Every finding on record at Axiom Healthcare of West Frankfort

Based on interview and record review the facility failed to apply a BIPAP (bilevel positive airway pressure) machine according to medical doctor orders and failed to provide training for nursing staff in application of BIPAP usage for 1 of 3 residents (R1) reviewed for respiratory care in the sample of 8.Findings include:R1's admission record dated 8/17/26 documents an admission date of 4/4/25. admission record also documents diagnoses including acute and chronic respiratory failure, chronic bronchitis, history of lobar pneumonia, atelectasis, chronic obstructive pulmonary disease, chronic respiratory failure, and dependence on supplemental oxygen.R1's order summary report dated 8/17/26 documents the following orders: R1 to wear a bilevel positive airway pressure/BIPAP machine at nighttime and for him to be observed every four hours while he was wearing it with an order date of 7/31/26; R1 to complete nebulizer treatments as directed at 5:00 AM, 11:00 AM, and 5:00 PM; then complete 20 minute session of pulmonary vest therapy as tolerated three times a day with a start date of 7/24/26; R1 to have supplemental oxygen at 3-5 liters per minute continuously with a start date of 4/22/26; Acetylcysteine Inhalation Solution 20% 3 milliliters/ML inhale orally three times a day; do duo nebulizer first, wait 5-10 minutes and then do hypertonic saline followed by mucomyst with a start date of 7/24/26; ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams/MG/3 ML 1 dose inhale orally every 6 hours as needed with a start date of 12/15/25; ipratropium-Albuterol Inhalation Solution 0.5-2.5 MG/3ML inhale orally four times a day; do duo nebulizer first, wait 5-10 minutes and then do hypertonic saline followed by mucomyst; sodium chloride inhalation nebulization solution 3% 4 ml inhale orally via nebulizer four times a day with a start date of 7/24/26.R1's most recent care plan documents a focus area identifying R1 has episodes of shortness of breath with a revised date of 5/28/25. Interventions for this focus area include to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger and monitor and document breathing patterns with an initiation date of 5/28/25; report abnormalities to MD: nasal flaring, respiratory depth changes, altered chest expansion, use of accessory muscles, pursed-lip breathing or prolonged expiratory phase, and increased anteroposterior chest diameter with an initiation date of 5/28/25. R1's care plan documents a focus area for Chronic Obstructive Pulmonary Disorder/COPD with an initiation date of 05/28/2025. Another focus area documented on R1's care plan is R1 uses a BIPAP machine while sleeping with a revised date of 5/28/25. Interventions documented for this focus area include applying oxygen as ordered via BIPAP with an initiation date of 05/28/2025; ensure proper settings on BIPAP machine with an initiation date of 5/28/25. R1's care plan documents a focus area that R1 requires oxygen therapy with a revised date of 8/17/26. Interventions for this focus area include continuing oxygen therapy per doctor's order with a revised date of 08/17/2026; give medications as ordered by physician; monitor/document side effects and effectiveness with an initiation date of 08/12/2026.R1's minimum data set/MDS dated [DATE] documents R1 has a brief interview for mental status/BIMS score of 14 indicating R1 is cognitively intact. MDS documents R1 has shortness of breath with exertion, when sitting at rest and when lying flat. MDS documents R1 is on oxygen therapy and a noninvasive mechanical ventilator.On 8/17/26 at 10:41 AM, R1 stated about 4 weeks ago a travel nurse named (he stated the name of V3, Licensed Practical Agency Nurse/LPN) refused to switch his oxygen over from his nasal cannula to the BIPAP machine. R1 stated he also remembered one night when he had fallen asleep and woke up to discover no one had put his BIPAP on which caused him to have difficulty breathing. R1 stated he put his call light on for assistance at which time V3 entered his room but reportedly did not know how to apply his BIPAP machine or how to switch his oxygen from nasal cannula to BIPAP.On 8/17/26 at 3:47 PM, V14, Certified Nurse Aide/CNA stated one shift he had reported to V3 R1 was requesting a nebulizer treatment. V14 stated about 1 hour later he went back in to check on R1 who informed him V3 had still not come and assessed him or administered a nebulizer treatment. V14 stated he approached V3 a second time and reminded her again of R1's request/need. V14 stated he could not remember her exact response, but her demeanor and words showed V3 wasn't really concerned. V14 stated he did see V3 eventually go into R1's room with what appeared to be a nebulizer treatment, so he wasn't sure what to do after that. V14 stated he did not report this incident to anyone. On 8/18/26 at 1:02 PM, V2, Assistant Director of Nurses/LPN stated she had heard from R1 he had not gotten some of his ordered nebulizer treatments, and one of the agency nurses did not get his BIPAP hooked up properly. V2 stated when she asked who it was R1 responded with V3's name. V2 stated I would expect nursing staff to at least evaluate a resident if they were requesting a nebulizer treatment and administer it if the resident had orders for it and it was due. When asked if facility should supply some training regarding on the use of BIPAP machines, V2 stated yes, it would be beneficial, but the problem was the facility had more than one style of machine in use in the facility. On 8/17/26 at 1:59PM, V9, CNA stated one day (she could not remember when) R1 had reported to her a nurse (she did not remember if R1 told her the name of the nurse) had told him he would have to wait for care because her nail polish had not dried yet.On 8/17/26 at 3:40 PM, V13, Licensed Practical Nurse/LPN stated R1 had reported to her he received a nebulizer treatment late from an agency nurse named (R1 told her the name of V3, LPN). V13 also stated R1 had told her V3 had told him she didn't need to assist him getting the nebulizer mask on because he could put his own nebulizer mask on and start the treatment.R1's Hospital Update with a scanned date of 7/28/26 to R1's electronic health records documents on page 8 in medical doctor's note, Has not used home (positive airway pressure)PAP therapy for at least 2 nights in the past week due to caregiver unable to set up the machine.On 8/18/26 at 11:21 AM, V18, Medical Doctor stated if a resident had a BIPAP machine ordered he would expect staff to apply it as ordered. V18 stated if a staff member didn't know how to apply the BIPAP machine he would expect them to reach out for assistance or to find out how.On 8/18/26 at 3:57 PM, V17, LPN stated if a resident had requested a nebulizer treatment she would at least go and assess the resident's current condition, then verify resident had an order for a nebulizer treatment and administer it as ordered. V17 stated if a nurse did not know how to operate a resident's BIPAP machine she would expect the nurse to reach out for training or call administration for instruction.On 8/18/26 at 3:58 PM, V12, LPN stated if a resident had requested a nebulizer treatment she would at least go and assess the resident's current condition, then verify resident had an order for a nebulizer treatment and administer it as ordered. V12 stated if a nurse did not know how to operate a resident's BIPAP/CPAP machine she would expect the nurse to reach out for training or call administration for instruction.On 8/18/26 at 10:40am and 2:20PM attempts were made to call V3. V3 could not be reached.

Based on interview and record review, the facility failed to ensure the notifications and required reasons for transfer/discharge were adequately communicated and documented in the medical record and failed to permit a resident to return to the facility after hospitalization for two (R1 and R2) of three residents reviewed for inappropriate transfer and discharge in the sample of 32. This failure would cause a reasonable person to experience feelings of fear, agitation, anxiety, and distress as a result of being removed from their home and taken to an unfamiliar location with unfamiliar people, far away from family. Findings include:1. R1's admission Record documented an admission date of 10/23/25 and included diagnoses of Cerebral infarction due to thrombosis of right middle cerebral artery, cerebral infarction due to embolism of left middle cerebral artery, dysphagia, major depressive disorder, adjustment disorder with depressed mood, vascular dementia with anxiety, vascular dementia with other behavioral disturbance, and vascular dementia with agitation. R1's admission Record also documents a discharge date of 2/25/26 to an Acute Care Hospital. Under Contacts V16 (Family-Power of Attorney/POA) is documented as R1's Emergency Contact #2 and V18 (Family) is documented as R1's Emergency Contact #1. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood. Under the Staff Assessment for Mental Status, R1 is documented as having a short term memory problem. Regarding cognitive skills for daily decision making the MDS documents R1 is moderately impaired, noting decisions poor and cues/supervision required. Under signs/symptoms of delirium, the MDS documents Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? which was answered with behavior present, fluctuates (comes and goes, changes in severity. R1's Care Plan includes (but not limited to) Focus Areas of Impaired Social Interaction, Behavior Management, Resistive to care, Physical Aggression, Wandering/Poor Safety Awareness, Impaired Communication, and Vascular Dementia with multiple interventions listed. The Care Plan does not include any Focus Area specific to discharge planning but has a Focus Area documenting I have expressed a desire to remain at (name of facility) for permanent placement. (initiated 10/27/25 and revised on 11/19/25). Corresponding interventions listed document: Arrange transportation PRN (as needed) to medical appointments (initiated 10/27/25), Concerns will be addressed in a timely manner (initiated 10/27/25), Resident and POAHC (Power of Attorney for Health Care) will be invited to bring any concerns to facility staff (initiated 10/27/25), and Will state comfort with current setting when questioned (initiated 10/27/26 and revised 1/26/26). This focus area does not include any new interventions after 1/26/25 and does not include any information regarding transfer/discharge plans related to seeking alternative placement for behavioral evaluation. On 04/28/26 at 12:15 PM, V17 (Hospital Case Manager) stated R1 came to them from a nursing facility 5 hours away, and they brought R1 up in the facility's van. The hospital was able to get R1 stable and tried to get her back to the facility but V1 (Administrator) has given them a hard time. V17 said V1 first stated they did not have transportation, then said they did not have a room for R1 because they were using it for an isolation room, and another person was currently in it. V17 said when she tried to reach back out to the facility, they would not take R1 back and then started not returning phone calls. V17 stated after V1 said R1 was not able to return to the facility, they advised V16 (Family Member-Power of Attorney/POA) of this and V16 went to go get R1's personal items. V16 then told V17 there was no one in R1's room and her items were still by her bed. V17 stated she has an email thread of the conversations between her and the facility. On 04/28/26 at 1:31 PM, V16 (Family Member/POA) stated she was at the facility for R1's birthday on 02/22/26, which was three days before R1 was sent to the hospital up north on 02/25/26. V16 stated she had a care plan meeting scheduled for R1 on 2/24/26 but unfortunately, V16 was in the hospital that day and did not make it to the facility for the meeting. V16 stated facility staff did not inform V16 they were sending R1 to (name of city approximately 5 hours north) while she was at the facility (on 02/22/26) nor did they call to tell V16 they were sending R1 to (name of city) until after R1 was there for 2 hours. V16 stated she even checked her phone call log to make sure she did not miss the call. V16 said she did not receive a text from V1 either and there are times V1 will text information. If the facility had called when she was in the hospital, someone would have answered the phone. V16 stated the hospital up north told her R1's facility would not take R1 back and that they had given R1's bed away, so V16 went to go get R1's personal items. V16 said R1's items were still by her bed and there was no one in her bed. V16 said she would like R1 closer to (home) because then she could visit, and she was able to visit R1 frequently before the facility discharged her on 02/25/26. V16 stated she went and retrieved R1's belongings because she was told the facility would not take R1 back. V16 said she never stated that she did not want R1 to return to the facility. V16 said she thought R1 was originally supposed to be returning to the facility after three days. V16 stated she has not received any paperwork from the facility regarding R1 leaving the facility, being transferred to a hospital, a bed hold policy, or any other paperwork. V16 stated the first she knew about R1 being discharged to the hospital was when the hospital told her on 2/25/26. V16 stated R1 would get agitated at the facility because of things she wanted, the pureed diet she was on and the thickened liquids they gave her. V16 said she tried to sign a waiver for R1 to have different food, but the facility would not let her, stating R1 could only have different food if V16 brought it in for her. V16 said she would bring R1 fast food with a soda and she would eat it but would just have to take drinks between her bites. V16 stated R1 hated the pureed food, and it would make her angry to eat it. V16 said there were also times the facility would call her because R1 would get agitated and they would want V16 to come by and calm R1 down, which she would do if she was able to get there. On 04/29/26 at 9:45 AM, V15 (Transportation) stated she has seen V16 (Family Member) and V18 (Family Member) visiting R1 at the facility. V15 was unaware if V16 was notified of R1 leaving the facility before they left (on 2/25/26). V15 stated she believes the paperwork they took with them was screening paperwork. V15 stated they originally took R1 to the front entrance but apparently that was not where they were supposed to go because they did not seem to know about the situation. V15 stated they went to the emergency room entrance next, and they must have sat there and waited about five hours before they were given a room to go to. V15 stated the trip was fine, R1 had no behaviors, and they even had to stop and go to the bathroom a couple of times. V15 said R1 didn't even have any behaviors when they were sitting in the waiting room for five hours. V15 said R1 did not have any behaviors until they went to her room and R1 realized that she was staying, and they were leaving. On 04/29/26 at 10:24 AM, V3 (Medical Director) stated he heard about the facility inquiring about a behavior hospital visit for R1 via hearsay, but they may have discussed it with V19 (Nurse Practitioner/NP). V3 stated he was not aware of a discharge or an involuntary discharge with R1. On 04/29/26 at 10:36 AM, V19 (NP) stated he was aware R1 is no longer at the facility. V19 stated he vaguely remembers R1, and that R1 had abnormal behaviors and was receiving Haldol and Ativan. V19 stated he does not see in his notes where he consulted or assisted with R1 going to a behavioral hospital or a facility-initiated discharge. On 04/29/26 at 6:57 PM, V7 (Licensed Practical Nurse/LPN) stated the facility found a place in (city name) for R1 to go to. V7 said R1 would hit, kick, bite, and throw things. V7 stated she does not know if R1 always just threw things at staff, the things R1 threw would just land where they landed. V7 stated she thought R1 was supposed to come back to the facility, but she wasn't sure. On 04/29/26 at 1:20 PM, V1 (Administrator) stated R1 was admitted to a hospital psych (psychiatric) unit in (city name approximately 5 hours away). V1 stated they were working with the psychiatric provider they utilize at the facility and V16 (Family Member). V1 stated they had a care plan meeting scheduled (02/24/25) and V16 did not show up but they were going to tell V16 then. V1 stated they had been working for months on trying to find a place that would evaluate R1 for increased behaviors/aggression. V1 stated V16 has come to R1's care plan meetings before and they had discussed it at length. The psychiatric provider they utilize made the recommendation for two facilities and the first one (facility name) was unable to take R1. V1 stated when she talked to V16 about R1 being admitted to the facility in (name of city approximately 5 hours away), she stated it was for an evaluation. V1 stated she was under the impression R1 was returning. V1 said that V16 was the one who told them R1 was not returning to the facility. V1 stated she never said R1 could not come back to the facility. V1 said she told the hospital they just needed four days before R1 could return because they were using the room for an isolation room and after that, she did not hear any more from the hospital. V1 stated she was under the impression the hospital was looking for different placement for R1. V1 stated V3 (Medical Director) was aware of the situation. On 04/30/26 at 10:37 AM, V17 (Hospital Case Manager) stated that V1 told them the facility would not accept R1 back straight out. V17 said V1 or V2 (Assistant Director of Nursing/ADON) never expressed to her that they only needed four more days before they could come and get R1. V17 stated V1 quit communicating with V17 after V1 said they would not take R1 back. V17 stated V1 was communicating and cooperative until she was told R1 was ready to return to the facility, then they quit answering the phone and returning phone calls. V17 stated they are a hospital, not permanent housing, so after V1 refused to take R1 back, they told V16 (Family/POA) that V1 would not take R1 back. After a discussion with V16 about R1 not being allowed to return, V16 agreed to have V17 send out some referrals to other facilities, however V16 said she would like the first referrals to go to locations in (V16's local area) so she could still see R1. V17 said after those referrals were denied, then V16 agreed to have referrals sent to other places. V17 stated it was her understanding that V1 was going to call V16 and tell her R1 could not return to the facility. On 04/30/26 at 10:46 AM, V16 stated she had never said she did not want R1 to return to the facility she was at. V16 stated someone at the hospital in (city name) told her on 03/19/26 that R1 was not being allowed to return to the facility, so she went to go get R1's belongings. V16 stated she was aware in February the facility was looking for a place to send R1 for an evaluation. V16 stated she knew they attempted referring to (hospital facility name) mid- February but that facility denied R1's admission. V16 said on 02/15/26 at 10:18 AM, V1 sent her a text asking if V16 could drive R1 to a hospital in the area (local hospital name) because they had a unit that could evaluate R1. V16 said she returned a text back to V1 at 10:22 AM that her vehicle is too high for R1 to get into and be transported. V16 stated she was not sure why they did not take R1 in the facility van. V16 stated V1 never told her about the hospital up north in (city name). V16 said the first time she was made aware was on 02/25/26 at 3:29 PM when that hospital let her know that R1 had been transferred up north to (city name) and she was already there. V16 stated neither she, her spouse, nor V18 (Family) ever stated they did not want R1 to return to the facility. When she was told R1 was in the hospital up north, it was her understanding that R1 would be returning. V16 stated every time she and the facility discussed R1 going anywhere for an evaluation it was always with the understanding it would be a temporary stay, and she would return to the facility. On 04/30/26 at 4:40 PM, V20 (Psychiatric Nurse Practitioner) stated R1 was having frequent episodes of aggression towards staff and due to her dementia, she could not be redirected. These episodes were becoming bad enough that staff felt R1 needed a higher level of care. V20 stated she is unaware if the plan was for R1 to return or not. The facility felt her aggression was out of control. V20 stated she had not spoken one to one with V16 (Family), usually the facility does that. V20 said in early February, staff had started requesting hospitalization for R1 and they suggested some hospitals they had worked with in the past. V20 stated she has not had any contact with the hospital R1 was sent to. V20 said sometimes it is a complicated situation with dementia when they do not respond to medications well. V20 stated R1 may respond better to redirection and to one-to-one care. V20 said there are times when R1's aggression was directed at staff; she is not sure if it was directed towards residents. V20 stated she was not sure what the plan for R1 was after hospitalization. R1's Progress Note dated 02/18/26 at 8:11 AM documents: received new orders from (psychiatric company) at this time. New orders as follows: Haldol 5mg (milligrams) po (per oral) Q (every) 8 hours prn (as needed) x (times) 14 days and Ativan 2mg IM (intramuscularly) Q 8 hours prn x 14 days. Called and spoke with V16 and was given verbal consent to begin medications. The orders were processed. Will monitor for change. R1's Progress Note dated 2/18/2026 at 5:02 PM documents: R1 self propelling with cup of hot coffee and proceeded to throw it on a staff member. PRN IM Haldol utilized at this time. R1's Progress Note dated 2/19/2026 at 12:14 PM documents: R1 was seen by facility nurse practitioner with (psychiatric company). No new orders. R1's Progress Note dated 2/20/2026 at 2:17 AM documents: no adverse effects noted related to recent medication change: Ativan and Haldol PRN. No behaviors noted and no complaints voiced. R1 is resting quietly in bed, call light in reach. No PRN Ativan or Haldol given this shift. R1's Progress Notes dated 2/20/2026 at 12:21 PM documents: called and spoke with V16 related to telehealth visit today and new orders. Medications explained along with desired benefits and possible ASE's (adverse side effects), received verbal consent to proceed with new medication orders. R1's Progress Note dated 02/21/26 at 5:53 AM documents: this nurse called POA, (V16) to notify her of resident being on floor at 12:10 AM. V16 thanked nurse for calling and had no further questions. R1's Progress Note dated 02/21/26 at 3:15 PM documents: resident in room at this time. No complaints of pain or discomfort. No s/s (signs or symptoms) of acute distress. No cough or sob (shortness of breath) noted. No adverse reactions noted related to change in psychiatric medications. No behaviors noted. Call light within reach. Will continue to monitor for change. R1's Progress Note dated 02/22/26 at 3:29 AM documents: No adverse effects noted related to recent medication change: Ativan prn, Haldol prn, start melatonin, start Depakote. No behaviors noted, no complaints voiced. Resting quietly in bed with eyes closed, respirations even and non labored. Call light in reach. No prn Ativan and no prn Haldol given this shift. R1's Progress Note dated 02/22/26 at 5:23 PM documents: the resident is on daily monitoring related to starting Melatonin, Depakote, Ativan IM PRN, and Haldol IM PRN. PRN medications have not been administered at this time. No adverse reactions noted/reported. No complaints noted. No signs of distress were noted. V16 was in to see the resident today. No behaviors present at this time. The plan of care is ongoing. R1's Progress Note dated 02/23/26 at 1:12 AM documents: R1 resting in bed, no behaviors noted at this time, call light within reach, will continue to monitor for change. R1's Progress Note dated: 02/24/26 at 10:00 AM documents late entry: V16 did not attend scheduled care plan meeting. R1's Progress Note dated 02/25/26 at 10:13 AM documents: late entry: Social Service supportive documentation note; documents: Behavioral symptoms: A. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior of this type occurred 1 to 3 days B. Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) Behavior not exhibited C. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds): Behavior of this type occurred 1 to 3 days D. Were any behavioral symptoms in question E0200 coded 1,2, or 3? Yes Provide examples of said behaviors from A, B, or C during the look back period, including dates. Resident gets mad at mealtime when she is given puree food. Or when certain staff is here that she thinks is someone else or she don't get her way. R1's Progress Note dated 02/25/26 at 2:07 PM documents: Yesterday I contacted (hospital name) in (city name) for services for (R1). They stated they needed current labs, doctor notes, face sheet, behaviors, and medication list. I sent that all over to them before lunch. They called back and stated they needed a petition for involuntary admission. I had never done one of those before, so (V2) (ADON) filled it out, and I sent it back over to (name of hospital). They then called back an hour or so asking when her ETA (estimated time of arrival) was, I told them I never did get an answer stating they was going to accept her and that we were five hours away and couldn't leave without a for sure admission. She stated please don't bring resident yet before I receive the original petition. I told her I was far away and it wouldn't be till tomorrow morning when we were leaving with her. That we wouldn't make it there till Wednesday late morning. She said that would be fine. They then called and talked to the charge nurse about (R1) asking about her ADL'S (activities of daily living) (name) the nurse explained to them that she needed help with all ADL's that she had been standing better but still needed assistance in the bathroom, showering, and transferring to and from bed and wheelchair. I called again after supper since I was in late to make sure it was all in place and we could come with (R1) there this morning. I talked to the lady back in admissions she said everything was good to go that she would be a direct admit to the ER. Will continue to monitor and report any changes. R1's Progress Note dated 02/25/26 at 2:41 PM documents: V16 did not show up for the Care Plan meeting yesterday I called her but no answer. Will continue to monitor and report any changes. R1's Progress Note dated 02/25/26 at 3:00 PM documents: R1 is currently in (hospital name) ER (emergency room). V1 received notification that resident could actually be admitted to (hospital name) medical floor with her medical background with an order for psychiatric evaluation. They will need our facility to call and give the floor nurse report/background information. (Hospital name) was called and spoke with both (nurse name) and (nurse name), updated them both on R1's medical background, most recent behaviors and escalation of behaviors causing the need for this evaluation. Facility faxed DNR (do not resuscitate) form, POA paperwork, (hospital name) records, and R1's current orders from here at the nursing home. Facility advised them to call if any further questions. R1's Progress Note dated 02/25/26 at 3:38 PM documents: V1 was able to speak to V16, after several attempts. V16 stated she had been in the hospital for a migraine headache. V16 was informed of the resident's admission to (hospital name) for further evaluation and treatment. R1's hospital Case Management Note dated 02/26/26 at 9:43 AM documents: initial discharge planning/case management note: documents the writer spoke with V16 (POA) to review and discuss the discharge plan. R1 is nonverbal and was unable to participate in the discussion. The patient has a POA on file. The writer will continue to follow up as needed. Objective: R1 is currently being treated for major depressive disorder, R1 resides at (facility name), R1 is not bed bound ambulates via wheelchair, R1 does require assistance with ADLs (activities of daily living), R1 is not using supplemental oxygen, and ongoing consultations with psychiatry. Assessment emergency: R1 remains medically complex with active management for major depressive disorder. Functional limitations and current living arrangement support planning for return to (facility name) upon medical clearance additional documentation from the attending physician and consulting teams is required to finalize the discharge plan. Plan: continue to monitor the patient's medical status and await medical clearance, plan for discharge back to (facility name), obtain recommendation forms from the attending physician and consultation notes from psychiatry, continue case management follow up until the discharge process is complete. R1's Progress Note dated 02/26/26 at 1:55 PM documents: V1 contacted (hospital name) this morning for an update on this resident. Spoke to V17 who stated a nurse would be calling me back to provide update status on this resident. V1 provided contact information including email and phone number for the nurse to respond. R1's Progress Note dated 02/26/26 at 3:42 PM documents: V1 received call back from the nurse, (hospital name). No changes for the resident at this time she has been admitted and is being followed by psychiatric. Behaviors present at the hospital. V1 confirmed they have contact information for V16 (Family/POA). R1's hospital Case Management Note dated 03/03/26 at 9:37 AM documents: the writer briefly spoke with V1 to provide a clinical update and faxed updated clinical information to the facility for review. The writer also discussed transportation arrangements for R1. At this time, the plan is for the original facility to arrange pick-up upon medical clearance. However, the facility requested advance notice to allow sufficient time to schedule transportation accordingly. The writer will continue to follow up and provide timely updates to ensure a smooth transition. R1's Progress Note dated 03/03/26 at 2:11 PM documents: Called (hospital name) and spoke with nurse, she reports there has been no change in resident at this time, she continues to be physically aggressive towards staff, requires physical restraint, and a sitter. Called (V17) and updated her with our correct fax number and requested she fax updates to our facility. R1's hospital Case Management Note dated 03/11/26 at 10:35 AM documents: the writer spoke with V1 from (facility name) to follow up regarding the patient's discharge and potential transportation arrangements. At this time, the facility is unable to provide a confirmed date or time for when they will be able to pick R1 up. The writer faxed updated clinical information to the facility to provide an update on the patient's current medical status and to assist with discharge coordination. The writer will continue to follow up with V1 at (facility name) regarding transportation arrangements and discharge planning. R1's Progress Note dated 03/11/26 at 4:05 PM documents: Late Entry: Note Text: (V17) with (hospital name) called to follow up with us on the updated records she sent us earlier this AM. She requested to speak with ADM (V1/Administrator), explained she was already gone for the day and asked if I could help her with anything. She explained she was wanting to get transportation set up for (R1) to return to our facility. I explained that we did receive records earlier in the day and I was aware of a few questions that Administrator (V1) had; she is requesting information on when restraints were removed (date) and if (R1) was being compliant with taking her medication. (V17) informed me that the restraints had been off for a few days. I requested we be sent documentation on the date this took place along with how she has responded since. As far as her taking her medication (V17) informed me that (R1) 1. 'told them she was ready to go back to her facility.' 2. She was 'not doing what they wanted until they put her back in her wheelchair and sent her back to her facility.' I clarified with (V17) that (R1) verbally told them these things to which she again replied 'Yes.' I informed (V17) that (R1) was non-verbal at this point. (V17) stated well, 'she wrote this out for the therapist' I requested she send our facility these notes along with the previously requested information and follow up with us in the AM once we had received the information and had time to review it, voiced understanding. R1's Progress Note dated 3/12/2026 at 3:29 PM documents: Called and spoke with V17 (Hospital Case Manager), at (hospital name) since she has not follow up with us yet today. Informed her we did receive the one note she sent this morning with the hand written message at time stating this shows date restraints were removed. I did question what kind of diet (R1) was currently receiving and how she was tolerating it. V17 reported a pureed thin diet and that she was tolerating it well. I requested a current weight and was given a weight of 168.0 pounds however was unable to provide a date of this weight. I also inquired if she still had a 1:1 sitter and was informed she did currently still have a sitter for her safety. I requested they supply us with behavior charting notes/documentation, stated they do not have anything like that. I requested nursing documentation and was told she could send safety notes. We scheduled a call between our two facilities for 03/13/2026 at 10:30 AM. R1's hospital Case Management Note dated 03/12/26 at 4:32 PM documents: the writer spoke with V2 (ADON) at (facility name) regarding R1 and discharge planning. V2 stated that the facility will need updated behavioral notes before making a decision about accepting the patient back. V2 also expressed concern that the hospital may be attempting to discharge the patient due to R1's stay being denied by the insurance company. V2 stated that the facility would like to have a phone meeting to further discuss R1's behaviors and discharge needs. The writer, along with the nurse, is scheduled to participate in the phone meeting with the facility tomorrow at 10:30 AM to further discuss R1's behavior and discharge planning. The writer will continue to follow up with the facility and care team regarding the outcome of the meeting and next steps. R1's hospital Case Management Note dated 03/13/26 documents: the writer contacted V1 at (facility name) in preparation for the scheduled meeting with the writer and the charge nurse to discuss R1's discharge planning and potential return to the facility. During the conversation, V1 expressed significant concerns regarding the patient's case and the documentation that had previously been faxed to the facility. V1 stated that she believed the clinical documentation that was faxed to the facility regarding R1's status was falsified. V1 communicated this concern in a confrontational and unprofessional manner during the call. The writer clarified that the documentation provided was based on the most recent clinical updates available in R1's medical record and was shared to assist with discharge planning and coordination of care. V1 further stated that (facility name) will not coordinate transportation for R1's return to the facility at this time. V1 indicated that the facility intends to consult with their legal team regarding R1's discharge and potential return to the facility before making any further arrangements. Additionally, V1 reported that the facility has reassigned R1's previous bed for use as an isolation room and stated that they currently do not have a bed available for R1. V1 also expressed concerns regarding R1's previous aggressive behaviors, which she stated contributed to the facility's decision not to hold the bed. The writer documented the conversation and will update the medical team regarding the facility's position and concerns. The writer will continue to collaborate with nursing staff, leadership, and the interdisciplinary team to determine appropriate next steps for discharge planning and potential alternative placement if necessary. The writer will continue to follow up. R1's medical record had no documentation of the facility participating in the 03/13/26 phone meeting with the hospital and although requested from V1, no reproducible evidence of this phone meeting was provided during the course of the investigation. R1's hospital Case Management Note dated 03/16/26 at 11:05 AM documents: spoke with V1 and she stated that the patient is still aggressive and medication regime has not [sic] successful based on the documentation. V1 further stated that R1's room is not available due to another patient is on isolation, the person will not be out of the room until about the 19th. V1 requested that we find alternative placement in (name of city approximately 5 hours away) for the patient (R1). Explained that we would need to get approval from the POA (V16) otherwise R1 would need to return to the nursing home facility. R1's hospital Case Management Note dated 3/19/26 at 9:50 AM documents: the writer contacted (V16), the patient's POA to discuss ongoing discharge planning and current barriers to placement. V16 was informed that R1 is unable to return to the previous nursing home due to behavioral concerns. The writer provided an update regarding R1's aggressive behaviors, which have impacted placement options. V16 verbalized understanding of the situation and acknowledged the challenges associated with securing an appropriate facility given R1's current presentation and care needs. The writer discussed the importance of identifying a safe and suitable discharge plan that aligns with R1's medical and behavioral needs. The writer will continue to collaborate with attending physician and interdisciplinary team to explore alternative placement options. The writer will also maintain ongoing communication with V16 to provide updates and involve her in discharge planning decisions. The writer will continue to follow up with (V16) and support coordination efforts to ensure a safe and appropriate discharge disposition. R1's Progress Note dated 03/19/26 at 9:58 AM documents V16 (Family) called at this time and stated resident will not be coming back to facility and that she would be coming to get her belongings. V2 (ADON) and V1 (Administrator) notified. (R1's) medication returned to pharmacy and narcotics destroyed per 2 nurses. Follow-up progress note dated 3/19/26 at 10:58 AM documents (V16) came and got R1's belongings. R1's hospital Case Management Note dated 3/19/26 at 3:22 PM documents: The writer spoke with (V16) to discuss alternative placement options. (V16) was informed of the current barriers to placement and expressed interest in identifying facilities closer to family for additional support. The writer faxed referrals to (name of 3 facilities in V16's local area) to assist with discharge planning. The writer will continue to follow up with the facilities regarding referral status and collaborate with (V16) to ensure an appropriate and safe discharge placement. R1's hospital Case Management Note dated 3/23/26 at 12:07 PM documents: The writer spoke with (V16) regarding discharge planning and placement status. T

