Every finding on record at Arcadia Care Rock Island

Based on interview and record review, the facility failed to perform Cardiopulmonary Resuscitation (CPR) in a manner to provide adequate oxygenation to a resident (R2). This applies to 1 of 3 residents reviewed for change in condition in the sample of 18.The findings include:R2's electronic face sheet printed on [DATE] showed R2 had diagnoses including but not limited to hemiplegia and hemiparesis, cerebral infarction, type 2 diabetes, vascular dementia with behaviors, anxiety disorder, and dysphagia.R2's POLST (Physician's Orders for Life Sustaining Treatment) dated [DATE] showed, Full Code.R2's care plan dated [DATE] showed, Resident and/or responsible party has chosen to have resident a FULL CODE; CPR will be initiated if resident's heart and respirations stop.R2's nursing progress notes dated [DATE] showed, This nurse was notified by CNA (Certified Nursing Assistant) that resident was not breathing around 4:25AM. This nurse confirmed she was a full code and proceeded to residents' room, this nurse checked for pulse, no pulse present and began to perform CPR. CNA took over compressions so this nurse could get crash cart and call 911. When returned to room this nurse took over compressions and CNA started to bag resident. Medics arrived at 4:35AM and took over chest compressions. They placed monitor on resident and no shock was advised. They confirmed residents time of death at 4:40AM .R2's ambulance run report dated [DATE] showed, Upon arrival to the scene, the patient was found lying in her facility bed and facility staff had initiated CPR and were performing chest compressions. One staff member was performing chestcompressions and a second member was attempting ventilation with a BVM (Bag Valve Mask) that did not have a mask connected and was not connected to O2 (oxygen). Staff had placed a backboard behind the patient for compressions. Once the crew arrived to the room, the staff members stopped compressions to allow for EMS (Emergency Medical Services) to swap with them. During this swap, the crew noted that the patient was cold to touch and that rigor mortis had set in her jaw. Patient was connected to the cardiac monitor via 4-lead which showed a rhythm of asystole. A staff member reported that she had last seen the patient at 0200 this morning when her shift began and when she saw the patient again was when she was doing her rounds on the floor which was when she noticed that the patient was unresponsive and pulseless. Patient information was obtained by staff members. Staff reported that the patient has been sick with Covid for the past few days,but that she has been alert and talking with them .On [DATE] at 3:55PM, V14 (Paramedic) stated, We were dispatched for a patient in cardiac arrest. When we got there, 2 staff members were there were performing CPR, one was doing compressions, and the other one was doing BVM with no mask on the patient's face. She just had the T-piece (plastic connection) in her mouth, The BVM wasn't even connected to oxygen. The only way to get proper oxygenation to a patient with a bag valve mask is to apply the mask, otherwise you aren't getting the air directly to their lungs. We took over the care and we were about to put her on the cardiac monitor and noticed she was rigored (stiff). There was no way she was going to be resuscitated but I felt like they should have known that. We asked the last time they had seen her and they said it had not been more than a few hours since the last bed check. I can't tell you 100% that she was a full code because I just glanced at the paperwork since she had already passed away. I just want to be sure that this is addressed because had this been someone who could have been resuscitated this would have not been the way to do it.On [DATE] at 2:06PM, V10 (CNA) stated, (R2) was sick with COVID. She wasn't really her normal self, she was more quiet. She was coughing a little that night. I want to say it was around 3:45-4:00am when I got to her room and I called her name and when I got over to her and was calling her name there was no response and I ran and got (V9-Licensed Practical Nurse/LPN). (V9) grabbed her phone to see if (R2) was a full code or DNR (Do Not Resuscitate) and found out she was a full code and called 911 and then ran to the room and we started CPR on her. We were taking turns doing compressions and she ran to get the crash cart and I kept doing CPR. She put a mask over her face and pumped the bag. EMS came and took over shortly after that. She never slept with blankets only a sheet and always had the fan on. She never wanted to be hot so I can't really say if she was cold or not. The nurse did the mask I didn't. I don't know how to deal with anything that's on the crash cart, that's what the nurse's do. I am CPR certified but I did not do the bagging, I did compressions. The last time I was in (R2's) room would have been around 2AM when I was doing my rounds. She was fine she was still breathing. She wasn't really talking and was quiet but she spoke to me.On [DATE] at 2:48PM, V2 (Director of Nursing) stated, Crash carts are located on every floor with residents. The unlocked items are checked on a daily basis to ensure everything is there. Locked drawers have different oxygen masks, AED (Automated External Defibrillator). AED is on 2nd floor and 4th floor. If a resident is found unresponsive, in an ideal world we would know the code status off the bat. If no pulse, then start CPR immediately and call for help. I would expect them to yell out of the room code blue and what room number. Activate emergency response system so that you have 911 en route. You have to have the bag attached to the mask in order to get adequate ventilation to a resident requiring CPR. If you don't have the mask on, there's no point in bagging them.On [DATE] at 3:10PM, V9 (LPN) stated, (V10) told me (R2) wasn't breathing and I knew she had COVID. I was pretty sure she was a full code, so I checked her code status, and we went to her room and started chest compressions. I left to go get the crash cart while (V10) did compressions. I don't think we messed with the bed, so it wasn't flat at the time I don't think. It was comfortable enough for us to do CPR on her. I went to (R2's) room with the crash cart, we put the board under her and then I resumed compressions. You have to attach the mask to the bag which was confusing because I didn't expect that. She (aide) was just standing there. We weren't really expecting it. We knew she was sick, but it was a shock to walk into her not breathing. I checked her carotid pulse, and she was cold and there was no pulse. She didn't just die 5 minutes before that. She was definitely cold. (Surveyor then read V9 her progress notes from the night in question and she then stated, Oh yeah, the aide was doing the bagging, not just standing there. I put the mask over her mouth, and the aide was bagging her really fast, so I had to slow her down.) I've worked in the ICU (Intensive Care Unit) and performed CPR immediately but never performed it on someone who was already cold and dead. When EMS arrived, they took over compressions and put AED pads on her and shock wasn't advised. They did a little bit of CPR but then told us she had passed.The facility's policy titled, CPR Revised 8/18 showed, The facility will provide basic life support, including CPR, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician's order and resident choice indicated in the resident's advanced directives .CPR supplies .backboard, face mask or resuscitator bag .10. If no pulse, begin CPR .ventilate 2 breaths after 30 compressions, each breath to be delivered over 1 second, causing chest to rise. Use face mask or respirator bag .

Based on interview and record review, the facility failed to implement interventions to assess a non-removable lower extremity cast for one of one residents (R1) reviewed for casts in a sample of three. Findings include: The facility's Cast Care policy, undated, documents to assess the cast every shift after the first 24 hours of application for the following: tightness or looseness (able to slip one finger between the cast and skin), circulation, motion, sensation, drainage, odor, and assess the skin for any signs of irritation. This form also documents to report and abnormal findings to the physician and document assessments regarding cast care in the nurses notes.R1's Treatment Administration Record, dated 9/19/25, documents to check CMST's (circulation, movement, sensation, and temperature) to right lower extremity for any abnormal findings and notify the MD (medical doctor) every shift. This order was discontinued on 10/7/25.R1's readmission orders, from the local hospital, dated 10/7/25, does not document any orders for the care of R1's cast on her right lower extremity.R1's Progress Notes, dated 10/11/25, documents that R1 offers complaints of increased pain to RLE (right lower extremity). Resident (R1) states that when she was in physical therapy on Thursday that is was relayed to her (R1) that her casting is damp and smells. Resident (R1) refuses repositioning. Resident (R1) is wondering if she could be seen at the clinic at an earlier date. Relayed a message to oncoming shift. R1's Orthopedic Note, dated 10/13/25, documents that R1 presents with increased right heel pain, and her splint is wet. R1 has increased right lower extremity pain, concern for neurovascular compromise, infected pressure ulcers, and sepsis, status post right closed reduction and transcalcaneal talus distal tibia pinning with use of C-arm fluoroscopy and placement of soft short leg splint pinning on 9/8/25. This form documents that R1's vitals are concerning for sepsis. Her foot discoloration is concerning for neurovascular compromise. It is recommended that R1 go to the emergency room for further evaluation. On 10/28/25 at 10:45am, V10, Certified Medical Assistant, stated that if R1's cast was assessed every shift, the wound on her foot could have been found sooner. V10 verified that R1 was seen in the orthopedic clinic, then was sent to the hospital on [DATE]. V10 stated that R1's cast was found to be saturated. On 10/28/25 at 11:00am, V9, Wound Nurse/Registered Nurse, verified that R1's readmision orders, dated 10/7/25, did not have orders for the care of the cast on her right lower extremity. V9 also stated that staff did not call to obtain orders for R1's cast care. V9 stated that she noticed on 10/12/25 that R1 did not have orders concerning the cast care, after she was told about R1 having a wound inside her cast. V9 stated that R1's original orders concerning her cast should have been continued when she was readmitted on [DATE].

Based on interview and record review, the facility failed to ensure a resident was safely transferred with a full mechanical lift according to their plan of care for 1 of 3 residents reviewed for safety/supervision in the sample of 5.The findings include:R2's electronic face sheet printed on [DATE] showed R2 has diagnoses including but not limited to congestive heart failure, morbid obesity, muscle weakness, and muscle wasting.R2's facility assessment dated [DATE] showed R2 has no cognitive impairment and is dependent on staff for transfers.R2's care plan dated [DATE] showed, The resident has an ADL (Activities of Daily Living) self-care performance deficit related to weakness, balance/endurance deficit .the resident requires mechanical lift with 2 staff assist for transfers.On [DATE] at 10:40AM, R2 stated, The first I had an issue with (V3-Certified Nursing Assistant-CNA) taking care of me was about 2 months ago. The (full body mechanical lift) wasn't working right or the battery was dead or something and it quit working and she wanted to sit me on the edge of the bed and she was going to lift under my arms and drop me in the chair. She picked me up under my arms and the other girl was behind me.There were 2 aides in here I just can't remember who the other one was. She scares me when she transfers me because she's not nice about it and she shouldn't be transferring me without the lift. They told me I need the lift at all times. That's the only way I feel safe.On [DATE] at 12:14PM, V3 stated, This incident was a few months ago. (R2) had her call light on in her wheelchair to use the bathroom. The (full body mechanical lift) was dying but we had enough battery to get her to bed. As we were getting her on the bed the (full body mechanical lift) died and we got her positioned onto the bed pan. We told her to wait a few minutes so we could charge it for about 15 minutes. We got her off the bed pan and there wasn't enough charge on the lift. We asked (V2-Director of Nursing) if we could do a 2 person transfer for her and he said it was fine. We do transfers like this all the time. I put the gait belt around her and (V2) was behind her. We put her in the wheelchair and it was just fine. There were a lot of people using the lifts that day so that's why it must have been dead.(V4-CNA) was the other aide in there. If I thought it was wrong or would have hurt her I never would have done it. I have seen people use a stand lift for her so I didn't really think it was much different.On [DATE] at 12:30PM, V4 stated, The transfer for (R2) was me and (V3) and we did it from the chair to the bed and she just kind of did the pivot transfer. I guided her hips onto the bed but didn't do much more. (V3) just grabbed her under her arms and got her to the bed that way. We didn't have any problems that day but her ability to bear weight isn't consistent. They have tried a stand lift with her but she was crying. (V2) was never even in the room or part of the conversation so I'm not sure why (V3) is saying that she got permission from him.On [DATE] at 12:54PM, V2 stated, I was not in the room at all during the transfer of (R2) nor did I have any knowledge that there was an issue with the lifts that day. They didn't ask me anything about transferring her without the (full body mechanical) lift.I honestly have no idea what they are talking about and I was never involved. A nurse could not change the residents transfer status without therapy evaluating them first or the doctor's order. If a resident is not able to be transferred with the (full body mechanical lift) we have back up batteries on each floor as well as another lift on each floor.The facility's undated policy titled, Transfer Belts/Gait Belt Policy showed, Policy: To promote safety in transferring and ambulating residents, a gait belt will be utilized by nursing or therapy staff.4. Grasp the secured gait belt to provide stability and balance during the transfer.The facility's undated policy titled, Limited Resident Lift Policy showed, . Use mechanical lifting devices and other approved patient handling aids for high-risk resident handling and movement tasks except when absolutely necessary such as in a medical or environmental emergency or evacuation.

Based on observation, interview, and record review, the facility failed to adequately supervise a known wandering resident (R1), failed to have systems in place to monitor the front door alarms after hours and failed to have interventions in place for a known faulty (electronic wandering device) door alarm system for one (R1) of twenty-two residents reviewed for elopement/wandering. These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of Vascular Dementia, eloping from the facility to a grassy area out front of the building, by a curb, close to a busy road attempting to get on a city bus. This failure has the potential to affect all seven (R4-R10) Elopement Risk residents who reside off the secured floor in the facility.These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 8/28/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.Findings include:The facility policy titled Door Alarm Policy, reviewed 8/22/25, documents but not limited to, It is the policy of Generations at Rock Island to ensure resident safety and security through the use of door alarms. All doors leading to the outside MUST meet these requirements: 1. The alarm must only be disengaged at the door itself, either by push button code or key. No alarm may be disengaged from the nurse's station or any other location without physical evidence gathered by a staff member of reason for trigger reported directly to the person silencing the alarm. 2. The alarm must ring continuously until physically disengaged through key or code. 3. Exit doors MUST NOT have the alarm codes posted. Door alarms require immediate attention and response by facility staff to ensure the safety of all residents.3. Immediate response requires any employee to physically go to the door that has an alarm sounding to establish why the alarm was triggered. 5. Testing (including actual activation) and documentation of testing will be completed weekly. Any malfunctions are to be reported to the Administrator and repaired as quickly as possible.R1's admission record documents R1's date of admission to the facility was 8/9/24 and his diagnoses include but are not limited to: Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Acute on Chronic Systolic (congestive) Heart Failure, Anxiety Disorder and Vascular Dementia Unspecified Severity with Agitation.R1's Minimum Data Set (MDS) Assessment, dated 6/2/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment, documents R1 has non-Alzheimer's dementia and documents R1's ambulation for distances over 10 feet as supervision or touching assistance.R1's physician orders dated 4/6/25, documents R1 has an order for a (electronic wandering device) ankle bracelet to prevent elopement from facility and orders dated 4/7/25 to check/record (electronic wandering device) placement and function every shift.R1's current care plan documents R1 Has cognitive deficits related to vascular Dementia and non-traumatic intracerebral hemorrhage and at risk for wandering r/t (related to) dx (diagnosis) of dementia. At times will wander around without purpose. Has entered other rooms and easily redirected. (electronic wandering device) in place. R1's current Care Plan contains no documentation of R1's elopement risk prior to 8/1/25.R1's elopement risk assessment dated [DATE], documents R1 is an elopement risk with a score of four (4).On 8/26/25 at 3:00pm, V1 (Administrator) stated, We do not have any documentation stating what the elopement risk assessment score means but anything greater than a one (1) means they are at risk so probably the higher the score the greater risk.R1's Risk Management Report, dated 7/31/25, documents, Exit behavior actively attempting to leave building staff successful in redirecting and (V14/Licensed Practical Nurse/LPN) statement: I (V14/LPN) received a phone call from dispatch around 8:33pm making us aware that a resident was trying to get on the bus. I was outside bringing him (R1) back in the facility when the police arrived. The resident was still on the facility property in the grass near the smoking patio/courtyard. He did not leave the property. He was easily redirected back inside. We moved him to the 4th floor for heightened supervision and increased security.On 8/22/25 at 1:30pm, V14 (Licensed Practical Nurse/LPN) stated on 7/31/25 around 8:30pm he (V14) was getting off the elevator onto the first floor when he noted the front lobby door alarm was going off and the reception phone ringing. V14 (LPN) answered the phone, and the local police dispatch was calling to inform the facility of a suspected resident attempting to get on the bus. V14 (LPN) went outside and found R1 in a grassy area, next to the curb in front of the facility attempting to get on a city bus.On 8/22/25 at 1:50pm V1 (Administrator) and V2 (Administrator in Training/AIT) stated that the front door alarm will alarm on the panel at the nurse's station on the second floor.On 8/22/25 at 1:55pm observation of alarm panel on second floor at the nurse's station shows no door alarm sounding when V1 (Administrator) set off the door alarm. V14 (Licensed Practical Nurse/LPN) was present at second floor nurse station and verified that the front door alarm was not sounding on the panel at the nurse's station.On 8/22/25 at 2:00pm, V16 (Maintenance Director) stated that he became aware approximately the middle of July 2025 of an issue with the facility's (electronic wandering device) door alarm system not always working as it should, meaning it should alarm at the nurse's station on the second floor if set off but it does not always do this. V16 verified V16 did not notify V1 (Administrator) or attempt to contact the electronic wandering device company regarding the faulty system. At this time, V16 showed the panel on the second floor at the nurse's station where the electronic wandering device system will sometimes alarm if set off. When asked about the door alarm going off not related to the (electronic wandering device), V16 stated, I don't know of any panel except for the front reception desk that will alarm if the front door is alarming. V16 verified that the front door alarm cannot be heard over the alarm panel at the second-floor nurse's station.8/22/25 at 2:10pm V13 (Human Resources) stated, No, if the front door alarm goes off and it is not because of a (electronic wandering device) then I am not aware that it is heard on any of the floors except the reception desk.On 8/22/25 at 2:30pm, V1 (Administrator) was noticeably frustrated and stated today is the first she has heard anything about there being issues with the door alarms. V1 verified V16 did not report the facility's (electronic wandering device) door alarm system not always working as it should to V1.On 8/26/25 at 11:55am, V17 (Registered Nurse/RN) stated, I was R1's nurse the evening he got out of the building. Approximately 8:30pm I received a phone call on my personal cell phone from V14 (Licensed Practical Nurse/LPN) stating he (V14) was outside with R1 because he (R1) was trying to get on the bus. I went down to assist getting R1 back into the building and then called V2 (Administrator in Training/AIT) and told her what had occurred and was advised to move R1 to the 4th floor to the secured unit for increased safety. R1 was fully dressed in only socks on his feet when he was found but did have his (electronic wandering device) in place to his ankle. The (electronic wandering device) was checked to make sure it was functioning, and it showed that it was but unsure why the door did not stop him from going out. I do not recall hearing any door alarms sounding from the panel at the second-floor nurse's station. I don't know how V14 (LPN) knew R1 was outside but if it wasn't for him, I'm not sure when we would have known R1 was gone since there is no one watching the front door after 8:00pm. I was informed a few days later that there is a glitch to the door system when it comes to the (electronic wandering device).On 8/26/25 at 11:44am, V18 (Certified Nursing Assistant/CNA) stated, I saw (R1) around 7:30pm-8:00pm when I was doing rounds on (R1's) roommate. (R1) had asked me if his shirt looked like it fit so I helped him button it up and then started telling him how nice he looked. He was wearing that button up shirt, a pair of boxers and socks sitting on the side of his bed. He then laid down in bed. I did not hear any door alarms go off on the panel at the nurse's station but was informed by V17 (Registered Nurse/RN) that (R1) was outside, so I ran down the stairs to assist getting him in the building and then realized he needed his wheelchair, so I went back up to get it. Once I got back downstairs, they had him in the building. I assisted him into the wheelchair, and he (R1) was yelling at me I told you I was going to the tavern to see the ladies. (R1) never said anything to me about going to the tavern prior to that statement.On 8/26/25 at 10:17am, V37 (City Bus Head of Security) stated, It is documented that our driver called 911 at 8:32pm stating there was a confused man in socks trying to get on the bus.On 8/26/25 at 10:39am, V38 (Front desk Clerk of Police department) stated, (City Bus) called around 8:21pm, police dispatched but no need to engage due to staff had resident and were taking him back to the building.On 8/26/25 at 12:25pm, V20 (Licensed Practical Nurse/LPN) stated, There is no way to hear the front door alarm up here on the third floor. Just the stairwell door alarms are heard here. I was not aware of an issue with the alarm system until (R1) got out. If a (electronic wander device) is near the doors, they lock down so you can't go out, so I don't know at what point it stopped working.On 8/27/25 at 9:15am, V1 (Administrator) stated, The alarms, front door alarm and (electronic wander device) are supposed to be sounding on the second-floor alarm panel.On 8/26/25 R4, R5, R6, R7, R8, R9 and R10's elopement risk assessments reviewed indicating they are all at risk for elopement and facility census report documents they all live on the second and third floors of the building which are not secured units. V1 (Administrator) and V2 (Administrator in Training/AIT) were notified of the Immediate Jeopardy on 8/27/25 at 11:32am.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 was immediately assessed by nursing and moved to the 4th floor secured unit on 7/31/2025.2. Staff were in-serviced/trained on elopement precautions and facility's policy and procedure for monitoring residents at risk for elopement on 8/1/2025 by facility management.3. Resident elopement assessments for all residents reviewed and updated accordingly on 8/1/2025 by the IDT/Interdisciplinary Team. Elopement care plans reviewed and updated by the IDT team.4. Staff educated by QAT (Quality Assurance Team) members on 8/1/2025 on identifying residents at risk for elopement and policy and procedure for reporting to leadership to ensure proper interventions/care plans are initiated timely. Residents at risk were placed/updated in missing resident binder at the reception desk.5. Social services assessed current residents for elopement precautions on 8/1/2025 and ensured all at risk residents have updated care plan and intervention in place.6. Code [NAME] (Elopement-missing person) drill was performed on 8/1/25 and ongoing by Administration.7. Maintenance Director (V16) completed an immediate audit of door security systems on 8/1/2025 and daily thereafter.8. On 8/1/2025 Local Vendor was in facility to check over the Access and Wander guard and noted it to be working with a low volume and inconsistently. Quote for upgrade was being drafted for wander guard system.9. 8/22/2025 Facility implemented 24/7 reception area observation until such time that all staff are educated on the camera monitoring process and/or the repairs are completed.10. 8/22/2025 facility placed a designated camera alert system at the main entrance to alert 2nd floor staff when the (electronic wandering system) and or main entrance door alarm sounds. This system will remain in place until (electronic wandering system) is fully operational. (V1) will conduct random audits every shift to ensure that the camera alert system at the main entrance functions appropriately.11. 8/22/2025 Local Vendor and (electronic wandering system) Vendor in communication with Maintenance Director and Facility V1 (Administrator)/V2 (Administrator in Training) in relation to repairs vs replacement. On 8/25/25 after communications with vendors it was determined that repair was not feasible, and system replacement would be required. On 8/26/2025 Quote for replacement of system was approved and signed for installation. 12. 8/29/25 Vendor representatives are scheduled to be on-site to coordinate final installation details and requirements. Installation will be initiated promptly thereafter.13. On 8/22/2025 all staff in all departments were in-serviced on Elopement prevention, Missing residents and Door Alarm Policies and procedures by QAT members. No staff will be allowed to work after 8/22/2025 without the listed training.14. Code [NAME] (Elopement-missing person) drill will be performed randomly for one month and monthly thereafter for 6 months by QAT members.15. Maintenance Director/Designee will do daily door alarm audits for 30 days and then weekly and as needed going forward.16. V1/V2 will enforce the interventions of plan of removal of immediacy and assurance of continued compliance.17. V1/V2 and QAT will ensure that monitoring interventions are implemented immediately, and care planned appropriately.

Based on interview and record review the facility failed to employ a full time qualified Social Worker in a facility licensed for 177 beds. This has the potential to affect all 70 residents who reside in the facility.Findings include: The facility Director of Social Services job description, not dated, documents but not limited to, Qualifications: 1. Either a B.A. (Bachelor of Arts) in Psychology or Sociology; a B.A. or M.A. (Master of Arts) in Social Work; or a Licensed Clinical Social Worker's certificate. 2. Two years experience in the field of social work in a long term care environment is preferred.Facility Midnight Census Report, dated 8/22/25, documents occupied facility beds at 70 with empty beds at 107 and Detailed Census Report, dated 2/1/25 through 8/28/25, documents a daily census ranging from 66-81.On 8/28/25 at 9:35am, V2 (Administrator in Training/AIT) stated, We are licensed for 177 beds. V2 also verified that V15 (Social Service Director/SSD) is not Licensed and stated that she was a CNA (Certified Nursing Assistant).On 8/28/25 at 10:26am, V15 (Social Service Director/SSD) stated, I was a CNA (Certified Nursing Assistant) prior to this Social Service position. I took this around the end of May. I do not have a license or certificate in Social Services or any type of degree and no previous Social work experience.Neither V2 (Administrator in Training/AIT) or V15 (Social Service Director/SSD) were able to produce a license or certificate for V15 (SSD) in Social Work.

Based on interview and record review, the facility failed to treat a resident (R1) with dignity. This applies to 1 of 3 residents reviewed for dignity in the sample of 3. The findings include:R1's electronic face sheet printed on 8/2/25 showed R1 has diagnoses including but not limited to acute & chronic respiratory failure with hypoxia, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, dysphagia, and Raynaud's syndrome.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment, is dependent on staff for toileting, and is frequently incontinent of bowel and bladder.On 8/2/25 at 12:27PM, R1 was asked if he has ever had any issues with any staff members and he stated, Oh yes. When I first came back from the hospital I was transferring from the stretcher to the bed and it hit me really fast that I had to have a bowel movement so I asked the aide if she could take me and she said We aren't going to walk you in there today. You just got back from the hospital. You can just go in your depends and we can clean it up. I was shocked because nobody has ever told me that. I was furious because I pay to be taken care of, not to be told to go to the bathroom in my pants. I had to wait until the next shift came on to get changed and the aide that helped me said it was a huge mess, and I never should have been treated like that. The aide that told me to go in my pants was (V4-Certified Nursing Assistant). She's not the normal aide that takes care of me. My regular aide is wonderful. This aide I am not very familiar with, and she hasn't taken care of me since that night. I know it was night shift because I got back to the facility after 11pm .On 8/2/25 at 1:20PM, V4 stated, The last time I worked with (R1) I was helping with cares. He was just coming in from the hospital and had just gotten off the stretcher. I helped him take his clothes off. He was wet and soaked through all of his clothes, so I started changing him. The other aide came in and we got him changed. In between the clothes being changed he said he needed to go to the bathroom, but he was already wet, so I told him he was already wet, so we didn't need to go into the bathroom. When the other aide (V5) came in, I told her he needed to go to the bathroom and then I was just in there for a bit and then I left the room. I don't even know what I did wrong. I didn't think he needed to go into the bathroom because he was already wet. Surveyor attempted to contact (V5-CNA-Certified Nursing Assistant with no return call).On 8/2/25 at 3:16PM, V3 (Director of Nursing) stated, If a resident requests to go to the bathroom, the aides should be honoring that request no matter what the circumstances are. (R1) is a resident who is able to walk and use the restroom so there would be no reason to deny him that right. I'm not sure what happened in this situation but it's definitely a dignity concern. The only reason an aide wouldn't take a resident into the bathroom is if it wasn't safe for the resident to go into the bathroom and then they should be attempting to explain that to the resident. That's not what happened in this situation from what I can tell. She (V4) just didn't want to take (R1) to the bathroom.The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities dated 11/18 showed, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life .your facility must provide services to keep your physical and mental health, at their highest practical levels .

Based on interview and record review, the facility failed to follow their policy and keep a resident (R1) informed of the status of a grievance. This applies to 1 of 3 residents reviewed for grievances in the sample of 3.The findings include:R1's electronic face sheet printed on 8/2/25 showed R1 has diagnoses including but limited to acute & chronic respiratory failure with hypoxia, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, dysphagia, and Raynaud's syndrome.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment.On 8/2/25 at 2:02PM, R1 stated, I am very frustrated by a complaint I had with (V4-Certified Nursing Assistant (CNA). The staff are aware of it and they reported it for me. I hope it never happens again. (V4-CNA) hasn't taken care of me since that day but I didn't hear anything more about it. Nobody from Administration ever came and interviewed me or anything so I don't even know if they have the full story.On 8/2/25 at 3:16PM, V3 (Director of Nursing) stated, On July 26th, it was reported to me that (V4) refused to provide cares to (R1). V1 (Administrator) was contacted, and she said it was a customer service issue, so we did an in-service on customer service for the staff and (V4) was suspended for 2 days but now she is back to work. I was just told that it would be investigated .I wasn't involved in any of it. I don't know who spoke with (R1), if anyone. I was just told since it wasn't an abuse investigation all we had to do was an in-service for all staff.On 8/2/25 at 3:58PM, V2 (Operations Specialist) stated, I feel so bad that this didn't really get handled correctly. I know we haven't spoken with (R1) about any of this and I feel like we kind of dropped the ball on this one. We should have followed up with him right away so that he knew we were addressing his concerns and let him know of the outcome.The facility's undated policy titled, Grievance Policy and Procedure showed, (Facility) is committed to protecting the rights of all residents and maintaining a culture of dignity, transparency, and responsiveness. Residents have the right to voice grievances without fear of coercion, discrimination, retaliation, or reprisal .Residents and/or their representatives have the right to .2. Receive prompt acknowledgment and a timely written response to grievances .

