Every finding on record at Beecher Manor NRSG & Rehab CTR

Based on interview and record review, the facility failed to ensure a resident was free from exploitation and sexual abuse by V5 (Maintenance Assistant).This applies to 1 resident (R1) reviewed for abuse in a sample of 5 residents.V5's abuse of power and manipulation resulted in mental anguish for R1.The findings include:On 7/15/26 at 11:04 AM, V7 (CNA/Certified Nurse Assistant) stated on 7/12/26 around 8:50 AM she walked into R1's room to deliver her breakfast tray and she saw V5 (Maintenance Assistant) and R1 kissing behind R1's door. V7 said that as she walked into R1's room and looked to her left, she saw R1 and V5's lips touching at the end of a kiss. V7 said R1's hands were on V5's neck/shoulders and R1's back was towards V7. V7 said V5's eyes were initially closed and when the kiss ended, as he opened his eyes. V7 stated when V5 saw V7 there, his eyes became wide and big. V7 said she did not think R1 knew V7 saw her kissing V5 because R1's back was towards V7 and R1 is blind. V7 said she left R1's room after V5 left and V5 approached her in the hall. V7 stated V5 told her R1 said she loved him and wanted to be with him. On 7/16/26 at 10:22 AM, V5 (Maintenance Assistant) stated R1 would wait outside her room in the hallway for V5 in the mornings and he would go right up to her face (because she is blind) and say something like boogey boogey and R1 would say she knew he was there because she could feel him. V5 said R1 would do her dance moves and he would say to her shake your booty. V5 said R1 had told him she loved him and she wanted V5 to take her out of the facility on the weekends. V5 said he told R1 he could not sign her out of the facility because then people would be looking at them and asking questions. V5 said he knew kissing R1 was wrong because he is an employee of the facility and she is a resident. V5 said after V1 (Administrator) was made aware V5 was seen kissing R1, V1 spoke to him on the phone and told him to leave the facility but he did not leave the facility right away and instead went back to check on R1 because he cares about R1. V5 said R1 kept telling him she wanted him and V5 asked R1 what she meant by that and R1 told V5 she wanted his body. V5 said on 7/12/26, R1 told him the resident in the adjacent room was sleeping and asked V5 to go into her room. V5 said he entered R1's room and went behind the door and R1 followed him, hugged him, and put her mouth up towards him and he kissed her. V5 said his hands were on R1's waist and his eyes were closed while he was kissing R1. V5 said V7 (CNA) walked into R1's room and saw him kissing R1. V5 said V7 looked startled, and he told her Shh because he didn't want her to say anything about what she saw. V5 said after he left R1's room, he approached V7 and told her R1 was in love with him. V5 said he could not recall having any abuse training and he didn't think that would pertain to him.On 7/16/26 at 12:27 PM, V4 (Maintenance Director) said a staff member kissing a resident is sexual abuse and V5 went over the line. V4 said he reviewed the facility camera footage on 7/13/26, the day after V5 was seen kissing R1. V4 said the footage showed V5 and R1 in the hallway outside R1's room, then V5 walked into R1's room for a moment then back out to R1 in the hall and they were face-to-face talking for a moment before they walked back into R1's room together. V4 said V5 and R1 were together in R1's room for about 4 minutes before V7 (CNA) walked into R1's room with the breakfast tray. V4 said about 1 minute passed before V5 walked out of R1's room looking distressed and he was noted pacing back and forth in the hallway. V4 said then V7 was seen leaving R1's room.On 7/16/26 at 3:58 PM, V1 (Administrator) said she is the Abuse Coordinator and a staff member kissing a resident is sexual abuse. V1 said she interviewed R1 and R1 told her she and V5 have had a relationship for years. V1 said R1 told her their relationship did not go any further than kissing. V1 said after she talked to V5 and told him to leave the building, he should have been escorted out by the manager on duty to ensure R1's safety.On 7/16/26 at 1:42 PM, V9 (LPN/Licensed Practical Nurse) said since the incident on 7/12/26, R1 has not been herself. V9 said R1 told her she is not okay and she and V5 are in love. V9 said on 7/12/26 R1 was crying up a storm and listening to love songs in her room. V9 said R1 told her, This is killing me, I love him. V9 said a staff member kissing a resident is sexual abuse. On 7/16/26 at 2:05 PM, V12 (CNA) said when she came in to work on 7/13/26, R1 was in her room with the door closed when she normally would get up early and get herself dressed and come out into the hallway to do her stretching and yoga. V12 said now R1 is staying in her room listening to sad love songs. V12 said a staff member kissing a resident is sexual abuse.On 7/16/26 at 3:28 PM, V11 (SSD/Social Service Director) said a staff member kissing a resident is sexual abuse. V11 said when she asked R1 what happened between her and V5, R1 told V11 she didn't want to talk about it and she was pleading the fifth. V11 said R1 also declined to talk to her earlier that day, on 7/16/26. R1's care plan had not been updated to include any sexual abuse concerns. V11 said she should have updated R1's care plan to include the abuse concerns so staff are aware they should be evaluating her mental status and making sure R1 is okay.R1's Face Sheet shows a primary diagnosis of schizophrenia and additional diagnoses include legal blindness, heart failure, cognitive communication deficit, psychotic disorder with hallucinations, and major depressive disorder. R1's Physician Order Sheet shows she is currently taking a daily antipsychotic medication. R1's Minimum Data Set, dated [DATE] shows her cognition is intact. R1's Care Plan dated 4/3/26 shows she is at risk for abuse due to her schizophrenia diagnosis. R1's Care Plan dated 10/28/24 states the resident uses antipsychotic medications related to schizophrenia, psychotic disorder, and depression.R1's alert note documented by V6 (Nurse Supervisor, LPN) on 7/12/26 at 10:00 states: CNA reported to writer that she observed a staff member kissing resident while dropping off [R1's] breakfast tray. Upon assessment, resident was alert and oriented and willing to discuss the reported incident. Resident stated that the relationship is her personal business and not anyone else's concern. Resident confirmed that she and the staff member have been in love for a while and reported these feelings have existed for over one year. While speaking with resident, staff member (V5) came back to resident's room after already being told to leave the building and was told by writer and associate nurses he (V5) needed to leave. Once he (V5) left, assessment was continued with resident. Resident stated that their interactions have consisted of hugging and kissing only. Resident expressed concern that the staff member (V5) may lose his job, stating she is worried because she won't see him anymore. R1's Health Status Progress Note dated 7/13/26 at 2:36 PM states resident was tearful with CNA during shower.The facility's undated policy titled, Abuse Prevention Policy states, .Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other then by accidental means. Abuse is the willful infliction of injury.with resulting harm, pain, or mental anguish to a resident.The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy defined exploitation as .taking advantage of a resident for personal gain through the use of manipulation.

Based on observation, interview and record review, the facility failed to provide meal delivery in a timely manner to ensure palatability. This applies to 3 of 3 residents (R4, R5 and R7) reviewed for dietary services. The findings include: On 07/09/26 at 11:42 AM, residents were in the main dining room waiting to be served lunch. On 07/09/26 at 12:09 PM, a small lunch cart with a few trays were delivered to the north unit nursing station. On 07/09/26 at 12:15 PM, R4 was in bed watching TV. R4 had not received her lunch tray. R4 stated all meals have been served an hour late for the last month. R4 stated the food is always cold and never warm. R4 stated there have been times when she has received breakfast at 11:00 AM, lunch at 2:00 PM, and dinner at 7:30 PM. On 07/09/26 at 1:00 PM, R4 continued to wait for lunch. R4 stated she was hungry and ready for lunch. On 07/09/26 at 1:08 PM, an enclosed lunch cart was delivered to the unit. The staff passed trays to the residents. On 07/09/26 at 1:11 PM, V6 (CNA/Certified Nursing Assistant) pushed R4 in a shower chair to the shower room. Twelve minutes later at 1:23 PM, V5 (CNA) delivered lunch tray to R4's room. A third zipped lunch cart arrived at the unit. On 07/09/26 at 1:20 PM, R5 was sitting at the nurse's station waiting for lunch. The staff continued passing lunch trays from the other cart. R5 was then pushed to the table across from the nurse's station to eat lunch and R5's tray was provided at 1:23 PM. On 07/09/26 at 2:02 PM, V6 pushed R4 back to her room from the shower room. R4 stated she did not want the lunch because it was cold, and she would eat a sandwich that she already had. R4 stated she did not want the lunch heated up. R4 was served chicken pot pie with gravy on top, peas, a brownie, and cranberry juice.On 07/09/26 at 2:10 PM, V7 (Dietary Manager) tested the temperature of the food for R4. The chicken pot pie temperature was 100 F (Fahrenheit), peas 90 F. V7 stated the temperature should be hotter for the pot pie and the peas for the meal to be palatable. V7 stated residents lunch trays should not be served to their rooms at 1:23 PM. V7 stated R4's hallway trays are last to be delivered. R7 stated the last food cart did not have the insulated base to keep the food warm since the facility ran out of the bases. On 07/10/26 at 10:10 AM, V10 (LPN/Licensed Practical Nurse) stated residents' meals are often served late. V10 stated there are times lunch is served when the day shift is almost over at 2:00 PM and the residents complain about the food being cold when it is served to them.On 07/10/26 at 1:42 PM, V11 (LPN) stated she works the 2:00 PM - 10:00 PM shift. V11 stated there had been several occasions when she had come in for work, residents were just being served lunch. V11 stated residents complain about the food being cold. On 07/10/26 at 11:44 AM, R7 stated dinner is served at 7:00 PM for the residents who eat in their rooms. R7 stated sometime the food is warm, and not always hot. On 07/10/26 at 4:24 PM, V1 (Administrator) stated lunch trays should not be delivered to residents after 1:00 PM. V1 stated dinner should not be delivered to residents at 7:00 PM. V1 stated meals should be delivered on time. V1 stated the facility has a guideline on when residents need to get their meals. V1 stated food should not be delivered to the residents cold.The facility's Mealtimes showed Breakfast: 7:30 AM tray line serving, 8:00 AM dining room serving/1:1 assist. Lunch Time: 11:30 AM tray line serving, 12:00 PM dining room serving/1:1 assist. Dinner Time: 5:00 PM tray line serving, 5:30 PM dining room serving/1:1 assist.The facility's Grievances and Resident Council Meeting Minutes were reviewed for the last three months. Grievance dated 04/01/26 showed family member expressed concern regarding late breakfast on 03/29/26. Grievance dated 05/05/26 showed resident expressed concern regarding late breakfast and lunch on 05/05/26. Grievance dated 05/11/26 showed resident's family expressed concerns regarding late meals on the weekend. Grievance 05/12/26 showed resident expressed concern regarding breakfast and late dinner.

