, R41, R50) reviewed for dignity in the sample of 38.Findings include: 1. R19's Minimum Data Set (MDS), dated [DATE], documents that R19 is cognitively intact and requires assistance from staff for activities of daily living (ADLs). On 3/2/2026 at 10:00 AM R19 stated there is not enough staff to provide care. R19 stated that they only have 2 CNA's (Certified Nurse's Assistant) on his hall and that is not enough for all the care. R19 stated that it takes a long time to answer the call lights because they don't have enough staff. 2. R41's MDS, dated [DATE], documents that R41 is cognitively intact and requires some assistance from staff with ADLs. On 3/2/2026 at 9:28 AM R41 stated that the facility does not have enough staff. R41 stated that she can do most things on her own, but when she needs something the call light can stay on for hours. 3. R20's MDS, dated [DATE], documents that R20 is cognitively intact and requires some assistance from staff for ADLs. On 3/2/2026 at 10:02 AM R20 stated there is not enough staff to provide care. R20 stated that it takes a long time to answer the call lights because there's not enough staff. 4. R50's MDS, dated [DATE], documents that R50 is cognitively intact and requires some assistance from staff for ADLs. On 3/2/2026 at 10:05 AM R50 stated that it takes a long time to answer the call lights. The Resident Council Minutes, dated 10/28/2025, documents that overnight staff are [NAME] (missing in action) most of time. Some call lights stay on for 2 hours. 5. On 3/3/2026 at 11:45AM V29 Certified Nursing Assistant (CNA) was standing up beside R24 feeding her lunch. At no time during the noon meal did V29 sit beside R24 during meal assistance. R24's Minimum Data Set (MDS) dated [DATE] documents R24 is severely cognitively impaired. R24's MDS documents R24 requires supervision or touch assistance during eating-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 3/6/2026 at 3:30PM V33, Certified Nursing Assistant (CNA) stated when feeding residents you would sit beside the resident, V33 stated you would never stand when feeding a resident. The facility policy Dignity, dated, revised4/2018 documents the facility shall promote car for residents in a manner that maintains or enhances each resident's dignity and respect in full of recognition of his or her individuality. The policy documents promote resident independence and dignity while dining, such as avoiding staff standing over residents while assisting them to eat.

Based on observation, interview and record review the facility failed to ensure resident call lights were within reach for 4 of 6 residents (R9, R26, R29, R50) reviewed for call lights in the sample of 38. Findings Include:1.R9's admission Record print date of 3/5/26 documents R9 has diagnoses including transient cerebral ischemic attack, COPD (chronic obstructive pulmonary disease), asthma, type 2 diabetes mellitus with diabetic neuropathy, idiopathic peripheral autonomic neuropathy, non-pressure chronic ulcer of unspecified part of right lower leg, non-pressure chronic ulcer of right heel and midfoot, and atrial fibrillation.R9's MDS (Minimum Data Set) dated 1/28/26 documents R9 is severely cognitively impaired and dependent on staff for mobility. R9's undated Care Plan documents ensure call light is in reach.On 3/1/26 at 8:42 AM during the initial tour of the facility R9's call light was observed on the floor under R9's bed. Surveyor asked R9 if she could reach his call light and R9 stated no.2.R26's admission Record with a print date of 3/3/26 documents R26 has diagnoses including legal blindness, COPD, chronic diastolic congestive heart failure, hypertension, weakness, unspecified hearing loss, reduced mobility, history of falling, and major depressive disorder.R26's MDS dated [DATE] documents R26 is severely cognitively impaired.R26's undated Care Plan documents R26 requires assist of 2 and a mechanical lift for transfers. R26's Care Plan also documents R26 is at risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unaware of safety needs with interventions including be sure the resident's call light is within reach and encourage the resident to us it for assistance as needed.On 3/3/26 at 10:30 AM R26 was observed sitting in her wheelchair in her room, R26's call light was hanging on the wall above her bed. R26 is legally blind. On 3/5/26 at 11:01 AM V2 DON (Director of Nursing) stated she expects call lights to be within residents' reach at all times.3. On 03/01/2026 at 8:28AM R29 was in bed with the head of bed elevated. R29's call light was on the floor out of reach of R29. R29's care plan dated, revised 2/20/2026 documents R29 has an Activity Daily Living (ADL) self-care performance deficit related to weakness, impaired mobility, neuropathy, chronic respiratory failure, peripheral venous insufficiency and dementia. R29's care plan documents intervention dated 12/16/2025; encourage resident to use call light for assistance. R29's care plan dated revised 9/24/2025 documents R29 is at risk for falls related to increasing forgetfulness and progression of dementia. R29's care plan documents intervention 8/9/2025 Be sure the resident's call light is within reach.R29's Minimum Data Set (MDS) dated [DATE] documents R29 is cognitively intact. R29's MDS documents R29 is dependent on staff for bathing, dressing, toileting, and personal hygiene 4. 3/01/2026 at 8:40AM R50 was in bed asleep on right side facing window. R50's call light was hanging over call light outlet on the wall on the opposite side of bed out of R50's reach.On 3/5/2026 at 8:42AM R50's call light was hanging over call light outlet on wall. When surveyor ask R50 if call light was out of reach, R50 stated yes, I have to remind them to attach to bed.R50's MDS dated [DATE] documents R50 is cognitively intact.R50's care plan dated 1/2023 documents R50 has an ADL self-care performance deficit related to activity intolerance. R50's care plan documents R50 requires total assist of one staff member with showering/bathing, Bed mobility assistance of 2 staff, dressing extensive assistance of 2 staff, eating, supervision and setup, R50's care plan documents R50 is at risk for falls related to impaired mobility. R50's care plan documents intervention dated 1/13/2023; be sure the resident's call light is within reach and encourage resident to use it.R50's face sheet dated 3/3/2026 documents a diagnosis in part of muscle weakness.The facility policy call lights, dated, revised 1/2022 documents the purpose is to respond to resident requests and needs in a timely manner. The policy documents all residents that have ability to use a call light should have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and needs of residents during evenings and every other weekend for 5 of 5 residents (R10, R19, R20, R52, and R62) reviewed for activities in the sample of 38.Findings Include:1. On 3/1/26 at 2:45 PM observed R62 pacing and walking in circles in the hallway. Did not observe any activities going on throughout the day. R62's admission Record with a print date of 3/3/26 documents R62 has diagnoses of Asperger's syndrome and autistic disorder. 2. On 3/2/26 at 11:40 AM R19 stated the facility has not had activities every other weekend for a long time because the company cut the budget. R19 stated the facility only has 2 employees in the activity department, that there are no evening activities, and residents have complained about it, but they won't do anything about it because it is not in the budget. R19 stated he is President of the Resident Council. R19's MDS (Minimum Data Set) dated 12/5/26 documents R19 is cognitively intact.3. On 3/3/26 at 10:16 AM R20 stated the facility does not have any activities in the evenings nor every other weekend. R20 stated the facility does not have enough staff for activities. R20 stated he would like more activities. R20'S MDS dated [DATE] documents R20 is cognitively intact.4. On 3/3/26 at 10:20 AM R10 stated the facility does not have activities every other weekend nor in the evenings. R10 stated it would be nice if they did have more activities, but they don't have the staff for it. R10's MDS dated [DATE] documents R10 is cognitively intact.5. On 3/3/26 at 10:23 AM surveyor asked R52 if there are activities every weekend and, in the evenings, and R52 replied no. R52 was alert and oriented at time of interview.On 3/2/26 at 9:53 AM V10 Activity Assistant stated there was no activity staff scheduled last weekend on 2/28/26 and 3/1/26. Surveyor asked if any staff provided activities and V10 stated no. On 3/2/26 at 1:24 PM V7 CNA (Certified Nurse Assistant) stated he has never observed R62 receiving 1 on 1 activities. On 3/3/26 at 10:13 AM V1 Administrator stated the facility does not have any staff scheduled in the Activity Department every other weekend. V1 agreed no activity department staff were on duty on 2/28/26 and 3/1/26. V1 stated the facility is not budgeted for activity staff every weekend. The survey began on Sunday, 3/1/26. During the initial tour and throughout observations conducted between approximately 8:15 AM until approximately 2:45 PM, no scheduled activities were observed taking place in the facility. Observations of all common areas including the activity room revealed residents sitting around the facility without any type of stimulation/entertainment. The 3/1/26 daily activity calendar documents activities of morning news, social hour club, afternoon movie, word puzzles, and evening news. The survey team did not observe any activities throughout the day including the activities scheduled for 3/1/26.The facility's February 2026 activity calendar documents resident initiated activities on the weekend dates of 2/1/26, 2/14/26, and on 2/15/26. No activities are scheduled in the evening through the weekdays after 4 PM. The facility's March 2026 activity calendar documents activities every weekend although there are no set times listed next to the activities every other weekend when there are no activity staff assigned to work. The facility's Activities Program policy dated 1/2026 documents Purpose: To provide an ongoing program of activities designed to appeal to the residents' interests and to enhance his or her highest practicable level of physical, mental, or psychosocial well-being. Guidelines: The Activity Director, trained staff, or volunteer will: 1. Identify and involve each resident in an ongoing program of activities that is designed to appeal to his or her interests and needs. 2. Enhance the resident's highest practicable level of physical, mental, and psychosocial well-being by offering a program of activities that provides the following: a. A heightened sense of well-being. b. Promotion of feelings of self-esteem, pleasure, comfort, education, creativity, success, and independence. c. That promotes education or intellectual thought and requires thinking. d. Age and gender specific. e. Produce something useful and provide purpose. f. Relate to previous work. g. Allow for socializing with visitors and participating in community events. i. Physically active programming. j. Produce or teach something. 3. A minimum of 4-7 organized activities will be scheduled daily. 4. Provide programs for residents who will not, or cannot, effectively plan their own activity pursuits. 5. Provide for residents needing specialized or extended programs to enhance their overall daily routine and activity pursuit needs. 6. The program of activities will include a combination of large and small groups, one to one's, and self-directed activities. 7. The program of activities will include a system that allows the activity staff to develop, implement, and evaluate the resident's interests and involvement in the activities provided and adjust the daily programming as needed in order to meet the needs of the residents.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care in accordance with professional standards by failing to maintain ordered wound dressings and by failing to identify and treat new wounds for 3 of 3 residents (R1, R9, R50) reviewed for wounds in the sample of 38.Findings Include:1.R9's admission Record print date of 3/5/26 documents R9 has diagnoses including transient cerebral ischemic attack, COPD (chronic obstructive pulmonary disease), asthma, type 2 diabetes mellitus with diabetic neuropathy, idiopathic peripheral autonomic neuropathy, non-pressure chronic ulcer of unspecified part of right lower leg, non-pressure chronic ulcer of right heel and midfoot, and atrial fibrillation. R9's MDS (Minimum Data Set) dated 1/28/26 documents R9 is severely cognitively impaired and dependent on staff for mobility. R9's undated Care Plan documents R9 has actual skin impairments of right dorsal foot, left dorsal foot and left medial ankle with interventions including treatment as ordered R9's Physician order dated 1/28/26 documents left dorsal foot: cleanse area with wound cleanser, apply collagen particles/powder, ABD pad, and wrap with (gauze) dressing every night shift and PRN (as needed). Left medial ankle: cleanse area with wound cleanser, apply collagen particles/ power, ABD, and wrap with (gauze) every night shift and PRN. Right dorsal foot cleanse area with wound cleanser, apply collagen particles/powder, ABD and wrap with (gauze) every night shift and PRN. On 3/1/26 at 8:42 AM during the initial tour of the facility R9 was observed lying in bed with 3 uncovered open wounds with blood-tinged wound bases noted on his left lower ankle and foot. A dark brown substance was observed under R9's fingernails on both hands. On 3/1/26 at 10:28 AM R9 was observed in bed, the wounds on his left lower extremity remain uncovered and exposed to environment. Small gnat like insects were observed flying around R9's bed. On 3/1/26 at 10:38 AM surveyor asked V7 CNA (Certified Nurse Assistant) if the dark substance under R9's fingernails is feces. V7 replied no, that is probably blood, he digs in his wounds. Surveyor asked if R9's left lower extremity wounds were uncovered when V7 came in at 6am today and V7 replied yes, the day shift nurse probably hasn't had a chance to do her treatments. On 3/1/26 at 10:45 AM surveyor asked V4 LPN (Licensed Practical Nurse - R9's nurse) if she planned on completing R9's treatments today. V4 replied his treatments are done on the night shift. On 3/1/26 at 12:40 PM observed R9 asleep in bed and R9's left lower extremity wounds continued to be uncovered and did not have dressings per R9's physician orders. On 3/1/26 at 2:40 PM R9 was observed in bed without any dressings to his left lower extremity. R9's TAR (Treatment Administration Record) nor his progress notes document dressings were ever applied to R9's open wounds on the day shift of 3/1/26. On 3/2/26 at 9:23 AM R9 was observed lying in bed, bilateral feet were wrapped with gauze although the wound on the top of R9's left foot was uncovered and exposed to the environment. Blood was noted in the base of the wound. R9's fingernails were noted to have a brown substance under them on both hands. On 3/2/26 at 10:02 AM while R9 was receiving indwelling urinary catheter care, R9 was observed digging in the wounds on the top of his left foot. R9's fingernails were noted to have a dark substance under them on both hands. Surveyor asked R9 if his feet itch and R9 replied yes. Surveyor then observed an approximate dime sized black area on the bottom of R9's 2nd toe on his right foot. On 3/2/26 at 11:30 AM R9 was observed lying in his bed with the head of the bed elevated at an approximate 30-degree angle, R9 was attempting to feed himself with difficulty and noted to be coughing. Surveyor asked V2 DON (Director of Nursing) to look at R9's positioning and surveyor asked V2 if she was aware of the blackened area on the bottom of R9's second toe on his right foot. V2 stated they were not aware of the wound. R9 was noted to have dark debris under his fingernails on both hands. On 3/2/26 at 12:20 PM Surveyor asked V8 LPN (Licensed Practical Nurse) if facility staff was aware of the wound on the bottom of R9's second toe on his right foot and V8 replied no. On 3/2/26 at 1:55 PM V1 Administrator stated she would expect facility nurses to apply a new dressing to R9's wounds relatively soon after R9 removes them. On 3/3/26 at 10:08 AM V1 Administrator stated she would have expected the nurse to place new dressings on R9's open wounds on 3/1/26 when they were observed uncovered for an extended time. V1 stated the facility staff were not aware of the wound discovered by the surveyor on the bottom of R9's second toe on his right foot. On 3/5/26 at 9:04 AM surveyor asked V1 Administrator how the wound Physician determined R9's wound on the bottom of his toe that was found by surveyor was caused by trauma and not from pressure as surveyor observed R9's bottom of his toes touching the footboard of his bed. V1 replied the wound Physician determined it by R9's history of picking his skin. 2. R1's admission Record print date of 3/3/26 documents R1 has diagnoses including type 2 diabetes, chronic obstructive pulmonary disease, dysphagia, congestive heart failure, hypertension, PVD (peripheral vascular disease), encephalopathy, and cardiomegaly. R1's MDS dated [DATE] documents R1 is moderately cognitively impaired and is dependent on staff for mobility. R1's undated Care Plan documents I am at risk for a skin impairment related to obesity, diabetes, PVD, incontinence, and non-compliance with turning and repositioning. R1's Physician order dated 2/26/26 documented right upper thigh: cleanse area with wound cleanser, apply calcium alginate and cover with bordered foam every night shift and PRN. On 3/3/26 at 1:02 PM R1 was observed sitting up in his wheelchair in his room. R1 stated he had an open area on his bottom for quite a while. No wheelchair cushion was observed in R1's wheelchair. Surveyor asked R1 if he had ever had a wheelchair cushion and R1 replied 'no. On 3/3/26 at 1:20 PM V26 LPN stated R1 has a pressure ulcer on his right upper thigh where his (incontinence brief) and the edge of his wheelchair seat rubs him. On 3/3/26 at 1:40 PM observed V6 CNA and V16 CNA transfer R1 from his wheelchair into his bed. No wheelchair cushion was observed in R1's wheelchair. V6 and V16 stated they have never seen a wheelchair cushion in R1's wheelchair nor does he have one in his room. No issues observed with mechanical lift transfer. V6 and V16 then removed R1's pants and (incontinence brief). An approximate 2 cm (centimeter) sized round wound was observed on R1's right gluteal fold. No dressing was observed on R1's wound. V6 and V16 removed R1's (incontinence brief) and no dressing was observed in R1's (incontinence brief) nor in his pants. V6 and V16 both confirmed no dressing was found. V16 stated R1 is up for all meals, R1 goes through phases where he is up in his wheelchair all day and other days he is not. It is up to him. On 3/3/26 at 2:20 PM V1 Administrator stated she would have expected R1 to have a dressing over his wound when it was observed by Surveyor. Surveyor asked V1 if R1's wound is considered a pressure ulcer since it is in an area where the edge of his wheelchair seat would rub. V1 stated the wound doctor will be at the facility tomorrow and will diagnose and stage the wound. On 3/5/26 at 9:02 AM Surveyor asked V2 DON if she made rounds with the wound Physician and if so, how the Physician determined R1's wound was caused by trauma and not pressure. V2 stated because the doctor said it was caused by R1's (incontinence brief) rubbing on the crease of R1's lower buttock. Surveyor asked, isn't that the same as pressure? V1 Administrator was present and stated no, it was caused by the (incontinence brief) rubbing against R1's skin. Surveyor asked if R1 should have a wheelchair cushion and V1 stated she would check with therapy as R1 has a history of sliding out of his chair. On 3/5/26 at 10:43 AM V32 Wound Physician stated he would expect R1 to have a pressure relieving cushion in his wheelchair and to have a dressing on his right gluteal region wound at all times. V32 also stated he would expect the facility nurses to apply new dressings to R9's bilateral extremity wounds as soon as possible when R9 removes the dressings. On 3/5/26 at 1:17 PM V1 Administrator stated R1's wound was noted on 2/26/26 and a treatment was ordered at that time. V1 stated R1 should have had a dressing on when surveyor observed R1's wound. The Facility's Pressure Injury and Skin Condition assessment dated 12/2025 documents Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. It continues, 14. Dressings which are applied to pressure ulcers, skin tears, wounds, lesions or incisions shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. 3. On 03/03/2026 at 8:58AM R50 is seen in bed on right side. R50 stated his dressing to his wound is to be changed daily but it is not. On 03/05/2026 at 9:01 AM V26, LPN washed hands with soap and water and donned gloves then removed dressing from R50's right foot which was date 3/4/2026 with tan drainage. V26 then removed gloves sanitized hands and donned new gloves. R50's great toe surgically removed. A thin open line running horizontal at base of foot was seen where toe was removed. V26, LPN did not cleanse wound with wound cleanser prior to applying med honey then applied border dressing. On 3/30/26 at 9:10 AM surveyor asked V26 LPN if she had cleansed the wound prior to treatment. V26 stated no I forgot. R50's PO dated 3/5/2026 documents Right Foot: cleanse wound with wound cleanser, apply honey and cover with border foam daily and as needed (prn). R50's care plan dated 12/16/2025 documents actual skin impairment R outer ankle and left medial leg related to aging process diabetes, fragile skin, impaired mobility, incontinence, noncompliance with turning and repositioning, and vascular insufficiency with intervention treatment as ordered. R50's MDS dated [DATE] documents R50 is cognitively intact. R50's face sheet dated 3/3/2026 documents diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy, non-pressure chronic ulcer of foot. On 3/5/2026 at 10:41AM V32 wound physician per phone interview stated would expect treatments to be done as ordered.

Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance received necessary activities of daily living (ADL) care, including nail care, grooming services, and proper positioning and assistance for meals. This resulted in a resident having visibly dirty hair and fingernails, being unshaven, and at risk for aspiration due to improper positioning during a meal for 2 of 6 residents (R9, R14) reviewed for ADL care in the sample of 38.Findings Include:1. On 03/01/2026 11:30AM lunch being provided was baked turkey with gravy, scalloped potatoes, sauteed cabbage, orange slices and roll. On 3/1/2026 at 11:48AM R14 was seen wandering up and down the hall. V3, Certified Nursing Assistant (CNA) was prompting R14 to come into the dining room and eat. R14 was walking away from table not eating or sitting down. On 3/1/2026 at 12:03PM R14 was sitting at the table, not eating. On 3/1/2026 at 12:05 PM R14 was seen pacing up and down the hall with a peer. On 3/1/2026 at 12:08PM R14 enters dining room and spears roll with fork and takes a bite of the roll in the hallway and the roll falls off the fork. No staff assistance was being provided to R14 with his meal. On 3/1/2026 at 12:15PM V4, Licensed Practical Nurse (LPN) entered the unit and is encouraging R14 to go to dining room. R14 enters dining room and V4, LPN hands R14 orange slices. R14 eats orange slices while walking around the dining room. On 3/1/2026 at 12:24PM V4, LPN hands R14 a roll. R14 eats roll while walking around dining room. R14 then sits down at table with V4, LPN. V4 with a piece of turkey on end of fork starts to feed R14. R14 takes piece of turkey off end of fork and eats with hands. R14 then starts eating cheesy potatoes out of foam bowl with hands. On 3/1/2026 at 12:27PM R14 started using spoon to eat potatoes with verbal prompting from V4. R14 then continued eating turkey and gravy with spoon. On 3/1/2026 at 12:35PM R14 drank a cup of lemonade, ate second bowl of cheesy potatoes, and another bowl of turkey and gravy. On 3/1/2026 at 12:42PM R14 was eating a peanut butter and jelly sandwich that has been cut in fourths and drank another cup of lemonade. On 3/1/2026 at12:46 R4 was eating third serving of orange slices. R14's Face sheet dated 3/3/2026 documents a diagnosis in part of unspecified protein calorie malnutrition, generalized anxiety disorder and restlessness and agitation. R14's MDS documents R14 requires supervision or touching assistance with eating. Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R14's Physician Order (PO) dated 2/20/2026 documents House 2.0 supplement every morning and at bedtime for weight status. R14's physician order dated 5/20/2025 documents regular diet, regular texture, thin consistency, super cereal at breakfast, double portions per resident preference, food in bowls to encourage oral (PO) intake. R14's care plan dated 2/11/2026 documents resident has an Activity Daily Living (ADL) self-care performance deficit related to confusion, psychological: Eating-g- requires set up assistance with eating. R14's care plan documents increased nutritional risk related to diagnosis of Chronic Obstructive Pulmonary Disease (COPD), anemia, hypertension, anxiety, protein malnutrition. Offer alternative at meals when appropriate. Care plan dated 2/11/2026 documents unplanned /unexpected significant weight loss due to (variable meal intake) anemia, anxiety and dementia care plan documents following interventions; encourage intakes at meals as needed. R14's Minimum Data Set (MDS) dated [DATE] documents that R14 has severe cognitive impairment. R14's weight record dated 2/3/2026 documents weight of 147 pounds R14's weight record dated 1/12/2026 documents weight of 148 pounds R14's record dated 12/15/2026 documents weight of 157 pounds. R14's quarterly nutritional assessment dated 2/232026 documents current weight of 147 pounds. R14's quarterly nutritional assessment documents loss of 5% or more weight in the past month or loss of 10% or more in last 6 months. R14's assessment documents R14 is eating 50-100% of meals. Significant weight loss noted. R14 discussed and house supplement added to diet order as of 2/20/2026. On 03/03/2026 at 9:40 AM V1 administrator stated R14 will not sit down. V1 stated we offer snacks/ food on the go. On 3/6/2026 at 3:30PM V33, Certified Nursing Assistant (CNA) stated R14 requires set up and assistance with meals. V33 stated R14 does like to use his hands and V33 stated she encourages R14 to use utensils. V33 stated at times R14 is a 1:1 with eating. On 03/09/2026 at 2:52 PM per phone interview V1, Administrator stated the facility does not have a policy for eating assistance. V1 stated the facility follows Illinois Department of Public Health (IDPH) guidelines for eating assistance. 2. R9's admission Record dated 3/5/26 documents R9 has diagnoses including transient cerebral ischemic attack, COPD (chronic obstructive pulmonary disease), asthma, type 2 diabetes mellitus with diabetic neuropathy, atrial fibrillation, non-pressure chronic ulcer of right lower leg, and non-pressure chronic ulcer of right heel and midfoot. R9's MDS (Minimum Data Set) dated 1/28/26 documented R9 is severely cognitively impaired and is dependent on staff for bathing and toileting hygiene needs. R9's undated Care Plan documents R9 has an ADL (Activities of Daily Living) self-care performance deficit and is on a restorative grooming program as resident is unable to bath/groom self independently. R9's Care Plan also documents personal hygiene: the resident requires extensive assist with personal hygiene. Check nail length and trim and clean on bath day and as necessary. On 3/1/26 at 8:42 AM R9 was observed lying in bed and appearing unkempt. R9's face was unshaven, and a dark brown substance was observed under R9's fingernails on both of his hands. On 3/1/26 at 10:28 AM R9 was observed in bed with small insects flying around R9's uncovered wounds on his left lower extremity. On 3/2/26 at 9:23 AM R9 was observed lying in bed and continuing to appear unkempt. R9 was unshaven with long facial whiskers. R9's fingernails were dirty with a brown substance under all his fingernails on both hands. On 3/2/26 at 11:30 AM R9 was observed lying in his bed. R9's head of his bed was elevated at an approximate 30-degree angle, R9 was attempting to feed himself his lunch with difficulty and noted to be coughing. Surveyor asked V2 DON (Director of Nursing) to look at R9's positioning as it did not appear that the head of his bed was elevated high enough for R9 to safely eat. V2 agreed and stated she would reposition R9. R9 was noted to have dark debris under his fingernails on both hands while he was eating his lunch and R9 continued to appear unkempt and unshaven. On 3/2/26 at 1:28 PM R9 was observed and continued to appear ungroomed with dirty fingernails and long facial whiskers. On 3/3/26 at 12:10 PM R9 was observed lying in bed and continues to appear unkempt with long facial hair and dark debris under fingernails on both hands. On 3/1/26 at 10:38 AM Surveyor asked V7 CNA (Certified Nurse Assistant) if the dark substance under R9's fingernails is feces. V7 replied no, that is probably blood, he digs in his wounds. Surveyor asked if R9's left lower extremity wounds were uncovered when he came in at 6am and V7 replied yes, the day shift nurse probably hasn't had a chance to do her treatments. On 3/3/26 at 10:10 AM Surveyor asked V1 Administrator if she expects staff to clean residents' hands and fingernails prior to eating meals. V1 replied yes. Surveyor asked V1 if R9's head of his bed should have been elevated more than 30 degrees before he was served his lunch meal and V1 stated yes, she would expect staff to properly position residents prior to eating. The Facility's Morning Care (A.M. Care) policy dated 12/2025 documents Purpose: To promote comfort, cleanliness and dignity. Equipment: bedpan or urinal, wash basin and emesis basin, denture cup and cleaner, toothbrush and toothpaste, towel and washcloth, lotion, shaving cream. Guidelines: Explain procedure to resident and bring equipment to bedside or to bathroom or offer bedpan, prepare water to wash, offer washcloth to wash hands. Allow/assist resident with cleansing body, face, hands, arms, underarms and perineum. Assist resident with oral hygiene. Allow/assist resident to brush/comb their own hair. If resident is unable, assist/perform the task for her/him.

Based on interview and record review the facility failed to provide mail to residents every Saturday for 2 of 5 residents (R19 and R20) reviewed for resident rights in the sample of 38.Findings include:On 3/1/2026 at 10:00AM during resident council meeting R19 and R20 both stated they do not get mail every Saturday. R20 stated activity staff only work every other weekend, and they deliver the mail.R19's Minimum Data Set (MDS) dated [DATE] documents R19 is cognitively intactR20's MDS dated [DATE] documents R20 is cognitively intactOn 3/3/2026 at 4:00PM V1, Administrator stated mail is only delivered every other Saturday.On 3/5/2025 at 4:55PM V1, Administrator stated the facility does not have a policy on mail, but follow resident rights for mail.

Based on observation, interview and record review the facility failed to provide proper assistance with ambulation and transfers for 2 of 4 residents (R24 and R43) reviewed for accidents in the sample of 38. Findings include:1. On 3/3/2026 at 11:18AM V14 Certified Nursing Assistant (CNA) and V28 CNA secured strap of sling to mechanical lift. V14, CNA operated the lift with V28 CNA holding onto R43 in sling, once up in air V28 CNA removed hands from sling. V28 CNA with back to R43 in the sling, moved reclining wheelchair to position under R43. V28 then put hands back on sling to guide R43 in sling to chair.R43's care plan dated, revision 1/5/2028 documents R28 has an Activity of Daily Living (ADL) self-care performance deficit relate to Dementia. R43's care plan documents interventions; transfer: R28 requires full mechanical lift and 2 assist to transfer between surfaces. R43's face sheet dated 3/3/2026 documents a diagnosis in part of weakness.2. On 3/3/2026 at 11:30AM R24 exits room with V29 CNA beside R24. R24 unsteady on feet. R24 does not have a gait belt on. R24 walks to dining room with V29 placing hands on R24 to steady R24. R24 sits in chair in dining room then pushes tray back and stands up exits dining room. V29 CNA attempting to redirect R24 in the hallway outside dining room. R24 with unsteady gait falls backward against wall, striking back on handrail and falls to the floor. R24's face sheet dated 3/3/2026 documents in part a diagnosis of unsteadiness on feet. R24's Minimum Data Set (MDS) dated [DATE] documents R24 is severely cognitively impaired with a Behavior Interview of mental status (BIMS) of 2. R24's care plan dated, revision 10/27/2025 documents R24 has an Activity Daily Living (ADL) self-care performance deficit related to weakness, lack of coordination, dyskinesia, cognitive impairment, and multiple psychiatric diagnosis. R24's care plan documents interventions; transfer: one-person physical assist with gait belt. Locomotion on unit: one-person physical assist with gait belt. R24's care plan documents R24 is at risk for fall related to weakness, medications, dyskinesia, abnormal gait and mobility, lack of coordination. R24's care plan documents intervention dated 1/27/2025; resident is to be walked with nursing with a gait belt.On 3/3/2026 at 3:46PM V1 Administrator stated she would expect staff to have hands on sling at all times during mechanical lift transfer. On 3/6/2026 at 3:30PM V33, CNA stated a gait belt is to be used for assisting resident with ambulation. V33 stated it takes 2 staff for the mechanical lift. V33 stated when using the mechanical lifts for transfers one person operates the lift and the other person maintains control of the sling with resident, so they are not left dangling in the air. The mechanical lift manual undated, documents the intended use of the lifting device is for the safe lifting and transfer from one resting surface to another. The manual documents have someone assist you when attempting to transfer a patient. The facility policy Transfers-manual gait belt and mechanical lift dated, retrieved 3/2026 documents use of a gait belt for all physical assist transfers is mandatory.

