Every finding on record at Arcadia Care Peoria Heights

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one (R1) of three residents reviewed for abuse. This failure resulted in R1 receiving one staple to an abrasion on R1's head. Findings include: The facility's final abuse investigation report, dated 8/6/2026, documents V1 (Administrator) was notified of physical abuse between R1 and R2 on 8/1/2026. This report documents R1 opened the bathroom door while R2 was in the bathroom. R2 then pushed R1 causing R1 to fall to the floor backwards. R1 sustained a laceration to the back of scalp and was sent to the emergency department via emergency medical services. R2 was arrested by local police and taken to the county jail. R1's electronic health record documents R1 is [AGE] years old with diagnoses which include, but are not limited to, muscle wasting and atrophy, lack of coordination, unsteadiness on feet, and abnormalities of gait and mobility. R1's Care Plan, dated 7/10/2026, documents R1 is at low risk for abuse with a goal that R1 would be free of abuse and be provided a safe and secure environment.R1's emergency room after visit summary dated 8/1/2026 documents one staple was applied to an abrasion on R1's head.R2's electronic health record documents R2 is [AGE] years old with diagnoses which include, but are not limited to, paranoid schizophrenia, dementia with other behavioral disturbance, depressive episodes, and anxiety disorder. R2's Abuse Screening, dated 5/28/2026, documents R2 is at moderate risk due to psychiatric history and diagnoses.R2's Care Plan, dated 6/10/2026, documents R2's use of psychotropic medications with interventions including monitoring for occurrences of target behavior symptoms such as violence/aggression towards others. R2's Psychiatry note dated 8/4/26 documents the following: Staff report that (R2) consumes energy drinks throughout the day. By approximately 10:30 AM today, he had already consumed two, and staff indicate this pattern continues throughout the day. Although he acknowledges consuming them, he demonstrates poor insight into their potential effects. Achieving psychiatric and behavioral stability will remain particularly difficult, even with medication adherence, while this degree of stimulant consumption continues, as it may worsen agitation, impulsivity, insomnia, paranoia, and psychosis. He reports adequate sleep, although the reliability of his report is limited by cognitive impairment and heavy stimulant intake. His denials are considered alongside nursing documentation of PRN (as needed) Haloperidol use on three consecutive days in mid-July for hallucinations, threatening behavior, and agitation, as well as the current physical aggression. He also has a recent history of being easily triggered, including prior racially focused threats in which he spoke about killing Black individuals around him. (R2's) POA (Power of Attorney) remains closely involved in his care and has previously expressed concern about medication-related sedation and increased confusion. Those concerns contributed to several psychotropic dose reductions over recent months. More recently, medication doses have required re-escalation due to recurrent psychotic symptoms, threatening behavior, and statements about harming others. On 8/13/2026 at 2:00 PM, R1 stated that R1 and R2's rooms were joined by a shared bathroom. R1 opened the unlocked bathroom door to enter the bathroom, however, R2 was in the bathroom and angrily shoved R1 in the chest. R1 stated he fell to the floor hitting his head on the bed frame, began to bleed from his head and was sent to the hospital for evaluation.On 8/13/2026 at 3:20 PM, R3 stated he is R1's roommate and witnessed the altercation. R3 stated that R1 opened the unlocked bathroom door to enter but R2 was already in the bathroom. R2 then angrily and intentionally shoved R1 causing R1 to fall backwards, hit the floor and hit his head on the bed frame. R1 began bleeding from the head and R3 called for nursing assistance.The facility's Abuse Prevention and Reporting policy, revised 3/2026, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This form documents that physical abuse is the infliction of injury on a resident that occurs other than by accidental means. [TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions during food service by ensuring sanitizing solutions were maintained at the required concentration and by maintaining potentially hazardous foods at required hot holding temperatures. This failure has the potential to affect all 79 residents who reside at this facilityFindings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/28/26 and signed by V1 (Administrator), documents 79 residents reside within the facility.The facility's Sanitizing Bucket Chemical Log documented red buckets are to be used for sanitizer, green buckets for soapy water, each bucket is to contain a clean cloth, quaternary ammonium (QUAT) sanitizer concentration is to be maintained between 200-400 parts per million (PPM), and sanitizer solution is to be changed every two hours.The facility's Serving Temperatures for Hot and Cold Foods policy, revised September 2023, documented meats and casseroles are to be maintained at 135-170 degrees Fahrenheit, gravy at 135-170 degrees Fahrenheit, and steam tables are to be monitored to ensure proper operation. Problems with steam table heating capability are to be reported immediately to the maintenance department.On 6/28/2026 at 9:26 AM, V21 (Dietary Aide) tested two sanitizing buckets located in the kitchen using QUAT test strips. Both test strips indicated a yellow reading, reflecting sanitizer concentrations below the required 200-400 PPM. V21 stated there were no sanitizing chemicals in either bucket and acknowledged being unaware the buckets did not contain sanitizer. V21 stated these buckets were used to clean food preparation areas.On 6/28/2026 at 11:31 AM, V22 (Dietary Manager) calibrated a food thermometer before checking food temperatures on the steam table. The glazed ham measured 132 degrees Fahrenheit, and V22 stated it was not warm enough for the steam table and removed it to be reheated. The mechanical soft ham measured 130 degrees Fahrenheit, and V22 stated it also required reheating. The pureed ham, which had already been portioned into bowls with plastic lids, was cold to the touch. V22 stated the steam table compartment holding the pureed ham was not heating properly and acknowledged ongoing issues with the steam table maintaining temperatures.On 6/28/2026 at 11:55 AM, V1 (Administrator) stated she was not aware the steam table was not functioning properly and stated she would notify the maintenance department.

Based on interview and record review, the facility failed to accurately code the MDS (Minimum Data Set) Assessments for eight of 18 residents (R3, R5, R29, R37, R39, R48, R63, and R67) reviewed for MDS Accuracy in the sample of 35. Findings include: The facility's MDS Coordinator Job Description dated 05/26 documents, The MDS Coordinator is responsible for the accurate and timely completion of all Medicare/Medicaid case-mix documents in order to assure appropriate reimbursement for care and services provided within the facility. Conducts continual MDS reviews to assure achievement of optimal allowable resource utilization group category. Responsible for the data entry function to assure date entry and electronic submission of MDS assessments. 1.R29's PASARR (Pre-admission Screening and Resident Review) Level II Outcome dated 6/3/20 documents, You have the following mental health conditions: Schizoaffective Disorder, Depressive Type. R29's MDS Assessments Section A1500 Preadmission Screening and Resident Review dated 6/10/20 and 12/17/25 were coded as R29 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. 2. R37's PASARR Level II Outcome dated 12/16/25 documents, You have the following mental health conditions: Schizophrenia and Bipolar Disorder. R37's MDS Assessment Section A1500 Preadmission Screening and Resident Review dated 12/25/25 was coded as R37 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. 3.R39's PASARR Level II Outcome dated 1/23/24 documents, You have the following mental health condition: Bipolar Disorder. R39's MDS Assessment Section A1500 Preadmission Screening and Resident Review dated 1/14/26 was coded as R39 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. 4. R3's PASARR Level II Outcome dated 8/16/24 documents, You meet PASARR inclusion criteria for Serious Mental Illness with the diagnoses of Major Depressive Disorder, Bipolar Disorder, Generalized Anxiety Disorder, and Borderline Personality Disorder. Your day-to-day life has been impacted by your illness. R3's MDS Assessment Section A1500 Preadmission Screening and Resident Reviews dated 2/8/26 is coded as R3 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. R3's MDS Section N0350 Insulin dated 6/12/26 is coded as R3 receiving one injection of insulin during the last seven days or since admission/entry or reentry. R3's Physician Orders, dated 6/5/26 through 6/12/26, does not document R3 had a physician order for insulin. R3's MAR (Medication Administration Record), dated 6/5/26 through 6/12/26, does not document R3 received an insulin injection. 5. R48's PASARR Level II Outcome dated 10/18/2024 documents, You meet PASARR inclusion criteria for Serious Mental Illness with the diagnoses of Schizophrenia. Your day-to-day life has been impacted by your illness. R48's MDS Assessment Section A1500 Preadmission Screening and Resident Reviews dated 9/1/25 is coded as R48 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. 6. R67's MDS Section N0350 Insulin dated 4/15/26 is coded as R67 receiving one injection of insulin during the last seven days or since admission/entry or reentry. R67's Physician Orders, dated 4/8/26 through 4/15/26, does not document R67 had a physician order for insulin. R67's MAR dated 4/8/26 through 4/15/26, does not document R67 received an insulin injection. 7. R63's PASARR Level II Outcome dated 9/25/25 documents, You have level II PASARR conditions of: Delusions, Paranoid Behavior, Paranoid Schizophrenia, Schizophrenia. R63's MDS (Minimum Data Set) Assessment Section A1500 Preadmission Screening and Resident Review dated 4/10/26 was coded as R63 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. 8. R5's PASARR Level II Outcome dated 8/13/25 documents, Primary Neurocognitive Disorder-No LOC. Schizoaffective diagnosis is at baseline per Psychiatric evaluation. R5's MDS (Minimum Data Set) Assessments Section A1500 Preadmission Screening and Resident Review dated 9/4/25 is coded as R5 is not considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. On 6/29/26 at 10:00 AM, V1 (Administrator) stated a facility wide audit was completed in August 2025 of PASARRs and the former MDS Coordinator must have missed coding these on R5's MDS. V1 stated this should have been coded on R5's September 2025 MDS. On 6/29/26 at V17 (Regional MDS Coordinator) verified R3, R5, R29, R37, R39, R48, R63, and R67's MDS Assessments were inaccurately coded.

Based on observation, interview, and record review, the facility failed to ensure nebulizer masks and tubing were dated and stored in a bag between uses, to post required oxygen safety signage, administer an inhaler per facility policy, and ensure oxygen tubing was labeled for three (R5, R67, R85) of three reviewed for respiratory care in a sample of 35.Findings include: The facility's Oxygen and Respiratory Equipment-Changing/Cleaning Policy, dated 6/2026, documents, Guidelines: Purpose: 3. To minimize the risk of infection transmission. Procedure: 2. Nasal Cannula: a. Nasal cannulas are to be changed once a week and PRN (as needed). 4. Oxygen Humidifiers: a. Oxygen Humidifiers should be changed weekly or as needed and will be dated when changed. The facility's Nebulizer-Medication Administration Policy, dated 6/2026, Guidelines: Nebulizer- Administering Medications through a Small Volume (handheld) Nebulizer. 23. When equipment is completely dry, store it in a plastic bag with the resident's name and the date on it. 24. Change equipment and tubing weekly. 1.R67's current Order Summary Report documents a Physician order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter), inhale orally three times a day. On 6/28/26 at 10:12 AM R67's nebulizer mask and nebulizer tubing was lying on R67's nightstand undated and not in a plastic bag. On 6/28/26 at 10:15 AM V8 (Licensed Practical Nurse/LPN) verified R67's nebulizer tubing and canister were undated and unbagged. V8 stated the nebulizer tubing/canister should be dated and be stored in a bag when not in use. 2. R85's current Order Summary Report documents a Physician Order for R85 to receive three liters of oxygen continuous via nasal cannula and R85 receives Budesonide-Formoterol Fumarate Inhalation 160-4.5 mcg/act (micrograms per actuation) two puffs inhale orally every morning related to Asthma. On 6/28/26 at 9:45 AM, V8 (LPN) administered R85's Budesonide-Formoterol Fumarate 160 mcg-4.5 mcg inhaler by delivering two puffs consecutively without waiting one minute between puffs, contrary to the facility's policy for inhaler administration. On 6/29/26 at 10:17 AM R85 was lying in bed with oxygen flowing via nasal cannula. R85's nasal cannula and humiliation bottle were un-dated. No oxygen sign was observed on the outside of R85's room. On 6/29/26 at 10:19 AM V8 (LPN) verified no oxygen signage was posted on the outside of R85's room and R85 oxygen nasal cannula tubing and humidification bottle were undated. V8 stated there should always be an oxygen in use sign on the outside of a resident's door when they are using oxygen and all oxygen tubing/humidification bottles should be labeled with a date. V8 also stated she was unaware that a one-minute interval should be observed between inhaler puffs. The facility's Inhaler Policy dated 01/26 documents, Guidelines Orally Inhaled Medications: Wait approximately one minute between puffs or as ordered by physician or according to manufacturer's recommendations. 3. On 06/28/2026 at 9:39 AM, R5's oxygen equipment revealed the oxygen tubing, humidification bottle, and nebulizer tubing were not dated. Oxygen tubing was observed hanging from the oxygen concentrator and was not stored in a clean, enclosed bag when not in use. R5's nebulizer mask was laying on top of R5's bedside table and was not stored in a clean, enclosed bag. No oxygen precaution sign was posted on R5's door at the time of observation. On 6/29/26 at 1:15 PM, V1 (Administrator) confirmed oxygen tubing is to be changed weekly and dated at the time of change. V1 also confirmed oxygen tubing and nebulizer masks should be stored in a bag when not in use.

Based on observation, interview, and record review the facility failed to check gastrostomy tube placement prior to administering medications for one (R85) of one resident reviewed for gastrostomy tube in the sample of 35.Findings include:The facility's Medication Administration-Gastrostomy or Nasogastric Tube policy dated 12/25 documents, Scope: RN/Registered Nurse and LPN/Licensed Practical Nurse may administer medication through a gastrostomy tube as allowed by state rules after demonstrating competency. Guidelines Gastrostomy Tube: Check tube for proper placement. Aspirate to visually verify stomach contents. After verifying placement, connect a 60 ml (milliliter) piston to the end of the enteral tube and flush tube with approximately 30 ml of tap water via gravity prior to medication administration. Scope: RN/Registered Nurse and LPN/Licensed Practical Nurse may administer medication through a gastrostomy tube as allowed by state rules after demonstrating competency. Guidelines Gastrostomy Tube: Administer medication: If more than one medication is being given at a dosing time, administer each medication separately, flushing the tube with approximately 10 ml (milliliters) of tepid water between medication or enough to clean the tubing. Tablets with be finely pulverized and dispersed will in tepid water.R85's current Care Plan documents, Check for tube placement and gastric contents/residual volume per facility protocol and record.R85's current Physician's Orders document R85 receives the following medications every morning by gastrostomy tube: Atorvastatin Calcium 40 mg (milligrams) one tablet, Clopidogrel Bisulfate 75 mg one tablet, Gabapentin 300 mg one tablet, Haloperidol 5 mb one tablet, Spironolactone 25 mg one tablet, and Valacyclovir 1 gram one tablet.On 6/28/26 at 9:45 AM R85 was lying in bed and non-verbal. V8 (Licensed Practical Nurse) crushed R85's prescribed medications, including Atorvastatin Calcium 40 mg, Clopidogrel Bisulfate 75 mg, Gabapentin 300 mg, Haloperidol 5 mg, Spironolactone 25 mg, and Valacyclovir 1 gram, combined them into a single medication cup, transferred them into a piston syringe, and administered all medications simultaneously through R85's gastrostomy tube. During administration of the medications, R85's gastrostomy tube became clogged twice and V8 had to push the medications into the gastrostomy tube using the piston syringe. V8 failed to flush the gastrostomy tube with water between each medication as required for safe enteral medication administration. V8 did not aspirate R85's stomach contents to check R85's gastrostomy tube placement prior to administering R85's medications through the gastrostomy tube.On 6/28/26 at 9:55 AM, V8 (LPN) stated she was unaware that medications administered through a gastrostomy tube should be given individually with a water flush between each medication. On 6/28/26 at 10:00 AM V8 stated, I check placement of (R85's) gastrostomy tube by looking at it.On 6/30/26 at 10:10 AM V2 (Director of Nursing) verified V8 should have given R85's medications individually with a water flush in between each medication, should have checked residual for proper placement of the gastrostomy tube prior to administering the medications.

Based on observation, interview, and record review the facility failed to ensure a resident's bed was safe and in good repair for one (R24) of six residents reviewed for accidents in the sample of 35.Findings include:The facility's Maintenance Director Job Description dated 12/22 documents, The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department to assure that our facility is maintained in a safe and comfortable manner. Repair facility/resident property as necessary. In the event of inability to repair, coordinate with outside vendors to make repair or replace as cost effectively as possible. Also ensure that services provided by outside vendors are properly completed/supervised in accordance with contracts/work orders. Ensure that supplies, equipment, etc. (etcetera) are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator. Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. Place orders for equipment and supplies as necessary or as may be required.R24's MDS (Minimum Data Set) assessment dated [DATE] documents R24 is cognitively intact.On 6/28/26 at 9:45 AM and 6/29/26 at 11:20 AM, R24 was observed lying in bed. The bed was missing the front right support leg, and a wooden block measuring approximately two inches by four inches had been placed underneath the bed to support it. As a result, the bed was leaning to the right, creating an unstable surface for R24.On 6/28/26 at 9:55 AM R24 stated, The leg of my bed has been broken for a week. I am scared I am going to roll out of bed. I have been asking for a new bed and (V15 Maintenance Director) just put a wooden block under the leg.On 6/29/26 at 11:25 AM V15 stated, The leg of (R24's) bed broke last week and I haven't had time to order (R24) a new bed yet. I placed a wooden block under the leg for now.On 6/30/26 at 9:14 AM V1 (Administrator) stated, (R24's) bed should have been replaced immediately when it was broken.

Based on observation, interview, and record review the facility did not implement a physician-ordered hand protector to prevent contractures, failed to conduct a hand contracture assessment, and omitted the hand contracture from a resident's comprehensive care plan for one (R85) of three residents reviewed for splints and contractures in the sample list of 35. Findings include: The facility's Restorative Nursing Program Policy, dated 12/2025, documents Purpose: To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but not limited to, programs in walking/mobility, dressing and grooming, eating, and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs. Identify residents who currently have splints/braces or previous range of motion programs or those that have actual or potential limitation with Range of Motion and/or pain. R85's admission Record documents R85 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side and Chronic Right Heart Failure. R85's MDS (Minimum Data Set) Assessment, dated 5/19/26, documents R85 requires dependent assistance with ADLs (Activities of Daily Living) and has an impairment on one side of R85's upper extremities. R85's current Physician Orders documents a physician order to remove hand splint every two hours for skin care related to Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side. R85's Care Plan does not document R85's left hand contracture. On 06/28/2026 at 9:45 AM R85 was lying in bed. R85 was non-verbal. Both of R85's hands were contracted with her fingers pointing inward towards her palms. R85 had no splinting devices in her hands. V8 (Licensed Practical Nurse/LPN) stated, Both of (R85's) hands are contracted and (R85) is unable to open either hand. I am not aware of (R85) wearing any splints or rolls inside the palms of her hands. V8 verified R85 did not have a splint to her left hand as ordered at this time. On 6/28/26 at 12:34 PM V11 (R85's Family Member) stated R85 was in the hospital back in November 2025 and R85's left, and right hands ended up becoming contracted. V11 stated, I would like for (R85) to have (R85)'s left splint on to prevent further decline. If (R85) was able to communicate, (R85) would want it on too. On 6/29/26 at 1:55 PM V1 (Administrator-in-Training) verified R85 should be wearing her left-hand splint as ordered. On 6/29/26 at 2:13 PM V17 (Regional MDS Coordinator) stated, I never performed an actual assessment of (R85's) left hand contracture, we (the facility) only documented (R85) had impairment to one upper extremity. I never care planned specifically that (R85) had a left-hand contracture.

Based on observation, interview, and record review the facility failed to assess, document, notify the physician, implement appropriate interventions, and update the care plan following identification of altered skin integrity for one (R71) of three residents reviewed for skin integrity. Findings include:The facility's Skin Condition Assessment and Monitoring - Pressure and Non-Pressure policy, revised June 2018, documents staff to observe residents daily for skin breakdown, complete a licensed nurse assessment when skin changes are identified, notify the physician and resident representative at the earliest sign of skin breakdown, document the findings in the medical record, and implement appropriate interventions.R71's Skin Observation task dated 6/25/26 documents Redness. R71's electronic medical record did not contain documentation of a licensed nurse assessment, physician notification, or follow-up after the skin change was identified.R71's current care plan documents R71 was dependent on staff for activities of daily living and incontinent of bowel and bladder; however, the care plan did not include interventions for pressure injury prevention or management of skin alterations.R71's Braden assessment dated [DATE] documents R71 is at Moderate Risk for Skin Impairment. R71's Wound Rounds assessments document R71 had a facility acquired stage three pressure ulcer identified on 4/3/26 and healed on 4/20/26.R71's Physicians Orders documents an order dated 4/20/26 for (medicated barrier cream) to the coccyx every shift and after incontinent episodes.On 6/28/26 at 10:00 AM, R71 stated she had a wound on her coccyx and staff were only applying cream to the area. R71 stated it's often painful especially when staff clean her coccyx after incontinent episodes. On 6/29/26 at 1:00 PM, V18 and V19 (Certified Nursing Assistants/CNA) stated R71's previously healed coccyx wounds had reopened several weeks earlier, and they had notified nursing staff on multiple occasions. V18 and V19 stated they apply barrier cream to R71's coccyx after incontinent episodes. On 6/29/26 at 9:36 AM, V3 (Wound Nurse) stated V22 (Wound Physician) evaluated R71's coccyx after surveyor inquiry regarding the resident's report of painful areas on coccyx. V3 stated that V22 feels these areas are abrasions and ordered a treatment for both sites. On 6/29/26 at 1:30 PM, V22 (Wound Physician) stated he evaluated R71 on 6/29/26 at request of V3. V22 stated he [NAME] R71's open areas may be from abrasions. V22 further stated he was not aware R71 had a stage three pressure ulcer in the same area that's not open on coccyx. V22 stated that the area could be stage the three-pressure reopening but he was unsure. V22 confirmed he was not made aware of any skin concerns for R71 until 6/29/26.R29's Nurse Progress notes dated 6/29/26 document a new skin concern identified on 06/29/2026 at 7:58 AM as abrasions/scratches located on the right buttock and left medial buttock. The right buttock abrasion measured 1.2 centimeters (cm) x 1.5 cm x 0.2 cm, and the left medial buttock abrasion measured 2.2 cm x 0.5 cm x 0.2 cm. Review of physician orders revealed treatment interventions for both areas consisting of hydrocolloid (moist wound dressing) thin dressings to be applied three times weekly and as needed (PRN).On 6/30/26 at 9:00 AM, V8 (Licensed Practical Nurse/LPN) stated V8 was aware of R71's skin breakdown but had not assessed the area because R71 did not have treatment orders and CNAs were applying barrier cream following incontinent episodes.On 6/30/26 at 9:30 AM, V7 (LPN) stated unknown CNAs notified V7 in the morning on 6/28/26 that R71 had open areas on the coccyx during morning care. V7 stated she notified V3 (Wound Nurse) later that evening and confirmed there was no documented nursing assessment or physician notification on 6/28/26.On 6/30/26 at 1:30 PM, V3 (Wound Nurse) confirmed R71 had an order for (medicated barrier cream) to the coccyx which was initiated after R71's stage three pressure ulcer healed to apply cream every shift and after incontinent episodes, confirmed the medication is to be applied by licensed nursing staff, and stated the resident was not utilizing a pressure-relieving mattress.

Based on observation, interview, and record review the facility failed to ensure the daily resident census and direct care staff posting was posted in an area accessible to residents and visitors. This failure has the potential to affect all 79 residents residing in the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/28/26 and signed by V1 (Administrator), documents 79 residents reside within the facility.On 6/28/26 at 9:30 AM a tour was done of the facility. During this tour, the direct care staffing report was posted in the front lobby behind the receptionist's desk. The direct care staffing report was dated 6/26/26. Throughout the facility there was no direct care staffing report documenting the resident census or direct care staffing posted for 6/28/26.On 6/28/26 at 9:35 AM V1 (Administrator) verified the direct care staffing report including the direct care staffing and census was not posted within the facility for 6/28/26. V1 stated, (V10 Certified Nursing Assistant Scheduler) is responsible for ensuring the direct care staffing report is posted every day.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one (R4) of four residents reviewed for abuse in a sample of four. Findings include: R4's Abuse Risk Assessment, dated 6/5/26, documents that R4 is at high risk for abuse due to history and diagnosis. R4's current care plan documents that R4 is at high risk for abuse/neglect, as noted in the abuse risk assessment. R4's intervention is to provide a safe and secure environment. R4's diagnosis includes Major Depression, Anxiety, Heart Failure, Pain, Seizures, Insomnia, Hemiplegia, Mood Disorder, Chronic Obstructive Pulmonary Disease, Prurigo Nodularis, and Urinary Tract Infections. R3's current care plan documents that R3 has behavior problems, agitation with peers and when in crowded spaces, physical and verbal aggression, agitation with peers, refuses meds, and cares at times. One of R3's interventions for this problem was to encourage (R3) back to the hallway after the smoke break. R3's diagnosis includes intermittent explosive disorder, dementia, unspecified severity with agitation, other mental disorders due to a known physiological condition, and violent behaviors. The facility's Final Abuse Investigation Report, dated 5/5/26, documents that V1 (Administrator) was notified of an alleged physical altercation in the dining room on 5/5/26 between (R4) and (R3). Residents were sitting in the dining room after smoke break, when (R3) was attempting to go back outside, and (R4) told him he could not. (R3) got upset and made physical contact with (R4). The facility nurse immediately separated residents and notified V1. This form documents that (R4) stated that she was trying to block (R3) from going outside. (R3) called me a cripple. (R4) said to (R3), someone said you cannot go outside because you're mean. Then he stood up and tried to choke me. On 6/15/26 at 10:00am, R4 stated that she was trying to stop R3 from going back outside because the smoke break was over. R4 stated that R3 got mad and stood up behind me and started to pull my hair and choke me. R4 stated that staff intervened. R4 stated that R3 is always yelling and fighting with somebody. R4 stated that he is just mean. On 6/16/26 at 11:40am, V8 (Certified Nursing Assistant/CNA) stated that she was walking through the dining room when she heard yelling. V8 stated that she saw R3 standing up behind R4, pulling her hair and choking her. V8 stated that she yelled for help and attempted to separate the two. V8 stated that R4 appeared to have red marks on her face. On 6/16/26 at 2:00pm, V1 (Administrator) stated that multiple interventions have been attempted to prevent R3 from getting into altercations with other residents, but nothing seems to work. V1 stated that R3 is on a new psychotropic medication that seems to be helping his outbursts. The facility's Abuse Prevention and Reporting policy, revised 3/2026, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This form documents that physical abuse is the infliction of injury on a resident that occurs other than by accidental means.

