Every finding on record at Axiom Healthcare of Mount Vernon

Based on interview and record review the facility failed to ensure a resident was free from the use of unnecessary psychotropic medications, including polypharmacy for 1 of 3 residents (R1) reviewed for chemical restraints in a sample of 8. This failure caused R1 to develop extrapyramidal symptoms (involuntary movements) and lethargy which contributed to a severe weight loss, the development of pressure ulcers, and overall decline in health. R1 was hospitalized on [DATE] and admitted to the Intensive Care Unit with diagnoses of Septic Shock, Dehydration, Hypernatremia, Transaminitis, Hypoxia, Elevated Troponin, Failure to Thrive, Acute Kidney Injury, Elevated Lactic Acid, Elevated Brain Natriuretic Peptide (BNP), Acute Respiratory Failure, and Multi-Organ Failure. The Immediate Jeopardy began on 6/4/26 when R1, who is diagnosed with a severe intellectual disability, began having adverse effects from serious drug interactions from multiple prescribed psychotropic medications. V1 Administrator, V5 Regional Clinical Director, and V35 Regional MDS Coordinator were notified of the Immediate Jeopardy on 8/13/2026 at 2:58PM. The immediacy was removed 8/17/2026 at 2:45PM, but non-compliance remained at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:Based on interview and record review the facility failed to ensure a resident was free from the use of unnecessary psychotropic medications, including polypharmacy for 1 of 3 residents (R1) reviewed for chemical restraints in a sample of 8. This failure caused R1 to develop extrapyramidal symptoms (involuntary movements) and lethargy which contributed to a severe weight loss, the development of pressure ulcers, and overall decline in health. R1 was hospitalized on [DATE] and admitted to the Intensive Care Unit with diagnoses of Septic Shock, Dehydration, Hypernatremia, Transaminitis, Hypoxia, Elevated Troponin, Failure to Thrive, Acute Kidney Injury, Elevated Lactic Acid, Elevated Brain Natriuretic Peptide (BNP), Acute Respiratory Failure, and Multi-Organ Failure.The Immediate Jeopardy began on 6/4/26 when R1, who is diagnosed with a severe intellectual disability, began having adverse effects from serious drug interactions from multiple prescribed psychotropic medications. V1 Administrator, V5 Regional Clinical Director, and V35 Regional MDS Coordinator were notified of the Immediate Jeopardy on 8/13/2026 at 2:58PM. The immediacy was removed 8/17/2026 at 2:45PM, but non-compliance remained at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1's admission Record documents an admission date of 11/27/2013. admission records include diagnoses of Hypertensive Heart Disease with heart failure, Crohn's Disease of both small and large intestines without complications, Muscle Wasting and Atrophy, Lack of Coordination, Dysphagia oral phase, Abnormal Posture, Hyperesthesia, Atherosclerotic Heart Disease, Hyperlipidemia, Anxiety, Sever Intellectual Disabilities, Osteoporosis, Major Depressive Disorder, and Physical Debility. R1's admission record documents R1 was discharged to a local hospital on 7/25/26 and did not return to the facility.R1's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 5 indicating R1 has severe cognitive impairment. Section K (Nutrition) dated 6/8/2026 documents a weight of 117 pounds and height of 63 inches (5 feet 3 inches). K0300. Weight loss documents no or unknown for loss of 5% or more in the last month or loss of 10% or more in last 6 months. K0310. Weight gained documents no or unknown for gain of 5% or more in the last month or gain of 10% or more in last 6 months. Section GG (functional abilities) documents R1 has no impairment to upper or lower extremities and used a manual wheelchair for mobility. Document shows R1 required supervision or touching assistance with eating. R1 is dependent on staff for oral care, toilet hygiene, upper and lower body dressing, personal hygiene, position/repositioning while in bed and transfers. Section D- Mood documents a total severity score of 15 with highest possible score of 30. Severity score refers to frequency of symptoms present as follows: little interest in pleasure of doing things, feeling or appearing down, depressed or hopeless, trouble falling or staying asleep and trouble concentrating on things, such as reading the newspaper or watching television, being short tempered, easily annoyed 12-14 days (nearly every day). Section E- Behaviors, documents none of the above for hallucinations and delusions. Physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, rejections of care, and wandering document that behaviors of this type occurred 4 to 6 days, but less than daily. Section N-Medications documents under High-Risk Drug Classes R1 is taking the following medications: Antipsychotics, Antianxiety, antidepressants and anticonvulsants and that R1 has an indication noted for each drug class marked. Under Antipsychotic Medication Review documents that R1 receives an antipsychotic on a routine basis, a Gradual Dose Reduction (GDR) was attempted on 4/19/26, and the physician documented that a GDR was clinically contraindicated on 6/1/26. R1's Care Plan documents the following Focus areas and interventions:R1 has a behavior problem with an initiation date of 7/9/2026 and a Goal of R1 will have no evidence of behavior problems dated 7/9/2026. Interventions include: 12/10/2025: Medication Audit and review completed MD and Pharmacist, 7/9/2026 administer medications as ordered, monitor and document side effects and effectiveness. On 7/9/2026 Anticipate and meet R1's needs. Care givers to provide opportunities for positive interaction, attention. Stop and talk with her as passing by initiated on 7/9/26. Explain all procedures to R1 before starting and allow the resident time to adjust initiated on 7/9/26. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert Attention. Remove from situation and take to alternate location as needed initiated on 7/9/26. Minimize potential for R1's disruptive behaviors by offering tasks which divert attention initiated on 7/9/26. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes initiated on 7/9/26. Praise any indication of R1's progress/improvement in behavior initiated on 7/9/26. Provide a program of activities that is of interest and accommodates resident's status initiated on 7/9/26. R1 is/has potential to be verbally aggressive dated 7/9/2026 and a Goal of R1 will demonstrate effectiveness coping skills thru the next 90 days dated 7/9/2026. Documented interventions include: analyze of key times, place, circumstances, triggers, and what de-escalates behavior and document; provide a program of activities that is of interest and accommodates residents status; and when R1 becomes agitated: intervene before agitation escalates; guide away from source of distress. Engage calmly in conversation; if response is aggressive, staff walk calmly away, approach later all initiated on 7/9/2026.R1 uses anti-anxiety medications related to anxiety. Documented interventions include: administer anti anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Educate R1/family/caregivers about risks, benefits and the side effects and or toxic symptoms dated 7/9/2026. Monitor R1 for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that look like dementia and increase risk of falls, broken hips and legs. Monitor/documentation/report as needed any reverse reaction to medication therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, nausea, stomach upset. Unexpected side effects: mania, hostility, rage, aggressive or impulsive behavior, and hallucination dated 7/9/2026.R1 will be/remain free of psychotropic, drug related complications including movement disorder, discomfort, hypotension, gait disturbances, cognitive/behavioral impairment through review date. Interventions include: Monitor for side effects, and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly, dated 7/9/2026.R1 uses antidepressant medication related to depression dated 7/9/2026. Interventions include monitor/document side effects and effectiveness every shift. Monitor/document/document/report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, withdrawal; decline in activities of daily living ability, continence, rigid muscles, movement problems appetite loss, weight loss, nausea and vomiting, and dry mouth dated 7/9/2026.R1 has a potential nutritional problem of weight/ loss related to cognition. Diet: Regular diet, Regular liquids dated 7/9/2026. Interventions include encourage intake of meals and snacks, encourage portion control, limit/avoid snacking and encourage physical activities within limitation, develop an activity program that include exercise , mobility. Offer activities of choice to help divert attention from food with date of 7/9/2026. Offer ice cream at all meals dated 8/7/2026, offer snacks in between meals dated 8/11/2026, power mashed potatoes lunch/dinner dated 8/11/2026, whole milk three times a day dated 8/11/2026.R1's Progress Notes dated 6/4/2026 document the following:7:45AM: resident is presenting with polydipsia (excessive thirst) and is diaphoretic (excessive sweating). Unable to perform stat labs in house, so we will be sending resident to local hospital. Primary group provider was in agreement with resident being out. Ambulance service called and report given to the emergency room. Resident's blood sugar level is 112. Blood pressure 145/91, Heart rate 121, respirations at 20 breaths per minute, and oxygen level at 96%. 3:45PM: Resident discharged from local hospital and arrived back to facility by ambulance service. No new orders were received from the hospital. Vital signs within normal limits for resident. R1's Progress Notes dated 6/19/2026 document the following:12:05PM: R1 was leaning more forward and to the left side. Unable to sit up straight. Vital signs temp 97.8, oxygen level 97%, Pulse 117, Respirations 20 breaths per minute, Blood Pressure 135/102, and Blood sugar was 116. Called primary care group back and Nurse Practitioner gave order for resident to go to the emergency room. Spoke to Power of Attorney who agreed with nurse practitioner's orders and would like resident to be sent to local hospital. Ambulance was called and report called.5:05PM: received call from local hospital regarding resident all tests and labs are good and is ready to return to the facility.R1's Progress Notes dated 7/3/2026 document the following:5:18PM: R1 soaking through clothes, Oxygen level 85%, Blood Pressure 80/55, Respirations 24 breathes a minute, and Pulse 68. Notified Power of Attorney, Hospital and ambulance. Call placed to primary care. R1 has white frothy phlegm. 10:30PM: nurse from local hospital called and stated resident is being admitted . Diagnosis was sepsis but not specified where per nurse trying to still find the source . R1's Power of Attorney notified.R1's Progress Notes dated 7/25/2026 at 5:32PM, authored by V21 (RN) called to R1's room by CNA who stated R1 looks terrible- is turning blue. Immediately went to assess and take vital signs. At first was unable to take vital signs because she would not hold still. Brought her to her room and put her to bed. Then able to obtain vital signs - 97.7 temperature, 162 Blood Sugar, 93/56 Blood Pressure, and Oxygen level of 80% on room air (without oxygen) 34 breaths per minute and unable to obtain pulse. Applied oxygen at 2 liters per minute per nasal cannula and raised oxygen levels to 85%. Called (on call physician group) and received new orders to send to emergency room if her blood sugar is low. Blood sugar not low but sending R1 to the emergency room due to R1's condition. Called ambulance at 5:10PM and arrival time of 5:15PM. Called local emergency room at 5:20PM and spoke with V3 (R1's Power of Attorney) at 5:25PM just as ambulance was leaving the facility. Notified facility on call nurse.On 8/5/26 at 10:55AM, V3 (Family Member/Power of Attorney) stated R1 was improving a little at the hospital. V3 stated the facility put her on a Psych medication because she was yelling. I demanded for them to take her off of the medication (Seroquel) because R1 kept losing weight. V3 stated R1 even got to where she could not even feed herself and they were not helping her eat like they should. V3 stated R1 almost died because of it. V3 stated R1 would not be returning to this facility and has been accepted by another facility. On 8/12/2026 at 9:00AM, V20 (Registered Nurse/RN at local hospital) stated she was working at the hospital when R1 came to the Intensive Care Unit (ICU) where she was working. R1 stated the physician and the family were very worried about R1's loss of weight and that she was profoundly dehydrated. V20 stated R1 was administered several bags of fluids to try to hydrate. V20 stated she remembers R1's sodium being very high. V20 stated R1 was very lethargic when she arrived but the next day R1 was becoming more arousable. V20 stated once R1 was cleared for swallowing then R1 was eating good for them. V20 stated that records show that Seroquel was never administered once she was admitted to the hospital. V20 stated R1 continued to be more alert as she was in the hospital. R1's Order Recap Report with a print date of 8/7/26 and Order Summary Report with a print date of 8/11/26 document the following orders:Diazepam (Valium) (Benzodiazepine) 5mg give 0.5 tablet (1/2 tab) one time a day related to Generalized Anxiety Disorder with an order date of 2/11/25 and an order status of active.Mirtazapine (Remeron) (Antidepressant) 7.5mg give 1 tablet by mouth at bedtime for depressive symptoms, restlessness, screaming, labile mood, appetite support with a start date of 4/23/26 and an end date of 5/13/26. Mirtazapine 15mg give 1 tablet by mouth at bedtime for depression with a start date of 5/13/26 and end date of 6/5/26. Mirtazapine give 22.5mg by mouth at bedtime for depression with a start date of 6/5/26 and an order status of active.Quetiapine Fumarate (Seroquel) (antipsychotic) tablet 25 mg one time a day at 8:00PM related to Generalized Anxiety Disorder, Major Depressive Disorder with a start date of 4/10/26 and end date of 7/6/2026. Quetiapine Fumarate tablet give 50mg one time a day at 9:00AM with a start date of 4/10/26 and end date of 7/6/26. Quetiapine Fumarate tablet 25 mg one time a day at 8PM with start date of 7/6/2026 and an end date of 7/20/2026. Quetiapine Fumarate tablet 25 mg one tab daily at 9:00AM with a start date of 7/7/2026 an end date of 7/20/2026. Quetiapine Fumarate tablet 25 mg twice a day with a start date of 7/27/26 and an order status of active.Venlafaxine HCl (Effexor) (Antidepressant) ER 150 mg one capsule daily for low mood related to Major Depressive Disorder (MDD), recurrent, mild, with a start date of 3/27/26 and an end date of 7/20/26. Venlafaxine ER 112.5mg one tablet daily with a start date of 7/21/2026 and an end date of 7/25/2026. Venlafaxine ER 75mg one tablet daily at 8:00AM with a start date 7/26/2026 and order status of active. Sertraline HCL (Zoloft) (Antidepressant) 25mg twice a day for low mood, agitation related to Generalized Anxiety Disorder, MDD, recurrent, mild, with a star date of 7/20/26 and an order status of active.Gabapentin (Neurontin) (anticonvulsant) 100mg give 1 tablet three times a day for neuropathy with a start date of 6/5/2026 and an end date of 6/23/26. Gabapentin 100mg give 2capsules 3 times a day for pain with a start date of 6/23/26 and an order status of active.R1's physician's orders indicate that R1 medication regimen from 6/5/26 to 6/23/26 included the following: Gabapentin (anticonvulsant) 100mg three times a day, Diazepam (benzodiazepine) 5mg, 1/2 tablet in the AM, Mirtazapine (antidepressant) 22.5mg at bedtime, Venlafaxine HCl (antidepressant) ER 150 mg one capsule daily, and Quetiapine Fumarate (antipsychotic) 50mg tablet at 9:00AM and 25mg at 8:00PM. On 6/23/26, R1's Gabapentin order was increased to two 100mg capsules (200mg) three times a day. On 7/6/26, R1's order for Quetiapine Fumarate was decreased to 25mg at 9:00AM and 8:00PM. On 7/21/26, R1's order for Venlafaxine HCl ER dose was decreased to 112.5mg daily and started Sertraline HCL (antidepressant) 25mg twice a day. R1's Seroquel order ended and was not ordered again until 7/27/26 after R1 was hospitalized . On 7/25/26, R1's Venlafaxine HCl ER dose was decreased to 75mg daily. At the time of R1's hospitalization on 7/25/26, R1's drug regimen included the following: Gabapentin two 100mg capsules (200mg) three times a day, Diazepam 5mg 1/2 tab (2.5mg) in the AM, Mirtazapine 22.5mg at bedtime, Venlafaxine HCl ER 75mg, Sertraline HCL 25mg twice a day.According to https://reference.medscape.com/drug-interactionchecker, the Drug Interaction Checker documents there are 19 interactions found for the medications of Gabapentin, Effexor, Zoloft, Remeron, Valium, and Seroquel. Serious interactions include increased serotonin levels and increased and/or decreased QTc levels (affecting heart rate and rhythm). Significant interactions include the increased risk for neuroleptic malignant syndrome and serotonin syndrome. Patients should be monitored for evidence of serotonin toxicity (mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (hyperthermia, muscle rigidity, autonomic dysfunction). Other significant interactions with the coadministration of Central Nervous Depressants (Gabapentin and Valium) can result in serious, life-threatening, and fatal respiratory depression. Use lowest dose possible and monitor for respiratory depression and sedation. It is recommended to avoid concomitant use or consider alternate drug therapy with medications causing serious interactions.Per The National Alliance for Mental Illness website (https://www.nami.org) under serious side effects for the treatment of Seroquel states: Some people may develop muscle related side effects while taking quetiapine (Seroquel). The technical terms for these are extrapyramidal symptoms (EPS) and tardive dyskinesia (TD). Symptoms of EPS include restlessness, tremor, and stiffness. TD symptoms include slow or jerky movements that one cannot control, often starting in the mouth with tongue rolling or chewing movements. The risks for the use of Seroquel further states: Tardive dyskinesia (TD) is a side effect that develops with prolonged use of antipsychotics.If you develop symptoms of TD, such as grimacing, sucking, and smacking of lips, or other movements that you cannot control, contact your health care provider immediately. All patients taking either first- or second-generation antipsychotics should have an Abnormal Involuntary Movement Scale (AIMS) completed regularly by their health care provider to monitor for TD.The facility policy titled AIMS Side Effect Monitoring with a revision date of 1/11/18 documents Purpose: Abnormal Involuntary Movement Scale (AIMS) - records the occurrence of tardive dyskinesia (TD- a neurological disorder characterized by involuntary movements of the face and jaw) of residents receiving psychotropic medications. To assess the presence of movement and non-movement side effects, and to follow the severity of TD over time. Under Guidelines documents The examination will be performed either at the time of resident's admission or when medications are initially prescribed. In addition, for residents taking psychotropic medication, AIMS examination procedures will be repeated at intervals of no less than every six (6) months.Assessment results will be conveyed to attending psychiatrist and NP (Nurse Practitioner) when abnormal findings or increasing in severity and side effects is noted. The Psychiatrist/NP shall work with the residents to determine the most appropriate course of treatment, considering both the effects of Tardive Dyskinesia and the resident's psychiatric condition.On 8/14/2026 at 12:00PM, V5 (Regional Clinical Director) was asked how often AIMS are completed for residents on Psychotropic /Antipsychotic medications. V5 stated with any change in condition, with any increase in medications, with new admissions, and every 6 months.The Electronic Health Record AIMS Evaluation instructions documents the following scoring codes for assessment categories: 0-None, 1-Minimal, maybe extreme normal, 2-Mild, 3-Moderate, and 4-Severe. R1's AIMS Evaluation (Abnormal Involuntary Movement) dated 1/2/2026 completed by V37 (former Director of Nursing) documents a total score of 12.0. Muscles of facial expressions: Moderate. Lips and perioral area: Moderate. Jaw: Moderate. Tongue: Minimal. Upper extremities (arms, wrist, hands, and fingers): Minimal. Lower lateral knee movements: none. Neck, shoulders, and hips: Minimal. Severity of abnormal overall: Moderate. Incapacitation due to abnormal movements: None. Residents' awareness of abnormal movement: no awareness. Resident cooperation level: Partial.R1's AIMS Evaluation (Abnormal Involuntary Movement) dated 7/2/2026 completed by V1 (Administrator) documents a score of 27.0 Muscles of facial expressions: Severe. Lips and Perioral Area: Severe. Jaw movement: Severe. Tongue: Severe. Upper extremities: Severe. Lateral knee movement: Severe. Severity of abnormal movements overall: Severe. Incapacitation due to abnormal movement: Moderate. Resident's awareness of abnormal movement: no awareness. Resident's cooperation level: none. A Summary Report from the psychiatric consultant group dated 5/27/26 documents a summary of residents seen by the psychiatric provider and documents new orders and diagnosis of each resident. This document further states The orders were not entered into the EMR (Electronic Medical Record) by the provider as agreed. We request that these be placed after consent is obtained for new medications or increases in doses. The effective date of the orders may be the date that consent is obtained, the date that new medications arrive from the pharmacy, the date that this email was sent or the date of the visit. This report documents that R1 was seen on 5/27/26 and Gabapentin 100mg three times a day for diagnoses of General Anxiety Disorder (GAD), anxiety, panic, pacing, screaming, yelling and increase Remeron from 15mg to 22.5mg at bedtime for Major Depressive Disorder (MDD), depressive symptoms, restlessness, screaming, labile mood, and appetite support. R1's Psychiatry Note dated 5/27/2026 by V14 (Psychiatric Nurse Practitioner) documents Chief Complaint: Assessment for medication adjustment in the context of increased anxiety and ongoing disruptive sounds. R1 has a history of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and severe intellectual disabilities, who's seen today sitting in wheelchair in the dining room. At last visit increased Mirtazapine (Remeron); no apparent adverse effect reported. During today's encounter, R1 presents minimally interactive and hypo verbal. However, she is observed very anxious and with ongoing disruptive sounds as another resident watching television located above and behind her table. Per chart review for past two weeks, frequent episodes of frustration, agitation, anxiety, panic, yelling quit it throughout the day, accusing disruptive sounds, screaming at others, repetitive motions. Medication changes: Patient's MDD/GAD are worsening and unstable at this visit start Gabapentin 100mg by mouth three times a day. Increase Remeron to 22.5mg by mouth at bedtime. Continue Seroquel for agitation and restlessness. Continue Effexor for depression. Continue Diazepam for anxiety.The Summary Report from the psychiatric consultant group for the date of service of 6/1/26 documents that R1 was seen by V14 and to start Gabapentin 100mg three times a day and increase Remeron to 22.5mg at bedtime, awaiting POA (Power of Attorney) consent.R1's Order Summary Report and Order Recap Report did not document an order to increase the Remeron to 22.5mg and start Gabapentin 100mg three times a day until 6/5/26.The Summary Report from the psychiatric consultant group for the date of service of 6/29/26 document that R1 was seen by V14 with orders to decrease Effexor ER from 150mg to 112.5mg in the morning for diagnoses of MDD, IDD, behavioral instability and start Escitalopram (Lexapro) (antidepressant) 5mg in the morning for diagnoses of MDD, GAD, IDD, depressive, anxiety symptoms.R1's Psychiatry Note dated 6/29/2026 by V14 documents Chief Complaint: Assess increased anxiety and episodes of frustration, agitation, screaming at others, hitting, pushing, and grabbing others. Note of history of present illness states R1 is a female patient with a history of Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) with severe intellectual disabilities (IDD). R1 is seen sitting hunched over in wheelchair in hallway near dining room. Her mood today appears slightly anxious. R1 was nonverbal with minimal interaction during encounter. R1 was observed sitting with her chest resting on her legs while exhibiting wriggling motions. Per Primary Care Provider visit 6/18/2026, increased spinal curvature was noted related to a prior T12 compression fracture. On 6/23/2026 Gabapentin was increased by (V16 Primary Nurse Practitioner) due to concerns that increased behaviors may be related to pain. Medication changes: Decrease Effexor ER from 150mg to 112.5 mg by mouth every morning for behavioral instability related to MDD and IDD. Start Escitalopram 5 mg by mouth every morning for depressive/anxiety symptoms related to MDD, GAD, IDD. Continue Seroquel for low mood, agitation, restlessness, and adjunct treatment related to MDD. Continuing Remeron for depressive symptoms, restlessness, screaming, labile mood, and appetite support related to MDD. Continue Gabapentin for anxiety, panic, pacing, screaming and yelling related to GAD. Continue Diazepam for anxiety for anxiety related to GAD.R1's Order Summary Report and Order Recap Report did not document any orders for Escitalopram and did not document an order to decrease Effexor ER from 150mg to 112.5 mg until 7/21/26.The Summary Report from the psychiatric consultant group for the date of service of 7/10/26 documents that R1 was seen by V23 (Psychiatric Nurse Practitioner) with orders to decrease Seroquel from 25mg twice a day to 12.5mg twice a day for the diagnosis of MDD with low mood, agitations, restlessness, adjunct treatment and decrease Effexor ER from 150mg to 112.5mg in the morning for diagnoses of MDD, IDD with behavioral instability.R1's Psychiatry Note dated 7/10/2026 by V23 documents Chief Complaint: Monitoring behavioral symptoms and mood stability. History of Present Illness: R1 is a female with MDD, GAD and severe intellectual disability. Today she was seen lying in bed, awake, alert, and observed pointing and making vocalizations, though her speech was dysarthric and difficult to understand. When asked about her mood she stated fine. Compared with the previous evaluation, she is more interactive and engaged. Staff reports no further episodes of agitation or aggression and no recent self-injurious behavior, throwing food, refusal of care, or other disruptive behaviors. Mood and anxiety appear improved overall. Sleep and appetite were not reported as problematic. No medication side effects were observed or reported. Medication Changes Seroquel 25mg twice a day to 12.5mg by mouth twice a day. Decrease Effexor ER 112.5mg to 75mg by mouth every morning.R1's Progress Note dated 7/20/26 at 4:05PM, authored by V2, documents to decrease Quetiapine to 12.5mg for GDR and decrease Venlafaxine ER 112.5 mg for GDR. The Summary Report from the psychiatric consultant group for the date of service of 7/24/26 documents that R1 was seen by V23 and received orders to decrease Effexor ER from 112.5mg to 75mg in the morning for GDR (Gradual Dose Reduction) for diagnoses of MDD, IDD with depressive symptoms, behavioral instability.R1's Psychiatric Note dated 7/24/26 by V23 documents Chief Complaint: Chief Complaint: Assessment of response to recent gradual dose reductions of quetiapine and venlafaxine while monitoring behavioral stability. History Of Present Illness: R1 is a female with major depressive disorder, generalized anxiety disorder, and severe intellectual disability. She is seen today seated in her wheelchair in the dining room. Her speech remains dysarthric and difficult to understand; however, she smiles and makes vocalizations when engaged. Staff report no behavioral escalations, agitation, aggression, self-injurious behaviors, or other disruptive behaviors since the previous psychiatric evaluation. She is currently undergoing a medical workup for significant weight loss. Mood appears stable, and anxiety is not observed to be increased. Sleep remains stable, and appetite continues to be monitored in the setting of her ongoing medical evaluation. No medication side effects are observed or reported. No hallucinations, paranoia, or manic symptoms are evident. No suicidal or homicidal ideation is reported. Psychiatric history documents diagnoses of: Intellectual Disabilities, Obsessive compulsive disorder, Depression with psychotic features, severe mental retardation, developmental delay, depression with aggressive behaviors, anxiety, mood disorder, and personality disorder. Under AIMS documents a score of 0 and a date of 12/18/25. Med changes documented under plan include: Psychotropic medication changes are indicated at this time. Major depressive disorder and generalized anxiety disorder remain stable without recurrence of agitation, aggression, self-injurious behaviors, or other disruptive behaviors following recent medication adjustments. Severe intellectual disability continues to require a structured and supportive environment. She is tolerating her current psychotropic regimen without reported adverse effects. Given her sustained psychiatric stability, venlafaxine will be gradually reduced to lessen overall psychotropic medication burden while monitoring closely for recurrence of depressive symptoms, anxiety, or behavioral instability. Decrease Venlafaxine ER 112.5 mg to 75 mg every morning. Under Medication List documents: Quetiapine (Seroquel) 12.5mg twice a day, Venlafaxine ER (Effexor) 75 in the AM, Escitalopram (Lexapro) 5mg in the AM, Mirtazapine (Remeron) 22.5mg at bedtime, Gabapentin (Neurontin) 200mg three times a day, Diazepam (Valium) 2.5mg in the AM. Most recent GDR's document the following: 07/24/26 decreased Venlafaxine ER from112.5mg to 75mg in the AM; 07/10/26 decreased Quetiapine from 25mg twice a day to 12.5mg twice a day; 06/29/26 decreased Venlafaxine ER from 150mg to 112.5mg in the AM; 06/29/26 GDR contraindicated for Mirtazapine due to patient has experienced a 9.4-pound weight loss since 6/1/26, with a current weight of 101.2 pounds and ongoing occurrences of disruptive vocalizations, anxiety, and repetitive motions; 06/29/26 GDR contraindicated for Gabapentin due to episodes of frustration, agitation, screaming at others, hitting, pushing, and grabbing others.The psychiatric consultant notes reviewed for R1 did not document any orders for Zoloft 25mg twice a day.R1's Medication Administration Records (MAR) for June 2026 and July 2026 document that R1 received Remeron 22.5mg at bedtime on 6/5/26 and received it daily through June and July until R1 was hospitalized . There is no documentation on the June and July 2026 MAR's of an order for Escitalopram or ever receiving Escitalopram. The July 2026 MAR documents that R1 received Zoloft 25mg twice a day from 7/20/26 until 7/25/26 when R1 was hospitalized .On 8/27/26 at 9:46AM, V2 (Di

Based on observation, interview, and record review, the facility failed to accurately assess, identify, document, implement interventions, and treat pressure wounds/injury for 2 of 3 residents (R1, R2) reviewed for pressure ulcers in a sample of 8. These failures resulted in R1 developing new wounds to the left hip, left ankles, and bilateral elbows and R2 developing a stage 2 pressure ulcer to the coccyx.Findings include:1. R1's admission Record documents an admission date of 11/27/2013 with diagnoses including Hypertensive Heart Disease with heart failure, Crohn's Disease of both small and large intestines without complications, Muscle Wasting and Atrophy, Lack of Coordination, Dysphagia oral phase, Abnormal Posture, Hyperesthesia, Atherosclerotic Heart Disease, Hyperlipidemia, Anxiety, Severe Intellectual Disabilities, Osteoporosis, Major Depressive Disorder, and Physical Debility.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognition impairment. Section GG (Functional Abilities) documents R1 does not have impairment to upper or lower extremities and uses a manual wheelchair for mobility. The same section documents that R1 is dependent on staff for position/repositioning while in bed and transfers. Section M (Skin Condition) documents that R1 is at risk for the development of pressure ulcers and that R1 does not have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The same section documents that R1 has pressure reducing devices for her chair and bed. R1's Braden Scale Pressure Ulcer Risk Evaluation by V1 (Administrator) dated 6/8/2026 documents Sensory Perception: No impairment. Moisture: Very moist. Activity: Chairfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: probably inadequate. Friction and shear: Potential problem. Braden Score of 14.0 indicating R1 is at moderate risk for developing pressure ulcers.R1's Care Plan documents R1 has impaired physical mobility with risk for impaired skin integrity related to prolonged wheelchair sitting and poor positioning and documents the following wounds: 1/21/2026- open area to left hip/thigh (resolved), 1/21/2026 open area to right buttocks (resolved), 3/25/2026- Bruise left chest (resolved), 6/3/2026- Right wrist open area, 7/23/2026-Open area right buttock (date initiated 7/9/2026 and revision date 7/28/2026). There is no documentation of current wounds to R1's left hip, left ankle or elbows documented on this Care Plan. This Focus area documents a Goal of R1 will maintain proper positioning in wheelchair and remain free from skin breakdown while using prescribed wheelchair cushion with an initiation date of 7/9/2026. Documented interventions include: 1/21/2026- Barrier cream to be applied daily and as needed to buttocks, 1/21/2026- refer to wound consult, 3/25/2026 resident to have lotion applied to skin when resident allows to prevent resident rubbing/ scratching, 6/3/2026 - ensure resident has appropriate accessories on to prevent rubbing on skin with a documented initiation date of 7/9/26, 7/23/2026- resident to be encouraged to lay down during down time hours to relieve pressure, as resident allows with a documented initiation date of 7/26/2026, and Ensure wheelchair cushion is placed correctly and secured prior to seating, Resident to wear skin sleeves on bilateral elbows, when resident allows, use prescribed wheelchair pressure relieving cushion at all times when resident is seated with documented initiation date of 7/9/26. R1's Visit Report from the wound care consultant dated 7/13/26 documents that R1 has a Stage 2 Pressure Ulcer to the Right Posterior Buttocks acquired on 7/9/26 measuring 0.7 centimeters (cm) (length) x 0.8cm (width) x 0.1cm (depth). R1's Visit Report from the wound care consultant dated 7/20/26 documents that the stage 2 pressure ulcer to R1's Right Posterior Buttocks acquired on 7/9/2026 now measures 0.6cm x 0.8cm x 0.8cm with a treatment order of: Clean wound with normal saline/house wound cleanser, foam border dressing, honey and skin prep to peri wound area. Change 3 times a week and as needed. The same note also documents that R1 now has a stage 2 pressure ulcer to the left hip acquired on 7/15/2026 measuring 0.5cm x 0.5cm x 0.1cm with treatment orders of: Cleanse with normal saline, collagen sheet, border foam dressing, and skin prep to peri wound. Change 3 times a week and as needed. Turn and reposition frequently per facility protocol. Nutrition: maximize protein intake target 1.4-2.1 grams/kilograms/day.R1's Visit Report from the wound care consultant for 7/13/2026 and 7/20/2026 did not document wounds to the left ankle, bilateral elbows, or right foot area. R1's Order Recap Report for orders dated 2/1/26-8/31/26 documents the following order with a start date of 7/14/26 and an end date of 7/21/26 to cleanse wounds to bil (bilateral) buttocks with normal saline/house wound cleanser, apply non-sling skin prep arounds wounds, apply honey, cover with bordered foam/bordered gauze, change daily every night shift for wound care. The same report documents the following active orders: Apply skin sleeves to bilateral elbows when in wheelchair, may pad elbows with soft gauze before applying sleeves every day shift for wound management with a start date of 6/24/2026; cleanse wound right posterior buttocks with normal saline/house wound cleanser, apply non sting skin prep around wound, apply honey and cover with bordered foam gauze dressing, change Monday, Wednesday, Friday and as needed every night shift with start date of 7/22/2026; cleanse wound to left hip with normal saline/house wound cleanser, apply non sting skin prep around wound, apply collagen sheet, cover with bordered foam gauze dressing, change Monday, Wednesday, Friday and as needed every night shift with start date of 7/22/2026; skin prep to left ankle 2 times a day for prophylaxis with a start date of 7/2/26; skin prep to right lateral foot 2 times a day for prophylaxis with a start date of 7/2/26; wear heel protectors at all times when in bed/recliner/ wheelchair with a start date of 7/2/26, R1's Progress Note dated 7/2/2026 at 3:32PM by V25 (Registered Nurse/RN) documents CNA notified this nurse that R1 had a dressing to left ankle, this nurse observed a 1cm x 1cm open area to left lateral ankle. Also noted non blanchable redness to right lateral foot and heel, Administrator, DON (Director of Nursing), and POA (Power of Attorney) notified. On 8/18/2026 at 1:46PM, V25 was asked about the above Progress Note on 7/2/26 and stated yes, I remember that and I filled out the new skin report and told the DON (Director of Nursing/V2) and I think I notified the Nurse Practitioner. I also looked at both elbows and they had open areas, and yes those areas were pressure from moving arms on wheelchair possibly. V25 also stated that she noted R1's right lateral foot/heel with non-blanchable redness. V25 stated there was a dressing to the left ankle but she is unsure of who applied the dressing and there were no orders documented. V25 stated that usually the physician or nurse practitioner will refer to wound care and the DON makes rounds with wound care, so she notifies the wound care team. V25 said that she works 1-2 days a week and hadn't made rounds with wound care in a while. R1's Progress Notes documents on 7/2/2026 at 5:18PM N.O (new order) received and processes related to wounds. Authored by V25. On 8/19/2026 at 10:36AM, V34 (Physician/Medical Director) was asked if he remembers ordering skin prep for R1's left lateral ankle on 7/2//2026. V34 stated, I don't really remember that but maybe it was one of the other physicians or nurse practitioners that seen R1 at the facility. V34 was asked if it is normal practice to order skin prep to an open wound, V34 stated I wouldn't think so but I would need to see the wound to give a direct answer. On 8/18/2026 at 1:56PM, V2 (Director of Nursing/DON) was asked if she informed the wound care team about the open areas to R1's left lateral ankle and bilateral elbow areas and V2 stated I didn't know anything about this area. V2 was asked if wound care ever looked at these areas on rounds and V2 stated no, because we did not know anything about the areas. V2 was asked if she would have an order for skin prep to open areas and V2 stated no, that would not be very pleasant. On 8/7/2026 at 9:30AM, V9 (Primary Physician) was asked if he was aware R1 had wounds as well. V9 checked his records and notifications and stated he was never made aware of R1's wounds. On 8/11/2026 at 8:30AM, V16 (Primary Nurse Practitioner) was asked if they were aware of R1 having wounds and V16 stated No, I was not aware of any wounds; I only know of a bruise they showed me on R1's shoulder and it looked like that was from (R1) leaning over so much in her wheelchair. On 8/11/2026 at 3:30PM, V1 and V2 were asked about the areas to R1's elbows and why no treatment if the elbows were actually open. V1 stated Oh yes, she had open areas to her elbows, and they started as like abrasions where (R1) was constantly moving her arms and rubbing them on the wheelchair arms, but they kept getting worse. V2 stated I never knew anything about her elbows, and I know the wound care team had never seen those or treated those. V1 stated I didn't realize there were never treatments on her elbows. Document titled Wound Care Visit Report for 7/13/2026 and 7/20/2026 and there is no documentation in these wound reports that note the areas to the left ankle, bilateral elbows, and right foot area. The facility's Weekly Wound Tracking dated July 2026 for R1 document wounds to the right posterior buttocks and left hip. There are no other wounds documented for R1.R1's Weekly Skin Observations dated 6/25/2026 at 3:36 PM, authored by V1 (Administrator), no foot concerns is marked. Documented skin concerns are right and left elbow abrasion and redness to the coccyx. Authored by V1 Administrator. Signed on 6/26/2026. R1's Weekly Skin Observations dated 6/25/2026 at 4:08 PM, authored by V25 Registered Nurse/RN), documents open areas to right and left elbow and no foot concerns is marked.R1's Weekly Skin Observations dated 7/2/2026, authored by V25 (Registered Nurse/RN), documents foot concerns new, dressing was applied to foot/feet and documents that there is an open area to the left lateral ankle that is 1cm x 1cm. Other documented skin concerns are open areas to the right and left elbow and right lateral foot heel/non blanchable redness. R1's Weekly Skin Observations dated 7/9/2026, authored by V26 (RN), no foot concerns is marked. Documented skin concerns include: open areas to the right and left elbows, left ankle (outer) open area 1cm x1 cm, and right lateral foot/heel non blanchable redness. R1's Weekly Skin Observations dated 7/16/2026 authored by V27 (Licensed Practical Nurse/ LPN) documents the following areas of concern: existing OA (open area to the right elbow, existing area to right buttock with dressing applied, existing area to the left buttock with dressing applied, and scabs on ankles and documents no new skin conditions observed. R1's Weekly Skin Observations dated 7/23/2026, authored by V25, document open lesions to the left ankle and right foot. Skin concerns documented are an open area to the left trochanter (hip), a new open area to the right buttock measuring 0.5cm x 0.5 cm, and an open area to the left buttock. R1's Progress Note dated 7/25/2026 at 5:32PM documents that R1 was sent to the emergency room at the local hospital via ambulance. R1's records from the local hospital document that R1 was admitted to the hospital on [DATE]. The hospital records document on 7/26/26 that R1 had the following wounds: 2 wounds to the left hip area measuring 1cm x 1 cm and 0.5cm x 0.5cm (no depth documented for the wounds), a wound to the left ankle measuring 0.8cm x 0.8 cm, and a wound to the right buttock with no documented measurements. On 8/6/2026 at 3:38PM, R1 was observed while in the hospital. There were dressings in place to both of R1's elbows and bilateral ankles. The left hip areas and buttocks were unable to be observed at this time. 2. R2's admission Record documents an admission date of 7/7/2026 and includes diagnoses of Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease stage 3A, Muscle Wasting and Atrophy, Systolic Congestive Heart Failure, Major Depressive Disorder, Peripheral Vascular Disease, Hyperlipidemia, Hypothyroidism, End Stage Renal Disease, Pressure Ulcer of Right Ankle Unstageable, Anxiety, Age related Physical Debility, and Cognition Communication Deficit. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 indicating R2's cognition is intact. Section GG (functional abilities) documents R2 has no impairment to upper and lower extremities and uses a wheelchair for mobility. R2 is dependent on staff for all activities of daily living except R2 requires supervision or touching assistance for eating. Section M Skin Conditions documents that R2 is at risk for pressure ulcers/injuries and R2 does not have any unhealed pressure ulcers/injuries. Under Skin and Ulcer/Injury Treatments has a pressure/reducing device for chair and application of dressings to feet are marked yes. R2's Care Plan documents a focus area of potential/actual impairment to skin integrity related to decreased mobility, Diabetes Mellitus, and incontinent at times. Interventions documented for this Focus area include: Monitor/document location, size and treatment of impairment. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration to MD with an initiation date of 4/1/24; Weekly Skin check with documentation with an initiation date of 8/19/24; and Wheelchair cushion to be placed in wheelchair when resident is up in wheelchair initiated on 10/29/25.R2's Progress Note dated 7/14/2026 at 9:45AM documents a Braden Scale for predicting Pressure Ulcer Risk Evaluation. Braden Evaluation: Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Chairfast. Resident is Slightly Limited: Makes frequent through slight changes in body or extremity position independently. Nutrition: Probably inadequate. Friction and Shear: Problem. Braden Score: 14.0 indicating R2 is at moderate risk for developing pressure ulcers. On 8/6/2026 at 12:10PM, R2 was observed sitting in the dining area in her wheelchair. R2 started crying and when asked what was wrong, R2 told this surveyor that her butt is hurting badly and is burning. R2 stated they were supposed to get me a cushion for my wheelchair, and they continue to keep putting me off. R2 stated I know there is an open area because it is burning bad from my urine. R2 was noted to continue crying and stated that open spot on her butt is burning and hurting so badly and her urine is burning on it like fire. There was no cushion observed in R2's wheelchair. R2 stated I keep telling the nurses that I need a cushion but they keep saying hospice did not bring one yet. On 8/6/2026 at 1:25PM, R2's skin was observed with V6 Certified Nurse Assistant (CNA) present. V6 assisted R2 with turning to observe R2's buttocks. R2 pointed to the area on her lower right buttocks. The area was noted to be red and had a slit-like open area to the crease of her right buttocks. R2 stated that is the area that rubs on the wheelchair seat. The left side of R2's buttocks has no open areas but has a scar area noted. R2 stated that was a bed sore too but has recently healed but she is afraid it will open back up too without a cushion in her wheelchair. The findings of R2's skin observation was reported by this surveyor to V1 (Administrator) and V5 (Regional Clinical Director) at this time. V1 stated they would look into this and get it addressed. R2's Progress Notes were reviewed for documentation of new area noted on 8/6/2026, to Right Buttocks and no documentation was noted related to the Right Buttocks open area. On 8/7/2026 at 9:30AM, V9 (Physician) was asked if he was notified of small open spot to R2's right buttocks, V9 stated No, I was not notified. On 8/7/2026 at 1:26PM, V2 was asked what the process is when a new wound is discovered on a resident. V2 stated the nurses usually tell her and an assessment is done. V2 stated then we notify the physician for orders and then we refer to the Wound Care Consults. V2 was asked if V9 was notified of R2's buttocks and V2 stated Yes, I faxed over a notification. This surveyor asked V2 to present the fax and the notification confirmation. V2 stated Well, now that you ask for it, no, I did not do it. On 8/14/2025 at 2:00PM, V2 was asked for notes from the wound care team for R2 and V2 stated wound care for R2 has been turned over to hospice. On 8/14/2026 at 2:05PM, V1 and V5 were asked what treatment has been put into place for R2's open spot on her right buttocks and V1 stated Well, the nurse's looked and they really did not see anything open, so Hospice ordered Zinc Oxide to be applied. On 8/17/2026 at 11:50AM, R2 was up in her wheelchair in the hallway and was observed to have a cushion in her wheelchair. R2 stated her bottom feels better now that she has a cushion and is now getting cream put on her spot on her bottom. R2's Hospice Team Visit Log dated 8/10/2026 at 10:00AM documents Routine Visit, Wound Care done by V36 Licensed Practical Nurse (LPN/Hospice) , and continue current plan of care. No measurements or description of site of wound/wounds. R2's Orders Summary Report documents an order with start date of 8/6/2026 of Barrier Cream to buttocks as needed. There is no order for Zinc Oxide documented. R2's Wound Care Visit Report from the wound consultant group dated 8/3/2026 was the last note as wound care was turned over to hospice. The note entails the wound to the right ankle and no mention of the right buttocks.R2's Residential Hospice Team Visit Log entry dated 8/7/2026 at 11:45AM documents wound care completed and wound will be monitored. There is no wound location or measurements documented. R2's Residential Hospice Team Visit Log entry dated 8/10/2026 at 10:00AM documents wound care done by writer and continue current plan of care. There is no wound location or measurements documented. On 8/19/2026 at 10:15AM R2 was lying in her bed. A hospice staff member was present in the room and stated they were going to do treatments. V30 (Hospice Nurse) and V29 (Licensed Practical Nurse/LPN) entered the room. V30 stated she did not see the right buttocks open just red. R2 stated now I have another pressure spot on my bottom, the first small one is better, but this one is in the middle, and it hurts now. Area to right buttocks is closed with [NAME] in color where small open area was noted before. A new area to R2's coccyx was noted to have a dressing on it and when dressing was removed the coccyx had an area with pink skin surrounding and a small whitish colored open spot in the center of the area. V29 stated she would get an order for a treatment for that as well. R2's Progress Note dated 8/2/2026 at 11:20PM titled Weekly Skin Observation documents skin concerns to right elbow, skin tear to right forearm, right ankle. Skin concerns to feet are not new. Authored by V27 Licensed Practical Nurse (LPN)R2's Progress Note dated 8/9/2026 at 9:47PM PM titled Weekly Skin Observation documents skin concerns right elbow, skin tear right forearm, right ankle existing wound. Skin concerns observed to feet are not new. Authored by V26 Registered Nurse (RN).R2's Progress Note dated 8/16/2026 at 11:54PM titled Weekly Skin Observation documents skin concerns right lower leg discoloration, right ankle existing open area, skin concerns not new. Authored by V27 Licensed Practical Nurse (LPN).R2's Weekly Wound Tracking dated August 2026 documents Right Lateral Ankle, Right Knee Skin Tear and Coccyx stage 2 Pressure area with acquired date of 8/17/2026. Area measures 2 centimeters in Length (cm) x 2 cm in Width x 0.1cm Depth.R2's Order Summary Report documents a treatment order for Zinc Oxide to Coccyx every shift and as needed with an order date of 8/19/2026. R2's Progress Note on 8/17/2026 at 7:19AM, documents a skin check performed on resident this morning, she has scab to left top of hand, bilateral forearms have scattered bruises and discolored, left foot dryness/scaley, wound to right ankle, small spot to top of coccyx. Resident is on hospice and hospice is taking care of her wounds.There was no documentation in R2's Progress Notes on 8/19/26 documenting R2's physician (V9) being notified of the wound to the coccyx or orders for a treatment to the coccyx.The facility policy titled Pressure Injury and Skin Condition Assessment with revision date of 1/17/2018 under Purpose documents To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assessing interventions are implemented. 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. 7. At the earliest sign of a pressure injury or other skin problem the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress note.