Based on interview, observation, and record review the facility failed to provide enough staff to perform care duties timely. This failure has the potential to affect all 49 residents residing at the facility.Findings include:On 04/27/26 at 11:27 AM, R14 stated previously it was only the night shift that had attitudes or was rude, but lately it is more of the staff. R14 stated, they will tell him, they do not have time to do whatever he has asked. Resident was alert and oriented at time of interview.On 04/27/26 at 1:50 PM, R10 stated the staff can be snippy and rude, especially on the weekend. R10 stated, maybe the staff are rude because they are running and don't have enough of them to get things done. Resident was alert and oriented at time of interview.On 04/28/26 at 12:03 PM, V8 (Certified Nursing Assistant/CNA) stated they start showers usually after breakfast but sometimes someone will be up at 6:00 AM or 6:30 AM and they can get a shower in before breakfast. V8 stated, it takes approximately 20 minutes to give a shower for most, a little less or a little more for some residents. V8 stated, they clean the shower between residents. V8 stated, it can make it challenging with other CNA duties to get the showers done especially with one shower room. V8 stated, sometimes they run a little behind because of something happening and residents will refuse their shower because they don't want to take it later.On 04/30/26 at 12:20 PM, R15 stated the other day they only had two CNAs and they did not have time to pass snacks, water or ice. R15 stated, there were a few residents that got their own ice out of the cooler but she did not because she knows their hands were not clean. R15 stated, sometimes they have run out of bed pads and wash cloths due to laundry getting behind. Resident was alert and oriented at time of interview.On 04/29/26 at 2:28 PM, R16 stated the weekend staff are probably the lowest staffed and they can get impatient with the residents because they are getting pulled in so many different ways. R16 stated, she believes the staff are disgruntled because they are working short that they take it out on the residents. Resident was alert and oriented at time of interview.On 05/03/26 at 6:17 PM, R10 stated they do not always get snacks because they are too low on snacks or they do not have enough staff to pass snacks and water. Resident was alert and oriented at time of interview.On 05/03/26 at 6:51 PM, V10 (CNA) stated there have been shifts lately that they did not have time to pass snacks, ice, or get all the showers completed because they did not have enough time.On 05/03/26 at 7:10 PM, R27 stated, sometimes it takes them longer than other times to answer his call light and sometimes it is a long time. Resident was alert and oriented at time of interview.On 05/07/26 at 6:44 AM, V28 (CNA) stated he has not been able to get the expected duties done several times due to not having enough staff.On 05/04/26 at 7:55 AM, V30 (Housekeeping) stated, the men's bathroom on the 300 hall does have odors. The men tend to miss the toilet and they will have to mop it up several times a day. V30 stated, if the urine does not get mopped up frequently it soaks into the tiles. V30 stated, the weekend housekeeping staff leave at 2:00 PM so then it is up to the CNAs to mop it up when they see it and have time.On 04/28/26 at 1:24 PM, R8 stated the CNAs all can have attitudes and be rude, she feels like it is because they are short staffed. R8 stated, they had two CNAs last night and she believes Wednesday and Sunday. Resident was alert and oriented at time of interview.On 05/03/26 at 7:10 PM, R28 stated, sometimes the staff are worse than other times about paying attention to his call light. R28 stated, today (05/03/26) and yesterday (05/02/26) after breakfast he turned on his call light to go to the bathroom and pooped his bed because the staff didn't get there in time. R28 stated, sometimes it takes them an hour to get there. R28 stated, he doesn't like to poop in his bed. Resident was alert and oriented at time of interview.On 05/03/26 at 7:10 PM, R28 stated there are times the staff forget to or don't have time to bring him an evening snack. Resident was alert and oriented at time of interview.On 05/12/26 at 12:28 PM, V1 (Administrator) stated, her expectation for a reasonable time a resident should wait for a call light to be answered in would be within 20 minutes.On 5/6/26 at 9:05am, V23 (Housekeeping Supervisor) said they cannot find anyone who wants to work in the laundry on Saturday and Sunday evening shift. V23 said the facility has a lack of laundry staff and the CNAs are expected to help out when no housekeeping or laundry staff are scheduled. V23 verified the facility does not have a laundry aide after the dayshift on Saturdays or Sundays. V23 said without the weekend staff, laundry doesn't get done in a very timely manner due to the lack of staff.On 05/12/26 at 12:28 PM, V1 stated her expectation of the CNAs are for the residents to be cared for and their needs met. V1 stated, some of these needs would include: assist residents with meals, pass trays, assist with ADLs (Activities of Daily Living), toilet resident, assist with transfers, changing residents, answering call lights, showers, passing snacks and water, the two 40 minute smoke breaks would alternate between CNAs and housekeeping if housekeeping are working. V1 stated, when there are not any housekeeping or laundry staff working then CNAs would clean the bathrooms and do any laundry if anything is running low. V1 stated, her expectation with approximately 49 residents they would need about 4 CNAs to 4.5 CNAs sometimes.Resident council minutes dated 05/07/26 at 10:06 AM documents: staff have bad attitudes towards residents and each other and residents feel as if some residents get more attention and care than others, leaving some residents wet for long periods of time, they are also leaving beds unmade and residents are laying on bare mattresses.The facility schedule dated 04/19/26-05/02/26 and payroll date in and out report documents on 04/25, 04/26, 04/27, 05/01, and 05/04 there were only two CNAs working the 2:00 PM -10:00 PM shift.The facility's Room Roster dated 4/27/26 documents a total of 49 residents currently reside at this facility.A facility policy titled Nurse Staffing (non-dated) documented in part: It is the policy of (facility name) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychological well-being of each resident.

Based on interview, observation and record review the facility failed to discontinue using the kitchen for food preparation during a sewage backup affecting the kitchen. This failure has the ability to affect all 49 residents residing in the facility.Findings include:On 05/04/26 at 2:48 PM, V24 (Dietary Manager) stated he was at the facility the day the sewer water was coming into the facility. V24 stated, the sewer water started coming in around 9:00 AM and the plumbers were called in. V24 stated, they were able to get the problem fixed at approximately 2:30 PM. V24 stated, the sewer water came up through the floor drains and accumulated as standing water about three feet out around the floor drains in the kitchen. V28 stated, he received a text at approximately 2:30 PM they were able to fix the problem with the sewage water but the staff was falling behind preparing dinner so he came in and cleaned and sanitized the floor.On 05/04/26 at 2:48 PM the floor drain by the dish machine was about 2.5 feet from the dish machine, the floor drain in front of the bathroom was off the left side of the kitchen area, and the drain in front of the cooler and freezer is in the main area of the kitchen and to get to the stove, oven and steamtable you need to walk with in approximately three feet of the floor drain.On 05/06/26 at 2:14 PM, V25 (Plumber) stated they came to the facility and was unable to unstop the drain. V25 stated, the kitchen area was backing up and other areas in the facility.The Plumbing work order/Invoice dated 04/17/26 documents description of work: camera and jet sewer pipes backing up.On 05/07/26 at 1:52 PM, V24 stated they did prepare and serve lunch and prepare dinner when there was sewage water in the kitchen. V24 stated, he was not told what the appropriate procedure was until after the day they had sewage water in the kitchen. V24 stated, he should not have prepared or served any food in the kitchen when there was sewage water in the kitchen and he should have served cold sandwiches out of a different room such as the breakroom.The facility's Room Roster dated 4/27/26 documents a total of 49 residents currently reside at this facility.The undated facility policy titled, Sanitation of Dining and Food Service Areas documents: the dining services staff will uphold sanitation of the dining areas according to a thorough, written schedule. 7. If indicated, additional infection control procedures should be followed for disinfecting high touch-point areas. It is recommended to use an approved disinfectant solution allowing for minimum contact time.The [NAME] County Food Sanitation Ordinance signed and approved on 7/17/2018 documents in part: Imminent health hazards and food protection: In the event of a fire, flood (including sewage backup), power outage, misuse of poisonous or toxic materials, foodborne illness outbreak, or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the permit holder or person in charge shall cease operations and contact the Health Department. Upon receiving notice of this occurrence, the Health Department shall take whatever action it deems necessary to protect the public health. If operations are ceased, the establishment must get approval from the Health Department to reopen. A permit holder is not required to discontinue operations in an area of the establishment that in unaffected by the imminent health hazard.

Based on interview, observation and record review the facility failed to treat residents with dignity, respond to residents quickly, and speak to residents respectively for 14 (R4, R5, R6, R8, R10, R13, R14, R16, R17, R23, R26, R28, R29, R32) of 14 residents reviewed for dignity in a sample of 32.Findings include:1. On 04/30/26 at 10:55 AM there was a puddle of urine under R26's chair. The puddle was over 12 inches by 7 inches, R26 was sitting at a table in the center of the dining room. At 11:23 PM the puddle was bigger approximately 14 inches by 9 inches and R26's shorts were visibly wet. At 11:40 AM V26 (Social Services Director) gave R26 hand sanitizer and walked right by the puddle of urine under his chair. At 12:05 PM R26 was still sitting in the dining room with the puddle under him. During this time, several staff walked by R26 bringing residents into the dining room and delivering food trays.On 05/04/26 at 7:35 AM there was a puddle of urine under R26's chair in the dining room, the puddle was approximately 12 inches by 6 inches. At 8:15 AM R26 left the dining room with his walker, his soaked feet stepped in the puddle while he was getting up and R26 made wet footprints down the hall. While R26 was walking down the hall V9 (CNA) stated to R26, lets go to the bathroom down here, and R26 followed.On 05/06/26 at 7:20 AM R26 was sitting at a table in the center of the dining room, there was a large puddle of urine under R26's chair in the dining room. R26 was eating breakfast. The puddle was over twelve inches in length and approximately five inches wide. Between 7:50 AM and 8:10 AM V9 (CNA) walked by R26 several times, at 8:10 AM R26 got up and left the dining room with his walker and left wet footprints out of the dining room and down the hallway.On 05/07/26 at 1:30 PM, R26 was asked if it bothered him if they left him wet in the dining room. R26 looked down and looked embarrassed and stated, he knows, he doesn't mean to. Resident was alert and oriented at time of interview.On 05/12/26 at 12:28 PM, V1 (Administrator) stated her expectation is if a resident is viably wet in the dining room or any other place in the facility, they would be taken out and the resident cleaned and changed and brought back to the dining room or wherever in the facility. V1 stated her expectations would be for residents to be changed before and after meals. V1 stated, if it was overnight her expectation would be for the CNAs to make rounds and when they finish the rounds the CNAs would start the rounds over again.2. On 05/04/26 at 12:07 PM, V11 (CNA) was heard telling R23, Well if you're going to cuss in here you are going to have to leave surveyor was standing less than two foot away from R23 and did not hear R23 cuss at anyone.On 05/07/26 at 1:36 PM, R23 stated, Yeah when asked if they tell him he has to leave the dining room if he cusses, even if it is not very loud. R23 stated, Sometimes when asked if he felt staff didn't talk to him very nice. Resident was alert and oriented at time of interview.On 05/12/26 at 12:28 PM V1 stated, if a resident cussed in the dining room and it was not disruptive, she would expect the staff to find out what the problem was and hopefully be able to address what is bothering the resident and resolve the concern then. V1 stated, she would not expect the resident to be told they would have to leave the dining room.3. On 05/03/26 at 7:10 PM R28 stated, sometimes the staff are worse than other times about paying attention to his call light. R28 stated, today (05/03/26) and yesterday (05/02/26) after breakfast he turned on his call light to go to the bathroom and pooped his bed because the staff didn't get there in time. R28 stated, sometimes it takes them an hour to get there. R28 stated, he doesn't like to poop in his bed. Resident was alert and oriented at time of interview.On 05/12/26 at 12:28 PM, V1 (Administrator) stated, her expectation for a reasonable time a resident should wait or a call light to be answered in would be within 20 minutes.4. On 04/27/26 at 10:50 AM, R6 stated the staff in the early mornings and evenings can be short and snipy sometimes. Resident was alert and oriented at time of interview.On 04/27/26 at 11:09 AM, R5 stated the evening staff can be snipy, snappy and impatient at times, like they do not want to be there. Resident was alert and oriented at time of interview.On 04/27/26 at 11:10 AM, R4 stated staff in general can be snipy with the residents. Resident was alert and oriented at time of interview.On 04/27/26 at 11:27 AM, R14 stated previously it was only the night shift that had attitudes or were rude, but lately it is more of the staff. R14 stated, they will tell him, they do not have time to do whatever he has asked. R14 stated, the staff can be rude, unkind, to almost hateful sometimes. Resident was alert and oriented at time of interview.On 04/27/26 at 1:50 PM, R10 stated the staff can be snippy and rude, especially on the weekend. R10 stated maybe the staff are rude because they are running and don't have enough of them to get things done. Resident was alert and oriented at time of interview.On 04/28/26 at 10:37 AM, R17 stated at times the staff can have attitudes and be rude, he is not sure if it is any shift in particular anymore. R17 stated, sometimes the residents may say something and the staff will just be rude back to them. R17 stated, he has heard the staff tell the residents to shut up before. Resident was alert and oriented at time of interview.On 04/29/26 at 2:28 PM, R16 stated the weekend staff are probably the lowest staffed and they can get impatient with the residents because they are getting pulled in so many different ways. R16 stated she believes the staff are disgruntled because they are working short that they take it out on the residents. Resident was alert and oriented at time of interview. On 04/30/26 at 2:18 PM R16 stated, some of the staff do give them attitudes and are rude to them, she feels bad for some of the other residents. Resident was alert and oriented at time of interview.On 04/28/26 at 1:24 PM, R8 stated the CNA's (Certified Nursing Assistants) all can have attitudes and be rude, she feels like it is because they are short staffed. R8 stated, they had two CNAs last night and she believes Wednesday and Sunday. Resident was alert and oriented at time of interview.On 04/29/26 at 3:00 PM, R13 stated, everyday staff are snipy, snappy, have attitudes, and have been rude to him. The staff will chastise him. Resident was alert and oriented at time of interview.On 05/04/26 at 2:23 PM, R14 stated the staff will snip at you if you ask a question. Resident was alert and oriented at time of interview.On 05/07/26 at 10:00 AM this surveyor attended a resident council meeting with R4, R16, R29, R8 and R10. During this meeting residents stated CNAs attitudes are bad, they show favoritism.The resident council minutes dated 05/07/26 at 10:06 AM documents: staff have bad attitudes towards residents and each other and residents feel as if some residents get more attention and care than others, leaving some residents wet for long periods of time, they are also leaving beds unmade and residents are laying on bare mattresses.The resident council minutes dated 04/02/26 document: nursing: CNAs are cranky.The undated facility policy titled, Resident's Rights Policy documents: our most important goal is to provide the highest standard of care to our residents in an environment safe, secure and free of clutter. All employees of (Name of Facility) are expected to treat all residents, their family members, co-workers and visitors with the utmost respect, kindness and professionalism at all times. In addition, all staff are reminded that every employee has a responsibility to answer a call light when a resident requires assistance. Employees that fail to provide superior care will be subject to corrective action, up to and including termination of employment. Resident's Rights: The residents have certain fundamental rights guaranteed by law, including, but not limited to, the following: to live a dignified existence and engage in self-determination. The (facility name) expects that each employee's conduct and performance will conform with the highest standards of professionalism with respect to the treatment of all residents, visitors and their families and our ethical practices; the requirements of their job; published and common-sense health and safety rules; and applicable federal, state and local laws, rules and regulations.

Based on interview, observation, and record review the facility failed to provide working showers and toilets and failed to provide an environment free of sewage backup and odors for 17 (R4, R5, R10, R14, R16, R17, R18, R19, R21, R22, R23, R26, R27, R29, R30, R31, R32) of 17 residents reviewed for sanitary environment in a sample of 32.Findings include:1. On 04/27/26 at 11:09 AM, R5 stated they only have one shower that works so there are times you have to wait for the shower to be open. Resident was alert and oriented at time of interview.On 04/27/26 at 11:10 AM, R4 stated they only have one shower that works so sometimes you have to wait. Resident was alert and oriented at time of interview.On 04/27/26 at 11:17 AM the shower room on the 300 hall did not have a shower head on the shower.On 04/27/26 at 11:22 AM, V4 (Certified Nurse Aide/CNA) stated the showers on the 200 hall and the 300 hall do not work, only the shower on the 100 hall works. V4 stated, the other showers have not worked for months.On 04/27/26 at 11:23 AM, V5 (CNA) stated the showers on the 200 and 300 halls do not work, only the shower on the 100 hall works. V5 stated, the other showers, besides the 100 hall, have not worked for months.On 04/27/26 at 11:27 AM, R14 stated they only have one shower that works. R14 stated he has refused showers lately because the CNAs have to do almost back to back showers to get them done and there was still feces in the shower room when he went in so he was not going to shower in there. R14 stated another time he didn't want to shower at that exact minute so they just put refused. Resident was alert and oriented at time of interview.On 04/28/26 at 12:03 PM, V8 (CNA) stated it can make it challenging with other CNA duties to get the showers done especially with one shower room. V8 stated, sometimes they run a little behind because of something happening and residents will refuse their shower because they don't want to take it later.On 05/03/26 at 5:40 PM, V27 (Licensed Practical Nurse/LPN) stated, the only shower room that works is the 100 hall.On 05/03/26 at 6:51 PM, V10 (CNA) stated they only use the shower room on the 100 hall because the shower rooms on the 200 and 300 halls do not work.2. On 04/27/26 at 1:50 PM, R10 stated there are always urine and feces odors on both halls. Resident was alert and oriented at time of interview.On 05/03/26 at 5:45 PM the men's bathroom on the 300 hall had a distinct odor of urine and feces.On 05/03/26 at 8:28 PM the men's bathroom on the 300 hall had a distinct odor of urine and feces.On 05/04/26 at 7:40 AM the 100 hall hallway had a smell of urine.On 05/04/26 at 7:50 AM the men's bathroom on the 300 hall had a very strong smell of urine.On 05/04/26 at 7:50 AM, R5 stated the toilet on the 300 hall does not flush all the way, the solids don't want to go down. R5 stated, the toilet is always clogged up. Resident was alert and oriented at time of interview.On 05/04/26 at 7:53 AM the men's restroom on the 300 hall had a small amount of fecal matter in the bottom of the toilet, the toilet was flushed and the fecal matter did not flush down the toilet and the water rose to the inside rim of the toilet bowl.On 05/04/26 at 7:55 AM, V30 (Housekeeping) stated the men's bathroom on the 300 hall does have odors. The men tend to miss the toilet and they will have to mop it up several times a day. V30 stated, if the urine does not get mopped up frequently it soaks into the tiles. V30 stated, the weekend housekeeping staff leave at 2:00 PM so then it is up to the CNAs to mop it up when they see it and have time.On 05/07/26 at 10:00 AM during resident council, R32 stated, there are odors on some of the halls.On 05/07/26 at 10:00 AM during resident council residents stated, staff need to check residents more often because they are wet and have odors.The resident council minutes dated 05/07/26 at 10:06 AM document Housekeeping: They do a great job working hard to clean up; however, there are some residents who miss the toilets when using the restroom, therefore bathrooms need cleaned more frequently. Bad smells are lingering in halls and bathrooms, especially.3. On 05/04/26 at 7:55 AM, V30 stated there was sewage that backed up on the hall through the floor drains on 04/17/26. V30 stated, they sanitized everything after they got it fixed. On 05/06/26 at 8:17 AM, V30 stated, the 200 hall did have sewage up by the double doors. V30 stated, the sewage was coming up through the floor drains, V30 stated, the 100 hall was worse.On 05/04/26 at 2:23 PM, R14 stated, when the sewage was in the facility it was coming up through the floor drains and was on the floors in the bathrooms and the shower room. Resident was alert and oriented at time of interview.On 05/06/26 at 8:32 AM, V31 (Housekeeping) stated there was sewage water coming up through the floor drains and under the toilet in the first bathroom on the left side on the hall. V31 stated the sewage was about two feet out around the drains and from the toilet. V31 stated, sewage also came up through the drain in the shower room the sewage was about four foot out from the drain in the shower room. V31 stated, the water was a brown color and did have particulates in it. V31 stated, they put two blankets over the drains to soak up the water. V31 stated, after they got it fixed, they cleaned and sanitized all the areas.On 05/06/26 at 2:14 PM, V25 (Plumber) stated, they came to the facility and was unable to unstop the drain. V25 stated, the kitchen area was backing up and other areas in the facility. V25 stated, they were able to get the drains unclogged from the outside. They were able to go into the pipes from the south side of the building and went in approximately 40 feet and were able to fix the clog and get the pipes moving again.The Plumbing work order/Invoice dated 04/17/26 documents description of work: camera and jet sewer pipes backing up.The resident roster documents R4, R5, and R29 reside on the 300 hall and use the men's bathroom and R16, R17, R18, R19, R21, R22, R23, R26, R27, R30, and R31 reside on the 100 hall.The undated facility policy titled, Physical Plant & Environmental Policy & Guidelines documents: policy statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA (The National Fire Protection Association) codes. This includes making certain a safe and hospitable environment as possible is maintained in the event of an emergency for sheltering in place. policy implementation: the facility administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Maintenance/approved contractors; routine care and repairs to interior finishings -repairing ceiling/wall damage, painting, floor, general plumbing - drains, faucets, showers, are maintained. Housekeeping: routine daily room cleaning and sanitizing, routine daily cleaning of all common areas and dining areas, routine daily cleaning of all shower rooms and restrooms, monthly scheduled room deep cleaning and organizing, and monthly scheduled shower room deep cleaning.

Based on interview, observation and record review the facility failed to maintain free passage through exit doors in case of emergency procedures. This failure has the potential to affect the 31 residents residing on the 200 and 300 Halls.Findings include:On 04/27/26 at 11:09 AM, R5 stated sometimes they would put the blue towel cart in front of the door on the other hall (R5 indicated the south hall/200 hall) to prevent R19 from hitting the door alarm or going out the door. Resident was alert and oriented at time of interview.On 04/27/26 at 11:10 AM, R4 stated he has seen the blue towel cart in front of the far door (R4 indicated the south hall) to keep R19 from hitting the door alarm. Resident was alert and oriented at time of interview.On 04/27/26 at 1:50 AM, R10 stated she has observed the linen tower in front of the door on the 200 hall. R10 stated, she believes they put it there to keep R19 from getting out. Resident was alert and oriented at time of interview.On 04/29/26 at 9:30 AM there was a plant cart in front of the exit door on the 300 hall, at 11:20 AM the plant cart was still in front of the door, at 2:07 PM the plant cart was still in front of the door, at 3:10 PM the plant cart was still in front of the door.On 04/29/26 at 2:28 PM, R16 stated she has seen the staff put the blue linen cart in front of the exit door on the 200 hall at night, she believes it is due to R19 hitting the door alarm and setting it off several times during the evening. Resident was alert and oriented at time of interview.On 04/28/26 at 1:24 PM, R8 stated she has seen the linen cart in front of the door on the 200 hall because of R19. Resident was alert and oriented at time of interview.On 04/30/26 at 12:20 PM R15 stated, she has seen the blue linen cart in front of the exit door on the 200 hall. R15 stated, she believes they do that because R19 will keep hitting the door alarm and [NAME] to get outside. Resident was alert and oriented at time of interview.On 04/30/26 at 1:30 PM, V1 (Administrator) stated there should not be anything in front of any of the exit doors.The facility's Room Roster dated 4/27/26 documents there are 22 residents living on the 200 hall and 9 residents living on the 300 hall.The undated facility policy titled, Physical Plant & Environmental Policy & Guidelines documents: policy statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA (The National Fire Protection Association) codes. This includes making certain a safe and hospitable environment as possible is maintained in the event of an emergency for sheltering in place. Policy implementation: the facility administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff.

Based on interview, observation, and record review the facility failed to provide food at a palatable temperature for 5 (R10, R13, R14, R30, R31) of 5 residents reviewed for cold food in a sample of 32.Findings include:On 05/03/26 at 6:17 PM, R10 stated the food is cold frequently. Resident was alert and oriented at time of interview.On 05/04/26 at 7:15 AM a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. The week at a glance documents breakfast day 9: assorted juice, choice of cereal, western egg bake, toast, margarine/jelly, milk and hot beverage.On 05/04/26 at 7:27 AM R10 received her breakfast in her room. R10's breakfast was 2 pieces of toast, 1 sausage patty, a bowl of dry cereal, a glass of milk and coffee. R10 stated, her sausage was cold, she was not eating it. R10 told surveyor to take the temperature of the sausage and tell her if it was considered cold. The temperature of the sausage patty was 86.0 degrees Fahrenheit. R10 stated her milk is warm so she does not want to use it for her cereal either, her milk was 51 degrees Fahrenheit. R10 stated, the coffee is not hot either but she will drink it. Resident was alert and oriented at time of interview.On 05/04/26 at 8:50 AM, V24 (Dietary Manager) stated they had to change the menu this morning to sausage, cereal, and toast.The week at a glance documents lunch day 9: beef pepper steak, mashed potatoes, steamed vegetables, fresh baked cookies, and a beverage.On 05/04/26 at 11:55 AM a refused tray by a resident was obtained by this surveyor, it contained a hamburger, mashed potatoes, and mixed vegetables of carrots, peas, and corn. The temperature of the hamburger was 105 degrees Fahrenheit (F), the mashed potatoes were 107 degrees F, and the vegetable was 111 degrees F.On 05/04/26 at 12:50 PM, V4 (Certified Nurse Aide /CNA) stated, the substitute today was a hamburger.On 05/04/26 at 2:19 PM, R30 stated sometimes the food is barely warm. Resident was alert and oriented at time of interview.On 05/04/26 at 2:23 PM, R14 stated the food is cold frequently. Resident was alert and oriented at time of interview.On 05/04/26 at 2:26 PM, R31 stated when he receives food that is cold, he sends it back. Resident was alert and oriented at time of interview.On 05/06/26 at 7:05 AM a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. The week at a glance breakfast day 10 documents: assorted juice, choice of cereal, bacon, French toast casserole, syrup, milk, and a hot beverage.On 05/06/26 at 7:10 AM R10 refused her breakfast plate. R10 stated, she has told them several times she does not like the eggs and they are probably cold. R10 stated, she will just eat the cold cereal. The eggs temperature was measured, the scrambled eggs were 103 degrees F. The eggs tasted cold. Resident was alert and oriented at time of interview.On 05/05/26 at 8:22 AM, V5 (CNA) stated, they had to switch the breakfast days and today was eggs, toast and cereal.The week at a glance lunch day 10 documents: sweet & sour pork, white rice, broccoli, egg roll, gelatin with whipped topping, and a beverage.On 05/06/26 at 12:02 PM, R13 received and refused his lunch tray. The food on the tray had the temperature measured, the broccoli was 97.2 degrees Fahrenheit (F), the rice was 113.5 degrees F, and the pork was 109.1 degrees F. The food tasted cold.On 05/07/26 at 6:44 AM, V28 (CNA) stated residents have complained to the CNAs about the food being cold.On 05/07/26 at 1:52 PM, V24 stated the residents should receive the food at approximately 135 degrees F if it is hot food items.The resident council minutes dated 05/07/26 at 10:06 AM document: food arrives cold, particularly on the hall.The food committee meeting minutes dated 05/07/26 documents under the heading: complaints/concerns: cold food.The undated policy titled, Food & Beverage Temperature Control documents: eggs should be cooked to 145 degrees Fahrenheit (F) if served immediately, to 155 degrees F for eggs held for service, and egg dishes are cooked to 160 degrees F. Hot foods are served at 135 degrees or higher and cold foods/beverages are served at 41 degrees or lower. Hot beverages such as coffee, hot tea, hot cocoa, and soups ideal service temperatures between 145 - 155 degrees F.

Based on interview and record review the facility failed to provide bed hold policy before/upon transfer from the facility for one (R1) of three residents reviewed for discharge process in the sample of 32.Findings include:On 04/27/26 at 3:44 PM, V6 (Ombudsman) stated the Ombudsman's office has not received any bed hold or transfer/discharge paperwork for R1 or R2 from (facility name).On 04/30/26 at 10:46 AM, V16 (Family-Power of Attorney/POA) stated she has never received any documents concerning R1's discharge or bed hold information.On 04/29/26 at 1:20 PM, V1 (Administrator) stated they did not send any paperwork to the Office of the Ombudsman and she is unaware if any paperwork was sent to V16.The Notice of Transfer and Discharge policy 08/14/17 documents: prior to discharge or transfer the facility will: notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility will send a copy of the notice to a representative of the office of the State Long-Term Care Ombudsman.