Based on observation, interview, and record review, the facility failed to implement dietician recommendations for a resident (R1) receiving tube feedings. This applies to 1 of 1 residents reviewed for tube feedings in the sample of 3.The findings include:R1's electronic face sheet printed on 8/2/25 showed R1 has diagnoses including but not limited to acute & chronic respiratory failure with hypoxia, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, dysphagia, and Raynaud's syndrome.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and receives tube feedings.R1's care plan dated 3/17/25 showed, The resident requires tube feeding related to oropharyngeal dysphagia. Receiving tube feeding and water flushes for all nutrition & hydration needs According to RD (Registered Dietician): BMI (Body Mass Index)- 22.3 low for age. Has significant weight loss of 8.2% in 4 days (4/28-5/2); however, weights are relatively stable x 1m. Regimen meets/exceeds calorie & protein needs RD to evaluate quarterly and PRN (as needed). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed.The resident is dependent with tube feeding and water flushes. See physician's orders for current feeding orders .R1's admission notes dated 7/26/25 showed, New order received from physician to use Osmolite 1.5 for continuous feed of 60ml/hr, 150 water flush every 4 hours until can clarify feeding with dietician on Monday and can get Osmolite 1.2 if needed .R1's RD progress note dated 7/30/25 showed, Recommendations: Osmolite 1.5cal 60ml/hr x 20 hours. Add liquid protein 30mL BID (twice daily).R1's physician's orders as of 8/2/25 showed, Osmolite 1.5 Cal Oral Liquid (Nutritional Supplements) Give 60 ml via G-Tube every shift forNutrition. Administer 60 mL every hour. As of 8/2/25, R1's dietician recommendations to feed R1 for 20 hours a day were not initiated nor were the recommendations for R1 to receive Liquid Protein 30mL BID.On 8/2/25 at 12:27PM, R1 stated, I receive my feedings 24 hours a day and that hasn't changed at all since I have been back from the hospital. I would know because I rely on my feedings as my only source of nutrition.On 8/2/25 at 3:09PM, V9 (Licensed Practical Nurse) stated, (R1's) current feeding orders are Osmolite 1.5 cal continuous feedings at 60ml/hr. Dietary recommendations are usually handled by 1st and 2nd shift and we would call and get the orders on the same day the recommendations are given I assume. I am a 3rd shift nurse but that's just basic nursing that if you get a recommendation, you call and get an order. The physicians rely on the dieticians to assess every resident's nutritional status, and they usually don't argue their orders and if they do we let the dietician speak with the physician.On 8/2/25 at 3:16PM, V3 (Director of Nursing) stated, I did ask for the dietician to see (R1) and she would give recommendations to the dietary manager and then she will also send me a copy. Dietary Manager will then call the dietician to clarify the recommendations. The nurse on the floor will call and get orders for the recommendations. I would expect that the recommendations were implemented within 24 hours but I'm not sure if it happens that way in this facility. I have only been here a month, but I would think if there were recommendations, we should have them entered as an order by now. It's already been 3 days so that is too long.The facility was unable to provide a policy related to dietician recommendations as of 8/2/25 at 4:00PM.

Based on observation, interview, and record review, the facility failed to obtain physicians orders for a resident (R1) with a G-tube (Gastrostomy tube). This applies to 1 of 1 residents reviewed for G-tubes in the sample of 3.The findings include:R1's electronic face sheet printed on 8/2/25 showed R1 has diagnoses including but not limited to acute & chronic respiratory failure with hypoxia, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, dysphagia, and Raynaud's syndrome.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and requires tube feedings.R1's care plan dated 3/17/25 showed, The resident requires tube feeding related to oropharyngeal dysphagia. Receiving tube feeding and water flushes for all nutrition & hydration needs .provide local care to G-Tube (Gastrostomy Tube) site as ordered and monitor for signs and symptoms of infection.R1's physician's orders for 7/25/25-8/2/25 showed no orders for G-tube site care.On 8/2/25 at 3:09PM, V9 (Licensed Practical Nurse) stated, (R1) used to have orders for g-tube site care but I don't see any in the system. It is important to clean that site to prevent infection so I'm not sure why he doesn't have any orders for it. Normally we would clean it at least daily and as needed if the dressing comes off or is soiled.On 8/2/25 at 3:16PM, V3 (Director of Nursing) stated, Any resident that has a G-tube should have orders for the head of the bed to be elevated, G-tube flushing, and G-tube site care. These are standard orders at any facility or hospital that you work in, and the nurses should have realized these were missing. We need to make sure we are cleaning the site to prevent infection.The facility's policy titled, Physician Orders Guidelines dated 5/2025 showed, At the time of admission, the facility must have physician orders for the resident's care. The facility will have orders to provide essential care to the residents, consistent with the residents mental and physical status upon admission .

Based on observation, interview, and record review the facility failed to implement interventions to ensure a resident was free from physical abuse resulting in potential injury for 2 of 3 residents (R2, R11) reviewed for abuse in the sample of 12. The immediate jeopardy began on 6/11/25 at 6:50 PM when R1 returned to the facility from being evaluated at the acute care hospital after grabbing R11 by the neck. R1's care plan was updated to include 1:1 supervision on 6/11/25. No evidence was found of R1 being on 1:1 supervision until 6/18/25 after the second incident when R1 pushed R2 to the floor. V1 (Administrator) was notified of the Immediate Jeopardy on 7/18/25 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance or removed on 6/18/25 and the deficient practice corrected on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance.Based on observation, interview, and record review the facility failed to implement interventions to ensure a resident was free from physical abuse resulting in potential injury for 2 of 3 residents (R2, R11) reviewed for abuse in the sample of 12. The immediate jeopardy began on 6/11/25 at 6:50 PM when R1 returned to the facility from being evaluated at the acute care hospital after grabbing R11 by the neck. R1's care plan was updated to include 1:1 supervision on 6/11/25. No evidence was found of R1 being on 1:1 supervision until 6/18/25 after the second incident when R1 pushed R2 to the floor. V1 (Administrator) was notified of the Immediate Jeopardy on 7/18/25 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance or removed on 6/18/25 and the deficient practice corrected on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance. The findings include:R1's face sheet showed she was admitted to the facility 7/2/23 with diagnoses to include severe dementia with agitation, Alzheimer's Disease, Type 2 Diabetes, generalized anxiety disorder, psychotic disorder not due to a substance or known physiological condition, insomnia, and depression. R1's facility assessment dated [DATE] showed she had been experiencing physical and verbal behavioral symptoms directed toward others 4-6 days of the 7-day review period. This same assessment indicated these behaviors had become worse since compared to R1's prior assessment.R1's Care Plan initiated 2/6/25 showed, Coping Psychotic Disorder. Resident has dementia and confusion. Can get angry and lash out at other residents and staff, both verbally and physically. Most times, there is no obvious trigger. Interventions: 6/11/25: 1 on 1 until at baseline for mood and behavior.R2's face sheet showed she was admitted to the facility 7/2/20 with diagnoses to include dementia with other behavioral disturbance, vascular dementia, heart failure, cerebrovascular disease, chronic kidney disease, peripheral vascular disease difficulty in walking, lack of coordination, and a history of falling. R2's facility assessment dated [DATE] showed she has severe cognitive impairment.R11's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease with late onset, cerebral infarction, vascular dementia with agitation, hypertension, psychophysiologic insomnia, nontraumatic subdural hemorrhage, anxiety disorder, and major depressive disorder. R11's facility assessment showed she has severe cognitive impairment.R1‘s Incident Report dated 6/11/25 at 2:50 PM showed, Resident to Resident Altercation. Statement from the CNA (Certified Nursing Assistant) was that this resident became agitated by another resident [R11] when [R11] banged her walker on the floor, which made [R1] stand up and grab the resident [R11] by the neck.R11's Incident Report dated 6/11/25 at 2:50 PM showed, This nurse was told by the CNA that this resident was banging her walker against the floor when another resident stood up and grabbed this resident by the neck.R1's Nursing Note dated 6/11/25 at 6:50 AM showed, Resident returned to the facility with no changes to her medication. Information packet on managing stress was attached to discharge orders.R1's Incident Report dated 6/18/25 at 4:01 AM showed, Resident to Resident Altercation. Nursing Description: At 3:45 AM, this nurse was called by CNA at doors to locked area while nurse was a nurse's station to come help because [R1] was agitated in her room. While quickly walking the 20 or so feet to the door to assist CNA this nurse and CNA witnessed resident quickly charge out of her room and self-ambulate across the lounge. CNA and myself hurried to [R1] and before we reached [R1] she reached another resident who was walking with a cane in the hallway next to the lounge and shoved her over causing her to fall back. CNA and myself separated [R1] and the other resident. [R1] continued to be aggressive swinging at and pinching staff while screaming nonsensical words. This nurse attempted to talk with [R1] and to calm her and to redirect her with no progress. Resident continued to be agitated.[physician] notified of resident status and situation and order to send to ER (emergency room) for evaluation was obtained.R1's care plan initiated 2/6/25 showed, . Psychotic Disorder. Resident has dementia and confusion. Can get angry and lash out at other residents and staff, both verbally and physically. Most times, there is no obvious trigger. Interventions: 6/11/25: 1:1 until at baseline for mood and behavior. R1's complete medical record was reviewed including her abuse investigations dated 6/11/25 and 6/18/25 with no evidence of 1:1 being conducted for R1 between 6/11/25 and 6/18/25.R1'S Care Plan initiated 2/6/25 showed, Behavior Management. Resident can be triggered by nothing and start to act angry and hard to calm down. It can lead to her hitting and getting belligerent toward other residents and staff. Has been known to shove tables when agitated. 1:1 Supervision initiated 6/18/25.R1's One on One Direct Care Log dated 6/18/25 showed she returned from the hospital at 7:15 AM and 1:1 supervision started.The facility's staffing scheduled showed they started scheduling staff to do 1:1 supervision starting 6/19/25.R1's Behavior Monitoring and Interventions Report showed, . 6/15/25: cursing at others, screaming at others, agitated, neglecting self care, refusing care.On 7/16/25 at 1:07 PM, V8 CNA said, With [R1] it is all about how you approach her when it comes to her behaviors. If you explain to her what you are doing, she complies pretty well. If she is agitated, she gets very aggressive. She hits and kicks, scratches. I was here when [R1] and [R11] had the incident (6/11/25). [R11] had been fine throughout the whole morning. It was in the afternoon when she gets agitated, she gets to shaking, I asked her what is wrong, that didn't help. [R11] proceeded to grab her walker and bang her walker on the floor. [R1] was sitting in [R1's] designated area and was resting her eyes and when [R11] banged the walker on the floor, it woke [R1] up. [R1] was confused and scared. [R11] was walking toward me aggressively so [R1] got up and walked toward [R11] and proceeded to try and hit [R11]. I separated them but she grabbed her by the neck. [R11] screamed. I separated them really quickly. She had no injuries from that. [R11] didn't know why [R1] did that. [R11] is very aggressive as well.On 7/16/25 at 12:01 PM, V9 CNA (Certified Nursing Assistant) said, [R1] has behaviors, she gets combative with cares, and she is attention seeking. If she sees you 1:1 providing care with another resident that irritates her. She comes at the patient you are caring for. She starts to yell but it depends on what kind of day she is having. She will try to hit them. Redirection is hard for [R1]. If she is going after another resident, she does not handle redirection at all, she gets locked in on them, you just have to try to intervene and keep the patient safe. The incident with [R1] and [R2] on 6/18/25, [R1 pushed [R2]. [R1] was getting irate, and I peeked out to the outside of the closed unit doors to let the nurse know [R1] had charged at [R2]. [R2] was pushed to the ground that day, she said she was hurting so the nurse sent her out and nothing was wrong with her. [R1] has been a 1:1 here lately.R1's Acute Care Hospital documents showed she arrived at the acute care hospital 6/18/25 at 4:45 AM for aggressive behavior. R1's same hospital documents showed, . Patient apparently pushed another resident down this morning.R2's 6/18/25 Nursing Note entered at 5:45 AM showed, At 3:45 this morning, Resident was witnessed self-ambulating with cane in hallway next to the lounge when another resident who came walking out of their bedroom and appeared to be agitated and quickly self-ambulated across the lounge, charging at this resident. Resident shoved her which caused her to lose her balance and fall to her back. Initially resident stated that she had no pain but quickly stated that she did indeed have pain in her lower back and bilateral hip area, unable to rate and states it is ‘bad'. Resident returned at 5:45 AM from emergency room with no new orders. Resident denies pain at this time. R2's care plan initiated 12/13/24 showed, The resident is at risk for falls related to confusion, gait/balance problems. On 7/16/25 at 11:15 AM, V6 CNA Scheduler (Certified Nursing Assistant scheduler) said, I schedule both nurses & CNAs. Only have one 1:1 resident here currently. That is [R1]. She has been 1:1 since mid June, maybe around the 15th, due to really bad behaviors. She needs 1:1 on all shifts, including while she is sleeping. The nursing staff gets an order for it and the Director of Nursing, or the Administrator tell me who needs it and how long they need to be on it. All schedules were requested from V6 for R1's 1:1 supervision. The first time 1:1 was documented on the schedule showed 6/19/25. On 7/16/25 at 12:25 PM, V12 CNA (Certified Nursing Assistant) said [R1] is really combative, she has been combative since she has been there. She has put her hands on damn near all the staff here. [R1] has terrible behavior. We are scared of her. She is like this with both staff and residents. If you aren't familiar to her, she gets really bad. She is not a good resident to have, and she is a lot of care. They have 1:1 now. [R1] gets agitated with redirection, sometimes it gets better, sometimes it doesn't. You got to know how to work with her and that is not an easy task because she will turn on you. You have to get her away from noise, light, and people. We have to keep her separated from the other people. The 1:1 has been going on for maybe a month now. Her behavior has been going on since she has been here.On 7/16/25 at 2:02 PM, V18 (Housekeeper) stated R1 gets irritated if the CNAs rush her during care. R1 yells out, Slow down when she is rushed. It is a defense mechanism. I saw R1 attack another resident in the past. It was 6 or 8 months ago. She grabbed another resident's head and shook it. It was [R12], I had to step in between both of them to get R1 to let go. [R12] was upset and crying. It happened really fast and quick. I told the nurse about it but can't remember her name. I haven't seen any behaviors recently. Lately she is just spaced out. On 7/18/25 at 12:45 PM, V2 (Regional Director of Clinical Operations) said, R1 has been on 1:1 since 6/18/25. On 7/18/25 at 1:50 PM, V3 DON (Director of Nursing) said, . If someone is placed 1:1 supervision, this means there are eyes on the resident. They also need to keep track of what is going on around them, maybe someone else is getting agitated and you know it is going to get this resident agitated as well. If a resident is on 1 on 1 supervision, I would expect a staff member to always be with the resident.The facility's policy and procedure with revision date 01/2019 showed, Abuse Prevention Program. Policy: It is the policy of this facility to prohibit and prevent resident abuse. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. Physical Abuse: Hitting, slapping, pinching, kicking, etc. The Immediate Jeopardy that began on 6/11/25 was removed on 6/18/25 when the facility completed the following actions: Investigation of abuse completed and reported to IDPH, alleged perpetrator and alleged victim's physician notified of alleged abuse. Both R11 & R2 were immediately separated and assessed for any signs of injury or trauma.R1 placed on 1 on 1 supervision effective 6/18/2025.The whole house audit for residents with aggressive behaviors completed and ensured care plan interventions are in place on 7.18.2025 by the MDS Nurse and Regional Reimbursement SpecialistAll staff In-servicing by LNHA and Designee initiated on 6/18/2025 on Abuse reporting policy and repeated on 7/18/2025 Abuse Prevention Policy, one on one supervision and dementia care including behavior emergencies.In-servicing training by QAT members on the Abuse Prevention Policy, supervision and dementia care including behavior emergencies. and one on one supervision with all staff will continue, and any remaining employees must be trained prior to reporting for work for their next shift scheduled. Quality Assurance Activities to ensure the alleged deficient practice will not recur include: QAT will Audit 3 Resident Behavior Tracking and Behavior care plans weekly x 4 to monitor for continues compliance. The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the Regional Consultants and facility QA Committee for follow up and review.In-service training by DON/LNHA on Abuse Prevention Policy, supervision and dementia care including behavior emergencies with all staff will continue monthly for the next 3 months, then quarterly x 3 by the LNHA/Designee. LNHA will enforce the interventions of plan of removal of immediacy and assurance of continued compliance. The Removal Plan is executed as required in response to a Statement of Deficiencies against the facility know as Generations at Rock Island. This Removal Plan is not an admission of an agreement with, the validity of any facts or violations cited in the summary statements of deficiencies. This Removal Plan is not a waiver of any rights of defense, which may be available under Illinois Statues, Illinois Administrative Code, or Federal Law of Regulations. The facility believes that the immediacy was removed as of 6/18/2025 with the establishment of residents initiated 1 on 1 & Staff training of facility Abuse Prevention and one on one supervision policies. Staff have been re-educated on facility policies and procedures and in-servicing will be ongoing.completion date: 7.18.2025

Based on interview and record review the facility failed to assess respiratory status for one resident (R3) who displayed respiratory changes of three residents reviewed for change of condition in the sample of five.This deficient practice resulted in a delay in the assessment of the resident's respiratory status and subsequent need for additional medical intervention.The findings include:Physician Order Summary Report indicates R3 was admitted to the facility on [DATE] with diagnoses that include, Dysphagia, Cerebral infarction, Generalized Anxiety Disorder, Gastrostomy, Acute Respiratory Failure with Hypoxia.On [DATE] V7, LPN (Licensed Practical Nurse) stated that she was R3's assigned nurse on [DATE]. V7 stated that R3 was more anxious than usual, had a persistent dry non-productive cough and was obsessed with wiping his tongue with toilet paper. V7 stated R3 appeared to be trying to clear his throat or cough something up. V7 stated R3's mouth was dry, and she gave R3 mouth swabs. V7 stated she did not assess R3's lungs or obtain an oxygen saturation level but did obtain vitals and they were ok.There are no vital signs or oxygen saturation levels documented for [DATE].Progress Note dated [DATE] at 8:08pm indicates V34 (LPN) went to assess resident due to increased lethargy and pale color; found oxygen saturation at 78% on room air; unable to obtain blood pressure; administered oxygen via nasal cannula and R3 became unresponsive. Note indicates Code Blue was called at 8:10pm and chest compressions initiated by staff; 911 dispatched at 8:12pm and EMS (Emergency Medical Services) arrived at 8:20pm and took over compressions. Note indicates R3 was then transferred to the hospital.On [DATE] at 9:50am V34 stated she was R3's assigned nurse on [DATE]. V34 stated she gave R3 his 3pm bolus tube feeding and noticed R3 was phlegmy, throaty. V34 stated at that time R3 was talking and asked for a pain pill. V34 stated when she went in to give R3 his 8pm tube feeding, R3's color was off pale and R3's oxygen saturation was 78%. V34 stated she went to get the portable oxygen and when she returned R3 was going unresponsive. V34 stated she did a sternal rub and yelled for the CNA to call a Code Blue. Staff immediately arrived assisted R3 to the floor and started CPR (Cardiopulmonary Resuscitation). V34 stated she did not know if there was a protocol for listening to a resident's lungs. V34 stated she did not listen to R3's lungs as R3 was not spitting anything up.On [DATE] at 9:25am V36, RT (Respiratory Therapist) stated that she was asked by V2, RDCO (Regional Director of Clinical Operations) to see R3. V36 stated there was no reason given (R3) was just on my list. I only saw him one time. V36 stated R3 was not gurgly at that time. and did not need any further respiratory support. V36 stated if R3 became gurgly she would think she would be contacted to reassess.R3's Care Plan indicated R3 received enteral nutrition via gravity or bolus with interventions that included to monitor/document/report as needed any signs/symptoms of dysphagia, choking, coughing, drooling.On [DATE] at 9:50am V4, ADON (Assistant Director of Nursing) stated e performed a respiratory assessment on R3 once per V2, RDCO request. V4 confirmed that assessment was completed on [DATE]. V4 stated there were no abnormal findings. V4 stated he had heard R3 had been congested before and thought that's why V2 wanted R3 assessed. V2 also stated that he had heard in passing that R3 frequently spit phlegm up into napkins. V4 stated if R3 were to become more gurgly or phlegmy or any other respiratory changes from baseline or just seemed different a respiratory assessment should be done, and physician should be notified.Facility Policy/ Guidelines for Enteral Feeding Adult dated [DATE] documents: The nurse will assess the following prior to initiating the tube feeding, each time the tube is accessed, every eight hours or as needed: Respiratory status, observe for signs of aspiration (i.e. sudden intense cough, increased amount of secretions, cyanosis or decreased breath sounds).Facility Policy/Change in Condition Guidelines 5/2025 documents: Change in Condition: Any deviation from a resident's baseline status, including physical, mental, or psychosocial changes. Immediate Response: Perform a nursing assessment; Notify the Charge Nurse and/or attending physician immediately if warranted; Initiate appropriate clinical interventions.Facility Policy/Respiratory assessment Guidelines dated 6/2025 documents: Purpose: To ensure best practices and (Federal) expectations for ongoing monitoring, early identification of deterioration and documentation for residents' respiratory status. Frequency of Assessment Guidelines: As needed for any change in condition (this may include increased cough, fever, confusion, shortness of breath, decreased oxygen saturation levels. All respiratory assessments and interventions/outcomes should be documented in the resident's health record.

Based on interview and record review, the facility failed to have an Infection Preventionist that has specialized training in infection prevention and control. This has the potential to affect all 79 residents residing in the facility. Findings include: Facility Infection Preventionist Nurse job description, reviewed November 2021, documents Maintains current knowledge of federal, state, and local regulations. Understands and complies with infection control, and safety procedures and regulations. Online https://www.cdc.gov/long-term-care-facilities/hcp/training/index.html, dated MARCH 28, 2024, documents Nursing Home Infection Preventionist Training At a glance- This course is for individuals responsible for infection prevention and control (IPC) programs in nursing homes. Participants can complete the 23 modules and sub-modules in any order and over multiple sessions. On 8/29/24 at 10:27 AM, V4 (Infection Preventionist/IP) stated, I thought I had my IP certificate done. V4 verified she had 15 of the 23 modules done and went into the CDC/Centers for Disease Control program and showed the surveyor where she had not completed the training or taken the posttest (2 tries to pass) and got her certificate. At that same time, V4 stated I have been in this position since December 2023, I work Monday thru Friday full time as the IP, and I need to finish this. Facility provided V4's IP certificates of 15 modules completed of the 23 modules for IP training. Facility Resident Census and Conditions of Residents form, dated 8/27/24, documents 79 residents reside in the facility.

Based on record review and interview the facility failed to provide the resident and the resident's representative the facility's written bed hold policy within 24 hours of transfer for two of two residents (R50 and R60) reviewed for bed holds in a total sample of 31. Findings include: The facilities Bed Hold Policy dated 3/2023 documents, Under Normal circumstances, if you leave the facility for a hospitalization , you will be readmitted to the first available bed in a semi-private room. Under certain conditions, we can reserve your existing bed for you, at your request, so when you return to the facility, you will have the same bed if you are hospitalized . If you are a private pay, Medicare, or Medicaid resident, we will hold your same bed and room for you as long as you wish, at a charge to you as established in the resident contract signed on admission. If your care is being paid for by the Veteran's Administration, we will hold your bed for 48 hours unless prior approval for a longer period has been received from the VA (Veteran's Administration) that initiated your contract. Per the NHCA (Nursing Home Care Act), this facility will hold a bed for a maximum of ten days when you are hospitalized . On the 11th day, the facility will no longer hold a bed for you, but as you are still a resident, you will receive the next available bed when you are ready to return, even if there is a waiting list. There is no requirement under the NHCA to hold a bed for ten days during a therapeutic home visit. However, you are still considered a resident and will be given the next available bed when you are ready to return, even if there is a waiting list. After the thirtieth (30th) day, the resident will be formally discharged from the facility's roster. At this time, the resident can reapply for admission to the facility. 1) R50's medical record documents hospitalization s on 10/14/23, 2/22/24, 5/28/24, and 6/10/24. R50's progress notes dated 10/14/23, 2/22/24, 5/28/24, and 6/10/24 has no documentation that facility's bed hold policy was given or reviewed with R50 or family. On 08/29/24 3:01 PM V1 (Administrator) stated that bed hold policy was not sent or gone over with R50 or his family on 10/14/23, 2/22/24, 5/28/24, and 6/10/24. 30899 2) Resident Census Record indicates R60 was transferred to the hospital on the following dates in 2024: 1/4/24, 2/11/24, 4/16/24, 4/30/24, 5/27/24, 6/7/24, 6/13/24, 7/27/24, 8/2/24 and 8/21/24. Facility Transfer/Discharge Status Form which includes Bed Hold Notices were only provided for transfers to the hospital in 2023, no Bed Hold Notices were found or presented for any of R60's transfers in 2024. On 8/29/24 at 10:30am R60 stated he did not recall receiving a bed hold form when discharged to the hospital. On 8/29/24 at 10:45am V1 (Administrator) stated R60 did not get a bed hold when transferred to the hospital.

Based on observation, interview, and record review, the facility failed to develop a care plan to include a resting hand splint for one (65) of one resident reviewed for devices in a sample of 31. Findings include: R65's current orders for August 2024, documents LUE (left upper extremity) RHS (resting hand splint) wearing schedule: Patient should wear LUE RHS two hours prior to each meal and at night. Splint off during hygiene/bathing and feeding. If red or white spots are present, discontinue use and contact therapy. Before Meals and At Bedtime 07:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. On 8/27/24 at 11:20 AM and 8/29/24 at 10:40 AM, R65's hand splint was sitting on a shelf in her room. R65's current care plan does not have R65's resting hand splint documented. On 8/29/24 at 4:01 PM, V8 (Registered Nurse/Care Plan Coordinator) verified R65's care plan needed updated.

Based on observation, interview, and record review, the facility failed to revise a care plan to remove checking an AV/Arteriovenous fistula site; failed to include who to contact for emergencies/complications, failed to include a target weight; failed to have an assessment and care of the central dialysis port; and failed to include resident specific dialysis orders for two (R13 and R50) of 18 residents reviewed for care plan revisions in a sample of 31. Findings include: The facility's Comprehensive Care Plans policy dated 4/2017 documents, To develop a comprehensive, person-centered plan of care, consistent with the resident's rights, that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. The comprehensive care plan will include: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being while preventing decline when possible, and areas of potential risk to the resident with interventions to eliminate or reduce risk. Care Plans are revised as changes in the resident's condition dictates, but no less than on a quarterly basis. 1. R13's medical record documents the following diagnoses: End stage renal disease; Dependence on renal dialysis. R13's medical record documents R13's AV fistula was discontinued, and his right chest dialysis port was put in 4/1/24. On 8/27/24 11:30 AM, R13 was in his room, alert and oriented, and had a right chest long central catheter port wrapped in gauze. At that same time R13 stated I go to dialysis five days a week here. R13's left upper arm had a scar that was healed and R13 stated I had a shunt there for dialysis, but it got infected, so they had to remove it and put in this chest catheter for dialysis. R13's current care plan has no specific dialysis orders related to the type of dialyzer, flow rate, and length of time; target weights; who to contact for emergencies/complications; or care or assessment of the dialysis port. R13's current care plan has R13's left upper arm AV/Arteriovenous fistula site still documented. On 8/29/24 at 4:01 PM, V8 (Registered Nurse/Care Plan Coordinator) stated V13's care plan was not updated to remove R13's left arteriovenous catheter. V8 also confirmed R13's Care Plan did not address complications, emergencies, target weight, nephrologist, or assessment of the right chest catheter site. V8 stated R13's Care Plan, needs updated. 50962 2. R50's physician orders, dated 6/20/24, documents site (left upper inner thigh): HD (Hemodialysis) Catheter- Monitor site for bleeding and signs and symptoms of infection. On 08/27/24 11:20 AM, R50's dialysis catheter observed in left upper, inner thigh. R50's Current Care Plan, as of 8/29/24 at 1:00 PM, has not been revised to reflect dialysis catheter to left inner, upper thigh. On 08/29/24 01:50 PM V8 (Registered Nurse/Care Plan Coordinator) and V9 (Licensed Practical Nurse/Restorative Nurse) stated R50's current care plan does not show documentation that R50 has a dialysis catheter to his left inner, upper thigh.

Based on interview and record review the facility failed to follow physician's orders to flush an indwelling urinary catheter and failed to identify and document changes in urine output/characteristics for one resident (R76) of four residents reviewed for urinary catheters in the sample of 31. Findings include: Facility Policy/Change in a Resident's Condition or Status dated 3/2023 documents: The nurse will notify the resident's attending physician or physician extender when: There is need to alter the resident's treatment significantly; deems necessary or appropriate in the best interest of the resident. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. R76's Physician Order Report indicates R76 was admitted to the facility on [DATE]. R76 is [AGE] years old and has diagnoses that include Diabetes Mellitus with Chronic Diabetic Kidney Disease, Stage 3 Chronic Kidney Disease, Personal History of Urinary Tract Infections, Polyneuropathy and Acute Cystitis without Hematuria. Physician Orders indicate R76 had an indwelling urinary catheter (order date 12/7/23) with the following orders: Order Date 5/17/24: acetic acid solution 0.25%, 60 ml (milliliters) irrigation; Special Instructions: Flush catheter with 60ml daily AND (as needed) for increased sediment/mucus or blockage. Order Date 5/17/24: Normal Saline Flush 0.9%, 60ml. Special Instructions: Flush catheter with 60ml daily AND (as needed) for increase sediment/mucus blockage. Diagnosis: Neuromuscular Dysfunction of Bladder. R76's Medication Administration Record (MAR) dated 8/1/24 to 8/8/24 indicates that R76 was transcribed for R76 to only receive (as needed) acetic acid and Normal Saline irrigation/flushes of her indwelling urinary catheter despite the MAR indicating the Special Instructions documented Daily and as needed. On 8/29/24 at 1:04pm V6 (Registered Nurse/RN) stated that during report (on 8/7/24/evening shift) she was receiving report from the off-going, evening shift nurse (V7) who told her that R76 was having possible catheter problems and indicated the problems had to do with R76's urine output. V7 (Licensed Practical Nurse/LPN) reported that R76 had no output on evening shift, had not looked into the problem and suggested irrigating R76's catheter. V6 stated that V7 reported that she was unsure if R76's catheter was blocked or R76 just didn't have any output. V7 reported that she did not irrigate R76's catheter on her shift. V6 also stated that during initial rounds to get the residents' oxygen readings - including R76 - she found R76 was sleeping comfortably. V6 stated that approximately 45 minutes later, R76 was yelling, and she went immediately to R76's room along with a CNA (Certified Nurse Assistant). V6 stated they changed R76's position however R76 continued to indicate she was uncomfortable. V6 stated that she noticed R76's urine in the catheter tubing at that time was mucus(y), milky and amber colored. V6 stated that was not what R76's urine usually looked like. V6 stated that she then flushed R76's catheter and then did a bladder scan to determine if R76's low urine output was due to the catheter being clogged and to determine how much urine was in R76's bladder. V6 stated that when she was talking to the day shift nurse the following morning (8/08/24) she was told that R76 also had no output during the previous day (9/07/24). V6 stated I was not aware of that until the following morning, the evening shift nurse (V7) did not report that. V6 also stated My rule of thumb is if there is no output in 8 hours, that is abnormal. If there is no output and if there are orders to flush, that's what should be done and also bladder scan - which is what I did. Progress Note dated 8/8/24 at 2:31am indicates This nurse heard (R76) yelling out from the hallway, and the CNA and myself ran down to (R76's) room to find (R76) in distress and pointing at her back/butt, indicating that she wanted to be turned. We turned (R76) and this seemed to be effective at that time. Note indicates R76 had reportedly had catheter issues/inadequate urine output on the previous shift and had 300 ml of opaque, milky, amber-colored urine in her drainage bag at this time. Note indicate V6 proceeded to irrigate (R76's) catheter and perform a bladder scan. Note indicates R76 was not yelling at that time and seemed to be relaxed while she was performing the bladder scan. Note indicates the scan resulted in 000 ml as the reading. On 8/29/24 at 2:15pm V7 (LPN) stated (on 8/7/24) R76 did have low urine output and told staff to push fluids. V7 stated R76 had approximately 300ml urine output on that evening, but usually has about 800ml out. V7 stated that R76's urine was yellow/amber with sediment. V7 stated I didn't think about irrigating (R76's catheter). (R76) used to have orders to flush her catheter every evening but then the order changed. (V6) suggested flushing (R76's) catheter not me. V7 stated she forgot to document R76's urine output (on 8/7/24) on the MAR. No progress notes from day shift or evening shift on 8/7/24 were found or presented to indicate R76's low or absent urine output or characteristics of urine that may have indicated a blockage or infection. On 8/29/24 at 12:45pm V9 (LPN) stated that she spoke with V11 (Nurse Practitioner/NP) who changed R76's orders to (as needed) only because she thought maybe the flushes were causing R76's UTI's (urinary tract infections). V9 stated I forgot to change the Special Instructions to take out the daily flushes. At that time V9 was asked if she had made a progress note regarding her conversation with V11 about the changes to R76's orders - V9 responded that she would check. V9 returned later with a progress note dated 5/17/24 at 12:45pm that indicated This nurse spoke with (V11) about UTI. (V11) voiced concern about flushes (and) gave NO (Nursing Order) for acetic acid from scheduled to (as needed). MAR updated to reflect changes. Progress Note dated 5/17/24 at 12:45pm Progress Note Details indicates R76's Progress Note dated 5/17/24 was created on 8/29/24 at 2:48pm. This creation date was not included in the progress note V9 provided earlier. On 8/30/24 at 10:32am V1 (Administrator) stated I don't know why (V9) put that note in there. No one told her to do that. I think she put it in after she realized her mistake. She shouldn't have done that. On 8/30/24 at 9:00am V11 (Nurse Practitioner) stated I don't recall changing the order or discussing it with the nurse. (R76) had chronic UTI's because she had a catheter. I don't recall changing the order because of the reason you're telling me. (R76) was followed by Urology. I don't know who originally ordered the daily flushes. R76 did have good fluid intake and urine output so it would be a change for her to have a decrease. NP Note dated 5/9/24 indicates R76 was seen by V11 on that date. Note indicates R76's urine in catheter was clear yellow. Note did not indicate any concern for catheter flushes causing R76's UTI's. Physician Note dated 5/14/24 indicates R76 was seen by the physician on that date. Note did not indicate any concern for catheter flushes causing R76's UTI's. On 8/30/24 at 9:40am V2 (Director of Nursing) stated It's up to the nurse's discretion when to flush the catheter. It would depend on what the urine looks like, not just on output. But according to V6 (RN) (R76's urine) was cloudy. V6 did the right thing by trying to flush and scanning. R76's Care Plan (edited 7/17/24) indicates R76 has an indwelling urinary catheter; has acetic acid solution flush daily for catheter. Care Plan indicates to avoid obstructions in drainage; document urinary output every shift/record amount, type, color, odor.