Based on observation, interview, and record review, the facility failed to ensure resident equipment is kept clean for one resident (R1) of four residents reviewed for cleanliness of resident medical equipment, in a total sample of four. Findings include:Facility policy, entitled Cleaning & Sanitizing-Wheelchairs and Other Medical Equipment, effective 01/2026, document Medical equipment/devices will be cleaned and sanitized weekly or more often if needed, when used by the same resident.R1's Electronic Medical Record/EMR document R1's diagnosis to include: Gout, Hypertension, Gastro-esophageal Reflux Disease, Major Depressive Disorder, Stress Incontinence, Psychosis, Hyperlipidemia, Diabetes Mellitus Type II, Benign Prostatic Hyperplasia, Chronic Respiratory Failure, Cerebral Infarction, Muscle Wasting, and Chronic Obstructive Pulmonary Disease. R1's Minimum Data Set/MDS, dated [DATE], document R1's Brief Interview for Mental Status/BIMS as 12/15-indicating cognition is moderately impaired.On 4/17/26 R1 was observed sitting in lounge by the dining room. His seated walker was in front of him and was noted to be sticky with dust covering the frame, splatter of a white substance on the black seat and thick mud-like substance to all 4 wheels. R1 stated that his walker has never been cleaned and agreed it could use it.On 4/17/26 V7 (Licensed Practical Nurse) stated that 3rd shift staff are assigned on the daily staffing sheet to clean all equipment (wheelchairs, walkers etc.) nightly.On 4/17/26 V1 (Administrator) stated that equipment cleaning such as walkers and wheelchairs are scheduled on 3rd shift and each room has their equipment cleaned weekly per the schedule. (R1's) room is scheduled for Tuesday nights. V1 stated that she has never had concerns brought to her from R1's son regarding his walker needing cleaned. V1 verified that R1's walker was dirty and needed clean and agreed that it did not appear that it had been done on Tuesday night. It's dirty. We'll clean this right now. V1 also housekeeping has two schedules one staff member is scheduled 6a-2p and is assigned the common areas starts in dining room, then main hallway and bathrooms then branch out to the hallways to clean the floors. Then other staff scheduled 8a-4p to clean resident rooms.

Based on observation, interview, and record review the facility failed to maintain a clean and homelike environment for four residents (R1, R2, R3) reviewed for clean and homelike rooms in a sample of four. Findings include: R1 voluntarily chose to discharge home with a family member on 1/24/26 and no longer resides in the facility.R2 was admitted to the facility on [DATE]. R2 currently resides in the same room R1 occupied prior to discharge. On 3/20/26 at 12:50pm R2 stated his room is not cleaned very often and the toilet has not been cleaned for 5 days, there are (feces) smears on the seat.On 3/20/26 at 12:55pm debris was obvious on the floor and near the baseboards, numerous dirty spots were present on the floor, and a dark grey substance clung to a large area in the toilet bowl, and three dried smears of dark brown substance was note in and on the shared toilet between R2 and R3's room.On 3/20/26 at approximately 1:20pm V1 (Administrator) stated the condition of R2's room and the toilet between R2 and R3's rooms needed to be cleaned and did not appear to have been cleaned recently.On 3/20/26 at 3:15pm V4 (Housekeeping Supervisor) stated, due to short staffing, the rooms are just getting a very light cleaning, and the toilet between R2 and R3's room probably had not been cleaned. V4 stated deep-cleaning of the residents' rooms is normally scheduled for Fridays and due to short-staffing, the deep-cleaning has not been done regularly.The facility's Housekeeper Job Description Summary documents the following under Essential Duties and Responsibilities: Clean, wash, sanitize, and/or polish fixtures, ledges, room heating/cooling units, bathroom fixtures, etc. and Clean floors including sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting, etc.

Based on observation, interview and record review, the facility failed to provide appropriate treatment to a facility acquired stage three pressure ulcer for one of three Residents (R4) reviewed for pressure ulcers in a sample of five.Findings include: R4's Physician Order Sheet/POS, dated 3/4/26, documents diagnoses including Paranoid Schizophrenia, Type Two Diabetes, Hypertension, Muscle Wasting/Atrophy and Unsteadiness on Feet. R4's Treatment Administration Record/TAR, dated 2/23/26 through 3/4/26, documents an order L. buttock: to clean with wound cleanser, apply topical medication (silver sulfadiazine) and cover with gauze dressing daily and as needed.R4's current Care Plan documents: reposition/ambulate as tolerated and at least every two hours; requires substantial/maximal staff assistance for Activities of Daily Living (sitting, transferring, bed mobility, showering, toileting and dressing); incontinent of bowel and bladder and provide peri-care after each incontinent episode and check frequently and assist with toileting as needed; and related to Left Buttock wound, minimize pressure over bony prominence and treatment as ordered.R4's Braden score/risk assessment on 9/8/25 and 12/5/25 were 18 (at risk). On 1/26/26 R4's Braden score/risk assessment was 15 (at risk).The Facility Wound Report, dated 1/1/26 through 3/3/26, documents 9/27/21 as R4's admission date to the Facility. The Wound Report documents a Facility acquired Stage Three Left Buttock Pressure Ulcer was identified on 1/26/26. On 3/3/26, R4's Stage Three Left Buttock Pressure Ulcer measured 1.50 centimeters/cm by 1.0 cm by 0.2 cm.R4's Initial Wound Evaluation and Management Summary, dated 1/26/26, documents an initial wound evaluation and assessment for R4's Left Buttock Stage Three Pressure Ulcer. R4's Left Buttock Stage Three Pressure Ulcer measured 2.2 cm by 1.5 cm by 0.3 cm, with moderate Serous exudate/drainage and fifty percent slough.On 3/4/26 at 9:10 am, V8 (Certified Nursing Assistant/CNA) and V9 (CNA) were transferring R4 with a mechanical lift out of R4's wheelchair. R4's incontinence brief was soiled with urine and R4's Left Buttock did not have a dressing. V8 and V9 applied a clean incontinence brief, without performing perineal care, and pulled up R4's pants and transferred R4 back into the wheelchair without a clean dressing to R4's Left Buttock. R4's bed did not have pressure redistribution mattress.R4's Initial Wound Evaluation and Management Summary, dated 3/2/26, documents an assessment for R4's Left Buttock Stage Three Pressure Ulcer. R4's Left Buttock Stage Three Pressure Ulcer measured 1.5 cm by 1.0 cm by 0.2 cm, with moderate Serous exudate/drainage and seventy-five percent slough.On 3/4/26 at 9:10 am, V8 (CNA) and V9 (CNA) verified that R4 did not have a dressing to R4's Left Buttock.On 3/4/26 at 12:26 pm, V7 (Wound Physician) stated, I have been treating (R4) for (R4's) pressure ulcer. This is a house acquired Stage Three Pressure Ulcer.On 3/4/26 at 10:15 am, V1 (Administrator) verified that R4's Left Buttock pressure ulcer was facility acquired. V1 stated, (R4) does not walk much anymore like (R4) used to. (R4) spends more time in (R4's) wheelchair and we just got a new wheelchair cushion for (R4). In the morning, after (R4) gets up for the day, it is hard to get (R4) out the wheelchair again.The Facility Skin Condition Assessment and Monitoring Pressure and Non-Pressure Policy, dated 12/2025, documents: to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other skin conditions and assuring interventions are implemented; dressings which are applied to pressure ulcers shall include the date of the licensed nurse who performed the procedure and will be checked daily for placement, cleanliness and signs/symptoms of infection; care plan will be revised as appropriate to reflect alteration of skin integrity, approaches and goals of care; and Physician ordered treatments shall be recorded after each administration.The Facility Resident Rights for People in Long Term Care Facilities, dated 11/2018, documents: Facility must provide equal access to quality care regardless of diagnosis, condition or payment source; and must provide services to keep your physical and mental health, at their highest practical levels.

Based on observation, interview and record review, the facility failed to ensure the medication cart was locked and medications were secured. This has the potential to affect all 23 (R4, R6, R7, R15, R29, R30, R32, R34, R41, R43, R50, R53, R54, R63, R64, R67, R68, R70, R75, R88, R89, R95, and R97) residents who reside on the hallway where the incident occurred.Findings include:The facility policy titled, Medication Storage, last approved 12/2025, documents not in its entirety, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.The facility policy titled, Medication Administration Policy, last approved 10/24, documents not in its entirety, Medication Storage Areas (medication room, medication cart, and treatment cart) must be locked when not in use by authorized personnel. Authorized personnel include licensed nurses, CMA (Certified Medication Aide) and the facility's pharmacists. Any other individual needing access to a medication storage area must be supervised by an authorized person while in the medication storage area.The Resident Room Roster dated 1/6/26 documents 23 residents reside on the XXXXX Hall.On 1/7/26 at 10:30 AM, V4 (Registered Nurse/RN) left a medication cart unlocked in the hallway across from room YY on XXXXX Hall when going to check R53's blood sugar leaving medications accessible to residents, staff, and visitors.On 1/7/26 at 10:35 AM when asked if the medication cart should have been locked prior to going into R53's room, V4 (RN) stated, It was locked, I always lock my med (medication) cart. Then when asked why he did not use his keys to open the cart when coming back out of R53's room to obtain her (R53) insulin V4 (RN) became flustered and stated, I guess I messed up. (referring to medication cart being unlocked).On 1/7/26 at 10:40 AM V2 (Director of Nursing) stated, Medication carts should always be locked when the nurse is leaving the cart. There should be nothing accessible on top of it such as medications, needles, or the keys.

Based on observation, interview, and record review the facility failed to perform hand hygiene between glove changes and failed to wear a gown when performing gastronomy tube flush for 3 (R3, R4 and R53) of 3 residents reviewed for infection control in a sample of 40.The facility policy titled, Glove Use-Nursing, last approved 10/2024, documents not in its entirety, Hand hygiene will be performed after removing gloves. When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method of cleaning your hands in the healthcare setting. Soap and water are recommended for cleaning visibly dirty hands. The facility policy titled, Hand Hygiene/Handwashing, last approved 10/2024, documents not in its entirety, Hand hygiene means cleansing your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Examples of when to perform hand hygiene (either alcohol based hand sanitizer or handwashing): Before glove placement, after glove removal. The facility policy titled, Enhanced Barrier Precautions, last approved 12/2025, documents not in its entirety, Statement of Purpose: Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Personnel: Personnel providing direct care. Personal Protective Equipment: Gown and gloves. Policy: EBP may be considered and implemented for: Wounds and/or indwelling medical devices (central line, feeding tube, tracheostomy, drains, AV (arterial venous) fistulas, etc); Infection or colonization with a novel or targeted MDRO (Multidrug Resistant Organism) when contact isolation does not apply (see CDC/Center for Disease Control listed MDRO list); At discretion of the Infection preventionist. Personal Protective Equipment- Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: dressing, bathing/showering, providing hygiene, changing linens, incontinence care, medical device care, wound care. 1. R3 was admitted on [DATE] with diagnoses of Osteomyelitis, Quadriplegia, Dysphagia, Cognitive Communication Deficit, Pressure Ulcers, Major Depressive Disorder, Neuromuscular Disfunction of Bladder and Suprapubic Catheter and Colostomy. On 1/7/26 at 11:00 AM, V3 (Infection Preventionist/Wound Nurse) changed gloves after cleansing the wound, then after packing the wound and again after completing the dressing change. No hand hygiene was conducted between glove change. On 1/9/25 at 9:55 AM, V1 (Administrator) agreed hand hygiene should have been conducted between glove change. 2. R4's admission Record documents R4's date of admission to the facility was 3/1/24 and his diagnoses include but not limited to Acute Respiratory Failure with Hypoxia, Encephalopathy, Dysphagia, Oropharyngeal, and Unspecified Protein-calorie Malnutrition. R4's Minimum Data Set (MDS) assessment dated [DATE], documents that R4 has a feeding tube. R4's current care plan documents R4 is on Enhanced Barrier Precautions related to: Feeding Tube. On 1/6/25 at 2:30 PM, V4 (Registered Nurse/RN) observed unhooking R4 from his enteral feeding and performing water flush. V4 (RN) performed hand hygiene, placed gloves, and filled a cylinder with water and with drew 100 milliliters of water into a syringe and proceeded to flush R4's gastronomy tube. V4 (RN) did not wear a gown through the entire procedure and when asked about what personal protective equipment should be worn, V4 (RN) stated, I was supposed to wear a gown with the gloves. On 1/6/25 at 2:35 PM, V3 (Infection Preventionist) stated, A resident with a G-Tube (Gastronomy Tube) would be on EBP (Enhanced Barrier Precautions), a gown and gloves are required to be worn by staff when doing any cares with the tube or any direct cares with the resident. The staff can also wear a face shield if they fill there is a potential for splashing to occur. V4 (Registered Nurse/RN) should have been wearing a gown because he was providing care. 3. R53's admission Record documents R53's date of admission to the facility was 9/16/25 and her diagnoses include but not limited to Cerebral Palsy, Type 2 Diabetes Mellitus without Complications and Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R53's physician orders dated 9/16/25 document R53 has an order for Accu-Check's QID (four times a day) before meals and at bedtime for diabetes and documents R53 has an order dated 11/11/25 for Humulin R (insulin) give 5 units subcutaneously before meals related to Type 2 Diabetes Mellitus without Complications. On 1/7/25 at 10:30 AM, V4 (RN) observed doing a medication pass. V4 (RN) parked medication cart across the hall, cleansed hands, placed on gloves and proceeded to R53's room to do blood sugar. V4 (RN) returned to the medication cart, removed soiled gloves, and placed clean gloves on without performing hand hygiene. On 1/7/25 at 10:40 AM, V2 (Director of Nursing) stated, Absolutely when asked if hand hygiene is to be performed between glove changes.

Based on interview and record review, the facility failed to ensure hospice communication was coordinated and the required documents were available and accessible to the facility staff. This deficiency affects one of one resident (R10) reviewed for hospice care management in a sample of 40 residents. Findings include:The Hospice Services policy dated 11/2012 documents the facility shall honor the advanced directives and care alternatives residents may desire when terminally ill and to afford residents with care that allows for dignity and comfort during the end stage of their lives. Hospice service will conduct assessments and develop a hospice plan of care which will be integrated with the resident's overall plan of care and maintained in the medical record or other location with the interdisciplinary care plan. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available for all interdisciplinary staff to access. Hospice service staff will attend care plan conferences and participate in the resident's care planning process. The Hospice Service Agreement dated 7/1/25 documents for each hospice resident, the facility will develop a facility care plan which is consistent with his/her Hospice care plan. For each hospice resident, the hospice will develop a Hospice care plan and furnish a copy to the facility. Communication between the hospice and facility shall be conducted weekly and/or at each resident visit and documentation of such communication shall be included in the medical record. R10 admitted on [DATE] and elected Hospice benefits on 11/28/25 with terminal diagnoses of Dementia, Congestive Heart Failure, Protein Malnutrition, Paranoid Schizophrenia and Traumatic Brain Injury. R10's current Care Plan lacked specific Hospice responsibilities/interventions. R10's medical record lacked a Hospice Plan of Care, Election forms, Physician Certification of Terminal Illness and/or copies of clinical notes. R10 Physician's Order for Life Sustaining Treatment (POLST) dated 10/9/23 documents R10 requested to attempt full cardio-pulmonary resuscitation and full treatment including mechanical ventilation and cardioversion to be conducted/attempted. On 1/7/26 at 10:15 AM, V12 (Licensed Practical Nurse) reviewed the electronic medical record and stated there was no documentation as to Hospice staff visit frequency, disciplines provided or instructions for cares. V12 stated the care plan identified R10 received Hospice services but lacked details of services provided and responsibilities for providers. V12 reviewed the Hospice binder and agreed there were no Hospice documents or communication notes included in the binder. V12 stated the Hospice nurse will usually ask for a verbal report prior to their visit but was unaware of the nurse visit frequency or other services being provided by the Hospice. On 1/7/26 at 10:20 AM, V13 (Certified Nursing Assistant) stated Hospice Aides do provide cares to R10 but was unaware of the days, time and/or frequency of the visits. On 1/7/26 at 1:15 PM, V11 (Hospice Registered Nurse) stated the facility updated the POLST (Physician's Order for Life Sustaining Treatment) although when the hospice received the new POLST, the form did not have the residents name on it, so it was sent back to the facility for correction. V11 stated the updated POLST had still not been received by the facility and was currently being addressed by the Hospice Physician. V11 stated prior to the residents visit, the Hospice nurse communicates with the facility's nurse to get a report of status. V11 stated there is a Hospice binder at the nurse's station but it does not have anything in it. Hospice staff does not document in the binder after visits. V11 stated he was R10's primary nurse and not attended or been involved in any care plan discussions or meetings with the facility. V11 receives Hospice skilled nurse visits, nurse aide visits, social worker and chaplain visits. On 1/9/26 at 9:55 AM, V1 (Administrator) agreed the facility failed to ensure that Hospice communication was coordinated, and the required documents were available and accessible to the facility staff.

Based on observation, interview, and record review the facility failed to implement restorative therapies and interventions to prevent contracture for one (R64) of two residents reviewed for positioning and mobility in a sample of 40.Findings include: The facility policy titled, Restorative Nursing Program, last approved 12/2025, documents not in its entirety, Purpose: To promote each resident's ability to maintain or regain the highest degree of dependence as safely as possible. Includes, but not limited to, programs in walking/mobility, dressing and grooming, eating, and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs. Guidelines: Each resident will be screened for restorative nursing upon admission, annually, quarterly, and with any significant change in function; Appropriateness for a restorative program will be determined by the interdisciplinary team as needed and/or may be determined as a continuation of care following a course of physical, occupational and/or speech therapy; Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care; Documentation of the interventions and the resident's response will be completed with each implementation. Identify residents who currently have splints/braces or previous range of motion programs or those that have actual or potential limitations with ROM (Range of Motion) and/or pain. R64's admission Record documents R64's date of admission to the facility was 6/6/23 and her diagnoses include but not limited to Hemiplegia and Hemiparesis following other Cerebrovascular Disease Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease, Seizures and Heart Failure. R64's Minimum Data Set (MDS) assessment dated [DATE], documents that R64 has a Brief Interview for Mental Status score of 15/15 indicating cognition intact, has functional limitation in range of motion to upper and lower extremity on one side, is dependent with dressing, hygiene and transfers and is not in Restorative Nursing Program. R64's current care plan as of 1/6/25 has no documentation regarding her contracted left hand and no interventions to prevent further decrease in range of motion. R64's Restorative Observation assessment dated [DATE] documents R64 is not receiving Restorative Programs for PROMS (Passive Range of Motion) or AROM (Active Range of Motion). On 1/7/25 at 9:44 AM R64 is lying in bed with her eyes closed and noted to have a contracted left hand. On 1/7/25 at 11:14 AM R64 stated she has minimal movement in her left hand, and they currently are not doing anything for it. On 1/09/2026 8:37 AM V1 (Administrator) stated that they have no documentation regarding attempting any form of Restorative Rehab for R64. V1 (Administrator) also stated, We have documentation showing she (R64) refuses cares frequently but nothing that pertains to Restorative Care. We did implement Restorative tasks for the CNA's (Certified Nursing Assistant) yesterday and today but up until then we had not been doing anything.

Based on observation, interview, and record review the facility failed to prevent resident to resident abuse for 2 residents (R24, R44) of 2 reviewed for abuse in a total sample of 40 residents.The Facility Reported Incident with finalization date of 12/31/25 documents on 12/25/25 at 5:55 PM V6, V8 (both Licensed Practical Nurses/LPN) and V9 (Certified Nursing Assistant/CNA) heard yelling coming from R44's room. When V6, V8, and V9 entered the room, R24 and R44 were hitting each other. The two residents were separated and assessed for injuries. R24 and R44 did not have any injuries. The Facility Reported Incident documents that R24 and R44 are both cognitively intact. On 1/6/26 at 10:12 AM R44 reported R24 was disrespectful to him and would not go into further detail.On 1/6/26 at 10:20 AM R24 reported R44 had his music loud and R24 asked R44 to turn it down. R44 did not turn his music down and R24 turned music off. R24 stated R44 then hit him in the face twice, but did not cause any injury. R24 stated he was then moved to a different hall.On 1/7/26 8:39 AM V6 (LPN) stated she heard a commotion and went to R44's room and separated residents. R44 and R24 were both in their wheelchairs at the time. V6 was not sure if R44 had his music loud. V6 verified R44 and R24 were not roommates at the time, but did live on the same hallway.On 1/7/26 at 10:16 AM V8 (LPN) reports when she entered R44's room, R44 and R24 were each in their wheelchairs and were punching each other. V8 reports she did not hear R44's music playing prior to incident.

Based on interview and record review, the facility failed to prevent resident-to-resident physical abuse and staff-to-resident verbal abuse for four of four residents (R1, R2, R3, R4) reviewed for abuse in a sample of four. Findings include:The facility's Abuse Prevention and Reporting policy, reviewed 09/2024, documents that this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds. To residents within hearing distance, regardless of age, ability to comprehend, or disability. A resident-to-resident altercation should be reviewed as a potential situation of abuse. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish, or pain must be reported in accordance with regulations.1. The facility's Final Abuse Investigation Report, dated 10/23/25, documents that at approximately 7:00 pm on 10/19/25, the facility Administrator was informed of what appeared to be a physical altercation between (R1) [Diagnosis: Anxiety disorder, Major Depression disorder, chronic pain, BIMS (brief interview for mental status) 15 (cognitively intact) and (R2)] the incident occurred in the smoking area and dining room. V4 Receptionist heard verbal disagreement between both residents. Both residents were assessed, and R2 was noted to have a hematoma above the right eye. R1's witness statement, dated 10/20/25, documents that (R2) came into the building staggering, being loud. (R2) asked me (R1) for a light, which I gave him. I seen (sic) the knot on his eye and asked him if he fell while he was out. (R2) said he was going to stab me when I was walking off. I took my jacket off and chest bumped him, who swung on me. I pushed him back and got my foot around his ankle, and he fell on the couch. On 12/10/25 at 11:00am, R1 stated that he and R2 were arguing on the smoking patio, then R2 went back into the building. R1 stated that he was walking back to his room when R2 continued to talk crap to me. R1 stated that he pulled his shirt off and ran towards him. R1 stated that he chest bumped R2 and he fell to the ground.On 12/11/25 at 9:40am, R2 stated that he was arguing with R1 on the smoking patio, then he went back inside and waited for him to come in. R2 stated that R1 came running at him and chest bumped him, and he fell to the ground. R2 stated that he did not remember what they were arguing about.On 12/11/25 at 10:15am, V4 (Receptionist) stated that R1 and R2 were arguing during the smoke break, which she thought was over. R1 was walking towards the hall to go to his room, then turned around, took his shirt off, and went after R2. V4 stated that R1 chest bumped R2. R2 tried to swing at R1, R1 pushed R2, and he fell. V5 (Certified Nursing Assistant) stated that R1 and R2 were separated. 2. The facility's Final Abuse Investigation Report, dated 11/25/25, documents that at approximately 6:50pm on 11/20/25, V1 (Administrator) was notified of an alleged physical altercation between (R3) and (R4). All the required parties were notified. R4's Alleged Victim-All Abuse Types, dated 11/26/25, documents I let (R3) borrow my phone. He wouldn't give it back. We started arguing. I threw my plate at him and punched him. R3's Alleged Victim-All Abuse Types, dated 11/26/25, documents I borrowed (R4's) phone. I gave it back, but he didn't think so. He was yelling at me accusing me of stealing it. He threw a plate at me and hit me. On 12/11/25 at 10:30am, V5, Certified Nursing Assistant, stated that she heard R3 and R4 arguing in their room. V5 stated that she was in their room, searching for R4's phone, when R4 threw a plate at R3, then went after him and hit him. V5 stated that R3 did hit R4 back. V5 stated that she yelled for help and other staff came in the room to help separate the two. V5 stated that the phone was later found in R4's possession. 3. The facility's Preliminary 24-hour Abuse Investigation Report, dated 12/8/25, documents that it was reported that (R1) and a staff member (V4) had a verbal disagreement. The staff member was suspended immediately. All parties were notified. On 12/11/25 at 11:00am, R1 stated that he was coming back into the building from an outing and was talking to a visiting Pastor when (V4) started to yell at me because she had to get up from the desk and let us in. She told me she was not letting me back in if I went outside to smoke. She was cussing at me, then started talking crap about my mom, and that's when I started yelling at her back. R1 stated that there was another staff member there who broke it up. On 12/11/25 at 10:30am, V5 (Certified Nursing Assistant) stated that she was going to the receptionist desk to pick up her food delivery. V5 stated that she heard V4 (Receptionist) yelling at R1, telling him he could not go out anymore, even though R1 had an independent pass. V5 stated that V4 called R1 stupid and was making comments about R1's mother. V5 stated that she told her to stop; she could not speak to him that way. V5 verified that she told the nurse, and V4 was sent home.

Based on interview and record review, the facility failed to prevent abuse for one (R2) of three residents reviewed for abuse in a sample of four.Findings include: The Facility's Abuse Prevention and Reporting policy, dated 9/2024, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Facility incident report to the state surveying agency documents the following: On 06/21/2025 at approximately 9pm, (R2) stated to the nurse on duty that (R1) slapped him two times on the left side of the head. Further investigation has revealed upon interview that (R1) did make physical contact to (R2) on the side of the head with an open hand. (R1) stated to (V1 Administrator) I'm gonna tell you the truth, yes I did make physical contact with him, because he was calling the staff names, and they are good girls they are here to help us, and he doesn't need to talk to them that way. (R1) stated to (V1) that (R2) was cursing at the CNAs/Certified Nurse Aides and calling them inappropriate names and he should not be, that is why (R1) confronted (R2) and made physical contact him in the side of the head. On 6/21/25, R1's nurse's note documents R1 was in a resident room (R2's room) visiting another resident, R2 was in the room, and then R2 went down the hallway and stated R1 hit him on the side of the head, and he was calling (family). On 7/8/25 at 9:25am, V1 stated she is the abuse coordinator and investigated R2's allegation of abuse and reported it to the state surveying agency. At that same time, she verified R1 told her he slapped R2 on the side of the head because he was calling the staff names. R2's BIMS (Brief Interview for Mental Status) score is 15, cognitively intact. On 7/8/25 at 10:30am, R2 stated he was slapped by R1 a while ago. R1's BIMS score is 15, cognitively intact. On 7/9/25 at 8:15am, R1 verified he hit R2 because he was not being nice to the staff that helps them.

Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 14 residents (R4) reviewed for elopement risk in the sample of 21. This failure resulted in a cognitively impaired resident (R4) exiting the facility without staff knowledge and being found at a local bus station approximately three miles away from the facility, in 34-degree Fahrenheit temperature and requiring Police transport back to the Facility. This failure resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy began on 1/18/24 when R4 exited the facility through the entrance door without supervision and was found at a local bus station, approximately three miles from the facility in 34 degrees Fahrenheit temperature. V1 (AIT/Administrator in Training) of the Facility was notified of the Immediate Jeopardy on 1/23/24 at 11:08 am. While the immediacy was removed on 1/23/24, the facility remains out of compliance at a Severity Level 2 while the facility continues to monitor the revised systems put into place related to supervision to prevent elopement. Additional time is needed to evaluate the implementation and effectiveness of the removal plan including their in-service training and audits. R4's Minimum Data Set/MDS, dated [DATE], documents R4's Brief Interview for Mental Status/BIMS score (10/15) as moderate cognitive impairment and Functional Abilities as partial/moderate assistance with Activities of Daily Living/ADLs. R4's Nursing Progress Note, dated 1/5/24 through 1/20/24, document R4's diagnoses including End Stage Renal Disease dependent on Renal Dialysis, History of Transient Ischemic Attack/TIA and Cerebral Infarct/CVA. R4's current Care Plan, undated, documents: R4 has communication deficit and speech is not clear, with word choice and usage limited. R4 is living with chronic health conditions and co-morbidities that require the support, services and structures of this care setting to maintain stability and highest practicable level of functioning; recognized that living with chronic medical/psychiatric illness, physical decline, the pandemic and requiring long term care. R4 has an alteration in mood state and psychosocial wellbeing secondary to Anxiety. R4 has an ADL self-care/mobility performance deficit related to Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, Renal Dialysis, and history of Transient Ischemic Attack/TIA; poor impulse control; at risk for falls; arrange transportation as needed/as ordered and assist R4 in/out of transport van as allows. R4 is at risk for abuse/neglect related to poor memory and depression. R4 requires support of a long-care facility secondary to compromised medical status. R4's Facility Elopement Risk and Community Survival Skills Assessment, dated 1/18/24, (not completed in entirety) documents that R4 is not capable of outside independent pass privilege. R4's Nursing Progress Note, dated 1/18/24 at 6:03 pm, documents R4 was noted to have followed someone (V15 Dietary Manager) out the front door, (R4) went to the bus station where Police located him, and he was returned to the Facility. The Progress Note also documents that R4 was alert, R4 had no issues and R4 was placed on one-on-one observation. R4's Police Report, dated 1/18/24, documents on the 1/18/24, V19 (Police Officer) responded to the Facility for a Missing Male (R4), that had been missing since 4:11 pm. The Report documents that V19 recognized the name of (R4) from (R4) previous Elopements wherein R4 went missing and was found on the (bus station) V19 then transported R4 back to the Facility. Upon arrival V1 (AIT/Administrator in Training) advised that the Facility waited to call Police for over an hour because they did not know R4 was missing. R4's Nursing Progress Note, dated 1/18/24 at 6:30 pm, documents R4 returned to the Facility at approximately 6:11 pm. with no injuries. The Progress Note also documents that Officers stated that (R4) was combative and that R4 was currently sitting by the fireplace in the front, watching the front door. R4 was placed on one-on-one observation. R4's Nursing Progress Note, dated 1/18/24 at 7:38 pm, documents that R4 was lying in bed and is currently still a one-on-one observation. R4's Nursing Progress Notes, dated 1/18/24 at 7:39 pm through 1/20/24 at 10:54 am, do not document R4's one-on-one observations. Facility Nursing Daily Assignment and Nurse Group Assignment, dated 1/20/24, do not document a staff member assignment for R4's one-on-ones. On 1/20/24 at 9:10 am, 9:50 am, 9:49 am, 9:50 am and 10:28 am, 1/23/24 at 12:09 pm and 12:56 pm R4 was lying in bed in R4's room, and no staff were present for one-on-one observations. On 1/20/24 at 12:09 pm, R4 was unable to respond to or recall the events of the 1/18/24 Elopement and was non-conversive. On 1/23/24 at 12:35 pm, V2 (Director of Nursing) could not identify the staff that were assigned to perform R4's one-on-ones (dated 1/18/24 through 1/20/24). V2 also stated, We have an elopement book, there are fifteen residents in there, but I do not see (R4's) information in there. On 1/20/24 at 9:45 am, V12 (CNA/Certified Nursing Assistant), I was working on Thursday night (1/18/24) when (R4) got out of the building. (R4) was last seen around 4:00 pm. We discovered (R4) missing at the beginning of the dinner time service and medication pass. We could not find (R4), and we searched the entire building inside and out and could not find (R4). I had remembered that a couple of months ago, (R4) was found at the bus station after (R4) went missing from a dialysis appointment. So, I went to the bus station and found (R4) sitting there. I could not get (R4) into my car because (R4) was combative, but there was a Police Officer (V19) already there, so the Police Officer brought him back to the building. Come to find out, (R4) followed (V15 Dietary Manager) out of the front door that night. On 1/20/24 at 10:43 am, V1 (AIT/Administrator in Training) stated, I started working here two weeks ago, I do not have any information for you. All I know is that (R4) got out of the building behind a staff member and was found at the bus station downtown. We think he got onto the bus down the road from the facility and rode the bus to the bus station, but we are not sure. The Police brought him back to the Facility. (R4) was last seen by staff around 4:00 pm on 1/18/24. On 1/20/24 at 10:43 am, V1 stated, (R4) was approved to be in the community, so I did not consider this an Elopement, so I did not investigate it. On 1/21/24 at 9:15 am, V16 (R4's Brother) stated, I was out in the Facility around lunch that day (1/18/24), seeing my brother to give him food and money. Then around 5:00 pm, I get a phone call from someone, not sure who, and asked me if my brother was with me and I said no, and they hung up real quick. Then a couple hours later, probably around 7:00 pm or 8:00 pm, I get a phone call from someone at the Facility again. They told me that they found my brother (R4) down at the city bus station. It was freezing out that day and I am not even sure he had a coat on at that time. The thing that makes me mad, is that he followed an employee, someone who works there, that is supposed to be protecting my brother. On 1/23/24 at 11:00 am, V1 (Administrator in Training) stated, I do not have an investigation. (R4) had left dialysis before and also was found at the same bus station, so I figured that he was okay to do that. We just updated the Elopement Binder today with (R4's) information. On 1/23/24 at 11:30 am, V15 (Dietary Manager) stated, I have worked here about a month and a half. On 1/28/24 around 4:00 pm, I was leaving the Facility to go home. I exited through the front door and (R4) was sitting in the chair in the reception area. I saw (R4) get up and stand at the exit door, but the door had closed, so I proceeded to my car. I am thinking that the alarm had not reset and that (R4) got out right behind me. I never thought to look back at the door and check to see if (R4) got out. Then I heard that (R4) had gotten out right behind me and I feel so bad. I should have stayed and made sure the door was alarmed or gotten someone to help get him. I do not think (R4) had a coat on. On 1/23/24 at 12:35 pm, the Facility Elopement Binder documents that (R2, R9 through R20) are Elopement Risks. The Elopement Binder does not document R4's information as an identified Elopement Risk. On 1/23/24, at 12:35 pm, V2 (Director of Nursing) confirmed that R4's information was not documented in the Elopement Binder. On 1/23/24 at 1:05 pm, V1 confirmed that R4 had diagnoses and cognitive deficit that should not allow (R4) out in the community alone and that I probably should have investigated this once I saw the Facility Policy. On 1/24/24 at 1:00 pm, V1 stated, I just assumed that it was okay for (R4) to go out in the community on (R4's own). But I do see now on (R4's) Community Assessment for Elopement that (R4) was not approved to be in the community and was not allowed to be out of the Facility alone. (R4) was placed on one-on-ones, when (R4) returned to the Facility, and remained on those until Sunday (1/21/24). Then (R4) has been on fifteen-minute checks since 1/23/24, when the local State Agency was talking to me about this being considered an Elopement, and now I am thinking that (R4) will remain on those for five days. I cannot find the documentation for the one-on-ones. We just put (R4's) Elopement information into the Elopement Binder yesterday. I am not even sure at this point what the interventions are going to be for (R4). I am thinking probably trying to arrange more family visits since it seems like every time he gets out, he goes to the bus station and tries to go see them. Facility Missing Resident/Elopement Policy, reviewed 11/15/2018, documents: all personnel are responsible for reporting a cognitively resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical; this includes any Resident that did not sign out on pass and/or did not notify a staff member of his/her leaving; should an employee observe a cognitively impaired Resident leaving the premises or attempting to exit the premises, he/she should attempt to prevent the departure without use of force, obtain assistance from other staff, notify the attending Physician, contact the legal representative/responsible party, make appropriate notations in the Resident's medical record, complete a new Elopement Risk Assessment and update the plan of care with appropriate interventions; example interventions such as (Electronic Monitoring Bracelet), increased monitoring (15 minute visual checks or one-on-one supervision); evaluate for secured unit and review and update the Elopement Risk binder; the Administrator and Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident; notify the sheriff and/or local police department and file a missing person report, complete incident report and notify the State Agency according to reporting guidelines; document appropriate notations in the medical record; and complete the incident report, indicating when Resident returned and condition of the Resident. On 1/24/24 at 12:00 pm, the surveyor confirmed through interview, observation and record review the facility took the following actions to remove the immediacy: 1.) R4 was immediately placed on one-on-one supervision. (AIT Completed 01/18/2024). Unable to confirm one on one supervision was being provided. Confirmed 15-minute checks were being conducted for R4 on 1/23/24. 2.) R4 was immediately assessed for injury with no injuries. (AIT Completed 01/18/2024) 3.) R4's Elopement assessment and care plan were reviewed and updated accordingly. (ADON (Assistant Director of Nursing), SSD (Social Service Director) Completed 01/18/2024). Confirmed R4's Elopement binder updated with R4's information on 1/23/24. 4.) All Staff have been educated on the Facility's Elopement Policy (Completed by IDT (Interdisciplinary Team) on 1/23/2024) 5.) All Staff have been educated on the Facility's Code Pink Guidelines (Completed by IDT Team 1/23/2024) 6.) All Staff have been educated on the Facility's Risk Identification & Prevention Guidelines (Completed by IDT Team 1/23/2024) 7.) All Resident's Elopement Assessments have been reviewed and updated accordingly. (Completed by SSD 1/23/2024) 8.) All Residents at Risk Plan of Care's has been reviewed and updated accordingly based off the individual Elopement Assessment. (Completed MDS (Minimum Data Set) Care Plan Coordinator 1/23/2024) 9.) An Elopement Drill was completed (Maintenance Director on 01/23/2024) 10.) ADM/Designee (Administrator in Training/Designee) will complete random 5 observations of the door alarms to ensure they are functioning properly a week for 12 weeks.

Based on observation, interview and record review the facility failed to allow the use of an electronic communication device/tablet for one of three Residents (R2) reviewed for communication in a sample of 21. This failure resulted in (R2) a deaf and aphasic resident experiencing agitation, crying and without a preferred source of communication. Findings include: Facility Resident Rights for People in Long Term Care Facilities, undated, documents: you have the right to dignity and respect; to make your own choices; care for you in a manner that promotes your quality of life; provide equal access to quality care regardless of diagnosis, condition, or payment source. The Facility must provide services to keep your physical and mental health, at their highest practical levels. You should receive the services and/or items included in your plan of care. You have the right to receive and make phone calls in private and access to the use of a telephone where calls can be made without being overheard; and you have the right to use your personal property. The Facility Abuse Prevention and Reporting Policy, revised 10/24/22, documents: the Facility affirms the right of the Residents to be free from misappropriation of property. Misappropriation of property means the wrongful temporary or permanent use of a Resident's belongings or money without the Resident's consent. Resident concerns will be recorded, reviewed, addressed, and responded to using the Facility's grievance procedure. Residents will be informed of the Facility's grievance procedures; an essential element of customer satisfaction is timely response back to Resident concerns expressed; and employees are required to report any incident of misappropriation of resident property they observe, hear about, or suspect to the Administrator immediately or to an immediate supervisor who must then immediately report it to the Administration. Residents are encouraged to report their concerns or suspected incidents and reports should be documented and a record kept of the documentation. The Facility Grievance Log, dated 9/1/23 through 1/20/24, does not document R2's concerns of a missing/stolen tablet. R2's current Care Plan documents that R2 has diagnoses including Impaired Communication related to Hearing Deficit, Hearing Loss/ Deaf, and prefers to communicate by using an electronic tablet, reading lips and sign language. R2's current Care Plan documents: will maintain current level of communication function by using appropriate gestures, responding to yes/no questions appropriately, using my electronic tablet; ensure able to utilize communication book; will use a communication tablet to communicate with staff and other residents. R2's Progress Notes, dated 11/1/23 through 1/20/24, do not document concern/grievance investigation/resolution of R2's missing tablet. On 1/20/24 at 9:08 am, R2 was crying, groaning, grunting, and throwing arms in the air and wrote on a piece of paper that They took my computer tablet. I cannot talk to anyone. R2 was unable to communicate and continued to grunt, frown, and throw arms in the air. R2 was agitated and was unable to find staff to interpret concerns. R2 walked to V2's (Director of Nursing) office door on R2's hallway and pointed. R2 then proceeded to walk to the opposite side of the Facility and pointed at V3 (Social Service Manager), who was sitting in V3's chair, and pointed. R2 verified that V2 and V3 had R2's computer tablet. R2's electronic communication device was not available to R2 and was not in R2's room. R2 verified that R2 had spoken to V2 (Director of Nursing) and V3 (Social Service Manager) and that V2 and V3 had taken R2's tablet and had not given it back. On 1/20/24 at 9:40 am, V3 (Social Service Department) stated, (R2) is deaf and cannot talk and uses a tablet, but since (R2) was communicating to the local Police on (R2's) tablet. I believe (R2's) tablet is now locked up in someone's room. I know that (R2) is upset that we took her tablet. We have not given it back to (R2) since she was communicating with the Police. I really do not know much more about it. I do not even know where it is at. I did not file a grievance for the missing tablet either. R2's electronic communication device/tablet was not available to R2 and was not in R2's room. On 1/20/24 at 11:15 am, V11 (Police Officer) stated, I have been dealing with this Facility for quite some time now. I am very familiar with (R2). (R2) is deaf and unable to speak. (R2) has an electronic tablet that interprets (R2's) sign language and allows (R2) to communicate. (R2) would communicate with the Police Department often and was very, very distraught and has a history of behaviors, but I believe it is because (R2) is unable to communicate (R2's) needs. I also think that the Facility took (R2's) tablet from (R2) because (R2) was communicating with the Police Department, and now (R2) has no way to communicate. (R2) told me that they took the tablet and are not giving it back. I have witnessed the staff with her, and they are unable to communicate with her through sign language. (R2) does have paper and pen to communicate, but (R2) prefers the electronic tablet and the tablet is easier, and it also allows (R2) to make phone calls. I have been at this Facility a lot, and I have witnessed the staff be belligerent to Residents and it is very disturbing. R2's electronic communication device/tablet was not available to R2 and was not in R2's room. On 1/20/24 at 9:55 am, V2 (Director of Nursing) stated, (R2) has a tablet that she communicates with and can make phone calls. I have no clue where she got it and I have no contact person that you can call to ask anything about it either. We took (R2's) tablet from (R2) because she was misusing it and kept calling the police. As of right now, I cannot tell you where the tablet is at. R2's electronic communication device/tablet was not available to R2 and was not in R2's room. On 1/20/24 at 9:45 am, V1 (Administrator in Training) stated, I started working here two weeks ago. I do not have any information for you. I do not even know where (R2's) tablet is at. On 1/23/24 at 11:30 am, V1 stated, I cannot find a personal inventory sheet or any documentation for (R2's) tablet. On 1/23/24 at 1:15 pm, V2 (Director of Nursing) stated, (R2's) tablet is locked up in the Medication Storage room at the Nurses Station. (R2) does not need her tablet, it is not hers, she does not own it. She can ask for it when she needs it.

Based on observation, interview and record review, the facility failed to maintain a clean kitchen that includes ovens, ranges, mixers, beverage drip trays, grease trays, microwave oven, large containers steam table area. The facility failed to label and date food products for refrigerated foods and dry goods. The facility placed raw meat over ready to eat food or food ingredients and failed to put raw meat in leak proof pans. The facility failed to consistently check the level of Quaternary Ammonia in the sanitation buckets. The facility failed to keep food off the floor of the walk-in refrigerator and walk-in freezer. The facility failed to place thermometers inside the walk-in refrigerator and walk-in freezer. The facility failed to keep dished up food in the cooler. The facility failed to store the dishes and silverware so that dust/grime could not reach the serving area of the dishes and silverware. The facility failed to consistently record steam table food temperatures and failed to follow/attain recommendations in heating foods in a microwave oven. These failures have the potential to affect all 82 residents living in the facility. These failures resulted in an Immediate Jeopardy due to failing to maintain a clean kitchen, store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings include: The Immediate Jeopardy began on 12/10/23 at 10:10 AM when the facility failed to maintain a clean kitchen, store, prepare, distribute, and serve food in accordance with professional standards for food service safety. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 1/04/24 at 9:50 AM. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 1/04/24 but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the implemented procedures. The kitchen was entered on 12/10/23 at 10:10 AM. V7 (Cook) was washing dishes. V7 stated, I'm working by myself. I'm new and we don't have a Dietary Manager. The kitchen was toured. The convection oven had dust wads on the top of the appliance and a buildup of black grease, grime, and food particles/crumbs on both the ledge on the outside of the oven and on the inside bottom of the oven. The windows on the oven were opaque with a layers of buildup grease. The pipes behind the convection oven were covered in cobwebs. The range has dried food splatters on the burners and on the back splash area. A drip pan on the side of the range was full of grease, some older layers that smelled rancid. The drip tray located under the burners had a buildup of dried splashes, unknown food particles/chunks, grease, and dust. The range and oven had dried food particles and grease burned on the bottom inside of the oven. The outside/front of the appliances had splashes of dried food/smears. The food preparation table across from the range has plates stored on a shelf underneath that are not upside down to prevent being exposed to dust/contaminants. Silverware and kitchen utensils do not have a cover over them to prevent contamination. The counter had a ham sitting in a pan uncovered. The cook's purse and personal drink container was sitting next to the pan. The area above the steam table and under the shelf to the dining room is full of old dried food splashes. The handwashing sinks all needed to be scoured/cleaned. One handwashing sink did not have soap in the soap dispenser, another handwashing sink did not have paper towels in the paper towel machine. The electrical boxes and the pipes on the ceiling have a layer of dust/grime by the food preparation table and by the beverage table. Another personal drink container was sitting on the beverage table. A rack holding two trays of fruit cocktail was sitting next to the walk-in refrigerator. V7 did not know how long it had been sitting out and stated, It may have been from Friday night (12/08/23). The walk-in refrigerator had five crates of milk and one crate of juice concentrate sitting on the floor. The second shelf held four ten-pound tubes of raw hamburger, unopened and one tube of raw hamburger, opened with 50 % used, no open date/label, and a ten-pound opened box of raw sausage, no label or date, all sitting directly on the rack without a leak-proof pan under them on the second shelf, located over two cases of hot dogs and a five-pound bag of hash browns. On another shelf there were two five pound bags of cheddar cheese, 75 % empty, no label/open date; one pound sliced American Cheese, no label/open date; two pounds of American Cheese, opened, no date/label; a half shallow pan of lettuce leaves, no date/label; an opened jar of mayonnaise, 75 % used - no label/open date; two large square containers of unknown liquid, no label/date; pan of bologna sandwiches (8 total), no label/date). There was no inside thermometer in the walk-in cooler. The freezer had eleven boxes sitting directly on the floor, four boxes of frozen juice concentrate, one box individual juices, two boxes of biscuits, two cases of hamburgers, one case of bread, one case of hot dog buns. There was no inside thermometer in the freezer. The large can opener had black debris on the blade and a large amount of black gummy/sticky unknown substance on the can opener base. The large stand mixer's top underneath area and protective steel guard had a large amount of old dried food splashes. The microwave oven had old, dried food splashes on the inside ceiling. The juice appliances on the beverage table had dark, sticky liquid in the drip pans that had a sour odor. The dry goods stock room had six large containers which held, flour, brown sugar, sugar (no label on the sugar container). Oatmeal, breadcrumbs, and rice containers were soiled with dried food splashes/dust on the top and outside of the containers. There were two five-pound bags of graham cracker crumbs, 75 % gone, no label/open date. There was a container of rice crisp cereal that had no label/date. During the morning, V7 was observed leaving the kitchen and returning without washing hands and putting new gloves on. V7 would change gloves without washing hands. On 12/10/23 at 10:15 AM, V7 (Cook) was working alone in the kitchen, currently washing dishes in the dish machine. V7 stated, I'm working by myself again. I've only been here for seven days and have worked the majority of the days by myself or with one other person. A couple of Certified Nursing Assistants came into the kitchen this morning to help me cook and get breakfast out. If they hadn't helped me, I don't know when I would have gotten the breakfast ready. The Facility Assessment, last reviewed on 5/2023, states, Dietary: Food Service Staff - Seven Dietary Workers per day. The Dietary work schedule for December, shows that for the first 10 days, only one day was fully staffed. One day with only two staff; four days with only three staff; two days with only four staff; two days with only five staff. On 12/10/23 at 10:30 AM, V2 (Director of Nursing) and V20 (Wound Nurse) came into the kitchen to assist V7. V20 put gloves on without washing her hands and began running the dishwasher. V20 was observed going from handling soiled dishes and pots and pans on the dirty side of the dish machine to pulling racks out of the dishwasher that had clean dishes, pots and pans and then handling these items and putting them on a cart to put away, all without washing V20's hands and putting clean gloves on. V20 did not have an Illinois Food Handlers Sanitation Certificate. On 12/10/23 at 10:45 AM, V2 (Director of Nursing), entered the kitchen and did not wash her hands or don gloves. V2 went inside of the Walk-In Refrigerator where V2 rummaged among the food items. After a few minutes, V2 came out of the walk-in and stated, I'm looking for the ham. When V2 found the ham sitting out on the food preparation table, V2 got a large roll of tin foil, wrapped the ham, and placed it into the convection oven. V2 stated, The kitchen is short staffed so I do what I can to help them out. On 12/10/23, V1 (Administrator) at 10:45 AM, went around the kitchen. V1 confirmed these issues. When V1 was asked to check the level of Quaternary Ammonia in the Sanitation bucket, V1 looked around and stated that he had not seen or used the strips to check the sanitation level since he had been in the kitchen. V7 also stated that she had not seen any test strips for the sanitation bucket since she had started working at the facility. V1 stated, I've only been here for seven weeks. I'm more concerned with the nursing care of the residents than how clean the kitchen is. We spent a lot of money on getting the new floor in the kitchen just recently. We didn't have time to come in and thoroughly clean the whole kitchen. It was difficult moving appliances for the new floor. The maintenance man had just one usable arm and has since left our employment. The new maintenance guy won't be starting until another three weeks. Our Dietary Manager left on 11/20/23. Other staff (not dietary) have been helping. My wife and I worked the kitchen last weekend. The new dietary manager starts tomorrow. I'm more concerned about a resident that might have a wound than the kitchen. When the importance of a balanced diet (to help prevent wounds) and sanitation (to prevent foodborne illness) was emphasized to V1. V1 stated, I started out as a Certified Nursing Assistant, so that side of nursing care is where I am most concerned. The document, Daily Data Sheet, used to record the sanitation bucket sanitation level three times daily, were reviewed for the past 30 days. Only eleven sheets for the sanitation buckets were dated and filled in during that time; four sheets were blank, two sheets had been logged for breakfast; three sheets had been logged for breakfast and lunch; two sheets had been logged for breakfast, lunch, and dinner. On 12/10/23 at 12:30 PM, V7 (Cook) was asked when she would be ready do take the steam table food temperatures. V7 stated, No one told me that I had to take temperatures! V7 began to take the food temperatures. When asked what the temperatures should be for food on the steam table, she said, Honestly, I don't know. V8 (Cook for evenings) came over and stated, The ham should be 165 degrees Fahrenheit (F). When asked what the lowest temperature that food could be when in the steam table, V8 stated, 165 degrees F. When V7 and V8 were asked what the danger zone temperature is, V8 stated, 70- or 90-degrees F. Neither V7 nor V8 were able to tell the lowest temperature allowed on the steam table (135 degrees F) or the correct danger zone temperature (which is 41 to 135 degrees F). V16 (Dietary Aide) got a book out and showed it to V7, and stated, This is where you record the temperatures after you take them. The last 30 days were reviewed on the Daily Data Sheet for Food Temperatures. Of the 30 days, only eleven sheets had meal temperatures logged: 20 days there were no temperature sheets; two days no temperatures were logged for any meal, but the sheets were provided; four days breakfast and luncheon temperatures were logged; two days temperatures were partially logged; and only two days the meal temperatures were logged for all three meals. On 12/10/23 at 2:05 PM, all the entree on the menu, which was ham, had been used. Several residents had not received their meal. V7 (Cook) got diced turkey out of the cooler and filled a large bowl full, putting it into the microwave oven. The turkey was heated for a few minutes. V7 took the turkey out of the microwave and immediately went to serve it. When asked what the temperature was, V7 got the thermometer and took the temperature in only one spot in the bowl of diced turkey. The temperature was 80 degrees Fahrenheit. V7 returned the large bowl of turkey to the microwave and heated the turkey, taking the temperature as required, with prompts. When asked, V7 stated she was unaware of the proper procedure for heating foods in a microwave oven. On 12/10/23, V3 (Assistant Director of Nursing) provided the Facility's Resident Roster, which shows that 82 residents are living in the facility. The document, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, states, General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and the date by which it should be discarded. Keep potentially hazardous food out of the temperature danger zone (41 degrees to 135 degrees Fahrenheit). Refrigerated storage guidelines to be followed: Place a thermometer in the warmest part of the refrigerator to monitor the air temperature in the refrigerator. Store raw animal food such as eggs, meat, poultry, and fish separately from cooked and ready-to-eat food. If they cannot be stored separately, place raw meat, poultry, and fish items on shelves beneath cooked and ready-to-eat items. Raw animal foods should be stored in drip proof containers. Wrap foods properly. Never leave any food item uncovered and not labeled. The document, Proper Hand Washing and Glove Use, dated 2020, states, All employees will wash hands upon entering the kitchen from any other location, after all breaks, and between all tasks. Gloves are changed any time hand washing would be required. When gloves are changed, they are removed, and hand washing is required. Gloves are never placed on dirty hands. The document, Sanitation of Dining and Food Service Areas, dated 2020, states, Dietary Services Staff will uphold sanitation. A cleaning schedule will be posted for all cleaning tasks. The document, Sanitizing and Disinfectant Solutions, dated 2020, states, The employee will prepare sanitizer solution in accordance with manufacturer guidelines. The document, Storing Dishes tableware and Equipment, dated 2020, states, Clean and sanitized dishes, utensils and equipment will be stored in a clean and dry location in a way that keeps them from contamination by splash, dust or other means. The document, Cleaning Rotation, dated 2020, states, Items cleaned and sanitized after every use: Can Opener, Mixer, Worktables and Counters. Items cleaned daily: Stove Top, Grill Microwave Oven; Hand Washing Sink; Exterior of Large Appliances. Monthly clean: Refrigerators and Freezers, Clean and Sanitize Ingredient Bins. Weekly: Clean Ovens. The document, Daily Cleaning Schedule, dated 2020, states, Wash and sanitize the can opener; wash and sanitize mixer; Wash and sanitize beverage table; Clean Stovetop/Grill; Clean Microwave Oven; Clean Handwashing sink; Clean Food Carts. The document, Weekly Cleaning Schedule, dated 2020 states, Clean shelves, clean ovens. The document, Dining Services Opening and Closing Checklist, dated 2020, states, Opening Duties: Prepare sanitation solution and test for proper concentration, log concentration. Closing Duties: Complete Daily Cleaning Schedule; Label, date, store all ingredients used. The document, Serving Temperatures for Hot and Cold Food, dated 2020, states, Foods will be served at the following temperatures to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking, or cooling of foods. These are minimum serving/holding temperatures. Hot food temperatures should range from 135 to 170 degrees Fahrenheit. The cook will take temperatures of hot food items using approved food thermometers prior to each meal service. The document, Daily Data Sheet, Food Temperatures, unknown date of publication, dated on a daily basis, states, Temperature Danger Zone 40 degrees to 140 degrees Fahrenheit. * Do not serve foods at inappropriate Temperature. *Note this is not the correct temperature range for the State of Illinois Sanitation requirements. The facility was unable to provide a policy and procedure for Microwave use. The Microwave Oven use recommendations of the United States Department of Agriculture (USDA), Food Safety and Inspection Service, dated 8/08/13, states, Microwaves do not cook food from the inside out. Microwaves penetrate the food to a depth of 1 to 11/2 inches. In thicker pieces of food, the microwaves don't reach the center. That area would cook by conduction of heat from the outer areas of the food into the middle. Bacteria will be destroyed during microwave cooking just as in other types of ovens, so food is safe cooked in a microwave oven. However, the food can cook less evenly than in a conventional oven. Microwave cooking can be uneven just as with frying and grilling. For that reason, it is important to use a food thermometer and test food in several places to be sure it has reached the recommended temperature to destroy bacteria and other pathogens that could cause foodborne illness. To promote uniform cooking, arrange food items evenly in a covered dish and add some liquid if needed. Cover the dish with a lid or plastic wrap. Allow enough space between the food and the top of the dish so that plastic wrap does not touch the food. Loosen or vent the lid or wrap to allow steam to vent. The moist heat that is created will help destroy harmful bacteria and ensure uniform cooking. Cooking bags also provide safe, even cooking. Stir, rotate, or turn foods upside down (where possible) midway through the microwaving time to even the cooking and eliminate cold spots where harmful bacteria can survive. Even if the microwave oven has a turntable, it's still helpful to stir and turn food top to bottom. Observe the standing time. Cooking continues and is completed during standing time. Most importantly, follow the manufacturer's instructions. Microwaves cause water, fat, and sugar molecules to vibrate 2.5 million times per second, producing heat. After the oven is off or food is removed from the oven, the molecules continue to generate heat as they come to a standstill. This additional cooking after microwaving stops is called carryover cooking time, resting time, or standing time. It occurs for a longer time in dense foods such as a whole turkey or beef roast than in less-dense foods like breads, small vegetables, and fruits. During this time, the temperature of a food can increases several degrees. For that reason, directions may advise to let a food rest for a few minutes after turning off the oven or removing food from the oven. The surveyor confirmed through observation, interview and record review the facility took the following actions to remove the immediacy. 1.The Convection oven has been cleaned. 2.The ledge on the outside of the oven including the inside bottom of the oven has been cleaned. 3.The windows on the oven have been cleaned. 4.The pipes behind the convection oven has been cleaned. 5.The range burners and back splash area has been cleaned. 6.The drip pan located under the burner has been emptied and cleaned. 7.The dried particles and grease have been removed. 8.The outside/front of the appliances have been cleaned. 9.The food preparation table across from the range has been cleaned. 10.The plates are being stored upside down. 11.The silverware and kitchen utensils have been covered. 12.The area above the steam table and under the shelf to the dining room has been cleaned. 13.The handwashing sinks have been cleaned. 14.The handwashing sink soap dispenser has been filled with soap. 15.The paper towel machine for the hand washing sink has been filled with paper towels. 16.The electrical boxes and the pipes on the ceiling by the preparation table has been cleaned. 17.The personal drink container setting on the beverage table has been removed. 18.The rack holding 2 trays of fruit cocktail has been removed. 19.The hamburger, sausage, cheese, lettuce, mayonnaise, bologna have been removed. 20.The frozen juice, individual juices, boxes of biscuits, frozen hamburgers, case of bread, case of hot dog buns have been removed. 21.The large can opener has been cleaned. 22.The large stand mixer's top underneath area and protective steel guard has been cleaned. 23.The microwave oven has been cleaned. 24.The juice appliance on the beverage table has been cleaned. 25.The six containers for dry goods have been cleaned and labelled. 26.The graham cracker crumbs, and rice crisp cereal have been removed. 27. All Dietary Staff have been educated on proper handwashing and glove usage. Completed 01/04/2023 by the Infection Control Preventionist. 28.The Daily, Weekly, Monthly cleaning schedules have been reviewed and updated accordingly. Completed 01/04/2024 by VP of Operations. 29.All Dietary Staff have been educated on the Facility's Monitoring Food Temperatures for Meal Service. Completed 01/04/2024 by Dietary Manager 30.All Dietary Staff have been educated on the Facility's Dishwasher Policy. Completed 01/04/2024 by Dietary Manager. 31.All Dietary Staff have been educated on the Facility's Refrigerator and Freezer Temperatures Policy Completed 01/04/2024 by Dietary Manager. 32.All Dietary Staff have been educated on Proper Food Storage, and the Facility's Labeling and Dating Foods Policy. Completed 01/04/2024. 33.All Dietary Staff have been educated on the following Facility's Policies: Completed 01/04/2024 Cleaning Instructions: Slicer Cleaning Instructions: Beverage Table Cleaning Instructions: Can Opener Cleaning Instructions: Reach-in Refrigerator and Freezer Cleaning Instructions: Ingredient Bins Cleaning Instructions: Hand-Washing Sink Cleaning Instructions: Flat - Top Grill Cleaning Instructions: Conventional Oven Cleaning Instructions: Ceilings and Walls 34.All handwashing sinks in the kitchen have both soap and paper towels. Completed 01/04/2024 by Dietary Manager. 35.All Dietary Staff have been educated on covering plates, dishes, silverware while stored to prevent contamination. Completed 01/04/2024 by Dietary Manager. 36.A Policy and Procedure has been developed for Microwave Oven usage. Completed 01/04/2024 by Dietary Manager. 37.All Dietary Staff have been educated on the Facility's Microwave Oven usage. Completed 01/04/2024. 38.Administrator/Designee will complete random 5 observations a week for 12 weeks to ensure Cleanliness of the Facility Kitchen, proper food handling and storage, and appropriate Food Temperatures. 39.The results of these interviews will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 100% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated.

