Every finding on record at Arcadia Care Toulon

Based on interview and record review, the facility failed to implement fall interventions, appropriately assess a fall, and provide supervision for residents at risk for falls for two of three residents (R1, R3) reviewed for falls in a sample of four. This failure resulted in R1 sustaining an acute transcervical right femoral fracture requiring surgical intervention and subsequently passing away. R3 sustained a chest fracture of the right posterior 11th and 12th ribs. R3's Cervical Spine CT documents a chalk stick fracture that involved the C5 (cervical) vertebral body and extended into the intervertebral disk as C4/C5 and through the anterior osteophytes Findings include: The facility's Fall Prevention Program, effective 01/2026, documents that the program will include measures that determine the individual needs of each resident by assessing their risk of falls and implementing appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to ensure ongoing effectiveness. This form documents that safety interventions will be implemented for each resident identified at risk. Transfer conveyances shall be used to transfer residents in accordance with the plan of care. The facility's Transfer-Manual Gait Belt and Mechanical Lifts policy, effective 12/2025, documents that, in order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use mechanical lifting devices for lifting and movement of Residents. This form also documents that mechanical lifting devices shall be used for any resident needing a two-person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. R3's admission Diagnosis, dated [DATE], documents diagnosis of trauma, fall from a bed, T9 (thoracic) and T10 superior endplate fracture, Rhabdomyolysis, and acute kidney injury. R3's Fall Risk Assessment, dated [DATE], documents a score of 13 indicating that R3 is at risk for falls. R3's care plan, initiated [DATE], documents that R3 has an ADL (activities of daily living) self-care performance deficit related to vertebral and rib fractures, spinal fusion with screws and rod, depressive symptoms, generalized osteoarthritis, right-sided weakness, generalized muscle weakness, and decreased mobility. This form documents that R3 requires substantial assist of two to transfer between surfaces. R3's care plan documents that R3 is at risk for falls related to vertebral and rib fractures, fusion of spine with screws and rod, depressive symptoms, osteoarthritis, hypertension, diabetes, asthma, atrial fibrillation, insomnia, anxiety, spinal stenosis, generalized muscle weakness, and decreased mobility. R3's Unwitnessed Fall Investigation, dated [DATE] at 2:50pm, documents that R3 was walking to the shower room from his room with a wheeled walker, and R3's knees buckled, and R3 was lowered to the floor. This form does not document immediate fall interventions implemented. R3's Witnessed Fall Investigation, dated [DATE] at 6:30pm, documents that R3 was standing up to be put to bed and his legs buckled, landing him on the floor. This form does not document any immediate fall interventions that were put into place. R3's Un-Witnessed Fall Investigation, dated [DATE], documents that R3 was sitting on the floor in the hallway. This form documents that R3 attempted to self-transfer to the toilet and back to bed. R3's Un-Witnessed Fall Investigation, dated [DATE], documents that R3 was lying on the floor on his back between the bed and bathroom door. R3's walker was lying on its side next to R3. R3's Un-Witnessed Fall Investigation, dated [DATE], documents that staff noted bruising around R3's right eye. R3 was asked what happened, and he stated he fell. R3 stated that he was trying to get out of bed, and he fell onto the floor and hit his eye on the floor. R3's Un-Witnessed Fall Investigation, dated [DATE], documents that R3 was noted on the floor by the bed with the wheelchair on top of him. R3 was unable to give a description of what happened. The facility's Final Report, dated [DATE], documents that (R3), a [AGE] year-old male with a BIMS (brief interview for mental status), sustained an unwitnessed fall. (R3) was immediately assessed by the nurse, who noted the resident to have neck pain and numbness in the extremities. R3's CT (computed tomography scan) of the chest dates [DATE] documents a chest fracture of the right posterior 11th and 12th ribs. R3's Cervical Spine CT documents a chalk stick fracture that involved the C5 (cervical) vertebral body and extended into the intervertebral disk as C4/C5 and through the anterior osteophytes. The fracture extends through the posterior element bilaterally. On the right, the fracture extends through the fused facets at C4/C5. The fracture also extends through the transverse process of C5 on the left, involving the foramen transversarium. Correlation with CTA is recommended. There is a current extensive fusion across the intervertebral discs as well as fusion of the posterior elements. R3's Progress Notes, dated [DATE], documents that R3 was readmitted to the facility. R3's Progress Notes, dated [DATE], documents that R3 expired at 10:30pm. On [DATE] at 11:30am, V5, Certified Nursing Assistant, stated that she was walking past R3's room and saw him on the floor. V5 stated that he was on his back with his head partially under his bed and his wheelchair on top of him. V5 stated that V11, Licensed Practical Nurse, did not assess R3 and told us to bodily lift him back to his chair. V5 stated that she, V8, Certified Nursing Assistant, and V11 picked R3 up and put him in his wheelchair. V5 stated that he was unable to sit up and was sliding back down to the floor, so they assisted R3 back to the floor. V5 stated that in the meantime, V9, Certified Nursing Assistant, went to get another nurse. V5 stated that R3 was unable to move his legs or his right arm. V5 stated that he kept asking if he was going to be ok. V5 stated that V6, Registered Nurse, told them not to move R3, and the emergency ambulance was called. V5 stated that V11 did not assess R3 properly, and we told her that we did not want to move him; she told us to get him off the floor. V5 also stated that R3 should have been a mechanical lift off the floor, not a bodily lift. On [DATE] at 12:30pm, V6, Registered Nurse, stated that she was called to R3's room because he was on the floor. V6 stated staff were trying to body lift him up to his wheelchair, but he could not move anything, so staff slid him back down to the floor. V6 stated that R3 could not move any extremities. V6 stated that she told them not to move R3 and called an ambulance. V6 stated that R3 kept asking if he was going to be OK. V6 verified that R3 should not have been moved from the floor and that he should have been a mechanical lift, not a body lift. On [DATE] at 2:45pm, V12, Medical Director, stated that the facility should have followed their policy as far as assessing R3 and lifting him up off the floor. On [DATE] at 9:15am, V8, Certified Nursing Assistant, stated that R3 was on the floor, face up. V8 stated that V11 told them they could get R3 up, so she and V5 and V11 tried to sit R3 in his wheelchair, but he just slid right back out. V8 stated that R3 could not move his legs or left arm. V8 stated that R3 could talk and move his right arm a little. V8 stated that she left the room to get V6 to reassess R3. V8 stated that they were told not to move him, and the ambulance came. V8 stated that it is the facility's policy for the nurse to properly assess the resident before they are moved, and he should have been mechanically lifted off the floor. V8 stated that prior to the fall, R3 was up and walking. R8 stated that morning that R3 was outside and walking down the road, because she followed him to get him back into the building. V8 stated that when R3 returned from the hospital, he could only move his right arm a little. V8 stated that R3 could not move his left arm or legs. On [DATE] at 2:00pm, V2, Director of Nursing, stated that R3 was admitted to the facility because he fell out of bed at home and fractured a couple of ribs and had to have surgery on his thoracic spine. V2 stated that he was a fall risk at the time of admission. V2 stated that residents who fall are supposed to be assessed appropriately to determine if they are safe to move. If they are not, then they are not to be left until the ambulance arrives. If the resident is safe to get up, then a mechanical lift is to be used, unless the resident can get up by themselves. V2 stated that from the interviews she conducted, V11 did not properly assess R3 and he should not have been moved. V2 verified that V11 is no longer employed at the facility. 2. R1's electronic face sheet includes the following diagnoses. Alzheimer's disease, chronic kidney disease, sleep apnea, anticoagulant use, restlessness, agitation, dementia with behavioral disturbances. R1's admission Fall Risk Assessment, dated [DATE], documents that R1 is at risk for falls. R1's care plan documents that R1 has an ADL (activities of daily living) self-care performance deficit related to Alzheimer's disease, dementia symptoms, generalized muscle weakness, and decreased mobility. This form documents that R1 required partial assist of 1-2 staff for stand pivot transfers between surfaces. R1 uses walker/cane/crutches/wheelchair) devices to improve ADL performance. R1's care plan also documents that R1 is at risk for falls related to Alzheimer's disease, dementia symptoms, poor hearing, poor vision, poor safety awareness, diabetes, hypertension, hypothyroidism, restlessness and agitation, generalized muscle weakness, and decreased mobility. R1's fall interventions include to anticipate R1's needs. Be sure R1's call light is within reach and encourage him to use it. Encourage R1 to participate in activities. Ensure that R1 is wearing appropriate footwear. Review the information on past falls and attempt to determine the cause of falls. Alter or remove any potential causes if possible. R1's Un-Witnessed Fall Investigation, dated [DATE], documents that V10, Licensed Practical Nurse, was notified, while she was passing medications on A-Hall, that R1 was on the floor. When V10 went down the hall, the resident was yelling, My hip is broken. The resident (R1) was lying in a supine position at the end of the hallway with his head towards the exit door and legs facing towards the nurses' station. R1 was unable to give a description of what happened. R1's Predisposing Situation Factors document that R1 was ambulating without assistance. All the required parties were notified, and R1 was transported to the hospital. V13, Certified Nursing Assistant, documented that she was walking down C-hallway to get linens to clean people up when she heard R1 screaming, and V14, Certified Nursing Assistant, went running. R1 was lying at the end of E hallway by the door, screaming. V14 documented that she was in the dining room keeping eyes on residents. She heard R1 screaming and went running to the end of the hall; R1 was on the floor. R1's right hip X-ray, dated [DATE], documents an acute transcervical right femoral fracture. R1's Discharge summary, dated [DATE], documents that R1 was admitted to the hospital following an unwitnessed fall at his nursing home resulting in inability to ambulate and right hip pain. Imaging revealed a displaced right femoral neck fracture, confirmed by orthopedic evaluation, and his right lower extremity was noted to be shortened and externally rotated on exam. Orthopedic surgery recommended and performed a right hip hemiarthroplasty on [DATE]. This form documents that on [DATE], after discussion with V3, R1's Power of Attorney, goals and care were reviewed and R1 was transitioned to comfort measures only. With plans for discharge to a facility under hospice care. This form documents that during R1's final days of admission, R1 experienced progressive decline, with increasing confusion, poor oral intake, and urinary retention managed with a urethral catheter. R1 was documented as a DNR (Do Not Resuscitate) and actively dying and was not considered appropriate for discharge, planning to a nursing home with hospice. R1 passed away on [DATE] at 10:40pm. R1's Certificate of Death, dated [DATE], documents the cause of death as A. Failure to Thrive. B. Fracture of the Femur Due to a Fall. On [DATE] at V3, R1's, Power of Attorney stated that R1 needed supervision at all times due to his confusion, but he did not get that the night he fell. V3 stated that R1 was up walking, then basically dying the next day. V3 stated that he never recovered from the surgery. On [DATE] at 11:30am, V5, Certified Nursing Assistant, stated that R1 would constantly take off his shoes and socks and walk around without assistance. On [DATE] at 9:00am, V10, Licensed Practical Nurse, stated that she was notified that R1 was on the floor. V10 stated that R1 was saying he broke his hip, so she did not move him and called an ambulance. V10 stated that R1 was up and down all night long, and due to his confusion, there was no way to educate him to ask for assistance. V10 stated that she was in another hall passing medications when R1 fell. V10 stated that the certified nursing assistants have tasks to get completed and have to monitor the residents up in the dining room; they are unable to supervise the rooms adequately. On [DATE] at 9:15am, V8, Certified Nursing Assistant, stated that R1 needed to be monitored every 10 minutes or so because he would get up by himself. On [DATE] at 2:00pm, V2 stated that she knows the facility has a problem with falls and she has done a lot of in-services concerning falls, transfers, and reporting. V2 stated that it is hard to come up with fall interventions for the residents on the dementia unit because of their confusion. V2 stated that she was just approved to add another CNA on 6:00pm-6:00am shift.

Based on interview and record review the facility failed to ensure all Certified Nurse Aides received behavioral health training. This failure has the potential to affect all 72 residents who currently reside in the facility. Findings include:The Facility Daily Census Report, dated 4/29/26, documents 72 residents are currently residing in the facility.The facility's Facility Assessment Tool dated 3/26/26 documents, Required in-service training for nurse aides must: Include Dementia management training and resident abuse prevention training. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired with behaviors.V9 (Agency CNA/Certified Nursing Assistant) and V10's (Agency CNA) Employee Records and Training Records dated 4/30/25 through 4/30/26 do not include behavioral health training.On 4/29/26 at 10:10 AM V9 (Agency CNA/Certified Nursing Assistant) stated, I have not received behavioral health training from the facility or from the agency that hired me.On 4/29/26 at 10:15 AM V10 (Agency CNA) stated she has not received any training within the last year. V10 also verified that she takes care of all of the residents within the facility.On 4/30/26 at 11:15 AM V1 (Administrator-In-Training) and V2 (Director of Nursing) both confirmed that V9 and V10 have not had received behavioral health training from the facility or the agency that hired them.

Based on interview and record review the facility failed to ensure all Certified Nurse Aides (CNAs) received the 12 hours of required annual competency in-service training. This failure has the potential to affect all 72 residents who currently reside in the facility. Findings include:The Facility Daily Census Report, dated 4/29/26, documents 72 residents are currently residing in the facility.The facility's Facility Assessment Tool dated 3/26/26 documents, Required in-service training for nurse aides must: Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year and address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.V9 (Agency CNA/Certified Nursing Assistant) and V10's (Agency CNA) Employee Records and Training Records dated 4/30/25 through 4/30/26 do not include the 12 hours of annual competency CNA training.On 4/29/26 at 10:10 AM V9 (Agency CNA) stated, I have not received 12 hours of annual competency training from the facility or from the agency that hired me. I had no idea that I needed to have 12 hours of annual training.On 4/29/26 at 10:15 AM V10 (Agency CNA) stated she has not received any training within the last year. V10 also verified that she takes care of all of the residents within the facility.On 4/30/26 at 11:15 AM V1 (Administrator-In-Training) and V2 (Director of Nursing) both confirmed that V9 and V10 have not had 12 hours of annual CNA training from the facility or the agency that hired them.

Based on record review and interview the facility failed to ensure ceiling tiles and a cold water pipe were kept clean, in good repair, and free of leaks. These failures have the potential to affect all 72 residents residing within the facility.Findings include:The Facility Maintenance Director Job Description dated 3/2024 documents, The primary purpose is to plan, organize, develop and direct overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing the facility and to assure that the facility is maintained in a safe and comfortable manner. Repair facility/resident property as necessary and in the event unable to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Assist in identifying, ensure that supplies and equipment are maintained to provide safe and comfortable environment and promptly report equipment or facility damage to the Administrator. Make weekly inspections of all maintenance functions to assure that quality control measures are maintained.The Facility Daily Census Report, dated 4/29/26, documents 72 residents are currently residing in the facility.V12's (former Maintenance Director) Corrective Action Form, dated 4/10/26, documents V12 was terminated from the facility for incompetence, substandard productivity or unsatisfactory job performance. This same form documents V12 did not complete tasks assigned such as fixing/replacing stained ceiling tiles by 4/10/26 as instructed to do so by V8 (Regional Maintenance Director).On 4/29/26 at 9:45 AM, a trash can was observed in the center of the ice machine/vending machine area collecting water from an actively leaking water pipe in the ceiling. The trash can contained approximately one inch of standing water and a two foot by two foot ceiling tile was missing, exposing insulation, wiring, and water pipes in the ceiling. There were two blankets and multiple towels soaked in water on the floor underneath the trashcan. Twelve ceiling tiles above the nurses' desk showed brown staining and visible bulging, indicating potential water damage.On 4/30/26 at 10:00 AM the ice machine/vending machine area still had two missing two foot by two foot ceiling tiles, exposing insulation, wiring, and water pipes in the ceiling.On 4/29/26 at 9:50 AM V4 (RN/Registered Nurse) stated she has worked at the facility since December 2025 and the ceiling tiles above the nurses' station have been stained since she has worked at the facility. V4 also stated a pipe in the ceiling in the vending/ice machine area burst yesterday and has been leaking since.On 4/29/26 at 10:00 AM V5 (LPN/Licensed Practical Nurse) stated, I have worked here for years and the ceiling tiles above the nurses' station have been stained for as long as I can remember. The ceiling has been leaking in the ice machine area for several days and the ice machine in that area is used for all the residents.On 4/20/26 at 11:10 AM V8 (Regional Maintenance Director) confirmed the ceiling tiles above the nurses' station are stained and stated, The tiles take a little time to cut, and no one has had time to change the tiles yet. V8 also confirmed a water pipe in the ice machine/vending area was leaking and the ceiling tile had been removed.

Based on observation, interview, and record review the facility failed to implement a fall intervention for one of three residents (R3) reviewed for falls in the sample of nine.Findings include:The facility's Fall Prevention Policy dated 01/26 documents, Purpose: To assure the safety of all resident in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. Accident/Incident reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. The Director of Nursing or designee is responsible for monitoring the Fall Prevention Program.R3's admission Record documents R3 is an [AGE] year-old admitted to the facility on [DATE] with diagnoses of Dementia and Abnormalities of the Gait.R3's Unwitnessed Fall Incident Follow-Up Progress Note dated 2/24/26 documents, IDT (Inter-Disciplinary Team) met and reviewed. Root Cause: (R3) slipped out of vinyl or leather recliner when attempting to get up. Intervention: (Non-Skid Material) to be applied to recliner seat.R3's current Care Plan documents, (R3) is at risk for falls related to Dementia and Disc Degeneration. Interventions: 2/21/26 (Non-Skid Material) to recliner to reduce risk of sliding out of recliner.On 4/30/26 at 9:45 AM R3's recliner was located in her room to the right side of R3's bed. R3's recliner did not have a non-skid material on the seat as noted by R3's current fall care plan.On 4/30/26 at 9:55 AM V14 (CNA/Certified Nursing Assistant) verified R3's recliner did not have a non-skid material on the seat. V14 stated, I have never seen a non-skid material on (R3's) recliner seat.On 4/30/26 at 11:20 AM V2 (Director of Nursing) stated R3's recliner seat should have non-skid material.

Based on observation, interview and record review the Facility failed to provide a functional, safe and comfortable environment for Residents and the public. This failure has the potential to affect all 71 Residents residing in the Facility.Findings include:The Facility Maintenance Director Job Description, dated 3/2024, documents: primary purpose is to plan, organize, develop and direct overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing the Facility and to assure that the Facility is maintained in a safe and comfortable manner; repair facility/resident property as necessary and in the event unable to repair coordinate with outside vendors to make repair or replace as cost effectively as possible; assist in identifying, ensure that supplies and equipment are maintained to provide safe and comfortable environment and promptly report equipment or facility damage to the Administrator; and make weekly inspections of all maintenance functions to assure that quality control measures are maintained.The Facility Daily Census Report, dated 4/17/26, documents 71 Residents residing in the Facility.V5's (former Maintenance Director) Corrective Action Form, dated 4/10/26, documents V5 was terminated from the Facility for incompetence, substandard productivity or unsatisfactory job performance and that on 3/25/26, V5 did not complete tasks assigned to the overall Facility environment issues as a result of a health survey.On 4/17/26 at 10:00 am, V1 (Administrator in Training/AIT) was unable to provide Maintenance Work orders (3/1/26 through 4/17/26).On 4/17/26 at 9:02 am, the entry into Hall A had a change of plane with an approximately eight feet by four feet area of missing floor tiles. Room A13 had a loose/peeling baseboard strip between the dresser and the bathroom. Room A10 had chipped paint on the corner wall between the bathroom and dresser and an approximately two feet by eight feet area of missing paint and exposed drywall. Room A6 had two exposed metal screws, an approximate six-inch area of exposed drywall area and two separate chipped drywall areas on the wall between the bathroom and dresser. Multiple Resident rooms had scratched, missing paint and wood chipped out of the doors.On 4/17/26 at 9:10 am, Room B1 had an approximate four-inch area of drywall chipped on the corner between the bathroom and dresser. Room B12 (R1's) room, had exposed black, white and green electrical cable cord wires attached out of a wall vent (approximately two feet from the floor) to the ceiling in the dresser cove and two metal screws approximately one-half inch out of the wall and the wall mount heating/cooling unit outside cover was laying on the ground covered with leaves/debris. Room B11 had an exposed black, white and green electrical cable cord wires attached out of a wall vent (approximately two feet from the floor) to the ceiling in the dresser cove. A wall mounted computer screen between Room B8 and the storage room, an approximately 6 feet electrical black cord was hanging from an electrical outlet onto the B Hall floor walk pathway. Multiple Resident rooms had scratched, missing paint and wood chipped out of the doors.On 4/17/26 at 9:20 am, Hall D had an approximately 6 feet electrical black cord hanging from an electrical outlet onto the B Hall floor walk pathway. Room D4 had an approximate six feet by six feet, brown exposed circular drywall area patch missing. Multiple Resident rooms had scratched, missing paint and wood chipped out of the doors.On 4/17/26 at 9:38 am, Room E1 had two approximate eight inch by ten-inch horizontal areas of drywall holes and two six-inch by eight-inch circular drywall holes with multiple scratches. The door to the bathroom had scratched and chipped wood. Room E2 had multiple paint colors on the wall, and the upper area of the heating/cooling unit had exposed crumbling yellow/brownish/gray exposed drywall and a missing wood frame board to the area between the heating/cooling unit and the window.The Main Dining Room had exposed drywall with no base boards on the entire wall between the exit door and windows and on the interior meal serving window wall.On 4/17/26 (8:00 am through 3:00 pm) and 4/18/26 (8:00 am through 1:00 pm) the men's and women's visitor bathrooms had out of order signs on the door.On 4/18/26 at 9:30 am, V1 (Administrator in Training/AIT) stated, This is an old building, and we realize that a lot of things need repaired, and we are working on getting a lot of things fixed. The visitor bathrooms are currently out of order. We have just terminated our Maintenance Director (V5) for failure to complete the job duties. We are looking to hire a new person, and, in the meantime, we have our corporate maintenance helping out.

