Every finding on record at Bria of Belleville

Based on interview and record review, the facility failed to ensure its residents were treated with dignity/respect and failed to answer their call lights in 5 of 6 residents (R29, R63, R68, R79, and R100) reviewed for resident rights in the sample of 49. Findings Include: 1) On 6/23/26 at 11:20 AM R29 stated it depends on who is working, it happens mostly during the evening time, it takes a long time to get care, get his call light answered, and the staff aren't rough with care but are rude. R29's MDS (Minimum Data Set), dated 4/8/26, documents that R29 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R29 is cognitively intact. 2) On 6/23/26 at 10:42 AM R63 stated the attitudes of some staff are terrible. R63 stated some staff don't like him and have an attitude with him. R63's MDS, dated [DATE], documents R63 has a BIMS score of 15, indicating R63 is cognitively intact.3) On 6/23/26 at 10:20 AM R100 stated the staff attitudes are horrible, they don't care to help her or other residents. R100's MDS, dated [DATE], documents R100 has a BIMS score of 14, indicating R100 is cognitively intact.4) R68's Face Sheet documents R68 was admitted to the facility on [DATE] with diagnoses including cerebral infarction and muscle weakness.R68's MDS dated [DATE] documented R68 was cognitively intact.On 6/25/2026 at 11:00 AM during the Small Group Resident Council Meeting, R68 stated call light response times are delayed and once had to wait two hours to get help.5) R79's Face Sheet documents R79 was admitted to the facility on [DATE] with diagnoses including fibromyalgia and asthma.R79's MDS dated [DATE] documented R79 was cognitively intact.On 6/25/26 at 11:00 AM during the Group Resident Council Meeting, R79 stated call lights take too long to get answered. R79 added it is scary if you're having a breathing problem and it takes staff a long time to help you.On 6/26/26 at 2:30 PM, V1, Administrator, stated she would expect that all residents are treated with dignity and respect.On 6/30/26 at 2:30 V1, Administrator, stated it depends on what is happening, but they should be responding as soon as they can, preferably within 15 minutes. The Resident Council Minutes, dated 8/28/25, 2/26/26, and 5/26/26, document the CNAs (Certified Nursing Assistants) are rude and disrespectful. The Resident Council Minutes, dated 7/31/25, document the CNAs have bad attitudes.The Resident Council Minutes, dated 8/28/25 and 2/26/26, document the CNAs are disrespectful.The Resident Council Minutes, dated 2/26/26, 3/26/26, and 5/26/26 document their call lights are not being answered. The Resident Rights Policy, undated, documents the residents have the right to be treated with dignity and respect.The Call Light Response Policy, dated 2/2017, documents to answer the resident's call light as soon as possible.

Based on interview and record review, the Facility failed to keep residents free from physical restraints for 1 of 3 residents (R2) reviewed for abuse in the sample of 9. This failure resulted in mild soft tissue swelling of R2's left hand and mental anguish, fear, agitation, irritation, or confusion, occurring for any reasonable person. This Past Non-Compliance occurred from 4/16/26 through 4/16/26.Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction and aphasia. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, had no behaviors, had impairment on both sides of upper and lower body, and was dependent for mobility. R2's Care Plan updated 4/19/26 documents R2 is non-verbal and has impaired functional mobility to right upper extremity and bilateral lower extremities due to stroke. The Care Plan documents R2 requires total assistance with care and is at risk for abuse and neglect. R2's Physician Orders do not document R2 ever having orders for restraints or behavior monitoring. R2's April 2026 Progress Notes do not document physical restraint use or need to obtain an emergency physical restraint. The Facility's Initial Report sent to Illinois Department of Public Health (IDPH) on 4/16/26 documents, CNA (Certified Nursing Assistant) reported alleged abuse to administrator and DON (Director of Nursing) at 10:55am. Resident assessed immediately, no injuries noted. Police, NP (Nurse Practitioner) and RP (Responsible Party) notified of incident. Investigation initiated. Final summary to follow. R2's Progress Note by V17, Licensed Practical Nurse (LPN), dated 4/16/26 at 10:55 AM documents CNA notified her that R2's arm had been tied to the bed. The Facility's 4/15/26 Written Statement from V4, Confidential Interview #1, documents, Went into room after the co-worker walked out and found the resident tied to the bed rail with a shirt. On 6/10/26 at 8:37 AM, V4, Confidential Interview #1 stated V5, CNA, left before her scheduled shift was over. V4 went in R2's room where he was in bed with genitals exposed and a shirt tied from his left wrist to the bed rail. R2 cannot walk or talk, and his left arm that was tied to the bed is the only body part he can really move. The Facility's 4/16/26 Written Statement from V6, LPN, documents, CNA from 300 hall came into my office asking me to come and look at Resident, went to Resident Room, Resident left arm tied to bed Rail with a brown shirt. Call HR (Human Resources) to inform them to a picture, sent to my administrator, assess Resident arm no bruise at this time, Inform (V14, Former DON). On 6/10/26 at 10:34 AM, V6 stated V4 told her to go to R2's room. V6 went down the hall and saw R2's arm was tied to the side of the bed rail with a shirt or bed sheet. The knot was on the bed rail, and it was a slip knot like you would do with a restraint. V5's Written Statement dated 4/16/26 documents, I, (V5, CNA), accidently had a Resident arm twisted in his shirt on his bed rail. I did that cause I was changing him and he was grabbing and clawing me. I didn't abuse him and never had to any of my Residents or clients I ever worked with or worked for. I apologize about it but he was truly not intended to be abuse. On 6/10/26 at 1:39 PM, V5 stated she left the Facility around 9 or 10:00 AM at which time R2 was lying in bed. R2's shirt was partially on and V5 was unable to tell whether or not R2 was connected to the bed. R2 would try to inappropriately touch staff but was not combative during care. On 6/10/26 at 1:50 PM, V1, Administrator, provided the photograph V6 sent her on 4/16/26. The photograph shows an appendage extending from underneath a blanket and resting on top of the bed rail with a dark colored material securing the appendage to the top of the bed rail. R2's X-Ray dated 4/16/26 documents mild soft tissue swelling of left hand. The Facility's Final Summary sent to IDPH on 4/16/26 documents, Based on the investigation, including staff statements, physical findings, and completed interviews, the allegation is substantiated. The application of fabric to secure the resident's wrist to the bedrail constitutes an unauthorized restraint and neglect, regardless of stated intent. On 6/10/26 at 11:57 AM, V12, Medical Director, stated R2 is non-verbal and has had a stroke so his psychosocial impact from the restraint is pretty minimal. It would be hard to say whether the soft tissue