Based on interview and record review the facility failed to implement appropriate fall prevention interventions and failed to investigate a fall with an injury (10/6/23), for two of nine residents (R17 and R38) reviewed for falls, in a sample of 43. These failures resulted in R17 sustaining a second fall from the bed with a fracture on 12/2/23. Findings include: The facility policy, Fall Prevention Program, dated (revised) 11/21/17 directs staff, The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: Assessment time frames, Immediate change in interventions that were successful, Care Plan incorporates: Addresses each fall, Interventions are changed with each fall, Preventative measures. 1. R17's facility Admission record documents that R17 was admitted to the facility on [DATE] with the following diagnoses: Syncope and Collapse (Principal Diagnosis), Unsteadiness on feet, history of Falling. R17's Care Plan, dated 6/20/23 includes the following Focus area: I am at risk for falls. Also included is the following Interventions: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Bed height to be placed where my feet are flat on the floor; PT (Physical Therapy) evaluate and treat as ordered or PRN (As needed). R17's (facility) Incident Notes, dated 7/17/23 at 1:12 P.M. document, (R17) located in bathroom of (R17's) room in supine position with knees bent near the toilet. Moderate amount of blood to left brow bone noted. First aid administered; pressure applied. 911 called for transfer to ED (Emergency Department). R17's Nursing Progress notes, dated 7/20/2023 at 12:09 P.M. documents, Fall IDT (Inter Disciplinary Team) Note: Summary of the fall (7/17/23): (R17) attempted self-transfer and lost balance. Root cause of fall: (urinary) catheter wrapped around (R17's) leg. Intervention and care plan updated: (R17) to wear leg bag (urinary) catheter during the day, switch to (urinary catheter) (bed) bag at night after laying down. R17's Nursing Progress Notes, dated 10/6/23 at 11:02 P.M. document, (R17) found sitting on the floor next to (R17's) bed at around 9:30 P.M. (R17) is very confused as usual when (R17) got here. No injury noted. Small amount of blood noted to (R17's) (urinary catheter) tubing. No facility Incident Report or Investigation was found in R17's chart. R17's (facility) Incident Notes, dated 12/2/23 at 10:00 P.M. documents, On 12/2/23 at 10:00 P.M., (R17) was found lying on the floor on his right side, next to his bed. It appears that (R17) rolled out of bed. (R17) said he was lying in bed and when he tried to lay on his side (R17) rolled out of bed. No injuries noted. R17's Nursing Progress Note, dated 12/5/2023 at 1:27 A.M. document, (R17) Follow up assessment post-fall. Swelling observed at site (right knee). Deep purple bruising noted. Reddish-purple bruising noted. Green bruising noted. Yellow bruising noted. Physician ordered a 2-view x-ray of the right knee. R17's Radiology Report, dated 12/5/23 documents, Right Knee. Indication: Right knee bruising. Findings: Acute soft tissue swelling of the anterior knee with cortical irregularity of the lateral border of the medial femoral condyle on the front view. Consider MRI of the joint for bone bruise. Small crescentic avulsion fracture medial aspect of the femur. On 12/12/23 at 11:42 A.M., V1 (Administrator) verified there was no facility investigation into R17's 10/6/23 fall. On 12/13/23 at 9:23 A.M., V19 (Licensed Practical Nurse/Care Plan Coordinator/Minimum Data Set Coordinator) stated, I am part of the Fall Inter Disciplinary Team that reviews all falls. When a resident falls or rolls out of bed, we place fall mats around their bed. I don't know why we didn't add fall mats for R17 after he was found next to his bed (on 10/6/23). Maybe it would have prevented the injury to his knee (from the fall on 12/2/23). 32189 2. R38 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Schizophrenia and Morbid Obesity. On 8/29/2023 at 12:00 PM, the record noted Resident in the dining room and stated (R38) slid off the toilet onto the floor and denies hitting (R38's) head. No redness or bruising noted. V2 (Director of Nursing) and V25 (doctor) notified of fall. On 9/1/23 at 10:47 AM, a Physician Note stated Patient was seen today for a fall f/u (follow up). Patient slipped out of the w/c (wheelchair) C/O (complains of) R (Right) foot pain. Discoloration noted to R foot. No c/o SOB (shortness of breath), chest pain, generalized pain, HA (headache), N/V/D (nausea, vomiting and diarrhea), dysuria (difficulty urinating), or any other complaints. Plan: R foot x-ray. On 9/6/2023 at 1:06 PM, a Nurses Note noted n.o. (new order) referral to ortho (orthopedics/bone doctor) for fracture rt (right) foot. On 9/5/2023 at 11:33 AM, the Fall IDT (Interdisciplinary) Note noted Summary of the fall: res (resident) slid off onto floor while using the toilet. Root cause of fall: res did not utilize staff assist. Intervention and care plan updated: res to utilize staff assist for transfers on/off toilet. On 12/10/23 at 1:00 PM, R38 was observed to have a boot at bedside and R38 stated I wear it (the boot) when I get up. I broke my foot. On 12/10/23 at 1:10 PM, R38's bathroom toilet had handrails mounted to the toilet although were loose, slid side to side and was unstable. The Witnessed Fall Investigation Report dated 8/29/23 noted Resident was in (R38's) bed when (R38) made the statement. Roommate stated she/he seen (R38) slide off toilet. No injuries observed at time of incident. Ambulatory without assistance. The Witnessed Fall Investigation lacked documentation R38 complained of pain in right foot, had an x-ray, was ordered a boot for right foot fracture nor was an investigation conducted to ensure safety intervention were functioning. The care plan dated 10/30/23 lacked documentation of right foot pain, foot fracture or safety measures related to the foot fracture and/or boot and equipment. On 12/13/69 at 2:00 PM, V2 (Director of Nursing) stated the facility failed to implement appropriate interventions to reduce a resident's risk of a fall with an injury and failed to investigate a fall with an injury.

Based on observation, interview and record review, the facility failed to protect a resident's right (R9) to be free from physical abuse by another resident (R8) out of four residents reviewed for abuse in a sample of 14. This failure resulted in R9 sustaining a fractured nose. Findings include: The facility's Abuse Prevention and Reporting policy revised 10/24/22 documents Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). The facility's incident report dated 9/28/23 documents On 9/28/23 at 7:30 PM, (R9) was pushing a resident in a wheelchair to the smoking area when (R8) suddenly punched him in the face. When (R9) fell to the ground then (R8) began to kick (R9) on his arms and chest area. (R9) stated that he did nothing to provoke this attack. (R9) was helped up off the floor and sat in a chair. Writer noted that (R9) was bleeding from his nose. Writer applied a cool towel to (R9)'s face and nose to stop the bleeding. Writer Checked the resident's vitals and called the resident's primary care physician and received telephone orders to send (R9) to the hospital for further evaluation and treatment. R9's hospital medical record dated 9/28/23 documents Closed fracture of nasal bone due to assault. R8's medical record documents a diagnosis of Schizophrenia. R8's medical records dated 9/18/23 documents After providing the resident his medication, resident told the nurse that he was hearing voices telling him to harm people. The nurse then relayed this information to MD (Medical Doctor) and DON (Director of Nursing). The nurse then contacted (Psychiatry Service) and spoke with the on-call psychiatrist. Received orders to provide Haloperidol (antipsychotic) 5 milligrams (mg) every six hours as needed for 14 days. Resident then had his smoke break upon returning, resident stated that he was feeling better. Will continue to monitor. On 10/3/23 at 8:30 AM, V1 (Administrator) stated (R8) hears voices in his head to hurt people. On 9/28, (R8) was in the dayroom when he started hearing voices, (R9) was walking down the hall, (R8) walked up to (R9) and punched him in the face breaking his nose. It's pretty cut and dry. It happened. (R9) didn't provoke (R8). (R9) just happened to be the unfortunate victim. We sent (R8) to the hospital for psych evaluation and called the police to file an assault report. On 10/3/23 at 11:44 AM, R9 observed lying in bed with a faint bruise to the left side of his nose. The bridge of R9's nose was also slanted to the right. R9 stated I was pushing a resident down the hall when (R8) came around the corner and out of the blue, just punched me in the face for no reason. I fell on the ground and then he started kicking me in the body and head. The nurse came and helped me. She got me off the ground and noticed my nose was bleeding. She sent me to the hospital to get checked out. The ER (emergency room ) doctor said was my nose was broken, but there's really nothing they can do about it and sent me back here. I don't know what provoked him. I've never talked to him before. I always keep to myself. He just came around the corner and [NAME]! Punched me right the in the face. On 10/4/23 at 8:50 AM, V13 (Certified Nursing Assistant) stated (R9) never provoked (R8). (R8) was hearing voices in his head to hurt (R9) and punched him with no warning. On 10/4/23 at 11:50 AM, R8 stated (R9) didn't do anything to me. I was not in the right place at the time. I heard voices in my head telling me to hurt (R9) so I did. I punched him in the face and then started kicking him. On 10/4/23 at 1:20 PM, R7 stated I was in the dayroom, and I saw (R8) come around the corner and punch (R9) in the face and then he started kicking him when he fell . (R9) was pushing (Resident) in his wheelchair minding his own business. I don't know why (R8) punched him. (R9) didn't say anything. He was literally just walking.

Based on observation, interview, and record review the facility failed to prevent physical resident-to-resident abuse for two of three residents (R1 and R2) reviewed for abuse in the sample of three. This failure resulted in a resident (R1) with a known history of physical behaviors physically assaulting R2 by straddling on top of R2, hitting R2 in the face multiple times, resulting in R2 sustaining a black eye and a laceration to his bottom lip. Findings include: The facility's Abuse Prevention and Reporting dated 10-24-22 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is a [AGE] year-old admitted to the facility on [DATE] and is moderately cognitively impaired. This same MDS documents R1 has verbal and physical behaviors and requires supervision with ambulation. R1's Physician's Order Sheets dated 8-9-23 document R1 has the diagnoses of Dementia with Moderate Agitation, Depression, Epilepsy, and Disorientation. R1's Care Plan dated 6-17-23 documents I have impaired cognition function/dementia or impaired thought processes due to Dementia. I wander and am confused. I can have agitation at times per history with physical aggression. R1's Progress Notes dated 7-23-23 at 9:02 PM and signed by V5 (LPN/Licensed Practical Nurse) documents, Resident physical altercation (attacker) with another resident in room, while staff attempting to diffuse situation, he becomes aggressive and combative with staff making it difficult to get resident to safety. R1's Hospital Notes dated 7-30-23 document, (R1) was admitted because of aggressive behavior at his nursing home. Significant for advanced dementia with behavioral disturbance. Two psychiatric admissions since May. V4's (CNA/Certified Nursing Assistant) statement dated 7-23-23 documents, I was walking down the hall when a resident yelled and said someone was fighting, I ran down the hall and found (R1) on top of (R2) repeatedly punching and kicking him. I tried to break them apart and (R1) began to physically assault me as well. While (R1) was trying to hit me, (R1) fell on the side of the bed. (R1) started hitting and biting me on my leg. I was able to get (R2) out (of) the room while (R1) was on the floor. (R2) has a black eye and his mouth was busted and bloody. R2's MDS assessment dated [DATE] documents R2 is a [AGE] year-old admitted to the facility on [DATE]. This same MDS documents R2 does not have behaviors, is severely cognitively impaired, and requires limited to extensive assistance with ADLs (Activities of Daily Living). R2's statement dated 7-24-23 documents, I have no clue what happened. Just know I got hit. R2's Emergency Department Notes dated 7-23-23 document, Chief Complaint: Assault Victim. (R2) comes into the emergency department via ambulance from (the facility) after an assault with another patient (R1) in the facility. Skilled Nursing Facility wanted (R2) to be sent to the emergency department for evaluation. (R2) has a black eye on the left side with a minor lip laceration on the bottom. Assault was unwitnessed until the very end, multiple hits. Staff reports that (R2) was lying in bed when the assault happened. Subjective (R2) is a [AGE] year-old presenting after an assault. (R1) assaulted (R2) this evening. The staff found (R1) punching (R2), and the roommate was pulled off and stopped. (R2) states that he was hit in the head multiple times. R2's After Visit Hospital Summary dated 7-23-23 documents, Reason for Visit: Assault Victim. Diagnoses: Injury of head. Alleged Assault. R2's Nurse's Note dated 7/24/2023 at 1:51 AM documents, Narrative: Resident returned from ED (Emergency Department) via transport wheelchair with no new orders or changes. CT (Commuted Tomography) scan performed, and results were negative. Resident denies any pain. Left eye swollen with bruising. Resident is sleeping in bed at this moment, will continue to monitor throughout the night. On 8-9-23 at 10:45 AM R1 was sitting in his room on the edge of the bed. R1 was confused and unable to answer questions. On 8-9-23 at 2:40 PM R2 was sitting at a table in the dining room. R2's left eye had dark brown discoloration to the area below the left lower eyelid that expanded across R2's left lower lid and down to the top of R2's left cheek. R2 stated, I do not know what happened. All I know is (R1) got on top of me and was punching me. I got a black eye. My mouth was bleeding. I did not do anything. On 8-9-23 at 2:45 PM R3 stated, I heard someone yelling for help (on 7-23-23) and yelled for someone to come help. All I know is two people were fighting. On 8-9-23 at 2:55 PM V4 (CNA/Certified Nursing Assistant) stated, I was working on 7-23-23 and (R3) yelled for help and said (R1 and R2) were fighting. I went into (R1 and R2's) room and (R1) was straddled on top of (R2) in (R1's) bed. (R1) kept hitting (R2) in the face. It was hard for me to get (R2) off of (R1). (R2) grabbed my leg and started to bite me. (R1) had a black eye and busted lip. (R1) tried shoving (R2) off of him, and (R2) slid to the floor. The ambulance was called for both (R1 and R2) and they (R1 and R2) were sent to the hospital.

Based on observation, interview, and record review the facility failed to prevent resident to resident verbal and physical abuse for two of four residents (R2 and R4) reviewed for abuse in the sample of five. This failure resulted in R2 calling R4 a racial slur, and R4 punching R2 in the nose, causing R2 to have a nose fracture and hematoma to the back of the head. Findings include: The facility's Abuse and Reporting policy dated 12-17-21 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and service by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. A resident-to-resident altercation should be reviewed as a potential situation of abuse. On 6-23-23 at 9:30 AM R2 was lying in bed. R2's nose had reddish/purplish bruising and was swollen. R2 stated, My nose hurts. I got punched. On 6-23-23 at 9:40 AM R4 was sitting in his wheelchair with V6 (Certified Nursing Assistant/CNA) sitting next to R4. R4 stated, H**l yes I punched R2. R2 called me a N****r. I will punch anybody that calls me that. On 6-24-23 at 10:20 AM V5 (Licensed Practical Nurse/LPN) stated, R4 hit R2 in the face after R2 called R4 a racial slur. R2's nose got broke. V5's (LPN) Statement dated 6-20-23 documents, Writer (V5) noted screaming and yelling coming from dining room. Upon arrival I noted (R2) bleeding from nose. (R4) stated the other resident called him a n****r so he punched (R2) in his face. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 is cognitively intact. R2's Care Plan dated 5-26-23 documents R2 has the diagnoses of Attention-Deficit Hyperactivity Disorder, Personality and Behavioral Disorders due to known Physiological Condition, Mood Disorder, and Major Depression. This same Care Plan documents R2 is at risk for abuse and neglect and has verbal aggression. R2's CT (Computerized Tomography) Head or Brain dated 6-21-23 documents, Indication: [AGE] year-old with blunt facial trauma. Reportedly beat up at (the facility). Impression: Soft tissue contusion/hematoma overlying the right occipital bone (back of the head). Acute fracture on chronic nasal septal (nose) and comminuted nasal bone fracture leftward deviation. R4's MDS assessment dated [DATE] documents R4 is cognitively intact. R4's Care Plan dated 5-26-23 documents R4 has the diagnoses of Anxiety Disorder, Obsessive-Compulsive Disorder, and Major Depressive Disorder. This same Care Plan documents, I have a behavioral problem and presents physical aggression towards other peers. R4's Progress Notes dated 6-20-23 documents, (R4) was involved in a physical altercation with another peer in the dining room. Send to (ER) emergency room for psychiatric evaluation. R4's Emergency Department notes dated 6-20-23 documents, [AGE] year-old presenting to the emergency department after striking another resident (R2) after being called a racial slur. R4's Police Report dated 6-20-23 at 6:08 PM and signed by V4 (Police Officer) documents, On the listed date and time I (V4) was dispatched to (the facility) for two residents fighting. Upon arrival I (V4) spoke with (V5 LPN) and (V5) advised that she was told that (R2) called fell ow resident (R4) a N****r, so (R4) punched (R2) on the face. I observed (R2) in a wheelchair holding a bloody rag to his nose. (V5) stated she was made aware of by (V6 R2's Friend) who was present during the fight. I then spoke to (V6). (V6) was difficult to understand but stated she observed (R4) punch (R2) in the face with a closed fist. I then spoke to (R4). (R4) was wheelchair-bound as well. (R4) advised (R2) was operating his wheelchair behind (R4). (R4) stated (R2) was trying to hurry (R4), so they could go smoke. (R4) advises he told (R2) to stop hurrying (R4). (R4) advised (R2) replied, F**k you N****r. F**k you, you f****g N****r. (R4) stated he then punched (R2) on the face.