Based on interview, observation, and record review, the facility failed to coordinate services for a neurology consult for abnormal movements, falls and a gagging incident for 1 of 16 residents (R30) reviewed for quality of care in the sample of 35. This failure resulted in R30 having increased involuntary movements that resulted in worsening involuntary movements. Findings include: R30's Admission record, print date of 11/21/24, documents that R30 was admitted on [DATE] and has diagnoses of Psychosis, Schizoaffective Disorder, Drug Induce Subacute Dyskinesia, and Schizophrenia. R30's Minimum Data Set, dated dated [DATE], documents that R30 is severely cognitively impaired, requires setup or clean up assistance for eating, supervision or touching assistance for sitting and walking. R30's Care Plan, revision date of 10/04/2022, documents, (R30) is at increased nutritional risk r/t (related to) DX (diagnosis): COPD (Chronic Obstructive Pulmonary Disease), Hypertension, Anxiety, Bipolar. Intervention: I use adaptive equipment to ensure my safety: plastic silverware therapy request her to get plastic do (sic) to resident poking herself so get plastic for a safety Date Initiated: 11/18/2024. Monitor/document/report PRN as needed) any s/sx (signs and symptoms) of dysphagia: coughing, drooling, pocketing food, swallowing attempts, refusing to eat. Date Initiated: 10/04/2022. R30's Care Plan, revision date of 11/18/24 , documents, (R30) has an ADL (Activities of Daily Living) ( self-care performance deficit r/t weakness, lack of coordination, dyskinesia, cog impairment and multiple psych (psychiatric) dx. (R30) needs pills whole in pudding at times. Plastic ware for all meals. Intervention: Bed Mobility: One person physical assist Transfer: Supervision One person physical assist at times Walk in room: Supervision One person physical assist with gait belt Walking corridor: Supervision Setup help only, One person physical assist at times Locomotion on unit: Supervision Setup help only, One person physical assist at times Locomotion off unit: Supervision Setup help only, One person physical assist at times Eating: Supervision One person physical assist at times. R30's Care Plan, revision date of 10/13/22, documents, (R16) risk for falls r/t weakness, medications, dyskinesia, abnormal gait and mobility, lack of coordination. I like to stand in the hall and sway side to side. Interventions: Be sure my call light is within reach and encourage me to use it for assistance as needed. Date Initiated: 04/30/2018. Bed height to be placed where my feet are flat on the floor. Date Initiated: 04/30/2018. Ensure resident is wearing shoes or non skid slippers when out of bed Date Initiated: 10/28/2024. Follow facility fall protocol. Date Initiated: 08/14/2019. R30's Care Plan, revision date of 11/08/2019, I have the potential for adverse side effects related to medication use r/t: antipsychotic use. Diagnosis: Schizophrenia, Schizoaffective disorder, and Psychosis. Interventions: Observe for: ANTI-PSYCHOTIC: COMMON SIDE EFFECTS: Sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. UNCOMMON SIDE EFFECTS: Tardive Dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, jaundice. Date Initiated: 08/14/2019. R30's Speech Therapy Discharge Summary, dated 11/19/24, documents, Patient Progress: Progress & Response to Treatment: Pt (patient) achieved max (maximum) rehab potential for the stated goals with d/c (discharge) complete. Communication: Team Communication / Collaboration: ST (Speech Therapy) instructed pt (patient) on small bites / sips, slowing the rate of consumption, and liquid wash every 1 - 3 bites. Pt requires staff supervision for staff to provide cues and assist during PO (oral) intake when needed. Discharge Recommendations and Status Oral Intake Solids = Mechanical soft / ground textures. Liquid - Thin liquids. Strategies Compensatory Strategies / Positions: with staff supervision. Aspirations precautions. Dining / Swallowing Program Established / Trained: Pt has restorative program / staff education in place for swallowing / dysphagia to ensure safety of the swallow. Outcome Risks Risk Areas that may impact Long Term Outcome (s) = lacks insight into condition and risk factors. Multiple medical conditions / history. Desired Change in Condition of Risk area: Dysphagia. R30's Fall Risk Assessment, dated 10/19/24, documents that R13 is at risk for falls. R30's AIMS - Abnormal Involuntary Movement Scale, dated 11/8/23, documents that R30 has Moderate movements of the muscles of the facial expression, mild movements of the lips and perioral area, jaw, and mild movements of the tongue. R30 has moderate movements of the upper arms, wrists, fingers, hands, legs, knees, ankles, and toes. R30 has moderate neck, shoulder, hips, e.g. (for example) rocking, twisting, squirming, pelvic gyrations. R30 severity of abnormal movements is moderate. Incapacitation due to abnormal movements is mild. R30 scores a 18. The higher the score (0-28), the greater the impact of observed movements on resident. R30's AIMS - Abnormal Involuntary Movement Scale, dated 10/19/24, documents that R30 has Moderate movements of the muscles of the facial expression, lips and perioral area, jaw, and mild movements of the tongue. R30 has severe movements of the upper arms, wrists, fingers, hands, legs, knees, ankles, and toes. R30 has severe neck, shoulder, hips, e.g. (for example) rocking, twisting, squirming, pelvic gyrations. R30 severity of abnormal movements is severe. Incapacitation due to abnormal movements is mild. R30 scores a 23. The higher the score (0-28), the greater the impact of observed movements on resident. R30's Electronic Medical Record fails to document an AIM scale between 11/8/23 and 10/19/24. R30's Physician Order, dated November 2024, documents, REGULAR diet, Mechanical Soft, Ground Meat texture, Thin consistency with staff supervision. Start date of 5/2/24. On 11/18/24 at 03:58 PM, R30 is in the hallway walking. R30 has very spastic jerky movements of the arms, legs, head, tongue, and mouth. R30 has involuntary backward arching of the back, shuffling of the feet sidewise and forward motion. R30 tripped over her feet and fell into surveyor. V9, Licensed Practical Nurse, (LPN) who was steps away came and assisted R30 to regain her footing by grabbing her under her arms. R30 remained unsteady even with assistance of V9 and surveyor. V9 attempted to get R30 to sit in a chair, however R30 proceeded to sit in the area beside the chair causing her to lose balanced and start to fall. V9 had to stop R30 from falling, stood her upright and got her over the chair to sit. On 11/18/24 at 4:05 PM, V9, LPN, stated, Thank goodness you were there. I could have never held her up on my own. She would have fallen. I normally don't work this hall. I have heard that they are suppose to be starting her on a medication for Tardive Dyskinesia. I started in August and she has always been this way. She follows her roommate around and she is very unsteady on her feet. On 11/18/24 at 4:07 PM, V10, Certified Nurse Aide, (CNA) stated, She was not this bad last year this is something recent. On 11/19/24 at 12:18 PM, R30 is sitting in the assisted dining room eating her noon meal which consisted of turkey, mashed potatoes, and gravy. R30 has very spastic jerky movements of the arms, legs, head, tongue, and mouth. R30 has involuntary backward arching of the back, shuffling of the feet sidewise and forward motion. R30 is very unsteady on her feet. R30 is unable to control the spontaneous movements. R30's turkey was not cut up. It was in larger pieces not bite size. R30 took her plastic fork and stabbed the meat then with her hand pulled off a meat and put it in her mouth. R30 began to gag. R30 grabbed her drink and took a drink. R30 continued to gag. R30 leaned forward and spit the drink out toward the table. R30 then leaned to the side and spit drink and the turkey meat out onto the floor. V15 CNA assisted R30 with a towel and removed her tray. V21 CNA assisted in moving R30's tablemates to another table. V15 then brought R30 a cup of soup with a metal spoon. On 11/19/24 at 4:45 PM, V19 LPN, stated that she was not aware of R30 gagging on her noon meal. On 11/21/24 at 2:09 PM, V15, CNA was asked if she let V19 know about R30 gagging on her lunch, V15 stated, I went and told (V19). I had her double check her diet too. She was suppose to get a mechanical diet. V15 stated that R30 did receive large pieces of turkey and not mechanical turkey on 11/19/24. V15 stated that R30 has worsened with her movements just recently. On 11/21/24 at 2:13 PM, V21 was asked if she let V19 know about R30 gagging on her lunch on 11/19/24, V21 CNA, stated, (V19) was told. (V15) went right up to (V19) and told her. She was standing right there at the nurses desk. R30's Nurses Note, dated 11/19/2024 19:00 (7:00PM), documents, (V16, Medical Director) notified of resident vomiting at lunch. Orders received to obtain chest xray per (V16). Resident chart updated and resident aware. (mobile) xray called. R30's Nurses Note, dated 11/20/2024 08:10PM, documents, Resident being transported to (local hospital) for STAT (now) chest x-ray r/t (related to) vomiting, resident leaving via facility transports order and face sheet sent with. On 11/20/24 at 11:50 AM, V34, Psychiatry Nurse Practitioner, stated, I saw her (R30) on 10/23/24. The facility asked me to see her because she was getting worse with her movements. I increased her Austedo from 24 milligrams (mg) to 30 mg. I also ordered for a consult to Neurology because I don't think we are dealing with Tardive Dyskinesia. I was not told that they were unable to get her the Austedo. I would have like to know that. Austedo is a drug that you can stop abruptly with no ill effects. V34's Progress Note for 10/23/24 fails to document an order for a consult for neurology. On 11/25/24 at 9:10 AM, V3, Assistant Director of Nurses, stated that she is not sure as to why R30's insurance company did not approve the Austedo medication. She stated that V2, Director of Nurses handled that and that she believes V2 did notify V16 and V34 of the need to place the order on hold. V2 is unavailable for interview to confirm this. V3 further stated that when V34 came in on 10/23/24 she did not write an order for a neurology consult. I have reached out to several neurologist and sent them R30's information and I am waiting for them to accept her as a patient. The facility's policy, AIMS Side Effect Monitoring, dated 10/2024, documented, The examination will be performed either at the time of resident's admission or when medications are initially prescribed. In addition, for residents taking psychotropic medication, AIMS examination procedures will be repeated at intervals of no less than every six (6) months. The facility's Diet Orders Policy dated 08/2023, documented diet orders are checked for accuracy regularly, at the quarterly care plan meeting, by comparing diet orders on file in Dining Services with the Physician Order Sheet (POS) in the health record. The facility's Fall Prevention Program Policy dated 10/2024, documented the purpose of the policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness.

Based on observation, interview and record review the facility failed to provide a Registered Nurse (RN) 8 hours a day, seven days a week for 18 of 18 days reviewed for RN coverage from 11/1/2024-11/18/2024. This failure has the potential to effect all 75 residents at the facility. Findings include: On 11/18/2024 at 9:00AM, an RN was not observed to be on duty. On 11/19/2024 at 10:14 AM, V2 Director of Nurses, stated the facility does not employ any full time RN's at the facility. V2 stated they are unable to provide RN coverage 8 hours a day. V2 stated the facility has 3 RN's who work per diem. The facility daily staffing schedule dated 11/1/2024-11/18/2024 documents no RN for 8 hours a day 7 days a week. On 11/19/2024 at 12:30PM V2, DON stated the facility does not have policy for staffing, V2 stated the facility follows Central Management Services (CMS) guidelines. The CMS 671 Long Term Care Application for Medicare and Medicaid documents a census of 75 residents at the facility.

Based on interview and record review the facility failed to provide 12 hours of Certified Nursing Assistant (CNA) training on a yearly basis for 3 of 5 CNA's (V13, V31 and V36) reviewed for training. This failure has the potential to affect all 75 residents residing at the facility. Findings include: The Facility's trianing records did not document on V13, V31 and V36 CNA's training record they received 12 hours of annual competency training. On 11/25/2024 at 9:42AM V35, Human resources director stated V36, V31, and V13 did not receive required in-service training of 12 hours for CNA's. V35 stated she provides staff with the training site they are to utilize and the log in . V35 stated she does not provide oversight to ensure the training is completed. V35 stated it is the expectation that staff completed required training. The facility policy, policy on training of Employees and documentation of such training dated 9/2023 documents the facility will train all members of its workforce on its policies and procedures with respect to protected health information, as necessary and appropriate for the the members of the work force to carry out their functions. The policy documents the facility will retrain each new workforce member whose functions are affected either by a material change in its privacy policies and procedures on in the members job function within a reasonable time after the changes. The CMS 671 Long Term Care Application for Medicare and Medicaid documents a census of 75 residents at the facility.

Based on record review and interview, the facility failed to notify residents and representatives, in writing, prior to being transferred to the hospital, for 6 of 6 (R7, R12, R17, R36, R54, R72) residents reviewed for discharge transfer notice requirements in a sample of 35. Findings include: 1. On 11/20/2024 at 09:14 AM, R17 stated that he didn't know why he was going to the hospital nor was he given a document explaining why he was sent to the hospital on 12/18/2023, 12/31/2024, and 1/1/2024. R17's Progress note, dated 12/18/2023 at 11:27 AM, documented, Resident being sent to (Emergency Department) for evaluation related to altered mental status, resident is unaware of who we are, low BP (blood pressure), not following commands as normal, (Nurse Practitioner) aware and resident agreeable for ambulance to take to hospital, resident also was seeing things in his bed that were not there. R17's Progress noted, dated 12/31/2023 at 5:10 pm documented, (4:50 PM)- labs received from (Regional Hospital). Emailed to (Nurse Practitioner) new orders received to transfer (patient) to hospital with altered mental status AKI (actue kidney injury), and CHF (congestive heart failure). (Patient) was still talking to people that were not in the room. Not making sense of his conversations. Decision made to transfer to hospital. (Local Ambulance) notified. 5:10 PM (local ambulance) here. (Patient) transferred to stretcher without complications. Report and (patient) status given to ambulance personnel. (5:18 PM) transferred per (Local ambulance) to (Local Hospital) with labs from (Regional Hospital) from today 12/31/2023. R17's Progress note, dated 1/1/2024 at 9:33 AM, documented, Resident returned to facility in the night. Now resident is cool and clammy-pale and hallucinating. BP 160/100-Eyes blood shot. Called (Local) Ambulance to take resident back to the hospital. Called report to the ER (local hospital) and again informed them that his BNP (B-type Natriuretic Peptide) was 1538. And that his mental status was worsening and so was his condition. Called his sister and his daughter and informed them of the need to transport back to the hospital for a re-evaluation of his condition. R17's Minimum Data Set (MDS), dated [DATE], documented that his cognition was intact. R17's Physicians order, dated 11/21/2024, documented diagnoses of Morbid severe obesity and COPD (Chronic Obstructive Pulmonary Disease). 2. R54's Progress note, dated 10/23/2024 at 10:48 pm documented, Staff found Resident on bedside mat face down. Resident was placed back on bed and resident was unresponsive. Staff attempted to arouse resident with sternum rubs, no response. Staff called 911. Staff attempted to notify family, no response. (V16, Medical Director) notified. EMS (Emergency Medical Services) here at 10:40pm for transport to (local hospital). Noted by (V18, LPN) R54's Progress note, dated 3/31/24 at 7:37 AM, documented, Resident sustained a fall on 03/31/2024 7:00 AM. The incident occurred in the Resident room. Resident is alert and oriented to time, person, place and situation. No changes in range of motion from normal baseline. Physician notified on: 03/31/2024 7:00 AM. Date/time family/responsible party notified: 03/31/2024 7:00 AM. Resident denies pain. The resident's pain is not a new onset. R54's Progress note, dated 3/31/24 11:41 am, After assessing resident after fall resident sent to ER (emergency room ) for a x-ray eval after portable unavailable due to holiday. Resident was alert and in agreement with this plan resident emergency contact (family member) was called and voicemail reached and left message for her to (return call) . Resident was sent to ER via (Local ambulance) ambulance and report was called to (Local Hospital). R54's Progress note, dated 1/15/2024 at 11:46 AM, documented, (Patient) (vital signs) BP 154/89 pulse 110 temp 99.1 (Patient) not oriented to person or time altered mental status noted. Transferred to (local hospital) per ambulance. R54's Minimum Data Set, dated dated [DATE], documented that his cognition was moderately impaired. R54's Physicians order sheet, dated 11/21/2024, documented a diagnoses was End Stage Renal Disease. 33112 3. R12's Admission Profile, print date of 11/20/24, documents that R12 was admitted on [DATE] and has a diagnosis of Dementia. R12's Incident Note, 9/10/2024 16:50, documents, Resident sustained a fall on 09/10/2024 4:35 PM. The incident occurred in the outside. Resident is alert and oriented to time, person, place and situation. Change in range of motion from normal baseline noted. Physician notified on: 09/10/2024 2:45 PM. Date/time family/responsible party notified: 09/10/2024 2:50 PM. Resident rates pain 10 out of 10. The resident?s pain is a new onset. A new skin concern or change in skin condition noted. New order/s received: Sent to ER (emergency room ) Care plan reviewed. On 11/20/24 at 1:18 PM, R12's Electronic Medical Records (EMR) fails documents a Bed Hold for the hospitalization of 9/10/24. On 11/20/24 at 10:33 AM, V26, Licensed Practical Nurse, (LPN), stated that when a resident goes out to the hospital she makes a copy of the residents medications, their profile, code status, and the medical necessity form which tells the hospital why they are being sent to the hospital. V26 stated that she does not give the resident a written explanation of why they are going to the hospital but does give them a bed hold letter. On 11/20/24 at 10:35 AM, V27, LPN, stated that when a resident goes out to the hospital she makes a copy of the residents medications, their profile, code status, and the medical necessity form which tells the hospital why they are being sent to the hospital. V27 stated that she does not give the resident a written explanation of why they are going to the hospital but does give them a bed hold letter. V27 stated that she does make a copy of the bed hold letter for the facility. On 11/25/24 at 9:33 AM, V4, Regional Nurse, stated that she was unaware of the need that residents need a letter in simple writing explaining why they are being sent out to the hospital. 50908 4. R72 was admitted to the facility on [DATE] with diagnosis of, in part, fracture of femur. R72's Progress Notes dated 9/7/24, documented, Resident sustained a fall on 09/07/2024 1:30 PM. The incident occurred in the Resident room. Resident is alert and disoriented per usual baseline. Change in range of motion from normal baseline noted. Physician notified on: 09/07/2024 1:45 PM. Date/time family/responsible party notified: 09/07/2024 1:45 PM. Resident rates pain 8 out of 10. The resident's pain is a new onset. No new skin concern or change in skin condition noted. 11/20/24 01:34 PM R72's Electronic Medical Record (EMR) does not have documentation of written notice of the reason for transfer to the hospital on 9/7/24 and a copy of the notice to the ombudsman. 32874 5. R7's Nursing Note dated 8/12/2024 at 09:56AM documents R7 lethargic and non responsive at times this a.m. Notes document R7 continues not to take meds or treatments as prescribed. Notes document R4 gets angry with staff when he is educated or encouraged to take meds. Notes document R7 sitting in wheelchair in dining room slouched over in chair. Very hard to arouse. Notes document R7 being sent to the local hospital emergency room for evaluation. R7's nursing note did not document that reason for transfer was provided to R7 or legal representative at time of transfer. 6. R36's nursing note dated 6/6/2024 at 11:15AM documents R36 sent to the hospital emergency room for evaluation due to a fall. R36's record did not document that R36 or legally responsible person was provided documentation of transfer in writing at the time of transfer. The facility policy notice of transfer and discharge date d revised 10/2022 documents prior to discharge or transfer, the facility will notify the resident and the residents' representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The policy documents reason for transfer or discharge may include emergency transfer to acute care. The policy documents when the facility transfers or discharges a resident the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health institution or provider.

Based on interview, observation, and record review, the facility failed to perform hand hygiene, change gloves when soiled, wear Personal Protective Equipment, and sanitize a multi-use blood glucose monitor to prevent cross contamination for 10 of 16 residents (R1, R4, R16, R20, R22, R24, R31, R57, R61, R71) reviewed for infection control in the sample of 35. Findings include: 1. On 11/19/24 at 09:11 AM, While toileting R20, V28 Certified Nurses Aide (CNA) and V21 CNA both donned gloves without hand hygiene. 2. On 11/19/24 V26 Licensed Practical Nurse, (LPN) was observed giving morning meds during the medication pass. At 7:33 AM, V26, Licensed Practical Nurse LPN was outside of R22's room with her medication cart. V26 donned gloves without hand hygiene, gathered the blood glucose monitoring machine, and the blood glucose test strip, alcohol pad and entered R22's room to obtain a blood glucose level. V26 wiped R22's finger with alcohol, pricked R22's finger and obtained the needed blood sample. The blood glucose monitor failed to read the sample. V26 removed her gloves, V26 exited the room, obtained another test strip from the medication cart, returned to room, donned gloves, cleansed R22's finger with alcohol and pricked R22's finger for a blood sample. The blood glucose monitor registered a blood glucose level of 226. V26 removed her gloves and returned to her medication cart and sanitized her hands. V26 prepared a 25 unit Lispro insulin subcutaneous injection, entered R22's room, donned gloves with no hand hygiene, and gave the injection in the right lower abdomen. On 11/19/24 at 7:40 AM, V26 returned to her medication cart and placed the blood glucose monitor on top of her cart. On 11/19/24 at 8:20 AM, V26 donned gloves, obtained a micro-kill cloth and using one wipe, wiped the front and back of the blood glucose machine. V26 then placed the blood glucose machine on top of the same micro-kill cloth. The facility provided a list of residents that would of had their blood glucose checked using the 300 Hall medication cart, dated 11/21/24. This list documents R4, R22, R24, R57, R61, and R71. The policy Glucometer Cleaning, dated 10/24, documents, Wipe meter with bleach wipe / towel disinfectant until all surfaces of the glucometer are visibly wet and note kill time of product. The (surface disinfectant cleaner) information, undated, documents (surface disinfectant cleaner) has a kill time of 30 seconds for HBV (Hepatitis B) and HCV (Hepatitis C) and 3 minutes for C Diff (clostridium difficile colitis) spores. 3. R16's Admission Record, print date of 11/21/24, documents that R16 was admitted on [DATE] and has a diagnosis of Multiple Sclerosis. On 11/20/24 at 11:21 AM, V27, Licensed Practical Nurse (LPN), entered R16's room to provide tube feeding for R16 through R16's Gastrostomy (G-tube). V27 washed her hands and donned gloves. V27 using a disposable syringe checked for residual through the G-tube. R16 had no residual. V27 gave R16 a 75 milliliter (ml) water flush, 250 ml of Jevity 1.5, and then a 75 ml water flush. V27 removed her gloves and washed her hands. On 11/20/24 at 11:27 AM, V27 was asked why she did not wear a gown while working with R16's G-tube, V27 stated, Oh, I forgot. 40650 4. R31's Physicians order sheet, dated 11/21/2024, documented diagnoses of COPD, Schizo-Affective Disorder and Bipolar Disorder. On 11/19/2024 at 9:27 AM, R31 was placed in to her bed per full mechanical lift. V14 (CNA) pulled R31's pants down and unfastened her adult incontinent brief, which were both saturated with urine. V14 did not perform hand hygiene or changed gloves prior to performing incontinent care. V14, then performed incontinent care on R31. R31 was then rolled on to her right side, V14 removed R31's soiled pants, incontinent brief and full mechanical lift pad from underneath her, placed items in a trash bag and without performing hand hygiene or glove changes, V14 cleansed R31's left hip and peri rectal area. V14 then placed a clean incontinent brief and R31 was then rolled slightly over for V13, CNA, to pull the clean incontinent brief rest of the way from underneath R31. On 11/21/2024 at 11:15 AM, V29, CNA, stated that she would wash her hands and change gloves when she has contaminated her gloves. On 11/21/2024 at 11:17 AM, V17, CNA, stated that she would wash her hands and change gloves when her gloves are dirty. On 11/21/2024 at 11:20 AM, V10, CNA, stated that she would wash her hands and change gloves when her gloves are dirty. On 11/21/2024 at 11:26 AM , V2, Director of Nurses, stated that she would expect the staff to change their gloves and wash their hands when their gloves have been contaminated. 50908 5. R1 was admitted to the facility on [DATE] with diagnosis of, in part, cerebrovascular disease, facture of femur, mild protein-calorie malnutrition, and joint replacement surgery aftercare. On 11/19/24 at 9:45 AM, V17, Lead CNA, and V8, CNA, provided catheter and peri care to R1. V17 and V8 turned R1 onto his right side, V8 pulled out a container of barrier ointment from his pocket. V8, applied the barrier ointment to R1's buttock then removed his gloves. V8 then applied new gloves without hand hygiene and rolled a new pad out under R1 for him to lie on. V17, cleansed R1's right buttock as he was turned on his left side. V17 then grabbed the barrier container without removing her gloves or performing hand hygiene and applied the ointment to R1's right buttock. V8 removed his/her gown and gloves then tied up the two plastic bags that were used to contain the dirty linen and towels after providing peri-care to R1. V8 grabbed the bags, touched the door handle to open the door and removed the items without hand hygiene. The facility's Use of Disposable Gloves Policy dated 09/2023, documented hands will be washed before putting on disposables gloves. Anytime a contaminated surface is touched, the gloves must be changed. Hands should be washed each time disposable gloves are removed. The facility's Hand Hygiene/Handwashing Policy dated 03/2023, documented hand hygiene should be performed if hands will be moving from a contaminated-body site to a clean-body site during patient care, before glove placement and after glove removal. The facility's Enhanced Barrier Precautions (EBP) Policy dated 03/2024, documented use of EBP to be for residents with chronic wounds or indwelling medical devices during high-contact care activities. The EBP policy documented further that gown and gloves must be worn when providing medical device care.

Based on interviews, observations, and record reviews the facility failed accommodate a resident's preference to eat in his room for 1 of 5 residents, (R8), reviewed for Resident's Rights in a sample of 35. Findings include: R8 was admitted to the facility on [DATE] with diagnosis of, in part, multiple sclerosis (MS), quadriplegia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. R8's Care Plan dated 10/18/24, documented he is dependent on staff for Activities of Daily Living (ADL's); he is able to move only neck/head, has a diagnosis (Dx) of end stage MS, has muscle spasms extremities involuntarily jerk, prefers to use safety belts on the electric wheelchair (w/c) to promote positioning and enhance mobility. R8 is unable to stand and has little use or movement in is extremities and per his request, R8 refuses to come to the dining room at times. R8's Care Plan further documented he isolates in his room a majority of the time. R8's Minimum Data Set (MDS) dated [DATE] documented R8 is cognitively intact. R8's MDS also documented that he has impairment to both sides of his upper extremity and is dependent on staff to assist him with all self-care abilities including eating. On 11/18/24 at 9:52 AM, R8 stated he does not eat his meals in the dining room, he prefers to eat in the comfort of his room. On 11/20/24 at 12:15 PM, R8 was out in the dining room for lunch. On 11/21/24 at 7:30 AM, R8 was out in the dining room for breakfast. On 11/21/24 at 9:05 AM, R8 stated he was told by the facility that they were short staffed and that he needed to eat out in the dining room. R8 stated he does not like eating in the dining room because it is noisy, the other residents are hollering and screaming. R8 stated the staff are too lazy to feed him in his room, he would prefer to have soup heated up so he could avoid the dining room. On 11/21/24 at 11:05 AM, V1, Administrator, stated the residents have the right for the facility to accommodate their preference to eat in their room if they choose. The facility's Statement of Resident Rights, undated, documented residents have the right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect. The statement further documented it is the resident's right to exercise free choice in selecting activities, schedules, and daily routines.

Based on interviews, observations, and record reviews the facility failed to report changes in condition to the physician for 1 out of 2 residents, (R30), reviewed for notification of changes in a sample of 35. 1. R30's Admission record, print date of 11/21/24, documents that R30 was admitted on [DATE] and has diagnoses of Psychosis, Schizoaffective Disorder, Drug Induce Subacute Dyskinesia, and Schizophrenia. R30's Minimum Data Set, dated dated [DATE], documents that R30 is severely cognitively impaired, requires setup or clean up assistance for eating, supervision or touching assistance for sitting and walking. On 11/18/24 at 3:58 PM, R30 is in the hallway walking. R30 has very spastic jerky movements of the arms, legs, head, tongue, and mouth. R30 has involuntary backward arching of the back, shuffling of the feet sidewise and forward motion. R30 tripped over her feet and fell into surveyor. V9, Licensed Practical Nurse, (LPN) who was steps away came and assisted R30 to regain her footing by grabbing her under her arms. R30 remained unsteady even with assistance of V9 and surveyor. V9 attempted to get R30 to sit in a chair, however R30 proceeded to sit in the area beside the chair causing her to lose balanced and start to fall. V9 had to stop R30 from falling, stood her upright and got her over the chair to sit. On 11/19/24 at 12:18 PM, R30 is sitting in the assisted dining room eating her noon meal which consisted of turkey, mashed potatoes, and gravy. R30 has very spastic jerky movements of the arms, legs, head, tongue, and mouth. R30 has involuntary backward arching of the back, shuffling of the feet sidewise and forward motion. R30 is very unsteady on her feet. R30 is unable to control the spontaneous movements. R30's turkey was not cut up. It was in larger pieces not bite size. R30 took her plastic fork and stabbed the meat then with her hand pulled off a meat and put it in her mouth. R30 began to gag. R30 grabbed her drink and took a drink. R30 continued to gag. R30 leaned forward and spit the drink out toward the table. R30 then leaned to the side and spit her drink and the turkey meat out onto the floor. V15, Certifed Nurse Aide, (CNA) assisted R30 with a towel and removed her tray. V21 CNA assisted in moving R30's tablemates to another table. V15 then brought R30 a cup of soup with a metal spoon. On 11/19/24 at 4:45 PM, V19, Licensed Practical Nurse, (LPN), stated that she was not aware of R30 gagging on her noon meal. On 11/21/24 at 2:09 PM, V15 was asked if she let V19 know about R30 gagging on her lunch, V15 CNA, stated, I went and told (V19). I had her double check her diet too. She was suppose to get a mechanical diet. V15 stated that R30 did receive large pieces of turkey and not mechanical turkey on 11/19/24. V15 stated that R30 has worsened with her movements just recently. On 11/21/24 at 2:13 PM, V21, CNA was asked if she let V19 know about R30 gagging on her lunch on 11/19/24, V21 CNA, stated, (V19) was told. (V15) went right up to (V19) and told her. She was standing right there at the nurses desk. R30's Nurses Note, dated 11/19/2024 19:00 (7:00pm), documents, (V16, Medical Director) notified of resident vomiting at lunch. Orders received to obtain chest xray per (V16). Resident chart updated and resident aware. (mobile) xray called. On 11/25/24 at 9:10 AM, V3, Assistant Director of Nurses, stated that the Physician should have been notified of R30's fall and gagging incident when it happened. The facility's policy, Physician-Family Notification- Change in Condition, dated 10/2024, documented, The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the residents legal representative or an interested family member when there is: A. An accident involving the resident which results in injury and has the potential for requiring physician intervention.

Based on interview, observation and record review, the facility failed to promote residents' dignity by addressing residents' needs timely for 4 of 5 residents (R2, R3, R4, R5) reviewed for dignity in the sample of 5. This failure resulted in R2 feeling humiliated after having to urinate in her water pitcher due to staff not assisting her. Findings include: 1. On 8/16/24 at 8:55 AM, R2 was in her bed with a large cow bell and air horn at bedside. R2 stated the call lights are not working and haven't been for a while. R2 stated they are telling her that the part has been ordered and when it comes in, it will be installed but they haven't given her a time frame for when that will occur. R2 stated they gave her a small bell to ring when she needed something, that didn't work, staff didn't come, so they gave her a pressure pad alarm to press to get staff's attention, that didn't work, staff still didn't come, so they gave her a larger cow bell and the staff still don't respond so she bought an air horn. R2 stated the staff don't come in her room unless they must, the only time she can get help is if she goes to her doorway and yells for staff. R2 stated there was one night, unsure of exact date, that she tried to get staff's attention at 2:30 AM and they didn't come until 4:00 AM, she had to urinate in her water pitcher, so she didn't have to urinate on herself. R2 stated about 2 or 3 days after that, she had a UTI (urinary tract infection) because she had to hold her urine for so long. On 8/20/24 at 9:40 AM, R2 stated when she was left in her urine and had to urinate in her water pitcher, this left her feeling humiliated. R2 stated that night, she had the smaller cow bell, and she isn't sure if staff heard it or not or just didn't respond to it. R2 stated they must keep her door closed because she was and is still on isolation for COVID. R2 stated the next day when she complained about it, she was given a pressure pad alarm and had the same problem, then they gave her the bigger cow bell to use. Surveyor left R2's room and moved about on the hallway, there was a resident going by in an electric wheelchair and R2's large cow bell could not be heard until the wheelchair passed and then it was audible but for only a few feet, it would have been unable to have been heard at the nurse's station. After the cow bell was rang, no one came into the room to see if anyone needed anything. R2's Face Sheet, undated, documents R2 has a diagnosis of Fibromyalgia. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 is cognitively intact, R2 requires substantial/maximal assist for toileting and is continent of bowel and bladder. R2's Care Plan, dated 7/10/24, documents R2 has an Activities of Daily Living (ADLs) self-care performance deficit and 8/8/24, R2 is on an antibiotic for UTI. R2's Progress Note, dated 8/7/24 at 11:00 AM, documents R2 has a UTI and will start Ciprofloxacin 500 milligrams (mg) twice daily for 7 days. 2. On 8/16/24 at 10:05 AM, R3 was observed up in wheelchair in room, clean, dry and without odors. Hospice aid in room with resident making his bed. Cow bell on bedside table. R3 stated the call system is not working, so they gave him a bell to use but the staff doesn't answer when he rings it. R3 stated he has had to call hospice to have them call the front desk so he could get help. R3's Face Sheet, undated, documents R3 has a diagnosis of CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease) and UTI. R3's MDS, dated [DATE], documents R3 has a BIMS score of 15, indicating R3 is cognitively intact, requires substantial/maximal assist with toileting, is occasionally incontinent of urine and frequently incontinent of bowel. R3's Care Plan, dated 5/24/24, documents R2 has an ADL self-care performance deficit. 3. On 8/16/24 at 10:25 AM, R4 was observed in room in bed, cow bell on bedside table. R4 stated the call lights don't work so they must use a bell, and no one comes in when they do use it. R4 stated they must yell for help, but they don't come in the room unless they must for meals, medications, etc. R4 pointed to her breakfast meal on her table that still needed picked up by the CNAs (Certified Nursing Assistant) but hadn't been because they haven't been in there since they dropped it off earlier this morning. R4 stated her family would have never put her here if they knew how she was being treated, it's more like a psych ward than a nursing home. On 8/20/24 at 9:45 AM, R4 was observed in room. R4 stated it is still a problem getting her cow bell to be answered with the door closed. R4 stated the door must be closed because she is still on isolation for COVID. Surveyor asked R4 to ring the small cow bell once the surveyor shut the door. Small cow bell was audible in the hallway but again only for a few feet and was not audible at the nurse's station. R4's Face Sheet, undated, documents R4 has a diagnosis of COPD, OA (Osteoarthritis) and Fibromyalgia. R4's MDS, dated [DATE], documents R4 has a BIMS score of 15, indicating R4 is cognitively intact, requires supervision or touch assist with toileting, is occasionally incontinent of urine and continent of bowel. R4's Care Plan, dated 4/2/24, documents R4 has an ADL self-care performance deficit. 4. On 8/16/24 at 2:25 PM, R5 was observed in room in bed with a cow bell on bedside table. R5 stated the call light had a short circuit and isn't working, so she must use that bell to get help. R5 stated staff don't come when you ring it, but they didn't come before when they used the call light either. R5 stated she is clean and dry at this time but has had to sit in her urine for a long time because staff won't come to help her. R5's Face Sheet, undated, documents R5 has a diagnosis of Cerebrovascular Disease, OA, and COPD. R5's MDS, dated [DATE], documents R5 has a BIMS score of 14, indicating R5 is cognitively intact, is dependent with toileting and is frequently incontinent of bowel and bladder. R5's Care Plan, dated 11/5/23, documents R5 has an ADL self-care performance deficit. On 8/20/24 at 10:15 AM, V1 (Administrator) stated the call light system has not been fixed, they are still waiting on the part. V1 stated the residents are still utilizing the cow bells in place of the call lights. On 8/20/24 at 10:20 AM, V10, (RN-Registered Nurse), stated sometimes you can hear the cow bells at the nurse's station, depending on how hard they are rung by the resident, but they are mostly heard on the hallways. On 8/20/24 at 11:50 AM, V1 stated on top of using the cow bells while the call light system is down, they have also implemented 15-minute checks on residents that cannot use the cow bell and staff have been doing extra rounding. V1 stated R2 had voiced concerns when the COVID outbreak started that staff were not responding to the cow bell and she was not receiving care timely. V1 stated R2 voiced that she wasn't sure if it was because the staff couldn't hear it or they were just not responding, so she was given a bigger cow bell, air horn and pressure pad alarm to use when needing assistance. On 8/20/24 at 12:50 PM, V3 (Maintenance Director) stated the call light system is still down, it has been down since 8/4/24. He emailed regarding the part that was ordered and was told that they don't have an estimated date for delivery, but as soon as it is delivered, he will install it. V3 stated they continue to use the cow bells for the residents and staff are always on the hall monitoring them, so they know if they need anything. The Resident Rights Policy, dated 8/2017, documents the following: The purpose of the policy is to promote the exercise of rights for each resident. Residents have a right to dignity and respect.