swelling on R2's left hand was related to the restraint. On 6/10/26 at 3:05 PM, V1, Administrator, stated V6 and V14 notified her that V5 left the Facility after getting into an argument with another CNA, then V4 found R2's arm tied to the bed. V5 said R2 was combative, and she was trying to keep his arm down and it must have gotten wrapped up on accident. R2 did not have previous orders for a restraint and had never had one before. R2 had occasionally been resistive to care but was generally not known to have been combative. V1 stated she would expect all staff to follow the Facility's policy regarding restraint use. The Facility's Physical Restraint/Device Policy reviewed 10/2025 documents, A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. If it is determined that the physical device is a restraint: A physician order will be obtained. Education will be provided to the resident/resident representative regarding the risks and benefits of the physical device. Informed consent will (be) obtained from the resident/resident representative using the Consent for use of Restraint/Device Form. If a resident is assessed to require the use of an emergency physical device, other less restrictive interventions will have been proved ineffective and documented in the medical record. The Physician shall be contacted immediately for an order. The behavior incident that prompted the use of the physical device will be documented in the progress note. The date and time the physical device was applied and released will be documented in the progress note. The name and title of the person responsible for the application and supervision of the physical device will be documented in the progress note. The action by the physician upon notification of the physical device use will be documented in the progress note. Prior to the survey date of 6/10/26, the Facility took the following steps to correct the non-compliance: 1. The Facility immediately removed the restraint, assessed the resident, and initiated a full investigation.2. Corrective actions were implemented immediately, including staff removal from resident care, facility-wide education, and restraint audits.3. Abuse, Seclusion, Protective Oversight Inservice was completed.4. Facility-wide restraint audit was completed.5. Audits of three staff were completed weekly for four weeks, then monthly for three months. Results to be reviewed in QAPI (Quality Assurance and Performance Improvement) with any variances addressed with immediate re-education and disciplinary action, if indicated. The Facility's Past-Noncompliance was confirmed through interviews with V1, V8, V16, V18, and V20-V23, review of in-service sign in sheets, and review of all Facility audits.

Based on observation, interview, and record review, the facility failed to maintain temperatures and palatability of the food in 2 of 4 residents (R8, R9) reviewed for dietary services in the sample of 9. Findings Include: On 6/11/26 at 8:00 AM, R8 stated the food is horrible, sometimes she isn't sure what it is, it's over seasoned and tastes bad. R8 stated if she asks for something different to eat, they get her grilled cheese but it's so greasy she can't eat it. R8 stated if she goes to the dining room the food is warm, if she gets it in her room, as long as it is passed right away, it's warm, if not it's cold. R8 stated the kitchen is trying to find out what they like and don't like but there haven't been any improvements yet. On 6/11/26 at 8:15 AM, R9 stated she doesn't eat hamburger or turkey, the kitchen knows that and it's on her diet card, but they send it to her anyway. R9 stated they offer her a salad, but it also has turkey in it. R9 stated she has asked for grilled cheese, and it is burnt and black, so she can't eat it. On 6/10/26 at 8:45 AM, the 500-hall meal trays were observed with the following noted: served in a closed Styrofoam container, the eggs, hashbrowns were 94 degrees. The eggs were watery and the toast was dark in color. On 6/10/26 at 8:50 AM, the eggs on the serving line were observed and were watery. R8's MDS (Minimum Data Set) dated 3/8/26, documents R8 has a BIMS (Brief Interview of Mental Status) of 15, indicating she is cognitively intact. R9's MDS, dated [DATE], documents R9 has a BIMS score of 15, indicating she is cognitively intact. On 6/11/26 at 1:30 PM, V1, Administrator, stated she would expect the food to be at the correct temperature and to maintain palatability. The Palatability and Nutritive Value Policy, dated 3/9/23, documents food will be prepared, held, and served in a manner that preserves nutritive value and palatability. Best efforts will be made to present hot and cold foods at the point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary.

Based on interview and record review, the facility failed to provide dignified existence in 2 of 5 residents (R8, R9) reviewed for resident rights in the sample of 11. Findings Include:On 6/11/26 at 8:00 AM, R8 stated the CNAs (Certified Nursing Assistants) are on their phones 24 hours a day, 7 days a week, they're on their phone while in providing care to her or they will stand outside her room, talking on the phone and won't come in to assist her until they are finished with their phone call. R8 stated when they are on their phones, sometimes they are disrespectful or cursing on the phone, and she feels that is disrespectful to her too because she doesn't want to hear that. R8 stated some of the staff will say they're tired because of stuff going on in their personal lives and again she doesn't want to hear that, it's their business, not hers, and when they're in the building, they should leave their personal lives at home. R8 stated some of the CNAs don't like her because when something is done right, she will tell V1, Administrator, and they don't like that. R8 stated the bad staff will stand outside her room gossiping with staff about other staff members so the runoff a lot of the good staff. R8 stated the agency staff is better than the facility staff. R8 stated she has heard staff telling the residents their breath if funky, you stink, you smell like p***. R8 was unable to provide any staff names or resident names. On 6/11/26 at 8:15 AM, R9 stated some of the staff are rude and disrespectful, but not abusive. R8's MDS (Minimum Data Set) dated 3/8/26, documents R8 has a BIMS (Brief Interview of Mental Status Score) of 15, indicating R8 is cognitively intact. R9's MDS, dated [DATE], documents R9 has a BIMS score of 15, indicating R9 is cognitively intact. The Resident Council Minutes, dated 3/26/26, documents CNAs: call lights not answered, talking on their phones, cursing, agency staff doesn't help to pass trays, and the CNAs sleep on the night shift. The Resident Council Minutes, dated 5/26/26, documents CNAs: getting residents up late, agency workers are bad, call lights are not getting answered, CNAs leave the halls, on their phones while taking care of the residents, they are disrespectful and rude. On 6/11/26 at 1:30 PM, V1, Administrator, stated she would expect resident rights to be followed. The Resident Rights Policy, dated 8/1/22, documents the objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the residents' own needs and preference.