Based on interview, observation, and record review, the facility failed to implement care plan fall interventions for 3 (R2, R4, and R13) of 5 residents reviewed for accidents in a sample of 46. This failure resulted in R2 being sent to the hospital after a fall and diagnosed with a closed fracture of left orbit and closed fracture of left side maxilla. The findings include:1. R2's admission record documents an admission date of 11/06/25 with diagnoses of Parkinson's disease, vitamin d deficiency, muscle wasting and atrophy, lack of coordination, dementia, and need for assistance with personal care.R2's MDS (Minimum Data Set) dated 02/13/26 documents in Section C a BIMS (Brief Interview for Mental Status) score of 13 which indicates R2 is cognitively intact. Section GG documents toileting and toileting transfer as dependent. Chair/bed to chair transfer as partial/moderate assistance. Section J documents has the resident had any falls since admission/entry or reentry or the prior assessment as yes. Number of falls since admission or prior assessment -no injury documents two or more. Injury (except major) documents two or more.R2's Care plan has a focus area of: I've had a recent fall that has caused a brain bleed with a date initiated of 11/24/25 with interventions of 1. administer medications per Dr. (Doctor) order. 2. Assess neurological status per facility policy and PRN. 3. Monitor for headaches, nausea, and vomiting and PEARL (Pupils, Equal, and Reactive to Light) 4. Monitor for pain per facility policy and PRN (as needed). 5. Monitor for seizures activity. Notify Dr. of any activity. 6. Monitor vital signs per facility policy and PRN. R2's Care plan has another focus area of: Risk for falls with interventions of 1. 01/16/26 Fall intervention updated to include assist resident to/from all destinations with staff attending needs before exiting. Staff to leave call light within reach. 2. 01/02/25 Fall Intervention updated to include encourage the resident to ask for help when he needs something picked up off the floor. 3. 01/2/26 Fall intervention updated to include educate resident on asking staff for assist with transfers. 4. 1/21/26 Fall Intervention updated to include new wheelchair with adjusted height for legs. 5. 01/27/26 Fall Intervention updated to include personal items within reach. 6. 01/28/26 Fall Intervention updated to include all personal items be within reach and at eye level. 7. 11/10/25 Fall intervention updated to include frequent checks when in bed. 8. 11/14/25 Fall intervention updated to include call light wrapped with yellow tape as visual reminder to ask for assist. 9. 11/24/25 Fall intervention updated to include move closer to nurse's station. 10. 12/13/25 Fall Intervention updated to include verbal reminder to use call light and wait for staff assist. 11. 12/13/25 Fall Intervention updated to include ensure bed is kept in lowest position. 12. 12/23/25 Fall Intervention updated to include 15-minute checks. (R2) continues to be seen by PT (Physical Therapy)/OT (Occupational Therapy) and a Call, don't fall sign placed in room. 13. 12/30/25 Fall intervention updated to include Call Don't fall sign place in room. 14. 02/10/26 Fall intervention updated to include continue antibiotic therapy for urinary symptoms. 15. 02/14/26 Fall Intervention updated to include PT/OT to evaluate and off frequent position changes. 16. 02/15/26 Fall intervention updated to include assist resident with transfers, utilizing therapy recommendations. 17. 02/17/26 Fall intervention updated to include activity director to assess for independent activities. 18. 02/19/26 Fall intervention updated to include to remind staff that AROM (active range of motion) can be performed PRN when (R2) wants to exercise. 19. 02/24/26 Fall Intervention updated to include snacks moved within reach of (R2). 20. 02/28/26 Fall Intervention move resident into room closer to the nurse's station to allow staff to better observed resident. 21. 02/07/26 Fall Intervention updated to include continue to monitor for abnormal behavior. Notify Dr. of change in behavior. 22. 02/07/26 Fall intervention updated to include encourage water intake and continue safety checks. 23. 03/30/26 Fall intervention updated to include grippy socks/proper footwear at all times. 24. 04/03/26 Fall intervention update to include med review. 25. 04/05/26 Fall Intervention updated to include activities to reassess resident interests and provide individual engagement (TV (television), music, structed activities) to reduce boredom, confusion and misperception-related behaviors, promoting safety. 26. 04/05/26 Fall intervention updated to include schedule telehealth with (Psychiatrist). 27. Ensure call light is available to resident. 28. Evaluate fall risk on admission and PRN. 28. Fall intervention updated for activities to reassess for interest, TV, music to provide when in room. 29. Fall Intervention updated to include Flomax time change to HS (Night) to help decrease urge to void. 30. Fall intervention updated to include monitor for s/sxs (signs and symptoms) of Delirium and notify MD (Medical Doctor). 31. If fall occurs, alert provider. 32. If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. R2's fall investigation dated 01/01/26 at 3:30PM documents under incident description: Nursing Description- This nurse was walking up the hallway when this nurse observed the resident drop an item onto the floor on the south hallway before this nurse could help the resident. The resident leaned forward to pick up the item and fell onto hand and knee. This resident did not hit his head. This nurse began to assess the resident and found no injuries. The resident did not have any complaints of pain ROM (range of motion) WNL (within normal limits). Resident description- I dropped something and was trying to pick it up. Immediate action taken. Intervention- Encourage the resident to ask for help when he needs something picked up off the floor. R2's fall investigation dated 01/02/26 at 10:30PM documents under incident description: Nursing description- This nurse and CNA (Certified Nurse Assistant) were walking past resident room and noted resident on floor. Upon entering room, resident noted laying on right side on floor at foot of bed with head towards door, facing the head of bed. Resident stated he was getting out of bed when he slid. Gripper socks on, blanket noted on floor on the side he stated he got out of bed on. Resident stated he hit his right knee and right elbow on the floor. Denies any pain at current time. No apparent injuries noted. ROM WNL Neuros WNL resident assisted to bed x 2 assist per resident request. 1:1 with resident about using the call light for assist with transfers. Resident stated he forgot to use call light. Call light clipped to shirt, resident stated, thank you, I think that will help me remember. Resident description- I slid when I was getting out of bed. Immediate action taken - resident assessed, assisted back to bed, 1:1 done with resident about asking for assist with transfers. Call light clipped to shirt rather than blanket. R2's fall investigation dated 01/15/26 at 12:30PM documents under incident description: Nursing description- CNA was walking by residents' room and observed him leaning forward out of wheelchair. Resident then dropped to knees and began crawling towards bed. CNA called for nurse and this nurse, and CNA assisted resident into bed for assessment. No injuries noted. Resident description- Resident unable to give description. Immediate action taken- resident assisted into bed and assessed for injuries. No injuries noted. Resident encouraged to use call light when needing assistance and stated, That's what i was trying to do. R2's fall investigation dated 01/20/26 at 3:30PM documents under incident description: Nursing description- This nurse was made aware by the MDS coordinator of the resident's fall. This nurse was not present for the resident's fall or when he was assisted back into his wheelchair. MDS coordinator stated that she was in dining room when resident was wheeling himself forward when he slowly started to lean forward and lightly fall out of wheelchair and onto his knees. Resident description- Resident unable to give description. Immediate action taken- This nurse was made aware and this nurse then requested a full set of vitals, assessed for injuries, began a neurological assessment, and then contacted the MD and POA (Power of Attorney).R2's fall investigation dated 01/26/26 at 5:20PM documents under incident description: Nursing description- This nurse was alerted by CNA that the resident was lying on the floor in his bedroom. This nurse immediately went to assess the resident and found the resident lying on his right side on the floor in the resident bedroom doorway. The resident was previously in the wheelchair. ROM WNL. Neuro checks initiated. The resident states that he did not hit his head and is not experiencing any pain. No evidence of head injury. No skin injuries observed at this time. Resident description- I was in my wheelchair trying to get my charger to plug my phone in. Immediate action taken- no intervention or action listed. R2's fall investigation dated 01/27/26 at 3:55PM documents incident description: Nursing description- This nurse was alerted by the resident that this resident (R2) was lying on the floor. This nurse went down to assess the resident, and the resident was up in the wheelchair. The resident stated that she saw the resident (R2) siting on the floor and watched the resident get back into the wheelchair. ROM WNL. No evidence of head injury. The resident declines hitting his head and declines any pain. No new skin injuries observed at this time. Resident description- The resident states that he was trying to get to his candy when his wheels on his wheelchair stopped and he fell forward landing on his knees. The resident states that he did not hit his head and he was not in any pain. Immediate action taken- intervention up at the nurse's station for monitoring. Review of R2's fall investigation dated 02/07/26 at 4:22AM documents incident description: Nursing description- This nurse was at nurses' station and heard someone down the hallway. Nurse looked and saw this resident standing outside of his door. Nurse got up to go to resident but could not get to resident fast enough. Resident fell to his left hitting the left side of his head on the door. Resident assessed. Denies pain, stated his head is a little sore. No red marks, bruising, open areas noted to left head. No apparent injuries noted. ROM WNL. Neuros WNL for resident. Wheelchair next to bed in res (resident) room. Resident assisted to wheelchair and brought to common area. Resident Description - I fell Immediate Action taken- Resident assisted to wheelchair and brought to common area. R2's fall investigation dated 02/07/26 at 6:10PM documents incident description: Nursing description- This nurse was in restroom when this nurse was made aware by nurse AM that resident was found on the floor on his knees beside the nurses' station closest to the exit. R2 stated he was trying to pull out the tubing to his catheter bag CNA's assisted resident up to his feet where they put him back in his bed. Resident description- resident unable to give description. Immediate action taken- This nurse ensured resident was helped safely to his room and placed in bed where she the instructed CNA to obtain vital signs and the nurse then began a neuro check. Following the initial neurological check, this nurse contacted the on-call provider at 1815 (6:15PM) where she instructed just to keep a close eye, continue neurological checks, and notify immediately of any changes. R2's fall investigation dated 02/14/26 at 11:30PM documents incident description: Nursing Description- Nurse at nurse's station, heard someone yelling help down south hall. This resident noted on hands and knees on floor with w/c (wheelchair) behind him in front of his door. denies pain. ROM WNL. Neuro WNL. No apparent injuries noted. Resident description- I fell out of my wheelchair 1:1 with resident to use call light if he needs anything, resident states understanding. R2's fall investigation dated 02/16/26 at 8:35PM documents incident description: Nursing description- This nurse was walking up north hall towards the nurse's station when this nurse observed the resident leaning forward with feet pulled up into the base of the wheelchair and fell onto his knees. The resident did not hit his head. The resident denies any pain. ROM WNL. No skin injuries. Resident description- I fell forward Immediate action taken- Intervention placed at nurses' station for monitoring. R2's fall investigation dated 02/19/26 at 12:10AM documents incident description: Nursing Description- Nurse heard noise down south hall. When investigating, this resident was noted on hands and knees on floor in front of his wheelchair in front of bathroom door in his room with a cup in the floor in front of him. Nurse asked resident what he was doing, resident states he needs to exercise. resident assessed, no apparent injuries noted. Denies pain. ROM WNL. Neuro checks WNL. While waiting on CNA to assist with getting resident up, resident got himself off of the floor and into wheelchair. Nurse SBA (stand by assisted), tried to encourage resident to wait for help. Resident declined to wait for assist. 1:1 with resident reminding him it is just after midnight, and everyone is sleeping. Resident agreed to go back to bed and wait until morning to exercise. Resident assisted to bed with 1A (one assist) CNA, call light in reach. No further needs at this time. Resident Description- I was going to exercise out there. Review of R2's fall investigation dated 02/22/26 at 9:45PM documents incident description: Nursing Description- This nurse was sitting at the nurses' station when this nurse observed the resident propelling himself up the hallway in his wheelchair when he was leaning forward and fell out of his wheelchair onto his knees. The resident did not hit his head. No skin injuries observed. ROM WNL. Resident description- I fell Immediate action taken- Intervention placed at the nurses' station for monitoring. Review of R2's fall investigation dated 02/23/26 at 10:30PM documents incident description: Nursing description- bright red blood noted on resident floor, resident lying on his bed. Had been propelling himself in the hallway in his wheelchair on his way to his room, asked resident what happened, resident reports he fell forward out of his wheelchair and hit the floor. Bright red blood noted to chin area. No other injuries apparent, alert to self. Resident description- I fell forward out of my chair and hit my chin on the floor. Some of my teeth broke off and I just got myself up and climbed in bed. Immediate action taken- [NAME] area cleansed, bleeding subsides, BP (blood Pressure) 137/77, P (Pulse) 80, R (respirations) 16, T (temperature) 97.7, SPO2 (oxygen saturation) 97% on RA (room air), approx. 2mm (millimeter) laceration noted to chin, unable to determine if any teeth are missing from fall due to dental condition. Resident jokes saying well at least the dentist won't have as many to deal with, since they are rotten this nurse unable to find any broken teeth in room. R2's fall investigation dated 02/28/26 at 3:10AM documents incident description: Nursing description- Nurse at nurse station, heard a noise down south hall. Upon entering this resident's room, resident noted lying on his right side on the right side of the bed with head towards the bed, feet towards the door. Drink spilled on floor behind him, w/c (wheelchair) in front of him. Resident states, I was trying to get up to find you guys and I fell. Neuro checks WNL. ROM WNL. Denies pain. Denies slipping in drink, feet not wet. Resident description- I was trying to get up to find you guys and I fell. Immediate action taken- resident assisted back to bed per request. 1:1 related to using call light, frequent checks. R2's fall investigation dated 03/30/26 at 3:55AM documents incident description: Nursing description- This writer was called to residents' room by cnas who observed resident on floor beside bed. Resident reports he fell. Alert with usual confusion. No injuries noted. Denied hitting head. Resident has no footwear in place. assessed for injuries and assisted back in bed. grippy socks placed on resident at this time. Call light placed within reach. Neuro checks initiated. Resident description- resident unable to give description. Immediate action taken- assessed for injuries and assisted into bed. Grippy socks placed on resident. Neuro checks initiated. Review of R2's fall investigation dated 04/02/26 at 6:15AM documents incident description: Nursing description- CNA alerted this nurse resident was lying on floor next to his bed. Upon entering room resident lying on right side of bed on his stomach with head turned to the left side towards the bed. Resident description- Res. states he dropped a piece of cookie on the ground and was trying to pick it up. Immediate action taken- assessed for any possible injuries. VS (vital signs) obtained. Neuro checks initiated. Assisted into bed. Call placed to 911. R2's fall investigation dated 04/04/26 at 8:55AM documents incident description: Nursing description: CNA was walking by room when she noted resident was not in his bed. CNA alerted nurse. Upon entering room resident noted on his left side under his bedside table on the left side of his bed. Resident states he did not mean to get out of bed. Resident denies hitting head, denies any pain. ROM WNL. No apparent injuries noted. Resident description- I didn't mean to get out of bed. I leaned over too far and went in the floor. Immediate action taken- 1:1 with resident on use of call light. HOB (Head of Bed) lowered, resident repositioned in bed. R2's progress note dated 03/30/26 at 4:21AM by V4 (Licensed Practical Nurse) documents This writer was called to residents' room, observed resident in floor beside bed. Resident reports he fell. Alert with usual confusion. No injuries noted. Resident has no footwear in place. Assessed for injuries and assisted back in bed. Grippy socks placed on resident at this time. Call light placed within reach. Neuro checks initiated. ADON (Assistant Director of Nursing), administrator, MD (medical doctor) and POA (power of attorney) notified. R2's progress note dated 03/30/26 at 6:47AM by V4 documents Resident has small amount of swelling noted to left cheek. Resident stated he couldn't remember if he hit his cheek during fall. POA called at this time and asked if she would like resident sent to hospital. She said only if resident has complaints of discomfort. Resident has no complaints at this time. Did report tooth discomfort and has several broken teeth which were like that prior to fall. Will continue to monitor and notify MD if swelling continues. Neuros continue WNL. R2's progress note dated 03/30/26 at 11:58AM (10:15) This nurse was alerted by CNA staff about the residents swelling/bruising. This nurse went down to assess the resident and found left sided facial and orbital swelling/bruising. Vital signs are as follows temp-97.3, RR (respiratory rate) 18, pulse 84, O2 97% on RA. and B/P 147/81. The resident states that he is experiencing head and neck pain. The resident is agreeable to be sent to the ER (emergency room) for further evaluation. (10:25) this nurse contacted (Local Ambulance) to have the resident transferred to (Local Hospital) (10:27) This nurse notified V1 of the resident being transferred to the ER. (10:30) this nurse attempted to contact (POA), no answer, unable to leave voicemail d/t (due to) mailbox being full. (10:35) MD was notified. (10:45) EMS (emergency medical services) arrived at the facility to transport the resident to (local Hospital) bed hold policy was sent. (10:53) This nurse called report into (Local Hospital emergency room). R2's progress note dated 03/31/26 5:23PM resident returned from hospital via ambulance with dx (diagnosis) of closed fracture of orbit. Resident very restless. New orders received and transcribed. R2's progress note dated 04/02/26 at 5:29PM CNA alerted nurse res was lying in floor next to his bed. Upon entering room, res lying on right side of bed on his stomach with head turned to the left side towards the bed. Resident reports he hit his head. Bruising r/t previous fall continues and is hard to tell if any new injuries are noted at this time. MD notified. New order: send to ER for eval and treat. POA notified. ADON here and aware of fall. EMS called and requested transfer to hospital for ground level fall. Awaiting EMS at this time.R2's progress note dated 04/02/26 at 9:53PM Spoke with (Local Hospital emergency room Nurse) at this time who stated while doing CT (Computed Tomography) scans, it did show old thoracic vertebrae fx,( fracture) that this is not new, but they do recommend spine surgery f/u. They have put in a referral. V2 and V1 aware.R2's local hospital emergency room records with a date of service of 03/30/26 documents under history of present illness facial trauma and periorbital swelling sustained facial injury after slipping and falling overnight/early morning on 03/30/26, struck L (left) face during the fall, swelling around the left eye, vision intact w/o (without) visual changes, no other visual changes and acute left sided neck pain mild left sided neck pain since fall, no shoulder pain, no difficulty moving arms. Clinical Impression documents closed fracture of let orbit and closed fracture of left side maxilla. fall encounter. R2's local hospital emergency room records with a date of service of 4/02/26 documents chief complaint fall. ED (emergency department) course documents 4/02/26 CT thoracic spine without contrast T4 spinous process fx (fracture) Pt. (patient) informed. Recommend spine surgery outpatient f/u (follow up). Clinical impression documents fall and head injury. On 04/12/26 at 9:03AM observed R2 door which was closed. Observed R2 lying in bed no staff observed in room. R2's call light out of reach of resident with no yellow tape wrapped around call light. On 04/13/26 at 10:22AM observed R2's call light which was out of reach of resident. No yellow tape wrapped around call light. Call light on top of nightstand on top of assistive devices. On 04/13/26 1:44PM observed R2's call light on nightstand on top of positioning device approximately 4 feet from where R2 was laying. R2 lying in bed. No yellow tape noted to call light. On 04/13/26 at 2:40PM observed R2's door closed and call light not in reach of resident and no yellow tape noted to call light. On 04/13/26 at 3:10PM observed R2's call light which was not in reach of resident who was lying in bed. Call light lying on nightstand on top of assistive device. No yellow tape observed on R2's call light. On 04/14/26 1:32PM observed R2's call light in reach of resident no yellow tape observed around R2's call light.On 04/15/26 at 1:02PM observed R2 wheeling himself in his wheelchair down the hallway back to his room no staff observed down the hallway or assisting R2 out of dining room. R2 was seen getting his front part of his wheelchair caught on the corner of his doorway. Observed R2 get out of his wheelchair with no staff in site re-adjust his wheelchair and then sit back in his wheelchair, but the wheelchair was still stuck on the doorway. R2 then couldn't get his wheelchair to move so he stood back up and got his right foot tangled in his catheter tubing and then began walking down the hallway pushing his wheelchair with an unsteady gait and right leg still tangled in catheter tubing. R2 pushed his wheelchair all the way to the end of the hallway and almost all the way back no staff was observed in site this whole time. At 1:10PM observed V16 (Housekeeper) yelling for staff to assist R2 who was still walking with unsteady gait behind wheelchair and tubing tangled around right leg. At 1:11PM 3 staff members observed coming to assist R2 back into wheelchair. On 04/15/26 at 1:15PM, V4 (Licensed Practical Nurse) V4 stated that R2 does have a lot of falls especially on midnight shift. V4 said that she works day shift and night shift often. V4 said they try to prevent R2 from falling but he just seems like a different person at night. V4 said that some nights if they are having a bad night that R2's 15-minute checks might not get done. V4 said that the staff are very good about trying to get them done, but there are some nights that are unpredictable, and the checks might not all get done. V4 said that she was working on 03/30/26 and she said R2 was found on the floor beside his bed. V4 said R2 said he didn't hit his face or head. V4 said that later she was checking on R2 and observed swelling and she let the nurse who was taking over for her know that R2 had some swelling and a little bruising to his face. V4 said that the nurse who took over for her sent R2 out and he had a facial fracture. V4 said that several days later R2 had another fall, and she noticed some bruising on R2 hip area and couldn't tell if it was new bruising from the current fall or from the old fall on 03/30/36 so she got orders to send R2 to the hospital. V4 said that R2 did come back from the hospital, and they told them that he had an old thoracic fracture and that he didn't have any new fractures. They didn't know when the thoracic fracture happened. V4 said that even after that fall R2 had another fall several days later. V4 said that they try to prevent R2 from falling as best as they can. On 04/15/26 at 1:26PM, V2 (Assistant Director Nursing) stated that she wasn't aware of any residents being on 15-minute checks currently. V2 stated that she feels like staff should be able to do 15-minute checks on R2 if he had 15-miniute checks. V2 said that staff have a really good working relationship and can help each other out. V2 said that she would expect R2 and all residents to have their call lights in reach of them when they are in bed. V2 said that she would expect R2's door to be open when R2 is in bed unless staff is in the room providing care. V2 said that R2 was supposed to have yellow tape around his call light so he could find his call light easier. V2 said that she knew that R2 got moved closer to the nurses' station so staff could check on him more. On 04/15/26 at 1:50PM R2's door was observed closed no staff noted in room. R2's call light at the foot of his bed and no yellow tape noted to call light. On 04/15/26 at 2:00PM R2 stated that he doesn't know why he falls all the time. R2 stated that he has Parkinsons and maybe that is why he falls a lot. On 04/15/26 at 2:15PM, V7 (Minimum Data Set Coordinator) she stated that she is trying to come up with new interventions for R2 and all the residents. V7 stated that she doesn't know if the interventions she put in place are working or not. V7 said that it is hard to come up with new interventions, because R2 has had so many falls. V7 said that she tries to get more detail with some of the new fall interventions or figure out a new way to put the intervention to see if it works better. 2. R4's admission record documents an admission date of 04/30/24 with diagnoses in part of unspecified convulsions, cerebrovascular disease, muscle wasting and atrophy, lack of coordination, and need for assistance with personal care. R4's MDS (Minimum Data Set) dated 02/06/26 documents in Section C a BIMS (Brief Interview for Mental Status) score of 07 which indicates R4 has severely impaired cognition. Section GG documents toileting as dependent. Transfers as Substantial/Maximal assistance with transfers. Section J documents under has the resident had any falls since admission/entry or reentry or the prior assessment as yes. Number of falls since admission or prior assessment- no injury 2 or more. R4's Care Plan documents a focus area of Risk for falls with a revision date of 05/06/24 with interventions of 1. 01/14/26 fall intervention update to include staff to monitor position when in wheelchair. 2. 01/22/26 Fall intervention updated to include Monitor Safety check 15 minutes r/t (related to) increased falls. 3. 01/05/26 Fall intervention updated to include encouraging the resident to ask for assistance during transfers. 4. 01/09/26 Fall intervention updated to include offer to lay down the resident after meals. 5. 10/13/25 Fall intervention updated to include Call Don't Fall sign in room. 6. 10/20/25 Fall intervention updated to include yellow on call light as visual reminder. 7. 10/31/25 Fall intervention updated to include proper footwear when out of bed. 8. 10/05/26 Fall intervention updated to increase visual checks when out of bed. 9. 12/30/25 Fall intervention updated to include nonskid mat on wheelchair. 10. 2/5/26 Fall intervention updated to include frequent checks when up. 11. 03/31/26 Fall intervention updated to include foam grip adaptive to regular spoon at meals. 12. 03/06/26 Fall intervention updated to include educate staff to anticipate resident needs during peak times of restlessness to provide assistance with transfers and prevent self-transfers.13. 04/05/26 Fall intervention updated to include resident be monitored at nurses' station after supper. 14. 09/12/25 Fall intervention updated to include education provided on using proper foot pedal/rest use. 15. Assist with Adl's (activities of daily living), transfers, PRN. 16. Educate on the importance of maintaining safe environment, free of potential fall hazards. 17. Ensure bed is kept in lowest position. 18. Ensure call light is available to resident. 19. Evaluate fall risk on admission and PRN. 20. Evaluate resident's environment to identify factors known to increase risk of falls, 21. Fall on 03/06/26 intervention educate staff to anticipate resident needs during peak times of restlessness to provide assistance with transfers and prevent self-transfers. 22. If fall occurs alert provider. 23. If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. 24. Review medication for drugs that increase the risk for falls.R4's Fall investigation dated 04/05/26 5:50PM documents under incident description: Nursing description- Staff observed the resident lying on the floor in the dining room. ROM WNL. No skin injuries observed at this time. Immediate Action taken- up at Nurses station for monitoring.On 04/12/26 at 9:16AM observed R4's room door closed no staff observed in room. R4 was lying in bed no call light in reach and no yellow tape noted to around call light.On 04/13/26 at 1:00PM observed R4 in a wheelchair wheeling self around facility from dining room. R4 was sitting on the edge of his wheelchair trying to propel himself around. Observed several staff going past R4. Observed R4 trying to get self out of wheelchair two times.On 04/14/26 at 1:35PM, V14 (Certified Nurse Assistant) stated that R4 is not on 15 minutes checks as far as she knows. V14 said that she is working on R4's hall today. V14 said all resident's call lights should be in reach of all residents when they are in bed, especially residents who are fall risk.On 04/14/26 at 1:37PM, V6 (Certified Nurse Assistant) stated that R4 is not on 15-minute checks. R4 said they did move R4 closer to the nurse's station, but he isn't on 15-minute checks. V6 stated that all resident call lights should be in reach of all residents when they are in bed.On 04/15/26 at 3:00PM observed R4 who was sitting in his wheelchair in foyer for over 16 minutes with no staff checking or monitoring R4.On 04/16/26 at 9:12AM, V7 (MDS Coordinator) stated that R4 is on 15 minutes checks and staff should be making sure that R4's call light is in reach of R4 at all times when he is in bed. R4 is also to have yellow tape wrapped around his call light to make it easier for R4 to find. V7 said that staff should also be offering to lay down R4 after meals and if they see R4 trying to get up or sliding out of his chair reposition him back in his wheelchair.On 04/16/26 at 9:53AM, V2 (Assistant Director of Nursing) stated that she doesn't know for sure if R4 is on 15-minute checks but if he is she would expect staff to be doing 15-minute checks. V2 said that all residents should have call light in reach of them when in bed. V2 said that if a resident is scooting out of their wheelchair, she would expect staff to assist them back in the wheelchair. V2 said that they should also be offering to lay down R4 after meals and assisting with toileting. V2 said that she would expect st[TRUNCATED

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure has the potential to affect all 46 residents residing at this facility.Findings included:1. R23's admission Record documents an admission date of 10/20/2023 with diagnoses of chronic pulmonary edema, mild intellectual disability, morbid obesity and need for assistance with personal care. R23's MDS (Minimum Data Set) dated 1/15/26 documented R23 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 total, which indicates R23 is cognitively intact. This same MDS documented R23 has impairment to both lower legs, uses a wheelchair and is dependent on staff for transfers and toileting care. On 4/12/2026 at 9:10am, R23, who is alert and oriented, said he had to wait 3 hours the previous night (4/11/2026) for his call light to be answered by staff because there are only two staff working on the night shift. R23 said this is how it is every night. R23 said he turned the call light on around 12:00am and the staff did not answer the call light until around 3:00am. R23 said most nights there are only two staff on the night shift and he must wait long periods of time for staff to provide him toileting care. 2. R22's admission Record documents an admission date of 3/31/2025 with diagnoses of peripheral vascular disease, muscle wasting/atrophy and chronic congestive heart failure. R22's MDS dated [DATE] documented R22 with a BIMS score of 15 out of 15 total, with indicates R22 is cognitively intact. This same MDS documented R22 has impairment in both legs, uses a wheelchair and is dependent on staff for toileting and personal hygiene care. On 4/12/2026 at 10:07am, R22, who is alert and oriented, said on the night of 4/11/2026, he had to wait two hours for his call light to be answered by staff. R22 said the facility needs more staff and only had two CNA's on staff last night. R22 said he turned on his call light around 1:00am and staff did not answer the call light until 3:10am. 3. R32's admission Record documents an admission date of 6/6/2025 with diagnoses of pulmonary fibrosis, atrial fibrillation, muscle wasting/atrophy and chronic congestive heart failure. R32's MDS dated [DATE] documents R32 with a BIMS score of 13 out of 15 total which indicates R32 is cognitively intact. This same MDS documented R32 uses a walker for ambulation and needs supervision/touch assistance for toileting and personal hygiene care. On 4/12/2026 at 11:10am, R32 said at night the facility only had two staff for all these people. R32 said it takes 30-45 minutes for the staff to answer my call light for help to the bathroom. R32 said she doesn't want to fall and get hurt. R32 said the facility needs more workers to care for the people who live here. 4. R15's admission Record documents an admission date of 12/12/2025 with diagnoses of emphysema, chronic obstructive pulmonary disease, seizures and need for assistance with personal care. R15's MDS dated [DATE] documents R15 with a BIMS score of 14 out of 15 total which indicates R15 is cognitively intact. This same MDS documents R15 has impairment to both legs, uses a wheelchair and is dependent on staff for toileting care. On 4/14/2026 at 12:04pm, R15, who is alert and oriented, was observed turning on her call light for assistance. At 12:15pm, two staff were observed walking past R15's activated call light and did not answer the call light. At 12:21pm, staff answered R15's call light. 5. R38's admission record documents an admission date of 4/4/2025 with diagnoses of chronic obstructive pulmonary disease, hypertension, need for assistance with personal care and dependence on supplemental oxygen. R38's MDS, dated [DATE], documents a BIMS score of 15 out of 15 total, which indicates R38 is cognitively intact. This same MDS documents R38 has impairment in both legs, uses a wheelchair and needs partial moderate assistance with toileting from staff. On 4/14/2026 at 3:35pm, R38 said he had already turned on his call light for assistance with his oxygen concentrator and oxygen tubing. R38 stated his call light has been on for a while already. At 3:49 pm staff answered R38's call light and assisted R38. On 4/12/2026 at 9:30am, V14 (Certified Nursing Assistant) said the facility does not have enough help. V14 said she has trouble getting all the needs of the residents met in a timely manner due to the lack of staff. V14 said call lights are especially hard to answer in a timely manner. V14 said residents must wait as long as 30-45 minutes until I can get to them. V14 said we do the best we can, but we need more help. The facility's CNA (Certified Nursing Assistant) schedule titled April 5-April18, 2026, documents two CNAs scheduled from 10:00pm-6:00am for 4/5, 4/6, 4/7, 4/9, 4/10, 4/11, 4/12, 4/13. Only one CNA was scheduled 10:00pm-6:00am for 4/8/2026. A non-dated census list of residents with type of assistance needed for transferring was provided by the facility. The list documented 7 residents transfer with a full body lifting machine, 6 residents need two staff to transfer, and 12 residents need one staff to transfer. On 4/15/2026 at 12:05pm, V1 (Administrator) said she handles the nursing scheduling for this facility since they don't have a Director of Nursing. V1 reviewed the current CNA schedule (4/5/26-4/18/26) which revealed only two CNA's work 10:00pm-6:00am and said, I really don't know if two CNA's are enough staff to provide adequate resident care in a timely manner. I'd have to review our facility policy to see what it said. V1 was asked if two CNA's would be enough to evacuate during an emergency? V1 replied I don't know. Only having two CNA's on the nightshift is how we have always done it, so that is what I schedule, I really wouldn't know if two are enough staff or not. On 4/15/2026 at 12:30pm, V15 (Certified Nursing Assistant) said she works on the nightshift from 10:00pm-6:00am. V15 said the facility only schedules two CNA's for the nightshift but she doesn't think there is enough staff to provide timely care to the residents. V15 said it is hard to get 15-minute checks completed for residents with increased supervision and get bed check done and get the call lights answered, so most of the time the checks don't get done. V15 said many times residents must wait to get their call lights answered because everybody needs something at the same time it seems like. V15 said the staff do the best they can with the number of staff they have available at the time. V15 said R2 falls often during the night and V15 thinks R2 should have 1:1 supervision at time due to his sundowners, but they don't have enough staff to always monitor R2 when he is up at night. The facility's matrix dated 4/12/26 documents a total of 46 residents currently reside at this facility. A facility policy titled Nurse Staffing (non-dated) documented in part: It is the policy of (facility name) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychological well-being of each resident.