Based on interview and record review the facility failed to prevent and thoroughly evaluate the cause of a severe weight loss for 1 of 3 residents (R1) reviewed for weight loss in a sample of 8. These failures resulted in R1 experiencing a 33.13% weight loss in 3 months and being admitted to the hospital with diagnoses to include dehydration, hypernatremia, acute kidney injury, respiratory failure and multi-organ failure. Findings include: R1's admission record documents an admission date of 11/27/2013. admission records include diagnoses of Hypertensive Heart Disease with heart failure, Crohn's Disease of both small and large intestines without complications, Muscle Wasting and Atrophy, Lack of Coordination, Dysphagia oral phase, Abnormal Posture, Hyperesthesia, Atherosclerotic Heart Disease, Hyperlipidemia, Anxiety, Sever Intellectual Disabilities, Osteoporosis, Major Depressive Disorder, and Physical Debility. R1's admission record documents R1 was discharged to a local hospital on 7/25/26 and did not return to the facility.R1's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 5 suggesting severe cognition impairment. Section K (Nutrition) dated 6/8/2026 documents a weight of 117 pounds and height of 63 inches (5 feet 3 inches). K0300. Weight loss: documents no or unknown for loss of 5% or more in the last month or loss of 10% or more in last 6 months. K0310. Weight gained: documents no or unknown for gain of 5% or more in the last month or gain of 10% or more in last 6 months. Section GG (functional abilities) documents R1 has no impairment to upper or lower extremities and used a manual wheelchair for mobility. R1's MDS documents R1 required supervision or touching assistance with eating. Section N Medications documents R1 is taking the following medications: Antipsychotics, Antianxiety, antidepressants and anticonvulsants.R1's care plan was reviewed and noted Focus R1 has a potential nutritional problem of weight loss related to cognition. Diet Regular diet, regular liquids, no food with skin intact. Date initiated 7/9/2026. 'Goal R1 will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date of 9/25/2026. Interventions include, administer medications as ordered. Monitor for side effects and effectiveness. Develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food. Encourage intake of meals and snacks. Encourage portion control, limit/avoid snacking and encourage physical activities within limitations. All interventions were initiated on 7/9/2026. R1's care plan documents a focus area of, R1 uses psychotropic medications. Date initiated 7/9/26. Interventions include: Monitor/document/report PRN (as needed) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms no usual to the person. Date initiated 7/9/26. R1 uses antidepressant medication related to depression dated 7/9/2026. Interventions include monitor/document side effects and effectiveness every shift. Monitor/document/document/report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, withdrawal; decline in activities of daily living ability, continence, rigid muscles, movement problems appetite loss, weight loss, nausea and vomiting, and dry mouth dated 7/9/2026.R1's Physician Order Sheet dated 7/1/2026 documents diet with order date of 10/15/2025 as Regular Texture. Thin consistency, no foods with skins (i.e. potatoes, tomatoes, apples). Patient may have if skin is removed.Facility document titled Weights and Vital Signs Summary dated 2/1/2026-8/31/2026 documents R1's weights as follows: R1 weighed 128.0 pounds (wheelchair) on 5/1/26 and 116.0 pounds (wheelchair) on 5/29/2026. This equals a 12 pound weight loss at 8.59 % (severe loss) for the month of May. R1 weighed 110.6 pounds (wheelchair) on 6/1/2026 and weighed 101.2 pounds (standing) on 6/28/2026. This equals a 9.4 pound weight loss at 8.5% (severe loss) for the month of June. R1 weighed 102.1 pounds (mechanical lift) on 7/1/26 and weighed 85.6 pounds (wheelchair) on 7/25/26. This equals a 16.5 pound weight loss at 16.16% (severe loss) for the month of July. R1's weight loss total over 3 months was 37.9 pounds at 33.13% (severe loss).According to the Centers for Disease Control (CDC) at https://www.cdc.gov/bmi/adult-calculator/index.html, R1 has a body mass index (BMI) of a 15.2 and is considered underweight with a weight of 85.6 pounds and a height of 5 feet 3 inches. According to the World Health Organization at https://apps.who.int/nutrition/landscape/help.aspx?menu=0&helpid=420#:~:text=Moderate%20and%20severe%20thinness%20%E2%80%93%20A,population%20has%20a%20BMI%20%3C18.5, a BMI of less than 17.0 indicates moderate and severe thinness. According to the WHO the consequences and implications of moderate and severe thinness: A BMI < 17.0 indicates moderate and severe thinness in adult populations. It has been linked to clear-cut increases in illness in adults studied in three continents and is therefore a further reasonable value to choose as a cut-off point for moderate risk. A BMI < 16.0 is known to be associated with a markedly increased risk for ill health, poor physical performance, lethargy and even death; this cut-off point is therefore a valid extreme limit.R1's Order Recap Report with a print date of 8/7/26 and Order Summary Report with a print date of 8/11/26 document the following orders:Diazepam (Valium) (Benzodiazepine) 5mg give 0.5 tablet (1/2 tab) one time a day related to Generalized Anxiety Disorder with an order date of 2/11/25 and an order status of active.Mirtazapine (Remeron) (Antidepressant) 7.5mg give 1 tablet by mouth at bedtime for depressive symptoms, restlessness, screaming, labile mood, appetite support with a start date of 4/23/26 and an end date of 5/13/26. Mirtazapine 15mg give 1 tablet by mouth at bedtime for depression with a start date of 5/13/26 and end date of 6/5/26. Mirtazapine give 22.5mg by mouth at bedtime for depression with a start date of 6/5/26 and an order status of active.Quetiapine Fumarate (Seroquel) (antipsychotic) tablet 25 mg one time a day at 8:00PM related to Generalized Anxiety Disorder, Major Depressive Disorder with a start date of 4/10/26 and end date of 7/6/2026. Quetiapine Fumarate tablet give 50mg one time a day at 9:00AM with a start date of 4/10/26 and end date of 7/6/26. Quetiapine Fumarate tablet 25 mg one time a day at 8PM with start date of 7/6/2026 and an end date of 7/20/2026. Quetiapine Fumarate tablet 25 mg one tab daily at 9:00AM with a start date of 7/7/2026 an end date of 7/20/2026. Quetiapine Fumarate tablet 25 mg twice a day with a start date of 7/27/26 and an order status of active.Venlafaxine HCl (Effexor) (Antidepressant) ER 150 mg one capsule daily for low mood related to Major Depressive Disorder (MDD), recurrent, mild, with a start date of 3/27/26 and an end date of 7/20/26. Venlafaxine ER 112.5mg one tablet daily with a start date of 7/21/2026 and an end date of 7/25/2026. Venlafaxine ER 75mg one tablet daily at 8:00AM with a start date 7/26/2026 and order status of active. Sertraline HCL (Zoloft) (Antidepressant) 25mg twice a day for low mood, agitation related to Generalized Anxiety Disorder, MDD, recurrent, mild, with a star date of 7/20/26 and an order status of active.Gabapentin (Neurontin) (anticonvulsant) 100mg give 1 tablet three times a day for neuropathy with a start date of 6/5/2026 and an end date of 6/23/26. Gabapentin 100mg give 2capsules 3 times a day for pain with a start date of 6/23/26 and an order status of active.R1's physician's orders indicate that R1 medication regimen from 6/5/26 to 6/23/26 included the following: Gabapentin (anticonvulsant) 100mg three times a day, Diazepam (benzodiazepine) 5mg, 1/2 tablet in the AM, Mirtazapine (antidepressant) 22.5mg at bedtime, Venlafaxine HCl (antidepressant) ER 150 mg one capsule daily, and Quetiapine Fumarate (antipsychotic) 50mg tablet at 9:00AM and 25mg at 8:00PM. On 6/23/26, R1's Gabapentin order was increased to two 100mg capsules (200mg) three times a day. On 7/6/26, R1's order for Quetiapine Fumarate was decreased to 25mg at 9:00AM and 8:00PM. On 7/21/26, R1's order for Venlafaxine HCl ER dose was decreased to 112.5mg daily and started Sertraline HCL (antidepressant) 25mg twice a day. R1's Seroquel order ended and was not ordered again until 7/27/26 after R1 was hospitalized . On 7/25/26, R1's Venlafaxine HCl ER dose was decreased to 75mg daily. At the time of R1's hospitalization on 7/25/26, R1's drug regimen included the following: Gabapentin two 100mg capsules (200mg) three times a day, Diazepam 5mg 1/2 tab (2.5mg) in the AM, Mirtazapine 22.5mg at bedtime, Venlafaxine HCl ER 75mg, Sertraline HCL 25mg twice a day.R1's Progress Notes documents on 7/25/2026 at 5:32PM, called to R1's room by CNA (Certified Nurse Assistant) who stated R1 looks terrible- is turning blue. Immediately went to assess and take vital signs. At first was unable to take vital signs because she would not hold still. Brought her to her room and put her to bed. Then able to obtain vital signs - 97.7 temperature, 162 Blood Sugar, 93/56 Blood Pressure, and Oxygen level of 80% on room air (without oxygen) 34 breaths per minute and unable to obtain pulse. Applied oxygen at 2 liters per minute per nasal cannula and raised oxygen levels to 85%. Called physician group on call and received new order to send to emergency room if her blood sugar is low. Blood sugar not low but sending R1 to the emergency room due to R1's condition. Called ambulance at 5:10PM and arrival time of 5:15PM. Called local emergency room at 5:20PM and spoke with V3 (R1's Power of Attorney) at 5:25PM just as ambulance was leaving the facility. Notified facility on call nurse. Authored by V21 Registered Nurse (RN). R1's Emergency Department-admission report documents. Present (11 days). Encounter date 7/25/2026 Altered Mental Status, unspecified altered, mental status type, Transaminitis, Hypoxia, Elevated Troponin, Failure to Thrive, Acute Kidney Injury, Elevated Lactic Acid Level, Elevated Lactic Acid Level, Elevated Brain Natriuretic Peptide (BNP), Acute Respiratory Failure with Hypoxia, and Multi- Organ Failure. Problem list includes Septic shock, Dehydration, and Hypernatremia. Document shows R1 was admitted to Intensive Care Unit (ICU) on 726/2026. R1's weight was recorded on 7/27/2026 at 12:00PM to be 71 pounds and 10.4 ounces. R1's Hospital Course documents R1 was admitted to Intensive Care Unit and started on pressors and intravenous resuscitation with hypotonic fluids. Shock resolved no evidence of infectious etiology. Hyponatremia is resolved. Acute Kidney Injury resolved with normalization of renal function. Rhabdomyolysis resolved well. Continued aggressive electrolyte replacement accordingly. Otherwise continued on full treatment systemic anticoagulation-developed thrombocytopenia with discontinuation; repeat CTA (computed tomography angiography) chest without Pulmonary Embolism. Continue Nothing by Mouth (NPO) as per Speech Therapy. Patient not able to follow commands, not able to swallow-did not deemed safe any further oral intake including dysphagia evaluation. Further discussion with family-okay for parental nutrition. Gastrointestinal (GI) consulted with Percutaneous Endoscopic Gastrostomy Tube (PEG) placement. Started on tube feeds with few water flushes and supplementations per nutrition given severe protein calorie-malnutrition- tolerated to mx goal rate prior to discharge. Patient is deemed stable for discharge at this time accordingly. On 8/6/2026 at 3:38PM, this surveyor arrived at local hospital where R1 was hospitalized . V8 (Registered Hospital Nurse) was asked what R1's weight was at this time and V8 weighed R1 (bed scale) and V8 now weighs 96.9 pounds. V8 stated R1 weighed 71.10 pounds upon admission on [DATE]. On 8/12/2026 at 9:00AM, V20 (Registered Nurse/RN) stated she was working at the hospital when R1 came to the Intensive Care Unit where she was working. R1 stated the physician and the family were very worried about R1's loss of weight and that she was profoundly dehydrated. V20 stated R1 was administered several bags of fluids to try to hydrate. V20 stated she remembers R1's sodium being very high. V20 stated R1 was very lethargic when she arrived but the next day R1 was becoming more arousable. V20 stated once R1 was cleared for swallowing then R1 was eating good for them. V20 stated that records show that Seroquel was never administered once she was admitted to the hospital. V20 stated R1 continued to be more alert as she was in the hospital. On at 8/17/2026 at 1:30PM, V28 (ICU physician) stated it didn't appear that R1 was in septic shock but was in shock from the dehydration when she got to the ICU. V28 stated R1 was very awake when he saw her once she was on the ICU wing. V28 stated R1 was very frail and fragile when he first saw her. V28 stated she was put on TPN (Total Parenteral Nutrition). V28 stated she had rapid constant movement especially her arms. V28 said the nurses reported she was having rapid frequent movement and was in critical condition when she arrived. V28 stated R1 was very sick when she arrived and we were working on trying to get her better. V28 stated R1's medications have been adjusted and she will no longer be on Effexor for now. V28 stated R1 did not receive Seroquel during her hospital stay.On 8/7/2026 at 9:30AM, V9 (Primary Physician) stated R1 was developmentally disabled and this was due to have Rheumatic Fever and Encephalopathy when she was a baby. V9 stated he remembers discussing R1's weight loss a couple of months ago. V9 stated he has done a lot of research on R1 trying to figure out what has been going on to cause the decline in function and weight loss. V9 stated R1 has gone out to the emergency room a couple of times but all of the scans and labs do not really show anything. V9 stated, I have not been able to figure it out. V9 was asked if he was always notified of weight losses throughout the last several months and V9 stated, I don't believe they notified me with every weight loss and I didn't realize she had lost so much weight. V9 stated, I have been seeing R1 since last October, but I noticed the decline starting slowly in January but really started declining in June. V9 stated R1 used to be normally up in her wheelchair but her Kyphosis has worsened. V9 stated his notes from back in March 2026 document, R1 was well nourished and was propelling herself in wheelchair. V9 stated R1 was always harmless and had staff that she loved. V9 was asked how R1 got the diagnosis of Major Depressive Disorder and V9 stated good question and that he did not know the answer. V9 stated, I try to stay in my lane and I feel like you need to be talking with the Psychiatry group, they manage all of her Psych medications. V9 was asked if he knew R1's last documented weight at the nursing facility was 84.6 pounds and V9 stated no. V9 was asked if he was aware the documented weight upon admission to the hospital was 71.10 pounds and V9 stated no. V9 was informed that R1's weight at the hospital is now 96.9 pounds. V9 stated he follows R1's emergency room visits and hospitalizations through electronic records at the hospital. V9 reiterated that he found no medical reason for R1's weight loss but was concerned about R1's psych medications. On 8/7/2026 at 1:40PM, V14 (Psychiatric Nurse Practitioner) stated she didn't realize R1 had a big weight loss. V14 was asked if she felt that taking multiple antidepressants could have contributed to the increased decline in cognition, appetite, and weight loss for R1. V14 stated, It is hard to say, and a slight chance with the Effexor. V14 stated they did see an increase in R1's decline. On 8/11/2026 at 1:10PM, V19 (Psychiatrist) stated he was made aware of R1's weight loss. V19 stated the weight loss was concerning but he can't relate the weight loss or decline to her psychotropic/antipsychotic medications. V19 stated it is possible that the weight loss and decline are related to the medications but medical needs to look at her as well. V19 discussed her recent hospitalization with no answers related to the weight loss. V19 stated he was unaware of the amount of weight that R1 had lost. V19 stated that the psychiatric group was not made aware of weights. V19 was asked if his group have access to the electronic medical records and V19 stated yes. V19 stated well, we will do better at watching the weights from now on. V19 stated I guess some of this decline could be related to the medications and hindsight is 20/20. V19 stated we always try to manage the residents to improve their quality of life but sometimes there are possible negative outcomes. V19 was asked if weight of a resident can affect the dosages of medications and V19 stated yes. V19 was asked if R1's weight loss was down to under 100 pounds, could that have made the dosages that were started before R1's weight loss impact the amount of medication that had effects on a resident. V19 stated yes, it is called volume distribution. V19 stated again that his team will do better at monitoring weights on all of the patients that they visit.On 8/7/2026 at 12:36PM, V13 (Certified Nurse Assistant/CNA) stated she has taken care of R1 over the last 7-8 months. V13 stated that R1 used to be bigger and talked a lot more than she did the last couple of months. V13 stated R1 had a decreased appetite for some reason. V13 stated R1 always wanted her turkey sandwiches at almost every meal, and she ate a lot of sandwiches but then over the last few months R1 did not hardly eat. V13 stated R1 started having more behaviors like yelling and resisting care. V13 stated we were trying to feed R1, but it was hard because her mouth was constantly moving. V13 stated R1's mental status changed too. V13 stated R1 was still on a regular diet. V13 stated R1's posture had a big change too. On 8/7/2026 at 12:25PM, V12 (CNA) stated R1 used to feed herself a regular diet. V12 stated over the last couple of months, R1 became aggressive and would push the food away and would only drink. V12 stated they would give R1 a big cup with a handle to keep with her but at times R1 would just let it spill out. V12 stated R1's diet never changed but she was only allowed 1 cup of fluids at meals because they said she had a fluid restriction or something.On 8/7/2026 at 12:20PM, V11 (CNA) stated she has been working at the facility for a few months. V11 stated when she first started working, she knew that R1 would feed herself and then she would want to sit outside the dining room with a bedside table. V11 stated R1 always wanted to eat sandwiches. V11 stated for the last month or so R1 had to be assisted with eating. V11 stated R1 had a big change in her cognition for a month or so before she went to the hospital. V11 stated, I know she had lost a lot of weight. V11 stated she knows that the last time that she weighed R1 she was down to 90 something pounds. V11 stated R1 would become irritated and would only drink. On 8/11/2026 at 8:30AM, V16 (Nurse Practitioner/NP) stated she has seen R1 multiple times. V16 stated herself and the primary physician alternates visits. V16 stated she had seen a decline in the last couple of months in R1. V16 stated R1 used to like sitting in the hallways and would be eating snacks and sandwiches. V16 stated she did witness R1 grabbing at the staff at times. V16 stated R1 used to be alert and awake most of the time but she made rounds in the early mornings, so she didn't see R1 in the dining room. V1 was asked if she ever noticed any signs of Tardive Dyskinesia with R1 and V16 stated, yes I did see the lip smacking and mouth movement recently. V16 stated she had been following R1's weights and she thought earlier in the year R1 was actually gaining a little weight. V16 stated she knows R1 was seen by the Dietician regularly and the Dietician would make recommendations. V16 stated the last weight she knew of was 101 pounds. V16 stated she was unaware that R1's last weight at the facility was actually around 85 pounds. V16 stated she did not know that R1's weight had declined to that low. On 8/18/2026 at 9:30AM spoke with V16 about R1's weights again. V16 stated she wasn't aware that R1's weight was down as low as she was in July but stated in June she had talked with the POA (Power of Attorney) about the next step for nutrition maybe a G tube with supplemental feeding but she didn't recommend that due to the quality of life for R1. V16 stated that V3 (POA) yelled and stated she just wanted some of the psych medications discontinued. On 8/6/2026 at 2:10PM, V2 (Director of Nursing/DON) stated she started working at the facility in the middle of March 2026. V2 stated that R1 had been changing for a little while and the Nurse Practitioner and V1 (Administrator) had talked with the sister. V2 stated R1's posture had been getting a lot worse and R1 became quieter. V2 stated R1 had declined, was quieter, lost some weight, and did not seem to be interested in eating as much. V2 stated R1 was seen by the dietician and they were following recommendations.On 8/11/2026 at 11:30AM, V1 (Administrator) was asked if she noticed the decline in R1. V1 stated, Yes, I noticed her declining rapidly over the last couple of months. V1 stated, I have known R1 for a long time and she always knew my name but recently she just looked at me like she didn't know who I was and was unable to say my name. V1 stated she did notice the rapid weight loss and kept telling everyone, We are missing something. On 8/7/2026 at 11:50AM, V10 (Speech Therapist) stated she had seen R1 in June because R1 had taken something out of a trash can and choked on it. V10 stated she tried R1 on a mechanical soft diet and R1 tolerated that better. V10 stated R1 had dental issues, no teeth and no dentures. V10 stated R1 had a change in condition and her cognition had declined and couldn't feed herself anymore. V10 stated R1's weight loss continued. V10 stated, I feel like there were other things going on like increased behaviors for some reason. V10 stated R1 had constant movement. V10 stated she was not aware that R1 continued to receive a regular consistency diet.R1's Speech Therapy Evaluation and Plan of Treatment documents certification dates of 6/11/2026-7/21/2026. This plan documents a start of care date as 6/11/26. Reason for referral/current illness; R1 referred to skilled speech therapy by nursing staff who report a recent choking episode due to residents eating items out of the garbage. R1 presents skilled speech therapy with developmental delays and decreased ability to self-regulate. Document shows R1 did not require mealtime supervision prior to onset. R1 needs assistance with feeding self. Oral Peripheral Exam documents Mandibular strength tone: impaired, Mandible Coordination: impaired. Labial (outer mouth) Function: impaired. Labial sensation/function: impaired. Lingual Function, Lingual Sensation/Function is impaired (the main function of the tongue). Under the heading of Assessment summary, Reason for therapy- Clinical impression/reason for skilled services: patient presents with oral phase dysphagia which necessitates skilled SLP services for dysphagia to assess/evaluate for safest level or oral intake in order to improve ability to decrease risk for weight loss and safely swallow without signs/symptoms of aspiration. Due to the documented physical impairments and associate functional deficits, without skilled therapeutic intervention, the patient is at risk for: aspiration and weight loss. Malnutrition risk factors identified as part of assessment= 10% weight loss over the last 6 months. Recommendations: What diet is recommended for the patient to swallow solids safely? Minced and moist.R1's Speech Therapy Discharge summary dated [DATE] documents R1's prior level of function was a regular diet and thin liquids. As of 6/29/26, R1 is tolerating mechanical soft solids and thin liquids as least restrictive diet. R1's summary documents risk areas that may impact long term outcome = multiple medications. Desired change in condition of risk area: medical management.On 8/7/2026 at 1:26 PM, V2 (Director of Nursing/DON) stated either herself or V1 look for therapy orders/ recommendations in the electronic health records and we process those orders. V2 stated the therapist usually tells the nurses as well of the recommendations. V2 stated she did not know anything about the speech recommendation for R1. V2 stated, I do not know how that got missed. V2 stated she does remember hearing about R1 choking on something that R1 got out of the trash. V2 stated she knew R1 had a huge decline with cognition.On 8/7/2026 at 1:40PM, V1 was asked if she has a part in processing the speech therapy recommendations, V1 said, well if I see an order from speech put in then I will process it. Speech orders are generally put in by the Speech Therapist, but we have to confirm before the order actually goes in. V1 stated she looked for the speech recommendation/order for R1 to have a mechanical soft diet but could not find the order. V2 asked who follows up when a resident comes off one of the therapy treatments, V2 stated, we usually know the plan from the orders but I guess we didn't think there were any if there was no order put in. V2 stated we do not see the therapy notes and if we want to review those the therapy department has to print those off for us. This recommendation did not get caught and the Mechanical Soft Diet was never ordered.On 8/7/2026 at 1:50PM, V10 stated she is usually the best at processing all of her order/recommendations, but she cannot find where she put in the recommendation for R1 to receive a mechanical soft diet. V10 was not sure if she told the dietary department or the nurses. V10 stated she did not know how this happened.R1 was seen by the Dietician on 5/29/2026 and the Consultant note documents: May weight 128.0 pounds with a significant weight loss noted x 6 months (16.78%) BMI: 22.67 (Underweight for age. Diet: Regular with thin liquids (no food with skins), Mighty Shake three times a day with meals, Whole Milk three times a day with meals, offer snacks three times a day in between meals, offer ice cream at lunch/supper and power mashed potatoes at lunch and supper. PO (by mouth) intake is reported at 51-100% of most meals per the 14 day look back reports. Meds reviewed- antidepressants/psychotic meds may alter appetite with diuretic prescription may alter fluid balance/wt/electrolytes; note Mirtazapine script was increased on 5/13/2026. Resident is receiving multiple different supplemental foods/snacks/fortified food/appetite stimulant/etc. Weight loss may be unavoidable; however will recommend to change might shake three times a day with meals, to mighty shake with ice cream three times a day with meals in an attempt to provide additional nutrition and RD (Registered Dietician) to follow up as needed. R1's Dietician Consult documented on 6/29/2026 reads as follows: June weights: 110.6 pounds with noted weight loss x 1 month (13.59%), x 3 months (14.92%) x 6 months (24.5%). Current weight on 5/28/2026, 101.2 pounds with BMI: 17.9 (underweight). Diet: Regular with thin liquids, mighty shake mixed with ice cream three times a day, whole milk three times a day with meals, offer snacks three times a day between meals, offer ice cream at lunch and supper and power mashed potatoes at lunch and supper. Feeding ability ranges from self with tray set up/supervision to staff dependent at meals. PO (by mouth) intake is reported varied 0-100% of meals per 14 days look back report; however, most meals are documented 51-100%. Meds reviewed- antidepressant/psychotropic meds may alter appetite/weight; diuretic may alter fluid balance/weight /electrolytes. Lab shows albumin 3.4. Staff reports that R1 has been sent to the emergency room several times this month and has had increased aggression/ behaviors. Weight loss continues despite increase in appetite stimulant and resident being offered/receiving multiple different supplemental foods/snacks/fortified food/etc. Per discussion with the dietary manager on this day, the resident does not drink the offered Mighty shake mixed with ice cream. Due to poor acceptance will recommend discontinuing Mighty shake with ice cream three times a day, add ice cream three times a day with meals and will recommend staff speak with resident's family about wishes surrounding enteral nutrition as weight loss continues and resident has exhausted all possible oral supplements/fortified food options available. A significant weight loss. This document was signed by the physician and had a written note discuss g tube with family. I recommended against it and suggest palliative care. No date or signature was noted under the note.On 8/12/2026 at 11:15AM, V15 (Registered Dietician/RD) stated she had been following R1 closely for 6-8 months now. V15 stated R1 had been losing weight for some time. V15 stated, I feel like R1 had a decline mentally and her behaviors had worsened like yelling and resisting care. V15 stated she has worked in this facility for about 10 years and R1 has gone up and down at times but this time she went down and did not come back up. V15 stated she saw R1 the last of June and believed her weight was around 110.0 pounds. V15 stated Remeron usually helps with appetite but it did not make a difference with R1 as she was losing weight every month. V15 stated she is always concerned with psychotropic medications and weights but normally you see weight gain.On 8/18/2026 at 9:10AM, V16 (Nurse Practitioner) stated sometime after the July dietary recommendation she had discussed with R1's Power of Attorney about the next step for nutrition could possibly be a feeding tube but V16 stated with R1's quality of life at this point that a feeding tube may not be the best choice. On 8/7/26 at 2:45PM, V3 (Family Member/POA) said the facility only wanted to talk to me about her medications and increasing those medications. V3 stated I kept telling them I did not want her on Seroquel and all they would say is we have to slowly reduce it and we need to increase something else to do that. V3 stated that was ridiculous and they would not listen to me and they kept giving it. V3 stated she was recently invited to a care plan meeting but I told them why should I come when they will not do anything I tell them to do and this was mainly about the Seroquel and the antidepressants. V3 stated she was not wasting her gas to drive down there just to fight with them. V3 stated years ago a psych doctor had put R1 on an antipsychotic and R1 went down really fast with weight loss and unable to function so our mother had a fit and it was discontinued and R1 started improving. V3 stated this is why I don't want her on antipsychotic medication. V3 said she knows R1 and knows what those types of medications do to her. V3 was asked if the facility ever talked to her about a feeding tube for R1 to provide nutrition, V3 stated, No they never talked to me about a gastrostomy tube or comfort care. They only wanted to talk to me about her medications and increasing those medications. V3 stated the facility did not ever really help R1 eat. On 8/11/2026 at 11:50AM, V18 (Dietary Manager) stated he thinks he remembers V10 (Speech Therapist) coming to the department and being notified of a diet change recommendation for R1. V18 stated he waited for the order but never got one. V18 stated he noticed a decline in R1 and stated he understood that R1's POA wanted her medications decreased. V18 stated a few months ago R1 always wanted 2 turkey sandwiches at meal time. V18 would not eat all of the sandwiches. V18 stated R1 was also leaning so bad in her wheelchair. On 8/12/2026 at 9:21AM, V21 (Registered Nurse/RN) stated she had noticed big weight loss with R1 bu

Based on interview and record review, the facility failed to ensure staff completed their required training. This has the potential to affect all 47 residents currently residing at the facility. Findings include:On 8/20/26 at 8:20 AM, staff training records provided to this surveyor by V1 (Administrator) for V25 (Registered Nurse/RN), V31 (License Practical Nurse), V26 (RN), V13 (Certified Nurse Assistant/CNA), V32 (CNA), and V33 (CNA) were reviewed. Review of provided training documentation revealed that V33 and V31 were missing all required training, V26 was missing training on rights of the resident and the responsibilities of the facility, QAPI (Quality Assurance and Performance Improvement), infection control, and compliance and ethics, V32 and V13 were missing training on effective communication, QAPI, infection control, and behavioral health, and V25 was missing training on effective communication, rights of the resident and the responsibilities of the facility, QAPI, infection control, compliance and ethics, and behavioral health. On 8/20/26 at 12:05 PM, V1 stated she provided me with any training and in servicing she has and what is not there isn't completed. V1 stated it is the expectation that all staff will complete their training by the due date. On 8/20/26 at 12:07 PM, V5 (Regional Clinical Director) stated the expectation is that all new hires have their new hire training completed within 30 days of hire. V5 stated when staff are assigned any further required training it is expected to be completed by the end of the month it was assigned. A facility policy title Employee Education dated 10/1/22 documents under Guidelines: The facility shall provide a staff education plan in accordance with State and Federal regulations. The facilities Daily Census dated 8/4/26 documents there are 47 residents residing in the facility.