Based on interview and record resident review, the facility failed to revise a resident's comprehensive care plan for Leave of Absence for care plans for 4 of 4 residents (R2, R3 R4 and R6) reviewed for care plans in the sample of 8.Findings include: 1-R2's Physician Order Sheets (POS) dated [DATE] documents a diagnosis of Schizophrenia, unspecified; major depression disorder, recurrent moderate; unspecified psychosis not due to substance or known physiological condition, cellulitis of neck, iron deficiency anemia, prediabetic, thrombocytosis; unspecified burn of unspecified degree of multiple sites of head, face and neck, subsequent encounter. May attend day program. May go out on pass with medication with family. R2's Care Plan with a Date initiated [DATE] to current does not document anything related to being able to sign himself out and/or leave the facility. 2-R3's POS dated [DATE] documents a diagnosis of generalized anxiety disorder, hyperglycemia, unspecified, person injured in collision between other specified motor vehicles (traffic), type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, and major depression. R3's POS also documents R3 May attend day program. R3's Minimum Data Set (MDS) dated [DATE] document R3 was cognitively intact for decision making of activities of daily living. R3 has no behaviors, no impairments and does not use a wheelchair. On [DATE] at 7:03 PM, R3 stated he did own a car, and it was a Ford Fusion, and it was parked on the side of the building. His car was currently not running and he needed to get it fixed. My health has not been that good, so I am not really driving the car either. He stated he is able to leave the facility whenever he wants to go and come back. R3's Care Plan dated [DATE] does not address him coming and going and/or leaving the facility. 3-R4's POS dated unspecified severe protein-calorie malnutrition, other abnormalities of gait and mobility, dysphagia, oropharyngeal phase, unspecified severe protein-calorie malnutrition, depression, bipolar disorder, altered mental status, unspecified personality disorder, and weakness. R4's POS also documents, May go to day programs and May go out on pass with medications with family. R4's POS does not document he may come and go on his own or take a LOA (leave of absence). R4's Care Plan does not address any LOA activity R4 may participate in. On [DATE] at 8:45 AM, R4 stated he does have a car here that he uses and he likes to visit his family and friends. No issues. No issues with staff not being available or signing in and out. He comes and goes as he wants. 4-R6's POS for [DATE] documents a diagnosis of cerebral infarction, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with hyperglycemia, transient cerebral ischemic attack, anxiety disorder, other specified disorders of brain, weakness, and tachycardia. R6's POS also documents May attend day program and May go out on pass with medication with family. R6's Care Plan with a Date initiated [DATE] to current does not document anything related to being able to sign out and/or leave the facility for LOA. On [DATE] at 4:43 PM, R6 stated she goes out to visit her family and friends and signs herself in and out. On [DATE] at 12:33 PM, V57, MDS/Care Plan, and V58, MDS/Care Plan both stated they were not sure what 'May attend day program' means and were not aware of any resident attending a day program. They had not Care Planned any resident for LOA but if they had an order for a LOA then they would care plan it. If a resident was cogntively intact, then they would think they should be able to come and go, but only if they had an order for it. 'May go out with pass with medication and family' they would consider a resident going out and doing a family activity and/or a visit. On [DATE] at 6:24 PM, V1, Administrator stated, (R1, R2, R3 and R4) all had cars here that are still on the premises. (R1) expired and his family came and picked up the car. (R2, R3 and R4's) cars are still on the property. R2, R3, R4 and R6 can all come and go and sign themselves out. The Facility Care Plan with a revision date of 3/2026 documents, The facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the residents' medical, nursing, mental, and psychosocial needs. The comprehensive care plan should drive the care and services provided for the resident and allow for the highest level of physical, mental, and psychosocial function based on the comprehensive MDS assessment.