Based on observation, interview and record review the facility failed to enter admission medication orders under the correct resident, failed to give the correct medications to the correct resident per physician orders, and failed to identify a change in residents condition until R1 was seen by V8 Physician Assistant during his routine new admission visits ([DATE]) resulting in a R1 being transported to the hospital. On [DATE] R1 was admitted to the hospital with the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Extensive failures in the admission process resulted in R1 staying in the hospital from ,d+[DATE]-[DATE]. R1 was admitted on hospice on [DATE] and expired on [DATE]. The facility also failed to enter R2's admission medication orders until three days after admit and failed to enter admission medication orders correctly per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1-R8 do not have admission photos and are new admits. Further non-compliance could result in additional deaths. These failures resulted in an immediate jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as the facility continues to educated staff on the admission process for admission/re-admission of residents, implement a monitoring process for admission/re-admission residents accuracy and completion of orders, audit all resident records for complete identification (photos) and accuracy of orders, and educate nurses on proper identification of each resident as they are arriving at the facility. Findings include: The Immediate Jeopardy was identified on [DATE] at 12:49 pm. The Immediate Jeopardy began on [DATE] at 7:30am when the facility failed to order and administer the correct medications to the correct resident. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 9:12 am. Facility Admission of Resident, undated, documents Obtain an admission photo and distribute to the nursing department for MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Facility Provider Pharmacy Requirements, undated, documents Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications. Accurately dispensing prescriptions based on authorized prescriber orders. Screening each new medication order for an appropriate indication or diagnosis; for duplication of therapy with other drugs in the same therapeutic class ordered for the resident. Facility Ordering and Receiving Non-Controlled Medications, undated, documents Medication orders are entered into the facility's EHR (electronic health record) and transmitted to the pharmacy. The medication order includes Date ordered, residents name and at least one other identifying information, medication name and strength, indication for use, and directions for use, if a new order. New Admissions/Re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Receiving Medications from the pharmacy: A licensed nurse verifies medications received and directions for use with the medication order form. Facility Medication Errors and Adverse Drug Reaction, revised [DATE], documents To safeguard the resident. To identify causes and prevent future errors. The residents receiving incorrect medication should be observed as needed. Facility Medication Administration General Guidelines, undated, documents Medications are administered as prescribed. Five Rights- right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. Facility Administration Procedures for all Medications, undated, documents To administer medications in a safe and effective manner. Prior to removing the medication package/container from the cart/drawer check the order, identify the resident before administering medication (photo, verbal confirmation of last name, monitor for side effects or adverse reactions immediately after administration and throughout each shift. Facility Physician-Family Notification- Change in Condition, revised [DATE], documents To ensure that medical care problems are communicated in a timely, efficient, and effective manner. A significant change in the resident's physical, mental, or psychosocial status (deterioration in health, mental, or psychosocial status). Facility Registered Nurse/RN and Licensed Practical Nurse/LPN job description, dated [DATE], documents The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities. Complete and file required record keeping forms/charts upon the resident's admission, transfer and/or discharge. Prepare and administer medications as ordered by the physician. Facility Resident Rights for People in Long-term Care Facilities, revised ,d+[DATE], documents You have the right to safety and good care. Facility Resident Rights Federal, undated, documents These resident rights policies and procedures ensure that each resident admitted to the facility: has a right to dignified existence. Each resident has the right to be free from Psychoactive drug administration not required to treat the resident's medical symptoms. Online American College of Physicians, Internal Medicine [CONDITION(S)], copyright 2015, documents Acute [CONDITION(S)] may be referred to as toxic. Toxic [CONDITION(S)] describes acute mental status alteration due to medications, or toxic chemicals. Causes of acute toxic [CONDITION(S)] include acute organ failure such as hepatic (liver) and renal (kidney), dehydration, medications. Facility Daily Assignment Sheet, dated [DATE], documents V5 staff RN/Registered nurse on day shift (6am-6pm) and V7 Agency LPN/Licensed Practical Nurse for 6pm-6am. 1. R1's local hospital note, dated [DATE] by V24 (R1's MD/Medical Doctor ED/Emergency Department) documents (R1) has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . States he is trying to quit drinking and stopped drinking 1.5 days ago. R1's EHR (electronic health record) documents R1 was admitted to the nursing home on [DATE], from ,d+[DATE]-[DATE] in the hospital, and [DATE] at the facility. R1's EHR from the facility documents the following: Diagnoses- Fatty Liver, Unspecified [CONDITION(S)], Anxiety, ETOH withdrawal, [CONDITION(S)]/Benign Prostate Hypertrophy, [CONDITION(S)], [CONDITION(S)], Metabolic [CONDITION(S)], Alcohol dependence, and elevated liver enzymes. R1's hospital After Visit Summary/AVS from a local hospital, dated ,d+[DATE]-[DATE], documents the following: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's head cat scan at local hospital, dated [DATE], documents No acute intracranial abnormality. R1 was admitted to the facility on [DATE] and already had admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Facility Incident Report reported to (state agency), dated [DATE], documents the following: On [DATE] at 4:54pm, (R1) with the diagnoses of 'Toxic [CONDITION(S)], psychoses not due to known physiological condition, anxiety, alcohol dependence with withdrawal, and fatty liver' received hospital updates for resident due to inpatient status. Upon reviewing hospital updates it was noted there are medications that are on his EMAR (Electronic Medication Administration Record) that are not his medications. Incorrect orders were entered into the residents EMAR. On [DATE], (V7) Agency LPN/Licensed Practical Nurse was asked if she could recall the events of the night of [DATE]. (V7) stated she was looking at (R1's) chart, two residents were trying to exit seek, staff were conducting a 'code pink', grabbed (R2's) medication orders to enter them into (online charting system). (V7) stated 'I did not mean to enter the wrong orders into (R1's) chart. It was crazy that night. I should have double checked I was on the correct person before I continued entering orders. I am horribly sorry for the medication error'. R1's EHR Order Recap Report from the facility, dated ,d+[DATE]-[DATE], documents the following: Order date [DATE] and [DATE] documents I have reviewed and concur with the plan of care, allergies, and diagnoses signed by V20 (R1's Medical Doctor/MD) at the nursing home. R1's [DATE] nursing home orders include the following: Occupational Therapy/OT evaluation and treatment; Tylenol 325mg/milligrams (2 tablets) po/by mouth every four hours as needed for pain; [MEDICATION(S)] 500mg chew take two tablets by mouth every eight hours as needed for heartburn; [MEDICATION(S)] 500mg by mouth two times daily/BID; [MEDICATION(S)] 1mg po daily; I-Vite 1 tablet by mouth daily; [MEDICATION(S)] 1 tablet by mouth three times daily/TID for five days (R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's [DATE] orders include the following: Physical Therapy/PT and Speech Therapy/ST evaluation and treatment as indicated; full code; and PT evaluation and treatment for ,d+[DATE] weeks for four weeks. R1's facility note, dated [DATE], documents (R1) arrived around 5:45pm, full code, regular diet, alert, 1 assist with gait belt and cares, and incontinent at times. R1's facility note, dated [DATE], documents (R1) admitted on [DATE] for skilled nursing/rehab after being hospitalized for alcohol abuse and withdrawal. Previously lived independently in his home prior to his hospitalization . R1's activities interview, dated [DATE], documents R1 was able to answer all the questions on his daily preferences and activity preferences. R1's [DATE] medical record has orders that include the following (These were R2's orders): [MEDICATION(S)] 2mg po BID for depression (no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's [DATE] orders include the following: OT and treatment for one week; and ST evaluation and treatment for ,d+[DATE] weeks for four weeks. The wrong orders entered into R1's nursing home medical record for [MEDICATION(S)] and [MEDICATION(S)] resulted in R1 having multiple bowel movements a day including incontinent episodes. R1's Bowel and Bladder Elimination record for bowel continence, dated [DATE] documents one incontinent and one continent, [DATE] one incontinent, and [DATE] one incontinent bowel episode. R1's [DATE] nursing home orders include the following: regular texture and consistency diet. R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Send to ER/emergency room for evaluation. R1's facility note, dated [DATE] at 7:31pm and 9:57pm, documents (R1) sent to hospital because of changes in his level of consciousness for the past two days. (R1) has been sleeping throughout this shift. R1's communication form and progress note from the facility, dated [DATE], documents (R1's) situation has gotten worse, mental status is unresponsiveness, functional status needs more assistance, and neurological is decreased level of consciousness. R1's EHR documents R1 went to the hospital on [DATE], and on [DATE] returned to the facility. R1's local hospital notes, dated [DATE]-[DATE], documents R1 was ordered and received the above medications during his hospital stay which were R2's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's local hospital notes, dated [DATE] by V26 (Registered Nurse Emergency Department), documents (R1) has no history of dementia but alcoholism. (R1) will not answer any questions, just screams when touched, and unable to obtain oral temp. R1's local hospital notes, dated [DATE] by V27 (Resident Doctor ED) documents I spoke to the nurse at (facility) and learned the following: (R1) was sent in to the hospital for increased lethargy and altered mental status. On [DATE] (V1) R1's PA at the nursing home evaluated (R1) and thought he had decreased level of consciousness. Other nursing notes in the last two days mentioned acute concerns from the patient and stable vital signs. They mentioned he has decreased appetite and thirst. (R1's) communication and mental status limits this history. Physical exam: Brown crusting in oropharynx, very dry. Neurological: Challenges communicating. Patient is arousable. History was somewhat difficult to obtain from the patient due to difficult to understand speech. Patient was initially somnolent but was arousable and able to answer questions. R1's local hospital notes, dated [DATE] by V28 (R1's case manager) documents (V9/R1's POA/power of attorney) is aware of (R1's) condition worsening. R1's local hospital notes, dated [DATE], documents (R1) has been very drowsy for most of the day. R1's note from a local hospital, dated ,d+[DATE]-[DATE], documents R1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . This form further documents discharge medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility's notes, dated [DATE], documents Resident arrived around 4pm by stretcher, lethargic, catheter draining dark urine, pureed diet, (mechanical) lift for transfers, incontinent of bowel, and medication concerns. R1's [DATE] facility orders include the following: I-Vite 1 tablet by mouth daily; pureed texture and regular consistency diet; may crush acceptable medications; (name of hospice) to evaluate and treat stat (immediately) for 'Toxic [CONDITION(S)]' ([CONDITION(S)] cause by toxic exposure); Do Not Resuscitate/DNR; and admit to hospice. R1's facility notes, dated [DATE] at 2:20am, documents (R1) is totally dependent on one to two staff for activities of daily living including bed mobility, transfers, eating, toileting, dressing, personal hygiene, walking, and bathing. R1's facility notes, dated [DATE] at 2:33am, documents Resident open eyes to name only. Nonverbal at this time. (Catheter) patent and intact, draining dark amber urine. R1's nursing home notes, dated [DATE] at 5:33am, documents Resident expired on [DATE] at 4:55am. R1's [DATE] facility orders include the following: Discontinue medications due to death. On [DATE] at 9:40am, R1 was in bed, fidgeting/twitching, mouth open, does not respond to my voice, does not respond to his name, eyes closed, and catheter on his right side draining amber urine. R1 is white (Caucasian), tall, and skinny. 2. R2's EHR documents R2 was admitted to the facility on [DATE] R2 was admitted on [DATE] and R2's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's hospital record from a local hospital, dated ,d+[DATE]-[DATE], documents the following: Why you were in the hospital: [CONDITION(S)] disorder, [CONDITION(S)] type; [CONDITION(S)]; hypertension, and peripheral [CONDITION(S)]. Discharge medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Discharge Summary from (local) hospital, dated [DATE], documents (R2's) medical history significant for [CONDITION(S)] AIDS currently on retroviral therapy, and [CONDITION(S)] disorder/[CONDITION(S)] disorder. R2's nursing home orders include the following order dates: [MEDICATION(S)] Acid 500mg po BID ordered [DATE] (R2's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's [MEDICATION(S)] 1mg po TID PRN was never entered into R2's nursing home medication orders. The wrong orders entered into R2's nursing home medical record for [MEDICATION(S)] resulted in R2 having multiple bowel movements a day including incontinent episodes. R2's Bowel and Bladder Elimination record for bowel continence, dated [DATE], documents: ,d+[DATE]/ continent; [DATE] continent, [DATE] continent; [DATE] continent; [DATE] two continent; [DATE] one continent and two incontinent; [DATE] two incontinent; [DATE] one incontinent; [DATE] one continent and one incontinent; [DATE] one incontinent; [DATE] two continent; and [DATE] two incontinent bowel episodes On [DATE] at 10:50am, R2 was in a manual wheelchair, stated he got the facility in August, unsure if he has had his picture taken, alert, and states he goes outside and around the facility in his wheelchair during the day. R2 is overweight/obese, and in a manual wheelchair. On [DATE] at 9:30am, V3 and V4 (both CNAs/Certified Nurse Assistants) stated (R1) could walk but he was unsteady and would use the wheelchair to self-propel himself thru the home. Before his last hospitalization he could feed himself but now we have to feed him, and he won't open his eyes. Before this last hospitalization we had to remind him to eat at times, but he fed himself. Now he can't walk or move, and he needs a (brand name of chair) or hi-back wheelchair for safety. (R1) came back yesterday ([DATE]) about four or five pm and he is not the same. He was at the hospital about two weeks. On [DATE] at 10:00am, V5 (staff Registered Nurse/RN) stated I work 6am to 6pm and have worked with (R1) frequently. Before (R1) went to the hospital last, he could stand, sit in the wheelchair, walk the hallways, and answer yes/no questions. Verified R1 had a catheter now. He (R1) was new, came from the hospital and was here five or six days before sent to the hospital again after getting the wrong medications. He (R1) fell a few times when he first got here, he was a person that needed a one to one and now he is not a one to one. He (R1) wore briefs before. (R1) got (R2's) medications for a few days. I was here working when (R2) was admitted ([DATE]) and performed his admission assessment, he came at change of shift, and the oncoming nurse (V7 agency LPN/Licensed Practical Nurse) put the orders in the computer. (V7) was to put the orders in for (R2) under (R2's) name but put (R2's) orders in the computer under (R1's) name. The orders go directly to pharmacy then for them to fill. When we put the orders in the computer, they are the orders for the residents. I gave (V7) R2's admission summary paperwork because I was the off going nurse and (V7) was the oncoming nurse and we help one another out. I probably should have stayed and finished the orders so we would not have had this happen. I was off work the next day ([DATE]) and came back on [DATE] and asked staff/management where (R2's) medications were in (online charting system). I spoke to V6 (Interim DON/Director of Nursing) about (R2's) missing medications in (online charting system). I knew (R2) had medications he needed to be given because I had started his admission on [DATE] and (V7) was to put the orders in. I left (R2's) admission packet on the desk for (V7) to complete. I did (R2's) admission assessment and the other nurse was supposed to put the orders in for (R2). We have a re-admit checklist we go by with each admission. On [DATE] at 9:30am, V4 (CNA) stated Our prior (V11) DON used to keep (R1) in his office as a one-to-one observation, or he would walk with (R1). We also used to keep (R1) up at the desk for close observation. He would go in his wheelchair and push himself around, he was really unsteady when walking. He did fall a few times when he was first here which is why he was on increased observation. He would ask for alcohol and clothes. He would disrobe himself at times. He did use the toilet but wore briefs(incontinent briefs) because he did have incontinent episodes. On [DATE] at 12:00pm, V6 (DON) stated I have been DON for about three weeks until someone gets hired. The nurse (V7 LPN) must have been under (R1's online charting system) access and put (R2's) orders under (R1's) name. (V7) did come to me to find where (R2's) orders were and we could not find any orders in (online charting system) for (R2). (R2) needed his medications so we re-entered them under (R2's) name so he could get his medications. [DATE] (R2's) medication orders were put in. When we put orders in (online charting system) it goes to pharmacy automatically so they can fill his medication orders. When (R1) was sent to the hospital on [DATE] (local hospital) called and wanted to know why (R1) was on medications without a diagnosis. I and V2 (RN Regional Nurse Consultant/RNC) both emailed and discovered (R2) was on the same medications so we called the hospital and gave the full list of medications (R1) should not have been on. (R1) is still on some medications from the hospital that he should not be on from his admission. I did call the doctor for clarification and verified these medications he was not on at admission ([DATE]). On [DATE] at 12:20pm, V2 stated (V11) was the DON until [DATE], and V8 (R1's PAC) was here [DATE]. (R1) was more lethargic and he was sent to the hospital per (V8's) request. The nurses did not identify (R1) had a change in condition until (V8) pointed it out. (V8) asked the nurse about [MEDICATION(S)] which was held ([DATE]) but (V8) felt (R1) was more lethargic from the week prior and sent him to the hospital. I was notified the hospital had concerns about the medications (R1) was on. I looked at (online) orders and (admission sheet) and compared and saw [CONDITION(S)] medications (R1) was not on but was on now. It was determined (R1) got (R2's) medications and orders were put in under (R1's) name. V7 (Agency LPN) stated she put (R2's) orders in (online charting) under (R1) and did not check to make sure she was in the correct chart which should have been (R2's). (R1) got (R2's) medications for five days (,d+[DATE]-[DATE]). New admission pictures should be in (online charting) within 24 hours of admit. Activities or social services take the residents pictures for admission. On [DATE] at 1:07pm, V7 (Agency LPN) stated I worked [DATE] and I took care of (R1) and (R2). (R2) was a new admit. I was going to put his orders in (online charting system) but at the time of putting in orders we had a 'code pink' (elopement) so I had to go take care of that. I was looking at (R1's) chart prior to the 'code pink', and when I got back from the 'code pink' I just entered (R2's) orders without verifying I was on (R2's) chart. I entered (R2's) orders on (R1's) record on accident. I had a lot of distractions going on, call lights, 'code pink', and residents very busy and demanding. I should have double checked the resident's records. I worked the next night and couldn't find the orders for (R2) I had entered. I know I put them in. I asked V6 (Interim DON) (who was the wound nurse at the time) to help me find them, she and I both looked, she notified V2 (RN RNC/Regional Nurse Consultant), (V11) prior DON (who was the DON at the time). It was a mistake, there were no pictures in the online record for (R1) or (R2). I work for agency. On [DATE] at 4:48pm, V9 (R1's brother and POA) stated My wife was there to take (R1) to smoke and then a few days later he was trying to die. He could carry on a conversation and hold his cigarette and smoke by himself before he got the wrong medications. Now he can't open his eyes and he is not eating. My wife noticed from his (local hospital) my chart he was on the wrong medications. My wife is at the nursing home now talking with them about putting (R1) on hospice. He was getting [CONDITION(S)] medications, blood pressure and (diuretic) medications at the nursing home which he has never taken before. He has low blood pressure so he shouldn't be getting a medication for high blood pressure. On [DATE] we thought he was going to die. On [DATE] at 5:48pm, V10 (R1's family) stated (R1) was in the hospital for alcohol abuse. When he was at the nursing home he recognized me, ate, and I took him outside to smoke cigarettes. He was sent to the hospital on [DATE] and he was out of his mind. He could not communicate or talk, he did not recognize me, and he moaned and groaned. He did have a fall at the nursing home where he had a cat scan done which was negative. I checked his (local hospital) my chart and noticed he was on [MEDICATION(S)], (diuretic), high blood pressure, and [CONDITION(S)] medications. I told the hospital he did not have [CONDITION(S)] and they called the nursing home. He got the wrong medications at the nursing home and hospital. He was at the nursing home for alcohol abuse and rehab. He lived in a two-story home by himself which he took care of prior to going to the nursing home. He was at the nursing home to dry out from alcohol, get some rehab since his legs were weak, and when he was physically able to, he was to go back home to live independently as he did before. On [DATE] at 9:,d+[DATE]:37am, V8 (PA-C/Physician Assistant Certified) for R1 at the facility stated (R1) has been lethargic, the last day I saw him for his evaluation ([DATE]) he was very lethargic and I sent him in for an evaluation at the hospital. [MEDICATION(S)] can cause falls, drowsiness, restlessness, and somnolence. [MEDICATION(S)] can sedate, affect ambulation, and increase your risk for falls. If you are on [MEDICATION(S)] double your usually dose it can sedate, absolutely, we give 2mg IV in ER for status epilepticus so 2.5mg of [MEDICATION(S)] TID would 'snow' (R1) for sure. [MEDICATION(S)] ([MEDICATION(S)]) can cause d

Based on observation, interview and record review, the facility failed to educate staff and agency nurses that there was [MEDICATION(S)] in their building, facility failed to educate staff and agency nurses on the medication dispensary machine, failed to give staff and agency nurses access codes and privileges to the medication dispensary machine, and failed to provide training to V6 (Interim DON/Director of Nursing). Further non-compliance could result in serious health issues and possibly death. These failures resulted in an immediate jeopardy. While the immediacy was removed on 9/20/22, the facility remains out of compliance at a severity Level II as the facility continues to in-service all staff and agency nurses on where the [MEDICATION(S)] is stored in the facility, educate, and provide access to all their nurses on their emergency medications and medication dispensary machine locations and contents, and in-service the DON on her job duties. Findings include: The Immediate Jeopardy was identified 9/16/22 at 1:28 PM. The Immediate Jeopardy began on 9/15/22 at 2:15am when the facility failed to educate and provide access to all their nurses on their emergency medications and medication dispensary machine locations and contents. V1 (Administrator) was notified of the Immediate Jeopardy on 9/20/22 at 12:58 PM. Facility Emergency Pharmacy and Emergency Kits, undated, documents Emergency pharmacy service is available on a 24-hour basis. The pharmacy supplies emergency medications in limited quantities in portable, sealed containers. Facility provided a document titled Department Head List, undated, documenting V6 (Interim DON/Director of Nursing/Wound Nurse). Facility First Dose Machine and (Brand name), revised 8/2015, documents The supply of medications will be referred to as the Automated Dispensing System (ADS) unit. The purpose of the emergency supply of medication is to ensure the residents will have access to pharmaceutical care in a manner that provides for the appropriate initiation and continuation of drug therapy. Each person who accesses the ADS will have his/her own individual electronic, biometric, or other authentication credentials permitting access. Access to the First Dose System will be limited to designated licensed nurses. The DON/Director of Nursing will be responsible for developing and maintaining a confidential system for assigning access codes and system privileges for nursing personnel. This information will be maintained current and easily retrievable by the DON. Facility pharmacy emergency kit content, emailed 9/20/22, documents [MEDICATION(S)] 0.4mg (milligram)/ml (milliliter) vial (1ml) ([MEDICATION(S)]) with a quantity of one. Facility pharmacy ADS medication list inventory, emailed 9/20/22, documents [MEDICATION(S)] 0.4mg (milligram)/ml (milliliter) vial (1ml) ([MEDICATION(S)]) with a quantity of two. On 9/20/22 at 12:48 PM, V22 (Pharmacy Director) emailed the following: Number (how many) of Emergency Kits provided to (nursing home) 3 kits (locations: Hillside unit, Riverside Unit, and one additional to be kept in nursing office for emergency), and Number (how many) (electronic medication dispensary) at (facility) 1 machine. Facility Director of Nursing/DON, dated 5/2/17, documents The primary purpose of the DON is to plan, organize, develop and direct the overall operation of our Nursing Department to ensure that the highest degree of quality care is maintained at all times. Make written and oral reports concerning the operation of the nursing services department. Develops methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care. Must have as a minimum three years of experience as a supervisor. Must be knowledgeable of nursing and medical practices and procedures as well as laws regulations and guidelines that pertain to nursing care facilities. Facility Registered Nurse/RN and Licensed Practical Nurse/LPN job description, dated 5/2/17, documents The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities. Complete and file required record keeping forms/charts upon the resident's admission, transfer and/or discharge. Prepare and administer medications as ordered by the physician. V1 (Administrator in training/AIT) provided the training for all the facility nurses and the training did not include any training for the medication dispensary machine, or convenience/emergency medication location/use, machine access, or contents. The provided training for V6 (Interim DON/Wound Nurse) did not include any training for the DON position. Facility was unable to provide any training the facility has done/provided to the agency nurses. Facility was unable to provide any DON training for V6 (Interim DON RN/Registered Nurse.) Facility staffing sheet dated 9/14/22-9/15/22 6pm-6am documents V15 (agency) and V16 (staff LPNs/Licensed Practical Nurses) were the only nurses scheduled to work in the building. R9's electronic nurses notes, dated 9/15/22 at 2:15am by V15 (agency LPN) documents the following: Writer alerted by staff that (R9) noted lying on his back on the floor at the foot of the bed. Resident lethargic, unable to respond to commands, pupils blown, respirations shallow with periods of apnea noted, and pulse weak/thready. 911 called. [MEDICATION(S)] 4mg (milligrams) administered in each nostril and resident began to respond appropriately to commands. He denies taking anything. (R9) taken to (hospital) for evaluation and treatment. All responsible parties notified. On 9/16/22 at 9:50am, V1 (AIT) stated the facility uses (Name of pharmacy) for their medications and they manage the medication dispensary machine. I started Tues 9/6/22 as the AIT. I do not know what agency gets for education. I do not know what we do for educating them to our building. We use a lot of agency nurses, have a lot of new staff, and only have a few of our own staff. Yes, there will be time when only agency may be in the building because we have three nurses on from 6am-6pm, and two nurses from 6pm-6am. On 9/16/22 at 10:30am, V6 (Interim DON/RN) stated We suspected drug overdose for (R9). (R9) went unresponsive. (R9) is normally alert and oriented to person and place. He possibly got drugs from the people he hangs out with on the patio. (R9) went unresponsive, was given [MEDICATION(S)] x2 doses at the nursing home, and then sent to the hospital. I am only helping out in the DON position until they hire someone. On 9/16/22 at 11:46am, V16 (staff LPN) stated I am new, started [DATE]th or 8th, 2022. I worked 9/14-9/15/22 from 6pm-6am. I am not entirely sure what happened with (R9). (R9) goes to bed late sometimes, goes to [CONDITION(S)] Tues, Thurs, and Saturdays, is a bilateral [CONDITION(S)], and self -propels his wheelchair around the nursing home. At midnight or 1am (9/15/22) the CNAs reported to me that (R9) was on the floor and unresponsive. I checked his vital signs, he was breathing shallow, he was asked what he took but did not respond, [MEDICATION(S)] was given x2 (V15), two doses in his nose, he started to arouse by taking deeper breaths and move his arms and head, I called 911 and sent him to the hospital. I am new and did not know we had [MEDICATION(S)] in the building. I am not sure where (V15) got the [MEDICATION(S)]. On 9/16/22 at 12pm, V15 (agency LPN) stated One of the CNAs found (R9) unresponsive, staff got me, pupils were dilated, periods of apnea, the nursing home has had some issues with people overdosing on drugs, and residents know which residents get drugs and go their rooms for drugs. I went to my car and got [MEDICATION(S)] that I had on hand. I gave [MEDICATION(S)] x2 in his nose, they are single use doses, so I had to use two to get him to respond. I have seen overdoses before, so I had [MEDICATION(S)] on hand and figured that is what he did, and after the [MEDICATION(S)] he started to come to. I don't know if [MEDICATION(S)] is in the building. I think the emergency medications are located in the ADS, and agency nurses do not have access to the ADS. I work on Hillside hall. On 9/16/22 at 11:30am, V17 (staff LPN) was in the building on Riverside hall and stated I work PRN/as needed and can't get in the (ADS). The C-Box/Narcotic box are located on Hillside in the (ADS). I do not have [MEDICATION(S)] on my cart, the convenience-box has [MEDICATION(S)] but it is in the (ADS) and I can't get into the (ADS) system. At that same time surveyor and nurse walked to Hillside hallway and entered the medication room where the ADS system was located. In the med room V17 was unable to find the [MEDICATION(S)] or access the ADS system where she believed the [MEDICATION(S)] was located. Upon surveyor looking around the med room with V17, surveyor found two sealed red medication tackle boxes from pharmacy located on a shelving unit on the bottom shelf. At that same time, V17 verified there were two separate red medication boxes that were secured with zip ties from the pharmacy, and one dose of [MEDICATION(S)] was in each medication box for a total of two doses in the building. V17 stated I did not know [MEDICATION(S)] was in the red box. At that same time, the nurse (V5 RN) working on Hillside was on lunch break and V6 (Interim RN DON/wound nurse) was out of the building on lunch. No ADON is employed or listed on the management roster. No other nurses not on break were working in the building besides V17 and V18. On 9/16/22 at 12pm, V18 (agency RN) was in the building on Riverside and stated I can't get in the (ADS). I am an agency nurse. the [MEDICATION(S)] is located in the (ADS), and I don't have [MEDICATION(S)] on my medication cart. On 9/19/22 at 11:57am, V6 (Interim DON/RN) stated I don't want the DON position permanently. I have worked as DON before at another place, but it has been a long time ago. I will have worked here two years in October 2022. I became the interim DON about four weeks ago. When (V11) prior DON left (8/19/22) we had no DON for one week and then I went into the Interim DON position (about 8/29/22). I did not get training as DON here, and when things come up, I call corporate nurse for guidance. I was supposed to be Interim DON for two weeks only. They hired a DON to start on 9/26/22 but I heard they are not coming now. I work during the week Monday thru Friday where I do the wound treatments first thing in the morning on Monday and Tuesday only, and then the rest of the day I spend as Interim DON. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.All nurses educated on e-box. Location, content usage of contents. Education completed by V2 RN/RNC (Registered Nurse/Regional Nurse Consultant). 9/20/22. 2.Corporate DON assigned to facility V30 (RN/DON). 9/20/22 3.All nurses educated by V2 (RN/RNC) on pharmacy electronic medication dispensary machines- locations, gaining access and content. 9/20/22. 4.List of all emergency medications available in e-box as well as medication dispensary machine posted in all med rooms. 9/20/22. 5.All agency staff will be educated on location/content of emergency medications prior to next shift worked by V30 (RN/DON). 9/20/22. 6.All nurses will receive education on medication dispensary machine and convenient box during orientation. Education completed by V30 (RN/DON). Initiated 9/20/22 on going. 7. All nurses educated on location of [MEDICATION(S)] and how and when to administer [MEDICATION(S)]. Education completed by V2 (RN/RNC). Initiated 9/20/22 will be completed by 9/21/22. 8.New orders for [MEDICATION(S)] for all residents who currently receive narcotics or have a history or substance abuse. 9/20/22. 9. V20 (MD/Medical director) notified of incident on 9/20/22 and reviewed the facility's immediate action plan. V20 was in agreement with immediate action plan. 9/20/22. 10. QAPI review with V20 (MD/Medical Director) to review emergency medication boxes including content/administration/location. 9/20/22.