Based on observation, interview, and record review, the facility failed to apply a resting hand splint for one (R65) of one resident reviewed for devices in a sample of 31. Findings include: Facility Splint-Brace Assistance, reviewed 6/24, documents When splints and other contracture devices are part of the plan, therapy will instruct nursing staff on their use and recommend a schedule for applying and removing the device. Facility Certified Nursing Assistant, updated 10/2013, documents Carry out assignments for resident care including restorative nursing procedures. R65's current orders for August 2024, documents LUE (left upper extremity) RHS (resting hand splint) wearing schedule: Patient should wear LUE RHS two hours prior to each meal and at night. Splint off during hygiene/bathing and feeding. If red or white spots are present, discontinue use and contact therapy. Before Meals and At Bedtime 07:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. R51's Treatment Record for August 2024 has no documentation of R65's application of her resting hand splint. R51's medical record has no charting in the CNA (Certified Nursing Assistant) charting of R65's resting hand splint. On 8/27/24 at 11:20 AM and 8/29/24 at 10:40 AM, R65 was in bed and does not have her left resting hand splint on. R51's hand splint was sitting on a shelf in her room. 08/29/24 3:32 PM - Observations of R65's room, R65 lying in bed with fall mat on right side of bed, wheelchair in corner of the room with foot pedals in the seat, metal trough with thick foam on shelf, hand splint on shelf. R65 states the trough pinches her arm and she doesn't like to wear it, It doesn't help anyway. 08/29/24 3:44 PM V12 (CNA) stated she is unfamiliar with R65's arm splints and referred to the nurse. 08/29/24 3:50 PM V7 (Licensed Practical Nurse) walked into R65's room and observed the trough and hand splint. V7 stated R65 does not like to wear the trough because it's uncomfortable, but she typically gets her to wear it. V7 stated she doesn't know what the hand splint is, she's never seen it before. 08/30/24 10:15 AM V14 (Physical Therapist) stated RHS stands for resting hand splint and confirmed R65 should be using both the trough and resting hand splint as ordered.

Based on observation, interview, and record review, the facility failed to have specific dialysis orders related to the type of dialyzer, flow rate, and length of time; target weights; and care of the dialysis port for two (R13 and R50) of two residents reviewed for dialysis in a sample of 31. Findings include: Facility Care of Dialysis Resident policy, revised 5/17, documents To prevent complications pre and post dialysis treatment and to provide a safe environment. Monitor access site, identify any problems with site and report to physician and dialysis center. All physician orders are to be followed. 1. On 8/27/24 11:30 AM, R13 was in his room, alert and oriented, and had a right chest long central catheter port wrapped in gauze. At that same time R13 stated I go to dialysis five days a week here. R13's medical record documents the following diagnoses: End stage renal disease; Dependence on renal dialysis. R13's medical record has no specific dialysis orders related to the type of dialyzer, flow rate, and length of time; target weights; or care of the dialysis port. On 8/29/24 at 11 AM, V17 (Licensed Practical Nurse/LPN) stated they have a communication form from dialysis, but it does not state any specifics on the dialysate from dialysis, no specific orders for dialysis except R13 goes to dialysis five days a week, no target weight, and care of the dialysis port is done by dialysis. On 8/29/24 10:03 AM, V15 and V16 (Registered Nurses/RNs) on the dialysis unit both stated they are contracted by the facility, facility does not have access to their records for specific resident orders for dialysis and expect the staff to observe and be aware of any concerns with resident's dialysis access sites. 50962 2. R50's physician orders dated 6/20/24 documents Dialysis 5 times a week. R50's physician orders as of 8/29/24 has no documentation of an individualized dialysis prescription. On 08/29/24 at 2:00 PM, V3 (Assistant Director of Nursing) stated R50's current physician orders do not have an individualized dialysis prescription, dialysis unit keeps specific orders. V10 (Registered Nurse) stated that specific individualized dialysis orders are kept in the dialysis unit because they administer the dialysis. Facility orders for dialysis patients are generic with additional orders to monitor sites and vital signs after treatment. V10 stated that dialysis communication sheets are sent with patient to dialysis and return with documentation from dialysis.

Based on interview and record review, the facility failed to have pneumonia vaccination records documented in the resident record and failed to offer pneumonia vaccinations for two (R13 and R65) of five residents reviewed for pneumonia vaccinations in a sample of 31. Findings include: Facility Immunizations, revised 7/2022, documents It is the policy of this facility to offer Influenza and Pneumococcal vaccinations to all residents. Pneumococcal vaccine will be offered to all residents upon admission unless they report prior immunization. Facility will make best efforts to validate prior immunization. 1. R13's medical record documents V13 was admitted to the facility on [DATE], and has no documentation R13 has received, or was offered the pneumonia vaccine. On 8/27/24 after surveyor spoke to V4 (Infection Preventionist/IP), V4 IP documented a progress note in R13's medical record of the following: Resident offered PNA (pneumonia) vaccine and he reports that he will take. Informed resident that the clinic will be 10/5/24 and I will return with a consent for him to sign and he was agreeable. 2. R65's medical record documents R65 was admitted to the facility on [DATE], and has no documentation R65 has received, or was offered the pneumonia vaccine. On 8/27/24 after surveyor spoke to V4, V4 documented a progress note in R65's medical record of the following: Resident offered PNA vaccine and declined. On 8/27/24 at 11:00 AM, V4 stated there is a vaccination clinic scheduled for October 15th for the flu/pneumonia vaccination for staff and residents. On 8/28/24 at 12:40 PM, V4 stated, I missed getting their immunizations on admission, and they did not have as a prior vaccination when I asked them yesterday.

Based on interview and record review, the facility failed to have Covid-19 vaccination records documented in the resident record and failed to offer Covid-19 vaccinations for three (R13, R61 and R65) of five residents reviewed for Covid-19 vaccinations in a sample of 31. Findings include: Facility Covid Vaccine Policy, undated, documents The facility has made arrangements with a pharmacy to provide Covid vaccines to residents. The facility will continue to promote, encourage, and provide vaccination for all residents. 1. R13's medical record documents V13 was admitted to the facility on [DATE], and has no documentation R13 has received, or was offered the Covid-19 vaccine. On 8/27/24 after surveyor spoke to V4 (Infection Preventionist/IP), V4 documented a progress note in R13's medical record of the following: Resident offered Covid-19 vaccine and he reports that he will take. Informed resident that the clinic will be 10/15/24 and I will return with a consent for him to sign and he was agreeable. 2. R65's medical record documents R65 was admitted to the facility on [DATE], and has no documentation R65 has received, or was offered the Covid-19 vaccine. On 8/27/24 after surveyor spoke to V4, V4 documented a progress note in R65's medical record of the following: Resident offered Covid-19 vaccine and declined. 3. R61's medical record documents R61 was admitted to the facility on [DATE], and has no documentation R61 has received, or was offered the Covid-19 vaccine. On 8/27/24 after surveyor spoke to V4, V4 documented a progress note in R61's medical record of the following: Resident offered Covid-19 vaccine and declined stating I don't believe in that stuff. On 8/27/24 at 11:00 AM, V4 stated there is a vaccination clinic scheduled for October 15th for the flu/pneumonia vaccination for staff and residents. On 8/28/24 at 12:40 PM, V4 stated, I missed getting their immunizations on admission, and they did not have as a prior vaccination when I asked them yesterday.

Based on record review and interview the facility failed to notify the physician of a significant change in a residents condition related to refusal of medications, medications being unavailable, refusal of food and liquids and orders for a urinalysis not completed for one resident (R1) of three reviewed for nursing care in the sample of three. This failure resulted in R1 being admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility's Change in a Resident's Condition or Status policy, dated 5/2017, documents Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. The nurse will notify the resident attending physician when: There is a significant change in the resident's physical, mental or psychosocial status; the resident repeatedly refuses treatment or medications. R1's Care Plan, dated 3/1/22, documents (R1) requires a therapeutic heart healthy diet. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Approach: Administer medication per Physician orders, Blood sugars per Physician order. Notify Physician when applicable. Document and report dietary non-compliance. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Accu-check (Blood glucose monitoring) once a day. [MEDICATION(S)] (anticoagulant medication) five milligrams by mouth two times a day, [MEDICATION(S)] (antihyperglycemic medication) 500 milligrams by mouth two times daily, and [MEDICATION(S)] (antidiabetic medication) five milligrams by mouth daily with meals twice a day. This same order sheet also documents R1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . This same Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nursing progress notes, dated 3/7/2022 at 1:59 PM, documents (R1) continues to refuse fluids. Offered several different fluids and asked for preferences. Resident ate maybe 10% of meal. Attempted to provide oral care throughout shift. Attempted to Straight catheter to obtain UA. Resident would not allow. R1's Nursing progress notes, dated 3/8/2022 at 6:17 AM, documents (R1) continues to refuse cares, and fluids at this time. (R1) is refusing all cares and medication at this time. Resident approached by nurse for medication administration. Resident lifted hands in front of face and refused to move them while repeatedly saying, no, no, no resident reproached 2nd and 3rd time with medication in applesauce and again with medication in juice. Resident refused to drink anything. When nurse attempts to offer resident a drink residents eyes begin to water and he places hands in front of mouth. Resident is alert and not oriented to person, place, or time. Resident not expressing any words verbally except for no. Resident pushes CNA (Certified Nursing Assistant) away while attempting cares. Nurse attempted to aid CNAs with cares witnessing resident pushing aids away hold arms out straight and pushing anyone that comes near. Nurse has made multiple attempts to speak with resident about any concerns or complaints reproaching each time with a different approach. Resident continues to stare at nurse and cover face with hands. Resident allowed staff to aid him in transferring to wheelchair where he is now sitting. R1's Nursing progress notes, dated 3/9/2022 at 3:57 AM, documents I received in report that (R1) has been refusing fluids. Resident has refused fluids for this writer too. This nurse contacted the nurse on call expressing concerns that resident is dehydrated. Skin turgor is greater than 3 seconds, lips are cracked due to dryness, eyes are sunken, no urine output (depends have been dry) since 2200. R1's medical record does not contain any record of urinalysis until a collection date of 3/8/22. This same record does not contain any documentation that V8 (R1's Physician) was notified of R1's refusal of medications, R1's insulin not being available, R1's refusal of cares, meals and fluids or that R1's urinalysis was not obtained until 12 days after it was ordered. On 3/16/22 at 10:05 AM, V2 (Director of Nursing), confirmed that V8 (R1's Physician) was not notified of R1 refusing cares, fluids and medications. V2 stated The Urinalysis (UA) was ordered on the 24th of February and I am not sure why it wasn't collected. (R1) was difficult as most residents with Dementia can be. The nurses know that if they can't get a UA to notify the Doctor. I could not find anything to show where the nurses contacted the doctor to let him know. On 3/16/22 at 11:10 AM, V2 stated I was not aware (R1) was not getting his insulin pen during his stay prior to today. R1's emergency room hospital records document that R1 was seen on 3/9/22 with a physical exam that documented Extremely dry [MEDICATION(S)] membranes, [CONDITION(S)] (increased heart rate) at 110 beats per minute, elevated White blood cell count (WBC) at 21.96 (normal range 3.8-10.6). This same record documents R1 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22 at 1:20 PM, V8 (R1's Physician) confirmed seeing R1 in the hospital setting. V8 stated he never saw R1 in the facility and stated I wasn't notified of (R1) refusing medications, food, water or that his daily insulin wasn't given during his stay. V8 also stated R1 was placed on Hospice after being admitted to the hospital.

Noncompliance resulted in two deficient practice statements. A. Based on interview, and record review, the facility failed to protect a resident (R1) in the locked Dementia Unit from an oriented, ambulatory resident (R2),who displayed increasing, escalating behaviors, for one of five residents (R1) reviewed for abuse, in a sample of 17. This failure resulted in R2 physically abusing R1 by throwing R1 to the ground resulting in R1 crying and being visibly upset. B. Based on record review, and interview, the facility failed to protect a resident from verbal abuse for one of five residents (R5) reviewed for abuse in the sample of 17. A. FINDINGS INCLUDE: R2's facility Referral Packet, dated 10/28/2021 and addressed to V9/Marketing Liaison documents R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This same packet included R2's current Care Plan with the following problems: I have a history of substance abuse, severe and alcohol abuse, moderate related to depression and anger. R2' facility Face Sheet documents that R2 was admitted to the facility on [DATE] to the Fourth floor, room [ROOM NUMBER]-3 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Nursing Progress Notes, dated 10/29/2021 at 4:48 P.M. and signed by V13/Nurse Practitioner document, (R2) is a [AGE] year old resident who transferred from (sister facility) today. (R2's) medical history is significant for [CONDITION(S)] ([CONDITION(S)]) Stage IV, nicotine dependence, and [CONDITION(S)] disorder. Admission notes indicate extremely non compliant behavior especially with smoking. (R2) likely needs supplemental oxygen 24/7 (around the clock) at 2-3 (liters) but has already refused to wear it consistently. (R2) has psychiatric illness requiring assistance with daily cares. (R2) is irritated and was difficult to assess upon admission due to aggressive behavior. (R2) kicked out at (V10/Admission Licensed Practical Nurse) at one point. Physical assessment was completed the best I could. I thanked (R2) for allowing me to assess (R2) and (R2) said F . you. (R2) is clearly extremely sob (short of breath) even at rest due to the severity of (R2's) [CONDITION(S)]. (R2) appears to only put the oxygen on when (R2) wants to. (R2) has already asked to go out to smoke. (R2) is not answering questions appropriately due to how irritated (R2) is. (R2) told (V10/Admission Licensed Practical Nurse) to get the f . away from me more than once. R2's Nursing Progress Notes, dated 10/29/2021 at 8:28 P.M. document, While moving the new resident (R9), who was scared to remain in the same room with (R2) stating (R2) is a f .ing psycho, (R2) attempted to grab or swing out at (V10/Admission Licensed Practical Nurse) while (V10's) back was facing (R2) while talking to (R9). Myself (V13) and two other CNAs (Certified Nursing Assistants) verbally shouted at (R2) to STOP!! to dissuade (R2) from attempting to make physical contact. (R2) sat back down on the bed abruptly after our verbal outcry. (R2) was offered anxiety medication to see if this would decrease some of (R2's) agitation but (R2) vehemently refuses. Message left on (V1/Administrator) phone about the incidents with (R2) regarding aggression towards V10/LPN) and (R1). R2's Nursing Progress Notes, dated 10/29/2021 at 9:04 P.M., by V10/Admission Licensed Practical Nurse document, Admission Note, admitted from: Long term care (sister facility). Cognition (Oriented to): Person, alert. Upon arrival (R2) was combative kicking at me. R2's clothes are dirty, (R2) refuse to let staff change him. (R2) is incontinent of urine and BM (stool). Open area on buttock (R2) refuse to let staff assess, measure, or clean the area. (R2) continue to refuse assistance and (R2) refuse medications as well calling staff bi .chs hitting at staff. (R2's) roommate (R9) was transferred to another room (R9) was scarred of (R2). Notified (V2) DON (Director of Nurses) and left message for (V1)Administrator. R1's Nursing progress Notes, dated 10/29/2021 at 8:15 P.M. by V13/Nurse Practitioner document, V10/Licensed Practical Nurse called me to report (R1) had been thrown to the floor by (R2). CNAs report they saw (R2) grab (R1) by the arm and throw (R1) down to the ground. It was reported (R1) was crying and visibly shaking. (R1) does wander but has been very pleasantly confused without issues of aggression. (R2) has been verbally aggressive and attempted to kick at (V10/LPN) earlier during my initial physical assessment. (R1) is resting in bed comfortably and does not remember the incident. No bruising or signs of pain, swelling, or injury. Diagnosis/Plan: Physical Abuse/Altercation: No signs of swelling, redness, or bruising. The nurse will pass on to first shift to monitor (R1) for limping, bruising, or swelling to the hips or any extremities. No further orders at this time. CNAs noted to watch closely to ensure (R1) does not wander into (R2's) room again. On 11/3/2021 at 8:50 A.M., V11/Certified Nursing Assistant (CNA) stated, I was working the afternoon that (R2) was admitted . (R2) was verbally and physically abusive from the time (R2) got here. At one point, I was out in the hallway taking care of another resident and I saw (R1) go into (R2's) and heard (R1) yelling. I saw (R2) grab (R1) by the arm and throw (R1) to the ground. I ran and got the nurse to check (R1) for injuries. On 11/3/2021 at 9:03 A.M., V10/Licensed Practical Nurse stated, I was the nurse on duty the day (R2) was admitted . I'm not sure why (R2) was admitted to the locked unit, (R2) didn't have a Dementia diagnosis. (R2's) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R2) is alert, and oriented. From the time (R2) got here he was verbally abusive to staff and other residents. (R2) was combative, trying to hit and kick me. I had to move (R2's) roommate (R9) because (R9) was afraid to stay in the same room as (R2). I was out of the unit charting at the nurse's station when (V11)/Certified Nursing Assistant (CNA) came and got me to tell me that (R1) had wandered into (R2's) room and (R2) had grabbed (R1) by the arm, and threw (R1) to the ground. (R1) didn't have any visible injuries, but (R1) was visibly shaken and crying. On 11/4/2021 at 10:12 A.M., V8/Admissions Coordinator stated, I wasn't the one who made the decision to place (R2) in the Dementia unit when (R2) was admitted . (V9/Marketing Director) made that decision. She said (R2) is an elopement risk, so V9 wanted (R2) in the locked unit. Usually a resident has to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . We received a referral for (R2) because (R2) requires oxygen now. (V9/Marketing Director) last day of employment is today. (V9) no longer works for our company. On 11/4/2021 at 1:35 P.M., V1/Administrator stated, Admission to our locked Dementia unit is dependent on a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (V9/Marketing Director) made the call to admit him there without my approval. B. FINDINGS INCLUDE: On 11/9/21 at 10:30 am, R5 was asked about the incident that occurred with R6 and V23 (R6's family). R5 started crying and stated, That was the worst day of my life! I got a new roommate (R6) who was very large and has a big wheelchair as well as lots of stuff. I wheeled my wheel chair to my bed and I got tangled with (R6's) wheelchair. I asked (R6) to help me by moving her wheel chair and she wouldn't say anything she just glared at me. (R6) had boxes and stuff everywhere in our room. I couldn't get around and they were moving all my stuff in my closet. I asked (V23) to not touch my stuff. I understand she needed a side of the closet, but she didn't need to touch my stuff. At one point, (V23) came thru the door mad. (V23) threw her arms up and said, You're a b ch. So, I said back to her well you're a b .h too. I knew I didn't do anything, and I thought oh my god I couldn't live like this. All I could think was is this my punishment, a roommate I can't get along with. I was crying when this all happened. I was pretty upset. On 11/9/21 at 11:00 a.m., V4 (CNA-Certified Nursing Assistant) stated, I was working the day (11/2/21) of the argument (between R5 and R6 and V23). I was sitting here at the nurses' desk charting. All I could hear was arguing and someone yelling, 'Give us a break. It's our first day here.' I went down to their room to see what was going on. When I got into the room, (R5) was crying, (R6) was crying, and (V23) was red faced and angry. I wondered why the residents were crying. I asked (R5) if she was ok, and (R5) said, 'That lady (V23) called me a b .ch.' Right away, (V23) said, 'Yeah, I was the one who called (R5) a b .tch because she called me a b .ch.' It was out of control and (V23) was out of control. These residents are completely with it. (V23's) a grown woman she shouldn't be arguing with any of the residents. I wouldn't want anyone talking to any of my family members that way. (V23) was verbally abusive to (R5), and (V23) was crazy you don't yell at a resident like that. The (undated) facility policy, Abuse Prevention Program directs staff, This facility prohibits mistreatment, neglect, exploitation, misappropriation of resident property, or abuse of it's residents. This facility is committed to protecting our residents from abuse by anyone, including, other residents. The facility's Abuse Prevention Program Facility Policy documents, This facility prohibits mistreatment, neglect, exploitation, misappropriation of resident property, or abuse of its resident. The policy also documents, Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident.

Noncompliance resulted in two deficient practice statements A. Based on interview, and record review, the facility failed to follow recommended transfer assistance during a transfer for one of three residents (R3), reviewed for falls, in a sample of 17. This failure resulted in R3 being improperly transferred and sustaining a fall which resulted in sustaining multiple fractures. B. Based on observation, interview, and record review, the facility failed to provide supervision to prevent a resident from exiting the facility unattended and have a properly functioning elopement monitoring system for six of six residents (R1, R5, R11-R13, R15) reviewed for elopement risk in the sample of 17. A. FINDINGS INCLUDE: The facility policy, Mechanical Lift, dated (revised) 02/2017 directs staff, A (mechanical) lift assists staff to lift and move a resident as safely and as easily as possible. A (mechanical) lift should be used for heavy residents or for those who are disabled. Two staff members are required for the procedure. The Mechanical Lift manufacturer's guide documents, allow's patients up to 400 and 500 pounds, respectively, to be lifted and transferred safely with minimal physical effort provided by the operator. That is due to it being a full electrical lift. Mechanical lift can lift the patient with ease from the floor to the bed. The six point spreader bar provides added comfort for the patient while moving from any surface. Battery: If the battery is critically low, the LCD (Liquid Crystal Display) Display Panel will show, Charge Battery Immediately. Lift operation is deactivated. Battery needs to be charged immediately before further use. The Battery Powered Patient Lift manufacturer's guide documents, (The manufacturer) recommends the battery be recharged daily to prolong battery life. A battery needing to be fully charged will take approximately four hours. R3's facility Resident Face Sheet documents that R3 was admitted to the facility on [DATE] with the following diagnoses: Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Hypertensive Heart and Chronic Kidney Disease, Diabetes Mellitus, Primary Generalized Arthritis, [CONDITION(S)], Bicipital Tendinitis, Muscle Weakness and [CONDITION(S)]. R3's current (undated) Care Plan includes the following Problem area: (R3) has (an) inability to transfer self related to weakness. (R3) is a (mechanical lift) for transfers. The following approaches include: Use two staff to transfer (R3). R3's current Minimum Data Set Assessment, dated 10/08/2021 documents: Cognition- 11:15 (cognitively intact); Functional Status, transfers-total dependence on two staff members. R3's PT (Physical Therapy) Discharge Summary, dated 10/15/2021 documents, Discharge Recommendations: Recommending discharge to this facility at a wheel chair level, continue (mechanical lift) with staff for safety. Lateral scoot transfer with board, moderate assist of two for safety. R3's electronic Nursing Progress Notes, dated 10/23/2021 at 8:58 P.M. and signed by V6/Registered Nurse (RN) document, (R3) had been up in wc (wheel chair) since early afternoon. CNAs (Certified Nursing Assistants) stated (mechanical lift) battery not charging, (V6/RN) did assess (mechanical lift) and charging light not coming on. Unable to leave (R3) in wc all night, (V6/RN) called for a non-emergency transfer from wc to bed. EMTs (Emergency Medical Transports) arrived in (R3's) room with (V6/RN) and four other staff members. Gait belt was placed for safety. On count of three, staff used gait belt to lift resident from wheel chair. EMTs were to grab backside of (R3) to assist with transfer. (R3's) legs buckled prior to EMTs getting ahold of (R3). (R3) landed on knees and left and right feet buckled inward and backward. (R3) complained of pain to right foot. (R3) unable to rate pain at that time. (V6/RN) applied ice to (R3's) right lateral foot. Staff aware to continue to assess for swelling, bruising or increased pain. R3's Nursing Progress Notes, dated 10/24/2021 at 8:01 A.M. document, (R3) was yelling out in pain this AM (morning). Complains of right foot pain and lower back pain. At 9:10 A.M. (R3's) notes document, (R3) sent out to ER (emergency room ). R3's Nursing Progress Notes, dated 10/24/2021 at 12:37 P.M. document, ER (emergency room ) Nurse called back and stated that (R3) will be returning within the hour. (R3) had a right ankle FX (fracture) and a left fibula fracture. Follow up with(Local Orthopedic Group) on Monday. R3's ED (Emergency Department) Provider Notes, dated 10/24/2021 document, (R3) presents with fall overnight. (R3) is obese, requiring a (mechanical lift). (R3) reports to me that the (mechanical lift) was malfunctioning at the (facility) and nurses attempted to transfer (R3) form the chair to the bed using a walker and assist of two. (R3) states that as she stood up, her feet went backwards underneath her and she fell on to her right side. (R3) states she did not strike her head. Diagnoses: Right ankle fracture and Closed fracture of proximal end of left fibula. On 11/3/2021 at 2:12 P.M., V6/Registered Nurse (RN) stated, I was here on 10/23/2021 around 8:00 P.M. when the accident with (R3) occurred. The CNAs had tried the lifts and neither of them would work. The battery was dead, it wouldn't run. I called for lift assistance from the ambulance service. I put a gait belt on (R3). When we tried to stand her, she went to her knees and yelled that her leg hurt. We did not go get the lift from the fourth floor. We did not attempt a slide board transfer before we tried to stand (R3). On 11/3/2021 at 3:10 P.M., V7/Maintenance Director stated, The (mechanical lifts) are supposed to be plugged in between use to recharge the batteries. There are two docking stations on the second floor, near the nurse's station and and clean utility room. When I looked at the lift, the fuse in the battery pack was blown. I had to replace it. It wouldn't hold a charge. On 11/4/2021 at 8:17 A.M., V5/Certified Nursing Assistant stated, (On 10/23/21), The lifts wouldn't work. The battery was dead. We had eight people to help lift (R3). But (R3) got weak and began to fall. We didn't try a slide board transfer on (R3). Nobody went to and got the lift from the fourth floor to try. On 11/4/2021 at 8:37 A.M., V3/Certified Nursing Assistant stated, I was working on the fourth floor and we got a call that they (second floor) needed help transferring (R3). Nobody asked us to bring our lift. We attempted to stand (R3) and she got weak and fell . Nobody attempted a slide board transfer. On 11/4/2021 at 8:42 A.M., V4/Certified Nursing Assistant stated, We tried to transfer (R3) from her wheel chair to the bed. She stood, but got weak and fell to her knees. On 11/4/2021 at 8:29 A.M., V24/Physical Therapist stated, (R3) hasn't stood to transfer for many years. She doesn't have the strength for that. (R3) was in Physical Therapy from 8/31/2021 until I discharged her on 10/15/2021. She was discharged at a transfer with a mechanical lift or a two person lateral scoot, using a slide board. R3's Progress Notes, dated 11/8/2021 by V25/Physician's Assistant document, (R3) presents to the clinic for evaluation of a bilateral leg pain. (R3) was attempting to transfer from her wheel chair to bed, when her legs buckled underneath her and she rolled her ankles. Pain is currently described as aching, throbbing and occasionally sharp. Pain is rated at 10:10 in severity, at it's worst. Radiology: views of the right foot, right ankle, left tibia/fibula and left foot were obtained. Assessment: Closed, nondisplaced right second metatarsal base fracture; closed, nondisplaced right second middle phalanx fracture; right ankle sprain with chronic appearing distal fibula fracture; left ankle sprain; chronic left proximal fibula fracture and diffuse disuse osteopenia. Plan: (R3) was placed into a right short-leg fiberglass cast and a pneumatic boot on the left. (R3) is currently non-weight bearing and utilizes a (mechanical lift) for transfers. B. Findings include: The facility's Elopement Risks policy, dated 5/2017, documents, Objective: To keep residents at risk for wandering safe from this behavior and thus risks associated with wandering. For those residents who are assessed as potential risk for, or known history of, or observed to wander: Are monitored frequently; All exits are alarmed or in visual control 24 hours a day. The facility's Wander Management policy, dated 2016, documents, How it works: Each resident wears a small radio transmitter and exits are protected by door controllers. When a resident approaches an exit, the door controller locks the door to prevent the resident from leaving; if the door is opened, an alarm sounds. The facility's Elopement tag User Guide, dated 8/2017, documents, Monthly testing and maintenance of this product is essential to verify the system is operating correctly and to ensure that the probability of detecting an alarm and/or locating the transmitter are maximized. The failure to undertake regular testing and maintenance will increase the risk of system failure and failure to detect resident wandering. The failure to undertake regular testing and maintenance will increases the risk of false reports of resident wandering. A written summary signed by V1 (Administrator) documents, Upon further investigation, it was found that the service elevator had malfunctioned. The button on the elevator was broken and was getting called to the fourth floor. R5 stated that no one was at the nurses desk and she wanted to go outside so she walked onto the service elevator and then walked out. On 11/9/21 at 10:30 a.m., R5 stated, I wear an elopement device (pointing to her right ankle where a device with strap was attached to her ankle) so that I don't leave the building. The staff are supposed to take us out to smoke after our meals. We only go out three times a day. Last Sunday (10/31/21), they kept telling me they didn't have time to take us out to smoke, and we weren't going to go out. So, when the elevator door was open and no one was around. I got on, and no one stopped me from going downstairs. I got off the elevator on the first floor turned right. Went through the double doors towards the laundry room. Then, I went thru another door that goes back to laundry. The exit door is right beside laundry, and it was propped open. With it being propped open I knew the alarm wouldn't go off. So, I thought to myself, 'hey why not get some fresh air, and maybe someone is out there smoking that I could bum a cigarette from.' That is where staff go to smoke. So, with my good leg, I kicked the door open and wheeled myself out onto the sidewalk. No one was out there, but I thought I'm free! I stayed on the sidewalk and just absorbed the fresh air. A doctor from next door eventually came over to me and asked if I was a resident. I told him yes and he brought me around to the front door where two CNAs (Certified Nursing Assistant) came down to get me and take me back up to the fourth floor. On 11/9/21 at 2:00 p.m., an exit door was located next to the laundry room. When opened the door alarmed. However, the door required to be pulled shut in order to reactivate the system. R5's Care plan, dated 7/22/21, documents, I (R5) wander at times. I have an elopement device in place. The care plan also documents the following interventions: Equip resident with a device that alarms when wanders. Check for placement of device as ordered. On 11/8/21 at 2:00 pm, V2 (Director of Nursing) stated, For some reason, (R5's) elopement device did not trigger the door lock when she went out the door. We think (R5) went out the front door. The elevator was malfunctioning and the door was opening randomly. So she didn't need the code to get onto the elevator. Her elopement device didn't work properly either. I'm not sure of who checks the functioning of the elopement device. I took the elopement device and checked it on the back door. It alarmed but did not lock. The front door did not alarm or lock when I tried it. A facility elevator service visit form, dated 10/31/21, documents, V7 (Maintenance Director) called on 10/31/21 at 10:51 a.m. reporting #2 East Kitchen elevator was shut down. When we arrived at 11:18 a.m. the unit was running with a door operation problem. We replaced the car pushbutton switch; replaced the car pushbutton contact; adjusted the car station wiring, and adjusted the car pushbutton contact. On 11/10/21 at 11:15 a.m., V13 (Registered Nurse) stated, Last time I saw (R5) was before 9:00 a.m. when I passed her medications. That morning, (R5) was yelling about going out to smoke. Then, I get a phone call that (R5) was outside the building. I was told she was found in a smoking area. There wasn't any alarms going off. The elopement device was on her ankle but nothing sounded. On 11/9/21 at 9:00 am, V7 (Maintenance Director) stated, My responsibility is to do a monthly test on the elopement devices by taking a resident to the front door or the resident smoking door and seeing if the alarm goes off. If it doesn't then we have an issue. I don't check their alarms on the laundry room exit door because the residents don't use that door. If a elopement device is near the exit, it will immediately lock the door and start beeping at the keypad. The front door was not signaling quick enough in response to what the nurses were telling me. I don't know what the manufacturers guidelines are to check the device and our wander system. I check the exit doors randomly throughout the week to make sure they are sounding, but I don't have any kind of log. The elopement device that was on (R5) when I checked it didn't lock the door immediately, like it is supposed to do when she approaches the door. The alarm then sounded. The nurses working stated the alarm did not even go off. I did not have anyone look into the elopement system. The elevator buttons are plunger so when the button is pushed it should plunge back out and this one did not. So no matter what if I was on 2nd floor it would take me to the first floor but then automatically take me up to the fourth floor. It was reading as if someone was pushing the button to get onto the fourth floor. So ultimately with the elevator door malfunctioning she was able to get onto the elevator, which she shouldn't have been able to, and then the wander guard system malfunctioned as well allowing her to get outside. On 11/10/21 at 12:30 p.m. V1 stated, (R5) exited out of the laundry room exit door. The alarms did not go off because the door was partially propped open. If the door had been completely shut the alarm would have went off when (R5) went through it. On 11/9/21, V1 (Administrator) provided a list of residents who are at risk for elopement and have a elopement risk device. This list included the following residents: R1, R5, R11, R12, R13, and R15.