Based on interview and record review the Facility failed to ensure no medication was left unattended on a bedside table for 1 of 3 residents (R2) reviewed for unattended medicine in the sample of 8. This past non-compliance occurred from 5/3/2026 to 5/6/2026. Findings include: R2's Physician Order Sheets (POS) dated May 2026 documents a diagnosis of Schizophrenia unspecified; major depression disorder, recurrent moderate; unspecified psychosis not due to substance or known physiological condition, cellulitis of neck, iron deficiency anemia, prediabetic, thrombocytosis; unspecified burn of unspecified degree of multiple sites of head, face and neck, subsequent encounter. R2 was prescribed Ativan 0.25 mg (milligram) (Lorazepam), give 0.25 mg by mouth twice a day for compulsiveness and risperidone oral tablet 1 mg, give 1 tablet by mouth two times a day for schizophrenia. R2's Police Report dated 5/4/2026 at 6:00 PM, document On 05/04/2026 at approximately 10:06 PM, I, (V23, Local Police Officer) responded to (Facility) in reference to a missing person. Dispatch advised the caller, later identified as (V1, Administrator) stated a resident, later identified as (R2) left the facility yesterday (05/03/2026) at approximately 6:30 PM, hours. I arrived on the scene and made contact with staff, identified as (V26, Agency Licensed Practical Nurse (LPN)). V26 stated the following, not verbatim: This is her first night at (Facility). She is in control of the wing that (R2) resides in. She does not know anything about (R2). She went into (R2's) room and saw his medications sitting bedside from the night before. (V25) guided me to (R2's) room. I did not locate anything of evidentiary value. I photographed the room and later placed the photos into the case file. On 5/27/2026 at 8:57 AM, V26, Agency LPN stated, I went into (R2's) room, and he had pills that were lying on his desk. I believe it was lorazepam and some other pills. We are never supposed to leave medications lying around and are supposed to always watch the resident take their medications. I am not sure why the pills and medications were in his room. On 5/28/2026 at 11:11 AM, V1, Administrator stated, We identified concerns with (R2's) medication being left on his bedside table. No staff should ever leave medication behind and should always pass out the medication only to the resident, and if the resident is not there, the medicine should not leave the cart. On 5/28/2026 at 11:33 AM, V2, Director of Nursing (DON) stated, I would not expect any of the nurses to leave any residents medication on the table. All staff should administer the medication and watch the resident take their medication and never leave any medication in their rooms. The Medication Administrator Policy dated 10/2025 documents, Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Prior to the survey date, the Facility took the following actions to correct the noncompliance on 5/6/26. Immediate Actions: 1-Director of Nursing, Assistant Director of Nursing, and/or Designee immediately in-serviced all nurses regarding Medication Administration to include accurate identification of patient/resident prior to medication administration and not leaving medications out.2-Director of Nursing, Assistant Director of Nursing, and/or Designee immediately initiated ongoing audits of medication administration per clinical managers to ensure that nurses are compliant with Medication Administration to be immediately addressed upon identification and/or re-education provided. 3- QAPI meeting was completed to review occurrence, immediate intervention, and plans for ongoing audits to ensure continued compliance. Ongoing Actions: 1-Education will be provided to new employees prior to being allowed to work in the Facility. 2-Concerns will be addressed immediately and discussed during the monthly QAPI Committee for resolution.

Based on observation, interview and record review the Facility failed to ensure critical sign-out procedures were implemented and followed for 1 of 5 residents (R2) reviewed for elopement in the sample of 5. R2 had expressed his desire to leave the facility. This failure resulted in R2 leaving the facility on 5/3/2026 around 6 PM, without proper authorization and staff thinking R2 would be returning to the facility, and nothing was reported until the following day at 6 PM on 5/4/2026. This failure resulted in a delay in reporting and as of 5/27/2026, R2 still has not been found, and remains missing. This past non-compliance occurred from 5/3/2026 to 5/6/2026. Findings include: R2's Physician Order Sheets (POS) dated May 2026 documents a diagnosis of Schizophrenia unspecified; major depression disorder, recurrent moderate; unspecified psychosis not due to substance or known physiological condition, cellulitis of neck, iron deficiency anemia, prediabetic, thrombocytosis; unspecified burn of unspecified degree of multiple sites of head, face and neck, subsequent encounter. R2 was prescribed Ativan 0.25 mg (milligram) (Lorazepam), give 0.25 mg by mouth twice a day for compulsiveness. Cleanse scar tissues to back/neck with normal saline then apply silicone boarded dressing as preventive measure. (To stop pt (patient) from scratching, every day shift, for preventative). Risperidone oral tablet 1 mg, give 1 tablet by mouth two times a day for schizophrenia. May attend day program. May go out on pass with medication with family. R2's POS does not document R2 may come and go in and out of the facility as he pleases and/or without supervision. R2's Minimum Data Set (MDS) 4/11/2026 document R2 was cognitively intact for decision making for activities of daily living (ADL's). R2 has no impairment and needs minimal assistance for most ADL's. R2's Care plan documents (R2) requires some assistance with daily care needs. He ambulates about facility with supervision. Date Initiated: 7/3/2025. [NAME]: (R2) is at risk for complications r/t DX (related to diagnoses of) anemia. (R2) is at risk for skin complications r/t (related to) Burn of unspecified degrees of multiple sites of head, face, and neck. Date initiated 5/9/2024. Discharge Planning: (R2) expresses the desire for the resident to continue long term. The resident's discharge potential and discharge planning needs have been assessed by the IDT (intradisciplinary team) and it has been decided to continue long term care, Date initiated 7/9/2025. Intervention: Continue to monitor and document all progress. (R2) has criminal behavior. (R2) has demonstrated stability during the admission screening process, does not appear to present an unusual risk. Aggravated unlawful use of weapons. Date initiated 7/3025. (R2) would like to move to a less structured environment. (R2) discharge potential and discharge planning needs have been assessed by the IDT (intradisciplinary team), Data Initiated 7/3/2025. Ambulation: Walk to dine to maintain endurance and mobility. Date initiated 7/3/2025. On 5/20/2026 at 5:40 PM, when entering the facility, the doors from the entrance to the residents' halls were locked and one needs a code to enter the resident area and a different code to exit. Two codes are needed to come and go into the resident's hall. One code is needed