Based on observation, interview and record review, the facility failed to maintain a full time Director of Nursing and to have a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 46 residents residing at this facility.Findings included:On 4/14/2026 at 1:04pm, V1 (Administrator) said the facility did not have the required 8 consecutive hours per day of Registered Nurse coverage. V1 said some days we do not have the required RN coverage. The facility schedule titled April 5-April 18, 2026, documented no RN (Registered Nurse) coverage for dates of 4/13/2026.The facility schedule titled March 22-April 4, 2026, documented no RN coverage for dates of 3/24/26 and 3/25/26.The facility schedule titled March 8-March 21, 2026, documented no RN coverage for dates of 3/18/26 and 3/13/26.On 4/14/2026 at 1:45pm, V1 (Administrator) said the facility has not employed a Director of Nursing since V11 (Registered Nurse) stepped down from the position on November 2nd of 2025. V1 said the facility has not been able find another Director of Nursing since then. V1 said Regional Nurses are monitoring this facility for Director of Nursing needs from afar but are not physically at this facility on a daily basis and hardly come to the facility unless needed.On 4/14/2026 at 1:30pm, V2 (Assistant Director of Nursing) said the facility had not had a Director of Nursing since mid-November of 2025 as far as she could remember.On 4/14/2026 at 2:00pm, V3 (Regional Nurse) said the facility was actively seeking to hire a Director of Nursing to fill the open position. V3 said the facility did not have a specific policy concerning Registered Nurse coverage or on having a Director of Nursing.The facility's matrix dated 4/12/26 documents a total of 46 residents currently reside at this facility.A facility policy titled Nurse Staffing (non-dated) documented in part: It is the policy of (facility name) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychological well-being of each resident. The Facility assessment dated [DATE] documents the following in part: Staffing Plan-Describe your general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time. 1 (one) DON (Director of Nursing) RN full time days; if has other responsibilities add more RN as Asst. (Assistant) DON to equal one FTE (full time employee).

Based on interview, observation, and record review the facility failed to maintain an effective pest control program to rid the facility of gnats. This failure has the potential to affect all 46 resident currently residing in the facility. The findings include:On 04/12/26 at 8:50AM, R29, who was alert and oriented, stated that the facility does have a problem with gnats. R29 stated that they are all over the building. On 04/12/26 at 8:51AM, R29's room was observed with 2 gnats flying over R29's bed. 04/12/26 at 9:03AM, gnats were observed on R2's food tray that was sitting on R2's bedside table in his room.On 04/12/26 at 9:09AM, R3, who was alert and oriented, stated that the facility has a problem with gnats. R3 said that the gnats are in the dining room and in all the bedrooms. R3 said she has one gnat that has been in her room for a while and won't leave her food or stuff alone. R3 said that she has one gnat that has gotten pretty big in her room, and her and the gnat are becoming friends now. On 04/12/26 at 9:17AM, R24, who was alert and orientated, stated that the facility has a terrible problem with gnats. R24 said that they are in the bedrooms and in the dining room. On 04/12/26 at 9:20AM, R21, who was alert and oriented, stated that the facility has a problem with gnats all over the building. R21 said when he is trying to eat in the dining room, he is having to swat at them to get them away from his food The facility policy dated 09/01/22 titled, Pest Control documents: 3. the pest control program will be conducted on a regular and as needed basis and 10. the facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents.The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 4/13/26 documents there are 46 residents living in the facility.

Based on interview and observation the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 5 of 5 residents (R15, R22, R23, R32 and R38) reviewed for call light response times in a sample of 46.Findings include:1. R23's admission record documents an admission date of 10/20/2023 with diagnoses of chronic pulmonary edema, mild intellectual disability, morbid obesity and need for assistance with personal care. R23's MDS (minimum data set) dated 1/15/26 documented R23 with a BIMS (brief interview for mental status) score of 15 out of 15 total, which indicates R23 is without cognitive impairment. This same MDS documented R23 has impairment to both lower legs, uses a wheelchair and is dependent on staff for transfers and toileting care.On 4/12/2026 at 9:10am, R23 said he had to wait 3 hours the previous night (4/11/2026) for his call light to be answered by staff because there are only two staff working on the night shift. R23 said this is how it is every night. R23 said he turned the call light on around 12:00am and the staff did not answer the call light until around 3:00am. R23 said most nights there are only two staff on the night shift and he must wait for staff to provide him toileting care. 2. R22's admission record documents an admission date of 3/31/2025 with diagnoses of peripheral vascular disease, muscle wasting/atrophy and chronic congestive heart failure. R22's MDS dated [DATE] documented R22 with a BIMS score of 15 out of 15 total, with indicates R22 is cognitively intact. This same MDS documented R22 has impairment in both legs, uses a wheelchair and is dependent on staff for toileting and personal hygiene care.On 4/12/2026 at 10:07am, R22 said on the night of 4/11/2026, he had to wait two hours for his call light to be answered by staff. R22 said the facility needs more staff and only had two CNA's (Certified Nursing Assistants) on staff at night. R22 said he turned on his call light around 1:00am and staff did not answer the call light until 3:10am.3. R32's admission record documents an admission date of 6/6/2025 with diagnoses of pulmonary fibrosis, atrial fibrillation, muscle wasting/atrophy and chronic congestive heart failure. R32's MDS dated [DATE] documents R32 with a BIMS score of 13 out of 15 total which indicates R32 is without cognitive impairment. This same MDS documented R32 uses a walker for ambulation and needs supervision/touch assistance for toileting and personal hygiene care.On 4/12/2026 at 11:10am, R32 said at night the facility only had two staff for all these people. R32 said it takes 30-45 minutes for the staff to answer her call light for help to the bathroom. R32 said she doesn't want to fall and get hurt. R32 said the facility needs more workers to care for the people who live here. 4. R15's admission record documents and admission date of 12/12/2025 with diagnoses of emphysema, chronic obstructive pulmonary disease, seizures and need for assistance with personal care. R15's MDS dated [DATE] documents R15 with a BIMS score of 14 out of 15 total which indicates R15 is without cognitive impairment. This same MDS documents R15 has impairment to both legs, uses a wheelchair and is dependent on staff for toileting care.On 4/14/2026 at 12:04pm, R15 turned on her call light for assistance. At 12:15pm, two staff were observed walking past R15's activated call light and did not answer the call light. At 12:21pm, staff answered R15's call light. 5. R38's admission record documents an admission date of 4/4/2025 with diagnoses of chronic obstructive pulmonary disease, hypertension, need for assistance with personal care and dependence on supplemental oxygen. R38's MDS, dated [DATE], documents a BIMS score of 15 out of 15 total, which indicates R38 is without cognitive impairment. This same MDS documents R38 has impairment to both legs, uses a wheelchair and needs partial moderate assistance with toileting from staff.On 4/14/2026 at 3:35pm, R38 stated he had turned on his call light about 15 minutes ago to get assistance with his oxygen concentrator and oxygen tubing. At 3:49pm staff answered R38's call light and assisted R38.On 4/12/2026 at 9:30am, V14 (Certified Nursing Assistant) said the facility does not have enough help. V14 said she has trouble getting all the needs of the residents met in a timely manner due to the lack of staff. V14 said call lights are especially hard to answer in a timely manner. V14 said residents must wait as long as 30-45 minutes until she can get to them. V14 said we do the best we can, but we need more help.On 4/15/2026 at 12:05pm, V1 (Administrator) said she handles the nursing scheduling for this facility since they don't have a Director of Nursing. V1 reviewed the current CNA schedule (4/5/26-4/18/26) which revealed only two CNAs worked 10:00pm-6:00am and said, I really don't know if two CNAs are enough staff to provide adequate resident care in a timely manner. I'd have to review our facility policy to see what it said. And then stated, I really don't know. Only having two CNA on the nightshift is how we have always done it, so that is what I schedule, I really wouldn't know if two are enough staff or not.The facility's CNA (Certified Nursing Assistant) schedule titled April 5-April18, 2026, documents two CNAs scheduled from 10:00pm-6:00am for 4/5, 4/6, 4/7, 4/9, 4/10, 4/11, 4/12, 4/13. Only one CNA was scheduled 10:00pm-6:00am for 4/8/2026.Facility policy titled Call Light (revision date of 2/2/18) documented the following in part: Purpose: To respond to residents' requests and needs in a timely and courteous manner.

Based on interview, observation, and record review the facility failed to provide a method to call for assistance from the toilets and shower rooms for 36 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46) of 36 residents reviewed for accommodations of needs in a sample of 46.Findings include: On 04/12/26 at 9:15 AM the shower room on the north hall had no call light in the shower stall. On 04/12/26 at 9:16 AM on the north hall, the first bathroom on the left side of the hall had no call light accessible from the floor, the first bathroom on the right side of the hall had no call light accessible from the floor, and the second bathroom on the right side of the hall had no call light accessible from the floor. On 04/12/26 at 9:24 AM on the south hall, the first bathroom had no call light accessible from the floor near the toilet. The second bathroom had no call light accessible from the floor near the toilet. On 04/16/26 at 3:46 PM V1 (Administrator) stated, all restrooms, shower rooms, and toilets should have call lights and should be able to be activated from the floor if a resident was to fall. The room roster dated 03/23/26 presented on 04/12/26 documents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46 reside on the north and south halls. The undated facility policy titled, Physical Plant & Environmental Policy & Guidelines documents: policy implementation: the facility administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Maintenance/approved contractors: nurse call light systems and door signaling systems/wander guard systems.

Based on interview, observation, and record review the facility failed to maintain repairs to windows, floors, and radiators and keep resident floors, bathrooms, and shower areas clean for 36 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46) of 36 resident reviewed for safe clean, comfortable environment in a sample of 46.Findings include: 1. On 04/12/26 8:41AM, R5 who was alert and oriented, stated that he has the insides of his incontinent brief from last night all over his floor. R5 said that his incontinent brief exploded last night, and no one would clean it up for him. On 04/12/26 at 8:42AM, there was a white polymer substance all of the floor next to R5's bed. 2. On 04/13/26 at 11:50AM, R28's room had two ceiling tiles that were pushed up into the ceiling and had what appeared to be some kind of insulation hanging around the ceiling tile track that was pushed up. The area where the ceiling tiles were pushed up is located above R28's nightstand and head of bed area. On 04/13/26 at 3:10PM observed what appeared to be the insulation that was hanging from the ceiling tile tracks now laying on R28's nightstand and floor. 3. On 04/12/26 at 9:18AM R24's room observed which had a very strong urine smell to the room. On 04/12/26 at 2:20 PM there was urine under R24's bed, the puddle of urine was covering an area of approximately four by three feet. There are two tiles missing under R24's bed and the space where the tiles should be appeared very saturated, there were brown marks around the edges of tiles spanning an area of approximately five foot by five foot. On 04/13/26 at 3:17 PM there was urine under R24's bed, the puddle of urine was covering an area of approximately four by three feet. There are two tiles missing under R24's bed and the space where the tiles should be appeared very saturated, there were brown marks around the edges of tiles spanning an area of approximately five foot by five foot. On 04/14/26 at 10:00 AM R24's bed had urine under his bed, the urine covered an area of approximately one foot by two foot. 4. On 04/12/26 at 8:47AM went into R5's room. There was a urine smell. Observed a cushion R5's wheelchair that appeared to have some liquid on cushion that had no cover and appeared to be some kind of foam. On 04/12/26 at 8:48AM, R5 who was alert and oriented, stated that his room does sometimes smell like urine. 5. On 04/12/26 at 8:51AM observed strong urine smell in R29's room 6. On 04/12/26 at 8:56AM observed a strong urine smell in R45's room. 7. On 04/12/26 at 9:03AM observed R2's room which had a strong smelled of urine and old indwelling catheter bag with urine in it observed in a trash can on top of R2's nightstand. 8. On 04/12/26 at 9:15 AM the bathroom next to the shower room on the north hall had a build-up of dirt and debris around the base of the toilet, on the north hall. The first restroom on the left side of the hall had a build-up of a dark substance around the base of the toilet. The second bathroom had a build up of a dark substance around the base of the toilet. The first bathroom on the right side of the hall had a build up of a dark substance around the base of the toilet. 9. On 04/12/26 at 9:20 AM the 2nd bathroom on the south hall had two cracked tiles to the left of the toilet, there was a buildup of dirt and debris around the base of the toilet, and there was a missing baseboard on the wall on the right side of the room and half the wall on the adjacent wall. 10. On 04/12/26 at 11:05 AM in R22's room there was broken window that measured 10 inches by 25 inches, it had a large crack that was taped, with the glass pieces offset by approximately 0.5 inches from each other. There was cardboard covering the window, there is what appears to be water damage at the bottom of the cardboard. 11. On 04/12/26 at 2:25 PM there was no covering over the baseboard radiator exposing sharp metal pieces along the radiator in R9 and R36's room. On 04/16/26 at 4:04 PM, V1 (Administrator) stated the bathrooms should not have any accumulation of dirt or debris in them. V1 stated they are working on an intervention for under R24's bed to be able to keep that area clean. V1 stated, the building should be maintained in good repair. The room roster dated 03/23/26 presented on 04/12/26 documents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46 live on the north and the south halls. The undated facility policy titled, Physical Plant & Environmental Policy & Guidelines documents: policy implementation: the facility administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Maintenance/approved contractors; routine care and repairs to interior finishings - repairing ceiling/wall damage, painting, floor. Housekeeping: routine daily room cleaning and sanitizing, routine daily cleaning of all common areas and dining areas, routine daily cleaning of all shower rooms and restrooms, monthly scheduled room deep cleaning and organizing, and monthly scheduled shower room deep cleaning.

Based on interview, observation, and record review the facility failed to provide supplements as ordered to underweight residents for 4 (R1, R2, R3, and R15) of 6 residents reviewed for nutritional status in a sample of 46.Findings include:1.R15's admission Record documents an admission date of 12/12/25 with diagnoses including: pan lobular emphysema, chronic obstructive pulmonary disease, conversion disorder with seizures or convulsions, chronic kidney disease, anemia, dementia, gastro-esophageal reflux disease, depression, and anorexia. R15's Care Plan documents a focus area of R15 has a potential nutritional problem dated 03/01/26 with interventions including: provide and serve supplements as ordered dated 03/01/26 and RD (Registered Dietitian) to evaluate and make diet change recommendations dated 12/15/25.R15's Order Summary Sheet documents a dietary order of regular diet, regular texture with super cereal at breakfast, whole milk in place of menu milk and fortified pudding at lunch and supper dated 01/28/26. On 04/12/26 during lunch service at approximately 12:07 PM, R15 did not receive any fortified pudding. R15 received Italian marinated pork loin, stuffing roasted broccoli, and apple pie. R15's dietary ticket dated lunch 04/11/26 given on 04/12/26 at lunch documents: fortified pudding 1 serving and nutritional ice cream.On 04/14/26 during the lunch service at 12:07 PM, R15 did not receive any fortified pudding. R15 received ranch baked chicken, potato wedges, buttered carrots, dinner roll, and mixed fruit dump cake.On 04/15/26 during the lunch service at 12:06 PM, R15 did not receive any fortified pudding with her lunch. R15 received hamburger stroganoff, buttered peas, pineapple, and a beverage.R15's Registered Dietician note dated 03/20/26 at 3:13 AM documents R15's March weight was 106.2 pounds with a significant weight loss noted for 3 months at 7.65% with a BMI of 18.8 which is considered underweight. R15's diet is regular diet with thin liquids, super cereal at breakfast, whole milk in place of menu milk and fortified pudding at lunch and supper. Weight is noted as up 1/11/26 - 03/09/26 (99.3, 104.5, 106.2 pounds respectively), but remains below admission weight of 115 pounds. V9 (Registered Dietician) recommends to offer 60 cc of 2.0 calorie supplement two times a day to provide additional nutrition. 2.R2's admission Record documents an admission date of 11/06/25 with diagnoses including: Parkinson's disease, severe protein-calorie malnutrition, vitamin D deficiency, anemia, hyperlipidemia, muscle wasting and atrophy, anxiety disorder, depression, dementia, and schizoaffective disorder.R2's care plan documents a focus area of R2 has a nutritional problem dated 11/24/25 with interventions including: provide and serve supplements per Dr. (doctor) order dated 11/24/25 and RD to evaluate and make diet change recommendations dated 11/06/25.R2's Order Summary Report documents a dietary order dated 11/21/25 of a regular diet with regular texture. R2 has a dietary order dated 12/18/25 of nutritional ice cream one time a day at lunch with an order status of active. R2's Order Summary report documents a dietary order dated 12/17/25 documents an order stating: continue with 100cc (cubic centimeter) water G-tube flush three times a day to keep tube patent after checking placement. Bolus feedings discontinued as of 12/17/25 per dietitian recommendations three times a day for hydration with no end date.R2's Nutrition/Dietary Note dated 12/16/25 at 6:44 AM documents: RD note, R2's December weight is 122.6 pounds with a significant weight gain noted for one month at 10.65% with a BMI of 18.5% which is considered underweight for his age. The current oral diet meets/exceeds estimated nutritional needs with appetite noted as generally good and weight up significantly for one month. R2's overall weight gain is acceptable as BMI remains underweight for age, however at this time will recommend to hold bolus feedings of 250 ml (milliliters) isosource 1.5 twice a day, continue 100 cc water flush three times a day to keep the tube patent and will recommend to add nutritional ice cream one time a day to support continued good PO (oral) intake/nutrition.R2's weight and vital sheet documents weights on 03/15/26 at 10:01 AM of 123.1 pounds, 03/22/26 at 11:27 AM of 128.2 pounds, 03/29/26 at 11:27 AM of 128.2 pounds, on 04/05/26 at 2:05 PM of 122.3 pounds, and on 04/12/26 at 1:31 PM of 122.4 pounds.On 04/12/26 during lunch service at 12:07 PM, R2 did not receive a nutritional ice cream with his lunch. R2 received Italian marinated pork loin, stuffing roasted broccoli, and apple pie. R2's meal ticket dated lunch 04/13/26 does not document a nutritional ice cream should be given.On 04/13/26 during lunch service at 12:11 PM, R2 did not receive a nutritional ice cream with his lunch. R2 received spaghetti with meat sauce, Italian blend vegetables, garlic bread, and gelatin with whipped topping.On 04/14/26 during lunch service at 12:18 PM, R2 did not receive a nutritional ice cream with his lunch. R2 received ranch baked chicken, potato wedges, buttered carrots, dinner roll, mixed fruit cake, tea, and water. On 04/15/26 during lunch service at 12:20 PM, R2 did not receive a nutritional ice cream with his lunch. R2 received hamburger stroganoff, buttered peas, pineapple, and a beverage.3. R1's admission Record documents an admission date of 02/28/25 with diagnoses including: severe protein calorie malnutrition, chronic obstructive pulmonary disease, supraventricular tachycardia, Alzheimer's disease, pan lobular emphysema, cervical disc degeneration, hypothyroidism, bilateral primary osteoarthritis of the knee, are related osteoporosis, iron deficiency, depression, major depressive disorder, spondylosis, cognitive communication deficit.R1's significant change in status Minimum Data Set assessment dated [DATE] documents a brief interview of mental status of 05 indicating severe cognitive impairment. Section K, Swallowing/Nutritional Status documents R1's weight is 89 pounds and R1 has had a loss of 5% or more in the last month or 10% or more in the last 6 months.R1's care plan documents a focus area of at risk for malnutrition dated 03/04/25 with interventions including: consult a dietician per order dated 03/04/25 and supplements per Dr. (doctor) order dated 03/25/26.R1's Order Summary Report documents the following orders: regular diet, regular texture with super cereal at breakfast, nutritional shake at all meals, whole milk three times a day with meals, and add fortified pudding at lunch and supper with an order status of active dated 4/3/26; 2.0 calorie supplement three times a day for weight loss give 150 ml (milliliters), may substitute with house supplement when not available dated 2/28/25; refer to residential hospice dated 3/13/26; Mitrazapine oral tablet 15 mg, give 1 tablet by mouth at bedtime for appetite stimulant.On 04/12/26 during lunch service at approximately 12:03 PM, R1 did not receive any fortified pudding or whole milk with her lunch. R1 received Italian marinated pork loin, stuffing roasted broccoli, apple pie and a nutritional shake. On 04/13/26 during breakfast service at approximately 7:35 AM, R1 did not receive any super cereal with her breakfast. R1 received scrambled eggs, sausage, toast with jelly, milk, and nutritional shake.On 04/14/26 during lunch service at 12:17 PM, R1 did not receive any fortified pudding or whole milk with her lunch. R1 received ranch baked chicken, potato wedges, buttered carrots, dinner roll, mixed fruit cake, tea, water and nutritional shake. On 04/15/26 at 12:12 PM, R1 did not receive any fortified pudding with her lunch. R1 received hamburger stroganoff, buttered peas, pineapple, a nutritional ice cream, a nutritional shake and a beverage.R1's Nutrition/Dietary Note dated 02/20/26 at 11:54 AM documents: R1's February weight was 88.4 pounds with a significant weight loss noted for 1 month of 7.05% with a BMI of 16.17% which is considered underweight. R1's diet is regular diet with thin liquids, encourage fluids, super cereal at breakfast, whole milk at all meals, nutritional ice cream and nutritional shake at all meals and 120 cc 2.0 calorie supplement three times a day. R1 has multiple supplements in place, will recommend to refer to MD (Medical Doctor) to review for possible dose increase of mirtazapine to 15 mg (milligrams) to better stimulate appetite and will additionally recommend to increase 2.0 calorie supplement to 150 cc three times a day as nursing reports good acceptance.4. R3's admission Record documents diagnoses including: severe protein-calorie malnutrition, muscle wasting and atrophy, anxiety disorder, post-traumatic stress disorder, major depressive disorder, polyarthritis, dementia, acute duodenal ulcer with perforation, anemia, amnestic disorder, vitamin D deficiency, and frontotemporal neurocognitive disorder.R3's Order Summary Report documents a dietary order of: regular diet, regular texture with fortified mashed potatoes at lunch dated 02/20/26.R3's order summary report documents an order dated 04/07/26 documenting: cleanse g-tube removal site, pat dry, apply dry dressing/non adherent and tape to affected area until healed.R3's Care Plan documents a focus area of I have a potential nutritional problem dated 01/05/26 with interventions including: provide and serve supplements as ordered dated 01/02/26 and RD to evaluate and make diet change recommendations dated 12/02/25.On 04/12/26 during lunch service at approximately 12:12 PM, R3 did not receive any fortified mashed potatoes with her lunch. R3 received Italian marinated pork loin, stuffing roasted broccoli, and apple pie. On 04/15/26 at 12:26 PM, R3 did not receive any fortified mashed potatoes with her lunch. R3 received hamburger stroganoff, buttered peas, pineapple, and a beverage.On 04/15/26 at 12:26 PM, R3 stated she is supposed to get fortified mashed potatoes with lunch, sometimes they will give her fortified pudding instead, today she did not get either.R3's RD Note dated 03/20/26/ at 3:49 AM documents: J-tube remains in place at this time with resident only receiving 100 cc (cubic centimeters) water flush three times a day to keep patent. R3's March weight was 97.4 pounds with a BMI (Body Mass Index) of 18.4 which is underweight for her age. R3's most recent weight dated 03/15/26 is up slightly at 103 pounds. R3's diet is a regular diet (upgraded 02/03/26) with thin liquids (lactose intolerance noted) and fortified mashed potatoes at lunch. Per discussion with V2 (Assistant Director of Nursing) resident has an appointment next month to review for possible tube removal.On 04/16/26 at 2:16 PM, V9 (Registered Dietician) stated, she expects all the residents including R1, R2, R3, and R15 to receive the supplements she has ordered to maintain weight or increase weight.On 04/16/26 at 2:50 PM, V8 (Dietary Manager) stated the residents should receive the supplements, the meal tickets should be reviewed more closely. V8 stated, he does not know why R2's supplement is not on his meal ticket.On 04/16/26 at 3:46 PM, V1 (Administrator) stated the residents that have supplements ordered should receive those supplements. The facility policy dated 2022 titled, Unintentional Weight Loss documents: unintentional weight loss can be rapid or sometimes slow and insidious. It is important that systems are in place to detect, assess and develop and individualized plan of care for persons with unintentional weight loss.

Based on interview, observation, and record review the facility failed to follow the menu provided for the residents receiving the mechanical soft diet for 6 (R9, R13, R16, R28, R31, and R37) of 6 residents reviewed portion sizes in a sample of 46.Findings include:The document titled, Diet type report documents R9, R13, R16, R28, R31, and R37 receive the mechanical soft diet.On 04/12/26 during lunch service starting at 11:50 AM R9, R13, R16, R28, R31, and R37 received 2 ounces of the ground marinated pork loin with gravy and 4 ounces of soft chopped broccoli with pieces of the broccoli being over one inch in size.The Diet Spreadsheet dated week 3, day 13 documents: mechanical soft ground meat diet: ground marinated pork loin with gravy #8 scoop (0.5 cup/3.75 fluid ounces) and soft chopped broccoli 4 ounce spoodle.On 04/12/26 during lunch service V17 (Dietary staff) served the blue scoop (2 ounces) of the ground pork with gravy to R9, R13, R16, R28, R31, and R37 on the mechanical soft diet. On 04/12/26 at 12:37 PM, V8 (Dietary Manager) stated the blue scoop, the one used to serve the mechanical soft meat, was 2 ounces. On 04/16/26 at 2:16 PM, V9 (Registered Dietician) stated she would expect the soft and chopped broccoli would be pieces smaller than an inch in size and she would expect the residents to receive the portions as directed by the diet spreadsheet. On 04/16/26 at 2:35 PM, V8 stated two scoops of the two ounce scoop should have been served, so 4 ounces of the ground pork loin should have been served to those receiving the mechanical soft diet.The recipe for the ground marinated pork loin with gravy documents portion size #8 scoop (4 ounces). 7. Portion #8 scoop of moist, ground meat and ladle an additional 1-2 ounces gravy over the top. The facility policy dated 2020 titled, Menu Planning and Requirements documents: menus are planned to provide nourishing, palatable attractive meals that meet the nutritional needs of residents served, (based on age, size, gender, physical activity, and state of health), in accordance with the dietary reference intakes/recommended dietary allowances as issues by the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences, unless otherwise contraindicated by medical conditions and needs.

Based on interview, observation and record review the facility failed to provide the mechanical soft diet as directed by the recipe for 6 (R9, R13, R16, R28, R31, and R37) of 6 resident reviewed for mechanical soft diets in a sample of 46.Findings include:The document titled, Diet type report documents R9, R13, R16, R28, R31, and R37 receive the mechanical soft diet.On 04/12/26 during lunch service starting at 11:50 AM V17 (Dietary staff) served 4 ounces of broccoli with pieces over one inch in size to R9, R13, R16, R28, R31, and R37 on the mechanical soft diet.On 04/12/26 during lunch service starting at 11:50 AM R9, R13, R16, R28, R31, and R37 received 4 ounces of soft chopped broccoli with pieces of the broccoli being over one inch in size.The Diet Spreadsheet dated week 3, day 13 documents: soft chopped broccoli 4 ounce spoodle.The recipe titled, soft chopped broccoli documents: 4. chop broccoli into bite-sized pieces (1/2 or less). Transfer to steam table pans. Cover and hold until ready to serve. On 04/16/26 at 2:16 PM, V9 (Registered Dietician) stated she would expect the soft and chopped broccoli would be pieces smaller than an inch in size and she would expect the residents to receive the portions as directed by the diet spreadsheet. The facility policy dated 2020 titled, Diet Summary documents: dental soft (mechanical soft) diet: this consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. This diet follows the regular diet planned and provides food that can be easily chewed. The diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods.