Based on observation, interview and record review the facility failed to identify, assess, and track wounds on a resident's toes for 1 of 3 residents (R2) reviewed for wounds in a sample of 8. Findings include:R2's admission record documents an admission date of 7/7/2026 and includes diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease stage 3A, Muscle Wasting and Atrophy, Systolic Congestive Heart Failure, Major Depressive Disorder, Peripheral Vascular Disease, Hyperlipidemia, Hypothyroidism, End Stage Renal Disease, Pressure Ulcer of Right Ankle Unstageable, Anxiety, Age related Physical Debility, and Cognition Communication Deficit. R2's Care Plan documents R2 has potential/actual impairment to skin integrity related to decreased mobility, Diabetes Mellitus, and incontinent at times. 5/15/2026 R1 to wear bilateral geri sleeves for prevention of upper extremity skin tears (when resident allows). 9/8/2026 Right Ankle. 1/14/2026 skin tear to right arm (resolved). Skin tear to right knee (resolved.) Skin tear to right hand (resolved). Interventions: Follow facility protocols for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Skin risk assessment: Braden scale weekly x 4 weeks upon admission or readmission and then quarterly and as needed. Monitor/document locations, size and treatment impairment. Report abnormalities failure to heal, signs and symptoms of infections, maceration etc. to MD. Weekly skin checks with documentation, and wheelchair cushion to be placed in wheelchair when resident is up in wheelchair. R1 has a wound that appears to be related predominately to pressure, Major contributing factors include Diabetes Mellitus Peripheral Vascular Disease, occasionally urinary incontinence, decreased mobility. Stage 3 chronic pressure wounds noted to right ankle. Interventions include but are not limited to : administer pain medications as per orders prior to treatment, assess/record /monitor healing at lease weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing process., Monitor/document/ report any changes in current wound and or skin status: appearance, color, wound healing, signs and symptoms of infection such as redness, swelling. R2's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 15 suggesting R2's cognition is intact. Section GG (functional abilities) documents R2 has no impairment to upper and lower extremities. R2 uses a wheelchair for mobility. R2 is dependent on staff for all activities of daily living except R2 requires supervision or touching assistance for eating. Section M Skin Conditions document M0100. Determination of Pressure Ulcer/Injury Risk documents the answer no to; resident has a pressure ulcer/injury, a scar over body prominence, or non-removable dressing/device. Document shows R2 was at risk for pressure ulcers/injuries and has a pressure/reducing device for chair and bed and no turning and repositioning program. R2's document titled Progress Note dated 7/14/2026 at 9:45AM includes a Braden Scale for predicting Pressure Ulcer Risk Evaluation. Braden Evaluation: Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Chairfast. Resident is Slightly Limited: Makes frequent through slight changes in body or extremity position independently. Nutrition: Probably inadequate. Friction and Shear: Problem. Braden Score: 14.0 Interpretation of Braden Score is 14 equals Resident is at moderate risk for developing pressure ulcers. R1's Progress Notes for 8/2/26 at 11:20 PM under Weekly Skin Observations document in part, Skin Concerns observed: right elbow- ST RFA (skin tear right forearm), right ankle (outer) - existing wound skin concerns are not new. Foot Observations/Care: skin to feet is cool to touch. Skin concern observed to feet is now new. Authored by V27 Licensed Practical Nurse (LPN).On 8/6/2026 at 11:00AM. R2 was resting in bed and noted on R2's right foot, toes 2, 3, and 4 were with black areas noted and toe #4 was black to 50% of toe. V4 Registered Nurse (RN) was asked if there was a treatment for the toes and V4 stated no there is no treatment for the toes and today was just her 2nd day and she had not seen R2's toes prior to today. R2 stated, my toes have been like that for a while now and nobody has done anything. R2 stated, they really hurt and I keep telling the nurses, but they don't do anything about it. R2 stated, my ankle hurts too. R2 stated they will give me pain meds for my shoulder but that is about it.On 8/6/2026 at 11:20AM, V1 (Administrator) and V5 (Regional Clinical Director) were informed of the observation made of R2's black toes. V1 stated the facility just did a skin sweep on Monday and nothing was mentioned about R2's toes. V1, V5 and this surveyor went to R2's room. V1 removed R2's sock to her right foot and when she saw R1's toes V1 stated, Oh my God! V1 asked R2 how long her toes had been like that and R2 stated they have been that way for a while and I keep telling everyone. R2 stated they do not even do the dressings on my ankle like they are supposed to. On 8/6/2026 at 1:50PM, V7 (Certified Nurse Assistant/CNA) stated she never seen R2's toes black but R2 always has socks on but R2 would always complain of foot pain. On 8/6/2026 at 2:10PM, V2 (Director of Nursing/DON) stated she is aware that R2 has black eschar on her toes and discoloration. V2 stated, I just seen them on Monday 8/3/2026 though. V2 was asked if she documented the change she seen to R2's toes and what she did about the change. V2 stated no she did not document on the toes or notify the physician at that time. R2's Physician Orders dated August 2026 document an order entered on 8/6/2026, Monitor toes to right foot for any changes in appearance every shift. R2's Progress note dated 8/6/2026 at 11:46AM documents, reported to hospice that toes are purple in color with no open areas. New orders to monitor toes each shift.R2's Progress note dated 8/6/2026 at 12:09PM documented R2's Power of Attorney was notified of discoloration to toes right foot. Explained the new orders to monitor.On 8/7/2026 at 9:30AM, V9 (Primary Physician) was asked if he was notified of R2's toes and the black color to her toes and small open spot on her right buttocks. V9 stated no I was not notified. V9 stated R2 has peripheral vascular disease, and she already lost her left lower leg. On 8/7/2026 at 10:45AM, V9 came to this surveyor in the facility and stated that he did check R2's toes and felt like the blackness was superficial and vascular but they must be monitored closely and he is to be notified with any changes at all like drainage or signs of infection.On 8/7/2026 at 1:26PM, V2 (DON) was asked if the physician V9 was notified of R2's toes and buttocks and condition of skin issues, on 8/3/2026 when wounds were identified. V2 stated, yes I faxed over a notification. This surveyor asked V2 to present the fax and the notification confirmation. V2 stated, well now that you ask for it no I did not do it. R2's Wound Care Visit Report include Right lateral ankle assessments for 8/3/2026 and 8/12/2026 assessments. Right knee skin tear with assessment date of 8/12/2026, and Coccyx 8/17/2026 assessment. There is no documentation on any issues or assessment of R2's toes.R2's Treatment Administration Record documents starting 8/6/2026, monitor toes to right foot for and changes in appearance every shift. Record shows monitored twice a shift with documentation that this was completed on all days that followed except on 8/17/2026 on day shift. No documentation of change in toes to right foot.On 8/19/2026 at 10:15AM, R2 was noted lying in bed and was asked how her toes were feeling and R2 stated they still hurt. V30 (Hospice Nurse) came into room with V29 (Licensed Practical Nurse /LPN). V29 stated hospice was going to do the treatments on R2. V29 removed R2's sock on right foot. V29 assessed R2's toes and noted that R2's great toe was red in color and had a black spot noted to the top of the great toe. V30 stated, oh, that wasn't red like that last week. V29 stated, we have to get an order for a treatment for these toes. V29 looked at the last toe on Right foot (4th toe) that the side of the toe is blackish in color and stated, this area is hard and it feels like it is deep. On 8/19/2026 at 10:30AM, V1 and V5 were informed of the observation and changes to R2's great toe. V1 was asked where the description of the toes could be found in the record and the date acquired. V1 stated, I haven't seen any but I will look. V1 was informed that the toes are not included in R2's weekly wound tracking log. On 8/19/2026 at 11:10AM, V2 was asked for the wound tracking sheets for R2. V2 stated, I just quit, but I do not have any tracking on the toes because the physician said they were not pressure wounds.On 8/19/2026 at 3:00PM, V29 (Licensed Practical Nurse) stated V2 notified the physician and received new orders to apply Betadine to R2's toes to right foot twice a day and this treatment has been done by V2 just now. Policy titled Pressure Injury and Skin Condition Assessment with revision date of 1/17/2018 documents, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assessing interventions are implemented. 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. 7. At the earlies sign of a pressure injury or other skin problem the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress note.

Based on interview and record review the facility failed to ensure a resident was free from significant medication errors for 1 of 3 residents (R1) reviewed for medication errors.Findings include:R1's admission Record documents an admission date of 11/27/2013. admission records include diagnoses of Hypertensive Heart Disease with heart failure, Crohn's Disease of both small and large intestines without complications, Muscle Wasting and Atrophy, Lack of Coordination, Dysphagia oral phase, Abnormal Posture, Hyperesthesia, Atherosclerotic Heart Disease, Hyperlipidemia, Anxiety, Sever Intellectual Disabilities, Osteoporosis, Major Depressive Disorder, and Physical Debility. R1's admission record documents R1 was discharged to a local hospital on 7/25/26 and did not return to the facility.R1's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 5 indicating R1 has severe cognitive impairment. Section N-Medications documents under High-Risk Drug Classes R1 is taking the following medications: Antipsychotics, Antianxiety, antidepressants and anticonvulsants and that R1 has an indication noted for each drug class marked. Under Antipsychotic Medication Review documents that R1 receives an antipsychotic on a routine basis.R1's Order Recap Report with a print date of 8/7/26 and Order Summary Report with a print date of 8/11/26 document the following orders:Quetiapine Fumarate (Seroquel) (antipsychotic) tablet 25 mg one time a day at 8:00PM related to Generalized Anxiety Disorder, Major Depressive Disorder with a start date of 4/10/26 and end date of 7/6/2026. Quetiapine Fumarate tablet give 50mg one time a day at 9:00AM with a start date of 4/10/26 and end date of 7/6/26. Quetiapine Fumarate tablet 25 mg one time a day at 8PM with start date of 7/6/2026 and an end date of 7/20/2026. Quetiapine Fumarate tablet 25 mg one tab daily at 9:00AM with a start date of 7/7/2026 an end date of 7/20/2026. Quetiapine Fumarate tablet 25 mg twice a day with a start date of 7/27/26 and an order status of active.Venlafaxine HCl (Effexor) (Antidepressant) ER 150 mg one capsule daily for low mood related to Major Depressive Disorder (MDD), recurrent, mild, with a start date of 3/27/26 and an end date of 7/20/26. Venlafaxine ER 112.5mg one tablet daily with a start date of 7/21/2026 and an end date of 7/25/2026. Venlafaxine ER 75mg one tablet daily at 8:00AM with a start date 7/26/2026 and order status of active. Sertraline HCL (Zoloft) (Antidepressant) 25mg twice a day for low mood, agitation related to Generalized Anxiety Disorder, MDD, recurrent, mild, with a star date of 7/20/26 and an order status of active.There were no orders documented for Escitalopram (Lexapro) on R1's Order Recap Report or Order Summary Report.R1's Care Plan documents the following Focus areas and interventions:R1 uses anti-anxiety medications related to anxiety. Documented interventions include: administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Educate R1/family/caregivers about risks, benefits and the side effects and or toxic symptoms dated 7/9/2026. Monitor R1 for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that look like dementia and increase risk of falls, broken hips and legs. Monitor/documentation/report as needed any reverse reaction to medication therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, nausea, stomach upset. Unexpected side effects: mania, hostility, rage, aggressive or impulsive behavior, and hallucination dated 7/9/2026.R1 uses antidepressant medication related to depression dated 7/9/2026. Interventions include monitor/document side effects and effectiveness every shift. Monitor/document/document/report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, withdrawal; decline in activities of daily living ability, continence, rigid muscles, movement problems appetite loss, weight loss, nausea and vomiting, and dry mouth dated 7/9/2026.The Summary Report from the psychiatric consultant group for the date of service of 6/29/26 document that R1 was seen by V14 (Psychiatric Nurse Practitioner) with orders to decrease Effexor ER from 150mg to 112.5mg in the morning for diagnoses of MDD, IDD, behavioral instability and start Escitalopram (Lexapro) (antidepressant) 5mg in the morning for diagnoses of MDD, GAD, IDD, depressive, anxiety symptoms.R1's Psychiatry Note dated 6/29/2026 by V14 documents Chief Complaint: Assess increased anxiety and episodes of frustration, agitation, screaming at others, hitting, pushing, and grabbing others. Note of history of present illness states R1 is a female patient with a history of Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) with severe intellectual disabilities (IDD). R1 is seen sitting hunched over in wheelchair in hallway near dining room. Her mood today appears slightly anxious. R1 was nonverbal with minimal interaction during encounter. R1 was observed sitting with her chest resting on her legs while exhibiting wriggling motions. Per Primary Care Provider visit 6/18/2026, increased spinal curvature was noted related to a prior T12 compression fracture. On 6/23/2026 Gabapentin was increased by (V16 Primary Nurse Practitioner) due to concerns that increased behaviors may be related to pain. Medication changes: Decrease Effexor ER from 150mg to 112.5 mg by mouth every morning for behavioral instability related to MDD and IDD. Start Escitalopram 5 mg by mouth every morning for depressive/anxiety symptoms related to MDD, GAD, IDD. Continue Seroquel for low mood, agitation, restlessness, and adjunct treatment related to MDD. Continuing Remeron for depressive symptoms, restlessness, screaming, labile mood, and appetite support related to MDD. Continue Gabapentin for anxiety, panic, pacing, screaming and yelling related to GAD. Continue Diazepam for anxiety for anxiety related to GAD.R1's Order Summary Report and Order Recap Report did not document any orders for Escitalopram and did not document an order to decrease Effexor ER from 150mg to 112.5 mg until 7/21/26.R1's Psychiatry Note dated 7/10/2026 by V23 (Psychiatric Nurse Practitioner) documents Chief Complaint: Monitoring behavioral symptoms and mood stability. History of Present Illness: R1 is a female with Major Depressive Disorder (MDD), General Anxiety Disorder (GAD) and severe intellectual disability. Today she was seen lying in bed, awake, alert, and observed pointing and making vocalizations, though her speech was dysarthric and difficult to understand. When asked about her mood she stated fine. Compared with the previous evaluation, she is more interactive and engaged. Staff reports no further episodes of agitation or aggression and no recent self-injurious behavior, throwing food, refusal of care, or other disruptive behaviors. Mood and anxiety appear improved overall. Sleep and appetite were not reported as problematic. No medication side effects were observed or reported. Medication Changes Seroquel 25mg twice a day to 12.5mg by mouth twice a day. Decrease Effexor ER 112.5mg to 75mg by mouth every morning.R1's Progress Note dated 7/20/26 at 4:05PM, authored by V2, documents to decrease Quetiapine to 12.5mg for GDR and decrease Venlafaxine ER 112.5 mg for GDR. R1's Psychiatric Note dated 7/24/26 by V23 documents Chief Complaint: Chief Complaint: Assessment of response to recent gradual dose reductions of quetiapine and venlafaxine while monitoring behavioral stability. History Of Present Illness: R1 is a female with major depressive disorder, generalized anxiety disorder, and severe intellectual disability. She is seen today seated in her wheelchair in the dining room. Her speech remains dysarthric and difficult to understand; however, she smiles and makes vocalizations when engaged. Staff report no behavioral escalations, agitation, aggression, self-injurious behaviors, or other disruptive behaviors since the previous psychiatric evaluation. She is currently undergoing a medical workup for significant weight loss. Mood appears stable, and anxiety is not observed to be increased. Sleep remains stable, and appetite continues to be monitored in the setting of her ongoing medical evaluation. No medication side effects are observed or reported. No hallucinations, paranoia, or manic symptoms are evident. No suicidal or homicidal ideation is reported. Psychiatric history documents diagnoses of: Intellectual Disabilities, Obsessive compulsive disorder, Depression with psychotic features, severe mental retardation, developmental delay, depression with aggressive behaviors, anxiety, mood disorder, and personality disorder. Under AIMS documents a score of 0 and a date of 12/18/25. Med changes documented under plan include: Psychotropic medication changes are indicated at this time. Major depressive disorder and generalized anxiety disorder remain stable without recurrence of agitation, aggression, self-injurious behaviors, or other disruptive behaviors following recent medication adjustments. Severe intellectual disability continues to require a structured and supportive environment. She is tolerating her current psychotropic regimen without reported adverse effects. Given her sustained psychiatric stability, venlafaxine will be gradually reduced to lessen overall psychotropic medication burden while monitoring closely for recurrence of depressive symptoms, anxiety, or behavioral instability. Decrease Venlafaxine ER 112.5 mg to 75 mg every morning. Under Medication List documents: Quetiapine (Seroquel) 12.5mg twice a day, Venlafaxine ER (Effexor) 75 in the AM, Escitalopram (Lexapro) 5mg in the AM, Mirtazapine (Remeron) 22.5mg at bedtime, Gabapentin (Neurontin) 200mg three times a day, Diazepam (Valium) 2.5mg in the AM. Most recent GDR's document the following: 07/24/26 decreased Venlafaxine ER from112.5mg to 75mg in the AM; 07/10/26 decreased Quetiapine from 25mg twice a day to 12.5mg twice a day; 06/29/26 decreased Venlafaxine ER from 150mg to 112.5mg in the AM; 06/29/26 GDR contraindicated for Mirtazapine due to patient has experienced a 9.4-pound weight loss since 6/1/26, with a current weight of 101.2 pounds and ongoing occurrences of disruptive vocalizations, anxiety, and repetitive motions; 06/29/26 GDR contraindicated for Gabapentin due to episodes of frustration, agitation, screaming at others, hitting, pushing, and grabbing others.The psychiatric consultant notes reviewed for R1 did not document any orders for Zoloft 25mg twice a day.There is no documentation on the June and July 2026 Medication Administration Records (MAR's) of an order for Escitalopram or ever receiving Escitalopram. The July 2026 MAR documents that R1 received Zoloft 25mg twice a day from 7/20/26 until 7/25/26 when R1 was hospitalized . The July 2026 MAR documents R1's Seroquel 25mg was discontinued on 7/20/2026. There were no orders on R1's June or July 2026 MAR to reduce the dose of Seroquel to 12.5 mg. R1's June and July MAR document that R1 received Effexor ER 150mg until 7/20/26 and started Effexor ER 112.5mg on 7/21/26 until 7/25/26 when R1 was hospitalized .On 8/27/26 at 9:46AM, V2 (Director of Nursing /DON) was asked about the process of receiving, and implementation of orders from the psychiatric consultant group. V2 stated the nurse practitioners come to the facility and they see the patients. After they leave they put the orders into the electronic record and they fall under Pending Orders. V2 stated she is usually the one that processes the pending orders. V2 stated if the order requires a new consent for a medication, then it stays pending until the consent is obtained then the order is processed. V2 was asked about R1's order for Zoloft 25mg twice a day. V2 reviewed order and stated, I do not remember where the order actually came from. V2 was asked if there is a way to review the pending orders and V2 stated, not once they are confirmed. V2 again stated I just really don't know where I got that order. V2 was asked about R1's progress note on 7/20/2026 at 4:05PM that documents to decrease Seroquel to 12.5mg for Gradual Dose Reduction (GDR) and Effexor 112.5 mg for GDR, and why these orders were not completely processed. V2 stated those orders must have been pending and she confirmed the orders. V2 was asked about why the Order Summary Report did not document an order to decrease the Seroquel to 12.5 mg. V2 stated I don't know, I just don't know, that has been too long ago. V2 was asked if there was an order received to discontinue the Seroquel completely and V2 stated I just don't know. V2 stated I just don't know why the Seroquel was discontinued. V2 was asked about the psychiatric consult note dated 6/29/2026 that had orders to decrease the Effexor from 150mg to 112.5mg but R1 continued to receive 150mg until 7/21/2026. V2 stated well, again I am really not sure, and I am not sure when the pending order was put into the electronic record by the Psych NP. V2 was asked about the order for Escitalopram 5mg daily that was documented on the same note dated 6/29/26. V2 stated I remember that order, but I had to get a consent from the POA because it was a new medication. V2 stated she never got the consent. V2 was asked where the order came from for the Seroquel 25mg twice a day on 7/6/2026, and V2 stated I am not sure where that came from. On 8/27/26 at 10:58AM, V5 (Regional Clinical Director/RCD) was asked if she was aware of the issues with some of the Psychotropic medication orders with R1. V5 stated yes, and I have reviewed all of that. V5 stated the facility met with the psychiatric consultant group last week and new processes are being put into place to avoid some of the issues that she has seen with R1's medications. V5 stated we are changing how the processes work and how orders are put so that the facility can monitor more closely and get the proper consents in place timely so the residents can receive the prescribed orders timely. V5 was asked if she can explain where the Sertraline order for R1 came from and V5 stated I can't and I have searched for it as well. V5 was asked why Seroquel was not decreased as the order to decrease was even documented in the progress notes and V5 stated I can't explain that either. V5 stated the process in place now will have a lot more eyes on the Psych orders and will be processed appropriately.On 8/27/26 at 1:39PM, V23 (Psychiatric Nurse Practitioner) was asked if she ever ordered Sertraline for R1. V23 stated she had reviewed all of her notes and she has never ordered Sertraline for R1. V23 stated R1 was already on antidepressants and did not need anymore. V23 stated that would be too many. V23 said she started R1 on Escitalopram (Lexapro) already. V23 made aware that there were no orders ever in place for Escitalopram for R1. V23 stated there had been some issues going on in the building that she noticed around 7/10/2026 and she had brought that to the facility's attention. V23 stated she noticed the Seroquel reduction did not get done correctly and the Seroquel was stopped instead of reduced. V23 stated that is about the time that I noticed the issues with the orders being processed. V23 stated she makes rounds and sees the residents, and she does not put the orders in while in the facility. V23 stated that usually the notes get put in the same day as the visit but if they are transcribed, it is sometimes the next day. V23 stated now the facility is going to receive a summary report with all of the new orders on there and the facility is going to process orders from the summary. V23 stated this should fix a lot of the problems and that provides a way to verify but several sets of eyes that the orders are completed and done correctly. V23 was asked if there is a way to pull up old pending orders and V23 stated not once they are confirmed then they move to that status and they are no longer pending. V23 stated Zoloft should never have been ordered for R1 and she does not know how that happened and she knows for sure it was not her.The facility policy titled Medication-Related Errors dated 5/01/2010 documents this policy sets forth procedures relating to medication error. The policy includes procedures for: unauthorized medication error: dispensing to the resident a dose of medication not authorized by physician/prescriber for the resident. Transcription error: Facility incorrectly transcribes to pharmacy an entire order or part of an order.

Based on interview and record review the facility failed to ensure residents were free from abuse from staff for 1 of 3 residents (R1) reviewed for abuse and neglect in the sample of 11. This failure resulted in a staff member physically forcing a resident in to the residents room and shutting the door causing bruising to R1's chest with vocal complaints of pain. Findings include:R1's admission Record documents an admission date of 11/27/13 with the following diagnoses listed in part; muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, severe intellectual disabilities, abnormal posture, age related osteoporosis without current pathological findings.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of a 5 indicating R1 is severely cognitively impaired. Section GG - Functional Abilities documents that R1 is dependent on staff for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Section GG documents that R1 is dependent on staff for transfers and uses a wheelchair. She also needs supervision or touching assistance for wheeling 150 feet in her wheelchair.R1's current care plan documents that R1 has impaired cognitive function/dementia or impaired thought processes and has a communication problem. R1's care plan does not document R1 as being at risk for abuse.R1's abuse/neglect screening dated 3/19/26 documents that R1 is at moderate risk for abuse.Facility Final report completed by V1(Administrator), dated 3/31/26 documents there was an incident on 3/24/26 with R1 of an injury on unknown origin with injuries including left index finger bruising. Follow-up/final report summary documents: Investigation reveals that nurse on duty on that night shift had pushed resident into her room and shut the door, because resident was yelling in the lobby as other residents were passing by. Resident states that she was knocking on her door in her room, which resulted in bruising to her finger. Abuse substantiated, nurse immediately DNR (Do Not Return) from building. Staff educated about involuntary seclusion .In R1's medical record an event record was opened on 03/25/2026 at 9:34pm by V1. This record documented a bruise on R1's right hand that was 0.7 inches (in) (length), 0.5in (Width), and bruising to R1's left chest that was 5 inches in length, and 5inches in width. With vocal complaints of pain.On 3/31/26 at 10:03am, V6 (Certified Nursing Assistant/CNA) stated she came in the morning of 3/24/26, and the night shift aides grabbed her and stated that the night nurse locked R1 in her room several times that night and they kept having to let her out. V6 stated when she went to R1's room she could hear her barely knocking. V6 stated they opened the door and let R1 out. V6 stated she did not notice any bruising on her finger at that time but did notice it a few days later, along with the bruising to her chest. V6 stated that V7 and V8 were the CNA's that night and they told her that R1 had been up front hollering throughout the night. V6 stated R1 does holler a lot but it is usually when there is something wrong or she is asking for assistance. V6 stated that R1 has continued to point at the bruised areas and say nurse hurt me to basically any staff that will listen. V6 stated she did not think that R1 had the strength to cause the bruise on her chest, and at the time she opened the door for her, she was not knocking hard enough to have caused that. V6 stated R1 does not normally accuse staff of hurting her or fabricating stories.On 3/31/26 at 10:05am, V9 (Certified Nursing Assistant/CNA) stated that R1 has a bruise on her finger as well as a large healing bruise on her chest. V9 stated at one point the bruise looked very painful. V9 stated the first day she saw the bruise, she was with the nurse doing a skin check. V9 stated the nurse told her that a night shift nurse was trying to push her into her room and collided with the door. V9 stated that R1 has bruised herself before but it will be tiny, tiny ones. V9 stated it was nothing like that and R1 is not capable of hitting herself that hard in the chest. V9 stated she did not think that R1 could cause those bruises to herself. V9 stated R1 does not have a history of saying staff hurt her.On 3/31/26 11:07am, R1 stated Nurse hurt me, Nurse hurt me, while pointing to her chest and finger.On 3/31/26 at 1:07pm, a bruise was observed on R1's chest. It started just below her left clavicle, covers most of her breast and extends into her upper abdomen. It was a faint yellow color, and appeared to be in later stages of healing. There was also a faint bruise noted to her left index finger that started just under the cuticle and extended through the first and second joint. On 3/31/26 at 2:45pm, V5 (agency nurse) stated the night that the incident happened with R1, it was just two aides and V3 (agency nurse). V5 stated she worked the following night and discovered the bruise on R1's chest. V5 stated she called V1 to report it at approx. 4am and V1 stated she was not surprised she pokes herself all the time. V5 stated she told V1, no it is not like that, she could not have done this. V5 stated R1 does occasionally leave a tiny fingerprint sized bruise on herself, but she does not have the strength to have caused something like that. V5 stated she was told by the CNA's that R1 was sitting up front being noisy. V5 stated the CNAs told her they saw her up front and went down the hall to get up other residents and saw the nurse pushing her to her room at one point. V5 stated the CNA's reported they went down the hallway and she was in her room with the door shut. V5 stated they said they brought her up front and continued to get residents up, and when dayshift arrived, they found her in her room again with the door shut and mad as could be when they found her. V5 stated that R1 has been consistently saying that nurse did it, nurse hurt me. V5 stated it has been reported to administration by not only her, but other staff as well.On 4/1/26 at 10:51am, R8 (R1's Roommate) who was alert to person, place and time stated R1 can be noisy at times. R8 stated she remembers there was a night where she heard a lot of commotion with R1 with a staff member that she didn't know her name, but knew she was not here anymore after that. R8 stated she could not see what happened because it was at night and she had her curtain pulled, but there was something going on and then the door was closed and R1 was still in the room making a lot of racket. R8 stated that shortly after the commotion some of the other girls opened the door and R1 left. R8 stated the staff member was yelling at R1 and R1 was kind of hollering back, but that's all she could really hear.On 4/1/26 at 11:03am, V7 (Certified Nursing Assistant/CNA) stated R1 was in the lobby hollering during the morning of 3/24/26. V7 stated that she and V8 went down the opposite hallway and continued to get people up. V7 stated when they came back up front, R1 was gone. V7 stated at this time V6, who is on day shift had arrived. V7 stated they started down the hallway R1's room is on and could faintly hear R1 yelling and knocking on the door. V7 stated they let R1 out of her room and she was so mad. V7 stated they brought her up front, and at this time she did not notice any bruises. V7 stated she was telling them that the nurse hurt her, nurse door, nurse my room, nurse hurt. V7 stated R1's hands were moving so fast it was hard to notice if the finger was bruised or not, she stated there was no bruise on her chest, but she continued to poke her chest and repeat everything she was saying about the nurse. V7 stated R1 was not able to open the door, because she has poor upper body strength. V7 stated she did not think the way R1 was poking her chest could have caused the massive bruise she had.On 4/1/26 at 11:48am, V4 (Registered Nurse) stated she came in the morning after the incident happened with R1. V4 stated she was under the impression that the nurse was upset because R1 was making too much noise whenever she was trying to pass meds, she stated that is just what R1 does is make noise. V4 stated if she is being loud, something is probably wrong. V4 stated when R1 saw her that morning she immediately pointed to her finger and chest. V4 stated R1's finger was red and swollen, she stated she pointed to the door and said, Nurse did it. V4 stated there's no way R1 could have caused the bruising on the chest, occasionally she will cause a small bruise, but nothing to the extent of her bruises. V4 stated the night shift CNA's contacted V1, she did not directly contact her that day. V4 stated R1's bruise to her chest was large and looked painful. V4 stated R1 did not complain of pain. V4 stated R1 is not capable of opening the door. V4 stated the bruise on R1's chest was reported to V1 and V11 (Former Director of Nursing) on multiple occasions and nothing was done.On 4/1/26 at 1:11pm, V11 (Former Director of Nursing) stated on the morning of the incident involving R1, she was very angry and pointing to her chest saying her did it. V11 stated they were told by night shift staff that V3 took R1 to her room and closed the door. V11 stated as soon as administration was made aware, they started an investigation. V11 stated V7 and V8, the night shift CNA's, said this happened twice. V11 stated it was confirmed that V3 put R1 in her room and closed her in there. V11 stated R1 was not capable of opening the door, she is not strong enough.On 4/1/26 at 1:24pm, V2 (Social Services Director) stated she came in the morning on 3/24/26 around 7:30am, and R1 was visibly upset. V2 stated that V7 and V8 reported V3 closed R1 in her room more than once that night. V2 stated R1 had a bruise on her finger but did not have bruise on chest at that time. V2 stated that R1 does not have a history of making false allegations towards staff. V2 stated that R1 does have a history of causing bruises to herself. V2 stated R1 could not open door.On 4/1/26 at 3:05pm, V1 (Administrator) stated the incident with R1 was reported to police and the agency V3 worked for. V1 stated R1 would not have been able to open the door. V1 stated V3 was interviewed that day and asked not to come back immediately.An incident report from the local police department with a print date of 4/7/26 documents and incident were reported on 4/11/26 at 10:45AM. This report documents in the section titled, involvement it lists R1 as the victim and V3 as the offender. This report was authored by V14 (Police officer).Facility policy titled Abuse and Retaliation Prevention and Reporting- ILLINOIS with an effective date of 1/8/26 documents under policy; This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment.

Based on interview and record review the facility failed to ensure residents were free from involuntary seclusion for 1 of 3 residents (R1) reviewed for abuse and neglect in the sample of 11. This failure resulted in R1 being forced in to R1's room and staff closing the door to keep R1 in R1's room multiple times causing R1 to knock on R1's door in attempts to have door opened. Findings includeR1's admission Record documents an admission date of 11/27/13 with the following diagnoses listed in part; muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, severe intellectual disabilities, abnormal posture, age related osteoporosis without current pathological findings.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of a 5 indicating R1 is severely cognitively impaired. Section GG - Functional Abilities documents that R1 is dependent on staff for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Section GG documents that R1 is dependent on staff for transfers and uses a wheelchair. She also needs supervision or touching assistance for wheeling 150 feet in her wheelchair.R1's current care plan documents that R1 has impaired cognitive function/dementia or impaired thought processes and has a communication problem. R1's care plan does not document R1 as being at risk for abuse.R1's abuse/neglect screening dated 3/19/26 documents that R1 is at moderate risk for abuse.Facility Final Report to IDPH (Illinois Department of Public Health) Regional Office completed by V1, dated 3/31/26 documents there was an incident on 3/24/26 with R1 regarding an injury on unknown origin with injuries including left index finger bruising. Follow-up/final report summary documents: Investigation reveals that nurse on duty on that night shift had pushed resident into her room and shut the door, because resident was yelling in the lobby as other residents were passing by. Resident states that she was knocking on her door in her room, which resulted in bruising to her finger. Abuse substantiated, nurse immediately DNR (Do Not Return) from building. Staff educated about involuntary seclusion .Included in the facility investigation regarding the injury of unknow origin for R1 was an interview conducted with V1 (Administrator) and R1. This interview did not include a date or time of the interview. In this interview, V1 asked What happen this morning with your nurse? R1 response, My nurse, my room. V1 asked, Your nurse took you to your room? R1 responded Yep. V1 asked, then what? R1 responded, Shut the door. V1 stated, Your nurse put you in your room and shut the door? R1 responded, Yep. V1 asked, Why did she do that? V1 responded, My nurse, my room.On 3/31/26 at 10:03am, V6 (Certified Nursing Assistant/CNA) stated she came in the morning of 3/24/26, and the night shift aides grabbed her and stated that the night nurse locked R1 in her room several times that night and they kept having to let her out. V6 stated when she went to R1's room she could hear her barely knocking. V6 stated they opened the door and let R1 out. V6 stated she did not notice any bruising on her finger at that time but did notice it a few days later, along with the bruising to her chest. V6 stated that V7 and V8 were the CNA's that night and they told her that R1 had been up front hollering throughout the night. V6 stated R1 does holler a lot but it is usually when there is something wrong or she is asking for assistance. V6 stated that R1 has continued to point at the bruised areas and say nurse hurt me to basically any staff that will listen. V6 stated she did not think that R1 had the strength to cause the bruise on her chest, and at the time she opened the door for her, she was not knocking hard enough to have caused that. V6 stated R1 does not normally accuse staff of hurting her or fabricating stories.On 3/31/26 at 2:45pm, V5 (agency nurse) stated the night that the incident happened with R1, it was just two aides and V3 (agency nurse). V5 stated she was told by the CNA's that R1 was sitting up front being noisy. V5 stated the CNA's told her they saw R1 up front hollering and went down the hall to get up other residents and saw V3 pushing R1 to her room at one point. V5 stated the CNA's stated they went down the hallway and R1 was in her room with the door shut. V5 stated they said they brought R1 up front and continued to get residents up, and when dayshift arrived, they found her in her room again with the door shut and mad as can be when they found her. V5 stated that R1 has been consistently saying that nurse did it, nurse hurt me.On 4/1/26 at 10:51am, R8 (R1's Roommate) who was alert to person, place and time stated R1 can be noisy at times. R8 stated she remembers there was a night where she heard a lot of commotion with R1 with a staff member that she didn't know her name, but knew she was not here anymore after that. R8 stated she could not see what happened because it was at night and she had her curtain pulled, but there was something going on and then the door was closed and R1 was still in the room making a lot of racket. R8 stated shortly after the commotion some of the other girls opened the door and R1 left. R8 stated the staff member was yelling at R1 and R1 was kind of hollering back, but that's all she could really hear.On 4/1/26 at 11:03am, V7 (Certified Nursing Assistant/CNA) stated R1 was in the lobby hollering during the morning of 3/24/26. V7 stated that she and V8 went down the opposite hallway and continued to get people up. V7 stated when they came back up front, R1 was gone. V7 stated at this time V6, who is on day shift had arrived. V7 stated they started down the hallway R1's room is on and could faintly hear R1 yelling and knocking on the door. V7 stated they let R1 out of her room and she was so mad. V7 stated they brought her up front, and at this time she did not notice any bruises. V7 stated she was telling them that the nurse hurt her, nurse door, nurse my room, nurse hurt. V7 stated R1's hands were moving so fast it was hard to notice if the finger was bruised or not, she stated there was no bruise on her chest, but she continued to poke her chest and repeat everything she was saying about the nurse. V7 stated R1 was not able to open the door, because she has poor upper body strength. V7 stated she did not think the way R1 was poking her chest could have caused the massive bruise she had.On 4/1/26 at 11:48am, V4 (Registered Nurse) stated she came in the morning after the incident happened with R1. V4 stated she was under the impression that the nurse was upset because R1 was making too much noise whenever she was trying to pass meds, she stated that is just what R1 does is make noise. V4 stated if she is being loud, something is probably wrong. V4 stated when R1 saw her that morning she immediately pointed to her finger and chest. V4 stated R1's finger was red and swollen, she stated she pointed to the door and said, Nurse did it. V4 stated R1 is not capable of opening the door.On 4/1/26 at 1:11pm, V11 (Former Director of Nursing) stated on the morning of the incident involving R1, she was very angry and pointing to her chest saying her did it. V11 stated they were told by night shift staff that V3 took R1 to her room and closed the door. V11 stated as soon as administration was made aware, they started an investigation. V11 stated V7 and V8, the night shift CNA's, said this happened twice. V11 stated it was confirmed that V3 put R1 in her room and closed her in there. V11 stated R1 was not capable of opening the door, she is not strong enough.On 4/1/26 at 1:24pm, V2 (Social Services Director) stated she came in that morning around 7:30, and R1 was visibly upset. V2 stated that V7 and V8 reported V3 closed R1 in her room more than once that night. V2 stated R1 is not always easy to understand, but if you know her you can communicate easily with her. V2 stated she was not sure whether or not R1 was strong enough to leave the bruise, but R1 was poking herself pretty persistently saying nurse hurt, she stated she did not believe R1 could not open door.On 4/1/26 at 3:05pm, V1 (Administrator) stated that R1 is known to make bruises on herself. V1 stated when she got here R1 was poking herself in the chest saying, she did it. V1 stated R1 could not open the door. V1 stated V3 was interviewed that day and asked not to come back immediately.An incident report from the local police department with a print date of 4/7/26 states this incident was reported on 4/11/26 at 10:45am. In the section titled, involvement it lists R1 as the victim and V3 as the offender.Facility policy titled Abuse and Retaliation Prevention and Reporting- ILLINOIS with an effective date of 1/8/26 documents under policy; This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This policy documents under the section titled definitions documents Unreasonable confinement or Involuntary seclusion means the separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident's legal representative.