Based on interview and record review, the facility failed to obtain MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R7 not receiving needed anti-[CONDITION(S)] medications which resulted in R7 experiencing a [CONDITION(S)], requiring R7 to be transferred to a local hospital. Findings include: Facility policy, entitled Admitting the Resident, dated 4/21, document, 12. F. The nurse is to review admission paperwork from the hospital, along with information obtained through nurse to nurse report to ensure that all care needs have been identified and physician/NP [Nurse Practitioner] informed of necessary monitoring, such as diagnostic, laboratory, or point of care monitoring such as BGM [blood glucose monitoring]; g. The nurse is to reconcile the hospital orders for medications and report these to the Physician/Physician extender to verify the continuation of orders. Resident document, used during the admission process/from local healthcare organization, entitled [R7's name, medical record number and date of birth], document the following [CONDITION(S)] medications, [MEDICATION(S)] 750 MG [milligram] take one tablet by mouth 2 (two) times daily; and [MEDICATION(S)] 300 MG take one tablet by mouth 2 (two) times daily; and Hx [history] of brain surgery after [MEDICATION(S)] head trauma 12/23/2015; [CONDITION(S)] disorder; and Seizures post brain surgery. A typed letter, dated 4/12/2021, from V6/Medical Doctor-Neurologist, documents, [R7] Is a patient in my office at [Blank] Health Group Neurology. Due to [R7's] neurological condition he is unable to care for himself and needs 24-hour supervision. R7's Electronic Medical Record [EMR] documents: 10/3/21 5:04 p.m., Admission Note Date and Time of arrival: 10/02/2021 4:16 PM admitted from: Home and admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's EMR, documents, medication orders were not received until 10/3/21 (1:55 PM) [V5/Medical Doctor/Director] contacted for medication orders and lab requests. Orders received for medications. R7's EMR, under Orders, dated 10/3/21, at 4:19 p.m., document, [MEDICATION(S)] tablet; 750 mg; amt: 1 tab; oral Twice A Day 08:00 AM, 08:00 PM and [MEDICATION(S)] tablet; 300 mg; amt: 1 tab; oral Twice A Day 08:00 AM, 08:00 PM. R7's EMR, dated 10/3/21, at 8:58 p.m., document, Resident (R7) noted sitting on bed talking on phone. CNA (Certified Nurse Assistant) ran over for nurse to respond emergently to (R7's) room around 8:30 p.m At that time resident noted laying on bed with head facing footboard, alert but unresponsive. Resident making moaning noises but unable to respond appropriately. Resident's pupils are equal but grossly enlarged. Resident noted to have urinated self when normally continent. Resident's left side of body appears limp. Hematoma noted to R[ight] side of head. Resident vitals 170/93, 84, 95% RA, (Respirations) 14, (Temperature) 99.1. CNA [Certified Nursing Assistant] noted seeing resident 10 mins [minutes] prior to event sitting on bed with no issue and responsive per norm. When returning on wellness checks, resident noted shaking violently on bed with eyes rolling toward back of head and unresponsive. [V5] made aware and orders resident to be sent out to ER [emergency room ]. 911 notified and taking (R7) to [local hospital] for further evaluation. POA [Power of Attorney] made aware. ADON [Assistant Director of Nursing] to f/u [follow/up] with POA regarding concerns d/t [due to] nurse gathering paperwork to send out resident. Administrator and DON [Director of Nursing] also made aware d/t being a new admit with sudden change. Hospital called with report. Local hospital documentation, encounter date 10/3/21, document, Neurology consult hospitalization . (R7), who was admitted yesterday to [nursing home]. According to the nurse, he was not taking his medication recently. I resumed his medication by the phone including [[MEDICATION(S)]]. At night, patient was transferred to the emergency room because of [CONDITION(S)]-like activity. He was having a [CONDITION(S)] during transfer and he was given IV [intravenous] [MEDICATION(S)] and he had [CONDITION(S)] in the emergency room and he was given IV Lorazepam. Patient has a history of brain aneurysm, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient was seen already by neurology service. CAT [Computerized Tomography] scan of the head showed nothing acute, but postoperative changes in the right frontal lobe. When I saw the patient, he was not communicating well, but he was comfortable in bed; and Reason for Consultation: [CONDITION(S)]. According to the record the daughter states that he had aneurysm causing a [CONDITION(S)] as his last [CONDITION(S)] was approximately 1 year ago, She noted that after the [CONDITION(S)] he takes a couple days to return to his normal baseline he does have paralysis afterwards causing difficulty with speech. On 10/6/21, at 10:05 a.m., V2/DON confirmed R7 was admitted from home and should have received R7's [MEDICATION(S)] and [MEDICATION(S)] due to R7's history of seizures and TBI [Traumatic Brain Injury]. V2 stated, There was a breakdown in communication with the Nurse Practitioner and the admitting Nurse. V2 confirmed R7 should have had medication orders in place, but the Medical Doctor did not return the facility phone call, requesting the medication orders, for 24 hours. V2 also confirmed R7 missed [MEDICATION(S)] and [MEDICATION(S)] medications on 10/2/21 at 8:00 p.m., and again on 10/3/21 at 8:00 a.m. and 8:00 p.m. On 10/6/21, at 12:00 p.m., V3/Registered Nurse stated that V3 was R7's admitting nurse. V3 confirmed that on 10/2/21, R7 arrived at the facility, from home, without admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/6/21, at 1:10 p.m., V4/Advanced Nurse Practitioner confirmed: being in the facility when R7 was admitted and deferring R7's care to V5 even though V4 was on call and in the facility; V4 confirmed that V4 did not order medications or assess the resident prior to leaving the facility. On 10/6/21, at 12:06 p.m., V6/Medical Doctor-Neurologist stated, regarding R7's anti-[CONDITION(S)] medications, (It was) critical to have those [CONDITION(S)] medications ordered and administered and that by missing those doses [3 total doses] lead to (R7's) [CONDITION(S)] and hospitalization . On 10/8/21, at 8:30 a.m., V2 confirmed, with new admissions from home, Nurses are to put orders in under V5 and the Advanced Practice Nurses are to review and sign off; V2 verified that V4 failed to sign off and that V4 stated, Not to input orders as she would not sign off on them; V2 stated that the nurses should have kept calling V5 until they reached him, but they didn't; V2 also stated that the Nurses should have reached out to the pharmacy where R7's medications were filled, but they didn't; V2 stated that R7 was admitted with no admission orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview, and record review, the facility failed to provide a resident with safety interventions and provide adequate supervision to ensure R1, a newly admitted resident with a recent history of a suicide attempt, did not engage in behavior of self-harm and maintained a safe environment free of hazards for one of three residents R1 reviewed for supervision, in a total sample of three. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on September 10, 2021, the facility remains out of compliance at Severity Level 2, as the facility continues to ensure a process and procedure is in place to screen R1 for potential suicidal risk upon re-admission, provide a comprehensive assessment of R1 and R1's environment to ensure the safety upon return to the facility and complete audits with each new admission for 4 weeks to ensure direct care staff and all departments are receiving pertinent information from the pre-admission screening. Findings include: R1's Pre-admission documentation, titled History & Physical Note, printed on 9/1/21, documents, Patient R1 was recently admitted on [DATE] to local hospital and was discharged on [DATE] for intentional ingestion of batteries; Consultation Note under Assessment/Plan-Intentional ingestion of batteries of two batteries. [CONDITION(S)] and [CONDITION(S)] disorder. Auditory hallucination and suicidal attempt. On 9/9/21, at 9:30 AM, V5/Marketing-Hospital Liaison confirmed during the screening process that R1 was determined to be in the yellow meaning take a second look at R1 prior to admission; V5 stated, R1 was in the yellow because she was COVID-19 positive, depression, psychiatric issues, and swallowing batteries which was shared to the facility in my email. V5 stated would definitely not give R1 batteries knowing R1 had a recent history of swallowing batteries. V5's electronic mail correspondence, dated 9/1/21, documents the recipients included: V1/Administrator, V2/Director of Nursing, V3/Assistant Director of Nursing, V6/Senior Vice President, and V7/Regional Director. V5's electronic mail documents, Good Evening team, new referral, patient R1 is COVID-19 positive, [CONDITION(S)] disorder, and she also swallowed batteries a week ago, she is also on 4L (liters) of O2 [oxygen] she is 403 pounds, her stay will be (rehabilitation) only, and will return to [another assisted living facility] after her discharge. Fasttrack is attached please advise thank you. R1's Electronic Medical Record (EMR) documents R1 was admitted to the facility on [DATE] at 7:02 p.m. R1's EMR does not contain a Care Plan/Interim Care Plan, nor suicide risk assessments. R1's EMR, dated 9/5/21 at 10:04 a.m., document, R1 continuously screaming inappropriate words to RN (Registered Nurse) and CNA (Certified Nursing Assistant) this morning. All medications given; [MEDICATION(S)] patch placed on Lumbar area with assistance from CNA for placement. At approximately 10:05 a.m., R1 screamed out 'I just ate the batteries, now what do you think of that?' CNA and Nurse went into R1's room and the (television) remote was on the bedside table with the battery cover removed. Batteries missing. 911 called and a search for the batteries took place in her room. Batteries were not found. V10/Nurse Practitioner contacted. No (POA) Power of Attorney information provided in paperwork, R1 stated, she had no one. R1 alert, and stable upon local Fire Department arrival to facility. Assist of two given to place on gurney. Commands followed with instructions to pivot and sit on gurney. R1's Local hospital documentation, dated 9/5/21, document, in part, D: R1 at local long term care facility brought to the (ED) Emergency Department for depression, (SI) Suicidal Ideation with attempt by ingesting batteries. Per report, R1 said she swallowed one a couple days ago and two more today with intent to kill herself as she doesn't like it at the local long term care facility. R1 tested positive for COVID about five days ago. At 12:12 PM, Looks to have batteries in stomach and one in small intestine. (GI) Gastro-intestinal paged. 1:00 PM, spoke with (GI) doctor who recommends daily x-rays until batteries passed. At the time of the State Survey, R1 remained hospitalized , and batteries remained inside of R1. On 9/8/21, at 9:15 AM, V4, Care Plan coordinator confirmed that no Care Plan, nor Interim Care Plan had been done for R1. On 9/8/21, at 9:25 AM, V1 (Administrator) confirmed knowing R1 had ingested batteries approximately a week prior to R1 being admitted to the nursing facility on 9/4/21. In addition, V1 confirmed R1 had no Care Plan, nor Interim Care Plan addressing R1's specific needs. On 9/9/21, at 3:50 PM, V1 confirmed the admitting staff should have known about R1's past battery swallowing incident. V1 stated staff should review the referral packet which contains all information on the incoming resident. On 9/8/21, at 2:10 PM, V11/Registered Nurse confirmed V11 was the nurse that did R1's admission on 9/4/21. V11 stated while receiving phone report, from the hospital, V11 was told R1 was on suicide precautions. V11 immediately called V2 (Director of Nursing) who in turn called the hospital to verify. V11 stated V2 reported back that R1 was not on suicide precautions. V11 confirmed having no idea about R1's previous battery swallowing incident, and R1 was not placed on suicide precautions. On 9/9/21 8:50 AM, V2 (Director of Nursing) stated V2 told V11/Registered Nurse who admitted R1 to be cautious because R1 did have a problem with swallowing batteries. I did not want to be lackadaisical; and I didn't come out directly and say don't give anything with batteries. V2 confirmed, based on knowledge of R1's past battery swallowing, that R1 should not have had the remote-control containing batteries. On 9/9/21, at 4:10 PM, V2 stated, Nurses are supposed to use an admission check off audit form which some do, and some don't. V2 confirmed V11 did not use the audit form, entitled 24-48hr Admission/Readmission Reconciliation/Audit, updated 5/2021, which documents, in part, under Checklist, Admission packet under observation in the EMR which would directed V11 to review the history of R1, had it been completed, the admitting nurse would have known of R1's previous battery swallowing hospitalization , as reviewing the admission packet is part of the admitting process. On 9/10/21, at 9:20 AM, V12/Activity Aide stated V12 knew nothing of R1 and never saw R1, V12 stated since R1 is on a COVID unit, she never entered the unit. V12 would leave coloring books and pencils with nurses. On 9/10/21, at 10:15 AM, V14/CNA confirmed working with R1 the day R1 was sent out to the hospital on (9/5/21). V14 confirmed R1 was verbally abusive to V14 by making racial slurs, and other name calling. V14 confirmed she was not aware of R1's previous suicide attempt by swallowing batteries. V14 also stated she was unaware of any suicide precautions for R1. On 9/10/21, at 10:30 AM, V15/Registered Nurse confirmed: working on the COVID Unit, with R1, the day R1 ingested the batteries (9/5/21); V15 stated she was in the hallway when she heard R1 yell that R1 swallowed batteries; when entering R1's room, V15 saw the television remote laying upside down with a battery cover off and the batteries missing; a quick cursory search was done and 911 was notified; V15 stated she was not aware of R1's previous suicide attempt by swallowing batteries; and no suicide assessments were done during R1's brief stay. On 9/10/21, at 11:15 AM, V16/Maintenance confirmed making sure R1's room was set up with a working television and remote control. V16 confirmed V16 had no knowledge of R1's past battery swallowing incident. V16 confirmed R1 was not on any precautions that would prohibit items containing batteries. The Immediate Jeopardy was identified on 9/9/21, at 12:18 PM, The Immediate Jeopardy began on 9/4/21, at 7:02 PM, when the facility failed to provide R1 with safety interventions, and provide adequate supervision, to ensure R1 did not swallow remote control batteries. This failure resulted in R1 taking the battery cover off the television remote control, removing two AAA batteries, and then swallowing the batteries. On 9/10/21, at 12:40 p.m., V1/Administrator, V2/Director of Nursing, and V6/Senior Vice President were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1) As of 9/14/21, R1 remains at the local hospital. 2) On 9/5/21, V15 (Registered Nurse) sent R1 to a local hospital for evaluation and conducted a room sweep to ensure that no small items remained that could be used for self-harm. 3) The facility held an emergency Quality Assurance meeting with Administration team on 9/10/21 to determine and implement a corrective action plan to remover the immediacy. 4) On 9/9/21, V1 (Administrator) and Admission Director trained admissions staff to highlight behaviors, including suicidal ideation, behavior of self-harm or harm to others 5) On 9/9/21, V1 (Administrator) conducted training for the Nursing staff regarding the admission process and the importance of reviewing all admission documentation and communicating resident behaviors with other staff. 6) On 9/10/21, V2 (Director of Nursing) completed audits of current behavior Care Plans and made updates as necessary

Based on observation, interview and record review, the facility failed to ensure an indwelling urinary catheter was secured with adequate slack to prevent tension during incontinence care for one (R41) of three residents reviewed for incontinence care out of a sample of 47. This failure resulted in R41 experiencing skin breakdown around the penis and subsequent ventral penile tearing resulting in permanent ventral penile erosion. Findings include: Facility Catheter Care policy revised 5/17 documents, To cleanse perineum. 5. After cleaning is complete. 7. Secure the catheter to the thigh and or lower abdomen in men to facilitate flow of urine and prevent excessive tension on the catheter. 9. Observe condition of resident's skin and report any significant findings to nurse. According to an article published in Advances in Urology (Vaidyanathan et al, 2010) titled Severe Ventral Erosion of Penis Caused by Indwelling Urethral Catheter and Inflation of Foley Balloon in Urethra - Need to Create List of Never Events in Spinal Cord Injury in order to Prevent These Complications from Happening in Paraplegic and Tetraplegic Patients, Severe ventral erosion of glans penis and shaft of penis caused by indwelling urethral catheter, and incorrect placement of (Indwelling urinary) catheter in urethra are preventable complications. R41's medical record documents R41 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's medical record dated 6/15/20 documents (Indwelling urinary) catheter placed this afternoon without difficulty. Draining medium yellow urine. R41's Care Plan dated 12/1/20 through 4/15/21 documents Problem start date: 10/23/20 through 4/13/21 - resolved. I have ventral erosion to my penis. R41's care plan dated 12/1/20 through 4/15/21 does not include additional interventions addressing R41's penile erosion after 10/23/20. On 04/13/21 at 01:24 PM R41 stated, A few months ago two CNAs (Certified Nursing Assistants) took my pants off a little too fast and ripped the catheter through my penis. I don't have the catheter anymore. I tried to use the urinal, but urine comes out the side of my penis and gets everywhere, so now I have to go in my (adult brief). I've tried urinating in the toilet, but I have the same issue of urine going everywhere. On 04/15/21 at 09:05 AM V2 (Director of Nursing/DON) stated, (R41) reported to me that some CNAs were pulling down his pants to get him cleaned up and ripped his penile erosion more. He didn't complain of pain and there was no blood. R41's medical record Nursing Progress note dated 10/22/20 at 11:12 AM, documents, CNA requested this nurse in the room, this nurse assessed (R41) and noted that his penis was flayed from the meatus to the shaft. No bleeding present. (urinary) catheter in place and stabilized and in place. No signs or symptoms of distress (R41) complains of minor pain during catheter care. No evidence of acute trauma. Nurse Practitioner (APN) notified and assessed area. Order given by APN to send (R41) to emergency room . R41's hospital record dated 10/22/20 documents, Would advise the nursing home to provide enough slack on the (indwelling urinary) catheter to prevent against further injury to the urethra. R41's medical record Nursing Progress note dated 10/23/20 at 1:21 AM, documents This writer performed first aid on the resident's penis shaft. The resident's split shaft was leaking blood. I used normal saline to wash away the dried blood and iodine to sterilize. Upon finishing it appeared that it was no longer actively bleeding. I will continue to monitor. On 4/15/21 at 3:12 PM, V11 (CNA) stated, I was working both days the incidents took place. The catheter tearing into his penis happened twice that I know of. I don't remember the exact dates. The first time it happened, (R41) told me the previous CNAs ripped his catheter into his penis during care. I looked and the catheter had torn into his penis. It was wedged between the skin. I immediately reported it to the nurse and (R41) was sent to the hospital. The second time it happened, I was changing him and saw blood in his depends. The catheter had cut down into his penis. I immediately told the nurse and I remember the nurse had to perform first aid to stop the bleeding on his penis and she stated she thought he would need stitches. On 4/15/21 at 12:25 PM, R41's incontinence care was observed. During this time, R41's penis was flayed open starting at the external urethral opening through the frenulum of the prepuce to midway down the shaft exposing the urethra approximately 5.0 cm from head to toe direction. R41's wound management record dated 10/23/20 documents, Wound: Penile - severe ventral erosion. 11/23/20 at 12:10 PM Length head to toe direction 1.5 centimeters(cm) and width hip to hip direction 0.5 cm wound healing status stable. R41's wound management record documents, Wound: Penile - severe ventral erosion. 11/5/2020 at 3:23 PM Length head to toe direction 1.5 cm and width hip to hip direction 0.4 cm wound healing status stable. 11/27/2020 at 11:14 AM length head to toe direction 5.0 cm and width hip to hip direction 1.5 cm. wound healing status declining. R41's wound management record documents, Wound: Penile - severe ventral erosion. 1/12/21 at 11:00 AM Length head to toe direction 5.0 cm and width hip to hip direction 1.5 cm wound healing status stable. On 4/14/21 at 1:30 PM, V5 (Wound Nurse) stated, (R41)'s ventral penile erosion shows up on the wound management, but it's been discontinued. We discontinued his treatments because the wound has healed. The erosion will always be open now. It won't heal back together.