Based on observation, interview and record review the facility failed to ensure a resident was treated with dignity by ensuring privacy when urinating and allowing residents to eat at same time as other residents for 4 of 4 residents (R10, R16, R63, R70) observed for dignity in the sample of 46. This failure resulted in R16 feeling frustrated and sitting hungry awaiting his food for an hour after meal service. Findings include: 1. On 11/5/2023 at 12:46 PM hall trays were placed on 100- hall. From 12:46 PM to 12:52 PM, hall trays were passed to the residents on the hall. At 12:47 PM R16 was sitting in his wheelchair in his room. R64's, R16's roommate's tray was placed on R64's over bed table next to R16. On 11/5/2023 at 1:00 PM was R16 sitting in wheelchair in room with no food tray. On 11/5/2023 at 1:07 PM was R16 sitting in wheelchair in room with no food tray. On 11/5/2023 at 1:07 PM R16 stated that he was hungry. R16 stated that he wants to eat. R16 stated that they delivered his roommates tray why can't they deliver his. R16 stated that sometimes they are later than this. R16 stated that sometimes it 2:00 PM. R16 stated that it's frustrating and he waits hungry. When asked if he told anyone he was hungry? R16 stated isn't everyone hungry? R16 stated that They brought his (R64's). Why can't they bring mine? R16 stated that it was frustrating. On 11/5/2023 at 1:22 PM R16 remained sitting in wheelchair leaning forward with head in lap without a meal tray. On 11/5/2023 at 1:24 PM V28, Certified Nurse's Assistance (CNA), stated that he (R16) was supposed to go to the dining room, and he never went. On 11/8/23 at 11:48 AM, V23, Dietary Manager, stated, I print the meal tickets out the night before. When meal service starts the hall trays are the first to be served then the main dining room and then the 300-hall dining room. We generally know who eats where. If we send out a hall tray because we believe they are eating in their room, and they actually are in the dining room the tray stays on the cart because we are not going to just serve on person in the dining room then when the dining room gets served the resident will get a whole new tray. So, if they change their mind, it is not a big deal for them to change their mind. The facility provided a Mealtimes document, dated 11/6/2023, documents Lunch:11:30 AM. 44967 2. R63's Face Sheet, undated, documents R63 was admitted to the facility on [DATE]. R63's Electronic Medical Record, documents R63's diagnosis include Neurocognitive disorder with Lewy Bodies,, Transient Cerebral Ischemic Attack (TIA),and Dementia. R63's Care Plan, dated 8/15/23, documents R63 has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, Hemiplegia. Interventions: Bathing/Showering: The resident requires assist of (#) staff member with bathing/showering. Bed Mobility: The resident requires assist of (#) staff member with bed mobility. The resident uses side rails to maximize independence with turning and repositioning in bed, Dressing: The resident requires (#) assist for dressing, Personal Hygiene: The resident requires (#) assist with personal hygiene and oral care. Toilet Use: The resident requires (#) assist with toileting, Transfer: The resident requires (specify equipment: gait belt, sit to stand, full mechanical lift) and (#) assist to transfer between surfaces. R63's Minimum Data Set, dated dated [DATE], documents R63 has a moderate cognitive impairment and requires dependence on staff for shower/bathing, substantial/maximal assistance from staff for dressing, personal hygiene, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. R63 MDS documents R63 requires supervision for toileting and is always continent of bowel and bladder. On 11/5/23 at 9:35 AM, R63, lying in bed, with V4, Licensed Practical Nurse (LPN), providing skin care to his legs. R63 stated that he had some loose stool and wanting to use restroom, so V4 told him she would be back after he was done and did not offer assistance to get R63 to the restroom. R63 was seen getting out of his bed to his wheelchair with some difficulty, and wheeled himself to the restroom, stood and pivoted, and then put himself on the toilet. R63 asked to have the restroom door closed, and the door was closed. There were feces seen in his incontinence brief, and his pants appeared wet. R63's bed linen had feces on the incontinence pad once R63 got up. V4 entered the restroom to assist R63 and left the restroom door open, which made R63 visible to two other residents in the room (R70, and R10). On 11/8/23 at 8:30 AM, R70, R63's Roommate, stated, via dry erase board, Don't like when someone leaves restroom door open. On 11/8/23 at 8:35 AM, R63 stated I would rather have the door to the restroom closed while I am in there. It's supposed to be closed. On 11/8/23 at 8:38 AM, V13, CNA, stated Of course I would close the restroom door when a resident is in there. I don't go with the restroom door open, so why should they. On 11/8/23 at 9:35 AM, R10, R63's roommate, stated No, I don't like it when the restroom door is open, and someone is in there using it. It should be closed so we don't see them. On 11/8/23 at 12:37 V2, Director of Nurses (DON), stated I would expect staff to maintain the resident's privacy at all times, especially while using the restroom and/or with resident care. The facility's Resident Rights Policy, dated 9/2023, documents To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems, and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Notice of rights will be provided upon admission to the facility. These rights include the resident's right to: Exercise his or her rights, and Privacy and confidentiality. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. Facility practices designed to support and encourage resident participation in meeting care planning goals as documented in the resident assessment and care plan are not interference or coercion.

Based on interview, observation and record review, the facility failed to provide adequate supervision and provide a secure environment to prevent elopement for 1 of 16 residents (R2) reviewed for elopement in the sample of 18. This failure resulted in R2 eloping without staff knowledge and has the potential to affect all 16 residents identified as being at risk for elopement (R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 and R18). This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 04/09/23 when R2 left the facility at 4:21PM without staff knowledge and was found by the local police department at 7:10 PM. V1 was notified of the Immediate Jeopardy on 04/12/23 at 13:30pm. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 4/13/23, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training, interventions, and the door monitoring device. Findings include: 1. On 04/11/23 at 8:35 AM, V1, Administrator, gave a list of residents identifying R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 and R18 were at risk for elopement. 2. On 04/11/23 at 10:40 AM, R2 was observed in his room, alert and oriented, (A&O), to person only. R2's Face Sheet, undated, documents R2 has a diagnosis of Dementia. R2's Minimum Data Set, (MDS), dated [DATE], documents R2 has moderate cognitive impairment and wanders which places him at significant risk of getting into dangerous places (outside of the facility). R2's Care Plan, dated 03/01/23, documents R2 is at risk for elopement/wandering related to being disoriented to place and a diagnosis of Dementia. R2's Elopement Risk Review, dated 03/09/23, documents R2 is at risk for elopement. R2's Progress Note, dated 03/09/23, documents R3 was assessed for elopement/unauthorized leave. R2 has a history of wandering/elopement and/or verbalizes a strong desire to leave. R2 has a diagnosis of dementia and/or severe mental illness. Resident has reported or documented episodes of elopement and/or attempts to elope. The resident's representative (i.e., Health Care Power of Attorney, close family member, guardian), has not requested that the resident be monitored on the Elopement Protocol. Behavioral Observations include spends time on the first floor or wanders between floors or units. Hangs around facility exits and/or stairways. R2 has the physical ability to leave the building. Resident is at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated. R2's Progress Note, dated, 04/09/23 documents R2 was assessed for elopement/unauthorized leave. The resident has a history of wandering/elopement and/or verbalizes a strong desire to leave. The resident has a diagnosis of dementia and/or severe mental illness. Resident has reported or documented episodes of elopement and/or attempts to elope. The resident's representative (i.e., Health Care Power of Attorney, close family member, guardian) has not requested that the resident be monitored on the Elopement Protocol. Behavioral Observations includes Spends time on the first floor or wanders between floors or units. Hangs around facility exits and/or stairways. Has the physical ability to leave the building. Resident is at risk for unauthorized leave due to substance use disorder and should be placed on the elopement risk protocol. A care plan for elopement is indicated. R2's Progress Note, dated 04/10/23 at 4:50 PM, documents R2 has been on 15-minute checks to prevent further elopement. R2's Progress Note, dated 04/09/2023 at 11:04 PM, documents, Resident recently admitted /readmitted to the facility. Resident left unattended, brought to hospital by local police department. No injuries found. The Facility Investigation, undated, by V1, Administrator, documents the following: On 04/10/23 the cameras were reviewed to determine which door R2 exited and how he was able to exit the facility. Due to the cameras not being close enough for detail, we were unable to determine how the door was opened. We did verify that the egress and alarm is functioning properly and that R2 was able to exit from the 200-hall door without being noticed at approximately 4:21 PM. R2 was clothed properly and was wearing shoes when he exited the facility. R2 reports he was going out to get fresh air. Staff report he was in the building for dinner, which he confirmed. The hospital notified the facility that the resident was picked up by the local police department at 7:10 PM and notified the facility that he was at the hospital (not seen in the emergency room because he had no injuries) at 7:27 PM. R2 was then brought back to the facility. No injuries were noted. All vitals were normal, no distress noted. Observation: although resident was frequently walking about the facility bare foot until last week when family brought shoes, he did not have proper attire to leave or walk outside. We are questioning that due to his previous living arrangements. We believe now that because he had proper attire, he thought it was reasonable to leave the facility and return where he wanted. V3, Agency LPN, statement, undated, documents she did not realize the resident was missing until the hospital had called. R2 was at the facility for dinner and was not due for medications until 8 PM, When the resident returned, V3 completed a skin assessment, vitals were within normal range and his skin was free of wounds or bruises. R2 stated that he was just out enjoying the fresh air. He did not appear to be in any distress and when asked if he was worried or concerned about being out, he again stated that he was just out enjoying the weather. R2 was wearing shoes and was dressed appropriately. R2 told V1, Administrator and LPN, (V3), that he ate lunch and dinner. R2 reports that he does not recall how he got out or what door he exited from. On 04/11/23 at 8:35 AM, V1, Administrator, states R2, eloped from the facility on 04/09/23. V1 states, they reviewed the cameras, and the 200-hall door was not shut, it was ajar, had something in it like a stone, that was preventing the magnet to engage/lock. V1 states, the alarm had been turned off for the smokers, so the alarm did not sound. V1 states, R2 exited the facility sometime between 4:30 PM and 5 PM. V1 states, they are unsure of the time he left the facility grounds. V1 states, R2 told her that he ate dinner and then left the facility to get some fresh air and cigarettes. V1 states, R2 was homeless and used to get food by knocking on people's doors asking for canned goods or food of some sort. V1 states, at 7:10 PM, a neighbor called the police because R2 was knocking on their door asking for canned goods, the police responded and picked up R2 at 7:30 PM by the high school, (approximately 0.5 miles from the facility). V1 states R2 is independent with care and ambulation. V1 states, R2 has a Brief Interview of Mental Status, (BIMS), of 12 and is confused at times. V1 states, R2 only gets medications twice a day. V2 states, the facility staff was not aware that he was out of the building until they received a call from the hospital. V1 states, R2 was taken to the hospital by the local police department but was never seen in the emergency room and didn't have any injuries related to his elopement. V1 states, R2 was back in the facility at 7:40 PM on 04/09/23. On 04/11/23 at 1:05 PM, V9, Certified Nurse Assistant, (CNA), states, R2 is at risk for elopement because he wanders. V9 states, if R2 is heading towards the 200-hall exit door, he, (V9), knows it is because, R2 is wanting to smoke, so he will remind him that someone will be taking him out at the next smoking time and R2 will go back to his room until that time. On 04/11/23 at 2:10 PM, V11, Resident Assistant, (RA), states, R2 paces back and forth and will say he wants to leave. On 04/11/23 at 2:18 PM, V13, Maintenance Assistant, denies concerns with the door alarms except, the 200-hall exit door because, the staff turn it off and must remember to turn it back on. On 04/11/23 at 2:40 PM, V15, CNA, states, she was working on 04/09/23, when R2 eloped. V15 states, around dinner time, unsure of exact time, R2 was walking down the 200-hall towards the exit door, she asked him what he was doing, he said he was going outside, she told him not right now and to go back to his room for dinner. V15 states, R2 went back to his room. On 04/11/23 at 3:15 PM, V3, Agency Licensed Practical Nurse, (LPN), states, she was working on 04/09/23 and came in at 6 PM. V3 states, she was working the 100 and 200-halls. V3 states, by the time she got to the 100-hall to do their medication pass, the hospital had already called stating R2 was picked up by the police and was taken to the hospital. V3 states, she was not aware R2 was not in the building until the hospital called. V3 states, she was told that a neighbor called the police around 7:10 PM and he was taken to the hospital. V3 states, the hospital notified the facility around 7:30 PM that R2 was at the hospital. V3 states, the police officer then brought the resident back to the facility. V3 states, when R2 came back, they assessed him for injuries with none noted. V3 states, R2 told her he went outside to enjoy the fresh air. V3 states, R2 wasn't sure how, which door, or what time he left the facility. V3 states, she works for agency and isn't familiar with R2 and is unsure if he is at risk for elopement. V3 states, when R2 returned to the facility he was placed on one-on-one supervision for the remainder of the evening and night. On 04/12/23 at 8:55 AM, V17, Nurse Practitioner, states, R2 is not able to make good/safe decisions, he does have some safety awareness but, not enough to navigate being out of the facility without supervision. V17 states, R2 had a wander guard at the hospital prior to coming to the facility and was at risk for elopement. V17 states, she would have expected the facility to provide a higher level of care for R2 to prevent his elopement. On 04/12/23 at 10:10 AM, V16, LPN, states, she was working days on 04/09/23 and was working on the 100-hall, where R2 resides. V16 states, she last saw R2 around 2 PM. 3. On 04/11/23 at 10:30 AM, R1 was observed and is confused. R1's Face Sheet, undated, documents R1 has a diagnosis of Dementia. R1's MDS, dated [DATE], documents R1 has moderate cognitive impairment and wanders. R1's Care Plan, dated 11/30/23, documents, R1 is at risk for elopement due to a history of attempts to leave the facility unattended. R1's Elopement Risk Review, dated 04/04/23, documents R1 is at risk for elopement 4. On 04/11/23 at 10:45 AM, R3 was observed and was alert and oriented to person, place and time. R3's Face Sheet, undated, documents R3 has a diagnosis of Schizophrenia and Major Depressive Disorder. R3's MDS, dated , 04/03/23, documents R3 is cognitively intact. R3's Care Plan, dated 07/29/18, documents R3 is at risk for elopement due to wandering the facility at times and verbalizes a desire to leave the facility without a proper discharge plan. R3's Elopement Risk Review, dated 04/03/23, documents R3 is at risk for elopement. 5. On 04/12/23 at 9:35 AM, R6 was observed and is alert to name only. R6's Face Sheet, undated, documents R6 has a diagnosis of Mild Cognitive Impairment, Schizophrenia, Anxiety and Schizoaffective Disorder of the Bipolar Type. R6's MDS, dated [DATE], documents R6 severe cognitive impairment. R6's Care Plan, dated 04/18/18, documents R6 is at risk for elopement due to being disoriented to place and wandering aimlessly. R6's Elopement Risk Review, dated 04/10/23, documents R6 is at risk for elopement. 6. On 04/12/23 at 10:15 AM, R7 was observed and is alert to name only. R7's Face Sheet, undated, documents R7 has a diagnosis of Major Depressive Disorder, Cerebral Infarction and Aphasia. R7's MDS, dated [DATE], documents R7 has severe cognitive impairment. R7's Care Plan, dated 02/01/19, documents R7 is at risk for elopement due to exit seeking, history of attempts to leave facility unattended, impaired safety awareness. R7 will push on the exit doors until the alarm sounds and the door unlocks. R7 watches staff to key in the door codes and open the doors. R7's Elopement Risk Review, dated 04/10/23, documents R7 is at risk for elopement. 7. On 04/12/23 at 9:55 AM, R8 was observed and was alert and oriented to person, place, and time. R8's Face Sheet, undated, documents R8 has a diagnosis of Dementia. R8's MDS, dated [DATE], documents R8 is cognitively intact. R8's Care Plan, dated 10/29/21, documents R8 is at risk for elopement due to wandering to the doors. R8's Elopement Risk Review, dated 04/10/23, documents R8 is at risk for elopement. 8. On 04/12/23 at 9:55 AM, R9 was observed and was alert and oriented to person, place and time. R9's Face Sheet, undated, documents R9 has an admitting diagnosis of Congestive Heart Failure. R9's MDS, dated [DATE], documents R9 has moderate cognitive impairment. R9's Care Plan, dated 06/22/22, documents R9 is at risk for elopement due to being disoriented to place. R9's Elopement Risk Review, dated 03/09/23, documents R9 is at risk for elopement. 9. On 04/12/23 at 9:48 AM, R10 was observed and was alert to self only. R10's Face Sheet, undated, documents R10 has a diagnosis of Dementia. R10's MDS, dated [DATE], documents R10 has severe cognitive impairment. R10's Care Plan, dated 01/27/21, documents R10 is at risk for elopement due to exit seeking and impaired safety awareness. R10's Elopement Risk Review, dated 04/10/23, documents R10 is at risk for elopement. 10. On 04/12/23 at 10:40 AM, R11 was observed and was alert to self only. R11's Face Sheet, undated, documents R11 has a diagnosis of Alzheimer's Disease. R11's MDS, dated [DATE], documents R11 has severe cognitive impairment. R11's Care Plan, dated 03/17/22, documents R11 is at risk for elopement. R11 will attempt to open exit doors and has a history of attempts to leave the facility unattended. R11's Elopement Risk Review, dated 03/28/23, documents R11 is at risk for elopement. 11. On 04/12/23 at 10:00 AM, R12 was observed and is alert and oriented to self and place. R12's Face Sheet, undated, documents R12 has a diagnosis of Dementia. R12's MDS, dated [DATE], documents R12 has severe cognitive impairment. R12's Care Plan, dated 01/01/15, documents R12 is at risk for elopement due to dementia and is exit seeking. R12's Elopement Risk Review, dated 03/14/23, documents R12 is at risk for elopement. 12. On 04/12/23 at 9:46 AM, R13 was observed and is alert to self only. R13's Face Sheet, undated, documents R13 has a diagnosis of Dementia. R13's MDS, dated [DATE], documents R13 has severe cognitive impairment. R13's Care Plan, dated 02/04/22, documents R13 is at risk for elopement due to impaired safety awareness. R13's Elopement Risk Review, dated 04/10/23, documents R13 is at risk for elopement. 13. On 04/12/23 at 9:45 AM, R14 was observed and is alert to self only. R14's Face Sheet, undated, documents R14 has a diagnosis of Alzheimer's Disease. R14's MDS, dated [DATE], documents R14 has moderate cognitive impairment. R14's Care Plan, dated 09/27/22, documents R14 is at risk for elopement due to a history of attempts to leave the facility unattended. R14's Elopement Risk Review, dated 04/10/23, documents R14 is at risk for elopement. 14. On 04/12/23 at 9:50 AM, R15 was observed and was alert and oriented to person, place and time. R15's Face Sheet, undated, documents R15 has a diagnosis of Paranoid Schizophrenia and Major Depressive Disorder. R15's MDS, dated [DATE], documents R15 is cognitively intact. R15's Care Plan, dated 07/11/22, documents R15 is at risk for elopement due to a history of attempts to leave facility unattended. R15's Elopement Risk Review, dated 03/17/23, documents R15 is at risk for elopement. 15. On 04/12/23 at 9:38 AM, R16 was observed and is alert and oriented to person and place. R16's Face Sheet, undated, documents R16 has a diagnosis of Dementia. R16's MDS, dated [DATE], documents R16 is cognitively intact. R16's Care Plan, dated 03/01/19, documents R16 is at risk for elopement due to dementia. R16's Elopement Risk Review, dated 04/10/23, documents R16 is at risk for elopement. 16. On 04/12/23 at 9:42 AM, R17 was observed and is alert and oriented to person and place. R17's Face Sheet, undated, documents R16 has a diagnosis of Schizoaffective Disorder of the Bipolar Type. R17's MDS, dated [DATE], documents R16 is cognitively intact. R17's Care Plan, dated 07/10/21, documents R17 is at risk for elopement due to a history of attempts to leave the facility unattended. R17's Elopement Risk Review, dated 4/10/23, documents R17 is at risk for elopement. 17. On 04/12/23 at 9:40 AM, R18 was observed and is alert and oriented to person, place and time. R18's Face Sheet, undated, documents R18 has a diagnosis of Mild Intellectual Disabilities, Disorganized Schizophrenia, Anxiety Disorder, Major Depressive Disorder, Schizoaffective Disorder of the Depressive Type, Symptoms and Signs Involving Cognitive Functions and Awareness, Transient Alteration of Awareness, Traumatic Brain Injury and Psychosis. R18's MDS, dated [DATE], documents R18 has moderate cognitive impairment. R18's Care Plan, dated 02/03/21, documents R18 is at risk for elopement due to a history of attempts to leave the facility unattended. R18's Elopement Risk Review, dated 12/15/22, documents R18 is at risk for elopement. On 4/11/23 at 3:10 PM, V2, Director of Nurses, (DON), states, all residents are to be checked on at a minimum of every 2 hours. V2 states R2 is now on 15-minute checks. The Alarm Service Company Service Order, dated 04/12/23, documents 200 and 300 doors not alarming when door propped open. Emergency - ASAP. Test, analysis, and wiring identification indicated the in place delayed egress locks did not have options for a door propped open alarm or door open/door closed status output and the existing keypads did not have a necessary optional wiring harness to connect to the central door alarm annunciator panel. Installed door position [NAME] switches on each door/frame. Installed a new monitoring keypad for each door. Programmed PRN and tested thoroughly. tested all other doors in facility to verify that when propped open a central audio/visual alarm alerts continuously until the door is closed completely. The Unauthorized Absence policy, dated 11/2012, documents the purpose is to ensure the ongoing health and safety when a resident has eloped and/or is otherwise unable to be accounted for during occurring time of day. An unauthorized absence is one that the resident is unable to be accounted for. The Code Pink - Missing Resident/Elopement policy, dated 11/2017, documents staff are to complete a new elopement risk assessment and update the plan of care with appropriate interventions as indicated. Examples of interventions may include but are not limited to: Wander guard bracelet, increased monitoring such as 15-minute visual checks, one on one supervision, evaluation for a secured unit if available and appropriate and review and update the elopement risk binder as appropriate. On 04/14/23 the following was completed to validate the abatement plan submitted by the facility: V2, DON; V3, Agency LPN; V5, CNA; V7, CNA; V8, RN; V11, RA; V14, CNA; V13, Maintenance Assistant, V15, CNA; V16, LPN; V18, Social Services Director; V21, Maintenance Supervisor; V24, CNA; V25, Laundry; V6, Housekeeping; V27, LPN; V28, Dietary Aid; V29, Dietary Aid and V30, CNA, were interviewed and all have been educated on the elopement policy, code pink policy, door alarms and where to locate information on residents at risk for elopement. R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 and R18's elopement assessments and care plans were reviewed and have been reviewed/revised by facility staff. R4 and R5's elopement assessments were reviewed and neither resident was assessed as being at risk for elopement, therefore their care plan did not need to be updated. R2's 15-minute checks were reviewed and are being completed. The door alarm audits were checked and are being completed. The elopement/code pink policies were reviewed with changes made by the facility. The in-services for the elopement policy/code pink and door alarms were reviewed and have been completed. All exit door alarms, 100 hall, 200-hall, 300-hall, front entrance) were checked with V21, Maintenance Supervisor, all are functioning as necessary. The Immediate Jeopardy that began on 04/09/23 was removed on 04/13/23 when the facility took the following actions to remove the immediacy: A. Identification of Residents Affected or Likely to be Affected: 1. From 04/10/23 to 04/12/23 all 16 residents (R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, & R18) that are at risk for elopement were reassessed by V18, Social Service Director using the Elopement/unauthorized Leave Risk. 2. On 04/12/23 all remaining residents currently residing in the facility were reassessed by V18, Social Service Director using the Elopement/unauthorized Leave Risk. 3. Newly admitted residents or residents that display a new behavior related to elopement will be assessed or reassessed. This will be ongoing. 4. Care plans were reviewed and updated by V20, MDS Nurse as indicated. On 4/12/23 all Resident's Care plans were reviewed and updated by V20, MDS Nurse as indicated. No further residents were identified as at risk for elopement. B. Actions to Prevent Occurrence/Recurrence: 1. On 04/12/2023 all staff were in-serviced by V18, Social Service Director on location of the elopement binders (nurse station, social service office) including interventions to address elopement behaviors. Any agency staff or new staff will be in-serviced prior to working the floor. This will be ongoing. 2. On 04/12/23 (Door alarm company) installed egress alarms that will alert staff when the door is left open for 20 seconds. Staff will be required to manually turn off the alarm at the door once staff manually enter the code the door will be reset. The alarm will not stop sounding until the staff member enters the code in the keypad at the door. Both 300 and 200 hall doors were updated with the new equipment. 3. On 04/12/2023 All staff have been in-serviced on the door alarm and not turning the alarm off at the control panel. Any agency staff or new staff will be in-serviced prior to working the floor. This will be ongoing. 4. 04/13/2023 100% All Staff in-service completed. Maintenance Supervisor V21, or Designee performs door alarm checks daily. This audit will continue indefinitely, and results will be reported to QAPI monthly for the next 2 months 5. On 04/12/2023 policy on Unauthorized Absence and Code Pink: Missing Resident/Elopement policy was reviewed, revised, and updated by V22, VP Clinical Operations Arcadia Care. 6. On 04/12/23 All Staff in-service initiated on revised policy on Unauthorized Absence and Code Pink: Missing Resident/Elopement policy. 04/13/23 90% completed. In-servicing will continue until 100 % completed. Staff will receive in-service prior to start of next scheduled shift. Any agency staff or new staff will be in-serviced prior to working the floor. This will be ongoing. 7. On 04/12/23 (Door alarm company) installed egress alarms that will alert staff when the door is left open for 20 seconds. Staff will be required to manually turn off the alarm at the door once staff manually enter the code the door will be reset. The alarm will not stop sounding until the staff member enters the code in the keypad at the door. Both 300 and 200 hall doors were updated with the new equipment. 8. On 04/12/23 all potential exits secured, and staff are able to recognize when a resident exits the facility.

Based on interview and record review the facility failed to provide safe transfers for 1 of 3 residents (R10) reviewed for falls in the sample of 14. This failure resulted in R10 falling out of a shower chair and receiving bilateral tibia and fibula fractures. Finding includes: R10's Electronic Medical Record face sheet dated 3/29/2022, documents R10 has diagnoses of [CONDITION(S)], paralytic syndrome, and abnormal posture. R10's Minimum Data Set (MDS) dated Jan12, 2022 documents that R10 requires extensive assistance and two plus physical assistance for bed mobility. R10's MDS (Minimum Data Set) documents that R10 is totally dependent and requires two plus staff physical assistance for transfers. R10's Care Plan dated, revised 8/26/2019 documents that R10 has Activity Daily Living (ADL) self-care performance deficit related to [CONDITION(S)] (MS), weakness and decreased mobility. R10's Care Plan documents intervention dated 8/27/2019 (full body mechanical lift) and staff assist of 2 for all transfers. On 3/29/2022 at 10:38 AM V2, Director of Nursing (DON) stated an employee had reported to her there was a rumor that R10 was found with fracture legs at the hospital. V2 stated that she started an investigation and did call the hospital and the hospital would not return her calls. V2 stated based on interviews and her investigation it appears V11, Agency Certified Nurse's Aide (CNA) was giving R10 a shower in the morning on 3/23 and dropped her out of the shower chair, got her back in bed and did not report the fall. V2's typed undated investigation report documents that V11 stated that she had R10 in a shower chair in the shower room on 300 hall. The report documents that another agency CNA (V12) was with her. The report documents V11 stated that R10 slid out of the shower chair, and she was unable to pick R10 up. The Report documents V11 stated she had V12 assist her. V2's report documents that V12 brought the mechanical lift into the shower room and assisted R10 into a shower bed, and then took R10 back to her room and assisted V11 putting R10 to bed. The report documents that V11 CNA told V12 CNA she had reported the incident to the nurse on duty and was told not to worry about it. V2's report documents that V12 stated she was asked by other agency CNA (V11) to come and assist with getting R10 in shower chair. V2's report documents that V12 got the mechanical lift and took it into the shower room and assisted R10 into a shower bed. V2's Report documents that V12 told V11 that R10 should have been a shower bed from the start, and then took R10 to her room, and assisted with getting R10 in bed. The report documents that V12 asked V11 if this was reported to the nurse on duty, and V11 stated yes, she told me not to worry about it. V2's investigative report document that V13, CNA was working on 3/24/2022 when R10 was sent out to the hospital. The report documents at that time V11 stated that R10 had fallen and V13 asked V11 if she had reported the fall. V13 encouraged V11 to report the fall. The report documents that V11 then told V13 that R10 fell forward out of her chair in the shower room. V11 then reported to V22, Licensed Practical Nurse (LPN) on duty. The report documents that V22 questioned V11 and V11 stated R10 slid out of the chair to the floor and assisted the fall. R10's Nurse's Note dated 3/24/2022 at 9:53 AM documents Resident being sent to (Local Hospital) for evaluation due to change of condition resident is alert but not oriented. Note documents resident is not able to be aroused. Vitals within normal limits. The Note documented per nurse practitioner R10 was to be sent to Emergency Department (ED) for evaluation. R10's Progress Notes dated 3/24/2022 at 15:18 by V6 LPN documents Spoke with ED nurse and resident has been admitted to Intensive Care Unit (ICU) for septic shock and pneumonia and intubated. V2 aware. R10's hospital ED general adult, ED merge intubation procedure report dated 3/24/2021 at 10:21 documents that R10 arrived at hospital with decreased responsiveness, difficulty breathing. The report documents that R10 had an episode of vomiting the night before and since then she has had heavy secretion and trouble clearing her secretions with cough. The report documents has had reduced mental awareness and increased confusion per extended care facility staff. R10's Hospital Consultation Note, dated 3/27/2022, documents reason for consult: Fractures in both legs. The consultation documents that X-rays of bilateral LE (lower extremities) suggested severe [CONDITION(S)], right distal tibial fracture, malunion complicated with new fracture in the distal tibia and fibula, left tibia nondisplaced spiral fracture. Ortho called for further evaluation. Consult physical exam documents Examination of the bilateral lower extremities suggested mild tenderness to palpation on the lateral aspect of the bilateral legs. Mild swelling was evident. Report documents difficult to flex the bilateral leg due to pain, unable to bear weight on the bilateral leg. Sensation was decreased to light touch. Radiology comments documents X-rays of bilateral LE suggested severe [CONDITION(S)], right distal tibial fracture malunion complicated with new fracture in the distal tibia, and fibula, left tibia nondisplaced spiral fracture. R10's surgical soap note from hospital, dated 3/28/22, documents Fall- resident reportedly fell on ,d+[DATE] prior to admission The Note documents Nursing home reports patient is a (full body mechanical) lift and requires total assistance with turn. The Note documented orthopedic physician consulted and recommends long leg brace with no surgical intervention at this time. On 3/30/2022 at 10:36 AM V20, CNA stated that R10 is to be transferred with a mechanical lift, so R10 should never be in a shower chair, but a shower bed. On 3/30/2022 at 12:05 PM V21, Nurse Practitioner stated that if R10 had been transferred with the use of a mechanical lift her fractures could have been prevented. On 3/30/2022 at 12:34 PM V2, DON stated that she would expect staff to provide safe transfers when transferring residents. The facility policy Transfers-Manual Gait Belt and Mechanical Lifts, revised 1/2018, documents In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Resident. The Policy documents 1. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted.