Based on observation, interview, and record review the facility failed to enter admission medication orders under the correct resident, and failed to give the correct medications to the correct resident per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 having a change in condition with a hospital stay from 8/23-9/12/22, and R2 missing three days of required medications from 8/18-8/20/22. Findings include: Facility Medication Errors and Adverse Drug Reaction, revised 1/4/2, documents To safeguard the resident. To identify causes and prevent future errors. To provide guidelines for reporting and recording. All medication, treatment errors, and drug reactions must be reported promptly. The residents receiving incorrect medication should be observed as needed. Facility Registered Nurse/RN and Licensed Practical Nurse/LPN job description, dated 5/2/17, documents The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities. Complete and file required record keeping forms/charts upon the resident's admission, transfer and/or discharge. Prepare and administer medications as ordered by the physician. Facility Medication Administration General Guidelines, undated, documents Medications are administered as prescribed. Five Rights- right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. Facility Resident Rights Federal, undated, documents These resident rights policies and procedures ensure that each resident admitted to the facility: has a right to dignified existence. Each resident has the right to be free from Psychoactive drug administration not required to treat the resident's medical symptoms. Facility Resident Rights for People in Long-term Care Facilities, revised 3/2011, documents You have the right to safety and good care. 1. R2's EHR/electronic health record documents R2 was admitted to the facility on [DATE] and R2's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's hospital AVS/after visit summary from a local hospital, dated 7/21-8/17/22, documents the following: Why you were in the hospital: [CONDITION(S)] disorder, [CONDITION(S)] type; [CONDITION(S)]; hypertension, and peripheral [CONDITION(S)]. R2's AVS Discharge Medications, dated 7/21-8/17/22, documents the following significant medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's nursing home orders include the following order dates: [MEDICATION(S)] 1mg po BID ordered 8/20/22; [MEDICATION(S)] 50-200-25mg po daily ordered 8/20/22 (R2's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's [MEDICATION(S)] 1mg po TID PRN was never entered into R2's nursing home medication orders. 2. R1's was admitted to the nursing home on 8/15/22 and already had admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Facility Incident Report reported to (state agency), dated 9/3/22, documents the following: On 8/29/22 at 4:54pm, (R1) with the diagnoses of 'Toxic [CONDITION(S)], psychoses not due to known physiological condition, anxiety, alcohol dependence with withdrawal, and fatty liver' received hospital updates for resident due to inpatient status. Upon reviewing hospital updates it was noted there are medications that are on his EMAR (Electronic Medication Administration Record) that are not his medications. Incorrect orders were entered into the residents EMAR. On 8/30/22, V7 (Agency LPN/Licensed Practical Nurse) was asked if she could recall the events of the night of 8/17/22. (V7) stated she was looking at (R1's) chart, two residents were trying to exit seek, staff were conducting a 'code pink', grabbed (R2's) medication orders to enter them into (online charting system). (V7) stated 'I did not mean to enter the wrong orders into (R1's) chart. It was crazy that night. I should have double checked I was on the correct person before I continued entering orders. I am horribly sorry for the medication error'. R1's 8/17/22 nursing home medical record has orders that include the following (These were R2's orders): [MEDICATION(S)] 2mg po BID for depression (no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's EHR documents R1 was admitted to the facility on [DATE], 8/22-9/12/22 in the hospital, and 9/12/22 at the facility. On 9/13/22 at 12:00pm, V6 (DON) stated The nurse (V7 LPN) must have been under (R1's online charting system) access and put (R2's) orders under (R1's) name. 8/20/22 (R2's) medication orders were put in, but he was admitted on [DATE]. When we put orders in (online charting system) it goes to pharmacy automatically so they can fill his medication orders. When (R1) was sent to the hospital on 8/22/22 (local hospital) called and wanted to know why (R1) was on medications without a diagnosis. On 9/15/22 at 9:20-9:37am, V8 (PA-C/Physician Assistant Certified) for R1 at the facility stated (R1) has been lethargic, the last day I saw him for his evaluation (8/22/22) he was very lethargic and I sent him in for an evaluation at the hospital. [MEDICATION(S)] can cause falls, drowsiness, restlessness, and somnolence. [MEDICATION(S)] can sedate, affect ambulation, and increase your risk for falls. If you are on [MEDICATION(S)] double your usually dose it can sedate, absolutely, we give 2mg IV in ER for status epilepticus so 2.5mg of [MEDICATION(S)] TID would 'snow' (R1) for sure. [MEDICATION(S)] ([MEDICATION(S)]) can cause drowsiness, sedation, dizziness and nervousness; [MEDICATION(S)] can cause liver and kidney problems; [MEDICATION(S)] can cause [CONDITION(S)] and sedation; [MEDICATION(S)] can dehydrate, cause confusion and kidney failure; [MEDICATION(S)] can cause diarrhea and dehydration, [MEDICATION(S)] can cause lightheadedness and [CONDITION(S)]; and [MEDICATION(S)] can cause drowsiness, loss of appetite, and cause severe liver failure. Taking medications that are not prescribed for you can harm your kidneys, liver can be harmed especially since most medications are metabolized in the liver and (R1's) liver was already compromised due to his alcoholism, so these medications can cause increased liver toxicity. When (R1) was sent to the hospital for falls he had a CT scan, and it showed no subarachnoid or [CONDITION(S)], so I don't believe that was the cause of his change in condition on 8/22/22. On 9/16/22 at 1:55pm, V13 (R1's attending physician at local hospital) from 8/24-8/29/22 stated If (R1) got medications for the heart, blood pressure, [CONDITION(S)] disease, [CONDITION(S)], an antipsychotic, and a diuretic medication, and he was not prior prescribed these medications they could contribute to his [CONDITION(S)]. If (R1) was dehydrated with these medications on board it could contribute to his co-morbidities and overall decline in health. This was very unfortunate for him.

Based on observation, interview, and record review the facility failed to ensure all facility doors were secured and properly alarmed; failed to provide adequate supervision; failed to ensure staff were able to properly identify R1; and failed to thoroughly investigate multiple elopements for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in R1, a cognitively moderately impaired resident with the diagnoses of [CONDITION(S)], Convulsions, [CONDITION(S)] with Seizures, [CONDITION(S)], and Lack of Coordination eloping from the facility on two different occasions, and on the last occasion on 6-11-22 around 10:00 PM being found 3.1 miles from the facility, after dark, scared, and wandering aimlessly on a four-lane highway that runs parallel to the Illinois River. Facility staff were unaware of R1 missing for over an hour and a half before an off-duty staff member (V3 Certified Nursing Assistant) found R1 walking in the road. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 6-17-22 to have started on 4-22-22 when the facility failed to provide adequate supervision and implement elopement interventions after R1 was found outside of the facility and unattended by staff. This resulted in R 1 eloping from the facility a second time on 6-11-22 around 10:00 PM being found 3.1 miles from the facility, after dark, scared, and wandering aimlessly on a four-lane highway that runs parallel to the Illinois River. On 6-17-22 at 6:10 PM V1 (Administrator) and V2 (MDS Coordinator) were notified of the Immediate Jeopardy. While the immediacy was removed on 6-22-22, the facility remains out of compliance at a severity Level II as the facility continues to provide in-servicing to all staff, including new hires, on R1's and all other residents at risk for elopement updated care plan interventions, provide in-servicing of all staff and new hires on identifying residents at risk for elopement and how to provide adequate supervision for those at risk to prevent elopement, along with the facility's elopement drill (code pink), assess all residents quarterly who wander/exit seek and with any changes in behavior, and check door alarms every shift. The facility's IDT (Inter-Disciplinary Team) will review elopement risk assessment quarterly and reviewed elopement plans of action monthly. Findings include: The facility's Code Pin Missing Resident/Elopement policy dated 11-15-18 documents, Should an employee discover that a resident is missing from the facility, he or she should: a) Immediately report the missing resident to the charge nurse or nursing supervisor. b) Review the physician order to determine if the resident is out on an authorized leave or pass. c) Alert staff by announcing Code Pink over the paging system. d) Inform staff of the name of the missing resident and visualized picture of resident if available. g) The Administrator and Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident. The following steps should occur: 1. A nurse should notify the attending physician. 2. Notify the resident's legal representative/responsible party. 7. Complete incident report and notify the state agency according to reporting guidelines. 8. Documents appropriate notations in the medical record. Upon return to the facility: 2. Contact the attending physician and report finding and condition of the resident. Follow physician's order. Notify the legal guardian/responsible party. 7. Complete the incident report, indicating when resident returned and condition of resident. 8. Make appropriate entries into the resident's medical record. 10. Complete a new Elopement Risk Assessment and updated plan of care as appropriate. 11. Review and update Elopement Risk binder. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with the diagnoses of Type II Diabetes Mellitus, Unspecified Convulsions, Lack of Coordination, Symptomatic [CONDITION(S)] and Epileptic Syndromes with Complex Partial Seizures, [CONDITION(S)], Psychoactive Substance Abuse. Tobacco Use, and Personal History of [CONDITION(S)]. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively moderately impaired and requires supervision with walking and locomotion on and off the unit. R1's Current Elopement Care Plan documents R1 is to have 15-minute checks. R1's Progress Notes dated 6-12-22 at 4:55 AM and signed by V11 (Registered Nurse/RN) document, (R1) attempted to exit the facility at around 9:40 PM (On 6-11-22). CNA (V3) on hillside noticed the attempt and brought back (R1) safely to the facility. (R1) is not on 15-minute checks. (R1) stayed in room and slept through the night. R1's Medical Record dated 4-1-22 through 6-12-22 does not include any documentation of R1's responsible party or R1's Physician (V13) being notified of R1's elopements in April 2022 and on 6-11-22. R1's Community Survival Skills Assessments dated 9-4-21 and 5-27-22 document, (R1) is sufficiently alert, orientated, and knowledgeable allowing him to be considered for independent outside pass privileges: No. Recommendations: The resident does not appear to be capable of unsupervised outside pass privileges at this time. R1's Elopement/Unauthorized Leave Risk Reviews dated 12-27-21, 2-23-22, and 6-14-22 document, Is there a history of wandering/elopement and/or does (R1) verbalized a strong desire to leave? Yes. Reported/documented episodes of elopement and/or attempts to elope? Yes. Signs of compromised decisional capacity and substantially impaired judgement and/or physical status limitation that would place (R1) at risk in the community: Yes. Elopement Risk Decision: At risk to elope and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. On 6-17-22 at 3:30 PM from 4:00 PM R1 was outside in the designated smoking area. At 4:05 PM R1 walked back into the facility and down the hallway. No staff checked on R1's location during this time. On 6-17-22 at 4:10 PM R1 was standing in the hallway across from the nurse's station on the hallway that R1 resides on. R1 was confused to time and place. When asked where R1 was and what date it was R1 replied, I am in Decatur Illinois. Hell, no I don't know what day it is! On 6-17-22 at 4:50 PM this surveyor and V4 (Maintenance Director) opened the exit gait (where R1 exited on 6-11-22) to the smoking area patio that is located off of the dining room of the facility. When (V4) opened the gait, the alarm did not alert/function. On 6-17-22 at 3:45 PM V9 (Social Service Director/SSD) stated, (R1) is very confused and always wants to go to Decatur Illinois. (R1) is not safe to be in the community unattended and is assessed as a high risk for elopement. I was told on Monday that a CNA found (R1) up the road at night around 10:00 PM clear up by the bridge (three miles away). I am unsure if he exited that back or front door. We decided to put (R1) on 15-minute visual checks. On 6-17-22 at 3:50 PM V10 (LPN/Licensed Practical Nurse) stated, (R1) is confused at times. I did not know (R1) left the building unattended. I am not aware of (R1) being on 15-minute checks. On 6-17-22 at 3:55 PM V5 (CNA) stated, I was working the night (R1) left the building (6-11-22). I was orientating with another CNA and did not know (R1). I am one of the CNA's taking care of (R1) tonight. I do not think that (R1) is no. any checks or supervision. On 6-17-22 at 4:00 PM V6 (LPN) stated, I am new to this job. I do not even know who (R1) is. On 6-17-22 at 4:05 PM V7 (Agency CNA) stated, I have only worked here for two nights. I am (R1's) CNA tonight. I know (R1) is on 15-minute checks, but I have not had time to do them because we have been taking care of other residents. On 6-17-22 at 4:25 PM V12 (Staffing Coordinator) stated, I know a few months ago (R1) got out of the facility unattended. (R1) has always been an elopement risk and tries to get out a lot. (R1) needs to be watched extra close. On 6-17-22 at 4:25 PM V2 (MDS/Minimum Data Set Coordinator) stated, (R1) has always been an elopement risk and should not leave the facility unattended. (R1) has tried to leave the facility before. On Monday (6-13-22) I read the twenty-four-hour report and saw that (R1) had left the building over the weekend. That was the first time I had found out that (R1) left the building. All department heads were in a meeting on Monday (6-13-22) including (V1 and V9/Social Service Director). In the meeting we all discussed that (R1) had left the building unattended on Saturday (6-11-22) and (R1) was found down [NAME] Road by (chain restaurant). (V1) knew (R1) was found by (chain restaurant). We decided to initiate 15-minute visual checks for the staff to monitor (R1). On 6-17-22 at 4:35 PM V11 (Registered Nurse) stated, On (6-11-22) I worked 6 PM to 6 AM. I was (R1's) nurse that night. The last time I had saw (R1) that night was sometime around 8:30 PM in the hallway. Next thing I knew a little after 10:00 PM (V3 CNA) had called the facility and said that she had found (R1) way up the road. I was not sure of (R1's) exact location of where he was found but was told it was over a mile away. I called (V1) and told (V1) that (R1) was found over a mile away, unattended by staff. I also told (V1) that no alarms were sounding. Staff did not know (R1) was missing from the facility. (V1) did not give me any instructions on what to do. I brought (R1) back into the building. (R1) is not capable of making his own decisions and should not leave the building without someone with him. (R1) has left the building unattended before. I do not know the exact day. I assessed (R1) when he got back and he was not hurt, just a little scared. On 6-17-22 at 4:55 PM V4 (Maintenance Director) stated, Someone must have de-activated the alarm to the smoking area gait. The alarm on the door that goes into the facility's dining room should alarm when the gait is opened. It should have worked. I check one or two door alarms to the facility exits weekly. I am not aware of the facility having an official policy on how often the door alarms are to be checked. (V1) did not tell me to check the door alarm to the smoking area until Monday (6-13-22) when I found that (V1) had saw on the cameras that (R1) had left the facility through that gait. On 6-17-22 at 4:40 PM V1 (Administrator) stated, I have not completed an investigation of (R1) leaving the facility or reported it to IDPH (Illinois Department of Public Health). I was told (R1) was just found in the parking lot of the facility. I was not told (R1) was found farther down the road until Monday (6-13-22). I have not confirmed that with the staff that supposedly found (R1). I am trying to figure out everything now. Everything I have found out so far is written down in chicken scratches. The elopement book resident pictures definitely need updated. You cannot even see (R1's) face in the book. I watched the cameras and (R1) left the building through the back smoking area gait on 6-11-22 at 8:38 PM. No staff were present when (R1) left the building. The nurse (V11) told me that no door alarms had went off the night (R1) left the building. (R1) is supposed to have 15-minute visual checks since Monday 6-13-22. I am not aware of (R1) ever leaving the premises before. On 6-17-22 at 5:00 PM V3 (CNA) stated, I have worked for four years at this facility. On Saturday (6-11-22) I left the facility at 9:53 PM. I was driving down the road after dark and saw a male who resembled (R1) walking in the road. It was dark and I could not tell if it was (R1) for sure. I called the facility and asked the staff if (R1) was there. No one could find (R1). (V11/RN) said no alarms were going off in the facility. I immediately stopped my car in the middle of [NAME] Road and went up to the man. It was (R1). (R1) was scared. There were no sidewalks beside the road, so (R1) had walked in the road and had gotten clear up to (Chain Restaurant located 3.1 miles from the facility). I could not believe (R1) had walked that far away from the building. The Illinois River is right beside that road. It would have been awful if (R1) would have drowned in the river. I took him back to the facility and made sure (R1) went back into the facility. I also notified (R1's) nurse (V11/RN). About two months ago in April around 4:00 PM, I was outside of the building smoking and saw (R1) walking around the next-door apartment buildings located off of the facility's grounds. (R1) was lost and the staff did not know (R1) was lost. I brought (R1) into the facility and immediately told (V1) that I had found (R1) at wandering outside, lost, and at the next-door apartments. (V1) did not ask me anything about finding (R1) down the road on 6-11-22 until yesterday. I told (V1) that I found (R1) in the road and down by (Chain Restaurant). I have never heard the alarm work or go off that is on the door going to the designated smoking area R1's Progress Notes/Medical Record dated 1-1-22 through 5-31-22 do not include any documentation of V3 finding R1 off of the facility grounds, unattended by staff, and at the apartments next door to the facility. The Google Maps website dated 6-17-22 documents the (chain restaurant) that R1 was found in front of on 6-11-22 was located 3.1 miles away from the facility at 3503 North-East [NAME] Street Peoria, Illinois . On 6-17-22 at 4:20 PM a binder containing picture and descriptions of residents at risk for elopement was located on the desk of the front lobby. R1's picture in this book was printed on a piece of 8.5 inch by 11-inch white paper. The picture was completely covered in black ink and R1's picture was unrecognizable. On 6-21-22 at 12:40 PM V16 (Chief Clinical Officer) stated, (R1's) medical record does not document anything about when (R1) left the facility premises in April (2022). After investigating (R1's) elopement in April the best date that we could come up with of when (R1) was found off the premises was 4-22-22. On 4-22-22 was the day that all staff (V3, V12, and V28/Human Resources) had worked together and were aware of (R1) leaving the premises and being found at the apartments next door. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. An investigation of both of R1's elopements was completed on 6-20-22 by V1 and sent to IDPH (Illinois Department of Public Health). 2. V1 was educated by V14 (Regional Nurse Consultant) on 6-20-22 on proper investigation of elopements and the facility's policy and procedure for reporting and completing an investigation. 3. All staff were educated by V1, V2, and V14 on all residents who are at risk for elopement along with their elopement interventions, behavioral sign and symptoms of elopement including wandering between units, hanging out around facility exits and verbalizing serious intent to leave facility. Staff were also educated on who has the physical ability to leave facility, who engages in this behavior, and who responds poorly to staff re-direction when wandering. Education of all staff took place between 6-17-22 and 6-22-22. 4. All staff were educated by V1, V2, and V14 on R1's elopement interventions as follows: increased monitoring/safety checks (1:1 or 15-minute checks), check door alarms for functioning and report any problems, keep resident occupied and in critical areas, notify administrator immediately if resident is exhibiting exit seeking behaviors or actual elopement of the resident occurs. Education of all staff took place between 6-17-22 and 6-22-22. 5. All staff were educated by V1, V2, and V14 to ensure all residents are provided adequate supervision to prevent any further elopements, and to ensure all staff were aware of who R1 and all other elopement risk residents are. Staff were also educated on identifying residents at risk for elopement and the policy and procedure for reporting to leadership to ensure proper interventions/care plans are initiated timely. Education of all staff took place between 6-17-22 and 6-22-22. 6. R1's care plan was updated with new elopement interventions. 7. All resident's elopement risk assessments were updated to ensure accurate assessment, and to implement interventions as needed along with updating those resident's care plans. 8. The Elopement Risk binder was updated with current, identifiable pictures of all residents who are elopement risks. 9. All exit doors were checked every shift for alarm function and to ensure alarms were in working order. All alarms were in working order and alarmed when checked by this surveyor on 6-21-22. 10. Code Pink (Elopement-missing person) drills were performed on 6-13-2022, and 6-18-22 through 6-22-22 by V1, V3, and V14. 11. V13 (Medical Director) was notified of R1's elopement on 6-12-2022 in the facility by V1. On 6-21-22 between 8:40 AM and 1:00 PM V24 (Physical Therapy Assistant), V25 (LPN), V26 (LPN), and V27 (CNA) stated that they had not received any in-services or training on who R1 is and what R1's elopement interventions are, residents who are at high risk for elopement and what their interventions are, notifying V1 on any resident who make elopement attempts, or providing increased supervision and activities to residents who are high elopement risks. V24, V25, V26, and V27 also confirmed that they had not received a Code Pink drill. Based on observation, interview, and record reviews conducted on 6-22-22 the facility completed all measures of the facility's abatement plan including the in-servicing regarding elopement procedures and Code Pink drills to all staff. Removal plan completion date 6-22-22.