Based on observation, interview, and record review, the facility failed to ensure restorative nursing services were consistently implemented in accordance with therapy recommendations and resident needs rather than residents approaching MDS (Minimum Data Set) assessment review periods. The facility failed to provide restorative programming when restorative aids were reassigned to work on the floor and given an assignment to perform patient care/ staffing duties.This applies to 11 of 13 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10, R12, R13) reviewed for restorative therapy services. The findings include:1.R12's Face sheet showed R12 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia, hemiparesis, lack of coordination, abnormal gait and mobility, abnormal posture, and reduced mobility.R12's MDS (Minimum Data Set) dated April 20, 2026, showed R1 had severe cognitive impairment and required maximal assistance/dependance on staff for completion of activities of daily living (ADLs).R12's current restorative care plan showed that R12 was to be assisted with an eating program, bed mobility and passive range of motion (PROM) to the right hand and joints.2. R13's Face sheet showed R13 was admitted to the facility on [DATE], with multiple diagnoses including lack of coordination, reduced mobility, abnormal posture, osteoarthritis, repeated falls and spinal stenosis.R13's MDS dated [DATE], showed that R13 was severely cognitively impaired and was dependent on staff for the completion of ADLs.R13's current restorative care plan showed R13 should receive active range of motion (AROM) to the bilateral upper extremities for eight to ten repetitions per joint daily for six to seven days per week.On May 19, 2026, at 11:00 AM, and 12:00PM, and on May 20, 2026, at 9:00 AM, 11:40 AM, and 1:15 PM, R11, R12, and R13 were sitting near the nurse's station without any engagement from staff for restorative programming or exercise.On May 19, 2026, at 12:20 PM, V8 (Restorative Aid/RA), said that the restorative team's daily routine starts with getting weights on those residents that need to be weighed, and then they have to review those residents who are listed as having a MDS assessment due that week. They are the priority, and their restorative programming gets completed first. The exercises are performed individually with residents if they are on the MDS list. Once they are done with those residents, and if time allows, they will work with other residents on their restorative programming. V8 said that those residents who have been identified as a high risk for falls, are seated around the nurse's station or at the table. The Restorative Aides will sit at the table with these residents and perform up and down leg kicks if time allows and the residents are able to do. V8 said that she was working on the unit as a CNA (Certified Nursing Assistant) for this shift and had not done any restorative programing on any of the residents sitting around the nurse's station.On May 19, 2026, at 12:40 PM, V7 (RA/CNA) said they do restorative programming for the residents sitting at the tables in front of the nurse's station maybe once or twice a week if time allows.On May 20, 2026, at 11:30AM, V2 (Director of Nursing/DON) said that residents on restorative programming should receive restorative programming six to seven days per week for fifteen minutes per day. V2 confirmed that residents who are vulnerable to decline should receive programming and that includes the residents who are often sitting at the tables in front of the nurse's station. 3.R2's face sheet showed R2 was admitted on [DATE], with multiple diagnoses including spinal stenosis, sciatica, muscle wasting, lack of coordination, difficulty walking, reduced mobility, repeated falls, and osteoarthritis.R2's MDS dated [DATE], showed R2 was cognitively intact and requires moderate to maximal assistance from staff to complete ADLs. R2's MDS showed R2 is to receive PROM and AROM six to seven days a week for a minimum of fifteen minutes.R2's current restorative care plan showed R2 was to participate in AROM to the bilateral upper extremities with 1-2-pound weights for five sets for three repetitions daily as tolerated. R2 was to participate in transfers by assisting with all transfers.On May 19, 2026, at 2:56 PM, R2 said she was walking before she came into the facility, and now she is no longer walking. R2 said she has only seen the restorative aide once and that was earlier this week. R2 has an elliptical under the desk that she uses on her own in her room. R2 said that no RA or CNA have assisted her with exercises.4. R1's Face sheet showed R1 was admitted on [DATE], with multiple diagnoses including osteoarthritis, spondylosis, pain, muscle wasting, and fracture of the left femur.R1's MDS dated [DATE], showed R1 was cognitively intact and required a wheelchair for mobility. R1 required assistance from staff to complete activities of daily living. R1's MDS showed R1 was to receive PROM and AROM six to seven days a week for a minimum of fifteen minutes.R1's current restorative care plan showed that R1 was to participate in AROM and will perform three sets of ten repetitions to bilateral upper extremities and left lower extremity 6 to 7 days per week. R1 was to participate in PROM and will receive three sets of ten repetitions of PROM to the right lower extremity six to seven days per week.On May 19, 2026, at 2:48PM, R1 said that she previously attended therapy, but was no longer in therapy. R1 said she has not received any restorative programming including any range of motion exercises. R1 said that she tries to do exercises on her own, but no one has helped her. R1 said that no RA or CNA have assisted her with exercises.5. R3's Face sheet showed that R3 was admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, difficulty walking, Sjogren syndrome, spinal stenosis, abnormal posture and muscle wasting.R3's MDS dated [DATE], showed R3 is cognitively intact and requires moderate assistance from staff to complete ADLs. R3's MDS showed R3 is to receive range of motion and bed mobility six days for fifteen minutes per day.R3's current restorative care plan showed R3 is to receive AROM to the bilateral upper extremities with two-to-three-pound hand weights daily as tolerated. R3's bed mobility care plan showed R3 will sit up in bed with contact guard assist and lay back down and roll side to side for two sets and two repetitions daily as tolerated.On May 19, 2026, at 11:51AM, R3 said that she had previously worked with therapy but no longer goes down to therapy. R3 said that no one has come into her room to help her move her arms or legs around. R3 said she does not remember anyone asking her to roll from side to side in her bed. R3 said that the CNA's or Ras have assisted her with exercises.6. R4's Face sheet showed R4 was admitted to the facility on [DATE], with multiple diagnoses including osteoarthritis in the right and left knee, lack of coordination, abnormal posture, reduced mobility, chronic pain, hemiplegia, and hemiparesis.R4's MDS dated [DATE], showed R4 was cognitively intact and required maximal to supervised assistance to complete ADLs. R4's MDS showed R4 was to receive AROM for seven days for fifteen minutes per day and bed mobility for six days for fifteen minutes per day.R4's current restorative care plan showed R4 was to receive AROM to bilateral lower extremities using three-pound weights and will stretch quads and Achilles while seated. R4 was too complete AROM to bilateral arms for eight to ten repetitions to each joint for six to seven days per week. R4' s bed mobility care plan showed R4 was to turn side to side to assist with proper bed alignment for six to seven days per week.On May 19th, 2026, at 3:17 PM, R4 said that she had not seen restorative aides in about three months or so. R4 said no one had been in her room to help her with range of motion to her arms or legs. R4 said that CNA's do not assist her with exercises. 7. R5's Face sheet showed R5 was admitted to the facility on [DATE] with multiple diagnoses including fracture of the neck, muscle wasting, difficulty walking, lack of coordination, abnormal posture, reduced mobility, sciatica, abnormalities of gait and mobility, dislocation of internal right hip prothesis and history of falls.R5's MDS dated [DATE], showed R5 was cognitively intact and requires moderate assistance from staff to complete ADLs. R5's MDS showed R5 was to receive AROM and walking seven days a week for fifteen minutes per day.R5's current restorative care plan showed R5 would ambulate 300 feet with a two wheel-walker with a gait belt. R5 would perform AROM to upper and lower bilateral extremities daily with three-pound weights daily as tolerated for five sets and five repetitions.On May 19, 2026, at 3:22 PM, R5 said that he had recently been discharged from physical therapy and was informed that someone would continue to help him after therapy, but he has not seen anyone yet. R5 said that no one helps him move his arms or legs around in the morning and he has not walked with anyone since he was in therapy. R5 said that the CNA's do not assist him with exercises.8. R6's Face sheet showed R6 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the sacrum, fracture of the right radius, fracture of the lumbar vertebrae, lack of coordination, low back pain, and osteoporosis.R6's MDS sheet dated March 20, 2026, showed that R6 was cognitively intact and requires touching assistance from staff to complete ADLS. R6's MDS showed R6 required assistance from staff to complete ADLs. R6's MDS did not show participation in restorative care planning.R6's current restorative care plan showed that R6 was to receive AROM six to seven days per week. R6's dressing care plan showed that R6 would dress with limited assistance and setup.On May 19, 20206, at 3:10 PM, R6 said she has not received any restorative programming from staff. R6 said no one has come in to give instructions on rotating her arms and legs. R6 said that staff is nice and help her when she needs it but said she is not receiving any form of therapy at this time. R6 said that CNA's do not assist her with exercises.9. R7's Face sheet showed that R7 was admitted to the facility on [DATE], with multiple diagnoses including difficulty walking, lack of coordination, spinal stenosis, disorders of the muscles, muscle weakness, reduced mobility, osteoporosis, abnormal posture, and muscle wasting and atrophy.R7's MDS dated [DATE], showed R7 was cognitively intact and required limited assistance from staff to complete ADLs. R7's MDS showed R7 received three days of AROM and transfer assistance for fifteen minutes each day.R7's current restorative care plan showed R7 performs AROM to bilateral upper extremities with two-to-three-pound weights for three sets and two repetitions daily. R7 transfers from bed to chair and chair to bed for three sets and two repetitions daily.On May 19, 2026, at 2:52 PM, R7 said that she had worked with therapy a month ago but now she does bed exercises on her own because therapy has ended and if she does not do them, she could lose all the progress she has made. R7 said that she does these exercises on her own and did not know what the restorative program was. R7 said that no one comes in to assist her with bed exercises or comes in to have her move her arms or legs around and she does not practice moving back and forth from her bed to her chair. R7 said that CNA's do not assist her with exercises.10. R8's Face sheet showed R8 was admitted to the facility on [DATE], with multiple diagnoses including left femur fracture, Parkinson's Disease, Osteoporosis, Osteoarthritis, difficulty walking, muscle wasting and atrophy, repeated falls, lack of coordination, abnormal posture. Reduced mobility, and rib fracture.R8's MDS dated [DATE], showed R8 was cognitively intact and requires moderate assistance from staff to complete ADLs. R8's MDS showed R8 received AROM and walking programming for six to seven days per week for fifteen minutes per day.R8's current restorative care plan showed R8 will ambulate 150 feet with contact guard assistance and rolling walker daily as tolerated. R8 will perform AROM to bilateral upper extremities for three sets and ten repetitions daily as tolerated.On May 19, 2026, at 2:41 PM, R8 said that she no longer has therapy. R8 said that restorative programming was supposed to get into gear but has not started yet. R8 said she has not done any exercises with CNAs, and no one has helped her to walk or move her extremities around. R8 said that CNA's do not assist her with exercises.11. R10's Face sheet showed R10 was admitted to the facility on [DATE], with multiple diagnoses including lack of coordination, reduced mobility, abnormal posture, muscle wasting, difficulty in walking and repeated falls.R10's current MDS dated [DATE], showed R10 was cognitively intact and required maximum to moderate assistance from staff to complete ADLs. R10's MDS showed R10 received six days of walking for fifteen minutes per day.R10's current restorative care plan showed R10 performs AROM to bilateral upper and lower extremities with two-to-three-pound weights for ten sets for three repetitions daily as tolerated. R10 performs dressing tasks by putting on upper and lower extremity garments with the assistance of one staff member.On May 19, 2026, at 2:33 PM, R10 said that she used to have therapy but no longer receives treatment. R10 said she does not receive exercise programming from restorative care or CNAs on the floor, but she does participate in resident led yoga sessions on Wednesdays and Saturdays to keep up strength.On May 19, 2026 at 11:25 AM, V9 (Certified Nursing Assistant/CNA) and V10 (CNA) said that there is a restorative team that completes restorative programs for the residents and if the residents are on tasks such as dressing then it is done when the resident gets up in the morning, but as far as actual programming it is performed by the restorative staff.On May 19th, 2026, at 11:35AM, V12 (CNA) said that all CNA's are responsible for providing restorative care for the residents.On May 19, 2026, at 5:56 PM, V11 (CNA) said that the CNA's do not perform restorative care and that there is a separate team, a restorative team that performs restorative care.On May 19, 2026, at 12:20 PM, V8 said that restorative programming is an extension of physical therapy. V8 said that typically there are two RA's on the floor and they start on opposite ends of the hallway focusing on the residents who are up for MDS review that week. Residents who are on the list for review who participate in walking will be walked to meals that week. V8 said that when RAs are pulled to the floor because they are also CNAs, the restorative programming does not get done. The RAs are used to cover open floor shifts a lot. V8 said that she has encouraged CNA's who are working on the floor to assist with restorative programming especially when RAs are pulled to the units to cover call offs. V8 said there are only a few CNA's who are willing to assist, but most will not do it. V8 said she has been requesting assistance, but it does not happen. V8 said that there is no daily task sheet, list of residents on programs, or schedule of residents that need to be seen daily. The staff would have to get the look back review sheet from the MDS coordinator which shows which residents' assessments need to be reviewed for MDS evaluation for that week. V8 said once they have completed the list they can then pick and choose who else to work with that day if time allows.On May 19, 2026, at 12:40 PM, V7 said that there is no daily task list. V7 said they complete the list of residents that have MDS assessments up for review for the week and then sign off on anyone that may be seen outside of that list. V7 said she normally asks the people who want to walk and perform walking programs. V7 said that they receive referrals from therapy, but restorative does not really work with therapy. V7 said that the restorative team is expected to do what the referral lists to keep up with what the resident had learned in therapy. V7 said that restorative aides are pulled from restorative to work the unit a lot. V7 said that V8 was pulled from restorative today and V7 was used to cover an open CNA shift on Sunday. V7 said that when there is no one from restorative performing tasks then they do not get done.On May 20, 2026, at 10:30AM V6 (RA) said every day the RAs come in, they ensure splints are on, perform daily weights, and then obtain list of residents who are due for MDS assessment. If all work is complete, she is then able to choose other residents to perform tasks on. V6 said residents receive restorative care for six to seven days. V6 said she only works part time and is pulled to the floor at least once a week. V6 said that when she is covering open CNA shifts restorative programming does not get done.On May 19, 2026, at 1:01PM, V4 (Restorative Nursing Director) said that weights are completed by restorative team on a daily basis and that the RAs are told to focus on the residents who are up for review for MDS assessment. This is to ensure nothing is missed on the assessment. V4 said she is responsible for looking at the referrals and inputting the restorative tasks into the electronic medical record. V4 said she monitors what is being done by the restorative aides via verbal discussion. V4 said that restorative aides are pulled to the floor a lot and when this occurs restorative care does not get done. V4 said that when RAs are covering floor shifts it is expected that CNAs on the floor complete the task, but this does not get done. V4 said that when RAs are pulled to the floor, V4 does not go to the floor to complete any programs herself. V4 said that she has to complete her portions of the MDS assessment, and it does not allow enough time for her to do so. V4 said restorative care should be provided for all residents on restorative care for six to seven days per week for fifteen minutes each day for the entirety of their stay unless there is a change in condition or the resident is placed back on therapy. V4 was unable to give an exact number of residents who were on restorative programming.On May 19, 2026, at 2:11 PM, V5 (Nursing Scheduler) said the facility is not short staffed and there is only one open day time position that has already been filled. V5 said the floor becomes short when there are calls offs especially if they are last minute call offs. V5 confirmed that the restorative aides are pulled often from restorative for unit coverage. Restorative team members are pulled at least two to three times per week. V5 said that V1 (Administrator) informed her that the restorative team needed to be used for call offs instead of calling agency. Agency staffing is used minimally. V8 said that V1 informed her that agency staffing can only been used if all restorative aids are on the floor and there are still open shifts for call offs.On May 20, 2026, at 11:30 AM, V2 (DON) said there is an expectation that restorative care is performed and followed as referred by therapy and that restorative should be performed for all residents on restorative care programming. V2 said that the RAs have been scheduled to cover the call offs lately and have been working patient care assignments a lot. V2 said that when the RAs are working to cover CNA call offs, the restorative programming does not get done.On May 20, 2026, at 11:00 AM, V1 said the facility is not short staffed and the facility may use agency when there are open shifts and call-offs. V1 said it is expected that the restorative nurse assists with restorative programming if the RAs are rescheduled to perform patient care. V1 said the restorative team is only used for last minute call offs.On May 19th, 2026, at 10:30 AM, V3 (Therapy Director) said that when residents are discharged from therapy, a referral is submitted to the restorative nurse. It is expected that the restorative team will follow up and complete the tasks referred to maintain function.The facility's daily schedules for the nursing department showed restorative staff were removed from the restorative schedule to cover open CNA positions on April 5th, May 1st, May 2nd, May 3rd, May 5th, May 8th, May 10th, May 11th, May 15th, May 16th, May 17th, and May 19th, 2026. There was no one scheduled to perform restorative care on April 12th, April 26th, and May 9, 2026. Currently, there is no one scheduled to perform restorative care on May 24, 2026.Review of restorative care reports for each resident showed gaps in restorative documentation and inconsistent completion of restorative programming. Record review also showed restoratives sessions were marked as completed despite staff and residents reporting that programming has not been done.

Based on interview and record review the facility failed to ensure privacy for 1 of 4 residents (R2) reviewed for personal privacy. This failure resulted in R2 feeling unsafe in the facility.The findings include:R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], and discharged on April 07, 2026. R2 had multiple diagnoses including, radiculopathy, osseous and subluxation stenosis of intervertebral foramina of lumbar region, spondylosis with radiculopathy in the lumbar region, spinal stenosis, difficulty in walking, lack of coordination, abnormal posture, reduced mobility, muscle wasting and atrophy, hyperlipidemia, depression, anxiety, hypertensive chronic kidney disease, atrial fibrillation, spinal stenosis and low back pain.R2's MDS (Minimum Data Set) dated March 18, 2026 showed R2 was cognitively intact and required supervision or touching assistance for toileting and transfers. R2's most recent care plan showed that R2 refused to use the restroom in the resident's room. R2 utilized a bedside commode instead.On March 27, 2026 R2 filed a grievance with social services and informed V3 (Social Services Director) that a man entered her room while her pants were down and no one knew who the man was.On May 02, 2026, at 10:30AM R2 said that an African American man from the outside entered into the facility and was brought down to her room by the nurse while she was using the commode. R2 said that the individual was not an employee and did not knock or introduce himself. R2 said that the individual told her that he was coming to ask her about her stay in the facility while she was still sitting on the commode. R2 asked the gentleman and V9 (RN/Registered Nurse) to come back later as she was not available at the moment. R2 said V9 and the gentleman remained in the room and kept telling her that he only wanted to ask her a few questions. R2 said that she felt her privacy was violated as she was forced to answer questions while sitting on the commode. R2 said that V3 attempted to find out who the gentleman was and questioned V9 but was unable to determine who the individual was. R2 said that she requested a room change later that day. R2 said that she had only just recently heard from V1(administrator) regarding the situation a few days ago and there was no resolution to the concern when she was still residing in the facility.On May 02, 2026, at 12:16PM V9 said that a gentleman informed her that he needed to interview her about R2. V9 informed the gentleman that R2 was alert and oriented and able to answer any questions he may have. V9 said she walked the gentleman to R2's room and believed R2 to be sitting in a wheelchair. V9 said she left the gentleman in the room with R2.On May 02, 2026, at 12:59AM, V1 (Administrator) said she was aware of the incident that occurred with R2. V1 said that grievances are discussed during morning standup. V1 said that when she heard about the issue, she assumed it was maintenance that entered the room and informed maintenance to knock before entering the room. V1 said that the facilities policy is that the receptionist at the front desk should ensure that everyone has signed in via the electronic kiosk before moving around the building. V1 confirmed that resident's privacy should be respected, and people should knock before entering rooms and respect a resident's choice to be seen later if requested. V1 confirmed that R2's privacy was not maintained.