Based on observation, record review and interview the facility failed to provide pressure ulcer treatments as ordered by the physician for 2 of 4 residents (R34, R60), reviewed for pressure ulcer in the sample of 54. This failure resulted in R34 sustaining a deep tissue injury to left heel. Finding include: 1. R34's Minimum Data Set, dated dated [DATE], documented severely impaired cognition. R34's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Braden Assessment, dated 11/11/21, documented at high risk for developing pressure ulcers due to slightly limited with movement, constantly moist and chairfast. R34's wound evaluation and management summary, dated 11/22/21, documented a stage 3 left buttock pressure ulcer, resolved on 11/22/21. A shear wound to left back of thigh continues treatment monitoring, measuring 3 x(by) 1.5 x 0.2 centimeters. R34's Local Hospital-Wound Clinic orders, dated 11/9/21, documented provided procedure for both lower legs wound treatments. On 11/23/21, documented procedure for cultures to both lower leg ulcers and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Nurse Note, dated, from 11/9/21 through 11/23/21, with multiple documentations of R34 refusing to take medications, get into bed and remaining in his wheelchair throughout the day and evening hours into the night. R34's Care Plan dated 5/8/21, documented the following interventions: 1. Transfers by a full mechanical lift with only one staff assistance, initiated 7/21/21. 2. Elevate legs every 2 hours initiated 11/19/21. 3. On 12/1/21, R34 is resistive to care and will refuse wound treatment and medicines, this documentation was put in place after this concern was mentioned, on 12/1/21 to V10, Licensed Practical Nurse, (LPN)/ wound nurse. R34's Progress Notes, on 11/23/21, documented left heel Deep tissue injury and order for foam boots to be worn at all times. No other documentation of non-compliance with wearing the foam boots and to keep both feet off-loaded from a hard surface area. On 12/1/21, at 9:24AM, documented a first notification with R34's wound clinic. On 11/29/21 at 8:45AM, initial observation, R34's bed was located near the door with privacy curtain completely closed around him. R34 was sitting in a wheelchair with both feet planted on a hard tile concrete slab floor with foam boots applied to both feet and the wheelchair foot extension dismantled and lying on the floor. Again, at 12:10PM and for every 15-minutes until 3:00PM, R34 remained in the same sitting position. On 11/30/21 at 8:15AM, R34 was up in a wheelchair in his room, both feet were in direct contact to the floor. R34 was not wearing the foam boots. R34 remained up in the wheelchair with his feet on the floor and no foam boots until 3:30PM when observation ended based on 20 minute observation intervals. R34's foam boots were not visible in his room. On 11/30/21 at 12:00PM, V9, Certified Nurse Aide (CNA), stated she always works this hall and when asked, if R34 is to wear waffle boots, she stated I saw him with them on when I left my shift on 11/29/21 and was not sure, because night shift gets him up. On 12/1/21 at 10:00AM, R34 was up in wheelchair in his room, with both feet in direct contact with the floor. R34 was not wearing the foam boots. R34's foam boots were not visible in his room. On 12/1/21 at 10:55AM, V10, Wound Nurse, stated that the local hospital wound clinic oversees his bilateral leg ulcer treatment and stated that he is to wear his foams boots at all times and was unsure where or why he did not have the boots on, as they may have been transported down to laundry. On 12/1/21 at 4:10pm, V19, Wound Clinic Registered Nurse (RN), stated R34 was seen in the office on 11/29/21 came in the office wearing both waffle (foam) boots, which were soiled and smelled of urine, they were then disposed and replaced with new ones but R34 refused to wear them because they make his feet hot, so he was sent back to the facility without any waffle boots. V19 stated, R34 was seen at the wound clinic on 11/9/21 without a deep tissue injury to either heel identified. V19, continues to state, that when R34 returned on his next visit of 11/29/21, the physician identified a deep tissue injury to R34's left heel, which V19 stated, the injury was a new occurrence, and described as deep reddish-purple in color which is caused by extensive length of time a skin area is in contact with a hard object, which can cause a pressure injury. V19, continues to state that she would expect the facility to follow the wound clinic treatment orders that were ordered on 11/23/21. On 12/2/21 at 923AM, V18, Corporate Crisis Nurse Manager, stated, she would expect staff to follow Physician orders, follow Care Plan interventions, keep in contact with the wound clinic and continue to educate the resident as much as possible. The facility's policy, entitled, Pressure Ulcer Prevention, dated 1/15/18, documented, use positioning devices or pillows, rolled blankets, etc. to reduce pressure and friction/shearing from heels. 2. On 11/30/21 at 09:46 AM, R60 stated I have a sore on my bottom. R60's Care plan dated 9/28/2021 documents R60 has an actual impairment to skin integrity. R60's Care Plan documents R60 has a coccyx stage 4 pressure sore. R60's care plan documents the following interventions: 10/26/21 Low air loss mattress, 9/28/21 Bilateral heel boots on at all times except for ADLS (activities of daily living) for pressure offloading prevention, administer/monitor effectiveness of medications as ordered, assess/record changes in skin status, avoid shearing: use lift sheet for repositioning, bilateral heel boots on at all times except for ADLs, Encourage good nutrition and hydration in order to promote healthier skin, ensure linens are wrinkle free, Foam wedge for repositioning and offloading, Minimize pressure over boney prominences, Protective skin barrier cream as ordered, provide barrier cream for preventative measure, provide/monitor effectiveness of pressure relieving or reducing devices, Air Loss pressure reducing mattress, heel protectors, air Cushion, Treatment as ordered. On 12/02/21 at 9:38 AM during incontinent care, R60 did not have a dressing in place to the pressure sore on coccyx. Adult incontinent brief and bed checked and no dressing present. Adult incontinent brief contained yellow drainage from wound. R60's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Facility Pressure Ulcer Prevention policy dated, revised 1/15/2018 documents moisture barrier may be applied by CNA (Certified Nursing Assistant) as needed to intact skin and may be kept at bedside. The Facility policy Skin Condition Assessment and Monitoring Pressure and non-pressure dated revision 6/8/2018 documents that dressings which are applied to pressure ulcers shall include the date of the licensed nurse who performed the procedure. On 12/06/2021 at 10:49AM, V2, Director of Nursing (DON), stated that she would expect dressings to be in place as ordered.

Based on record review, observation and interviews, the facility failed to implement interventions, provide supervision to prevent falls, and provide safe transfers for 3 of 6 residents (R13, R34, R53), reviewed for falls in the sample of 54. This failure resulted in R53 sustaining a laceration to his right top of head requiring 11 sutures. Findings include: 1. R53's Physician Order Sheet, dated for 11/2021, documented the following: [CONDITION(S)] (without receiving oxygen) brain damage, [CONDITION(S)], Dysphagia, receiving Enteral Feedings, [CONDITION(S)], Nothing by Mouth, contracture of the muscles to multiple sites. Enteral Feeding order for [MEDICATION(S)] 1.5 calories to infuse at a rate of 99 ml, (milliliters) starting at 6:00 PM and to run via feeding pump until 8:00 AM or until total volume of 1386 ml. has been infused, with an active date of 11/9/21. R53's Minimum Data Set (MDS), dated [DATE], documented, severe mental cognition. R53's Fall Risk Assessment, dated 10/25/21, documented intermittent confusion, 3 or more falls in past 3 months, gait and balance, not able to perform function at a score of At Risk for Falls. Fall Risk Assessment, dated 11/1/21, documented a repeat of assessment 10/25/21, At Risk for Falls. R53's Care Plan, initial date of 3/19/21, documented, at risk for falls due to non-weight bearing status, Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance, date initiated: 4/1/21. On 11/29/21 at 9:00 AM, R53 was holding a rolled cloth in his right hand and right arm bent up and contracted up towards his chin, also, right hand contracted, both legs extended straight and rigid and both feet extended downward, unable to communicate clearly, however, R53 could understand by rolling his eyes or make non-verbal sounds. On 12/1/21 at 1:10PM, V9 and V20, Certified Nurse Aides (CNA's), were providing incontinent care for R53. V20 stated at 1:15 PM, that R53 cannot move himself or assist with care. V9 and V20 rolled R53 side to side in his bed for incontinent care. R53 was unable to provide assistance, with both arms contracted and both legs extended out during the roll from side to side and support provided by staff. R53's Incident Report, date range for 6/1/21 to 11/30/21, documented an un-witnessed Fall Incidents on 6/21/21 at 10:27 AM, 7/11/21 at 10:16 PM, 9/7/21 at 10:30 PM, 9/13/21 at 3:16 AM, 9/14/21 at 11:40 PM, 9/23/21 at 11:30 AM and 10/25/21 at 1:30 AM. These Incident Reports, all document an un-witnessed fall, with R53 lying on the floor near the side of the bed. R53's Fall incident of 9/23/21 at 11:30AM is the only fall event where R53's Enteral Feedings would not have been infusing as scheduled. R53's Fall Incident Report, dated 10/25/21 at 1:30 AM, documented, Writer while doing night treatments found resident lying on the floor on his stomach beside his bed. Noted a moderate amount of blood and during assessment found a 3 cm. (centimeter) laceration to his right forehead in his hairline. A new intervention to reposition in bed. R53's Progress Note, dated 10/25/21 at 5:01 AM, documented transferred to a local hospital for evaluation and treatment of a fall. R53's Emergency Area Hospital report, dated 10/25/21 at 2:43 AM documented, R53 brought to hospital due to fall from rolling out of bed with laceration to top of scalp and R53 is severely contracted in extremities and neck and later admitted for treatment of Fecal impaction, Dehydration and Aspiration Pneumonia. R53's Progress Note, dated 10/31/21, R53 returned to facility from hospital receiving 11 sutures to the right top of his head. R53's Fall IDT (interdisciplinary team), date 11/3/21, documented a root cause of fall, resident likes to scoot himself out of bed, intervention to remove bookshelf from room. On 10:50 AM, V2 Director of Nursing (DON), stated, she would expect her staff, especially with R53 to be observed frequently. V2 stated, that R53 will scream out, and feels that staff walk by his room and ignore him. V2, also stated, that one nursing staff is not enough to provide care, especially the hall where R53 resides. On 12/6/21at 1:30P M, V31, R53's Physician, stated, he would expect residents to be observed at least every two hours and that the facility should increase their staffing levels to assure monitoring. The facility's policy and procedure, entitled Fall Prevention Program, dated 11/21/17, documented, to assure the safety of all residents in the facility, will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions. The Care Plan will identify all risk and issues, to address each fall which will include interventions to be changed with each fall, as appropriate. 2. On 11/30/21 at 08:19 AM, R13's nurses notes document that R13 had a fall and received Hematoma to right side of head on 10/23/21 with root cause being identified as R13 wanting to go shopping. R13's note documents Intervention to place wheelchair in hallway and dycem (non-slip) strips on floor beside bed. On 12/01/21 at 11:36 AM, there were no dycem strips on the floor beside R13's bed. On 12/01/201 at 12:50PM, R13's wheelchair beside bed and unlocked. R13's Fall Risk assessment dated [DATE] and 10/12/2021 documents that R13 is at risk for falls. R13's Care Plan dated 2/9/2021 documents that R13 is at risk for falls related to physical mobility limitations. R13's Care Plan documents as part of intervention to review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter and remove any potential causes if possible. On 12/01/21 at 03:46 PM, V2, DON, stated that she would expect interventions for falls identified in the care plan to be in place. 3. On 12/01/2021 at 11:30 AM, V9 CNA, operated the full mechanical lift to transfer R34. V16 CNA did not provide support, nor did she check to see if the sling straps were secure when R34 was being lifted up off of the bed. When V9 raised R34 with the full mechanical lift, she raised him up in the air, to an approximate height of over 5 feet, based on surveyors standing height. V16 CNA did not support R34 in the sling allowing R34 to swing back and forth and eventually rotate in a full circle while being up in the air during the transfer. On 12/06/2021 at 09:30 AM, V13 CNA, stated that when they use the full mechanical lift, they are to use 2 staff members, 1 to operate the lift and the other is to guide the resident into the bed or chair. They are to have their hands on the resident while they are moving. On 12/06/2021 at 09:40 AM, V28 CNA, stated that when they use a full mechanical lift, they are to be supporting the resident in the sling while the other CNA is operating the lift. R34's Care Plan, dated 10/19/2021, documents Use mechanical lift for transfers to prevent further injury. On 12/06/21 at 10:50 AM, V2 DON, stated when using the full mechanical lift, she would expect the CNA's and nurses to use 2 staff with 1 staff member operating the lift and the other staff member to have hands on the resident providing support throughout the transfer. The facility's policy, How to use a (full mechanical lift) dated 10/2013, documented a picture of 2 attendants, one attendant was operating the lift and the other supporting the resident legs and the resident backside.

Based on interview and record review the facility failed to implement progressive interventions and supervision for two of three residents (R2 and R3) reviewed for falls in a sample of seven. This failure resulted in R3's fall sustaining a Inferonasal Laceration, a Nasal Contusion with possible Occult Nasal Fracture, Epistaxis (nosebleed), and another fall sustaining a [CONDITION(S)] requiring hospitalization and surgical repair. This failure also resulted in R2 sustaining a Subarachnoid Hemorrhage and Subdural Hematoma (brain bleeds). Findings include: R3's Care Plan, dated 06/16/2021, documents I am at risk for falls R/T (Related To) Hypertension, weakness and medication use. It also documents Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R3's Electronic Health Record (EHR) documents R3 has had 11 falls from 06/01/2021 to 10/08/2021. R3's Fall Risk Assessment, dated 06/17/2021 documents Intermittent Confusion it also documents R3 is at risk for falls. R3's Fall-Initial Occurrence Note, dated 06/18/2021 3:42 PM, documents R3 had an unwitnessed fall in his bedroom. Alert and disoriented per baseline. No investigation provided by facility upon request. New intervention-call for assistance by using the call bell. R3's Fall-Initial Occurrence Note, dated 07/09/2021 1:40 PM, documents fall in resident room attempting to pick up water pitcher. Alert and disoriented per baseline. Intervention instructed to use call light. R3's Fall- Initial Occurrence Note, dated 07/13/2021 1:15 PM documents fall in resident's bathroom room. Resident observed attempting to walk from bathroom. Resident unsteady and staff lowered to floor. The facility did not provide investigation upon request during this investigation. No immediate intervention documented. R3'S EHR documents R3 was found on floor on 07/16/2021 at 3:45 AM. No investigation provided upon request during this investigation. No intervention put in place. R3's EHR, dated 07/19/2021 4:35 PM, documents Fall IDT Note: Attendee's present: IDT (Intermediate Disciplinary Team) members. Summary of the fall: resident lowered to the floor by aide. Root cause of fall: resident became unsteady. Intervention and care plan updated: resident assisted back to chair, increased monitoring. R3's EHR, dated 07/29/2021 8:38 PM documents Other/General Note, Note Text: CC (Chief Complaint)/HPI (history of present illness) This Visit Chief Complaint/Reason for this Visit: Fall. HPI Relating to this Visit (R3) is being seen today S/P (Status Post) fall. On 07/27/2021, he was attempting to go to the restroom. He lost his balance and fell to his buttocks in the restroom. He was incontinent of urine and stool when the nurses found him. He was cleaned up and helped back to bed. He denies pain during exam. He uses a wheelchair to move about the facility but states that the chair is too big to fit in the bathroom. He states that he feels fine and does not have any issues today. R3's Fall Risk Assessment, dated 07/30/2021 05:30 AM, documents that R3 has intermittent confusion is chair bound with balance problems while standing, walking and decreased muscular coordination. R3's EHR, dated 07/30/2021 at 6:12 AM, documents R3 was found on floor. No intervention put in place. R3's Fall Risk Assessment, dated 08/03/2021 8:31 AM, documents that R3 has intermittent confusion is chair bound with balance problems while standing and requires use of assistive devices. R3's EHR, dated 08/04/2021 4:30 PM documents Fall IDT Note: Attendee's present: IDT members. Summary of the fall: resident found on floor on bottom. Root cause of fall: resident gets up on his own as he does not remember he is weak. Intervention and care plan updated: resident spoke with his son regarding resident getting up. R3's Fall Risk Assessment, dated 08/09/2021 11:55 AM, documents that R3 has intermittent confusion is chair bound with balance problems while standing and requires use of assistive devices. R3's Nurses Notes, dated 08/09/2021 12:02 PM documents Fall: Time of fall; location of fall; vital signs: resident stumbled on way to bathroom, fell to knees and then got right back up, able to move all extremities WNL (Within Normal Limits), resident is his own Power of Attorney, so no notification of family was required, NP (Nurse Practitioner) notified, resident educated on asking for help with transfer of ambulation. R3's EHR, dated 08/11/2021 10:43 AM documents Fall IDT Note: Attendee's present: IDT members. Summary of the fall: resident witnessed stumbling, fall to knees, then get back up to bed. Root cause of fall: resident walking around on his own. Intervention and care plan updated: therapy to evaluate/treat, fall leaf placed by name on door frame. R3's Fall-Initial Occurrence Note, dated 08/30/2021 12:22 AM, documents vitals and responsible party name and number only. No investigation provided and no intervention put in place documented. R3's EHR, dated 09/07/2021 10:39 AM documents Fall IDT Note: Attendee's present: IDT members. Summary of the fall: resident found on floor. Root cause of fall: resident attempted to get up on his own. Intervention and care plan updated: sitter initiated. R3's Fall Risk Assessment, dated 09/21/2021 11:13 PM, documents that R3 is disoriented x3 (x-times) (to person, place, and time) at all times, 3 or more falls in past 3 months, and balance problems while standing. R3's Fall-Initial Occurrence Note, dated 09/21/2021 11:15 PM, documents witnessed fall in his room between bathroom and bedroom. Description of occurrence: Resident was walking back from the bathroom, without assist and stumbled and went to the floor onto his knees. Resident statement: Resident was walking back to bed from the bathroom when he stumbled and went to his knees hitting his nose on the bed. Alert and disoriented per baseline. Resident has a medium sized abrasion on his left knee. And bloody nose. No new interventions initiated to prevent further falls were documented. No investigation provided by facility. R3's Nurses Notes, dated 09/22/2021 3:00 PM, documents Narrative: Resident returned from (Local Hospital) ED (Emergency Department) facility (08:00 AM) with discharge diagnosis of mechanical fall with Inferonasal Laceration repaired with Dermabond, Nasal Contusion with possible Occult Nasal Fracture and Epistaxis which was easily controlled in the ED. R3's EHR, dated 10/08/2021 11:57 AM, documents FALL-INITIAL OCCURRENCE NOTE, Fall Description: Resident had a witnessed fall 10/08/2021 11:40 AM Location of Fall: Resident fell in his room. Resident got out of his bed and started walking towards his bathroom, before staff could reach resident, he fell on the floor landing on his left hip and shoulder. Resident has full ROM (range of motion) in left upper and lower extremities, but resident is complaining of pain rated 7.5/10 in left hip after standing up. Resident stated his left hip was not hurting very bad at all before he stood up. Resident denies any pain in left shoulder. Resident did not hit his head. Fall was witnessed. on 10/08/2021 11:40AM. Resident statement (if applicable): Resident stated he was trying to walk to the bathroom and fell . Resident denies hitting his head and denies pain in left shoulder. Resident stated his hip was not hurting very bad at all before he stood up, but once resident was standing, he stated his left hip was hurting and rated the pain 7.5/10. R3's EHR, dated 10/08/2021 12:43 PM, documents Nurses Note Narrative: Resident left facility via ambulance en route to (Local) hospital d/t (due to) resident falling and c/o (complaints of) pain in left hip rated 7.5/10. R3's EHR, dated 10/09/2021 at 12:43 AM, documents Nurses Note Narrative: Resident admitted to Hospital. R3's EHR, dated 10/10/2021 at 2:15 AM, documents Nurses Note Narrative: Per (Hospital RN) from (Local Hospital) resident is having surgery in the AM and they are in need of his POA (Power of Attorney) paperwork. Will call back in AM. R3's EHR, dated 10/11/2021 at 4:46 PM, documents Admission Note Text: resident received to room 104-3 at approximately 4:18 PM, by wheelchair from (Local) area hospital related to recent fall resulting in a fracture of the left femur, resident noted to have 20 staples in left hip, no other skin issues noted at this time. On 10/18/2021 at 11:15 AM, V3, Quality Assurance Nurse, stated that R3 had a fall that caused a fracture. Stated that R3 was sent to hospital and fracture was repaired (R3) returned back to the facility. V3 stated that R3 is noncompliant with safety interventions. On 10/18/2021 at 12:15 PM, R7 stated that (R3) has problems with his vision and can only read at a third to fourth grade level. R7 stated that he had witnessed R3's fall and witnessed the last one that sent him to the hospital. R7 stated that he is not sure if R3 pulled the call light but knows that R3 was yelling for help before getting out of the bed. On 10/19/2021 at 9:11 AM, V6, Certified Nurse's Assistant (CNA), stated that R3 is at risk for falls. V6 stated that R3 did have times when he was confused but could tell you when he needed to go to the bathroom. V6 stated that he needed assistance with going to the bathroom. V6 stated that he used his call light, or he would yell for help. V6 stated that you had to get to him quick or he would try to take himself. V6 stated that R3 needed to be monitored but with only 1 CNA on the hall that is not possible. V6 stated that if you are taking care of someone else you may not know that his light is on and it will take a while to get to him. On 10/19/2021 at 10:44 AM, V2, Director of Nursing (DON), stated that R3 is a fall risk. V2 stated that R3 was brought to the facility because he was having falls at home, during his stay at the facility this has continued. V2 stated that they have placed him on increased monitoring and every hour toileting program. On 10/19/2021 at 11:30 AM, V3 stated that increased monitoring means resident will be checked on every 30 minutes. On 10/19/2021 at 11:40 AM, V12, Licensed Practical Nurse (LPN), stated that she does not know what the leaves on the resident's door mean. V12 stated that she was not aware that the leaves were to indicate who was at fall risk. On 10/19/2021 at 12:39 PM, V7, CNA, stated that R3 fell a lot. V7 stated that R3 had to be watched. V7 stated that R3 would use his call light or yell help. V7 stated that they are understaffed and can't monitor R3 every 30 minutes and are not able to take him to the bathroom every hour. V7 stated that they rely on him to let them know when he needs to go and try to get to him before he tries to transfer himself. V7 stated that when you are in the room and we are short staffed this is not possible. V7 stated that this has happened before and R3 fell . On 10/19/2021 at 1:44 PM, V8, LPN, stated that she was called to R3's room and he was on the floor. R3 stated that she wasn't sure if he was going to or coming from the bathroom. V8 stated that he was assessed on the floor and did not complain of pain but when he got up, he started complaining of pain. V8 stated that she sent him to the hospital. V8 stated that R3 is someone that you have to answer his light or his yell for help quick or he will try to take himself. V8 stated that R3's confusion is his normal state. V8 stated that she had 2 CNAs on the hall 1 of her CNAs went to lunch, 1 CNA was doing something, and she was passing pills. V8 stated that she doesn't know if R3 is on 30-minute monitoring or to be toileted every hour. V8 stated that they just couldn't get to him quick enough. On 10/20/2021 at 10:39 AM, V10, Primary Physician, stated that if the staff were following the interventions that were put in place, the fall could have been prevented. On 10/20/2021 at 12:13 PM, V13, CNA, stated that she was assigned to the hall when R3 fell . V13 stated that she returned from break and was told he fell . V13 stated that she asked him what happened and R3 said that he pulled his call light and yelled for help and no one came so he tried to take himself and fell . V13 stated that she repeatedly tells R3 this to keep him from falling. V13 stated that you have to respond to R3's call light quickly or he will fall. V13 stated that she was not aware that staff were to check on R3 every 30 minutes and place him on the toilet every hour. On 10/20/2021 at 2:36 PM V2, DON, stated that she would expect her staff to follow the interventions that were put in place. V2 stated that R3 had a sitter put in place due to his falls and the sitter had to be discontinued. V2 stated that if she had enough staff that she would have continued the sitter as R3 needs to be monitored. R2's Care Plan, dated 08/09/2021, documents I am at risk for falls. Goal: I will not sustain serious injury through the review date. Interventions 08/09/2021 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 08/09/2021 Follow facility fall protocol. PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team) as to causes. No further updates/revisions were made to R2's fall care plan. The Facility's Accident and Incident log, dated September 2021, documents R2 had a fall on 09/22/2021 with no injury. It also documents October 2021, R2 had a fall on 10/02/21 with injury. The facility did not provide Occurrence report or investigations for either fall upon request during this investigation. R2's Fall Risk Assessment, dated 08/06/2021, documents R2 is not at risk for falls. R2's Fall Risk Assessment, dated 09/22/2021, documents R2 is at risk for falls. R2's EHR does not document 09/22/2021 fall. R2's EHR, dated 09/24/2021 12:40 AM, documents Nurses Note, Narrative: (R2) returned from (Local emergency room ) visit via ambulance transport. (R2) appeared in pleasant mood and was cooperative with author's interactions. paperwork received from (local hospital) was noted for no negative findings from lab and diagnostic tests. (R2) was negative for any hip, back or cranial fractures. author advised (R2) to remain seated and to please wait for assistance with any transfers. vitals noted at 116/82 blood pressure 98.4F temperature 92 pulse 93 SPO2 (Pulse Oximetry). No new treatment orders were advised. R2's EHR, dated 09/24/2021 09:34 AM, documents Nurses Note, Narrative: Resident had c/o (complaints of) nausea without vomiting. NP made aware and received NO (new order) for [MEDICATION(S)] 10 mg (milligrams) PO (by mouth) q6 (every 6) hours PRN (as needed) R2's EHR, dated 09/28/2021 3:43 PM, documents Fall IDT Note Attendees present: IDT members Summary of the fall: resident found on floor between bed and chair after fall. Root cause of fall: resident states she was getting back into bed and her legs got weak and she fell . Intervention and care plan updated: resident to see therapy. R2's Progress Notes, dated 10/02/2021 3:15 PM, documents Health Status: Late Entry: Note Text: Writer was notified by floor nurse that this resident had been found on the floor in her room at end of her bed, by her wheelchair. Resident was able to tell staff she fell while trying to get up. Nurse states that she remained alert and was orientated to time and place. States that she did hit her head, but it was in the same place that she hit her head last week. One of the CNA's had brought in her clothing and the resident was able to go thru it and decide what she wanted to keep. Resident has been showing signs of confusion for the past week and was noted to be removing her oxygen a lot. Staff did start neuro checks. R2's EHR, dated, 10/04/2021 05:57 AM documents Transfer to Hospital Summary, Note Text: O2 sat (Oxygen Saturation) 75% on room air. O2 sat fluctuates between 85% and 91%- and 5-liters oxygen via nasal cannula. Nasal cannula switch to face mask, patient continues to de-sat to 85%. Patient cognition severely decreased from the time this RN (Registered Nurse) came on shift at (11:00 PM) 10/03/2021 (confusion with slurred speech). Transport called to take patient to (Local) ER (emergency room ). Patient transported to (Local) ER at approximately (05:30 AM) on 10/04/2021. R2's EHR, dated 10/04/2021 09:01 AM, documents Nurses Note Narrative: Spoke with (Local Emergency Doctor) regarding resident. She asked if resident had fallen recently- I informed her that she had in fact fallen 10/02/2021 and it was unwitnessed. I gave a report to MD (Physician) regarding resident, that she is usually AOX3 (alert and oriented to person, place, and time), but at times can be confused. MD informed me that resident had in fact sustained a subdural and subarachnoid bleed and would be sent to Memorial Medical Center. Resident is also confused at ED currently. R2's (Local Hospital) CT (Computed Tomography) of the Head without Contrast, dated 10/4/2021 9:39 AM, documents Impression: 1. Subarachnoid hemorrhage overlying the left cerebral hemisphere. 2. Small subdural hematoma layering along the falx cerebrum anteriorly. R2's (Regional Hospital) Discharge Paperwork, dated 10/11/2021, documents Hospital Summary: I was in the hospital because of a brain bleed. On 10/18/2021 at 3:15 PM, V4, CNA, stated that R2 is confused and requires more help than before. On 10/19/2021 at 12:39 PM, V7, CNA, stated that she took care of R2 prior to falls. V7 stated that when R2 got sick she became weak and needed more help with transfers. V7 stated that R2 went from transferring by herself to needing 2 people to transfer. V7 stated that after R2's fall in September there wasn't nothing new put in place to keep her from falling. V7 stated that R2 was more confused. V7 stated that she had changed. On 10/19/2021 at 11:40 AM, V12, LPN, stated that R2 was a needy resident. V12 stated that she would pull her call light and kept her door open so she can see people walk pass. V12 stated that she would yell at staff to come in her room for different things as they walked by. V12 stated that she is not sure what interventions were put in place for R2 after her fall. V12 stated that the residents that are positive for COVID have their doors closed so she wouldn't be able to call for anyone. V12 stated that she is not aware of what the leaf on the resident name plate means. On 10/19/2021 at 1:44 PM, V8, LPN, stated that she was not here when R2 fell but she had taken care of her prior to the fall. V8 stated that R2 is more confused and requiring more assistance than before. On 10/20/2021 at 10:39 AM, V10, Physician, stated that R2 brain bleed was from the fall. V10 stated that he is not sure about the fall but that the facility monitored the resident and notified the physician when resident started to show changes. The Facility's Fall Prevention Program, Revision date 11/21/2017, documents Purpose: to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. It also documents Fall/safety interventions may include Call lights are answered promptly. It continues In the event safety monitoring is initiated for 15- 30-minute periods, a documentation will be used to validate observations.

Based on observation, interview and record review the facility failed to provide physician prescribed diet for 1 (R3) of 3 residents reviewed for enteral feedings in a sample of 6. This failure resulted in R3 experiencing a significant weight loss of 23.9 % in 6 months. Finding includes: R3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .), run continuous for 14 hours or until complete, may come off tube feed for ADLs (Activities of Daily Living). On 09/13/2021 at 2:30 PM, R3 was lying in bed receiving nutrition via an enteral feeding of [MEDICATION(S)] 1.5 calorie, 1000 milliliter (ml) bottle. The liquid nutrition was infusing per pump at 60 milliliters (mls) per hour (hr.). R3 appeared emaciated; bilateral eyes and cheeks were sunken in. R3's bilateral hands and fingers were contracted and were drawn up towards his chest. On 09/14/2021 at 10:25 AM, there was a bottle of [MEDICATION(S)] 1.5 calorie, 1000 ml bottle hanging on infusion pole next to R3's bed. The bottle had documentation that it was hung on 9/13/2021 at 2200 hrs. (10:00 PM) with an infusion rate of 60ml/hr. with R3's name on it. There was approximately 400 ml of feeding left in the bottle. On 09/15/2021 at 8:55 AM, there was a 1000 ml bottle of [MEDICATION(S)] 1.5 calorie hanging on an infusion pole next to R3's bed. It had R3's name on it. The bottle was dated 09/14/2021 at 2200 hr. (10:00 pm) with an infusion rate of 99ml/hr. There was approximately 200 ml left in the bottle. When the pump was turned on, total volume infused was 843 ml. R3's Admission Record, undated, documents R3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Nutrition Assessment, effective date 3/18/21, documented Resident admitted w (with)/ Acute respiratory failure w/ [CONDITION(S)] requiring resident to be NPO (Nothing by mouth) and on bolus TF (Tube Feeding) for all nutrition and fluids. The Assessment documents Will recommend continuing the Current TF and re-evaluate when current height and weight are available. He has had some history of pressure wounds to his right outer foot and sacrum in the past. TF will also meet extra protein needs for healing. Will continue the current feeding and monitor. R3's Nutritional Assessment, effective date 4/22/21, documented R3's most recent weight was 138.2 pounds. The Assessment documented that R3 had Stage 2 pressure ulcers to his outer left and right feet. The Assessment documented increase nutrient needs r/t (related to) decreased skin integrity as evidenced by Stage 2 PU's (pressure ulcers) of L (left) & R (right) outer foot. R3's Dietary Initial/Quarterly Annual, effective date 6/18/21 documents that R3 weighed 116 pounds as of 6/16/21. This was a 22.2 pounds (lb.) weight loss since 4/22/21. R3's Nutrition Assessment, written by V9 (Dietician), effective date 7/23/21, documented that R3 received [MEDICATION(S)] 1.5 232 bolus Q (every) 4 hours. The Assessment documented R3's most recent weight was 110.4 lbs. The Assessment documented (R3) had unplanned significant weight loss w/BMI (body mass index) falling below normal range at 15.4 - very underweight status. NPO status maintained. (R3) is receiving an enteral feeding bolus of [MEDICATION(S)] 1.5. Noted he often refused the feeding resulting in weight loss and stage 3 pressure ulcer noted per wound report on 7/15/21. R3 is receiving increased adequate nutritional intervention for wound management. The Assessment documented Will suggest possibly changing (R3's) enteral feeding to run via pump at night which may alleviate some of his refusal of bolus feedings. There was no documentation in R3's medical record that facility acted upon V9's recommendation on 7/23/21. There was no documentation in R3's medical record he was refusing his bolus feedings. R3's Nutrition Progress Note, effective date 8/20/21, documented (R3) had unplanned significant weight losses of 5.8 % x 3 weeks, 25.6 % x 3 months and 23.7 % since admission x 5 months with BMI falling below normal range at 15.2 = very underweight status. NPO status maintained. (R3) is receiving an enteral feeding bolus of [MEDICATION(S)] 1.5 providing an established 2088 kcal 88.8 g pro, 139% RDIs, 2200-2300 mL's total free water and 29 cal/kg bw/day exceeding established nutritional needs. Noted he often refused the feeding resulting in weight loss. Recommendation to change feeding to run via pump at night still pending. Will re-suggest possibility. Will follow PRN. R3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ., continuous for 14 hours or until complete, may come off tube feeding for ADLs. R3's Nutrition Progress Note, dated 09/10/2021 at 1320 (1:20 pm), V9 (Dietician) documented, (R3) had unplanned significant (weight) losses of 6.1% (in) 1 (month), 9.6% (in) 3 (months) and 23.9% since admission (in) 6 (months) (with a Body Mass Index) of 15.1 - very under (weight) status. (Nothing by mouth) status maintained. (R3) is receiving an enteral feeding of [MEDICATION(S)] 1.5 60ml/hr (for) 14 (hours) which is not adequate to meet nutritional needs. It continues, Will recommend increasing feeding to 99ml/hr. (times) 14 (hours) for total volume of 1386 ml. R3's Order summary report, dated 09/15/2021, documented, Enteral feed order in the evening [MEDICATION(S)] 1.5 (calorie), run at 99ml/hr. for 14 hours or until complete. May come off tube feed for (Activities of Daily Living). It also documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Weights and Vital Exceptions, dated 09/13/2021, documented that R3's weight that day was 104.8 pounds (LBS). It continued to document, -7.5% change (comparison weight 6/16/2021, 116.0 LBS, -9.7%, -11.2 LBS); -5.0% change (comparison weight 8/4/2021, 112.2 LBS, -6.6%, -7.4 LBS); -10.0% change (comparison weight 3/19/2021, 138.5%, -24.3%, -33.7LBS). On 09/14/2021 at 9:49 AM, V10 (R3's sister) stated that she was very concerned about her brother's appearance on 09/11/2021 when she saw him. V10 continued to state that R3 looked like he had lost a lot of weight and was skin and bones. On 09/14/2021 at 12:30 PM, V7 (Registered Nurse/RN) stated that R3's tube feeding was started in the evening and that she shuts it off around 8:00 AM the next morning. V7 also stated that she was unaware if R3 has had any weight loss. On 09/15/2021 at 12:24 PM, V7 (RN) stated that she shut R3's tube feeding off at 8:00 AM this morning but she did not remember what the total amount infused was. V7 stated that there were no orders for amount to be infused, and she was not for sure about how much he should be getting in 14 hours. On 09/14/2021 at 2:00 PM, V2 (Director of Nurses/DON) stated that the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 continued to state that she and the dietary manager make sure weights are reported to the resident's doctor and to the Dietician. V2 also stated that she would expect the nurses to run tube feedings as prescribed by the doctor. On 09/15/2021 at 10:10 am, V9 (Dietician) stated that she has been dealing with R3's weight loss and tube feeding since his admission to the facility. V9 continued to state that she just changed his tube feeding and increased ml/hr. from 60 ml/hr. to 99 ml/hr. and that this was done on 09/10/2021. V9 stated that if the enteral feeding of [MEDICATION(S)] 1.5 is ran at 99 ml/hr. for a total volume infused at or around 1300 ml, then (R3) should hopefully gain weight or maintain his current weight. V9 also stated that if a resident was on tube feedings, then they should not be losing weight. V9 stated that the nurses need to be infusing the total volume recommended and not just shut it off at a certain time. The facility's policy Gastrostomy Tube-Feeding and Care, dated 08/03/2020, documents To provide nutrients, fluids and medications, as per physician orders, to resident requiring feeding through an artificial opening into the stomach. It continues, 1. Licensed nurse will review physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It continues, 3. Label container with resident's name, flow rate, date and time. It continues, b. Record date/time container is hung.