Based on observation, interview, and record review, the facility failed to ensure two staff assisted with a mechanical lift transfer (R5). The facility failed provide supervision to prevent falls (R6), investigate each fall to determine the root cause analysis, and implement appropriate interventions after a fall (R6), for two of three residents (R5, R6) reviewed for falls in the sample of seven. These failures resulted in R5 being dropped out of a mechanical lift sling onto the floor, fracturing R5's left humerus (bone between elbow and shoulder) that caused R5 pain and R6 falling while unsupervised in R6's room that resulted in R6 fracturing R6's right talus (bone in foot that forms part of the ankle joint). Findings include: The Facility's Fall Prevention Program dated 11/21/17, states 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. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. The Director of Nursing is responsible for monitoring the Fall Prevention Program. Residents who require assistance will not be left alone after being assisted to bathe, shower, or toilet. This policy is a guideline only. Each resident has his or her own set of circumstances which may require that this policy not be followed. The needs of each resident supersede this policy. The Facility's Transfers-Manual Gait Belt and Mechanical Lifts policy dated 1/19/18, states 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 Residents. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: Independent, 1-person transfer, 2-person transfer (ONLY when use of mechanical lift is not possible, sit to stand lift with 2 caregivers, and Mechanical lift with 2 care givers. Failure to comply with lifting guidelines may result in disciplinary action as deemed appropriate. 1. On 12/8/21 at 11:30 a.m., R5 was lying in bed with a sling on the left arm. R5 stated I have a broken arm because I was dropped. R5 stated (V10 Certified Nurse Aide/CNA) was transferring R5 from the wheelchair to bed and the next thing I knew I was on the floor. I was sent to the hospital, but I don't think I was admitted . My family and I declined surgery because of my age. I have been in terrible pain in my left arm and shoulder area. The nurses give me pain medications, but it just doesn't last long enough. R5's Minimum Data Set assessment dated [DATE] document R5 has severely impaired cognition. R5's Care Plan dated 11/16/21, documents R5 is total assist of two staff for transfers. R5's Fall Report dated 12/2/21 at 9:00 p.m., documents the following: R5 was being transferred to bed by V10 (Certified Nurse Aide) via full mechanical lift when a strap came loose by R5's left shoulder and R5 fell to the ground landing on R5's left side. V14 (Licensed Practical Nurse) assessed R5 and found R5 had pain and swelling at the left shoulder area. R5's Physician ordered an urgent X-ray which showed a humeral surgical neck fracture. R5's Shoulder X-Ray dated 12/2/21 at 4:18 a.m., states Acute mildly displaced fracture of the left proximal humeral surgical neck. R5's Emergency Department Physician Note dated 12/3/21 at 3:51 a.m., states (R5) complaining of left shoulder, elbow and wrist pain. R5's Final Report to the State Agency dated 12/9/21, documents (in addition to above fall report) (R5's) family refused any surgical intervention and (R5) was returned to the facility. (R5) is to wear a sling to left arm at all times and pain management is in place. Staff re-educated on full mechanical lift procedure and ensuring all straps of (mechanical lift) sling are secure prior to starting transfer. Facility (mechanical) lifts and slings were checked for any mechanical issues and safety (with no concerns identified). On 12/8/21 at 12:55 p.m., V14 (Licensed Practical Nurse) stated I was (R5's) nurse working 6 p.m. to 6 a.m. on 12/2/21 when V10 (Certified Nurse Aide) dropped (R5) out of the (mechanical lift). I was passing medications down the opposite end of the hall from (R5's) room when (V10) came to me and reported that (R5) had shoulder pain. I told her I would be headed to (R5) soon and to tell (R5) I would bring (R5) pain medicine. I asked (R5) what was going on. (R5) told me that (R5's) shoulder hurt and that (R5) had fallen. Then (V10) started telling me that (R5) fell on the floor because the (mechanical lift) sling fell off the loop/clip. I educated (V10) that all (mechanical lift) transfers are to be done with a minimum of two staff assist. V10's statement regarding R5's fall from the mechanical lift on 12/2/21 documents the following: V10 transferred R5 from the wheelchair to bed with a mechanical lift and no other staff assistance. R5's sling loop slipped off the hook and R5 fell to the ground with V10 trying to catch R5, V10 fell on top of R5. V10's statement does not document any further details. On 12/13/21 at 1:43 p.m., V10 stated (via telephone interview) that she could not give any details of R5's fall on 12/2/21 until her union told her it was okay to do so. On 12/9/21 at 11:12 a.m., V2 (Director of Nursing) stated V10 (CNA) did transfer R5 with a mechanical lift by herself when R5 fell from the mechanical lift on 12/2/21, and the facility policy is that all mechanical lift transfers require a minimum of two staff assist. On 12/14/21 at 10:37 a.m., V2 stated My investigation of (R5's fall on 12/2/21) documents that (V10) transferred (R5) by herself. (V10) was terminated (12/13/21). 2. On 12/8/21 at 12:40 p.m., R6 was propelling self in a wheelchair by using R6's feet, from R6's room to the dining room for lunch. R6's right leg/foot had a hard plastic boot in place. R6's Minimum Data Set assessment dated [DATE], documents R6 was admitted on [DATE], has moderately impaired cognition; requires extensive assistance with transfers; is unable to ambulate; uses a wheelchair; and R6 has an unsteady balance moving from seated to standing position and surface to surface transfer. R6's Care Plan dated 11/16/21, documents R6 is at high risk for falls related to deconditioning, gait/balance problems, incontinence, and being unaware of her safety needs. R6's Fall Report dated 11/5/21 at 11:55 a.m. documents the following: R6 had an unwitnessed fall in R6's bathroom. R6 stated R6 thought R6 could go to the bathroom by self and ended up on the floor. R6 had no injury. Immediate intervention was to educate R6 to use the call light and wait for help. R6's Fall IDT (Interdisciplinary Team) note dated 11/8/21 at 10:57 a.m., states The root cause of R6's fall (on 11/5/21) was transferring without assistance. New Intervention and care plan updated. (R6) receiving (Physical and Occupational) therapy. R6's Fall Report dated 11/12/21 at 2:15 p.m., documents the following: R6 had an unwitnessed fall in R6's room and was found sitting next to R6's bed. R6 stated R6 dropped R6's phone and leaned over to pick it up and fell forward out of the wheelchair. R6 did not have any injuries. A Reacher was provided to R6 and R6 was educated on its use and to use the call light for assistance. R6's Fall IDT note dated 11/15/21, states The root cause of fall (11/12/21 at 2:15 p.m.): Leaning too far forward in (wheelchair). Intervention and care plan updated: (R6) was given a Reacher to utilize for picking things up off the ground. R6's Fall Report dated 11/13/21 at 6:30 a.m., documents the following: R6 had an unwitnessed fall in R6's bathroom. R6 stated I couldn't wait for help to come, I did it myself. R6 had no injuries. New interventions: Laboratory orders received and encouraged (R6) to stay in supervised area when up in wheelchair. V20's (Certified Nurse Aide) statement on the fall report states I was getting (R6) up and I took (R6) to the bathroom (and) I went to get assistance with (R6's) transfer to the toilet. When I came back (R6) was on the floor in the bathroom face down. (R6) did not call for help. R6's fall IDT note dated 11/15/21, states Root cause of fall (11/13/21 at 6:30 a.m.): (R6) attempting to use bathroom and transfer without staff assistance. Intervention and care plan updated: Staff to offer toilet (every two) hours. On 12/14/21 at 11:57 am., V2 stated I must have missed (V20's) statement (on R6's Fall Report dated 11/13/21) because the intervention we put in place was not appropriate. V2 stated a more appropriate intervention would have been not to leave R6 alone in the bathroom. V2 stated R6 must be supervised because she is very confused and forgets that she is not independent. R6's Physician Note dated 11/17/21 at 3:26 p.m., documents R6 was seen by the physician who noted R6 had several falls attempting to self-transfer since admission. R6's physician stated R6's lab work was negative with a plan to Monitor (R6). R6's Fall Report dated 11/19/21 at 7:00 p.m., documents the following: R6 had an unwitnessed fall in R6's room. R6 was heard yelling from the room and R6 was found lying on floor, abdomen side down, near the dresser and wheelchair. R6 stated R6 was trying to reach for something, but R6's vision was poor, and misjudged the distance. R6 stated R6's ribs hurt and R6 did hit R6's head and it was also sore. R6 was sent to the hospital for evaluation. R6's Hospital X-Ray report dated 11/19/21 at 10:03 p.m., states Impression: Suspect acute Talar fracture. R6's Hospital Physician Note dated 11/19/21 at 11:21 p.m., states Clinical Impression: 1. Other fracture of right talus 2. Head contusion 3. Fall. R6's Nurses Note dated 11/20/21 at 8:32 a.m., states (R6) returned to the facility via (ambulance) stretcher. (R6) sent to the hospital on 11/19/29 related to a recent fall, rib pain, ankle pain. (R6's) diagnosis is fracture of right talus and head contusion. (R6) complaining of pain at this time, rating pain (at 7 out of 10 on the pain scale). R6's Fall Report dated 11/21/21 at 3:22 a.m., documents the following: R6 had an unwitnessed fall and was found lying on the floor in R6's room next to the bed. R6 reported R6 was sleeping in R6's bed when R6 suddenly rolled out of bed and landed on the floor. R6 had no injuries. On 12/14/21 at 10:37 a.m., V2 stated there is not a Fall IDT note or documented investigation with root cause analysis and updated interventions for R6's falls on 11/19/21 and 11/21/21 falls. V2 stated we missed them for some reason. R6's Fall Report dated 11/26/21 at 5:35 p.m., documents the following: R6 had an unwitnessed fall in R6's room. R6 was calling for help and was found lying on the left side, head near bed, legs toward door, oxygen off but right next to face. R6 had no injury. Immediate Intervention that (R6) will be the last one up and first one to bed around mealtime. R6's Fall IDT note dated 11/29/21, states The root cause of fall (11/26/21 at 5:35 p.m.): non-compliance with staying in dining room and went to room attempting to pick up something off the floor while in (wheelchair). Intervention and care plan updated: will be taken to dining room for meals close to mealtime as resident agrees to. R6's Fall Report dated 11/27/21 at 11:25 a.m., documents the following: R6 had a witnessed fall in her room. R6 was observed to be sitting on buttocks with back against the bed and legs extended forward. R6 stated I didn't fall. I just slid off the bed. There was no witness statement with this report. R6's Fall IDT note dated 11/29/21 at 10:12 a.m., states Root cause of fall (11/27/21 at 11:25 a.m.): (R6) had sock with no shoes on. Intervention and care plan updated: (R6) to have proper footwear on at all times when not lying in the bed. On 12/8/21 at 12:30 p.m., V18 (Licensed Practical Nurse) stated (R6) is usually not a problem with falls when R6 is in bed, it's usually when R6's in the wheelchair and reaching for things on the floor. We have given R6 a grabber to use due to R6's poor balance. We try to keep R6 in sight at all times unless R6's in bed but R6's quick and sometimes gets past us. V18 stated R6 did recently have a fall that resulted in a fracture (right Talar) and now is wearing a boot on R6's right foot. On 12/8/21 at 12:15 p.m., V17 (Certified Nurse Aide) states R6 is wearing a boot on the right foot due to a fracture received from falling. V17 stated R6 likes to pick things up off the floor. V17 states R6 is confused and doesn't remember that R6 has poor balance. V17 stated staff gave R6 a Reacher/grabber to use but R6 still will lean over and try to pick something up off the floor. On 12/9/21 at 11:13 a.m., V2 (Director of Nursing) stated R6 Likes to pick stuff up off the floor. We've given R6 a Reacher. R6 has poor balance. I've implemented a lot of interventions, but R6's still had quite a few falls. R6 is non-compliant and confused. R6 forgets that R6 needs help. R6 did have a fall that resulted in a Talar fracture. R6 had taken self back to R6's room and fell . I don't know what else I can do to keep R6 from falling.

Noncompliance resulted in two deficient practice statements. A. Based on observation, interview and record review the facility failed to educate one resident (R16) about R16's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to develop interventions to protect residents from potentially having unprotected sex with R16. These failures resulted in R16 having access to all 82 residents in the facility from admission (9/14/21) to 10/29/21. These failures resulted in an Immediate Jeopardy being called on 11/23/21 at 1:20pm. While the immediacy was removed on 11/24/21 at 12:05 the facility remains out of compliance at a Severity Level 2, as the facility continues to educate all staff on identifying and protecting residents with [CONDITION(S)] and the facility's Abuse policies and procedures. B. Based on interview and record review the facility failed to prevent physical abuse for one of eight residents (R1) reviewed for physical abuse in a sample of 32. A. Findings include: Facility Policy/Abuse prevention and Reporting dated/revised 1/22/19 documents: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. The facility will conduct an investigation and protect the resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. Resident Room Roster dated 10/29/21 indicates 82 residents in the facility. Current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Comprehensive assessment dated [DATE] indicates R16 is cognitively intact, understands, is understood and is independently mobile. Per (R16's guidelines) implemented on 10/29/21, R16 had access to the entire facility including the smoking area prior to 10/29/21. State Police Record dated 9/14/21 indicates R16 has criminal history of numerous prostitution convictions among other felony charges and convictions. State Criminal History Analysis Report/Identified Offender's Program dated 10/25/21 indicates the facility received the Report Via Facsimile on R16 on that date. Report indicates details whether and to what extent, the identified offender's criminal history necessitates the implementation of security measures within the long-term care facility. Report indicates R16 was identified as a Moderate Risk - the resident requires closer supervision and more frequent observation than standard or may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. Report indicates the following specific considerations were important in arriving at the above recommendations: (R16) criminal history consisted of convictions for possession of drug paraphernalia. prostitution - several times, criminal trespass to land, possession of stolen vehicles - twice, resisting arrest. Report indicates R16 is diagnosed with both psychiatric and medical disorders. Report further indicates Nursing facility staff stated that R16 has inappropriately fondled a male resident and made several attempts to obtain sexual favors for money with him. In view of R16's inappropriate behavior with a male resident and psychiatric condition, R16 is a moderate risk and supervision status is recommended. Written Statement by V11 (SSD) dated 11/3/21 is documented as follows: (R17) talked to me about (R16) asking for (R17) cigarettes and that (R16) offered (R17) 'sex for cigarettes' I discussed how to decline/stay away from (R16). (R17) expressed (R17) was comfortable telling (R16) 'No.' I provided suggestions to let staff know if (R16) did not stop asking when (R17) said 'No.' (R17) stated R17 was not afraid of (R16) or anyone else. Physician's Progress Note dated 10/27/21 at 1:17pm indicates Reason for visit - (R16) has allegedly been making sexual advances toward other residents. Discussed the importance of not making any sexual advances toward other residents. On 11/8/21 at 9:10 V22 (Licensed Practical Nurse/LPN) stated that she had been told by R17 that R17 had been offered sex by R16, but R17 said No. On 11/4/21 R30 reported R16 would beg for food and cigarettes and offer sex for money to other residents. On 11/4/21 V1(Interim Administrator) acknowledged V11 (SSD) was aware of R16 propositioning R17 sex for money. V1 stated that she asked other staff and they also were aware of R16's behavior. On 11/4/21 at 3:45pm R4 stated that R4 had been in a consensual relationship with R16, however R16 did not have boundaries and wanted more of a sexual relationship than R4 wanted. R4 stated that R16 did not understand No and would still persist in initiating sex. R4 stated that eventually R16 moved on to R15. No additional monitoring or supervision was identified, implemented or documented related to R16's Identified Offender status, Criminal History Analysis Report or medical diagnoses. No attempts by the facility to counsel, educate or address R16's [CONDITION(S)] or [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] No interventions to protect other residents were implemented. On 11/23/21 at 2:00pm V2 (Director of Nurses/DON) stated that the physician and V25 (previous Administrator) discussed R16's [CONDITION(S)] status with R16 and stated, I don't know if any of it is documented though. V2 stated that R16 was told to disclose R16's [CONDITION(S)]/[CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated that the facility was without a care plan coordinator for a while and Corporate was doing the care plans. On 11/23/21 at 2:05pm V1 (Administrator) stated that R16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was aware of R16's offering sex in exchange for money/cigarettes prior to 9/30/21, was aware of R16 fondling a male resident (R17) per State Criminal History Analysis Report dated 10/14/21 and aware of the consensual intimate relationship with R4 who stated that R16 wanted more of a sexual relationship than R4 wanted and that R16 didn't understand No. No additional monitoring or supervision was identified, implemented or documented related to R16's Identified Offender status, Criminal History Analysis Report or medical diagnoses. No attempts by the facility to counsel, educate or address R16's [CONDITION(S)] or [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Adequate interventions to protect other residents were not implemented until 10/29/21. The Immediate Jeopardy was identified to have begun on 9/14/21 when R16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 (Administrator) was notified of the Immediate Jeopardy on 11/23/21 at 1:20pm. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Corporate Nurse Consultant/RN (Registered Nurse) educated all staff during an in-service after initiation of an extended survey when substandard quality of care was identified. The education included how to recognize sexual abuse and the facility's protocol to prevent abuse of residents - training included indicators of abuse. This training will be ongoing. All staff hired after 11/5/21 or on leave/vacation were educated by the Human Resources Director on 11/5/21. 2. On 11/5/21 All interviewable residents were interviewed to ensure they were not experiencing sexual abuse. 3. On 10/28/21 R16 was placed into a private room. 4. On 10/29/21 R16 was placed on 15-minute checks when in R16's room and remains on 15-minute checks. R16 was also provided scheduled smoking times/location (which is separate from general smoking area) and staff accompany R16 when out of R16'sroom. 5. On 10/28/21 Social Service Director, Director of Nursing and V1 (Administrator) met with R16 and reviewed written guidelines of smoking times and monitoring by staff when out of R16's room. At that time, R16 signed a written agreement of the guidelines. 6. On 11/23/21 All residents identified as having the potential to be sexually active will be educated on safe sex practices. 7. On 10/27/21 Physician's Assistant educated R16 on R16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician Assistant also educated R16 on the importance of responsibly notifying any potential sexual partner of her [CONDITION(S)] status. 8. On 10/27/21 R16 was started on a new medication (antidepressant) to decrease R16's sexual urges. This was confirmed through review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9. R16 was found to be compliant with the anti-[CONDITION(S)] medication R16 has received for [CONDITION(S)] since admission. 10. Social Service Director will discuss and re-educate R16 on safe sex practices on a regular basis. 11. Random audits will be conducted by the Administrator /Designee regarding resident concerns, psychosocial needs. Results of audits will be reviewed by Quality Assurance committee for a minimum of 12 weeks. 12. On 11/24/21 R16 was interviewed and observed to be in a private room and visible from the nurses' station. R16 stated that staff do monitor R16 when out of R16's room. Social Service Director was observed accompanying R16 to a psychosocial group. B. Findings include: An Abuse Prevention and Reporting policy dated as revised 1/22/19 states, Residents have the right to be free of abuse, neglect, misappropriation of resident property, and exploitation. This policy also documents that, Abuse is the willful infliction of injury. R4's current care plan documents that R4 has, the potential to be physically aggressive (related to) Anger, Depression, Poor impulse control. R1's nurse's note dated 10/12/21 and entered by V2 (Director of Nurses) documents, (R1) was hit in head by peer. R1 and R4's abuse investigation dated as initial 10/12/21 and final dated 10/22/21 documents that on 10/12/21 physical abuse occurred when R4 made contact with (R1's) head with (R4's) hand, because R4 became upset with R1 because R1 was calling R4 names. This investigation documents R4 was sent to the emergency room following the incident to have a Psych evaluation. In addition, this investigation documents that when R4 was interviewed R4 stated, I got really upset and I lost my temper, I couldn't handle the names. (R1) poured coffee on the ground by my feet and I hit (R1). This report documents that the local police were notified and came to the facility following the incident. The investigation also documents the responding police officer declined to file an official report but instead instructed R1 and R4 to stay away from each other. The investigation concluded that physical abuse from R4 to R1 was unsubstantiated because R4 didn't intend to hurt R1. On 11/3/21 V1 (Administrator) verified that on 10/12/21 R4 purposefully hit R1 in the head after R4 thought R1 was calling R4 names. V1 stated she did not substantiate the incident as abuse because V1 thought R4 didn't really mean to harm R1.

Noncompliance resulted in two deficient practice statements. A. Based on interview and record review the facility failed to immediately investigate and protect residents from sexual propositions by R16 for money and cigarettes. Prior to 9/30/21, R17 reported to V11 (Social Service Director) that R16 had offered sex in exchange for money and/or cigarettes. This allegation was not investigated until 10/29/21 allowing R16 to remain unsupervised with full access to all residential areas within the facility. These failures have the potential to affect all 82 residents in the facility. These failures resulted in an Immediate Jeopardy being called on 11/23/21 at 1:20pm. While the immediacy was removed on 11/24/21 at 12:05pm the facility remains out of compliance at Severity Level 2, as the facility continues to educate all staff on identifying, reporting and protection of residents regarding sexual abuse. B. Based on interview and record review the facility failed to conduct a timely investigation of an allegation of sexual abuse by a staff member to a resident for 1of 5 residents (R14) reviewed for sexual abuse of a resident by a staff member. A. Findings include: Facility Policy/Abuse Prevention and Reporting dated/revised 1/22/19 documents: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. The facility will conduct an investigation and protect the resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. Internal Investigation: All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or documents. Resident Room Roster dated 10/29/21 indicates 82 residents in the facility. Current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Comprehensive assessment dated [DATE] indicates R16 is cognitively intact, understands, is understood and is independently mobile. Per (R16's guidelines) implemented on 10/29/21, R16 had access to the entire facility including the smoking area prior to 10/29/21. Current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Current Comprehensive Assessment indicates R17 is mildly cognitively impaired. Progress Note dated 9/30/21 indicates R17 was transferred to the hospital on that date and did not return to the facility. Criminal History Analysis Report dated 10/25/21 indicates R16 was identified as a Moderate Risk - the resident requires closer supervision and more frequent observation than standard or may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. Report indicates the following specific considerations were important in arriving at the above recommendations: (R16) criminal history consisted of convictions for possession of drug paraphernalia. prostitution - several times, criminal trespass to land, possession of stolen vehicles - twice, resisting arrest. Report indicates R16 is diagnosed with both psychiatric and medical disorders. Report further indicates Nursing facility staff stated that R16 has inappropriately fondled a male resident and made several attempts to obtain sexual favors for money with him. In view of R16's inappropriate behavior with a male resident and psychiatric condition, R16 is a moderate risk and supervision status is recommended. Written Statement by V11 (SSD) dated 11/3/21 is documented as follows: (R17) talked to me about (R16) asking for (R17) cigarettes and that (R16) offered (R17) 'sex for cigarettes' I discussed how to decline/stay away from (R16). (R17) expressed (R17) was comfortable telling (R16) 'No.' I provided suggestions to let staff know if (R16) did not stop asking when (R17) said 'No.' (R17) stated R17 was not afraid of (R16) or anyone else. On 11/4/21 at 9:45am V11 (SSD) stated that V26 (State Identified Offender Investigator) held a video meeting (on 9/30/21) regarding R16. V11 stated that V26 interviews her then interviews R16 and that no one else participated. V11 stated that she was aware of R16 propositioning other residents - sex for money and that's why she put it on R16's care plan (on 10/4/21). V11 stated - at that time - staff told her about R16's behavior and that it involved R17. V11 stated that she did report R16's behavior to V25 (previous Administrator). On 11/4/21 at 12:51pm V19 (State Identified Offender Program Manager) stated V26 (Investigator) conducted the interview with V11 (SSD) and R16 via a video meeting on 9/30/21. V19 stated no other staff contributed to the meeting or the information - V11 was the only staff who provided information to V19. V19 stated that V11 (SSD) provided information to V26 (Investigator) that R16 had displayed inappropriate sexual behavior, including propositioning male residents with sex in exchange for money since admit to the facility on [DATE]. V19 stated V26 requested the incident reports/investigations from the facility regarding R16's behavior and never received any reports or follow up from V11. On 11/8/21 at 9:30am V11 (SSD) stated that it was actually R17 who told her that R16 had been offering R17 sex for money and/or cigarettes - not staff. V11 acknowledged that she updated R17's care plan on 9/19/21 and it may have been due to R17's allegations regarding R16. V11 stated that she updated R16's care plan on 10/4/21 in response to R17's allegations and stated, I just didn't get around to it until then. V11 stated that R17 was mildly cognitively impaired and at increased risk of abuse. V11 stated that R17 may not have an official diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/8/21 at 9:10 V22 (Licensed Practical Nurse/LPN) stated that she had been told by R17 that R17 had been offered sex by R16, but R17 said No. On 11/4/21 R30 reported R16 would beg for food and cigarettes and offer sex for money to other residents. No investigation or prevention of further inappropriate sexual behavior by R16 was done until 10/29/21 involving R16 and R17. No documentation of any of the known behaviors by R16 were documented in R16 or R17's medical record. On 10/29/21 at 4:15pm V1 (Administrator) stated that she was unaware of R16's behaviors of propositioning residents with sex for money or any allegations made by R17 until (10/29/21) and that the allegations should have been investigated, including interventions to protect other residents - immediately. Current Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Current Comprehensive Assessment indicates R15 is cognitively intact and make needs known. Abuse Investigation Report dated 10/27/21 indicates on 10/27/21 at approximately 9am, R7 reported to a nurse that R7 saw another resident (R16) in bed with R7's roommate (R15). On 10/29/21 at 2:53pm R7 stated that R16 had been coming into their room for several days and (on 10/26/21) R16 was on top of R15 in R15's bed and R15 was saying No. R7 stated that R7 also saw R16 hold R15 up against the wall, trying to kiss R15. R7 stated that R7 is afraid of R16 and doesn't want R16 in their room. R7 stated that R7 reported the concerns to V16 (Therapist) the next day. On 11/3/21 at 3pm V16 (Therapist) stated that R7 told her early on 10/27/21 that R16 came into their room last night, got into R15's bed and was trying to hump R15 for 20 minutes while R15 was sleeping. V16 stated that R7 told her R7 was scared. V16 stated that she immediately told R15's nurse. V16 stated that later that day R16 was moved to the other side of the facility. No interview of V16 was found in the investigation report. On 11/4/21 at 4:15pm R30 stated R30 saw R15 and R16 out on the patio smoking. R30 stated that R30 told R16 to leave R15 alone because R16 would try to be inappropriate with R15 and wouldn't leave R15 alone. On 11/4/21 at 3:45pm R4 stated that R4 had been in a consensual relationship with R16, however R16 did not have boundaries and wanted more of a sexual relationship than R4 wanted. R4 stated that R16 did not understand No and would still persist in initiating sex. R4 stated that eventually R16 moved on to R15. On 11/4/21 at 10:00am V11 (SSD) stated that R15 is very private and very passive and doesn't want to get anyone into trouble. On 11/8/21 at 9:20am V22 (LPN) stated that in the evening of (10/26/21), she received a phone call from R2 who stated that R7 told R2 that R16 said or did something inappropriate with R15 (R7's roommate). V22 stated she interviewed both R15 and R16 at that time - and both denied anything inappropriate - however did not interview R7 who made the allegation and was a witness. V22 did not immediately report R7's concerns about R16 to a supervisor or to the administrator and an investigation was not initiated until the next day when R7 again reported R7's concerns to V16 (Therapist.) R16 was not moved to the other side of the building (away from R15) until the afternoon of 10/27/21. On 10/29/21 R15 refused to answer any and all questions regarding R16. At that time V1 (Interim Administrator) stated that R15 also refused to speak to the police and insisted nothing happened and that R16 was her friend. Current Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was identified to have begun on 9/30/21 when R16 was known to have propositioned R17 with sex for money and/or cigarettes, known to have a history of criminal prostitution and known to have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to initiate an investigation until 10/29/21. V1 (Administrator) was notified of the Immediate Jeopardy on 11/23/21 at 1:20pm. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Corporate Nurse Consultant/RN (Registered Nurse) educated all staff during an in-service after initiation of an extended survey when substandard quality of care was identified. The education included how to recognize sexual abuse and the facility's protocol to prevent abuse of residents - training included indicators of abuse. This training will be ongoing. All staff hired after 11/5/21 or on leave/vacation were educated by the Human Resources Director on 11/5/21. 2. On 11/5/21 All interviewable residents were interviewed to ensure they were not experiencing sexual abuse. 3. On 10/28/21 R16 was placed into a private room. 4. On 10/29/21 R16 was placed on 15-minute checks when in R16's room and remains on 15-minute checks. R16 was also provided scheduled smoking times/location (which is separate from general smoking area) and staff accompany R16 when out of R16's room. 5. On 10/28/21 Social Service Director, Director of Nursing and V1(Administrator) met with R16 and reviewed written guidelines of smoking times and monitoring by staff when out of R16's room. At that time, R16 signed a written agreement of the guidelines. 6. On 11/23/21 All residents identified as having the potential to be sexually active will be educated on safe sex practices. 7. On 10/27/21 Physician's Assistant educated R16 on R16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician Assistant also educated R16 on the importance of responsibly notifying any potential sexual partner of R16's [CONDITION(S)] status. 8. On 10/27/21 R16 was started on a new medication (antidepressant) to decrease R16's sexual urges. This was confirmed through review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9. R16 was found to be compliant with the anti-[CONDITION(S)] medication R16 has received for [CONDITION(S)] since admission. 10. Social Service Director will discuss and re-educate R16 on safe sex practices on a regular basis. 11. Random audits will be conducted by the Administrator /Designee regarding resident concerns, psychosocial needs. Results of audits will be reviewed by Quality Assurance committee for a minimum of 12 weeks. 12. On 11/24/21 R16 was interviewed and observed to be in a private room and visible from the nurses' station. R16 stated that staff do monitor R16 when out of R16's room. Social Service Director was observed accompanying R16 to a psychosocial group. 13. Any residents that R16 may have had intimate/sexual contact with will be offered confidential STD (Sexually Transmitted Disease) testing - initiated on 11/23/21. 14. Any resident that may have had intimate/sexual contact that are no longer residing at the facility will be notified they may have been exposed to [CONDITION(S)] and will be offered testing - initiated on 11/23/21. 15. All residents will have abuse/neglect risk screening completed. All high-risk residents will have care plan and interventions updated - initiated on 11/5/21. B) Findings include: On 11/8/21 at 9:15am V22 (LPN) stated that R14 has V23 (CNA's/Certified Nurse Assistant) personal cell phone number and stated (R14) shouldn't have his personal number. He's an employee here and (R14) is a resident. V22 stated V23 works the night shift, only works the other unit but comes over there to see R14 when he's working. V22 stated V23 goes into R14's room and shuts the door for like 15- 20 minutes. V22 stated They're not supposed to be friends. (V23) brings (R14) food and clothes. I told the previous administrator and (V2 DON) - they said they spoke with (V23) and he's not supposed to go into (R14's) room when he's at work, but he still does. I tell him he's not supposed to be in there, but he still does it anyway. This has been going on for about three months. V22 stated that she and R14 are related and has spoken to R14 about V23, and R14 stated that R14 loves V23 and wants to marry him. V22 stated that R14 denies any intimate or sexual relationship and she has never seen them in any type of sexual act But I think it's possible. V22 stated that V25 didn't always take things seriously and tended to blow things off. On 11/8/21 at 9:30am V2 stated that she was present during a meeting (a few months ago) that V25 had with V23 regarding R14. V2 stated that V23 was told if he wanted to visit R14 he couldn't visit while he was working and when not working has to be identified as any other visitor. V2 stated that she was unaware that V23 was still visiting R14 during working hours. V2 stated that V22 should have reported her concerns about V23 still visiting R14 during working hours. V2 stated If someone would've done an investigation, that would've been V25 - not me. No investigation into the allegations of a sexual relationship between V23 (CNA) and R14 was initiated until 10/29/21. Prevention of potential further abuse to R14 or other residents was not addressed until 10/29/21 when V23 was suspended. On 11/8/21 at 9:30am V1 (Administrator) stated that the previous administrator should have investigated and reported the allegations, including suspending V23 when the allegations were first reported.