Based on observation, interview and record review the Facility failed to provide proper nourishment of normal meal hours for five of nine Residents (R13, R14, R15, R16 and R17) reviewed for mealtime in a sample of 17.Findings include:The Facility Week at a Glance Dietary Menu Week Three, dated 3/12/26, documents breakfast meal at 8:00 am, lunch meal at 12:00 pm and dinner meal at 5:00 pm.The Dietary Manager Job Description, dated 7/2023, documents: responsible for partnering with the Dietitian to plan, organize, develop and direct the overall operation of the Dietary Department in accordance with current, federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe and sanitary manner; and assist in planning, developing, organizing, implementing, evaluating, and directing the Dietary Department.The Facility Concern/Compliment Form, dated 4/1/26, documents trays not getting picked up in rooms at night and that staff do not always pick up the meal room tray in R14's room.The Facility Inservice Sign-In Sheet, dated 4/1/26, documents an in-service with Certified Nursing Assistant's for Breakfast, Lunch and Dinner trays that need to be collected and sent back to the kitchen and that trays do not get left in Residents rooms.On 4/17/26 at 11:01 am, V9 (Certified Nursing Assistant/CNA) was picking up Hall A breakfast room trays and placing onto a dietary tray cart. V9 stated, These are the breakfast room trays.On 4/17/26 at 11:09 am, R15 was eating a breakfast room tray in R15's room. R15 stated, I am just finishing up my breakfast. I did not get to go to Activities at 10:00 am this morning, because I got my breakfast tray late.On 4/17/26 at 2:11 pm, R16 was sitting on the edge of R16's bed, beginning to eat a lunch room tray. R16 stated, I just received my lunch.On 4/17/26 at 1:35 pm, V9 (Activity Director) and V10 (Activity Aide) were pushing a dietary meal tray cart and were delivering room trays on Hall B. The dietary meal tray cart had 13 room trays that had not been served. V9 stated, We are delivering room trays, the kitchen is really far behind today.On 4/17/26 at 2:07 pm, R13 was eating a lunch room tray in R13's room. R13 stated, I just got my lunch tray.On 4/17/26 at 2:08 pm, R17 was eating a lunch room tray in R17's room. R17 stated, They just dropped this tray off.On 4/18/26 at 9:05 am, V1 (Administrator in Training/AIT) stated, We have way too many room trays, we need to re-look at those. They should not be receiving the trays so late and should be picking them up shortly after they are done.

Based on observation, interview and record review, the facility failed to ensure one of 21 residents (R10) was free from involuntary seclusion, failed to ensure criteria was met for admission to the Secured Dementia Unit and failed to follow physician's guidance for resident's wellbeing to prevent a change in condition reviewed in a sample of 41.These failures resulted in R10, a cognitively intact resident with admitting diagnoses of Post-Traumatic Stress Disorder and Generalized Anxiety, to be admitted to the Secured Dementia Unit on 1/30/26 and remained in the unit until 2/26/26.These failures resulted in Immediate Jeopardy.The Immediate Jeopardy was noted to begin on 1/30/26, when the facility failed to ensure a resident was free from Involuntary Seclusion when a cognitively intact resident was placed in a Secured Dementia Unit preventing the resident from leaving. Immediate Jeopardy was identified on 2/26/26. V31 (Regional Director of Operations) and V32 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on 2/26/26 at 3:15 PM. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 2/26/26, but noncompliance remains at a level 2 because additional time is needed to evaluate the implementation and effectiveness of the plan of correction. Findings include:The Dementia Unit Admission/Discharge Criteria Program policy, revised 10/2017, documents The Secured Dementia Unit exist to provide residents with cognitive or Alzheimer's/Dementia related diagnoses a safe and comfortable environment where staff has been trained to care for their special needs, Residents may be admitted based on the following guidelines: 1. Resident does not display disruptive behaviors such as repetitive yelling or calling out. 8. Does not display wandering that is not easily directed or poses a risk to the resident or others. May include but not limited to excessive attempts to exit the unit or facility.The Facility's 671 dated 2/24/26 documents they have a Dedicated Special care Unit labeled as Alzheimer's Disease and has 53 beds.R10 was admitted on [DATE] with diagnoses of Post-Traumatic Stress Disorder and Generalized Anxiety Disorder. R10 was transferred to the Secured Dementia Unit on 1/30/26. R10's record did not include an admitting diagnosis of Dementia/Alzheimer's Disease.The Brief Interview for Mental Status (BIMS) documents on 1/29/26 R10's cognition was moderately impaired and from 2/3/26 to present has been cognitively intact.The Preadmission Screening and Resident Review Level 1 dated 1/27/26, documents R10 did not have a Dementia or Alzheimer's Disease Diagnosis, and Level 2 was not required.V56's (R10's Family Physician) visit notes dated 12/30/25,10/31/25 and 8/22/25 documents R10 had been evaluated for Dementia and passed the given test. No diagnosis of Dementia or Alzheimer's Disease were identified on the visit notes.R10's Elopement/Unauthorized Leave Risk review dated 1/29/26, documents R10 has a . history of or verbalizes a strong desire to leave-yes. Is there a history of dementia? No.A Progress Note dated 1/30/26 documents to move resident to Secured Dementia Unit for high elopement risk.On 2/3/26, V54's (Psychiatric Family Nurse Practitioner) Progress Note documents R10 would benefit from and resident requests to be out of the unit. V54 stated R10 has taken on a role as a caretaker for the residents in the Dementia unit.On 2/24/26 and 2/25/26, R10 was observed in bed with the lights out and stated I told them (facility staff) I didn't want to be here (facility), so they put me back here (Secured Dementia Unit). I don't feel like it's right. I shouldn't be locked in here. R10 stated she had passed all her cognitive tests and was not going to leave the facility (elope). R10 did not participate in activities because I don't want to be with old people, and I can't stand to see them (cognitively impaired residents) like that. I'd rather be alone.On 2/25/26 at 2:50 PM, R10 stated she had not slept the previous night because another resident was crying, and staff did not help the resident. I was worried she was going to die, so I kept checking on her. On 2/24/26 at 11:18 AM, V55 (R10's family member and Healthcare Power of Attorney) stated My mom does not have Dementia or Alzheimer's. She lived independently until (Financial Power of Attorney) stole her house and sent her to the nursing home.On 2/25/26 at 9:45 AM, V12 (CNA/Certified Nursing Assistant) stated she has cared for R10 since she was transferred to the Secured Dementia Unit on 1/30/26. V12 stated R10 does not appear to be confused, has expressed wanting to leave the locked unit and go back to the general non-secured unit with the general population, although R10 has not attempted to elope from the unit or has not displayed exit-seeking behavior. V12 stated the only behavior R10 has exhibited was Anxiety. She doesn't need to be down here (Secured Dementia Unit).On 2/25/26 at 9:40 AM, R10 was observed to ask if anyone could take her outside to smoke. V23 (LPN/ Licensed Practical Nurse) stated It's past time. The scheduled mid-morning smoking time is 9:30 AM.On 2/25/26 at 10:55 AM, V23 (LPN/Licensed Practical Nurse) stated the residents smoking times were at 7:00 AM, 9:30 AM, 1:30 PM, 5:00 PM and 7:00 PM. V23 stated R10 is the only smoker on the unit and Down here (Secured Memory Care Unit) we try to stick to the times. We have to have some kind of schedule.On 2/25/26 at approximately 10:05 AM, V12 (anonymous staff member) stated V23 did not allow R10 to smoke this morning because she didn't ask to smoke until 9:40 AM, 10 minutes after smoking time. Staff deny R10 of her smoking privileges if she is late for the scheduled smoking time.On 2/26/26 at 10:52 AM, V54 (Psychiatric Family Nurse Practitioner) stated she had voiced and emailed her concerns to V1 (Administrator), V2 (Director of Nursing) and V20 (Social Worker) on 2/3/26 and 2/17/26 regarding R10's overall well-being, increased anxiety, as well as acting as being a caregiver to the other cognitively impaired residents by being in the Secured Dementia Unit and did not meet the criteria or benefit from being housed there. V54 stated she was told no that R10 was not being moved because she was an elopement risk.On 2/26/26 at 10:21 AM, V54 (Physician's Certified Medical Assistant) stated their office did not refer R10 to the facility. On 1/20/26, the facility called the physician's office and requested R10's records. V54 stated R10 did not have a Dementia diagnosis and the facility had called two times today (2/26/26) and requested the doctor to add a Dementia diagnosis code to R10's diagnosis lists.On 2/26/26 at 10:40 AM, V39 (Medical Director/R10's Physician) stated many residents experience delirium the first 24-72 hours of admission. They get confused from taking them out of their environment. If the referring physician says R10 does not have a dementia diagnosis, R10 doesn't have a dementia diagnosis. R10 did not have a Dementia diagnosis and did not meet the criteria to be admitted to the Secured Dementia Unit.Immediate Jeopardy Removal Plan:The Facility submitted its original Abatement plan on 2/26/26 at 4:10 PM.The Regional Office returned the Facility's Abatement Plan for corrections on 2/26/26 at 4:30 PM.The Facility submitted an Abatement Plan with corrections at 5:03 PMThe Facility's Abatement Plan was accepted on 2/27/26 at 8:42 AM.On 2/27/26 this surveyor confirmed through interview and record review the facility took the following steps to remove the immediacy:On 2/26/26, V32 (Regional Nurse Consultant) reviewed all residents residing on the secured unit for meeting placement criteria. 100% completed on 2/26/26 at 4:56 PM.On 2/26/26, the Interdisciplinary Team was in-serviced on abuse pertaining to involuntary seclusion. 100% completed by V31 (Regional Director of Operations).On 2/26/26, the Interdisciplinary Team was in-serviced on adhering to physician guidance. 100% completed by V31.On 2/26/26, the interdisciplinary Team was in-serviced on dementia unit admission/discharge criteria and program. 100% of all 23 residents residing on the secured unit had BIMS review completed by V20 (Social Services).BIMS are reviewed quarterly or as needed. 100% of all 23 residents residing on the secured unit had BIMS review completed by V20 and V40 (Regional Social Services Director) on 2/26/26.R10 removed from the secured unit. 100% completed by V20 on 2/26/26.Completion date 2/26/26

:Based on observation, interview and record review, the facility failed to provide adequate administrative oversight to ensure the facility implemented their policies for protecting resident's dignity, be free of involuntary seclusion and restraints, accurately assessed residents and provided quality of care based on those assessments, services were provided to meet professional standards, ADL (Activities of Daily Living) cares were provided for dependent residents, medications were safely administered, infection prevention measures were implemented and appropriately utilized, staff were qualified and competent and maintained a safe/ clean/comfortable environment. These failures resulted in a facility-wide lack of supervision and care leading to residents experiencing a lack of dignity by being exposed to other residents, visitors and other staff members not involved in the residents care, lack of nursing assessments which led to a residents decline and resulted in hospitalization, involuntarily seclusion which caused psychosocial harm, residents received unnecessary medications and amounts of medications without a diagnosis or behaviors to indicate the need for those medications, untimely assistance with showers resulting in residents being left disheveled and a sense of being dirty, lack of assurance the right resident received the right medication, right dose, right route at the right time, and not providing a competent and trained staff to provide resident cares. These failures have the potential to affect all 67 residents residing in the facility. Findings include:The facility's Daily Census Report, dated 2/24/26, documents 67 residents reside in the facility. The Facility assessment dated [DATE]-[DATE], documents in Part 4 Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies Staff type include Administrator, Staff Development, Quality Assurance Performance Improvement, Infection and Control and Prevention, Environmental Services, Social Services, Discharge Planning, Human Resources and Compliance and Ethics. On 2/24/26 at 9:15 AM, V1 (Interim Regional Administrator) stated the facility has not had an Administrator for probably a year, year and a half. V1 stated Regional Interims have filled in during this time. R5 was not provided dignity by staff by not utilizing a privacy curtain prior to pulling down his pants and incontinent brief before performing catheter care. R27 was not provided dignity by closing the door to the hallway for wound care. V29 (Certified Nurse Aide/CNA) was standing while feeding R76 and repetitively called R76 honey and sweety. R51 was not accommodated with her toileting preferences to get her up in a chair to toilet to prevent constipation due to staff time constraints. The facility was not maintained, safe, clean and comfortable due to leaves being in piles in the hallway and dirty floors on multiple occasions. R58 was observed in his room, wearing a heavy winter coat and complained of his room being cold because his heater had not worked in awhile. R58 stated it had been reported multiple times and staff say maintenance will come fix it. V6 (Maintenance) stated he was not informed of the broken heater in R58's room. R48 and R1 stated their joining bathroom sink had been clogged for six months and were unable to wash hands after toileting or brush their teeth at the sink. This has been reported to the Resident Council as well. R48 and R1's sink were observed half full of water which was not draining. The Dementia Care Unit had two floor drainage metal caps which were not secured, and one had a screw sticking upward approximately one inch causing a tripping hazard. The ceiling tile in the common areas had water stains on ceiling tiles and dust hanging from ceiling vents. V6 stated the water damaged ceiling tile was from a roof leak a year ago. Staff can submit electronic work orders although V6 did not have access to a computer from a water leak in his office. R10 was admitted on [DATE], was alert and reported she wanted to leave the facility. On 1/30/26, facility staff transferred R10 to the Secured Dementia Unit to prevent elopement. During this time, R10 did not meet admission criteria to the Secured Dementia Unit, had no diagnosis of Dementia, took on a role as a caretaker to Dementia residents, wound not participate in activities because I can't stand to see them (cognitively impaired residents) like that and V58 (Psychiatric Family Nurse Practitioner) addressed verbally and via email with the Interdisciplinary Team that R10 needed to be in the general population, had not stated she was going to leave and didn't meet requirements to be in a locked unit against her will, although the Interdisciplinary Team denied the transfer because of the elopement risk. R10 resided in the Secured Unit until 2/26/26 when Immediate Jeopardy for Involuntary Seclusion was identified. R9 had a Physician's Order and Care Plan documents to use a self-releasing seat belt while in motorized wheelchair, although R9 was unable to release the seatbelt when prompted. R6 was prescribed and administered an antipsychotic, although no behaviors were exhibited to account for the use of the medication. R7 was prescribed and administered three antidepressant medications for a diagnosis of Depression, although R7 had no behaviors to account for the use of the medication. The resident nor staff could verbalize why R7 was on three antidepressant medications. R11 was prescribed and administered an antidepressant and a medication for Bipolar Mania. R11's guardian stated R11 had been nonverbal, frail and did nothing except lie in her chair. R71's medical record documented R71 was sent to the Emergency Department for evaluation of wounds. The medical record did not document any further information including whether R71 was admitted , expired or went home from the hospital. R7 sustained a fall at the facility and new interventions were not implemented on the care plan. R10 was admitted on [DATE] with diagnoses of Post Traumatic Stress Disorder and Generalized Anxiety and was alert and oriented and. R10 stated she wanted to leave and was deemed to be a high risk for elopement therefore was transferred to the Secured Dementia Unit on 1/30/26. A Dementia diagnosis was added to R10's diagnosis list although there was no Physician's Order or supporting documentation to support the Dementia diagnosis. During an interview with R10's family physician, it was stated that R10 was tested prior to admission to the facility and passed testing and did not have a diagnosis of Dementia. R11 was admitted with diagnoses of Alzheimer's, Conversion Disorder with Seizures and Hypothyroidism. A new physician order documents a new diagnosis of schizoaffective disorder. The Psychiatric physician's note did not mention a new diagnosis of schizoaffective disorder. V26, R11's Guardian stated R11 had no history of mental illness. R6 was sitting in his recliner, hair appeared disheveled, was in just shorts, fingernails were long and jagged, and he had facial hair. R6 stated he has been at the facility for approximately a year and has only had 5 showers. R6 had no documented showers given. R43 stated she had not received showers twice weekly as scheduled and felt dirty. R48 stated she had not been showering twice weekly and felt sticky all over from being sweaty and lying in bed. R43 and R48's shower sheets dated December 2025, January 2026 and February 2026 lacked documentation showers were received twice weekly. The facility did not assess, develop and/or implement a care plan, or provide an ongoing program of activities based on residents' assessments and preferences for R51 and R11. The facility did not assess or address R1's change in condition and ensure diagnostic tests were completed as ordered which resulted in hospitalization on 2/25/26. The hospital records documented R1 was lethargic, had a cough, was short of breath, wheezing, confused and tested positive for RSV (Respiratory Syncytial Virus), Acute Bronchiolitis due to RSV, Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and Acute Hypoxia Respiratory Failure. R1 was ultimately transferred to another hospital for a higher level of care. R1 was still hospitalized upon exit on 3/3/26. R8 had a physician's order to remove an indwelling catheter and implement voiding trial. Staff denied knowledge of a voiding trial or that urinary output should have been monitored and recorded. R55 was observed to have oxygen at 2 liter per nasal cannula. R55's oxygen tubing had not been changed weekly as ordered and the prefilled humidification bottle was empty. R55 stated he had requested it to be refilled for 2 days and now had a dry nose. V1/Administrator stated she did not have documentation demonstrating staff employed at the facility received education and competencies related to the facility's standards, policies, and procedures. R48 was observed resting in bed with the light out. Two medications were in a medicine cup sitting on her bedside table. R48 woke up, turned her light on and took her medications. R48 did not have a physician's order or was it care planned to self-administer medications. The facility did not ensure medications were safely administered. The facility did not dispose of food which was not safe for consumption. The facility failed to properly contain garbage and refuse in the facility's dumpsters. The facility failed to ensure residents and staff were monitored and tracked for communicable diseases, ensured a process to prevent the spread of diseases to other residents and staff, wear masks properly while in close proximity to residents, to wear appropriate PPE (Personal Protective Equipment) for Enhanced Barrier Precautions and failed to perform hand hygiene. The facility failed to provide a Pneumococcal Immunization to 2 residents (R1, R60) that requested to receive it and failed to offer a Pneumococcal Immunization to 3 (R13, R52, R55) residents. The facility did not maintain the facility by repairing holes in the wall, torn wallpaper and exposed dry wall. V1/Administrator stated she did not have documentation demonstrating staff employed at the facility received the required staff training/education and competencies for Infection Prevention and Control, Compliance and Ethics. In addition, the is no documentation Certified Nurse Aides were provided and completed a minimum of 12 hours of in-service training per year.

Based on observation, interview and record review, the facility failed to assess a resident's change in condition and ensure diagnostic tests were completed as ordered for one of two residents (R1) with a change in condition, in a sample of 41. This failure resulted in R1 being transferred to the hospital with a diagnosis of RSV (Respiratory Syncytial Virus), Findings include: The Licensed Practical Nurse (LPN) and Registered Nurse (RN) job descriptions, dated 7/2023, documents to chart nurse's notes in an informative and descriptive manner that reflects the care provided to the residents, as well as the resident's response to the care. The nurse must be knowledgeable of nursing and medical practices and procedures. The Assessment of Resident policy documents to document the resident's comments, complaints as appropriate and assessment findings in the nurse's progress notes and initiate nursing interventions. R1 was admitted on [DATE] with diagnoses of Orthopedic Aftercare, Fracture of Femur Shaft, Morbid Obesity, Chronic Respiratory Failure, Type 2 Diabetes and Major Depressive Disorder. The Minimum Data Set, dated [DATE] section C documents R1 had a Brief Interview for Mental Status score of 15, cognitively intact. The Active Physician Orders on 2/20/26 at 3:10 PM included an order for a chest x-ray. On 2/24/26 at 10:30 AM, R1 stated she did not feel well. Complained that her chest felt heavy and it was hard to breathe. When asked if she had sputum, she said Yes. I've been bringing up (coughing up) yellow and greenish junk. R1 stated she had not had a chest x-ray because They (contracted x-ray staff) never came. On 2/24/26 at 11:00 AM, V3 (Assisting Director of Nursing/Infection Preventionist) was unaware R1's chest x-ray had not been completed. V3 stated the x-ray staff come whenever they have the staff to do the x-ray. V3 stated R1 had not been tested for Influenza, RSV (Respiratory Virus) or COVID-19 because testing is not done unless ordered by the Physician. On 2/25/26 at 9:15 AM, R1 stated she felt even worse than yesterday, appeared to have difficulty breathing and stated No one pays attention to me. I'm going to die. On 2/25/26 at 9:20 AM, V3 (Assisting Director of Nursing/Infection Preventionist) was notified by this surveyor of R1's complaints of her difficulty breathing, comments about staff not paying attention to her and feeling like she was going to die. R1's Progress Note documents on 2/20/26, R1 was weak and had a cough which was productive at times with yellowish/greenish mucus, wheezing throughout lung fields and received a new order for a chest x-ray; on 2/21/26, awaiting chest x-ray, still wheezing; on 2/23/26 and on 2/24/26, still wheezing. The progress notes do not document that vital signs or oxygen saturations were monitored between 2/20/26 and the morning of 2/25/26 (after V3 was notified of R1's complaints by surveyor); on 2/25/26 at 10:00 AM, documents R1 was confused, lethargic, responds to verbal stimuli but falls right back to sleep, shallow respirations, lung sounds diminished with Rhonci (rattling lung sound cause by obstructions or secretions in the large airway), oxygen saturation of 53% (normal limits are 90-100%), oxygen was applied at 2 L (liters) and oxygen saturations went up to 72%, oxygen increased to 4 L and oxygen saturations went up to 76%-78%, V39 (Medical Director) was notified of altered level of consciousness and hypoxia (low oxygen saturation) and received orders to send R1 to hospital. R1 remains hospitalized as of 3/3/36. The Emergency Department Physician Notes dated 2/25/26 documents upon admission, R1 was lethargic, had a cough, was short of breath, wheezing, confused and tested positive for RSV (Respiratory Syncytial Virus), Acute Bronchiolitis due to RSV, Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and Acute Hypoxia Respiratory Failure and was ultimately transferred to another hospital for a higher level of care.R1's Hospital Inpatient Progress Notes dated 2/25/26, documents R1's Primary Diagnoses are Acute Metabolic Encephalopathy due to Hypercarbia, Acute and Chronic Hypoxemia and Hypercarbic Respiratory Failure, Acute Chronic Obstructive Pulmonary Disease (COPD) Exacerbation secondary to RSV Bronchiolitis and Acute Kidney Injury.On 2/20/26 an Infection Screening Evaluation documents R1 had no active infection, had a new onset of functional decline, new/unchanged lung exam abnormality, new/increased cough, productive/purulent sputum and Loeb's Criteria was triggered as suspected Lower Respiratory Tract Infection and McGreer's Criteria triggered suspected Bronchitis or Tracheobronchitis.On 3/3/26 at 12:00 PM, V39 (Medical Director) stated the facility's county was currently at a very high activity level for RSV and that RSV in the facility's resident population can be fatal.On 2/27/26 at 2:30 PM, V32 (Regional Nurse Consultant) stated the facility initiates an Infection Screening Evaluation if a resident is suspected of having an infection. Loeb's and/or McGreer's Criteria are utilized to determine if there is an infection. V32 reviewed R1's record and stated an Infection Screening Evaluation had been started on 2/20/26 although had not been completed until V32 closed the evaluation during the interview. V32 agreed R1's record did not include documentation that ongoing assessments were conducted, and her condition was monitored after the change in condition was identified nor was an x-ray was completed as ordered and should have been.

Based on observation, interview and record review, the facility failed to properly contain garbage and refuse in the facility's dumpsters. This failure has the potential to affect all 67 residents residing in the facility posing the risk of attracting insects, pests and rodents to the facility.Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 Residents resided in the Facility. The facility was unable to provide a waste disposal policy. On 2/26/25 at 11:30 AM, V6 (Maintenance Director) stated the facility disposes of garbage and refuse outside in two large trash dumpsters located behind the facility. The dumpsters should be closed and all garbage stored inside the dumpsters and not on the ground around the dumpsters.On 2/26/26 at approximately 2:45 PM, both dumpsters were uncovered, full and overflowing with garbage bags and refuse. Six large bags of garbage were on the ground around the dumpsters and there is a foul odor emanated from the dumpster storage area.