Based on interview, and record review, the facility failed to ensure that a residents nutritional needs were met. This applies to 1 resident (R1) reviewed for significant weight loss in the sample of 9.The findings include: R1's electronic medical record (EMR) showed R1 was admitted to the facility on [DATE], and discharged from the facility on February 15, 2026. R1 had multiple diagnoses including fracture of the left femur, sepsis, difficulty walking, moderate protein calorie malnutrition, dysphagia, hemiplegia, type II diabetes, lack of coordination, dementia, pain, reduced mobility, epilepsy, cerebral ischemic attack, polyneuropathy, hypertension, osteoarthritis, spondylosis, and falls.R1's minimum data set (MDS) dated [DATE], showed R1 had severe cognitive impairment and required maximal assistance from staff for eating and oral hygiene.R1's most recent care plan showed R1 had a potential nutritional problem and was receiving a therapeutic and mechanically altered diet. Staff were to monitor, record, and report to physician any signs and symptoms of malnutrition including significant weight loss. The registered dietitian was to evaluate and make diet change recommendations as needed.R1's physician's orders showed, R1 was on a low concentrated sweets, pureed texture diet with honey thickened liquids and required one to one feeding assistance. However, a nursing progress note entered on February 13, 2026, showed R1 was a partial self-feed, despite R1's order for one-to-one feeding assistance.R1's electronic medical record showed R1 weighed 121 pounds on January 16, 2026, and 108 pounds on February 05, 2026. R1 was last seen by the dietitian on January 20, 2026. R1 was seen by the nurse practitioner on February 13, 2026, and R1's weight loss was not addressed during the visit. There were no additional dietitian notes in R1's chart and no new dietary recommendation orders since R1's weight loss in February. On April 30, 2026, at 5:39PM, V16 (Family Member) said that he came to the facility often because the staff were not feeding R1 and that the amount of food given was not enough for a single person to eat. V16 said that when he brought in items for R1 to eat he would get yelled at. V16 said that he came quite often and began to perform most of the care on his own because staff were not providing care for R1. V16 said R1 had a fall in mid-February and was sent to the hospital. V16 said it was during this time that he learned that R1 had gone from 121 pounds down to 100 pounds in less than one month.On May 02, 2026, at 1:38PM, V10 (LPN/Licensed Practical Nurse) said that V16 was not compliant with R1's specialized diet and would often bring in additional food for R1 to eat despite being educated not to. V10 said she was not aware of R1's weight loss.On May 02, 2026, at 12:45PM, V2 (Director of Nursing) said she was unaware of R1's weight loss and had not been notified. V2 said that she had only just started working at the facility during this time and was still getting to know the residents. V2 said that R1 should have been followed by the dietitian and confirmed that no additional orders had been placed to address R1's significant weight loss.V1 was asked to provide the contact information for the dietician, but V1 never provided the requested information. The facility's policy Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol showed Assessment: 4. The staff will notify family of significant weight gains or losses or any abrupt or persistent decline from baseline appetite or food intake. Treatment: 2. The physician and or designee will authorize appropriate general or cause-specific interventions. Monitoring: 1. The physician and staff will monitor nutritional status, response to interventions, and possible complications of such interventions of individuals with impaired nutritional status.

Based on observations, interviews and record reviews the facility failed to ensure a resident was transferred in a safe manner, resulting in a fall.This applies to 1 of 5 residents (R1) reviewed for falls in a sample of 5. The findings include:R1's records showed that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including asthma, rheumatoid arthritis, type 2 diabetes, lack of coordination, muscle wasting and atrophy, difficulty walking, and osteoarthritis.On 4/7/26 at 12:34 PM R1 was in her room and staff were transferring R1. R1 was observed with bruising around her right eye, a bruise to her right elbow, an approximate 1-inch wound with 2 steri strips (Steri strips are thin sterile adhesive bandages used to hold edges of small wounds or surgical incisions together while they heal) over the wound and a bruise to her right upper thigh. R1's 4/3/26 11:19 pm progress note R1 had fallen and was observed on the floor on her right side holding her head. R1 was observed with bruising around the right eye, redness to her right knee and ankle and a skin tear to her right forearm and her pain being 7 out of 10. The progress note showed that R1 was sent to the local community hospital for evaluation. R1's 4/3/26 hospital after visit summary show that R1 sustained facial contusion, arthralgia (joint pain or discomfort), and skin tear. R1's Care Card (no date) showed that staff are to use R1's walker for stand pivot transfers. R1's 4/6/26 MDS (Minimal Data Set) showed that R1 needs partial to moderate assistance with transferring. R1's 4/3/26 care plan showed that R1 is a high risk for falls and interventions include anticipate and meet the resident's needs and follow fall protocol.On 4/7/26 at 3:56 PM, V10 CNA said that on 4/3/26 she was transferring R1 from the bed to her wheelchair and R1's feet slipped, and she fell to the floor on her right side and sustained a cut to her right elbow. V10 said that she did not use a gait belt or R1's walker while she was transferring R1.On 4/7/26 at 4:50 PM, V11 (Registered Nurse) said that on 4/3/26 she was R1's nurse. V1 said that R1 was a 1 person assist for transferring and the staff are required to use a gait belt when they transfer R1. V11 said that on 4/3/26, R1 did not have a gait belt on and R1's walker was nowhere near R1. V11 said that on the day that R1 fell her Care Card showed that staff are to use R1's walker when transferring or pivoting. V11 said that R1 sustained bruising to her outer right eye, above and below the eye, a skin tear to her right elbow, a red spot below her right knee, and a red spot on her right ankle. V11 said that R1 complained of her pain being a 7 out of 10. V11 said that the purpose of the gait belt is to assist during transfers to keep the resident stable, and to help prevent injuries or prevent falling when the resident is unstable or lose their balance. V11 said if the gate belt had been used it would have helped R1, and if the walker had been used it would have been the best prevention from R1 falling. V11 said that when R1 returned from the hospital she had bruising to her right flank area and to her right hip.On 4/7/26 at 3:40 PM, V16 PTA (Physical Therapy Aide) said that she provides care for R1 and R1 is a one person transfer with a gait belt and walker. V16 said that all staff are to use gait belts with one-person transfers. V16 said gait belts are to be used to help residents from falling when they lose their balance.On 4/8/26 at 10:52 AM, V13 (Restorative Nurse) said that she filled out R1's Care Card when she was admitted to the facility and updated the Care Card before her fall on 4/3/26 to add that the walker is to be used for standing and pivoting while transferring. V13 said the information was also discussed in the facility's morning meetings. V13 said that when transferring R1, or anyone who has weakness or is at a high risk for falls, a gait belt is used.On 4/8/26 at 3:37 PM, V1 (Administrator) said that V10 did not use a gait belt or a walker while transferring R1 on 3/4/26. V1 said that R1's Care Card indicated that the walker is to be used for transferring and pivoting and the staff should have used it. V1 said that on 4/3/26. R1 sustained bruising to her face, a skin tear and that R1 said that she was sore.On 4/9/26 at 2:03 PM, V2 DON (Director of Nursing) said that the gait belt is used as a safety precaution, and its purpose is to assist with transfers and ambulation. V2 said that R1's family had requested that the staff use the gait belt when transferring R1. V2 said that the staff should have used the walker for R1's transfer from the bed to the wheelchair on the day of her fall. V2 said that the walker could have served as extra support during the transfer.The facility's Gait Belt Use Guideline (02/23) showed the purpose of the gate belt is to provide a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfer. A belt can support a lower to the floor if a resident begins to fall or lose balance during a transfer or ambulation. The facility's Gait Belt Application and Use (no date) showed that the gait belt should be placed around the person's waist with the rationale to promote safety and prevent injury. For transfers, grasp both sides using an underhand grip with the rationale to promote safe transfers and ambulation.The facility's Falls and Fall Risk, Managing policy dated August 2008, showed that based on evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.

Based on observations, interviews, and record reviews the facility failed to follow fall prevention interventions for residents at high risk of falls for two of six residents (R4, R8) reviewed for falls and safety. The findings include:1. R4 is an [AGE] year-old male with a history of Dementia, Parkinson's Disease, Muscle Wasting and Atrophy, Lack of Coordination, and Repeat Falls who was admitted to the facility 03/17/2017. On January 23, 2026, at 12:11 PM, A picture of a leaf was located next to R4's name outside of his room, R4 was lying in his room in his bed, R4's bed was raised approximately 2 feet from the floor and not in the lowest position, R4 said he has had a fall at the facility. On January 23, 2026, at 1:09 PM, R4 was lying in his bed, R4's bed was raised approximately 2 feet from the floor and not in the lowest position. On January 24, 2026, at 9:40 AM V10 (Certified Nursing Assistant) said she was not assigned to be R4's aide today but was assigned to him yesterday, there were no specific fall precautions for R4 that she was aware of. R4 was sleeping in bed his bed was raised approximately 2 feet from the floor and not in the lowest position, R4's care card located in his room closet states fall precautions include low bed. 2. R8 is a [AGE] year-old female with a history of Dementia, Non-Pathological and Pathological Fractures, Disorders of Bone Density and Structure, and Repeated Falls who was admitted to the facility 06/21/2023. On January 23, 2026, at 11:23 AM, A picture of a leaf was located next to R8's name outside her room door, R8 was lying in her bed sleeping with her bed raised approximately 2 feet from the floor and not in lowest position, R8 said she was trying to get some rest. On January 26, 2026 at 4:00 PM V3 (Assistant Director of Nursing/Registered Nurse) said fall risk assessments are completed on admission, quarterly, annually, and as needed, and are completed again when new falls occur, the facility reviews all falls and previous fall interventions, and attempts to determine the root causes of falls, the restorative director is the facility's fall coordinator, the fall coordinator for the facility was V6 (Former Restorative Director) until recently. V3 said if fall precautions for resident's include a low bed, the bed should be in the lowest position low when the resident is in bed, the beds are able to be lowered pretty close to the floor when in the lowest position.

Based on interview, and record review, the facility failed to have safety measures in place to prevent a fall. This failure led to a resident sustaining a 3-centimeter laceration to the left parietal scalp, requiring 3 staples for closure. This applies to 1 of 5 residents (R1) reviewed for falls. The findings include:R1's electronic health records showed that on 10/22/25, R1 was admitted with diagnoses including a displaced fractured left femur, Parkinson's disease, and a history of repeated falls.On 11/12/25 at 9:21 am, V5 Certified Nurse's Assistant (CNA) said that on 10/30/25 around 10 am, she was providing personal hygiene and dressing R1 while R1 was in bed. At this time R1's upper body was shaking and jerking heavily. V5 said that she had never provided care for R1 before. V5 said she also had not received a report from the off going staff or the nurse on duty about R1. V5 said that she thought that with R1 jerking so heavily that she needed a 2nd staff and a full body mechanical lift. V5 said that she should have done this before she sat R1 on the side of the bed. V5 said she slid R1 to the side of the bed and put her in a sitting position without a 2nd staff assisting. V5 said that she reached for a wipe to clean R1's face when R1 jerked again and fell off the bed and on to the floor, causing a laceration to her head. R1's 10/30/25 hospital records showed that R1 had a 3-centimeter laceration to the left parietal scalp requiring 3 staples for closure. On 11/12/25 at 9:52 am, V6 LPN (Licensed Practical Nurse) said that it is the facility's policy that you have 2 staff present when putting a resident on the side of the bed prior to transferring them with a sit-to-stand. On 11/12/25 at 5:20 pm, V2 DON (Director of Nursing) said that no staff should put a resident on the side of the bed when the resident is heavily jerking without getting a 2nd staff first. V2 said that if you don't, you are putting the resident at risk of falling. V2 said that her expectations and the facility's practice and policy is always have 2 staff with the sit-to-stand including prior to sitting the resident on the side of the bed. On 11/12/25 at 3:24 pm, V9 (CNA) said that she was V5's partner on 10/30/25 and V5 never asked her to assist her with R1. V9 said that you must have 2 staff present when you put a resident on the side of the bed prior to transferring them with a sit-to-stand mechanical lift.On 11/12/25 at 12:16 pm, V8 (R1's Primary Care Physician) said that R1's fall on 10/30/25 caused a laceration to her head. V8 said that in his professional opinion 2 staff were needed before R1 was placed in a sitting position on the edge of the bed. V8 said that this was important because R1 has Parkinson's, and she was jerking at the time. V8 said that if 2 staff had been there, they could have prevented the fall and laceration.On 11/12/25 at 5:15 pm, V1 (Administrator) said that 2 staff should have been present before putting R1 on the edge of the bed in a sitting position since R1's body had been jerking. V1 said that this should have been done for safety. R1's 10/23/25 - 12/2/2025 Physical Therapy Evaluation & Plan of Treatment showed that R1 is dependent on staff for chair/bed-to-chair transfer. The facility's Fall and Fall Risk, Managing policy dated August 2008, showed that based on previous evaluations and current data the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Staff will identify and implement relative interventions. to try to minimize serious consequences of falling. R1's 10/22/25 Fall Risk Assessment showed that R1 scored 14 and was categorized as a high risk for falls. The document showed R1 had decreased muscular coordination with contributing factors of neuromuscular/functions and orthopedic conditions.