Based on observation, interview and record review the facility failed to identify, assess, monitor and provide treatment to prevent residents from developing pressure ulcers for 3 of 3 residents (R3, R8, R9) reviewed for pressure ulcers in the sample of 15. This failure resulted in R3 developing a facility acquired stage 4 pressure ulcer. Findings include: 1.R3's Electronic Medical Record (EMR) dated June 2021 documents R3 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation prior to 6/4/21 that R3 had a pressure ulcer on her sacrum. R3's Wound Report, dated 6/4/21 documents, R3 developed a facility acquired stage 4 pressure ulcer to her sacrum which was identified on 6/4/21 with measurements of 20.00 centimeters (cms) by (x) 20 cm x 5 cm. R3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Treatment Administration Record (TAR) dated June 2021 documents Sodium Hypochlorite Solution 0.25% apply to coccyx topically every shift for wound care, cleanse area with normal saline, wet to dry with Dakins and cover with dressing twice daily or as needed. R3's TAR documents R3's pressure ulcer treatment was completed only once per day on 6/5/21, 6/6/21, 6/7/21, 6/8/21, 6/9/21, 6/11/21, 6/12/21, 6/13/21, 6/14/21, 6/16/21, 6/17/21, 6/18/21. The dressing was not changed at all on 6/15/21. R3's Care Plan dated 6/7/21, documents R3 had pressure ulcers. The Care Plan documented Provide wound care treatment as ordered. The Care Plan documented If the resident refused treatment, confer with the resident, IDT (Interdisciplinary Team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. R3's Minimum Data Set, dated dated dated [DATE] documents Brief Interview for Mental Status cognitively intact. R3's Nurse's Notes dated 6/19/21 at 8:10 AM document, Certified Nurse Aide (CNA) reported to nurse that resident 'Isn't acting right.' observed altered mental status upon entry. Resident disoriented and hallucinating. Unable to make out audible words, just groans. Observed eyes rolling to back of head. Arms flailing behind head. unable to obtain blood pressure or SPO2 (blood oxygen saturation level) due to flailing arms. Temperature 94.0 F. Alert and Oriented (AO) x 0 with baseline of AO x 3. No shortness of breath (SOB) observed. Radial pulse weak and thready. Notified Director of Nurses (DON) of emergency transfer to (hospital). R3's local hospital Discharge Summary dated 6/20/21 documents R3 was admitted on [DATE] with date of death as 6/20/21. The Summary documents Primary cause of death: 1. Acute kidney injury. 2. Septic shock. 3. Pneumonia. 4. GI bleed. The Hospital Course includes, The cause of death was acute kidney injury and GI bleed secondary to septic shock from a presumed pneumonia etiology, although the patient had extensive necrotic wounds as well, which potentially could be a source of her [CONDITION(S)]. On 6/30/21 at 10:50 AM, V2, Director of Nurse (DON) stated, I am aware that weekly skin checks were not being done properly. I was there when we found (R3's) stage 4 pressure ulcer to her sacrum, the measurements were 20 X 20 cm. (R3) liked to stay in her wheelchair a lot, when she finally went into her room, I made her stand up. I was appalled by the wound. I started here in April and we have found pressure ulcers that should have been identified sooner. The wound nurse was fired. V2 agreed the CNA's also were not doing their skin checks and notifying the nurse with skin issues. R9's EMR dated 6/24/21 documents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation R3 had pressure ulcers to her sacrum prior to R9's wound report dated 6/24/21 documents, R9 developed a facility acquired stage 4 pressure ulcer to her sacrum. Date identified 12/14/20. Measurements 3cm X 4cm X 0.4cm. R9's Care Plan dated 4/4/21 documents (R9) has potential for skin impairment r/t history (Hx) of pressure ulcers and chronic red areas to outer ankle. Refuses to lay down, refuses to work with restorative programs, takes dressings off at times. R9's Care Plan documents I am at risk for further impairment. Goal: Area will show signs of healing by next review date. Interventions: Apply moisture cream to bilateral hands daily. Barrier cream- may keep at bed side. Apply moisturizers to feet. Check placement of coccyx dressing every shift and replace if needed. Foot care with mild soap and water. I use an air mattress on my bed. Medications/supplements as ordered. Observe feet for redness or open areas and report to MD. Off load pressure. Turn and reposition. Regular Podiatric evaluation and treatment. R9's Care Plan documents Cushion in wheelchair (w/c). Pressure reducing mattress on bed. Remind and assist resident to turn and reposition at least every two hours, more often as needed or requested. R9's Care Plan documents I have pressure injuries to my sacrum. Goals: Wounds will remain free from complications through next review. Interventions: Administer medications/ treatments as ordered. Monitor/document for side effects and effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. If The resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Monitor dressing to ensure it is intact and adhering. Replace dressings as needed. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X width X depth), stage. (R9) requires low air loss mattress and wheelchair cushion on bed/wheelchair. R9's MDS dated [DATE] documents R9 is severely cognitive impaired. R9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Treatment Administration Record dated 6/2021 documents wound care for R9's Stage 4 pressure Ulcer was only done on 6/21/21 and 6/24/21, not every 3 days and prn. On 6/28/21 at 3:10 PM, V5 Licensed Practical Nurse (LPN) and V4 LPN rolled R9 over to her left side, V5 cleansed the wound with wound cleanser and 4 X 4 gauze. With same gloves applied Calcium Alginate and bordered foam dressing, dated dressing 6/28/21. R8's EMR dated 6/2021 documents, R8 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Wound Report dated 6/23/21 documents, R8 was admitted with Stage 4 pressure ulcer to left buttock measurements 2cm X 1cm X 0.7cm, an unstageable pressure ulcer to Left Trochanter measuring 6cm X 4cm X 1.5cm, a Stage 4 Pressure Ulcer to right buttock measuring 2cm X 2.5cm X 1.5cm and an unstageable Pressure Ulcer to Right trochanter measuring 4cm X 5cm X 1 cm. R8's POS dated 5/25/21 documents, Apply to left lower buttock, right lower buttock, right upper buttock and left upper buttock topically every shift for wound, cleanse with normal saline, apply Santyl with fluff gauze to fill cover with bordered foam twice daily. R8's TAR dated 6/2021 documents R8's dressing changes were not done to the right upper and lower buttock and left upper and lower buttock on 6/2/21 day shift, 6/5/21 night shift, 6/9/21 night shift, 6/11/21 day shift, 6/14/21 night shift, 6/16/21, 6/17/21, 6/18/21, 6/19/21. 6/20/21 day shifts, 6/21/21 night shift, 6/24/21 night shift, 6/25/21, 6/26/21, 6/27/21 day shifts. On 6/28/21 at 2:10 PM, V5 and V4 positioned R8 on his left side. V5 removed the dressing on R8's right upper buttock, changed his gloves with no hand hygiene between glove changes. V5 cleansed the wound to the right upper buttock with wound cleanser. V4 cleansed the wound to the right lower buttock. V5 placed the Santyl and gauze to both wounds with same gloves, then placed a 4 X 4 gauze dressing on both wounds, taped and dated the dressings. V5 and V4 both changed their gloves with no hand hygiene between glove changes. V4 and V5 rolled R8 over to the right side. V4 removed the dressing to the left upper and lower buttock, changed her gloves with no hand hygiene between glove changes. V5 cleansed the wound to the left upper buttock, removed his gloves, performed hand hygiene and donned new gloves. V5 then cleansed the wound to the left lower buttock, removed his gloves performed hand hygiene and donned new gloves. V5 applied Santyl to the left upper buttock wound and the left lower buttock wounds. V4 placed 4 X 4 gauze dressing to both wounds and V5 taped them. V5 then removed his gloves and dated the dressings. The facility Policy and Procedure for Pressure Injury and Skin Condition dated 11/28/12 documents Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven days by licensed nurse and documented in the resident's clinical record. The Policy documents #3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by a licensed nurse. #4. each resident will be observed for skin breakdown daily during care and on the assigned bath day by the Certified Nurse Aide (CNA). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. #5. If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttock area and groin. #6. Caregivers are responsible for promptly notifying the charge nurse of skin breakdown. The Policy documents #10. Pressure injuries and other ulcers (arterial, diabetic, venous) will be measured at least weekly and recorded in centimeters in the resident's clinical record. #11. A wound assessment for each identified open area will be completed and will include a. Site location b. Size (length X width X depth) c. Stage of pressure ulcer d. Odor e. Drainage f. Description g. Date and initials of the individual performing the assessment. The Policy documents #18. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurse's notes. #20. The attending physician shall be notified within 7 to 14 days of the resident's lack of response to treatments.

Based on record review and interview, the facility failed to implement effective interventions and provide supervision to prevent injury for multiple falls for 1 of 3 residents (R2) reviewed for falls in the sample of 3. This failure resulted in R2's fall sustaining a laceration to her head which required 5 sutures, and R2's fall sustaining a left [MEDICAL CONDITION] which required surgery and pinning of her left hip. Findings include: R2's Fall Risk Assessment, dated 9/12/18, documents a score of 11 indicating at risk for falls. R2's Fall Risk Asssessment, dated 9/28/18, documents a score of 14 indicating at risk for falls. R2's Fall Risk Assessment, dated 2/7/19, documents a score of 15 indicating at risk for falls. R2's admission Minimum Data Set (MDS), dated [DATE], documents that R2 requires extensive assistance and two plus physical assistance for bed mobility transfers and toileting. R2's MDS, dated [DATE], documents that R1 requires extensive assistance and two plus physical assistance for bed mobility, transfers and toileting. R2's MDS also documents R2 has severely impaired cognitive skills for daily decision making. R2's MDS, dated [DATE], documents that R2 requires extensive assistance and two plus person physical assistance for bed mobility, transfers and toileting. R2's Nurses Notes, dated 9/12/18, document that R2 had an unwitnessed fall at 3:45 PM when R2 was found on the floor next to bed. The Notes document that R2 stated that she was attempting to get into bed and slid. R2 noted to have a laceration to forehead. Call light in reach but was not turned on. Res had non-skid socks on foot. The Nurses notes document R2 was sent to the hospital. Nurses notes, dated 9/12/18, document R2 returned at 9:33 PM from the hospital with 5 sutures to forehead. R2's Fall Interdisciplinary Team (IDT) note, dated 9/13/18, documents root cause of fall: attempting to get out of bed per self to go to supper. Poor safety awareness, Poor visual eyesight. Appears resident was furniture surfing. Interventions: Skid strips to bedside and bathroom, therapy to screen. R2's Nurses Notes, dated 9/28/18, documents resident had an unwitnessed fall at 1:30 PM when found lying on the floor in room. Appears to have been trying to transfer herself from the bed to the wheelchair. Nurses Notes, dated 9/28/18, Fall IDT note documents root cause as resident was self transferring from her wheelchair to her bed and fell on to the floor. Intervention resident was reminded to ask and wait for assistance. Resident's room was rearranged. Staff to assist resident when resident is approaching her room as tolerated. Therapy to screen. MD (Medical doctor) and POA (Power of Attorney) notified. The Facility's fall incident report, dated 2/7/19 at 2:05 PM, documents an unwitnessed fall with R2 trying to transfer with the help of another resident and fell on her bottom. The form documents no injuries. R2's Care Plan, dated 3/1/19, documents that R2 is at risk for fall related to severely impaired cognition, unsteady gait, incontinence, medication, non- complaint use call light. Intervention listed are: 2/7/19 therapy to screen, peer resident room moved, remind to use call light, Bright tape placed around call light to remind to use. R2's Nurses Notes, dated 7/2/19 at 9:55 PM, documents R2 found to be sitting upright on floor next to bed. R2 stated she was trying to get out of bed. R2 had very small laceration to back of the head with minimal bleeding and small hemotoma surrounding the area. Nurses notes document physician via live video regarding incident, send to hospital for CT (computerized tomography) of head. CT results within normal limits. R2's Care plan documents the intervention dated 7/2/19 documents resident sent to ER (emergency room ) for evaluation, therapy will screen upon return, resident will be checked on by staff prior to shift change and after toileting, snack and conversations. The facility's fall incident report, dated 7/24/19 at 3:45 AM, documents R2 pulled the fire alarm, and slid out of the wheelchair on the floor. R2's Nurses note, dated 7/24/19 at 8:59 AM, documents that R2 up in wheelchair at change of shift and yelling help me. R2's Nurse's Notes document R2 stated that her leg hurt, and yelled out in pain when leg touched. R2's Nurse's notes document that R2 was sent to hospital for evaluation at 9:18 AM. R2's hospital x-ray report dated 7/24/19 at 9:40 AM documents acute fracture of Left distal femur with soft tissue swelling, and deformity. R2's Exam : Hip Pinning Left dated 7/24/19 documents that R2 had left hip nailing done in the Operating room. R2's Care Plan documents intervention dated 7/24/19: sent to ER for evaluation and treatment. A non slip pad placed in wheelchair will be evaluated upon return from the hospital. On 8/14/19 at 10:23 AM, V9, R2's primary physician, was interviewed by telephone. V9 stated that reminding a resident with Dementia is an ineffective intervention as they will not remember. The Facility's Fall Prevention Program policy and procedure, dated 11/28/12, documents the fall prevention program includes the component of immediate change in intervention that were unsuccessful.

Based on interview, observation and record review, the facility failed to adequately assess/identify sexual vulnerability and increased risk of resident to resident abuse and failed to implement/monitor interventions and prevent resident to resident abuse for two of three residents (R6 and R7) reviewed for abuse in a sample of 11. This failure resulted in R7 being sexually assaulted by R6. Findings include: 1. On 3/12/19, throughout the day, R7 was observed to have a 1:1 staff in attendance and was noted to roam independently throughout the facility and in/out of rooms. R7's Electronic Health Record (EHR) Profile Page documents R7 as being a [AGE] year-old female admitted to the 300 halls at the facility on 2/5/19 with [DIAGNOSES REDACTED]. R7's EHR Progress Note, dated 2/5/19, documented R7 ambulates independently. R7's Progress Note, dated 2/6/19, documented R7 had severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 3. R7's SS (Social Service) Abuse/Neglect Screening, dated 2/5/19, completed by V4, Social Service Designee (SSD) assessed R7 to be at high risk for Abuse/Neglect. The Screening documents factors that increase her risk for abuse/neglect as dementia, confusion, and poor judgement. R7's Care Plan, dated 2/5/19, documents R7 has a behavior problem related to dementia as R7 will take on a caregiver role. The Care Plan documents will attempt to transfer residents, will clear tables of dishes, will push peer resident w/c (wheelchairs). The goal was R7 was to have no harm to self-related to care giver and no harm be done to others related to her caregiver role. The Care Plan interventions documented the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Anticipate and meet the resident's needs; Caregivers to provided opportunity for positive interaction, attention; Stop and talk with him/her as passing by; Explain all procedures to the resident before starting and allow the resident ample time to adjust to changes; If reasonable, discuss the resident's behavior; Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the rights and safety of others; Approach/Speak in a calm manner; Divert attention; Remove from situation and take to alternate location as needed; Monitor behavior episodes and attempt to determine underlying cause; Consider location, time of day, persons involved, and situations; and Document behavior and potential causes. The Care Plan does not address her high risk of abuse/neglect or her being vulnerable sexually due to her nurturing nature and her tendency to touch, rub backs etc. as described by staff members. The facility did not revised and develop a person-centered care plan based on R7's high risk for abuse and neglect. No revisions have been made to the care plan as of 3/15/19. R7's EHR Progress Note, dated 2/10/19, documented R7's first incidence of wandering for R7 and was entered by V4, SSD Resident has been wandering the halls frequently today and been wandering into others rooms. Resident has been redirected from entering rooms. R7's Progress Note, dated 2/12/19 at 1:50 PM, written by V17, Social Service Director, documented R7 wandering in/out of other resident's room daily, has severe decision-making skills, and will interfere with resident care and fight staff during periods of confusion. On 3/14/19 at 9:25 AM, V18, Certified Nurse's Aide, CNA, stated she was working Sunday 2/24/19 and kept seeing R6 going in and out of R7's room. V18 stated she initially thought R6 was rummaging in R7's personal items and had asked him several times to not go into R7's room. V18 stated R7 was in bed and she observed R6 entering R7's room door and slamming the door behind him. V18 stated she ran down the hall knocking/opening the door at the same time to find R6 with his leg lifted getting ready to get on top of R7 while she slept in bed. V18 stated she immediately told V6, Licensed Practical Nurse, that R6 had been going in and out of R7's room all morning and that she had just caught him with the door shut trying to get in bed with R7. V18 stated as she was talking to V6, she saw V2, Administrator coming in the door and informed her as well since she is the facility's Abuse Coordinator. V18 stated she gave V2 the details. V18 stated V2 then gave her permission to immediately move R7 to the 200 hall. V18 stated she moved R7 to the new room herself. V18 stated R6 had taken a liking to R7 shortly after her admission and had been seen repeatedly going in and out of her room prompting them to redirect him numerous times day. V18 stated before finding him trying to get in bed with her, they thought he was just rummaging because he had the behavior of taking others items. V18 stated she never saw R6 go into R7's room after she was moved to the 200 Hall away from R6's room. V18 stated she couldn't believe they moved R7 back across the hall from R6. V18 stated R6 knew exactly what he was doing. R7's Progress Note, dated 3/9/19 at 3:57 PM entered by V2, Acting Administrator/Registered Nurse (RN), documents This writer was notified that resident was observed in her room with peer resident having intimate contact. Residents were immediately separated. Police, POA (Power of Attorney) and physician was notified. Charge Nurse assessed resident for pain and injury and none was noted. This resident was moved to a different hallway and is also on 15-minute checks. On 3/10/19 at 12:20 PM, V10, Assistant Director of Nurses/RN ADON, stated she was on her way in when she got the call regarding a sexual incident between R6 and R7 described to her as engaged in sexual intercourse in R7's room on 300 Hall. V10 stated she informed R7's POA, V14, that an incident occurred but didn't provide details because she didn't know any at the time. On 3/10/19 at 1:30 PM, V10 identified R6 as the resident found with R7. V10 stated V13, Housekeeper, was the staff member who initially found the two residents together and V6, Licensed Practical Nurse (LPN), was nurse caring for both R6 and R7 as the time of the incident. V10 also stated the facility immediately moved R7 to another hall and implemented 15 minutes checks and put R6 on continuous one-to-one (1:1) observations. On 3/13/19 at 11:16 AM, V13, Housekeeper, stated on 3/9/19 she had found R7's baby doll at the nurse's station and knew R7 would be upset if she couldn't find it. V13 stated she took the doll to R7's room and noted the door was shut which was unusual. V13 stated she knocked/opened the door to find R6 completely naked on top of R7 on the bed and R7 had her pants pulled down to her ankles. V13 stated R6 was in a panic mode, jumped up and grabbed his clothes and R7 just laid there not really knowing what was going on. V13 stated she started yelling for staff and V6 came running into the room. On 3/12/19 at 2:55 PM, V6 stated she heard a commotion down the hall and heard V13 yelling. V6 stated when she entered R7's room, R6 was grabbing his clothes and R7 was just lying on the bed. V6 stated R7 did not appear to be physically hurt but upon exam of her peri area, she observed what she thought was semen on R7's pubic hairs. V6 stated the Physician, Police and V14, R7's POA were notified. V6 stated V10, Assistant Director of Nurses (ADON/RN) informed V14 and told V6 that V14 did not want R7 to be sent to the hospital for a rape kit and/or exam. V6 stated she has never known R6 to have any sexual behavior with anyone. V6 described R7 as having severe dementia but being nurturing loveable huggy in a non-sexual way and will rub peoples back and touch them sometimes unwanted. When asked if R6 knew what he was doing, V6 stated absolutely. V6 stated she had never witnessed any inappropriate behavior between the two before but did know he was observed one time standing over R7 in her room while she slept and had shut the door behind him when entering which prompted her (V6) to move R7 to the 200 Hall. V6 couldn't' recall the date of the move and stated she did not document it but did confirm the incident was reported to V2, Administrator, at the time. V6 identified V18 Certified Nurse Aide (CNA) as the staff member who found R6 standing over R7 in bed and said she didn't understand why they would have moved her back to the hall across from his room knowing this information. V6 stated the alleged rape occurred just a short while after moving R7 back to her previous room which was across the hall from R6's room. R7's Progress Notes reviewed from 2/23/19 through 3/9/19 do not document any room changes as occurring at all. On 3/14/19 at 12:15 PM, V22, Activity Assistant, stated on 3/9/19, she was in her room when she heard yelling and ran down to R7's room where V13 was. V22 stated R6 was sitting on the bedside with his pants in his lap covering his genitalia and R7 was on the bed. V22 stated she assisted V6 with a visual exam of her peri area and stated, You could definitely tell there had been intercourse because there was semen at the vaginal area. V22 stated R6 knew he had done something wrong and in trouble by the way he acted. On 3/14/19 at 2:10 PM, V24, CNA, stated she was here 3/9/19 the alleged rape happened and was in the room when three staff, V6 the nurse, an activity person and another person (couldn't remember who) were examining her and stating they all saw semen on her and the bed clothes. On 3/14/19 at 3:20 PM, V20, CNA, stated on 3/9/19, she heard V13 yelling from R7's room and when she entered, R6 was naked grabbing at his clothes. V20 stated she assisted V6 with R7's exam. V20 stated R7 had semen on her panties and in the vaginal pubic hair. V20 stated she remembers R7 saying he was so over powering. V20 stated they had moved R7 off 300 Hall due to R6 being caught standing over while she (R7) slept and she couldn't imagine why they would have moved her back knowing that. V20 stated V21, CNA moved R7 from 200 hall back to 300 hall to her previous room just prior to the incident. On 3/14/19 at 3:42 PM, V21, CNA, stated she remembers an altercation occurring between two other residents on the 200 hall and having V12 tell her to move R7 back to her old room on 300 Hall around on 3/8/19. V21 stated none of the 3rd shift staff knew about the incident that occurred on 2/24/19 which was the cause of R7 being moved to the 200 Hall. V21 stated that no one's room is changed without V2, Administrator knowing it and giving permission. On 3/15/19 at 8:10 AM, V25, Police Detective, stated they were called the afternoon of 3/9/19 immediately after the assault occurred and stated it was reported to them that a sexual assault had occurred on a female resident from male resident. V25 stated they were told during interviews with staff that semen was found in R7's panties and in her pubic hair. V25 stated the investigation is still pending and a report is not yet finished. On 3/12/19 at 3:50 PM, V4, SSD, stated he was unaware of R6 having any sexual behaviors directed toward females or males. V4 states he has never known R6 to seek out R7. V4 was asked if he thought R6 was aware of wrongdoing and responded, I believe without a doubt in my mind, he knew what he was doing was wrong. V4 continued to stated I don't think he understood the gravity of the situation as he has impulse control issues. V4 stated he spoke with R6 following the incident and stated R6 said yes when asked if he and R7 had sexual intercourse. V4 stated the police did not arrest him nor did the family want to press charges. V4 stated he did not know why R7 was moved to 200 Hall even though V6, LPN, stated he did. V4 stated he understood R7 had two room changes since her admission but was not involved in either one of them. On 3/13/19 at 10:50AM, V14, R7's daughter/POA stated she was informed of the incident immediately after it occurred and was given very little detail. V14 stated her mother is severely demented and has no safety awareness. V14 stated she could hear her mother talking in the background immediately afterward and she didn't appear to be upset so she told them not to send her to the hospital as she didn't want to upset her. V14 stated her mother is nurturing and has a tendency to want to take care of everything for you. V14 stated her mother is not sexual at all but does touch and rub arms, etc. V14 stated one Friday night when she came in to see her, her mother's hallway door was shut along with the bathroom door in her room. V14 stated she finally checked the bathroom and R7 was not in there. V14 stated she then went out into the hall and asked the CNA (she didn't know his name but described as a black male) if he knew where her mother was. The male CNA stated he didn't and said Now we've got to look for her where we don't want to find her going directly to the closed door across the hall from her mother's room. V14 stated R7 was found in the room with R9 who was R6's roommate. V14 stated they were sitting on the bed and nothing sexual appeared to be going on. On 3/14/19 at 5:41 PM, V14 stated she was unsure as to why her mother's room had been changed several times during her short stay at the facility. V14 stated she was not notified of those changed or told why they moved her. V14 stated she was told at the time of the call on 3/9/19 that a sexual assault had occurred on her mother by another resident. V14 stated yes her mother would have been devastated had this occurred even 5 years ago. On 3/15/19 at 11:02 AM, V2 and V3 Director of Nurse (DON) stated neither knew of the incident that occurred on 2/24/19 between R6 and R7 when he was found trying to crawl into her bed as she slept. V2 stated she had been called the evening on 2/23/19, the night before, and told R7 had been going in and out of R6's room and he has inappropriate sexual behaviors. V2 stated she told them at that time to move her to 200 Hall to separate R6 from R9. V2 and V3 stated there is nothing documented in the clinical record regarding it. Both stated an incident report should also have been filed. R6's MDS dated [DATE] identifies him as a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) The MDS also documents R6 to be independent in ambulation. R6's Care Plan revision date of 2/8/19 identifies him to have the following focused areas: physical/verbal aggression and mood problem r/t sexual activity: resident will offer to perform sexual acts on peer residents and will come into hall with genitals exposed. There have been no revisions done to R6's behavioral management plans in regard to his inappropriate behavior towards R7 even though it resulted in a room change for R7. On 3/15/19 at 8:48 AM, V16, Medical Director/Physician, stated she was familiar with both R6 and R7. V16 stated she was aware that R6 seemed impulsive in a sexual manner toward females because as she was assessing him, he was trying to touch her the whole time. V16 stated she was unaware of R6's inappropriate behavior toward R7 but her exchange was called on 2/24/19 with a message left which reported an incident occurring between R7 and R6 naming R6 specifically. V16 stated whenever the facility calls her exchange, they get a summary with no details. V16 stated on 3/9/19, she received a call from her on call service reporting a sexual assault on R7 by R6. V16 stated all staff should have been made aware of R6's behavior toward in R7 when the behavior first occurred and certainly after the incident on 2/24/19. V16 stated having uninformed staff is a dangerous thing and they need to document and communicate better to one another to prevent this kind of thing from happening again. V16 stated she considered this sexual assault as harm even though R7 is severely cognitively impaired. The facility's policy/procedure entitled Abuse Prevention and Reporting - Illinois dated 11/28/16 documents The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy documents the Definition of Abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy documents Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: unwanted intimate touching of any kind especially of breasts or perineal area, all types of sexual assault or battery such as rape, sodomy or coerced nudity, in part. The policy documents Generally, sexual contact is nonconsensual if the resident is either: appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur.