Based on observation interview and record review, the facility failed to monitor stored fresh produce and destroy spoiled produce stored in the kitchen's walk-in refrigerator. This failure has the potential to affect all 67 residents residing in the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 Residents resided in the Facility. The facility's Food & Supplies: Storage policy dated 01/2026 documents, Food and supply storage areas shall be maintained in a clean, safe and sanitary manner.On 2/24/26 at 8:50am a produce box in the kitchen's walk-in refrigerator containing whole individual zucchini squash included three zucchini squash with wrinkled areas, dark areas approximately 1/2-centimeter square, several open white spots approximately 1 centimeter square, and soft areas noted on each of the three-zucchini squash.On 2/24/26 at 8:50am V14 Dietary Manager verified the three spoiled zucchini squash were moldy and should not be served to the residents and should have been thrown away.

These failures resulted in two deficient practices.A. Based on interview, observation and record review, the facility failed to ensure residents and staff were monitored and tracked for communicable diseases and ensure a process to prevent the spread of diseases to other residents and staff. The facility also failed to wear masks properly while in close proximity to residents. These failures have the potential to affect all 67 residents who currently reside in the facility.B. Based on observations, interview and record review, the facility failed to wear appropriate PPE (Personal Protective Equipment) for Enhanced Barrier Precautions and failed to perform hand hygiene for four of twenty-four residents (R2, R5, R27, R60) reviewed for Infection Control, in a sample of forty-one. The facility's Daily Census Report, dated 2/24/26, documents 67 residents reside in the facility. A. Findings Include: 1. On 2/24/26 upon entrance to the facility, there were multiple signs stating, Please wear masks due to high rate of respiratory illnesses in the community. The current Weekly ARI (Acute Respiratory Illness) level for the facility's county for Influenza was marked moderate and RSV (Respiratory Syncytial Virus) was marked very high. On 2/24/26 at 8:50 AM, V4 (Certified Nurse Aide) was seated and feeding R11 and R63. V4 (CNA) was coughing, sneezing and rubbing her nose and face area frequently. V4 sneezed and said, I'm sorry, I have Laryngitis. V4's voice was hoarse when she spoke. On 2/24/26 at 8:30 AM, V14 (Dietary Aide) was in the main dining room with multiple resident's present preparing food and serving residents with her mask under her nose. On 2/24/26 at 8:30 AM, V7 (Activity Aide) was in the main dining room leaning over on tables talking to multiple residents with her mask under her nose. On 2/24/26 at 8:50 AM, V5 (/CNA) was seated and feeding R29 and R51 with her mask under her nose. On 2/24/26 throughout breakfast, V10 (Registered Nurse) had been present in the dining room and confirmed that V14 (Dietary Aide), V7 (Activity Aide), V5 (CNA) all had their masks under their noses while in close proximity to residents. V10 (RN) also confirmed V4 (CNA) had her mask under her nose and had been sneezing, coughing, touching her face and that V4 had a hoarse voice. On 2/25/26 at 8:00 AM, V15 (CNA/Scheduler/Transporter) was serving trays in the main dining room to multiple residents with mask under her nose. V15 was frequently touching her face/mask/nose. On 2/25/26 at 10:20 AM, V20 (Certified Nurse Aide) was in R2's room talking to her, V20 was standing within arm's reach of R2 with her mask under her chin. On 2/25/26 at 1:15 PM, V14 (Dietary Aide) was in main dining room picking up condiments off the tables where multiple residents were sitting with her mask under nose. On 2/26/26 at 8:15 AM, V30 (Licensed Practical Nurse) was passing medications to multiple residents with her mask under her nose. On 2/26/26 at 10:05 AM, V21 (CNA) wa transferring R55 from chair to bed with her mask under nose. V21 stated It falls down and sometimes poke me in the eye when she is giving cares. On 2/26/26 at 1:45 PM, V11 (CNA) was in hallway with multiple residents present with her mask under her nose. On 3/3/26 at 9:00 AM, V3 (ADON/Infection Preventionist) stated the facility was requiring mask for all staff and visitors because corporate says we have to. On 3/3/26 at 12:00 PM, V39 (Medical Director) stated respiratory illnesses, especially RSV are everywhere right now. Everyone should be wearing masks that cover their mouth and nose and wash their hands frequently to control the spread. V39 stated that the elderly in nursing homes usually have multiple comorbidities and can't handle the respiratory viruses that are going around in the community. If (Nursing Home Residents) get sick they could get a lot sicker than people who are healthy, they can get very sick and actually die from it. The Center for Disease Control (CDC) Viral Respiratory Pathogen Toolkit for Nursing Homes dated 1/23/26, documents Preventing the spread of respiratory viruses in nursing homes requires a comprehensive approach that includes not only vaccination, but also testing, treatment, and the prompt implementation of proven infection prevention and control measures. Examples of Respiratory Pathogens are COVID, Influenza (flu) and RSV (respiratory virus). Be aware when levels of respiratory virus spread are increasing in the community. Develop plans to provide rapid clinical evaluation and intervention to ensure residents receive timely antiviral treatment and/or prophylaxis when indicated. When an infection due to a respiratory virus is suspected in a resident or HCP (Healthcare Provider), it is important to take rapid action to prevent the spread to others in the facility. When an infection due to a respiratory virus is suspected in a resident or HCP, it is important to take rapid action to prevent the spread to others in the facility. Apply appropriate Transmission-Based Precautions for symptomatic residents based on the suspected cause of their infection. Test residents and Health Care Providers with new respiratory illness signs or symptoms. At a minimum, testing should include SARS-CoV-2 and influenza viruses with consideration for other causes (e.g., RSV). Upon entrance to the facility on 2/24/26, 2/25/26 and 2/26/26, the facility's front door had a sign posted which documented the county's acute respiratory illness rate was at high risk and to wear a mask while in facility. 2. R1 was admitted on [DATE] with diagnoses of Orthopedic Aftercare, Fracture of Femur Shaft, Morbid Obesity, Chronic Respiratory Failure, Type 2 Diabetes and Major Depressive Disorder. The Minimum Data Set, dated [DATE] section C documents R1 had a Brief Interview for Mental Status score of 15, cognitively intact. On 2/24/26 at 10:30 AM, R1 was observed in the dining room at a table with four other residents all without a mask and stated she did not feel well. Complained that her chest felt heavy and it was hard to breathe. When asked if she had sputum, she said Yes. I've been bringing up (coughing up) yellow and greenish junk. R1 stated she had not had a chest x-ray because They (contracted x-ray staff) never came. On 2/24/26 and 2/26/26, R1's room did not indicate using Transmission Based Precautions nor was personal protective equipment available for staff use. On 2/25/26 at 9:15 AM, R1 was observed in the Television seating area with six other residents all without a mask and stated she felt even worse than yesterday, appeared to have difficulty breathing and stated No one pays attention to me. I'm going to die. An Infection Screening Evaluation dated 2/20/26 (created date 2/25/26 and locked date of 2/27/26) documents R1 was experiencing new onset of functional decline, new or changed lung exam abnormalities, new or increased cough and productive-purulent sputum. Loebs Criteria: Suspected Lower Respiratory Tract Infection. McGeer's Criteria: Suspected Bronchitis or Tracheobronchitis. R1's Progress Note documents on 2/20/26, R1 was weak and had a cough which was productive at times with yellowish/greenish mucus, wheezing throughout lung fields and received a new order for a chest x-ray; on 2/21/26, awaiting chest x-ray, still wheezing; on 2/23/26 and on 2/24/26, still wheezing. The progress notes do not document that vital signs or oxygen saturations were monitored between 2/20/26 and the morning of 2/25/26 (after V3 was notified of R1's complaints by surveyor); on 2/25/26 at 10:00 AM documents R1 was confused, lethargic, responds to verbal stimuli but falls right back to sleep, shallow respirations, lung sounds diminished with Rhonci (rattling lung sound cause by obstructions or secretions in the large airway), oxygen saturation of 53% (normal limits are 90-100%), oxygen was applied at 2 L (liters) and oxygen saturations went up to 72%, oxygen increased to 4 L and oxygen saturations went up to 76%-78%, V39 (Medical Director) was notified of altered level of consciousness and hypoxia (low oxygen saturation) and received orders to send R1 to hospital. R1 remains hospitalized as of 3/3/26. The Emergency Department Physician Notes dated 2/25/26 documents upon admission, R1 was lethargic, had a cough, was short of breath, wheezing, confused and tested positive for RSV (Respiratory Syncytial Virus), Acute Bronchiolitis due to RSV, Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and Acute Hypoxia Respiratory Failure. And was ultimately transferred to another hospital for a higher level of care. The Call Off Symptom Tracking-Employees log dated February 2026, documents five employees called off due to cough and runny nose: one on 2/3/26 was tested on [DATE] (2 days after) and was positive for RSV and was treated with antibiotics; one on 2/10/26 tested positive for influenza; two on 2/20/26 had symptoms of cough and a runny nose although were not tested and returned to work on 2/14/26. On 2/24/26 at 11:00 AM, V3 (Assisting Director of Nursing/Infection Preventionist) was unaware R1's chest x-ray had not been completed. V3 stated R1 had not been tested for Influenza, RSV (Respiratory Virus) or COVID-19 (all which are communicable/contagious diseases) because respiratory pathogen testing is not conducted unless ordered by the Physician. A symptomatic staff member could have respiratory pathogen testing done by their own provider if they choose to do so. On 2/27/26 at 10:40 AM, V3 (Assisting Director of Nursing/Infection Preventionist) and V32 (Regional Nurse Consultant) stated the facility does not have a policy on testing for communicable diseases. V3 stated they would only test if a physician ordered it. V32 stated they would do a Mcgreer's screening and/or Loeb's Screening. V3 reviewed R1's record and stated an Infection Screen Evaluation was conducted on 2/20/26 but had not been completed or finalized in the electronic health record. On 3/3/26 at 12:00 PM, V39 (Medical Director) stated the facility's county was currently at a very high activity level for RSV and that RSV in the facility's resident population can be fatal. B. Findings Include: The Facility's Enhanced Barrier Precautions policy dated 12/2025 documents Enhanced Barrier Precautions (EBP): recommendations now include use of residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: Dressing, Bathing/Showering, Providing Hygiene, Changing Linens, Incontinence Care, Medical Device Care, and Wound Care. 1. R2's Medical Record documents Enhanced Barrier Precautions for (indwelling catheter) and chronic wounds. Throughout the survey, R2's door had a sign hanging that said, Enhanced Barrier Precautions. On 2/25/26 at 1:30 PM, V24 (Licensed Practical Nurse) performed indwelling catheter care and then wound care using only Standard Precautions. V24 did not don a gown. On 3/3/26 at 9:00 AM, V24 (LPN) confirmed that she had not worn a gown while performing catheter care and wound care for R2. Oh, right. That (Enhanced Barrier Precautions) new thing. I should have worn a gown. The Centers for Disease Control and Prevention February 27, 2024 publications titled Clinical Safety: Hand Hygiene for Healthcare Workers documents glove usage is not a substitute for hand hygiene and hand hygiene should be performed immediately after glove removal. 2. R5's medical record documents R5 was admitted to the facility on [DATE] with diagnoses to include Spina Bifida, Paraplegia, Chronic Obstructive Pulmonary Disorder, Hydronephrosis, ESBL (Extended-Spectrum Beta-Lactamase) Infection, and Urinary Retention. R5's Physician's Order dated 11/03/2025 documents Straight catheterization four times daily. On 02/25/2026 at 2:15 PM, R5 was lying in bed. V18 (LPN) went to right side of the bed and opened a sterile intermittent urinary catheterization kit with nonsterile gloves on. V18 removed a wrapped package of sterile gloves from the kit and placed on the bed. V18 removed sterile drape, opened the drape, and then placed it on the bed. V18 continued to wear nonsterile gloves. V18 removed the cleansing swabs from catheterization kit, opened them, and placed them on the sterile drape. V18 opened lubricant packet and squeezed lubricant onto sterile drape. V18 then used cleansing swabs to cleanse R5's urethral meatus and placed the soiled cleansing swabs back onto the sterile drape. V18 removed nonsterile gloves and donned sterile gloves. Hand hygiene was not performed prior to applying sterile gloves. V18 then removed the sterile single use catheter from the packaging, dipped tip of catheter into the lubricant on the sterile field and inserted the catheter into the urinary meatus. 3. R27's medical record documents R27 was admitted to the facility on [DATE] with diagnoses to include Paraplegia, Hypothyroidism, Coarctation of Aorta, Viral Hepatitis C, History of Methicillin Resistant Staphylococcus Aureus Infection, and Arthritis. R27's Physician's Order dated 01/12/2026, documents Right lower extremity: cleanse with normal saline, pat dry, apply Dakins (antiseptic solution) soaked gauze then apply hydrocolloid paste to peri wound (skin and tissue immediately surrounding a wound) only. Cover with border dressing. On 2/25/26 at 2:30 PM, R27 was sitting in his room in his motorized chair with previous dressing already removed from wound on right outer knee. V18 (LPN) donned gown and gloves to perform R27's wound care. V18 cleansed wound and placed hydrocolloid paste around wound. V18 then changed gloves without performing hand hygiene in between glove change. V18 packed wound with Dakins soaked gauze and covered the wound with a bordered foam dressing. 4. R60's Minimum Data Set (MDS) Assessment, dated 9/8/2025, documents R60 was admitted to the facility on [DATE]. R60's Care Plan, dated 12/11/25, documents, R60 has medical diagnoses including but not limited to: Osteomyelitis Chronic Obstructive Pulmonary Disease, Psoriasis, Personal History of Other Diseases of the Circulatory System, and Chronic Pain. This same care plan documents, R60 has an Actual skin impairment: Non-pressure wound to the left lower leg, distal from the knee as a focus. There is no documented intervention for Enhanced Barrier Precautions (EBP) under R60's focus of Actual skin impairment, nor does this same care plan include a specific focus for EBP with a goal(s) and interventions. R60's Physician Order Summary, dated 2/27/26, documents a telephone Treatment Administration Record order was received from V39/Medical Director for Enhanced Barrier Precautions every shift and was created on 2/24/26 at 9:33 AM by V3/Assistant Director of Nursing with an order effective date of 2/17/26 at 9:33 AM. On 2/24/2026 at 9:09 AM, no EBP sign was observed on or near R60's door. At this same date and time, there was no Personal Protective Equipment (PPE) observed in or near R60's room, or on the hall that R60 resides. On 2/24/2026 at 11:35 AM, R60 stated he has a wound below his left knee. R60 stated the EBP sign was not on R60's door previously. Staff just came and put that sign (EBP sign) up on my room door before you came in to talk to me. No one wears a gown when taking care of my wound. On 2/27/26 at 3:32 PM, V3/Assistant Director of Nursing stated R60 has a vascular wound that started in December of 2025. V3 stated (R60) should be in EBP due to a vascular wound on (R60's) left leg, staff should wear PPE while providing high contact cares to R60, and PPE should be easily accessible to staff outside of R60's room since (R60) requires EBP due to his wound. V3 verified the telephone order for EBP was entered on 2/24/26 at 9:33 AM by V3 and was backdated to 2/17/26 at 9:33 AM. On 2/27/26 at 3:35 PM, V18/Licensed Practical Nurse verified no PPE was in or by R60's room, or on the hall where resident resides. V18 stated PPE should be readily available to staff since R60 is on EBP for the wound to his left leg.

Based on observation, interview, and record review, the facility failed to maintain or repair residents' missing and peeling wall coverings and exposed dry wall for 8 residents (R13, R16, R31, R39, R42, R44, R62, R69), and failed to repair the wall area between the HVAC/heating, ventilation, air-conditioning unit and the window sill for two residents (R30, R37) in the total sample of 41 residents reviewed for clean, comfortable and homelike environments. This failure has to potential to affect all 67 residents living in the facility Findings include: The facility room roster, dated 2/24/26, documents 67 residents reside in the facility.The facility's Maintenance Director Job Description, dated 03/2024, documents The primary purpose of the Maintenance director is to plan, organize, develop, and direct the overall operation of the Maintenance in accordance with current federal, state and local standards, guidelines, and regulations governing our facility., and Essential Duties and Responsibilities: Repair facility/resident property as necessary. In the event of inability to repair, coordinate with outside vendors to make repair or replace as cost effectively as possible. On 2/24/26 at 1:45 PM, the room repair needs for the following residents' rooms were identified: In R42 and R69's room a section of wallpaper approximately two feet by six inches was peeling and drywall was exposed on the wall across from R42's bed; R39 and R62's room a six inch wide by 1-1/2 inch high hole through the drywall was present behind the room door, where the door handle hits the wall; R13 and R44's room, a 1-1/2 feet by 8 inch area of peeling wallpaper and exposed drywall on the wall next to the 'A' bed in the room; R16's room had a four feet long by 2 1/2 foot wide area of exposed dry wall with peeling wallpaper. The following areas were identified in R30 and R37's room, between the HVAC unit under the window and the window sill: several black spots in the caulking, identified as mildew by V6/Maintenance Director, crumbling and missing caulking, broken wooden framing, and a hole through the drywall measuring approximately 3-inches by 2 1/2-inches, exposing wire mesh. On 2/25/26 at 1:50 AM, a tour of the facility was conducted by this surveyor with V6 Maintenance Director who stated the rooms identified in need of repairs had yet been addressed in the remodel attempt of the facility. Regarding the rooms in need of repairs, V6 stated the following: We have an app called 'Tels' that they use to notify me of work requests in the building. My computer has been down for a while, and I didn't get work requests. On 2/27/26 at approximately 9:50 AM, V6 provided a computer-generated compilation of work orders dated 6/30/25 through 1/24/26. This compilation of work orders included 11 work orders requesting repairs on the designated hall where R13, R16, R30, R31, R37, R39, R42, R44, R62, and R69's rooms are located. The February 2026 work order/repairs request list was not provided as of 3/3/26.On 2/27/26 at approximately 1:00 PM, V31 (Regional Director of Operations) verified the areas in need of repair in the rooms identified above.

Based on record review and interview, the facility failed to ensure all staff received mandatory training and education for infection prevention and control. This failure has the potential to affect all 67 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 residents resided in the facility.The facility's Facility Assessment Tool for (facility) 11/1/2025-11/1/2026, dated 12/9/25, documents, Staff training/education and competencies: see Healthcare Academy (online education platform). Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program.On 3/3/26 at 11:00 AM, V1/Administrator stated she did not have documentation demonstrating staff employed at the facility received the required staff training/education and competencies. V1 stated she reviewed the reports for the required education in the online education platform and most of the required in-services/education for staff members were either incomplete or not completed at all. On 3/3/26 at 3:45 PM, V31/Regional Director of Operations confirmed all staff should receive regular training and education to ensure competence. V31 stated there was no documentation to show all staff received their required education and training to ensure competence.

Based on record review and interview the facility failed to ensure all staff were provided education, in-services, and training regarding the facility's standards, policies, and procedures for Compliance and Ethics. This failure has the potential to affect all 67 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 residents resided in the facility.The facility's Facility Assessment Tool for (facility) 11/1/2025-11/1/2026, dated 12/9/25, documents, Staff training/education and competencies: See Healthcare Academy (online education platform) to include but not limited to: communication; residents' rights and facility responsibilities; abuse, neglect, and exploitation; infection control; culture change; identification of resident changes in condition; and cultural competency. Consider the following competencies (this is not an inclusive list): person-centered care, activities of daily living, disaster planning and procedures, infection control, medication administration, measurements (vital signs), resident assessment and examination, caring for persons with Alzheimer's or another dementia, specialized care (catheterization insertion/care, colostomy care, wound care/dressings, dialysis care, etc.), and caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. This same document states, Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year; Include dementia management training and resident abuse prevention training; Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by facility staff; For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.On 3/3/26 at 11:00 AM, V1/Administrator stated she did not have documentation demonstrating staff employed at the facility received education and competencies related to Compliance and Ethics. V1 stated she reviewed the reports for the required education in the online education platform and most of the required in-services/education for staff members were either incomplete or not completed at all. On 3/3/26 at 3:45 PM, V31/Regional Director of Operations confirmed all staff should receive regular training and education to ensure competence. V31 stated there was no documentation to show all staff received their required education and training to ensure competence.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) were provided and completed a minimum of 12 hours of inservice training per year. This failure has the potential to affect all 67 residents residing in the facility. Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 residents resided in the facility.The facility's Facility Assessment Tool for (facility) 11/1/2025-11/1/2026, dated 12/9/25, documents, Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year; Include dementia management training and resident abuse prevention training; Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by facility staff; For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.On 3/3/26 at 11:00 AM, V1/Administrator stated she did not have documentation demonstrating the CNAs working at the facility received the minimum of 12 hours of required education. V1 stated she reviewed the reports for the required education in the online education platform and most of the required in-services were either incomplete or not completed at all. On 3/3/26 at 3:45 PM, V31/Regional Director of Operations confirmed the CNAs working at the facility should receive 12 hours of continuing education yearly at minimum. V31 stated there was no documentation to show all CNAs received 12 hours of the minimum yearly training.

Based on record review and interview, the facility failed to ensure that nursing staff (Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants) were competent to perform their job duties as evidenced by the facility's lack of education, in-service, and competency assessment records. This failure has the potential to affect all 67 residents residing within the facility.Findings include:Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 residents resided in the facility.The facility's Facility Assessment Tool for (facility) 11/1/2025-11/1/2026, dated 12/9/25, documents, Staff training/education and competencies: See Healthcare Academy (online education platform) to include but not limited to: communication; residents' rights and facility responsibilities; abuse, neglect, and exploitation; infection control; culture change; identification of resident changes in condition; and cultural competency. Consider the following competencies (this is not an inclusive list): person-centered care, activities of daily living, disaster planning and procedures, infection control, medication administration, measurements (vital signs), resident assessment and examination, caring for persons with Alzheimer's or another dementia, specialized care (catheterization insertion/care, colostomy care, wound care/dressings, dialysis care, etc.), and caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. This same document states, Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year; Include dementia management training and resident abuse prevention training; Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by facility staff; For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.On 3/3/26 at 11:00 AM, V1/Administrator stated she did not have documentation demonstrating staff employed at the facility received education and competencies related to the facility's standards, policies, and procedures. V1 stated she reviewed the reports for the required education in the online education platform and most of the required in-services/education for staff members were either incomplete or not completed at all. On 3/3/26 at 3:45 PM, V31/Regional Director of Operations confirmed all staff should receive regular training and education to ensure competence. V31 stated there was no documentation to show all staff received their required education and training to ensure competence.