Based on interviews, observations, and record review the facility failed to follow and maintain proper infection control practice for indwelling catheters and while providing indwelling catheter care and proper sanitation for glucometers for 6 (R2, R5, R19, R29, R31, and R34) of 12 residents reviewed for infection control in a sample of 46. The findings include: 1. R2's admission Record documents an admission date of 11/06/25 with diagnoses in part of obstructive and reflux uropathy. R2's MDS (Minimum Data Set) documents in Section C a BIMS (Brief Interview for Mental Status) score of 13 which indicates R2 is cognitively intact. Section GG document toileting as dependent and transfers as partial/moderate assistance. Section H documents indwelling catheter as yes. R2's Care Plan documents a focus area of enhanced barrier precautions r/t (related to) indwelling urinary catheter with a revision date of 04/01/26. Another focus area of I have indwelling catheter with a revision date of 11/24/25 documents interventions in part of 1. check tubing for kinks PRN (as needed) each shift. 2. The resident has 16 FR (French) 5 cc (Cubic Centimeters) foley (Indwelling catheter). Positioning catheter bag and tubing below the level of the bladder. R2's Progress Notes dated 04/08/26 at 3:04AM documents in part Infection Type: Type of infection: Urinary Tract Infection. Treatment/orders: (R2) is receiving Bactrim DS (Double Strength) oral tablet 800-160MG (Milligram) 1 tablet by mouth every 12 hours. Interventions: (R2) is receiving receives [sic] oral antibiotic. Head of bed elevated. Additional fluids offered and accepted. Evaluation/Notifications: Condition is stable, no distress noted . Contact isolation maintained related to ESBL (Extended-Spectrum Beta-Lactamases)/urine. R2's Progress Note dated 04/13/2 at 6:47AM documents New order per (Infectious disease physician) d/c (discontinue) contact isolation r/t (related to) completion of abt (antibiotic therapy). Resume EBP (Enhanced Barrier Precautions) R2's Order Summary Report documents an order for contact isolation d/t ESBL with a start date of 04/01/26 and an end date of 04/12/26 and an order for Bactrim DS Oral tablet 800-160mg give 1 tablet by mouth every 12 hours for ECOLI/ESBL for 10 days with a start date of 03/29/26 and an end date of 04/08/26. On 04/12/26 at 9:03AM, a 3 drawer bin containing PPE (Personal Protective Equipment) was observed outside of R2's room and contact isolation signage was observed on R2's door. R2 was observed lying in bed with his indwelling catheter bag lying on the floor under R2's bed. There was no cover over the indwelling catheter bag. There were no isolation bins for trash or linens observed in R2's room. A small trash can with a regular liner was sitting on a nightstand that had an old indwelling catheter bag in it with urine still in the bag. There were no isolation barrels in room to throw away PPE that was removed. R2's room smelled of urine. On 4/13/26 at 1:30pm, V5 (CNA) and V6 (CNA) performed urinary catheter care on R2. Prior to beginning the procedure, V5 and V6 washed their hands and donned clean gloves. Throughout the urinary catheter care procedure, V5 changed his gloves but did not perform any hand hygiene between the glove changes. On 4/13/26 at 2:20pm, V5 (CNA) said he should have used alcohol-based hand rub to cleanse his hands between glove changes, but he was nervous and forgot. 2. R5's admission Record documents an admission date of 02/6/24 with diagnoses in part of obstructive and reflux uropathy. R5's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicated R5 is cognitively intact. Section GG documents toileting as dependent. Section H documents indwelling catheter as yes. R5's Care Plan documents a focus area of: I have a foley (Indwelling) catheter with a revision date of 03/02/26 with interventions of 1. Monitor and document intake and output as per facility policy. 2. Monitor/document for pain/discomfort due to catheter. On 04/12/26 at 8:47AM, R5 was observed in bed with indwelling catheter laying on the floor under his bed. There was no indwelling catheter cover bag observed to the side of R5's bed. On 04/12/26 at 8:49AM, R5 stated that they always throw his indwelling catheter bag on the floor under his bed when they put him to bed or sometimes, they leave it in the bed with him. On 4/13/26 at 2:00pm, V5 and V6 performed urinary catheter care for R5. Prior to starting the procedure, V6 washed her hands and applied clean gloves. Throughout the procedure, V6 changed gloves, but failed to perform hand hygiene between the glove changes. 3. R19's admission Record documents an admission date of 07/27/2018 with diagnoses of generalized (acute) peritonitis, malignant neoplasm of prostate, benign prostatic hyperplasia without lower urinary tract symptoms, and obstructive and reflux uropathy. R19's MDS (Minimum Data Set) dated 02/19/26 documents in Section C a BIMS score of 12 indicating that R19 has moderately impaired cognition. Section GG documents toileting as dependent. Section H documents indwelling catheter as yes. R19's Care Plan documents a focus area of Enhanced Barrier Precautions r/t (related to) indwelling urinary catheter with a revision date of 01/28/26. Another focus area of I have a indwelling catheter r/t obstructive uropathy with a revision date of 01/28/26 interventions include in part: 1. The resident has foley (indwelling) catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. 2. Check tubing for kinks PRN (as needed) each shift. On 04/12/26 at 8:43AM, R19 was observed lying in bed with the indwelling catheter bag lying on the ground under R19's bed. There was no bag observed for R19's indwelling catheter bag to keep off the ground. On 04/12/26 at 8:45AM, R19 stated that he always keeps his indwelling catheter bag on the floor or in the bed next to him. R19 stated where else I'm I going to put it? On 04/12/26 at 12:20PM, R19 was observed in the dining room with his indwelling catheter bag sitting next to him in his wheelchair with the bag 1/4 full of urine and the bag sticking out from under the right wheelchair arm. When R19 is propelling in his wheelchair, the wheel of wheelchair keeps hitting the indwelling catheter with the urine in it. On 04/13/26 at 12:30PM, R19's indwelling catheter bag was observed lying in his wheelchair on R19's right side. An indwelling catheter bag holder was observed under R19's chair, but indwelling catheter bag was not in it. 4. R29's admission Record documents an admission date of 11/29/25 with diagnoses including obstructive and reflux uropathy. R29's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R29 is cognitively intact. Section GG documents toileting as supervision and touching assistance. Section H documents indwelling catheter as yes. R29's Care Plan document a focus area of: I have indwelling catheter with a revision date of 01/07/26 with interventions in part of 1. change indwelling catheter per Dr. (doctor) orders, 2. Check tubing for kinks PRN (as needed). 3. Position catheter bag and tubing below the level of the bladder and away from entrance door. On 04/12/26 at 8:50AM, R29's indwelling catheter bag was observed lying on ground under R29's bed with no bag to place catheter bag in. On 04/13/26 at 11:00AM, R29's indwelling catheter bag was observed in a covered bag that was connected to the bed frame. On 04/13/26 at 11:05AM, R29 stated that usually his indwelling catheter bag lays on the floor, but he said that yesterday evening he went and got a indwelling catheter bag holder and put it on his bed frame to hold his catheter bag off of the floor. R29 said that he does have problems with frequent Urinary Tract infections, but he currently does not have a Urinary Tract Infection. 5. R31's admission Record documents an admission date of 03/20/26 with diagnoses in part of overactive bladder and neuromuscular dysfunction of bladder. R31's MDS dated [DATE] documents in Section C a BIMS score of 14 which indicates R31 is cognitively intact. Section GG documents toileting as dependent. Section H documents indwelling catheter as yes. R31's Care Plan documents no focus area regarding indwelling catheter. R31's care plan is in review and update at this time. On 04/12/26 at 9:05AM, R31 was observed lying in bed with her indwelling catheter laying on the floor under her bed. There was no indwelling catheter cover bag observed to R31's bed. On 04/14/26 at 1:35PM, V14 (Certified Nurse Assistant) stated that all indwelling catheter bags should be in a cover on the resident bed and not on the floor. V14 stated that she thinks that all of the indwelling catheters are in bags either on their bed or under their wheelchair. V14 stated that she didn't know if on 04/12/26 if the indwelling catheter bags were in covers or not and off the floor. V14 said all catheters need to be below the bladder to drain. On 04/14/26 at 1:37PM, V6 (Certified Nurse Assistant) stated she worked on 04/11/26 and thought that all of the indwelling catheters were in covers and bag to the wheelchairs and bed and not on the floor. V6 said that she only worked 4 hours on 04/11/26 so she isn't sure if all the indwelling catheters were for sure or not in a bag cover to wheelchair and beds and not on the floor. V6 stated that all indwelling catheters need to be below the bladder to drain. On 04/14/26 at 1:38PM, V4 (Licensed Practical Nurse) stated that R2 came off contact isolation yesterday on 04/13/26. V4 stated V2 (Assistant Director of Nursing) called the Infectious disease doctor, and they gave V2 orders to discontinue the contact isolation and switch over to EBP (Enhanced Barrier Precautions) on R2. On 04/14/26 1:40PM, V2 (Assistant Director of Nursing) stated that she did call the Infectious disease doctor yesterday on R2 about him being on contact isolation because of ESBL (Extended Spectrum Beta Lactamases). V2 stated all indwelling catheters should not be on the floor and they should be in a protective bag that is attached to the bed or the wheelchair to make sure that the indwelling catheter is not dragging on the floor. V2 said that all indwelling catheters should also be below the bladder to help them drain. V2 stated that R2's old indwelling catheter drainage bag should not have been in a regular trash bag in R2's room when he was on isolation. V2 said the old indwelling catheter bag should have been placed in a biohazard bag and thrown in the biohazard bin. On 4/15/2026 at 2:15pm, V2 (Assistant Director of Nursing) said all staff should be performing hand hygiene between glove changes when providing resident care. The facility policy titled Hand Hygiene/Handwashing (revision date of 12/5/24) documents the following in part: Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare workers. Examples of when to perform hand hygiene (either alcohol-based hand sanitizer or handwashing) -After glove removal. The facility policy titled Urinary Catheter Care with a revision date of 2/14/19 documents Purpose: To establish guidelines to reduce the risk of or prevent infection in resident with an indwelling catheter. #6. Catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the bladder or tubing, during transfer, ambulation and body positioning. #7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. May place drainage bag and excess tubing in a secondary vinyl bag or other similar device to prevent primary contact with floor or other surfaces. 6. On 4/13/2026 at 11:50am, V10 (Licensed Practical Nurse) performed a blood sugar test using the facility's portable glucometer machine. V10 donned clean gloves, but did not use alcohol based hand rub or wash her hands with soap and water prior to donning the clean gloves. V10 gathered the needed supplies and entered R31's bedroom and placed them on R34's bed on top of R34's bottom sheet, as the bed was not made. V10 then performed the test and exited the room. V10 set the facility's portable glucometer on top of her medication cart. V10 removed her gloves, gathered insulin administration supplies and reapplied clean gloves. V10 did not perform hand hygiene prior to donning the clean gloves. V10 entered R34's room and administered the insulin to R34. V10 returned to her medications cart, removed her gloves and did not perform hand hygiene. Next, V10 took an alcohol wipe and wiped it on the facility's portable glucometer and placed the glucometer back into the medication cart drawer. On 4/13/2026 at 11:55am, V10 said she works at this facility often and this is how she cleanses the facility's portable glucometer machine when she works. V10 said she doesn't like to use bleach wipes because it makes her fingers hurt, so she uses the alcohol wipes instead. The facility policy titled Glucometer Cleaning dated 11/1/2024 documents the following in part: Purpose: to prevent the growth and spread of microorganisms and bloodborne pathogens. The blood glucose monitor should be cleaned and disinfected between each resident test. Procedure: To clean and disinfect the meter, use pre-moistened wipe/towel of 1 ml (milliliter) or 5-6% sodium Hypochlorlorite solution (household bleach) and 9ml water to achieve a 1:10 dilution final concentration of 0/5-0.6% sodium hypochlorite. Wipe meter with 1:10 solution bleach wipe/towel until all surfaces of the glucometer are visibly wet. Discard bleach wipe/towel. Place glucometer on a clean surface such as a paper towel and allow to air dry for no less than 3 minutes. Remove gloves and wash hands.

Based on observation, interview, record review the facility failed to provide supervision during smoking to prevent an accident and failed to provide an appropriate intervention to prevent future falls for 1 of 15 residents (R27) reviewed for accidents in a sample of 48. This failure resulted in R27 falling outside in the designated smoking area and then having to be sent out to the emergency room for laceration on her left and right arm and having to be seen by a wound care specialist. Findings include: R27's admission Record dated 09/10/25 documents an admission date of 06/06/25 with diagnoses of history of falling, tobacco use, type 2 diabetes mellitus with diabetic neuropathy, unspecified sequelae of nontraumatic intracerebral hemorrhage. R27's MDS (Minimum Data Set) dated 08/18/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 13 which indicates R27 is cognitively intact. Section GG documents walk 10 feet as supervision and touching assistance, walk 50 feet with two turns as supervision and touching assistance, and walk 150 feet as supervision and touching assistance. R27's Care Plan with a revision date of 06/10/25 with a focus area of Risk for falls which has a goal of resident will be free of falls. Interventions for this focus include 08/04/25 Fall intervention updated to include maintenance supervisor to fix concrete in courtyard, 06/06/25 determine residents' ability to transfer, 06/06/25 ensure call light is available to resident, 06/06/25 evaluate fall risk on admission and PRN (as needed), 06/06/25 if fall occurs, alert provider, and 06/06/25 if fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. R27's witnessed fall report dated 08/03/25 document's incident location: Outside, Nursing Description: Nurse visualized pt (Patient) laying on back outside on floor, skin tear to the left wrist, left forearm, right forearm with blood present applied pressure to the skin tear to stop bleeding. Pt voiced no pain in lower extremities, no inverting turn to feet. VS (Vital Signs) obtained other nurse called appropriate persons. Pt sent to (Local Hospital) with bed hold policy. Resident Description: Patient stated she was trying to get out of the way of another pt when she tripped and lost her balance. Pt stated she did not have pain in lower extremities, but her arms were a 10/10. Injuries observed at time of incident: laceration left forearm, skin tear left wrist, and skin tear right forearm. A statement taken by V2 (Director of Nursing) from V24 (Certified Nurse Assistant/CNA) dated 08/03/25 documents under statement: “I was passing cigarettes to the residents and heard yelling. I saw (R27) on the concrete next to the railing holding her arm saying I was trying to get out of his way.” R27's hospital discharge records from local hospital dated 08/03/25 documents her diagnosis as other skin changes- large skin tears bil (Bilateral) forearm left greater than right. Special notes document leaves covered, until you can get an appt (appointment) with pcp (Primary Care Physician) or wound care. R27's hospital records document that R27 was sent back to the facility with a prescription for Doxycyline Hyclate (antibiotic) every 12 hours and Hydrocodone-Acetaminophen (pain medication) every 6 hours for pain control. R27's hospital records for a visit on 8/5/25 document, “Pt (patient) states, “I was trying to move away from somebody yesterday and I was kind of knocked over and I fell and I hit the concrete my body and scraped my arms real bad. They sent me to (Name of local ER). Today my arm just won't stop bleeding so they sent me back in.” These records document Final diagnoses as skin tear of left upper extremity and hand swelling. R27's wound assessment and plan from the wound care doctor dated 08/05/25 documents right forearm wound measurement 4 cm (centimeter) length X 5 cm width X 0.1cm depth and left forearm wound measurement: 10 cm length X 6.5 cm width X 0.1cm depth. On 09/09/25 at 9:40AM, R27 stated on 08/03/25 that she was walking outside down the ramp to go smoke with all the smokers. R27 said she had her rolling walker and was holding on to the rail to go down the ramp. R27 stated she was trying to go down that ramp when she saw R10 who had already gone down the ramp and was coming back her way, R27 said she was trying to get out of his way because he doesn't pay attention, and he will run you down. R27 said that she was trying to get out of his way and tried to back up, but his walker bumped into her walker, and she went back and fell. R27 said that R10 didn't stop he just kind of bumped her as he went past, and she was on the ground bleeding. R27 said that she had large skin tears to both of her arms from the fall and that there was blood all over. R27 said that she was yelling out in pain. R27 said that the staff had her sit up on her wheeled walker and was trying to get the bleeding to stop. R27 stated that she did not trip or fall over any cracks or broken concrete. R27 stated she heard that R10 bumped into another resident the next day she didn't know who it was. R27 said that her wounds on her arms were so bad she had to have a wound doctor take care of them and they talked about a wound graft to the left arm, but they didn't have to do a graft. R27 said that the wounds to her arms are just now starting to heal. R27 stated that she doesn't feel safe around R10 when they go out to smoke. R10's admission Record dated 09/10/25, documents an admission date of 05/11/21 with diagnoses schizophrenia, need for assistance with personal care, anxiety, depression and nicotine dependence. R10's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates R10 has moderately impaired cognition. Section GG documents walk 10 feet as supervision or touching assistance, walk 50 feet as supervision and touching assistance, and walk 150 feet as supervision and touching assistance. R10's Care Plan has a focus area of Tobacco use with a revision date of 04/24/25 with a intervention in part of: The resident requires supervision while smoking with a date initiated of 05/10/25. Another focus is: The resident has a history of being impatient during smoke breaks when he is waiting in line to enter/exit building r/t (related to) poor impulse control with a revision date of 09/09/25 with interventions in part of: The resident's triggers for impatience are during smoke breaks when entering/exiting the building d/t (due to) becoming impatient with peers. Resident is educated on single file line with peers wanting to enter/exit also and that cutting in line is not allowed. Resident educated at each smoke break time to reduce aggression revision on 09/09/25, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of resident posing danger to self and other with a date initiated of 08/20/24, and when the resident becomes agitated: Intervene before agitation escalates: Guide away from source of distress: Engage calmly in conversation: If response is aggressive, staff to walk calmly away, and approach later revision on 09/09/25. On 09/09/25 at 10:58AM, R10 stated he has bumped into several residents before when going outside for his designated smoke break. R10 stated that it is his fault sometimes when he bumps into other residents and other times it is the other resident fault. R10 stated he remembers R27 falling outside on one of their designated smoke breaks. R10 said that the resident doesn't get out of his way. R10 said that when R27 fell she was yelling and bleeding all over. R10 said that he doesn't know who all he has bumped into at the facility. R10 said that when he goes out to smoke, they try to make him last in the line. R10 said that he doesn't know why he must be last that is just what they told him at the facility. On 09/09/25 at 11:30AM observed R27 right and left arm. R27 had an area to her left forearm which appeared to be approximately 10cm long and around 7 cm wide with some redness noted, along with areas that appeared to be scar tissue and raised. R27's right forearm arm had an area which appeared to be scar tissue no open area noted areas appears to be approximately around 5cm in length. On 09/08/25 at 3:00PM, R26 who was alert and oriented stated she is a smoker, and she was outside on the designated smoke break when R10 fell. R26 stated R10 was trying to hurry up and get his cigarette and R27 was coming down the ramp and that R27 was trying to get out of the way of R10 and R27 backed up and fell. R26 stated that R10 just went over and bumped R27 as she was laying on the ground. R26 stated that a nurse has her write a statement about what happened on 08/03/25 with R27's fall. R26 stated that R10 is always in a hurry and doesn't look where he is going and bumps into everyone. R26 said R10 has bumped into her before. On 09/09/25 at 10:38AM, R3 who was alert and oriented stated that she is a smoker and that she was outside on 08/03/25 when R27 fell. R3 stated that R27 was coming down the ramp to go outside to smoke and that R10 was going to run over R27 with his rolling walker so R27 was trying to get out of the way and fell. R3 said after R27 fell that R10 plowed right over her. R3 stated that R10 has bumped into her with his rolling walker and caused a skin tear to her leg. R3 said that R10 is always in a hurry to be the first out to smoke and he wants to get his cigarettes first. R3 said that she thought he has bumped into another resident legs and caused a skin tear. On 09/09/25 at 10:46AM, R28 who was alert and orientated stated that she is a smoker and goes out for the designated smoke breaks. R28 stated she remembers when R27 had her fall outside on 08/03/25. R28 stated R27 was trying to get out of the way of R10 so he didn't run her over. R28 stated she is not sure if R10 bumped her or pushed her causing the fall. R28 said R10 is always in a hurry to get outside to smoke and will pass all the residents up on the ramp and try to get outside first. R28 stated that she knows that R10 has bumped into a couple of residents while trying to get outside to smoke. R28 could not remember who all R10 has bumped into. On 09/09/25 at 2:25PM, R4 who was alert and oriented at that time stated that she does go outside to smoke. R4 stated that she thought a guy bumped into her when she was outside smoking but couldn't remember who it was. R4 stated that she didn't know if she got a skin tear or not from the guy bumping into her. On 09/08/25 at 3:00PM, V16 (Licensed Practical Nurse/LPN) stated that R27 fell on [DATE]. V16 said that she wasn't outside when R27 fell but that she heard that R27 was trying to get out of the way of R10 and that R27 fell and received skin tears to both arms. V16 said that she was taking witness statements to help the agency nurse out because residents were saying R10 bumped into R27. On 09/08/25 at 3:13PM, V1 (Administrator) stated that R27's accident on 08/03/25 when R27 fell outside on the designated smoking break was because R27 was trying to back up out of R10's way and then she fell. On 09/08/25 at 3:31PM, V22 (Agency LPN) stated that R27 fell outside on her designated smoke break on 8/3/25. V22 stated that when R27 fell outside she caused skin tears to both arms that were bleeding bad and that she had to send R27 out to the local hospital. On 09/09/25 at 11:55AM, V25 (Social Service Director) stated that she has only worked at the facility for around month. V25 said that R10 must go last in the line when they are going out on the designated smoke breaks. V25 stated that when she started working at the facility that is what they told her, she didn't remember who told her. V25 said she doesn't know why they didn't make him the first person to go out because he is always in a hurry to get outside and smoke. V25 said that R10 gets in hurry and tries to get down the ramp as fast as he can. V25 stated that when she takes the residents outside for their designated smoke breaks, she has heard several residents talking about how R10 has bumped into them, but she has never had any of those residents come to her complaining about it. V25 said she tries to wait to pass out the cigarettes to the residents until all the residents are outside so she can make sure all the residents get outside first safely. On 09/09/25 at 2:33PM, V28 (MDS/Care Plan Nurse) stated that R10 use to have a focus area on the Care Plan about his impulse control of getting in a hurry to go outside and smoke. V28 stated that she resolved that focus area on the care plan because she went back and looked at the social service notes and nurses' notes and did not see any more concerns with R10 rushing to get outside to smoke. V28 stated the last incident that R10 had with getting into a hurry was back on 03/11/25 when R10 was in a hurry to get out and bumped someone with his rolling walker. V28 said that she was putting the focus area back on R10's care plan today about him having impulse control and getting in a hurry to smoke. V28 said that the reason she was putting the focus area back on his care plan is because she was told today that R10 was rushing and getting in front of people to get outside. On 09/09/25 at 3:46PM, V21 (Maintenance Director) stated that he did repair some concrete out in the designated smoking area. V21 stated that he didn't know why he must repair the area. V21 said that the concrete around the smoking area did have a few cracks, and it had a dip in one of the areas and he filled it the best he could. V21 said that he didn't know if some of the wheels on the wheelchairs were getting stuck on the cracks or what. V21 said that the cracks and the dip are on the patio part not by the handrail. V21 said that he doesn't remember if he got a work order about it or if he was just told about the cracks. On 09/09/25 at 3:51PM, V1 stated that when R27 fell outside in the designated smoking area they talked about her fall in their daily meeting. V1 said they were trying to figure out how R27 fell so they went outside to the designated smoking area and found some cracks in the concrete, and they thought those could be a fall hazard, so they had V21 repair the cracks. V1 said that she doesn't know why R10 is last coming when they take the residents out on their designated smoke breaks, but she is currently doing an in-service with staff about taking residents out to smoke and monitoring for behaviors when they are outside smoking along with being mindful about what is going on outside when the residents are smoking. On 09/10/25 at 11:02AM, V2 (Director of Nursing) stated on 08/03/25 R27 was trying to get out of the way of R10 when she fell. V2 stated that the staff member who was outside supervising when R27 was R24. V2 said that R24 said in her statement that she was passing out cigarettes when R27 fell, and she heard her yelling. V2 said that R24 should not have passed out any cigarettes until she had made sure that all the residents made it out to the smoking area and was able to observe all resident when they smoked. V2 said that she thought fixing the cracks in the concrete was an appropriate intervention for R27's fall, because she thought it said somewhere that R27 fell because of the cracks. On 09/09/25 at 3:45 PM there were six residents outside smoking with nine residents lined up making their way out the door to the smoking area. R10 was in line to go out to the smoking area. R10 would shuffle his feet pushing his walker forward coming within approximately an inch of hitting the resident in front of him and then would move backwards almost stepping into the resident behind him. This action continued until R10 was in the outside area. The facility policy titled “Fall Prevention Program” with a revision date of 11-21-17 documents the purpose as: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines include in part: Methods to identify risk factors. The facility policy titled ‘Safe Smoking and Vaping Policy/Procedure” with a last update date of 09/10/25 documents under policy: The facility works to provide appropriate care for residents, keeping safe and comfort in mind. Residents may have the desire to smoke/vape, and accommodations will be provided as the facility deems appropriate. The facility treats the use of vaping products the same as traditional smoking products. Procedure documents in part: 3. The rules are as followed # 3. Conduct while smoking must promote safety. #4. No negative behaviors related to smoking are permitted. B. The timeframes above are the only times smoking materials may be distributed. Continued disruption of resident care responsibilities over smoking break times constitutes a violation of the “No negative behaviors related to smoking are permitted.”

Based on interview and record review, the facility failed to ensure a resident requiring dialysis received dialysis treatments for 1 of 2 residents (R1) reviewed for dialysis in the sample of 11. This failure resulted in R1 being admitted to the hospital to receive dialysis treatment and pulmonary venous congestion. Findings include: R1's admission Record documents an admission date of 3/31/25 and diagnoses including peripheral vascular disease, end stage renal disease, iron deficiency anemia, chronic diastolic heart failure, dependence on renal dialysis, sepsis, bacteremia, and essential hypertension. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. The same MDS documents under special treatment, procedures, and programs that R1 is receiving dialysis. R1's most recent Care Plan documents a focus area with an initiation date of 3/31/25 of R1 receives dialysis and a goal area of R1 will remain free of complications related to dialysis. On 5/28/25 at 12:49 AM, R1 stated he has missed appointments for dialysis since the van has been broken down and dialysis is a life sustaining treatment. R1 said he has been sent to the hospital twice for dialysis. R1 stated the first time they did not even do dialysis there and he was sent back to the facility without receiving dialysis and the next time he was sent to a different hospital and had to stay overnight to receive dialysis. R1 stated the facility does keep checking his blood he guesses because he missed his dialysis. R1 stated he is unsure how many times he has actually missed. R1 stated they gave him grief at the hospital because he did not know they did not do dialysis, that is where he was sent, he did not have any control over that. R1 stated the next time he was sent to another hospital and stayed overnight but then he received dialysis in the morning. R1 said that he did not refuse to go to dialysis on 5/16/25, the transportation van was broken down. R1 stated his dialysis is every Monday, Wednesday, and Friday. R1's Progress Notes document the following: 5/16/25 at 5:12 AM: Resident refused AM meds and is now refusing to go to dialysis. Transportation aide made aware. Will monitor for change. 5/19/25 at 8:06 AM: R1 did not attend dialysis. 5/19/25 at 12:45 PM: Call placed to (name of dialysis center) r/t (related to) missed dialysis appointment this am. New order received to send res (resident) to ER (Emergency Room). This writer spoke with (R1), he is in agreeance . 5/19/25 at 3:00 PM: V15 (Medical Records/Transportation) reached out to a local transportation company, and they stated they do not start transporting early enough to transport R1 to dialysis. 5/19/25 at 6:00 PM: Resident returned from (name of local hospital). Nurse on duty stated that resident did not receive Dialysis because labs did not indicate he needed Dialysis at this time and ER cannot do Dialysis. Resident would need to be admitted there was no need for him to be admitted because his condition is stable but resident needs to go to Dialysis tomorrow. Writer informed DON (Director of Nurses). 5/20/25 at 3:05 PM: V15 called a local transportation company, and they told her they do not service their area. 5/21/25 at 5:40 AM: Resident up in dining room at this time awaiting ride for dialysis. Transportation aide here and notified this nurse that transportation van is unavailable for transport at this time and would need to be transported another way to dialysis. DON notified and awaiting further orders. 5/21/25 at 6:34 AM: The dialysis center was called due to R1 missing dialysis treatment today. New orders were received to send R1 to the emergency room. EMS (Emergency Management Service) was called to transport R1 to the local hospital. 5/21/25 at 2:15 PM: Spoke with (name of hospital Case Manager) at (name of local hospital). She states resident is telling them we will not take him to his dialysis appts (appointment), she is wanting to know what is going on with this. This nurse explained resident missed his appt Friday the 16th due to his own refusal, he did not want to go to dialysis that day. Resident missed dialysis Monday the 19th due to the van lift not working that morning. We contacted (name of dialysis center) to let them know what was going on. They stated they would like resident to go to the ER. Resident was sent to (name of a local hospital) for eval and possible dialysis. (Name of a local hospital) reported to us they did labs and he does not require dialysis at this time. Resident missed dialysis this am (Wednesday 21st) due to van lift still being broken and unable to find other transportation. (Name of dialysis center) was notified, they stated to send to ER. Resident was then sent to them at (name of local hospital). (Name of hospital Case Manager) states understanding. I let her know we were having a lot of trouble finding transportation for him while our van is being repaired. (Name of hospital Case Manager) suggested (name of a transportation company), I let her know we have already tried them and they do not service [NAME] County. But if she has any other suggestions for transportation to please let us know and we will try. (Name of hospital Case Manager) said she will call us back with any suggestions. (Name of hospital Case Manager) asked if this will be an issue for Friday as well, are we going to send him back to them for dialysis? I told her I could not say for sure. At this time we do not have transportation for Friday, but we are working on it. (Name of hospital Case Manager) states they may admit and keep (R1) until after her receives dialysis Friday. They are unsure of that plan at this time, they will call us back to let us know. 5/23/25 at 5:30 AM: The dialysis center was called to inform them that the facility's van was still out of service and R1 has no transportation to his dialysis appointment today. The dialysis center's staff stated to monitor intake and output and to monitor for noticeable decline in condition and if condition changes send to the emergency room to get dialysis. 5/26/25 at 6:23 AM: The dialysis center was called related to missed dialysis treatment today. The dialysis center's nurse stated to monitor R1 for nausea, vomiting, diarrhea, and increased shortness of breath and if these symptoms are noted send to the emergency room. 5/27/25 at 11:28 AM: V15 spoke with a local transportation company to see if they could privately pay the transportation company to transport R1 to dialysis and the transportation company said they do not provide transportation that early. V15 then called R1's dialysis center to see if there was a later chair time for R1, they stated they would look and call them back. 5/27/25 at 12:00 PM: V15 spoke with the dialysis center, and they could do a later chair time at a different dialysis clinic location, but the transportation company does not run as late as the appointment and would not be available to transport R1 back to the facility after the appointment. R1's local hospital document titled Hospital Discharge Summary Brief Overview dated 5/22/2025 documents an admission date of 5/21/2025 and a discharge date of 5/22/2025 and a primary discharge diagnosis of End Stage Renal Disease. R1's local hospital Dialysis Note, Hemodialysis Post Treatment Summary dated 5/21/2025 documents R1 received a dialysis treatment with a duration of treatment of 3 hours. R1's Chest Radiograph from local hospital dated 5/21/25 at 10:13 AM-5/21/25 at 10:35 AM documents under impression: 3. Pulmonary venous congestion with equivocal interstitial edema and trace bilateral pleural effusions. On 5/28/25 at 10:16 AM, V6 (Registered Nurse at dialysis center) stated R1 has not been to treatment since 5/14/25 due to transportation. V6 stated the facility told them their transportation van was broken down and they didn't have any other transportation. V6 stated today was his first day there since 5/14/25. On 05/28/25 at 3:25 PM, V3 (Assistant Director of Nursing) stated the facility van has been broken for approximately 1.5 weeks. R1 has been sent to the hospital twice to receive dialysis, one time he received dialysis and one time he did not receive dialysis. The first hospital stated they do not do dialysis, but they did his labs and stated he did not need dialysis immediately, so they returned him to the facility. The next time they sent him out, they sent him to (a different local hospital) he was admitted and stayed overnight and received dialysis the next day. V3 stated, dialysis is always beneficial for a resident that is on dialysis treatment but maybe not always immediately crucial. V3 stated, R1 missed dialysis on the previous Friday (05/16/25) because he refused, on 05/19/25 he was sent to the hospital but did not receive dialysis, on 05/21/25 he was sent to the hospital and received dialysis, on 05/23/25 and 05/26/25 he did not receive dialysis, today (05/28/25) they were able to borrow a van and he went to dialysis. V3 stated he believes he missed four days total of dialysis due to the van not working. V3 stated, the moment they were aware the lift gate on the van didn't work they started looking into other options to get him to dialysis. On 05/28/25 at 11:26 AM, V4 (Licensed Practical Nurse) stated the facility van has been broken for about a week that she is aware of, she has been at school. V4 said that R1 has missed dialysis due to the van being broken. V4 said R1 was able to go to dialysis today due to borrowing a van from another facility. On 5/29/25 at 8:41 AM, V12 (Registered Nurse dialysis center) stated R1 needs to be at dialysis for his scheduled treatment 3 days a week per the physician order. V12 stated R1's creatinine was reasonably high at his last labs so that indicates R1 does need dialysis. V12 stated R1's fluid status wasn't bad when he came to treatment on 5/28/25. V12 stated R1 had lost 4.6 kilograms since the last treatment. V12 stated there is also the risk of R1 becoming uremic if he doesn't get dialysis as ordered. On 5/29/25 at 10:01 AM, V13 (Nephrologist) stated R1 does need dialysis at this time. V13 stated they drew labs on 5/28/25 at the dialysis center but those labs have not resulted yet. On 5/29/25 at 1:17 PM, V14 (Regional Administrator) stated they have purchased a new accessible van, and it should be here in about one week, it was shipped from another state. On 5/29/25 at 1:17 PM, V1 (Administrator) stated until the new van arrives, they will be borrowing a van from a sister facility. The transportation aide is picking the borrowed van up today and it will be available to transport residents to their dialysis appointments until the new van arrives. V1 stated it is the expectation that if they accept a resident that is on dialysis, they are responsible for providing the transportation to their dialysis appointments. The facility policy dated 2/13/18, titled Dialysis Monitoring and Observation documents under Purpose: To ensure residents receiving hemodialysis are monitored for complications. The facility policy dated 12/19/23, titled Transportation for Residents documents under Guidelines 4. Designated personnel shall assist residents in obtaining transportation when it is necessary to obtain medical, dental, diagnostic, or other services outside the facility.