Based on interview and record review, facility staff failed to notify law enforcement in a timely manner of an alleged staff to resident abuse incident for 1 of 3 residents (R1) reviewed for abuse and neglect in the sample of 11. Findings includeR1's admission Record documents an admission date of 11/27/13 with the following diagnoses listed in part; muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, severe intellectual disabilities, abnormal posture, age related osteoporosis without current pathological findings.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of a 5 indicating R1 is severely cognitively impaired. Section GG - Functional Abilities documents that R1 is dependent on staff for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.R1's abuse/neglect screening dated 3/19/26 documents that R1 is at moderate risk for abuse.Facility Final Report to IDPH (Illinois Department of Public Health) Regional Office completed by V1, dated 3/31/26 documents there was an incident on 3/24/26 with R1 regarding an injury on unknown origin with injuries including left index finger bruising. Follow-up/final report summary documents: Investigation reveals that nurse on duty on that night shift had pushed resident into her room and shut the door, because resident was yelling in the lobby as other residents were passing by. Resident states that she was knocking on her door in her room, which resulted in bruising her finger. Abuse substantiated, nurse immediately DNR (Do Not Return) from building. Staff educated about involuntary seclusion .On 4/6/26 at 11:29am, V14 (Police Officer) stated a report was made on 4/1/26. V14 stated V1 told him they could not file a police report until the Department of Public Health had been in to investigate. V14 stated he was finishing up the report and would have it finished by the end of the day.On 4/6/26at 2:46pm, V1 (Administrator) stated she reported the abuse to the police on Wednesday 4/1/26 or Thursday 4/2/26 of last week. V1 stated truthfully in the midst of the investigation it slipped her mind, and one of the corporate employees reminded her that she needed to do it, she reported it right after.An incident report from the local police department with a print date of 4/7/26 documents an incident was reported on 4/11/26 at 10:45AM. This report documents in the section titled, involvement lists R1 as the victim and V3 (Agency Nurse) as the offender. This report was completed by V14 (Police Officer).Facility policy titled Abuse and Retaliation Prevention and Reporting- ILLINOIS with an effective date of 1/8/26 documents under the section titled External Reporting, The facility shall also contact local law enforcement authorities (i.e., telephoning 911 where available) in the following situations . When there is a reasonable suspicion that a crime has been committed in the facility by a person other than a resident.

Based on interview, observation and record review, the facility failed to thoroughly investigate bruising from potential staff to resident abuse for 1 of 3 residents (R1) reviewed for abuse and neglect in a sample of 11. Findings includeR1's admission Record documents an admission date of 11/27/13 with the following diagnoses listed in part; muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination, severe intellectual disabilities, abnormal posture, age related osteoporosis without current pathological findings.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of a 5 indicating R1 is severely cognitively impaired. Section GG - Functional Abilities documents that R1 is dependent on staff for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Section GG documents that R1 is dependent on staff for transfers and uses a wheelchair. She also needs supervision or touching assistance for wheeling 150 feet in her wheelchair.R1's current care plan documents that R1 has impaired cognitive function/dementia or impaired thought processes and has a communication problem. R1's care plan does not document R1 as being at risk for abuse.R1's abuse/neglect screening dated 3/19/26 documents that R1 is at moderate risk for abuse.Facility Final report completed by V1(Administrator), dated 3/31/26 documents there was an incident on 3/24/26 with R1 of an injury on unknown origin with injuries including left index finger bruising. Follow-up/final report summary documents: Investigation reveals that nurse on duty on that night shift had pushed resident into her room and shut the door, because resident was yelling in the lobby as other residents were passing by. Resident states that she was knocking on her door in her room, which resulted in bruising to her finger. Abuse substantiated, nurse immediately DNR (Do Not Return) from building. Staff educated about involuntary seclusion .In R1's medical record an event record was opened on 03/25/2026 at 9:34pm by V1. This record documented a bruise on R1's right hand that was 0.7 inches (in) (length), 0.5in (Width), and bruising to R1's left chest that was 5 inches in length, and 5inches in width. With vocal complaints of pain.On 3/31/26 at 10:03am, V6 (Certified Nursing Assistant/CNA) stated she came in that morning, and the night shift aides grabbed her and stated that the night nurse locked R1 in her room several times that night and they kept having to let her out. V6 stated when she went to R1's room she could hear her barely knocking. V6 stated they opened the door and let R1 out. V6 stated she did not notice any bruising on her finger at that time but did notice it a few days later, along with the bruising to her chest. V6 stated that V7 and V8 were the CNAs that night and they told her that R1 had been up front hollering throughout the night. V6 stated R1 does holler a lot but it is usually when there is something wrong or she is asking for assistance. V6 stated that R1 has continued to point at the bruised areas and say Nurse hurt me to basically any staff that will listen. V6 stated she was not interviewed. V6 stated she did not think that R1 had the strength to cause the bruise on her chest, and at the time she opened the door for her, she was not knocking hard enough to have caused that. V6 stated R1 does not normally accuse staff of hurting her or fabricating stories.On 3/31/26 at 10:05am, V9 (Certified Nursing Assistant/CNA) stated that R1 has a bruise on her finger as well as a large healing bruise on her chest. V9 stated at one point the bruise looked very painful. V9 stated the first day she saw the bruise, she was with the nurse doing a skin check. V9 stated the nurse told her that a night shift nurse was trying to push her into her room and collided with the door. V9 stated that R1 has bruised herself before but it will be tiny, tiny ones. V9 stated it was nothing like that and R1 is not capable of hitting herself that hard in the chest. V9 stated she did not think that R1 could cause those bruises to herself. V9 stated R1 does not have a history of saying staff hurt her. On 3/31/26 at 11:07am, R1 stated Nurse hurt me. Nurse hurt me. while pointing to her chest and finger.On 3/31/26 at 1:07pm, a bruise was observed on R1's chest. It started just below her left clavicle, covers most of her breast and extends into her upper abdomen. It was a faint yellow color, and appeared to be in later stages of healing. There was also a faint bruise noted to her left index finger that started just under the cuticle and extended through the first and second joint. On 3/31/26 at 2:45pm, V5 (agency nurse) stated the night that the incident happened with R1, it was just two aides and V3 (agency nurse). V5 stated she worked the following night and discovered the bruise on R1's chest. V5 stated she called V1 to report it at approx. 4am and V1 stated she was not surprised she pokes herself all the time. V5 stated she told V1, no it is not like that, she could not have done this. V5 stated R1 does occasionally leave a tiny fingerprint sized bruise on herself, but she does not have the strength to have caused something like that. V5 stated she was told by the CNA's that R1 was sitting up front being noisy. V5 stated the CNAs told her they saw her up front and went down the hall to get up other residents and saw the nurse pushing her to her room at one point. V5 stated the CNA's reported they went down the hallway and she was in her room with the door shut. V5 stated they said they brought her up front and continued to get residents up, and when dayshift arrived, they found her in her room again with the door shut and mad as could be when they found her. V5 stated that R1 has been consistently saying that nurse did it, nurse hurt me. V5 stated it has been reported to administration by not only her, but other staff as well.On 4/1/26 at 10:51am, R8 (R1's Roommate) who was alert to person, place and time stated R1 can be noisy at times. R8 stated she remembers there was a night where she heard a lot of commotion with R1 with a staff member that she didn't know her name, but knew she was not here anymore after that. R8 stated she could not see what happened because it was at night and she had her curtain pulled, but there was something going on and then the door was closed and R1 was still in the room making a lot of racket. R8 stated that shortly after the commotion some of the other girls opened the door and R1 left. R8 stated the staff member was yelling at R1 and R1 was kind of hollering back, but that's all she could really hear.On 4/1/26 at 11:03am, V7 (Certified Nursing Assistant/CNA) stated R1 was in the lobby hollering during the morning of 3/24/26. V7 stated that she and V8 went down the opposite hallway and continued to get people up. V7 stated when they came back up front, R1 was gone. V7 stated at this time V6, who is on day shift had arrived. V7 stated they started down the hallway R1's room is on and could faintly hear R1 yelling and knocking on the door. V7 stated they let R1 out of her room and she was so mad. V7 stated they brought her up front, and at this time she did not notice any bruises. V7 stated she was telling them that the nurse hurt her, nurse door, nurse my room, nurse hurt. V7 stated R1's hands were moving so fast it was hard to notice if the finger was bruised or not, she stated there was no bruise on her chest, but she continued to poke her chest and repeat everything she was saying about the nurse. V7 stated R1 was not able to open the door, because she has poor upper body strength. V7 stated she did not think the way R1 was poking her chest could have caused the massive bruise she had. On 4/1/26 at 11:48am, V4 (Registered Nurse) stated she came in the morning after the incident happened with R1. V4 stated she was under the impression that the nurse was upset because R1 was making too much noise whenever she was trying to pass meds, she stated that is just what R1 does is make noise. V4 stated if she is being loud, something is probably wrong. V4 stated when R1 saw her that morning she immediately pointed to her finger and chest. V4 stated R1's finger was red and swollen, she stated she pointed to the door and said, Nurse did it. V4 stated there's no way R1 could have caused the bruising on the chest, occasionally she will cause a small bruise, but nothing to the extent of her bruises. V4 stated the night shift CNA's contacted V1, she did not directly contact her that day. V4 stated R1's bruise to her chest was large and looked painful. V4 stated R1 did not complain of pain. V4 stated R1 is not capable of opening the door. V4 stated the bruise on R1's chest was reported to V1 and V11 (Former Director of Nursing) on multiple occasions and nothing was done.On 4/1/26 at 1:11pm, V10 (Former Director of Nursing) stated on the morning of the incident involving R1, she was very angry and pointed to her chest saying her did it. V10 stated they were told by night shift staff that V3 took R1 to her room and closed the door. V10 stated as soon as administration was made aware, they started an investigation. V10 stated V7 and V8 the night shift CNAs said it happened twice. V10 stated V3 put her in her room and closed her in there. V10 stated a complete skin assessment should be done at the beginning of an investigation. V10 stated V1 handled all the investigation, but the bruise on R1's chest should have been documented and investigated. V10 stated R1 does not have a history of making false accusations against staff. V10 stated R1 statements nurse do it and nurse hurt me should have been taken seriously. V10 stated R1 was not capable of opening the door.On 4/1/26 at 1:24pm, V2 (Social Services Director) stated she came in that morning around 7:30, and R1 was visibly upset. V2 stated her first question was had anyone called V1, call was made to V1 immediately. V2 stated R1 had a bruise on her finger but did not have bruise on chest at that time. V2 stated that R1 does not have a history of making false allegations towards staff. V2 stated that R1 does have a history of causing bruises to herself. V2 stated the reason why R8 was not interviewed was because she was under the impression R8 was not in the room at the time it happened. V2 stated that V7 and V8 stated V3 closed R1 in her room more than once that night. V2 stated she was not sure whether R1 was strong enough to leave the bruise, but R1 was poking herself persistently saying nurse hurt. V2 stated R1 could not open door.On 4/1/26 at 3:05pm, V1 (Administrator) stated that R1 is known to make bruises on herself. V1 stated when she got here R1 was poking herself in the chest saying see did it, V1 stated she told R1 to stop poking herself in the chest she was going to leave a bruise. V1 stated R1 does not have a history of making false allegations against staff. V1 stated R1 had a bruise on her hand that was later determined was from knocking on the door. V1 stated she did not investigate the bruise on the chest because it was initially not there. V1 stated she was not sure why the bruise wasn't investigated after it was discovered, but that was a good question. V1 stated an incident was opened about it in R1's chart. V1 stated it was reported to police and the agency V3 worked for. V1 stated R1 could not open the door involuntary seclusion was substantiated. V1 stated V3 was interviewed that day and asked not to come back immediately. V1 stated staff was educated on involuntary seclusion. V1 stated V6 was not interviewed because she was not there the whole night, just when they opened her door.Facility initial investigation of an injury of unknown origin to R1's left index finger documents an undated and untimed interview performed by V1 with R1. In this interview, V1 asked, Your nurse took you to your room? R1 responded Yep V1 asked, then what? R1 responded, Shut the door. V1 stated, Your nurse put you in your room and shut the door? R1 responded, Yep.In R1's medical record an event record was opened on 03/25/2026 at 9:34pm by V1. This record documented a bruise on R1's right hand that was 0.7 inches (in) (length), 0.5in (Width), and bruising to R1's left chest that was 5 inches in length, and 5inches in width. With vocal complaints of pain.Facility Final report completed by V1, dated 3/31/26 documents under the section follow-up/final report summary; investigation reveals that nurse on duty on that night shift had pushed resident into her room and shut the door, because resident was yelling in the lobby as other residents were passing by .Abuse substantiated, nurse immediately DNR from building. Staff educated about involuntary seclusion.The facility was unable to produce any evidence that the bruise on R1's chest or the statements made by R1 were thoroughly investigated.Facility policy titled Abuse and Retaliation Prevention and Reporting- ILLINOIS with an effective date of 1/8/26 documents under policy; This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. In the section titled, Internal investigation it documents; Any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property will result in an investigation . An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on interviews and record review the facility failed to ensure they maintained sufficient staff to meet the needs of the residents timely for 3 of 3 residents (R1, R2, and R3) reviewed for staffing in the sample of 7. This failure has the potential to affect all 47 resident who currently reside at the facility.Findings include: The facility document titled Daily Census dated 12/16/2025 documents 47 residents reside at the facility.1.R1's document titled Transfer/Discharge Report documents R1's admission date of 9/19/2025 and includes diagnoses of Chronic Obstructive Pulmonary Disease, Multiple Sclerosis, Muscle Wasting, Dysphagia, Major Depressive Disorder, and Conversion Disorder with Seizures or Convulsions.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 indicating R1's cognition is intact. Section GG documents R1 uses a walker for mobility. R1 requires supervision or touching assistance with eating and oral care. R1 requires partial/moderate assistance with toileting hygiene, shower/bathing, lower body dressing, putting on and taking off footwear, sit to lying positioning, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfers, toilet transfers and waling 10 feet. R1 is independent for bed mobility.R1's current Care Plan documents R1 is at moderate risk for falls related to Multiple Sclerosis (MS) unsteadiness on feet. R1 has had unwitnessed falls on 11/9/2025, 11/13/2025, and 11/30/2025. Goal is documented as R1 will not sustain serious injury through review date of 12/31/2025. Interventions include 11/13/2025, educate the resident/family/caregivers about safety reminders and what to do if fall occurs proper shower chair use. The resident's call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt response to all request for assistance, dated 11/9/2025.On 12/17/2025 at 10:30AM, R1 was asked if she had any concerns with her care. R1 then stated, the care is not too bad I guess. R1 stated she usually gets her showers twice a week. R1 stated sometimes it takes a long time to get the call light answered and sometimes she has to start yelling for help especially if she has fallen. R1 stated the night shift is often short staffed and that is when most of the problems are with call lights. R1 stated sometimes they just don't answer the call lights at all. R1 stated she has waited very long times for the call light to be answered before. R1 stated she had fallen out of bed and laid in the floor for a while and had to yell for help after using her call light and nobody answered so she started yelling for help before anyone came.2.R2's document titled Transfer/Discharge Report documents an admission date of 12/3/2025 and includes diagnoses of Hereditary Ataxia, Deformities of Right Lower Leg and Left Leg, Ataxic Gait, and GERD.R2's Minimum Data Set (MDS), section C, dated 12/11/25 documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R2 is cognitively intact. R2's Activities of Daily Living documentation in the Point of Care section of the Electronic Health Record documents that R2 requires supervision or touching for toilet hygiene. R2 requires substantial/Maximal assistance for showers and sometimes with chair/bed-to-chair transfers.R2's current Care Plan documents R2 has limited physical mobility related to Ataxia, with interventions to provide supportive care, assistance with mobility as needed. R2 has an alteration in musculoskeletal status related to Ataxia with interventions to educate the resident/family/caregivers on joint conservation techniques. Follow the MD orders for weight bearing status. See MD (Medical Doctor) orders and/or PT (Physical Therapy) treatment plan.On 12/17/2025 at 10:40AM, R2 was asked how her care was and R2 stated the nights are rough because they take forever to bring medications or answer call lights. R2 stated she does as much as possible by herself and she gets her showers twice a week. R2 stated she does require help with some tasks. R2 stated the night shift does not always have enough staff to take care of all of us.3.R3's document titled Transfer/Discharge Report documents an admission date of 7/7/2025 and includes diagnoses of Type 2 Diabetes, Major Depressive Disorder, Anxiety, Congestive Heart Failure, and Hypothyroidism.R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 indicating R3's cognition is intact. Section GG documents R3 requires assistive device of a walker for mobility. R3 requires setup or clean up assistance for eating, oral hygiene, and toileting. R3 is dependent for showers. R3 is independent for position changes, ambulation and transfers. Section H documents R3 is occasionally incontinent of urine and always continent of bowels.R3's current Care Plan documents R3 has self-care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADLs (Activities of Daily Living), dated 6/6/2024 with revision date of 6/16/2024. Goal is that R3 will participate in bathing and dressing during am and pm cares for the next 90 days with revision date of 10/16/2025 and target date of 1/19/2026. Interventions include: assist with ADLs as necessary with staff assist of one. Set up at bedside, sink side, dated 6/6/2024 with revision date of 6/16/2024. On 12/17/2025 at 12:30PM, R3 was observed sitting up in her recliner in her room with call light within reach. R3 stated she sleeps in her recliner. R3 stated care was pretty good on all shifts but sometimes it takes a while for her call light to be answered. R3 stated if it takes too long and she needs help then she just walks around and finds a staff member. R3 stated sometimes the wait is the same on both shifts.On 12/17/2025 at 10:24AM, V4 CNA (Certified Nurse Assistant) stated there are 3 CNAs total today so one of the CNAs on East Hall is trying to help the other hall too. V4 stated when there are 3 CNA's they cannot get all the work done. V3 stated with 3 CNAs they work hard to get the residents repositioned and fed. V3 stated the documentation doesn't get done. V3 stated yesterday none of the showers were done because they only had 3 CNAs. V3 stated they are going to try to get some of the showers from yesterday done today. On 12/17/2025 at 11:00AM, V1 Administrator (ADM) stated staffing has been challenging with the COVID outbreak. V1 stated we have resorted the use of agency nurses as of lately. V1 stated they are not using agency staff for CNAs yet. V1 was asked to provide their staff/census ratio and V1 stated she just has a budget, and it allows 2 CNAs on the night shift. V1 stated she feels like 2 CNA's can get the work done on the night shift. V1 stated there was 3 CNAs and the Transportation CNA working the floor today.On 12/17/2025 at 11:15AM, V6 (CNA) stated she normally works the dayshift. V6 stated they always run 3-4 CNAs on the dayshift. V6 stated the night shift has been running 1-2 CNAs on the night shift and when the dayshift gets in the nightshift work is not done. V5 stated some residents are wet and the residents that require a mechanical lift are not up because 1 CNA cannot get them up alone. V5 stated it is hard on the dayshift to try to catch up and keep things done especially if there is only 3 CNAs on the dayshift. V6 stated there are times that residents have to wait 20-30 minutes to have their call lights answered. V6 stated that is way too long. V6 denied incontinence due to long wait times.On 12/17/2025 at 11:20AM, V7 (CNA) stated the dayshift normally runs 2-3 CNAS and we are lucky to get 4 CNAs. V7 stated we can't provide good care when there is only 2-3 CNA's. V7 stated when we have 2-3 CNAs, we have a hard time changing and repositioning the residents every 2 hours. V7 stated we normally have 3 CNAs, and it is very difficult to answer call lights in a timely manner. V7 stated sometimes the residents aren't always changed by the night shift and we can tell when we get here on dayshift, but they are running so short on nights, they can't keep everyone changed. V7 stated there is usually always 2 nurses on the dayshift.On 12/17/2025 at 2:23PM, V9 (Anonymous) stated staffing is really bad. V9 stated 2 CNAs to take care of 47 residents is not ideal and is hard to take good care of them. V9 stated the call lights have to go on for a long time sometimes and we can't help it. V9 stated there are times that there is 1 CNA in the facility at night and that is impossible to get things done. V9 stated it takes 1 CNA at least 2 hours to make a round and then you just start all over again. V9 stated if you are the only CNA then while you are caring for a resident and another resident has on their call light then they have to wait until you finish with the resident you are already helping. V9 stated the nurses try to help too but they are very busy as well. V9 stated just this week there were 2 nights that after 10:30PM to 6:00AM there was only one CNA in the building on 12/14/2025 and just last night 12/16/2025 there was only 1 CNA after 12:00PM until 6:00AM. V9 was asked if residents became incontinent due to waiting on the call light for assistance. V9 stated usually not because while she makes her rounds it not only includes changing residents, but it also includes taking residents to the bathroom. The long time sometimes in between rounds does cause residents to not be changed as quickly as they would be if there were more staff to help with care. On 12/17/2025 at 2:42PM, V10, (CNA) there was only one CNA for several hours. V10 stated it is very hard and rough when there is only one CNA, and we can't provide good patient care. V10 stated the call lights have a long wait time due to low staffing. V10 stated they try to keep 2 CNAs on nights but even with 2 CNAs it is very hard but when there is only 1 it is impossible to take care of all of the residents like they should be taken care of. V10 stated she does not do any mechanical lifts unless another staff member is there to help, it takes 2 staff members to use a mechanical lift. V10 stated that she was by herself on 12/16/2025 after 12AM and on 12/14/2025 she was by herself for several hours.On 12/17/2025 at 2:50PM, V11 (CNA) stated she has not worked at the facility since October 2025, and she is an as needed employee. V11 stated when she worked there was usually 2 CNAs and 1 nurse after 10:30PM or 12:00AM. V11 stated it was rough to care for all of the residents with short staffing and call light wait times were very long at times.The document titled CNA Schedule December 2025 was provided by V1 on 12/17/2025, after request of the actual working schedule. V1 stated some of the call ins may not be reflected on the schedule due to staff being sick with COVID. The CNA's schedule reflects on 12/14/2025, there were 2 CNAs scheduled for 6PM-6AM (V10 and V12). V1 validated that V12 was off on 12/14/2025 due to illness. V1 stated V13 CNA came in and worked to help out. Requested V13's payroll information and payroll reflected V13 clocked in at 5:55PM and clocked out at 10:26PM on 12/14/2025. The document shows on 12/16/2025 there were 2 CNAs scheduled (V10 and V15) for 6PM-6AM. The document shows a line marked through 6PM and has 6PM/12AM wrote in for V15. V1 was asked about this and stated she didn't know at that time that V15 went home sick at 12AM. V1 stated she didn't try to get it covered at 12AM because she did not know that V15 was sick and left the facility. The schedule documents an average of 4 CNAs for the day shift 6AM-6PM and 2 CNAs for the night shift (6PM-6AM).On 12/17/2025 at 3: 33PM an attempt was made to reach V15 via phone without success. On 12/17/2025 at 3:15PM, V1 was asked if it was acceptable for the night shift to run with 1 CNA. V1 stated no it is not acceptable. V1 was asked if she was aware that there was only one CNA in the building just last night after midnight to 6AM and V1 stated, I was not aware of that. V1 was asked if she was aware that on Sunday 12/14/2025 there was only 1 CNA after 10:30PM, V1 stated she knew a CNA came in at 6PM and stayed until 10:30PM to help out. V1 was asked if she was ok with the fact that after 10:30PM there was only 1 CNA in the facility and V1 stated well it is not what I want but we have had some sick people and soon the DON will return from illness, and she should be able to help more. V1 was asked if she gets notified when there is short staffing in the facility and V1 stated usually but I don't know why they didn't notify me last night. V1 was asked if proper care could be provided with only 1 CNA in the facility and V1 stated well, that would be hard to do. V1 was asked about facility assessment and the assessment calls for 10 CNAs for a 24-hour period and as the schedule reflects there is normally 6 CNA so is this acceptable and V1 stated no. V1 stated I just go by the budget numbers, and it shows 2 CNAs for the night shift. V1 was unsure of the census number that was used for her budget.The Facility Assessment Tool with dated 12/4/2025 documents assessment based on 46 residents (6-Dependent, 5-Assistive Device used to ambulate, and 35 in chair most of time.) Resident's Assistance with Activities of Daily Living: Independent: 3 -dressing,0 bathing, 13 transfers, 0 eating, 7 toileting, and 6 mobility. Assist of 1-2 staff: 35 dressing, 24 bathing, 25 transfers, 42 eating, 26 toileting, and 5-mobility. Dependent: 8 dressing, 22 bathing, 8 transfers, 4 eating, 13 toileting, and 35 in chair most of the time. Under Staffing Plan the total number needed for each position documents the following: Licensed Practical Nurse providing direct care: 3, Nurses' Aides: 10, Other nursing personnel 3.

Based on observation, interview, and record review the facility failed to ensure staff donned the required Personal Protective Equipment. The facility also failed to ensure contaminated Personal Protective Equipment was discarded as required after use, failed to separate covid positive residents from covid negative residents, and failed to monitor vital signs of covid positive residents. These failures affected 6 of 6 residents (R1-R6) who were reviewed for infection control practices. These failures also have the potential to affect all 44 residents living in the facility. Findings include: The facility Census Report documents on 3/28/2025 there were 44 residents living in the facility. The Resident Infection Control and Antimicrobial Log dated for March 2025 documents on 3/16/2025 6 residents tested positive for COVID - 19, on 3/17/2025 3 residents tested positive, on 3/18/2025 1 resident tested positive, on 3/19/2025 1 resident tested positive, on 3/21/2025 4 residents tested positive, on 3/24/2024 1 resident tested positive and on 3/26/2025 4 residents tested positive. On 4/1/2025 at 10:55AM, V2 (Director of Nursing/DON) provided an undated March 2025, Covid-19+ list that included residents that were on isolation for Covid and when their isolation was to be completed. At that time V2 stated, I put possibly on these because if they still have symptoms I leave them on isolation. 1. R1's Admission Record documents an admitted [DATE] and includes diagnoses of Type 2 Diabetes Mellitus, Major Depressive Disorder, Parkinson's Disease, End Stage Renal Disease, Chronic Atrial Fibrillation, and COVID. MDS (Minimum Data Set) dated 2/7/2025 includes a BIMS (Brief Interview for Mental Status) score of 6 suggesting severe impairment. The Resident Infection Control and Antimicrobial Log documents R1 tested positive for Covid-19 on 3/26/2025 and isolated. The March 2025, Covid-19+ list documents R1's isolation will be completed possibly on 4/3/2025. On 3/28/2025 at 10:10AM, R1 was observed lying in her bed in her room with the door open. Signage of droplet isolation was present with PPE (Personal Protective Equipment) outside the door, all necessary items in the bin except gloves. There was a bin to discard PPE inside the room by the door. R1 noted to be coughing several times during observation. R1 is in a private room. On 4/1/2025 at 2:05PM observed V9 (Certified Nurse Assistant/CNA) walking out of R1's room with only a surgical mask on. The door to the room was noted to have signage for airborne (droplet) isolation with bins noted outside the room with proper PPE equipment. V7 (CNA) was with V9 leaving the room and V7 had on a N95. On 4/1/2024 at 2:07PM, V9 was asked why she only had on a surgical mask and V9 stated R1 is not positive anymore and someone has not taken down the signage for droplet isolation' V9 was asked when she last received training on infection control and Covid training, V9 stated, Not too long ago it seems but I don't know for sure. On 4/1/2025 at 2:07PM, V4 (Registered Nurse/ Resident Care Coordinator) was present for conversation with V9, and stated she did not think R1 was positive for covid. V4 looked back at records and noted R1 tested positive on 3/28/2025 and was negative on 3/27/2025, which is a different date than what is present on the Infection Control Log. On 4/1/2025 at 2:10PM, V7 (CNA) was asked if she had been trained on Infection Control/Covid and V7 stated no but she had only been here a couple of weeks. V7 was asked if she had been advised to change N95 mask after caring for a Covid positive resident, V7 stated No. On 4/1/2025 at 2:45PM, V2 (Director of Nursing) was asked if she expected her staff to change PPE including an N95 mask when they leave a Covid positive room to care for other residents. In reply, V2 stated, Yes, I absolutely expect them to change PPE at the door before leaving the room. V2 was asked if she expected the staff to wear the proper PPE while caring for the Covid positive residents and V2 stated, Yes they must wear the N95's gowns, gloves, and eye protection. V2 was asked if she expected the staff to follow the signage on the door for precautions and V2 stated, Yes I do. 2. R2's Admission Record documents R2 admitted to the facility on [DATE] with diagnoses of Osteoarthritis bilateral knees, hypokalemia, muscle weakness, cognitive communication deficit. R2's MDS (Minimum Data Set) dated 3/24/2025 includes a BIMS (Brief Interview for Mental Status) score of 11 suggesting moderate impairment. The Residents Infection Control and Antimicrobial Log documents, R2 tested positive for Covid on 3/26/2025 and isolated. The March 2025, Covid-19+ list documents R2's isolation will complete possibly on 4/2/2025. On 3/28/2025 at 10:30AM observed R2's room with noted droplet isolation signs with bin outside door with all necessary PPE except gloves. R2 was not in her room. Observed a roommate R7 sleeping in bed. Infection Control log documents R7 was positive for Covid on 3/16/2025. The Residents Infection Control and Antimicrobial Log documents, R7 tested positive for Covid on 3/16/2025 and isolated. The March 2025 Covid Positives list did not document when R7 was to come off of isolation. On 3/28/2025 at 10:42AM observed R2 sitting in the dining room with no mask at the dining room table. R2 stated they tested her for Covid and, she was positive. R2 stated she was not offered a mask. R2 remained in the dining room for the lunch meal with other residents present at the table. On 4/1/2025 at 12:17PM observed R2 eating lunch at a table with other residents with no mask present. On 4/1/2025 at 1:03PM, R2 was observed propelling self in wheelchair down the hallway with no mask on. 3. R3's Admission Record documents an admitted [DATE] and includes diagnoses of Atherosclerotic Heart Disease, Depression, Atrioventricular Block, Hypertension Cognitive Communication Deficit, Unspecified Dementia, Anxiety. MDS (Minimum Data Set) dated 1/18/2025, BIMS (Brief Interview for Mental Status) documents resident is unable to complete due to never or rarely understood. The Resident Infection Control and Antimicrobial Log documents R3 tested positive for Covid on 3/21/2025, and isolated. The March 2025, Covid-19+ list documented R3's isolation to be completed on 3/28/2025. On 3/28/2025 at 10:08 AM observed R3's room with signage of droplet precautions on the door with bins with PPE noted outside the door. Three residents R3, R5, and R6 were present in the room at this time. R6 who was alert to person, place, and time, stated, My roommate (pointing at R3) is the one with Covid. R3 was noted to be sitting up in her wheelchair. R3 did not have a mask on, and the curtain was not drawn. R3 was noted to be coughing several times during observation. R6 stated R3 has been eating meals in the room as well. R6 stated, They said we were far enough apart, so we are safe. R3 was not interviewable. The Resident Infection Control and Antimicrobial Log, did not document R5 or R6 had tested positive for Covid. On 3/28/2025 at 11:15AM, V2 was asked why R3 was in a room with 2 residents that are Covid negative, V2 then stated, We were told we don't separate them anymore and the reason is to avoid spreading the virus. V2 was asked what their policy reads and V2 stated I am not sure I would have to review the policy. On 3/28/2025 at 11:30PM, V1 (Administrator) was asked if their policy gave direction to cohort Covid positive residents with Covid negative residents, V1 stated she was told by the Regional Nurse that the residents don't move anymore to try to avoid the spread of Covid-19. On 3/28/2025 at 2:16 PM, V7 CNA was observed walking into R3's room with only a N95 mask on. V7 was then observed going into the resident's bathroom looking in the mirror, no observation of hand hygiene or changing of mask. V7 did not don gloves or a gown while in R3's room. V7 exited the room and went down the hall into another resident's room without changing her mask. 4. R4's Admission Record includes an admitted [DATE] and includes diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, Unspecified Dementia with Anxiety, Hypertension, Cognition Communication Deficit, and Hodgkin's Lymphoma. MDS (Minimum Data Set) dated 3/5/2025 includes a BIMS (Brief Interview for Mental Status) score of 13 suggesting cognitively intact. The Resident Infection Control and Antimicrobial Log documents R4 tested positive for Covid-19 on 3/24/2025 and isolated. The March 2025, Covid-19+ list documents R4's isolation will be completed on 3/31/25. On 4/1/2025 at 12:20PM, R4 was noted to be eating lunch in the dining room with no mask on and was at a table with other residents. On 4/1/2025 at 1:25PM, R4 stated she had Covid but was doing pretty good. R4 stated she has had it a few days and still had a runny nose. R4 was asked if she stays in her room or goes out to the dining room. R4 stated, I have always gone to the dining room, and nobody has said anything. R4 was asked if she wears a mask while out in the halls. R4 stated, No, and nobody has told me I need to either. 5. On 3/28/2025 at 1:10PM the electronic health records (EHR) were reviewed for R1, R2, R3, and R4. These residents records did not include documentation that R1, R2, R3 and R4 had vital signs checked every shift after being diagnosed with Covid. On 4/1/2024 at 11:45AM, V4 (Registered Nurse/ Resident Care Coordinator) stated the vitals should be done every shift for the COVID positive residents and those that are symptomatic. V4 stated the nurses make the list, the CNA's get the vitals, then the nurses get the vitals put into PCC (Point Click Care/electronic records). V4 was asked to see the list and V4 stated, I don't have one made yet. On 3/28/2025 at 2:10PM, V5 RN (Registered Nurse) stated, When a resident test's positive we should move them, if at all possible, to a room by themselves. V5 stated we should be doing vital signs at least every shift for the residents that are positive. V5 was asked if she had vitals for her shift yet and V5 stated, 'No I have not made the list yet. V5 stated the CNA's get the vitals and we put them in. On 3/28/2025 at 2:30PM, V1 was asked about the policy on vital signs and V1 stated, 'I think we are supposed to get the vital signs on the COVID positive residents once a shift. V1 then confirmed that R1, R2, R3, and R4 did not have vital signs done every shift according the EHR. V1 stated she expects the staff to obtain vital signs every shift on the COVID positive residents. Policy titled Infection Control-Interim Covid-19 dated revised 7/24/2023 documents under Guidelines: the following information is only intended to be used as guidelines to address health care concern of Human Corona virus specifically COVID-19. This policy will address prevention, education, screening, surveillance, investigation, and reporting of persons at risk. As this is an evolving situation, frequent updates may be made to these guidelines as recommendations are released by CDC. Process Surveillance: Infection Preventionist or designee will frequently monitor staff compliance with hand hygiene and PPE practices on varied shifts. Immediate actions and education will be provided as needed when concerns noted. Education: Provide staff, residents, families and visitors with education on COVID-19, including transmission and symptoms of COVID as indicated. Educate staff on current infection control and standard precautions and proper PPE selection, use and donning/doffing as indicated. When caring for residents with suspected or confirmed SARS CO V2 infection, an N95 respirator should be worn and the N95 should be removed and discarded after the patient care encounter and a new one should be donned (out on). PPE Use in Red and Yellow Zone: HCP who enters the room of a resident with suspected or confirmed SARS-COV-2 infection should adhere to Standard Precautions and use a NIOSH- approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. PPE (Personal Protective Equipment) including N95 should be discarded and new applied between residents. In general, residents should be encouraged to wear source control if able until symptoms resolve or, for those who never developed symptoms, until they meet the criteria to end isolation. Management and Care of Residents with Suspected or Confirmed COVID-19 Infection: The recommendations described below (e.g., resident placement, recommended PPE) apply to residents with symptoms of COVID-19 (even before results of diagnostic testing). These residents should not be cohorted with patients with confirmed SARS-COV-2 infection unless they are confirmed to have SARS-COV-2 infection through testing. Place a patient with suspected or confirmed SARS-COV-2 infection in a single room if available, the door should be kept closed (if safe to do so). Monitoring and Assessment: Monitor for signs and symptoms every shift: Fever > 100 degrees Fahrenheit, cough, cold symptoms, new shortness of breath, sore throat, chills, muscle pain, headache, GI upset, nausea/vomiting, diarrhea, new loss of smell/taste.

Based on interview and record review, the facility failed to designate an individual as the Infection Preventionist. This failure has the potential to affect all 44 residents living in the facility. Findings include: On 3/28/2025 at 9:30AM, V2 (Director of Nursing/DON) was interviewed with V1 (Administrator) present. V2 was asked who the infection preventionist was in the facility and V2 stated that V4 (Resident Care Coordinator) was working on getting her certification for Infection Prevention but had not completed it yet and she takes care of the Infection Control stuff. V1 stated I have my Infection Control Preventionist Certification, but I don't use it now that I am the Administrator, I don't think I can do that. V1 stated I don't do anything with the Infection Control Program. On 4/1/2025 at 2:10PM, V4 was asked when she last had Infection Control and Covid training at this facility and V4 stated I have never had training at this facility on either one. V4 stated she has only been employed at the facility since October 2024. V4 stated she has tried to pass the Infection Preventionist certifications test but has been unable to pass. V4 stated she does most of the infection control program but has not provided staff education. V4 stated she does most of the Covid testing for the staff and residents. V4 was unsure of the policies for Infection Control and Covid. The Facility Assessment Tool dated 1/15/2025, documents under section 3.11 We have a certified Infection Control Preventionist nurse that has been trained to track infections and assist in making decisions on exposures and treatments in collaboration with the medical director and their team of nurse practitioners. The policy titled Infection Prevention and Control Program dated 12-5-2024, documents Purpose: to comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing service under a contractual arrangement. Guidelines #3 documents The designated Infection Control employee and Quality Assurance Committee is responsible for monitoring the effectiveness of the program and continually improving outcomes. The facility Census Report documents on 3/28/2025 there are 44 residents living in the facility.