Based on interview, observations and record review, the facility failed to provide enteral feeding according to the physician's orders and failed to provide services including correct technique in flushes for 2 of 2 residents (R13, R4) reviewed for enteral feedings in a sample of 15. This failure resulted in an unplanned weight loss of 9.6 percent for R13 within 5 months. Findings include: 1. R13's Minimum Data Set (MDS), dated [DATE], documented R13 [DIAGNOSES REDACTED]. The MDS documented R13 to have severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6 and was totally dependent on staff for all activities of daily living (ADL's) except bed mobility. The MDS documented R13 received enteral feeding (gastrostomy tube feedings) and oral pleasure feedings. R13's October 2017 Physician's Order Sheet (POS) documented R13 was to receive 85 cubic centimeters (cc) of [MEDICATION NAME] 1.5 for 20 hours from 10:00 AM until 6:00 AM (which calculates to 1700 cc) ordered 8/17/17. The POS also documented R13 to receive 200 cc water flushes every 4 hours. R13's Monthly Weight record documented R13's weight in March 2017 as 151.6 pounds and was stable through 7/5/17 when he was documented as weighing 150.8 pounds. R13's weight was documented on 8/9/17 as142.8 pounds, 9/6/17 as 137.9 pounds and on 10/18/17 as 136.8 pounds for a total loss of 14.6 pounds in 4 months or a 9.6 % weight loss. On 10/26/17 at 8:30 AM, R13 was in his room at bedside in his wheelchair. R13's tube feeding was not running. The 1500 bottle of [MEDICATION NAME] 1.5 cal had 300 cc left and was labeled as being hung at 10:00 AM on 10/25/17, the day before. Calculating R13's rate at 85 cc/hr (hour) for 20 hours, R13 should have received 1700 cc during this 20 hours period of time. R13's feeding for this time frame was lacking 500 cc or 750 calories. At 10:40 AM on 10/26/17, R13's tube feeding was connected and running via pump at 85 cc/hr. The 1500 cc bottle of [MEDICATION NAME] was labeled as being hung at 10:20 AM on 10/26/17. On 10/26/17 at 3:25 PM, E10, Registered Dietician (RD), stated R13 should have used a whole bottle and 200 cc of the second bottle from 10 AM to 6 AM or 20 hours confirming that R13 was shorted 500 cc. E10 acknowledged that R13 had significant weight loss in the past few months and she had increased his tube feeding accordingly in an effort to decrease the unplanned weight loss. A Nutritional Assessment, dated 5/15/17 and completed by E10, documents R13's tube feeding as [MEDICATION NAME] 1.5 at 60 ml (milliliters) x (times) 16 hours with a flush of 200 cc every 6 hours. R13's BMI (Body Mass Index) was 20.7 with no weight change identified. The Comment documented R13 to havegradual weight loss 5/10 148.4 # (pounds), 11/10/16 158#, 5/16/16 151# BMI remains WNL (within Normal Limits.) The comment continues good tolerance, no residuals. On 5/17/17, E10 increased the [MEDICATION NAME] 1.5 to 75 ml (milliliters) x 16 hours per continuous nocturnal feeding starting at 3 PM and stop at 6 AM. Calculated out at 75 cc x 16 hours indicate R13 should receive 1200 cc per feeding or 1800 calories. A Nutritional Assessment, dated 8/16/17 and completed by E10 documents Resident w/gradual wt (weight) loss noted 7/5 150.8l 8/2 142.8# (8# 5.3% loss x 1/mo (month). BMI barely WNL (Within Normal Limits). Oral feedings offered w/minimal intake, nutritional needs provided via [DEVICE] (gastrostomy tube) which resident was recently pulling on, TF (tube feeding) stopped briefly, currently running w/o (without) difficulty. E10 recommended an increase in feeding and documented Wt (weight) down - Please increase TF [MEDICATION NAME] 1.5 at 75 cc x 20 hours Flush 150 cc every 4 hrs (hours.) This order was not obtained until 8/21, 5 days later. Calculated out for 20 hours at 75 cc/hour, R13 should receive 1500 cc of [MEDICATION NAME] per feeding. The August 2017 Medication Administration Record [REDACTED]. Intakes were recorded for evening and night shifts. The September 2017 MAR indicated [REDACTED]. Again, the [MEDICATION NAME] intake was recorded for evening and night shifts only with intakes being less than ordered numerous times. The largest amount of [MEDICATION NAME] recorded as given to R13 during this time was 1323 cc and the least amount recorded was 840 cc. A Dietary Note written by E10, dated 9/27/17, documented R13's weight as 138 pounds, BMI 19.2 barely remains WNL. [MEDICATION NAME] 1.5 continues to be well tolerated with no recommendations made. A Dietary note completed by E10, dated 10/11/17, documents Enteral note for resident w(with)/slow continued wt (weight) loss. 10/11 135.4# (pounds), 9/13 137.6#, 7/12 149.8#/ BMI 18.9 now underweight. Pureed diet w pudding thick liquids continues w/fair/good intakes per meal record, majority of nutrition provided via tube feeding [MEDICATION NAME] 1.5 @ (at) 75 cc/hr x 16/hr w 150 cc flush every 4 hours. Skin intact, no [MEDICAL CONDITION], no new labs. Recommend increasing [MEDICATION NAME] 1.5 to 85 cc/hr x 16 hrs w flush 150 cc q (every) 4 hrs and Monitor for safe swallow during meals, monitor tolerance and residuals. RD will continue to follow or refer PRN (as needed). A telephone order shows the feeding increase was not obtained until 10/17/17, 6 days later. E10's Note of 10/25/17 documented f/u (follow up) to confirm that prior recommendation to increase tube feeding and flushes have been implemented. Wt 136.8#, Good tolerance continues. The October 2017 MAR indicated [REDACTED]@ (at) 75 ml x 16 hrs per continuous nocturnal feeding start at 3 PM and stop at 6 AM. The amounts infused document intakes less than amount required/ordered at times with the least amount recorded in a 16 hour period of time as 656 cc with the most recorded as 1340 cc. The MAR indicated [REDACTED]. Calculated on 85 cc per 20 hours, R13 should receive 1700 cc/feeding which calculates to 2550 calories. The October 2017 MAR indicated [REDACTED]. Intakes recorded documented the least amount R13 received in this time from 10/17/17 through 10/26/17 as 880 cc (9/20/17) and the most recorded intake being 1180 cc on 10/18/17. Calculating the [MEDICATION NAME] at 1.5 calories per cc, R13 received only 1320 calories on 9/20/17 and only 1770 calories per feeding. A Nutritional note, dated 10/11/17 by E10, documented, Addendum: recommend increase flush to 200 cc/q/4hrs. The Dietary initial/Quarterly/Annual note, completed by E10 on 10/26/17, documented R13's current order as Pleasure feeding @ (at) breakfast and lunch. Pudding consistency and Tube fed [MEDICATION NAME] 1.5 @ 85 ml cont (continue) on at 1000 (10 AM) off at 0600 (6 AM). The Comment section documented by E10 documents, Nurse to calculate total feeding tube intake in part. R13's Care Plan, dated 8/28/17, documented him to require a tube feeding due to history of aspiration, dementia and difficulty swallowing. The Care Plan identifies the pleasure feedings. The goal was for R13 to maintain adequate nutritional status via tube feedings thru next review with intervention documenting staff to flush tube as ordered, elevate head of bed, record intake every shift, [MEDICATION NAME] as ordered, RD evaluation as needed, nurse to re connect tube feeding if noted to be disconnected, pleasure feedings as desired, and report significant weight changes to MD (Physician) and RD. On 10/25/17 at 3:00 PM, E4, Licensed Practical Nurse (LPN), was asked about documenting total intake for the shift and stated they document it in the MAR, but do not calculate a 24 hour intake to check total amount infused. On 10/26/17 at 2:30 PM, E4 stated the facility messed up and stated they are looking at the pump as not working correctly. At 4:00 PM, E4 stated they had been checking the pump for proper functioning and found it to be in error. E4 stated he ordered a new pump and on 10/27/17, R13 had the new pump. On 10/27/17 at 12 PM, Z2, Medical Physician, stated she was aware of R13's continued weight loss and would have expected the nurses to make sure he's getting the amount of formula ordered to prevent the weight loss. Z2 stated she would be concerned if the recommendations are held over 4 days when contacting her and adding that they probably waited until she came to the facility the next time since she makes weekly visits. The facility's Tube feeding - infusion pump Method policy, dated 3/18/13, documents It policy is to provide nutrients, fluids and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. 2. On 10/24/17 at 9:45 AM during the initial tour, E4, LPN, entered R4's room and as the tube feeding pump was being checked, E4 stated that he wanted to go look at the orders, due to he wasn't familiar with the order, but he thought that the tube feeding should have been shut off. E4 left the room. When E4 returned, E4 shut off the tube feeding. E4 did not flush the [DEVICE] with water or check R4's lungs. R4's Physician Order, dated 1/23/17, documented, 60 ML/HR X 20 HRS. OFF AT 0800 (8 AM) ON AT 1200 (noon). R4's Physician Order, dated 9/12/17, documents, Flush [DEVICE] with 60 ml's H2O (water) before and after meds & disconnections. On 10/26/17 at 12:00 PM, E8, LPN, did not check g- tube placement before administrating medications. E8 stated I messed up didn't I?' R4's Care Plan, dated 10/3/17, documented to check residual, positioning of tube prior to feed, give 150 cc of water via tube q (every) 4 hours, and check lung sound prior to and following each feeding. On 10/27/17 at 10:20 AM, E2, Director of Nursing (DON), stated that she expects her staff to check placement of [DEVICE] before administration of medications. The Facility's undated 'Tube Feeding' policy and procedure reads, After each tube placement check, before and after medications and feedings, the tube is flushed with clear water (patency check) to completely clear the tube to remove all residues. Feedings are to be administered at room temperature. Contents should be used within eight (8) hours if open system or twenty-four (24) hours if closed system or in accordance with manufactures' recommendation.

Based on interview and record review, the facility failed to adequately assess for injuries following falls and failed to identify a change in condition that included increased pain, change of location/intensity of pain and decreased functional ability/cognition for one of three residents (R3) reviewed for falls/fractures in a sample of 3. This failure resulted in a delay, approximately 10 hours, in identifying and treating R3's fracture to his left femur. Findings include: 1. Admission Records document R3 was admitted to the facility on [DATE] following hospitalization for a fracture/repair of right hip. The Minimum Data Set ((MDS) dated [DATE] documents R3 to required extensive assist of two staff for transfers and bed mobility. The Assessment reports documents R3 to have moderate pain from his right hip. The Interim Care Plan dated 8/18/17 documents only that R3 is a full code and is resistive to care at time and fails to reflect pain. R3's Progress Note, dated 8/19/17 entered by E11, Registered Nurse (RN) at 2:26 AM documented R3 had an un-witnessed fall in bathroom and Res (resident) was in room yelling, staff went to check on res and he was sat on toilet by two assist. One staff member went to get supplies to change res as the other was making his bed. Res slid to floor causing skin tear to left forearm. Writer assessed res and res denied any pain or hitting his head. R11's entry continues res then began to dig at PICC (peripherally inserted central catheter) line stating needles were broke off in arm and started to c/o (complain) of right hip pain. At 2:40 AM, Z2, the on-call Physician and Z3, R3's family member, were documented as informed. A report to Illinois Department of Public Health with an occurrence date of 8/19/17 completed by E3, Assistant Director of Nurse (ADON) documented on 8/19/17 at 2:30 AM, staff responded to hearing R3 yelling out in his room. The Report documented Staff asked (R3) what he was screaming about and (R3) stated he needed to use the restroom. The report continued With the assistance of 2 CNA's (Certified Nurse Aides), (R3) was assisted to the bathroom and sat on the toilet. The report documents R3 fell when one CNA left the room for supplies and the other was changing his bed. The Report documented after R3 was back in bed for a while, he started to complain of right hip pain and picking at his PICC line. The Immediate Action Taken section documented E11 performed body assessment, started Neuros (neurological checks), clean and dressed left forearm and redressed PICC line. E11 documented she was unable to reach R3's POA, Z4, but was able to reach Z3, another family member, to notify her of the fall. E11 documented she explained that R3 sustained a skin tear in the fall and c/o (complained of) right hip pain and she advised the family to send him to the hospital for evaluation since it was a newly set hip. E11 documented Z3 stated did not want to send, to give res anti-anxiety med and when family comes in morning, they will see if res is still complaining and take him themselves if they feel he needs to go. E11 also documented that the on-call physician, Z2, was notified and advised to send to hospital and when told what family wanted, stated it was their choice. There was no further documentation on R3 for the remainder of the 11-6 shift by E11 in the progress notes. On 8/25/17 at 12:34 PM, E11 confirmed the information in the report and stated she relayed the information regarding family not wanting anything done until they come in to the 6-2PM RN, E4/RN, in report the morning of the fall. E11 stated she did not note any change in R3 for the rest of the shift and did give him some Tylenol and [MEDICATION NAME] after he fell . On 8/25/17 at 12:10 PM, E6, Certified Nurse's Aide (CNA) stated on 8/19/17 between 6:15 AM and 6:30 AM, she entered R3's room with E5, CNA, and proceeded to get R3 ready to get him up for breakfast. E6 stated when she and E5 started to roll him from side to side to get his pants on, R3 started grabbing at his left thigh and screaming in a high pitched scream. E6 stated she immediately left the room and reported this to E4. E6 stated R3 screamed and guarded his left upper leg whenever they provided care throughout shift. On 8/29/17 at 9:40 AM, E6 stated that she did not assist nor did she observe E4 entering R3's room and assessing him during her shift on 8/19/17. E6 stated R3 did not eat any breakfast or lunch on 8/19/17 and remained in bed the entire shift. On 8/29/17 at 9:43AM, E5 confirmed that R3 grabbed at his left upper thigh and screamed loudly when they attempted to provide care initially on 8/19/17 at around 6:15AM to 6:30AM and then throughout the rest of the shift. E5, when asked if she noted anything different about R3's legs or hips during care, stated she did notice that his right foot toes pointed up and his left foot lay over to the side. E5 confirmed that R3 ate none of his breakfast or lunch on 8/19/17. On 8/25/17 at 12:00 PM, E4, RN stated when she took report from E11 at 6:00AM on 8/19/17, E11 told her she (E11) thought R3 had a fracture but family had chosen not to send him to the hospital for evaluation. E4 confirmed that E5 and E6 reported R3 grabbing at his left upper thigh and screaming to her at approximately 6:30 AM that morning but that he was lying still with no evidence of pain when she went down and assessed him. E4 confirmed that he was lying still in bed when the assessment was done and she did not attempt to move him nor did she observe him when he was being moved. E4 stated she did not call the physician and/or family to inform them that R3's pain location had changed from right hip immediately after the fall to left upper thigh with high pitched screaming because she understood the family did not want to treat until they came in. E4 stated she R3's family member came in later that morning and seeing that R3 was in extreme pain, they decided to have the leg X-ray. She stated she then called the physician for an X-ray order. E4 stated she did not know why she didn't document anything that happened on 8/19/17, including R3 being in extreme pain. When asked if she assessed R3's pain level including for any non-verbal signs/symptoms, E4 stated she gave him an [MEDICATION NAME] early in the morning but couldn't recall the time. E4 stated she was not at the facility when the results of the X-ray came in and that she passed all the information on to E14, RN in shift report the afternoon of 8/19/17. The Progress Note dated 8/19/17 at 8:45 AM entered by E4 documents Resident has no complaints of pain. No non-verbal expressions of pain. No facial grimacing or facial expressions of pain noted. No guarding, rubbing, hold body part or other signs of pain during movement but fails to document the change in condition reported to her by E5 and E6. On 8/29/17 at 2:05 PM, E14 recalled being told by E4 that R3 had fallen in the early morning and an X-ray had been done. E14 stated E4 had told her the family did not wish to send him out but had agreed to the X-ray. E14 stated she went to R3's room and looked at him but did not do a head to toe assessment as the X-ray results were pending. E14 stated she did not assess for non-verbal signs/symptoms of pain when care was provided. E14 stated she had cared for R3 the day before and his level of consciousness was a lot different than it was the day before. E14 stated she came on at 2:00 PM and did not provide any pain medication. E14 stated when the X-ray came back showing a femoral neck fracture, she called 911. E14 stated she assisted the Emergency Medical Technician (EMT) in transferring R3 over to the gurney and he acted like it really hurt. E14 stated she documented everything that occurred but when told it wasn't in the progress notes, looked herself and could not find it. R3's Progress Notes were reviewed. The Progress notes did not document any of E4's actions including a physical assessment and/or pain assessment for the 6AM to 2PM shift on 8/19/17. There was no documentation an assessment was completed for R3 on the 2 PM to 10PM shift. There was no documentation regarding when the X-ray was done and when the report came in identifying the fracture. The progress notes did not record what time R3 was transferred out to the emergency room . R3's Admission physician's orders [REDACTED]. The August 2017 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R3's Pain Assessment record on the August 2017 MAR indicated [REDACTED]. The Pain Assessment for the Night shift on 8/18/17 was documented as O as is day and evening shift on 8/19/18 just prior to being transported for a fractured femur. On 8/29/17 at 1:00 PM, E2 Director of Nurses (DON) stated all three medications were available in the convenience box and that staff pulled a couple [MEDICATION NAME]'s and Tylenol ([MEDICATION NAME]) from stock to give to R3 but couldn't say when any of them were given and could not provide any documentation to verify that information. On 8/29/17 at 12:30 PM, a hand written note on notebook paper was provided that documented E4 gave R3 an [MEDICATION NAME] at 7:00 AM on 8/19/17 and E11 gave R3 an [MEDICATION NAME] at 3:00 AM following his fall and then two Tylenol's approximately 45 minutes later. On 8/25/17 at 2:26 PM, Z1, Primary Physician for R3 and Medical Director, stated Z2 was on call for her at the time R3 fell . Z1 stated the facility should have consistently assessed R3 for possible injuries sustained in the fall, including pain both verbal and non-verbal signs/symptoms given his cognitive impairment. Z1 stated the nurse should have notified the physician immediately when the location of the pain changed and his behaviors increased. Z1 also stated the family should have been notified as well and given the information. Z1 stated identification of the fracture would have been sooner as well as treatment. On 8/25/17 at 2:00 PM, Z3, R3's family member, confirmed the facility informed her of R3's fall around 2:30AM on 8/19/17 due to being unable to reach Z4, R3's Power of Attorney/POA, at the time. Z3 did not recall being told R3 was complaining of right hip pain and she received no further calls from the facility regarding a change in pain location or increased confusion/behaviors. Z3 stated she passed the information on to Z4 later in the morning. On 8/29/17 at 10:36 AM, Z4, stated she did not receive any notification from the facility but did get a call from Z3 informing her that R3 had fallen in the night the morning of 8/19/17. Z4 stated she arrived at the facility between 10:00 AM and 11:00 AM on 8/19/17 and observed R3 in pain grabbing at his left thigh and screaming/crying. Z4 stated she would have sent him to the hospital had she been told he was in extreme pain and the pain location had changed to his left upper thigh. An X-ray report dated 8/19/17 document A fracture through the femoral neck is identified. Superior lateral displacement of the distal fracture fragment is noted. An Emergency Report dated 8/19/17 documents R3 was transported to the emergency room at 1649 (4:49PM.) On 8/29/17 at 2:00 PM, Z5, Emergency Medical Technician (EMT), stated R3 was in extreme pain when they arrived to transport and that he cried out in pain when moved grabbing at his upper left thigh. Z5 described R3's demeanor as altered mental status, agitated, combative. The facility's policy/procedure entitled Pain Management Program dated 1/1/14 documented the definition as 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. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the presence of pain. The policy continued to document The resident's physician will be notified of the residents' complaints of pain which are not relieved by comfort measures, including pain medication.

Based on interview and record review, the facility failed to adequately assess risks for falls, develop/implement an effective plan to prevent falls and provide adequate supervision for one of three residents (R3) reviewed for falls in a sample of three. This failure resulted in R3 falling after being left alone on the toilet. R3 sustained a fracture to his left femur. Findings include: 1. Admission Records document R3 was admitted to the facility on [DATE] following hospitalization for a fracture/repair of right hip. R3's Minimum Data Set ((MDS) dated [DATE] documented R3 required extensive assist of two staff for transfers and bed mobility. The Admission/Readmission Observation sheet dated 8/18/17 at 11:44 AM documented R3 to required limited assist of one for bed mobility and extensive assist for transfers. The Chair/Bed to Chair transfer section indicated R3 required maximum assist (helper does more than 1/2 the effort) and the toilet transfer indicates the same. The Assessment documented R3 to have moderate pain from his right hip. The Fall Assessment done on Admission 8/18/17 at 11:44 AM identified R3 to be high risk for falls and having intermittent confusion, 1-2 falls past three months, and chair bound. Hospital Discharge Instructions dated 8/18/17 documented under activity level toe touch weight bearing to right lower extremity. The Interim Care Plan dated 8/18/17 documented only that R3 was a full code and was resistive to care at times. R3's history of falls and subsequent fractured right hip and the assistance required for transfers/mobility was not reflected in the interim care plan. The Progress Notes dated 8/19/17 entered by E11, Registered Nurse (RN) documented at 2:26 AM R3 had an un-witnessed fall in bathroom and Res (resident) was in room yelling, staff went to check on res and he was sat on toilet by two assist. One staff member went to get supplies to change res as the other was making his bed. Res slid to floor causing skin tear to left forearm. Writer assessed res and res denied any pain or hitting his head. R11's entry continues res then began to dig at PICC (peripherally inserted central catheter) line stating needles were broke off in arm and started to c/o (complain) of right hip pain. At 2:40 AM, Z2, on call physician, and family member were documented as informed. An X-ray report dated 8/19/17 document A fracture through the femoral neck is identified. Superior lateral displacement of the distal fracture fragment is noted. On 8/25/17 at 12:34 PM, E11 stated she had no information as how R3 transferred or what his care level/supervision was when she received report on the eve of 8/18/17 at 10:00PM. E11 stated the two Certified Nurse's Aides (CNAs), E7 and E8, transferred R3 to the toilet to change his bed. E11 confirmed that after transferring R3 to the toilet, one staff left for supplies and the other was at bedside changing sheets when R3 fell to the floor. E11 confirmed she was aware that R3 had just had surgical repair of his right hip prior to admission but stated again they were unsure of what type of assistance/supervision he needed as no information was passed on to them and she couldn't find any paper work on it. E11 stated she realized he was more confused that she first thought when she assessed him after the fall. E11 stated R3 had a canoe bed and mats bilaterally on his floor bedside which were placed upon admission earlier that day. On 8/25/17 at 12:00 PM, E4 RN stated she worked 6AM - 2PM on 8/19/17 following R3's fall and called the physician when R3's family came in a requested an X-Ray due to increased pain and guarding left up thigh. On 8/25/17 at 2:00 PM, E9 CNA stated she cared for R3 on 2-10PM shift following his admission on 8/18/17 and that he was resistive to care, definitely had dementia as he was confused and attempted to transfer himself without assistance at least three times before supper. E9 stated R3 was able to stand and didn't know of any restrictions. E9 stated they transferred him to the wheelchair then to the toilet and back again. On 8/25/17 at 2:26 PM, Z1, Primary Physician for R3 and Medical Director, stated R3 was a high fall risk and staff should have kept an eye on him. On 8/29/17 at 1:30 PM, E2 Director of Nurses (DON) stated the facility does not have a policy/procedure on Falls Prevention.

Based on record review and interview, the facility neglected to follow operational policies related to the discharging a resident against medical advice and the emergency medical care of a mentally ill adjudicated resident, as established by the State Guardianship & Advocacy Commission. These failures resulted in staff allowing R3 to leave the facility Against Medical Advice on 12/16/16. As a result of this, R3's whereabouts are currently unknown. These failures resulted in an Immediate Jeopardy and has the potential to affect the other nine adjudicated residents (R1, R2, and R31-R37) currently residing in the facility. While the immediacy was removed on 1/31/17, the facility remains out of compliance at a Severity Level II as the facility instates ongoing Quality Assurance measures to ensure staff are knowledgeable and compliant with the rules set forth by the Guardianship & Advocacy Commission for adjudicated individuals and as the facility continues to develop the programming required for SMI (Serious Mentally Ill) residents. Findings include: The facility policy, titled Discharge Against Medical Advice (no date), documents Purpose: To define the facility's responsibility when a resident and/or legal guardian voluntarily discharges him/herself from the facility without the consent of or an order from the attending physician. Policy: It is the policy of the facility to acknowledge the right of a resident to sign him/herself out of the facility without the consent of or an order from the attending physician, providing that the resident has the decisional capacity to do so .In the event that it is questionable as to whether the resident and/or legal guardian has the decisional capacity to make an informed decision about an AMA (Against Medical Advice) discharge, professional and administrative staff are to be consulted in collaboration with the resident's psychiatrist. A letter from the State Guardianship & Advocacy Commission, dated 11/01/16, documents On September 14, 2016 the Office of State Guardian was appointed Person Only Temporary Guardian for (R3), as guardian this office is responsible for the well-being of the ward and is legally authorized to make fundamental decisions concerning the ward's health, medical treatment, placement and personal well-being. The letter further documents, In the event of an emergency, the facility staff .is authorized by the Office of State Guardian to arrange for transportation, routine emergency room evaluation and treatment, and for hospitalization and general medical treatment for [REDACTED]. The Office of State Guardian shall be notified of routine emergency room treatment or hospitalization by the next working day .In no event shall treatment be withheld from a ward of the Office of State Guardian due to the ward's age, disability, quality of life or legal status. The facility policy, titled Staff Obligations to Prevent and Report Abuse, Neglect and Theft (no date), defines Neglect as the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. A Progress Note, dated 11/01/16, documents R3 was admitted .with a (history) of confusion,[MEDICAL CONDITION], pneumonia and [MEDICAL CONDITION] disorder and possible (history) of abuse and [MEDICAL CONDITIONS]. A Plan of Care, dated 11/01/16, documents R3 has an ADL (Activities of Daily Living) self-care performance deficit, [DIAGNOSES REDACTED]. Nursing Notes, dated 11/16/16, document R3 as having delusions of his coffee tasting like body fluids .explained that he has worked around death, amputations, murder victims, and lived near a cemetery in the past and he knows what it tastes like, after refusing to take his anti-psychotic ([MEDICATION NAME]) the night before. The Electronic Medication Administration Record, [REDACTED]. Behavior Monitoring for R3, documents R3 had developed intermittent hallucinations and delusions starting on 11/26/16 through 12/15/16. Nursing Notes, dated 12/01/16, document R3 was having visual hallucinations of snakes coming out of holes in the wall,and continued to refuse to take the [MEDICATION NAME] due to the side effect of an upset stomach. A Progress Note, dated 12/15/16 at 10:39 p.m., documents (R3) became upset when another resident (R5) was attempting to use adjoining bathroom. (R3) pushed (R5) after works were exchanged. CNA (E6) attempted to redirect, (R3) slapped (E6 - Certified Nursing Assistant) in the face. Police were notified. Guardian (Z2) notified. Police did arrest (R3) for battery due to he does not require medical care, is refusing to take medication and (R5) did want to press charges. A Social Service Note, dated 12/16/16, documents (E4 - Social Service Director) notified of incident and left message with OSG (Office of State Guardian). Resident did return to facility and was in vestibule in between the two doors. (E4) and nurse (E3 - Licensed Practical Nurse) went to speak with resident this afternoon, who stated he was released on his own recognizance and was told to return in February for court. Staff was unaware resident was released and resident states someone gave him a ride back to the facility. Resident stated he .only wanted his belongings. Resident was educated on risks of AMA and resident signed AMA paper. Resident stated he planned on returning to police station .Resident left building and began walking towards police station. (E4) contacted police dept. to notify them of situation and request they assist resident. Dispatch stated she would notify police officers that resident was heading in their direction. Nursing staff was able to reach OSG and guardian on call stated that they would contact police department and recommend resident be sent to hospital for (evaluation). It was ensured that resident made it safely to police station. On 1/25/17 at 2:52 p.m., E4 (Social Service Director) stated R3 returned to the facility from the police station at approximately 1:00 p.m. on 12/16/16. E4 stated R3 refused to come all the way inside the building and requested his belongings. At that point, E3 (Licensed Practical Nurse) attempted to contact the OSG. E4 stated R3 communicated better through writing, so she gave R3 the AMA: Release from Medical Discharge form so R3 could understand the risks of leaving the facility. E4 stated R3 read and signed the AMA: Release From Medical Discharge form, took his belongings and left the faciity on foot. According to E4, R3 stated he was walking to the police department. E4 called the local police department to inform them R3 was on his way to the station. E4 notified Z1 (Medical Director) that R3 left the facility AMA at 1:55 p.m. On 1/30/17 at 10:15 a.m., E4 stated she was unaware that the facility had a Policy to follow when a resident left AMA. E4 stated the Director of Nursing (E2) was present in the building on 12/16/16 when R3 wanted to leave, but she didn't get E2 involved because she didn't want to overwhelm R3. E4 stated they attempted to reach the OSG to notify them that R3 needed medical assistance and was leaving the facility, but did not consider calling 911 for medical transport to a hospital for treatment. E4 stated she was familiar with the legal documentation provided by the State Guardianship & Advocacy Commission regarding the facility's authorization to obtain emergency medical treatment for [REDACTED]. E4 stated Z2 (Guardian) called her approximately 4 days after R3 left the facility and told them that R3 was technically considered a missing person at that point, because his whereabouts were unknown. On 1/04/17 at 9:24 a.m., E1 (Administrator) stated R3 communicated through reading and writing. E1 stated E4 showed R3 the AMA papers as an intervention to attempt to get R3 to come back into the building; however, R3 signed the AMA papers and walked away from the facility. On 1/25/17 at 11:18 a.m., E3 (Licensed Practical Nurse) stated he was present on 12/16/16 when R3 returned to the facility from the police department. E3 stated R3 told him that the police stated he was not allowed to return to the facility. According to E3, R3 requested his belongings and indicated he was walking back to the police department. E3 stated he attempted multiple times to reach someone at the OSG office and eventually demanded to be put through to talk to someone. E3 spoke with Z3 (OSG On-Call Guardian) and explained that R3 was not stable, needed medical help and was off his medications. At this point, R3 had been at the facility for approximately 10 minutes, when R3 decided to leave on foot for the police station. According to E3, Z3 stated she would call the police station and let them know what needed to be done with R3. E3 stated E5 (Transportation Aide) was able to catch up with R3 and give him a ride to the police station. On 12/28/16 at 11:10 a.m., E5 (Transportation Aide) stated R3 left the faciity on [DATE] on foot, to return to the police station. E5 stated he took his truck and was able to get R3 to agree to a ride to the police station. E5 stated he took R3 to the West door of the police station, did not go inside the police station with R3, but watched him enter the building and then E5 left. On 1/30/17 at 11:14 a.m., Z5 (Office of State Guardian Supervisor) stated R3 lacked the decisional capacity to make any decisions for himself, which was exactly why he was a ward of the State. Z5 stated the OSG provides the facility with all the necessary guidelines that are to be followed for adjudicated individuals, at the time of admission. Z5 stated that the legal documentation provided by the OSG allows the facility to obtain routine and emergent medical care without prior approval from the Guardian. Z5 concluded that the facility should have called for emergency medical care for R3 on 12/16/16, when R3 returned to the facility, rather than trying to contact the Guardian. Z5 confirmed that R3's whereabouts are currently unknown. On 1/25/17 at 12:45 p.m., Z1 (Medical Director) stated if R3 had a change in condition, such as acute onset of aggression, she would have expected a call from the facility. However, Z1 stated the facility does not need an order to send a resident out for a psychiatric evaluation if needed, and that would have been appropriate in this situation. Z1 stated the facility saw this as a transfer of care to the police, but that's incorrect, because (R3) needed medical care. Z1 stated, It is the facility's responsibility to ensure the resident is medically taken care of .and no one clearly communicated up front what the real plan for (R3) was at the time of or after the arrest. Z1 stated, if R3 had [MEDICAL CONDITION] with Delusions, he should not be out living on the streets for his own safety and a psychiatric evaluation would have been appropriate. The Immediate Jeopardy was noted to have started on 12/16/16 when the facility failed to enact their policy. Facility Administrator was notified of the Immediate Jeopardy at 1:40PM on 01/31/17. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. The facility provided in-service training by the facility's Director of Nursing and Social Service Director to all licensed and unlicensed staff at the nursing home regarding the expectation of the Office of State Guardian regarding routine and emergent medical care for adjudicated individuals, physician notification of change in resident condition, behavior management for new/worsening behaviors and status of resident transfers. 2. The Administrator and Director of Nursing reviewed facility Policy and Procedure on Behavior Management for Agitated Behavior, Change in Condition/Physician Notification Overview Guidelines, Behavioral Management for New or Worsening Behavior Symptoms, Medical Record Documentation and Transfer/Discharge. 3. The Administrator has developed a plan to ensure compliance with Subpart S - SMI State Regulations has been developed and is ongoing. The facility has identified which residents qualify for SMI and what programming would be appropriate for those individuals; however, those programs have yet to be implemented. 4. Additionally, the Director of Nursing will perform a Quality Assurance Audit of all OSG residents weekly for two weeks (or as needed thereafter) to ensure compliance with all reviewed facility policies and that appropriate mental health services are provided.