Based on interviews and record reviews, the facility failed to provide a Pneumococcal Immunization to two residents (R1, R60) that requested to receive it and failed to offer a Pneumococcal Immunization to three (R13, R52, R55) residents out of 8 residents reviewed for immunizations, in a sample of 41.Findings include: The facility's Influenza and Pneumococcal Immunizations Policy dated 12/2025 documents: Each resident is offered a pneumococcal immunization. The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident either received or did not receive the pneumococcal immunization due to medical contraindications or refusal. On 2/25/2026 at 1:00 PM, V3 (ADON/Infection Preventionist) reported a pneumococcal immunization clinic was held at the facility on 12/01/2025. 1. R1's medical record documents R1 was admitted to the facility 09/12/2025 with diagnoses to include Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Diabetes, Depression, and Pneumonia. R1's Physician's Order dated 09/12/2025 documents May have pneumonia vaccine unless contraindicated. R1's Authorization and Release for Vaccinations included in her admission packet (includes but not limited to consents, bed hold policy, resident rights, transfer policies, arbitration agreement, and services provided by facility) indicates R1 requested to receive the pneumococcal vaccine. R1's medical record documents she received an Influenza vaccine on 10/28/2025. R1's medical record did not have a documented pneumococcal immunization.2. R60's medical record documents R60 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Depression, Atrial Fibrillation, and Bipolar Disorder.R60's Physician's Order dated 08/26/2025, documents May have pneumonia vaccine unless contraindicated.R60's Authorization and Release for Vaccinations included in his admission packet indicates R60 requested to receive the pneumococcal vaccine.R60's medical record documents R60 received the influenza vaccine on 10/28/2025 and a Covid vaccine on 12/01/2025. R60's medical record did not have a documented pneumococcal immunization.On 02/27/2026 R60 reports he has not received a pneumococcal vaccine, and he wants to have one.3. R13's medical record documents R13 was admitted to the facility on [DATE] with diagnoses to include Dementia, Depression, and Hypertension.R13's Physician's Order dated 11/01/2025, documents May have pneumonia vaccine unless contraindicated.4. R52's medical record documents R52 was admitted to the facility on [DATE] with diagnoses to include Subdural Hemorrhage, Depression, Epilepsy, and Polyneuropathy.R52's Physician's Order dated 11/01/2025, documents May have pneumonia vaccine unless contraindicated.5. R55's medical record documents R55 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Diabetes, Venous Insufficiency, Polyneuropathy, and Schizophrenia.R55's Physician's Order dated 11/26/2025, documents May have pneumonia vaccine unless contraindicated.R13, R52 and R55's medical records did not have a Pneumococcal Immunization documented.On 03/03/2026 at 10:15 AM, V1 (Administrator) reported the facility could not find or provide the admission packets including Authorization and Release for Vaccinations forms for R13, R52 and R55.

Based on observation, interview and record review the facility failed to treat three residents (R5, R27,R76) with dignity in three reviewed for dignity in a total sample of 41.1. R5's medical record documents R5 was admitted to the facility on [DATE] with diagnoses to include Spina Bifida, Paraplegia, Chronic Obstructive Pulmonary Disorder, Hydronephrosis, and Urinary Retention. On 2/25/26 at 2:15 PM, V11 (Certified Nurse Aide/CNA) and V16 (CNA) transferred R5 via mechanical lift from his wheelchair to his bed. R5's privacy curtain was not pulled prior to V11 and V16 pulling down his pants and incontinent brief to prepare him for catheter procedure. V18 (Licensed Practical Nurse/LPN) entered room and pulled the privacy curtain between R5 and his roommate. 2. R27's medical record documents R27 was admitted to the facility on [DATE] with diagnoses to include Paraplegia, Hypothyroidism, Coarctation of Aorta, Viral Hepatitis C and Arthritis. On 2/25/26 at 2:30 PM, R27 was in his room with the door open. V18 (LPN) placed the treatment cart in front of the doorway. The treatment cart did not cover the width of the doorway. V18 proceeded to provide wound care to R27's right knee wound. 3. R76's Medical Record documents she was admitted on [DATE] with diagnosis to include but not limited to Unspecified Dementia, Severe Depression and Unspecified Intellectual Disabilities. Throughout the survey, R76 seemed confused and did not answer any questions appropriately. On 02/25/2026 at 1:21 PM, V29 (Certified Nurse Aide/CNA) was standing and feeding R76 at lunch. V29 (CNA) was repeatedly referring to R76 as honey and sweetie. On 2/25/26 at 1:30 PM, V29 (CNA) stated she sometimes stands when she assists residents with their meals. V29 stated Oh no, sorry. I shouldn't have said that when asked about referring to R76 with pet names. On 2/25/26 at 1:35 PM, V24 (Licensed Practical Nurse/LPN) stated All staff should sit when they are feeding residents. No one should refer to any residents as honey or anything other than their given name unless the resident requests that. V24 (LPN) confirmed that R76 just admitted to the facility on [DATE] and stated, She is pretty confused and does not answer questions.

Based on observation, interview, and record review, the facility failed to protect two cognitively impaired residents (R1, R8) who were at risk for abuse; and failed to prevent resident to resident physical abuse by two cognitively impaired residents (R2, R9). This failure affected 4 of 4 residents (R1, R2, R8 & R9) reviewed for abuse in a sample of 9. The failure resulted in R2 placing both of his hands around R1's neck and forcefully squeezing into R1's neck; and resulted in R8 being physically punched in the face with a closed fist by R9. Findings include: The final abuse investigation report provided by V1 (Administrator) documented an incident date of 04/27/2025 and indicated, resident was noted to have his peer put his hands around his neck. Report documented that R1 placed his hands around the neck of R2, however, during staff interviews, it was determined that R2 was the aggressor and R1 was the victim. 1. R1's electronic record documented last admitted [DATE] with a past medical history not limited to Alzheimer's disease, dementia, and major depressive disorder. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated severe cognitive impairment. R1's care plan report provided by facility on 05/14/2025 reads in part: impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, dementia, impaired decision making, psychotropic drug use and is at a medium risk for abuse/neglect as noted from abuse screening related to diagnosis of Alzheimer's, dementia, and major depressive disorder. Report also indicated that R1 has a terminal condition and is receiving hospice services that was initiated on 11/25/2024. R1's hospice note dated 04/27/2025 at 03:11 PM documented that resident is alert with usual confusion, and has been fine since incident this morning. R1's abuse/neglect screen dated 04/28/2025 indicated that R1 is at moderate risk for abuse and/or neglect. R1's psychosocial assessments dated 04/28, 04/29, and 04/30/2025 documented R1 was unable to recall any details related to a resident to resident physical altercation. On 05/13/2025 at 09:45 AM and 05/14/2025 at 08:44 AM, R1 was observed resting in a wheelchair on the memory care unit in front of the nurse's station. R1 was alert to self and was not interviewable. R2's electronic record documented admitted [DATE] with a past medical history not limited to vascular dementia, mood [affective] disorder, anxiety disorder and convulsions. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated severe cognitive impairment. Behavior note dated 03/26/2025 at 02:11 PM documented R2 was punching nurse during medication administration. Behavior note dated 03/27/2025 at 11:43 PM documented R2 would be aggressive to staff when trying to help resident sit down. Behavior note dated 04/06/2025 at 10:38 PM documented R2 can be resistive to care and can be combative at times. Behavior note dated 04/09/2025 at 02:43 PM documented R2 is aggressive with staff and was hitting, scratching, cussing. R1 was uncooperative and shoving with hospice staff at facility to shower resident. Behavior note dated 04/13/2025 at 06:02 PM documented R2 was pacing prior to supper then suddenly became agitated and refused nursing care. Behavior/Mood Charting dated 04/27/2025 at 12:03 PM documented R2 had agitation and was exit seeking. Physical aggression incident happened at 9:45 am with another male peer. no injuries noted. Intervention included as needed lorazepam administered at 11:30 AM. Hospice aware of both hospice residents involved and indicated could administer R2 a second lorazepam in 2hours if needed. Behavior note dated 04/28/2025 at 04:51 PM documented R2 struck nurse's hand when trying to administer medications to resident. R2's psychosocial assessments dated 04/28/2025 documented R2 was unable to recall any details related to a resident to resident physical altercation. R2's aggressive behavior assessment dated [DATE] documented resident does not have a history or recent episode of aggressive/agitated behavior and/or non-compliance with medications, treatments, regimen or resisting care with no known triggers. Behavior note dated 04/30/2025 at 12:46 AM documented R2 will usually follow directions but can become aggressive to staff and other residents. R2's psychiatry note dated 04/30/2025 indicated resident was seen per staff request because R2 had an altercation with another resident. Appearance/Behaviors displayed were exit seeking and pleasantly confused. Plan of action indicated R2's diagnosis of dementia is worsening and unstable at visit with new orders to start haloperidol (antipsychotic) 5 milligrams (mg) intramuscularly every eight hours as needed for dementia and agitation, increase divalproex (mood stabilizer) 500mg to three times daily. R2's medication list includes sertraline 100mg daily for anxiety symptoms, trazadone 75mg nightly for sleep disturbance and lorazepam 0.5mg nightly for anxiety symptoms. Most recent gradual dose reduction on 04/30/2025 for sertraline, trazodone and lorazepam was contraindicated due to increased risk for worsening of anxiety and/or insomnia. (Review of active orders showed medication orders as indicated). Behavior note dated 05/07/2025 at 02:51 PM documented R2 was administered as needed lorazepam due to being restless, resistive with cares, punching staff, saying negative statements to staff, and wandering. Medication Administration Note dated 05/08/2025 at 04:29 PM documented R2 was administered haloperidol 5 mg due to agitation, cursing, walking fast up and down the hallway reaching out at staff. Behavior note dated 05/10/2025 at 02:06 PM documented that R2 was combative with staff while trying to record his vitals and was administered an as needed lorazepam for agitation. R2's care plan report reviewed at facility on 05/13/2025 documented that resident has impaired cognitive function, is/has the potential to be physically aggressive, the potential to be verbally aggressive at times, and is resistive to personal care at times related to dementia and is receiving anti-psychotic medications related to behavior management that was initiated on 05/13/2025 which is after the date of incident with R1. Care plan's focus for trauma informed care indicated that resident had a traumatic event, and circumstances occur and R2 is triggered by loud noises. On 05/13/2025 at 09:46 AM V4 (Licensed Practical Nurse) said R2 was anxious and resistive with cares this morning. At 09:59 AM, V4 indicated that R2 is aggressive at times with staff but not to his peers. On 05/13/2025 at 10:02 AM, V5 (Alzheimer Coordinator/Aide) said R2 was the aggressor in the incident between R1 and R2 on 04/27/2025. On 05/13/2025 at 10:06 AM, observed R2 was lying in bed and was not interviewable at this time. At 10:06 AM, V5 said R2 is very confused and can be combative at times. On 05/13/2025 at 12:00 PM, V1 (Administrator) said in the incident between R1 and R2, R2 was the aggressor and R1 was the victim. V1 then said both residents were sitting down at different tables on the memory unit not close to each other when something triggered R2 and he put his hands around R1's neck. V7 (Certified Nursing Assistant) ran over to the residents and had to wedge her hands under R2's hands and R1's neck to separate them. V1 added that R1 had no signs of injuries, R1 was monitored frequently, R2 was placed on 1:1 monitoring for the remainder of the shift (12 hours) and both residents were seen by a psych physician. On 05/13/2025 at 12:52 PM, V6 (Licensed Practical Nurse) said on 04/27/2025 at approximately 9:45 AM she was seated in the dining area on the memory (E) unit administering medications to another resident when V7 (Certified Nursing Assistant) rushed across the room. V6 couldn't see what was going on but V7 informed her that R2 had both his hands, one in front, and one to the back of R1's neck. V7 was trying to separate R2's hands from his neck. V6 said after R1 and R2 were separated, she assessed R1, but didn't see any markings on his neck. R1 complained that his neck hurt. V6 then said she administered an as needed lorazepam to R2 because he was pacing and wandering. R2 was placed on 1:1 monitoring, and staff performed frequent safety checks on R1. V6 said that R2 can be combative with staff, has behaviors, and is resistive with cares at times. She added a few days prior, R2 was hitting an aide that was trying to get his vital signs. On 05/13/2025 at 1:52 PM, V7 (Certified Nursing Assistant) said at 09:45 AM, she was clearing breakfast trays in the memory care unit. She added that R1 was seated at the table facing the nurse's station and R2 was wandering around the dining room then towards the nurse's station. V7 then said she heard R1 yell out, ouch stop it and when she looked over towards R1, V7 said she saw R2's right hand to the front of R1's throat and his left hand was to the back of R1's neck. V7 added that R2's fingers were digging into R1's neck and he looked mad. V7 then said she wedged her fingers in between R2's fingers which he was still squeezing around R1's neck and while also trying to push her away. V7 added that she yelled out for the other aide (V11) who was seated on other side of room feeding another resident to assist. V7 said she was able to pry R2's hands from R1's neck by the time V11 arrived and after they were separated, V7 and V11 both took R2 to his room and tried to calm him down. V7 said she made other reports on R2 to V1 (Administrator) about R2 grabbing her wrists and pulling her around the dining room who then followed her around after she got away from him. On 05/13/2025 at 2:05 PM, V7 said not too long after this incident, R1 was at the table with his walker next to him when R2 walked towards R1 and grabbed his walker then started walking away. V7 said when she attempted to get the walker from R2, he got agitated and shook the walker at her with a mean and irritated look to his face. V7 added that R2 tried to push her away with the walker but couldn't, so he let go of the walker then reached over and hit her in the stomach. V7 said the nurse gave him anxiety medication but he was still up walking around and was agitated so the nurse had to give him more medication. V7 also said that R2 has good days and bad days, and on his bad days, it is very bad. At times, R2 is resistive and combative and can't be redirected. On 05/14/2025 at 12:38 PM, V11 (Certified Nursing Assistant) said R2 is moody and will swing punches at staff for no reason, curse at us, etc. V11 then said on day of incident, she saw R2's hands around R1's neck and he was squeezing his hands. She added that V7 was trying to pry his fingers away from R1's neck and after they were separated, R1 had red marks to his neck that looked like finger marks. V7 added that the nurse (V6) said she didn't see any redness but she and V7 both saw them on R1's neck. She also said on the morning of this incident, R2 had grabbed her arm in which she had to pry his hands off and finally got away form R2, but he then started walking after V11. She added that R2 had punched V7 on the same day of incident. 2. Review of R8's abuse investigation report documented on 05/01/2025 (per V1 date is 5/11) at 05:40 PM, staff reported that a physical altercation occurred between R8 and a male resident. This report documented R8's diagnosis and mental status includes dementia, Brief Interview of Mental Status (BIMS) score of 01/15 which indicates severe cognitive impairment. R8's electronic record documented admitted [DATE] with a past medical history not limited to dementia, mood [affective] disorder, anxiety disorder and depression. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated severe cognitive impairment. R8's incident note dated 05/11/2025 at 07:24 PM documented another resident (R9) was walking very fast toward R8 and was witnessed by staff striking R8 on the right side of her face. R8 then complained of pain. R9 called R8 [NAME] and when he was informed by staff that R8 was not [NAME], R9 said he was sorry. R8's abuse/neglect screen dated 05/12/2025 indicated resident is at moderate risk. On 05/13/2025 at 10:00 AM, R8 was seated at a table in dining area on memory care unit. R8 was alert to self and was not interviewable. R8's care plan report reviewed at facility on 05/13/2025 documented that resident has impaired cognitive function/dementia or impaired thought processes related to dementia; is at a medium risk for abuse/neglect as noted from abuse screening related to dementia and mental health diagnosis. On 05/13/2025 at 11:52 AM, V1 (Administrator) said R8's incident occurred approximately at 5:40 PM, a male dementia resident (R9) hit R8 in the face. V1 added that R9 thought R8 was his daughter named [NAME] and after staff intervened and explained she was not, R9 apologized. V1 said that R8's face was red with no indication to send out emergently. R9 was added on the list to be seen by psych. On 05/13/2025 at 12:50 PM, V6 (Licensed Practical Nurse) said around 5:40 PM on 5/11/2025, she was finishing her med pass in the dining area on memory unit. She added that the aides were either still feeding residents or cleaning up from dinner; V10 (CNA) was in dining room and V9 (CNA) was down the hall. V6 then said R8 was sitting at the table being quiet when she noticed R9 get up fast and started walking fast to R8's table so she followed him. V6 said that R9 went right up to R8, called her [NAME], then hit her in the face with a closed fist. R8's right cheek looked red. On 05/13/2025 at 02:54 PM, V10 (Certified Nursing Assistant) said R9 had walked past him in the memory care dining room then he heard R8 scream out; prior to she was sitting quietly eating her dinner. V10 said when he turned, he heard R8 verbally reacting to what R9 did but V10 did not see any physical contact. He added that V6 (LPN) was by them and had it under control. V10 added that he did not see any injuries, but V6 said R8 had a mark on her face. R8's psychosocial assessments dated 05/14/2025 documented resident to resident physical altercation, resident hit R8 in the face. R8 is unable to recall incident. R9's electronic record documented admitted [DATE] with a past medical history not limited to dementia and history of falling. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated moderate cognitive impairment. R9's aggressive behavior assessment dated [DATE] documented resident has a history or recent episode of aggressive/agitated behavior and/or non-compliance with medications, treatments, regimen or resisting care including non-compliance with medications, resisting cares, and may be agitated at times. Incident Note dated 05/11/2025 at 06:33 PM documented that R9 was walking very fast toward R8 and was witnessed by staff striking R8 on the right side of her face. R8 then complained of pain. R9 called R8 [NAME] and when he was informed by staff that R8 was not [NAME], R9 said he was sorry. Incident Follow Up note dated 05/12/2025 at 10:58 AM indicated R9 had a witnessed altercation with another resident, root cause determined to be dementia. New intervention is to have a medication review done by psych. R9's care plan report reviewed at facility on 05/13/2025 documented that resident has a behavior problem; is resistive to cares related to dementia; resident is/has potential to be physically aggressive related to dementia (05/12/2025); has impaired cognitive function. On 05/13/2025 at 10:15 AM, observed R9 seated at table in dining area on memory care unit. R9 was alert to self and not interviewable. On 05/14/2025 at 02:00 PM, V1 (Administrator) said the abuse incidents between R1, R2, R8, and R9 can be substantiated but could not be prevented due to the population and their unpredictable behaviors. Abuse policy effective 09/2024 reads in part: this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.

Based on observation, interview, and record review the facility failed to prevent staff physical abuse for one resident (R1) of three residents reviewed for abuse in the sample of four. Findings include: The facility's Abuse Prevention and Reporting policy and procedure, dated 9/2024, documents This facility affirms the right of our residents to be from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. This same policy documents Resident-to-Resident Abuse (of any type): A resident-to-resident altercation should be reviewed as a potential situation of abuse. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish, or pain must be reported in accordance with regulations. R1's medical record documents R1 with the following diagnoses: Dementia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety disorder, and Generalized Idiopathic Epilepsy and Epileptic Syndromes. The Abuse/Neglect Screening for R1, dated 11/10/24, documents R1's risk measure for likelihood for a history of previous/recent mistreatment and/or potential future problems/symptoms related to mistreatment at a 6; Indicating high risk due to score greater than five. On 11/14/24 at 11:00 am, interview attempted with R1. R1 closed his eyes and when he opened his eyes, noted R1's eyes would roll up and only white sclera visible, then would lower eyes. R1 became tearful and began mumbling distorted words and not making sense. The initial Abuse Investigation for R1, dated 11/10/24 documents an allegation of physical abuse to R1 by V8 Agency CNA/Certified Nursing Assistant was reported to V1 Administrator on 11/10/24 at approximately 4:18 am by V7 Agency LPN/Licensed Practical Nurse. V7 Agency LPN reported that (V8 Agency CNA) was assisting (R1) when (R1) became combative during the transition, (V8 Agency CNA's) hand made contact with (R1's) head during assistance. (V8 Agency CNA) suspended immediately. Investigation initiated. Police notified and Responsible Parties notified. 5 day to follow. The Progress Note for R1, dated 11/10/24 at 4:03 am, documented by V7 Agency LPN documents (R1) found on floor by CNA, Nurse responded and attempted to perform assessment and vitals but unable to do so due to resident being combative. Nurse received help from CNA to get the resident off the floor, when attempting to do so (R1) became combative with a male CNA in return the CNA struck (R1) on the left side of face. CNA was instructed to leave the residents room and 911 was initiated. Sheriff department and EMS (emergency medical service) responded. Nurse gave sheriff department details of incident. (R1) sent out to (local hospital) via EMS for further evaluation. Administrator and POA (Power of Attorney) notified via telephone. The Alleged Victim Interview form for R1, dated 11/11/24, documents I was asleep, and they came into my room. they woke me up and tried to take my pants off. I wouldn't let them. They called the police. I was in a dead sleep. I thought I was having a dream. R1 stated the incident occurred about 3:30 at night in his room. R1 stated he can't remember the staff names that told him Take all your clothes off - Take his socks. R1 reported he did not suffer injuries. The Alleged Perpetrator Interview form for V8 Agency CNA, dated 11/11/24, documents The nurse asked for help in (R1's) room. I went in (R1's) room with the nurse and two other staff members. (R1) was out of his bed and on the floor. (R1) was kicking and cursing and throwing his slippers at us. We placed the wheelchair close to him, we proceeded to lift him up off the floor and put him in his wheelchair. As soon as (R1) was placed in his wheelchair he punched me closed fisted on the right side of my face. I had a reflex and I hit (R1) open handed on the top of his head. After I hit him, I apologized. (R1) hit me closed fisted two more times on my shoulder area. (R1) went out to into the hallways cursing and yelling. On 11/15/24 V17 SSA/Social Service Assistant stated she did all the staff and resident interviews for R1's physical abuse allegation. V17 SSA stated she called all the staff who worked during the time of the allegation and wrote word-for-word everything they said. V17 SSA stated she did talk to V8 Agency CNA who did say he hit R1 and that it was reflex only and hit him open handed on the head. On 11/15/24 at 10:45 am, V1 Administrator stated she was notified on 11/10/24 at approximately 4:15 am by V7 Agency LPN that there was an altercation between R1 and V8 Agency CNA. V7 Agency LPN sent V8 Agency CNA home, called the local police, and R1 was sent out to the local hospital for evaluation. V1 Administrator stated she called V8 Agency CNA and told him he was not allowed back into the facility pending investigation and notified the staffing agency of the allegation. V1 Administrator confirmed V8 Agency CNA admitted to hitting R1 and has been added to the facility's DNR (do not return) listing.