Based on observation, interview and record review, the facility failed to use appropriate alternatives prior to installation of bed rails, adequately assess and monitor residents for risk of injury/entrapment prior to installation, ensure adherence to appropriate dimensions and manufacturer's recommendations, and failed to obtain a physician order for use of bed rails for 6 (R2, R3, R4, R7, R8, R9) of 9 residents reviewed for bed rails in the sample of 29. This failure resulted in R2's death by positional asphyxiation, when R2 was found in the sitting position on the floor beside the bed with legs straight out and head and neck between mattress and bed rail. This failure also has the potential for risk of serious harm/injury and possible death for R3, R4, R7, R8 and R9. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility added side rails to R2's bed without proper assessment and installation per manufacturer's recommendations which resulted in R2's death via asphyxiation on [DATE]. V1 (Administrator), V34 (Regional Clinical Director), V16 (Regional Minimum Data Set Coordinator), and V33 (Regional Reimbursement) were notified of the Immediate Jeopardy on [DATE] at 9:57am. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], but the noncompliance remains at Level Two due to additional time to evaluate implementation and effectiveness of training. Findings include: 1. R2's Admission Record documented an admitted [DATE], and included diagnoses of Parkinson's Disease, Type 2 diabetes mellitus, morbid obesity, dementia, and hydrocephalus. R2's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Under Functional Abilities and Goals, the MDS documented R2 had no impairment to upper and lower extremity, R2 used a wheelchair (w/c) for mobility, R2 required partial/moderate assistance for eating and oral hygiene, was dependent for toilet hygiene, bath/showers, lower body dressing, putting on and taking off footwear, and personal hygiene, and R2 required substantial/maximal assistance for upper body dressing. Under Cognitive Patterns, the MDS documented R2 exhibited no physical or verbal behaviors, and under Restraints and Alarms, a 0 was entered to indicate not used for bed rails as well as any bed, chair, or other alarm. R2's Baseline Care Plan dated the day of admission ([DATE]) had the following items checked: Assist of 2+ for bed mobility, Assist of 2+ and Dependent for transfer, Ambulation was marked N/A (not applicable), and Assist of 1 and Wheelchair were checked for Locomotion. Under the section titled Identified Safety Risks: Safety Plan of Care, the following boxes were checked: High Risk Fall Assessment, Poor Safety Awareness, Fall History, Gait, Balance, and Weakness. The section titled Enabler/Positioning Device/Positioning Cushion/Alarm/Safety Device Plan of Care is incomplete with nothing checked for any assessments or devices in use. This baseline care plan is blank in the section for any updates and signatures. Problem areas identified on [DATE] included: R2 requires staff assist with ADL's (Activities of Daily Living), R2 is at risk for falls, risk for injury from falls r/t (related to) unsteady gait/Parkinson's/history of falls, R2 is at risk for uncontrolled movement r/t Parkinson's, R2 has impaired cognition, and confusion at times r/t Parkinson's Dementia. Interventions for these identified areas included assist with bed mobility, transfers, bathing/toileting, etc., call light and personal items in reach (all dated [DATE]); Proper Footwear (dated [DATE]) and Pin Alarm (dated [DATE]). This care plan had no documentation addressing the use of side rails for R2. The next Care Plan for R2 documented Focus areas initiated on [DATE] that included R2 was a Full Code, had impaired cognitive function r/t dementia, Parkinson's, and hydrocephalus, and noted R2's Parkinson's affected speech and thought processes. This Care Plan did not include information regarding R2's risk for falls or history of falls and did not include any documentation addressing the use of side rails. The facility document titled Physical Restraint/Enabler Consent has R2's name and a date of [DATE] (date of admission) written in. The Reason for Restraint/Enabler: is documented as ,d+[DATE] side rails and the Type of restraint/enabler: is documented as positioning and bed mobility. The consent further states Please be advised all residents using physical restraints/enablers will be assessed for a reduction program. All reductions will be based on the assessment performed by a Licensed Nurse in the facility . The consent is signed by V9 (R2's Power of Attorney/POA) . The facility's [DATE] Fall Log documented R2 had a fall on [DATE] at 10:00AM, location Residents room, root cause is weakness/loss of balance, intervention in place is educated nursing staff to assure patient is wearing proper footwear. The facility's [DATE] Fall Log documented R2 had a fall on [DATE] at 3:30PM. Location resident's room, root cause was attempting to sit on side of bed independently, intervention is orders obtained for pin alarm to person while awake. R2's Bed Rail/Transfer Bar Evaluation dated [DATE] is a two page document with instructions that state to Check all that apply in last 7 days. This document includes handwritten check marks, but also has handwritten Y (yes) and N (No) answers in some of the boxes. Under Medical Need Affecting Bed Mobility/Transfer Safety the following items have a check mark: Weakness, Pain, difficulty moving to a sitting position on the side of the bed, difficulty with balance sitting on bed and/or getting in/out of bed, poor trunk control, difficulty/unable to move legs in bed without device, changes in blood glucose levels, knees buckle, and mattress requires/suggests use of side rails. The following items are marked N for no: Difficulty/Unable to move trunk in bed without device, visual deficit, orthostatic hypotension and/or vertigo, musculoskeletal disorders affecting resident (fractures/contractures, etc.), neurological disorders causing involuntary movements, and history of falls in last 30 days. Under Mental Status Affecting Bed Mobility/Transfer the following items have a check mark: Able to make needs known, fluctuations in level of consciousness and altered/poor cognitive status. N is marked for Able/Willing to participate in bed mobility. Under Alternative Attempted Prior to Bed Rail/Transfer the following items have a check mark: Assisted Transfer, Frequent Staff monitoring/assisted turning and positioning while in bed, and reminders to use call light. The following items are marked N for no: Physical or Occupational Therapy, Restorative Care, Bedside Commode and/or Urinal/Bedpan, periodic assisted toileting, altered bed height, transfer bar and trapeze. Under indications for bed rail/transfer bar, all items are marked N for no and include: bed rails do not appear to be indicated at this time, at least two medical needs exist and two alternatives have been attempted ., resident has been evaluated-does not overhang bed-able to turn comfortably, serves to remind resident to seek help-unaware of physical limits, serves as Enabler - unable to enter or exit bed independently without enabler use, serves as Enabler to promote independence in turning side to side and puling self to lying/sitting and resident expresses desire to have the side rail for security. On the 2nd page under Benefits of Bed Rail/Transfer Bar Use, the following items are checked: Enhanced functional ability-decrease dependence on others for ADL's (Activities of Daily Living), Reduce injury related to random/unpredictable movements during transfers and prevent injury to self or others. Under Entrapment Considerations during use, N for no is marked for the following questions: Is resident at risk for climbing over rails?, Is there a Neurological Disorder causing involuntary movements?, Is Resident combative with care?, Is Resident known to have any thrashing, jerking or unpredictable physical movements that may cause entanglement in bar? Y or yes was answered in response to the following questions: Does the bar prevent resident from exiting bed? (Yes = Restraint-Additional complications may be possible obtain consent-CP (care plan) accordingly) and Does the bar interfere with the resident's access to their own body? (Yes = Restraint-Additional complications may be possible obtain consent-CP accordingly). The bottom of the 2nd page of the evaluation has four sections to indicate quarterly review, each stating The IDT (Interdisciplinary Team) has reviewed the resident's capabilities, needs and preferences in relation to bed rail use and has determined with boxes for the team to choose No Bed Rail Indicated, Benefits of enabler outweigh risks; consent obtained for: Assist Bar: Bilat (bilateral) Rt (right) Lt (left), Full Side Rail: Bilat, Rt, Lt, ,d+[DATE] Side Rails: Bilat, Rt, Lt, ,d+[DATE] Side Rails: Bilat, Rt, Lt, an area for comments, and an area for staff signature, initials and date. These four sections on R2's evaluation are left blank, therefore incomplete. A second Bed Rail/Transfer Bar Evaluation was completed the next day on [DATE] and some items were answered differently on this evaluation, such as difficulty/unable to move legs in bed without device and knees buckle were both answered N for no. The whole section under Alternative Attempted Prior to Bed Rail/Transfer had no alternatives checked, and Bed rails do not appear to be indicated at this time was checked. The differences under the Benefits of Bed Rail/Transfer Bar Use documents: enhanced safety during ADLS, and reduced potential for falls. Again, the bottom four sections of this evaluation form where the IDT reviews and makes determinations regarding bed rails were left blank with nothing selected and no staff signatures, initials or dates. The local Fire Department incident report documents an EMS (Emergency Medical Services) call with an incident date of [DATE] at 1:04 AM. Under Patient Narrative, the following is documented: Responded to nursing home facility for male patient unresponsive, not breathing. Upon arrival, find [AGE] year-old male supine on floor next to bed. Nursing staff performing chest compressions and ventilations with BVM (bag-valve-mask). Patient is pulseless and apneic. Skin is cold and cyanotic. Cardiac monitor applied showing asystole. Nursing staff reports possible down time 45 minutes or more. Resuscitation efforts discontinued; medical control contacted to confirm. Staff reports patient had been found with most of his body on the floor, with head and upper torso stuck between bed and bed rail. Coroner contacted via dispatch. Cleared scene with nursing staff awaiting communication with coroner. End of Report. R2's Progress Notes dated [DATE] at 3:25AM, documented the following Late Entry: At approximately 0100 (1:00AM), CNA (Certified Nurse Assistant) alert this nurse that resident needed immediate assist. This nurse immediately ran into resident room and saw the resident in a compromised position. Resident appeared to be in sideways sitting position with head between grab bar and mattress. Resident unresponsive and no pulse palpable. Resident lowered to the floor. CPR (Cardiopulmonary Resuscitation) initiated. All staff alerted EMS alerted. This nurse and other nurse continued CPR until EMS arrived. Time of Death 0110 (1:10AM). IDT (Interdisciplinary Team) notified. EMS notified coroner. Family Notified. The Medical Examiner/Coroner Certificate of Death documented R2's date of death was [DATE] and time of death was 1:15AM. Under Cause of Death, Part 1, a. documented Positional Asphyxiation, due to or as a consequence of b. found in a seated position on floor beside bed, due to or as a consequence of c. legs straight out and head and neck between mattress and bed rail. Part 2 lists the following under Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part 1 Diabetes, hypertension, Parkinson's, dementia, and obesity. The manner of death is documented as Accidental with date of injury listed as [DATE], time of injury listed as 1:00AM, and place of injury listed as Nursing Home. The death certificate was certified by V5 (Coroner) on [DATE]. On [DATE] at 11:10 AM, V5 (Coroner) stated he was the one that determined the cause of death for R2. V5 stated he was notified by EMS that the resident (R2) was expired upon arrival and R2 was very cold to touch. V5 stated EMS relayed that the nurses were doing CPR upon their arrival but the efforts were stopped upon assessment due to the condition of R2. V5 stated the EMS estimated R2 had been expired for at least 45 minutes upon their assessment. V5 stated he came to the facility and met with the nurse (V3 - Licensed Practical Nurse/LPN) who was working the night of R2's death. V5 stated V3 demonstrated the position of R2 when V3 entered the room and the position of R2's head in between the mattress and the bedrail. V5 stated the nurse demonstrated the position of R2's body as sitting on the floor with his legs straight out and body turned sideways with head caught in between the mattress and bedrail, which made it difficult to impossible for R2 to breathe. V5 stated R2's cause of death was positional asphyxiation. V5 stated he had the EMS report and has reviewed all records. V5 stated the cause of death was due to R2's head being trapped between the mattress and bedrail causing positional asphyxiation. On [DATE] at 12:56PM V2 (Director of Nursing/DON) was asked who at the facility does the Side Rail assessments and who decides if they are needed. V2 stated she wasn't familiar with Side Rail Assessments, and she was not sure who does them. V2 was asked who obtains the consents and again V2 stated she wasn't sure. V2 was asked if there was documentation regarding alternative interventions attempted prior to implementing side rails or where that documentation would be and V2 stated she was not aware of any such documentation, but she would look for it. V2 was asked if she completed side rail assessments for R2, to which she responded No. V2 stated she is new in the position since October or November of 2024, and she was not sure who does assessments or consents. V2 stated she assumes bed rails are used for bed mobility. On [DATE] at 1:34PM, V1 (Administrator) was asked for the incident/investigation report on R2's incident that occurred on [DATE]. V1 stated we did not do one because we did not think his death was related to a fall or any type of injury. V1 was asked if there was an incident report made on this occurrence and V1 stated no. On [DATE] at 2:20PM, V3 (LPN) stated she was the nurse in charge of R2's care on the morning R2 expired ([DATE]). V3 stated she was an agency nurse but had worked at this facility several times. V3 stated she was summoned to (R2's) room at approximately 1:00AM by V11 (CNA) and the V11 stated R2 was needing assistance. V3 stated when she entered R2's room, he was noted to be in a compromised position. V3 was asked to explain what she meant by that and V3 stated R2 was sitting on his bottom on the floor with his legs stretched out and he was sort of turned with his head lodged between the mattress and handrail. V3 stated R2 did not have a pulse or respirations. V3 stated she and V11 had to lift R2 up to get his head and torso out of the rail so she could lay him flat on the floor to start CPR. V3 stated R2 was cold to touch. V3 stated she had already sent V12 (CNA) to call 911 while she continued CPR. V3 stated when EMS arrived, they stopped the CPR and called the coroner. V3 stated the bed R2 was in was a very old-style bed. V3 stated the siderail present on the bed was the old brown metal ones that mount on the bed and were very big. V3 stated there was a large gap between the mattress and siderail, estimating it was at least a 6-inch gap. V3 stated it was the most horrible thing she has ever seen as a nurse. V3 stated she notified V1 and V2 of R2's incident and his death. V3 stated the staff that were working that night told her R2 has tried to get out of bed numerous times in the past. When questioned if R2 had an alarm, V3 stated she was not aware of an alarm and no alarm was sounding. V3 stated she met with the coroner at the facility a few days after the incident and reenacted the position R2 was in and his condition when she entered the room. V3 stated she knew it was due to his head being stuck between the rail and mattress and it was asphyxiation. On [DATE] at 10:05AM, V1 stated she received a call from V11 at 1:09AM on [DATE] and V11 stated R2 was hanging out of bed gasping for air, and it did not look good. V11 stated CPR was being started. The next call was from V3 at 1:50AM stating R2 had expired. V1 stated when I went in with the coroner for the reenactment, I knew something major had happened. V1 stated I also thought something was up when the coroner kept coming into the facility. V1 stated R2 had a history of throwing his legs out of the bed. V1 was asked what intervention was put into place for R2 throwing his legs out of bed and V1 stated there are no interventions for that, but it is sort of a common thing for people to do that. V1 stated R2 had a clip-on alarm when he was up in his wheelchair. V1 stated R2 would not have had that while in bed. V1 stated the clip-alarm was for a fall intervention. V1 stated R2 had siderails on for positioning, he would help roll himself in bed. V1 stated maintenance puts on the siderails and we do routine checks on siderails. V1 stated I don't know about the gaps on siderails, but maintenance does all of that. V1 stated, R2 had an air mattress on his bed. V1 was asked if she knew the manufacturers recommendation for side rails with the air mattress and V1 stated no, I don't know anything about gaps. V1 was asked what process they use to determine who needs side rails and V11 stated well sometimes the family wants them on so we put them on, and sometimes physical therapy may recommend. V1 said there should be a side rail assessment, consent, and (physician) order completed at the time of installation of siderails. On [DATE] at 12:41PM, V6 (Maintenance Director) stated he is the person that puts on the side rails. V6 was asked who sends him the work order or request for side rails, and V6 stated either a CNA, Nurse, or Administrator just comes and tells him who needs side rails put on. V6 stated he went to other facilities that have closed and got all the side rails he could find as he was told to gather all of them and bring them to this facility. V6 stated these side rails are very old but so are the beds. V6 stated he did not receive any Owner's Manual or specifications on the side rails or beds from the other facilities. V6 stated he had not seen any specs on the beds, side rails, or mattresses in the facility. V6 was asked if he checks the gap when he installs the side rails and V6 stated all I know is that the side rails must be 4 inches from the headboard. V6 was asked what the gap space was for between the side rail and mattress and V6 stated he didn't know anything about that. V6 stated he is told to keep a few vacant beds with side rails installed for any new admissions. V6 was asked if he checks the side rails monthly or routinely and V6 stated I was asked that same question this morning by V1 and I told her I did not know anything about needing to do that, so no I never go check the side rails. I will start doing that from now on. V6 stated I did find a book under my desk that has the logs to check side rails and gaps, but it has not been kept up or has not been done for a long time, the last one done was in 2023. V6 was asked if he remembers putting R2's side rails on and V6 stated No I really don't remember if I did, and chances are they were already on the bed. V6 was asked if he at any time checked R2's siderails and V6 stated No. V6 stated he started the job in October of 2024, and he is learning as he goes. V6 was asked if he could show this surveyor the bed that R2 was last in before he expired and V6 stated No I couldn't be sure as we switch beds all the time. V6 stated he doesn't even recall what type of bed R2 had or what type of side rails were on his bed. On [DATE] at 1:35PM, V2 (DON) stated she got notified by V3 (LPN) that R2 had passed. V2 stated R2 was a full code, and they did CPR but he did not make it. V2 stated V3 reported that R2 was found with no vitals, so they lowered him to the floor and started CPR while V12 (CNA) called 911, then EMS took over and stopped working on R2. V2 stated that V3 said R2's head was against the rail, and he was in a compromised position. It looked to her like R2 may have sat on the side of the bed and slid down onto the floor. She stated he had to be moved away from the rail to get him to the floor. He had an air mattress on the bed at the time. V2 stated R2 did have an order for a pin alarm to be on during hours R2 was awake. V2 said I don't think you use a pin alarm in the bed on residents. The next workday I went in and looked at the room and looked at the progress note and contacted the CNAs to start getting statements. V2 stated she also had to get documents for the coroner. V2 said At this point my opinion is that you really can't strangulate from a siderail. I feel like this was cardiac. I am afraid an event happened prior to him slipping. I have seen him move himself around with no issues. V2 stated she was not sure what type of bed R2 was in at the time he expired. V1 stated, I do know that he had an air mattress on. V2 stated she has never been trained on gap measurements for beds with side rails and did not know that these had to be checked. On [DATE] at 2:32PM, V8 (Registered Nurse/RN - Resident Care Coordinator/RCC) stated she cared for R2 several times. V8 stated R2 had started sitting on the side of bed and trying to get up recently. V8 stated R2's health issues were bad when he first admitted but he was getting much better. R2's wife visited every day but recently she was in the hospital herself. V8 stated she only remembered R2 having one fall. V8 stated I assume he had the siderails because he tried to get out bed, but his side rails were too big, they were just too big for the bed. V8 said the nurses do the siderail assessments and the MDS Coordinator decides if they need siderails. V8 stated side rail consents are in the admission packet, so we automatically get them signed for permission for siderails upon admission in case they ever need side rails. V8 stated she was told by V3 that R2 coded, and it was very unfortunate. V8 stated R2 was alert with confusion and no behaviors or hallucinations. V8 said that daily R2 would constantly throw his legs out (of bed). V8 stated when she worked and R2 would start throwing his legs out of the bed, she would have the staff get him up in his wheelchair. V8 stated she was not aware of R2 having an alarm of any kind. V8 stated there should be side rail assessments completed with a consent and orders before side rails are installed on any resident. On [DATE] at 2:44PM, V9 (Family/Power of Attorney/POA) stated she doesn't remember when or why R2 had bed rails put on his bed. V9 stated no staff ever told her why but she thought it was because R2 kept trying to get out of bed. V9 stated she doesn't ever remember signing a consent for side rails. V9 stated she visited R2 every day. V9 stated she was told of one fall, and they did not tell her of any interventions. V9 stated she asked for an alarm for R2 while in bed because R2 would try to get out of bed. V9 stated R2 had confusion most of the time. V9 was asked if she ever attended a care plan meeting and she replied she was never told of such a meeting, and it would have been nice to have one. V9 stated she just doesn't understand why they had the side rails on except to keep him in the bed. V9 stated the plan was to get R2 back home so she and her daughter could provide care for him at home. On [DATE] at 7:53 PM, V11 (CNA) stated she was working on [DATE] when R2 expired. V11 stated she is the one that found R2. V11 stated she had done a bed check on R2 at 10:00PM, and the next time she went into R2's room was around 1:00AM when she had walked by and seen his feet were not in the bed. V11 stated R2 was constantly throwing his legs out of bed and trying to get up. V11 stated when she entered R2's room at around 1:00AM, she saw him sitting on the floor beside the bed sort of sideways with his neck caught between the bed rail and bed frame. V11 stated it was like he was hung by his neck, but his body was on the ground. V11 stated R2 was not breathing, and she noted he was discolored. V11 stated she ran and got the nurse and she and the nurse had to lift R2 up to get his neck out from the bedrail because it was stuck. V11 stated they finally got him loose and started CPR. V11 was asked if she knew why R2 was out of the bed and V11 stated yes R2 was really wet, and he was poopy too. V11 was asked if anyone else had checked on R2 between 10:00PM and 1:00AM and V11 stated I don't know. V11 stated they really aren't assigned a specific hall; they all just work together. V11 stated she thinks R2 was on a special mattress but doesn't know the name of it. V11 stated there was a big gap between the mattress/bed rail and bed frame and was big enough for his head and neck to fit in and get stuck in. V11 stated R2 has had ,d+[DATE] rails on his bed for a long time and they were the big old rails too. V11 stated R2 was confused and did not usually use a call light. V11 didn't know anything about an alarm for R2. V11 stated she called V1 and explained what had happened and she stated she told V1 that R2 was found hung in the side rail and he expired but they were doing CPR. On [DATE] at 8:54 AM, V14 (LPN) stated she was working the morning of [DATE] at the time R2 expired. V14 stated she was summoned to R2's room to assist with CPR for R2. V14 said when she entered the room CPR was in progress and she took over helping the other nurse (V3). V14 stated she didn't notice R2 being extremely cold, but she did notice his color was bad. V14 stated once EMS got there, the paramedics took over and stopped CPR as it was evident R2 was expired. V14 stated she remembered when she stood up her pants were wet from urine that was on the floor from R2. V14 stated she was not familiar with R2 as she has never worked the hall R2 was on. On [DATE] at 8:21AM, V1 stated maintenance had not been checking the specification on the beds, mattresses, or side rails before installation. V1 stated the Side Rail Installation assessment should be done by maintenance prior to installation. V1 stated she does not believe she has the specifications for the beds or bed rails due to the equipment being so old and most of the beds in use came from other facilities that closed. V1 stated she would try to find them but does not know if she will find them as she has never seen them. V1 stated she plans on taking off all side rails in use due to safety. On [DATE] at 8:45AM, V6 (Maintenance Director) stated he does not measure the beds, mattresses, or side rails before installation of side rails. V6 stated he put most of the side rails that are in use on the beds. V6 stated some of the beds he brought from other facilities already had side rails in place, so they just left them on. V6 stated he does not check the weight or height of the residents either. V6 stated he does not have the specifications on the beds, mattresses, or side rails that are in use currently in the facility. V6 stated he brought most of the beds in use from other facilities along with side rails and he did not get the specifications or Owners Manuals on the beds or bed rails. On [DATE] at 9:00AM, V13 (MDS Coordinator) stated she does not do the initial Side Rail Assessments or consents; these are included in the admission packets and the floor nurses do all assessments upon admission. V13 stated she does the quarterly assessments. V13 stated she does the care plans too. V13 stated she doesn't have all the side rails put on the care plans as she is behind and just started mid-November. V13 was asked if she could provide a list of when the siderails were installed on each residents' beds and V13 stated she has never seen a list or log of when the siderails were put in place on any of the residents and without orders it is impossible to determine. On [DATE] at 9:14AM, V12 (CNA) stated she was working the night R2 expired. V12 stated there were 3 CNAs and 2 Nurses working that night. V12 stated she and another CNA were just coming in from a smoke break when V11 (CNA) came running and told them to get to R2's room to help with CPR. V12 stated when she entered the room, R2 was lying on the floor beside the bed and V3 was performing chest compressions. V12 stated she was directed to call 911, so she did and stayed on the phone with the dispatcher until EMS arrived approximately 6 minutes after she called. V12 stated she followed them to the room and after EMS assessed R2 they stopped CPR. V12 was asked when she last saw R2 alive and V12 stated at 10:00PM she helped with a bed check on R2. V12 was asked if she had checked on him in between 10:00PM and 1:00AM and V12 stated No. V12 stated the CNA's usually get bed checks done every 3 hours. V12 was asked how R2 was at 10:00PM and she stated, he was his normal self, confused but very nice. V12 stated R2 was constantly throwing his legs out of bed and trying to get out of bed. On [DATE] at approximately 8:00AM, V1 stated they found where R2's bed was moved to another room. On [DATE] at approximately 10:52 AM, this surveyor and V6 (Maintenance Director) observed the bed that R2 was in at the time he expired. The bed had an air loss mattress on it with metal ,d+[DATE] side rail in place and gaps were observed between the mattress and the side rails. V6 was asked to measure the gap on the left side between the mattress and the side rail (as this was the side of the bed where R2's head/neck was caught). The gap measured approximately 4 ,d+[DATE] inches. This surveyor then sat on the air mattress on the left side and the gap expanded to 5 inches. This surveyor reached out to grab the left side rail and it was loose and moved outward, so V6 was asked to measure again and noted a 7 ,d+[DATE]-inch gap. R2's Physician Orders dated ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] had no documented orders for side rails. 2. R3's Admission Record documented an admitted [DATE] and included diagnoses of Ischemic Cardiomyopathy, Depression, Anxiety, Vascular Dementia, and Insomnia. R3's MDS dated [DATE] documented a BIMS score of 2, indicating R3 has severe cognitive impairment. Under Functional Abilities and Goals, the MDS documented R3 was dependent for rolling left to right, the ability to roll from lying on back to left and right side and return to lying on back on the bed, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer. R3 was also dependent for eating, oral hygiene, toileting, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Under Restraints and Alarms, R3's MDS documented a 0 to indicate bed rails are not used. R3's current Care Plan documented the following Focus areas: R3 has impaired cognitive function/dementia or impaired thought processes r/t vascular dementia, has a communication problem r/t HOH (hard of hearing), receives Hospice services, and is high risk for falls including risk factors of medication and dementia (all initiated [DATE]). Interventions for the high risk for falls focus area include Pad bed alarm and w/c alarm. R2 not to be alone in room in w/c due to will try to transfer self without help and possibly fall. Must be put to bed and CNA's t [TRUNCATED]

Based on interview and record review, the facility failed to seek emergency care for a resident with Type 2 Diabetes Mellitus who was experiencing elevated blood sugars too high for accurate readings to be obtained with facility glucose monitoring device for 1 of 3 residents (R16) reviewed for change in condition in a sample of 29. This failure resulted in R16's death with cause of death listed as possible diabetic ketoacidosis. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to seek emergency care for R16 who was experiencing high blood sugar readings which lead to R16's death as possible diabetic ketoacidosis. V1 (Administrator), V33 (Regional Reimbursement), and V34 (Regional Clinical Nurse) were notified of the Immediate Jeopardy on [DATE] at 11:35 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], but the noncompliance remains at Level Two due to additional time to evaluate implementation and effectiveness of training. Findings Include: R16's Admission Record documents an admitted [DATE] with diagnoses of Cerebral Palsy, Type 2 Diabetes Mellitus with Ketoacidosis, without coma, Hyperlipidemia, Hyperkalemia, Epileptic Syndrome, Quadriplegia, Acute Kidney Failure, Chronic Kidney Disease, Microcephaly. R16's MDS (Minimum Data Set) dated [DATE] includes a BIMS (Brief Interview for Mental Status) assessment that suggests BIMS should not be conducted as resident rarely/never understood. R16's MDS documents R16 requires substantial/max assist with oral hygiene, putting on/off footwear, roll from left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed -to- chair transfers, and toilet transfers. R16's MDS documents R16 is dependent upper and lower body dressing. R16's Physician Orders dated [DATE] to [DATE] documents orders for Humalog Kwikpen (insulin) 100 units/3 milliliters, inject 6 units subcutaneous three times a day (8:00AM, 11:00AM, and 4:00PM) with meals. Lantus (insulin) 100 units/milliliters, inject 23 units subcutaneous once daily (8:00AM). Fingerstick glucose monitoring three times a day (8:00AM, 11:00AM, and 6:00PM) with meals with sliding scale insulin including parameters: less than 150 =0 units, ,d+[DATE]= 2 units, ,d+[DATE]=4 units, ,d+[DATE]=6 units, ,d+[DATE]=8 units, ,d+[DATE]=10 units, and over 400 give 12 units and call the physician. R16's December medication administration Record (MAR) documents orders for Fingersticks Glucose Monitoring: TID (three times a day) with meals with sliding scale insulin at 8:00AM, 11:00AM, and 6:00PM. The Blood Glucose Monitoring System, User Instruction Manual on page 53 documents your blood sugar is more than 600mg/dl (milligrams per deciliter). Instructions to repeat test with new test strip. If the message shows, again contact your healthcare professional right away. If blood sugar is over 600mg/dl the monitor will read HI. On [DATE] at 11:59AM, V20 (Certified Nurse Assistant/CNA) stated we got R16 up that morning and he was acting ok but seemed tired. As the day progressed, he didn't seem right like yelling at us, so we told the nurse. V19 (Agency Licensed Practical Nurse/LPN) was the nurse, and she checked R16's BS (blood sugar) and it was high. We told the nurse that he needs to be sent out to the hospital, but V19 did not listen and said she was going to try some things first. V20 stated V19 would not listen to the CNA's and the nurse is just temporary and does not know the residents like we do. V20 stated R16 didn't eat much that day. Right before lunch is when R16 started getting worse. V20 stated in the evening V19 kept checking R16's blood sugar and it kept reading high. V20 stated V19 had never worked dayshift before so she did not know how R16 was during the day. On [DATE] at 11:59AM, V19 (LPN) stated she was working the dayshift 6A-6PM on [DATE]. V19 stated she was the charge nurse for R16. V19 stated R16 was mostly fine through the earlier part of the day. V19 stated she really didn't know R16 that well. V19 stated around 3:,d+[DATE]:30PM the CNA's reported to her that R16 wasn't acting right, and he looked bad. V19 stated she checked R16's blood sugar around 3:30PM and the glucometer just read HI. V19 stated she gave R16, 12 units of regular insulin at this time and called the on-call physician but had to leave a message. V19 stated at 4:00PM she gave 6 more units of regular insulin as scheduled. V19 stated R16 was a little sluggish and was acting tired. V19 stated as she was waiting for the return call from the physician, she called V2 (Director of Nursing/DON) and V2 informed her that this has happened before with R16 and sometimes they send him to the hospital if the physician orders to send to the emergency room . V19 stated that V2 said to just wait on the physician to call back and see what the physician wants to do. V19 was asked if she has had training at the facility on change in condition, blood glucose monitoring such as how high does the glucometers read, and V19 stated she has not had any kind of any training at the facility. V19 stated she had no idea of how high the blood sugar is when it read HI. V19 stated R16's vital signs were within normal limits, and she did not receive a return call from the physician during the remainder of her (day) shift that ended at 6PM. On [DATE] at 2:00PM, V19 stated she was not sure what number she called for the on-call physician on [DATE], it was on a note at the nurse's station. V19 stated she doesn't know about the facility's (electronic communication system) and communication like that. V19 stated, I was advised by V2 to wait for the physician to call back and if V2 would have said send R16 to the ER (emergency room ), I would have sent him to the ER. V19 stated she gave report to V22 (Agency Registered Nurse/RN) when she came in at 6PM with information about R16's high blood sugars and a call placed to the on-call physician. On [DATE] at 11:04AM, V22 (Agency Registered Nurse/RN) stated she worked on [DATE], 6AM -6PM. V22 stated she received in report that R16 had been running high blood sugars and insulin per orders was given and the on-call physician was called, and a message was left for a return call. V22 stated she went to R16's room around 6:30PM to check on R16, she stated she could arouse R16, and he would answer yes or no to questions. R16's blood sugar was checked at this time and the reading was HI. V22 stated she had put in another call to the on-call physician and left a message. V22 stated she received a call back from a physician around 7:30PM and received orders to give another dose of 12 units of insulin, in addition to the scheduled dose of 6 units and recheck in a little while. V22 said that she was not sure who the physician was that called. V22 stated she did not document the physician's name in the medical record and did not write the orders given to her on the Physician Order Sheet. V22 stated she was the only nurse in the facility for that shift. V22 stated she could arouse R16 at that time and he was unchanged from previous assessment at around 6:30PM. V22 stated she remembers rechecking R16's blood sugar about 45 minutes later, approximately 8:15PM and the blood sugar was down to 488. V22 stated, I thought we were finally going in the right direction with the blood sugar going down. V22 stated, Sometime around 10:00 PM, I was called to R16's room by a CNA, upon entering room R16 was having a hard time breathing, heart rate was irregular, color was bad and R16 was nonresponsive. V22 stated at this time she and the CNA lowered R16 to the floor to prepare for CPR (Cardiopulmonary Resuscitation), when lowering R16 to the floor, R16 stopped breathing. V22 stated CPR was started and help was called for from the other CNA's. When the other CNA entered the room V22 asked her to call 911 and the CNA stated, CNAs are not allowed to call 911, so that CNA took over chest compression and V22 went to call 911 and check R16's chart for code status. V22 stated code status was found and R16 was a DNR (Do Not Resuscitate) so she went to the room and stopped CPR. V22 stated EMS (Emergency Medical Service) arrived and pronounced death around 10:30ish. V22 stated she remembers R16 having a strong sweet fruity smell as they were transferring him to the floor. V22 stated she has had no training at the facility on policies or resources to look up policies. On [DATE] at 1:20PM, V21 (Certified Nurse Assistant/CNA) stated, she came into work on [DATE] at 6:00PM and shortly after getting to work she saw R16. V21 stated R16 was not responding to the staff and his color was not good. V21 described R16's color as not a good color and sort of gray. V21 stated, As the evening went on there really was not many changes with R16. V21 stated, I was working on another hall when I heard someone yell and when I got down there, the nurse was doing chest compressions on R16. When another CNA got in there, she took over chest compressions and the nurse went to check the chart to see if R16 was a DNR or a Full Code. The nurse returned stating R16 was a DNR, so the CPR stopped. When EMS arrived, they checked R16 and stated to leave R16 in the floor until cleared by the coroner. V21 stated, When I got report from the day shift CNA's, the CNA's reported that R16 was not doing good at all and the CNA's tried to get the dayshift nurse to send him to the emergency room , but she wanted to try some other things first. V21 stated this was an agency nurse and they do not know the residents like we do. On [DATE] at 4:20PM, V25 (CNA) stated she was working the night R16 passed. V25 stated she worked 6PM -6AM that day. V25 stated she had checked in on R16 a few times and R16 was sleeping. V25 stated when she went in to do bed check on R16 she noted he was gray in color and not responding. V25 stated she was unsure of the time. V25 stated she yelled for help, and everybody came. V25 stated they moved him to the floor and started CPR. V25 stated they did CPR for about 15 minutes until EMS arrived then they stopped CPR. V25 stated R16 had been out to the hospital multiple times in the past because of his blood sugars. On [DATE] at 12:18PM, V2 (DON) stated she remembers the phone call she received from V19 LPN on [DATE]. V2 stated it seems like it was somewhere around 5:00PM. V2 stated V19 was an agency nurse that informed her that R16's blood sugar was reading HI and that she had followed doctor's orders and had given him insulin and was waiting on the physician to call her back. V2 stated she asked how R16 was doing, and the nurse stated his vital signs seemed to be normal. V2 stated the nurse stated she thought he was acting ok to her. V2 stated she told the nurse that if she felt like he needed to be sent out that she could do that or just wait on the physician to call back with orders. V2 was asked if she had investigated R16's death records. V2 stated, I read the nurses notes because she didn't see anything really concerning. V2 stated she talked with the night nurse V22 after R16 passed. V2 stated the night nurse said R16 acted fine at 6:00pm when she arrived at work and then V22 was called to his room later and she called 911. V2 stated she thought V22 had called back the doctor or the doctor called her and order more insulin. V2 stated she had seen where his blood sugar went down a bit after V22 gave the ordered insulin. V2 stated his blood sugar was down in the 400's after that. V2 was asked if she would have sent him out with the high blood sugars, V2 stated, If he was not acting right, I would have. V2 stated his blood sugars reading high meant it was over 500. V2 was asked how high the glucometers reads and V2 stated, I believe 500 or 550 but I would have to read the book on that to make sure. V2 was informed the Owners' Manual to the glucometer states these glucometers read up to 600 then automatically go to read HI. V2 stated Wow! V2 stated she would have sent him out knowing his blood sugar was over 600. V2 stated she feels it was a long time for the physician to get back with the facility and this is unusual, and she would have sent him out. V2 stated R16 had started making a pattern of having DKA (Diabetic Ketoacidosis) and he had been placed in ICU (Intensive Care Unit) with an Insulin drip over the last several months, with the last time was [DATE]. V2 stated R16 was normally very active, talking to the staff, V2 stated he had the mind of a child, and we all loved him. V2 was asked if the (Nurses Agency Staffing Organization) nurses receive any or are required to complete any training at the facility level, V2 stated the only requirement is a valid nurse's license. V2 stated she doesn't like to have agency nurses in her facility working because they don't know the residents usually, but we don't have a choice right now. On [DATE] at 1:45PM, V1 (Administrator), stated she has been employed at the facility for 5 years and she was very familiar with R16. V1 stated she had not investigated R16's death. V1 stated R16 had been sent to the hospital several times for elevated blood sugars, DKA, and R16 would get treated and return. V1 was handed R16's progress notes from the day he expired. V1 was asked to read the progress notes. V1 then stated, I would have sent him out at 488 but I would have sent him out before that when the blood sugar was too high to read on the glucometer. V1 stated she and V15 (Nurse Practitioner/NP) had talked about this after his death and R16's life expectancy was only to live until his 20's, he was in his 50's and he had many health issues. V1 stated the nurse that was working that day was an agency nurse. V1 stated, I would have sent him out and if they would have sent him out when it was high, he would still be alive, but I was very familiar with R16 and knew his medical issues. On [DATE] at 1:50PM, V23 (R16's sister/Power of Attorney) stated R16 was her brother, and he had resided in the facility for a few years. V23 stated up until the last several months the care was good and R16 was thriving, but the last several months had been bad. The facility has a lot of nurses that only work occasionally, and they do not know the residents or how to care for them. V23 stated on [DATE] she came to visit R16 in the afternoon and R16 did not seem himself and seemed very tired. V23 stated she thought maybe he was just sleepy as no staff said anything to her about his blood sugars or anything being wrong. V23 stated, The next thing I knew I got a call between 10:30PM and 11:00PM that my brother had passed. V23 stated R16 was in the hospital recently with Ketoacidosis on [DATE]. V23 stated if R16 doesn't get his insulin right his blood sugars get too high. On [DATE] at 9:25AM, V24 (Medical Director), was asked if he was familiar with R16. V24 stated, That name does not ring a bell, I don't know him. V2 was asked how the on-call services work and V24 stated, The nurses have to use (facility notification system) to reach the nurse practitioner and on weekends from 9PM to 6AM there is a number to call and usually I am the one on call. V24 was asked if he received any calls on [DATE] or after midnight on [DATE], V24 checked his records and personal phone and stated, No I did not. V24 was explained the condition of R16 and his high blood sugars. V24 stated, We can sometimes manage high blood sugars in the facility but if we give treatment and the condition doesn't change then they need to be sent to the hospital. V24 stated he believes the problem is with the nursing staff and some of them only being in the facility a few times. V24 was asked if he thought that hindered communication with physicians and he stated, Yes if they do not know our system. V24 was asked when the last time he made rounds in the facility to see the residents and V24 stated, I do not see the patients, the Nurse Practitioners see the patients and they work through me. I only come per requirement quarterly for the meeting. V24 stated the facility should have done a better job with R16, and I am sorry for his death. V24 stated education needs to be done and corrected. On [DATE] at 12:04PM, V15 (NP) stated she was looking for messages on [DATE] on the call log and on her cell phone and no messages were left and there were no missed calls for this facility for [DATE]. On [DATE] at 2:20PM, a call was placed to the Physician Service office and spoke with the receptionist/secretary (V35) who stated she would send a call log for the date of [DATE] for this facility. The call log was received and did not show that the Physician Service office received any calls from the Facility log on [DATE]. R16's Nurses Notes authored by V19 dated, [DATE] at 5:50PM, documents, right before dinner had started it was time for me to check R16's. I checked his blood sugar, and the monitor said high. So I check it again on another finger and it still said high. I looked at his chart to see his sliding scale, I followed the sliding scale and called the on-call doctor like it stated on his order. I called and left and voicemail for the on-call doctor letting him know what was going on and what he would like for me to do next. I checked R16's vital signs before I called the doctor, and his vital signs were wnl (within normal limits). While waiting on the call back I checked R16's blood sugar again 40 minutes later after given insulin, and it still said high. So, I called the DON and told her what was going on and she said he had issues with his blood sugar being high before. While doing shift change, I informed the on-coming nurse about what was going on and that she should receive a call from the doctor soon. I also charted what was going on, on the shift change sheet. R16's Nurses Notes authored by V22, dated [DATE] at 1:00AM, documents report received at approximately 6PM from the day shift nurse that resident's blood sugar had been running high today and most recent blood sugar reading prior to evening meal read hi on the blood glucose monitoring machine. Dayshift nurse reports calling provider on call for further insulin orders. Call back from PCP (Primary Care Provider) received at approx. 7:30PM with new orders for additional 12 units insulin x 1. Insulin given per orders RUQ (right upper quadrant) abd (Abdomen). At that time resident able to respond yes/no to questions asked. No active distress. Respirations even and unlabored, heart RRR (regular rate and rhythm), BS (Bowel Sounds) per 4 quads. Skin color WNL. Recheck of blood sugar at approx. 8:30PM with result of 488. No change in condition from an hour ago. No acute distress. During med pass CNA's notified this nurse that resident looked terrible. Upon entering resident's room, he was laying in bed color pale resp uneven and labored, fruity/sweet smell odor noted to resident's breath, unresponsive, heart irregular rate and rhythm. V/S (Vital signs) ,d+[DATE], 56, 28, 96.2 unable to obtain O2 (Oxygen) sat. Resident moved to the floor in anticipation of CPR if required, while this writer and CNA moved resident to floor, he stopped breathing, chart checked for code status and rescue breaths given. POLST (Physician's Order for Life Sustaining Treatment) form - DNR (Do Not Resucitate). No further breaths given. Emergency responders/fire department arrived at facility at approx. 10:33PM. Time of death 10:33PM. This writer called sister/guardian at 10:35 PM and 11:15, sister returned call to facility and spoke with this nurse with situation relayed. Sister began crying and stated she was glad for being able to see him this morning for a visit and was thankful to all facility staff for care given to brother. On-call after hours MD (medical doctor) called x2 awaiting call back. This nurse called local funeral home and body removed from facility at approximately 12:45AM. R16's [DATE] MAR (Medication Administration Record) documents on [DATE], R16's blood sugar at 8:00AM has numbers that are scribbled out but looks like 200 written beside the scribbles with V19's initials. On [DATE] at 11:00AM, the MAR documents blood sugar of 272 with initials of V19. There was no amount of sliding scale insulin documented to be given at that time, however the scheduled Humalog Kwikpn 6 units at 11:00AM and initialed by V19. On [DATE] 4:00PM, the MAR documents 6 units of Humalog Insulin was given as scheduled and initialed by V19, and at 6:00PM fingerstick glucose monitoring is initialed by V19 and results were scribbled out. On [DATE] at 2:00PM, V19 was asked about the blood glucose monitoring checks being scribbled out on MAR and V19 stated she did not do that. R16's December MAR contains no documentation that 12 units of Humalog insulin were given around 4:00PM on [DATE]. The MAR does document at 7:30PM on [DATE] R16 received 12 units of Humalog due to blood sugar reading Hi on Blood Glucose monitoring machine. R16's State of Illinois Certificate of Death includes a date of death for [DATE], and cause of death Probable Diabetic Ketoacidosis. Time of death 10:33PM. Facility Physician- Family Notification-Change in Condition Policy with a revision date of [DATE], documents in part: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: .(B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a stage II pressure sore, onset or recurrent periods of delirium, recurrent urinary tract infection, or onset of depression. (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before). (D) A decision to transfer or discharge the resident from the facility. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Facility administrator was in-serviced by Regional Reimbursement Consultant on [DATE] on ensuring that glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner. Facility administrator was in-serviced by Regional Reimbursement Consultant on [DATE] on ensuring that licensed nursing personnel will inform the physician or authorized designee with any change in condition of the resident in an effective, timely and efficient manner. Facility administrator was in-serviced by Regional Reimbursement Consultant on [DATE] on medications being administered in accordance with the good nursing principles and practices and only by persons legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system. Facility's administrator in-serviced by Regional Reimbursement Consultant on [DATE] on using nursing judgement to seek emergency treatment when appropriate. Facility Administrator initiated in-servicing on [DATE] for nursing staff on using nursing judgement to seek emergency treatment when appropriate. Facility Administrator initiated in-servicing on [DATE], for all nursing staff, on ensuring glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner to be completed before the start of their next shift. Facility Administrator initiated in-servicing on [DATE], for all nursing staff, on medications being administered in accordance with the good nursing principles and practices and only by legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system, to be completed before the start of their next shift. Facility policy for physician notification has been reviewed by Regional Director of Operations and has been found to be in compliance on [DATE]. Facility completed an audit of all diabetic residents to ensure that their blood sugars are within therapeutic range and a weekly audit will be per formed by the DON or designee weekly for four weeks. Quality Assurance and Performance Improvement (QAPI) plan has been revised to include that the facility will ensure residents experiencing an acute critical situation receive timely emergency care and lacks a process for physician notification and receiving orders in an acute situation. QAPI revisions will be discussed at the next QAPI meeting in [DATE]. Monitoring will be ongoing in the morning Quality Assurance (QA) meeting by the QA team (Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS)), the QA team will review the 24-hour report and follow up on any changes in condition to ensure that proper care was received and proper procedures were followed.