Based on interview and record review the facility failed to ensure residents were free from chemical restraints when staff administered an injectable anti-psychotic medication twice within an 8 hour time frame without the resident's consent and without a physician's order to include adequate indications for use, and failed to attempt less restrictive alternative treatments prior to administration of the medication for 1 (R1) of 3 residents reviewed for chemical restraints in the sample of 7. This failure resulted in R1 being sent to the emergency room for lethargy, facial swelling, and possible allergic reaction to the anti-psychotic medication administered. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 12/3/24 at approximately at 10:30 PM when V10 (Licensed Practical Nurse) administered Chlorpromazine (Thorazine) 100mg Intramuscular injection and again on 12/4/2024 at 5:30AM. V1 (Administrator) was notified of the Immediate Jeopardy on 12/17/24 at 3:40 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on 12/18/24, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. The findings include: R1's Admission Record documents an admitted [DATE] and includes diagnoses of Parkinsonism, Paranoid Schizophrenia, unspecified Psychosis, Heart Failure, Anxiety Disorder, Hypertension, Schizoaffective Disorder and Major Depressive Disorder. R1's Admission Record also documents R1's allergies as Clonazepam (Klonopin), Fluphenazine (Prolixin), Haloperidol (Haldol), and Mellaril (Thioridazine). R1's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 99, indicating that R1 was unable to complete the interview. Section E, Behavior, Delusions is marked under potential indication for Psychosis. Section E also documents that verbal behavioral symptoms directed toward others occurred 4 to 6 days, but less than daily, during the 7 day look back period. Physical and other behavioral symptoms directed at others is marked as the behavior was not exhibited. Section N, Medications, documents that R1 received antipsychotics on a routine basis only. R1's Physician Orders dated 9/6/2023 documents an order for Chlorpromazine 100mg IM every 6 hours as needed for Psychosis. Offer by mouth first give with Benztropine in same syringe. R1's Physician Orders for September, October, November, and December 2024 were reviewed with no orders noted for Chlorpromazine (Thorazine). R1's document titled Medication Administration Record for December 2024 has no documentation of an order for, or administration of, Chlorpromazine (Thorazine). On 12/13/2024 at 10:58AM, V18 (Registered Pharmacist) stated R1's order for Chlorpromazine (Thorazine) 100mg IM was ordered on 9/2/2023 and stopped on 9/21/2023 and the reason for that date is because the order was processed on 9/7/2023 and 14 days later it was stopped on 9/21/2023. V18 said that there was not a restart date or updated order date for Chlorpromazine (Thorazine). V14 stated the order was stopped on 9/21/2023 due to being an as needed psychotropic medication and cannot be valid after 14 days so it is stopped by the pharmacy due to regulations. On 12/11/2024 at 2:40PM, V12 (Certified Nurse Assistant/CNA) stated she worked on the night of 12/3/2024-12/4/2024 from 8PM -6AM and she was the one-on-one sitter for R1. V12 stated when she arrived at work that evening, she was told in report that R1 had thrown a urinal at staff. V12 stated at approximately 9:30PM she was being assisted by another CNA with R1's care and R1 spit on the other CNA. V12 stated V10 came in and told R1 she was going to give him something to calm him down if he didn't stop having behaviors. V12 stated around 10:30PM she and another CNA (V14) was standing R1 up so he could use the urinal, and V10 came in and went behind R1 and gave him a shot in his bottom. V12 stated R1 said That was a sneaky thing you just did. V12 stated earlier in the shift, V11 (LPN) had come into the room and told R1 she would give him a shot if he had any behaviors. V12 stated after the injection R1 had behaviors for about 15 minutes then he went to sleep and slept like a baby all night. V12 was asked if she witnessed the 2nd Injection that was said to have been given at approximately at 5:30AM on 12/4/2024, V12 stated I did not and I was watching him very closely as I would push a resident just up to the dining room and then went back in to check on R1, not leaving him out of my sight for more than a couple of minutes at a time. V12 stated when she left at 6:00AM, R1 was sleeping soundly. V12 stated V10 told her she had given a second shot, but she didn't witness this and R1 was sleeping. On 12/11/2024 at 3:28PM, V10 (LPN) stated she was familiar with R1, and she worked on the night shift that started on 12/3/2024 at 10:00PM and ended at 6:00AM on 12/4/2024. V10 stated R1 started having behaviors of biting, spitting, and kicking staff so she pulled 2 ampules of Chlorpromazine (Thorazine) to administer to R1. V10 stated the medication was in a box in the medication cart with R1's name on the box with instructions. V10 stated she went to R1's room and 2 CNA's (V12 and V14) were standing him up with his pants down to either change him or let him use the urinal. V10 stated each CNA had ahold of R1's arms. V10 stated I sneaked in behind them and jabbed him in the butt with the shot of medication of Chlorpromazine. V10 was asked if she explained to R1 what she was doing and V10 stated Lord no, he would not have let me do it. V10 was asked what R1's response was when she gave him his injection, V10 stated well he swung at me and I dodged the hit and R1 stated, that was sneaky and that was not right. V10 was asked if she validated the orders for R1 before administration and V10 stated No. V12 stated she gave a second injection on 12/4/24 at 5:30AM. R1's Nurse's Note dated 12/3/2024 at 10:30PM, authored by V10 (LPN), documents Resident screaming and cursing staff during care spitting on CNA's PRN (as needed) injection given. Remains 1:1. On 12/12/2024 at 2:45PM, V10 was asked why the injection of Chlorpromazine (Thorazine) was given at 5:30AM on 12/4/2024, V10 stated he was acting up and starting to get revved up again. V10 stated she can't remember who assisted her with the injection, but she did give him an injection at 5:30AM on 12/4/24. V10 was asked if she explained to R1 what she was administering and V10 stated No I just jabbed it in his arm. V10 stated V10 is very strong and can hurt people. V10 was asked why there is no documentation of giving this injection, V10 stated I was busy trying to pass medications and I was helping the CNA's as well. V10 stated she had not had time to check physician orders or the medication administration record prior to administering the medication or even after she administered either dose she had administered. On 12/12/2024 at 12:10PM, V13 (CNA) stated he was aware R1 received an injection at 10:30PM the night of 12/3/2024. V13 stated he worked 10PM to 6AM on 12/3/204-12/4/2024. V13 stated he was unaware that a second injection was given at 5:30AM on 12/4/2024. V13 stated he went and checked on R1 before he left at 6:00AM and he was really sleeping. V13 stated the reason the injection was given at 10:30PM on 12/3/2024 is R1 was starting to kick us and using obscene language. V13 stated after the injection R1 slept all night. On 12/12/2024 at 12:52PM, V14 (CNA) stated she worked 10PM-6AM on 12/3/2024-12/4/2024. V14 stated R1 was yelling down the hall and spit on staff around 10PM. V14 stated that R1 was trying to get out of bed. V14 said she was told by V10 to help V12 get R1 in a standing position and pull his pants down so V10 could give him an injection. V14 stated V10 came in the room and got behind us and gave the injection in R1's buttocks, this occurred around 10:30PM. V14 stated R1 swung at V10 and R1 stated that was sneaky. V14 stated we offered R1 the urinal after the injection and he refused to use the urinal. V14 stated R1 rested the rest of the night, and he was fine throughout the night. V14 stated she was not aware of a second injection being given. V14 stated she checked on R1 before she left at 6:00AM and he was sleeping well. On 12/12/2024 at 1:17PM, V15 (CNA) stated she came to work on 12/4/2024 at 5:00AM. V15 stated she did not know of any behaviors from R1 and did not get anything in report, but she was assigned to a different hall. V15 stated she did see V10 with a syringe in her hand but did not know who the medication was for and what room V10 went into. On 12/12/2024 at 1:30PM, V16 (CNA) stated she worked on 12/4/2024 from 5:00AM to 1:00PM. V16 stated when she arrived at work and made some rounds, she did not know of any residents having behaviors. V16 stated she was busy getting residents up and she did see V10 with a syringe in her hand but did not know who it was for. V16 stated she did not witness or assist with any injections being given. On 12/12/2024 at 12:15PM, V9 (LPN) stated on 12/4/2024 she was the charge nurse for R1. V9 stated she received report from V10 (LPN) at 6:00AM, V10's report included information that V10 had administered Haldol IM (intramuscular injection) at 10:30PM on 12/3/2024 and 5:30AM on 12/4/2024. V10 reported to V9 that R1 had been aggressive. V9 stated she went to check on R1 before breakfast and R1 was sleeping, and he didn't arouse when she softly called his name. V9 stated R1 did not eat breakfast because he was sleeping. V9 stated I just thought he was tired from the medication. V9 stated she went back to his room to check on him a short time before lunch and she could not get him to wake up, so she asked V7 (LPN) to come help her with him. V9 stated she and V7 went immediately back to R1's room and turned him over a little and noted R1 to arouse a little and he was mumbling with worsened slurred speech, lips swollen, side of his face was red with some edema noted and the top of his head was very red with a rash like appearance. V9 stated she ran and got V3 (LPN/Assistant Director of Nursing), and this is when they called EMS (Emergency Medical Services) to transport R1 to the ER (emergency room ). V9 stated she then went to investigate what actual medication was given. V9 stated she noted a box of Chlorpromazine with 20 ampules in the box and the box had contained 25 ampules when it was filled. R1's Nurse's Note dated 12/4/2024 at 12:20PM, authored by V9 (LPN), documents that EMS in facility to transport resident to ER. On 12/11/2024 at 2:22PM, V3 (Licensed Practical Nurse/Assistant Director of Nursing) stated on 12/4/2024 she arrived at work around 11:00AM. V3 stated V7 (Licensed Practical Nurse/LPN) and V9 (Licensed Practical Nurse) were working the floor at the time, and reported to V3 that R1 was not acting right, and his eyes were swollen, as well as his mouth. V3 stated she called the ambulance. V3 stated R1 was sent out to the emergency room . V3 stated during her investigation she spoke with V12 (Certified Nurse Assistant/CNA) who was the sitter on the previous night of 12/3/2024, for R1. V3 stated that V12 reported she witnessed an injection being given to R1 by V10 (Licensed Practical Nurse/LPN) the night of 12/3/2024. V3 stated she was under the impression that R1 had to be held for the injection and that is not allowed as that is physically restraining a resident, then giving the medication to calm him down is a chemical restraint. R1's Nurse's Note dated 12/4/2024 at 11:30AM, Medication removed from medication cart Chlorpromazine IM (Intramuscular) vials removed and discarded. R1's Nurse's Note dated 12/4/2024 at 11:59AM, authored by V3 (LPN/Assistant Director of Nursing), documents Resident noted to have symptoms of allergic reaction. Upon entering residents (R1) room this nurse noted that resident has a swollen face, eyes, and hives. Called (V8-Physician) with symptoms and gave orders to send to ER (emergency room ) for eval and treat. EMS (Emergency Medical Service) called. R1's Nurse's Note dated 12/4/2024 at 12:45PM, authored by V7 (LPN), documents that report called to local hospital ER. On 12/12/2024 at 12:31PM, V7 (LPN) stated she was working the day of 12/4/2024. V7 stated she was asked to go with V9 to check on R1. V7 stated we got him aroused, his face/jaw area was swollen, and I remember the top of his head was so red with a rash noted. V9 stated she noted his tongue seemed a little thick and his speech was really slurred. V7 stated when EMS got to the facility R1 was still lethargic and he didn't even resist care as he normally does. V7 stated all R1 did was mumble. V7 stated she has never given R1 any type of injections and she did not know those injections were in the medication cart. R1's Emergency Department document titled: Physician Documentation dated 12/4/2024 at 1:29PM documents this [AGE] year-old white male presents to Emergency Department by EMS (Emergency Medical Service) with complaints of possible allergic reaction. Patient at nursing home was sent in because nurses thought he was having an allergic reaction to some medication. Patient was seen yesterday by this Emergency Department, was found to have emergency medical condition (complaint was abdominal pain). Patient was given Benadryl Intravenously in rout by EMS they felt like his face was flushed and had some swelling, patient knocked out from Benadryl, he does react if you touch him. Will CAT SCAN head. The ER Notes documents allergies of: Fluphenazine, Haldol, Klonopin, Mellaril, Penicillin, Porlixin. The ER Course documents at 2:48PM: in lieu of the labs done yesterday that were within normal limits and patient is back to normal limits after IV (Intravenous) Benadryl wore off. Will return to nursing home. There is no allergic reaction to medication because he did not get any yesterday while in this Emergency Department and he did not get any nursing home medications today either. On 12/12/2024 at 7:11PM, V17 (emergency room Physician) stated he was working the day of 12/4/2024 and he provided care for R1. V17 pulled the ER visit that occurred on 12/4/2024 and was reading his report to this surveyor. V17 read the report stating R1 had not received any medications the day before (12/3/2024) while in the emergency room and there is no evidence of medications being given in between ER visits. V17 was asked if he was aware R1 had received 2 injections of Chlorpromazine (Thorazine) with one being on 12/3/2024 at 10:30PM and the other one at 5:30AM on 12/4/2024, V17 stated I was not aware of that at all, and nobody reported this to me. V17 stated well this changes things because it makes sense why the paramedics administered IV (Intravenous) Benadryl, this patient probably was having an allergic reaction. V17 stated the paramedics would not have administered any medications while in route if it was not deemed necessary for the safety for the patient. V17 stated I saw (R1) probably at least 30 minutes after the Benadryl was administered and the redness and swelling would have decreased from the Benadryl by that time. V17 stated (R1) was really lethargic but I thought it was from the Benadryl. V17 stated No wonder he was so out of it, he had a big dose of Thorazine just a few hours before and one before that 6 hours apart. V17, stated I reviewed (R1's) medication sheets and those did not even list Thorazine and there sure was no documentation of Thorazine given. V17 was asked if this was a potential for harm to this patient and V17 Absolutely and not even just the allergic reaction, the fact that this patient had received 2 large doses of Thorazine within hours of coming to the ER and me as the physician not even knowing that, this could have been a bad situation for the patient. I could have ordered a medication that was contraindicated with Thorazine. Attempts were made on 12/13/2024, 12/16/24, and 12/17/24 to reach the ambulance service for an ambulance report for R1 on 12/4/2024 without success. On 12/13/2024 at 10:58AM, V8 (Physician) stated he does recall being informed R1 was administered 2 separate doses of Thorazine and was sent to the emergency room due to possible reaction. V8 stated he was not notified until R1 was in the emergency room . V8 was asked if he was aware the order for Thorazine was discontinued on September 21st, 2023, V8 stated I am not sure I knew that part. V8 stated he recalls the ER did not think it was an allergic reaction for some reason. V8 was informed the ER was unaware of the Thorazine injections. V8 stated Ok, makes sense. V8 stated I hope that is now on his allergy list along with other psych medications on his list. V8 stated R1's Psychosis has worsened since November. R1 started refusing his medications and was very paranoid of his medications. On 12/10/2024 at 1:45PM, V1 (Administrator) stated she was aware of the medication error that was made on R1. V1 stated she had terminated 2 nurses over the incident. V1 stated one nurse was fired because she intended to give the medication if a behavior would have occurred on her shift and the other nurse (V10) actually gave the medication not once but twice. V1 stated she could not believe a nurse would give a medication without checking the records. V1 stated there is nothing she could have done to stop it unless she was asked prior to administering the medication. V1 stated R1 was sent to the hospital with what looked like an allergic reaction. An incident report titled Report to IDPH (Illinois Department of Public Health) Regional Office dated 12/4/2024, documents the following Description of Occurrence: On early AM 12/5/2024 (R1) was unable to speak clearly, noted his face and lips are slightly swollen, and some red rashes on his upper torso. (V8-Physician) was called immediately, and the order was received to transport resident to local hospital for further evaluation. It was discovered that a med that was given in the past had been used for (R1) due to behaviors. These injections were discontinued in September of 2023. The medication was good until 3/2025. This medication was accidently given to the resident at 10:30PM and again at 5:30AM for continued behaviors. The Action Taken on the incident report documents the following: Patient (R1) transported to (name of local hospital) by ambulance for treatment and observation. Resident was evaluated and a CT (Computed Tomography) was completed with no finding. Resident was returned to the facility with acting behaviors. Resident was placed on 1:1 with a staff member and referrals were sent to several facilities. The Final Summary documents the following: (R1) was taken immediately to local hospital, he was gone only a short time and returned to our facility with no findings of medications being the issue. They did perform a CT without contrast, and it came back clear as well. R1's Care Plan documents a Focus area of the resident is/has potential to be verbally aggressive with an initiation and revision date of 5/6/2024. Documented interventions for this focus area include the following: Provide positive feedback for good behavior, Emphasize the positive aspects of compliance (5/8/2024); Psychiatric/Psychogeriatric consult as indicated (5/8/2024); the resident tolerates minimal people at a time. The resident needs much amount of personal space. The resident reacts to touch by striking (5/8/2024); When the resident becomes agitated, intervene before agitation escalates. Guide away sources of distress. Engage calmly in conversation, if response is aggressive, staff to walk away calmly and approach later (5/8/2024). R1's Care Plan also documents a Focus area of the resident is/has potential to be physically aggressive with an initiation date of 6/10/24. The documented Goal of The resident will not harm self or others thru the next 90 days with an initiation date of 6/10/2024 and a revision date of 12/5/24. Documented Interventions include: administer medications as ordered. Monitor/document for side effects and effectiveness (6/10/2024), assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. (6/10/2024) Communication: provide physical and verbal cues to alleviate anxiety, give positive feedback, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated (6/10/2024). Give the resident as many choices as possible about care and activities (6/10/2024). Modify environment (6/13/2024). Monitor, document observed behavior and attempted interventions in behavior log (6/13/2024). Monitor/document/report any signs or symptoms of resident posing danger to self and others 6/10/2024). Psychiatric/Psychogeriatric consult as indicated (6/10/2024). When the resident becomes agitated intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If aggressive, staff to walk calmly away and approach later (6/10/2024). R1's Care Plan also documents a Focus are of The resident uses anti-psychotic medications with a Goal of The resident will remain free of psychotropic drug related complication, including movement disorder, discomfort, hypotension, gait disturbances, constipation/ impaction, or cognitive/behavioral impairment through review date with an initiation date of 5/8/2024. Intervention: Administer Psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. (5/6/2024). Review behavior/interventions and alternate therapies attempted and their effectiveness as per facility protocol. Educate the resident/family/ caregivers about risk, benefits and the side effects and toxic symptoms (5/8/2024). R1's Behavior Tracking was requested from V3 on 12/12/2024 and 12/13/2024 for December 2024 and none was provided. R1's Behavior Tracking was requested again from V1 on 12/19/24 and was received. R1's Behavior Tacking Records provided documents the dates of 12/17/24-12/31/24 and do not document any behaviors occurring or need to attempt interventions. There were no Behavior Tracking Records for R1 provided for December prior to 12/17/24. The facility policy titled Medication Administration (undated) documents under procedures #2, Review and confirm medication order for each resident on the Medication Administration Record prior o administering medications to each resident. Review medication administration record for any tests or vital signs that need to be determined prior to preparing the medications. Number 9 documents, chart medication administration on Medication Administration Record immediately following each resident's medication administration. The facility policy titled Psychotropic Medication Policy with a revision date of 11/28/2017, documents it is the policy of this facility that residents shall not be given unnecessary drug. Definition of Chemical Restraint documents any medication that is administered with the intent of altering consciousness, responsiveness, or to modify behavior, convenience, punishment, or discipline. The section titled procedure documents #1. Attempt to rule our social and environmental factors as causative agents of maladapted behavior. 2. Psychotropic medications shall not be prescribed prior to attempted non-pharmacological interventions to decrease behaviors. 5. Psychotropic medication shall not be prescribed or administered without the informed consent of the resident, the resident's guardian, or other authorized representative. The immediate jeopardy that began on 12/3/24 was removed on 12/18/24 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review: Facility Restraint Policy was reviewed by Regional Director of Operations (V19) on 12/17/24 and was found to be in compliance with state and federal regulations. Facility Administrator (V1) initiated in-servicing, for all staff, on the use of non-pharmacological interventions for resident behaviors initiated on 12/18/2024 all other staff will be in-serviced before the beginning of the next shift. The Administrator (V1) will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff, understand using non-pharmacological interventions for resident behaviors. Director of Nursing (V2) in-serviced all nurses to obtain orders for the administration of an injectable anti-psychotic initiated on 12/17/2024 to be completed by the beginning of the next scheduled shift. Director of Nursing (V2) in-serviced all nurses on documenting all medication administration in the MAR initiated on 12/17/2024 to be completed by the beginning of the next scheduled shift. Social Service Director will interview 3 residents, 3 times weekly x4 weeks to ensure that residents are getting their medication as prescribed. IDT (Interdisciplinary Team) has assessed R1 and care plan updated to reflect non-pharmacological interventions for behaviors on 12/17/24. IDT team reviewed all residents for the potential to not be free of abuse and care plans updated to reflect interventions to protect residents from abuse. Completed on 12/18/24. IDT in-serviced by Regional Director of Operations (V19) on 12/18/24 to review any resident for changes in behaviors, increase in behaviors or new behaviors in order to investigate and identify any potential triggers prior to an incident, ensure that person centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff. Residents who trigger during this IDT review will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. Individualized intervention will be developed to decrease episodes of behaviors, in order to prevent situations that may cause abuse to a resident. (on-going) On 12/4/24 the nurses in question (V10 and V11) were suspended pending investigation of the med error and ultimately terminated on 12/5/24. ADON (Assistant Director of Nursing-V3) completed an audit of the medication carts and medication room on 12/5/24 to ensure there were no medications present that did not have orders from the physician.