to enter, and another code is needed to exit. R2's Progress Notes dated 4/21/2026 at 1:54 PM (LATE ENTRY actually created on 5/6/2026 at 2:01 PM), Resident voiced to social service directors that he was wanting to discharge to a shelter. Resident stated he felt suffocated in his room and just wanted to go back to the shelter he was at before. SSD (Social Service Director) educated resident it was not a safe discharge and how he needs wound care and how they would not have that at the shelter. Resident voiced understanding and said he was just going to stay. SSD told resident if he was continuing to feel that way to let us know. SSD told him that I would have psych (psychiatry) review his medications if that could help him. Resident appeared OK with that and voiced understanding of needing to be here for his wound care at this time. R2's Progress Notes dated 4/21/2026 at 3:03 PM, Resident verbalized desire to leave the facility against medical advice (AMA) at this time. Resident expressed feelings of depression and stated intent to leave. Writer spoke with resident regarding risks associated with leaving AMA and provided education on safety concerns, continuity of care, and available support service. Emotional support and reassurance provided. Resident agreed to remain in facility at this time following discussion. Resident has been added to the list to follow psych. On 5/27/2026 at 12:01 PM, V28, Former Nurse Practitioner stated, she no longer works for the facility. She remembers (R2) was a young man and at that time she saw him he was not symptomatic, but he was also on medication and was stable. I only saw him twice. He shared with me an event when he was homeless. He was on risperidone. That's all I can remember. I cannot say if stopping the medications would be detrimental to his health as it may or may not be, it's hard to say. He would need the diagnoses to determine this. On 5/27/2026 at 12:05 PM, V29, Social Service Director stated (R2) came to us about a month ago asking if he could go to a shelter. He said he wanted to go back to the shelter where he was at one time. He did not remember the name, and I was not sure where it was or even what town it was located at. We talked about him wanting to leave and I documented it in his chart. He seemed fine after that. We had the Nurse Practitioner (V28) see him when she came to do her rounds and he seemed fine after that. R2's Progress Notes (LATE ENTRY) dated 5/3/2026 (but actually created on 5/5/2027 at 8:17 PM), at 6:30 PM, Resident reported to CNA (Certified Nurse Aide) he was going to the laundromat down the alley. Resident remains alert x 4. Shows no signs of distress or discomfort, no new concerns noted at this time. On 5/26/2026 at 8;22 AM, V11, Certified Nursing Assistant (CNA) stated, I saw (R2) coming down the hall on Sunday 5/3/2026 and he had two clear bags of clothes with him and was walking down the hall. I asked him where are you going and (R2) said he was going to the laundromat to wash his clothes. (R2) comes and goes as he pleases, and I was at the nurse's station and was not at the entrance way. (R2) keeps to himself mostly, and if you talk to him, he will talk to you. I never told any nurse or reported to anyone that I saw him leaving until we found out later, he was missing. I have never known him to take his clothes to the laundromat before. Normally, we do have everyone sign off at the receptions desk. Having residents sign in and out is not my responsibility. I never reported (R2) leaving because I thought he was going to do all that with the receptionist because he always has in the past. I did not know until afterwards there was no receptionist working at that time. I have never known (R2) to take his clothes to the laundromat. R2's Progress Notes dated 5/4/2026 at 7:19 PM, While receiving report from the day shift nurse this nurse was informed that resident had left facility the night before around 6:30 PM, going to the laundry mat. Day shift nurse stated to this nurse that she had not seen resident today on her shift. This nurse reported to (V3, Assistant Director of Nursing). On 5/22/2026 at 2:46 PM, V10, Licensed Practical Nurse (LPN) stated, I was working the 7AM to 7PM shift the day (R2) got out. At the start of each shift, they give us a report and (R2) was marked as LOA (leave of absence). At first, I was not concerned because the report paper said (R2) was out on leave, at the laundromat. I kept coming back and forth and checking to see if I could find him because he needed his medicine. I was not sure when he left or when he was coming back. After my shift ended at 7 PM, (R2) was still was not back and I started asking questions like when was he coming back, and that's when we found out (R2) had not signed out or told us when he would be returning. (R2) was always nice to me and talked with me. He never told me he wanted to leave or that he was unhappy. I was told he still has not come back and is still missing. I do not believe I ever saw (R2) take his clothes to the laundromat. V10's statement dated 5/5/2026 at 2:14 PM, documents, Tell me what happen on 5/3/2026 during your shift. Did you look for the resident? 'She read report sheet that stated (R2) was on LOA'. Resident is known to leave and is independent. Due to that she didn't feel that it was an immediate concern as this wasn't abnormal for him. She gave report to the night shift nurse that he was LOA. On 5/20/2026 at 6:30 PM. V1, Administrator stated, (R2) told staff on 5/3/2026 around 6 PM, that he was going to the laundromat and he left with two bags and has never returned. (R2) is still missing. I talked with his former roommate, and he told me (R2) told him he was going to a shelter. We watched the camera footage and (R2) walked out of the facility towards the laundry mat and never returned. I notified his family, and we have been attempting to contact shelters, and I alerted the police. The police have a national registry for missing people (CODAS) and (R2) is on the list now. (R2's) family was not close to him. He did have a grandma that he was close with and went to her house and (R2) was not there. (R2) is ambulatory and alert and orientated. He was here because he suffered some burns, and he had been here for a little bit and then went and lived with his grandma, and then his wounds opened back up, so he came back here. (R2) likes to pick at his wounds. We contacted the police and shelters, the hospital and morgue. (R2) also had a sister that did come sometime last year to visit him. In the past (R2) would sign himself in and out. This time was a Sunday and there was no staff at the front desk, and he left with his two bags. He does have a car outside, it is a white Chevrolet. I am not sure if it will run, but it looks like a decent car. We did not consider (R2) an elopement because he told us where he was going. I am not sure if (R2) actually went to the laundry mat, or if they have cameras. In the past (R2) had talked about wanting to go to a shelter, and I explained to him that that would not be safe and would not be a safe discharge. The only way he could do that would be if he signed out AMA (against medical advice). This was a few weeks