Based on observation, interview, and record review the facility failed to ensure a resident's bed was kept in the lowest position, failed to keep resident personal items and call light within reach, failed to ensure a resident was secure while being transported in the facility van, failed to investigate a fall, failed to implement and revise fall interventions, and failed to update the fall care plan after a fall for one of three residents (R1) reviewed for falls with injuries in the sample of five. These failures resulted in R1 falling out of bed while reaching for his cell phone while his bed was in a high position, sustaining a left femur fracture, and R1 falling forward out of his wheelchair while being transported in the facility van causing R1 to experience neck and shoulder pain, fear, and emergency department treatment for pain. Findings include: The facility's Fall Prevention dated 11/10/2018 documents, Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: All staff. All falls will be discussed in the morning quality assurance meeting and any new interventions will be written on the care plan. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. 6.The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or in a A.I.M. (Acute Illness Management) for Wellness form along with any new fall interventions deemed to be appropriate at the time. 1. On 6/15/24 at 9:15 AM R1 was sitting in wheelchair in the dining room. R1 stated, When I rolled out of bed (on 7/19/23) I was reaching for my cell phone and could not reach it. My remote to my bed was hanging down and I could not reach it. The staff did not leave it on my table beside me. I fell to the floor and broke my leg. The staff had left my bed high, so I fell from really far up. I needed help forever. I called my mom to come and help me. (V7/R1's Family Member) showed up to help me before the staff even came in to help. On 6/15/24 at 10:20 AM R1 was lying in bed flat, with the bed in the highest position. (V7) was at (R1's) bedside. No staff were supervising R1 in the room during this time. V7 stated, The staff always leave (R1's) bed in the highest position when I visit. I do not know how many times I have told staff that (R1's) bed needs to be low. When (R1) rolled out of bed and fractured his femur (on 7/19/23) he called me while he was on the floor and asked me for help because no staff was responding to him. I got to the facility and found (R1) laying on the ground beside his bed. (R1) had bruising to his hip and his bed was in the high position when (R1) rolled out. (R1) said he was reaching for his cell phone because the staff did not leave his phone within his reach. (R1's) knee was swelling more every day after the fall on 7/19/23 so I insisted the facility get (R1) an x-ray and that is when they found (R1) had a fractured his femur. (R1) would not have fractured his femur if his bed was low and his cell phone was within reach. R1's Admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Paraplegia, [NAME]-Chiari Syndrome with Spina Bifida, Abnormal Posture, and Wheelchair Dependence. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact. R1's A.I.M. for Wellness dated 7/19/23 and signed by V16 (RN/Registered Nurse) documents R1 had a change of plane (fall) while trying to reach for his cell phone and slight discoloration was noted to the right hip. R1's Investigation Report for Falls dated 7/19/23 and signed by V16 documents R1 stated he was tired of waiting and wanted out of bed, was incontinent when found on the floor, and R1's call light was not within reach. R1's Progress Notes dated 7/27/23 document R1 was at another medical facility receiving care and R1's left knee was swollen, so an x-ray was obtained. R1's X-Ray Left Knee Report dated 7/27/23 documents, Impression: Distal Lateral Femur concerns for acute mildly displaced fracture. R1's Hospital After Visit Summary dated 7/28/23 documents, Reason for visit: Knee injury. Diagnosis; Aftercare for healing traumatic fracture of left femur. Instructions: Leave knee brace intact until evaluated by orthopedics (8/1/23). R1's Orthopedic Progress Notes dated 8/1/23 and signed by V18 (Orthopedic Surgeon) document, (R1) fell while trying to lean over for cell phone and injured his femur. He has a lateral femoral condyle fracture. Non-operative care and follow-up in six weeks. 2. The facility's Van Usage Policy and Procedure (undated) documents, The purpose of this policy is to establish procedures by which employees formally acknowledge and accept responsibilities of operating a facility owned van on behalf of (the facility). Further, it establishes requirements for enforcement of operating procedures and safe driving practices. When employees operate a facility owned van, they have inherent responsibilities to care for the vehicle and the residents, obey all state and local traffic laws, and abide by established driver operating procedures. Employees must practice safe driving procedures and obey the rules of the road when operating a facility owned van. b. Secure seat belts anytime the vehicle is in motion and require all passengers to wear seatbelts. c. Ensure all residents and wheelchairs are safely secured. On 6/15/24 at 9:15 AM R1 was sitting in wheelchair in the dining room. R1 stated, (V10/Maintenance Assistant) was bringing me home from the wound clinic (on 4/25/24) in the facility van and slammed on the brakes. I fell forward out of my wheelchair and hit my head on the seat in front of me. My shoulders and neck were hurting from hitting them on the seat. I thought I was paralyzed. I was so scared since I am already paraplegic. (V10) did not seat belt me in right. It hurt my neck and shoulders and I was taken to the hospital to make sure I was okay. R1's Medical Record does not include documentation of R1 having a fall while in the van on 4/25/24 and does not include an investigation into the root cause of R1's fall or the implementation of new fall interventions to prevent further falls. R1's current Care Plan does not address R1's fall on 4/25/24. On 6-15-24 at 9:45AM V10 (Maintenance Assistant) stated, On (4/25/24) I had to take (R1) to the wound clinic and had never driven the van before. While on the interstate the stop light switched quickly to red, and I had to hit the brakes quick. I did not check to make sure the d-ring was clamped onto the back of (R1's) seat belt. The d-ring keeps (R1's) seat belt secured. R1 fell face first and hit his head on the back of the seat. (R1) said he could not move his arms or chest or anything. After we went a little farther (R1) could feel his hands again. I took R1 into the emergency room there (in the same town) and asked the nurses to get (R1) off the floor and assess him. (R1) did not have any injuries. (V7) asked me to take (R1) to her house for the night. This was the first time I transported a resident in the facility van. I was not trained prior to transporting (R1) in the van on how to properly buckle residents in wheelchairs in the van or use the d-rings or seat belts in the van. On 6/15/24 at 1:10 PM V1 (Administrator-In-Training) stated, I cannot find evidence of an investigation being completed after (R1's) fall on 4/25/24. I had (V10) pick (R1) up from the wound clinic on 4/25/24. I did not realize (R1) was not trained on securing the residents in the van.

Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions once a resident was assessed as being at high risk of developing pressure ulcers, failed to assess a pressure ulcer's stage and size once identified, failed to perform daily skin checks as ordered by the physician, failed to perform physician ordered wound treatment, and failed to perform pressure ulcer risk assessments every week for four weeks after admission and quarterly thereafter, as instructed by the facility's policy, for one of three residents (R1) reviewed for pressure ulcers in the sample of five. These failures resulted in R1 developing a facility acquired stage three pressure ulcer to the right medial ankle. Findings include: The Pressure Sore Prevention Guidelines policy dated 3/16/23, documents Policy: It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale. Responsibility: all nursing staff and the dietary manager. Interventions/Comments for High-Risk residents. Special Mattress/Specify type of mattress on the Care Plan. Daily Skin Checks/follow protocol for coding skin conditions. Interventions/Comments for High or Moderate Risk residents: Turn and reposition every two hours. Turning and positioning may be more often than every two hours for high risk, if indicated. Care Plan Entry/Skin risk and appropriate interventions are to be placed on the Care Plan. If despite interventions a pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further prevention of Pressure Ulcers. Interventions/Comments as needed for High or Moderate Risk residents. Positioning Devices/Devices while in chair or in bed as needed to maintain turning. Specify on Care Plan. Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse. The facility's Preventative Skin Care policy dated 01/2018 documents, Policy: It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, well-groomed, and free from pressure ulcers. Procedures: All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly times four then will be re-assessed at least quarterly and/or as needed. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two hours. Pillows and/or bath blankets may be used between two skin surfaces to slightly elevate bony prominences/pressure areas off the mattress. Pressure relieving devices may be used to protect heels and elbows. Ensure proper fit of wheelchairs, splints, braces, prosthesis, and shoes. R1's Admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Paraplegia, [NAME]-Chiari Syndrome with Spina Bifida, Abnormal Posture, and Wheelchair Dependence. R1's Admission Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] documents R1's risk score 16 indicating R1 was at a high risk of development of pressure ulcers. This same Braden Scale Risk Assessment documents R1 did not have any pressure ulcers or wounds upon admission to the facility. R1's Medical Record dated 6-22-23 through 6-15-24 does not include any further Braden Scale Pressure Ulcer Risk Assessments. R1's Baseline Admission Care Plan dated 6-22-23 documents R1 was dependent upon two staff for bed mobility, toileting, and transfers. This same Baseline Admission Care Plan does not include any identified pressure ulcer risks or pressure relieving interventions. R1's MDS (Minimum Data Set) Assessments dated 7-3-23 (admission), 12-28-23 (quarterly), and 3-25-24 (quarterly) document R1 is cognitively intact, requires assistance of staff for turning left to right in bed, is at risk for development of pressure ulcers, and does not have any pressure ulcers. R1's MDS dated [DATE] documents R1 is not on a turning and repositioning program. R1's Physician's Order dated 9-10-23 documents, Hydrofera Blue (antibacterial foam dressing) ready foam external pad apply to lower right ankle every Sunday. R1's Medical Record does not include documentation of an assessment of R1's pressure ulcer to the right ankle once identified on 9-10-23. R1's Progress Note dated 9-27-23 documents, (R1's Family Member/V7) called and wanted to make sure staff knew that (R1) needed to be repositioned around 12:30 in the morning and every two hours. She stated she spoke to (R1), and he stated he hadn't been repositioned since earlier in shift. R1's Wound Care Visit Summary Initial Encounter dated 1-16-24 documents, Wound of right ankle initial encounter. Cleanse with soap and water. Apply lotion to peri-wound. Apply hydro (water-filled) dressing blue ready transfer to wound bed. Wear tubigrip (elastic bandage). Change dressings every other day and as needed if dressings get wet or soiled. Skin checks must be done every shift to ensure no bunching of (elastic bandages). R1's Wound Care Visit Summary dated 6-6-24 documents, Today's Visit: Pressure injury of right ankle, stage three. Wound Care Dressing: Right Medial Ankle. 1. Wash wound with soap and water. 2. Apply Prisma (collagen dressing formulated with oxidized regenerated cellulose and silver) to open part of the ulcer. 3. Cover with bordered foam. 4. Compression stockings during the day and take off at night. 5. Change dressing three times weekly and as needed if dressings get wet or soiled. R1's Physician's Order dated 6-12-24 and signed by V4 (R1's Primary Physician) documents, Cleanse right medial ankle with soap and water, apply (collagen dressing formulated with oxidized regenerated cellulose and silver) to wound bed, cover with border foam every day shift (on) Mondays, Wednesdays, and Fridays for wound care. R1's Treatment Administration Records (TARs) dated 1-16-24 through 6-15-24 do not include documentation of evidence of skin checks being performed every shift as ordered on the Wound Care Visit Summary dated 1-16-24. These same TARs document R1 only received skin checks weekly during this timeframe. On 6-15-24 at 9:15 AM R1 was sitting in wheelchair in the dining room. R1 had only a sock covering his left foot and the left foot was placed on the left wheelchair foot pedal. R1 had a cotton cushioned boot to the right foot. R1 stated, The sore on my ankle (right ankle) was caused from rubbing on either my wheelchair or my bed. I am not sure because I have no feeling in my feet. On 6-15-24 at 10:40 AM R1 was lying in bed and V7 (R1's Family Member) was visiting (R1) at the bedside. V9 (LPN/Licensed Practical Nurse) removed a wound dressing to R1's right medial ankle. R1's right medial ankle wound was approximately 2 cm (centimeters) long by 1 cm wide by 0.2 cm deep, pink in color, with a small amount of clear drainage. V9 cleansed the right medial ankle wound with wound cleanser, applied collagen dressing to the wound and covered with a four-by-four bordered gauze. V9 stated, (R1) was supposed to get a (collagen dressing formulated with oxidized regenerated cellulose and silver) treatment to the right medial wound. The wound clinic ordered (collagen dressing formulated with oxidized regenerated cellulose and silver) on Wednesday (6-12-24) and I ordered it from pharmacy. I have not worked the last two days, so I do not know if anyone has followed up on trying to get the (collagen dressing formulated with oxidized regenerated cellulose and silver) in. I just used the collagen dressing for now. On 6-15-24 at 10:50 AM V7 (R1's Family Member) stated, (R1) got the wound to his right ankle because when (R1) got here the staff were not putting on boots (pressure relieving boots) to (R1's) feet and (R1's) feet were not lifted off the bed. (R1) cannot feel his feet and cannot lift them off the bed. Somebody should have let me know or the wound clinic know that (R1) needed Prisma so we could have gotten it for him. I would have gone to the wound clinic myself and picked up the (collagen dressing formulated with oxidized regenerated cellulose and silver) had I known the facility did not have it. On 6-15-24 at 11:50 AM V9 stated the nurses have only been doing R1's skin checks weekly. On 6-15-24 at 11:30 AM V1 (Administrator-In-Training) stated, We (the facility) do not have a Care Plan Coordinator or MDS Coordinator currently. (R1's) medical record does not include any Braden Scale Pressure Ulcer Risk assessments since (R1's) admission to the facility. V1 also verified R1 did not have a care plan developed with pressure relieving interventions once R1 was assessed as being at high risk for pressure ulcer development upon admission to the facility. On 6-15-24 at 3:20 PM V2 (Director of Nursing) I was not aware of (R1) having an order from the wound clinic to check (R1's) skin every shift. The only documentation I can find is that (R1's) pressure ulcer to the right ankle started on 9-16-23. I cannot find an assessment in (R1's) medical record that indicates what the pressure ulcer looked like, the stage, or what it measured when it was found. That is the first date that I see a physician's order for a treatment to the wound on (R1's) right ankle. (R1's) skin checks have only been done weekly. I did not know there was an order from the wound clinic to do the wound checks daily on every shift.

Based on observation, interview, and record review, the facility failed to investigate unwitnessed falls and adequately supervise a resident (R65) with a known history of wandering to prevent them from entering another resident's room (R60) startling her and causing a fall for two of two residents (R60, R65) reviewed for falls in the sample of 34. This failure resulted in R60 obtaining a hemorrhagic pelvic fracture. Findings include: The facilities ELOPEMENT PREVENTION POLICY, dated 10/06, documents 5. The Interdisciplinary Team will initiate a plan of care for any resident determined high risk for elopement. Facility specific measures as well as resident specific measures will be included in each high-risk resident's plan of care to minimize risk factors. R65's Care plan, dated 4/24/23, documents, (R65) has behaviors that others may find disruptive/socially inappropriate. This same care plan also documents Behaviors noted of verbal aggression, seeking female peers' attention, refuses medication, is easily agitated during redirection, is socially inappropriate. (R65) has a diagnosis of late onset Alzheimer's, dementia with behavioral disturbance, bipolar d/o (disorder), and anxiety. (R65) ambulates without device with supervision, directional, and verbal cues. (R65) does wander. R65's Psychosocial History, dated 4/14/23, documents that R65 is an elopement risk. R65's Elopement Evaluation, dated 4/14/23 and 4/25/23, documents that R65 has an inability to identify safety needs, has altered perception of awareness leading to seeking exit/escape, his level of agitation has required supervision, and he wanders in the vicinity of exit doors. R60's PT (Physical Therapy) Daily Treatment Note, dated 5/4/23, documents (R60) ambulated within the facility on even and uneven surfaces such as carpet with FWW (front wheeled walker) at a supervision level. Completed all transfers with SBA (stand by assistance) using FWW. The PT Daily Treatment Note, dated 5/8/23, documents (R60) has continued to progress towards all established goals. (R60) has demonstrated improved endurance and ability to complete all daily tasks with less assist. R60's A.I.M. (Assesses, Intercommunicate, Manage) for WELLNESS, dated 5/20/23, documents, R60 was Noted on floor lying on her right side. Pain pill given c/o (complaints of) pain everywhere. Unable to ambulate. Neuro (neurological) checks WNL (within normal limits). Had 1 emesis during lunch. Sending her to ER (emergency room ) to eval (evaluate) and Tx (treat). She was startled by another resident (R65) in her bathtub in her bathroom. R60's Nurses Notes, dated 5/20/23 at 7:30 PM, documents Received update from (local hospital), patient has a fracture of pelvis in multiple places, it is hemorrhaging. Transferring to (a critical care hospital) ICU (Intensive Care Unit). R60's Discharge Summary, dated 5/25/23, documents (R60) was initially evaluated in the trauma bay by the trauma team after a ground level fall at SNF (Skilled Nurse Facility). She was found to have: pubic rami fracture, bilateral sacral insufficiency fractures. Fracture dislocation of left glenohumeral joint. Ortho (Orthopedics) took her the OR (Operating Room). Was discharged back to SNF in stable condition on 5/25. On 9/26/23 at 10:00 AM, R60 stated After breakfast (on 5/20/23), I went back to my room and took a 2-hour nap. I heard some knocking, but I thought it was construction or somebody fixing something. I got up to use the bathroom and when I opened the door, a guy was laying in my bathtub. It startled me and I turned to head out the door and that's when I went down. I landed on my right side. I was taken to the hospital within 30 minutes. I know who he is. His name is (R65) and he has dementia. He's known around here for going into peoples' rooms. He must have been in the bathroom when I came back from breakfast. I was doing great with therapy. I was riding the bike for 20 minutes and walking fast. Then I had to start all over (with rehabilitation) after I fell . The facility's Final Report to the State Agency, dated 5/20/23, documents, Female resident noted on ground in room. Resident sent to ER for eval and treat. 5 day to follow. Resident was admitted to hospital due to fractured pelvis. Root cause determined the be loss of balance. Intervention resident educated to use walker during ambulation. Resident will return to facility with therapy services. Care plan and POA (Power of Attorney) updated. The report lacked documentation R65 was on elopement precautions; was a known wanderer and found in the bathroom which resulted in R60's fall. On 9/26/23 at 12:30 PM, V14 (Licensed Practical Nurse) stated (R65) was laying in the bathtub. It looked like he sat on the edge of the tub and fell back with a leg hanging over the side and his hands behind his head. He looked really comfortable. He didn't have any injuries. I did neuro checks and movement assessments He is very much so a wanderer. He required extreme supervision with activity's but does walk independently. If we have wanderers, we should be doing every 15-minute checks and try to keep them close to us. On 9/26/23 at 1:25 PM, V10 (LPN) stated Yes, I remember it (5/20 incident). That's not something you find every day. When I got into the room. (R60) was lying on the floor with her walker beside her. Other people were in there checking out R65. I was checking out (R60). I had to send her to the hospital because she was unable to ambulate. No one from higher up asked me any questions after the fact. On 9/28/23 at 10:00 AM, V11 (Certified Nursing Assistant) After breakfast, we were looking for (R65). I heard (R60) scream and found R65 in R60's bathtub. I think he fell backwards. He said he wanted to take a bath. We yelled up the hall for help. I was helping with (R65) and V12 (CNA) was assisting (R60). (R60) went that day to the hospital for complaints of hip pain. V11 denied being interviewed by the Director of Nursing (V2) or the Administrator (V1) regarding R60's fall. On 9/28/23 at 10:15 AM, V12 (CNA) stated I told V11 Let's go check on (R60). When we got there (R60's room), R65 was in the bathtub and R60 was on the floor. I don't know how long (R65) was in there. R60 told me she heard knocking but thought it was construction. (R60) complained of pain. After the nurse checked her out, we sat her up and put her in a chair. On 9/26/23 at 11:45 AM, V1 (Administrator) stated an investigation and interviews were not conducted related to (R60's) falls which were unwitnessed. V1 confirmed R60's root cause for the fall on 5/20/23 was not related to just the loss of balance but also from R65's wandering and an investigation was not conducted and should have been.

Based on interview and record review, the facility failed to identify and treat a residents pain for one of three residents (R4) reviewed for pain in the sample of four. This failure resulted in R4 suffering a fall with a laceration to the forehead and requiring emergency medical treatment. Findings include: The facility's Pain Prevention and Treatment policy, dated 12/7/17, documents, It is the facility policy to assess for, reduce the incidence of and the severity of pain in effort to minimize further health problems, maximize ADL (Activities of Daily Living) functioning and enhance quality of life. Responsibility: All Nursing Personnel. This policy also documents, Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment intervention and resident response. R4's recent Minimum Data Set assessment, dated 10/12/21, documents R4's cognition is severely impaired. R4's current Care Plan, dated 10/27/21, documents (R4) has pain risk, alteration in comfort/pain related to [CONDITION(S)] and unstageable area to coccyx. Intervention: Monitor for indicators of pain. Assess location and duration of pain and any contributing factors. R4's Nursing Progress Notes, dated 12/5/21 and signed by V7 (Licensed Practical Nurse), documents, 1:00 AM, (R4) alert with usual confusion, combative and resistive with ADLs. Turn/Position frequently, incontinent of bowel and bladder, peri-care provided and treatment done per orders. 1:45 AM, See AIMs (Assess. Intercommunicate. Manage.) form. R4's AIM for Wellness form, dated 12/5/21 at 1:45 AM, documents R4 was found face down on the floor with behaviors of being resistive and combative and expressing non-verbal signs of pain by crying and tearfulness. This form also documents R4 suffered a laceration measuring 3 centimeters to her forehead and was transported to the local emergency room for treatment. R4's Investigation Report for Falls, dated 12/5/21 and signed by V2 (Director of Nursing), documents, Resident (R4) is non-verbal, found lying face down next to her bed. Areas of concern identified for further analysis: Pain control. R4's Quality Care Reporting form, dated 12/6/21 and signed by V2 and V1 (Administrator), documents, Summary of event and action taken: Noted (R4) on floor, root cause due to increased pain from wound treatment completed, and progressive Dementia disease process. On 12/13/21 at 3:52 PM, V7 (Licensed Practical Nurse) confirmed she took care of R4 on 12/5/21 at the time of her fall. V7 stated she had completed R4's wound treatment just prior to R4 falling. V7 stated, During her wound treatment, before she fell , (R4) was hitting, that's what she does. (R4) does have pain but she's non-verbal. She can be combative or resistive and tearful when she has pain. I don't know if she was tearful that night. If it were me, yeah I'd be in pain. (R4's) wound and treatment probably hurts. I don't have her chart so I don't know if she was given pain medication. On 12/14/21 at 1:45 PM, V9 (Certified Nursing Assistant) confirmed she assisted V7 with R4's wound treatment and cares on 12/5/21. V9 stated, During (R4's) dressing change that night she was combative with care. When (R4) is in pain, she will groan and cry out and be resistive and combative. R4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This same MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/21 at 11:30 AM, V2 (Director of Nursing) stated, (R4) has a significantly large pressure ulcer on her coccyx and it causes her a lot of pain. The root cause of her fall is pain and the pain is from her wound treatment being done that night. Her pain medication is only given in the morning. Her wound treatment is scheduled for third shift. V2 confirmed R4 does have orders for PRN (As Needed) Tylenol but was not given any on 12/4/21 or 12/5/21. On 12/13/21 at 1:00 PM, V1 (Administrator) stated, The root cause of (R4's) fall ultimately was determined to be pain due to the nurse (V7) telling us that (R4) was having pain during her wound treatment which occurred prior to the fall.