Based on record review and interview, the facility failed to follow operational policies related to behavior management and failed communicate, identify and anticipate the medical needs of a mentally ill resident (R3), upon his arrest for battery on 12/15/16. These failures resulted in R3 not receiving the emergent psychiatric care he needed and lead to R3 leaving the facility AMA (Against Medical Advice) on 12/16/16. As a result of this, R3's whereabouts are currently unknown. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1/31/17, the facility remains out of compliance at a Severity Level II as the facility instates ongoing Quality Assurance measures to ensure staff are knowledgeable and compliant with the rules set forth by the Guardianship & Advocacy Commission for adjudicated individuals and as the facility continues to develop the programming required for SMI (Serious Mentally Ill) residents. Findings include: The facility policy, titled Behavior Management for Agitated Behavior (no date), documents In the event staff needs to physically intervene to prevent the resident from harming self or others, techniques to provide interim control will be implemented. Non-violent crisis intervention is a safe, non-harmful behavior management system designed to aid human services in the management of disruptive and assultive people, even during the most violent moments. When the interim control is used, the physician will be notified and a determination made as to the need for acute mental health services. Should staff not be able to manage the resident's behavior, staff members will make every attempt to protect the resident and others and another staff member will call 911 for assistance. The facility policy, titled Discharge/Transfer of Resident (no date), documents Purpose: To provide safe departure from the facility. To provide continuity of care and treatment .Complete Transfer Form accurately and completely, including vital signs. Ensure that resident's current physical and psycho/social assessment, medications and current treatment is completely described and available to the receiving facility upon transfer. A Progress Note, dated 11/01/16, documents R3 was admitted .with a (history) of confusion,[MEDICAL CONDITION], pneumonia and [MEDICAL CONDITION] disorder and possible (history) of abuse and [MEDICAL CONDITIONS]. A Plan of Care, dated 11/01/16, documents R3 has an ADL (Activities of Daily Living) self-care performance deficit, [DIAGNOSES REDACTED]. Nursing Notes, dated 11/16/16, document R3 as having delusions of his coffee tasting like body fluids .explained that he has worked around death, amputations, murder victims, and lived near a cemetery in the past and he knows what it tastes like, after refusing to take his anti-psychotic ([MEDICATION NAME]) the night before. The Electronic Medication Administration Record, [REDACTED]. Nursing Notes, dated 12/01/16, document R3 was having visual hallucinations of snakes coming out of holes in the wall, and continued to refuse to take the [MEDICATION NAME]. On 12/01/16, a physician's orders [REDACTED]. (Z4) notified of delusional and scattered thoughts and verbal accusations. (Z4) orders to continue to encourage resident to take medication and if resident becomes agitated or aggressive to send resident for a psych (psychiatric) evaluation immediately. A Progress Note by E1 (Administrator), dated 12/15/16 at 10:39 p.m., documents (R3) became upset when another resident (R5) was attempting to use adjoining bathroom. (R3) pushed (R5) after words were exchanged. CNA (E6) attempted to redirect, (R3) slapped (E6 - Certified Nursing Assistant) in the face. Police were notified. Guardian (Z2) notified. Police did arrest (R3) for battery due to he does not require medical care, is refusing to take medication and (R5) did want to press charges. R3's progress notes contain no further documentation, until R3 returned to the facility upon his release from jail 12/16/16. On 1/24/17 at 2:10 p.m., E1 (Administrator) stated she was working the floor on the night of 12/15/16, when she heard a noise from the 200 Hall. E1 observed R5 running down the hall after being shoved by R3 for using the adjoining bathroom. Immediately after the incident, E1 stated R3 de-escalated, went straight to his room and laid down in his bed like nothing happened. E1 stated the police were contacted and came to the facility to question R3. E1 stated R3 would not answer the policemen's questions directly and R3 was arrested. E1 stated she informed the police that R3 was a Ward of the State and offered to send the legal documentation from the OSG (Office of State Guardian) with them, but declined. After R3 was taken to the local police department, E1 asked the oncoming nurse to contact the physician and OSG regarding R3's arrest. E1 stated she would have sent R3 out for a psychiatric evaluation, but R3 was arrested first and she did not communicate the need for R3 to have a psychiatric evaluation to the police department. On 1/30/17 at 1:30 p.m., E2 (Director of Nursing) stated she informed the arresting police on the night of 12/15/16 that R3 had no medical needs that need to be met overnight. E2 stated she explained to the police that R3 had been refusing his [MEDICATION NAME] and that R3 had a State Guardian, due to poor mental health; however, she did not discuss with the police that R3 had an order for [REDACTED]. E2 stated nothing was discussed with the police regarding what would happen to R3 upon his release from jail. On 12/29/16 at 7:05 p.m., Z9 (Police Officer) stated he responded to a call from the facility regarding a resident out of control. Z9 stated they were not going to arrest R3, but was told by the facility that R3's mental capacity was o.k. (R3) could come and go as he pleased and R5 wanted R3 arrested. Z9 stated they would not have arrested R3 if they had known R3 had a State Guardian. On 1/25/17 at 2:52 p.m., E4 (Social Service Director) stated she was informed on the morning of 12/16/16 that R3 had been arrested the night before. E4 did attempt to reach the OSG to notify them that R3 had been taken to jail. E4 stated that R3 returned to the facility from the police station at approximately 1:00 p.m. on 12/16/16. E4 stated R3 refused to come all the way inside the building and requested his belongings. At that point, E3 (Licensed Practical Nurse) attempted to contact the OSG. E4 stated R3 communicated better through writing, so she gave R3 the AMA: Release from Medical Discharge form so R3 could understand the risks of leaving the facility. E4 stated R3 read and signed the AMA: Release From Medical Discharge form, took his belongings and left the faciity on foot. According to E4, R3 stated he was walking to the police department. E4 called the local police department to inform them R3 was on his way to the station. E4 notified Z1 (Medical Director) that R3 left the facility AMA at 1:55 p.m. On 1/30/17 at 10:15 a.m., E4 stated they attempted to reach the OSG to notify them that R3 needed medical assistance and was leaving the facility, but did not consider calling 911 for medical transport to a hospital for treatment. E4 stated Z2 (Guardian) called her approximately 4 days after R3 left the facility and told them that R3 was technically considered a missing person at that point, because his whereabouts were unknown. On 1/25/17 at 11:18 a.m., E3 (Licensed Practical Nurse) stated he was present on 12/16/16 when R3 returned to the facility from the police department. E3 stated R3 told him that the police stated he was not allowed to return to the facility. According to E3, R3 requested his belongings and indicated he was walking back to the police department. E3 stated he attempted multiple times to reach someone at the OSG office and eventually demanded to be put through to talk to someone. E3 spoke with Z3 (OSG On-Call Guardian) and explained that R3 was not stable, needed medical help and was off his medications. At this point, R3 had been at the facility for approximately 10 minutes, when R3 decided to leave on foot for the police station. According to E3, Z3 stated she would call the police station and let them know what needed to be done with R3. E3 stated E5 (Transportation Aide) was able to catch up with R3 and give him a ride to the police station. On 12/28/16 at 11:10 a.m., E5 (Transportation Aide) stated R3 left the faciity on [DATE] on foot, to return to the police station. E5 stated he took his truck and was able to get R3 to agree to a ride to the police station. E5 stated he took R3 to the West door of the police station, and watch him enter the building and left. On 1/04/17 at 9:24 a.m., E1 (Administrator) stated she thought R3 would be coming back to the facility, but expected to hear from the guardian or police before R3's return. On 1/30/17 at 12:57 p.m., E1 stated, Due to the short time frame, of about twelve and 1/2 hours from R3's arrest (on 12/15/16) to when R3 returned to the facility (on 12/16/16), I can't answer the question as to who/when staff should have followed up with the police department regarding (R3's) status following his arrest. E1 stated she was shocked at how quickly R3 was released from jail and they were not prepared when R3 returned to the facility. On 1/25/17 at 12:45 p.m., Z1 (Medical Director) stated if R3 had a change in condition she would have expected a call, but the facility does not need an order to send a resident out for a psychiatric evaluation, if needed. Z1 stated the facility saw this as a transfer of care to the police, but that's incorrect, because (R3) needed medical care. Z1 stated she would expect the facility to determine up front, is his medical care going to be met at the time of arrest. Z1 stated It is the facility's responsibility to ensure the resident is medically taken care of .and no one clearly communicated up front what the real plan for (R3) was. Z1 stated, her review of the documentation in R3's medical record indicated staff handed (R3) off to the police and there was no follow up or clear delineation as to where R3 was going to go. Z1 stated no one clearly communicated up front, what the real plan for (R3) was going to be after his arrest. On 1/30/17 at 11:14 a.m., Z5 (Office of State Guardian Supervisor) stated R3 lacked the decisional capacity to make any decisions for himself, which was exactly why he was a ward of the State. Z5 stated the OSG provides the facility with all the necessary guidelines that are to be followed for adjudicated individuals, at the time of admission. Z5 stated it is the expectation of the OSG that the facility will follow through with any transfer out of the facility, whether it is to the emergency room , jail or programming, to ensure the resident's medical needs are going to be met. Z5 stated that the legal documentation provided by the OSG allows the facility to obtain routine and emergent medical care without prior approval from the Guardian. Z5 concluded that the facility should have called for emergency medical care for R3 on 12/16/16, when R3 returned to the facility, rather than trying to contact the Guardian. Z5 confirmed that R3's whereabouts are currently unknown. The Immediate Jeopardy was noted to have started on 12/15/16 when R3 refused to take ordered antipsychotic medications. Facility Administrator was notified of the Immediate Jeopardy at 1:40PM on 01/31/17. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. The facility provided in-service training by the facility's Director of Nursing and Social Service Director to all licensed and unlicensed staff at the nursing home regarding the expectation of the Office of State Guardian regarding routine and emergent medical care for adjudicated individuals, physician notification of change in resident condition, behavior management for new/worsening behaviors and status of resident transfers. 2. The Administrator and Director of Nursing reviewed facility Policy and Procedure on Behavior Management for Agitated Behavior, Change in Condition/Physician Notification Overview Guidelines, Behavioral Management for New or Worsening Behavior Symptoms, Medical Record Documentation and Transfer/Discharge. 3. The Administrator has developed a plan to ensure compliance with Subpart S - SMI State Regulations has been developed and is ongoing. The facility has identified which residents qualify for SMI and what programming would be appropriate for those individuals; however, those programs have yet to be implemented. 4. Additionally, the Director of Nursing will perform a Quality Assurance Audit of all OSG residents weekly for two weeks (or as needed thereafter) to ensure compliance with all reviewed facility policies and that appropriate mental health services are provided.

Based on observation, record review and interview, the facility failed to follow its policy and procedure for neglect by not accurately assessing for and implementing a plan for preventing falls for 1 of 5 residents (R2) reviewed for falls in the sample of 15. This failure resulted in R2 repeatedly falling from bed and sustaining multiple second and third [MEDICAL CONDITION] his back, buttocks, both shoulders and arm. Findings include: The policy and procedure titled, "Abuse Prevention Program Facility Policy" was reviewed. This was not dated. Under Neglect it documented "Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or in the deterioration of a resident's physical or mental condition." The policy and procedure titled, "Fall Prevention Program" was reviewed. This was not dated. Under policy it documented "...to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary." It documented under "Care Plan incorporates: Identification of all risk/issue, Addresses each fall, Interventions are changed with each fall, as appropriate and Preventative measures." It documented under "Standard Fall/Safety Precautions For All Residents: 2. At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times. 9. At the time of the initial assessment, a determination will be made to determine if the resident needs or desires side rails as a safety measure or as a mobility aide for self turning and repositioning." The physician's orders [REDACTED]. The Minimum Data Set, (MDS)dated 03/08/13, documented R2 has memory loss with moderate cognitive impairment with altered level of consciousness and psychomotor [MEDICAL CONDITION] and requires extensive assistance of at least two staff for transfers and extensive assistance of at lease one staff for dressing, toileting, hygiene and bathing and limited assist of one staff for bed mobility and locomotion. The MDS also documented R2 had Range of Motion, (ROM), deficits on both upper and lower of one side and is frequently incontinent of both bowel and bladder. The MDS documented that R2 had balance deficits requiring human assistance to maintain balance and is not on a toileting program. The Care Plan, dated last review 09/17/13, documented R2 had been identified for Falls due to wanting to get up or toilet and having had multiple [MEDICAL CONDITION]'s with left sided weakness and sleep on the edge of the mattress. Interventions included, in part, as assist with Activities of Daily Living, (ADL;s), as needed, attempt to anticipate needs, "I have a bell in my room as a call light, I do not always utilize this, please check on me while passing, I think it's funny to put myself onto floor - refer to my behavior care plan, Do not leave me in room unattended when up in wheelchair, Helmet for safety to prevent head injury, now utilizing a low bed to prevent me from attempting to transfer myself, continues on falling leaf program." The Fall Risk Assessment, dated 08/23/13, documented R2's score of 18 indicating he was at risk for falls. On 11/14/13, it documented a score of 19, at risk for falls. On 11/12/13 at approximately 9:30 PM, an Incident Summary Form documented R2 was found on the floor by E22 and E25, CNA's. It documented that R2 was found lying on the floor between his bed and the wall lying up against the base board heater. It documented that E19, Licensed Practical Nurse, (LPN), was notified and E22 and E25 assisted R2 back to bed and positioned him on his stomach. It documented that there were [MEDICAL CONDITION] his right shoulder, right scapula and right back. It documented that R2's facial pain scale was obtained and scored between a 7 and 8. It documented that he had blisters and some had broken open with transfer. It documented that the physician and responsible party was notified and R2 was sent to the hospital via ambulance. The Incident Summary Form further documented interventions put into place was the bed was moved to the doorway and room rearranged so R2 is no where near heater. Maintenance checked heating unit for proper function. The Incident Summary Forms for R2 were reviewed and from 11/03/12 to 11/12/13, R2 had 15 incidents where he fell /rolled or slid from his bed to the floor. Most of these incidents were recorded as "behaviors." On 11/22/13, R2 was observed on the mat on the floor next to his bed, call light on the floor against the far wall and the curtain pulled around him. E22, CNA stated he had gotten himself out of bed, but he is a two assist with transfers and she was waiting on another CNA to help. E21 and E22 then came into room and attempted to assist R2 back to bed, but noticed that his bed linens were wet with urine, so they transferred him to his wheelchair. E21, CNA stated that R2 can tell staff what he needs by using a thumbs up or down for yes or no, and he usually rolls out of bed when he needs something for pain, needs to go to the bathroom or has already wet or soiled his bed. She further stated that R2 will roll out of bed and urinate on the mat on the floor if he cannot wait and he puts himself on the floor everyday, sometimes multiple times during the shift. E20, E21 and E22, CNA's, stated that R2 can and will use his call light and they have never seen a bell in his room. They also stated that R2 can remove himself from bed and can roll or scoot himself out into the hall when he wants to. The Admission/Re-Admission Assessment documented R2 is a one person assist with transfers. The Care Plan/Behavior Tracking Record for October and November, 2013 were reviewed and documented in October 10 incidents of placing self on floor and in November 7 incidents. The interventions ranged from contacting the nurse to ensure resident is safe, to redirect and to explain that the behavior is inappropriate. During this time, none of these interventions were done. The Room Heater Temp Log was reviewed for the past month, or when the heat was turned on 10/31/13. The room that R2 was in had recorded temperatures on 10/31/13 of 118.6 degrees (with air conditioning unit on too) and documented "adjusted heat in R2's room, back and checked went down to 102 and 98 degrees. On 11/13/13, the Room Heater Temp Log documented R2's room heater recorded at 122.6 degrees (with the air conditioning unit on) and documented "adjusted heat in R2's room checked hour later was 101.6, air conditioning unit on." The temperatures documented for R2's room were recorded between 101.4 and 111.8 degrees with side notations of air conditioning units on at the same time. During an interview on 11/15/13 with E10, Maintenance Supervisor, he stated that staff can and will adjust the heater in the rooms to the residents request. He also stated that he is the only one that checks room temperatures at this time. On 11/15/13 at 10:30 AM, R2 was observed in his room, lying in bed on his left side. A low bed with a mat on the floor was observed. The call light was observed at the end of R2's bed lying on the floor. At 10:45 AM, E17 and E18, LPN's were observed during dressing changes for R2. R2 was lying on his left side and E17 had removed the dressing with serosanguineous drainage noted to the right lower flank/buttocks. E18 stated that R2 likes to lay on his left side because of where the burn is on the right side causes him pain. The area was observed to be very large with pink, blood tinged tissue throughout surrounded by a scab-like perimeter. After cleansing with soap and water, E17 applied [MEDICATION NAME] cream, an oil [MEDICATION NAME] dressing with a thick pad and taped to the wound. During this R2 made grimacing faces and would slightly move away when the burned area was touched. E18 asked E17 when R2 had been last medicated for pain, and E17 replied 8:00 AM with Tylenol. E17 was observed to do the same procedure with the remaining wounds. R2 had wounds on the right shoulder, left shoulder had three areas and left upper arm. The wounds measured on 11/21/13, right buttocks/flank 28 cm x 13.7 cm, left shoulder posterior 10 cm x 10.2 cm and 4.7 cm x 2 cm, left deltoid 18.5 cm x 5.2 cm and right shoulder posterior 1 cm x 0.5 cm. The history and physical exam done at the hospital on [DATE] documented R2 had sustained partial-[MEDICAL CONDITION](second to third degree) to those areas mentioned. On 11/21/13 at 9:30 AM, R2 was observed without his helmet on sitting in his wheelchair in his room with no staff in or around room. At 11:45 AM, R2 was in the assisted dining room without his helmet on. On 11/22/13, E21 and E22, CNA's, stated that R2 is to wear his helmet when up in his wheelchair. During an interview on 11/22/13 at 10:20 AM with E2, DON (Director of Nursing), it was discussed that R2 was identified for behavior management due to being non-compliant with transfers and taking himself out of his wheelchair and bed and laughing and thinking it's funny. She further stated that he can use his call light for assistance, but doesn't always do that. She also stated that he would always fall out of bed on the left side, never the right side. She stated that R2 is on every two hour checks by staff and was on every 15 minute checks but had been taken off recently for better behavior. When asked if R2 had safety awareness and is assessed for that, E2 stated yes. E2 further stated that R2 "obviously does not" have safety awareness. There was no documentation presented where R2's safety awareness was assessed and the interventions that were put into place were monitored for effectiveness and necessary changes were made to prevent further falls. There were no interventions put into place that would have prevented R2 from rolling off the bed to the right side and landing against the base board heater and sustaining burn injuries.

Based on observation, interview and record review, the facility failed to assess, monitor the effectiveness of current interventions, change interventions if necessary and implement progressive interventions to prevent frequent falls for 2 of 5 residents (R2 and R7) reviewed for falls in the sample of 15. This failure resulted in R2 sustaining 2nd and 3rd degree burns to his back, buttocks, shoulders and arm from repeatedly falling/rolling out of bed; and R7 sustaining fractured ribs from repeated falls. Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set, (MDS), dated [DATE], documented R2 has memory loss with moderate cognitive impairment with altered level of consciousness and psychomotor retardation and requires extensive assistance of at least two staff for transfers and extensive assistance of at lease one staff for dressing, toileting, hygiene and bathing and limited assist of one staff for bed mobility and locomotion. The MDS also documented R2 had Range of Motion, (ROM) deficits on both upper and lower of one side and is frequently incontinent of both bowel and bladder. The MDS documented that R2 had balance deficits requiring human assistance to maintain balance and is not on a toileting program. The Care Plan, dated last review 09/17/13, documented R2 had been identified for Falls due to wanting to get up or toilet and having had multiple CVA's with left sided weakness and sleep on the edge of the mattress. Interventions included, in part, as assist with Activities of Daily Living, (ADL's) as needed, attempt to anticipate needs, "I have a bell in my room as a call light, I do not always utilize this, please check on me while passing, I think it's funny to put myself onto floor - refer to my behavior care plan, Do not leave me in room unattended when up in wheelchair, Helmet for safety to prevent head injury, now utilizing a low bed to prevent me from attempting to transfer myself, continues on falling leaf program." The Fall Risk Assessment, dated 08/23/13, documented R2's score of 18 indicating he was at risk for falls. On 11/14/13, it documented a score of 19, at risk for falls. On 11/12/13 at approximately 9:30 PM, an Incident Summary Form documented R2 was found on the floor by E22 and E25, Certified Nursing Assistants (CNA's). It documented that R2 was found lying on the floor between his bed and the wall lying up against the base board heater. It documented that E19, Licensed Practical Nurse, (LPN), was notified and E22 and E25 assisted R2 back to bed and positioned him on his stomach. It documented that there were multiple burns on his right shoulder, right scapula and right back. It documented that R2's facial pain scale was obtained and scored between a 7 and 8. It documented that he had blisters and some had broken open with transfer. It documented that the physician and responsible party was notified and R2 was sent to the hospital via ambulance. The Incident Summary Form further documented interventions put into place was the bed was moved to the doorway and room rearranged so R2 is no where near heater. Maintenance checked heating unit for proper function. The Incident Summary Forms for R2 were reviewed and from 11/03/12 to 11/12/13, R2 had 15 incidents where he fell /rolled or slid from his bed to the floor. Most of these incidents were recorded as "behaviors." On 11/22/13, R2 was observed on the mat on the floor next to his bed, call light on the floor against the far wall and the curtain pulled around him. E22, CNA stated he had gotten himself out of bed, but he is a two assist with transfers and she was waiting on another CNA to help. E21 and E22 then came into room and attempted to assist R2 back to bed, but noticed that his bed linens were wet with urine, so they transferred him to his wheelchair. E21, CNA stated that R2 can tell staff what he needs by using a thumbs up or down for yes or no, and he usually rolls out of bed when he needs something for pain, needs to go to the bathroom or has already wet or soiled his bed. She further stated that R2 will roll out of bed and urinate on the mat on the floor if he cannot wait and he puts himself on the floor everyday, sometimes multiple times during the shift. E20, E21 and E22, CNA's, stated that R2 can and will use his call light and they have never seen a bell in his room. They also stated that R2 can remove himself from bed and can roll or scoot himself out into the hall when he wants to. The Admission/Re-Admission Assessment documented R2 is a one person assist with transfers. The Care Plan/Behavior Tracking Record for October and November, 2013 were reviewed and documented in October 10 incidents of placing self on floor and in November 7 incidents. The interventions ranged from contacting the nurse to ensure resident is safe, to redirect and to explain that the behavior is inappropriate. During this time, none of these interventions were done. The Room Heater Temp Log was reviewed for the past month, or when the heat was turned on 10/31/13. The room that R2 was in had recorded temperatures on 10/31/13 of 118.6 degrees (with air conditioning unit on too) and documented "adjusted heat in R2's room, back and checked went down to 102 and 98 degrees. On 11/13/13, the Room Heater Temp Log documented R2's room heater recorded at 122.6 degrees (with the air conditioning unit on) and documented "adjusted heat in R2's room checked hour later was 101.6, air conditioning unit on." The temperatures documented for R2's room were recorded between 101.4 and 111.8 degrees with side notations of air conditioning units on at the same time. During an interview on 11/15/13 with E10, Maintenance Supervisor, he stated that staff can and will adjust the heater in the rooms to the residents request. He also stated that he is the only one that checks room temperatures at this time. On 11/15/13 at 10:30 AM, R2 was observed in his room, lying in bed on his left side. A low bed with a mat on the floor was observed. The call light was observed at the end of R2's bed lying on the floor. At 10:45 AM, E17 and E18, LPN's were observed during dressing changes for R2. R2 was lying on his left side and E17 had removed the dressing wounds were observed on the right lower flank/buttocks. E18 stated that R2 likes to lay on his left side because of where the burn is on the right side causes him pain. During the dressing change R2 made grimacing faces and would slightly move away when the burned area was touched. E18 asked E17 when R2 had been last medicated for pain, and E17 replied 8:00 AM with Tylenol. E17 also had wounds on the right shoulder, left shoulder had three areas and left upper arm. The wounds measured on 11/21/13, right buttocks/flank 28 cm x 13.7 cm, left shoulder posterior 10 cm x 10.2 cm and 4.7 cm x 2 cm, left deltoid 18.5 cm x 5.2 cm and right shoulder posterior 1 cm x 0.5 cm. The history and physical exam done at the hospital on [DATE] documented R2 had sustained partial-thickness burns (second to third degree) to those areas mentioned. On 11/21/13 at 9:30 AM, R2 was observed without his helmet on sitting in his wheelchair in his room with no staff in or around room. At 11:45 AM, R2 was in the assisted dining room without his helmet on. On 11/22/13, E21 and E22, CNA's, stated that R2 is to wear his helmet when up in his wheelchair. During an interview on 11/22/13 at 10:20 AM with E2, DON (Director of Nursing), it was discussed that R2 was identified for behavior management due to being non-compliant with transfers and taking himself out of his wheelchair and bed and laughing and thinking it's funny. She further stated that he can use his call light for assistance, but doesn't always do that. She also stated that he would always fall out of bed on the left side, never the right side. She stated that R2 is on every two hour checks by staff and was on every 15 minute checks but had been taken off recently for better behavior. When asked if R2 had safety awareness and is assessed for that, E2 stated yes. E24 further stated that R2 "obviously does not" have safety awareness. There was no documentation presented where R2's safety awareness was assessed and the interventions that were put into place were monitored for effectiveness and necessary changes were made to prevent further falls. There were no interventions put into place that would have prevented R2 from rolling off the right side of the bed and preventing the burn injuries. 2. On 11/19/13 at 1:30pm R7 was transferring herself from her wheelchair into the restroom. E15 CNA entered the room and assisted R7 off the stool using a gait belt and performed a standing transfer to wheelchair. On 11/21/13 at 12:00pm E15 was asked if R7 is capable of transferring independently. E15 responded," No she needs our help." Review of Minimum Data Set ((MDS) dated [DATE] Section G Activities of daily living assistance, transfer and walk in room and corridor documents R7 needs EXTENSIVE ASSISTANCE -resident involved in activity, staff provide weight-bearing support. MDS dated [DATE] Section G documents the same. MDS dated [DATE] and 9/22/13 Section G under Balance During Transitions and Walking is documented as Not steady, only able to stabilize with staff assistance. Record review documents falls with R7 being sent to hospital for x-rays on 6/10/13, 8/22/13 and 9/1/13 with no fractures found. On 6/3/13 R7 was sent for x-ray after a fall and x-ray confirmed fracture of right seventh and eighth rib fracture. Nurses notes documents other falls on 8/21/13, 8/31/13, 9/11/13, 9/14/13 and 9/26/13 with no injury noted. Care plan has no interventions for falls 8/21/13, 8/22/13, 9/1/13 and 9/14/13. Care plan revision date of 9/27/13 Problem : 001 documents I have poor standing balance & (and) wide unsteady gait. Approaches/Interventions: Assist me to toilet routinely between meals and prn (as needed). 9/26/13 Res (resident) to lay down et (and) toilet with assist.

Based on interviews, observations and record review, the facility failed to provide double portions and supplements as ordered for 2 residents (R2 and R3) reviewed for weight loss on a sample of 4. This failure contributed to a significant unplanned weight loss of 11.6% (20 pounds) in 6 months for R3. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], R3 has short/long term memory deficits with severe cognitive impairment and requires minimal assist of staff for eating. The MDS identifies a significant unplanned weight loss of 10% or more within the last 6 months. The weight record for 2012 documents a gradual weight loss for R3 from 156 pounds in January 2012 to 137 pounds in August. The current physician's orders [REDACTED]. On 9/7/12 at 10:10am, R3 was sitting in his wheelchair in the lobby area of the facility. He was dosing in the chair. He appeared very thin with his clothes being large on him. At 12:57pm, R3 received single portion lunch meal in separate dark green bowls which consisted of slightly more than a 1/2 bowl of meatloaf, one scoop of mashed potatoes with gravy and a 2/3 bowl of creamed corn. He has a glass of water, grape drink and 2 prepackaged chocolate cookies. E9, Certified Nurses Aide (CNA) assisted/fed him. He took slow bites with long periods of time in between. He did, at times, attempt to feed himself. He ate 100% of all food items except the potatoes which he ate 50% of. No second helpings were offered or encouraged. Interview with E5, Dietary Manager (DM) on 9/7/12 at 3pm insisted R3 did get double portions "just like everyone else at the table did" and that it just didn't look like double portions. E5 agreed that R3 is losing weight but added that he gets a sandwich at bedtime which the nurses come in to the kitchen and get. He provided a "Snack List" which included R3 "1 1/2 sandwich." R2 is one of R3's table mate and was observed to get single portions as well. Review of the Medication Administration Record (MAR) for September 2012 did not include documentation of R3's 2 Cal 120cc being given at all for the month as of 9/7/12. The MAR for August shows the 2 CAL 120cc being given beginning on 8/20/12 but no 2 Cal 60cc being given at all prior to 8/20/12. Registered Dietician (RD), E6, initial assessment on admitted d 6/29/11 documents his weight as 193 pounds with his usual weight being 198 pounds. R3's height is 67 inches. The RD did not calculate ideal body weight. R3's Annual assessment dated [DATE] identifies R3 to be eating 50-75%, on a Hi Calorie/Hi Protein portions/supplements added diet. The June Annual assessments reflect the double portions and 2 CAL 120cc TID (Three times daily.) An RD assessment dated [DATE] identifies his weight in June 2012 as 144 pounds with current weight on 8/12/12 as 137 pounds. Problems documented for nutritional problems include weight loss with constant pacing. physician's orders [REDACTED]. A WEIGHT CHANGE NOTIFICATION dated 4/20/12 identifies 2.0 Med Pass but includes no amount. A WEIGHT CHANGE NOTIFICATION dated 5/10/12 to R3's physician lists R3 to be getting 2 CAL 60cc at bedtime at that time. A Dietician's recommendation completed E6 RD dated 8/7/12 identifies the 10% weight loss in 6 months with recommendations to increase the 2 Cal to 120cc TID which wasn't added to the MAR until 8/20/12. The facility was unable to provide any documentation that showed R3 received any 2 Cal prior to 8/20/12. On 9/7/12 at 2:40pm, interview with E11, LPN, caring for R3 was unable to recall if R3 ever gets 2 CAL or not but stated if he did, it would definitely be documented on the MAR as that is the policy of the facility. E11 confirmed that it was not on the September MAR. Interview with E7, License Practical Nurse, on 9/7/12 indicates that she fills out the weight change sheets and faxes them to the physician. She was unsure as to why the 2 CAL wasn't on the August MAR or the Sept MAR and confirmed that the increase recommended on 8/7/12 wasn't implemented until 8/20/12. E7 was unable to explain why the RD's recommendation took 13 days to implement. E7 did acknowledge that the RD fills out her own sheets to fax to the physician which she thought the nurses faxed to him. On 9/11/12 at 1:50pm, E6 RD recalled R3 and stated she makes recommendations on a fax ready sheet to send directly to the physician and didn't know why the supplements and/or the increase recommended took 13 days to implement. In addition, she stated she did not routinely check the MARs to see if the recommendations are followed through on and that she assumes they are unless informed by the facility. E6 stated she prefers the 2 CAL over the health shakes because it is usually on the MAR and the nurses have to document giving it. She stated R3's not getting the 2 CAL as ordered along with double portions as ordered/recommended contributes to unplanned weight loss. E6 acknowledged that R3 has had a significant change since a fall in August where he is not as active with pacing and wandering and is more dependent on staff. E6 stated it is beneficial to the resident when dietary recommendations are followed. On 9/11/12 at 1:38pm, Z3, R3's Physician acknowledged that R3 has had a significant change in condition since a fall in August when he sustained a subdural hematoma which he identifies as a "significant issue for him that nutrition fits in too.". Z3 stated he is currently using a wheelchair more. Z3 stated he always agrees with the RD's recommendation and that he assumes the facility is following physician's orders [REDACTED]. On 9/11/12 at the breakfast meal, R3 was again served a regular portion breakfast which included oatmeal, and french toast. The care plan reviewed on 9/11/12 shows no reference to R3's significant weight loss but indicates he needs constant cues/encouragement to feed himself and complete his meals. The goal is to have no weight loss gaining 1-2 pounds by next review 9/19/12. Interventions include the double portions, 1/2 meat sandwich which was added 1/16/12 and no reference to the 2 CAL included. E2 Director of Nursing confirmed that the 2 CAL was not documented as given prior to 8/20/12 and that policy is that 2 CAL is always documented on the MAR since the nurses give it. E2 stated adding it to the September MAR was missed by the nurse that reviews it but was added on 9/7/12 after being notified of the omission. E2 acknowledged R3's weight loss and agreed that physician's orders [REDACTED]. E2 didn't know if E7, LPN, was responsible to send the RD"s recommendations or if the nurses sent the RD"s fax ready recommendations and couldn't determine why it took 13 days to implement R3's increase in 2 CAL or why it wasn't documented before that time. E2 also confirmed that R3 has had a significant change since his fall which includes pacing/wandering less and is spending more time in the wheelchair. On 9/7/12 at 10:15am, Z1, R3's family member stated that R3 has loss a tremendous amount of weight since his admission to the facility in June 2011. She stated she thought he wasn't getting enough food to meet his needs because up until a few weeks prior, he was continually wandering and pacing. Z1 identified his normal weight as 200 pounds. Z1 also stated R3 is not feeding himself as much anymore and is more dependent on staff. Z1 is concerned about him not getting enough food and that staff are not taking time to feed him. 2. The MDS dated [DATE] identifies that R2 requires set up/supervision for eating and that he is 68 inches tall and weighs 125 pounds. The RD Initial assessment dated [DATE] indicates R2's weight on admission was 146 pounds, showing a gradual loss of 21 pounds. September 2012 POS documents diet orders as mechanical soft with ground meat, thin liquids and "may have double portions as meat times." The DM notes dated 8/2/12 document R2 "current receiving a mech (mechanical) soft double portions at meals." The care plan dated 8/1/12 fails to identify R2's gradual loss but does include a goal to maintain adequate nutrition without a significant weight loss. Interventions include serve diet as ordered, supervise eating, among others. On 9/7/12 at 1:05pm, R2 was served a single portion meal in a divided plate. He had one scoop of potatoes with gravy, a small bowl of creamed corn and a pureed meat portion. R2 ate his meal in less than 6 minutes scooping large portions as staff cued him to take smaller bites. Once finished, he left the dining room ambulating independently. Within a few minutes, he returned to his seat, looked at his plate, looked at others then left the dining room again. He did this several times until staff was asked if he was still hungry. E9, CNA, stated this was routine behavior for him and that at times, he will take food from others plates. Asked if he was still hungry, E9 stated she didn't know and asked him. He shook his head "yes". An additional plate was provided of a full meal and he ate 100% of the second portion. Double portions were not provided at first. Interview with the RD, E6, at 1:55pm on 9/11/12 indicates she may have to word the order to give double portions instead of "may have" if staff are not offering them when appropriate. Z3, MD, stated at 1:38pm on 9/11/12 that he felt the residents needed the RD's recommendation and the facility should provide them accordingly. .

Based on interview and record review, the facility failed to provide Intravenous (IV) antibiotics and IV line flushes as ordered for one of two residents, (R3) reviewed for IV medication in a sample of four. This failure resulted in R3 beig readmitted to the hospital with [REDACTED]. Findings include: Review of the Facility Admission Information sheet documents that R3 has [DIAGNOSES REDACTED]. R3 was admitted to the facility on [DATE] with Physician orders to maintain his Peripherally Inserted Central Catheter (PICC) line, by Flushing with [MEDICATION NAME] Lock Solution 10 units per 5 milliliters every eight hours. R3 also had Physician medication orders including; [MEDICATION NAME] 600 milligrams (mgs) in 100 milliliters (ml) of Sodium Chloride to be given once daily for 13 days, and [MEDICATION NAME] 1 milligram IV push every two hours as needed for pain. Review of the Facility Policy which is undated and titled; Intermittent Intravenous Administration, under the area of "Responsibility" documents RN/Trained LPN only. Under #1) is documented that "only qualified, licensed nurses with sufficient knowledge and training may administer intermittent IV antibiotics.". Review of the R3's February 2012 Medication Administration Record (MAR) documents that R3 did not receive any [MEDICATION NAME], or PICC line [MEDICATION NAME] Flushes on 2/25 and 2/26/12. The MAR also documents that on 2/23/12 E5, RN, administered the IV antibiotic and IV line flushes to R3. The Nursing Schedule for the month of February 2012 documents, that no Registered Nurses were scheduled to work on any shift, the weekend of 2/25 and 2/26/12 and that on 2/23/12, E5 RN had called off work on 2/23/12. In an interview on 3/9/12 at 4:00 PM E5 RN reviewed the MAR and confirmed he did not work 2/23/12. During an interview on 3/9/12 at 11:00 AM with E2 RN/DON she stated, she set it up initially to come in to work to give the pain medication and IV antibiotics when E5, the only staff RN, was not scheduled to work. E2 assumed that E5 RN was working that weekend so she didn't go in. The Licensed Practical Nurses that worked the weekend did not call anyone to let them know the medication had not been given. On 3/13/12 at 11:55 AM E4, the Licensed Practical Nurse (LPN) that had cared for R3 on the weekend in question stated,"We do not have assigned charge nurses on the weekend. We each take care of our own residents. I did not know we were supposed to call someone to come in to give the IV medicine. I thought the DON had that all set up. LPN's aren't allowed to give IV medications so I didn't even look at that medicine or know if they were coming in later to give (R3) the medicine. On 3/9/12 at 9:45 AM R3 was interviewed in his hospital room. He previously had a right [MEDICAL CONDITION]. On 3/7/12, R3 underwent a right above the knee debridement and amputation. R3 stated "The last six days I was in the home they only gave me my antibiotics once. E2 only came in to give me my IV pain medication once, after that they got it changed to a shot or a pill. Neither one helped as much as the IV pain medicine so I was always in pain." R3's Minimum Data Set completed on 2/22/12, R3 is documented as being fully alert and oriented. Nurses Notes dated 2/26/12 document that at 3:00 PM, R2 had complained of pain and a burning sensation throughout the right thigh. The right outside of the thigh is red, tender to the touch and slightly swolled. Pain is not relieved with Intra-Muscular pain medication. Temperature is 99. The nurse received an order for [REDACTED]. R2 was transported per facility van at 8:30 PM. Per the hospital emergency room documentation dated 2/26/12, R2 was admitted with [MEDICAL CONDITION] of the right thigh. The hospital emergency room nurse documented after contacting the facility, that R2 had no IV medication given the previous two days because they did not have an RN on duty to administer it. On 3/8/12 at 2:00 PM Z1 Medical Doctor and R3's Surgeon stated, (R3) had a severe leg and muscle injury to begin with. Missing those antibiotics did not help and allowed the infection to flare up again. The antibiotics were there to prevent further spread of the infection. It contributed to his re-admission to the hospital, but the re-admission is also a result of the injury that was present to begin with." "I did request a copy of the medication administration record to be sent to me so that I could verify how many doses of medication had been missed. I was concerned.