before he left. He had gone out that day earlier and came back with no issues. Again, he was always signing himself in and out. As of today (R2) is still missing and has not been located. On 5/26/2026 at 9:21 AM, V9, Licensed Practical Nurse (LPN) stated, I saw (R2) earlier in the day, and he seemed okay. He keeps to himself mostly and when I went to do rounds around 6:00/6:30 PM on Sunday 5/3/2026, (R2) was not in his room. I went around and was asking staff if they had seen him and (V21, Certified Nursing Assistant (CNA) told me she had seen him, and he told her he was going to the laundromat. (R2) comes and goes all the time. (R2) cannot even get out of the building unless he knows the code or someone buzzes him out because those doors are locked. I am not aware of him ever taking his clothes to the laundromat before. At that time, I did not think (R2) was missing. Normally, we have a receptionist, and they have the residents sign in and out and tell us when they are coming back. Because (R2) signed in and out when I gave my report, I said he was at the laundry mat and did not think this as a concern because he was always coming and going. I never looked at the sign out sheets, I just assumed he signed out with the receptionist. I did not realize the receptionist staff had called off that night. On 5/26/2026 at 7:55 AM. V22, Receptionist stated she had been working in the facility for about five or six years as a receptionist. If she has a resident who wants to go out with their family or go out on their own, like to a store, then they have to fill out two forms. The first form is the 'Release of Responsibility Form' required during any leave of absence. The form has their name, signature and tells us where they are going and when they are coming back. Then we have a tracking form that says who is out of the building, date, the date of the leave of absence, planned return, signature, date returned, return time of LOA and when they are coming back. Typically, if a resident wants to leave, then I contact the nurse and run everything with her to make sure they can leave. (R2) has a history of coming and going. He was always leaving and going somewhere. I never knew him to take his clothes or say he was going to the laundromat. The day he left I worked the first shift 7 AM to 3 PM. There was supposed to be another receptionist from 3 PM to 8 PM, but they called off so there was no receptionist that was working when he left that day. I told the nurses to keep an eye on the residents since the receptionist called off. To my knowledge (R2) is still missing. On 5/27/2026 at 8:40 AM, V23, Business Office Manager stated we were in the process of hiring another receptionist and I had said I could work on 5/3/2026 from 3 PM to 8 PM, but then I had a family emergency and was not able to work on any of that schedule. To my knowledge, no other staff was able to cover that shift and that was the day (R2) left the facility. I was supposed to be working that shift when (R2) left without signing out and no other staff member was working the front desk. On 5/22/2026 at 3:44 PM, V3, Assistant Director of Nursing stated, Typically, (R2) was really good about signing himself in and out. (R2) told (V21, CNA) that he was going to the laundromat and had some bags in his hands. Typically, we have a staff member housed at the front desk and they sign residents in and out when they are going on a LOA (leave of absence), and this happened around 6PM, shift change and the replacement staff was late so nobody was at the front desk to sign (R2) out and nobody knew when he was going to come back. V3's statement dated 5/5/2026 no time documents, See attachment, it was reported to this writer at approximately 8:00 PM on 5/4/2026 that resident had not been observed in the facility since approximately 6:30 PM on 5/3/2026. Per report, resident was last seen leaving the facility stating intent to go to a nearby laundromat. It was further reported that resident returned to the facility later that evening and subsequently left again; exact times of return and second departure are unknown. NP (Nurse Practitioner)/physician, DON and administrator were notified immediately upon awareness. Resident's family was contacted and reports no knowledge of resident's location. Local hospitals and shelters were contacted with no success in locating resident at this time. Police department was notified and missing person report filed per administration. On 5/22/2026 at 4:02 PM, V2, Director of Nursing (DON) stated the nurse (V26, LPN) was completing her rounds when she noticed (R2) was not in his room. She asked the CNA if she had seen him. (V21 was the CNA). (V21) told the nurse she saw (R2) leaving around 6:30 PM, he had two bags and said he was going to the laundromat. (R2) has a history of coming and going, so nobody thought anything of it. The receptionist that was supposed to be working the desk called off, so there was no staff member at the desk. The next day the nurse was concerned and contacted V3 himself. V2 statement dated 5/5/2026 at 11 AM, Documents, Nurse was completing her 6:00 PM rounds when she notified that the resident (R2) was not in his room. She asked the hall CNA if she had seen (R2) and she stated that he left around 6:30 PM to go to the laundromat. It was normal for him to leave the facility. She was not concerned at that time. She reported it to the oncoming night shift nurse that (R2) was LOA. On 5/27/2026 at 10:02 AM, V1, stated, I am not sure how (R2) got through the doors. I am not sure if he figured out the code or if someone buzzed him through the doors. On 5/27/2026 at 8:57 AM, V26, Agency LPN stated, When I started my shift the day shift nurse was reading an old report, and she hadn't the time to make a new report. She started going down the list and several residents were marked LOA. When she got to (R2) he had LOA next to his name written and I asked her if he was still gone because it did not make sense to me because they said he was at the laundromat, and I was asking if anyone had seen him because by this time he should have been back in the building. The CNA's work eight-hour shifts and the nurse's work 12-hour shifts and I started asking if anyone had seen him. Nobody had seen (R2), and I told the nurse to call her supervisor and let them know because it has been over 24 hours and that is an elopement, and he has been missing, and administrator needs to know and to call somebody. I went into (R2's) room, and he had pills that were lying on his desk. I believe it was lorazepam and some other pills. We are never supposed to leave medications lying around and are supposed to always watch the residents take their medications. I am not sure why the pills and medications were in his room. I asked the nurse if she wanted me to do something else, then about an hour later the police showed up and I walked the policewoman to his room, and she took some pictures. I told her as I am telling you this was my first day working in the building and I was not familiar with (R2). The police talked with his former roommate, and I believe he told them (R2) came and said goodbye to him and that he wanted to leave the facility. I put in