Based on observation, interview, and record review, the facility failed to implement the Centers for Disease Control and Prevention (CDC) guidance and the facility's COVID-19 policy to prevent the potential spread of a highly contagious disease to residents and staff by not having dedicated staff to care for residents with confirmed COVID-19 and allowing symptomatic staff members to work, not posting designated isolation precautions signage for residents on isolation precautions/units, not don/doffing proper PPE (Personal Protective Equipment), not performing proper hand hygiene and glove changes, not allowing adequate contact times for sanitizing/disinfecting surfaces and not disinfecting contaminated dietary equipment prior to transportation. This has the potential to affect all 76 residents residing in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when V21 (Alzheimer's Coordinator-E hall) worked in direct care of the residents while displaying signs/symptoms of COVID-19. On [DATE] at 1:00 p.m., V1 (Administrator) was notified of the Immediate Jeopardy situation. While the immediacy was removed on [DATE], the facility remained out of compliance at a Severity Level 2. The facility is in the process of performing random audits with housekeeping staff to ensure disinfecting contact times are understood. The facility is also performing random weekly audits of quarantined/isolation rooms to ensure Contact and Droplet Isolation Precaution signage is posted. The facility's Director of Nursing or designee is also performing random weekly audits of staff to ensure proper donning and doffing of PPE as well as hand hygiene compliance. Findings include: The facility's COVID-19 Cohorting of Residents policy, dated [DATE], documents, Identify space within the facility to be dedicated to monitor and care for residents with COVID-19. Ideally, this space should be physically separated from other rooms that house residents without confirmed COVID-19. Identify HCP (Healthcare professionals) who will be assigned to work only within the dedicated area, when in use. The facility's COVID-19 Control Measures policy, dated [DATE], documents, All staff is to perform hand hygiene when exiting a residents' room, after direct contact with residents or potentially contaminated surfaces (high touch areas). Contact precautions: Post Signage on door: Implement when a resident is suspected of having any fever, respiratory symptoms, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell. Wear gloves when there is a potential for contact with respiratory secretions or contaminated surfaces. Wear a gown if clothing could potentially come into contact with respiratory secretions or possible contaminated surfaces. Change gloves and gowns after contact with a resident and perform hand hygiene. Perform hand hygiene before and after touching the resident, resident's environment and/or residents respiratory secretions even if gloves are worn. Remove PPE (Personal Protective Equipment) when leaving a resident's room. Use an alcohol-based hand rub for routinely decontaminating hands, when hands are not visibly contaminated. Clean and disinfect non-dedicated, non-disposable resident care equipment after each use. The policy also documents, Droplet Precautions: Post signage on door: Implement when a resident is suspected of having any fever, respiratory symptoms, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell. Restrict all residents with fever, respiratory symptoms, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste/smell to their room. Place symptomatic residents in a private room. Wear facemask/N95, gloves, gown, goggles, or face shields when entering room or when working within six feet of residents on droplet precautions. Remove PPE when leaving residents' room and perform hand hygiene. Clean and disinfect non-dedicated, non-disposable resident care equipment after each use. The CDC's Responding to COVID-19: Considerations for the Public Health Response to COVID-19 in Nursing homes, dated [DATE], documents, Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum, this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. This form also documents, Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. The facility's Employee, Vendor, Consultant COVID Screening Questionnaire, dated [DATE], documents, Please complete upon entrance to the facility and give to the Nurse/DON (Director of Nursing). In an effort to protect our residents and staff from illness, we are screening all employees, vendors, surveyors, Ombudsman, and consultants. Subsequent evaluation should be completed every four hours while in attendance of residents. Proper hand hygiene and appropriate use of PPE is expected upon entrance to the facility and while in the facility. The questionnaire also documents, Physical Evaluation: After recording temperature, please also note yes or no to the presence of the listed symptoms below. If you mark yes to any new onset of a symptom below you are to be evaluated by a nurse. While at work, if you develop any new symptoms that includes cough, shortness of breath, fever, etc, immediately stop direct resident care, perform hand hygiene, put on a surgical mask, notify your supervisor and wait for instructions. If a new symptom develops at home, stay at home, self isolate, follow the Local Health Department's instructions, and notify your supervisor you are not coming to work. The symptoms listed on the questionnaire to answer yes or no to are the following: New or worsening cough, sore throat, chills or shaking with chills, muscle pain, headache, new loss of taste or smell, any new onset of shortness of breath, any new or worsening fatigue, runny nose or nasal drainage, gastrointestinal upset (vomiting or diarrhea). The facility's COVID-19 Control Measures, dated [DATE], documents, Restrictions for Health Care Personnel: Educated all employees if having symptoms of a respiratory infection, fever, sore throat, nausea, vomiting, diarrhea, extreme fatigue, muscle pain, loss of taste and/or smell not report to work and to contact their regular provider. Initiate screening at entryway of facility for symptoms of COVID-19 and/or fever. The facility's Crisis Staffing for COVID-19 policy, dated [DATE], documents, Educate all employees if having symptoms of a respiratory infection, fever, sore throat, nausea, vomiting, diarrhea, or extreme fatigue not to report to work and to contact their regular provider. Screen all employees prior to the beginning of the shift and middle of the shift. If any are identified as being ill, apply facemask, and ask them to return home and contact their primary physician. Suspected or diagnosed COVID-19 in Long term care facility of any employee that is symptomatic will not be allowed to work until meets criteria. The facility's Cleaning & Transporting of Food Trays for Resident in Isolation policy, dated [DATE], documents, Policy: To ensure proper transporting and cleaning of resident food trays and to prevent the spread of microorganisms. A facility sanitizing policy, no date, documents, Disinfect high-touch areas frequently. Think about the fact that every time you touch a high touch object such as a door handle or even the faucet handles, there is a good change you now have some sort of germ on your hands. Avoid touching your eyes, nose and mouth, or eating foods after touching this high touch objects until you have had time to properly wash your hands. The policy also documents that the contact time for the facility's hydrogen peroxide disinfectant is 30 seconds, and the germicidal bleach disinfectant is one minute. The facility Designated Zones During a COVID-19 Outbreak policy, no date available, documents, Red zone: For residents who have been tested and confirmed to have COVID-19. Yellow zone: Designated area for residents who have had exposure to COVID-19. Green Zone: Designated area for residents with no known exposure to COVID-19. The facility floor plan, provided by V1 (Administrator) on [DATE], documents that the A, C, and D hall are all residents who have not been exposed to COVID-19 by a roommate nor are they symptomatic (green zone). B Hall is split in half with the back half being COVID positive residents (red zone), and the front half are symptomatic, exposed by a roommate, and new admit but testing negative for COVID-19 (yellow zone). The E hall is also a COVID positive hallway (red zone). On [DATE] at 9:00 a.m., the facility's designated entrance was located on the end of their D hall. No staff members were dedicated to monitoring the facility's entrance. The facility's daily assignment sheet, dated [DATE], documents the following assignments for the day: 1st (6:00 a.m. to 2:00 p.m.) and 2nd shift (2:00 p.m. to 10:00 p.m.) one nurse is assigned to work both A & B hall; 3rd shift (10:00 p.m. to 6:00 a.m.) one nurse is assigned to work both A & B hall, and one nurse is assigned to work both C, D and E hall. The facility's daily assignment sheets, dated [DATE] to [DATE], document the same assignments. On [DATE] at 9:40 a.m., V4 (Housekeeper) was cleaning the dining room following breakfast, V4 stated that she is cleaning the front lobby and D hall today as well as helping with the dining room. V4 also stated, I don't know what you mean by high contact surfaces. I clean the door handles and hallway railing once on my shift. I work 6:30 a.m. to 2:00 p.m. I use the bleach disinfectant wipes or the hydrogen peroxide disinfectant spray. I don't know what the contact times are. Then, V4 stated, We are screened (for COVID-19) when we get to work. I take my own temperature and fill out the questionnaire myself. No one is at the door when we come in. After four hours I check my temperature myself again. On [DATE] at 9:45 a.m., V5 (Housekeeper) was mopping the dining room after breakfast, and stated that she is working A & C hall today as well as in the dining room. V5 also stated, I clean the high contact surfaces once or twice per shift with the bleach disinfectant wipes. I don't know what the contact time is. Then, V5 stated, I screen myself when I get to work by checking my temperature and the questionnaire. Then, I do it again four hours later. On [DATE] at 9:55 a.m., V6 (Licensed Practical Nurse-LPN) was sitting at the central nurses' station with another nurse V7 (LPN). V6 stated she was working C & D halls today. V6 stated, I screens myself by taking my temperature and filling out the questionnaire when I get to work and again four hours later. We do not have a receptionist at this time. If a visitor or someone else comes into the facility, an available staff member goes and answers the door and does the COVID screening. V6 also stated, One nurse that works both A and B. That is her (V7) sitting there at the desk. The back portion of B hall is COVID positive. One CNA (Certified Nursing Assistant) is dedicated to back there, one CNA works A Hall, and the third CNA works the quarantine (yellow portion) of B hall. The COVID positive CNA normally stays behind the curtain, but the other two CNAs go back there to help if she needs help with a two assist resident. The CNA (V20) who is working back there right now is COVID positive herself. V22 (CNA) also tested positive at the beginning of her shift back on E hall. She continued working the rest of her shift, but she hasn't been back since that day. That is when this outbreak really starting getting worse. This was about a week ago. On [DATE] at 10:00 a.m., V8 (CNA) was standing in the hallway holding the vitals equipment, V8 stated that she was working C and D halls (green) today. V8 also stated, I disinfect the vitals equipment after each residents. I use the bleach disinfecting wipes. I don't know what the contact time is. Then, V8 stated, Staff from the COVID positive halls are able to come into the rest of the building. On [DATE] at 10:05 a.m., the E Hall double doors opened. A staff member pushed an enclosed food cart out into D hallway and left it. At 10:15 a.m., V10 (Dietary Cook) wheeled the food cart up the D hall, past the nurses' desk, and into the dining room stopping at the window of the dishwasher in the dining room. V10 opened the food cart. The food cart contained multiple hard plastic trays, with a disposable food container, plastic cups/mugs, and silverware on each one. V10 confirmed that this cart was from the COVID positive E hall and that it is not disinfected before she takes it throughout the facility to the dining room. On [DATE] at 10:40 a.m., B Hall yellow zone: exposed/symptomatic/COVID negative quarantine rooms. B1-B4 and B12-B16 all had stop signs only on door. No specific isolation precautions were posted. A plastic curtain was hanging midway down the hallway starting at room B5 to separate the red zone from the yellow zone. The other side of the curtain was the COVID positive residents. The plastic curtain only contained a stop sign, no isolation precautions were posted nor designation that this was a COVID positive zone. On [DATE] at 11:20 a.m., V13 (CNA) was working the yellow side of B hall. V13 entered R5's room with a gown, N95 mask covered by a surgical mask, goggles, and gloves on. At 11:25 a.m., V13 exited the room wearing the same gown and gloves. Then, V13 entered R6's room, with the same gown and gloves on, exited that room and entered R7's room. V13 exited R7's room with no gloves, but still with the same gown. Then, V13 entered room R8's room, still with the same gown on and no gloves. Without applying gloves or a new gown, V13 picked up R8's glass of water on R8's bed side table, and assisted R8 with taking a drink of water. V13 set the glass back on the bed side table, and without performing hand hygiene or changing her gown, V13 exited R8's room, and walked to the central nurses' station, touching her hair and face multiple times. On [DATE] at 11:35 a.m., R6 had a loose non productive cough audible from the hallway On [DATE] at 11:55 a.m., V13 stated, All of the residents that I am taking care of are on quarantine and isolation. The doors do not have specific isolation precautions posted on the doors nor does the COVID-19 curtain separating this hall. I don't know what the specific isolations are for each resident. I just know I have to wear a new gown and gloves with each room I enter. I wear the same gown out in the hallways. I have to change into another one as soon as I go into the rooms. V13 also stated that the nurse caring for B hall also works A hall all the time. On [DATE] at 11:45 a.m. V14 (Housekeeping/Laundry Supervisor) stated, We use bleach germicidal wipes and spray, and hydrogen peroxide disinfectant spray to clean/disinfect. Both have a contact time of 30 seconds to one minute. Our high contact surfaces are supposed to be cleaned every two hours. Today, V23 (Housekeeper) is working the COVID positive hallways. She starts with the yellow side of B hall, then the COVID positive side of B hall, and she finishes on E hall. She takes her cleaning cart throughout the facility. On [DATE] at 12:10 p.m., V15 (Registered Nurse) was passing medications to residents on A hall. V15 stated she took over for V7 when she left at 10:00 a.m., and is now working the A hall and the B hall. A hall is the residents who have not tested positive, the front side of B hall is the residents who are on quarantine for being symptomatic or have been exposed, and the back side of B hall is the COVID positive residents. The medication cart for the COVID positive residents is kept in the general medication room by the central nurses' station. I prepare one resident's medications, go to the unit and administer the medication, and then return to my cart. I repeat this process until I've passed all the medications on the COVID positive unit. The quarantine rooms (yellow) on B hall and A hall, I just wash my hands or use hand sanitizer before entering the room and after leaving the room. I wear the same gown, and I don't use gloves unless its needed specifically for some type of care. On [DATE] at 12:15 p.m., An open side meal cart was located inside of the B hall COVID unit curtain, with meal trays. On [DATE] at 12:30 p.m., V20 (CNA) stated, I am working the COVID positive only hallway. The nurse that works back here with me also works the rest of B hall and A hall. I have two assist residents that I care for. If I need assistance the nurse helps if she is back here or whoever else I can get to help me. This past Monday ([DATE]) I tested positive for COVID. Before I got to work, I knew that I had lost my taste and smell, but I went to work anyway. It's just like they say it just suddenly shuts off. I was working on C Hall (green) that day. When I got to work, I screened myself. On the questionnaire it asks if you have lost your taste or smell, and I answered no. I worked for a little while before I told anyone I was having symptoms. When I told them, I was immediately tested for COVID, and of course it came back positive. They did not send me home. V20's Employee Screening Questionnaire, dated [DATE] to [DATE], documents that V20 answered no to having any COVID related symptoms. The questionnaire also documents on [DATE] that V20 answered yes to having a new or worsened cough and gastrointestinal upset (vomiting or diarrhea), and on [DATE] V20 answered yes to having a sore throat and new loss of taste or smell. V20's [DIAGNOSES REDACTED] CoV 2 RNA (COVID 19) test results document that V20 was COVID positive from a specimen that was collected [DATE] and reported on [DATE]. V20's [MEDICATION NAME] Testing and Results documents that V20 was rapid tested on [DATE] for displaying COVID-19 symptoms, and V20 was positive. The facility's Daily Assignment sheets, dated [DATE] to [DATE], document that V20 worked the following shifts/halls: [DATE] 1st shift (6:00 a.m. to 2:00 p.m.) on C and D hall; [DATE] and [DATE] 1st shift on B hall. On [DATE] at 1:00 p.m., V17 (RN-Registered Nurse) was working E hall. V17 stated, Our hall is 100% positive. We go back through the building to clock out, leave, take breaks, or if we need anything. On [DATE] at 3:00 p.m., V22 (CNA) stated, I tested positive for COVID on [DATE]. On [DATE], I was having symptoms. I had a headache, and I just didn't feel right when I got to work. When I screened myself I said I had symptoms, and V1 rapid tested me. She did a rapid test on [DATE] and it came back negative, and they did the one you send off. After the testing, I continued on with my shift on the E hall on [DATE], and worked after that. During my shift on the [DATE], I was notified of being positive and I finished my shift. On [DATE], I started to feel really bad and I haven't worked since. V22's Employee Screening Questionnaire, dated [DATE] to [DATE] and [DATE] to [DATE], document that V22 answered no to having any COVID related symptoms. V22's [DIAGNOSES REDACTED] CoV 2 RNA (COVID 19) test results document that V22 was COVID positive from a specimen that was collected [DATE] and reported on [DATE]. The facility's Daily Assignment sheets, dated [DATE] to [DATE], document that V22 worked the following shifts/halls: [DATE], [DATE], and [DATE] 1st shift (6:00 a.m. to 2:00 p.m.) on E hall. On [DATE] at 4:30 p.m., V24 (CNA) stated, I worked last on [DATE] on the E hall where the outbreak started. I went to work with a headache, but I didn't answer yes on the screening when I got to work. By the end of my shift, my headache was obnoxious and I had a cough that had started. I contacted V1 (Administrator) that evening when I got home and told her I was symptomatic. I really felt sick Monday. I was swabbed Monday at the facility, but that was the test that takes up to 72 hours for results. We got rapid tested on Tuesday, and that one came back positive. I didn't work after the [DATE] . COVID positive staff worked back with COVID positive residents. V25 (LPN) was working as a CNA in the red zone of E hall with me one evening. If V25 needed assistance, I was the one assigned to go back to help him with residents. V25 was COVID positive at the time. It was after that when I tested positive. V24's [DIAGNOSES REDACTED] CoV RNA (COVID-19) test results, dated [DATE] and reported on [DATE], document that V24 was positive for COVID-19. The facility's Daily Assignment sheet, dated [DATE], documents that V24 worked 2nd shift (2:00 p.m. to 10:00 p.m.) on the E hall. On [DATE] at 10:30 a.m., V21 stated, I am the Alzheimer's coordinator (E Hall) Monday thru Friday, but I also pick up hours on the floor as a floor nurse. Normally, my day will consist of working on the Alzheimer's hall (E Hall) then I will pick up hours in the evening for A and B Hall. 1st shift and 2nd shift nurses are assigned to work both A and B hall at the same time. After 10:00 p.m. through 3rd shift, that nurse covers not only A and B, but also covers E hall as well. I tested positive on [DATE] on the rapid test, and as well the test that was sent off for results. My symptoms started back on [DATE]. I had a runny nose and chest tightness. I was rapid tested that day for the routine testing, and it came back negative. So I kept working. On [DATE], I was still having symptoms so I called in to V1 before I got to work. I was directed to come in and have a rapid test completed. This test came back negative, and I worked that day. I was tested next on [DATE] when I called into work saying I was having symptoms again. I was tested in the parking lot during the rapid routine tests. I was still having symptoms, but it was negative. I continued to work. The last time I was tested was [DATE]. This was our routine testing day. They were actually doing the test that they send off and a rapid test at the same time. I was still symptomatic, and my test results finally came back positive, both the rapid and the one that was sent off. I was off work after that. The local health department told me I was assumed positive from [DATE] since that was when my symptoms started. V21's [MEDICATION NAME] Testing and Results, documents that on [DATE], V21 was routine COVID-19 tested with negative results received on the same day (Rapid test), and on [DATE] was Rapid tested because of having COVID symptoms with those negative results being received the same day. It also documents that V21 was Rapid routine tested again on [DATE] with that result being negative, and Rapid routine tested and having COVID symptoms again on [DATE] with these results being positive for COVID-19. V21's [DIAGNOSES REDACTED] CoV RNA (COVID-19) test results, dated [DATE] and reported on [DATE], document that V21 was positive for COVID-19. V21's Employee COVID Screening Questionnaire, dated ,[DATE]-[DATE], documents that V21 self answered that she was not exhibiting any symptoms of COVID-19. V21's Employee COVID Screening Questionnaire, dated ,[DATE]-[DATE], documents on [DATE] at 4:00 p.m., that V21 left the following symptoms blank without an answer: Headache, new loss of taste or smell, any new onset of shortness of breath, any new or worsening fatigue, runny nose or nasal drainage, gastrointestinal upset (vomiting or diarrhea). The Questionnaire also documents on [DATE] at 8:00 a.m. and 12:00 p.m., [DATE] at 8:00 a.m., 12:00 p.m., and 4:00 p.m., and [DATE] at 9:00 a.m. and 1:00 p.m., that V21 answered yes to exhibiting the symptoms of muscle pain and runny nose/nasal drainage. V21's Hours Worked Simplified Report, dated [DATE], documents that V21 worked [DATE] from 8:30 a.m. to 4:45 p.m., [DATE] from 8:00 a.m. to 5:00 p.m., [DATE] from 8:15 a.m. to 5:15 p.m., [DATE] from 8:15 a.m. to 5:00 p.m., and [DATE] from 9:00 a.m. to 5:30 p.m. on the E hall as the Alzheimer's coordinator. The facility's COVID Room list, dated [DATE], documents that the each resident in the facility who has tested positive for COVID-19 along with their location when they were diagnosed . The first COVID-19 resident (R9) was on [DATE] and she was located on the E hall. The E hall then had the following positives isolated to that hall only: [DATE] R10 and R3, [DATE] R11, R12, R13, R14, R15, and R16. On [DATE], four more residents (R4, R17, R18, R19) on the E hall tested positive, as well as two residents (R29, R30) on the C hall and R35 on D hall. On [DATE], R20 and R21 tested positive on the E hall and R24 on the B hall. On [DATE], R22 and R23 tested positive on the E hall, to bring the E hall to 100% COVID positive. Also, on [DATE], R31 tested positive on the C hall. On [DATE], R25 who was located on the B hall tested positive. On [DATE], R1, R34, and R35 from A hall, R26 and R27 from B hall, and R32 from C Hall tested positive. On [DATE], R28 from B hall tested positive. On [DATE], R36 from A hall, R2 and R33 from C hall, and R36 tested positive for COVID-19. On [DATE] at 12:00 p.m., V1 stated, On 1st shift and 2nd shift, one nurse is assigned to both the A and B hall. On 3rd shift, one nurse is assigned to A and B hall, and the 2nd nurse is assigned to C, D, and E hall. V1 also stated, The PPE requirements for the yellow zone portion of B hall is to enter each room with a new gown and new set of gloves. Then, when exiting the residents' room, staff should remove their gown and gloves and perform hand hygiene. V13 should have known that each resident on yellow side of B hall is treated as being on isolation precautions, meaning a new set of PPE is applied with each entrance to a room, and removed before leaving the room as well as washing/sanitizing her hands. V1 also stated, Every two hours, housekeeping staff is ultimately responsible for cleaning high contact surfaces. The staff have been educated on what surfaces need disinfected, and what the contact times for the disinfectants are. The dietary staff takes the meal loaded dietary carts to the red zones and leaves them. The red zone staff distributes the meals to the residents. E hall uses an enclosed cart that goes into the unit. The open sided cart for the red zone of B hall does not go into the curtain area. They should leave the cart at the curtain and reach through to get the meals, and distribute them. Dietary staff go back to the red zone and collect the dietary carts. The dietary carts should be disinfected before being transported throughout the building back to the dining room. On [DATE] at 1:00 p.m., V3 (Infection Preventionist) stated, On [DATE], a red zone was started on the E hall with our first COVID-19 positive resident. The hall was separated by a curtain. The curtain kept moving forward as more positive cases appeared on that hallway, until it was 100% positive on [DATE]. On [DATE], B Hall was converted to a red zone with the development of positive COVID-19 cases outside of E Hall. The COVID units do not have dedicated staff to work only the COVID units red zone during their shift. All three shifts, A and B hall are worked by the same nurse. On 3rd shift, the E hall is worked by the A/B hall nurse or the nurse working the C-hall. V3 also stated, All of the staff self-screen themselves at the D hall and I check them when I get to work. I check 2nd shift and then 3rd shift is checked when I get to work after they've left. If a staff member has symptoms, they should be calling me before they work. If they answer yes on the questionnaire or have a high temperature when they screen them self, they should be contacting me. Anyone with a high temperature will be sent home. If someone is exhibiting COVID-19 symptoms they will be sent home or have rapid COVID test completed. If the rapid test comes back positive, we send them home. However, depending on the symptoms we may keep them at work. They could possibly work the red. V20 should have contacted us prior to coming to work that she was exhibiting symptoms and she would have got tested and/or advised to stay home. She should have notified us right away. The facility's up to date West Region COVID Testing list for Residents, provided by V1 on [DATE], documents that since the facility's first case of COVID-19 on [DATE], 56 residents have tested positive for COVID-19, and eight of those 56 have expired as a result of COVID-19. The facility's room roster, dated [DATE] and provided by V1, documents that 76 residents reside in the facility. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when V21 (Alzheimer's Coordinator-E hall) worked in direct care of the residents while displaying signs/symptoms of COVID-19. V21 tested positive for COVID-19 on [DATE], but was considered positive dated back to [DATE]. Then, on [DATE], the facility had their first confirmed COVID-19 positive resident (R9) on the E hall. The 3rd shift nurse that took care of this resident also took care of the C and D hall, which housed residents who had not been exposed to COVID-19 nor displayed symptoms. Then, on [DATE], two residents (R29, R30) on C hall and one resident (R35) on D hall tested positive for COVID-19, in addition to the 12 residents (R3, R4, R10-R19) who had previously tested positive on the E hall. On [DATE], a COVID-19 unit was developed on the facility's B hall to house the COVID-19 positive residents from A, B, C, and D hall, and R29, R30, and R35 were moved there. The nurse assigned to care for this red zone (B hall) was also assigned to work the A hall on both first and 2nd shift. The A hall housed residents who had not been exposed to COVID-19 nor displaying symptoms. Also, both V22 and V24 worked while displaying signs/symptoms of COVID-19. V22 worked on [DATE] and V24 worked on [DATE]. The facility failed to dedicated staff to care for residents that had confirmed COVID-19 versus the residents who were COVID negative, and staff continued to work while displaying signs/symptoms of COVID-19 exposing the residents to a highly contagious infectious disease. On [DATE] at 1:00 p.m., V1 (Administrator) was notified of the Immediate Jeopardy situation. On [DATE], the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy on [DATE]: 1. On [DATE], V1 (Administrator) placed Contact and Droplet signage and CDC donning/doffing diagrams on all doors of residents who are in isolation related to confirmed COVID-19, exposure to COVID-19, or newly admitted /quarantined residents, as well as entrances to units/hallways of confirmed COVID-19. 2. On [DATE], V1 and V2 (Director of Nursing) dedicated nursing staff to confirmed/exposed COVID-19 units as well as recovered or non-exposed residents. Resident room moves were performed to further ease and facilitate designated staffing. On [DATE], daily staff assignment sheets were revised to further clarify designated staffing areas. 3. On [DATE], V1 and V2 in-serviced and educated all of the facility staff on the following: donning/doffing PPE competency including gowning and gloving; disinfectant products and correlating contact times; procedure to disinfect dietary carts and transportation of them back to the kitchen after meal delivery; reportable conditions/signs and symptoms of COVID-19 to be reported to the supervisor prior to or during their shift should any signs or symptoms arise. 4. On [DATE], V1 changed the employee entrance to the main lobby where the door is alarmed and accessible from secured coded key pad from the inside only. All s(TRUNCATED)