Based on observation, interview and record review the facility neglected to provide skin assessments and physician ordered treatment for [REDACTED]. This failure resulted in impaired healing and worsening skin conditions for four residents with known wounds (R1, R40, R62, R95). The facility also neglected to provide timely lifting assistance for R87 after a fall and failed to provide appropriate lifting equipment for R40 resulting in a missed [MEDICAL TREATMENT] appointment for R40 on 8/13/2020. The facility neglected to provide skin care to R40 causing R40 to refuse [MEDICAL TREATMENT] in 09/01/2020 because of extreme pain. This systematic failure resulted in worsening wounds, increased pain, and missed [MEDICAL TREATMENT]. These failures resulted in an Immediate Jeopardy While the Immediacy was removed on 9/11/20, the facility remains out of compliance at Severity level 2 while in the process of implementing re-education components and training related to: Emergency Response, Skin Assessments, Skin Treatments and Documentation, Pain Management and Medication Administration. Findings include: The facility's undated Abuse Prevention Program, documents Neglect means the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. 1. On 9/1/2020 at 12:00PM R40 stated, I missed [MEDICAL TREATMENT] a couple of weeks ago because there wasn't a sling to get me out of bed. I had to go to the hospital for [MEDICAL TREATMENT]. I have trouble sometimes getting out of bed because there isn't always enough staff to get me up either. I have only had three showers since I was admitted in December and I do not think my hair has been washed for a couple of months. They do not have any caps to wash my hair with like they do in the hospital. I have two treatments. One on my right hip and the other towards the groin. I got bandage put on yesterday. I am lucky to have my treatment done once a month. No one ever shows up to do it on the weekend. On 9/1/2020 at 11:30AM V32 (Registered Nurse/RN/[MEDICAL TREATMENT] RN) stated, The nursing home did not have sling to transfer R40 out of bed on Friday 8/14/2020 so V29 (Nephrologist) sent her to the hospital for [MEDICAL TREATMENT]. She could not go through the weekend without [MEDICAL TREATMENT] treatment. We do try to accommodate the lack of staff time or equipment if the residents cannot get in at their time for [MEDICAL TREATMENT]. We cannot do anything if they cannot get them out of bed. On 9/2/2020 at 1:00p.m. V29 stated, (R40) had to be sent to the hospital for [MEDICAL TREATMENT] because the facility did not have sling to transfer (R40) out of bed for [MEDICAL TREATMENT]. It was Friday and she could not go the entire weekend without [MEDICAL TREATMENT]. It could be very detrimental to her health if she had not been hospitalized . On 9/1/2020 at 1:40PM V3 (Licensed Practical Nurse/LPN/Treatment Nurse) stated, (R40) went to the hospital and returned on 8/22/2020. The treatment order did not get 'pulled forward' (entered into R40's medical record) so there was not a treatment until yesterday (08/31/2020, nine days later). Now she has an open area on her right abdominal apron too. On 9/1/2020 at 1:45p.m. V3 (Certified Nurse Aide/CNA) and V10 (CNA) assisted R40 to roll on to her left side. R40's right hip and back of her right thigh had multiple round and linear shaped open areas ranging from pinpoint to larger than a quarter in diameter with defined borders, bright red in color with scant bleeding. This surveyor counted 12+ wounds on the back of R40's thigh and another 4+ wounds on her hip at beginning of the crease in her belly fold and under her apron belly flap. V18 (LPN) verified the presence of the wounds then cleaned the areas. R40 started to complain and wanted to be placed on her back to rest. V18 and V10 lifted R40's belly apron further to perform a treatment to the center lower abdomen. R40's lower abdomen was observed to be covered with a malodorous thick, white, mucous substance and more open wounds. V3 and V10 then assisted R40 to her left side. As they repositioned R40 on her right side, there was dried stool down the back of R40's left leg. R40 was observed to have draining blood blister on the upper right quadrant of her abdomen and open areas in the creases of the outer aspect of her left thigh and abdominal fold verified by V3. R40 complained of pain at this time and wanted to be rolled onto her back. On 9/1/2020 at 1:20p.m. V18 (Licensed Practical Nurse/LPN/Treatment Nurse) verified the two treatment orders for R40 to be completed: Left lower apron abdomen - cleanse with wound cleanser, place a 6x10 Optilock (moisture absorbing dressing) x2 lengthwise to absorb weeping, change daily, start date 8/31/2020. The second order was to the right lower aspect of the lower abdomen: cleanse with soap and water, pat dry, apply [MEDICATION NAME] (adhesive dressing with an absorbent center), 4x4 change daily, start date 8/31/2020. There were no other treatment orders present for the other wounds. During the treatment R40 stated to V3, I have so much pain in that sore (motioning to her left lower belly) that I didn't go to [MEDICAL TREATMENT] this morning. On 9/2/2020 at 12:50 p.m.V30 ([MEDICAL TREATMENT] Office Manager) verified R40 did refuse [MEDICAL TREATMENT] on 9/1/2020. On 9/1/202 at 2:40PM V3 stated, (R40's) 8/22/2020 readmission skin assessment did not get done that day because it was a Saturday or Sunday, because I don't work on Sundays. Mondays and Tuesdays I do the COVID testing so I did not do treatments on those days. The last Skin Management report provided was 8/19/2020, not a readmission report post the 8/22/2020 hospitalization . On 8/22/2020 V31 (LPN) completed an admission assessment that stated R40's pressure wounds were the same as they were before her hospitalization . No wound measurement or location was noted on the assessment. On 9/1/2020 at 2:15p.m. V3 stated, All those open areas were new. I did not know about them. And that white stuff under (R40's) belly is just 'funk' from not having a shower. R40's June, July and August shower sheets were reviewed. R40 has not received a shower in those months. R40's Activity of Daily Living documentation does not document R40 as having a daily bed bath for cleanliness. 2. R95 was admitted to the facility on [DATE] with daily wound care orders for a recent trans metatarsal (toe) amputation on her right foot, [MEDICAL CONDITION] in her left lower leg, and an open area on her left heel. R95 discharged home on[DATE]. The admission skin assessment documents R95 had a pressure ulcer on her left heel, however no measurements of the wound were documented. There was no mention of the surgical site on this assessment. The facility policy for Wound Care dated 5/17 documents, Follow physician's orders for wound care. Documentation of wound care must be completed each time the treatment is done. This documentation will be done on the Treatment Administration Record (TAR). Current wound status must be documented no less than once a week. Facilities using (Electronic Health Records) EHR will complete a weekly treatment (Non-Pressure Ulcer) documentation observation. Wound changes and other pertinent observations must be documented in the Nurses Notes as they occur. R95's Physician's Orders document treatment orders: Right lower extremity. [MEDICATION NAME] swabs. Apply topically for wound paint to incision sites. Cover with 4x4's and Kerlix. Complete the treatment daily. The order date was 8/8/2020. The treatment for [REDACTED]. Wrap with Kerlix and wrap with Ace Wrap. On 9/4/2020 at 10:30 a.m. R95 stated, I can tell you that I did not get a shower during my stay at Generations. I was not offered one the entire time I was at the facility. No one was 'mean' to me, they just would not do anything for me. I could not get out of bed for breakfast until sometimes 11:00 a.m. I have Acid Reflux and cannot eat while I am lying in bed, so I missed breakfast on those days because I would not eat it. When I first got to the facility, I laid in bed for two days because they said the lift wasn't charged. Now, you and I both know it does not take two days to charge a lift. They just didn't want to get me out of bed. I even asked someone why they agreed to take me if they could not take care of me! The first three days, no one changed my dressing. They only changed it one time while I was there. On 9/4/2020 at 12:00p.m. V28 (Podiatrist) stated he had been treating (R95) and was continuing to treat her. V28 verified her treatments were to be completed on a daily basis for both right and left feet. He stated on 8/18/2020 she came to the wound clinic with a dressing in place dated 8/10/2020. The facility was not able to provide the Treatment Administration Record for R95's stay at this facility. There was not a wound management note completed for R95. 3. R1's admission transfer orders, dated 4/2/20, document R1's wounds to be followed by podiatry with the following treatment orders to bilateral heels: Cleanse bilateral heels with Dakins solution, apply SSD (Silver [MEDICATION NAME]), cover with non adherent pad and wrap with gauze three times a week. R1's admission skin assessment documents R1 had diabetic ulcers to bilateral heels and right ankle. No wound measurements were obtained until 4/13/20. R1's EHR documents R1 was not seen by facility wound nurse until 4/13/20, was not seen until 6/30/20 by wound consultant services, and not seen by podiatrist until 8/18/20. R1's EHR documents the facility Registered Dietician (RD) saw R1 and made recommendations for R1 to receive 30ml (milliliters) of a liquid protein supplement on 4/8/20, 5/6/20, and 6/3/20. These dietary recommendations were signed off as orders by V8 (Nurse Practitioner/NP) and not processed until 7/6/20, was discontinued on 7/26/20 and reordered on [DATE]. On 4/21/20 V34 (former Registered Nurse/RN/Wound Nurse) documented she applied [MEDICATION NAME] mixed with collagen to the wound bed, covered with non adherent dressing and ace wrap the right heel and right ankle. Autolytic debridement of the above treatment applied to wound bed. There is no physician order for [REDACTED]. On 8/28/20 at 4:29 pm, R1 stated she went to the facility for wound care and [MEDICAL TREATMENT] and her right heel wound only got worse. R1 stated she was supposed to have a follow up with a podiatrist when she admitted to the facility in April and that did not happen until August. R1 stated her wound treatments were not done, she did not get a supplement the dietician tried to order for her for four months and did not receive the antibiotics like she was supposed to. R1 stated even when she asked for the treatments to be done, they would tell her they would tell the Wound Nurse, they didn't have the supplies to do the treatment, or would tell the next shift nurse. R1 stated V3 (Licensed Practical Nurse/Wound Nurse) only looked at her feet three or four times during her stay and when she asked V3 how it looked, V3 would say looking good or just fine. R1 stated if they would have changed her dressing or even looked at it, they would have seen the changes. R1 stated she tried to tell the staff and the doctor that her wound was getting worse and did talk with the podiatrist at the hospital who told her if her wound got any worse she would most likely have her leg amputated. R1 stated she is currently in the hospital and having her right lower leg amputated tomorrow morning on 8/30/20. Hospital Admission Records for R1, dated 4/2/20, document Bilateral feet ulcers: Not infected as per podiatry. Outpatient follow up with podiatry recommended. The Physician Order was to cleanse bilateral heels with Dakins solution, apply SSD (Silver [MEDICATION NAME]), cover with non adherent pad and wrap with gauze three times a week. Hospital Record for R1, dated 6/19/20, documents treatment Plan - use silver AG and a Mepelex (dressing) to right calcaneus (heel) for protection and to refer to wound clinic for consult for right heel [MEDICAL CONDITION]. R1's June and July TAR's were not changed to reflect this Physician Order. Hospital Record dated 7/28/20, documents right heel MRI (Magnetic Resonance Imaging) and biopsy were completed with a suspicion of [DIAGNOSES REDACTED] and V27 (Doctor of Podiatric Medicine) following with plan to debride (surgical removal of devitalized tissue). Plan: Patient is at a high risk for limb loss. Due to patients [MEDICAL CONDITIONS] patient will require intervention for improvement of her vascular flow to her right lower extremities. If this wound further breaks down, she will most likely require a [MEDICAL CONDITION]. On 8/18/20 V27 documented (R1) stated the facility has not been doing her dressing changes and she is afraid that her leg has gotten worse due to this .(R1) is concerned about losing her leg. (R1) became very emotional during the visit. (R1) is to continue [MEDICATION NAME] dressing changes daily with assistance from nursing staff at (the facility). She states they have not been doing this .A referral will be placed for a consultation with a vascular surgeon. R1 has no TAR to reflect this Physician Ordered treatment. On 9/4/20 at 12:03 pm, V27 stated on 8/18/20 he did order daily [MEDICATION NAME] dressing changes to R1's right heel to keep the wound bed dry and the treatment certainly needs to be done. There is no August TAR for R1. On 8/3/20, V8 (Nurse Practitioner) documented after R1's 7/28/20 hospitalization , a referral for R1 to see a Vascular Surgeon. R1's TAR's, dated April through July 2020, include documentation of facility treatment for [REDACTED]. There is no August TAR for R1. On 8/27/20 at 10:45 am, V7 (RN) stated, (R1) had osteo[DIAGNOSES REDACTED] in her right foot wound and her treatment wasn't getting done. V8 (NP) documented on R1 in the Resident Progress Notes on 4/3/20, 4/9/20, 5/14/20, 6/3/20, 6/11/20, 6/14/20, 6/17/20, 6/22/20, 7/1/20, 7/6/20, 7/21/20, and 8/17/20. The only note that mentions R1's wound is from admission note on 4/3/20 that documents, (R1) with open wounds on bilateral feet with bandages in place. The note, dated 8/17/20, documents what procedures were completed for R1's lower extremities while R1 was in the hospital and documents V27's referral for a vascular surgeon consult. On 8/27/20 at 10:50 am, V8 stated she did not see R1's right foot wound while R1 was residing in the facility. V8 stated, V3 (LPN/Wound Nurse) was responsible to do (R1's) treatments and the nurses were to do them when (V3) was not in the facility. On 8/31/20 at 11:34 am, V2 (Director of Nursing/DON) stated (R1) only saw V27 one time after her hospitalization in August. V2 stated, We didn't end up getting the vascular consult for (R1) because she left against medical advice. V2 stated she could not find an August TAR for R1. On 9/9/20 at 2:06 pm, V3 (LPN/Wound Nurse) stated she was hired in March 2020 to work as the facility wound nurse. R3 stated she worked as a floor nurse until 3/23/20 and was off until 4/13/20 for medical reason. V3 stated when she returned, she worked the first five weeks as a floor nurse and in May the DON walked out and she was pulled from the floor to assist with DON duties and is still doing this. V3 stated she has also been doing weekly testing on Mondays and Tuesdays which only leaves her Wednesday through Friday to work with wounds. V3 confirmed this is why she is unable to do all the wound treatments, why there is not weekly wound documentation done every week, and why the facility just hired a new wound nurse. V3 also stated she does not know why the RD's recommendations for R1 to receive the oral protein supplement for wound healing was not addressed or ordered in April, May, or June but was ordered in July. V3 stated R1 was ordered antibiotics in August for [DIAGNOSES REDACTED] for her right heel wound and does not know if the medications were administered or not due to the Medication Administration Record [REDACTED]. V3 also stated she cannot confirm that R1's wound treatments were completed either due to the treatments not being signed out as done. V3 confirmed that R1 admitted to the facility with an order for [REDACTED]. MAR (Medication Administration Record). The only treatment documented on R1's MAR indicated [REDACTED]. R1's TAR, dated June through August 2020, documents treatment not completed as Physician Ordered. There is sporadic Weekly Wound Tracking and Wound Management Notes between 6/3/20 through 8/19/20, not weekly. On 8/28/20 at 4:29 pm, R1 stated, They weren't taking care of me like they were supposed to, so I signed out AMA (Against Medical Advice) and left. I hope I can find a place closer to home that will take care of me better. R1's Progress Notes, dated 8/21/20, document R1 discharged home against medical advice. 4. R62's Physician Orders, dated 6/30/20, documents Right Malleolus: Cleanse with wound cleanser, pat dry. Apply thin layer of Santyl to center slough area. Cover with Silicon 4 x 4 foam dressing. Change Monday, Wednesday, Friday and PRN (as needed). On 9/1/20 at 12:20 pm R62's right Malleolus was covered with a foam dressing dated 8/26/20 with visible dark drainage underneath the dressing. On 9/1/20 at 12:20 pm, R62 stated he usually has to tell the staff when the dressing comes off, otherwise they change it every couple of weeks. R62's August TAR (Treatment Administration Record) documents V3 (LPN/Wound Nurse) performed the treatment to R62's right lateral malleolus on 8/26/20. This same TAR does not document R62's treatment was completed on 8/28/20 or 8/31/20. There is sporadic Weekly Wound Tracking and Wound Management Notes between 6/3/20 through 8/26/20, not weekly. A Wound Management note, dated 8/26/20 by V3, documents R62's right malleolus measurement at 0.8 cm (centimeters) x 1.2 cm x 0.2 cm, moderate amount of [MEDICAL CONDITION] exudate, unstageable with 100% granulation, wound edge attached to base, dark purple or rusty discoloration. Improving. There is no weekly wound documentation for R62's wounds between 6/30/20 and 8/26/30. On 8/27/20 at 10:38 am, V6 (RN) stated, The wound nurse does the treatments, or we would. They don't tell us if the treatments were done or not. On 8/27/20 at 10:45 am, V7 (RN) stated, We have a fulltime wound nurse, Monday through Friday who does the treatments, but they aren't getting done. No one tells us if the Wound Nurse did the treatments or not. We do them on the weekends if we can. On 8/31/20 at 2:20 pm, V19 (LPN) stated, I do not do wound treatments when the treatment nurse is here. I am not sure if there are any days she doesn't do them, but I don't do them. On 8/31/20 at 2:25 pm, V17 (RN) stated, I do the treatments if the Wound Nurse is out. I understand the treatment nurse does all the treatments. On 8/31/20 at 2:30 pm, V37 (LPN) stated, I orientated a new nurse for the facility today. No treatments were done today. There is a treatment nurse today. I work here frequently, and I have not done treatments for the last two months. On 9/1/20 at 1:05 pm, V43 (RN) stated, Only one time has anyone ever told me that treatments weren't done and that I needed to do them, and the agency nurses tell us they don't do treatments. On 9/10/20 at 12:30 pm, V19 (LPN) stated, I never get the chance to do treatments. The workload doesn't allow for time. I've told V2 (DON) that residents complain about their treatments not getting done and that therapy has complained of not being able to do therapy treatments due to resident wound dressing falling off. I can be off for three to four weekdays or weekends and come back and the treatments will still not be done. 5. R87's Face Sheet documents R87 with the following Diagnoses: [REDACTED]. R87's EHR documents R87's current weight on 8/4/20 at 433 pounds. On 9/1/20 at 11:45 am, R87 stated on 8/22/20 he rolled out of bed onto the floor at 4:50 am and laid there until day shift came in. R87 stated he yelled for help and R70, his roommate, turned on the call light to call for help. R87 stated about an hour later V19 (LPN) came to his door, made a rude comment, and walked away. R87 stated R70 called 911 and when 911 called back V19 told them not to come to the facility. R87 stated the fire department came at 6:45 am and helped the day shift get him up off the floor at 7:00 am. R87 stated no one, including V19, ever checked him for injuries and he was on the floor for over two hours. On 9/4/20 at 11:00 am, R70 stated on Saturday, 8/22/20, about 5:00 am, R87 fell out of bed and stated he (R70) put his call light on to call for help for (R87) and a hour or so later V19 came to the door and said I don't know what you expect me to do. R87 stated If you see someone lying on the floor you help them or call for help. R70 stated V19 left and never came back. R70 stated he called 911 to get some help but no one came until about 7:00 am. I felt really bad for him because I couldn't help him. R87's Progress Notes, documented as a late entry on 8/23/20 at 12:10 pm regarding R1's fall on 8/22/20, documents R1's fall at 5:10 am. The facility Fall Report documents R1's fall occurred at 5:10 am. There is no timeline of events documented by V19 for R87's fall. On 9/10/20 at 12:30 pm, V19 stated, We generally only have one nurse and one CNA (Certified Nursing Assistant) on each floor during the night. The night (R87) fell I only had one CNA on the fourth floor with me. There was a TNA (Temporary Nurse Aid) working with V31 (LPN) on the third floor. I have talked to V2 numerous times and told her I do not feel comfortable working with so little staff. That night we didn't have a sling to fit R87, and we could not leave the floor to go to the basement laundry area to retrieve the proper fitting mechanical lift sling for R87 due to not enough staff to cover the floor. We had to wait until day shift came and called the Fire Department to get R87 off the floor. On 9/1/20 at 12:05 pm, V9 stated, (R87) fell on third shift around five in the morning and they waited until we got here on day shift so someone could go to laundry and find a bariatric sling to use with the mechanical lift. It was after seven a.m. before we finally got him up off the floor. The Immediate Jeopardy was identified on 9/2/2020 at 12:30PM. The Immediate Jeopardy began on 8/22/2020 when the facility failed to obtain a treatment order for R40 (resident with known wounds) after a brief hospitalization returning on 8/22/2020 not obtaining an order until 8/31/2020. The facility failure to provide wound assessments for a condition change causing one resident (R40) to refuse [MEDICAL TREATMENT] on 9/1/2020 due to pain from multiple deteriorating wounds, failing to provide transfer assistance to [MEDICAL TREATMENT] due to lack of staffing and equipment (8/14/2020 R40 sent to the hospital for [MEDICAL TREATMENT] by the Nephrologist due to this failure), failure to provide treatments as ordered, failed to provide bathing and grooming for R40 resident (3 showers since December with no hair washing in the past two months according to resident). V1 (Administrator) was notified of the Immediate Jeopardy on 9/11/20 at 2:00PM. The surveyor confirmed through observation, interview and record review the facility took the following actions to remove the immediate jeopardy: 1. Facility Ad hoc Quality Assurance meeting. Completed 9/2/2020 at 3:30pm 2. Education was completed with nursing staff on the following. All staff not trained at this time will be in-serviced prior to working their next shift. This education is being completed by facility staff and Corporate staff on: Emergency Response, Skin Assessments, Treatments and Documentation, Pain Management, Medication Administration. Started September 11, 2020 and ongoing. 3. Shower schedule audit. Completed September 11, 2020 at 7:00PM. 4. Audit of (full mechanical lifts) and sling inventory. Completed September 11, 2020 at 7:00pm. 5. Full house skin sweep has been conducted. Weekly Body Audit form has been completed on all in house residents. Completed on September 11, 2020 at 5:00pm. 6. An audit of wound management in the Electronic Health Record (EHR) to verify all skin issues are documented within the wound management in the (EHR), appropriate order and care plans are in place. The wound management documentation includes description and measurements. Completed September 12, 2020. 7. Quality Assurance Plan to monitor performance to make sure corrections are achieved and permanent: Director of Nursing or designee will conduct weekly audits for 6 months that include 100% review of resident skin assessment, (Treatment Administration Records (TAR)), and care plans related to skin. Identified concerns for further corrective action will be discussed and implemented as needed. Ongoing.

Based on observation, interview and record review the facility knowingly failed to provide skin assessments and daily treatment resulting in lack of healing or worsening skin condition for six of eight residents with known wounds (R1, R2, R6, R40, R62, R95) reviewed for wounds in the sample of 95. These failures resulted in an Immediate Jeopardy. While the Immediacy was removed on 9/11/20 the facility remains out of compliance at Severity level two while the facility is in the process of implementing education, facility wide skin assessment, and audits of wounds and treatments related to skin conditions. Findings include: Medical-Surgical Nursing Clinical reasoning in Patient Care, LeMone,(NAME) Bauldoff and Gubrud, 6th Edition 2015; documents, The skin and its accessory structures (the integumentary system) enclose and cover the body, providing protection by serving as a barrier between the internal and external environments. The facility policy for Wound Care, dated 5/17, documents Follow physician's orders [REDACTED]. This documentation will be done on the Treatment Administration Record (TAR). Current wound status must be documented no less than once a week. Facilities using (Electronic Health Records) EHR will complete a weekly treatment (Non-Pressure Ulcer) documentation observation. Wound changes and other pertinent observations must be documented in the Nurses Notes as they occur. 1. On 8/28/20 at 4:29 pm, R1 stated her wound treatments were not completed as ordered, no one measured her wounds every week, she did not receive a protein supplement or intravenous antibiotics as she should have. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with [MEDICAL CONDITION] to her right and left heels and right ankle. The Admission Assessment also documents R1 with rash and skin disruption to R1's abdominal fold and admitted with a PICC (Peripherally Inserted Central Catheter) line. The POS (Physician order [REDACTED]. This POS also documents [REDACTED]. The TAR (Treatment Administration Record) for R1 documents R1's wound treatment was not completed on 4/3/20, 4/6/20, or 4/10/20, was done twice on 5/5/20 and 5/17/20, and was done four times on 6/1/20, 6/5/20, and 6/12/20. This treatment order was discontinued on 6/19/20, however was done again on 6/23/20. This TAR also documents that [MEDICATION NAME] was not applied during the months of April, May or June. The POS for R1, dated 4/13/20, documents PICC line dressing change .measure arm circumference and catheter length, change caps with dressing change once a day every seven days. R1's PICC line order was discontinued on 6/19/20. The TAR for R1, dated 4/1/20 through 4/30/20 does not include the treatment for [REDACTED]. The TAR, dated 5/1/20 through 5/30/20, 6/1/20 through 6/30/20, and 7/1/20 through 7/31/20 does not document treatment was ever completed. R1's PICC line was discontinued on TAR on 7/6/20. The POS for R1, dated 6/19/20, documents [MEDICATION NAME] to be applied topically twice a day. The TAR for R1, dated 6/19/20 through 6/30 documents [MEDICATION NAME] treatment was not completed. The TAR for 7/1/20 through 7/31/20 documents [MEDICATION NAME] was not applied on 7/1/20, 7/3/20 in am, 7/4/20 through 7/6/20, 7/7/20 in pm and facility was unable to provide a treatment record for the month of August 2020. The POS for R1, dated 6/30/20, documents treatment for [REDACTED]. Apply thin layer of Santyl to necrotic center. Apply collagen sprinkles mixed with scant amount of water to make paste and apply to granulated tissue. Cover with soft 6x6 silicon foam dressing. Change Monday, Wednesday, Friday and PRN (as needed) and to Apply skin prep to left heel daily. The TAR for R1, dated 6/1/20 through 6/30/20 does not include the 6/30/20 treatment orders or document that they were completed. The TAR dated 7/1/20 through 7/31/20 documents the treatment was not completed on 7/8/20, 7/17/20, 7/20/20, or 7/24/20. This same TAR documents R1's left heel treatment was not completed on 7/4/20, 7/5/20, 7/16/20 through 7/21/20, and 7/23/20 through 7/31/20. The facility was unable to locate or provide an August TAR for R1. The RD (Registered Dietician) made recommendations for R1 to Start 30 ml (milliliters) of liquid protein BID (twice daily) to aid in healing on 4/8/20, 5/6/20, 6/3/20, and on 7/1/20. This recommendation was not followed or ordered until 7/6/20. There is not weekly wound documentation for R1's right heel wound and only sporadic Weekly Wound Tracking and Wound Management Notes between 6/3/20 through 8/26/20. 2. The facility policy for Wound Care, dated 5/17, documents Follow physician's orders [REDACTED]. This documentation will be done on the Treatment Administration Record (TAR). Current wound status must be documented no less than once a week. Facilities using (Electronic Health Records) EHR will complete a weekly treatment (Non-Pressure Ulcer) documentation observation. Wound changes and other pertinent observations must be documented in the Nurses Notes as they occur. R62's Physician Orders, dated 6/30/20, documents Right Malleous: Cleanse with wound cleanser, pat dry. Apply thin layer of Santyl to center slough area. Cover with Silicon 4x4 foam dressing. Change Monday, Wednesday, Friday and PRN (as needed). On 9/1/20 at 12:20 pm R62's right malleous was covered with a foam dressing dated 8/26/20 with visible dark drainage underneath the dressing. The edges of the foam dressing were rolled up and not adhered to R62's foot. R62 stated he usually has to tell the staff when the dressing comes off, otherwise they change it every couple of weeks. R62's July 2020 TAR (Treatment Administration Record) documents Physician ordered wound treatments were not completed as ordered. The facility was initially unable to locate an August TAR for R62; however, on 9/11/20 the facility provided an August TAR which also documents Physician ordered wound treatments were not completed as ordered. R62's dressing was not changed on 8/28/20 or 8/31/20 per Physician order. There is not weekly wound documentation for R62's right malleolus wound and only sporadic Weekly Wound Tracking and Wound Management Notes between 6/3/20 through 8/26/20. On 9/9/20 at 2:06 pm, V3 (Licensed Practical Nurse/LPN/Wound Nurse) stated she was hired in March 2020 to work as the facility wound nurse, however worked the floor until 3/23/20 and was then off work until 4/13/20. V3 stated she worked as a floor nurse for the first 5 weeks and the week after Mother's Day, the DON (Director of Nursing) walked. V3 stated she was pulled from the floor to assist with DON duties and is still currently doing this as well as testing on Mondays and Tuesdays, which only leaves Wednesday through Friday to work with wounds. V3 stated, This is why I am unable to do all the wound treatments and why there is not weekly wound documentation done every week. V3 stated she cannot confirm and there is no way to know that R1's wound treatments were done because they were not signed off that they were done. The nurses have been in-serviced and should be signing off that they completed the treatments. Back to Nursing 101; not signed out, wasn't done. 3. On 9/1/2020 at 12:00p.m. R40 was reclined in bed with her noon meal on an over bed table in front of her. R40 stated, I have two treatments. One on my right hip and the other towards the groin. I got a bandage put on them yesterday. I am lucky to have my treatment done once a month. No one ever shows up to do it on the weekends. On 9/1/2020 at 1:20p.m. V18 (Licensed Practical Nurse/LPN/Treatment Nurse) verified the two treatment orders to be completed was: Left lower apron abdomen: cleanse with wound cleanser, place a 6x10 Optilock (moisture absorbing dressing) x2 lengthwise to absorb weeping, change daily, start date 8/31/2020. The second order was to the right lower aspect of the lower abdomen: cleanse with soap and water, pat dry apply [MEDICATION NAME] (adhesive dressing with an absorbent center, 4x4 change daily, start date 8/31/2020. On 9/1/2020 at 1:40p.m. V3 stated, (R40) went to the hospital and returned on 8/22/2020. The treatment order did not get 'pulled forward' (entered into R40's medical record) so there was not a treatment until yesterday (08/31/2020, nine days later). Now she has an open area on her right abdominal apron too. On 9/1/2020 at 1:45p.m. V3 and V10 (Certified Nurse Aide/CNA) assisted R40 to roll on to her left side. R40's right hip and back of her right thigh had multiple round and linear shaped open areas ranging from pinpoint to larger than a quarter in diameter with defined borders as the appearance of ulcers that were bright red in color with scant bleeding. This surveyor counted 12+ wounds on the back of R40's thigh and another 4+ wounds on her hip at beginning of the crease in her belly fold and under her apron belly flap. V18 verified the presence of the wounds then cleaned the areas with 4x4 gauze dressing and soap and water. This caused each wound to bleed. R40 started to complain and wanted to bed placed on her back to rest. V18 and V10 lifted R40's belly apron further to perform a treatment to the center lower abdomen and revealed R40's skin was covered with a malodorous thick, white, mucous substance and more open wounds. V3 and V10 then assisted R40 to her left side. As they repositioned R40 on her right side, there was dried stool down the back of R40's left leg. R40 was involuntary of BM stool. V10 attempted to perform perineal care. R40 was not tolerating this process well so an observation of her skin was not completed. R40 was observed to have draining blood blister on the upper right quadrant of her abdomen and open areas in the creases of the outer aspect of her left thigh and abdominal fold verified by V3. R40 complained of pain at this time and wanted to be rolled onto her back. R40 stated to V3, I have so much pain in that sore (motioning to her left lower belly) that I didn't go to [MEDICAL TREATMENT] this morning. On 9/1/2020 at 2:15p.m. V3 stated, All those open areas were new. I did not know about them. And that white stuff under (R40's) belly is just 'funk' from not having a shower. She refuses them all the time. On 9/2/2020 at 12:50 p.m.V30 ([MEDICAL TREATMENT] Office Manager) verified R40 did refuse [MEDICAL TREATMENT] on 9/1/2020. On 9/1/2020 at 2:40 p.m. V3 stated, (R40's) 8/22/2020 Readmission skin assessment did not get done that day because it was a Saturday or Sunday. I don't work on Sundays. Mondays and Tuesdays, I do the COVID testing so I did not do treatments on those days. The last Skin Management report provided was 8/19/2020, not a readmission report after her 8/22/2020 hospitalization . On 8/22/2020 V31 (LPN) completed an admission assessment that stated R40's pressure wounds were the same as they were before her hospitalization . No measurement or location was noted on the assessment. The last Skin Management report provided by the facility dated 8/19/2020, did not have a readmission skin report for (R40) upon return from her 8/22/2020 hospitalization . On 8/22/2020 V31 completed an admission assessment that stated R40's pressure wounds were the same as they were before her hospitalization . No wound measurements, stages or locations were noted on the assessment. The National Pressure Ulcer Advisory Panel (NPUAP) Clinical Practice Guideline Manual 2009 documents, Skin Moisture: General measures, as well as urinary and fecal incontinence, emerge in epidemiological studies as factors associated with pressure ulcer development. Failing to provide appropriate strategies when an individual has been identified to be at risk of pressure ulcer development is a failure in the duty of care owed by the health professional and can be determined as negligence. It is important to note that skin damage from moisture is not pressure, but that presence of skin damage from moisture may increase the risk of ulceration. 4. The facility Wound Care policy dated 5/17 documents, Observe all wounds and notify the physician of signs of infection, swelling, of affected part, redness of affected part and sensation of heat along with throbbing pain, tenderness, fever, evidence of pus, or red streaks leading from the wound. Current wound status should be documented no less than once per week and should be done on the Treatment Administration Record (TAR) in the space provided or Nurse's Notes as they occur. Facilities using (Electronic Health Records) will complete a Weekly Treatment (Non-pressure Ulcer) documentation observation. R95 was admitted to the facility on [DATE] with daily wound care orders for a recent trans-metatarsal amputation on her right foot and [MEDICAL CONDITION] in her left lower leg and an open area on her left heel. R95 discharged home on[DATE]. The Admission skin assessment documents R95 had a pressure ulcer on her left heel, however no size, stage or measurements of the wound were documented on the assessment. There was no mention of the surgical site. R95's physician's orders [REDACTED]. [MEDICATION NAME] swabs. Apply topically for wound paint to incision sites. Cover with 4x4's and Kerlix. Complete the treatment daily. The order date was 8/8/2020. The treatment for [REDACTED]. Wrap with Kerlix and wrap with Ace Wrap. On 9/4/2020 at 10:30 a.m. R95 stated, The first three days, no one changed my dressing. They only changed it one time while I was there. On 9/4/2020 at 12:00p.m. V28 (Podiatrist) stated he had been treating (R95) and was continuing to treat her. V28 verified her treatments were to be completed on a daily basis for both right and left feet. V28 stated, On 8/18/2020 she came to the wound clinic with a dressing in place dated 8/10/2020. The facility was not able to provide the Treatment Administration Record for R95's stay at this facility. There was not a wound management or a Weekly Treatment (Non-pressure Ulcer) documentation observation completed for R95. 5. R2 was admitted to the facility on [DATE]. The admission documents from the previous facility document R2 was being treated with a wound vac after chemical burn after surgical intervention to her right buttock and thigh. R2's March Treatment Administration Record (TAR) documents two treatments dated 3/22/2020 which document to Apply wound vac to right buttock hip area Monday, Wednesday, Friday which was not documented as completed for the month of March. Another treatment is documented on the March MAR Cleanse the right buttock and calf area with normal saline or wound cleanser, pat dry, apply collagen powder mixed with [MEDICATION NAME]. Apply twice a week on Sunday and Thursday. This treatment was documented as completed one time on March 22. R2's 4/2/2020 Progress notes document the wound orders were changed due to her lack of compliance with the wound vac. R2's April treatment orders have a line drawn through both orders with a notation that states wet to dry dressing to right hip with no date on the order. There are no initials in the spaces allotted to note the treatment was completed during the month of April. R2's May TAR documents the ordered treatment dated 4/8/2020 to Cleanse wound daily with wound cleanser. Apply wet to dry dressing with Dakins solution daily. This treatment order does not document which area of the body to perform the treatment but was documented as completed 15 days in April. R2's June MAR documents this same treatment was completed on June 1, 2, and 5, 2020 R2's last wound assessment for the right calf was documented by V34 (Registered Nurse Treatment Nurse/RN/Tx). V34 assessed the wound as a Stage 3 pressure ulcer, not a burn as documented upon admission. R2's last wound assessment on her right buttock dated 6/10/2020 documented by V3 assessed the wound as a Stage 4 pressure ulcer and was not healed. R2 discharged (Against Medical Advice) on 6/15/2020. 6. On 8/27/2020 at 10:30AM V3 provided care to R6's wounds in her right groin. V3 pretreated the open areas at R6's request with [MEDICATION NAME] gel from a jar of clear gel removed from the green hospital bag on the floor next to R6's bed. V3 then irrigated R6's wounds, packed with an [MEDICATION NAME] gauze rope and then placed a large gauze pad over the areas. When V3 completed the treatment, she explained there was not an order for [REDACTED]. On 8/27/2020 at 10:45 a.m. R6 stated she does not receive her treatment as ordered. R6 pointed to a bag of dressings and wound care items on the floor. R6 stated, Those are from the hospital. I keep them in my room so they (the nurses) do not have a chance to leave 'to get wound care supplies'. They say that and then do not come back. I have an abscess and it just got drained. They are supposed to keep an eye on it, but they don't check it much. I just tuck a pad in there if it starts leaking. R6's current treatment order documents: Cleanse with wound cleanser, pack wound to right groin with [MEDICATION NAME] daily and cover with an large gauze pad date 8/25/20. There is no order for [MEDICATION NAME] gel to be administered to the open wounds. The facility Wound Care Policy last revised 5/17 documents, Follow the physician's orders [REDACTED]. Documentation of wound care must be completed each time the treatment is done. This documentation will be done on the Treatment Administration Record (TAR). Current wound status must be documented not less than once a week and should be done in the TAR or the Nurses Notes as they occur. Facilities using ERH (Electronic Health Record) will complete a Weekly treatment (Non Pressure) Documentation Observation. The Immediate Jeopardy was identified on 9/2/20 at 12:30pm. The Immediate Jeopardy began on 5/5/20 when the facility failed to perform R1's wound treatments as ordered until R1 discharged against medical advice on 8/21/20. V1 (Administrator) was notified of the Immediate Jeopardy on 9/11/20 at 2:00PM. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the immediate jeopardy: 1. Facility will ensure appropriate staff is aware of who is responsible to perform daily treatments. The facility will identify on the daily staffing sheet who is responsible to complete the treatments. 2. September 11, 2020 at 3:30pm facility held ad hoc QA meeting. 3. September 11, 2020 at 6pm Education was completed with nursing staff on the following. All staff not trained at this time will be in-serviced prior to working their next shift. This education is being completed by Interim Director of Nursing, Administrator, Regional Reimbursement Nurse, VP of Clinical Operations, LPN Supervisor, and Wound-Restorative Nurse on Emergency Response, Skin Assessments, Treatments and Documentation, Pain Management, and Medication Administration. 4. September 11, 2020 at 4pm Administrator educated nursing management on the requirements of routine audits of TARs. This education included that the Director of Nursing or designee will conduct weekly audits for 6 months of the TARs, resident skin assessments and care plans related to skin. 5. September 12, 2020 at 5:00pm a full house skin sweep has been completed by Wound-Restorative Nurse and Wound Nurse. Weekly body audit form has been completed on all in house residents. 6. September 12, 2020 at 7:00pm an audit of wound management in the Electronic Health Record has been completed by VP of Clinical Operations, Regional Reimbursement Nurse, and Interim Director of Nursing to verify all skin issues are documented within wound management in EHR, appropriate orders and care plans in place. The wound management documentation includes description and measurements. 7. Quality Assurance Plan to monitor performance to make sure corrections are achieved and permanent: Director of Nursing or designee will conduct weekly audits for six months that include 100% review of resident skin assessments, TARs, and care plans related to skin. Identified concerns shall be reviewed by the facilities QAPI team. Recommendations for further corrective action will be discussed and implemented as needed. The Director of Nursing or designee will conduct weekly audits for 6 months to ensure the person responsible for daily treatments is denoted on the daily staffing sheet. Identified concerns shall be reviewed by the facility QAPI team. Recommendations for further corrective action will be discussed and implemented as needed.