Based on interview and record review, the facility failed to prevent physical abuse between two residents. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in a sample of 4. The findings include: R2's face sheet shows an admitted [DATE]. R2's face sheet shows diagnoses of Alzheimer's disease, unspecified and Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's MDS (Minimum Data Set) dated 4/27/25 shows nothing entered for the BIMS (Brief Interview for Mental Status) summary score. R2 was assessed as modified independence, meaning some difficulty in new situations only under cognitive skills for decision making. R2's care plan dated 4/25/25 shows he has compromised mental status. R2's progress notes indicate the following: On 4/27/25 at 10:00 AM, (R2) struck (R1) outside of the cafeteria with both hands. (R2) struck the other resident in the face and neck area on the left side. (R2) has a broken nail and some bleeding noted to the right left pinky finger. It was reported to writer from housekeeping that (R2) was ambulating without walker before the incident occurred POA (Power of attorney) agreed to have (R2) sent out for evaluation and on call for primary doctor gave a verbal order to send (R2) to (Hospital). Writer spoke to administrator who spoke to son about resident going to a different facility for a neuro psychiatric evaluation. On 4/27/25 at 3:10 PM, (R2) left facility with ambulance service. On 4/27/25 at 3:15 PM, (R2) left facility per nurse practitioner's order. (R2) left per stretcher with all paperwork for (R2)'s involuntary discharge per petition given to paramedics. Report given to accepting facility about (R2)'s reason for transfer out of facility. R2's petition for involuntary/judicial admitted d 4/27/25 shows Person continues to be subject to involuntary admission on an inpatient basis. On 4/26/25, (R2) attempted to choke floor nurse. On 4/27/25, (R2) punched and scratched (R1) repeatedly. R2's incident report dated 4/27/25 shows: (R2) became physically aggressive towards another (R1). Residents immediately separated for safety. (R2) is unable to recall what happened. R1's face sheet shows an admitted [DATE]. R1's face sheet shows diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and depression. R1's MDS (Minimum Data Set) dated 4/15/25 shows a BIMS score of 6, which means R1 has severe cognitive impairment. R1's care plan dated 1/16/25 shows he has a psychosocial well being problem related to anxiety. It also documents that he has impaired cognitive function/dementia or impaired thought process related to dementia/impaired decision making. R1's incident report dated 4/27/25 shows: (R1) got into a physical altercation with another resident. (R1) sustained an abrasion to the left side of his neck right below his ear. Scant amount of blood. Area cleansed and pat dry. Unable to recall what happened. Denies pain or discomfort. Both residents were separated and closely monitored. Neck area cleansed and pat dry. Nurse's assessment dated [DATE] documents that R1 had a reddened area to nose, right side of face and left side of face just below the left ear and has a scratch. There was also a reddened, small scratch to the left side of the neck and right back of hand. On 5/1/25 at 10:58 AM, R1stated, We were looking at each other. He hit me. I don't remember what or where it happened. I can't remember if I had bleeding or bruising. I can't remember. I have not seen (R2) since then. I don't remember nothing. R1 and R2's initial abuse incident report dated 4/27/25 shows: At 10:00 AM, (R2) hit (R1). Residents immediately separated. Full body assessment completed on both residents. Families and physicians notified for both (R2) and (R1). (R2) sent to the hospital for psychiatric evaluation. Investigation initiated. On 5/1/25 at 10:16 AM, V1(Administrator) and V2 (DON-Director of Nursing) were interviewed. They both stated the following: (R2) came to us on Friday 4/25/25. He had no prior history of aggression. He had dementia and exit seeking behaviors. On Saturday 4/26/25, (R2) was exit seeking and running towards the door. He put his hands around (V3-LPN/Licensed Practical Nurse) as she stood in front of the door. (V5-LPN) was behind (R2) and she was able to remove (R2)'s hands from (V3)'s neck. (R2)'s son was called on the phone and he came to the facility and sat with (R2). He was able to calm (R2) down. (V1), (V2), and the psychiatric nurse practitioner were notified. (R2) was ordered new medications of Ativan 0.25 MG (Milligrams), Trazodone 25 MG, and Aricept 5 MG. He took the medications from the nurse with the help of his nurse. On Sunday 4/27/25, V4 (LPN, Agency Nurse) called us at home and she said that (R2) hit (R1) on the side of head (right side) outside the dining room. (R1) became verbally abusive with (R2). They both have dementia. (R1) told us that (R2) didn't like him because he was from another country. (R1) had a scratch to the right side of his face and there was a scant amount of bleeding. (R1) didn't hit (R2) back. They were separated and both were given first aid. We did a petition for involuntary/ judicial admission for (R2). (R2) was sent to this hospital where he is supposed to get neuro psychiatric testing. His POA (Power of Attorney) was in agreement with this. (R2) is still in the hospital. On 5/1/25 at 12:07 PM, V3 (LPN) stated, On Saturday 4/26/25, (R2) was trying to leave the building. He was basically sundowning and exit seeking. I was facing him and trying to redirect him. (R2) put his hand around my throat. He was agitated and was trying to leave. My coworker (V5-LPN) pulled him off me by grabbing the back of his shirt. I called (R2)'s POA, (V1) and (V2). (R2) and (V1) came to the facility. We were initially going to send him to the hospital, but the psychiatric nurse practitioner said to not send him. She wanted us to give (R2) some new medications. (R2) took his medications and was able to calm down. The next day at 2 PM, I started my shift. I heard from the morning nurse (V4-LPN) that there was resident to resident contact between (R2) and (R1). I was told that (R2) scratched (R1). I don't know the full details. I remember me and the two managers were working on the paperwork. On 5/1/25 at 12:24 PM, V5 (LPN) stated, I worked with (V3) on Saturday 4/26/25. (R2) was in his wheelchair. He proceeded to get up and go to the doors. I didn't want him to fall. So, I came behind him with the wheelchair. (V3) came in front of him so he wouldn't leave. Then, (R2) grabbed (V3)'s neck. I grabbed (R2) by the shirt and he let go of (V3). We put him back in his wheelchair. The psychiatric nurse practitioner ordered him some medication. He got the medication, and he was able to calm down. The next day I worked from 2 PM to 10 PM. I heard in the morning that (R2) choked (R1) and they sent (R2) to the hospital. On 5/1/25 at 12:45 PM, V4 (LPN, Agency Nurse) stated, I worked on Sunday 4/27/25 in the morning. The housekeeper and other staff members didn't actually see (R2) and (R1) fighting. I think it was outside the dining room. (R1) came to me and told me that (R2) hit and scratched him on the face. He didn't know why. There was a scratch to the left side of the neck below his ear and it was bleeding a little. (R2) had a broken nail bed and it was bleeding a little. V6 (RN-Registered Nurse/Wound Nurse) helped me. She did a head to toe assessment and cleaned them both up. I notified (V1), (V2), and the doctor. We did an involuntary petition and we sent (R2) to the hospital. (V1) and (R1)'s POA agreed to the transfer. On 5/1/25 at 2:05 PM, V1 (Administrator) stated, It's our job to prevent abuse as best as we can and protect our residents. Absolutely! Facility's policy titled Abuse Prevention Policy (Undated) shows: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment. This facility therefore prohibits abuse .abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation. Interview and record review the facility failed to maintain the kitchen in a manner that would prevent foodborne illness. This applies to 112 residents that receive their meal from dietary services. Findings include: On [DATE] at 4:43 PM, 112 residents served from the kitchen on [DATE] was confirmed with V2 DON (Director of Nursing). On [DATE] at 10:03 AM, the kitchen tour was conducted with V25 Dietary Consultant. The dry storage floors were sticky. Vanilla wafers 16 oz (ounce) bag was opened and did not have an open on date or use by date. Spaghetti 10 lb. (pounds) was opened. Walk in cooler- Bag of carrots, celery and onion mix opened no label identifying contents, opened on date use by date [DATE]. Five-gallon bucket of pickles with unsecured lid Seven cartons of strawberry topping dated [DATE]. Two 24 oz jars of marinara, one half empty, one with the safety seal broken and no opened on or use by date. Two metal trays of ham chunks covered with saran wrap stored over three pans of Jello, two pans of uncooked roll and three pans of uncooked biscuits. Deli sandwiches one bologna, one turkey and one roast beef dated [DATE]. V25 stated he has worked in the facility for two weeks. V25 stated he would not serve the strawberry topping because he did not know if it was expired. V25 stated he would not serve the deli sandwiches because they should not be kept longer than 48 to 72 hours. V25 stated there were no logs for the sanitization buckets. Walk in freezer- Two fast food restaurant cups with frozen brown liquids and a 16 oz ,d+[DATE] empty bottle of water. One sanitization bucket in use measured at 100 ppm (parts per million). On [DATE] at 11:40 AM, V25 was in the kitchen with facial hair not covered with hair net. On [DATE] at 12:46 PM, two large clear bags in the facilities walk in cooler were identified by V18, Dietary Manager, as shredded chicken did not have a label identifying contents or expiration date. Water was observed dripping from the ceiling and the kitchen floor was wet. On [DATE] at 12:16 PM, V25, Dietary Consultant, stated facial hair should be covered. V25 stated the sanitization buckets are changed every two hours and as needed. The sanitization ppm should be documented every shift / meal. Review of the facility provided documentation showed the facility did not conduct consistent daily monitoring of chemical sanitization level in the or three compartment sinks from [DATE] thru [DATE]. The facility did not provide any documentation for the monitor of their red sanitization buckets. The facility provided logs for food cooking and holding temperatures from June thru August that show temperature monitoring is not consistently done with every meal every day. The facility policy Sanitization and Infection Control dated [DATE] states sanitizer solution should read at 200ppm. The facility policy Dishwashing and Sanitization dated [DATE] states adequate food temperature will be maintained throughout meal service and delivery. The facility policy Food Storage date [DATE] stated food storage areas shall be clean at all times. Left over foods are labeled, dated, immediately placed under refrigeration and used within 72 hours or discarded. All exposed foods should be stored tightly covered. No personal items will be stored with food items. The facility policy Personnel Health and Sanitization dated [DATE] states employees who handles food and food contact surfaces use hairnets, caps or other effective hair restraints in order to keep hair from contacting food and food contact surfaces. The facility policy Food Temperatures dated [DATE] states hot food temperatures will be taken upon cooking, holding and on the line before service at each meal. Temperatures will be recorded each time in a temperature logbook. The undated facility provided chart for refrigerator storage states always store ready to eat foods on the top shelf. Arrange other shelves by cooking temperature with the highest cooking temperature on the bottom.

Based on observation, interview and record review the facility failed to provide hygiene care and maintenance. This applies to 4 of 6 residents reviewed for ADL (Activities of Daily Living) in a sample of 37. Findings include: 1. R65 admitted to the facility on [DATE] with diagnoses that includes cerebral infarction, dysarthria, weakness, aphasia, Alzheimer's, foot drop, basal cell carcinoma, and left artificial knee joint. R65 MDS (Minimum Data Set) dated 7/15/24 shows she is cognitively impaired and dependent on staff for all care needs. On 8/27/24 at 12:47 PM, V16 RN (Registered Nurse) and V3 ADON (Assistant Director of Nursing) was observed providing incontinence care for R65. R65's incomitance brief was overly saturated with urine. R65's coccyx and perineum were reddened. On 8/28/24 at 1:59 PM, V19 CNA (Certified Nursing Assistant) assisted R65 with incontinence brief. R65's coccyx and perineum were still reddened. On 8/28/24 at 2:08 PM, V6 RN stated R65 had a skin assessment done on 6/12/24 showing she was a high risk for skin break down. V6 stated a new order was entered for R65 for zinc cream to coccyx every shift on 8/27/24 by V16 RN. No order in place prior to 8/27/24. 2. R106 was admitted to the facility on [DATE] with diagnoses that includes osteoarthritis, morbid obesity, polyneuropathy, hypertension, gout, muscle wasting and atrophy and pain. R106's MDS dated [DATE] shows she cognitively intact and dependent on staff for her care needs. On 8/27/24 at 1:05 PM V19 CNA (Certified Nursing Assistant) was observed providing care to R106. R106' s incontinence brief was saturated with urine. V19 stated she started work at 6am but that was her first-time providing care to R106. R106 stated she had not been provided incontinence care since 5am. R106 stated staff have come in the room turned her call light off without providing her care. R106 stated around 11:30 am V3 ADON (Assistant Director of Nursing) came in her room and told her she would get V19 to provide her care, but no one came. On 8/28/24 at 1:48 PM, 106 stated it was very upsetting to be left sitting in a wet undergarment and not receiving any help from the staff. On 8/29/24 at 1:51 PM, V2 DON (Director of Nursing) stated if staff are unable to complete their tasks, they should inform her. V2 stated her expectation is that residents receive incontinence care every two hours and as needed. The facility policy Perineal Care date August 2008 states the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. 48526 3. On 08/28/24 at 10:55 AM R4 was sitting in the dining room watching other residents play a game. R4 had long chin hairs. R4 said she wanted the chin hairs removed. She said, she does not like when hairs grow. On 08/28/24 at 1:56 PM V5 (CNA) stated that female residents should not have chin hairs. [NAME] hairs should be removed on shower days and as needed. V5 said chin hairs on females are a dignity issue. On 08/29/24 at 9:37 AM V2 (DON) said female residents should not have chin hairs. Facial hair should be removed whenever the staff does ADL care and notices it. It is a dignity issue for a woman to have chin hairs, she could be embarrassed. The staff is expected to shave women. R4's Face Sheet showed R4 had diagnoses of rhabdomyolysis, lack of coordination, need for assistance with personal care, atrial fibrillation, rheumatoid arthritis, major depressive disorder, polymyalgia rheumatica, and osteoarthritis. R4's MDS dated [DATE] showed R4 had moderate cognitive impairment. 4. On 08/27/24 at 11:00 AM R90 was sitting in the hallway. R90 had a left-hand splint. R90's fingernails to his left hand were long and curled in a downward position. R90's fingernails to his right hand were long and curled in a downward position. R90 stated he wanted his fingernails cut. On 08/28/24 at 10:18 AM R90's fingernails to both hands remained long and curled in a downward position. On 08/28/24 at 2:01 PM V5 stated residents fingernails should not be long, dirty, and curled downward. V5 stated residents nails should be cut on their shower days and as needed. V5 stated the resident could scratch himself and get an infection from long, dirty nails. On 08/29/24 at 9:37 AM V2 said residents nails should not be long and curled in a downward position. Nail care should be performed weekly. Residents with long nails can create skin tears or scratch themselves. The staff is expected to provide nail care when they provide ADL care. R90's Face Sheet showed R90 had diagnoses of sequelae of cerebral infarction, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, dysphagia, metabolic encephalopathy, seizures, chronic pain, and spinal stenosis. R90's MDS dated [DATE] showed R90 had severe cognitive impairment. The same MDS showed R90 was dependent upon staff for personal hygiene. R90's ADL deficit care plan showed an intervention to provide care with dignity and respect. The facility's Nail Care Guideline effective 02/2023 Guideline showed: 1. Nail care includes routine cleaning and regular trimming. 2. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The facility's Activities of Daily Living (ADL) policy effective 02/2023 Guideline showed: 1. In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: A. Hygiene: bathing, dressing, grooming and oral care. B. Elimination: toileting. Our collaborative professional team, together with the resident and/or resident representative: 1. Will recognize and evaluate an inability to perform ADL's or risk for decline in any ability to perform ADL's. 2. Develop and implement interventions in accordance with the resident's evaluated need, goals for care, and preferences and will address the identified limitation in an ability to perform ADL's.