Based on observation, interview and record review, the facility failed to supervise R5 during episodes of agitation and aggression, resulting in R5 causing injury to R4. R5 is one of three residents reviewed for abuse in a sample of three. FINDINGS INCLUDE: R4's (local hospital) Patient Transfer Form, dated 09/08/15 includes the following Diagnoses: [REDACTED]. And the following (patient)'s Condition at Time of Transfer, Skin Condition- scattered bruises in various stages of healing. R4's New Admission Information form, dated 09/08/15 includes the following information, Court-ordered Health Care Guardian and Financial Guardian. R4's Psychotropic Medication Progress Notes dated 9/9/15 documents, Resident admitted [DATE] from (local hospital emergency room ) due to unfit home environment. R4's medical record contains the following e-mail, dated 9/10/15, addressed to E1 Administrator, (E1) this is to inform you that Judge (local judge) has appointed (Z1) R4's Guardian, the temporary guardian of person and estate for (R4). (Attorney -at-Law) said to (Z1) that he has 'sole control' over (R4) and that (R5) has no authority to remove (R4) from the facility. The email is signed by R4's Adult Protective Services Caseworker. R4's Cognitive Assessment, dated 9/16/15 documents R4's cognitive status as 4 (severely impaired). R4's Nurse's Notes dated 9/8/15 (day of admission) document, (Spouse) here wanting to take resident home. (E1) Administrator spoke to (spouse) and encouraged (R5) to keep (R4) here. The facility Incident Report Form- (State Agency) Notification dated 9/10/15 documents, Facility was notified by the local bank about (R4)'s spouse (R5) making threatening statements about removing (R4) from the facility. (R5) was in the bank asking for help in getting (R4) home. The statement (R5) made to the bank president was,' I guess the only way I can get (R4) out of the nursing home is to go in there with a machine gun.' Due to notification of the statement by (R5), the facility was put on lock down and the local Sheriff's office was contacted. Temporary guardianship has been assigned to (Z1). R5's History and Physical, dated 9/14/15 documents, Upon calling the patient's daughter-in-law, the patient's (spouse) was recently placed in a nursing home. The patient is apparently reported to have been increasingly forgetful, more demented, more angry and agitated, so much that (R5) becomes violent. R5's Admission Physicians Order Sheet, dated 9/16/15 includes the following Diagnosis: [REDACTED]. R5's Pre-Screening/Screening Assessment for Harmful Behaviors dated 9/16/15 documents R5 scored High in the following Assessment Category, Talks about/threatens harm towards others and /or aggressive behavior toward others. Resident maintains considerable anger and hostility. Has poor judgement. R5's total score is 14 ( > 10 = High Risk). R5's Admission Care Plan, dated 9/16/15 includes the following Problems/Needs: Resident has a known history of displaying inappropriate behavior and/or resisting care/services. Has a history of aggression and restlesness. After (spouse) (R4) was admitted to facility this resident went to local bank asking for their help in removing (R4) from the nursing home. Made statements of going into nursing home with a machine gun. Local police removed all guns from resident's property. R5's Nurses Notes dated 9/17/15 includes the following documentation, Resident has been anxious this shift about (R5)'s (spouse), wallet, truck and son. Resident kept taking (personal) alarm off and threw it at this nurse. The notes also document on this date, Resident very agitated, verbally aggressive with staff. States (R5) is going to get (R5)'s (spouse) up and out of bed. Resident wandering into other resident's rooms. R5's Nurses Notes dated at 9/18/25 document, Resident alert with confusion. Up wandering into other resident's rooms. Verbally and physically aggressive towards staff. R5's Nurse's Notes dated 9/20/15 document, Resident very agitated. Getting up on own setting off alarm. Wanting to go home. yelling at staff. Taking confused (spouse) (R4) by the hand and telling (R4) that they have to leave. Resident threatening staff saying I should hit you. R5's Nurses Notes dated 9/21/15 at 1:00 A.M. document, Becoming anxious and agitated. Yelling out. R4's Nurses Notes dated 9/21/15 at 4:00 P.M. document, Resident's (spouse) (R5) picked (R4) up and tried to put (R4) on (R5)'s lap. Lowered to the floor. R4 sustained a skin tear to the right elbow. R5's Nurses Notes dated 9/23/15 document, Resident alert with confusion. Very combative with staff. Increased frequency attempting to transfer wife. R5's Nurses Notes dated 9/26/15 at 3:45 A.M. document, Resident with increased agitation, wanting to leave facility. unable to reason or try to talk to resident. (R5) just keeps getting more upset. Resident got up several times and almost fell . Resident was combative and yelling at staff. R4's Nurses Notes dated 9/26/15 at 5:00 A.M. document, (CNA) Certified Nursing Assistant came to this nurse and reported that resident cried out. CNA seen spouse's (R5)'s hand on (R4)'s hair. The facility Incident Report Form- (State agency) Notification dated 9/26/15 at 5:00 A.M. documents, Staff reported they heard resident (R4) crying and upon investigation (R4) told staff, (R5) pulled my hair. On 9/28/15 at 10:30 A.M., E1 Administrator stated, (R5) was admitted to the facility after (R5) was at the bank . (R5) was upset because Protective Services had removed (R4) from the house. (R5) wanted (R4) back home, but Protective Services took (R4) out due to ongoing issues with abuse and neglect. (R5) was sent to (local hospital) and then we admitted (R5) here. This past week end evidently the staff had them sitting together at the nurse's station in side-by-side recliners. Nobody was around, but someone heard (R4) yelling and crying. (R4) said '(R5) pulled my hair. On 9/28/15 at 3:12 P.M., E7 Admissions Coordinator stated, I screened (R4) at the (local hospital) ER (emergency room ). (R4)'s caseworker was there. (Z2) Adult Protective Services Caseworker said they were working on a Court Order to get (R4) out of the home and a Guardian appointed. (Z2) felt (R4 and R5) were in an unsafe environment. (Z2) said they (R4) and (R5) had ben under investigation for some time. (R4's spouse ) (R5) was unable to take care of (R4) and was mean and neglectful. I passed all of this information on to the Administrator (E1). On 9/28/15 at 3:45 P.M., Z3 Guardian ad Litem (for R4) stated, I have known (R4 and R5) for twenty-five plus years. (R5) has always been authoritarian. (R5) was the bread winner. (R5) made all the decisions. (R5) has always been mean to (R4) .(E1) was aware there were problems with (R5). (E1) was aware (R5) was mean to (R4) and had been neglectful. On 9/28/15 at 4:00 P.M., Z4 Case Manager from the local Elder Abuse Agency stated, We opened the case for (R4) in May 2015 after receiving multiple complaints alleging abuse and neglect by (R5). All (R4) would ever say was (R5) was very mean and verbally abusive to (R4). (R4) would only talk when (R5) wasn't around. We had multiple calls and complaints filed against (R5). We were actively pursuing removal of (R4) from the home. The (nursing) facility became involved in this case back in July 2015. We had called them for possible admission to the facility. I had multiple phone calls and e-mails with the (facility) Admission Coordinator (E4) concerning (R4). (E4) was made aware of the allegations of abuse and neglect of (R4) by (R5) from the beginning of their involvement. (E1) was also aware of the abuse and neglect. On 9/28/15 at 3:40 P.M., E8 Licensed Practical Nurse (LPN) stated, I was working down the hall (on 9/26/15 around 5:00 A.M.) E9 came and got me and said she was working down the hall and heard (R4) yell out. (R4) said (R5) pulled my hair. On 9/29/15 at 5:15 A.M., E9 Certified Nursing Assistant (CNA) stated, I was working on (9/26/15) around 4:30 or 5:00 in the morning down the hall. I heard (R4) whimpering, (R4) was upset. (R5) had (R5)'s hand on (R4)'s head. (R4) said (R5) is pulling my hair. (R5) said I can pull (R4)'s hair if I want to. On 9/29/15 at 10:34 A.M., Z5 (Physician) stated, (R5) has a long standing history of abuse and neglect of (R4). Those two (R4) and (R5) should never be left in an area together. (R5) becomes agitated easily and then lashes out at (R4) and hurts (R4). They need to be separated, maybe not even in the same nursing home. On 9/28/15 at 12:45 P.M., R4 was seated in a recliner in the lounge area with (R5) in a recliner next to (R4). On 9/29/15 at 5:05 A.M., R4 was seated in a recliner in the lounge area with (R5) in a recliner next to (R4).

Based on record review and interview the facility failed to follow it's Abuse Prohibition policy requirement of immediate notification of the Administrator of: multiple incidents of witnessed and alleged physical and/or sexual abuse perpetrated by two of six residents (R18, R28) on the sample of 18 and one resident (R33) on the supplemental sample reviewed for abuse/neglect policies and an incident of alleged theft for one resident (R35) on the supplemental sample; and based on observation, interview and record review the facility failed to incorporate the Elder Justice Act into facility policy; failed to post signage regarding the Elder Justice Act and failed to educate facility staff regarding the Elder Justice Act. These failures have the potential to affect all 88 residents in the facility R28 had one documented incident of fondling another resident which was witnessed by a nurse, as well as several nonspecific incidents documented as "sexually inappropriate" or "sexually aggressive." R33 had two documented incidents of punching other residents, and R18 had three documented incidents of striking other residents in the face. R35 reported $100.00 being stolen. Because the administrator wasn't notified of any of the aforementioned events, they were not investigated as abuse nor were they reported to the State Agency, which is also a requirement of the facility's Abuse Prohibition policy. These failures resulted in an Immediate Jeopardy. While Immediate Jeopardy was removed on 9/26/13, 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 CMS -672, Resident Census and Conditions of Residents, dated 9/23/13 and signed by E1 Administrator, notes the facility census to be 88 residents. Facility policy titled "Abuse Prevention Program," with a revision date of 11/11/11, states, "Physical Abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment"..."Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault"..."Employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator"..."Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation" and "A written report shall be sent to the (State Agency) initially within 24 hours and within five working days after the report of the occurrence." 1. Nursing Notes for R28 dated 8/4/13 at 9:15 AM, document, "Alert with usual confusion. Verbally, physically and sexually aggressive this AM." Nursing Notes for R28, dated 8/4/13 at 6:05 PM, document, "Continues to be sexually inappropriate, verbally abusive and combative at times..." On 9/25/13 at 3:06 PM, E16/RN (Registered Nurse) stated, "When (R28) was sexually inappropriate (R28) would try to grab females' breast or crotch when one walked by." E16/RN stated that R28 would masturbate wherever possible. E16/RN stated that E16 did not recall specific female residents that R28 tried to grab. E16/RN stated when R28 was sexually inappropriate E16 documented it on a 24 hour report sheet and on a behavior report sheet. Nursing Notes for R28, dated 8/17/13 at 9:30 AM, document, "Resident up, wandering about unit. Sexually aggressive towards female residents. Frequently going to them. Not easily redirected. Found fondling female resident breast." On 9/25/13 at 3:06 PM, E16/RN stated that E16 was passing medications on 8-17-13 when R28 walked over to R41 and lifted up R41's shirt and fondled R41's breast. On 9/26/13 at 11:30 AM, E1/Administrator verified that E1 was not notified until 8/19/13 regarding the incident on 8/17/13 involving R28 lifting up R41's shirt and fondled R41's breast. E1/Administrator stated that the police were not notified, R41's POA (Power of Attorney) was not notified and the State Agency was not notified. E1 also stated that E1 was never notified of any other incidents of R28 being verbally, physically, or sexually inappropriate. 2. Nurses Notes, dated 8/12/13 at 6:00 pm, document R33 "walked past another resident and hit (the resident) in the chest." On 9/27/13 at 9:38 am, E2/LPN stated E21 made the entry on 8/12/13 documenting R33 hit another resident. E21 also stated E21 could not remember who R33 hit, whether E21 filled out an incident report or if E21 notified anyone. Nurses Notes for R27, dated 8/20/13 at 12:00 pm, document that R27 was walking to the dining room and another resident was walking in opposite direction and as they passed the peer "punched (R27) in back of head. (R27) fell on to floor onto (R27's) stomach, then rolled from side to side got to R27's knees and stood up." The same Nurses Notes document E1/Administrator was notified of the incident. On 9/26/13 at 11:15 am, E16 RN (Registered Nurse) stated E16 made the entry on 8/20/13 in R27's medical record. E16 stated R33 was the resident who punched R27 in the back of the head and E16 stated E16 reported the incident to the on call Nurse and to E1/Administrator. On 9/25/13 at 1:30 pm, E1 Administrator stated that there are no abuse investigations involving R27 or R33 and that the incident on 8/20/13 was investigated as a fall. E1 Administrator also stated "They are both demented, so do you ever really know?" E1 also confirmed that neither the 8-12-13 incident nor the 8-20-13 incident was reported to the State Agency. 3. Nurses Notes for R18, dated 4/18/13 at 3:00 pm state, "(R18) continues to be combative with staff and other residents at times." Nurses Notes for R18, dated 4/30/13 at 2:00 pm, document R8 complained "(R18) got out of bed, came over and hit (R8) in the left jaw and returned to bed." On 9/24/13 at 3:00 pm, E18/LPN stated the documentation in R18's Nurses Notes on 4/30/13 was written by E18 and state R18 was put back to bed after supper because there were no further behaviors between 2:00 pm and supper. E18 stated E18 did not complete an incident report and did not document R18's behavior on the Behavior Monitoring Record. E18 stated, "I don't think I filled out one for this incident due to it was questionable as to whether it happened or not" E18 also stated E18 was unable to recall if E18 reported the incident to anyone. On 9/24/13 at 12:50 pm, E1/Administrator stated E1 does not have any abuse investigations for R18 and cannot recall any particular incident for R18 on 4/18/13, 4/30/13 or any other date. E1 also stated E1 would normally do an investigation for abuse but there were no marks on R8 and E1 was unsure E1 would do an investigation if both the residents were confused. Nurses Notes for R18, dated 5/10/13 at 5:15 am, state R18 was sitting at nurses station "then resident (R18) hit at other resident (R32) striking his nose" Nurses Notes for R32, dated 5/10/13 at 5:45 am, document at 5:30 am a "nurse witnessed (R32) hit at another resident (R18). That resident then hit (R32) in the face, causing a scratch to his left upper cheek" This note also contains documentation of "on call manager notified of occurrence." Nurses Notes for R18, dated 5/10/13 at 8:25 pm, state R18 "pushed off other resident (R32)in right side of face ..." Nurses Notes for R32, dated 5/10/13 at 9:00 pm, document R32 was sitting at the nurses station when another resident pushed R32 in right side of R32's face. This note also documents E1/Administrator was notified of the incident. On 9/25/13 at 1:05 pm, E1/Administrator stated, "I was not aware, it is very disheartening," regarding the incidents between R18 and R32 on 5-10-13 at 5:30 am and 8:25 pm. E1 verified at that time that none of the incidents involving R18 being aggressive to other residents were investigated, nor were they reported to the State Agency. Facility policy titled "Abuse Prevention Program," with a revision date of 11/11/11, documents the following investigation procedures: Regardless of the specific nature of the allegation (Physical, sexual, verbal/mental, theft or neglect), the investigation shall consist of...An interview with the resident." Nurses Notes for R35, dated 2/24/13 at 10:00 am, document "Res (resident) approached LPN (Licensed Practical Nurse) and informed her that Res has $100.00 (one hundred dollars) missing." Incident Report Form for R35, dated 2/25/13, indicates R35 complained of missing one hundred dollars from R35's wallet. Incident Report Form states the police were notified on 2/24/13 at 1:30 pm. There is no documentation that R35 was interviewed regarding the missing one hundred dollars. There is no documentation of any conclusions regarding what happened to the money in the investigation notes. Fax Transmittal Form indicates State Agency was notified on 2/25/13 at 4:30 pm which is 30.5 hours after R35 made the initial complaint of missing one hundred dollars. This Fax Transmittal Form also documents this is the first and final report. On 9/26/13 at 9:48 am E1 Administrator stated that E1 does not know the times the interviews or investigation regarding R35's missing money were initiated. E1 stated E1 received a phone call that R35 called the police but was unable to recall when E1 received the call or when R35 made the call to the police. E1 also stated "I didn't talk to him. That's all I have." 4. On 9/23/13 at 6:00 am and on 9/24/13 at 11:00 there was no evidence of the Elder Justice Act posted within facility. Employees were interveiwed on the following dates and times, regarding Abuse Prohibition: 9/23/13 at 6:15 am-E9/CNA (Certified Nursing Assistant), 9/23/13 at 9:55 am-E10(CNA), 9/23/13 at 10:05 am-E11(Helping Hand), and 9/23-13 at 10:10 am-E12 Helping Hand. E9 through E12 all stated they are unaware of the Elder Justice Act and have not had any training. E9 also stated, "I would report to the Nurse and let them handle the rest." On 9/24/13 at 11:20 am, E1/Administrator confirmed that the abuse posting is the standard posting the facility has always had and stated that E1 is unsure what the Elder Justice Act is. On 9/24/13 at 1:00 pm, E1 confirmed abuse posting does not include the Elder Justice Act. Abuse Policy and Procedure, Revised 11/11/11, does not incorporate the Elder Justice Act. On 9/26/13 at 2:24 PM at 2:24 pm an Immediate Jeopardy was identified to have begun on 4/30/13, when facility staff failed to report or investigate an allegation of physical abuse made by R8 that R18 hit R8 in the jaw. On 9/26/13 at 2:30 PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through observation, record review and interview the facility took the following actions remove the Immediate Jeopardy: *The Administrator was inserviced by corporate staff regarding the facilities policies related to abuse, neglect and misappropriation of resident property. Initiated and completed 9-26-13. *The Administrator was inserviced by corporate staff regarding the Elder Justice Act. Initiated and completed 9-26-13. *The staff reporting for work for the next immediate two shifts (second and third shift) were educated by corporate staff in recognizing resident to resident abuse and facility policy regarding abuse. Initiated and completed 9-26-13. *All residents in the facility were screened for harmful behaviors using the Pre-Screening/Screening Assessment for Harmful Behaviors. Based on the screening, interventions were evaluated and modified as appropriate. Initiated 9-26-13 and completed 9-27-13.