Based on interview and record review the facility failed to provide supervision and failed to identify a possible injury of unknown origin for two (R9, R94) of six residents reviewed for falls in the sample of 95. These failures resulted in R9 not receiving increased supervision from a known prior fall intervention that resulted in R9 having another fall with a [MEDICAL CONDITION], and R94 obtaining an intraventricular hemorrhage of bilateral ventricles of the brain. Findings include: The facility's Accident and Incident Report, Revised ,[DATE], documents 1. Resident: c. Follow-up to be continued at minimum for 72 hours - which include vital signs, ROM (range of motion), skin abnormalities, responsiveness, general condition, changes observed in injury site, etc. Facility Resident Census and Conditions of Residents form, dated [DATE] by V1 (Administrator) documents 86 residents reside in the facility. This form further documents 75 residents require the assist of one or two staff for transferring and 8 are dependent. Facility Assessment, no date, documents the facility has an average census of 85 with 43 residents on third floor and 42 residents on fourth floor. 45% have falls. We review care needed by residents on each unit/floor to determine staff assigned. This is a combination of ADL needs, psychological needs, and any other special considerations to provide person centered care. Facility Fall Log, no date, documents 20 falls for the Month of [DATE]. 1. The Face Sheet for R94, dated [DATE], documents R94 was admitted to the facility with the following Diagnoses: [REDACTED]. The Admission Restorative Assessment for R94, dated [DATE], documents R94 requires supervision with bed mobility, limited assist with transfers and ambulation with a walker, balance unsteady but able to stabilize self, limited assist with bathing and dressing, supervision for personal hygiene and eating. R94's EHR (Electronic Health Record) documents R94 had falls on [DATE] at 4:30, on [DATE] at 2:45 am, on [DATE] at 2:50 pm, and on [DATE] at 11:30 pm. R94's Admission Fall Risk Assessment, dated [DATE], scored R94 as (17) High Risk for falls with history of one or two falls in the last 3 months with referrals recommended for Occupational Therapy/Physical Therapy (OT/PT). Fall Risk Assessments, dated [DATE] and [DATE] post falls document R94 scored (22) High Risk for falls. R94's Admission Care Plan documented Assure the floor is free of glare, liquids, foreign objects. Keep bed in lowest position with brakes locked. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Obtain PT consult as needed. Occupy resident with meaningful distractions. Orient resident when there has been new furniture placement or other changes in environment. Proved proper, well-maintained footwear. Provide resident and environment free of clutter. Provide toileting assistance before and after meals, at nighttime and as needed. The Fall Report for R94, dated [DATE], documents This resident was noted to be in a left side lying position next to her bed with a large contusion on her left upper forehead. This resident stated, 'I fell out of bed.' The Root cause was determined to be related to resident's functional state. Fall Intervention - therapy to screen post fall. The local hospital CT Scan, dated [DATE], documents, Diagnoses: [REDACTED]. R94's Fall Risk Assessment, dated [DATE], scored R94 as (19) High Risk for falls with history of One or two falls in last 3 months with referral for Falls Prevention Program. R94's Care Plan was updated to include: Therapy to screen post fall. R94's Care Plan does not include Falls Prevention Program. The Progress Notes for R94, dated [DATE], documents Hematoma noted to left side of forehead, resident given Tylenol 500mg (milligrams) with relief noted. The Progress Note, dated [DATE] at 10:54 am, documents Lump and discoloration to left forehead and discoloration to left jaw. Denies pain. The Progress Note dated [DATE] at 2:53 pm documents Resident has slept most of the day. Will continue to monitor. The Progress Note, dated [DATE] at 12:15 pm, documents Resident refused breakfast this morning, and refused to let nurse take VS (vital signs). Resident stated, Just leave me alone today, all I want is to sleep. The Progress Note, dated [DATE] at 1:55 pm, documents This nurse communicated with NP due to concerns of large knot on left side of resident's head from fall on [DATE] and resident complaining of pain. NP (Nurse Practitioner) assessed and ordered for resident to be taken to ED. V8's (Nurse Practitioner/NP) Progress Note for R94, dated [DATE] at 8:17 pm, documents Left forehead [MEDICAL CONDITION]. The Progress Notes made by Nursing Staff are documented here. The Progress Note, dated [DATE] at 2:06 pm, documents Received call from (Hospital) Nurse .CT (Computed Tomography) scan was done and patient does have bleed and she will contact family to inform them so they can decide on treatment. V8's Progress Note for R94, dated [DATE] at 8:20 pm, documents Nursing reports that patient has [MEDICAL CONDITION] knot of left side of forehead in area where she fell on [DATE]. Pt's [MEDICAL CONDITION] is the size of a golf ball. ED cleared patient on [DATE] after CT [DIAGNOSES REDACTED]. The local hospital discharge record documents Final Diagnoses: [REDACTED]. Comfort measures only status. The local hospital CT Scan, dated [DATE], documents Reason for Exam: Intermittent headache. Trauma. Findings: A CT of head was performed without IV (intravenous) contrast. The cerebellum and supracellar cistern appear normal. Prominent scalp hematoma left frontal region. Acute intraventricular hemorrhage in both lateral ventricles. Focal hematoma in left lateral ventricle measuring 2 cm (centimeters). Diffuse atrophy with ventricular dilation. No obstructive [DIAGNOSES REDACTED]. Asymmetric low density adjacent to the right posterior temporal bone which may represent arachnoids cyst adjacent to the right cerebellar hemisphere. Chronic ischemic change in the basal ganglia regions and prominently seen in the pre-ventricular white matter. No subdural hemorrhage identified. No calvarial fracture. Postsurgical change in the right emporal bone. Final result documented as Impression: 1. Prominent soft tissue hematoma left frontal region without underlying calvarial fracture. 2. Associated acute hemorrhage in both lateral ventricles left greater than right. No obstructive [DIAGNOSES REDACTED]. 3. No subdural hematoma or intraparenchymal hemorrhage identified. 4. Atrophy and chronic ischemic change. R94's Care Plan does not document any new interventions, Falls Prevention Program, or referrals for R94 other than for Hospice Services. V8's Progress Note for R94, dated [DATE] at 11:22 am, documents Declining condition: Nursing concerned patient is declining. On [DATE] Pt was sent to ED due to fall and collision with roommate. Pt was sent back with dx (diagnosis) of contusion of forehead. A CT of cervical spine and head done [DATE]th. Pt was sent back to ED due to a prominent soft tissue hematoma to the left frontal region of forehead. Dx on return was acute hemorrhage or Intracranial hematoma with loss of consciousness in both lateral ventricles, left greater than right and acute intractable headache. Pt came back hospice. Pt has been declining ever since, pt now lays in bed, not alert, patient is not eating, no gross muscle activity. Breathing is still clear. No sign of impending death at this time. The Significant Change MDS (Minimum Data Set) Assessment for R94, dated [DATE], documents R94 cognitively impaired. This MDS documents R94 requires total assist with bed mobility, bathing, personal hygiene, and dressing and required extensive assistance with toileting. R94 was also frequently incontinent of bowel and bladder. On [DATE] at 12:40 pm, V8 stated R94 did have a fall on [DATE] and went to the local hospital for an evaluation, CT was done which was negative. On [DATE] V8 stated she sent R94 back to the local hospital because she had swelling and looked like someone hit her in the head with a hockey puck and the CT results came back that she had a subdural hemorrhage and returned to the facility on hospice services. V8 stated she is unaware of any other falls or incidents for R94. The Progress Note for R94, dated [DATE], documents R94 expired. 2. R9's electronic medical record documents R9 was admitted to the facility on [DATE]. R9's current care plan documents R9 was care planned on [DATE] for wandering at times and has impaired vision. R9 was also care planned on [DATE] for being at risk for falls related to dementia and difficulty in walking. R9's fall report, dated [DATE], documents R9 fell in the doorway of her bedroom and got a laceration and bump to her forehead. The root cause was the resident's confusion and the resolution was to increase rounding. R9's fall assessment, dated [DATE], documents R9 is a high risk for falls and staff is to perform 15 minute checks. R9's fall report, dated [DATE], documents a loud band was heard and R9 was found on the floor on top of a broken tray table. R9 was sent to the hospital to rule out a broken hip. R9's nurses notes by V13 (Registered Nurse/RN), dated [DATE] at 4:06pm, documents R9 was admitted to the facility from the local hospital with a right [MEDICAL CONDITION]. R9's progress notes by V8 dated [DATE] at 3:34pm documents (R9) fell on [DATE], patient was transported to ED (Emergency Department) for assessment and treatment if needed, and (R9) was dx (diagnosed ) with a intertrochanteric fracture to the right hip. Facility was unable to provide any documentation on increased rounding or 15 minute checks for R9. On [DATE] at 10:45 am, V7 (RN) stated, There are 42 people on this floor (4th floor). They only had one nurse and one CNA (Certified Nursing Assistant) last night ([DATE]), we had a resident fall (R9), and we sent her to the hospital. Her call light was on, but no one answered it. On [DATE] at 2:05pm, R43 stated, I was in the room when (R9) fell . I put the call light on for (R9); she needed to go to the bathroom. She leaned against her table while waiting and she fell and broke her hip. They take a long time to answer call lights here. No one had been around here for quite a while, at least a half hour or so. On [DATE] at 10:20am, V28 (Licensed Practical Nurse/LPN) stated, I was the nurse taking care of (R9) on [DATE] and I work second and third shifts. On [DATE] I heard a loud bang and I found (R9) sitting on her night stand/tray table next to her bed about 5pm. I did an assessment, I followed our protocol to get her up, she complained of her leg hurting so I called (V8) to send her out to the hospital. I think the only staff working that night was one nurse and two CNAs (Certified Nurse Assistants). R9 is on the fourth floor, which has the Alzheimer's unit and other confused residents who do not need a secure unit. One of the nurse aides has to stay in the secured unit at all times, and one of the nurse aides is out on the regular unit. I am busy all the time I am there, and we have mostly agency nurses and CNAs.

Based on observation, interview, and record review, the facility knowingly failed to have enough staff to accommodate the needs of the residents in the facility as evidenced by multiple complaints by residents, resident family members, staff, resident council minutes, and grievances where residents are not getting call lights answered, toileting, and grooming needs met. This failure to provide sufficient staff led to R9 not getting increased supervision from a known prior fall intervention that resulted in R9 having another fall with a [MEDICAL CONDITION]. This failure to provide sufficient staff also led to R87 falling and lying on the floor for over 2 hours while waiting for the next shift to come on duty to assist with transferring R87 due to insufficient staff in the building on midnight shift. Findings include: Facility Resident Census and Conditions of Residents form, dated 8/28/20 by V1 (Administrator) documents 86 residents reside in the facility. This form further documents 60 residents are occasionally or frequently incontinent, 56 require the assist of one or two staff for bathing and 26 are dependent, 75 require the assist of one or two staff for transferring and 8 are dependent, 81 require the assist of one or two staff for toilet use and 3 are dependent, and 69 require the assist of one or two staff for eating and 2 are dependent. Facility Assessment, no date, documents The facility has an average census of 85 with 43 residents on third floor and 42 residents on fourth floor. 48% have urinary incontinence, 39% have concerns with activities of daily living (ADLs), 37% have cognitive loss or dementia, 45% have falls, and 50% have concerns with nutrition. Facility has three bariatric residents that require additional staff to accomplish ADL care daily. Facility acuity is considered for staffing purposes in order to provide adequate ADL (Activities of Daily Living), skin, and medical care for each resident. Facility Staffing Plan checks daily staffing needs based on census, and skilled and non-skilled residents. Facility currently staffs slightly above these requirements to meet the acuity needs of facility residents. Licensed Nurses Providing Direct Care total number needed or average is one Nurse Practitioner and 17 Licensed Nurses. Nurse Aides total number needed or average is 37 CNAs (Certified Nurse Aides). Agency Staff - facility utilizes agency nurses and CNAs to meet daily staffing needs as needed. We review care needed by residents on each unit/floor to determine staff assigned. This is a combination of ADL needs, psychological needs, and any other special considerations to provide person centered care. Facility Fall Log, no date, documents 20 falls for the Month of August 2020. Facility resident council minutes, dated 4/29/20, documents residents would like to see more nurses and would like to understand why there is so much turnover; dated 5/27/20 documents residents would like more CNAs and feels there is not enough help; and dated 6/24/20 documents residents feel the CNAs and nurses are undermanned. V1's email, dated 9/2/10 at 10:46am, documents the following: Nurses work -1st: 6a-2:30p, 2nd: 2p-10:30p, 3rd: 10p-6:30a; and CNAs work -1st: 6:30a-3p, 2nd:230p-11p, and 3rd: 10:30p-7a. On 8/27/20 at 11:50am, V5 (Nursing Scheduler) stated, I was told by V2 Director of Nursing/DON) to use the ratios of three CNAs on the 3rd floor and four CNAs on the 4th floor for day shift and pm shift. I staff two CNAs on the 3rd floor and four CNAs on the 4th floor for midnights. I staff two nurses on day shift and pm shift for 3rd and 4th floor. I put one nurse on 4th floor for midnights, and two nurses on 3rd floor for midnights. I do not use the state staffing form; I don't know what that is. And I was unaware of any minimum staffing requirements. I was told how to staff by V2 and that is how I staff. 1. R9's Electronic Medical Record documents R9 was admitted to the facility on [DATE]. R9's current care plan documents R9 was care planned on 6/1/20 for being at risk for falls related to dementia and difficulty in walking. R9's current care plan documents R9 was care planned on 6/14/20 for wandering at times and has impaired vision. R9's fall report, dated 7/3/20, documents R9 fell in the doorway of her bedroom and got a laceration and bump to her forehead. The root cause was the resident's confusion and the resolution was to increase rounding. R9's fall assessment, dated 7/3/20, documents R9 is a high risk for falls and staff is to perform 15 minute checks. R9's fall report, dated 8/26/20, documents a loud bang was heard and R9 was found on the floor on top of a broken tray table. R9 was sent to the hospital to rule out a broken hip. R9's progress notes by V8 (Nurse Practitioner/NP), dated 9/1/20 at 3:34pm documents, (R9) fell on [DATE], patient was transported to ED (Emergency Department) for assessment and treatment if needed, and (R9) was dx (diagnosed ) with a intertrochanteric fracture to the right hip. Facility was unable to provide any documentation on increased rounding or 15 minute checks for R9. On 8/27/20 at 10:45 am, V7 (Registered Nurse/RN) stated, There are 42 people on this floor (4th floor). They only had one nurse and one CNA last night (8/26/20), we had a resident fall (R9), and we sent her to the hospital. Her call light was on, but no one answered it. We have multiple residents that require at least two assist and we do not have the staff for them. We've had more falls because we don't have enough staff to answer call lights and take care of residents like we need to. The Alzheimer's unit is up here too (4th floor). We can't do everything with one nurse and one CNA. Call lights will go off for hours. Just not enough staff to give the care. On 8/27/20 at 2:05pm, R43 stated, I was in the room when (R9) fell . I put the call light on for (R9); she needed to go to the bathroom, she leaned against her table while waiting and she fell and broke her hip. They take a long time to answer call lights here because there is not enough of them. No one had been around here for quite a while, at least a half hour or so. There is never enough staff here, and you never see anybody to help you. R43's Minimum Data Set (MDS), dated [DATE], documents R43 is cognitively intact and requires supervision with one assist for transfers and personal hygiene. It further documents R43 is occasionally incontinent of bowel and bladder. On 9/4/20 at 10:20am, V28 (LPN) stated, I was the nurse taking care of (R9) on 8/26/20 and I work second and third shifts. On 8/26/20 I heard a loud bang and I found (R9) sitting on her night stand/tray table next to her bed about 5pm. I did an assessment; I followed our protocol to get her up. She complained of her leg hurting so I called V8 to send her out to the hospital. The only staff working that night (on our floor) was one nurse and two CNA's (Certified Nurse Aides). (R9) is on the fourth floor, which has the Alzheimer's unit and other confused residents who do not need a secure unit. One of the nurse aides has to stay in the secured unit at all times, and one of the nurse aides is out on the regular unit. So that only left one nurse aid to care for R9 when she fell and to answer call lights. The 3rd floor is busier and we try to have four staff (two nurses and two CNAs). The residents on 3rd floor require more care, go out to appointments more, have insulins, and get more medications given. I am busy all the time I am there, and we have mostly agency nurses and CNAs. I don't get my breaks like I am supposed to and the aides are not able to work together because one has to stay in the secured unit. I do not know how they get the residents' cares all met because I am busy passing medications and performing nursing duties so I do not have time to help them. I am working 50 hours this weekend where I am going in today (9/4/20) at 2pm. There was a time I worked 21 hours in a day because they needed me to work. We work with our own staff, agency nurses, and agency CNAs. These people deserve to get good care and have good nurses take care of them. Facility Resident Current Status Report, dated 8/26/20, documents 83 residents were in the building. Seventeen residents need skilled care and 66 need non-skilled care. Staff time sheets provided by the facility, dated 8/26/20, documents a total of four nurses were assigned to work the afternoon shift from 2pm-10:30pm, and a total of six CNAs were scheduled for second shift from 2:30pm-11pm for the entire facility. There was also one CNA scheduled to work from 2:30pm-6pm. 2. On 9/1/20 at 11:45am, R87 stated, On 8/22/20 I rolled out of bed onto the floor at 4:50am and laid there until day shift came in. I yelled for help and my roommate (R70) turned on the call light for help. Twenty minutes later V19 (LPN) came to my door. The fire department came at 6:45am and helped the day shift get me up off the floor at 7:00am. I was on the floor for over two hours because there was not enough staff to get me off the floor. The weekends and night shift are the worst. They have one CNA and one nurse working. It takes forever for them to answer our light. I rarely see any staff. R87's MDS, dated [DATE], documents R87 is cognitively intact. On 8/27/20 at 10:45 am, V7 (RN) stated, On 8/22/20, there was only one nurse and one CNA and (R87) fell out of bed and was left there for over two hours until day shift came in. On 9/4/20 at 11:00 am, R70 stated, I pulled the call light on 8/22/20 when (R87) fell . No one came to help so I called 911. He laid on the floor for two hours before they got him up off the floor. The weekends and nights are the worst when they only have one nurse and one CNA for the whole building for both floors. I have had to wait an hour to an hour and a half for someone to come help me before. Review of R87's medical record documents R87 is morbidly obese and needed to be transferred as a maximum assist of two plus staff members from the floor and they did not have the staff or the equipment on the unit to do it. Facility Resident Current Status Report, dated 8/22/20, documents 83 residents were in the building. Sixteen residents need skilled care and 67 need non-skilled care. Staff time sheets provided by the facility, dated 8/21/20 for midnight shift, documents a total of two nurses were assigned to work the midnight shift from 10pm-6:30am, and a total of one CNA and one Nurse Aide (not certified) were scheduled for the midnight shift from 10:30pm-7am for the entire facility. 3. On 8/27/20 at 11:00 am, R43 stated, It can take 15 to 30 minutes, sometimes more, for them to answer our call light. They need more help here. I can never get help going to the toilet. R43's medical record documents R43 is cognitively intact. 4. R12's Facility Concern form, dated 7/27/20, documents resident has concerns on call light response times, missing items, incontinence concerns, and communication. On 8/27/20 at 2:12pm, R12 stated, They are short staffed and call lights take forever to get answered. It takes about 20 minutes, give or take, to answer the call light and it doesn't matter the time. I wear briefs, but can't always hold it until someone comes, and I wear briefs because I can't hold it that long and I am afraid I will mess myself because staff doesn't come in time. I can tell when I have to go to the bathroom, I put on the light but no one ever comes because they are short staffed. I spoke to the administrator about the concerns but nothing ever changes. R12's nurses notes, dated 7/27/20, documents R12 is alert and oriented and able to make needs known. R12's MDS, dated [DATE], documents R12 requires total assistance of two for transfers and toileting, and total assistance of one for personal hygiene. It further documents she is frequently incontinent of bowel and bladder. On 8/27/20 at 11:15am, V1 stated, (R12) had a concern about call lights and incontinence so we had a zoom meeting to talk with family about how we can work on that. 5. On 8/27/20 at 2:25pm, R13 stated, There is never any staff to answer call lights here when I need to go to the bathroom. I need help with everything. 6. On 8/28/20 at 3:38pm, V44 (R4's family member) stated, July 20th I came to visit (R4) and he had a full beard and hadn't been shaved in weeks. He had on a dirty shirt with stains all over it, and it wasn't even his shirt. I am his Power of Attorney because he cannot speak for himself. R4's MDS, dated [DATE], documents R4 is severely impaired cognitively and requires extensive assistance of one for personal hygiene and toileting. It further documents R4 is frequently incontinent of bowel and bladder. 7. On 8/28/20 at 4:29 pm, R1 stated, I would put my call light on and it would take them 45 minutes to an hour to come. I would have accidents with my stool and then they would be mad at me. I know when I need to go but had to wait too long. They would also say be right back and never come back. There is never enough staff there. R1's MDS, dated [DATE], documents R1 is cognitively intact, requires extensive assistance of two for transfers and extensive assistance of one for personal hygiene and toileting. It further documents R1 is frequently incontinent of bowel and bladder. 8. On 8/31/20 at 2:10 pm, V25 (CNA) and V40 (both 2nd shift CNAs) stated, We generally only have one CNA and one Nurse on second shift. There is no way to get cares done. We do our best to pass meal trays and answer call lights, but most of the time it is impossible. We have the nurses that try to help but they have their own work to do. Someone is going to get hurt if we continue to work like this. 9. On 8/31/20 at 2:15 pm, V35 (Unit Manager) stated there have been times when staff have been unable to get oxygen and slings for transfers/toileting residents because they are located in the basement and there is not enough staff in the building to allow staff to leave the unit. 10. On 9/1/20 at 12:20 pm, R62 stated, I'm close to the nurses' station and it takes the CNA a long time for them to answer my light when I need to toilet. They don't have much staff here at night and sometimes I have accidents. R62's MDS, dated [DATE], documents R62 is cognitively intact, requires limited assistance of one for personal hygiene, total assistance of two for transfers, and extensive assistance of two for toileting. It further documents R62 is frequently incontinent of bowel and has a catheter. 11. On 9/1/20 at 12:25 pm, R56 stated, Depends on how many are working. I've had to wait over an hour for them to come. They only have two staff working at night, and sometimes only one. I put on my light when I need to toilet. 12. On 9/1/20 at 1:40pm, V9 (LPN) stated, We don't have enough staff when it takes two-three persons to roll a resident and that is all that is scheduled on the total floor for 40 residents. When we are all in with one resident, we do not have anyone else to answer call lights. And when we come out of the room, sometimes almost all of the call lights are lit up on the board. We have had an increase in falls because we never have enough staff, ever. 13. On 9/1/20 at 1:50pm, V22 and V39 (both CNAs) stated, We all are tired, we work extra shifts, but we can't be here all the time. There are usually two CNAs with one nurse in the dementia unit (4th floor) to care for about 20 residents and when one of us goes on break, it is one CNA for all 20 residents. It is the same outside of the dementia unit on 4th floor where there are one to two CNAs with one nurse who is busy doing their own work. On 3rd floor there are two to three CNAs with one nurse for about 40 residents and we can't be everywhere. Most of these people require two assist for toileting and transferring, and when we have to toilet, transfer, and feed there is not enough of us to go around. People are not getting the care they need because there is not enough staff. 14. On 9/4/20 at 12:20pm, V17 (RN) stated, We need staff at that place. Can I pass medications on 40 people? Yes, but then I have to do assessments on all those people and I am unable to do that. Some days the people on the posted staffing paper do not show up, are late, or are a no call, no show. I was told by management that if people call off then they have calls out to replace them, but if someone does not show up then you are missing half of your staff for the shift. I have had 3rd or 4th floor by myself as a nurse where you are responsible for 40 plus residents on each unit. We are required to assess respiratory status of everyone on each shift and get a full set of vitals, and it is not able to be done. You have to pick and choose who you are going to assess and perform vitals on, and that is usually the people most as risk. Usually we have two CNAs working with us on 4th floor and on 3rd floor we can have three CNAs in the afternoon. They do not have a mandating system in place at (facility) and we cannot mandate the CNAs if they don't want to work. We have some staff that will work extra, some staff that will not work over, and then you are stuck with who shows up for the shift. The CNAs come on at 2:30pm; management will usually still be there at that time (if it is during the week), and if we call them, they state they cannot help because they are performing other duties. I am not sure what those duties are for management, but they are not on the units helping these residents. I rarely see management up on the units. 15. On 9/10/20 at 2:51pm, V16 (Ombudsman) stated, I was going to resident council monthly due to multiple complaints on staffing and call lights. I had residents calling me and complaining they are not getting the cares they need, call lights aren't getting answered, not enough staff to help them, and (R87) called me a couple days after he fell because he was so upset. 16. On 9/10/20 at 4:15pm V7 (RN) stated, I have asked V2 for a number for corporate and I have never been provided a number from management for them. We have a punch in/out clock for our shift. I have texted concerns to V1 and I call the on call phone. I almost never get a meal break during my work shift, I am always in charge while there, I don't get my other breaks, and I don't get out on time. It takes me 1.5 hours extra to finish charting every night. I don't have time to take all vitals or assessments on everyone on our shift, and I do check some residents, but I can't get to all to see except give medications. I try to help CNAs when I can, I help when passing medications, and I can't monitor my CNAs because they are busy with cares and I am busy. My hours have increased but I told them I don't want to work extra, they do ask people to stay, and some stay because they get paid time and a half after eight hours for pay. Nurses call V2's on call cell, and CNAs call V5's on call cell. V5 is on call for CNAs 24/7, and V2 refuses call and gave the DON on call phone to V3 (LPN Wound Nurse). 17. On 9/10/20 at 4:54pm, V1 stated, V5 works Monday through Friday 8a-4p. The facility provides her with a cell phone so that she can take call 24/7. When she is on vacation that phone then goes to our designee who will take the call-ins and work to replace staff as needed. I also have a facility provided cell phone and I am on call 24/7 where the facility can reach me at anytime. If I am unavailable there is a designee that will take call in my place. Upon return, there is a facility activity report which I review on Matrix; we also hold a morning meeting to discuss occurrences from prior day. The facility activity report is pulled by the leadership team daily and then it is discussed during morning meeting. On 9/11/20 at 8:12am V1 stated, This report (facility activity report) is generated determined on selections made. It is setup that we can select what details we are looking for such as progress notes, observations, events, vitals, etc. Anything that is charted in Matrix can be pulled on this report. Nurses notify the on-call nurse when staff no call, no show and nursing call-ins. Then the on call nurse will call scheduler to review options and if needed on-call nurse comes in to fill openings. We do have the capacity to hold a total of 177 beds. At that same time, V1 was asked, Does this facility activity report tell you of any falls, accidents/incidents, wounds, hospitalization s, infections, resident decline, behaviors, or anything out of the ordinary from the prior day? At 8:19am V1 stated, Yes all that information is on the facility report. Anything that occurs during the day and charted in Matrix is available for review on the facility activity report. The on-call nurse knows they have to come in, that is part of being on-call. The facility staff is based on census. The facility has not had a census of 177 at any time during my time with the facility. At 8:25am V1 was asked, What happens when the on call nurse is unable to come in, and the scheduler is unable to find someone to replace the nurse that called off? Have you ever been notified of any no-call, no shows, or late employee arrivals of CNAs or Nurses? V1 refused to the answer questions. On 9/11/20 at 8:49am, V3 stated, We do a department head meeting everyday Monday through Friday to discuss things that have been brought to our attention and are in the facility activity report. We have all department heads present such as V1, V2, myself, V4 (Laundry/Housekeeping/Maintenance Supervisor), and V33 (Dietary Manager) when she is able because sometimes she is cooking. We do a team effort to work on things. Sometimes corporate are included in our meetings when they are in the building. On 9/15/20 at 11:25am, V2 stated, V1 stated she has sent/given you all the staffing for August 2020.