Based on interview and record review the facility failed to assess pain; provide pain relief; and provide wound care treatment for one of three residents (R3) reviewed for pain and wound care in a sample of four. This failure resulted in R3 being readmitted to the hospital with [REDACTED]. Findings include: R3's facility admission sheet documents that R3 was admitted on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], documents that R3 is alert and oriented and cooperative. R3 was discharged from the hospital on [MEDICATION NAME] 5/325 1-2 tablets every 6 hours as needed and [MEDICATION NAME] 1 milligram Intravenous (IV) every 2 hours as needed. R3's Nurses notes and the Medication Administration (MAR) dated 2/15/12 document that no pain assessment is included in the admission documentation or the nurses notes. R3's Physician order [REDACTED]." On 3/8/12 E1 and E3 stated at 2:30 PM that they did not have a facility policy or protocol for treatment with a Negative Pressure [DEVICE]. They were following the provider's information to change the dressing every three days, and the canister when full. Documentation by E10, Social Services, on 2/23/12 documented that the resident informed her that he had not had any drainage canisters for his [DEVICE] for two days and he has no pain medications. E10 notified E3, Licensed Practical Nurse, (LPN)/ Quality Assurance Nurse. E3 called and made sure canisters will be at the facility in the morning and contacted the Physician for a one time order for pain med's and other medication will arrive around 7 or 8 PM tonight. Review of the facility Treatment record documents that R3 did not have the [DEVICE] in place for 2/15/12 and 2/16/12. It was not initiated until 2/17/12. On 3/9/12 at 9:45 AM R3 was interviewed in his hospital room. R3 stated, "The air seal on the [DEVICE] kept leaking the nurses didn't know what to do with it so they just keep adding more tape, but it still leaked. The canister on the thing would be full and they didn't change it for two days, they had to order some." On 3/9/12 at 9:10 AM Z1 Plastic Surgery Resident working with Z2 stated, " the standard of care for Negative Pressure [DEVICE] is to change them every other day. It may be left on longer if the wound is healing and there is minimal drainage, but that would not be true for (R3), he had a lot of drainage. The every other day change of the dressing is a standard and common knowledge. There should be no deviation. Canisters need to be changed when almost full, or if the seal is broken." On 3/8/12 at 2:00 PM Z1, Medical Doctor and Surgeon stated, "(R3) had a severe leg and muscle injury to begin with. Missing those antibiotics did not help and allowed the infection to flare up again. The antibiotics were there to prevent further spread of the infection. It contributed to his re-admission to the hospital, but the re-admission is also a result of the injury that was present to begin with." Z1 also stated, "I did request a copy of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. I was concerned. According to the hospital surgery report dated 3/7/12 on 3/7/12, R3 underwent a right above the knee debridement and amputation. On 3/9/12, Z2 stated, "I did see (R3) in my office on 2/23/12. There are two reasons why I would have stopped the [DEVICE] at that time. One is when the wound is healed, two would be that the [DEVICE] was not working effectively and there was so much drainage we needed to open it up and let it drain in hopes of promoting healing. I believe that is why I discontinued the [DEVICE] for (R3)." Review of the Nurses Notes from 2/15/12 to 2/23/12 do not document any dressing changes or wound assessments. 2/24/12 and 2/25/12 do not document any wound assessment. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There is no documentation reflecting the effectiveness of the medication. R3 again complained of pain at midnight and requested Intravenous (IV) pain medication. E11 Licensed Practical Nurse (LPN) documented she explained to R3 that he had oral pain medication two hours ago and could not have more at this time. E11 also explained that LPN's were not able to give IV pain medication, and she would have to call the doctor. The physician returned her call at 1AM and gave an order for [REDACTED]. On 2/16/12 at 2:00 PM [MEDICATION NAME] was again administered with no pain assessment documented as to the level of pain. After administration it is documented that R3's pain was only somewhat relieved. There is no nursing documentation of pain assessment or relief on 2/17, 2/18, or 2/19/12. On 2/20/12 E4 Registered Nurse (RN) requested an order for [REDACTED]. On 2/23/12 there is documentation that IM [MEDICATION NAME] was given but no pain assessment as to why there was a need for a change in the pain medication order. On 2/24 there is a request for pain medication but no assessment, or documentation of what medication was given and if there was any relief obtained. There is no no pain assessment documented on 2/25, and on 2/26 there is documentation that R3 complained of pain that is not relieved by IM pain medication. That day R3 was transferred back to the hospital for treatment of recurrent [MEDICAL CONDITION]. On 3/9/12 at 9:45 AM, in his hospital room R3 stated, "I only got my IV pain medication once after hours. The Registered Nurse (RN) would not come in after that so they had to get an order for [REDACTED]. Nurses Notes dated 2/26/12 document that at 3:00 PM, R2 had complained of pain and a burning sensation throughout the right thigh. The right outside of the thigh is red, tender to the touch and slightly swolled. Pain is not relieved with Intra-Muscular pain medication. Temperature is 99. The nurse received an order for [REDACTED]. Per the hospital emergency room documentation dated 2/26/12, R2 was admitted with [MEDICAL CONDITION] of the right thigh. The hospital emergency room nurse documented after contacting the facility, that R2 had no IV medication given the previous two days because they did not have an RN on duty to administer it. According to the hospital Surgery Report dated 3/7/12, R3 underwent surgery for [REDACTED].

Based on observation, record review and interview, the facility failed to revise and implement effective interventions for prevention of repeated falls 3 of 6 residents (R1, R2, R4) reviewed for falls in a sample of 17. Findings include: 1. On 11/01/11 at 10:23 AM, during the tour of the 100 hall, R4 was observed in his room on the floor in front of the toilet with a wheelchair at his side. E23, Social Services Director, stated that R4 has been getting up on his own and falling lately. R4 was alert, but not oriented, in which E23 reported that is normal for R4. At 10:26 AM, E4, Licensed Practical Nurse, (LPN), assessed R4 for injuries and found no obvious signs of injury. E22 (Restoratives PT) and E6, Certified Nurse Aid, (CNA) then assisted R4 up to wheelchair and transferred R4 to bed. While E6 (CNA) was performing incontinent care, it was observed that R4 had multiple bruises to his left side from the upper ribs down to mid thigh in varying stages of healing. E4 (LPN) stated that the bruises were caused from R4 having so many falls lately. On 11/11/11 at 10:30 AM, E22 stated, "He is supposed to be a walk to dine, but lately I haven't been walking him because he has fallen so much the past few days." R4 was admitted on [DATE] and has medical diagnoses, in part as, dementia, Alzheimer's Disease, epilepsy and seizure. The Minimum Data Set (MDS), dated [DATE], identified R4 as moderately cognitively impaired with short and long-term memory deficits, needs extensive assist with at least one staff person for all transfers, ambulation, dressing and hygiene and bathing. It also identified R4 as occasionally incontinent of bowel and bladder. The care plan, last updated 08/23/11, identified R4 as an increase risk for falls due to "impaired cognitive and safety awareness...nonambulatory...receive meds which increase risk for falls..." The Falls Risk Assessment, dated 08/05/11, identified R4 scoring 18 points which indicates he is at high risk for falls. The Fall Prevention Program policy and procedure was reviewed on 11/04/11. Under, "#10. Care incorporates: c. Interventions are changed with each fall, as appropriate, and d. Preventative measures. #12. b. Recommendations for changes in the plan of care to minimize reoccurrence." On 03/11/11 at 12:30 PM, the Incident Summary documented that R4 was found on the floor by another resident. R4 was found "lying on the floor face lying in blood, blood coming from nose and head." R4 was sent to hospital for treatment for [REDACTED]. There were no new or revised interventions put into place on R4's care plan. On 03/15/11 at 5:55 AM, the Incident Summary documented that R4 was on floor between bed and dresser and wheelchair. The care plan, dated 03/15/11, documented "refer to PT/OT for strengthening." On 07/16/11 at 11:00 AM, the Incident Summary documented that R4 was found on the floor in his room. It further documented "It appears he was attempting to transfer from chair to bed." The intervention on the care plan, dated 07/16/11, documented "Ensure I am wearing proper footwear before transfers." On 10/17/11 at 5:30 PM, the Incident Summary documented "Found on floor sitting up..." The intervention, dated 10/17/11, documented "refer to restorative CNA for poss strengthening, P/O (PT Physical Therapy/OT Occupational Therapy)." On 10/24/11, the Incident Summary documented "went to room after eating supper and tried to transfer self, became weak in legs and sat on floor." Interventions documented on the care plan were "PT/OT screen." No new interventions documented on the care plan. On 10/27/11, the Incident Summary documented "Resident roommate informed writer that this resident on floor. Resident sitting on bottom in bathroom with wheelchair behind him." Interventions documented on the care plan for 10/27/11 "PT/OT continue." On 10/30/11 at 5:30 AM, the Incident Summary documented "found on floor between bed and wheelchair. Resident was transferring self. Wheels on wheelchair locked." Interventions on the care plan, dated 10/30/11 "PT/OT." On 11/01/11, the Incident Summary documented two separate unwitnessed falls. One at 10:23 AM, and the other at 12:30 PM. The Incident Summary documented at 12:30 PM, "observed on floor next to bed trying to lie down." The interventions documented "frequent checks and 72 hour charting." 2. R2's MDS, dated [DATE], documented R2's [DIAGNOSES REDACTED]. R2's Incident Summary, dated 10-13-11, documented R2 was found on the floor by her roommates bed. It was also documented that R2 had a laceration to the left side of her forehead and a hematoma to her forehead. R2's Incident Summary, dated 10-16-11, documented R2 was found on the floor in her bathroom. It was also documented that R2 was admitted to a local hospital. R2's chart documented R2 was readmitted to the facility, on 10-20-11, with a fractured right hip. R2's Care Plan, goal dated 10-31-11, documented R2 was at risk for falls related to self care deficits and impaired cognition and impaired mobility. R2's Care Plan did not document her 10-13-11 and 10-16-11 falls and fall prevention interventions for her falls. Interview of E3, Director of Nursing (ADON), on 1-3-11 at 9:45a.m., E3 stated R2 was confused and had a history of [REDACTED]. Interview of E7, Certified Nursing Assistant (CNA), on 11-4-11 at 11:00a.m., E7 stated R2 had a history of [REDACTED]. Interview of E14 (CNA), on 11-4-11 at 11:05a.m., E14 stated R2 had a history of [REDACTED]. Interview of E11, Care Plan/MDS Coordinator, on 11-3-11 at 9:20a.m., E11 stated R2's Care Plan was in the "down file". E11 provided an updated fall Care Plan on 11-3-11 on placed in R2's Chart. R2's updated fall Care Plan documented R2 was referred to Physical Therapy/Occupational Therapy after her 10-13-11 and 10-20-11 falls. R2's fall prevention Care Plan did not document R2's history of attempting to self ambulating or new interventions to prevent falls as a result of her self ambulating. R2's chart did not document assessments or causative factors of R2 falls. 3. R1's MDS, dated [DATE], documented, diagnosis, in part, as [DIAGNOSES REDACTED], no signs and symptoms of Delirium, no short or long term memory problems, total dependence of two plus persons physical assistance with transfer and bilateral functional limitation in range of motion for upper and lower extremities. Interview of E3 (ADON), on 11-1-11 at 10:00a.m., E3 stated R1 was reliably interviewable. R1's Preliminary 24-hour Incident Investigation Report, dated 7-5-11, documented R1 complained of right ankle swelling on 7-4-11 a 10:30a.m. and a portable X-ray revealed a fractured of the distal fibula. Interview of R1, on 11-2-11 at 2:35p.m., R1 stated a staff member, name not stated, caught her right foot in her reclining chair during a transfer. She also stated her right foot was broken during the transfer. R1's Final Incident Investigation Report, dated 7-7-11, documented "all nursing staff have been re-inserviced regarding proper transfers include Hoyer lifts, transfers et techniques."

Based on record review and interview the facility failed to assess and monitor 1 of 1 resident (R3) reviewed for constipation in a sample of 17. This failure resulted in R3 being hospitalized with fecal impaction. Findings include: 1. It is documented in R3's Hospital and Physical Examination of 9-23-2010, R3 has a [DIAGNOSES REDACTED]. Nurse Practitioner Note of 3-28-11 documents R3 has Chronic Constipation. Hospital History and Physical of 7-26-11 documents R3 's chief complaint is fever, abdominal pain, nausea and vomiting. It is documented under Assessment and Plan, in part, Chronic constipation. Hospital X ray report of 7-26-11 shows mild ileus was seen with the fecal impaction in the colon. Hospital Emergency Department report of 8-7-11 shows R3 was in the emergency room with a [DIAGNOSES REDACTED]. Much worse today. No bowel movement (BM) for 5 days until yesterday with small hard stool. Past medical history includes small bowel obstruction. Abdomen tenderness, some high pitch and some distention. Clinical Impression is abdominal pain - resolved constipation. R3's November 2011 Physician order [REDACTED]. R3 has an order for [REDACTED]. R3's Nurses Notes of 8-3-11 states R3 has complaints of constipation and has been refusing [MEDICATION NAME] but agreed to take to have a BM. There are no further Nurses Notes addressing BM until 8-6-11 at 2200 stating R3 complaining of abdomen pain but refusing treatment. Large, soft BM noted. Note of 8-7-11 at 1530 documents R3 approached writer with complaint of pain to lower right abdomen that radiates to lower back, is constipated with "rock solid pebbles" in stool. R3 became tearful and stated pain has increased. R3 agreed to be seen by a Doctor and was sent to the ER. Note at 2100 states R3 is back from ER with a [DIAGNOSES REDACTED]. Facility BM Tracking records for August 2011 show no BM recorded until 8-8-11. Records show documentation of 6 BM's in the month of August. BM record for September 2011 show documentation of 1 BM and October 2011 shows documentation of 3 BM's for the month. On 11-2-11 at 9:30AM, E2, Director of Nursing (DON) stated R3 is at increased risk for constipation and fecal impaction due to [DIAGNOSES REDACTED] and taking pain medications. B) Based on observation, interview and record review, the facility failed to assess, monitor and treat pain for 1 of 6 residents (R2) reviewed for pain in the sample of 17. This failure resulted in R2 crying with pain. Findings include: R2's Minimum Data Set (MDS), dated [DATE], documented R2's [DIAGNOSES REDACTED]. R2's Incident Summary, dated 10-13-11, documented R2 was found on the floor by her roommates bed. It was also documented that R2 had a laceration to the left side of her forehead and a hematoma to her forehead. R2's Incident Summary, dated 10-16-11, documented R2 was found on the floor in her bathroom. It was also documented that R2 was admitted to a local hospital. R2's chart documented R2 was readmitted to the facility, on 10-20-11, with a fractured right hip. R2's Pain Screening Form, dated 10-20-11, documented R2's score as a 14 and "score 5 or greater indicates comprehensive assessment needed. R2's Comprehensive Pain Assessment was not dated or completed. Interview of E11, Care Plan/MDS Coordinator, stated on 11-3-11 at 10:30a.m., R2's Comprehensive Pain Assessment had not been done. R2's PRN (as needed) Medications sheet, dated 10-20-11 to 11-19-11, documented R2 was administered "[MEDICATION NAME] 50mg...pain" 10-26-11 at 1600, 10-27-11 at 1600, 10-28-11 at 12noon and 1600 and 10-31-11 at 12noon. R2's PRN Medications sheet did not document the reason for administering the medication, site of pain and the result of the medication administration. R2's PRN Medications sheet, dated 11-1-11 to 11-30-11, documented R2 was administered "[MEDICATION NAME] 50mg...for pain" on 11-1-11 at 1230 and 1630 and on 11-2-11 at 1545. R2's Nursing Notes, dated 11-1-11 and 1-2-11 and PRN Medication sheet did not document the reason for administering the medication, site of pain and the result of the medication administered. R2 was observed, on 11-2-11 at 12:00 noon, sitting in the dining room with a weepy, tearing right eye that she repeatedly blinked. R2 was observed until 3:20p.m. repeatedly blinking her right eye which continued to drain. Interview of R2, on 11-2-11 at 3:20p.m., R2 nodded her head up and down when asked if her right eye hurt. Interview of E7, Certified Nursing Assistant (CNA), on 11-4-11 at 11:05a.m., E7 stated R2 answered questions by nodding her head up and down for yes. Interview of E8, Licensed Practical Nurse (LPN), on 11-2-11 at 3:20p.m., E8 stated R2's eye was weepy and that R2 indicated she was in pain. E8 also stated she would contact R2's physican. R2's PRN Medication sheet, dated 11-1-11 to 11-30-11, documented R2 was administered "[MEDICATION NAME] 50mg..for pain" on 11-23-11 at 1545 but the reason for administering the medication, site of pain and the result of the medication administered. R2's Nursing Notes, dated 11-1-11 to 11-3-11, did not document R2's physician was called for R2's right eye or the effectiveness of the administered medication. The facility's Pain Management policy and procedure, dated 9-02, documented the first step in pain management was assessment and to assess and documented at regular intervals after initial treatment plan and at suitable interval after each pharmacologic or nonpharmacologic intervention.

Based on record review and interview, the facility failed to assess, monitor, implement interventions, develop a plan of care and provide supervision at meals for 1 of 2 residents (R3) reviewed for swallowing difficulties and eating behaviors, in the sample of 6. This failure resulted in R3 choking on a sandwich during unsupervised dining. R3 was transported to the hospital at 6:16 pm and was pronounced dead at 6:42pm on that same date. Findings include: R3's Resident Incident Report, dated [DATE], documented " while in dining room, res (resident) (R3) noted to have difficulty swallowing et (and) turned blue. Staff initiated Heimlich maneuver without success. 911 called finger sweep done. Res. placed on floor. CPR (Cardiopulmonary Resuscitation) initiated. 911 arrived et took over CPR. Res taken to hosp (hospital) via stretcher." The hospital Emergency Nursing Record, dated [DATE] at 1816 (6:16PM), documented, "Pt (patient) eating sandwich at dinner table became unresponsive after choking. EMS (emergency medical staff) gave Epi x2 (times two), Atropine x2, PEA (?) on the monitor. ET (?) tube 7.5 Placed pt bagged per EMS. EMS suctioned removing sandwich." R3's death was called at 1842 (6:42PM) on [DATE]. On [DATE] at 11:20a.m., R4 stated "that night the girl put the sandwich in a bowl down in front of R3 then walked away to go get a spoon... by the time she came back R3 was unresponsive and blue." On [DATE] at 2:55p.m., E14 Certified Nurse Aid (CNA), stated she had placed a bowl of ground meat and whole bread in front of R3 on [DATE], left R3 to get another meal tray and returned to R3's table to check on her. E14 stated R3 was confused at times, had a history of [REDACTED]. On [DATE] at 3:20p.m., E12, CNA, stated she saw chunks of "white", bread, in R3's mouth. E12 also stated R3 was a choking precaution, at risk for choking, had a history of [REDACTED]. On [DATE] at 10:16a.m., Z8, Outside Agency Care Provider, stated the Sunday prior to R3's choking incident, of [DATE], she had informed staff about R3's coughing when eating a sandwich. Z8 also stated that staff could not put food in front of R3 and walk away because R3 would grab at food, cram food in her mouth, pouch food and shovel food without supervision. Z8 also stated R3 had a history of [REDACTED]. A physician's orders [REDACTED]. A line was drawn through the "provide 1:1 supervision at meals" without a documented date, time and/or initial (signature). On the same POS, a line was drawn through the diet order and "d/c (discontinue) [DATE]" but, again, there were no initials or signature. On [DATE] at 12:55a.m., Z3, R3's Physician, stated it would be out of character for him (Z3) to draw a line through an order and not initial a change of order. R3's Initial Annual Significant Change Nutritional Assessment, dated [DATE], documented R3's inability to swallow regular food/fluids due to Dementia and a history of coughing/choking. It was also noted R3 required full supervision and cueing at meals and was at risk for aspiration. On [DATE] at 1:00p.m., E19, Dietitian, stated the [DATE] assessment was most current. R3's Rehab Discharge Summary, Speech Therapy, dated [DATE], documented "Pt (patient) seen for about (?) treatments for dysaphia. Pt. remains on mechanical soft & (and) nectar thick fluids. Pt needs supervision for rates and bolus size to increase safety of swallow. Pt. required instruction including both verbal and tactile cues." On [DATE] at 11:32a.m., Z6 Speech Therapist confirmed R3's needed supervision for safety. Physician order's, dated [DATE], documented "d/c skilled st (speech therapy) due to goal achieved at optimal level. Pt. still requires supervision in dr (dining room) to rate of intake & (and) bolus size." On [DATE] at 2:50p.m., E18, Dietary Manage, stated R3 should be served one bowl at a time. R3's current diet card documented "mechanical soft, nectar thicken liquids food in bowls served one at a time." On [DATE] at 11:20a.m., E5, LPN stated R3 needed supervision and cueing to slow down. E8, CNA, stated on [DATE] at 11:20a.m., that R3 shoveled in her food and needed to be told to slow down all the time. On [DATE] at 11:30a.m., E10, CNA, stated R3 ate too fast and had to be slowed down all the time. On [DATE] at 11:25a.m., E9, CNA, stated "you had to sit by her and get her to slow down when eating...she ate so fast." On [DATE] at 2:35p.m., E13, LPN, stated R3 had a problem with pocketing food and eats too fast. On [DATE] at 11:24a.m., E6, LPN, stated R3 ate too fast and needed supervision and R3 would not swallow before putting more food in her mouth. R3's MDS, dated [DATE], did not document R3 had signs and symptoms of a swallowing disorder or that she had eating behaviors. It was also noted R3 was assessed as a supervision of set up help only with eating and fluids. Interview of E16 (RN), on [DATE] at 11:45a.m., E16 confirmed R3's eating behaviors were not documented on R3's MDS. R3's Care Plan, goal date [DATE], documented R3 was on a mechanically altered diet related to chewing difficultly and history of swallowing difficultly. R3's Care Plan did not document R3's eating behaviors of, rapid eating, shoveling food, coughing, choking, aspiration potential nor her level of needed supervision. Interview of E16 (RN), on [DATE] at 11:45a.m., E16 confirmed R3's eating behaviors were not documented on R3's Care Plan. R3's Choking Risk Assessments, dated [DATE], [DATE] and [DATE], did not document R3's eating behaviors, or difficulty with swallowing and /or gagging or choking episodes. The facility's Choking Assessment Policy and Procedure, dated [DATE], documented a choking risk assessment was to be completed on all residents quarterly and as necessitated by resident need.

Based on record review, interview and observation, the facility failed to assess nutritional needs, provide and document treatment, provide adequate cleansing, follow physician orders [REDACTED]. This failure resulted in R3 acquiring a stage 4 pressure ulcer on the coccyx at the facility which became septic. R3 was admitted to the hospital and required surgical debridement of the ulcer. The findings include: According to the current face sheet in his medical record, R3 was admitted to the facility with diagnoses, in part, of Vitamin D deficiency, [MEDICAL CONDITIONS], Tremor. The "Braden Scale for Predicting Pressure Sore Risk" dated 7/8/11 and 8/15/11 assessed R3 as "mild" risk for developing pressure sores. The nurses notes on the "daily medicare Charting Flow Sheet" dated 7/11/11 documented "Res (resident) noted (with) multiple reddened areas to scrotum et (and) penis (with) areas of necrotic tissue coccyx et (and) surrounding area is dark red, looks bruised". The 7/22/11 and 7/29/11 "Pressure Ulcers/Wounds" log documented R3 had facility acquired pressure ulcers as follows: 1. left testicle: unstageable, necrotic 3.7 x 1.8 centimeters (cm) 2. right testicle: unstageable, necrotic, 0.7 x 1.3 cm 3. coccyx: stage 3, 1.4 x 0.5 cm. with an increase on 7/29/11 to 1.4 x 0.8 cm The 8/5/11 and 8/12/11 "Pressure Ulcers/Wounds" log documented: 1. left testicle: unstageable, necrotic, 1.0 x 0.7 cm 2. right testicle: unstageable, closed 3. coccyx: stage 3, 4.0 x 1.5 x 0.8 cm with the depth decreasing to 0.7 on 8/12/11 The following treatments were done on the coccyx pressure ulcer according to the physician orders: 7/11/11 Lantaseptic to coccyx three times a day. 7/14/11 [MEDICATION NAME] twice a day for wound healing-Dietitian to see. 7/22/11 Speech evaluation for dysphagia. 7/22/11 double portions at all meal. 8/6/11 Silver Alginate to wound and cover with collasorb and foam daily. 8/14/11 Physician at facility. Refer to wound clinic, [MEDICATION NAME] DS for 10 days. 8/18/11 low air loss mattress. 8/18/11 Send to emergency room due to increased temperature, drainage and odor to coccyx wound. E2, Director of Nursing, stated on 8/30/11 at 2:30 PM that the facility was without water for 3 weeks due to a storm. E2 stated they had to use bottled water, periwash and do bed baths as no showers were allowed due to contamination of the water. E2 stated it was during that time the areas developed and the area on the coccyx was worse. E2 stated Z1, Physician, was at the facility on 8/14/11 and ordered an antibiotic and referred R3 to the wound clinic. E2 stated the area became black and necrotic with an increase in odor and temperature overnight and R3 was sent to the hospital on [DATE]. R3 was admitted [MEDICAL CONDITION]. E2 confirmed R3 did not have osteo[DIAGNOSES REDACTED]. E2 stated on 8/31/11 at 1:40 PM that the boil order was in effect from 6/18/11 to 7/8/11. The "Wound Care Nurses Notes" by E2, dated 8/6/11 documented "Wound noted to have (increased) in size to 4 x 1.5 x 0.8 to coccyx, 1 cm x 0.7 cm to scrotum, Coccyx wound noted with odor, darker in color. 20% [MEDICATION NAME] remains, (increase) in serosanguinous drainage of moderate amount. Tx. (treatment) (changed"... According to the "physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E2 stated on 8/31/11 that the medication order wasn't processed correctly causing the delay in R3 getting the antibiotic. E4, Registered Nurse, stated on 8/30/11 at 1:20 PM that the area on the coccyx started shortly after the boil order ended. E4 stated the area started as a small slit in the crack of the buttocks. E4 stated the boil order may have contributed as the area was hard to see and they could give bed baths only. E4 stated if R3 had been properly bathed it could have helped. E4 stated the area progressed fast and they were about a month working on it. E4 stated R3 was put at the "feeder" table to help with the weight loss. E4 stated before R3 went to the hospital they could put a foam dressing on the coccyx but since it was debrided the area is "quite large" and now you could put your fist in the wound. The "Admission/Readmission Assessment" from readmission 8/27/11 measured the area on the coccyx as a "cavity size wound" 9 x 2 x 2 cm. The "Pressure Ulcers/Wounds" log does not identify treatments on the log for assessment of improvement of the pressure ulcer with that treatment. The log identified R3's pressure ulcers were facility acquired until 8/19/11 when it changed to indicate R3 was admitted with the areas. E2, Director of Nursing, (DON),stated on 8/30/11 at 2:30 PM that it would have changed because he went to the hospital. Treatment records did not always document treatments were completed for R3. Review of the "Treatment Record" for July and August 2011 noted numerous blanks on the record where initials for completion of the treatment should have been. The orders for [MEDICATION NAME] to all open areas of the penis, scrotum and coccyx three times per day had blanks 23 of 63 times treatments should have been done. On 8/6/11 the order was changed to Silver Alginate with Collasorb covered with foam dressing daily. There are 6 out of 13 blank documentation that the treatment had been done on the August Treatment Record. When R3 returned from the hospital on [DATE] with orders for santyl to wound base cover with moistened gauze and fill ulcer cavity with calcium alginate cover with gauze and secure with tape daily has no documentation that the dressing changes were done as of 8/30/11. E2, Director of Nursing, stated on 8/30/11 at 2:30 PM that the treatments had been done but the documentation was not. R3's weight decreased from 201 pounds in June. 2011 to 186 pounds in July and August 1, 2011 for a significant weight loss of 7.5%. R3's weight on 8/31/11 was 182 pounds. R3's [MEDICATION NAME] level was 3.1 grams/decaliter on 6/30/11, which indicates a moderate visceral protein deficiency. On 7/14/11 the physician ordered a consult for the registered dietitian. This was not done until 7/28/11. On 7/14/11 the Physician ordered [MEDICATION NAME] supplement twice a day for wound healing. On 7/27/11 the physician ordered double portions for R3 at all meals. The Registered Dietitian documented on 7/28/11 that R3 had a significant weight loss but did not note R3 had multiple pressure ulcers. It also noted R3 had problems with food spillage due to tremors and noted the double portions were appropriate to help provide more calories. There was no indication on assistance required by R3 for intake only that R3 was working with the Occupational Therapist for "self feed". The Minimum (MDS) data set [DATE] that R3 required limited assist of one person for eating. The assessment did not identify R3 was receiving [MEDICATION NAME] supplement. The note stated to consider a supplement if weight loss continued. Observation of the noon meal on 8/29/11 noted R3 received a regular portion meal. The tray card for R3 noted R3 was on a Mechanical Soft, No added salt diet with double portion of meat or eggs at breakfast. It did not have double portions on the tray card as ordered by the physician. R3 did not receive whole milk with the meal as recommended by the Registered Dietitian on 2/25/11. Staff attempted to feed R3 with R3 drinking his own fluids. R3 ate less than 40% of the meal and did not receive any bread with the meal the first tray of mashed potatoes and gravy, Salisbury steak, jello, and winter mix vegetables. R3 received water and tea as beverages. E2, Director of Nursing, stated on 8/30/11 at 2:30 PM, that the dietitian was coming to the facility on e time per month and did the assessment then. E2 stated they would fax her information regarding tube feedings if she was not scheduled to come to the facility soon. E2 confirmed that the dietitian, Z3, had not assessed R3 until 7/28/11. On 7/14/11 the physician ordered [MEDICATION NAME] 1 package in liquid twice a day. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The record also indicated R3 did not receive the supplement from Aug. 1 thru the 4th. There is no explanation on the record as to why R3 did not receive the supplement. E6, Licensed Nurse, stated on 8/31/11 at 9:45 AM that they sometimes ran out of the [MEDICATION NAME] and that would explain the circles. E6 stated they "ran out more frequently than not". The nurses notes and "Wound Care Nurses Notes" dated 8/14/11 documented Z1, Physician, was at the facility. The "Wound Care Nurses Notes" documented "(Z1) here to see res (resident) D/T (due to) (increase) in wound size, drainage et (and) foul odor. Gave orders for p.o (passing orally) ABT (antibiotic therapy) et referral to wound clinic. POA (power of attorney) notified. Wound dark in color, (coccyx) et (with) (increase) odor et drainage". Z1 stated on 8/30/11 that he was at the facility on 8/14/11 but did not see the pressure ulcer on the coccyx. Z1 stated the nurse told him about the odor and drainage and expressed concern. Z1 stated he ordered an antibiotic. Z1 stated he was not aware that R3 did not receive the antibiotic until 8/17/11 and it should have been given when it was ordered. Z1 stated it was his impression the area had been there for some time and had recently really progressed. Z1 stated anytime the wound increases treatment should be changed. Z1 stated although he would defer to the wound care clinic he did not feel R3 should have been sitting up for 1 and half hours. On 8/18/11 R3 was sent to the hospital due to a temperature of 102.9 degrees Fahrenheit, drainage and foul odor from coccyx wound. There are no temperatures documented in the medical record since 8/13/11. E2 confirmed on 8/30/11 at 1:40 PM that the temperatures would be documented in the nurses notes only. R3 was admitted to the hospital with [REDACTED]. The consultation report from Z2, Surgeon, states as the "Impression: Infected sacral decubitus with gangrenous tissue in need of debridement". The report states the wound showed no signs of osteo[DIAGNOSES REDACTED] and was approximately 8 cm in diameter. The pressure ulcer was surgically debrided on 8/21/11. The discharge summary documented R3 pressure ulcer as a stage 4 with staph infection in the wound. R3 was observed sitting up in his wheelchair at the noon meal from 11:55 AM until 1:10 PM when he was laid down. The dressing was observed with no date on it. The surgeon, Z2, had written orders for R3 on 8/23/11 and these orders were sent with R3 to the facility. The surgeon noted to turn R3 "side to side (every) 1-2 hrs (hours) and PRN (as needed)". The hospital discharge summary dated 8/27/11 also documented "Turn side to side every two hours". E2 stated on 8/31/11 at 1:40 PM that she had clarified the order with Z2 and he had said to roll side to side every 1-2 hours but did not say about being up in the wheelchair for a specific time. E2 stated they got R3 up last for the meal and laid him down first. The current care plan dated 7/22/11 thru 10/21/11 states "Reposition me routinely at least every two hours".