Based on interview and record review, the facility failed to provide safe administration of peritoneal dialysis by qualified trained staff as ordered by a physician for 1 (R22) of 3 residents reviewed for dialysis in the sample of 29. This failure resulted in R22 experiencing severe shortness of breath requiring transfer to local hospital, R22 receiving intubation and mechanical ventilation for respiratory failure to prevent imminent deterioration and further organ dysfunction from hypoxia and hypercarbia. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 10/22/24 at 11:15 AM when V29 (Registered Nurse/RN) and V30 (Licensed Practical Nurse/LPN) manually infused 2.5 liters of dialysate fluid into R22's peritoneal space (totaling approximately 4 liters of dialysate fluid in R22's peritoneal space) causing R22 to experience shortness of breath and be transferred to the hospital for further treatment. This past non-compliance occurred from 10/22/24 to 10/31/24. V1 (Administrator) and V7 (Regional Director of Operations) were notified of the Immediate Jeopardy on 3/18/25 at 4:00 PM. The Surveyor confirmed by observation, interview, and record review that the immediacy was removed on 10/31/24. Findings include: R22's New Admission Information documented an admitted [DATE]. R22's Cumulative Diagnosis Log documented diagnoses that included sepsis, peritonitis, and dependence on dialysis. R22's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On 3/11/25 at 2:45 PM, V33 (Regional Reimbursement) said the facility was not able to produce R22's Care Plans due to a change of ownership and was now unable to access the electronic medical records. On 3/12/25 at 2:14 PM, V2 (Director of Nursing/DON) said when she came into the facility on [DATE] the nursing staff were having some issues with R22's Peritoneal Dialysis (PD) infusion due to the PD cycler alarming through the night. V2 said she was told by V30 (LPN) that due to R22's PD cycler alarming, V30 had called V28 (Dialysis Company Registered Nurse). V2 said around 9:30 AM to 10:00 AM, V28 called the facility requesting to speak with V2 to give new orders for R22. V2 said the facility did not have the bag of dialysate that V28 gave an order for and had to go to the dialysis company to pick up the bag of dialysate. V2 said she returned to the facility and V29 (RN) was the nurse caring for R22. V2 said she gave V29 the order for a 1.5 liter PD manual fill and asked V29 if V29 was familiar with how to set and infuse a PD manual fill because V2 was not familiar with infusing PD solution with gravity. V2 said V29 said she was used to completing PD manual fills and had completed them in the past. V2 said R22 received 2.5 liters of PD dialysate, started to have some shortness of breath, and was sent to the hospital for further evaluation. V2 said she had never completed a PD manual fill of dialysate at that time. V2 said she had received training from the dialysis company for PD but the training only included how to hook a resident up to the PD cycler. On 3/13/25 at 10:13 AM, V30 (LPN) said R22's peritoneal cycler machine messed up. V30 said she called the dialysis company and was unable to fix it when the dialysis company said to come to the dialysis facility to get a bag of dialysate solution for R22. V30 said V2 brought R22's dialysate solution back to the facility. V30 said V29 (RN) asked V30 if V30 could walk V29 through how to put the fluid into R22's peritoneal space. V30 said V2 did not speak to V30 about R22's peritoneal dialysis order when she returned from the dialysis facility. V30 said V29 was the staff that approached her to assist with infusing R22's dialysate fluid. V30 said she did not check R22's orders because R22 was not her patient and V30 was only there to tell V29 how to hook up the manual dialysate tubing to R22 because V29 had not been trained. V30 said she had not received any training by the dialysis company on how to manually fill or drain a peritoneal dialysis patient. V30 said after R22 had been hooked up to the bag of dialysate fluid V29 infused the whole bag (2.5 L). V30 said R22 became short of breath and was transferred to the hospital. V30 said when she was on the phone with the dialysis company earlier in the day the dialysis nurse had not told V30 how much dialysate fluid to infuse. V30 stated the dialysis nurse just said come get a bag to put in. On 3/7/25 at 11:53 AM, V29 (RN) said she was caring for R22 on 10/22/24. V29 said she had received information in report from the night shift nurse R22's Peritoneal Dialysis (PD) cycler had been alarming throughout the night and V29 would need to follow up with the dialysis company to make sure R22's PD cycle had completed and ask if there were any new orders if it hadn't. V29 said she called the dialysis company and told them R22 had trouble with the PD cycler and V30 (LPN) took over the phone call. V29 said V2 came into the facility with a box from the dialysis company and placed it in R22's room. V29 said she was hard of hearing and deaf in one ear. V29 said she did not know what V2 said to her. V29 said she and V30 went to R22's room and V29 hooked R22's PD catheter up to the bag of dialysate and V30 unclamped the tubing infusing R22 with the dialysate. V29 said she was not sure how much dialysate was supposed to be infused. V29 said the dialysate bag was a 2.5-liter bag and if only 1 liter or however much was supposed to be put in was ordered why would V2 not have told the nurse (V29) who was going to be completing the treatment. V29 said after the dialysate was infused into R22, R22 looked like R22 was in fluid overload. V29 said R22 became hypotensive and short of breath with very low blood oxygen saturations. V29 said she put oxygen on R22 and called an ambulance to transport R22 to the hospital. V29 stated I was just observing. I didn't hook (R22) up. I just connected it. (V30) unclamped it and the fluid started going in. V29 said the whole 2.5 liters of dialysate was infused in R22 and no orders were written so V30 could not have known how much to infuse. V29 said she had not received any training on dialysis. V29 said training was completed through the dialysis company and due to V29 being a float nurse from a sister facility no dialysis training was ever offered to V29. V29 said she thought V30 was certified in dialysis. V29 said during the facility's investigation V29 was told R22 was supposed to receive 1.5 liters of the manual fill dialysate solution but nothing was written in R22's medical record. V29 said she had been in communication with V28 (Dialysis Company RN) and V29 had given V28 some of the readings from R22's PD cycler but when V28 started asking more questions she handed the call off to V30. V29 said she was not sure if there were any infusion directions in R22's Medication Administration Record. On 3/14/25 at 4:31 PM, V32 (Nephrologist) said overfilling of dialysate fluids can cause lung problems and discomfort with breathing. V32 said extra fluid in the abdomen pushes on the diaphragm and causes discomfort with breathing and can make it difficult. V32 said he knew R22 and R22 was already compromised respiratory wise as R22 just had pneumonia and had pulmonary edema. V32 said the normal amount of fluid left in the abdomen is 1.5 liters. V32 said the facility is supposed to follow the orders from the dialysis center. V32 said the dialysis center faxes over the orders to the facility and the facility should not be doing dialysis without current orders. V32 said if a nurse does not know how to perform or was never trained in peritoneal dialysis they should not perform the dialysis and should call the dialysis center. On 3/13/25 at 10:42 AM, V36 (Emergency Department Physician) said he was the Physician treating R22 on 10/22/24. V36 said he was not made aware by the facility R22's peritoneal space had been overfilled. V36 said the more fluid in the abdomen would push up on the diaphragm making it difficult to breathe. V36 said R22's CT (Computed Tomography) scan documented moderate volume ascites (fluid in the abdomen). V36 said, looking at R22's CT scan, they called it moderate, but it looks like a lot. V36 said the fluid in R22's abdomen would have made it harder to breath. V36 said R22's CT scan of the lungs did show pneumonia with consolidations in bilateral lungs, but the extra fluid would have made it even harder to breath. R22's dialysis company's Progress Note dated 10/22/24 at 8:30 AM documented in part Patient had been discharged from the hospital on 10/21/24. RN unaware of discharge from the hospital back to SNF (Skilled Nursing Facility). (V30/LPN) . called and states 'We are having trouble with the patient's machine. It has been alarming for 20-30 minutes and it has not completed the last fill. The whole treatment is done but it hasn't done the purple bag' Writer advised (V30) to terminate the treatment and instructed to do a manual last fill. Discussed with (V30) supplies that were needed and would need to be picked up from dialysis facility . spoke with (V2/DON). Discussed with her the conversation of the above with (V30). And RN concerned supplies had not been picked up. (V2) then asked about a manual last fill that should be put into the peritoneum. Writer gave instructions at this time. Last fill would be 1.5L or 1500ml. It would not have to be manually drained, that it would drain during the initial drain with treatment this evening . R22's 10/21/24 through 10/22/24 dialysis company's Treatment Summary Report documented a cycler total on 10/22/24 at 8:48 AM of 1552 ml being in R22's peritoneal space. On 3/13/25 at 9:00 AM, V1 (Administrator) said the facility was unable to produce any orders for R22 from the dialysis company. V1 said after reviewing R22's medical record no orders for what peritoneal dialysis solutions were being administered was ever written on R22's September 2024 or October 2024 Physician's Order sheets. V1 said she did not know how staff were completing R22's peritoneal dialysis with no written orders. R22's Physician's Orders documented a 10/22/24 order documenting in part . T.O. (Telephone Order) Administer 1.5 L (Liters) of purple bag . manually. Hold purple bag night of 10/22/24 . R22's Nurse's Notes dated 10/22/24 at 11:15 AM and completed by V2 (DON) documented in part . This nurse received a call from (V28 Dialysis Registered Nurse) at (dialysis company) who gave T.O. to do a manual fill of 1500 ml (1.5L) to (R22). This nurse was instructed to come to (dialysis company) and pick up bag needed for manual fill . R22's Nurse's Note dated 10/22/24 at 11:50 AM completed by V2 documented in part . This nurse returned to facility with dialysis bag needed for manual fill . this nurse placed unopened box in (R22's) room and explained to (R22) what (dialysis company) wanted (V29/RN) floor nurse to do for her next appointment on 10/23/24. This nurse spoke to (V29) about what orders (V28) at (dialysis company) gave and what supplies were brought back . R22's Physician's Orders dated 10/1/24 through 10/31/24 included a 10/22/24 order documenting in part . Administer 1.5 L (1500 ml) of purple bag (dialysate fluid) .manually . No other orders for peritoneal dialysis were documented. R22's Medication Administration Record (MAR) dated 10/1/24 through 10/31/24 documented no orders for peritoneal dialysis other than the 10/22/24 order for 1.5 L manual fill. R22's Nurse's Note dated 10/22/24 at 12:30 PM completed by V29 documented in part .(R22) was doing well this AM had visitor, awake, conversating. No (signs/symptoms) of distress. Was called to room by staff. (R22) was noted to be in respiratory distress (blood oxygen saturation) in the 70's placed on (oxygen at 5 Liters via nasal cannula oxygen saturation) wouldn't go above 81. States 'I can't breath' (Blood pressure) 88/42 . Lung fields sound tight to auscultation . Sending to (hospital emergency department) . R22's Nursing Home to Hospital Transfer Form dated 10/22/24 completed by V29 documented in part . Additional Relevant Information . Just completed (peritoneal dialysis) last bag by gravity she said she feels like her stomach is about to blow up. Unable to breath (blood oxygen saturation) in the 70's. Placed on (5 Liters of oxygen blood oxygen saturation) 70's-81 . R22's Emergency Department Encounter dated 10/22/24 documented in part . presents to the (Emergency Department with) severe shortness of breath . is dusky and diffusely cyanotic (oxygen saturation) 80's on (15 liters of oxygen via non-rebreather) on arrival, panting . abdominal distention noted . repeating help me . (R22) was intubated due to respiratory distress . R22's Progress Notes & Medical Decision Making form dated 10/22/24 documented in part . Seen and assessed on arrival, weak inspiratory effort, dusky and mottled on arrival. Intubated due to severe respiratory failure . R22's hospital Progress Note dated 10/22/24 at 6:00 PM by dialysis nurse documented in part . Initial drain >3900 ml abdomen is no longer firm . Reported (initial drain) volume to primary RN . R22's ICU (Intensive Care Unit) Progress Note dated 10/23/24 documented in part .Assessment and Plan . Pulmonary: Acute hypoxemic respiratory failure: intubated due to respiratory distress. Continue managing the mechanical ventilation for respiratory failure to prevent imminent deterioration and further organ dysfunction from hypoxia and hypercarbia . Renal: . Nephrology is following. ?excessive (sic) dialysate instillation at NH (Nursing Home) as 4L removed overnight . R22's ICU Progress Note dated 10/26/24 documented in part .Assessment . Acute respiratory failure with hypoxia status post intubation on mechanical ventilation, extubated 10/25/24 . R22's hospital Discharge Summary dated 10/4/24 through 10/21/24 documented a 10/21/24 chest Xray documenting in part . Impression: Suggestion of small bilateral pleural effusion with bibasilar atelectasis or pneumonia . The facility's 10/30/24 final report regarding R22's 10/22/24 incident documented in part . On 10/22/24 at approximately (3:00 PM) this administrator was notified that (R22) was noted to be in respiratory distress and was being sent to the (hospital) for evaluation . Investigation reveals that (R22) was connected to the dialysis cycler at approximately (8:00 AM). The cycler continued to alarm, was turned off and (dialysis company) notified. At approximately (11:15 AM) the facility received orders from (dialysis company) for a manual fill of 1.5 L bag. (V2) picked up supplies from (dialysis company) which were (sic) 2.5 L bags. (V29) and (V30) connected (R22) to the manual fill bag at approximately (12:00 PM). At approximately (12:30 PM) (V29) was notified by staff (R22) appeared to be in (respiratory) distress . sent to (hospital) for evaluation . In conclusion, the facility was able to substantiate that (R22) experienced an adverse reaction secondary to receiving a manual fill during peritoneal dialysis . The surveyor confirmed through interview and record review that the facility took the following actions, which were initiated on 10/23/24 and completed on 10/31/24 to remove the Immediate Jeopardy: The contract for dialysis was terminated with the facility 10/31/2024. Facility Administrator (V1) and Director of Nursing (V2) reviewed all the residents at the time of the event and no other residents were receiving PD (peritoneal dialysis) services at the time of the event and no other residents have received PD services since this event. Facility Administrator (V1) and Director of Nursing (V2) were in-serviced by (dialysis company) on manual fill PD on 10/24/2024. Both nurses involved in the event were suspended pending investigation 10/23/2024 and terminated on 10/28/2024. Facility policy for dialysis was reviewed by Regional Director of Operations and found to be in compliance on 10/24/2024. QA (Quality Assurance) meeting was held on 10/24/2024 with (dialysis company) and policies and procedures were reviewed. Administrator or designee will review PD patients weekly times 4 weeks.

Based on observation, interview and record review, the facility failed to implement new fall interventions for a resident who was a high risk for falls for 1 of 3 residents (R25) reviewed for falls in the sample of 29. This failure resulted in R25 being sent to the hospital for a fall that that resulted in a new hyper density in the posterior right globe and swelling/hematoma to the right scalp. Findings include: R25 's document titled Admission Record documents R25 was admitted to the facility on [DATE] with diagnoses including Anemia, Chronic Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, History of Falls, Unspecified Dementia, History of Transient Ischemic Attack, Legal Blindness, and Cerebral Infarction without residual deficits. R25's MDS (Minimum Data Set) dated 12/17/24, documents under section C (cognition patterns) that R25 has long term and short-term memory problems, cognitive skills for daily decision-making are marked severely impaired, and no BIMS (Brief Interview for Mental Status) was completed due to resident unable to participate. Section GG documents, functional limitation in range of motion shows impairment on both sides, of lower extremities. R25 has mobility by wheelchair. MDS documents R25 is, upper and lower body dressing, putting on/taking footwear, rolling left and right, sit to lying, and chair-bed-to chair transfer. Section H Bladder and Bowel documents always incontinent of bladder and always incontinent of bowels. Section J health condition, under Fall history/any falls since on Admission/Entry or Reentry or prior assessment, documents R25 has not had any falls since admission/entry or the prior assessment. Number of falls since admission/Entry or Reentry or Prior Assessment is left blank. Section M Skin Condition documents resident is on a turning and repositioning program. Section P Restraints and Alarms documents R25 had no alarms such as bed alarms, chair alarms, floor mat alarm, motion sensor alarm, or wander/elopement alarm. R25's Care Plan documents under Focus, resident is at risk for falls related to cognitive impairment and unaware of safety needs, 3/7/2025 resident unwitnessed fall out of bed, scoop mattress placed on bed, date initiated 7/18/2024, Revision date on 3/13/2025, with same date for canceled. Interventions: Resolved (with no date) 1/2 side rail to help with bed mobility and improve safety per POA (Power of Attorney) request. The residents call light is within reach and encourage the resident to use it for assistance as needed, anticipate and meet the resident's needs, follow fall policy, observe nonverbal signs of restlessness that may precipitate movement and attempts to stand /walk unattended, OT (Occupational Therapy) to evaluate and treat as ordered, review information on past falls and attempt to determine cause of falls, record possible root cause, after remove any potential causes of possible and up ad lib with 1 assist. R25's Fall Risk assessment dated [DATE] documents score of 21 which instructions read :10 Points or More= High Risk Score. R25's, 7/17/2024 fall risk assessment documented a score of 24, and R25's 5/21/2024 assessment documented a score of 12. R25's Unwitnessed Fall report dated 3/7/25 documents, at 4:00PM, Incident description: Unwitnessed fall from bed. 4:00PM resident's roommate came to Admin office stating that resident was in the floor next to her bed. Resident was hoyer lifted from floor to bed by nurse and CNA's. Resident is unable to give description. Immediate action: POA (Power of Attorney) declined to send to ER (emergency room ) to eval and treat. Scoop mattress placed on bed. Neuro checks initiated. Approx 4:00AM on 3/8/2025, resident was sent to ER related to change in condition/change in neuro assessment. Injuries observed at time of incident Bruise to top of scalp and face. Predisposing Environmental Factors is marked none. Predisposing Physiological Factors is marked none. Predisposing Situation Factors is marked none. On 3/14/2025 at 1:20PM, V31(Certified Nurse Assistant/CNA) stated she was working the day R25 had a fall. V31 stated she and V21 had laid R25 down around 2:00PM that afternoon. V31 stated R25 was incontinent of bowel and bladder and required 2 people to transfer because R25's legs were bent. V31 stated R25 did not ever move very much in the bed. V31 stated R25 used to have a small siderail but it was removed recently. V31 stated the rail had been there a long time but R25 had not been able to use the rail for bed mobility for quite some time. V31 stated the rail was there to keep R25 in the bed but it was taken off. V31 stated R25 's family requested that the bed be moved up against the wall as well. V31 stated R25 had fallen one other time a while back but she was unaware of the intervention that was put into place. V31 stated when he had laid R25 down, R25 was facing the wall on her right side, and closer to the wall. V31 said when she entered the room when she heard that R25 had fallen, R25 was lying in the floor in the same position, on her right side with knees bent. V31 stated R25 had her eyes open but was not screaming and yelling like she normally does when someone touches her. V31 stated she has no idea how R25 fell out of bed as she normally never moves. On 3/14/2024 at 2:12PM, V20 (CNA) stated she was working on the day R25 fell . V20 stated she and V31 laid R25 down around 2:00PM and they positioned her on her right side facing the wall and about in the middle of the bed. V20 stated she had never seen R25 move by herself. V20 stated as they were making rounds between 3:30PM -4:00PM to get residents up for supper we found R25 lying on the floor facing the wall on her right side. V20 stated in the past if R25 would get mad she would move her legs from side to side. V20 stated R25 used to have a side rail and her bed against the wall to keep her from falling, but the rail was removed recently. V20 was asked if any other fall interventions were put into place like alarms, lower bed, or a fall mat and V20 stated not that she knew of. V20 stated R25 was not able to get out of bed by herself as her knees were contracted. V20 stated R25 always screamed and yelled when anyone touched her as she did not like to be bothered. V20 stated they summoned the nurse to R25's room and the nurse assessed R25, then R25 was hoyer lifted back to the bed with 2 assists. V20 stated R25 was totally dependent on the staff for all her care. On 3/14/2025 at 2:29PM, R9 who was alert to person, place and time, stated she was in the room on the evening R25 fell out of bed. R9 stated R25 never moved much at all anymore. R9 stated, she was snoozing and reading, remembered looking up and R25 was lying on the floor on her left side facing R9. R9 stated she always tried to check on R25 frequently as she was old. R9 stated she went to tell V1 (Administrator) as fast as she could that R25 was on the floor. R9 stated the nurses came and got the hoyer and lifted her back to bed. R9 stated she believed R25 slipped out of bed, and she couldn't stand at all. On 3/13/2025 at 2:30PM, observed R25 lying in bed on right side, facing the wall, in fetal-like position. At that time the right side of bed was up against the wall with no side rail noted but concave mattress in place. R25 had noted bruising/swelling noted to right eye and right side of head with noted hematoma. R25 was not responding to verbal stimuli. Hospice nurse present at time of observation. R25's document titled Nurses Notes documents on 3/7/2025 at 5:57 PM, resident roommate came out of room and notified CNA that resident was in the floor and had rolled out of bed. Resident was found lying on right side with hematoma to right side of head and swelling and bruising to right eye. Notified POA due to this nurse feeling like resident wound need to go to emergency room for eval due to resident being on Eliquis (blood thinner). POA stated to hold off that he was going to come up here and check on R25. POA showed up about 10 minutes later and stated he did not want her sent to the emergency room at this time. Provider notified. On 3/8/2025 at 2:47 AM, upon taking residents vital signs blood pressure decreased to 92/50, pulse 58, respirations 16, temperature 97.7 and Oxygen saturations at 89-91% room air, resident not responding to blood pressure cuff being applied or tough. Called POA and updated POA on resident's condition, stated we recommend R25 being seen at the emergency room , possible brain bleed related to blood thinners and fall. POA stated to monitor her and call him back in 1 hour with vital signs after redoing them, will continue to monitor. On 3/8/2025 at 3:40AM, went to check on resident, resident's vital signs are as follows: blood pressure 87/42/ pulse 63, respirations 16, temperature 97.7, oxygen saturations 85% on room air, resident is still not responding to touch. Bruising, swelling remains to right eye and right side of head. Called POA back with new vital signs per POA requested update, had to encourage POA for resident to be seen. POA stated to send R25 to local emergency room for eval and treat. Notified MD on electronic messaging system, called ambulance for transport and called local hospital to give report on R25. On 3/8/2025 at 9:30AM, resident returned to facility from local hospital via ambulance. POA at bedside. CNAs assisted with repositioning resident for comfort. On 3/8/2025 at 9:40AM, Vital signs Oxygen saturations 96% on room air, pulse 86, respirations 24 and blood pressure 98/58. The only medication change/orders when resident came back from local hospital, were to stop taking Eliquis (blood thinner). Bruising and swelling, and hematoma continues to right peri orbital and scalp area. Bruising noted to right hand and bilateral arms and right leg. Resident is on a scoop mattress. POA present at bedside and updated V15 NP (Nurse Practitioner) of readmit. Documents from local hospital titled CT (Computerized Tomography) Head without Contrast dated 3/8/2024 at 6:10AM, documents under Impression: No CT evidence of acute intracranial abnormality. There is new hyper density in the posterior right globe. Can not exclude acute hemorrhage. Recommend ophthalmologic evaluation. Right frontal scalp and right periorbital soft tissue swelling/hematoma. Document titled Nurses Notes dated 3/9/2025 at 7:38PM, spoke with POA about V15 asking if family wanted hospice and POA stated it would be a good idea. POA chose hospice team and to consult tomorrow. Document titled Hospice Admission Summary dated 3/11/2025, documents terminal diagnosis of: Cerebral Atherosclerosis with code status documented of DNR (Do Not Resuscitate). Policy titled Fall Prevention Program with revision date of 11-21-2017, documents purpose as: To assure the safety of all residents in the facility, when possible. The program will include ensures which determine the individual needs of each resident by assessing the risk of falls and implantation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Section titled Fall/safety interventions may include but are not limited to documents, to inform family of risk factors and reinforce interventions a needed.

Based on interview and record review, the facility failed to ensure the physician reviews the resident's plan of care and sign and date orders. This failure has the potential to affect all 50 residents residing in the facility. The findings include: On 3/6/2025 at 10:01AM, V8 (Registered Nurse/Resident Care Coordinator) was asked if the V24 reviews the plan of care of the residents or reviews the physician orders and signs those, V8 stated no, (V15) does all of that. V8 validated the signatures on the physician orders reviewed were the signatures of V15. On 3/6/2025 at 11:08AM, V1 (Administrator) was asked if V24 (Medical Director) reviews the plan of care or signs the Physician Orders for the residents, V1 stated No he does not. V1 stated all of that is done by the V15 (Nurse Practitioner). On 3/6/2024 at 3:05 PM, V16 (Minimum Data Set/Float Nurse) was asked if she could pull up any physician's orders in the Electronic Health Record that were signed by the physician. V16 brought back her computer and had physician's orders that were needing to be signed electronically. V16 stated as you can see there have been no physician orders signed by V24 or other physicians since the facility went with electronic medical records on 1/29/25. On 3/7/2025 at 9:25AM, V24 (Medical Director) was asked when the last time he made rounds in the facility to see the residents and V24 stated I do not see the patients, the Nurse Practitioners see the patients and they work through me. V24 said he only comes per requirement for the quarterly meetings. V24 said that the reimbursement is poor so the nurse practitioners do the rounds. On 3/6/2025 at 1:02PM, V15 stated she signs the physician orders and reviews plan of care for the residents. R4, R8, R9, R11, R12, R16, and R17's paper medical records for October 2024, November 2024, and December 2024 were reviewed, including physician orders. All orders were noted to be signed by the V15 (Nurse Practitioner). There were no progress notes signed by V24 noted in the resident's records. The facility Medical Director Agreement dated 6/1/24 and signed by V24 documents under Article III Services of Physician section (i) Provision of Physician Services including (but not limited to) .(ii) Review of resident's overall condition and program of care at each visit, including medications and treatments; (iii) Documentation of progress notes with signatures; (iv) Frequency of visits, as required; (v) Signing and dating all orders, such as medications, admission orders, and re-admission orders. The 2/12/25 Midnight Census Report documented 50 residents residing in the facility.

Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. This failure has the potential to affect all 50 residents residing in the facility. Findings include: On 3/6/2025 at 11:08AM, V1 (Administrator) was asked if V24 (Medical Director) makes rounds in the facility. V1 stated No, he comes for the quarterly QA (Quality Assurance) meetings and that is all. V1 stated that V24 said in a QA meeting that he is still within regulations because the Nurse Practitioner sees the residents. On 3/6/2025 at 10:01AM, V8 (Registered Nurse/Resident Care Coordinator) stated she does not make rounds with a physician. V8 stated that V24 (Medical Director) only comes to the facility for quarterly QA meetings. V8 stated she makes rounds with V15 (Nurse Practitioner) every other Thursday, and on the opposite Thursdays she does Telehealth for the residents that need to be seen. On 3/6/2025 at 9:30AM, R11 stated he has been in the facility over a year. R11 stated he has never seen a physician since he has been admitted . R11 stated he has seen V15 (Nurse Practitioner) once in a while. R11 stated I think it is pathetic that the doctor can't come by and check on me. R11 was alert to person, place, and time. On 3/6/2025 at 9:32AM, R18 stated she would be going home tomorrow. R18 stated she was here for therapy after a fall at home. R18 stated her total time stayed was 5 weeks. R18 stated I have never seen a doctor during my stay or a nurse practitioner. R18 was alert to person, place, and time. On 3/6/2025 at 9:35AM, R8 stated I saw (V15) a couple of weeks ago but I have never seen a physician and I don't think they have a doctor. R8 stated all I have seen is an x-ray technician and a Nurse Practitioner. R8 was alert to person, place, and time. On 3/6/2025 at 9:40AM, R19 was asked if she knows the last time she was seen by a physician. R19 stated I haven't seen a doctor since I have been here and I have only seen (V15) once but that was to ask a question, (V15) was not actually here to see me. R19 stated she has been in the facility since October 2024. R19 was alert to person, place, and time. On 3/6/2025 at 9:44AM, R10 stated the last time she was seen by a physician was a long time ago. R10 stated she has been at the facility since September 2024 and has not been seen by a doctor in this facility. R10 stated she has not been seen by the Nurse Practitioner either. R10 was alert to person, place, and time. On 3/6/2025 at 9:48AM, R20 stated he was admitted in November 2024. R20 stated he has not been seen by a physician since he has been at the facility but he was seen a month ago by V15. R20 was alert to person, place, and time. On 3/7/2025 at 9:25AM, V24 (Medical Director) was asked when the last time he made rounds in the facility to see the residents and V24 stated I do not see the patients, the Nurse Practitioners see the patients and they work through me. V24 said he only comes per requirement for the quarterly meetings. V24 said that the reimbursement is poor so the nurse practitioners do the rounds. R4, R8, R9, R11, R16, R12, and R17's paper medical records for October 2024, November 2024, and December 2024 were reviewed. There were no progress notes signed by V24 noted in the resident's records. The facility Medical Director Agreement dated 6/1/24 and signed by V24 documents under Article III Services of Physician section (i) Provision of Physician Services including (but not limited to) . (iv) Frequency of visits, as required. The 2/12/25 Midnight Census Report documented 50 residents residing in the facility.

Based on interview and record review, the facility failed to ensure the medical director was available 24 hours a day for emergencies. This failure has the potential to affect all 50 residents residing in the facility. The findings include: On 3/4/2025 at 11:59AM, V19 (Licensed Practical Nurse) stated on 12/22/2024 around 3:00PM the CNA's reported to her that R16 wasn't acting right, and he looked bad. V19 stated she checked R16's blood sugar between around 3:00-3:30PM and the glucometer just read HIGH. V19 stated called the on-call physician but had to leave a message. V19 stated as she was waiting for the return call from the physician, she called V2 (Director of Nursing/DON) and V2 informed her that this has happened before with R16 and sometimes they send him to the hospital if the physician orders to send him. V19 stated, V2 told her just wait on the physician to call back and see what the physician wants to do. On 3/6/2025 at 2:00PM, V19 stated she was not sure what number she called for the on-call physician on 12/22/25, it was on a note at the nurse's station. V19 stated she doesn't know about (name of the Electronic Communication System used by the Facility) and communication like that and she has had no training on any of that stuff. V19 stated again she was advised by V2 to wait for the MD to call back and if she would have said sent to ER (emergency room ), she would have sent R16 out. On 3/6/2025 at 11:04AM, V22 (Registered Nurse) stated she worked on 12/22/2024, 6AM -6PM. V22 stated she received in report that R16 had been running high blood sugars and that the on-call physician was called, and a message was left to return call. V22 stated she went to R16's room around 6:30PM to check on R16, she stated she could arouse R16, and he would answer yes or no to questions. R16's blood sugar was checked at this time and reading was high. V22 stated she had put in another call to the on-call physician and left a message and was unsure of the time. V22 stated she received a call back from a physician with orders for insulin and recheck in a little while but she was unsure of the physician's name. On 3/7/2025 at 9:25AM, V24 (Medical Director) stated his phone has been accidentally silenced, so he hasn't been able to be reached for a couple of days. V24 was asked how the on-call services work and stated, The nurses have to use (name of the Electronic Communication System used by the Facility) to reach the nurse practitioner and on weekends from 9PM to 6AM there is a number to call and usually I am the one on call. V24 was asked if he received any calls on 12/22/2024 or 12/23/2024, V24 checked his records and personal phone and stated, No I did not. The facility Medical Director Agreement dated 6/1/24 and signed by V24 documents under Article III Services of Physician section (i) Provision of Physician Services including (but not limited to) .Availability of physician services 24 hours a day in case of emergency. The 2/12/25 Midnight Census Report documented 50 residents residing in the facility.