Based on observations, interviews, and record reviews, the facility failed to have proper fall precaution measures in place for 4 residents (R33, R14, R69 & R52) who are at risk for falls in a sample of 37. The findings include: 1. On 08/27/24 at 10:46 AM R33 was observed in her bed with her bed in a high position. R14 said that the CNA (Certified Nurse's Assistant) had left the bed in that position for the last hour. V3 ADON (Assistant Director of Nursing) was present at that time. R33's 8/27/24 care plan showed that she is at risk for falls related to injury, weakness, impaired balance, decreased mobility and transfers, poor judgment and decreased safety awareness, dementia, and a history of falls. The interventions showed keep bed in lowest position with brakes locked. 2. 08/28/24 at 03:09 PM R14 was observed in bed with a mat on the left side of her bed but not on the right side of her bed. R14's 6/17/24 care plan showed that she is at risk for fall related injury due to a diagnosis of CVA (cerebral vascular accident) with left hemiparesis, obesity, decreased mobility and transfers. The care plan interventions showed floor mats to bedside. 3. On 08/29/24 at 11:45 PM R52 was observed in bed with only 1 mat on the floor on the right side of his bed. R52's 7/5/24 care plan showed resident has a history of falling related to status post fall diagnosis Parkinson disease, dementia, poor safety awareness, and weakness. The intervention showed floor mats at bedside. 4. On 08/27/24 at 11:31 AM R69 was observed in bed with only one mat on the floor on the left side of his bed. On 08/28/24 at 03:07 PM R69 was observed in bed with only one mat on the floor on the left side of the bed. R69's 6/21/24 care plan showed that R69 has a history of falls and remains at risk for falls related to diagnoses of Alzheimer's, Dementia, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), Chronic contractures, Closed left femoral neck fracture, and right cerebellar. The interventions showed floor mats. On 08/28/24 at 02:25 PM V7 (Physical Therapist) said that if the resident is a high fall risk, there should be a mat on both sides of the bed, and the bed should be in a low position. On 08/29/24 at 4:06 PM V2 DON (Director of Nursing) said that if the resident is a high risk for falls, her expectations are that residents' beds are kept in low positions and that they have mats on the floor on both sides of the bed. The facility's Falls and Fall Risk, Managing policy (August 2008) showed, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of Falling.

Based on observation, interview, and record review, the facility failed to follow its Enhance Barrier Precautions (EBP) Guidelines by staff not wearing gowns during incontinent care to EBP residents and not having a trash can inside the resident room and near the exit for discarding PPE after removal. The facility also failed to maintain effective hand hygiene during resident care. This applies to 4 of 4 residents (R1, R56, R40, and R80) reviewed for infection control practices in a sample of 37. The findings include: 1. R1 is an [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 8/28/24 at 1:57 PM, V8 (Licensed Practical Nurse / LPN) stated that R1 is on EBP because of her wounds, suprapubic catheter, and nephrostomy tube. On 8/28/24 at 10:20 AM, the surveyor observed V9 (Certified Nursing Assistant -CNA) & V10 (CNA) providing incontinent care to R1 without wearing a gown. On 08/28/24 at 10:25 AM, V8 stated that anybody with wounds or catheters is treated as EBP. When staff provide incontinent care to those residents, they are supposed to wear gowns. 2. R56 is a [AGE] year-old female with mild cognitive impairment who has a suprapubic catheter due to bladder dysfunction. On 08/28/24 at 11:15 AM, her room was observed with an EBP sign, no PPE cart at the door, and no trash bin at the exit door to discard used PPEs. V8 was observed checking R56's blood sugar without wearing a gown. On 8/28/24 at 11:18 AM, observed V8 administering 9 units of Aspart insulin to R56 without wearing gown. V8 stated that R56 is on EBP due to suprapubic urinary catheter. On 8/29/24 at 10:37 AM, V6 (Infection Preventionist) stated, As V8 and V9 were giving direct care to R1, they should have worn gowns. V8 also should have worn a gown when she was checking R56's blood sugar. There should have been a trash bin at the exit door for R56 to discard used PPEs. On 8/28/24 at 11:20 AM, no trash bins were available at R56's exit door to discard PPEs ((Personal Protective Equipment). The facility presented EBP Guidelines documents: 2. Initiation of Enhanced Barrier Precaution b. Implement EBP for residents with wounds, urinary catheters, and feeding tubes 3. Implementation of EBP c. Position a trash can inside the resident room and near the exit for discarding PPE removal . 5. EBP should be followed . when anticipating close physical contact while assisting with transfers and mobility or any high-contact activity. 4. High-contact resident care activities include: f. Changing briefs or assisting with toileting. 41384 3. On 08/27/24 at 12:21 PM R40 was in her room sitting in her recliner. Her Foley catheter bag was hanging from her wheelchair in front of her. At 12:27, V2 DON (Director of Nursing) asked V4 CNA (Certified Nurses' Assistant) to move the bag to R40's bed frame closer to R40. V4, with ungloved hands, moved the catheter bag that was filled with reddish colored urine, from under R40's wheelchair to the bedframe next to R40. Then V4 assisted in setting up R40 lunch tray touching the food items on her tray including opening up her carton of milk. V4 did this with ungloved hands. On 08/27/24 at 12:30 PM V4 said that she should have cleaned her hands after moving the catheter bag and before setting up R40's tray including opening the carton of milk. V4 said she should have done this so she would not contaminate R40's food. On 8/29/24 at 4:06 PM V2 DON said that the staff should have clean her hands after moving R40's catheter bag before she setup her lunch including opening R40's carton of milk. R40's electronic health record showed that R40 has a history of urinary tract infections. R40's 8/29/24 physician orders showed - Culture, catheter urine, related to history of urinary tract infections and Urinalysis, related to history of urinary tract infections. R40's MDS (minimum data set) section GG showed that R40 needs setup assistance for eating. The facility's Hand -Washing/Hand Hygiene Policy (March 2020) showed, it is the policy of the facility to assure staff practice recognized hand washing hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. When hands are not visibly soiled, employees may use alcohol based hand rub, foam, gel, liquid containing at least 60% alcohol in all of the following situations: after direct contact with residents, before performing a non-surgical invasive procedure, before handling clean or soiled dressing gauze pads etc., after contact with the residents intact skin, after handling used dressings, potentially contaminated equipment, etc., after contact with objects such as medical devices or equipment in the immediate vicinity of the resident that may be potentially contaminated, after contact with potentially infectious materials, during resident meal service, in between tray pass if contact with resident is made hand hygiene should be used, when removing trays hand hygiene should be used, & before contact with fresh tray or with a resident. 4. 08/27/24 at 12:40 PM R80 was receiving perineal care from V4 & V5 CNAs (Certified Nurses' Assistants). R80 was in the bathroom in a standing position with the use of a Sit to Stand lift. V4 was observed wiping R80's buttocks 7 times without folding or turning the cloth towel. Then with the same cloth towel V4 washed R80 perineal area at least 9 times without folding or changing the towel. On 08/27/24 at 01:04 PM V4 (CNA) said that she should have had had another cloth or folded the washcloth or only wiped one time when she was providing perineal care. V4 said that this should be done to prevent cross contamination. V4 said that she did it because she was rushing because she did not want R80 to fall. On 08/29/24 at 04:06 PM V2 (DON) said that her expectations are that when staff are providing perineal care they wipe once then fold the washcloth before wiping again. R80's electronic health record showed diagnoses including hemiplegia and hemiparesis, muscle wasting and atrophy, altered mental status, attention and concentration deficit following cerebral infarction, lack of coordination, and weakness. R80's 7/30/24 MDS (minimum data set) Section GG showed that R80 is dependent on staff for toileting hygiene. The facility's Perineal Care policy (revised August 2008) showed the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. For female residents wash peroneal area wiping from front to back, then wash the rectal area thoroughly wiping from the base of the labia towards and extending over the buttocks do not reuse the same washcloth or water to clean the labia.

Based on observation, interview, and record review, the facility failed to provide an ambulatory resident with continuous oxygen (a portable oxygen tank holder). This applies to 1 of 1 residents (R76) reviewed for oxygen in a sample of 37. Findings include: On 8/27/24 at 10:52 AM, R76 was observed lying in bed wearing 4 liters of oxygen per nasal cannula. R76 said 4 liters was her baseline oxygen setting and what she was wearing at home before coming to facility. R76 said she is able to walk to the bathroom by herself, but she does not have a way to bring the oxygen with her to the bathroom. R76 said she has a portable oxygen tank holder on the back of her wheelchair, but her wheelchair is bariatric and is too wide to fit into the bathroom. R76 said when she has a bowel movement she requires staff assistance to help wipe and it can take them a long time to come and help her in the bathroom. R76 said she feels short of breath after a few minutes without her oxygen on while bearing down for a bowel movement, while waiting for staff assistance, and while pulling her pants up. On 8/28/24 at 2:00 PM, R76 said she needs her oxygen while she is in the bathroom. R76 said being in that small of an area makes her breathe heavier and she has not been offered a portable oxygen tank holder on wheels. On 8/28/24 at 1:50 PM, V8 (LPN/Licensed Practical Nurse) said R76 wears continuous 4 liters of oxygen per nasal cannula and she is able to take herself to the bathroom. V8 said the facility does have portable oxygen tank holders, but they don't use them because the residents have an oxygen tank holder on the back of their wheelchairs. V8 said she was aware that R76 had a bariatric wheelchair that it did not fit in the bathroom. V8 said she knew R76 would go to the bathroom without her oxygen on. V8 said R76 was just given the okay to go to the bathroom on her own within the past week, and now that the staff is not aware when R76 is in the bathroom, R76 should be given a portable oxygen tank holder so she can bring her oxygen with her. On 8/29/24 at 2:30 PM, V2 (DON/Director of Nursing) said an ambulatory resident with a continuous oxygen order should be able to go to the bathroom with their oxygen on. V2 said R76 should have been provided a portable oxygen tank holder for the bathroom because with her chronic respiratory failure she can experience difficulty breathing and/or her oxygen level could drop if she goes without her oxygen. R76's Face Sheet shows diagnoses of chronic obstructive pulmonary disease, morbid obesity, and chronic respiratory failure. R76's MDS (Minimum Data Set) shows her cognition is intact. R76's POS (Physician Order Sheet) shows an order dated 7/8/24 for 4 liters oxygen per nasal cannula indefinitely related to chronic respiratory failure. R76's Care Plan dated 7/1/24 shows she has oxygen therapy related to respiratory failure and COPD (Chronic Obstructive Pulmonary Disease). Interventions include oxygen via nasal cannula per doctor's orders. The facility's policy titled, Oxygen Administration last revised March 2004 states, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or the facility's protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed . Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Portable oxygen cylinder (strapped to the stand) .

Based on interview and record review the facility failed to maintain current and accurate advanced directives for 2 residents (R69, R115) in a sample of 37. Findings include: On 08/28/24 at 02:03 PM until 02:09 PM, the state surveyor and V2 DON (Director of Nursing) were conducting a record review for R69 and R115. 1. R69's electronic health record showed 6/21/24 Full Code Status POLST (Physician Orders for Life Sustaining Treatment) Declaration form, and the Advance Directive book at the nurses' station showed R69's 2/23/21 DNR (Do Not Resuscitate) form. 2. R115's electronic health record showed a 5/11/24 DNR form and in the Advance Directive book it showed R115's 2/16/24 Full Code form. On 08/28/24 02:13 PM V2 (DON) V2 said that both the Advance Directive book and the electronic health record should be the same because if they are not the facility may not give the right life sustaining measures that the person wants. The facility's Advance Directive policy dated November 2016 showed that copies of written advance directives documents will be filed uploaded in the residence clinical records and for staff not having access rights to the residents' clinical records the residents' advanced directives is maintained on the nursing unit and available to staff members for reference to and consideration of in rendering care and services to residents to whom they are assigned for duty.

Based on observation, interview, and record review, the facility confined a resident to her bed by placing interconnected bed bolsters on both sides of the bed and two upper side rails up. This applies to 1 of 1 resident (R81) reviewed for physical restraint in a sample of 37. The findings include: R81 is a [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set, dated dated dated [DATE]. On 8/29/24 at 9:45 AM, during wound care with V3 (Assistant Director of Nursing) and V16 (wound care nurse), R81 was observed with a wedge to her right upper body with both upper side rails up and two Bolsters to the bottom of bed inter-connected with a strap. On 8/29/24 at 9:45 AM, V3 (Assistant Director of Nursing / ADON) stated, Those bolsters are inter-connected with a strap restricting her to get out of bed. It can be a restraint if we don't have a physician order. We put it there to prevent her fall. R81's care plan does not indicate any use of bed bolsters planned for resident care (falls). R81's physician order sheet (POS) for 08/24 does not indicate any physician order for bolsters. On 08/29/24 at 12:27 PM, V2 (Director of Nursing / DON) stated, There should have been a physician order for using bolsters and should have been care planned. The purpose statement of the facility presented physical restraint policy dated 02/2014 document: Restraint shall not be used for the purpose of punishment or for staff convenience. A review of the facility-provided physical restraint policy (effective date February 2014) document: 3. Restraint use data will be provided to the physician for review and prior to ordering/re-ordering restraint use.

Based on record review and interview the facility failed to provide written notice of the facility's bed hold policy to 1 resident (R69) or representative before being transferred to the hospital in a sample of 37. Findings include: On 08/28/24 at 11:46 AM a review of R69's electronic health record showed that on 8/6/24 R69 was sent to the hospital for labored breathing, oxygen saturation at 86% while on 2 liters of oxygen, a blood pressure of 100/46, and a heart rate of 143. The record review did not show any documentation that R69, or his representative, received a copy of the facility's bed hold policy. On 8/29/24 02:14 PM, V2 DON (Director of Nursing) said that the facility did not have any documentation showing that the resident or representative received the facility's bed hold policy. On 8/29/24 at 4:06 PM, V2 DON said that it is her expectations that the facility staff provide the resident or the resident's representative, the facility's bed hold policy when they are being transferred to the hospital.