Based on record review and interview the facility failed to immediately notify the Administrator of multiple incidents of witnessed and alleged physical and/or sexual abuse perpetrated by two of six residents (R18, R28) on the sample of 18 and one resident (R33) on the supplemental sample. R28 had one documented incident of fondling another resident which was witnessed by a nurse, as well as several nonspecific incidents documented as "sexually inappropriate" or "sexually aggressive." R33 had two documented incidents of punching other residents, and R18 had three documented incidents of striking other residents in the face. Because the administrator wasn't notified of the events, they were not investigated as abuse, nor were they reported to the State Agency; and based on record review and interview the facility failed to immediately notify the Administrator of an allegation of theft; failed to interview the resident (R35) and failed to notify the State Agency within 24 hours of an allegation of theft for one resident (R35) on the supplemental sample. These failures had the potential to affect all 88 residents in the facility. These failures resulted in an Immediate Jeopardy. While Immediate Jeopardy was removed on 9/26/13, 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 CMS -672, Resident Census and Conditions of Residents, dated 9/23/13 and signed by E1 Administrator, notes the facility census to be 88 residents. Facility policy titled "Abuse Prevention Program" with a revision date of 11/11/11 documents, "Physical Abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment" and "Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault." 1. Nursing Notes for R28 dated 8/4/13 at 9:15 AM, document, "Alert with usual confusion. Verbally, physically and sexually aggressive this AM." Nursing Notes for R28, dated 8/4/13 at 6:05 PM, document, "Continues to be sexually inappropriate, verbally abusive and combative at times..." On 9/25/13 at 3:06 PM, E16/RN (Registered Nurse) stated, "When (R28) was sexually inappropriate (R28) would try to grab females' breast or crotch when one walked by." E16/RN stated that R28 would masturbate wherever possible. E16/RN stated that E16 did not recall specific female residents that R28 tried to grab. E16/RN stated when R28 was sexually inappropriate E16 documented it on a 24 hour report sheet and on a behavior report sheet. Nursing Notes for R28, dated 8/17/13 at 9:30 AM, document, "Resident up, wandering about unit. Sexually aggressive towards female residents. Frequently going to them. Not easily redirected. Found fondling female resident breast." On 9/25/13 at 3:06 PM, E16/RN stated that E16 was passing medications and R28 walked over to R41 and lifted up R41's shirt and fondled R41's breast. E16/RN stated E16 separated R28 and R41 and "probably" charted the behaviors in the ADL (Activities of Daily Living) book. E16/RN stated that R41 "just sat there" when R28 lifted up R41's shirt and fondled R41. E16/RN stated that R41 probably did not know what was going on. On 9/26/13 at 11:30 AM, E1/Administrator verified that E1 was not notified until 8/19/13 regarding the incident on 8/17/13 involving R28 lifting up R41's shirt and fondled R41's breast. E1/Administrator stated that the police were not notified, R41's POA (Power of Attorney) was not notified and the State Agency was not notified. 2. Nurses Notes, dated 8/12/13 at 6:00 pm, document R33 "walked past another resident and hit (the resident) in the chest." On 9/27/13 at 9:38 am, E2/LPN stated E21 made the entry on 8/12/13 documenting R33 hit another resident. E21 also stated E21 could not remember who R33 hit, whether E21 filled out an incident report or if E21 notified anyone. Nurses Notes for R27, dated 8/20/13 at 12:00 pm, document that R27 was walking to the dining room and another resident was walking in opposite direction and as they passed the peer "punched (R27) in back of head. (R27) fell on to floor onto (R27's) stomach, then rolled from side to side got to R27's knees and stood up." The same Nurses Notes document E1/Administrator was notified of the incident. On 9/26/13 at 11:15 am, E16 RN (Registered Nurse) stated E16 made the entry on 8/20/13 in R27's medical record. E16 stated R33 was the resident who punched R27 in the back of the head and E16 stated E16 reported the incident to the on call Nurse and to E1/Administrator. On 9/25/13 at 1:30 pm, E1 Administrator stated, "I have nothing" and stated that there are no abuse investigations involving R27 or R33 and that the incident on 8/20/13 was investigated as a fall. E1 Administrator also stated "They are both demented, so do you ever really know?"At that time, E1 also confirmed that R28 and R33 both were ambulatory and could have abused any of the other residents on the Alzheimer's Unit. 3. Nurses Notes for R18, dated 4/18/13 at 3:00 pm, state, "(R18) continues to be combative with staff and other residents at times." On 9/24/13 at 12:50 pm, E1/Administrator stated E1 does not have any abuse investigations and cannot recall any particular incident involving R18 for 4/18/13. Nurses Notes for R18, dated 4/30/13 at 2:00 pm, document R8 complained "(R18) got out of bed, came over and hit (R8) in the left jaw and returned to bed." On 9/24/13 at 3:00 pm, E18/LPN stated the documentation in R18's Nurses Notes on 4/30/13 was written by E18 and state R18 was put back to bed after supper because there were no further behaviors between 2:00 pm and supper. E18 stated E18 did not complete an incident report and did not document R18's behavior on the Behavior Monitoring Record. E18 stated, "I don't think I filled out one for this incident due to it was questionable as to whether it happened or not" E18 also stated E18 was unable to recall if E18 reported the incident to anyone. On 9/24/13 at 12:50 pm, E1/Administrator stated E1 does not have any abuse investigations for R18 and cannot recall any particular incident for R18 on 4/30/13. E1 also stated E1 would normally do an investigation for abuse but there were no marks on R8 and E1 was unsure E1 would do an investigation if both the residents were confused. At that time, E1 confirmed that R18 was able to access all wings of the facility, except the Alzheimer's unit while in his enclosed wheel chair. Nurses Notes for R18, dated 5/10/13 at 5:15 am, state R18 was sitting at nurses station "then resident (R18) hit at other resident (R32) striking his nose" Nurses Notes for R32, dated 5/10/13 at 5:45 am, document at 5:30 am a "nurse witnessed (R32) hit at another resident (R18). That resident then hit (R32) in the face, causing a scratch to his left upper cheek" This note also contains documentation of "on call manager notified of occurrence." Nurses Notes for R18, dated 5/10/13 at 8:25 pm, state R18 "pushed off other resident (R32)in right side of face ..." Nurses Notes for R32, dated 5/10/13 at 9:00 pm, document R32 was sitting at the nurses station when another resident pushed R32 in right side of R32's face. This note also documents E1/Administrator was notified of the incident. On 9/25/13 at 1:05 pm, E1/Administrator stated, "I was not aware, it is very disheartening," regarding the incidents between R18 and R32 on 5-10-13 at 5:30 am and 8:25 pm. E1 verified at that time that none of the incidents involving R18 being aggressive to other residents were investigated, nor were they reported to the State Agency. 4. Facility policy titled "Abuse Prevention Program," with a revision date of 11/11/11, documents the following investigation procedures: Regardless of the specific nature of the allegation (Physical, sexual, verbal/mental, theft or neglect), the investigation shall consist of...An interview with the resident." Nurses Notes for R35, dated 2/24/13 at 10:00 am, document "Res (resident) approached LPN (Licensed Practical Nurse) and informed her that Res has $100.00 (one hundred dollars) missing." Incident Report Form for R35, dated 2/25/13, indicates R35 complained of missing one hundred dollars from R35's wallet. Incident Report Form states the police were notified on 2/24/13 at 1:30 pm. Interviews were initiated on 2/24/13 however, documentation does not include the date and time or who conducted the interviews.There is no documentation that R35 was interviewed regarding the missing one hundred dollars. There is no documentation of any conclusions regarding what happened to the money in the investigation notes. Fax Transmittal Form indicates State Agency was notified on 2/25/13 at 4:30 pm which is 30.5 hours after R35 made the initial complaint of missing one hundred dollars. This Fax Transmittal Form also documents this is the first and final report. On 9/26/13 at 9:48 am E1 Administrator stated that E1 does not know the times the interviews or investigation regarding R35's missing money were initiated. E1 stated E1 received a phone call that R35 called the police but was unable to recall when E1 received the call or when R35 made the call to the police. E1 also stated "I didn't talk to him. That's all I have." On 9/26/13 at 2:24 PM at 2:24 pm an Immediate Jeopardy was identified to have begun on 8/19/13, when facility staff failed to identify the fondling of R41's breasts by R28 as sexual abuse. On 9/26/13 at 2:30 PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through observation, record review and interview the facility took the following actions remove the Immediate Jeopardy: *The Administrator was inserviced by corporate staff regarding the facilities policies related to abuse, neglect and misappropriation of resident property. Initiated and completed 9-26-13. *The Administrator was inserviced by corporate staff regarding the Elder Justice Act. Initiated and completed 9-26-13. *The staff reporting for work for the next immediate two shifts (second and third shift) were educated by corporate staff in recognizing resident to resident abuse and facility policy regarding abuse. Initiated and completed 9-26-13. *All residents in the facility were screened for harmful behaviors using the Pre-Screening/Screening Assessment for Harmful Behaviors. Based on the screening, interventions were evaluated and modified as appropriate. Initiated 9-26-13 and completed 9-27-13.

Based on interview and record review the facility administration failed to have knowledge of the facility's Abuse Prohibition policy regarding identification, reporting and investigation of potential abuse. As a result, the administration failed to provide education and instruction to subordinate staff regarding the same. This deficient practice created a systemic failure having the potential to affect all 88 residents in the facility. The facility failed to identify physical and sexual acting out as abuse; failed to immediately report allegations of abuse to both the Administrator and the State Agency, failed to report a sexual assault to local law enforcement and failed to report abuse to the POA (Power of Attorney) of either the perpetrator or the victim. The facility failed to thoroughly investigate allegations of abuse and to completely document those investigations and their conclusions. The facility failed to protect residents from being abused during and after the investigations. The facility failed to be familiar with and operationalize the facility's abuse policy. The facility failed to post the Elder Justice Act within the facility. The facility failed to educate staff on the Elder Justice Act. The facility failed to incorporate the Elder Justice Act into the facility's abuse policy. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/26/13, the facility remains out of compliance at a Severity Level Two because additional time is needed to monitor the efficacy of staff training and corporate oversight. Findings include: The CMS -672, Resident Census and Conditions of Residents, dated 9/23/13 and signed by E1 Administrator, notes the facility census to be 88 residents. 1. Facility policy titled "Abuse Prevention Program" with a revision date of 11/11/11 documents, "Physical Abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment"..."Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault"..."Employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator"..."Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation" and "A written report shall be sent to the (State Agency) initially within 24 hours and within five working days after the report of the occurrence." 2. The facility failed to identify verbal and physical sexual harassment as sexual abuse on the Alzheimer's Unit. The facility failed to recognize a sexual assault (male resident lifted up the shirt of a female resident and fondled her breast) of one resident. The facility failed to notify the Administrator immediately; failed to protect the victim from further abuse; failed to notify local law enforcement of a crime; failed to notify the POA of the victim. The Administrator completed a document titled, "Follow up to behavior reported..." The Administrator's report did not include witness statements, did not indicate that the Illinois Department of Public Health was notified and did not indicate any change in the perpetrator's interventions regarding his sexually abusive behaviors. Refer to F223, F225 and F226. 3. In two of two residents reviewed for physically abusive behaviors the facility failed to identify physical abuse (punching, hitting in the jaw, hitting in the nose). The facility failed to investigate witnessed and alleged abuse; failed to protect the residents and failed to report abuse to the Illinois Department of Public Health. One nurse indicated that he would not report an abuse allegation if it was questionable if the abuse really happened. The Administrator indicated that she would not investigate an alleged abuse between confused residents, "because you just never really know." Refer to F223, F225 and F226. 4. The Administrator failed to thoroughly investigate an alleged theft of $100.00 by not interviewing the resident making the allegations and not notifying the Illinois Department of Public Health within 24 hours. The resident notified local law enforcement himself. 5. The facility did not incorporate the Elder Justice Act into their Abuse Policy, did not post signage regarding the Elder Justice Act and had not educated the facility staff. The Administrator was unaware of the Act and needed to consult her corporate office. On 9/26/13 at 2:24 PM at 2:24 pm an Immediate Jeopardy was identified to have begun on 8/19/13, when facility staff failed to identify the fondling of R41's breasts by R28 as sexual abuse. On 9/26/13 at 2:30 PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through observation, record review and interview the facility took the following actions remove the Immediate Jeopardy: *The Administrator was inserviced by corporate staff regarding the facilities policies related to abuse, neglect and misappropriation of resident property. Initiated and completed 9-26-13. *The Administrator was inserviced by corporate staff regarding the Elder Justice Act. Initiated and completed 9-26-13. *The staff reporting for work for the next immediate two shifts (second and third shift) were educated by corporate staff in recognizing resident to resident abuse and facility policy regarding abuse. Initiated and completed 9-26-13. *All residents in the facility were screened for harmful behaviors using the Pre-Screening/Screening Assessment for Harmful Behaviors. Based on the screening, interventions were evaluated and modified as appropriate. Initiated 9-26-13 and completed 9-27-13.

Based on record review and interview the facility failed to identify physical and sexual abuse for two of six residents (R18, R28) reviewed for abuse in sample of 18 and one resident (R33) on the supplemental sample. This failure had the potential to affect all 88 residents in the facility. The facility failed to recognize R28's ongoing physical/verbal sexual harassment and one documented incident of sexual assault (fondling the breast of a demented female resident) as sexual abuse. The facility failed to identify ongoing physical aggression by R18 (punching the head of another resident on one occasion and punching the chest of a different resident on a another occasion) and R33 (hitting the jaw of one resident and striking the nose of another) as physical abuse. These failures resulted in an Immediate Jeopardy. While Immediate Jeopardy was removed on 9/26/13, 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 CMS -672, Resident Census and Conditions of Residents, dated 9/23/13 and signed by E1 Administrator, notes the facility census to be 88 residents. Facility policy titled "Abuse Prevention Program" with a revision date of 11/11/11 states, "Physical Abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment" and "Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault." 1. Psychosocial Progress Notes for R28, dated 7/31/13, states, "Resident was admitted yesterday to Alzheimer's Unit. Was to be placed on the other side but for... safety...was placed on the unit. Resident was restless during the nite (sic). (R28) had inappropriate behaviors towards female residents..." On 9/26/13 at 11:00 AM, E6/Alzheimer's Unit Coordinator stated that E6 was aware that R28 had a history of [REDACTED]. kiss" and "Come sit on my lap." E6/Alzheimer's Unit Coordinator stated E6's plan to keep the vulnerable population of the Alzheimer's Unit safe included "redirecting" R28 and "separating the residents when needed." Nursing Notes for R28 dated 8/4/13 at 9:15 AM, document, "Alert with usual confusion. Verbally, physically and sexually aggressive this AM." Nursing Notes for R28, dated 8/4/13 at 6:05 PM, document, "Continues to be sexually inappropriate, verbally abusive and combative at times..." On 9/25/13 at 3:06 PM, E16/RN (Registered Nurse) stated, "When (R28) was sexually inappropriate (R28) would try to grab females' breast or crotch when one walked by." E16/RN stated that R28 would masturbate wherever possible. E16/RN stated that E16 did not recall specific female residents that R28 tried to grab. E16/RN stated when R28 was sexually inappropriate E16 documented it on a 24 hour report sheet and on a behavior report sheet. Nursing Notes for R28, dated 8/17/13 at 9:30 AM, document, "Resident up, wandering about unit. Sexually aggressive towards female residents. Frequently going to them. Not easily redirected. Found fondling female resident breast." On 9/25/13 at 3:06 PM, E16/RN stated that E16 was passing medications and R28 walked over to R41 and lifted up R41's shirt and fondled R41's breast. E16/RN stated E16 separated R28 and R41 and "probably" charted the behaviors in the ADL (Activities of Daily Living) book. E16/RN stated that R41 "just sat there" when R28 lifted up R41's shirt and fondled R41. E16/RN stated that R41 probably did not know what was going on. Current Care Plan for R28, dated 7/30/13, includes the following problem/need, "Resident (R28) has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against the resident. Resident at times has verbally expressed sexual comments to females and has also kissed them." Current Care Plan for R28, was not updated, includes no new interventions to address ongoing sexually inappropriate behaviors throughout R28's stay at the facility . On 9/26/13 at 10:00 AM, E6/Alzheimer's Unit Coordinator stated (E6) "Doesn't recall updating (R28's) care plan and usually (E6) would update after every incident." On 9/26/13 at 11:30 AM, E1/Administrator verified that E1 was not notified until 8/19/13 regarding the incident on 8/17/13 involving R28 lifting up R41's shirt and fondling R41's breast. E1/Administrator stated that the police were not notified, R41's POA (Power of Attorney) was not notified and the State Agency was not notified. On 9/26/13 at 2:30 PM, Z1/Medical Director states Z1 was aware of R28's escalating behaviors, but Z1 could not recall being notified of an incident when R28 put R28's hand on another resident's breast. A document titled, "Follow-up to behavior reported regarding (R28) touching female resident breast," dated 8/19/13 and completed by E1/Administrator, states, "Continuous monitoring was implemented with no further episodes of inappropriate fondling noted." On 9/26/13 at 11:30 AM, E1/Administrator verified that R28 was on continuous monitoring (15 minute checks) prior to the 8/17/13 incident and that the facility interventions did not change after the incident. 2. Nurses Notes, dated 8/12/13 at 6:00 pm, document R33 "walked past another resident and hit (the resident) in the chest." Behavior Monitoring Record for R33 includes entry for 8/12/13 for second shift documenting "Not joking aggression, punched female resident in the chest." Current Care Plan for R33, dated 8/24/13, includes no new interventions following the 8/12/13 incident. On 9/27/13 at 9:38 am, E2/LPN stated E21 made the entry on 8/12/13 documenting R33 hit another resident. E21 also stated E21 could not remember who R33 hit, whether E21 filled out an incident report or if E21 notified anyone. On 9/25/13 at 1:30 pm, E1 Administrator stated, " I have nothing " and stated there are no abuse investigations for R33. Nurses Notes for R27, dated 8/20/13 at 12:00 pm, document that R27 was walking to the dining room and another resident was walking in opposite direction and as they passed the peer "punched (R27) in back of head. (R27) fell on to floor onto (R27's) stomach, then rolled from side to side got to (R27's) knees and stood up." The same Nurses Notes document E1/Administrator was notified of the incident. On 9/26/13 at 11:15 am, E16 RN (Registered Nurse) stated E16 made the entry on 8/20/13 in R27's medical record. E16 stated R33 was the resident who punched R27 in the back of the head and E16 stated E16 reported the incident to the on call Nurse and to E1/Administrator. Current Care Plan for R33, dated 8/24/13, includes no new interventions following the 8/20/13 incident. On 9/25/13 at 1:30 pm, E1 Administrator stated, "I have nothing" and stated that there are no abuse investigations involving R27 or R33 and that the incident on 8/20/13 was investigated as a fall. E1 Administrator also stated " They are both demented, so do you ever really know? " At that time, E1 also confirmed that R28 and R33 both were ambulatory and could have abused any of the other residents on the Alzheimer's Unit. 3. Nurses Notes for R18, dated 4/18/13 at 3:00 pm, state, "(R18) continues to be combative with staff and other residents at times." R18's Current Care Plan, dated 4/17/13, includes no new interventions following the 4/18/13 incident. On 9/24/13 at 12:50 pm, E1/Administrator stated E1 does not have any abuse investigations and cannot recall any particular incident involving R18 for 4/18/13. Nurses Notes for R18, dated 4/30/13 at 2:00 pm, document R8 complained "(R18) got out of bed, came over and hit (R8) in the left jaw and returned to bed" R18's Behavior Monitoring Record and Current Care Plan, dated 4/17/13, include no new interventions following the 4/30/13 incident. On 9/24/13 at 3:00 pm, E18/LPN stated the documentation in R18's Nurses Notes on 4/30/13 was written by E18 and state R18 was put back to bed after supper because there were no further behaviors between 2:00 pm and supper. E18 stated E18 did not complete an incident report and did not document R18's behavior on the Behavior Monitoring Record. E18 stated, "I don't think I filled out one for this incident due to it was questionable as to whether it happened or not" E18 also stated E18 was unable to recall if E18 reported the incident to anyone. On 9/24/13 at 12:50 pm, E1/Administrator stated E1 does not have any abuse investigations for R18 and cannot recall any particular incident for R18 on 4/30/13. E1 also stated E1 would normally do an investigation for abuse but there were no marks on R8 and E1 was unsure E1 would do an investigation if both the residents were confused. At that time, E1 confirmed that R18 was able to access all wings of the facility, except the Alzheimer's unit while in his enclosed wheel chair. Nurses Notes for R18, dated 5/10/13 at 5:15 am, state R18 was sitting at nurses station "then resident (R18) hit at other resident (R32) striking his nose" Nurses Notes for R32, dated 5/10/13 at 5:45 am, document at 5:30 am a "nurse witnessed (R32) hit at another resident (R18). That resident then hit (R32) in the face, causing a scratch to his left upper cheek" This note also contains documentation of "on call manager notified of occurrence." Behavior Monitoring Record for R18 includes no documentation of 5/10/13 5:15 am incident. Current Care Plan for R18, dated 4/17/13, includes no new interventions following the 5/10/13 5:45 am incident. Nurses Notes for R18, dated 5/10/13 at 8:25 pm, state R18 "pushed off other resident in right side of face ..." Behavior Monitoring Record for R18 does not document any behaviors for R18 on 5/10/13. Current Care Plan for R18, dated 4/17/13, includes no new interventions following the 5/10/13 at 8:25 pm incident. Nurses Notes for R32, dated 5/10/13 at 9:00 pm, document R32 was sitting at the nurses station when another resident pushed R32 in right side of R32's face. This note also documents E1/Administrator was notified of the incident. On 9/25/13 at 1:05 pm, E1/Administrator stated, "I was not aware, it is very disheartening," regarding the incident between R18 and R32 on 5-10-13 at 5:30 am and 8:25 pm. On 9/26/13 at 2:24 PM at 2:24 pm an Immediate Jeopardy was identified to have begun on 8/19/13, when facility staff failed to identify the fondling of R41's breasts by R28 as sexual abuse. On 9/26/13 at 2:30 PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through observation, record review and interview the facility took the following actions remove the Immediate Jeopardy: *The Administrator was inserviced by corporate staff regarding the facilities policies related to abuse, neglect and misappropriation of resident property. Initiated and completed 9-26-13. *The Administrator was inserviced by corporate staff regarding the Elder Justice Act. Initiated and completed 9-26-13. *The staff reporting for work for the next immediate two shifts (second and third shift) were educated by corporate staff in recognizing resident to resident abuse and facility policy regarding abuse. Initiated and completed 9-26-13. *All residents in the facility were screened for harmful behaviors using the Pre-Screening/Screening Assessment for Harmful Behaviors. Based on the screening, interventions were evaluated and modified as appropriate. Initiated 9-26-13 and completed 9-27-13.

Based on interview and record review, the facility failed to safely transfer one of three residents (R2) from a total sample of three residents having had recent falls, with the appropriate number of staff specified by the resident's assessment and care plan. Findings include: A facility incident report dated 3/30/11 indicated that R2 had been lowered to the floor at 9:30 PM that day by one Certified Nurse Aide (CNA) who had been in the process of transferring the resident from a recliner chair to a wheelchair. The report indicated that as a result of the accident, R2 had no complaint of pain and did not sustain any injuries. The "Root Cause with Recommendation " section on the report stated, "Re-educate assist of two." CNA E2 stated on 4/27/11 at 2 PM with regards to the transfer incident, that R2's knees became weak while R2 was standing to pivot, and R2 started to slide past E2 on E2's right side. E2 said that she then lowered R2 to the floor. E2 said that she was transferring R2 by herself at the time, and that staff have only used one person to transfer R2. E2 said that after this incident, two staff were required to transfer R2. R2's Minimum Data Set (MDS) assessment dated [DATE] indicated under the Activities of Daily Living Section that R2 was coded as a "3" for Transfer Support, or "Two + persons physical assist." R2's care plan dated 2/9/11 indicated that R2 was at "High risk for falls," and required "Transfer with assist x 2" under that section.