a note in his chart, and alerted others to (R2's) elopement. R2's Incident Report documents, Incident Type: Missing Resident- Unauthorized Departure. Incident Overview: On May 3, 2026, at approximately 6:00 PM, resident (R2) departed the facility without proper authorization and has not returned as of the date of this report. The resident was initially believed to be on an authorized leave of absence based on his established pattern of voluntary departures: however subsequent investigation revealed that proper sign-out procedures were not followed. The facility has implemented comprehensive search efforts and notified all appropriate authorities. Current status: Resident remains missing. Active search efforts continue with law enforcement, healthcare facilities, and community organizations. Police report filed with local authorities on May 4, 2026, at approximately 11:00 PM. Immediate Safety Concerns: Resident has documented history of mental health conditions including schizophrenia, psychosis, major depression disorder, and major depression which may impact his ability to care for himself independently. Iron deficiency condition may also affect his physical well-being during extended absence. Departed with two bags of clothing. The resident has the following documented medical conditions that create safety concerns during his absence and require immediate medical attention if located: Iron deficiency: Ongoing condition requiring medical monitoring and potential treatment. Schizophrenia: Chronic mental health condition requiring consistent medication management and psychiatric care. Psychosis: Active psychiatric condition that may impair judgment and decision-making capacities. Major depression disorder, Recurrent, Moderate: Mental Health requiring ongoing therapeutic interventions and medication management. These conditions collectively create significant safety risk during unauthorized absence including potential for self-harm, inability to seek appropriate medical care, medication, non-compliance, and impaired capacity to make safety decisions regarding shelter, food and personal safety. R2's Police Report dated 5/4/2026 at 6:00 PM, document On 05/04/2026 at approximately 10:06 PM, I, (V23, Local Police Officer) responded to (Facility) in reference to a missing person. Dispatch advised the caller, later identified as (V1, Administrator) stated a resident, later identified as (R2) left the facility yesterday (05/03/2026) at approximately 6:30 PM, hours. (V1) was informed by a roommate of (R2's) that he was going to a shelter. I arrived on the scene and made contact with staff, identified as (V26, LPN). V26 stated the following, not verbatim: This is her first night at (Facility). She is in control of the wing that (R2) resides in. She was told by the day shift nurse, whom she knows as (V10) that (R2) has not been at the facility since last night, 05/03/2026, at approximately 6:30 PM. She told the administrator, (V1). She does not know anything about (R2). She went into (R2's) room and saw his medications sitting bedside from the night before. She knows she was told by the day shift nurse that (R2) can sign himself in and out. (V26) printed out a face sheet with (R2's) information. I noted that (R2) had a listed history of schizophrenia and major depressive disorder. I requested (V25) to provide (R2's) last brief interview mental status (BIMS) to determine his cognitive impairment. I reviewed the last BIMS report from 04/10/2026; (R2) scored a 15/15, demonstrating intact orientation, attention, and short-term memory at the time of the assessment. (V25) guided me to (R2's) room. I did not locate anything of evidentiary value. I photographed the room and later placed the photos into the case file. (V25) was advised by other staff members that (R2) did not have a roommate at this time. (R2) had a previous roommate, later identified as (R5). I met with (R5) and he stated the following, not verbatim: V23, Local Police talked with (R5) and he stated the following: He last talked to (R2) on either Friday (05/01) or Saturday (05/02). (R2) told him that he did not want to be at the facility anymore. He tried to get (R2) to stay at (Facility) and told him that he was moving back in the room with him. (R2) told him that he got a spot at a shelter and wanted to stay there. (R2) further told him that if he did not go, the shelter would give his spot away. (R2) did not say what shelter he was going to. (R2's) grandmother lives in the area. He does not know about (R2's) brother, but his sister lives out of town. On 5/26/2026 at 1:31 PM, R5 stated he was roommates with (R2), but I had an infection, so they moved me. We were friends and they talked. (R2) told him he wanted to leave, and (R2) told him he was going to leave and go to a shelter, but he told me this on Saturday but then he was still here. So, I was not sure he was for real. Then I found out he left on Sunday and has not been back. (R2) did not tell me the name of the shelter. I do not know if he is safe. He has not contacted me since he left. The LOA tracking form for 5/3/2026 does not document R2 signed himself out on 5/3/2026. Despite R2's established pattern of authorized departures, proper documentation protocols were not followed on 5/3/2026. R2 was missing sign-out documentation. No entry was found in facility sign out book for 5/3/2026, or any subsequent date. Staff assumed R2's departure was authorized based on resident's historical pattern of coming and going without following up and ensuring/verifying the proper documentation was actually in place. The information shared was passed between shifts without any staff checking the LOA book and verification of authorization status for R2 leaving. R2's Medical Records document R2 had expressed to the facility that he wanted to leave but no interventions were put into place to ensure R2 was safe and had a safe discharge. On 5/27/2026 at 10:23 AM, V27, Psychiatric Doctor stated he would expect the facility to follow all sign out/supervision policies for all of the residents. On 5/27/2026 at 11:42 PM, V27 stated he oversees the Nurse Practitioners, but he is not on the ground providing care. If a resident stops taking medications and the patient is stable, we do a gradual dose reduction before just taking them off the medications. It is hard to say if there would be harm as it could be minimal harm or possibly more depending on the resident. It just depends on the resident. Some residents may have a diagnosis that they got at the hospital, and it was an inaccurate diagnosis. Other residents could potentially be affected if it was an accurate diagnosis. I am not sure with (R2) because I never saw him. The possibility of harm with a psychiatric resident not receiving their medications as ordered and if they needed it could be harm but only if it was an accurate diagnosis. R2's Physician Admission/Follow up Schizophrenia Diagnosis Confirmation Evaluation Form dated 4/27/2026 documents, R2 has had previous hallucinations, assessment of hallucinations: More currently present with current medication management. Patient states I started to hear a lot of voices in a crowd around 2014, R2 was documented as meeting