Based on observation, interview, and record review, the facility failed to follow the physician's order to provide wound care. This applies to 1 of 3 residents (R1) reviewed for wound treatment and care in a sample of 37. The Findings include: R1 is an [AGE] year-old female with mild cognitive impairment as per the minimum data set (MDS) dated [DATE]. On 8/29/24 at 10:01 AM, V16 (Wound Care Nurse) and V3 (Assistant Director of Nursing) provided wound care to R1. V16 removed the old dressing from the right hip wound and observed no hydrofera blue (thick blue pad to absorb exudate/drainage from the wound). V16 then cleansed the right hip wound with saline, pat dry it, and applied Hydrofera blue with a gauze dressing. On 8/29/24 at 10:10 AM, V16 removed the old dressing from the right hip superior wound and observed no hydrofera blue (thick blue pad to absorb exudate/drainage from the wound). On 8/29/24 at 10:10 AM, in response to the surveyor's inquiry, V16 stated that she changed R1's wound dressing yesterday and didn't have an explanation for why hydrofera blue wasn't used yesterday. On 8/29/24 at 10:15 AM, V16 cleansed right hip superior wound with saline, pat dried, and applied Hydrofera blue with gauze dressing. A record review of the R1's Physician Order Sheet indicates cleansing the right hip and right hip superior wound with saline, applying hydrofera blue, and covering it with a dry dressing. On 8/29/24 at 11:15 AM, V16 stated, V2 (Director of Nursing) talked to V15 (wound care physician/MD) and on 8/27/24, during wound rounds, we discussed changing dressing from hydrofera blue to Santyl, and that's why Hydrofera blue was not used yesterday. I will go and change the Hyfrafera blue dressing to the Santyl dressing. On 8/29/24 at 11:27 AM, V15 (Wound Care Physician) stated, We discussed the wound dressing on Tuesday (8/27/24), and the most updated order is Calcium Alginate with form dressing. The resident has been on Hydrofera Blue for a while. The staff should have updated the system to reflect my new order and should have followed.

Based on observation, interview and record review the facility failed to provide restorative care services. This applies to 2 of 2 residents (R65 and R74) reviewed for rehab services in a sample of 37. Findings include: 1. R65 admitted to the facility on [DATE] with diagnoses that includes cerebral infarction, dysarthria, weakness, aphasia, Alzheimer's, foot drop, basal cell carcinoma, and left artificial knee joint. R65 MDS (Minimum Data Set) dated 7/15/24 shows she is cognitively impaired and dependent on staff for all care needs. R65 current care plan includes nursing rehab PROM (Passive Range of Motion) to right hand with 3 sets 4 reps 6-7 days a week as tolerated. Restorative program to apply right wrist splint apply upon rising remove at night. Review of R65's restorative care documentation for August 2024 shows she received PROM 18 times August 1st through August 29th. R65's right hand splint was placed 17 times August 1st through August 29th. On 8/27/24 at 12:44 PM, R65 did not have a splint on her hand. On 8/28/24 at 1:39PM, R65 did not have a splint on her hand. 2. R74 admitted to the facility on [DATE]. R74 has diagnoses that includes chronic obstructive pulmonary disease, morbid obesity, fibromyalgia, schizoaffective disorder, bipolar, depression, stiffness of left ankle, anxiety, seizures, heart failure, lymphedema, gout, polyarthritis, and systemic lupus. R74's MDS shows she is cognitively intact and dependent on staff for hygiene, dressing and repositioning. R74's current care plan includes restorative program for AROM (Active Range of Motion) to bilateral upper and lower extremities 8 to 10 reps 2 sets twice daily 6-7 days a week. Bed mobility requires assistance with bed mobility. Resident will turn from side to side in bed 3 set of 3 reps and move up and down and reposition 6 -7 days a week as tolerated. Review of R74's restorative documentation show she received AROM 9 times and side to side turning exercise 9 times August 1st thru August 29th. In July 2024 R74 received AROM 18 times and side to side activity 20 times. In June 2024 R74 received AROM 18 times and side to side activity 16 times. On 8/27/24 at 12:21 PM, R74 stated she is supposed to get up a couple of times per week but has not been gotten up. On 8/27/24 at 2:21 PM, R74 stated she is supposed to receive restorative visits 6 to 7 times per week but has gone months without seeing them. R74 stated she saw them the prior week after complaining, but has not seen them since. On 8/29/24 at 12:14 PM V20 Restorative Director stated NA restorative documentation means the task was not done. On 8/29/24 at 12:20 PM, V21 Restorative Aide stated R65 and R74 have never refused restorative services. V21 stated she receives a daily list of residents that are to be seen. Residents that have an up coming MDS are seen first followed by residents that receive walking assistance. All other residents receiving restorative services are seen after that if there is time. On 8/29/24 at 12:29 PM, V22 Restorative Aide stated R65 and R74 have never refused restorative services. States residents that have an MDS scheduled are seen 100% first, walers and everyone else in between. V22 states she always documents. If the activity did not occur, she documents NA. V22 stated there is an option to document if a resident refuses. V22 stated she informs V20 of any changes in a resident if they are not able to do the task so that the care plan can be updated. The facility policy Rehabilitative Nursing Care dated April 2007 states rehabilitative nursing care is provided to for each resident admitted to the facility. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence.

Based on observation, interview, and record review, the facility failed to label, date, and discard old food and beverages from resident's personal refrigerators. This applies to 2 of 2 residents (R34 and R49) in the sample of 37. The findings include: 1. On 08/27/24 at 10:52 AM R34's personal refrigerator in her room had nine soft, and old individual ice cream sandwiches in the freezer. The ice cream sandwiches did not have an opened or expiration date. R34 said it's been a long time since I ate one. R34 stated the staff assists her with cleaning out the refrigerator. On 08/28/24 at 1:43 PM the individual ice cream sandwiches remained in the freezer. On 08/28/24 at 1:46 PM V13 (Housekeeper) stated she cleans the resident's refrigerators out. V13 said she did not know R34 had old ice cream sandwiches. V13 said old, soft ice cream should not be in the refrigerator. R34 could get sick if she eats it. On 08/29/24 at 9:37 AM V2 (Director of Nursing) said all residents food in the personal refrigerators should labeled and dated. V2 said the ice cream sandwiches should have been dated and labeled. Residents can get sick if they eat old food. R34's Face Sheet showed multiple diagnoses which included heart failure, dementia, muscle wasting, abnormalities of gait and mobility, depression, hypertension, and ischemic cardiomyopathy. R34's MDS (MDS/Minimum Data Set) dated 06/05/24 showed R34 was cognitively intact. 2. On 08/27/24 at 11:38 AM R49's personal refrigerator in her room had three cups with an unknown liquid in them. The cups were not dated or labeled. R49 said she consumes the drinks that are in the refrigerator. On 08/28/24 at 1:51 PM the cups with unknown liquids remained in the refrigerator, without a date or label. On 08/28/24 at 1:52 PM V13 said all liquids and cups should be labeled and dated. V13 said residents can get sick if they drink old beverages. On 08/29/24 at 9:37 AM V2 said all drinks that are opened should be labeled and dated. Residents can get sick if they eat old food or drink an unknown beverage. On 08/29/24 at 2:02 PM V1 (Administrator) said our housekeeping staff is responsible for cleaning all resident's personal refrigerators. We clean them out, discard old food and drinks whether the resident can clean it or not. I'm not sure how often they are cleaned. If a resident consumes old food and beverages, the residents could potentially become sick. There could also be an odor in the room from old foods. R49's Face Sheet showed multiple diagnoses which included fracture of left pubis, osteoporosis, chronic kidney disease, atherosclerotic heart disease, major depressive disorder, dysarthria, dementia, and anxiety disorder. R49's MDS dated [DATE] showed R49 had severe cognitive impairment. The facility's Use and Storage of Outside Foods in Resident's Room Policy showed: To ensure that food brought into the facility is stored, handled, and consumed safely, these instructions must be followed. 2. Any food or beverage must be dated and labeled with the resident's name. 3. Unlabeled food will be discarded. 5. Any perishable food or leftover foods not consumed after 3 days will be discarded. Refrigerator in resident's room: 4. Facility staff are responsible to ensure the refrigerator is clean at all times. 5. Date and label all food items.

Based on observation, interview and record review the facility failed to provide safe bed mobility assistance for one (R1) of three resident reviewed for resident injury and siderail use in a sample of seven. These failures resulted R1 incurring a right femur fracture, a nasal fracture and a laceration requiring sutures. This was identified as past non-compliance that occurred from 04/02/2024 to 04/05/2024. Findings include: The 5/7/2024 Admission Record shows R1 with diagnoses to include morbid obesity, Hemiplegia and Hemipariesis following brain bleed affecting the left non-dominant side, and contractures. On 5/7/2024 at 10:20 AM R1 laid in bed with an air mattress and one quarter siderail at the top of each side of the bed. R1 had an immobilizer brace to her right lower leg, and contractures to her feet and hands. R1 stated her leg and nose were broke when she was being provided personal care with one staff person instead of the two staff she requires. R1 stated she uses the siderail to assist staff with positioning which was not loose but when she was rolled onto her left side all her weight was placed onto the rail and it broke off causing her to fall to the floor. R1 stated she has had little use of her extremities on her left side, and limited ability to move her right leg, right hand and right arm. On 5/8/2024 at 1:22 PM V4 (Nursing Assistant) stated she was alone providing care to R1 and when V4 turned R1 onto her left side, with R1 assisting and grabbing the siderail with her right hand and arm, the siderail broke and R1 fell to the floor. V4 confirmed R1 was a 2 person assist but was not aware at the time of this incident. The Facility Event Report dated 4/2/2024 at 4:15 AM documents R1 was turned on her side while being changed, the siderail broke and she fell from the bed onto the floor landing on her face. R1 incurred a laceration to the bridge of her nose and complaining of pain and was transferred to the hospital for evaluation. R1 returned from the hospital with diagnoses to include a nasal fracture and laceration with 4 sutures and a right lower leg immobilizer for a right femur fracture. On 5/7/2024 at 12:18 PM V2 (Director of Nurses) stated R1's care card used by the direct care staff to determine resident care needs showed R1 as one person assist for bed mobility. V2 stated as she investigated this incident, she discovered R1's care card should show R1 as a two person assist for bed mobility per her assessments and plan of care. V2 stated R1 denied the siderail being loose during the incident and the facility was unable to prove the siderail failed or was not secured properly during this incident. On 5/7/2024 at 12:55 PM V5 (Nursing Assistant) stated she is familiar with R1, and R1 is a two person staff assist to roll from side to side in bed. V5 stated R1 can assist using the siderails but R1 is not steady when she is laying on her side and one staff is needed on each side so she does not tip over and fall out of the bed. On 5/7/2024 at 1:10 PM V6 (Nursing Assistant) stated R1 always requires two staff to provide bed mobility because she is a larger person and needs assistance to turn. V6 stated when rolling R1 from side to side one staff person is placed on each side of the bed to keep her from toppling over and falling out of the bed. The Care Plan dated 3/17/2009 documents R1 with decreased mobility and transfers related to left sided Hemipariesis and obesity requiring the extensive assistance of two staff members for bed mobility. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as cognitively intact and dependent on staff to roll right and left. R1's Weight on 03/11/2024 is documented at 203.0 pounds. The hospital After Visit Summary dated 4/2/2024 documents a Cat Scan of the facial bones showing a nasal fracture, a nasal laceration was repaired with sutures, and an X-Ray of the right knee showed a fracture of the distal right femur. On 5/8/2024 at 4:20 PM V9 (Nurse Practitioner) stated confirmed staff should follow the residents plan of care to ensure the safe provision of care. V9 stated, I agree if staff had followed her care plan and utilized the correct number of staff while performing her care during this incident she likely would not have fallen. V9 confirmed R1 incurred a fracture to her nose, laceration to her nose requiring sutures, and a fracture to her right lower leg during this incident. The manufacturers safety ring (siderail) instructions show the device can be used for residents weighing up to 1000 pounds. These instructions also document, . although the device is rated for such use, it may break if excessive force is exerted on the device. The surveyor confirmed through observation, interview and record review the facility took the following actions prior to the survey date, which were initiated on 04/02/2024 and completed on 04/05/2024, to correct the deficient practice: 1. R1's care plan and resident care card were reviewed and updated on 4/2/2024. 2. All residents with siderails had siderails inspected by Maintenance on 4/2/2024. Audits were conducted weekly by Maintenance for 4 weeks, then are ongoing monthly thereafter. 3. Audits for the use for the correct number of staff during the provision of care were completed by V2 (Director of Nursing) on 4/5/2024. Audits were conducted weekly by V2 for 4 weeks, then ongoing weekly thereafter. 4. Audits of the resident care cards and ADL (Activities of Daily Living) Care Plans were completed by Restorative Nursing on 4/5/2024. Audits were then conducted weekly for 4 weeks and will are ongoing weekly by Restorative Nursing thereafter. 5. Ongoing daily monitoring will occur for resident changes in condition requiring an updated plan of care. 6. Staff reeducation occurred and was completed by 4/5/2024 as follows: A. Nursing and Nursing Assistants were inserviced on resident care cards, following provision of resident care per their care plan, and notification of any status changes. B. Housekeeping movement of resident care cards during room changes. 7. A Quality Assurance and Performance Improvement meeting was held on 04/03/2024. In attendance - V1 (Administrator), V2 (Director of Nurses), V3 (Assistant Director of Nurses) and V17 (Medical Director). These meetings were held weekly for 4 weeks, then resumed their regular monthly schedule.