Based on observation, interview, and record review the facility failed to assess, treat, and implement interventions to prevent pressure ulcers for 2 of 3 (R33 and R18) residents reviewed for pressure ulcers in the sample of 24. This failure resulted in R33 developing a Stage 3 pressure ulcer to his right Ischium and R18's left heel pressure wound worsening/declining. The Findings Include: 1. R33's admission record documents an admitted [DATE]. This same document includes the following diagnosis: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS Section GG documents that R33 is dependent on staff for toileting, hygiene and bed mobility. Section M0100 of this MDS documents R33 is at risk for developing pressure ulcers/injuries and that he has unhealed pressure ulcer/injury at the time of this assessment. Section H, Bladder and Bowel, documents that R33 always has urinary and bowel incontinence. R33's Braden Scale dated 8/16/24 documents a score of 14, which indicates R33 is at high risk of skin breakdown. R33's Care Plan has a focus area with an initiation date of 7/11/24, that R33 has potential impairment to skin integrity relate to incontinence of bowel and bladder. The goal for this focus area, with an initiation date of 7/11/24, documents that R33 will maintain clean and intact skin by the review date. Documented interventions for this focus area include: Keep skin clean and dry, use lotion on dry skin PRN (as needed), pressure relief device for w/c (wheelchair) and bed, skin risk assessment: Braden Scale weekly x 4 weeks upon admission or readmission and then quarterly and PRN, and weekly skin assessment with documentation. R33's Care Plan also documents a focus area with a revision date of 7/11/24 of the resident has limited physical mobility related to Parkinson's, weakness, and arthritis. The goal, with a revision date of 11/21/24 for this focus area, is that the resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date. The interventions for this focus area includes: 1/2 side rails per resident request related to safety, nursing restoratives as ordered, the resident is weight bearing and up as needed with one assist. R33's Wound Assessment and Plan, with a visit date 11/4/24, documented by V24 (Nurse Practitioner) lists a left ischium Stage 3 pressure injury with an onset date of 10/21/24 for the wound that is in the Active/initial phase of treatment. The treatment order included preventative wound recommendations: air mattress and pressure reduction chair cushion, and to offload as tolerated. The same assessment also documents a right ischium Stage 3 pressure injury with an onset date of 10/17/24 with wound measurements of 2.1 cm. (centimenters) Length x 1.7cm. Width x 0.1 cm. Depth. The treatment order is for preventative wound recommendations of air mattress and pressure reduction cushion. A Wound Assessment and Plan, with a visit date of 11/19/24, documented by V24 that a right ischium Stage 3 pressure injury with an onset date of 10/17/24. Treatment order for preventative wound recommendations include an air mattress and a chair pressure reduction cushion. The same assessment also documents a left ischium Stage 3 pressure injury with an onset date of 10/21/24 is healed. Treatment order for preventative wound recommendations include an air mattress and chair pressure reduction cushion. A Wound Assessment and Plan, with a visit date of 11/26/24, documented by V24 that a right ischium Stage 3 pressure injury with an onset date of 10/17/24 is healing. Treatment order for preventative wound recommendation includes an air mattress and chair pressure reduction cushion. A Wound Assessment and Plan, with a visit date of 12/3/24, documented by V18 (Physician Assistant) that a right Stage 3 pressure injury to right Ischium with an onset date of 10/17/24 is stable with measurements of 3.3cm. Length x 2cm. Width x 0.1 cm. Depth. Treatment ordure for preventative wound recommendation includes an air mattress a chair pressure reduction cushion. On 12/12/24 at 2:30 PM, V2 (Director of Nursing) stated that the wound group that comes in weekly leaves their progress notes and orders to be filed in the chart. V2 went on to state that those are considered the physician orders and are to be carried out as noted. On 12/10/24-12/11/24, R33 was observed to be seen on a mattress that was scooped but not an air mattress. On 12/11/24 at 11:30AM, V4 (Registered Nurse) confirmed that this was not an air mattress nor did R33 have an extra pressure relieving cushion on his wheelchair seat. V4 went on to state that she has not seen a cushion in R33's chair ever and this is the scoop mattress he normally has. On 12/10/24, intermittent observations were made of R33 at: 8:30AM, 11:00 AM, 12:00 PM, 2:30 PM and 3:30PM in his wheelchair with no pressure reduction cushion in his wheelchair. On 12/11/24, intermittent observations were made of R33 at: 8:05 am in the dining room eating breakfast in his wheelchair with no pad in his chair, 8:58AM in the hallway by his room in the wheelchair with no pressure reduction pad, 9:30 am in his room in front of the television in his wheelchair with no pressure reduction pad, 9:51 AM in his room in front of television in his wheelchair with no pressure reduction pad, 10:40 AM in his room in front of television in his wheelchair with no pressure reduction pad, 11:05 AM in room in front of television in his wheelchair with no pressure reduction pad, 12:50 PM in dining room in his wheelchair with no pressure reduction pad at table, 1:20 PM by his room in hallway in his wheelchair with no pressure reduction pad, 1:40 PM by his room in hallway in his wheelchair with no pressure reduction pad, 1:53 PM by room in in hallway in his wheelchair with no pressure reduction pad stated that he was got up at 5 am and that is the last time he went to the bathroom and been out of this chair, 2:06 PM took to bingo still in chair, 2:47pm still in bingo and told V2 (Director of Nursing) that R33 had been in the chair since 5 AM with no peri care or repositioning, and 3:03 PM R33 was transferred by mechanical lift to bed and peri care was observed. On 12/17/24 at 1:00PM, V18 (Wound Physician Assistant) stated that she was not aware that R33 did not have the recommended seat cushion or the mattress to promote wound healing. V18 stated that these interventions help off load the weight and aide in wound healing. V18 stated at this time she would expect them to follow the recommendations/doctor orders. On 12/17/24 at 3:00PM, V1 (Administrator) stated that she found a gel pad that fits the wheelchair seat and they will start using that for R33 when he is sitting up in the wheelchair. 49663 2. R18's Admission Record documents an admitted to the facility of 2/28/23 with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, type 2 diabetes mellitus with diabetic nephropathy, Parkinson's disease, and end stage renal disease. Additional diagnoses include osteomyelitis left heel dated 11/12/24. R18's MDS dated [DATE] documents R18 has a Brief Interview for Mental Status (BIMS) score of 4, which indicates R18 has severe cognitive impairment. This same MDS documents R18 required substantial/maximal assist for roll left to right, sit to lying, and lying to sit, and dependent for sit to stand and transfers, and was at risk for developing pressure ulcers. Section M, Skin Conditions, documents that R18 has 1 unstageable pressure ulcer. R18's current Care Plan documents a Focus area of (R18) has potential /actual impairment to skin integrity r/t (related to) decreased mobility, incont (incontinence) of B&B (Bowel and Bladder) dated 5/06/2024 and currently has an unstageable pressure area to left heel revision date 10/21/2024. This same focus area documents an intervention initiated on 8/15/2024 of Grape (protein) liquid (nutritional protein supplement drink) as ordered. R18's Wound Assessment and Plan dated 11/4/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: Unstageable (Depth Obscured). Wound Measurement: 6.1 cm. (centimeter) Length x 1.5cm. Width x 0.2 cm. Depth Wound Bed Tissue Composition at Beginning of Visit: 80% Granulation / 20% Eschar R18's Wound Assessment and Plan dated 11/19/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: Unstageable (Depth Obscured), and Wound Bed Tissue Composition at Beginning of Visit: 20% Granulation / 10% Slough /70% Eschar R18's Wound Assessment and Plan dated 11/26/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: Unstageable (Depth Obscured), and Wound Bed Tissue Composition at Beginning of Visit: 10% Granulation / 90% Eschar R18's Wound Assessment and Plan dated 12/3/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: Unstageable (Depth Obscured) and Wound Bed Tissue Composition at Beginning of Visit: 5% Granulation / 95% Eschar R18's Wound Assessment and Plan dated 12/10/2024 by V18 documented under Wound Onset Date: 2/28/2023, Pressure Injury Stage Upon Completion of Visit: 4 (F/Thk (full thickness) Exposed Underlying Structure), Wound Measurement: 6cm. Length x 1 cm. Width x 0.1 cm. Depth. Wound Bed Tissue Composition at Beginning of Visit: 5% Granulation / 95% Eschar On 12/11/2024 at 8:05 AM, V4 (Registered Nurse/RN) stated, the dietary department had been out of protein supplement for some time. V4 stated, R18 had not been getting the protein supplement for at least a few weeks, if not longer. V4 stated, R18's physician had not been notified that R18 had not been getting the ordered supplemental or to request a different protein supplement. On 12/11/24 10:42 AM, V2 (Director of Nursing/DON) stated, the facility had not had any protein supplement since 12/1/2024. V2 stated, there has been some issues in dietary and she is not sure why it had not been ordered. V2 stated, R18 had orders to receive a protein supplement and had not been receiving it since 12/1/2024 to her knowledge. V2 stated, R18 physician had not been notified that the facility had been out of protein supplement or to request a new supplement. On 12/17/2024 at 12:17 PM, V18 (Wound Physician Assistant) stated, she had not been notified via telephone or during her weekly rounds in the facility that R18 had not been receiving their protein supplement. V18 stated, she could not speculate, but in general, protein supplements do aid in promoting wound healing. R18's December 2024 Physician's Order Sheet (POS) documents an order dated 11/14/24 for (High protein supplement) Liquids Sugar Free (SF) Grape take 30 milliliters (mL) by mouth twice daily with an administration time of 0800 (8:00 AM) and 1800 (6:00 PM). R18's November 2024 through December 2024 Medication Administration Record (MAR) documents the order for high protein supplement Sugar Free (SF) Grape take 30 milliliters (ml) by mouth twice daily with an administration time of 0800 (8:00 AM) and 1800 (6:00 PM). The November MAR indicated missed doses 11/5/24 through 12/12/24. The facility policy titled Skin condition Assessment & Monitoring-Pressure and Non-Pressure (revision 6/8/18) documents under Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and non-pressure skin conditions and assuring interventions are implemented. The facility policy titled Pressure Ulcer Prevention, with a revision date of 1/15/18, documents the Purpose: To prevent and treat pressure sore/pressure injuries. Guidelines: .5. Turn dependent resident approximately every two hours or as needed and position resident with a pillow or pads protecting bony prominence as indicated .9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds .10. Use pressure reducing pads in chairs (all types) to protect bony prominences for residents identified as Moderate/High/Severe risk .12. Encourage resident to maintain proper nutrition and hydration, providing supplements as ordered and necessary assistance at mealtime as needed.

Based on interview and record review, the facility failed to obtain timely wound care orders and implement pressure wound treatment for 1 (R3) of 5 residents reviewed for wounds in the sample of 5. This failure resulted in R3 receiving no treatment to pressure wounds on his bilateral buttocks from 12/27/2023 to 1/02/2024 with wounds deteriorating as evidence by an increase in size, staging, and onset of odor. Findings include: Review of R3's New Admission Information sheet documents an admitted to the facility as 09/15/2023. The same document listed V9 (Physician) as R3's physician. R3's Cumulative Diagnosis Log (undated) includes diagnoses listed as, but not limited to, of: Urinary Incontinence, moderate intellectual disabilities, drug-induced Parkinson's, chronic obstructive pulmonary disease, and edema. R3's Baseline Care Plan, dated 10/02/2023, documented an entry made on bottom of care plan, dated 1/02/2024, with following note-New Wounds-(contracted wound company) to see, air mattress placed, weekly skin checks, wound care. No previous entries or documentation of communication or wounds was noted. Review of an additional care plan provided by the facility, dated 12/27/2023, with goal and interventions noted on 1/02/2024, for pressure injury/skin breakdown. Although requested from V1, the comprehensive care plan in place prior to 12/27/23 could not be provided. R3's Minimum Data Set (MDS), dated [DATE], documents in section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) of 99, indicating that R3 was unable to complete the interview. Additionally, this same MDS documents in section M, Skin Conditions, that R3 is at risk for developing pressure ulcers/injury but has none at this time. R3's Weekly Skin Assessment was documented as being completed on 12/15/23, with no areas of concern documented. R3's nurses note, dated 12/16/2023 at 6:40 PM, documented R3 was vomiting and less responsive than usual. Vomit was cleared from nose and mouth, with R3 not responding. V9 was notified at 6:44 PM and R3 was transferred to local Emergency Department via ambulance for evaluation and treatment. R3's local hospital discharge summary, dated 12/27/2023, documented an admission to the local hospital as 12/16/2023 to 12/27/2023. Final diagnoses were as follows: 1. Urinary Tract Infection 2. Malnutrition noted. R3's Hospital Transfer Chart in the hospital records document an entry dated 12/17/2023, in which R3 is noted to have pressure injuries to his right and left buttock. The origination date of the pressure injuries to R3's right and left buttock were not documented and could not be determined. R3's Nursing Admission Assessment, completed on 12/27/2023, with no time entered and no signature on the documentation, documents, 1 inch by 0.5 inch, stage 2 to right buttock and 1.5 inch by 1 inch, stage 2 to left buttock area. On 1/11/2024 at 12:03pm, V6 stated although her assessments were documented in inches she meant to document in centimeters for wound measurements. This would indicate the final measurements as being 1 centimeter (cm) by 0.5 cm to the right buttock and 1.5 cm by 1 cm to the left buttock. V6 also confirms she was the nursing staff who completed the Nursing Admission Assessment, dated 12/27/23. R3's wound pictures from the hospital records, dated 1/07/2024 at 12:47 AM, documented a 5.5 cm by 4 cm wound to the right buttock area, and at 12:51 AM a 4 cm by 3.8 cm wound to the left buttock. These photos were taken by the hospital upon an unrelated re-admission R3 had to the hospital on 1/6/23. R3's (Facility Name) Weekly Wound Tracking, dated January 2024 with a late entry date of 1/02/2024, documented right buttock wound as stage 3, 2 cm by 3 cm, 1 cm depth, moderate drainage and odor noted and left buttock wound as stage 3, 4.6 cm by 3 cm, 1 cm in depth, moderate drainage and odor noted. This same document has an entry for 1/05/2024 with same measurements and no change in drainage and odor from 1/02/2024 documentation. R3's Physician Orders, dated from 1/01/2024 to 1/31/2024, documented the following telephone orders from V9 (Physician) dated 1/2/23: 1. cleanse area on right buttock with normal saline, pat dry. Apply calcium alginate, cover with dry dressing daily and prn (as needed). 2. Cleanse area on left buttock with normal saline. Pat dry. Apply Calcium alginate cover with dry dressing daily and prn. 3. Apply betadine to left lateral foot daily. R3's Physician Orders, dated for 12/1/23 - 12/31/23, noted no wound care orders to R3's buttocks were in place. On 1/10/24 at 10:15 AM, V5 stated she does the wound tracking for the facility. V5 stated R3's cognition varies due to being hard to communicate with, as he is Spanish speaking in nature. V5 stated R3 can understand English, but does not speak it well. V5 stated staff are able to communicate using yes/no and pointing gestures to make needs known. V5 stated all residents receive weekly skin checks by nursing staff assigned to that hall. V5 explained prior to R3's most recent hospitalization , no skin breakdown was present, although occasional redness was treated and resolved with barrier cream. V5 stated on 1/2/24, she was made aware of wounds to R3's buttocks by V7 (Certified Nurse Assistant/CNA). V5 stated that V7 reported that the 2 brown bandages to R3's buttocks smelled so bad that he had to take them off during R3's shower. V5 stated she did not view the bandages as they had been thrown away. V5 stated in reviewing R3's re-admission data to the facility on [DATE], V6 (Licensed Practical Nurse/LPN) was determined to have completed the assessment. V6 documented wounds to both buttocks, although no treatment orders were carried out or physician notification of wounds was noted. V5 stated once she had been made aware, she immediately notified V8 (Advanced Practice Registered Nurse), who made the referral to (contracted wound company). V5 stated she viewed the wounds, which were pressure in nature to both buttocks, with tan, foul smelling drainage. V5 stated it is the policy of the facility that wounds are immediately reported to the physician for treatment orders to be obtained. On 1/10/24 at 10:37 AM, V2 (Director of Nursing) stated R3 only speaks mumbled Spanish, so it's hard to determine his true cognition. V2 stated R3 does not have a history of wounds and was ambulatory in the past, until recently having an overall decline starting around the end of November, where he has routinely been in and out of the hospital and started utilizing a wheelchair. V2 described R3 as being incontinent and developmentally disabled. V2 stated during R3's most recent readmission to the facility from the local hospital, it was brought to nurse's attention on 1/2/24 of R3's presence of wounds to his buttocks by V7. V2 confirmed no wound care orders, no nursing notes, and no physician notification regarding the wounds was in place prior to 1/2/24. V2 acknowledged the untimely wound evaluation, treatment and care provided to R3 upon his return to the facility, and stated a discipline form has been initiated for the nurse (V6) who completed R3's re-admission assessment to the facility on [DATE], notating the presence of wounds, but taking no further action. On 1/10/24 at 10:55 AM, V1(Administrator) stated she would expect residents that have wounds or impaired skin integrity to be evaluated with physician notification for orders and interventions implemented immediately. V1 acknowledges there was a delay in wound care treatment for R3, as R3's wound care had not begun until 1/2/24, when herself and V5 were notified of wounds present to R3. V1 stated a staff education and counseling form has been initiated. On 1/10/24 at 11:20 AM, V7 (Certified Nursing Assistant/CNA) stated he was changing R3 on 1/2/24, and noticed he had foul smelling, visibly soiled, tan/brown bandages, one to each buttock. V7 stated he cannot recall for sure what the dressings were dated. V7 stated he immediately notified V5 that R3's dressings would need changed, in which V5 then expressed she wasn't aware R3 had any wounds. V7 stated he cannot say when the wounds had formed. On 1/10/2024 at 12:15 PM, V5 stated R3 was not seen by (contracted wound company) on 1/2/2024 because the facility had not received orders for R3 to be referred until after (contracted wound company) had left the building for the week, and R3 was transported to the (name of local hospital) on 1/06/2024. On 1/10/24 at 12:26 PM, V6 (Licensed Practical Nurse/LPN) stated she was the nurse who had sent R3 to the hospital for his 12/16/23 hospitalization . V6 described R3 as being lethargic and having emesis. V6 stated she had contacted the physician who ordered R3 to be sent to the local Emergency Department for evaluation. V6 stated R3 had no wounds on his buttocks prior to being transferred to the hospital, and she can say this confidently as he is frequently incontinent during the night, in which she helps assist in his care and views his buttocks routinely. V6 stated she is a newer nurse and confirmed she was the nurse who did R3's re-admission to the facility on [DATE], in which stage 2 pressure wounds were noted to his bilateral buttocks. V6 stated she measured the wounds upon his return, also including depth. V6 stated the wounds did not have any foul odor and the tissue was red in color. V6 stated she documented her wound findings on the nursing home assessment form which is completed upon a resident's admission. V6 stated she then passed on in report the next morning the presence of R3's wounds to V2 (Director of Nursing) or V5 (LPN), stating she cannot remember which one was working. V6 stated she had not contacted the physician for wound care orders because she didn't think it was an urgent matter to disrupt the physician. V6 stated she assumed day shift would contact the physician the next day when she told them in report that R3 had wounds to his buttocks. On 1/10/24 at 1:08 PM, V5 (Licensed Practical Nurse/LPN) stated she was the staff member V6 gave report to upon R3's return from the hospital to the facility on [DATE]. V5 stated no report of R3's wounds was made to her. On 1/10/24 at 3:02 PM, V9 (Physician) stated it would be his expectation to be notified of skin integrity concerns or wounds immediately and have treatment promptly initiated. V9 stated if he was not notified, he would also find it acceptable if the facility notified the wound care physician directly to obtain wound care orders from them. V9 stated he cannot recall if he was notified, but would expect those correspondences to be documented. V9 agreed it is accurate to say that without treatment, a wound has the potential to significantly deteriorate from 12/27/23 - 1/2/24. R3's history of weight loss was also discussed with V9, in which V9 stated nutrition can affect wound healing or formation, but acknowledged, despite nutritional status, determining if a wound is unavoidable is difficult when there is no treatment in place to promote healing. On 1/11/24 at 7:55 AM, V8 (Advanced Practice Registered Nurse) stated she would expect for herself or V9 to be notified of wounds immediately to have interventions and treatment implemented. V8 stated she was notified of wounds present to R3 on 1/2/24, and orders were given at that time for treatment. Review of Supervisor Report of Counsel for V6, dated 1/10/2024, documented a date of occurrence as 12/27/2023, with a description of the occurrence as follows-skin assessment was not signed. No new skin report filled out, no nurse's notes were written, and no treatment orders reviewed for wounds to bottom. No documentation on 24-hour report. Counseling summary for V6 noted for education on skin protocol, how to approach new wounds, when to fill out quality assurance forms, and where to document new wounds. This document was noted to be signed and dated by V6, V1 and V2 on 1/10/24. The facility policy titled, Skin Condition Monitoring with a most recent revision date of 1/18 documented, It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities .1. Upon notification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document the findings in the nurses notes and complete the QA (Quality Assurance) form for Newly Acquired Skin Condition. 2. The Nurse will then implement the following procedure: a. Notify the physician and obtain treatment order. b. The treatment order will include: 1. Type of treatment. 2. Location of area to be treated. 3. Frequency of how often treatment is to be performed. 4. How area is to be cleansed. 5. Stop date, if needed .4. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed .

Based on observation, interview, and record review, the facility failed to implement interventions and dietary recommendations for residents at risk for altered nutritional status for 2 of 3 residents (R3 and R1) reviewed for nutrition in a sample of 3. These failure resulted in R3 experiencing a significant weight loss of 8.09% in 1 month, and R1 experiencing a significant weight loss of 11% in 6 months. The findings include: 1. R3's New Admission Record in the medical record documents R3 was admitted to the facility on [DATE]. R3's January 2024 Physician's Order Sheet documents diagnoses including Ogilive Syndrome, hemiplegia and hemiparesis following cerebral infarction, and dysphagia. R3's MDS (Minimum Data Set), dated 9/8/23, documents a BIMS (Brief Interview of Mental Status) of 10, which indicates R3 has moderate cognitive impairment. R3's Care Plan (start date of 6/8/23) documents a problem area of potential risk for altered nutritional status and/or weight loss. Interventions documented are: monitor weight weekly first 4 weeks after initial admission, monitor weights monthly, report significant changes in weight to MD (Medical Doctor) and RD/LDN (Registered Dietician/Licensed Dietician Nutritionist). A facility document titled Weekly Weight Monitoring documents the following weights for R3: 11/30/23: 136 lbs (pounds) 12/13/23: 141 lbs 12/20/23: 140 lbs 12/27/23 125 lbs This indicates an 8.09% weight loss (11 lbs) in 1 month (11/30/23 to 12/27/23), and a 10.71% weight loss (15 lbs) in 7 days (12/20/23 to 12/27/23). A facility document titled Daily Weight Monitoring documents the following weights for R3: 12/11/23 133.5 lbs 12/12/23 No weight recorded 12/13/23 140.5 lbs 12/14/23 No weight recorded 12/15/23 139 lbs 12/16/23 to 12/19/23 No weights recorded 12/20/23 139.5 lbs 12/21/23 to 12/27/23 No weights recorded 12/28/23 124.5 lbs This indicates a 6.74% weight loss (9 lbs) in 17 days (12/11/23 to 12/28/23), and a 10.75% weight loss (15 lbs) in 8 days (12/20/23 to 12/28/23). R3's Report of Monthly Weights and Vitals documents on 1/2/24, R3's weight was 130.5 lbs. R3's Dietary Quarterly Assessment signed by V4 (Dietary Manager) documents on 8/30/23, R3 weighed 144.4 lbs, and on 12/28/23 R3 weighed 133.5 lbs. This indicates a 7.55% weight loss. R3's Nutritional assessment dated [DATE] documents a recommendation by V13 (RD/LDN) to add nutritional juice drink at meals. There are no other Nutritional Assessments completed by V13 or a Registered Dietician in R3's medical record. There are no orders for V13's recommendation of nutritional juice at meals on the November 2023, December 2023, or January 2024 Physician's Order Sheets. On 1/4/23 at 1:30pm, V4 was asked about the R3's 15 lb weight loss from 12/20/23 to 12/27/23, and said she did not see that. V4 said she was guessing she hit the wrong buttons when entering R3's weight of 124.5 lbs on 12/28/23. V4 said she did not ask V13 to see R3 when V13 came to the facility on [DATE]. V4 said when V13 makes a dietary recommendation, she gives the recommendation to the nurse and they contact the physician for orders. On 1/3/24 at 12:10pm and 1/4/24 at 12:20pm, there were no nutritional juice drinks observed on R3's lunch tray. On 1/4/24 at 12:20pm, R3 was asked if he received nutritional juice drinks with his meals and R3 sated no. 49664 2. R1's New Admission Information sheet documents R1 was admitted to the facility on [DATE]. R1's January 2024 Physician's Order Sheet documents diagnoses including Parkinson's, weakness, diabetes mellitus (DM), dysphagia, altered mental status, and Percutaneous Endoscopic Gastrostomy (PEG) tube. R1's Care Plan, dated 10/10/2022, documents under Nutrition R1 is at risk for alteration in nutrition related to dementia and Parkinson's and may impact resident ability to swallow or feed self. R1's Care Plan documents interventions including follow recommendations of Registered Dietician Licensed Dietician Nutritionist (RD/LDN) and notify RD/LDN of discrepancy of recommendation with resident's preferences or care goals. An intervention, dated 8/3/2023, documents tube feedings were changed to 240 bolus 5x day with 75 mL H2O flush before and after. R1's Report of Monthly Weights and Vitals sheet for 2023 document R1's weights for R1: June- 157 lbs, July- 154.3 lbs, August-151.8 lbs, September- 149.8 lbs, October- 142.4 lbs, November- 137.2 lbs, and December-139.2 lbs, indicating a weight loss of 11% (17.8 lbs) in 6 months. A facility document titled Weekly Weight Monitoring documents the following weights for R1: 10/11/23- 139.8 lbs 10/19/23- 144 lbs 10/25/23- 137 lbs 11/8/23- 135 lbs 11/15/23- 133.2 lbs 11/22/23- 133 lbs 11/30/23- 138.4 lbs 12/4/23- 139 lbs 12/13/23- 141 lbs 12/20/23- 142 lbs 12/27/23- 143 lbs R1's Dietary Notes by V13 (Registered Dietician/ Licensed Dietician Nutritionist), dated 10/27/23, documents current wt (weight) 142.4# (pounds) indicating cont. (continuous) wt loss. BMI (Body Mass Index) 19.0. He is currently on Mechanical Soft with Magic Cup TID (three times a day), whole milk @ (at) meals and continues to receive 240 mL (milliliters) Jevity 1.5 w/ (with) 75 mL water flush before and after 5x/ day (times per day). No signs of intolerance reported. No new labs. Recommended changing formula from Jevity 1.5 to 2 cal (calorie) or Nutren 2.0. Maintain current volume. Continue to monitor and refer to RD as needed. R1's November 2023 Physician's Order Sheet (POS) documents an order dated 11/7/23 (no time documented) of per signed dietary recommendation: change tube feeding to 2 cal or Nurten 2.0, 240 mL with 75 mL water flush before and after. An order clarification written below the previous order on the same POS, also dated 11/7/23 (no time documented), documents, due to recent weight gain continue Jevity 1.5 240 mL 5x/day with 75 mL water flush before and after. R1's weights recorded on the Report of Monthly Weights and Vitals and Weekly Weight Monitoring documentation does not document any weight gain since V13's recommendation was made per the Dietary Notes on 10/27/23. R1's Dietary Notes by V13, dated 11/28/23, documents, current wt 137.2# indicating cont. wt loss. BMI 18.1. Diet to be clarified to NAS (no added salt), CCD (Carbohydrate Controlled Diet), mech (mechanical) soft, nectar thick, whole milk w/ meals, magic cup w/ meals, pleasure foods per resident/ family request, 240 mL Jevity 1.5 w/ 75 mL water before and after 5x/day (times per day) .recommended changing TF (Tube Feeding) formula to 2 cal or Nutren 2.0 per previous recommendation. The November 2023 POS documents a telephone order, dated 11/30/23, from V12 (Nurse Practitioner) for an order clarification for NAS, CCD diet, mechanical soft, nectar thick liquids, Jevity 1.5 bolus peg tube 240 mL 5x/day, 75 mL H2O flush before and after. R1's Dietary Notes by V13,dated 12/6/23, documents, current wt 139.2# indicating significant weight loss x 3 mos (months) and 6 mos. Noted slight gain x 1 month. BMI 18.4. Current diet ordered is NAS, CCD, mechanical soft, nectar liquids, no bread, magic cup TID, whole milk at meals, 240 mL Jevity 1.5 with 75 mL water before and after 5x/day. On 1/5/24 at 10:35am, V13 said she goes to the facility monthly, and V4 gives her a list of resident's weights and a list of residents with significant weight loss. V13 said she is given the monthly weights and not the weekly weights. V13 said she was not given anything regarding weight loss on R3, and R3 was not on her list to be seen when she was at the facility on 12/28/23. V13 said she was told R1 was on the upward side and had gained a few pounds, and that is why they did not change his tube feeding. On 1/3/24 at 12:00pm, V2 (Director of Nursing) said they usually do follow the Dietitian's recommendations and does not know of any reason the physician would not agree with any of the recommendations from the Registered Dietitian. V2 said the nurses get the dietary recommendations from the V4 (Dietary Manager) and sends them to the V11 (Physician) or has V12 (Nurse Practitioner) look at them. On 1/3/24 at 10:30am, V3 (Licensed Practical Nurse) said she is not aware of any dietary recommendations on R1, and R3 and did not contact the physician about this that she is aware of. V3 said if they are not in the chart she did not do it. On 1/4/24 at 11:30 AM, V10 (Licensed Practical Nurse) said she does not recall sending any dietary recommendations on R1 or R3 to V11 (Physician) or V12 (Nurse Practitioner), but if they are not in the chart, she probably did not do it. On 1/4/24 at 3:13pm, V12 said she was not notified of any weight loss on R1 or R3. V12 also said she was not asked about any dietary recommendations made by the Registered Dietician. V12 said she has seen some issues with the facility following recommendations made by the Registered Dietician. On 1/5/24 at 9:43am, V11 (Physician) said he would expect that the facility follow the Registered Dietician's recommendations. V11 said he thinks he was notified of R1 and R3's weight loss, and he thinks he was notified of the Registered Dietician's recommendations. V11 said these notifications could be in a big stack of papers he has not acted on yet. Facility policy titled Resident Weight Monitoring (revised 10/13, 10/14, 3/19) documents in procedure step 5 that If there is an actual significant weight change (i.e. +/- 5% x 1 month, +/- 7.5% x 3 months, +/- 10% x 6 months), the resident/POAHC (power of attorney for healthcare)/family/guardian, physician and dietician are notified. Procedure step 9 documents that The Dietician shall review and document all significant weight changes along with any recommended nutritional interventions in the dietary progress notes in the medical record monthly.

Based on interview and record review, the facility failed to provide a mechanically altered diet as ordered for 1 of 4 (R17) residents reviewed for mechanically altered diets in a sample of 35. This resulted in R17 choking on [DATE], requiring the Heimlich maneuver, chest compressions, and evaluation in the emergency room , and a subsequent choking episode on [DATE], in which the Heimlich maneuver was again required. These failures resulted in an Immediate Jeopardy, which was identified to have begun on [DATE], when the facility failed to provide the proper mechanically altered diet as ordered. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:58 pm. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1. R17's New Admission Information documented an admitted [DATE]. R17's Cumulative Diagnosis Log documented diagnoses: anxiety, lewy body dementia, dementia with agitation, and physical deconditioning. R17's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. R17's MDS section G documented limited one person assistance with setup or clean-up assistance with eating. R17's care plan documented an [DATE] potential risk for altered nutritional status with a [DATE] intervention that R17 must be monitored during meals related to choking hazard. R17's Social Services Interim Treatment Plan, dated [DATE], documented, . List perceived weakness based on admission assessment: a choking risk- doesn't appear to take the time to chew properly- must be monitored . R17's [DATE] Nutritional Assessment documented R17 was edentulous (no top or bottom teeth). R17's Speech Therapy Daily Treatment Note, dated [DATE], documented, . was seen for skilled dysphasia therapy this date during lunch meal with (R17) continuing with trial of mechanical soft solids. (R17) demonstrates adequate mastication and bolus formation given (minimal) verbal cues for use of bite size and rate of modification. Continue with current diet trail of mechanical soft solids R17's [DATE] Physician's Orders documented a [DATE] diet order of .Mechanical Soft Solids . Must be monitored at meals (related to) choking . R17's [DATE] Physician's Orders documented a [DATE] diet order change to pureed solids and a [DATE] diet order change to . (Mechanical) Soft Solids, (Finely Chopped and Heavy Moistened with) No Breads . R17's Skilled Progress Note, dated [DATE] at 11:50 am, by V5 (Licensed Practical Nurse/ LPN) documented . sitting in dining room CNA (Certified Nursing Assistant) . noticed (R17) was choking on pizza. (V4, LPN) and other CNAs started the Heimlich (maneuver). (V5, LPN) switched with (V4) and attempted the Heimlich (maneuver) as well. Resident legs started to buckle and lose consciousness. We then lowered (R17) to the ground while 911 was being contacted . started CPR compressions as (V5) went to grab the (ambu-bag). There was pieces of pizza crust retrieved. (R17) regained consciousness as the fire department and police department arrived at 11:55 am . ambulance arrived at 11:57 am and took (R17) to the hospital . On [DATE] at 12:27 pm, V4 (LPN) said she was caring for R17 on [DATE] during the noon time meal. V4 said she was called by a CNA due to R17 choking. V4 said R17 had been served a whole piece of pizza by Dietary staff. V4 said she and other facility staff had attempted the Heimlich maneuver on R17, and were not able to clear R17's airway. V4 said R17 then lost consciousness and was lowered to the floor and facility staff started chest compressions on R17. V4 said she was able to complete a finger sweep to remove the pizza crust from R17's throat. V4 said by the time Emergency Medical Services (EMS) arrived, R17 had regained consciousness and was transferred to the Emergency Department (ED) for further evaluation. V4 said R17 returned to the facility the same day from the ED. On [DATE] at 12:42 pm, V5 (LPN) said she was present on [DATE] when R17 choked on a piece of pizza. V5 said R17 was served a whole piece of pizza from Dietary staff. V5 said R17 was sitting in the dining room when R17 choked. V5 said the Heimlich maneuver failed to clear R17's airway and chest compressions had been started, and two pieces of bite sized pizza crust were removed from R17's throat. V5 said R17 had several instances of choking in the past. On [DATE] at 12:58 pm, V3 (Dietary Manager) said a piece of pizza was considered mechanically soft. V3 said pizza has always been considered mechanically soft, and no one had ever told her otherwise. On [DATE] at 2:50 pm, V3 said there was no difference between the pizza served to residents with regular diet orders and mechanically soft diet orders; all the pizza served was made with a biscuit crust. V3 was asked how thick the pizza crust was supposed to be, V3 responded about half an inch to an inch thick depending on who is cooking. V3 said the pizza served on [DATE] to residents with mechanically soft diet orders did not have sausage and was only cheese pizza. On [DATE] at 1:47 pm, V7 (Speech Pathologist) said mechanically soft diets should be defined as foods that are soft and fork tender with ground meats. V7 said the texture of the food should have a moist cohesive texture. V7 said she would not expect resident's with orders for mechanically soft diets to receive pizza with crust. V7 said even when using a biscuit mix for the pizza crust, V7 did not feel it would be appropriate for residents with mechanically soft diet orders. On [DATE] at 1:56 pm, V8 (Regional Dietitian) said, The facility did not have a recipe for mechanically soft pizza. Dietary staff should ensure the crust of the pizza is soft, the meats are ground, and there is added moisture. V8 was asked how staff were trained to know it is soft enough to be appropriate for mechanically soft diets, V8 responded staff were trained upon hire to know what on the diet spreadsheet is soft enough to serve to residents with mechanically soft diet orders. On [DATE] at 2:10 pm, V6 (Social Services Director) said she had made a note on [DATE], when R17 was first admitted to the facility, that R17 was at risk for choking to alert staff to cut up R17's food and to monitor for choking. V6 said she expected staff were assisting R17 to cut R17's food into bite sized pieces due to having some difficulty swallowing. V6 said R17 eats very fast, and must be monitored by staff at all times when eating. R17's hospital After Visit Summary, dated [DATE], documented, . Diagnoses . Choking episode . Choking due to food in larynx . The facility's Diet Spreadsheet Week 3 documented on [DATE] the evening meal was substituted for the noon time meal, and mechanical soft diets should receive cheese pizza with soft crust. The undated facility recipe for Sausage Pizza which included using a biscuit dough crust did not indicate what type of diet it was for, and did not contain any special instructions for mechanically soft diets. R17's Speech Therapy Plan of Care, dated [DATE], documented, . Treatment Diagnosis . Dysphagia, Oropharyngeal . was referred to skilled speech therapy by nursing staff following a choking episode on [DATE] in which (R17) had to be administered the Heimlich maneuver and was found to have pieces of unchewed food blocking her airway . Diet Level . Prior Level . Mechanical Soft . Current Level . Puree . R17's Speech Therapy Daily Treatment Note documented a [DATE] note . (R17) was seen during the evening meal with (R17) receiving a tray of puree solids and thin liquids. (R17) is visibly opposed to current puree diet, making statements such as I'm not eating that and that looks gross. A [DATE] note, . (R17) was seen during the noon meal with (R17) receiving a trial of mechanical soft solids (without bread) and thin liquids. (R17) requires supervision through entire meal as impulsive behaviors appear periodically . demonstrates effective bolus formation and swallow initiation, (minimal) to no oral stasis and effective airway protection . A [DATE] note, . Staff inservice / education provided regarding diet change and maintenance program to maximize (R17's) safety during (oral) intake while providing (R17) with the safest, least restrictive diet . R17's Nurse's Notes, dated [DATE] at 12:45 pm, by V4 (LPN) documented, . began choking at lunch (related to) was given potato wedges for lunch. Able to encourage resident to cough, staff began Heimlich (maneuver) and potato wedge became dislodged and was in side of throat and this scribe was able to remove with finger sweep. Spoke with kitchen (manager) about approved foods for resident based on diet order . On [DATE] at 10:11 am, V4 (LPN) said she was caring for R17 on [DATE] during the noon time meal. V4 said R17 was served whole potato wedges from the Dietary staff. V4 said R17 was sitting in the dining room when R17 began to cough, then choked on a potato wedge. V4 said she was able to clear R17's airway by completing the Heimlich maneuver. V4 said V4 then went to the kitchen to speak with V3 (Dietary Manager). V4 said she told V3 that R17 should never be served anything like whole potato wedges, due to R17s frequent choking events. V4 said after the potato wedge was cleared from R17's airway, V4 removed the rest of the potato wedges from R17 plate and R17 received mashed potatoes as a replacement. V4 said EMS was not called due to V4 being able to clear R17's airway. On [DATE] at 2:50 pm, V3 (Dietary Manager) said the potato wedges served to R17 on [DATE] did have a skin on them. V3 said residents with mechanically soft diets should not have been served potato wedges, but instead mashed potatoes. V3 said she did recall speaking with V4 (LPN) about mechanically soft diets, but did not recall the specifics of the conversation due to the conversation happening over two weeks ago. On [DATE] at 9:30 am, V7 (Speech Therapist) stated the facility should not have provided the potato wedge to a mechanical soft diet on [DATE], unless it was cut up in small pieces and no skin. V7 went on to state she would expect the facility to follow the diet spreadsheet for a mechanical soft diet. If the spreadsheet indicated mashed potatoes, she would expect them to follow the recipe for mashed potatoes. The facility's Diet Spreadsheets Week 2 documented on [DATE] the noon time meal mechanical soft diets should have received mashed potatoes to replace the potato wedges. On [DATE] at 3:36 pm, V1 (Administrator) said she did not investigate R17's [DATE] choking incident because V1 was present, therefore, she had no documentation to provide in addition to what was in the nursing notes for that incident. V1 said she had not completed an investigation on the [DATE] incident when R17 choked on a potato wedge due to V1 not having knowledge of the incident until [DATE]. On [DATE] at approximately 2:30 pm just prior to exit, V1 produced a [DATE] Quality Improvement Review document that was handwritten by V1 documenting R17's [DATE] choking event. The document described R17's [DATE] choking event to be different from V4 (LPN) and V5's (LPN) interviews, and documented, . Staff reported resident in DR (dining room) choking. Nurse on duty attending to another resident. (V1) immediately responded. Upon assessment noted resident staring but not talking or coughing. Unable to perform Heimlich (related to) resident size (and) inability to stand long enough. (R17) taken to the floor (and) chest thrusts preformed until food particles able to be observed. Able to extract some of the loose pasty food from airway . CNA present for meal stated pizza product served. Was soft, cut up (and) bread like, food extracted was wet (and) in small little bits . The facility's Therapeutic & Mechanically Altered Diets policy, revised ,d+[DATE], documented, . A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake . 1. A physician's order is written for all diets including therapeutic and mechanically altered diets . 3. The Food Service Manager and/ or dietitian write an extension of the regular diets using the same food when possible. 4. The dietitian approves signs and dates all menus . 8. The facility prepares and serves all therapeutic and mechanically altered diets as planned . The facility's undated Mechanical Soft Diet policy documented vegetables to avoid .most raw or undercooked vegetables and those with tough skins . Fried Vegetables . and grains to avoid as .Breads, rolls, muffins with dry hard crusts . The Immediate Jeopardy that began on [DATE] was removed on [DATE]/23, when the facility took the following actions to remove the immediacy as confirmed through observation, interview, and record review: Immediate actions: 1. For the Resident found to be affected by the alleged deficient practice, the following corrective action has been taken to achieve compliance: A. V3 (Dietary Manager) and V1 (Administrator) reconciled all diets to ensure residents diet orders were current and correct. B. Current Dietary Policy and Procedure for Mechanically Altered Diets was reviewed and found to be current and is being utilized for in-servicing of Dietary staff and additional staff that assist with delivery of meals. C. V1 (Administrator) was in-serviced by the regional team on dietary orders and mechanically altered diets. D. Current Dietary staff was in-serviced by V1 (Administrator) on all residents' dietary orders and mechanically altered diets. E. All other Dietary staff will be in-serviced by V1 (Administrator) on following resident's dietary orders and mechanically altered diets prior to starting their next scheduled shift. F. All staff currently working were in-serviced by V1 (Administrator) on mechanically altered diets and on reading the diet order cards for each resident prior to serving a meal, to ensure that proper diet is being served. G. All staff and Department Managers will be in-serviced by V1 (Administrator) on mechanically altered diets and reading the diet order cards for each resident prior to serving meal, to ensure that proper diet is being provided, prior to starting their next scheduled shift. H. Review of all residents with swallowing guidelines or other feeding recommendations was completed and noted on resident's diet card, if applicable. I. R17's MDS, section GG, was reviewed and updated. J. Removal Plan reviewed and approved by the V11 (Medical Director). 2. The following systematic measures have been implemented to ensure that proper diets are being followed: A. All newly hired Dietary staff will be in-serviced on following individualized plan, menus, and mechanically altered diets. B. V1 (Administrator) or Nurse Manager will monitor all meals for 7 days to ensure the proper diets are being served. Any concerns will be immediately corrected and addressed with employee through additional education. C. V3 (Dietary Manager) will monitor serve out of meals, at various times, 3 times weekly for 1 month to ensure Dietary servers are providing diets as ordered and then randomly, thereafter. 3. As part of the facilities ongoing quality assurance program: A. Any identified break in procedure noted by observations will be addressed immediately. B. Progress and identified problems noted during observations will be discussed during morning QA and action plan developed to prevent further occurrence. C. Compliance will be monitored through the internal QA process.