Based on interview and record review the facility failed to provide behavioral health care and services and develop individualized interventions to address a residents behavior associated with [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), and Major Depressive Disorder for one of one resident (R1) reviewed for behavioral health services in a sample of 32. These failures resulted in R1 developing a sudden escalation in behaviors resulting in R1's emergent admission to the hospital. Findings include: R1's hospital physician's progress notes and recapitulation of R1's hospital stay dated 9/24/21, from prior to R1's admission to the facility and obtained from R1's medical records at the facility, documents that R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This progress note documents that R1 was homeless, not taking any medications for his psychiatric conditions, and would, Need to establish Psych care after discharge. This note further documents R1, Will only do what (R1) wants to do. Can be argumentative, and had Disorganized thought processes. A Facility assessment dated [DATE] documents that the facility can accept residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the Facility Assessment states under section 1.9 that the facility's process to make admission or continuing care decisions for persons that have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy, (Medical Supply Resources), Medical Director, Lab resources. The Administrator and D.O.N. (Director of Nurses) would discuss what services or resources were needed to care for patient and how to come about those resources when needed. Work with Medical Director and VP (Vice President) of Clinical Services to determine facility is capable to meet needs. Equipment and in-services completed prior to admission. This assessment indicates there are at least eight other residents who have Behavioral Health Needs residing in the facility. The assessment documents that specific care of practices provided for residents' Mental Health or Behavior includes, Contract with social work services group, manage medical conditions and medication related issues causing symptoms and behavior. Identify and implement interventions to help support anxiety, cognitive impairment, depression. Further, this assessment documents a list of employed staff, contracted staff, consultants, and ancillary staff providing care or services to residents which includes a Psychiatric Rehabilitation Service Coordinator, Behavior aides, a Psychologist, and a Psychiatrist. On 10/27/21 V6 (Admissions) stated he evaluated R1 prior to accepting R1 as a resident at the facility. V6 stated that he did not assess R1 in person but rather read through R1's hospital records to determine if the facility could meet R1's needs. V6 stated he is not a licensed nurse or medical practitioner. V6 stated that R1's hospital record did not show that R1 had any behaviors. V6 stated that R1 did have some mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 said that after R1 had to be emergently admitted to the hospital on 10/13/21 for behaviors, the facility did not want R1 to return unless R1 had a psych eval. R1's facility list of current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physicians' orders from the time of R1's admission until R1 was emergently discharged dated 10/1/21 to 10/13/21 do not indicate R1 was prescribed any psychiatric care, treatments or medications to treat R1's psychiatric/mood disorders. R1's orders do not include any referrals for psychiatric or mood order specialists to address R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Minimum Data Set (MDS) assessment dated [DATE] documents that R1 is cognitively intact but has verbal behavioral symptoms directed at others four to six days per week, displays behaviors that significantly disrupt care or living environment, rejects care four to six days per week. R1's MDS documents that R1 has a psychiatric history including psychotic symptoms and possible misinterpretation of events and the intentions of others, demonstrates denial and/or evasiveness: when discussing mental health issues, minimizing significance of mental health/psychosocial issues, has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS also documents that R1 has a history and presence of dysfunctional behavior such as provoking, aggressive, manipulative, derogatory, disrespectful, obnoxious, abhorrent, insensitive, attention-seeking, and/or otherwise abrasive, /inappropriate behavior including wandering into peer's rooms/ personal space. This MDS concludes based on these indicators that R1 is at high risk for a history of previous/recent mistreatment and/or potential future problems/ symptoms related to mistreatment. R1's care plan does not address R1's behavioral symptoms or R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's medical record does not include documentation that R1 was receiving behavior monitoring. R1's Social Services notes documented by V11 (Social Services Director) dated 10/13/21 document that R1 was transferred emergently to the hospital on that date after exhibiting the behaviors of yelling, cursing, threatening, name calling, and delusions. On 11/1/21 at 11:00a.m. V11 stated that R1 had been displaying delusions of grandeur and talking continuously to no one in particular using vulgar or inappropriate language since the time of R1's admission. V11 stated the only interventions that were put into place were, The usual things like redirection. V11 could not describe any interventions that were implemented to address R1's specific psychological and mood disorders or symptoms. V11 stated that on 10/13/21 R1 was yelling, cursing, and threatening. V11 stated that R1 was brought into her office to calm down. V11 stated that the more she talked to R1 the worse R1 became so she told R1 she would stop talking if that would help. V11 stated that when no attempt at calming R1 down worked. The facility called for an ambulance to take R1 to the hospital for a psychiatric evaluation. R1's facility progress notes from the time of admission to discharge date d 10/2/21 to 10/13/21 includes only two physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Neither physician's progress notes indicate that R1 has resident needs that cannot be met at the facility or that the facility does not offer services to meet R1's needs. These two physician's progress notes do not address R1's psychiatric/mood disorders or recommend any treatments. There are no progress notes indicating R1 was referred to or evaluated by a Psychiatrist, a Psychologist, a Psychiatric Rehabilitation Service Coordinator, or Behavior aides. R1's hospital Interdisciplinary Team (IDT) meeting notes dated 11/1/21 document that R1's principal problem is [CONDITION(S)] in Elderly. These same notes document that on 10/25/21, (R1) is ready for discharge; writer will contact (the Facility) as (R1) has not received an involuntary discharge from the facility. R1's IDT notes also document that on 10/28/21 R1 was still at the hospital because, Discharge is pending placement. These same notes document as of 11/1/21, (R1) will be discharged on ce placement is found. On 10/27/21 at 9:30a.m., at 12:55p.m. and on 11/1/21 at 1:00p.m. V1 stated that R1 cannot return to the facility until R1's mental status is stabilized. V1 stated that the facility does not have the services R1 needs in R1's current condition. V1 stated that V6 (Admissions) sends her regular updates on R1's condition while R1 is admitted to the hospital. V1 stated that based on R1's hospital notes, R1 is not suitable to come back to the facility despite R1's hospital IDT notes recommending discharge back to the facility. V1 also stated that no facility physician including the Medical Director, any other facility physician or physician's surrogate has reviewed R1's circumstances for being emergently admitted to the hospital, R1's hospital treatment plan, or current condition/ behaviors to determine whether R1 is appropriate to return to the facility. V1 verified that the Facility Assessment documents that the facility is supposed to be able to care for residents with behaviors and a psychiatric diagnosis, however, V1 stated she didn't accept R1 as a resident in the facility. V1 stated R1 was accepted by the previous Administrator who no longer works at the facility. V1 stated she does not know what type of behaviors R1 had prior to being admitted to the facility. On 11/1/21 at 9:11a.m. V13 (Hospital Social Worker) stated that R1 was involuntarily admitted to the hospital on 10/13/21 because of behavioral problems R1 had on that date. V13 stated that R1 was evaluated by psychiatric specialists who prescribed psychoactive medications and interventions to treat and address R1's symptoms after R1 was admitted to the hospital. V13 stated that R1's behaviors are now in stable condition and R1 is ready for discharge back to the facility, however, the facility is refusing to take R1 back.

Based on interview, and record review, the facility failed to ensure a Physician ordered laboratory value was obtained in a timely manner for one of three residents (R4) reviewed for laboratory values in the sample of nine. This failure resulted in R4 being hospitalized with the [DIAGNOSES REDACTED]. Findings include: The facility's Laboratory Services Agreement, dated 1/31/20, documents, Provider Services: STAT (Urgent life threatening) services will be completed within 4-6 hours period of time. The agreement also documents that the STAT turn around time is 4-6 hours, from the time of the initial call to results reporting back to the facility. On 11/24/20 at 11:25 a.m., V9 (R4's Family) stated, I tried calling (R4) from 9:50 a.m. to 2:15 p.m. on 11/12/20. She normally talks to me every morning, so it was weird that she didn't answer her phone. I called the facility at 2:27 p.m. and the nurse said (R4) was napping, which she doesn't normally do at all. At 5:00 pm, I was finally able to speak to (R4), and I couldn't even understand her. I spoke with (V13, Licensed Practical Nurse-LPN), and she said (R4) seemed normal. At 7:55 p.m. on Thursday (11/12/20), (V13) called me, and said she did notice something different and would contact the doctor. On 11/13/20, I called at 12:00 p.m. and spoke with (V13), and she said (R4) seemed back to normal. At 12:49 p.m., I was on the phone with (R4). She still didn't seem right, and she wasn't making any sense. While I was on the phone with (R4), the staff were feeding (R4). This was a red flag because (R4) doesn't need help with eating. I kept calling the facility waiting to hear what (R4)'s lab results were. At 4:00 p.m., I called, still no labs. At 8:30 pm, I called and still no labs. I woke up to three missed calls at 6:50 a.m (on 11/14/20). I called the facility at 8:00 am and they said my Mom had been sent to the ER (emergency room ) because she wasn't able to respond properly and was having trouble eating. Then, she was admitted [MEDICAL CONDITION], and Pneumonia. R4's Nurses' notes, dated 11/13/20 at 1:21 p.m., document, (R4)'s family stated that (R4) is not sounding like herself while on the phone. (R4) does have history of [MEDICAL CONDITION] and UTI (Urinary Tract Infection) and, per her family, this has been her behavior prior to these occurrences. (V8, Physician's Assistant) notified and order obtained for STAT BMP (Basic Metabolic Panel). R4's Physician order, dated 11/13/20 at 1:25 p.m., documents a new order for a STAT BMP for R4's Altered mental status. R4's Current Medical record has no documentation of the results of R4's STAT BMP that was ordered on [DATE]. R4's Transfer to Hospital Summary, dated 11/14/20 at 7:44 a.m., documents, (R4) was transferred to hospital at 7:30 a.m. per doctor. (R4) has increasing intermediate altered mental status, and decrease in ADLs (Activities of Daily Living), as well as shivering of the lips. R4's Hospital History and Physical, dated 11/14/20, documents, Chief Complaint: (R4) presents with weakness. (R4) was noted to have mild confusion on 11/13/20 along with generalized weakness and was sent to ER for further evaluation as there was no relieving factors. In the ER, (R4) was found to have oxygen saturations of 88% at rest. She was placed on oxygen with improvement of oxygen saturations. (R4) also found to have acute [MEDICAL CONDITION]. Chest x-ray showed pneumonia (R4) is [MEDICAL CONDITION] requirements with leukocytosis of 20,000 and heart rate in the 90's. The History and Physical also documents, Assessment/Plan: Left pneumonia, Acute [MEDICAL CONDITIONS], and acute metabolic [MEDICAL CONDITION]. On 11/23/20 at 3:50 p.m., V3 (Assistant Director of Nursing) stated, I spoke with (R4)'s family that day (11/12/20) I notified (V8) after talking with the family and he ordered a STAT BMP. It varies a lot on the lab's STAT response time. It could be anywhere from 30 minutes to a few hours. I left that day at around 3:30 p.m. and the lab still had not came to the facility. On 11/24/20 at 10:00 a.m., V13 stated that the lab company came out to draw R4's labs after 9:00 p.m V13 also stated, I called that morning for the results before I got off my shift. The labs said that (R4)'s labs needed redrawn. (R4) had a change of condition for me. (R4) had altered mental status, she was needing more help with her ADLs, for instance she couldn't feed herself breakfast that morning, and her lips were shivering. I notified the doctor that (R4)'s labs needed redrawn and that she had a change of condition, and the doctor ordered to have her sent to the emergency room instead of waiting for the lab to come back and redraw the labs. On 11/24/20 at 9:15 a.m., V14 (Contracted Laboratory) stated, On 11/13/20 we received a STAT lab order at 2:33 pm for (R4). We got to the facility at 9:17 pm to perform the blood draw. (R4) was a hard stick for our phlebotomist. So the facility nurse scheduled for the labs to be drawn the next day. Our STAT turn around is normally 4-6 hours, and we did not do that with this order. On 11/23/20 at 4 pm, V8 stated, If I order a STAT order I expect it do be done immediately, just as if it was in a hospital. I want STAT labs in order to figure out what is causing the altered mental status, and try to treat it before sending them to the emergency room .

Based on interview and record review, the facility failed to follow a physician's order and follow interventions to prevent the development of an unstageable pressure ulcer for two of three resident (R1, R3) reviewed for pressure ulcers in a sample of three. This failure resulted in R1 developing an unstageable pressure ulcer on R1's right ischium, requiring surgical excisional debridement. Findings include: The facility's Quick Reference Guideline for Wound Care, dated 2016, documents that an unstageable pressure ulcer is full thickness tissue loss, covered by slough (yellow, tan, gray, green or brown), and/or eschar (tan, brown or black) in the wound bed. This form also documents that the true depth cannot be determined until slough and/or eschar are removed to expose the base of the wound. The facility's Wound Care Policy, revised 2010, documents to initial the treatment administration record to reflect the treatment as completed. This form also documents that the following information should be recorded in the resident's medical record: the type of wound care given, with the date and time, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, if the resident refused the treatment and why. 1. R1's admission Minimum Data Set, dated dated [DATE], documents in Section M-Skin Conditions that R1 is at risk for developing pressure ulcers, but does not have any pressure ulcers documented. R1's Head to Toe Skin Assessment, dated 11/30/17, documents that R1's skin is intact. R1's Braden Scale, Pressure Ulcer Risk Worksheet, dated 12/2/17 documents that R1 is a moderate risk for pressure ulcers. R1's TAR, (Treatment Administration Record), dated November 1 through November 30, 2017, documents that R1 is to have a preventative moisture skin barrier cream applied three times a day, once on each shift. R1's TAR shows that R1's treatment was completed 15 out of 90 times for the month of November, 2017. R1's Progress Notes, dated 12/2/17, documents that an open area was observed on R1's right buttocks. R1's Wound Care Specialist Initial Evaluation, dated 12/4/17, documents that R1 has a stage two pressure ulcer on R1's right ischium, measuring 1.2cm (Centimeters) by 1.5cm by 0.1cm. This same form documents that the wound is consistent with a pressure injury. V6, Wound Care Specialist, ordered an occlusive medicated dressing to be changed three times a week. R1's Wound Care Specialist Evaluation, dated 12/11/17, documents that R1's right ischium wound is an unstageable necrosis, measuring 2.0cm by 1.5cm by unable to determine depth. This form documents that a surgical excisional debridement was performed. R1's TAR, dated 12/4/17 through 12/11/17, documents that R1's medicated dressing to R1's right ischium is to be changed every two day. There is no documentation that R1's wound care was completed as ordered, from 12/4/17 through 12/11/17. From 12/11/17 through 12/31/17, R1's wound care was not completed six times. On 1/31/18 at 10:54am, V5, R1's Primary Care Physician, stated that all Physician orders are to be followed as ordered. V5 stated that if wound care orders are not completed as ordered, it will cause a new or worsening pressure ulcer. 2. R3's Minimum Data Set, dated dated [DATE], documents that R3 is at risk for developing pressure ulcers. This same form documents that R3 has a stage three/four pressure ulcer measuring 0.7cm by 2.0cm by 1.5cm. R3's Wound Care Specialist Evaluation,dated 1/8/18, documents that R3 has a stage four pressure ulcer on R3's left hip. This same form documents to pack the wound with [MEDICATION NAME] and cover with a dry dressing daily. R3's TAR, dated 1/1/18 through 1/31/18, documents to pack R3's stage four pressure ulcer wound on R3's left hip with [MEDICATION NAME] packing gauze and cover with a dry dressing two times a day and as needed. This form does not have any documentation that R3's treatment was not completed 15 times. On 1/31/18 at 10:10am, V2, Director of Nursing, stated that if there are no initials on the TAR then the treatment is considered not completed. V2 verified that V2 could not find any documentation anywhere in R1 or R3's chart proving that the treatments were completed as ordered, for the dates the treatments were not initialed as completed. On 1/31/18 at 12:30pm, V6, Wound Care Specialist, stated that I expect all treatment orders to be completed as ordered, failure to do so could lead to the deterioration of the wound. V6 stated that R3's wound care has to be completed as ordered, due to R3's comorbidities and the increase risk for infection. On 1/31/18 at 1:15pm, V4, Wound Care Nurse, verified that wound care is to be signed out as completed. V4 stated that V4 could not find any documentation as to why R1 and R4's treatments were not completed on the dates in question.

Based on observation, record review, and interview, the facility failed to provide dressings as ordered by the physician and failed to identify and obtain treatment for [REDACTED]. R1's coccyx pressure sore increased in size and new Stage I and Stage II pressure sores developed. R2's pressure sore on the left buttocks increased in size. Findings include: 1. R1's admission sheet dated 04/16/10 documents R1's [DIAGNOSES REDACTED]. R1's Minimum (MDS) data set [DATE] documents R1 is alert and oriented with no behaviors. R1's care plan dated 01/02/11 documents R1 requires: two care givers to assist with moving R1 in his wheelchair, a mechanical lift and staff assistance to move from one surface to another, two care givers to assist R1 with his activities of daily living and with R1's positioning in bed. R1's Admission Nursing assessment dated [DATE] indicates R1 had no pressure sores. Physician orders [REDACTED]. On R1's 03/02/11 Weekly Skin Report, the Stage II pressure sore that had developed on 08/25/10 on the coccyx shows increased measurements of 3.0 centimeters (cm) long x 1.3 wide x 2.0 cm deep. The pressure sore is "beefy red in color with moderate amount of serous drainage." A new treatment was ordered by R1's physician on 03/02/11 for Silver [MEDICATION NAME] to the macerated edges of the wound and to pack the wound with Purachol AG then cover the wound with gauze and change the dressing every other day. A new physician order, dated 03/09/11, documents a new order to "impregnated gauze with Santyl Sprinkle with [MEDICATION NAME] powder and pack the impregnated gauze into the wound, cover the wound with gauze, and change the dressing daily or when necessary." A Cat Scan was ordered for the non-healing ulcer. On 03/31/11 at 10:a.m., E3 (Wound/Treatment Nurse) stated that on the 03/09/11 weekly treatment assessment, R1's pressure sore on the coccyx was assessed as an unstageable area with eschar (dead tissue/thick crust) on the coccyx. E3 stated the only pressure sore R1 had was on R1's coccyx. Nurses notes dated 03/14/11 at 6:56 pm state R1 was choking on food and an ambulance was called to take R1 to the ER (emergency room ). The ER room notes dated 03/14/11 document: R1 was sent from the nursing home via ambulance related to "choking" and became unresponsive. R1 arrived at the ER at 7:14 pm. Pt. (R1) has very large, Stage IV tunneling bed sore on coccyx--in between the size of a golf ball and a baseball. Wound smells very foul. Tissue is blackened. A dressing that was previously applied in the Stage IV pressure sore was falling out. The Stage IV pressure sore measured approximately 4 inches by 3 inches (approximately 10 cm. by 3.5 cm.) wide with tunneling in all directions. There is feces inside the wound, and the wound has a very foul odor with blackened tissue. There is an open area on top of the left ankle, a Stage II pressure ulcer on top of the left, lower extremity, and multiple, small, reddened areas on both feet-- mostly over the bony prominences. R1 had been started on intravenous fluids and antibiotic therapy for Sacral Osteo[DIAGNOSES REDACTED] (inflammation of bone marrow)/Sepsis (Toxins in blood and/or tissue). On 03/31/11 at 4:00 p.m., R1 stated that the nurses did not always remember to check or change her pressure sore dressings everyday. R1 was alert and oriented to person, place and time. R1 stated that she complained of not feeling well for a couple days prior to coming into the emergency roiagnom on [DATE]. E3 (Wound Nurse) stated on 04/18/11 at 2:30 p.m. and E4 (Licensed Practical Nurse) stated at 2:15 p.m. on 04/18/11 that E3 is the only one that assesses and measures the wounds for residents with pressure sores. Both stated that the nursing staff change the dressings as ordered. E3 stated assessing the wounds was "my job." E4 stated nursing write their initials on the treatment record when a dressing change is done but nursing do not document in nursing notes or treatment records a description of the wound or the type of dressing used, only E3 does that weekly. The facility policy titled "Wound Care" documents to record the type of wound care given, date and initial wound care, any changes in resident's condition, problems or complaints, if the resident refused treatment, to notify the supervisor if the resident refuses treatment, and report other information in accordance to the facility policy. 2. A Weekly Wound Log, dated 02/16/11, documents R2 acquired a Stage II pressure sore on the Right Ischium (buttocks) that measured 0.3 cm (centimeters) long x 0.4 cm wide x 0.10 cm deep and a Stage II pressure ulcer on the Left Ischium (buttocks) that measured 0.8 cm long x 0.8 cm wide x 0.10 cm deep. On 03/30/11 the Weekly Wound Report documents no change in the size of the areas On 03/31/11 at 10:35 a.m., E5 and E6 (CNAs/Certified Nursing Aides) had removed R2's slacks and transferred R2 from his wheelchair to his bed. R2 had a small, pin point size, Stage II area on the right buttocks and a Stage II open area on the left buttocks that were not covered with a dressing. E5 stated that R2 had been up in his wheelchair since approximately 7:40 a.m. and was given incontinence care after breakfast. After receiving his care, R2 was placed back into his wheelchair. E5 and E6 stated they did not notice a dressing on R2's buttock this morning (03/31/11). On 03/31/11 at 10:50 a.m. E3 (Wound Treatment Nurse) and E7 (Licensed Practical Nurse) were asked if R2 was suppose to have a dressing covering the open Stage II pressure sores on the right and left buttocks. E3 stated that the dressing was discontinued for the right buttocks because the area is no longer open and is healing. The Stage II, open area on the buttocks, requires a dressing after cleansing. E3 stated that R2's dressing was changed on 03/30/11 (day before) after E3 did R2's weekly wound assessment. E3 went ahead and measured both the right and left pressure sores and found that the left pressure sore had increased in size from 0.8 cm long x 0.8 cm wide x 0.1 deep (measured on 03/30/11) to now measuring, 0.8 cm long x 1.2 centimeters wide x 0.1 deep on 03/31/11 at 10:50 a.m. E3 continued to cleanse the areas on the right and left buttocks, and applied a new dressing ([MEDICATION NAME]) to R2's left buttocks/ischium area. On 03/31/11 at 11:15 a.m., R2 stated that a dressing was put on his buttocks yesterday (03/30/11) but has not had a new one placed on yet today (03/31/11). R2 stated he did not know when or how long the dressing has been off since he doesn't check "back there". E7 (Licensed Practical Nurse) stated on 03/31/11 at 10:50 a.m. that E3 does the weekly skin measurements and that other nurses or E3 changes R2's dressing on the left buttocks every three days or when necessary. R2's physician orders, dated 03/02/11, document R2 has a "small island that is separating into two areas at the left ischium area ordered. There is an order to cleanse the area with Wound Wash, apply a [MEDICATION NAME] dressing, and change the dressing every three days or when necessary." R2's care plan dated 03/07/11 documents R2 requires an assist of two staff for transfers, bathing and hygiene, dressing, and positioning.