Based on observation, interview, and record review, the facility failed to ensure a resident was provided care in a safe manner. This failure resulted in a resident (R2) being rolled out of bed by staff, sustaining a right ankle fracture. This applies to 1 of 3 residents (R2) reviewed for accidents. The findings include: On 3/7/2023 at 9:23 AM, R2 was in bed with a cast on her right leg. R2 stated that on February 5, 2023, at around 6 AM, V17 CNA (Certified Nurse Assistant) came to her room to provide incontinence care. R2 stated V17 provided care alone even though she asked V17 to get another staff to assist. R2 stated V17 turned R2 away from her, then pulled the sheets from underneath R2. R2 stated when V17 pulled the sheets, R2 rolled out of the bed and fell to the floor on top of her right leg. R2 stated she fractured her ankle, and had ankle, shoulder, and rib pain. R2's nursing progress note from February 5, 2023, at 6:17 AM showed, .notified by CNA that as she was providing [activities of daily living] care resident slid off bed onto floor landing on her right side. Writer went into room and observed resident lying on floor on left side of bed lying on her right side . R2's February 5, 2023, right ankle X-ray Patient Report showed an age-indeterminate nondisplaced fracture . [differential diagnosis] includes acute fracture . the patient is acutely symptomatic in this region . R2's Face Sheet showed her diagnoses includes nondisplaced fracture of medial malleolus of right tibia, weakness, morbid obesity, polyarthritis, and idiopathic progressive neuropathy. R2's November 21, 2022, MDS (Minimum Data Set) showed she is cognitively intact and requires extensive assistance from two or more staff for bed mobility, toileting, and personal hygiene. R2's Weight Record showed she weighed 271.8 pounds on February 28, 2023. On March 10, 2023, at 10:16 AM, V17 stated she was the only CNA in the room providing care to R2 when she fell on [DATE]. V17 stated the facility provided information sheets at the start of her shift regarding each resident's assistance needs. V17 stated R2's information sheet did not specify how many staff assist was needed for bed mobility or incontinence care and it showed she required a mechanical lift for transfers. On March 7, 2023, at 2:51 PM, V11 LPN (Licensed Practical Nurse) stated that on February 5, 2023, V17 reported R2 slid off the mattress to the floor when she was turning R2 in bed. V11 stated there should have been two staff members caring for her due to the extent of R2's care needs. On March 7, 2023, at 11 AM, V8 (Physical Therapy Aide) stated R2 required at least two staff members for incontinence care and bed mobility, and a staff member should be on each side of R2's bed when providing cares. V8 stated staff need to be careful because low air loss mattresses can be slippery or become puffy underneath residents, making it easier for a resident to slide off the bed. V8 also said if a resident only required one staff member for assistance with turning in bed, it is safest to position the resident closer to her to give more space, then walk to the opposite side of the bed and roll the resident towards her, not push the resident away from her. On March 7, 2023, at 10:55 AM, V7 (Occupational Therapy Aide) stated R2 needed total assist with bed mobility and was dependent on staff because of poor hand coordination and because she cannot move by herself. On March 8, 2023, at 10:45 AM, V14 (Nurse Practitioner) stated it was her expectation that if R2 required two staff members to provide care, it should be two staff members. V14 said the fall was the cause of her fracture to the right ankle. Under the Steps in the Procedure section of the facility's Repositioning policy (revised August 2008), it showed 1. Check the care plan, assignment sheet, or the communication system to determine resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to complete the procedure .

Based on interview and record review, the facility failed to ensure that a resident's Do Not Resuscitate (DNR) order was honored when she was found without a pulse. This failure resulted in the resident having Cardiopulmonary Resuscitation (CPR) initiated, followed by intubation, then ventilator placement in an Intensive Care Unit (ICU). This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE], when R1 was found without a pulse and CPR was initiated against her wishes. This applies to all residents residing in the facility. The [DATE] Resident Roster showed 84 residents reside in the facility. V1 (Administrator), V2 (Director of Nursing), and V19 (Social Services Consultant) were notified of the Immediate Jeopardy on [DATE] at 2:26 PM. Although the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level II due to the need to train all staff, and to implement policies and Quality Assurance monitoring. The findings include: R1's Face Sheet showed she was admitted to the facility on [DATE]. R1's Face Sheet showed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:05, V6 LPN (Licensed Practical Nurse) stated she remembered R1. V6 stated she remembered R1 being alert and oriented and not really very motivated for care. R1's Practitioner Order for Life-Saving Treatment (POLST) Form showed R1's wishes were that she did not want resuscitation to be attempted if she had no pulse and was not breathing. Signatures on R1's POLST Form were dated [DATE]. R1's EMR (Electronic Medical Record) showed the Form was uploaded on [DATE], under the Resident Forms tab at 11:16 AM. R1's POLST Form specified that R1 had chosen Selective Treatment: Primary goal of treating medical conditions with selected medical measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV fluids and IV medications (may include antibiotics and vasopressors), as medically appropriate and consistent with patient preference. Do Not Intubate. May consider less invasive airway support (e.g. [CONDITION(S)], BiPAP). Transfer to hospital if indicated. Generally, avoid the intensive care unit. On [DATE] at 3:17 PM, V10 LPN (Licensed Practical Nurse) said she was checking R1's vital signs on [DATE]th, 2021 at 4:15AM and found R1's oxygen saturation to be 66%. V10 said she turned R1's oxygen up and there was no improvement. V10 said R1 started to decline and V10 called for V9 RN (Registered Nurse) to assist her. V10 said she checked both the Advanced Directives binder and R1's EMR for presence of a POLST Form and was unable to find one. V10 said when she returned to R1's room, R1's fingers were blue, and no pulse could be found. V10 said CPR was started. V10 stated 911 was called and R1's POLST was found after Emergency Medical Service (EMS) had arrived. V10 said the Physicians Orders for Life-Sustaining Treatment (POLST) form should be in the Advanced Directives tab in the EMR. On [DATE] at 1:40 PM, V9 (RN) said she was asked by V10 (LPN) to assist her with R1 during the early morning of [DATE]. V9 said V10 went to look for R1's POLST and was unable to find it in the Advanced Directives binder or in the EMR. V9 said R1 went unresponsive and had no palpable pulse and no respirations. V9 said CPR was started and 911 was called. V9 said after the EMS arrived the POLST was found. V9 said EMS had intubated R1 before the POLST was found. V9 stated as a nurse, we should know each resident's code status as soon as possible when coming on the shift. V21's (Admission Coordinator) [DATE] typed and unsigned statement from the investigation of R1's incident showed V21 .noticed the crash cart on the outside of [R1's room]. I also know since I just did admission paperwork that [R1] was a DNR-since the paperwork was something I had seen with admission paperwork contact. I entered the room-informed the nurses [R1] was a DNR-went to the binder to find and retrieve the POLST form. The POLST form was located in the advanced directive book under the [first initial of R1's last name] tab. Copies were made and given to paramedics. On [DATE] at 12:15PM, V7 (RN) said she was the Director of Nursing (DON) on the day R1 was given CPR. V7 said CPR consisted of chest compressions and artificial ventilation. V7 stated that V10 had told her R1's POLST DNR Form was not in the Advanced Directives binder, and it was not under the Advanced Directive tab in the EMR. The facility's undated Do-Not-Resuscitate Directives Policy showed Screening for DNR Directives upon Admission .A copy of this form will be placed in the resident's medical record under 'Advanced Directives' tab. Advanced Directives are not effective until a copy is provided to the facility and made a part of the resident's medical record. Under the Checking the Medical Records portion of the Policy, it showed In the event of an emergency, staff should also check in Resident's Medical Record under 'Advanced Directives' tab. On [DATE] at 12:41 PM, V8 (LPN) said Advanced Directives can be found under the Advanced Directives tab in the Electronic Medical Record or in the Advanced Directives binder kept at the nurse's station. On [DATE] at 12:53PM, V6 (LPN) also said a resident's POLST DNR would be kept in the EMR under the Advanced Directive tab. V6 stated if I was in a bad situation I would not have time to open every tab under documents (in the EMR). On [DATE] at 1:10 PM, V17 (R1's Primary Care Physician and Facility Medical Director) said he would not expect CPR to be performed on any resident with a completed POLST DNR. V17 said if a resident has Pulseless Electrical Activity (PEA), the outcome after resuscitation is usually [CONDITION(S)] or brain death. V17 said any resident with a completed POLST DNR (with resident, medical provider, and witness signature) is to be considered a DNR when the facility receives the form. R1's [DATE] progress note from 4:14 AM (authored by V10) showed Upon entering residents room resident stated that she is having a hard time breathing, this nurse took her [oxygen level], it was 66, turned [oxygen] to 5L, gave a breathing [treatment], [oxygen level] was then 52. Another nurse called in for assistance, resident became unresponsive- 911 called. CPR initiated. On call for . NP (Nurse Practitioner) was notified of 911 and resident going to the hospital . R1's [DATE]th, 2021 Ambulance Run Report showed .upon arrival crew found nursing home staff doing CPR [Cardiopulmonary Resuscitation]. CPR stopped for pulse check, no pulse or breathing period crew asked if patient was a full code or DNR [Do- Not- Resuscitate]. Nursing home told crew not sure if there is a DNR. CPR started with the nursing home staff assisting, along with monitor, IO [Interosseus], ET [Endotracheal Tube], BVM [Bag Valve Mask], and meds . the [NAME] CPR machine with started. Again, asked nursing home staff if any DNR, reply was the same. Crew was getting ready to move patient over to the cot when another nursing home staff member found a valid DNR . R1's [DATE]th, 2021 hospital note from 6:10 AM showed .arrives by ambulance status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is intubated and unresponsive Nursing home staff doing chest compressions to resuscitate the patient The medics successfully resuscitated the patient while at the nursing home . Medics state that after the patient was resuscitated, they did locate a DNR form. R1's 9:25AM showed . 100% oxygen per ventilator, patient noted with decerebrate posturing (body posture indicating significant brain stem damage) and startle reflex, focal seizures to face noted . R1's [DATE]th, 2021 hospital note from 10:16AM (two days later) showed . is in the ICU and on ventilator support. She opens her eyes to the calling of her name and tracks my movements . She does not squeeze either hand upon command, nor does she move her feet. She does retract each hand upon nail bed pressure, and she does move her feet upon plantar stimulation. A copy of her Illinois POLST form is in her hard chart indicating DNR/ DNI . R1's [DATE]st, 2021 at 11:04AM hospital record showed . Continues to be maintained on ventilator support, day five. Not following any commands to open her eyes or move any of her extremities. She does retract in nail bed pressure all extremities . R1's 1:49PM hospital note showed .Patient remains intubated on mechanical ventilation. She is responsive to noxious stimulus She is not following commands. EEG show signs of [CONDITION(S)] [CONDITION(S)]. MRI shows diffuse white matter injury. R1's hospital note from 2:33PM then showed . explained the likelihood [CONDITION(S)] [CONDITION(S)] from going for a prolonged period of time without breathing and the likelihood of her returning to her previous state. They [R1's family] are in agreement that they will not be pursuing [CONDITION(S)] or feeding tube. We discussed compassionate extubation/ withdrawal of life sustaining measures and they [R1's family] are in agreement for discontinuation of life support . On [DATE] at 8:48 AM, V12 (R1's Daughter) said R1's family was notified by the facility around 5:30AM on [DATE] that R1 had went unresponsive with no heartbeat. V12 said R1's family was later notified by the hospital that R1 had been intubated and they got a heartbeat back. V12 said R1 was cognitively intact and had told her I don't want to be on any machines (meaning a ventilator). V12 said R1 did have a DNR on file in the facility. On [DATE] at 3:51 PM, V5 HIMC (Health Information Management Coordinator) said R1's POLST was in the Resident Documents tab and not Advanced Directives tab in error. V5 said V1 (Administrator) had asked her to scan the POLST form in to the Advanced Directives tab on [DATE] (during the investigation by the Illinois Department of Public Health). [On [DATE] at 4:20 PM, V1 (Administrator) said he asked V5 to scan the POLST form into the Advanced Directives tab on [DATE] because it was in the wrong place.] V5 said she was on medical leave at the time R1 was admitted . V5 said V13 (Medical Records Assistant) was the staff member to upload the POLST DNR form into the EMR. V5 said V13 must not have known where to put it. V5 said she was on medical leave from [DATE] through [DATE]. V5 said her tasks were delegated to V13 (Medical Records Assistant) during that time. On [DATE] at 9:49AM V5 (HIMC) said the medical records personnel schedule is Monday through Friday 8:30AM to 5:30PM. V5 said Nursing staff are not able to scan records into the Electronic Medical Record (EMR). V5 said if a POLST DNR form is brought in after hours or on the weekend it will be placed in the to be scanned box and scanned into the EMR when medical records personnel arrive for their next shift. V5 said medical records were responsible for uploading the POLST DNR form when it was given to them by Social Services. V5 said Social Services were responsible for auditing the Advanced Directive Binder on the unit. V5 said Social Services performed an audit every Friday. V5 said if a resident's POLST DNR Form was not placed in the correct place earlier in the week, it would not be found until Friday. V5 stated she did not know who is responsible for auditing the EMR. On [DATE] at 2:03 PM, V13 (Medical Records Assistant) said she was hired by the facility because V5 (HIMC) was going to be on medical leave. V13 said she was trained by V5 (HIMC). V13 said she was not adequately trained. V13 said she was responsible for uploading POLST DNR forms into the EMR. V13 stated if I would have been properly trained the DNR (R1's POLST DNR form) would be in the right place. V13 said she did not know if anyone was responsible to audit where she placed documents in the EMR. On [DATE] at 10:20AM, V3 (Social Services Director) said that the Social Services personnel schedule was Monday through Friday from 8:00AM to 5:00PM. V3 said if a resident's family brought in a POLST DNR form after hours or on the weekend, it was the responsibility of the nurse to place the form in the Advanced Directives binder. V3 said if the nurse was to place the POLST DNR form in the to scan box it would not be found until Social Service staff were to return. V3 said she was also off on medical leave from [DATE] through [DATE]. V3 said during her absence, V15 (Social Services Assistant) was responsible to audit the POLST DNR forms in the binder. V3 said the Social Service department was not responsible for auditing the EMR. V3 said Social Services was responsible for auditing the Advanced Directives binder. V3 stated she did not have an audit tool. V3 said a roster is used to check the Advanced Directives binder on Fridays and an email is sent to the Administrator, Director of Nursing, and Medical Records Personnel. V3 said she was unsure how the audits were verified that are completed weekly. V3 stated she did not know who was responsible for auditing the EMR for POLST Forms, nor was she aware of any special audits completed on new resident admissions. On [DATE]th, 2021 at 10:45AM V15 (Social Services Assistant) said she was acting as the Social Services Director from [DATE] through [DATE] during V3's absence. V15 said Social Services are not responsible for auditing the EMR. V15 said when a POLST DNR form is brought into or completed in the facility, it is placed in the Advanced Directives binder and then given to Medical Records. V15 stated she did not know who was responsible for auditing the EMR. On [DATE] at 11:38AM V11 (LPN, Minimum Data Set [MDS] Coordinator) said she was responsible for auditing the EMR. V11 said she audits EMRs when doing resident assessments. V11 said MDS assessments are completed on admission, with any significant change, and quarterly. V11 said when auditing the scanned documents, she goes through everything and does not look at the specific tabs the documents are under. V11 said if a resident who wished to be a full code (to have CPR initiated if found without a pulse) changed their wishes to DNR, she would not specifically audit the chart until the next scheduled MDS assessment. V11 said she is not made aware of any changes to residents' code status. V11 said R1's chart was reviewed on [DATE] (five days after her DNR POLST was signed and four days before she was given CPR). The Facility Advanced Directives policy dated [DATE] showed . 6. Copies of the written advance directive documents will be filed/ uploaded in the resident's clinical record .10. For staff not having access rights to the resident's clinical record, the resident's advanced directive is maintained on the nursing unit and available to staff members for reference to and consideration of in rendering care and services to residents to whom they are assigned for duty. Through observation, interview, and record review conducted on [DATE], the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: V17 (Facility Medical Director) stated an ad hoc QA Meeting was held on [DATE] regarding R1's [DATE] incident. Education/training was provided to licensed staff regarding checking the POLST and DNR advanced directives in the binders at each nursing station. Education was provided to licensed nursing staff on [DATE], [DATE], [DATE], and [DATE]. Education was provided to three more licensed nurses in [DATE], two on [DATE], and one on [DATE]. Log Sheets were checked and interviews were conducted to ensure compliance. Nurses on Leaves of Absence or PRN continue to be inserviced prior to returning to work. New hires will be educated during core orientation process, prior to starting, and ongoing. A binder with resident DNRs was present at each nursing station. Advanced Directives for all residents in the facility were present in the binders at both of the nursing stations to be readily accessible in case of emergency. The Social Services Director/designee has conducted audits of the binders.