Based on observation, interview and record review the facility failed to ensure ventilator dependent residents (R32, R83) received routine and emergency care, and failed to ensure [MEDICAL CONDITION] residents (R13, R32, R44, R83) were assessed, monitored and care needs were met. These failures resulted in one resident (R32) attempting to suction her own tracheotomy which was obstructed with a mucus plug and one resident (R13) requiring a bleeding tracheotomy to be replaced and the potential for life threatening respiratory complications for (R13, R32). These failures resulted in an Immediate Jeopardy being called on 6/28/19 at 2:33 P.M. While the immediacy was removed on 6/28/19 at 7:07 P.M., the facility remains out of compliance at a Severity Level 2, as the facility continues to educate nursing staff on [MEDICAL CONDITION] suctioning and care. Findings include: Facility assessment dated (YEAR) indicates: Facility currently employs one Respiratory Director and eight Respiratory Therapists. On 6/25/2019 at 10:00pm, V7, RRT (Registered Respiratory Therapist stated that there was only one CRT (Certified Respiratory Therapist) and one RRT Registered Respiratory Therapist remaining at the facility. On 6/24/19 at 4pm V6, CRT stated that previously the facility had 24 hour respiratory therapist (RT) coverage, but as of 6/14/19 the facility let all of the RTs go and residents only get coverage by one RT eight hours per day Monday through Friday. V6 stated that currently she is the only RT left in the building and works Monday through Friday 10am to 6:30pm. V6 stated that this past weekend was the first weekend there was no RT in the building to care for residents. 1. Physicians Order Sheet (POS) dated 6/2019 indicates R32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS/BIMS (Minimum Data Set/Brief Interview for Mental Status) dated 4/26/19 indicates R32 has no memory impairments and scored 15/15 (indicating R32 is cognitively intact). On 6/24/19 at 1:30pm R32 stated that V5, LPN (Licensed Practical Nurse) did not come into assess, monitor or suction her tracheotomy during the night. V5 stated she had her call light on for 40 minutes, told a CNA (Certified Nurse Assistant) who told V5, but V5 never came. R32 stated that she suctioned herself, by putting the head of her bed down, reaching over and turning on the suction machine. R32 stated that the suction catheter is inline and already attached to the ventilator tubing. R32 stated, I had a mucus plug and I don't ever want (V5) to be my nurse again. R32 stated that she texted V6 at 3am to tell her that V5 refused to suction her. R32 stated that over the weekend (on 6/22/2019 and 6/23/2019) V6 came to the facility at 7pm and put me on the vent(ilator) and then came back and took me off the vent(ilator) the next day on her own time. R32 stated V6 now leaves at 6:30pm so she has to go back to bed at 6pm, but prefers to stay up later. Respiratory Therapy staff schedule dated 6/2019 indicates V6, CRT was not scheduled on 6/22 or 6/23/2019. On 6/24/19 at 2:00pm V6 stated that it was the first weekend that respiratory would not be available to residents that needed respiratory care and she only came in - on her own - because she was worried about the residents who require respiratory care. V6 confirmed that R32 had texted her at 3am indicating she had to suction herself because the nurse was not available. V6 also stated that R32 gets very emotional when she knows there is no respiratory staff at night or on the weekends. 2. POS dated 6/2019 indicates R83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS/BIMS dated 5/20/19 indicates R83 has no memory impairments and scored 15/15 indicating R83 is cognitively intact. On 6/25/19 at 4pm V5, LPN/Agency stated that during night shift (on 6/23/19) R32 asked to be suctioned and R83 also needed to be suctioned at the same time and she was the only nurse on the floor. V5 stated that she suctioned R83 first and by the time she got back to R32, she, (R32) stated that she had already suctioned herself and didn't need her any more. V5 stated that she did not check vent settings, only checked R32 oxygen saturation and administered a nebulizer treatment. POS dated 6/2019 indicates R83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS/BIMS dated 5/20/19 indicates R83 has no memory impairments and scored 15/15 indicating R83 is cognitively intact. On 6/24/19 at 4:00pm V6 stated, (R83) was in the hospital when they cut respiratory staff and I refused to take R83 back because she is ventilator dependent 24/7 and I no longer had the staff. V6 stated that the decision was made to bring R83 back anyway and V6 was called in by the admitting nurse to put R83 on the ventilator when she came back from the hospital at 9:00pm on a Sunday. V6 stated that she is the only staff who knows how to put in R83's speaking valve and that R83 won't be able to speak unless she is here to insert the speaking valve. V6 stated if a resident'[MEDICAL CONDITION] comes out, staff need to know what to do quickly as the stoma starts to swell immediately. On 6/25/19 at 3:45pm V8, LPN stated that there are times she has been left on the floor without another nurse and if a resident extubated himself she would have to call 911 as she does not know how to replace a [MEDICAL CONDITION]. V8 stated It's scary, and tonight I'm the only nurse on that floor and I don't feel comfortable transporting (R83) with the vent to [MEDICAL TREATMENT]. V8 stated that R83's vent needs to be unplugged and then plugged back in when she gets to the [MEDICAL TREATMENT] room and feels she would not know what to do if R83 had a problem. V8 stated there are times there is not an RN (Registered Nurse) in the building at night and now there is no respiratory staff either. V8 stated she does not know how to put a resident on or off a ventilator. On 6/25/19 at 10:00am V9, LPN stated she is not comfortable managing the vents or caring for vent patients, and definitely not comfortable weaning a resident on and off of the vent. V9 stated that if [MEDICAL CONDITION] out, she would have to ask for assistance. On 6/25/19 at 10:20am V11, LPN stated We have respiratory here Monday - Friday from 10am - 6pm. If they aren't here, the nurses are responsible. I don't feel comfortable with the vents. If respiratory wasn't here and the [MEDICAL CONDITION] out, I'd have to call 911. V11 also stated that recently the staffing has been cut and respiratory used to be here 24 hours a day. On 6/25/19 at 10:30am V12, RN/Agency stated that she did help transport a vent resident to [MEDICAL TREATMENT] yesterday, but didn't mess with the vent or any of the settings and stated I know nothing about how to do this. I am not comfortable weaning a patient on or off a vent. If [MEDICAL CONDITION] out, I'd have to call 911, because I've had no training and wouldn't know what to do. 3. POS dated 6/2019 indicates R13 was admitted to the facility 3/15/19 with [DIAGNOSES REDACTED]. MDS/BIMS dated 6/21/19 indicates R13 is cognitively intact and scored 14/15. On 6/25/19 at 10:45am R13 stated that a couple days ago he had bleeding from [MEDICAL CONDITION] V6, CRT came to help. R13 stated that the nurse did not help him and that he is worried when V6, CRT or V7, RRT are not working because he does not know if the nurses will know how to help him. At that time V6 was in the room administering a breathing treatment to R13 through [MEDICAL CONDITION]. V6 stated that in the evening (on Sunday 6/23/19) she was putting R32 back on the ventilator (on her own time) when a CNA asked her to look at R13. V6 stated that R13 had a napkin full of blood and a lot of bleeding from [MEDICAL CONDITION] that if R13'[MEDICAL CONDITION] dry it has a tendency to bleed and she had to replace R13's trach. V6 did not recall if the water humidification bottle was empty at that time, but stated that it is more common for bleeding when R13's trach/stoma get dry. V6 stated that R13's water humidifier for the [MEDICAL CONDITION] was completely empty this morning when she assessed R13 and should be monitored and not allowed to go dry. V6 stated the nurse was not aware of the bleeding from R13's trach. 4. Respiratory Flowsheets dated 6/1/19 to 6/30/19 indicates R13 did not receive [MEDICAL CONDITION] (Continuous Positive Airway Pressure) at 10pm as ordered by the physician from 6/14/19 to 6/22/19. R13 confirmed [MEDICAL CONDITION] was not provided on those nights. No documentation was found or presented to indicate R13 [MEDICAL CONDITION] or care on 6/23/19 by nursing which includes: Check liter flow every shift Monitor and document oxygen saturation every shift and as needed Oxygen at (1-6 tK>92%) lpm via cannula or [MEDICAL CONDITION] bleed Oxygen at 3 lpm during day via cannula and mask at night 35% every shift Cool aerosol [MEDICAL CONDITION] mask This care and monitoring for R13 were previously provided by the respiratory therapist. 5. POS dated 6/2019 indicates R44 was admitted to the facility 4/19/05 and has current [DIAGNOSES REDACTED]. MDS/BIMS dated 4/29/19 indicates R44 has severe cognitive impairments. Respiratory Flowsheets dated 6/1/19 through 6/30/19 indicate on 6/22/19 (Saturday) and 6/23/19 (Sunday) no documentation was found to [MEDICAL CONDITION] was provided to R44 by nursing. This care and monitoring for R44 were previously provided by the respiratory therapist. Care Plan dated 10/25/16 indicates R44 has increased potential for complications for respiratory distress related to [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Respiratory Flowsheet dated 6/2019 indicates nurses were not monitoring vent settings, oxygen [MEDICAL CONDITION] for R83 on 6/23/19. This care and monitoring for R83 were previously provided by the respiratory therapist. On 6/26/19 at 3:10pm V2, Interim DON (Director of Nursing) stated that The Respiratory Flowsheets are kept in the Respiratory book on the Respiratory cart in the hallway. V2 stated that nurses do have access to the book just like the treatment book. V2 stated that she charted in the book on 6/22/19 however the nurses were not aware of the flowsheets as it was not part of the inservice given by V6, CRT. V2 acknowledged that Nursing is responsible for the physician ordered respiratory treatments when respiratory therapy is not here. Facility Job Description for Respiratory Therapist (undated) indicates (in part) Main Duties include: Differentiates between resident and equipment problems and intervenes appropriately. Selects, assembles and checks equipment for proper function, operations and cleanliness. This includes mechanical ventilators, [MEDICAL CONDITION] systems, oxygen analyzers, demand values, manual resuscitators with and without PEEP (Positive end-expiratory pressure), spirometers, suctioning equipment, oral/nasal airways and tracheal tubes. The Job Description for LPN and RN's does not include the above respiratory therapist duties. On 6/27/19 at 1:40pm V28, Physician for (R13, R32 and R83) stated that he was not aware until now that the facility reduced respiratory therapy staff and believed that his residents had 24 hour respiratory care. V28 stated not having respiratory available is not the best care for his residents and is a quality of care issue. V28 agreed R13 may not have had to be sent to the hospital yesterday when his oxygen levels were low if respiratory had been available. V28 stated that R32 requires a high level of respiratory care and is definitely at risk and cannot be left off the ventilator an entire weekend and R83 would be at significant risk if no qualified staff are available. V28 stated that there is definitely a risk to residents with trachs and ventilator dependent residents unless there is a back up plan of trained staff who can recognize problems. Ideally I would like to have been notified as this decision to reduce respiratory staff impacts my residents. V28 stated the Medical Director also should have been notified prior to this decision On 6/27/19 at 9:03am V18, Medical Director stated that he was not aware until this morning that the facility had reduced respiratory staff and [MEDICAL CONDITION] ventilator dependent residents did not have 24 hour coverage by respiratory therapists. V18 stated that residents will be sent to the emergency room more often which is not good for anyone. V18 also stated that not having respiratory therapists available at all times does put residents at risk for harm [MEDICAL CONDITION] ventilator dependent residents. The Immediate Jeopardy was identified to have begun on (MONTH) 14, 2019 at 6:30 P.M. when the facility had no certified Respiratory Therapist in the facility to provide respiratory services for it's [MEDICAL CONDITION] residents and ventilator residents. V1/Administrator was notified of the Immediate Jeopardy on 6/28/19 at 2:33 P.M. The surveyor confirmed through interview and record review that the facility took the following Immediate Corrective Action: Actions Completed (MONTH) 28, 2019 by V1/Administrator: *A Contract was signed with PEL VIP to provide continuous respiratory therapy services when V6/Certified Respiratory Therapist was unavailable. * Extension of V6/Certified Respiratory Therapist hours until Contractual Staff from PEL VIP were onsite at approximately 1:00 [NAME]M. on 6/29/19. Actions Completed (MONTH) 28, 2019 by V6/Certified Respiratory Therapist: * All residents with [MEDICAL CONDITION]'s were reassessed by V6. * R13's humidifier was reassessed and validated to have water in the reservoir. Actions Completed (MONTH) 28, 2019 by V2/Interim Director of Nurses: * All residents with [MEDICAL CONDITION]/ventilators Care Plans were reviewed and updated as necessary. Actions Began on (MONTH) 28, 2019 by V6/Certified Respiratory Therapist through (MONTH) 15, 2019: * All licensed nursing staff will be re-educated and complete competencies on [MEDICAL CONDITION] Care including but not limited to: suctioning, mucous plugs, water humidification, respiratory flow sheet documentation and humidifier validation.

Based on observation, interview and record review the facility failed to ensure competently trained staff are present to provide routine care and emergency management to residents who are ventilator dependent (R32, R83) and require [MEDICAL CONDITION] care (R13, R32, R44, R83). These failures resulted in one resident (R32) attempting to suction her own [MEDICAL CONDITION] which was obstructed with a mucus plug; one resident R13 requiring a bleeding [MEDICAL CONDITION] to be replaced and the potential for life threatening respiratory complications for (R13, R32, R44, R83). These failures resulted in an Immediate Jeopardy being called on 6/28/19 at 2:33 P.M. While the immediacy was removed on 6/28/19 at 7:07 P.M., the facility remains out of compliance at a Severity Level 2, as the facility continues to educate nursing staff on [MEDICAL CONDITION] suctioning and care. Findings include: 1. Physicians Order Sheet (POS) dated 6/2019 indicates R32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS/BIMS (Minimum Data Set/Brief Interview for Mental Status) dated 4/26/19 indicates R32 has no memory impairments and scored 15/15. On 6/24/19 at 1:30pm R32 stated that V5, LPN (Licensed Practical Nurse) did not come into assess, monitor or suction her [MEDICAL CONDITION] during the night.V5 stated she had her call light on for 40 minutes, told a CNA (Certified Nurse Assistant) who told V5, but V5 never came. R32 stated that she suctioned herself, by putting the head of her bed down, reaching over and turning on the suction machine. R32 stated that the suction catheter is inline and already attached to the ventilator tubing. R32 stated I had a mucus plug and I don't ever want (V5) to be my nurse again. R32 stated that she texted V6, Certified Respiratory Therapist (CRT) at 3am to tell her that V5 refused to suction her. R32 stated that over the weekend (on 6/22/2019 and 6/23/2019) V6 came to the facility at 7pm and put me on the vent(ilator) and then came back and took me off the vent(ilator) the next day on her own time. Respiratory Therapy staff schedule dated 6/2019 indicates V6, CRT was not scheduled on 6/22/2019 or 6/23/ 2019. V6 stated that it was the first weekend that respiratory would not be available to residents that needed respiratory care and she only came in - on her own - because she was worried about the residents who require respiratory care. 2. POS dated 6/2019 indicates R83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS/BIMS dated 5/20/19 indicates R83 has no memory impairments and scored 15/15 indicating R83 is cognitively intact. V5 stated that she did not check vent settings as she was not aware of the resident care directions located in the Respiratory Flow Sheets, only checked R32 oxygen saturation and administered a nebulizer treatment. POS dated 6/2019 indicates R83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS/BIMS dated 5/20/19 indicates R83 has no memory impairments and scored 15/15 indicating R83 is cognitively intact. On 6/24/19 at 4pm V6 stated (R83) was in the hospital when they cut respiratory staff and I refused to take R83 back because she is ventilator dependent 24/7 and I no longer had the staff. V6 stated that the decision was made to bring R83 back anyway and V6 was called in by the admitting nurse to put R83 on the ventilator when she came back from the hospital at 9pm on a Sunday because there was no other trained staff who could put (R83) on the ventilator. V6 stated that she is the only staff who knows how to put in R83's speaking valve and that R83 won't be able to speak unless she is here to insert the speaking valve. V6 stated if a resident'[MEDICAL CONDITION] comes out, staff need to know what to do quickly as the stoma starts to swell immediately. 3. POS dated 6/2019 indicates R13 was admitted to the facility 3/15/19 with [DIAGNOSES REDACTED]. MDS/BIMS dated 6/21/19 indicates R13 is cognitively intact and scored 14/15. On 6/25/19 at 10:45am R13 stated that a couple days ago he had bleeding from [MEDICAL CONDITION] V6, CRT came to help. R13 stated that the nurse did not help him and that he is worried when V6, CRT or V7, RRT are not working because he does not know if the nurses will know how to help him. At that time V6 was in the room administering a breathing treatment to R13 through [MEDICAL CONDITION]. V6 stated that in the evening (on Sunday 6/23/19) she was putting R32 back on the ventilator (on her own time) when a CNA asked her to look at R13. V6 stated that R13 had a napkin full of blood and a lot of bleeding from [MEDICAL CONDITION] that if R13'[MEDICAL CONDITION] dry it has a tendency to bleed and she had to replace R13's trach. V6 did not recall if the water humidification bottle was empty at that time, but stated that it is more common for bleeding when R13's trach/stoma get dry. V6 stated that R13's water humidifier for the [MEDICAL CONDITION] was completely empty this morning when she assessed R13 and should be monitored and not allowed to go dry. V6 stated the nurse was not aware of the bleeding from R13's trach. 4. POS dated 6/2019 indicates R44 was admitted to the facility 4/19/05 and has current [DIAGNOSES REDACTED]. MDS/BIMS dated 4/29/19 indicates R44 has severe cognitive impairments. Respiratory Flowsheets dated 6/1/19 through 6/30/19 indicate on 6/22/19 (Saturday) and 6/23/19 (Sunday) no documentation was found to [MEDICAL CONDITION] was provided to R44 by nursing. This care and monitoring for R44 were previously provided by the respiratory therapist. Care Plan dated 10/25/16 indicates R44 has increased potential for complications for respiratory distress related to [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. On 6/26/19 at 3:10pm V2, Interim DON (Director of Nursing) stated that The Respiratory Flowsheets are kept in the Respiratory book on the Respiratory cart in the hallway. V2 stated that nurses do have access to the book just like the treatment book (The Respiratory Flowsheets are separate from Medication Administration Record [REDACTED]. On 6/24/2019 at 4pm, V6, CRT stated that she offered to train the ADONs who could then train the nurses but it was not her responsibility to ensure the nurses knew what to do. On 6/25/19 at 10am V7, RRT (Registered Respiratory Therapist) stated that early in (MONTH) (2019) all of the RT's were told they were phasing out respiratory therapy and that nursing would assume all [MEDICAL CONDITION] and vent care. V7 stated the majority of the nurses in the facility are LPN's and/or from Agency. V7 stated that nursing staff received the bare minimum training and they are not competent to provide the level of respiratory care required to care for ventilator dependent residents. V7 stated it takes years of education and training to troubleshoot ventilator equipment, skill to understand alarms, know the difference [MEDICAL CONDITION] types, deflating the cuff when capping, and the list goes on. V7 stated the facility has no trained respiratory therapist at night and some nurses have never used an ambu bag if a resident on [MEDICAL CONDITION]. V7 stated that ventilator dependent residents require frequent monitoring of settings and need trained staff to troubleshoot equipment and assess the resident quickly when problems happen. On 6/25/19 at 3:45pm V8, LPN stated that there are times she has been left on the floor with out any other nurse and if a resident extubated himself she would have to call 911 as she does not know how to replace a [MEDICAL CONDITION]. V8 stated It's scary, and tonight I'm the only nurse on that floor and I don't feel comfortable transporting (R83) with the vent to [MEDICAL TREATMENT]. V8 stated that R83's vent needs to be unplugged and then plugged back in when she gets to the [MEDICAL TREATMENT] room and feels she would not know what to do if R83 had a problem.V8 stated there are times there is not an RN (Registered Nurse) in the building at night and now there is no respiratory staff either.V8 stated she does not know how to put a resident on or off a ventilator. On 6/25/19 at 10:00am V9, LPN stated that the previous respiratory supervisor gave her some training for the vents but she is not comfortable managing the vents or caring for vent patients, and definitely not comfortable weaning a resident on and off of the vent. V9 stated that if [MEDICAL CONDITION] out, she would have to ask for assistance. V9 stated that she mostly does not work on the floor with residents who are on vents but has floated to that floor before. V9 stated that the previous respiratory supervisor gave her some training for the vents but she is not comfortable managing the vents or caring for the vent patients. On 6/25/19 at 10:20am V11, LPN stated We have respiratory here Monday - Friday from 10am - 6pm. If they aren't here, the nurses are responsible. I don't feel comfortable with the vents. If respiratory wasn't here and the [MEDICAL CONDITION] out, I'd have to call 911. V11 stated that she is not comfortable weaning a resident on/off the vent because I have not had formal training from the facility and has not received any traing since respiratory staff have been cut to eight hours per day. On 6/25/19 at 10:30am V12, RN/Agency stated that she did help transport a vent resident to [MEDICAL TREATMENT] yesterday, but didn't mess with the vent or any of the settings and stated I know nothing about how to do this. I am not comfortable weaning a patient on or off a vent. If [MEDICAL CONDITION] out, I'd have to call 911, because I've had no training and wouldn't know what to do. V12 stated that she has not had any tracing on managing vent settings or any type of care or treatment for [REDACTED]. On 6/24/19 at 4pm V6, CRT stated that previously the facility had 24 hour respiratory therapist coverage, but as of 6/14/19 the facility let all of the RT's go and residents only get coverage by one RT (Respiratory Therapist) eight hours per day Monday through Friday. V6 stated that currently she is the only RT left in the building and works Monday through Friday 10am to 6:30pm. V6 stated that this past weekend was the first weekend there was no RT in the building to care for residents. Facility Job Description for Respiratory Therapist (undated) indicates (in part) Main Duties include: Differentiates between resident and equipment problems and intervenes appropriately. Selects, assembles and checks equipment for proper function, operations and cleanliness. This includes mechanical ventilators, [MEDICAL CONDITION] systems, oxygen analyzers, demand values, manual resuscitators with and without PEEP, spirometers, suctioning equipment, oral/nasal airways and tracheal tubes. The Job Description for LPN and RN's does not include the above respiratory therapist duties. Inservice Understanding Vent Troubleshooting indicates 5 LPNs and 2 RNs were inserviced on 6/13/19. Inservice does not indicate what troubleshooting was provided or how many minutes the inservice took. Six of the nurses were from the first shift, one nurse was from the 2nd/3rd shift. On 6/24/19 at 2pm V6, CRT stated that she provided the inservice to the nurses on 6/13/19 and only covered the three most common problems related to vent care. V6 stated that every resident has unique problems and ventilator care is much more complicated than the brief inservice she was required to provide and was not adequate for nurses to independently provide respiratory care at the level of a respiratory therapist. On 6/27/19 at 9:03am V18, Medical Director stated that he was not aware until this morning that the facility had reduced respiratory staff and [MEDICAL CONDITION] ventilator dependent residents did not have 24 hour coverage by respiratory therapists. V18 stated the facility should have competently trained respiratory staff in sufficient numbers to care for residents. V18 stated that LPN's training does not equal the training of a respiratory therapist. V18 stated that residents will be sent to the emergency room more often which is not good for anyone. V18 also stated that not having respiratory therapists available at all times does put residents at risk for harm [MEDICAL CONDITION] ventilator dependent residents. The Immediate Jeopardy was identified to have begun on (MONTH) 14, 2019 at 6:30 P.M. when the facility had no certified Respiratory Therapist in the facility to provide respiratory services for it's [MEDICAL CONDITION] residents and ventilator residents. V1/Administrator was notified of the Immediate Jeopardy on 6/28/19 at 2:33 P.M. The surveyor conformed through interview and record review that the facility took the following Immediate Corrective Action: Actions Completed (MONTH) 28, 2019 by V1/Administrator: *A Contract was signed with PEL VIP to provide continuous respiratory therapy services when V6/Certified Respiratory Therapist was unavailable. * Extension of V6/Certified Respiratory Therapist hours until Contractual Staff from PEL VIP were onsite at approximately 1:00 [NAME]M. on 6/29/19. Actions Completed (MONTH) 28, 2019 by V6/Certified Respiratory Therapist: * All residents with [MEDICAL CONDITION]'s were reassessed by V6. Actions Completed (MONTH) 28, 2019 by V2/Interim Director of Nurses: * All residents with [MEDICAL CONDITION]/ventilators Care Plans were reviewed and updated as necessary. Actions Began on (MONTH) 28, 2019 by V6/Certified Respiratory Therapist through (MONTH) 15, 2019: * All licensed nursing staff will be re-educated and complete competencies on [MEDICAL CONDITION] Care including but not limited to: suctioning, mucous plugs, water humidification, respiratory flow sheet documentation and humidifier validation.