Based on interview and record review the facility failed to ensure residents are free from physical and verbal abuse for 2 of 5 residents (R26, R44) reviewed for abuse in the sample of 14. This failure resulted in R26 experiencing incidents of mental anguish, fear, anxiety, and feeling unsafe as a result of V34's (Certified Nursing Assistant/CNA) mental and verbal abuse. The Immediate Jeopardy began on 5/7/24 at approximately 2:00 AM when V34 (Certified Nursing Assistant/ CNA) verbally and physically abused R26 by ripping R26's clothing while transferring R26 to the wheelchair and wheeling R26 to the dining room to wait for breakfast. V44 (Regional Director of Operations) was notified of the Immediate Jeopardy on 5/15/24 at 12:35 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 5/16/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1. R26's document titled Admission Record documented an admitted [DATE] with diagnoses including: Ischemic Cardiomyopathy, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, Hypertension, Hyperlipidemia, Chronic Kidney Disease stage 3, Schizoaffective Disorder, Atrial Fibrillation, Anxiety, Chronic Obstructive Pulmonary Disease, presence of Automatic (implantable) Cardiac Defibrillator, Alzheimer's Disease, Unilateral Inguinal Hernia, Diabetes Mellitus, and Unspecified Urinary Incontinence. R26's MDS (Minimum Data Set) dated 4/23/2024 documented a BIMS (Brief Interview for Mental Status) with score of 10, indicating moderate cognitive impairment. R26's 4/23/24 MDS section GG documented R26 required maximal assistance with toileting and hygiene; dependent for shower and bathing, and lower body dressing; and partial to moderate assistance with transferring. R26's care plan did not document R26 having the potential for abuse. On 5/8/2024 at 10:32 AM, R26 was an alert and oriented resident sitting in the dining room. R26 stated his care is good here except for the night shift. R26 stated he gets his clothes ripped by a night shift CNA (Certified Nursing Assistant), V34. R26 pointed to the upper right shoulder area of his shirt that was ripped and stated V34 ripped it when he was pulling me out of bed. R26 stated, He (V34) gets me up at 2:00 AM-3:00 AM and brings me to the dining room and I have to sit here until breakfast. On 5/10/2024 at 12:15 PM, R26 stated I get tired of the treatment from (V34) CNA. I don't feel safe when (V34) is working. I want to just pull my pacemaker out and end it all sometimes, but only when (V34) is taking care of me. R26 then stated if R26 used the bathroom in bed V34 would roughly get R26 out of bed, ripping R26's clothes at times, and wheel R26 to the dining room to wait for breakfast. R26 stated V34 was also verbally abusive. R26 said the last time V34 had been abusive like this to R26 was within the past week of this survey (5/3/24 through 5/10/24). R26 stated facility staff were aware of V34 being abusive but nobody does anything about it. R26 was not able to give any staff names. On 5/10/24 at 3:14 PM, V34 (CNA) stated he assisted R26 with care around 2:00 AM on 5/7/24, 5/8/24, 5/9/24, and 5/10/24 during bed check. V34 said R26 was usually one of the last residents V34 would assist because R26 was usually not wet. V34 said he did not like to put a wrap around pullup on R26 because it gave R26 an excuse to pee in the bed instead of using the urinal. V34 stated he was not trying to be a d**k, but I know (R26) can use the urinal during the day. V34 said he was not trying to argue with (R26) but If (R26) wets the bed, I make (R26) get up in his chair so I can change the bed and put a pullup on (R26). V34 stated (R26) was not an easy resident to care for. V34 said when he is providing care for R26, V34 just tells (R26) like it is when things have to get done. V34 said he was very direct with residents and I feel like being direct is the only was for a resident to fully understand what is about to happen. On 5/10/2024 at 12:30 PM, R37 a roommate of R26 stated nightshift gets (R26) up around 3:00 AM and will make (R26) stay up if (R26) has soiled the bed. (V34 CNA) is very dismissive and verbally aggressive with (R26). R37 stated he has heard V34 tell R26 You must stay up because you pissed the bed. R37 said he had witnessed V34 handling R26 rough when getting R26 out of bed at night. R37 stated the last time it happened was this past week. R37 states V1 (Administrator) knows but nothing happens. R37's 3/26/24 MDS (Minimum Data Set) documented a BIMS (Brief Interview for Mental Status) score of 15, indicating R37 was cognitively intact. R26's 5/15/24 final reportable incident documented in part . Regional Director interviewed the resident (R26) and he stated that CNA (V34) grabs his shirt pocket and rips them when he is attempting to get him out of bed. Resident stated that CNA gets him up at 2 or 3 AM for no reason . Resident state that CNA talks rudely to him . Regional Director interviewed (R26's) roommate (R37). (R37) is (alert and oriented times 4). (R37) stated that (R26) is pulled around by (V34) in the middle of the night because resident doesn't want to get up at 2 AM. (R37) stated that (V34) is verbally demeaning to resident and his tone of voice is aggressive when speaking with (R26) . Conclusion After a thorough investigation the facility is able to substantiate the allegation. (V34) has been terminated . 2. R44's face sheet documented an initial admitted [DATE] with diagnoses including, aftercare following joint replacement surgery, paranoid schizophrenia, conversion disorder with seizures or convulsions, gout, hypertension, schizoaffective disorder bipolar type, anxiety disorder, and hyperlipidemia. R44's 3/8/24 MDS documented a BIMS score of 00, indicating severe cognitive impairment. R44's 3/8/24 MDS section GG documented R44 was dependent for all Activities of Daily Living (ADL) except eating. R44's care plan did not document R44 was at risk for abuse. On 5/10/2024 at 12:20 PM, R44 was interviewed but was a poor historian with some confusion noted. On 5/10/24 at 3:14 PM, V34 (CNA) said he recalled when R44 returned to the facility from the hospital because it was a sad time because R44 was very sick. V34 said after answering R44's call light one night, V34 had gotten about halfway back down the hall after answering R44's call light when R44 turned his call light on again. V34 said he had joked with R44 saying what do you need now? It's been 5 seconds since I left. V34 said there were times R44 has been half awake and V34 did not know if R44 knew he was joking. V34 said staff will get frustrated with R44 using the call light. V34 said R44 was a very confrontational resident. V34 said he had gotten frustrated with R44 in the past when R44 would not use the urinal. V34 said when R44's urinal is empty, V34 has told R44 that V34 knows no staff have emptied R44's urinal and R44 needs to start using it. V34 said he was not sure if V34 telling R44 to use the urinal would be taken as threatening because we have to tell (R44) that every night. On 5/10/24 at 12:15 PM, V37 (CNA) said he had worked in the facility for about 7 months. V37 said he had never witnessed any physical abuse while in the facility but had witnessed verbal abuse. V37 said R44 had just returned from the hospital and there was something wrong with R44's stomach. V37 said R44 kept turning on the call light thinking R44 had to use the restroom but when staff would get to R44's room R44 would say he didn't have to go anymore. V37 said he witnessed V34 (CNA) say to R44 that V34 was going to take R44's call light away from R44 if R44 did not stop turning the call light on. V37 said he did not report the incident because he wanted to give V34 a chance, but it didn't do any good. V37 said he knew what V34 had done to R44 was abuse. V37 said V34 could be rough with residents during care. R44's 5/14/2024 Incident Investigation Form documented an interview by V37 (CNA) .(R44) was on the light quite a bit thinking he had pooped. He had been on the call light a lot. (V34 CNA) told (R44) if you didn't s**t, I'm going to take that call light away from you. Didn't report because (V37) was busy and didn't want to see (V34) get in trouble . On 5/14/24 at 12:57 PM, V44 (Regional Director of Operations) said that she had forgotten about R44's abuse allegation on 5/10/24. V44 said she would have R44's investigation completed on that day (5/14/24). On 5/14/24 at 4:00 PM, V44 (Regional Director of Operations) presented R44's 5/4/24 facility investigation and verified the one staff interview of V37 (CNA) was the complete investigation. R44's 5/14/24 facility investigation file did not contain any other staff interviews or resident interviews. On 5/15/2024 at 2:10 PM, V1 (Administrator) stated the staff she usually interviews are the supervisors and/or directors. V1 stated she usually only interviews the staff that are around. V1 stated I only interview the residents that are alert and oriented. R44's 5/15/24 final reportable to Illinois Department of Public Health (IDPH) documented in part . Summary . it was reported to (V44 Regional Director of Operations) by (V37 CNA) that at an unknown date and time (R44) had recently returned from the hospital and was on his call light quite a bit. (V34 CNA) came into work at 6pm and (R44) had been continually putting on his call light thinking that he had had a (bowel movement) but had not. (V37) stated that one time when the call light went off he went to answer it and (V34) went with him. (V37) then stated that (R34) told (R44) if you have not s**t I'm taking the call light away for the rest of the night . Conclusion . After a thorough investigation the facility is able to substantiate the allegation. (V34) has been terminated . On 5/8/24 at 10:55 AM, V19 (CNA) said she worked day shift in the facility. V19 said she had heard a resident say the guys on midnight shift are mean. V19 said V34 (CNA) was related to someone who used to be in management at the facility. On 5/8/24 at 1:16 PM, V42 (Licensed Practical Nurse/ LPN) said on 5/4/24 she had reported other allegations to V1 (Administrator) regarding V34 (CNA) as being physically and verbally abusive. V42 said (V34 CNA) was related to someone who used to be in management at the facility. V42 said she had heard some things about V34 being rough but had never witnessed any abuse by V34 herself. On 5/14/2024 at 4:20pm, V44 (Regional Director of Operations) stated the investigations were completed for the allegations of abuse on both R26 and R44 and both investigations substantiated that abuse occurred. V44 stated she terminated V34 on this date. Document titled Abuse Prevention Program with Revised date of 11/28/2016 documented in part .this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation . The Immediate Jeopardy that began on 5/7/24 was removed on 5/16/24 when the facility took the following actions to remove the immediacy. 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. IDT (Interdisciplinary Team) team has assessed (R26) and care plan updated to reflect potential for abuse and interventions to protect (R26) from abuse. Completed on 5/15/2024. B. (V34 CNA) had been suspended on 5/10/2024 pending outcome of an investigation and was terminated on 5/14/24. 2. The following systematic measures have been implemented to ensure that the revised 11/28/16 Abuse Prevention Program policy is being followed: A. Facility Abuse Prevention Policy was reviewed on 5/13/24 and was found to be in compliance with state and federal regulations. B. On May 14, 2024 (V44) Regional Director in-serviced the Administrator (V1) on the Abuse Prevention Policy, which included identifying types of abuse, investigating and reporting all alleged abuse allegations and immediately suspending employee, accused. C. Facility Administrator (V1) initiated in-servicing, for all staff, on the Abuse Prevention Policy on 5/16/2024 prior to their shift, all staff on shift and will inservice all other staff prior to their next shift. D. The Administrator (V1) will interview 3 staff members, 3 times weekly x 4 weeks to ensure that staff, understand the Abuse Prevention Policy, timely reporting of abuse, who to report abuse to, types of abuse and immediately separating residents or suspending a suspected staff member. Initiated on 5/14/2024. E. Resident council meeting was conducted on 5/14/24 to review the Abuse Prevention Policy and how to report abuse or perceived mistreatment. Resident council president and IDT team members present. F. Social Service Director (V6) will interview 3 residents, 3 times weekly x 4 weeks to ensure understanding of abuse and reporting of any abuse or perceived mistreatment, by another residents or a staff member. Initiated on 5/14/2024. G. IDT team reviewed all residents for the potential of abuse and care plans updated to reflect interventions to protect residents from abuse. Completed on 5/16/2024. H. IDT in-serviced to review any resident for changes in behaviors, increase in behaviors or new behaviors in order to investigate and identify any potential triggers prior to an incident, ensure that person centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff. Initiated on 5/14/2024. 3. As part of the facilities ongoing quality assurance program: A. Residents who trigger during this IDT review will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. Individualized intervention will be developed to decrease episodes of behaviors, in order to prevention situations that may cause abuse to a resident. (on-going).

Based on interview and record review, the facility failed to thoroughly and timely investigate an allegation of staff to resident abuse, and failed to prevent further abuse from occurring while allowing staff to continue to have direct care with residents after allegations were made for 4 of 5 residents (R26, R44, R46, and R300) reviewed for abuse in a sample of 14 residents. Due to this failure R26 was verbally and physically abused by V34 (Certified Nursing Assistant/CNA) on 5/7/24 at approximately 2:00 AM. This also had the potential to affect all 47 residents residing in the facility. Findings include: 1. Document titled Admission Record documented R300 admitted as 4/5/2024 with diagnoses including Intervertebral Disc Degeneration, Thoracic Region, Polyarthritis, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Anemia, Vitamin D Deficiency, Hypertension, Mild cognitive impairment. R300's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates R300 is cognitively Intact. On 5/8/2024 at 9:59 AM, R300 was alert and oriented stated, I know why you are here so I will explain what happened to me. On the night that I was admitted (4/5/2024) I just wanted to go back to live in my car or go live with my grandson that lives her in (town of facility). R300 stated I was walking outside of the building when V34 CNA (Certified Nursing Assistant) grabbed me around the waist, tackled me from behind, and drug me to the ground face first. I didn't see anyone else outside, but I thought I heard someone say, get him. R300 stated I have a bad back from a vehicle wreck that happened years ago, and this just made the pain worsen. My pain has increased since this occurred. R300 stated he told people about being tackled but wasn't sure of their name as he was new in the facility or the time he reported it. R300 stated I do not feel safe, and I have to sleep lightly because V34 is always in my room taking care of my roommate. R300 then stated, I am afraid that V34 will come in here with a club and hit me in the head. On 5/10/2024 at 11:20 AM, V38 PRSC (Psychiatric Rehabilitation Service Counselor) stated R300 came to her on Friday evening (5/3/2024) and reported his allegation of physical abuse. V38 stated R300 came to her and told her when he was out front a guy came up and wrapped his arms around R300 and threw R300 down. V38 stated I just didn't think it happened on dayshift. V38 said R300 described the guy that allegedly did this was Mexican and the facility did not have anyone employed that fit that description. V38 stated the way it was brought to me by (R300) didn't give me all the details. He was just looking for the guy that threw him on the concrete. V38 stated she didn't report this to V1 (Administrator) until the following Monday (5/6/2024) and V1 came in and asked V38 for a grievance form. When V38 was questioned about abuse training, V38 stated abuse is to be reported immediately to the administrator. V38 also stated she knew what an allegation of abuse was and assists in training facility staff with abuse training. On 5/10/2024 at 10:58 AM, V6 SSD (Social Service Director) stated on 5/7/2024 R300 came and told her he knew the name of the guy that tackled him in front of the building, and it was V34 (CNA). V6 stated she asked him what he was talking about and V6 stated she was unaware of any situation like that. On 5/7/24 at 9:10 AM, V1 (Administrator) said R300 had reported the allegation of abuse to V6 (Social Services Director) on the evening of 5/6/24. On 5/15/2024 at 2:10 PM, V1 (Administrator) stated she questioned V34 (CNA) on the allegation involving R300 but was unsure of the date and time. V1 then stated she interviewed V34 on 5/10/2024 and V34 was suspended at that time. On 5/10/24 at 3:14 PM, V34 (CNA) said he was never questioned about R300's allegations. V34 said he was not aware there was any suspicion he was the alleged perpetrator. V34 said he had worked in the facility on 5/6/24, 5/7/24, 5/8/24, and 5/9/24. V34 said he was not suspended related to R300's abuse allegations prior to 5/10/24. V34's undated facility timecard provided by the facility on 5/10/24 documented V34 was working in the facility on 5/3/24 from 5:54 PM to 5/4/24 at 6:03 AM, 5/6/24 from 9:56 PM to 5/7/24 at 6:03 AM, 5/7/24 from 9:55 PM to 5/8/24 at 6:05 AM, 5/8/24 from 9:56 PM to 5/9/24 at 6:11 AM, and 5/9/24 from 9:54 PM to 6:01 AM. On 5/13/2024 at 4:25 PM, via phone interview V12 (CNA) stated, I heard V34 shoved R300 down to the ground. V12 said she did not witness V34 shove R300 but have heard about in the facility. V12 stated she works 6:30 AM to 2:00 PM shift. V12 stated I have been told that V34 will call R6 a fat a** and lazy a** the CNA that says these things is V34. On 5/17/24 at, 2:50 PM, V44 (Regional Director of Operations) said she expected staff to be suspended pending an investigation. V44 said she expected V34 (CNA) to have been suspended on 5/6/2024. V44 said she expects all staff to be interviewed in an abuse allegation investigation. On 5/10/2024 at 1:00 PM, R300's investigation file was reviewed and noted initial time of staff acknowledgment was on 5/3/2024, but investigation was not started until 5/6/2024. V34 was the perpetrator named by R300 and no statement or interview was completed by V34. V34 was allowed to work on 5/3/2024, 5/6/2024/, 5/7/2024/ 5/8/2024 and 5/9/2024. V34 was interviewed on 5/10/2024 and at this time V34 was included in R300's facility investigation. 2. R26's document titled Admission Record documented an admitted [DATE] with diagnoses including: Ischemic Cardiomyopathy, Atherosclerotic heart Disease of Native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, Hypertension, Hyperlipidemia, Chronic Kidney Disease stage 3, Schizoaffective Disorder, Atrial Fibrillation, Anxiety, Chronic Obstructive Pulmonary Disease, presence of Automatic (implantable) Cardiac Defibrillator, Alzheimer's Disease, Unilateral Inguinal Hernia, Diabetes Mellitus, and Unspecified Urinary Incontinence. R26's MDS (Minimum Data Set) dated 4/23/2024 documented a BIMS (Brief Interview for Mental Status) with score of 10, indicating moderate cognitive impairment. On 5/8/2024 10:32 AM, R26 was an alert and oriented resident sitting in the dining room. R26 stated his care is good here except for the night shift. R26 stated he gets his clothes ripped by night shift CNA, V34. R26 pointed to the upper right shoulder area of his shirt that was ripped and stated V34 ripped it when he was pulling me out of bed. R26 stated he (V34) gets me up at 2:00 AM-3:00 AM and brings me to the dining room and I have to sit here until breakfast. On 5/10/2024 at 12:15 PM, R26 stated I get tired of the treatment from (V34) CNA. I don't feel safe when (V34) is working. I want to just pull my pacemaker out and end it all sometimes, but only when (V34) is taking care of me. R26 stated if R26 used the bathroom in bed V34 would roughly get R26 out of bed, ripping R26's clothes at times, and wheel R26 to the dining room to wait for breakfast. R26 stated V34 was also verbally abusive. R26 said the last time V34 had been abusive like this to R26 was within the past week of this survey. R26 stated facility staff were aware of V34 being abusive but nobody does anything about it. On 5/10/24 at 2:07 PM, R26 said the last time he had issues with his care by V34 (CNA) had been Monday night 5/6/24 / Tuesday morning 5/7/24. On 5/10/24 at 3:14 PM, V34 (CNA) said R26 was assisted with care around 2:00 AM during bed check. V34 said R26 was usually one of the last residents V34 would assist because R26 was usually not wet. V34 said he did not like to put a wrap around pullup on R26 because it gave R26 an excuse to pee in the bed instead of using the urinal. R26 stated he was not trying to be a d**k, but I know (R26) can use the urinal during the day. V34 said he was not trying to argue with (R26). If (R26) wets the bed, I make (R26) get up in his chair so I can change the bed and put a pullup on (R26). V34 stated (R26) was not an easy resident to care for and V34 just tells (R26) like it is when things have to get done. V34 said he was very direct with residents and I feel like being direct is the only was for a resident to fully understand what is about to happen. R26's 5/15/24 final reportable incident documented in part . Regional Director interviewed the resident (R26) and he stated that CNA (V34) grabs his shirt pocket and rips them when he is attempting to get him out of bed. Resident stated that CNA gets him up at 2 or 3 AM for no reason . Resident states that CNA talks rudely to him . Regional Director interviewed (R26's) roommate (R37). (R37) is (alert and oriented times 4). (R37) stated that (R26) is pulled around by (V34) in the middle of the night because resident doesn't want to get up at 2 AM. (R37) stated that (V34) is verbally demeaning to resident and is tone of voice is aggressive when speaking with (R26) . Conclusion After a thorough investigation the facility is able to substantiate the allegation. (V34) has been terminated . On 5/10/2024 at 12:30 PM, R37 was alert and oriented. R37 is a roommate of R26 and stated nightshift gets (R26) up around 3:00 AM and will make (R26) stay up if (R26) has soiled the bed. (V34) CNA is very dismissive and verbally aggressive with (R26). R37 stated he has heard V34 tell R26 You must stay up because you pissed the bed. R37 said he had witnessed V34 handling R26 rough when getting R26 out of bed at night. R37 stated the last time it happened was this past week. R37 states V1 knows but nothing happens. R37's 3/26/24 MDS (Minimum Data Set) documented a BIMS (Brief Interview for Mental Status) score of 15, indicating R37 was cognitively intact. On 5/17/24 at, 2:50 PM, V44 (Regional Director of Operations) said she expected staff to be suspended pending an investigation. V44 said she expected V34 (CNA) to have been suspended on 5/6/2024 due to the R300 abuse allegation. 3. R44's document titled Admission Record documented an admitted [DATE] with diagnoses including aftercare following Joint Replacement Surgery, Paranoid Schizophrenia, Atherosclerotic Heart Disease, Conversion Disorder with Seizures or Convulsions, Gout, Hypertension, Schizoaffective Disorder, Bipolar Type, Hypothyroidism, Anxiety, Polyosteoarthritis, Hyperlipidemia. R44's MDS (Minimum Data Set) dated 3/8/2024 documented a BIMS (Brief Interview for Mental Status) score of 00, indicating severe cognitive impairment. On 5/10/2024 at 12:15 PM, V37 (CNA) stated he has received training on abuse during employment at the facility. V37 stated, I have never witnessed physical abuse, but I have witnessed verbal abuse and threats to residents. V37 stated he had witnessed an incident of verbal abuse/threat to R44 by V34 (CNA). V37 stated R44 had just returned from the hospital, and something was wrong with his stomach. V37 stated R44 kept putting on his call light thinking he felt like he needed to use the restroom but when staff would get to R44's room, R44 felt like the need to use the restroom had passed. V37 stated that he went into the room with V34 and witnessed V34 threaten R44 by telling him he (V34) was going to take his call light away from him if he didn't stop turning the call light on. V37 stated he didn't report the incident involving verbal abuse to R44 because he wanted to give V34 a chance but it didn't do any good, I guess. On 5/10/2024 at 12:20 PM, R44 was interviewed but was a poor historian with some confusion noted. On 5/10/24 at 3:14 PM, V34 (CNA) said he recalled when R44 returned to the facility from the hospital because it was a sad time because R44 was very sick. V34 said he had joked with R44 after answering R44's call light V34 had gotten about halfway down the hall when R44 turned his call light on again. V34 said he had joked with R44 saying what do you need 5 seconds later. V34 said there were times R44 has been half awake and V34 did not know if R44 knew he was joking. V34 said staff will get frustrated with R44 using the call light. V34 said R44 was a very confrontational resident. V34 said he had gotten frustrated with R44 in the past when R44 would not use the urinal. V34 said when R44's urinal is empty V34 has told R44 V34 knows no staff have emptied R44's urinal and R44 needs to start using it. V34 said he was not sure if V34 telling R44 to use the urinal would be taken as threatening because we have to tell (R44) that every night. On 5/13/2024 at 4:25 PM, via phone interview V12 CNA (Certified Nurse Assistant) stated she has received training on abuse but, unsure of last time. I have never seen abuse, but I have been told that midnight CNAs call resident's names, names that are not nice, and the main one that does this is R34. V12 stated I know he tells R44 not to push his f**king call light anymore. I didn't witness this but was told about it, so I didn't report it. V12 states she has never been questioned or part of an investigation for abuse. R44's document titled Incident Investigation Form documents V44 (Regional Director of Operations) interviewed V37 (CNA) dated 5/14/2024. Document reads .(V34) - (R44) was on the light quite a bit thinking he had pooped. He had been on the call light a lot. (V34 CNA) told (R44) if you didn't s**t, I'm going to take that call light away from you. Didn't report because he was busy and didn't want to see (V34) get in trouble . On 5/14/24 at 12:57 PM, V44 (Regional Director of Operations) said that she had forgotten about R44's abuse allegation on 5/10/24. V44 said she would have R44's investigation completed on that day (5/14/24). On 5/14/24 at 4:00 PM, V44 (Regional Director of Operations) presented R44's 5/4/24 facility investigation and verified the one staff interview of V37 (CNA) was the complete investigation. R44's 5/14/24 facility investigation file did not contain any other staff interviews or resident interviews. On 5/15/2024 at 2:10 PM, V1 (Administrator) stated the staff she usually interviews are the supervisors and/or directors. V1 stated she usually only interviews the staff that are around. V1 stated I only interview the residents that are alert and oriented. 4. R46's face sheet documented an initial admitted [DATE] with diagnoses including: pulmonary hypertension, chronic obstructive pulmonary disease, post- traumatic stress disorder, attention- deficit hyperactivity disorder, hypothyroidism, anxiety disorder, depression, borderline personality disorder, mild intellectual disabilities, need for assistance with personal care. R46's 2/28/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R46 was cognitively intact. On 5/8/24 at 9:56 AM, R46 said a CNA told him to turn his f**king music down. R46 said he (V34/CNA) was always complaining about R46's music. R46 said he has not had any problems with any other staff. R46 said this incident happened on 5/3/24. R46 said the next day (5/4/24) V1 (Administrator) came to speak with R46. R46 said V1 had told him that V34 had never cussed at him, and the incident didn't happen. R46 said V1 told him that V1 did not believe him. R46 said he did not feel safe when V34 was working. R46 said he had not told V1 he did not feel safe while V34 was working because V1 had never asked. On 5/8/24 at 12:26 PM, V40 (Housekeeper) said she reported that R46 had made an abuse allegation to her on 5/4/24. V40 said R46 had made an allegation V34 (Certified Nursing Assistant/ CNA) had cussed R46 out in the dining room on 5/3/24 due to R46's tablet being too loud. V40 said she had reported R46's abuse allegation to V42 (Licensed Practical Nurse/ LPN) and had given V42 a written statement. On 5/8/24 at 1:16 PM, V42 (LPN) said on 5/4/24 V40 (Housekeeper) had reported an abuse allegation pertaining to R46. V42 said she asked V40 to complete a written statement and called V1 (Administrator) to report the abuse allegation. V42 said there were 2 abuse allegations reported to her very close together on 5/4/24 and V42 had reported both to V1 via telephone. V42 said she went to speak with R46 on 5/4/24 and R46 reported V34 (CNA) on midnight shift had cussed at him over R46's music being too loud. On 5/8/24 at 2:20 PM, V1 produced written statements by staff pertaining to R46's abuse allegation. A 5/4/24 Nurses Note written and signed by V40 (Housekeeper) documented in part . (R46) told me this morning that a black haired CNA cussed him out and was yelling at him over his TV being to (sic) loud. I said are you talking about (V34) and he said yes. I told him to tell the nurse about it . Another 5/4/24 Nurses Notes written and signed by V42 (LPN) documented in part . This nurse asked resident (R46) what happened in the middle of the night, (R46) said that he was cussed out by (V34) (R46) said that (V34) told him to turn the f**king music down. On 5/8/24 at 2:20 PM, V1 (Administrator) said R46's abuse allegation was not substantiated so V1 did not feel the allegation needed to be reported. V1 presented R46's 5/4/24 facility investigation documents with all persons questioned. R46's 5/4/24 facility investigation file documented only staff were interviewed but no residents were interviewed. On 5/15/2024 at 2:10 PM, V1 (Administrator) stated I feel like our standard investigations are good. V1 stated yes we do notify the physicians when there is an abuse allegation. On 5/15/2024 at 1:53 PM, this surveyor received a return call from V33 (Physician). V33 stated he was not notified of allegation of abuse on R300 or R26. V33 stated he was not aware of any of this, but he ordered x rays for R300 because of increased pain but thought it was from old injuries from an accident. V33 stated he changed R300's pain medication because he knew that the pain medication (tramadol) was a medication that the resident was on for a long time. V33 stated he changed R300's pain medications to help reduce the pain that he knew was a chronic issue. On 5/15/2024 at 2:10 PM, V1 (Administrator) stated on Monday morning (5/6/2024) V38 (PRSC) reported an allegation of abuse to R300. V1 stated she instructed V6 (Social Services Director) to go talk to R300. V1 stated the staff she usually interviews are the supervisors and/or directors. V1 stated she usually interviews the staff that are around. V1 stated I only interview the residents that are alert and oriented. While V1 was being questioned about the investigation procedure of an abuse allegation by a resident V1 stated sometimes it is the resident's fault. When V1 was asked to clarify what she meant by sometimes it is the resident's fault V1 said yeah and turned her chair around at her desk and started going to through papers and refused to say any more. On 5/13/2024 at 3:23 PM, via phone interview V43 (housekeeper) stated she has worked for 4 and a half years at the facility. V43 stated I have never received abuse training and has never been questioned about any abuse investigations. V43 stated she has witnessed verbal abuse on several occasions in the past by CNA's and Nurses' especially loudly in the hallway. V34 states I recently took family leave and was off about a month. V43 stated I think you need to go talk to the residents and see if they tell you anything. V43 stated she didn't report because everyone hears it. The facility's undated census list provided on 5/7/24 documented 47 residents residing in the facility. Document titled Abuse Prevention Program with Revised date of 11/28/2016 documented in part .Upon learning of the report, the administrator or designee shall initiate an investigation. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions . V. Protection of Residents . The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway . employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee .

Based on interview, observation, and record review, the facility failed to provide treatment and monitoring for wounds and failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. The Admission and Discharge Record in R37's medical record documents that R37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/21/22 at 3:30 PM, R37 states that R37 has a wound on R37 right stump. R37 said that there was a dressing on it but R37 took it off to let the wound air out. R37 said that R37 thinks the area is infected and was put on an antibiotic and it didn't seem to help. R37 states that the wound is warm and tender around the edges and R37 is concerned that it is infected. R37 said that R37 dressing change doesn't get done every day like it is ordered. R37 has a wound observed to the right upper leg near the above the knee amputation healed surgical site. The wound edges are reddened, and the wound bed is pink and appears to be bulging. There is no drainage observed. A copy of Nurse's Notes from R37's medical record received from the facility on 3/22/22 documents a note by V9 (Licensed Practical Nurse) dated 3/7/22 documents that R37 has an open area (OA) to the left groin that is 0.6 cm x 0.5 cm and resident complains of pain to right stump and area is hardened with inflammation. A note dated 3/11/22 by V9 documents that the right stump has a wound present that is not open with purulent drainage and new orders were received. A copy of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse OA to inner left groin with wound cleanser. Pat dry. Apply medicated ointment/ dry dressing (DD) daily and as needed (PRN). 2. Apply equal parts of 3 medicated ointments to left inner groin three times a day (TID) and PRN. 3. X- ray right stump (femur) 2 views. Diagnosis (Dx): pain/ inflammation. The POS also documents [MEDICAL RECORD OR PHYSICIAN ORDER] . A document titled Wound Management and Evaluation Summary by V28 (Wound Specialist/ Medical Doctor) dated 3/16/22 documents that R37 has a post-surgical wound of the right anterior thigh (site 1) that measures 2 centimeters (cm) x 2 cm x 0.3 cm with a duration of greater than 2 days. The dressing treatment plan documented for site 1 is ointment apply once daily for 30 days, powder apply once daily for 30 days, medicated ointment applies once daily for 30 days with gauze island dressing for 30 days. The summary also documents that R37 has a post-surgical wound of the left anterior thigh (site 2) that measures 2 cm x 1 cm with a duration greater than 3 days. The dressing treatment plan documented for site 2 is [MEDICATION(S)] apply twice daily for 30 days. A copy of R37's Treatment Administration Record (TAR) for March 2022 received from the facility on 3/22/22 documents the orders for treatment received on 3/7/22. The order for the daily treatment to the open area on the left groin that was ordered on 3/7/22 is not initialed on 3 days since the order began on 3/7/22. The order for treatment to be completed three times a day to the left inner groin area was not initialed as being completed 10 times since the order started on 3/7/22. The orders for treatment documented on the Wound Management and Evaluation Summary dated 3/16/22 are not on the March TAR or Physicians Order Sheet for March 2022. There were no treatments documented on the March TAR for the wound to the right stump that was documented in the progress notes on 3/11/22. R37's March TAR documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The days that were initialed as being completed do not document any findings when wounds were documented as being present in the Nurse's Notes on 3/7/22 and 3/11/22. On 3/23/22 at 1:15 PM, V9 said that R37 was going to the emergency room per R37's request to have the wound to R37 right leg evaluated. On 3/24/22 at 9:30 AM, V9 said that R37 was admitted to the hospital on 3/23/22. On 3/31/22, updated copies of R37's TAR for March 2022, March 2022 POS, and Nurse's Notes were requested and received from the facility to review documentation regarding R37's hospitalization . R37's Nurse's Notes received on 3/31/22 documents a note by V9 dated 3/16/22 documenting that R37 was seen by V28 (Wound Specialist/ MD) related to wounds to the right and left anterior thigh, see POS, and TAR updated. The copy of the March POS received on 3/31/22 documents an order dated 3/16/22 for the orders as documented on the Wound Management and Evaluation Summary by V28 on 3/16/22. The copy of the March TAR documents those treatments with a start date of 3/16/22 and initialed as completed beginning on 3/16/22. The copies requested from the facility on 3/22/22 of the March POS, Nurse's Notes, and March TAR did not document the orders from V28 on 3/16/22 or that the treatments were provided as ordered on the March TAR, March POS, and Nurse's Notes. On 3/31/22 at 3:00 PM, V26 (Regional Clinical Nurse) states that V26 cannot explain why the documentation requested on 3/22/22 does not contain the notes and orders dated 3/16/22 that was documented on the requested records received on 3/31/22. V26 sates that the notation late entry must be made if an entry is made later. V26 said that V26 is unable to determine if the treatment to R37's right thigh was being completed since it was not documented on the records received 3/22/22. A Nurse's Note dated 3/26/22 documents that R37 returned to the facility. A document titled Discharge Information for Receiving Facility from the hospital dated 3/26/22 documents that R37 was admitted to the hospital with primary encounter diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital records document that R37 received [MEDICATION(S)] and [MEDICATION(S)]-tazobactam (antibiotics) intravenously during the hospital stay and was discharged on [DATE] with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/28/22 at 9:30 AM, R37 said that she went to the hospital and received several bags of antibiotic for the infection in the wound to the right thigh. R37 said that the part of the wound that was bulging before R37 went to the hospital was infected and since then the area has drained and is now smaller. On 3/28/22 at 9:35 AM, V9 removed the dressing from R37 right thigh. The wound to R37's right thigh was diminished in size. The center to the wound bed was flat and there was no drainage noted. The wound edges were pink. The wound appeared to be approximately 2 cm in diameter. On 4/5/22 at 9:40 AM, V28 (Wound Specialist/ MD) said that when R37 was admitted to the facility R37's surgical incision sites from the bilateral amputations were infected. V28 said that they were healed within a couple weeks after R37's admission. V28 said that R37 is prone to infection. V28 said that although V28 cannot guarantee that hospitalization could have been prevented, V28 feels the wound would have healed quicker if the dressings were completed as ordered. R37's most recent care plan provided is titled Baseline Care Plan dated 10/28/21. There is no documentation on the care plan regarding identification of the wounds, treatments, goals, or interventions regarding wound care or prevention of skin breakdown 2. The Admission and Discharge Record in R29's medical record documents that R29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R29's March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/28/22 at 3:00 PM, R29 said that R29 has wounds to the left ankle. R29 said that the nurses do not always change R29 dressing and states that the nurses tell R29 that they have run out of time. R29 said the nurses will tell the next shift to do it but the next shift will not do it. R29 said that R29 dressing is ordered to be changed daily on second shift and R29 has gone over a 24-hour period without getting the dressing changed. R29 said that R29 doesn't want to see V28 (Wound Specialist/ MD) for the care of R29 wound and requested to see a vascular surgeon since R29's wounds are venous ulcers. R29 said that R29 has not seen V28 and was referred to a vascular surgeon several months ago and no one will help her find a vascular surgeon to go to. R29 said the person that makes the appointments at the facility has quit and no one made R29 an appointment. R29 has a dressing in place to the left lower leg. The gauze is visibly soiled with dried blood-tinged drainage. The dressing is dated 3/27/22. On 3/31/22 at 9:35 AM, V9 (Licensed Practical Nurse) removed the dressing from R29's left lower leg. R29 complained of pain to the wounds with the removal of the dressing. The old dressing was saturated with dried blood-tinged drainage and tan colored exudate was noted to the dressing and the wound beds. There were 3 large open areas to R29's left lower leg. The edges of the wounds appeared dry and darker in color. The center of the wounds was red with tan exudate. V9 said that R29's dressing is done on 2nd shift and V9 had not seen R29's wounds in a while. V9 said that weekly wound assessments are completed weekly on the 2PM-10 PM shift. V9 said that the weekly skin check assessment findings are documented on the back of the Treatment Administration Record (TAR). V9 said that V28 sees residents with wounds weekly and measures the wounds. V9 said that R29 has not seen V28 in a couple of months and R29 refuses to be evaluated by V28. A document titled Wound Management and Evaluation Summary by V28 dated 11/25/21 documents the following wounds: Site 1-venous wound of the left, lower, lateral leg full thickness measuring 3 cm x 1 cm x 0.2 cm (length x width x depth). Site 2- shear wound of the left, anterior, lower leg full thickness measuring 3 cm x 3 cm x 0.3 cm. Site-3- shear wound of the left, upper, lateral leg full thickness measuring 1 cm x 1 cm x not measurable. Site 4- arterial wound of the left, lateral ankle full thickness measuring 1 cm x 3 cm x not measurable. R29 's TAR for January 2022, February 2022, and March 2022 were reviewed. On the January TAR there are 14 days that there were no initials indicating that the treatment to the left lower leg was completed. On the January TAR, the weekly skin checks were all initialed as being completed. The back of the TAR skin assessment findings was documented for the assessments completed on 1/12/22 and 1/19/22. The assessment completed on 1/19/22 documents the following: Left lower leg 1.) 5 cm x 4.5 cm 2.) 4 cm x 2.5 cm 3.) 5 cm x 2.5 cm. Right lower leg 1.) 2 cm x 2 cm. R29's wound measurements documented an increase in size from V28's previous wound assessment completed on 11/25/21. R29's TAR for February 2022, document there are 17 days that there were no initials indicating that the treatment to the left lower leg was completed. The weekly skin checks were not initialed as being completed for the month of February and there are no assessment findings or measurements documented on the back of the TAR. R29's TAR for March 2022, document there are 8 days that there were no initials indicating that the treatment to the left lower leg was completed. All the weekly skin checks are initialed as being completed. The documentation for the weekly skin checks on the back of the TAR document that there are 4 open areas to the left lower leg. There are no documented wound measurements or descriptions of the wounds. On 3/30/22 at 4:50 PM, V10 (Licensed Practical Nurse) said that there are times that not all of the treatments get done due to time constraints. V10 said that there are a lot of residents with behaviors that make it difficult to get everything done. V10 said that when V10 is unable to complete a treatment, V10 lets the nurse on the next shift know. On 3/31/22 at 3:00 PM, V26 (Regional Clinical Nurse) said that residents with wounds are assessed on at least a weekly basis. V26 said wound assessments should contain measurements of the wound and descriptions of the wound. V26 verified that the last assessment by V28 was 11/25/21 and there were no recent wound measurements of R29's wounds. On 3/31/22 at 3:25 PM, V4 (Licensed Practical Nurse) and V10 (Licensed Practical Nurse) were observed measuring R29's wounds. R29 has 3 wounds that measured: 1.) 6 cm x 5 cm x 0.1 cm 2.) 6.5 cm x 3 cm x 0.1.cm 3.) 7.5 cm x 2.5 cm x 0.3 cm. R29's wound culture and sensitivity (C &S) lab report with a documented collection date of 3/22/22 documents heavy growth of the organism Proteus Mirabilis. R29's Nurse's Notes and POS did not document an order or a rationale for obtaining a wound C & S. On 4/5/22 at 4:15 PM, V4 said that she obtained an order from V31 (Medical Doctor) to obtain a wound C & S because R29's wound had an increase in yellow drainage. V4 said that R29 had been on different antibiotics off and on and thought that they should do a wound C & S to determine the correct antibiotic to use to treat R29's wound infection. V4 said that she documented the order on a Telephone Order Sheet. V4 said that the Telephone Order Sheets usually go to the Director of Nursing (DON) until they get signed by the doctor and then they are filed in the medical file. On 3/31/22 at 11:30 AM, V27 (Nurse Practitioner) stated that she had referred R29 to a vascular surgeon a few months ago and stated that R29 never went and is not sure why. V27 said that V27 reviewed the wound culture and is placing R29 on [MEDICATION(S)] and is going to do another referral for R29 to see a vascular surgeon and go to a wound care clinic to be evaluated. A clinic note completed by V27 dated 11/30/22 documents that R29 is requesting to be evaluated by a vascular specialist. An order is documented for a referral to a vascular surgeon. On 4/4/22 at 1:30 PM, V3 (Regional Director) verified that R29 has not been seen by a vascular surgeon as ordered on 11/30/22 by V27. The facility policy titled Skin Condition Monitoring (revision date 1/18) documents It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. Procedure step 4 states Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: A.) Characteristic- 1. Size 2. Shape 3. Depth 4. Odor 5. Color 6. Presence of granulation tissue or necrotic tissue. B.) Treatment and response to treatment . C.) Prevention techniques that are in use for the resident. 3. The Admission and Discharge Record in R3's medical record documents that R3 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/22 at 3:45 PM, V4 (Licensed Practical Nurse) said that R3 no longer resides at the facility and has transferred to another Long-Term Care facility on 3/21/22. R3's March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wound Management and Evaluation Summary by V28 dated 1/26/22 documents have an arterial wound to the right heel partial thickness measuring 1 cm x 1 cm x not measurable. The wound treatment plan documents the treatment as [MEDICATION(S)] twice daily for 24 days. A Wound Management and Evaluation Summary by V28 dated 3/16/22 documents that R3's arterial wound to the right heel is now full thickness and measures 1.5 cm x 1 cm x not measurable. R3's Treatment Administration Record (TAR) for January 2022 does not have any initials as being completed for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's TAR for February 2022 does not have any initials as being completed for the order for [MEDICATION(S)] to the wound of the heel twice daily 15 times on the 6 AM to 2 PM shift and 10 times on the 2 PM to 10 Pm shifts. R3's TAR for March 2022 does not have any initials as being completed the order for [MEDICATION(S)] to the heel wound twice daily 10 times on the 6 AM to 2 PM shift and 6 times on the 2 PM to 10 PM shift. On 3/30/22 at 4:50 PM, V10 (Licensed Practical Nurse) said that there are times that not all the treatments get done due to time constraints. V10 said that when she is unable to complete a treatment, V10 lets the nurse on the next shift know. 4. R34's Physician Order's Sheet, dated March 01-March 31, 2022, documents a current dose of [MEDICATION(S)] ([MEDICATION(S)]) 500 mg (milligrams), 1 tablet by mouth two times a day for Dx (diagnosis): [CONDITION(S)]. R34's Physician Order's Sheet documents labs were ordered by V27 (Nurse Practitioner/NP) on 3/14/22, for CBC (complete blood count), CMP (comprehensive metabolic panel), TSH ([CONDITION(S)] stimulating hormone), Vit (vitamin) D, Vit B12, HbA1C, Lipids, [MEDICATION(S)], and [MEDICATION(S)]). R34's document titled American Health Associates lab report shows labs were drawn on 3/16/22, however the Vit D, Vit B12, & [MEDICATION(S)] labs were not drawn. On 3/31/22 at 1:00 p.m., V9 (Licensed Practical Nurse/LPN), stated that labs are contracted out by (American Health Associates) and they come daily to draw labs. V9 stated that if a lab is ordered other than a routine lab, it will be drawn on the very next day or if it is a STAT order, it will be drawn as soon as possible. On 3/30/22, at 8:30 a.m., V11 (Regional Director) stated that the nurses take care of the lab results, notify the primary care physician, and await further orders. V11 stated that V27 (Nurse Practitioner/NP) comes to the facility on ce a week and reviews labs, orders, etc. V11 stated that V27 (NP) is scheduled to be at the facility on 3/31/22. On 3/31/22 at 11:00 a.m., this surveyor notified V27 (NP) of R34's Vit D, Vit B12, & [MEDICATION(S)] labs that were not drawn on 3/16/22 in accordance with V27's order on 3/14/22. V27 stated that there has been some confusion in getting notifications of lab results and was not aware of the Vit D, Vit B12, & [MEDICATION(S)] labs being missed. V27 stated that those labs would be addressed today along with any changes in medications that might be needed. The facility's policy, Laboratory Tests, reviewed date 9/17/2017, under Policy, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. Under Procedure, 1. Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. 2. Obtain laboratory orders upon admission, readmission and PRN for medication and condition monitoring per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to prevent the verbal and physical abuse of a resident from another resident with a known history of abuse for 1 of 2 residents (R35) reviewed for abuse in the sample of 41. This failure resulted in psycho/social harm to R35 having feelings of fear, irritation, anger and feeling of being unsecure when R11 was at the facility. Findings Include: R11's Admission and Discharge Record documents R11 is a [AGE] year male resident with an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's Minimal Data Set (MDS) dated , [DATE] documents R11's Brief Interview of Mental Status (BIMS) is documented as 09 (Moderately Impaired). R11's Behavior tracking dated ,d+[DATE] documents for the days between [DATE] and [DATE]: Target Behavior: R11 will yell and cuss at peers 5 days a week, with a Goal listed as: R11 will yell and cuss at peers 2 days a week. R11's Behavior tracking documents: one shift of constant behaviors, 16 times that the behaviors occurred and 10 shifts with no documentation. R11's Care Plan dated [DATE] documents: Category: 7 Psychosocial: R11 has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against this resident. Behavior exhibited history of verbal outburst. The goal dated [DATE] with new dates documented as: ,d+[DATE] (no year noted) and ,d+[DATE] (no year noted) states, Behavior of verbal outburst will have improved/deceased in the presence of others within the next 90 days. Category: 17 [CONDITION(S)] drugs: states, R11 requires use of [CONDITION(S)] medication to manage mood and/or behavior issues, with a goal date of [DATE] and revision dates of [DATE] and ,d+[DATE] (no year noted). R11's Intervention documented dated [DATE] states, refer to psychiatrist or neuro-psychologist for effective and safe behavior and medication management. R11's Nurse's Notes on [DATE] at 10:15 PM document: I (V4,Licensed Practical Nurse) was putting window shades down when resident (R11) kicked me in the chest and said, you ugly b**tch I will kick you again. R11's Nurse's Notes on [DATE] at 12:30 PM document: resident (R11) was seen walking across hall to engage a peer-resident. Was going to hit the peer when staff intervened. R11's Nurse's Notes on [DATE] at 3:45 PM document: resident (R11) was seen standing in hall and starting to hit two peers as they passed R11 room- staff intervened, R11's Nurse's Notes on [DATE] at 7:30 AM documents: resident (R11) verbally assaulted peer and nurse and battered nurse while passing nurse in hall. R35s Admission and Discharge Record documents R35 is [AGE] year old male resident with an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's Minimal Data Set (MDS) dated , [DATE] documents R35's Brief Interview of Mental Status (BIMS) is documented as 14 (Cognitively Intact). R11's Departmental Notes (Social Service Progress Notes) document on [DATE] at 8:20 AM ; Resident (R11) called another resident names. Then threw a cup of coffee in (R35) face. He (R11) then kicked him (R35) as staff separated them. There were no injuries noted by the nursing staff. R11's Departmental Notes (Social Service Progress Notes) on [DATE] at 10:35 AM documents: As a peer (R35) was propelling by in R35 wheelchair, a resident (R11) shook his (R11) fist and threatened to cut his(R35) penis off. Resident (R11) then tried to kick his peer (R35). Peer (R35) was not doing or saying anything to him (R11). Staff separated wheelchairs and behavior ceased. R35's Departmental Notes (Nurse's Notes) dated [DATE] at 9:30 PM documents, resident (R11) was standing in hall by the nurse's station waiting for nurse to pass by, nurse had staff stay by nurse to care for other residents, resident (R11) verbally threatened peer (R35) in dining room. On [DATE] at 2:05 PM, R35 stated R11 did kick R35, threw coffee at R35 face and told him, he was going to cut off R35 penis three times. R35 stated, R11's actions did upset R35, irritated R35 and made R35 angry. R35 stated, he would hope that R11 does not try to cut off his penis. The coffee was not hot so R35 was not injured but R35 did not like someone throwing coffee at R35 face, that made R35 angry also. R11 should not be able to do that to R35. On [DATE] at 2:45 PM, R35 stated he(R35) feels more comfortable and secure at the facility now that R11 no longer lives at the facility. On [DATE] at 11:40 AM, V14 (Social Service Assistant (SSA)) stated, R11 is the one that verbally threatened R35 in the dining room, R11 told R35 that, He was going to cut his penis off on [DATE] and [DATE]. R11 also threw coffee in R35's face on [DATE]. R11 does get verbally and physically aggressive. The staff will try to separate the residents quickly. There previously was a psychologist that came to the facility but they have not been in the facility since before Covid-19. V14 (SSA) stated, if physical or verbal aggression is witnessed between residents or with staff and a resident, it should always be reported to the Administrator, Director of Nursing, or charge nurse at the time. On [DATE] at 2:40 PM V25 (Regional Administrator) stated, there was no investigation done for the incidents that happened between R11 and R35 on [DATE] or [DATE]. Residents and staff were not interviewed about the incident. Those incidents were not reported to IDPH or the police. V25 (Regional Administrator) stated, she is not aware of those incidents being reported to Administration. V25 (Regional Administrator) stated, the incident with the coffee and kicking should have been investigated and reported however, she is not sure about the verbal incident, she is not for sure R35 heard him or was bothered by him. Someone would have had to ask R35 about the incident to know if it bothered him. The facility's Abuse policy was not followed. The Facility policy dated [DATE] titled, Abuse Prevention Program documents: Policy: This facility affirms the right of out residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is t assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents.

Based on interview, observation, and record review, the facility failed to provide treatment and monitoring for wounds and failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. The Admission and Discharge Record in R37's medical record documents that R37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/21/22 at 3:30 PM, R37 states that R37 has a wound on R37 right stump. R37 said that there was a dressing on it but R37 took it off to let the wound air out. R37 said that R37 thinks the area is infected and was put on an antibiotic and it didn't seem to help. R37 states that the wound is warm and tender around the edges and R37 is concerned that it is infected. R37 said that R37 dressing change doesn't get done every day like it is ordered. R37 has a wound observed to the right upper leg near the above the knee amputation healed surgical site. The wound edges are reddened and the wound bed is pink and appears to be bulging. There is no drainage observed. A copy of Nurse's Notes from R37's medical record received from the facility on 3/22/22 documents a note by V9 (Licensed Practical Nurse) dated 3/7/22 documents that R37 has an open area (OA) to the left groin that is 0.6 cm x 0.5 cm and resident complains of pain to right stump and area is hardened with inflammation. A note dated 3/11/22 by V9 documents that the right stump has a wound present that is not open with purulent drainage and new orders were received. A copy of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse OA to inner left groin with wound cleanser. Pat dry. Apply medicated ointment/ dry dressing (DD) daily and as needed (PRN). 2. Apply equal parts of 3 medicated ointments to left inner groin three times a day (TID) and PRN. 3. X- ray right stump (femur) 2 views. Diagnosis (Dx): pain/ inflammation. The POS also documents [MEDICAL RECORD OR PHYSICIAN ORDER] . A document titled Wound Management and Evaluation Summary by V28 (Wound Specialist/ Medical Doctor) dated 3/16/22 documents that R37 has a post-surgical wound of the right anterior thigh (site 1) that measures 2 centimeters (cm) x 2 cm x 0.3 cm with a duration of greater than 2 days. The dressing treatment plan documented for site 1 is ointment apply once daily for 30 days, powder apply once daily for 30 days, medicated ointment apply once daily for 30 days with gauze island dressing for 30 days. The summary also documents that R37 has a post-surgical wound of the left anterior thigh (site 2) that measures 2 cm x 1 cm with a duration greater than 3 days. The dressing treatment plan documented for site 2 is [MEDICATION(S)] apply twice daily for 30 days. A copy of R37's Treatment Administration Record (TAR) for March 2022 received from the facility on 3/22/22 documents the orders for treatment received on 3/7/22. The order for the daily treatment to the open area on the left groin that was ordered on 3/7/22 is not initialed on 3 days since the order began on 3/7/22. The order for treatment to be completed three times a day to the left inner groin area was not initialed as being completed 10 times since the order started on 3/7/22. The orders for treatment documented on the Wound Management and Evaluation Summary dated 3/16/22 are not on the March TAR or Physicians Order Sheet for March 2022. There were no treatments documented on the March TAR for the wound to the right stump that was documented in the progress notes on 3/11/22. R37's March TAR documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The days that were initialed as being completed do not document any findings when wounds were documented as being present in the Nurse's Notes on 3/7/22 and 3/11/22. On 3/23/22 at 1:15 PM, V9 said that R37 was going to the emergency room per R37's request to have the wound to R37 right leg evaluated. On 3/24/22 at 9:30 AM, V9 said that R37 was admitted to the hospital on 3/23/22. On 3/31/22, updated copies of R37's TAR for March 2022, March 2022 POS, and Nurse's Notes were requested and received from the facility to review documentation regarding R37's hospitalization . R37's Nurse's Notes received on 3/31/22 documents a note by V9 dated 3/16/22 documenting that R37 was seen by V28 (Wound Specialist/ MD) related to wounds to the right and left anterior thigh, see POS, and TAR updated. The copy of the March POS received on 3/31/22 documents an order dated 3/16/22 for the orders as documented on the Wound Management and Evaluation Summary by V28 on 3/16/22. The copy of the March TAR documents those treatments with a start date of 3/16/22 and initialed as completed beginning on 3/16/22. The copies requested from the facility on 3/22/22 of the March POS, Nurse's Notes, and March TAR did not document the orders from V28 on 3/16/22 or that the treatments were provided as ordered on the March TAR, March POS, and Nurse's Notes. On 3/31/22 at 3:00 PM, V26 (Regional Clinical Nurse) states that V26 cannot explain why the documentation requested on 3/22/22 does not contain the notes and orders dated 3/16/22 that was documented on the requested records received on 3/31/22. V26 sates that the notation late entry must be made if an entry is made at a later date. V26 said that V26 is unable to determine if the treatment to R37's right thigh was being completed since it was not documented on the records received 3/22/22. A Nurse's Note dated 3/26/22 documents that R37 returned to the facility. A document titled Discharge Information For Receiving Facility from the hospital dated 3/26/22 documents that R37 was admitted to the hospital with primary encounter diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital records document that R37 received [MEDICATION(S)] and [MEDICATION(S)]-tazobactam (antibiotics) intravenously during the hospital stay and was discharged on [DATE] with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/28/22 at 9:30 AM, R37 said that she went to the hospital and received several bags of antibiotic for the infection in the wound to the right thigh. R37 said that the part of the wound that was bulging before R37 went to the hospital was infected and since then the area has drained and is now smaller. On 3/28/22 at 9:35 AM, V9 removed the dressing from R37 right thigh. The wound to R37's right thigh was diminished in size. The center to the wound bed was flat and there was no drainage noted. The wound edges were pink. The wound appeared to be approximately 2 cm in diameter. On 4/5/22 at 9:40 AM, V28 (Wound Specialist/ MD) said that when R37 was admitted to the facility R37's surgical incision sites from the bilateral amputations were infected. V28 said that they were healed within a couple weeks after R37's admission. V28 said that R37 is prone to infection. V28 said that although V28 cannot guarantee that hospitalization could have been prevented, V28 feels the wound would have healed quicker if the dressings were completed as ordered. R37's most recent care plan provided is titled Baseline Care Plan dated 10/28/21. There is no documentation on the care plan regarding identification of the wounds, treatments, goals, or interventions regarding wound care or prevention of skin breakdown 2. The Admission and Discharge Record in R29's medical record documents that R29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R29's March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/28/22 at 3:00 PM, R29 said that R29 has wounds to the left ankle. R29 said that the nurses do not always change R29 dressing and states that the nurses tell R29 that they have run out of time. R29 said the nurses will tell the next shift to do it but the next shift will not do it. R29 said that R29 dressing is ordered to be changed daily on second shift and R29 has gone over a 24 hour period without getting the dressing changed. R29 said that R29 doesn't want to see V28 (Wound Specialist/ MD) for the care of R29 wound and requested to see a vascular surgeon since R29's wounds are venous ulcers. R29 said that R29 has not seen V28 and was referred to a vascular surgeon several months ago and no one will help her find a vascular surgeon to go to. R29 said the person that makes the appointments at the facility has quit and no one made R29 an appointment. R29 has a dressing in place to the left lower leg. The gauze is visibly soiled with dried blood tinged drainage. The dressing is dated 3/27/22. On 3/31/22 at 9:35 AM, V9 (Licensed Practical Nurse) removed the dressing from R29's left lower leg. R29 complained of pain to the wounds with the removal of the dressing. The old dressing was saturated with dried blood tinged drainage and tan colored exudate was noted to the dressing and the wound beds. There were 3 large open areas to R29's left lower leg. The edges of the wounds appeared dry and darker in color. The center of the wounds were red with tan exudate. V9 said that R29's dressing is done on 2nd shift and V9 had not seen R29's wounds in a while. V9 said that weekly wound assessments are completed weekly on the 2PM-10 PM shift. V9 said that the weekly skin check assessment findings are documented on the back of the Treatment Administration Record (TAR). V9 said that V28 sees residents with wounds weekly and measures the wounds. V9 said that R29 has not seen V28 in a couple of months and R29 refuses to be evaluated by V28. A document titled Wound Management and Evaluation Summary by V28 dated 11/25/21 documents the following wounds: Site 1-venous wound of the left, lower, lateral leg full thickness measuring 3 cm x 1 cm x 0.2 cm (length x width x depth). Site 2- shear wound of the left, anterior, lower leg full thickness measuring 3 cm x 3 cm x 0.3 cm. Site-3- shear wound of the left, upper, lateral leg full thickness measuring 1 cm x 1 cm x not measurable. Site 4- arterial wound of the left, lateral ankle full thickness measuring 1 cm x 3 cm x not measurable. R29 's TAR for January 2022, February 2022, and March 2022 were reviewed. On the January TAR there are 14 days that there were no initials indicating that the treatment to the left lower leg was completed. On the January TAR, the weekly skin checks were all initialed as being completed. The back of the TAR skin assessment findings were documented for the assessments completed on 1/12/22 and 1/19/22. The assessment completed on 1/19/22 documents the following: Left lower leg 1.) 5 cm x 4.5 cm 2.) 4 cm x 2.5 cm 3.) 5 cm x 2.5 cm. Right lower leg 1.) 2 cm x 2 cm. R29's wound measurements documented an increase in size from V28's previous wound assessment completed on 11/25/21. R29's TAR for February 2022, document there are 17 days that there were no initials indicating that the treatment to the left lower leg was completed. The weekly skin checks were not initialed as being completed for the month of February and there are no assessment findings or measurements documented on the back of the TAR. R29's TAR for March 2022, document there are 8 days that there were no initials indicating that the treatment to the left lower leg was completed. All of the weekly skin checks are initialed as being completed. The documentation for the weekly skin checks on the back of the TAR document that there are 4 open areas to the left lower leg. There are no documented wound measurements or descriptions of the wounds. On 3/30/22 at 4:50 PM, V10 (Licensed Practical Nurse) said that there are times that not all of the treatments get done due to time constraints. V10 said that there are a lot of residents with behaviors that make it difficult to get everything done. V10 said that when V10 is unable to complete a treatment, V10 lets the nurse on the next shift know. On 3/31/22 at 3:00 PM, V26 (Regional Clinical Nurse) said that residents with wounds are assessed on at least a weekly basis. V26 said wound assessments should contain measurements of the wound and descriptions of the wound. V26 verified that the last assessment by V28 was 11/25/21 and there were no recent wound measurements of R29's wounds. On 3/31/22 at 3:25 PM, V4 (Licensed Practical Nurse) and V10 (Licensed Practical Nurse) were observed measuring R29's wounds. R29 has 3 wounds that measured: 1.) 6 cm x 5 cm x 0.1 cm 2.) 6.5 cm x 3 cm x 0.1.cm 3.) 7.5 cm x 2.5 cm x 0.3 cm. R29's wound culture and sensitivity (C &S) lab report with a documented collection date of 3/22/22 documents heavy growth of the organism Proteus Mirabilis. R29's Nurse's Notes and POS did not document an order or a rationale for obtaining a wound C & S. On 4/5/22 at 4:15 PM, V4 said that she obtained an order from V31 (Medical Doctor) to obtain a wound C & S because R29's wound had an increase in yellow drainage. V4 said that R29 had been on different antibiotics off and on and thought that they should do a wound C & S to determine the correct antibiotic to use to treat R29's wound infection. V4 said that she documented the order on a Telephone Order Sheet. V4 said that the Telephone Order Sheets usually go to the Director of Nursing (DON) until they get signed by the doctor and then they are filed in the medical file. On 3/31/22 at 11:30 AM, V27 (Nurse Practitioner) stated that she had referred R29 to a vascular surgeon a few months ago and stated that R29 never went and is not sure why. V27 said that V27 reviewed the wound culture and is placing R29 on [MEDICATION(S)] and is going to do another referral for R29 to see a vascular surgeon and go to a wound care clinic to be evaluated. A clinic note completed by V27 dated 11/30/22 documents that R29 is requesting to be evaluated by a vascular specialist. An order is documented for a referral to a vascular surgeon. On 4/4/22 at 1:30 PM, V3 (Regional Director) verified that R29 has not been seen by a vascular surgeon as ordered on 11/30/22 by V27. The facility policy titled Skin Condition Monitoring (revision date 1/18) documents It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. Procedure step 4 states Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: A.) Characteristic- 1. Size 2. Shape 3. Depth 4. Odor 5. Color 6. Presence of granulation tissue or necrotic tissue. B.) Treatment and response to treatment . C.) Prevention techniques that are in use for the resident. 3. The Admission and Discharge Record in R3's medical record documents that R3 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/22 at 3:45 PM, V4 (Licensed Practical Nurse) said that R3 no longer resides at the facility and has transferred to another Long Term Care facility on 3/21/22. R3's March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wound Management and Evaluation Summary by V28 dated 1/26/22 documents has an arterial wound to the right heel partial thickness measuring 1 cm x 1 cm x not measurable. The wound treatment plan documents the treatment as [MEDICATION(S)] twice daily for 24 days. A Wound Management and Evaluation Summary by V28 dated 3/16/22 documents that R3's arterial wound to the right heel is now full thickness and measures 1.5 cm x 1 cm x not measurable. R3's Treatment Administration Record (TAR) for January 2022 does not have any initials as being completed for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's TAR for February 2022 does not have any initials as being completed for the order for [MEDICATION(S)] to the wound of the heel twice daily 15 times on the 6 AM to 2 PM shift and 10 times on the 2 PM to 10 Pm shift. R3's TAR for March 2022 does not have any initials as being completed the order for [MEDICATION(S)] to the heel wound twice daily 10 times on the 6 AM to 2 PM shift and 6 times on the 2 PM to 10 PM shift. On 3/30/22 at 4:50 PM, V10 (Licensed Practical Nurse) said that there are times that not all of the treatments get done due to time constraints. V10 said that when she is unable to complete a treatment, V10 lets the nurse on the next shift know. 4. R34's Physician Order's Sheet, dated March 01-March 31, 2022, documents a current dose of [MEDICATION(S)] ([MEDICATION(S)]) 500 mg (milligrams), 1 tablet by mouth two times a day for Dx (diagnosis): [CONDITION(S)]. R34's Physician Order's Sheet documents labs were ordered by V27 (Nurse Practitioner/NP) on 3/14/22, for CBC (complete blood count), CMP (comprehensive metabolic panel), TSH ([CONDITION(S)] stimulating hormone), Vit (vitamin) D, Vit B12, HbA1C, Lipids, [MEDICATION(S)], and [MEDICATION(S)]). R34's document titled American Health Associates lab report shows labs were drawn on 3/16/22, however the Vit D, Vit B12, & [MEDICATION(S)] labs were not drawn. On 3/31/22 at 1:00 p.m., V9 (Licensed Practical Nurse/LPN), stated that labs are contracted out by (American Health Associates) and they come daily to draw labs. V9 stated that if a lab is ordered other than a routine lab, it will be drawn on the very next day or if it is a STAT order, it will be drawn as soon as possible. On 3/30/22, at 8:30 a.m., V11 (Regional Director) stated that the nurses take care of the lab results, notify the primary care physician, and await further orders. V11 stated that V27 (Nurse Practitioner/NP) comes to the facility on ce a week and reviews labs, orders, etc. V11 stated that V27 (NP) is scheduled to be at the facility on 3/31/22. On 3/31/22 at 11:00 a.m., this surveyor notified V27 (NP) of R34's Vit D, Vit B12, & [MEDICATION(S)] labs that were not drawn on 3/16/22 in accordance with V27's order on 3/14/22. V27 stated that there has been some confusion in getting notifications of lab results and was not aware of the Vit D, Vit B12, & [MEDICATION(S)] labs being missed. V27 stated that those labs would be addressed today along with any changes in medications that might be needed. The facility's policy, Laboratory Tests, reviewed date 9/17/2017, under Policy, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. Under Procedure, 1. Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. 2. Obtain laboratory orders upon admission, readmission and PRN for medication and condition monitoring per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]