Based on interview and record review the facility failed to provide emergency medical treatment due to lack of comprehensive post fall assessment. This failure resulted in R1 receiving delayed treatment for [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 8. Findings include: The review of R1's EHR (Electronic Health Record) showed R1 was [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's initial MDS (Minimum Data Set) dated 11/19/20 showed R1 required extensive assistance of one staff with bed mobility, transfer, and toilet use. The MDS also showed R1 had no impairment to both upper and lower extremities. On 12/9/20 at 8:39am, V15 (Family Member) stated on 11/13/20, R1 was admitted to the facility from the hospital for rehabilitation after a brief illness. V15 stated on 11/20/20 she received a call from the facility around 1:00am that R1 had a fall and was fine. V15 stated she later received another call from the facility around 10:00am that R1 had been sent to the hospital due to bleeding. V15 stated R1 was noted with a fracture and dislocation of the left ankle at the hospital. V15 stated R1 had to undergo surgery and is still hospitalized due to her injuries. Review of R1's physician admit progress note dated 11/15/20 showed R1 was admitted to the facility for short term rehabilitation, for strengthening and gait training after hospitalization . The note showed R1 with normal, atraumatic extremities, no cyanosis, no clubbing, 3+ [MEDICAL CONDITION] present. Maintain fall precautions. Review of V13's (Nurse Practitioner) note dated 11/17/20 showed R1 was seen due to shortness of breath after bathroom (use) by self. The plan was to maintain fall precautions for R1. The review of R1's progress note dated 11/20/20 written by V4 (Night Nurse) showed on 11/20/20 at 12:39am, R1 had an unwitnessed fall with no injuries. Further review of R1's progress note written by V7 (Day Nurse) dated 11/20/20 at 8:55am, showed CNA noted large amount of blood on the floor and it was coming from left inner ankle. Pressure applied to wound, resident denies pain to area, NP called. At 9am, 911 was called, continued to apply pressure. The facility's hospital transfer form dated 11/20/20 showed reason for R1's transfer as injury to left lower leg from fall. Review of hospital record showed R1 with one centimeter opening on the medial aspect of left ankle. The hospital record showed R1's entire ankle was noted with obvious deformity, significant swelling and tenderness. The orthopedic surgery consultation dated 11/20/20 under the plan showed .This injury will require urgent surgery due to the open nature delayed presentation . Review of R1's safety events-fall event (Head to Toe) Full body and Pain report dated 11/20/20 showed R1 had a fall in the bathroom at 12:39am. The report showed it was an unwitnessed fall and R1 was noted with weakness in both lower left and right extremities. The report also showed a note written by V13 (Nurse Practitioner) stating R1 was noted in the morning of the fall with a gaping wound on the left ankle while being assisted with transfer. The note further shows the wound spontaneously began bleeding. A large amount of bright red blood was noted on the floor and bed. The bleeding initially improved with pressure but began again. R1 was noted with mild pain to the site. Review of R1's hospital x-ray dated 11/20/20 showed R1 with Bimalleolar left ankle fracture/dislocation with moderate displacement at the fracture planes circumferential left ankle [MEDICAL CONDITION]. There was also minimal displaced [MEDICAL CONDITION] left fibular metaphysis. Review of ER (emergency room ) record showed R1 was found with open malleolar left ankle fracture. On 12/9/20 at 12:24pm, V9 (Certified Nursing Assessment/CNA) stated she cared for R1 on 11/19/20-11/20/20 during the night shift. V9 stated at around 1:00am, she heard the call light in R1's toilet. V9 stated on getting there, R1 was found on the floor. V9 stated R1 mentioned she was trying to use the toilet and missed the toilet bowl. V9 stated it was her first time working with R1 and did not really know her preferences or whether R1 was confused. V9 stated she called V4 (Nurse) to the scene. While V4 reached R1's toilet, V4 asked R1 whether she was in pain and R1 said no. V9 stated V4 then looked over R1's body for bruises. V9 stated the mechanical lift was used to transfer R1 from floor to her wheelchair. V9 stated R1 was taken to her bedside and transferred to bed. V9 stated she did not get R1 up from the bed after the fall. On 12/8/20 at 1:40pm, V4 (Nurse) stated she cared for R1 on 11/19/20-11/20/20 during the night shift. V4 stated she was called to R1's toilet at around 1:00am when she noticed R1 sitting on the floor perpendicular to the wall. V4 stated she believed R1 was two-assist with walker. V4 stated R1 was able to bend all extremities but she did not remove R1's socks to check R1's feet. V4 stated she and V9 used the mechanical lift to transfer R1 to bed. V4 stated she informed the physician it was an unwitnessed fall without injury, so R1 was not sent out immediately. On 12/8/20 at 8:05am, V5 (CNA) stated she worked the day shift at the facility and received R1 in bed on 11/20/20. V5 stated when she later went to answer R1's call light, R1 stated she wanted to use the toilet. V5 stated she attempted to stand R1 up from the bed, R1 said My foot! and that's when she saw blood coming out of R1's socks to the floor. V5 stated she immediately put R1 back in bed and alerted V7 (Nurse). V5 stated at this point, blood was everywhere including on R1's bed. V5 stated R1's ankle must have been punctured when I stood her up. V5 stated there was no visible blood until she got R1 up. On 12/8/20 at 7:40am, V7 (Nurse) stated she worked the day shift at the facility. V7 stated on 11/20/20 at around 8:30am, she was called into R1's room by V5. V7 stated on getting there, there was blood on the floor and on R1's bed. V7 stated the blood appeared gushing out from inner part of R1's left ankle sock. V7 stated she removed R1's left sock and applied pressure dressing on the wound. V7 described the wound to be a quarter size or less but it was deep. V7 stated she asked V13 (Nurse Practitioner) to see R1. V7 stated V13 assessed R1 while she applied the pressure on the wound. On 12/8/20 at 8:15am, V13 (Nurse Practitioner) stated she was called to R1's room on 11/20/20 because R1 was bleeding. V13 stated R1 had a gaping wound to her left inner ankle. V13 stated she performed head to toe assessment on R1 and found R1's left ankle with a weak tone, redness and was warm to touch compared to the right ankle which had a strong tone and was cool to touch. V13 stated R1 had some mild pain to the left ankle. V13 stated she expected nursing staff to perform a thorough assessment of R1 immediately following the fall. V13 stated during the assessment by the night nurse, if the same abnormality was found with R1 after the fall, R1 would have been sent out immediately. On 12/9/20 at 12:13pm, V13 further stated as per facility protocol, R1 was moved to her bed at night after the fall by mechanical lift, so R1 did not stand on the legs until the morning. The bleeding started when R1 put weight on the ankle. V13 stated the facility applied pressure to R1's wound until paramedics came. On 12/9/20 at 9:42am, V18 (MDS Coordinator) stated nursing staff were expected to perform a thorough head to toe assessment of any resident after a fall. V18 stated nursing staff are expected to ask residents if they experience pain, perform full range of motion of upper and lower extremities and obtain vital signs. The nursing staff should use the mechanical lift to assist resident off the floor. V18 further stated if there is a notable injury, nursing staff are expected to get a pillow and leave the resident on the floor until paramedics arrive. V18 stated in R1's case, it was suspected that the fracture had occurred when the resident fell and the bone pulled through the skin while R1 put weight on the leg in the morning which led to the bleeding. The facility's policy titled, Evaluating Falls and Their Causes with a revised date of August 2008 showed, After a fall: If a resident has just fallen, or is observed on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities.

Based on observation, interview and record review, the facility failed to monitor a resident who was taking [MEDICATION NAME] (blood thinner). The facility failed to ensure that a resident does not receive an unnecessary and discontinued medication. This resulted in R307 having critical INR (International Normalized Ratio) of greater than 11 (therapeutic level 2 to 3), R307 was hospitalized and admitted to ICU (Intensive Care Unit), R307 was intubated, had severe [MEDICAL CONDITION] and the CT (Computed Tomography) scan showed a hematoma measuring 7.4 X 7.7 X 10 centimeter to R307's right thigh. This applies to 1 of 4 residents (R307) reviewed for inadequate monitoring and 1 resident (R62) in the supplemental sample observed during medication pass. Findings include: 1). The electronic health record showed R307 was admitted to the facility on [DATE] at 6:15 PM with [DIAGNOSES REDACTED]. R307's Physician order [REDACTED]. R307's Medication Flow sheet showed [MEDICATION NAME] 3 mg was administered from 12/7/17 through 12/21/17 as ordered. R307's Lab Order record showed V17 (nurse) obtained an order on 12/19/17 for a PT ([MEDICATION NAME] time) and INR lab to be drawn on 12/21/17. Review of R307's POR showed this is the first and only time the order for PT and INR was obtained but it was not drawn as R307 was hospitalized . R307's progress note dated 12/20/17 at 2:26 PM showed R307 remained in bed due to not feeling well. R307's progress note dated 12/21/17 at 8:38 AM showed R307 as slow to respond. R307's progress note dated 12/21/17 at 9:30 AM showed R307's family member requested R307 be sent to the hospital R307's progress note written by V27 (nurse practitioner) dated 12/21/17 at 10:00 AM showed R307 was minimally responding to verbal questions, following some commands and was ordered 325 mg of aspirin to be administered at that time. R307's progress note dated 12/21/17 at 10:43 AM showed R307 was transported to community hospital. R307's care plan showed a start date of 12/18/17 and with a problem identified as resident is prescribed anticoagulant therapy' with approaches that included to adjust medication dosage per facility protocol and to monitor lab work. R307's hospital history and physical recorded by V30 (Physician) showed the following about R307: UTI (Urinary Tract Infection); Hemoglobin of 6 and INR of more than 11 in the emergency room . In ICU (Intensive Care Unit) R307 was intubated; CT (Computed Tomography) scan showed a right anterior thigh hematoma measuring 7.4 X 7.7 X 10 centimeter and R307 received 2 units of packed RBCs (Red Blood Cells) and FFP (Fresh Frozen Plasma). R307's discharge summary printed 1/24/17 showed R307 was found to have severe [MEDICAL CONDITION], right thigh hematoma and supratherapeutic INR due to the use of [MEDICATION NAME] ([MEDICATION NAME]). R307 was on anticoagulation because of an aortic valve replacement. On 5/16/18 at 12;58 PM, V2 (Director of Nursing) stated monitoring of R307's INR levels began after R307 returned from the hospital and added V2 could not find any records of INR being drawn prior to hospitalization on [DATE]. On 5/17/17 at 11:27 AM, V30 (Physician) stated the following: A baseline INR should have been ordered as well as monitored; lack of monitoring contributed to R307 being hospitalized due to continued administration of the medication without monitoring of the INR. R307's critical INR level was greater than 11 upon arrival to the emergency room . The therapeutic level is between 2-3 and R307 was critical upon arrival to the hospital. On 5/17/18 at 11:39 AM, V29 (Nurse Practitioner) stated there should have been ongoing INR monitoring for R307 between 12/6/17 to 12/21/17. Upon viewing R307's hospital INR results, V29 responded that the lack of monitoring contributed to R307's hospitalization . The facility policy titled Orders for Anticoagulants Policy dated (MONTH) 2014 showed . anticoagulants are only prescribed when proper clinical and laboratory monitoring is in place. Prior to initiating a [MEDICATION NAME] regimen, a baseline INR will be obtained and results report to the Attending Physician . 2). R62 has multiple [DIAGNOSES REDACTED]. R62's quarterly MDS dated [DATE] showed a BIMS score of 05 which meant that the resident is severely impaired with cognition. During medication pass observation on 5/15/18 at 8:50 AM, V18 (nurse) prepared and administered multiple medications to R62 which included Aspirin 81 mg, 1 tablet. R62's physician order [REDACTED]. R62's consultant pharmacist note to attending physician/prescriber faxed to the facility on [DATE] showed in-part, This resident is receiving the following antiplatelet/anticoagulant therapy with history of GI (gastro-intestinal) bleed. Combining anticoagulant and antiplatelet medications increases the risk of bleeding. Please take a moment to assess risk vs.(versus) benefit of this combination in therapies and consider discontinuing Aspirin therapy while on Eliquis, if appropriate. R62's progress notes dated 4/27/18 (4:52 PM) created by V2 showed, New pharmacy recommendations to d/c (discontinue) ASA (Aspirin). Floor nurse notified. R62's prescription order dated 4/27/18 showed an order to discontinue the daily Aspirin 81 mg. Review of R62's medication administration flow sheet on 5/16/18 showed that the resident had been receiving Aspirin 81 mg, 1 tablet by mouth, every 8:00 AM from (MONTH) 1 through (MONTH) 16, (YEAR). On 5/16/18 at 4:15 PM, V2 (Director of Nursing) stated that she received and transcribed the physician order [REDACTED]. On 5/16/18 at 4:30 PM, V26 (consultant pharmacist) stated that he recommended to discontinue R62's Aspirin therapy because R62 was receiving Eliquis which is an anticoagulant and Aspirin which is an antiplatelet; together these medications increase the risk for bleeding. Per V26, Aspirin is not necessary for the resident, because it increases her risk for GI irritation.