Based on observation, record review and interview the facility failed to follow physician orders, failed to follow hand hygiene practices during pressure ulcer dressing changes, failed to promote the healing and development of additional pressure ulcers and failed to monitor weekly progression of pressure ulcers for two (R1 and R3) of three residents reviewed for pressure ulcers in a sample of three. These failures resulted in R1 developing additional pressure ulcers and the worsening of R1 and R3's existing pressure ulcers. Findings include: The Facility Pressure Ulcer Treatment and Management Policy, revised 5/17, documents that residents with pressure ulcers will have a physician's orders [REDACTED]. The Pressure Ulcer Prevention Protocol Policy, revised 5/18, documents that daily skin checks conducted by either the Certified Nursing Assistant or Licensed Nurse to ensure early identification of potential problem areas; and that residents will have their skin checked and documented utilizing the Treatment Administration Record; and the skin check will be performed at a minimum of weekly. The Facility Bath Policy, revised 5/17, documents that the resident is to be cleansed and refreshed at least weekly by providing one complete bath and hair wash; and to follow physician's orders [REDACTED]. The Facility Handwashing Policy, undated, documents that handwashing shall be regarded by this organization as the single most important means of preventing the spread of infections; all personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients and visitors; handwashing must be performed before handling clean/soiled dressings, after handling used dressings, after contact with body fluids and upon completion of a duty; and the use of gloves does not replace handwashing. 1. R1's Physician order [REDACTED].), cover with border foam every other day and as needed; Left Proximal Posterior Thigh (cleanse with saline/wound cleanser, apply dressing (Triad), cover with border foam every other day and as needed; Right Ischium (cleanse with saline/wound cleanser, apply calcium alginate to wound bed, cover with pad, daily); and Right Medial Buttock (cleanse wound with saline/wound cleanser, apply dressing (Triad) and cover with border foam every other day and as needed. R1's Care Plan documents to treat per Physician Orders, conduct a systematic skin inspection daily and to check and change during routine rounds every 2 hours and as needed. R1's Treatment Administration Record/TAR, dated 2/1/19 through 3/22/19, does not document treatment administration to R1's Coccyx/Buttocks and Right Ischium on 2/5/19, 2/6/19, 2/7/19, 2/9/19, 2/10/19, 2/11/19, 2/16/19 2/18/19, 2/19/19, 2/20/19, 2/22/19, 2/24/19, 2/25/19, 2/26/19, 2/27/19, 2/28/18, 3/1/19, 3/3/19, 3/4/19, 3/5/19, 3/6/19, 3/7/19, 3/8/19, 3/11/19, 3/12/19, 3/13/19 and 3/21/19. R1's Wound Clinic Assessment Details, dated 1/24/19, documents R1's Right Ischium Pressure Ulcer with an onset of 6/14/18 and measurements of 0.2 centimeters/cm X 1.2 cm X 0.1 cm. R1's Wound Clinic Assessment Details, dated 2/25/19, documents R1's Right Ischium Pressure Ulcer measurements of 0.4 cm X 2.7 X 0.1 cm. R1's Facility Skin Assessment, dated 3/10/19, documents four pressure ulcers on R'1 left buttock/ischium measuring 3.9 cm X 1.4 cm, 2.0 cm X 1.0 cm, 5.4 cm X 1.0 cm and 3.7 cm X .7 cm; and on two pressure ulcers on R1's right buttock/ischium measuring 1.8 cm X 1.9 cm x 1.5 cm and 4.5 cm X 2.0 cm; and a pressure ulcer on R1's left posterior thigh measuring 4.5 cm X 2.0 cm. The Facility Weekly Pressure Injury Report, dated 2/13/19, documents one pressure ulcer, R1's Right Ischium, measuring 1.2 cm X 0.4 cm X 0.1 cm. R1's Wound Clinic Assessment Details, dated 3/25/19, documents four pressure ulcers to R1's Right Ischium (onset 6/14/18) measurements of 5.5 cm X 7.5 cm X1.7 cm; Left Proximal Posterior Thigh (acquired 2/25/19) measurements of 1.0 X 0.5 X 0.2 cm; and Left Proximal Medial Buttock (acquired 2/25/19) measurements of 1.6 cm X 3.7 cm X 0.1 cm. Facility staff did not document R1's shower sheets/records for 1/1/19 through 3/25/19. The Facility Weekly Pressure Injury Reports, dated 2/13/19 through 3/27/19, were not completed and no documentation could be produced by the facility. On 3/27/19, at 1:30 pm, V6 (Licensed Practical Nurse/LPN) performed pressure ulcer care to R1. R1 performed hand hygiene and applied clean gloves and performed R1's Left Proximal Medial Buttock, Left Proximal Posterior Thigh and Left Posterior Thigh pressure ulcer treatment. With the same gloves, V6 picked up a tube of medicated cream (Triad) that had fallen onto the floor, and placed it back onto the bedside table. Then with the same gloves, V6 cleansed R1's Right Ischium and Right Medial Buttock pressure ulcers and discarded the soiled dressings into the trash bag that was laying on the floor next to R1's bed. V6 then applied the same medicated cream (Triad) with a cotton tip applicator to R1's Right Medial Buttock and Right Ischium. No hand hygiene was performed. V6 removed the soiled gloves into the trash bag on the floor and put on a new pair of gloves. No hand hygiene was performed. V6 then positioned R1 in the bed. On 3/27/19, at 1:48 pm, V6 (LPN) stated, I usually wash my hands and glove, set up my field and remove the old dressings, then I wash my hands. Then I do the dressing change and take off my gloves and wash. I am not really sure, I do not usually do her dressing changes because the wound nurse does them. On 3/26/19, at 1:49 pm, V2 (Director of Nursing/DON) stated, We have not been doing (R1's) pressure ulcer treatments as ordered, the shower sheets are not getting done, the weekly skin assessments and weekly Facility Pressure Ulcer Reports have not been done since 2/13/19. On 3/27/19, at 1:15 pm, V4 (Would Clinic Registered Nurse) stated, We send the treatment orders for (R1's) pressure ulcers and the facility should absolutely follow those orders or the ulcers will get worse. 2. R3's current Minimum Data Set Assessment, dated 2/23/19 documents under Section M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage: (1) Stage 4 wound. R3's current (local) Wound and Hyperbaric Institute Wound Notes, dated 2/25/19 document, Left Ischial, Stage 4 Pressure Injury, measuring 1 CM (centimeter) X 0.3 CM X 0.5 CM with no tunneling. This same document includes the following physician orders: Cleanse wound with non-cytotxic agent. Apply Barrier Ointment (Baza Cream) to protect surrounding skin to wound daily. Pack wound with [MEDICATION NAME]. Cover wound and secure dressing in place. Change dressing every other day and as needed. (MONTH) shower two times a week. Wound must be kept covered and dry with (occlusive dressing). Additional orders include,Follow up appointment, return in 1 month. Use wheelchair cushion. Mattress Overlay or Speciality Bed or Mattress. Follow a nutritious diet. Dietary supplement-Increase Prostat 30 ML (milliliters) per dose to three times daily, mix with soda pop or juice. R3's current Physician order [REDACTED]. The Wound Clinic Physician orders [REDACTED]. R3's current Care Plan, dated (revised) 12/13/18 includes the following Problem: (R3) has a pressure ulcer, stage 4 on left ischium. Included under Approaches for staff are: [MEDICATION NAME] paste to left ischium daily and Assess the pressure ulcer for location, stage, size (length, width, depth), presence/absence of granulation tissue and epithelization weekly. R3's Treatment Administration Record, dated 2/1/19-2/28/19 documents R3's treatment was not completed 12 out of 28 days for the month of February. On 3/28/19 at 1:00 P.M.,V2/Director of Nurses verified staff failed to perform R3's treatment as ordered by the physician, failed to apply protective barrier cream and failed to provide R3 dietary protein supplements. On 3/26/19 at 9:35 A.M., V3/Registered Nurse (RN) prepared to perform wound care to (R3's) left ischium. V3/RN washed hands, applied gloves and removed the old dressing from R3's left ischium. V3/RN cleansed the area with wound cleanser and applied a border foam dressing smeared with [MEDICATION NAME] to the area. V3/RN did not apply barrier cream to the surrounding skin or pack the ischial wound with [MEDICATION NAME]. On 3/26/19 at 12:20 P.M., V2/Director of Nurses (DON) performed wound measurements to R3's left ischium. The area currently measures 5 CM X 3 CM X 2 CM with tunneling of 1.8 CM at 10:00 o'clock, 1 CM at 12:00 o'clock and 1 CM at 1:00 o'clock. On 3/27/19, at 9:50 am, V5 (Medical Director/R1's Physician) stated, That is absolutely wrong if they are not doing the treatments. They should be doing the treatments as ordered, regardless if there is a wound nurse in the facility or not. That definitely can affect the wound progress.

Based on observations, interviews, and record reviews the facility failed to provide pressure sore interventions to prevent pressure sores, and failed to identify a stage II pressure sore for two of five residents (R1, R5) reviewed for pressure sores in a sample of five. These failures resulted in R5 acquiring two stage two pressure sores on her left palm and one stage two on the buttocks. Findings include: 1. R5's facility Occupational Therapy Recommendation Note dated 1/23/19 reads, RN educated on the need to use palm protector washcloths to prevent ongoing contracture development. Incident report dated 3/16/19 noted that R5's daughter reported to nursing staff and Administrator concerns regarding the care of resident's (R5) contracted hand. Initial review revealed skin appeared possibly being pierced due to fingernails. Family demanded resident (R5) be sent to ER for evaluation. Hospital Emergency Department noted, Open wounds of left hand without foreign body, unspecified wound type, initial encounter: Pressure injury of buttock, stage 2, unspecified laterally. On 3/19/19 at 5:15 P.M. at V5 (R5's daughter) stated that she was unaware of R5 having a pressure sore on her buttocks. V5 stated that R5 had never had any splint or barrier to protect her left palm from from her contracted fingers. On 3/20/19 at 11:32 A.M. V1 (Administrator) stated that the facility staff had failed to follow through with the Occupational Therapy recommendation with palm protectors which resulted in the two open palm wounds. V1 also stated that the facility staff did not know R5 had a pressure sore on his buttocks prior to going to the hospital, so they had not been treating it. On 3/19/19 at 10:35 A.M. R5 was noted in reclined wheelchair. R5's left palm was noted to have two open pressure sores from R5's fingernails digging in. R5's fingernails were noted to be very long. 2. R1's physician's orders [REDACTED]. On 3/14/19 at 1:10 P.M. V3 (R1's daughter) stated that back at the end of (MONTH) R1 had been ordered protein liquid for pressure sore healing, but staff never followed through with the order. V3 stated that R1 did not receive the protein liquid for about two weeks before staff had caught the error. R1's medication administration records dated (MONTH) 2019 and (MONTH) 2019 notes that on 2/27/19, R1 was ordered 30 ml of protein liquid to be given three times a day for wound healing. Medication administration records note that the liquid protein was missed from 2/27/19 until 3/13/19. On 3/20/19 at 11:32 A.M. V1 stated that they did miss giving R1 his protein liquid from 2/27/19 through 3/13/19.

Based on observation, interview, and record review, the facility failed to accurately assess, document, treat as ordered and report the condition of a pressure ulcer for two of two residents (R2, R4) reviewed for pressure ulcers in the sample of 4. This failure resulted in R2's pressure ulcer requiring surgical excision debridement and R4's pressure ulcer requiring aggressive antibiotic treatment. Findings include: The facility's Wound Assessment Policy and Procedure (revised 06/12) documents the following: 1. It is the policy of this facility to do a systemic, ongoing wound assessment on all wounds in order to determine the response to nursing care and treatment modalities. 3. The wound assessment will contain the following information: a. Wound classification b. Wound location c. Pressure ulcer staging OR description of the extent of tissue damage d. Description of the wound bed, drainage, margins/surrounding skin and odor e. Wound measurements f. Wound related pain The facility's Pressure Ulcer Risk Assessment Policy and Procedure documents the following: 5. All residents AT HIGH RISK for pressure ulcer development will receive a documented daily visual inspection of their skin by the RN/LPN (Registered Professional Nurse/Licensed Practical Nurse) or CNA (Certified Nursing Assistant) delivering care. The facility's Skin Assessment Policy and Procedure (revised 09/2013) documents the following: In addition to ongoing assessment of the skin, the facility will implement measures to protect the resident's skin integrity and to prevent skin breakdown. On 07/27/2017 at 09:35 AM E12 LPN Wound Nurse stated I'm responsible for assessing, documenting and doing the treatments for all the residents wounds. (R2's) wounds were there when she admitted here. The reason the wound measurements were the same on the 3rd and 13th was because the wound was the same. It had not changed. That is why I put her on the wound Dr's list to be seen on the 12th (07/12/2017). The Observation Detail List Report dated 07/03/2017 and signed by E12, LPN/Wound Nurse records Left buttock area presents with an un-stageable Decubitis with measurements of 7.3 x (centimeters) X (by) 6.4 cm wound bed presents as 25 % slough, 75% necrotic tissue present on admission. Coccyx area presents with a stage 4 which measures 3.2 x 0.9 x 0.3cm present on admission. The Observation Detail List Report dated 07/13/2017 and signed by E12, LPN/Wound Nurse records Left Buttock , unstageable 7.3 x 6.4 cm, granulation-25%, Describe progress-wound is noted to be at a stand still in the healing process at this time. Site 2 Coccyx, stage 4, 3.2 x 0.9 x 0.3cm, granulation-50%, Slough-50%. Describe progress-wound is noted to be at a stand still in the healing process at this time. The Physician's Progress Note dated 07/12/2017 by Z1, Medical Doctor/Wound Specialist documents Surgical consult for sacral ulcer debridement. Santyl on her sacral ulcer pending surgery. Low loss air mattress, keep her on her side and change position at least every two hours. On 08/01/2017 at 11:26 AM Z1, Medical Doctor/Wound Specialist stated When I saw (R2) on the 12th she needed the debridement. I was not aware that the debridement hadn't been done prior to learning about it on the 18th (07/18/2017). I also was not aware that the treatment orders I had written on the 12th (07/12/2017) had not been put into practice. All I can do is write the orders for treatment what they do with them is up to their staff. On 07/27/2017 at 09:35 AM E12 LPN (Licensed Practical Nurse) Wound Nurse stated I never saw the order changes for (R2) after (Z1's) visit. I kept treating the wounds with [MEDICATION NAME]. I never saw the order for the debridement. On 07/31/2017 at 08:38 AM Z6, Registered Professional Nurse (discharging hospital/R2) stated There was an area on (R2's) coccyx when she discharged . The wound had been treated and it was healing well when (R2) was discharged . The Discharge Wound assessment dated [DATE] from discharging local hospital for R2 documents Coccyx -Pressure Wound Stage II, Color Purple, Drainage present, Wound thickness- partial, 6 x 6.5 x 0.2cm, Edge-Attached to wound bed, Wound bed tissue- Agranular, Surrounding skin color-normal. On 07/31/2017 at 04:00 PM Z2 Dietician stated I did not visually inspect the wounds, I used the nursing notes and progress notes that were in the record to describe the wounds and make my recommendations. The Resident Progress Notes dated 07/03/2017 at 10:25 AM by Z2, Dietician RD (Registered Dietician) initial observation completed. admits with stage 2 to coccyx. The Resident Progress Notes dated 07/17/2017 at 10:25 AM by Z2, Dietician RD wound review-Treatment to Right buttock, unstageable to left buttock and coccyx stage 4 , 07/14 measurements reviewed. The facilities Progress Notes dated 07/17/2017 at 04:38 PM document Family here and concerned about residents condition change- (Z9, MD for R2) notified -order received to send to (local) hospital for evaluation/treatment. The Initial Wound Evaluation from admitting local hospital dated 07/17/2017 at 04:51 PM records Wound location: bilateral buttocks-present on admission, Etiology: unstageable ulcer, Measurements 5.5cm x 13cm x 3.0cm, Wound Base-black 80%, red 10%, yellow slough 10%, Wound Thickness-full, Wound Edges/Margin-irregular, Wound Drainage-black red. On 08/01/2017 at 03:00 PM Z7, Wound/Ostomy Nurse for admitting local hospital for R2 stated I am one of the wound specialist ostomy specialist nurses here at the hospital. I manage wounds every day and have for over three years. The state of this wound for (R2) upon her admission was that of a wound that has not been managed. On 07/28/2017 at 01:29 PM Z9, Medical Doctor for R2 stated I was really surprised to hear the wound was in the state it is. I can't believe it deteriorated so quickly. This was a really bad wound. It was infected and required surgical intervention which was done right in the emergency room . Infectious disease saw her and she was treated with IV (intravenous) antibiotics. The surgical notes dated 07/17/2017 at 07:55 PM for R2's debridement by Z10, Surgeon documents Indications: sacral Decubitis ulcer Findings:12 x 8 cm stage 4 sacral Decubitis ulcer with 6 cm tunneling to the left Procedure Details: Cleaned the area debrided sharply with pick up knife. Cut through viable ad nonviable skin and adipose tissue. Stopped when we reached excellent bleeding subcutaneous tissues. Then debrided the skin edge sharply as well with a knife. Covered with sterile dressing. 2. On 08/01/2017 at 01:30 PM R4 stated I've been at Generations for a month and a half now. In that time the wound on my thigh continues to get worse not better. The wound nurse there (E12, LPN/Wound Nurse) does not do a good job taking care of the wound. The dressing is not changed everyday. Sometimes it goes two and three days without the dressing being changed. I had a Dr. appointment for a check up on Thursday (07/27/2017). When (Z3, Medical Doctor) saw the wound he sent me right to the emergency room . He was upset by the condition of the wound. On 07/28/2017 at 02:00 PM Z5 Advanced Practice Nurse, [MEDICATION NAME] under Z3, Medical/Wound Doctor for R4 stated I was with Dr when (R4) came into the clinic. I saw the wound. The wound was covered in slough. This was a very bad high risk wound and so we couldn't keep him here (local hospital). (R4) needed to be transferred to the hospital that could provide infectious disease interventions. There was a high risk of amputation due to the condition of the wound. This wound was not healing it was getting worse. (R4) is oriented to person, place and time. He told us the wound nurse doesn't change his dressings or provide care timely. The physician progress notes [REDACTED]. MRI (magnetic resonance imaging) done today shows large stage 3 to 4 deep wound in the right thigh with sinus track and developing abscess. I saw the patient in emergency department and I transferred him to (local hospital) for further evaluation and management. R4's Wound Documentation (weekly wound monitoring sheet) dated 07/13/2017 signed by E12 LPN/Wound Nurse documents R4's pressure wound of the right hip. Deepest Stage of wound-Stage 4, Size- 10.3 x 6.0 x 2.3cm, Exudate Amount- Moderate, Color- Serosanguineous, Wound Base-Granulation-75%, Slough- 25%, Skin surrounding- normal. The review of R4's medical record contained no documentation regarding the infection of this wound. E12 LPN/Wound Nurse refused to make any comment.

Based on observation, interview and record review, the facility failed to follow its policy on abuse prevention by not immediately reporting an incident of potential sexual assault to the facility Administrator, physician, law enforcement, and responsible party; and failed to follow their policy and investigate timely an incident of potential sexual assault involving one resident (R4) of 14 residents reviewed for abuse in a sample of 22. R4 exhibited multiple bruising on the arms, face, handprint type bruising on R4 ' s right inner thigh, scratches on R4 ' s right inner thigh as well as a swollen, reddened and bruised labia (vaginal area). These failures have the potential to affect nine residents (R4, R14, R15, R18, R19, R20, R24, R25, and R27) in the sample of 22 and 19 residents (R5, R32 to R48 and R86) in the supplemental sample who live on the second floor of the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 06/01/15, the facility remains out of compliance at a Severity level 2 as the facility is still educating management and staff on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Additional time is needed to monitor the effectiveness of the implementation of new policies and procedures. ¡¡ Findings include: The undated facility policy, titled Abuse Prevention Program Facility Policy instructs staff, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, 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 designee shall initiate an incident investigation. The nursing staff is additionally responsible for documenting the appearance of suspicious bruises, lacerations or other abnormalities as they occur. Upon report of such occurrences, the nursing staff is responsible for assessing the resident, reviewing the documentation and reporting to the administrator. If the resident complains of physical injuries or if injury is suspected, the resident's physician will be contacted for further instructions .The facility shall also immediately contact local law enforcement authorities (i.e., telephoning 911 where available) in the following situations:sexual abuse of a resident by a staff member, another resident or a visitor. On 05/29/15 at 2:50 P.M., R4 was lying in bed in R4's room on the second floor, looking around the room. There was multiple bruising on R4 ' s arms, face, and handprint type bruising on R4 ' s right inner thigh. There were also scratches present on R4 ' s right inner thigh as well as a swollen and bruised labia (vaginal area). R4's labia was swollen and red. R4's Nurses' Notes dated 05/24/15 at 5:03 P.M. document, CNA assigned to resident alerted this nurse to resident's 'red vaginal area'. Upon exam (examination) per this nurse labia (right side) is red and swollen and resident's clitoris has obvious swelling. Origin of swelling and redness is unknown, will pass information to oncoming shift to monitor and have (Z1 Nurse Practioner) examine area in the A.M. The same notes contain no documentation that there was any notification to the facility Administrator, attending physician, responsible party, or law enforcement R4's Nurses' Notes dated 05/25/15 at 5:36 A.M. (over 12 hours later) document, Noted bruising to inner thighs injury. Skin report made. 5:25 A.M., (E1) notified. Also (E14 Assistant Director of Nurses) called at 5:27 A.M. The same nurse's note contained no documentation of attending physician, responsible party, or law enforcement being notified. On 05/29/15 at 3:25 P.M., E4 Registered Nurse stated, After supper (on 05/24/15),( E3 Licensed Practical Nurse) asked me to come look at something on (R4). It was around 5:00 P.M. (R4)'s vagina was swollen and red. There was fresh bruising on (R4)'s inner thighs. (R4) was withdrawn, which wasn't like (R4). She also had a bruise to (R4)'s right eye, around the cheek bone. I told (E3) we need to report it. Instead (E3) had the two third shift nurses look at (R4) around 10:00 or 10:30 (P.M.). On 05/29/15 at 4:35 P.M., E1 (Administrator) stated, (E12) Licensed Practical Nurse called me about 5:30 A.M. on Monday morning (05/25/15). (E12) said (E12) had found bruising on (R4)'s inner thighs and redness and swelling of (R4)'s vaginal area. I was out of town, so I called (E2 Director of Nurses) and (E2) came in. On 05/29/15 at 3:50 P.M., Z1 (Nurse Practioner) stated, Last Monday (05/25/15) I was off. I got called at 6:30 A.M. by (E9 Licensed Practical Nurse). (E9) let me know there was some bruising to (R4)'s upper extremities and thighs and swelling to (R4)'s vaginal area. I came in at 10:30 A.M. (R4) had contusions to the left upper arm and left posterior shoulder. Contusions to the left hip area, over the greater trochanter, pin-point bruises to the right upper arm and bruising to the posterior inner thighs. I checked (R4)'s vaginal area and noticed slight [MEDICAL CONDITION] to the labia majora. I was on call for (E10 Physician) Sunday night (05/24/15) and I did not receive a call that night. If I knew the way (R4) was acting, how (R4) was withdrawn and fearful along with all the bruising and scratches I would have sent (R4) to the ER (emergency room ) that night to be assessed for sexual assault. On 06/02/15 at 10:00 A.M., E10 (Physician/Medical Director) verified that E10 would expect to be notified of bruising to labia, inner thighs, hips, around the right eye and scratches to the right inner thigh and a resident acting unnaturally withdrawn and fearful immediately, so that further medical investigation, possibly including a sexual assault evaluation, could be completed. E10 stated, Bruising develops on the extent of the injury. The harder you are hit, the deeper it develops. There is nothing in (R4)'s medical record to indicate (R4) has a condition that causes a delay in developing bruising. (R4) has advanced dementia. It's hard to know what (R4) is feeling. It is hard to communicate with (R4). We have to rely on labs (laboratory) to tell us what (R4)'s condition is. The facility's Nurses' Midnight Census Report presented on 6/1/15 indicates that 28 residents (R4, R5, R14, R15, R18, R19, R20, R24, R25, R27, R32 to R48 and R86) currently live on the second floor. The Immediate Jeopardy was identified on 05/29/15 at 5:30 P.M. to have begun on 05/24/15 at 5:00 P.M. when R4 was found with bruising, redness and swelling to the genital area and bruising to the right eye, arms and inner thighs. E1 (Administrator) was notified of the Immediate Jeopardy on 05/29/15 at 6:00 P.M. Surveyors confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: On 05/29/15 the Facility Consultant in-serviced the Abuse Prevention Coordinator and the Director of Nurses on the abuse prevention program including timely reporting of alleged abuse to IDPH, resident physician or physician extender and the police department. On 05/29/15 the Administrator in-serviced staff regarding the abuse prevention program including appropriate reporting of alleged abuse to the Abuse Prevention Coordinator. Any staff not receiving training by 05/31/15 will be removed from the schedule until training completed. On 05/29/15 an Investigation Guidance Checklist for abuse allegation investigation and reporting has been developed and will be utilized for all allegations of potential abuse. On 05/29/15 a Quality Assurance Review Tool has been developed to randomly assess abuse investigations to ensure reports are thorough and follow policy. On 05/29/15 an emergency QA/CQI meeting was held to review the Removal Plan. On 05/29/15 (R4)'s Physician has been contacted in order to determine further need for medical evaluation of the resident's condition. ¡¡ ¡¡ ¡¡ ¡¡ ¡¡

Based on observation, interview and record review, the facility failed to recognize swollen and bruised female genitalia as potential sexual abuse, failed to immediately report an incident of possible sexual abuse to the administrator and failed to promptly investigate an incident of possible sexual abuse involving R4, one of 14 residents reviewed for abuse in the sample of 22 . This failure has the potential to affect nine residents (R4, R14, R15, R18, R19, R20, R24, R25, and R27) in the sample of 22 and 19 residents (R5, R32 to R48 and R86) in the supplemental sample who live on the second floor of the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 06/01/15, the facility remains out of compliance at a Severity level 2 as the facility is still educating management and staff on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Additional time is needed to monitor the effectiveness of the implementation of new policies and procedures. Findings include: On 05/29/15 at 2:50 P.M., R4 was lying in bed in R4's room on the second floor, looking around the room. Yellow/green bruising was present around R4's right eye and multiple purple bruises of various sizes were present on both of R4's arms, including fingertip bruising to R4's right upper arm. A yellow/purple 20 X 10 CM (centimeter) bruise was present on R4's posterior right upper thigh. A green/purple hand print shaped bruise was present to R4's left upper, inner thigh. Scratches were also present to R4's right inner thigh. A 3 CM purple bruise was present on R4's right labia. The labia was also swollen and red. R4's Nurses' Notes dated 05/24/15 at 7:03 P.M. document, CNA assigned to resident alerted this nurse to resident's 'red vaginal area'. Upon exam (examination) per this nurse labia (right side) is red and swollen and resident's clitoris has obvious swelling. Origin of swelling and redness is unknown, will pass information to oncoming shift to monitor and have Nurse Practioner (Z1) examine area in the A.M. R4's Nurses' Notes dated 05/25/15 at 12:46 A.M. document, Res (resident) vaginal area remains red and swollen and very tender to touch. Tylenol [MEDICATION NAME] given for discomfort. R4's Nurses' Notes dated 05/25/15 at 5:36 A.M. document, Noted bruising to inner thighs injury. Skin report made. 5:25 A.M., Administrator (E1) notified. Also (E14 Assistant Director of Nurses) called at 5:27 A.M. R4's Nurses' Notes dated 05/25/15 at 8:33 P.M. document, Resident sleeping most of shift. Noted right side of face to be slightly 'puffy' especially around resident right eye. Resident repositioned per staff. Resident noted to have what appears to look like scratch mark on her right inner thigh, and resident remains very 'guarded of her genital' area. The facility form, titled Initial Report to IDPH Regional Office dated 05/25/15 includes a Fax Transmission Journal with a time stamp of 08:40 (8:40 A.M.). On 05/29/15 at 3:00 P.M., E3 (Licensed Practical Nurse) stated, This past Sunday (05/24/15), around 5:00 P.M., E5 (Certified Nursing Assistant) came and got me and said I want you to look at (R4). When I got to the room, (R4)'s covers were down. (R4) was very guarded of (R4)'s vaginal area. (R4) kept (R4)'s legs closed, (R4) didn't want anyone looking at it. I noticed right away that the right side of (R4)'s vagina was very swollen and (R4) had scratch marks on (R4)'s right thigh. There also appeared to be a hand print on (R4)'s right thigh. I did not notice any vaginal bleeding. I also noticed swelling and bruising under (R4)'s right eye. (R4) did not have any bruising when I saw (R4) before (Sunday). On 05/29/15 at 3:25 P.M., E4 (Registered Nurse) stated, After supper (on 05/24/15),( E3 Licensed Practical Nurse) asked me to come look at something on (R4). It was around 5:00 P.M. (R4)'s vagina was swollen and red. There was fresh bruising on (R4)'s inner thighs. (R4) was withdrawn, which wasn't like (R4). She also had a bruise to (R4)'s right eye, around the cheek bone. I told (E3) we need to report it. Instead (E3) had the two third shift nurses look at (R4) around 10:00 or 10:30 (P.M.). On 05/29/15 at 3:35 P.M., E5 (Certified Nursing Assistant) stated, When I went into (R4)'s room, (R4) had (R4)s private area exposed. It looked unusual. There was a flap of skin hanging from the vagina. There was redness. We (E8/Certified Nursing Assistant and I) had E3 and E4 come into the room and look at (R4). On 05/29/15 at 3:50 P.M., Z1 (Nurse Practioner) stated, Last Monday (05/25/15) I was off. I got called at 6:30 A.M. by (E9 Licensed Practical Nurse). (E9) let me know there was some bruising to (R4)'s upper extremities and thighs and swelling to (R4)'s vaginal area. I came in at 10:30 A.M. (R4) had contusions to the left upper arm and left posterior shoulder. Contusions to the left hip area, over the greater trochanter, pin-point bruises to the right upper arm and bruising to the posterior inner thighs. I checked (R4)'s vaginal area and noticed slight [MEDICAL CONDITION] to the labia majora. I was on call for (E10 Physician) Sunday night (05/24/15) and I did not receive a call that night. If I knew the way (R4) was acting, how (R4) was withdrawn and fearful along with all the bruising and scratches I would have sent (R4) to the ER (emergency room ) that night to be assessed for sexual assault. On 05/29/15 at 4:10 P.M., E6 (Certified Nursing Assistant) stated, I worked Sunday (05/24/15) from 6:00 A.M. until 10:30 P.M. (R4) was in my group. I saw (R4) for the first time that day around 7:00 A.M. I did A.M. (morning) care that day. I noticed a few bruises on (R4)'s arms. I also did peri care (perineal care) that morning and didn't notice anything unusual. We did not get (R4) up that day in the (mechanical lift). (R4) was in bed all day. I became aware of the situation around 5:00 P.M., when the CNAs (Certified Nursing Assistants) and Nurses started talking about it. On 05/29/15 at 4:20 P.M., E2 (Director of Nurses) stated, E1 (Administrator) called me on Monday morning (05/25/15) at 5:30 A.M. and told me we have a possible abuse allegation. (E1) stated that staff had noticed bruising and redness on (R4)'s labia and inner thighs. I came to the facility immediately, (R4) was in [MEDICAL TREATMENT]. Around 10:00 A.M., I took E11 (Licensed Practical Nurse) with me and looked at (R4). I noticed redness under (R4)'s right thigh, a small bruise on (R4) left inner thigh. Nothing obvious to (R4)'s vaginal area. I called the non-emergency police number. They told me that if it was an emergency to hang up and call the emergency number. I called the elder officer a few days later and reported it. On 05/29/15 at 4:35 P.M., E1 (Administrator) stated, (E12) Licensed Practical Nurse called me about 5:30 A.M. on Monday morning (05/25/15). (E12) said (E12) had found bruising on (R4)'s inner thighs and redness and swelling of (R4)'s vaginal area. I was out of town, so I called (E2 Director of Nurses) and (E2) came in. R4's Minimum Data Set ((MDS) dated [DATE] documents a score of 3 (severely impaired) under section C: Cognitive Patterns. On 06/02/15 at 10:00 A.M., E10 (Physician/Medical Director) verified that E10 would expect to be notified of bruising to labia, inner thighs, hips, around the right eye and scratches to the right inner thigh and a resident acting unnaturally withdrawn and fearful immediately, so that further medical investigation, possibly including a sexual assault evaluation, could be completed. E10 stated, Bruising develops on the extent of the injury. The harder you are hit, the deeper it develops. There is nothing in (R4)'s medical record to indicate (R4) has a condition that causes a delay in developing bruising. (R4) has advanced dementia. It's hard to know what (R4) is feeling. It is hard to communicate with (R4). We have to rely on labs (laboratory) to tell us what (R4)'s condition is. Multiple attempts to notify E8 Certified Nursing Assistant to discuss this incident were unsuccessful. The facility's Nurses' Midnight Census Report presented on 6/1/15 indicates that 28 residents (R4, R5, R14, R15, R18, R19, R20, R24, R25, R27, R32 to R48 and R86) currently live on the second floor. The Immediate Jeopardy was identified on 05/29/15 at 5:30 P.M. to have begun on 05/24/15 at 5:00 P.M. when R4 was found with bruising, redness and swelling to the genital area and bruising to the right eye, arms and inner thighs. E1 (Administrator) was notified of the Immediate Jeopardy on 05/29/15 at 6:00 P.M. Surveyors confirm through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: On 05/29/15 the Facility Consultant in-serviced the Abuse Prevention Coordinator and the Director of Nurses on the abuse prevention program including timely reporting of alleged abuse to IDPH, resident physician or physician extender and the police department. On 05/29/15 the Administrator in-serviced staff regarding the abuse prevention program including appropriate reporting of alleged abuse to the Abuse Prevention Coordinator. Any staff not receiving training by 05/31/15 will be removed from the schedule until training completed. On 05/29/15 an Investigation Guidance Checklist for abuse allegation investigation and reporting has been developed and will be utilized for all allegations of potential abuse. On 05/29/15 a Quality Assurance Review Tool has been developed to randomly assess abuse investigations to ensure reports are thorough and follow policy. On 05/29/15 an emergency QA/CQI meeting was held to review the Removal Plan. On 05/29/15 (R4)'s Physician has been contacted in order to determine further need for medical evaluation of the resident's condition.