Based on observation, interview, and record review, the facility failed to anticipate a residents pain and administer as needed pain medication prior to wound care for one resident of one resident (R12) reviewed for pain in the sample of 35. This failure resulted in R12, while being repositioned and treated during wound care, crying out in pain and distress. The Findings Include: R12's Face Sheet documented an admitted [DATE]. R12's Cumulative Diagnosis Log documented diagnoses including Diabetes Type 2, Lung Cancer, CVA (Cerebral Vascular Accident) by history, and Dementia. R12's 8/28/23 Minimum Data Set (MDS) documented a Brief Inventory for Mental Status Score of zero, indicating R12 experiences severe deficits in cognition. The same MDS documented in the five days previous to the assessment, R12 experienced non verbal indicators of pain (crying, whining, gasping, moaning or groaning) and facial expressions indicative of pain (grimaces, wincing, wrinkled forehead, furrowed brow, clenched teeth or jaw). R12's Care Plan, dated 10/12/23, documented a problem area,Comfort alteration related to lung cancer, potential for air hunger, and impaired mobility, with a corresponding intervention, Observe for non-verbal indicators of pain. Ask resident if she is in pain, however she may not always be able/willing to give verbal response. Complete pain assessment prn (as needed). Administer pain medication as ordered. On 11/17/23 at 9:11am, V9 and V10, both Licensed Practical Nurses, were observed providing wound care for R12, who was awake but non verbal. R12 was noted to have large stage 4 pressure ulcers to her sacrum and left hip, and an unstageable pressure ulcer to the left ankle. When R12 was repositioned during the procedure and as the wounds were being cleansed, R12 would cry out and whine loudly. When asked if R12 had had any pain medication prior to the procedure, V9 stated she had not given R12 anything for pain prior to the treatment. V9 stated R12's dressings are normally changed in the afternoon and pain medication is given prior to the treatment. V9 stated she would give R12 pain medication after the treatment was over. At the conclusion of the procedure, R12 was positioned to her back and was no longer crying out. V9 was then observed administering the morphine to R12. R12's November 2023 Physicians Order Sheet documented an order for Morphine Sulfate 100 milligrams per milliliter (ml) take 0.5 ml every hour prn (as needed) for moderate to severe pain. R12's November 2023 PRN Medication Administration Record and November 2023 Pain Flow Sheet contained no documentation R12 received morphine on 11/17/23, nor that her pain had been assessed. On 11/21/23 at 9:40am, V2, Director of Nursing, confirmed R12 should have received pain medication prior to the wound care treatment. The facility's Pain Prevention and Treatment Policy, dated 12/7/17, documented, It is the facility's policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL( Activities of Daily Living) functioning and enhance the quality of life. Assessment of pain will be completed with changes in the residents condition, self reporting of pain or evidence of behavioral cues indicative of pain and documented in the nurses notes or on the Pain Management Flow Sheet. The Pain Management Flow Sheet will be initiated for those residents with but not limited to routine pain medication, daily pain, and diagnosis that may anticipate pain (for example arthritis, wounds, fractures, etcetera.)

Based on interview and record review, the facility failed to develop and implement a plan of care, follow physicians' orders and provide care in accordance with professional standards of practice for the treatment of [REDACTED]. This failure resulted in R3 being found unresponsive, having critically high blood sugar levels above 1200mg/dL and requiring R3 to be sent to the local emergency room for treatment on [DATE]. R3's condition deteriorated at the emergency room causing R3 to be transferred to the Intensive Care unit at a larger hospital. R3 expired on [DATE] with cause of death listed as Acute [MEDICAL CONDITION], Multiorgan Failure [MEDICAL CONDITION], and [MEDICAL CONDITIONS]. These failures resulted in an immediate jeopardy, which was identified to have begun on [DATE], when the facility failed to administer insulin as prescribed to R3. This has the potential to affect 13 residents, with diabetes, living in the facility. V15 (Licensed Practical Nurse), V25 (Regional Director of Clinical Operations) and V26 (Regional Director of Operations) were notified of the Immediate Jeopardy on [DATE] at 3:45 PM. The surveyors confirmed by observations, record review, and interview, that the Immediate Jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in service training. Findings include: R3's New Admission Information Sheet in the medical record show R3 was admitted to this facility on [DATE] and was discharged to the local hospital for emergency treatment of [REDACTED]. R3's Cumulative [DIAGNOSES REDACTED]. R3's Care Plan, developed on [DATE] by V15 (MDS/ Care Plan Coordinator/ Licensed Practical Nurse), did not include R3's [DIAGNOSES REDACTED]. On [DATE] at 12:00 PM, V15 was interviewed regarding R3's stay at this nursing home. V15 stated if a resident has the [DIAGNOSES REDACTED]. V15 states she forgot to add a plan of care for R3's Diabetes. R3's Medication Administration Records (MAR) and Physicians Order Sheets for [DATE] to February 2020 were reviewed. Physician order [REDACTED]. sugars at the times indicated. V15 said any initials circled on the MAR indicates the insulin was refused, and if no initials are present it indicates the insulin was not offered and not given. From [DATE] until R3's transfer to the hospital on February 2, 2020, R3 refused or was not given insulin as ordered 152 times (22 times in November, 36 times in December, 87 times in January, and 7 times in February). R3's physician's orders [REDACTED]. R3's MARs and forms titled Blood Glucose/ Accucheck Sheet, in the medical record for [DATE] until February 2020, were reviewed and found R3's blood sugar testing was refused or not done by nursing staff a total of 174 times from [DATE] until February 2, 2020, when R3 was transfer to the hospital emergency room for acute treatment of [REDACTED]. On [DATE], R3 was seen by V14 (Nurse Practitioner) for noncompliance of insulin and blood sugar testing and wrote a new order for the nursing staff to notify V14 if R3 continued to refuse her ordered insulin injections or blood sugar testing. On [DATE] at 1:00 PM, V14 states that she was not aware that R3 refused her insulin 130 times and glucose monitoring 171 times after V14 wrote the order for the nursing staff to notify her of R3's refusals on [DATE]. V14 said she did not realize R3 refused so many times and the nursing staff definitely did not notify her as ordered to do so. R3's physician's orders [REDACTED]. The dosage scale states to Notify the MD if blood glucose is over 350 mg/dL. R3's MAR and form titled Blood Glucose/ Accucheck Sheet in the medical record for [DATE] until February 2020 were reviewed. R3's records indicate that R3's blood glucose level was over 350 mg/dL a total of 49 times from [DATE] until R3 was transferred to the hospital on [DATE] (16 times in November, 18 times in December, 14 times in January, and 1 time in February.) On [DATE] at 1:00 PM, V14 states that V14 and V20 were not notified every time R3's blood glucose level was over 350. V14 further states that the facility utilizes an afterhours physician service company after 4:30 PM when physician notification is needed. On [DATE] at 2:10 PM, V21 (Medical Director of afterhours physician service company) states that the facility utilized their services on 5 occasions (2 times on [DATE], [DATE], [DATE], and [DATE]) to notify a physician of a blood glucose level above 350 mg/dL. V14 also said if there isn't documentation in R3's medical record stating she (V14) and V20 were notified of a blood glucose level over 350 mg/dL, then V14 and V20 were not notified. R3's nursing home medical records were reviewed from [DATE] through February 2020, and no documentation of V14 or V20 being notified of R3's blood sugars being above 350mg/dL were found. V1 (Administrator) reviewed R3's medical records and could not find any documentation of V14 or V20 being notified any of the 49 times R3's blood sugar test results were recorded as being over 350mg/dL. On [DATE] at 7:45 PM, Nurses Notes state that R3 was found unresponsive in her room, R3's blood sugar was checked at that time, and the glucometer results were displayed as high. As verified by V15, The User Instruction Manual for the Glucometer that is used by the facility on R3, states that when the blood sugar reading is displayed as high, it indicates that the blood sugar level is greater than 600 mg/dL and R3 was transported to the local emergency room . The local ER (emergency room ) records states that R3's blood glucose level was 1250 mg/dL when she arrived at 9:30 PM. Due to R3's severe level of medical distress, R3 was transferred and admitted to Intensive Care Unit at a larger hospital more equipped to provide the critical care R3 needed 2 ,[DATE] hours later. Hospital Admission History and Physical notes state that Diabetic Ketoacidosis was suspected at the time admission. According to the Mayo Clinic Laboratory website (https://www.mayocliniclabs.com/it-mmfiles/DLMP_Critical_Values_-_Critical_Results_List.pdf), serum blood glucose level of 400 mg/dL or higher is considered a critical value. The Mayo Clinic Laboratory defines a critical value as A value/result that represents a pathophysiological state at such variance with normal (expected values) as to be life-threatening unless something is done promptly and for which some corrective action could be taken. R3's forms titled Blood Glucose/ Accucheck Sheet in the medical record and MAR's for [DATE] through February 2020 show R3's blood glucose level was 400mg/dL or higher 16 times (7 times in November, 3 times in December, 5 times in January, and 1 time in February). On [DATE] at 1:00PM, V14 (Nurse Practitioner) said the facility could have done more to prevent R3's condition from becoming so critical and The facility did not do everything they could have done. On [DATE] at 4:30 PM, V22 (Registered Nurse/ Director of Nursing at a local hospital where R3 was admitted ) stated that she was the nurse who admitted R3 to the Intensive Care Unit. V22 states that R3 was very sick when she arrived at the hospital and felt that R3 did not receive very good care at the Nursing Home. On [DATE] at 10:00AM, V16 (Hospitalist for the Intensive Care Unit) stated she provided care for R3 in the Intensive Care Unit. V16 states that R3 was in poor condition and was receiving poor care while at the Nursing Home. R3 expired on [DATE]. R3's death certificate, completed by V16, states cause of death is Acute [MEDICAL CONDITION], Multiorgan Failure [MEDICAL CONDITION], and [MEDICAL CONDITIONS]. An Immediate Jeopardy was identified to have begun on [DATE] when the facility failed to administer insulin to R3 as prescribed. V15 (Licensed Practical Nurse), V25 (Regional Director of Clinical Operations) and V26 (Regional Director of Operations) were notified of the Immediate Jeopardy on [DATE] at 3:45 PM. On [DATE] the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediacy: The facility completed audits of Care Plans, Medication Administration Records, blood glucose monitoring, 24 hour nursing report and MD notication on [DATE]. The facility assigned staff member V15, LPN (Licensed Practical Nurse), began In-servicing Nursing staff on Diabetes, Care Plans, Conformance with physician orders, MD and POA notification of change in condition and refusal of treatment on [DATE]. Systematic & ongoing review of notification of change in condition are being completed daily by QA Committee. All began on [DATE] and was completed on [DATE], but QA review will be ongoing. The facility assigned staff member V15, LPN, to review the 24 hour nursing report daily for changes in condition and QA reviews are done daily, weekly, and monthly. The facility assigned staff member V15, LPN, to complete Care Plan audits, glucose monitoring and medication administration record review. These reviews are done daily. The facility assigned staff member V15, LPN, to in-service staff regarding the facility Conformance with Physician order [REDACTED]. Date completed [DATE]. The facility assigned staff member V15, LPN, to in-service staff regarding the facility policies for Physician Notification and glucose monitoring on [DATE]. Daily QA review of 24 hour report and review of telephone orders , daily chart reviews to ensure MD notification is completed as policy requires. Date completed [DATE]. The facility assigned staff member V15, LPN, to in-service staff on [DATE] regarding AIM for Wellness and communication for change in condition. Date completed: [DATE]. The facility assigned staff member V15, LPN, to in-service staff on [DATE] of refusal of treatment and MD notification. Date completed: [DATE]. The facility will continue to In-service staff regarding Diabetes, blood glucose monitoring, conformance with physician orders, Notification of change in condition, Aim for Wellness and Care Plans.

Based on observation, interview and record review the facility failed to prevent severe weight loss and provide meal assistance for one of 3 residents (R26) reviewed for nutrition in a sample of 14. This resulted in R26 having tooth pain and experiencing poor appetite with corresponding lack of participation in skilled therapies, an 8.8% weight (wt.) loss in 1 month, 9.63% wt. loss in 3 months, and 28.8% wt. loss in 6months. The findings include: According to R26's Profile Face Sheet, R26 is [AGE] years old, and was admitted on [DATE]. The Report of Monthly weight and Vitals form indicates in July, 2017 R26 was 5 feet and 5 inches tall and weighed 193.6 lb. (pounds). This same weight record lists the following weights for R26: August, 2017: 176.50 lbs., September, 2017: 159.50 lbs., October, 2017: 180 lbs., November, 2017: 178.50 lbs., and December, 2017: 137.8 lbs. This form indicated a 17.1 pound weight loss from July to August (8.8% loss in one month), and another 17 pound weight loss from August to September (9.63% loss in one month, or a 17.6% weight loss in the two months combined). R26's admission weight of 193.6 in September 2017 to her recorded December 2017 weight of 137.8 denotes a 55.8 pound weight loss (28.8% loss in 6 months). On 12/19/2017 at 11:00 AM, R26 stated I have lost over 20 pounds since I've been here, I don't like the food here, it looks like puke and I cannot eat because my teeth hurt. On 12/19/17 at 12:08 PM V7, Certified Nurses Aide (CNA) brought R26's lunch tray into her room and sat the lunch tray on the overbed table. Noted on the lunch tray was pureed food and at that time V7 stated R26 has to have puree food because she has no teeth. V7 stated to R26 They told me you did not want lunch but I brought it anyway just in case. Do you want to try to eat? R26 stated No, I don't want it I think I'm going to puke. V7 removed the lunch tray from the overbed table and left the drinks from the lunch tray on the overbed table, but left a plastic cover covering the top of the water glass and left the room, not offering to feed or obtain a different food alternative. R26 started touching the water glass with the plastic cover and said I can't get to this as she was touching the plastic cover. Then R26 asked how do I get into this? This surveyor explained how R26 could remove the plastic top to be able to drink the water and R26 removed the plastic top from the water and started to drink it. On 12/21/17 at 12:13 PM, a meal tray was located on R26's overbed table. R26 was in bed with the Head of the bed elevated to 45 degrees and R26 was sleeping and leaning to right side of the bed. The food on the tray was untouched, the ice cream top remained unopened, and a plastic covering was over the top of the water glass. According to the meal intake record for December 21, 2017 at Lunch, R26 refused the meal. A nursing note dated September 22, 2017 for R26 states Care Plan meeting with R26, husband, daughter and IDT (interdisciplinary team) present. (R26) is alert to person, place. Daily confusion and redirection. Poor cognition. Staff assist with verbal cues to complete daily tasks. Medically stable. Poor appetite with weight loss and lack of participation with skilled therapies is purpose of care plan meeting . August 11, 2017 weight was 176.50 lbs. and September 14, 2017 weight is 159.50. (R26) frequently refuses to eat meals/snacks. Currently mechanical soft diet we will attempt puree diet, continue to encourage medication review and obtain a dental appointment. A physician's Telephone Order form dated September 22, 2017 at 1:30 PM states 1. Change diet to CCD (Carbohydrate Controlled Diet) NAS (No Added Salt) puree consistency. D/C (discontinue) vegetarian diet related to poor appetite, wt. (weight) loss, unable to tolerate textures. 2. Dental appt. (appointment) R/T (related to) C/O (complaint of) to family of 'teeth pain.' A Care Plan with a start date of October 17, 2017 lists R26 with a problem area of Actual/Potential need for dental/oral care related to own teeth/poor condition. with an activity listed as Obtain dental consult. R26's Dietary Notes written by, V9 (Dietician) dated October 30, 2017 state Staff to encourage/assist resident PRN (as necessary) with meals. According to R26's Minimum Data Sets Assessment (MDS) dated [DATE], Section G, functional Status for eating, self performance R26 is coded as a 4 indicating total dependence - full staff performance every time during entire 7-day period and is coded with 2 for support for eating meaning R26 needed one person physical assist for eating. R26's dietary interventions in place according to the Dietary Services communication reports on October 3, and 30, 2017 include: Discontinuing No Salt Added diet and fortified milkshake three times a day and increasing medpass to 160 cc three times per day, adding magic cup one time a day, Nutritional juice drink one time per day, and 30 cc of prostat twice per day. No mention of dental appointments or teeth issues. physician progress notes [REDACTED]. R26's Food and Fluid Intake Sheet from December 1, through December 21, 2017, documented R26 refused breakfast 15 days, lunch 16 days, and supper 12 days. A Physician Notification of weight change form signed by V10, on December 11, 2017 notifies V10 of R26 having a 23% weight loss in 30 days, however nothing reported to the physician regarding R26's report of dental issues. On 12/21/17 at 2:13 PM V4 was questioned about R26's dental appointment, and V4 (Social Services) stated The medical appointments were made by medical records and she no longer works here. I did not make her an appointment. We use a Medicaid Dentist in (formal name of a distant town). We take all of the Medicaid residents there. On 12/21/17 at 1:50 PM, V2 (Director of Nursing) was questioned regarding R26's dental appointment and oral assessment documentation, and V2 reported there is not an independent oral assessment other than the MDS and states R26 has not been to the dentist since she has been here. She (R26) has not complained of a toothache that I know of. On 12/22/17 at 10:40 AM, V7 (Certified Nurses Aide), in response to being asked how much assistance with meals does R26 need, stated She is a feeder at all meals. She doesn't pick up her silverware anymore. She doesn't eat much but we're supposed to get her up for meals to prevent her from choking. That order came from Therapy.

Based on observation, interview and record review, the facility failed to provide the level of supervision needed during an identified period of agitation and restlessness, failed to implement fall prevention interventions and failed to ensure that fall prevention interventions such as alarming devices were functioning, for 4 of 14 residents ( R2, R5, R6 and R7 ) reviewed for fall risk in the sample of 14. These failures resulted in R2 falling and sustaining a fracture at the C5 - C6 level of the cervical spine as noted on a hospital Cervical Spine Computed Tomography (CT) report dated [DATE] and which resulted in R2's death on [DATE], 2 days after the fall, as noted on the Certification of Death record with an issue date of [DATE]. These failures resulted in an Immediate Jeopardy. On [DATE] the facility identified 11 current residents (R5, R6, R7, R8, R10, R11, R12, R13, R14, R15, R16) at risk for falls who were using some type of fall intervention device. While the Immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of their interventions to ensure that residents identified as being at risk for falls receive the appropriate level of supervision, have appropriate interventions in place, and that those interventions which include the use of an alarming device, are working properly. Findings include: 1. R2 was admitted to the facility on [DATE] with a history of falls as noted on the Admission Minimum Data Set ((MDS) dated [DATE]. R2's [DIAGNOSES REDACTED]. The [DATE] MDS indicated that R2 had fallen twice with no injury since the date of the previous MDS (of [DATE]). A physician's orders [REDACTED]. A Fall Risk assessment dated [DATE] had assessed R2 as high risk for falls. R2's Care Plan with a start date of [DATE] includes problem areas of falls and risk of self injury,disruptive/socially inappropriate behaviors, history of aggression, hallucinations and/or delusions and pain issues. Interventions included intervene as needed as soon as behaviors are noted, take to a quiet location and divert from distracting stimuli, observe for non verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended, and bring to nurses station when out of bed for observation. R2's Nurses Notes indicated the following falls occurring after the [DATE] MDS was completed: A) [DATE] at 8:15 pm, fall from bed with no injury. Nurses notes indicated that the bed alarm was in place but was not sounding. An approach was added to use a raised edge bed mattress on [DATE]. The bed alarm was discontinued on [DATE]. B) [DATE] - 8:30 pm, fall from bed with no injury. The raised edge bed mattress was discontinued on [DATE] and a bed alarm was restarted. C) [DATE] - 8:00 pm, fall from wheel chair and received a "small bump" to head. Facility determined on [DATE] that R2's pin chair alarm was not in place. D) [DATE] - 9:30 pm, fall from wheel chair and no injury. New intervention was for Occupational Therapy (OT) to screen and placement of a lap cushion positioning device while up in wheel chair was added. OT screen was completed on [DATE] with no new recommendations. E) [DATE] - 8:45 pm, Nurses Note indicates that Z1, Medical Doctor, was notified of an incident but it does not state that it was a fall. E2, Director of Nurses verified on [DATE] at 11:00 pm that R2 did have a fall from her wheel chair with no injury on [DATE]. E2 stated that the investigation found that R2 was screaming and hollering in the hall, as was normal for R2, and E11 Registered Nurse (RN) took R2 into her room, in her wheel chair and instructed E10 to sit at R2's door and keep an eye on R2 until R2 had calmed down. E2 stated the investigation indicated that R2 was very agitated, attempting to self transfer and did not have R2's intervention of a lap cushion device in place and that the pin chair alarm did not sound at the time of the fall. E2 further stated that the investigation indicated that R2's door had gotten partially closed and E10 did not maintain direct visual observations of R2 as instructed. E2 stated that a new intervention of starting 15 minute checks for R2 was added and staff were inserviced to remember to check resident Care Plans for determining which assistive devices are used for each resident. E10, CNA, stated on [DATE] at 2:00 pm that when she had worked on R2's hall on [DATE], she was not able to use the chair alarm for R2 because the clip was missing from the alarm cord. E10 further stated that she was not aware that R2 was to have a lap cushion positioning device when up in the wheel chair. E10 verified that R2 had a fall from her wheel chair on the evening of [DATE]. E10 stated that for approximately 2 weeks, every time she had worked with R2, she had not been able to find the clip for the chair alarm and stated that "we" had reported it. E2 Director of Nurses (DON) stated on [DATE] at 10:45 am that she was not notified and had no knowledge of the missing clip to the chair alarm. E8 (CNA) stated on [DATE] at 10:40 am that R2 was always yelling "let me out of here and other stuff." E8 stated two days prior to the fall on Sunday [DATE], R2 was really upset at start of the shift around 2:15 pm and E8 stayed with R2 in her room, holding her hand until she had calmed down. F) [DATE] fall at 8:40 pm, from the bed, with a change in condition that required transfer to the emergency room . The Nurses Notes for [DATE] indicate that at 8:40 pm, R2 was found on the right side of R2's bed, face down, incontinent of urine and denied pain or discomfort. R2 was repositioned and lifted back to bed with the use of a mechanical lift device and 2 staff. The notes indicate that R2's grasp was weak and that R2's pupils were "sluggish with light". The documentation does not include whether there was an alarm device sounding at the time of the fall. R2's neuro checks indicated weak grasps, pupils slow to react and muscle tone flaccid. R2 was noted to have a 1 centimeter by 1 centimeter sheared area to R2's left forehead "X 2" with a raised area. Orders were received from Z1 to send to the emergency room . R2 was transferred to a local hospital emergency room shortly after the fall, and several hours later (on [DATE]) was transferred by ambulance to an out of state hospital where she died on [DATE], as documented in the Nurses Notes of [DATE] thru [DATE]. The local hospital's Emergency Department notes indicate that as a result of a fall at the nursing home, a "CT (computed tomography) Cervical Spine Non Contrast" was done on [DATE] at 3:30 am and R2's [DIAGNOSES REDACTED]. Notes indicated that R2 needed resources not available at the local hospital and that R2 was being transferred to an out of state hospital. A Cervical Spine Computed Tomography (CT) dated [DATE] from the out of state hospital indicates the following: Hperextension injury at the C5-C6 level with C5 avulsion fracture and C5-C6 disc distraction injury. It further indicated that R2 had severe canal stenosis at the involved level with a suspicion of a hematoma within the canal. It further stated "When compared to the outside study performed [DATE], there has been no significant change in the above findings." The Certification Of Death record states the following: "Underlying Cause: Manner: Accident, Complications of Cervicospinal Blunt Trauma." date of death -[DATE]. Z4- Chief Investigator, Medical Examiners Office, stated on [DATE] at 3:30 pm that R2's death was attributed to the [DATE] fall, which R2 sustained at the facility, where she resided. E10 stated that she did not work on R2's hall on [DATE] but she recalled seeing R2 up in her wheel chair sometime during the evening, upset and agitated, which was normal stuff for R2, but could not recall an exact time. E8 stated on [DATE] at 10 :40 am, that on the evening of [DATE], E8 wasn't working on R2's hall but that she had come onto the hall to help with a resident around 8:00 pm and R2 was sitting in her wheel chair in the hall at that time. E8 stated that when she was finished helping with the other resident she came back up the hall past R2's room and noticed she was in bed at that point, maybe 5 minutes later. E4 Certified Nurse Aide (CNA) stated at 10:15 pm on [DATE] that R2 fell between 8 and 9 pm on [DATE]. E4 stated that after putting R2 to bed for the evening, R2 kept trying to get up from the bed and E4 and E3- CNA had gotten R2 back up into R2's wheelchair and sat R2 in the hallway where E3 and E4 had R2 in visual (site) while they worked on the books. E4 stated that she went on break and while she was on break, E3 came and got her and told her that R2 had fallen. E3, Certified Nurse Aide (CNA) stated on [DATE] at 10:30 pm that E3 and E4 had put R2 to bed for the night on [DATE] but R2 kept trying to get up out of bed. E3 stated that R2's bed alarm was working at that time because it kept sounding when R2 would try to get up. E3 stated that she and E4 got R2 back up and placed R2 in a wheel chair and placed her out in the hallway so staff could keep an eye on R2. E3 stated that she left the hall to go help another CNA with a transfer and that she told the nurse (E6- Licensed Practical Nurse LPN) to watch R2 who was still in her wheel chair in the hall near her room. E3 stated that she thought the other CNA- E4 had gone into another resident's room. E3 stated that when she returned from assisting with the transfer on a different wing, as she neared R2's doorway, she could see R2's head in the floor and that R2 was face down near the doorway inside R2's room. E3 stated that E6 was still in the hall a couple feet from R2's doorway with her back to the door and was not aware of R2 falling. During a second interview on [DATE], at 2:30 pm, E3 stated that she was "pretty sure" R2 had the chair alarm in place but not a lap cushion when she left R2 but that there was no alarm sounding when she returned to the hall a few minutes later. E3 stated that R2's bed was turned down and her wheel chair was on the room mates side of the room (window side) with wheels locked. E3 stated that she recalled having made R2's bed up when they had gotten R2 up from it earlier. E3 stated that as they were assisting R2 into bed using the mechanical lift, she noted R2 was limp like a wet noodle and had been incontinent of a large amount of urine. E3 stated that no one else working stated that they had put R2 to bed but E3 felt that R2 could not have walked from the wheel chair to the bed on her own. E6 Licensed Practical Nurse (LPN) stated on [DATE] at 3:00 pm, that E6 had instructed E3 and E4 around 7:45 - 8:00 pm to to put R2 to bed because she was yelling out in the hall way. E6 stated that at about 8:30 pm she went into R2's room to give the room mate her medications and that R2 was in bed with the head of the bed up and her two half rails in the up position. E6 stated that she could not recall seeing R2 back up in the wheel chair prior to the fall but that at about 8:45 pm, E3 had stuck her head out of R2's room and stated that R2 was in the floor. E6 stated that there was no alarm sounding and indicated that she recalled that R2's wheelchair was out in the hallway but did not think R2 would have been able to get from her wheelchair to her bed or push herself into her room, lock the wheel chair and then get into her bed on her own. E6 stated that she observed R2 laying in the floor with one arm to the side and the other in front of her with her legs straight and face forward partly in the door way. E6 stated she assessed R2 and did not find any injury but did note that after R2 was placed in bed with the mechanical lift and 2 staff, she did a neuro check and noted R2's pupils were sluggish but then became brisker. E6 stated that she also noted that R2 was a little flaccid but that "she would do that, kinda go limp then turn around and try and hit you." E6 stated she notified Z1 of her findings and received an order to send R2 to the emergency room . E6 stated that when the ambulance crew arrived, R2 kept swinging at them when they were trying to put a soft collar on R2. E1, Administrator and E2 stated during the daily status meeting on 2//,[DATE] at 4:15 pm that R2 had a history of [REDACTED]. Moderate compression deformities at T5 and C5, The exact age of these is uncertain. On [DATE] at 10:45 am, E2 was asked if after R2's fall on [DATE], when the investigation revealed that R2's alarms did not sound and staff had not been consistently using the lap cushion device, if there was a facility wide check for the proper functioning and placement of the alarms and lap cushion devices for all residents with alarm devices and lap cushions. E2 stated that E6 had verbally told E2 that E6 had checked other resident devices after R2's fall on [DATE]. E2 stated that there was no protocol for checking them after a fall and there was no hard copy record of a check being done after R2's [DATE] fall, specifically related to assessing other residents for any potential alarm or lap cushion device concerns. E2 stated that staff are to check for the presence of fall prevention alarms each shift and document daily on the monthly Treatment Administration Record (TAR). R2's [DATE] TAR was noted to contain several blanks where nurses did not initial that the bed alarm had been checked. The [DATE]th, 2015 date is not signed off as checked during the 6 am to 6 pm shift nor for the 6 pm - 6 am shift. There is no area on this TAR for nurses to initial that a chair alarm was in place and working. As noted above, R2's fall and serious injury occurred on [DATE] at 8:40 pm. 2. R5's Care Plan for Falls was updated on [DATE] for a Bed Alarm. R5's Fall Risk Assessment completed on [DATE], [DATE], [DATE] and [DATE] all document that R5 is scored as a High Risk. On [DATE] at 11:35AM, R5 was lying in his bed sleeping. At this same time, R5's bed alarm was in place but the battery box to the bed alarm was turned off. On [DATE] at 11:45AM, E14, Certified Nurse Aide (CNA), looked at the batteries in R5's battery box and stated that the batteries were in backwards. At this same time, E14, CNA, put the batteries in correctly but R5's bed alarm still did not work. E14, CNA, went on to say, "I guess the batteries are dead". On [DATE] at 10:45AM, E2, Director of Nursing (DON), stated the CNAs check the bed alarms every shift and when they put the residents to bed. E2, DON, went on to say that bed alarm maintenance is done by changing out the batteries around the 15th of every month and that all of this informaton is recorded on the resident's Treatment Record. R5's December, 2014, January, 2015, and February, 2015 Treatment Records do not have any documentation regarding a Bed Alarm. 3. R6's Care Plan for Falls was updated on [DATE] for a Bed Alarm. R6's Fall Risk Assessment completed on [DATE] documents that R6 was scored as a High Risk. On [DATE] at 11:50AM, R6 was lying in her bed. On [DATE] at 11:55AM, E15, Certified Nurse Aide (CNA), came into R6's room and assisted R6 out of bed but R6's bed alarm did not sound. At this time, E15, CNA, checked R6's bed alarm pad and noted that the pad had slipped down to the foot of R6's bed. On [DATE] at 11:58AM, E15, CNA, stated that R6's bed alarm pad, which is long and narrow, has to be positioned directly under the resident's body weight, preferably resident's hips, otherwise the alarm will not work. E15, CNA, went on to say that some bed alarm pads tend to slip down to the foot of the bed and that some CNAs do not know how to position the bed alarm pads correctly on resident's beds. R6's February, 2015 Treatment Record does not have any documentation regarding a Bed Alarm. 4. R7's Nurses Notes document that on [DATE] at 1900PM (7PM), R7 was found on the floor with no injury noted. R7's Nurses Notes document that on [DATE] at 9:30AM, the Interdisciplinary Team met and determined the root cause of R7's fall on [DATE] was because R7 continues to attempt to self transfer from bed to wheelchair without assist or using a call light. R7's Care Plan for Falls was updated on [DATE] for a Bed Alarm while in bed. R7's Fall Risk Assessment completed on [DATE] documents that R7 was scored as a High Risk. On [DATE] at 11:20AM, R7 was lying in her bed. At this same time, the battery box for R7's bed alarm was fastened to the right front leg of R7's bed and the alarm was turned off. On [DATE] at 11:25AM, E14, Certified Nurse Aide, stated that R7 turns her bed alarm off. R7's January, 2015 Treatment Record documents that R7 is to have a bed alarm while in bed related to decreased cognition and increase in falls. The Treatment Record documentation for R7's bed alarm, is to be completed twice a day. There are 14 times during the month of January, 2015 where the bed alarm documemtation was not completed. E1, Administrator, E2, Director of Nurses and E16 Assistant Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 4:15 pm. The Immediate Jeopardy was determined to have begun on [DATE] between 8:00 and 9:00 p.m when R2, who was agitated, restless and had numerous attempts of getting out of bed, was left unsupervised without fall interventions in place. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: A. E2-DON, E16- Assistant DON and E17- MDS Coordinator audited all residents who have alarms as a fall prevention intervention to ensure proper function of the alarms. This included R5, R6 and R7. Completion Date: [DATE] B. E1, E2, E16 and E17 reviewed Care Plans of all residents identified as a fall risk to ensure that all prevention interventions were being utilized per residents's plan of care. Completion Date: [DATE] C. E1 and E2 inserviced all staff on: Fall Prevention Program, Fall Interventions which includes use of personal alarms, lap cushion positioning devices and appropriate monitoring of residents who are identified as a fall risk, Fulfilling Fall Prevention Responsibilities, Fall Documentation. Facility staff will not be allowed to work until the in-service is completed. Completion date: [DATE] D. E1 in-serviced licensed personnel regarding the responsibility of personal alarms to be checked every shift to ensure proper function and to now be documented on the monthly Medication Administration Record (MAR). Checking function of alarms includes- is it working, is it placed appropriately, and are batteries in properly. Completion Date: [DATE]. E. E2 will ensure that all new employees will be trained and educated on policy and procedure for the Fall Prevention Program per facility protocol during their orientation process. F. The Quality Assurance team will assure compliance through the daily Quality Assurance Process. The Administrator will monitor for effectiveness of staff training of the Fall Prevention policy.