the criteria for the DSM-5-TR (The Diagnostic and Statistical Manual of Mental Disorders) criteria of schizophrenia. (This diagnosis was completed by V28). The Facility Leave of Absence Policy with a revision date of 3/11/2026 documents, This policy outlines the procedures for documenting and managing resident Leaves of Absence (LOA) to ensure resident safety, regulatory compliance, and continuity of care. Residents have the right to leave the facility for therapeutic or personal reasons. A physician's order is required prior to any Leave of Absence. For therapeutic leave, the facility is not obligated to hold the resident's bed; however, the resident retains the right to return to the next available bed in a semi-private room, even if there is a waiting list. The facility must provide written information about bed-hold and return rights to the resident or their representative upon admission and at the time of any leave. A physician's order must be obtained prior to the resident taking Leave of Absence. The resident or responsible party must notify the nurse of their destination and estimated return time. The resident or responsible party must sign out using the facility's Sign-Out Sheet. If medications are to be taken during the LOA, the nurse must verify the order, provide labeled medications, and give instructions. If the resident is delayed in returning, the responsible party should notify the facility. If the resident does not return as anticipated, nursing staff must attempt to contact. If unsuccessful, the DON and/or Administrator must be notified and for further instructions. If the resident fails to return and no contact is made, the physician must be notified and the situation may be documented as a discharge Against Medical Advice (AMA), if appropriate. The party responsible must be notified within 24 hours of any failure to return. The past noncompliance began on 5/3/2026 and was corrected on 5/6/2026 after the facility took the following actions to correct the noncompliance. The DON/Designees provided in-servicing on Elopement and Supervision, Rounding and Providing care for the Resident, Identifying Residents that Wander and Exit Seekers, Alarm Codes and LOA and AMA Policy to all staff and agency staff on 5-5-26. In-service is ongoing, and all staff and agency staff who were not present on 5-5-26 will be in-serviced prior to the start of their next scheduled shift. The DON/Designees provided in-serving on Change in Condition and Medication Administration to licensed staff and licensed agency staff on 5-5-26. In-servicing is ongoing and will be in-serviced prior to the start of their next scheduled shift. The Maintenance Director inspected all facility door alarms and confirmed they were functioning appropriately on 5-5-26. The Maintenance also called (door alarm company) to assist with changing facility door alarm codes on 5-5-26. The alarm codes were successfully changed on 5/5/26. All residents were reassessed by the Clinical Leadership Team, using the Elopement Risk Assessment Tool and this was completed on 5-5-26. All residents identified as at risk for elopements have had their care plans reviewed by the MDS nurses for resident specific interventions. This was completed on 5/6/26. An elopement binder was reviewed by the Regional Nurse Consultant, to ensure those residents at risk for elopement, have a face sheet and picture in the binder. 5-5-26. The Facility has implemented a 24/7 front desk receptionist on 5-5-26 (until can ensure doors. The IDT will review if the need for a 24/7 receptionist is still warranted weekly during QA meetings. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5-6-26). The DON/Designee will in-service staff and agency on facility elopement policy, on Elopement and Supervision, Rounding and Providing care for the Resident, Identifying Residents that Wander and Exit Seekers, Alarm Codes and LOA and AMA on 5-5-26. The DON/Designees provided in-serving on Change in Condition and Medication Administration to licensed staff and licensed agency staff on 5-5-26. In-servicing is ongoing and will be in-serviced prior to the start of their next scheduled shift. The MDS/DON/Designee will review all new admissions within 24 hours after admission for elopement risk 5 days a week for 4 weeks, any residents who trigger as high risk will be place in the elopement binder along with care plan with resident specific interventions. The DON/MDS/designee will review all elopements at the daily stand-up meeting with the IDT for three months to ensure appropriate elopement interventions are implemented, the resident's care plan has been reviewed and revised, and the individualized service plan The DON/MDS/designee will review 5 resident MARs/TARs weekly for 4 weeks, monthly for the next 3 months for proper documentation and following physician orders. QAPI meeting was held on 5/6/26 with IDT and MD. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months.

Based on interview and record review the facility failed to honor resident rights for 2 (R4, R13) of 3 residents reviewed for resident rights in the sample of 21.Findings Include:1.R4's Undated Face Sheet documents R4 was originally admitted to the facility on [DATE] and has a medical diagnosis of Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Lack of Coordination, Chronic Atrial Fibrillation, Heart Failure, and End Stage Renal Disease.R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact.On 4/3/2026 at 8:24 AM R4 stated the facility loses his clothing all the time and his sister brings in receipts to be reimbursed for his clothing. R4 stated he will get his clothing from Good Will because the facility tends to lose it.2.R13's Undated Face Sheet documents R13 was originally admitted to the facility on [DATE] and has a medical diagnosis of Metabolic Encephalopathy, Hypertension, Spinal Stenosis Cervical Region, Cervicalgia, and End Stage Renal Disease.R13's MDS dated [DATE] documents R13 is cognitively intact, using a motorized wheelchair and/or scooter, and has an upper and lower extremity impairment on both sides.On 4/3/2026 at 9:00 AM R13 stated the facility loses his clothing. R13 stated he sent 7 pairs of pants to the laundry and only received 1 pair of pants back. R13 stated he should not have to worry about the facility losing his clothing. R13 stated the facility has never replaced anything that he is missing and just lies to him saying they will investigate it. The Facility's Resident Council Minutes dated 1/29/26 documents Laundry: missing items and delayed.The Facility's Resident Council Minutes dated 2/26/26 documents Laundry: clothes still missing and not getting returned.On 4/3/26 at 12:00 PM V1, Administrator, stated they have had a lot of missing clothing over the past few months, their company had switched in January 2026 to a different company, prior to that they had a laundry aid that they suspected wasn't following the resident roster and was placing it where ever she could find a spot and not in the correct residents room, the old company did terminate that laundry aide and things got better. V1 stated then when the company changed to the new laundry service, that company rehired that laundry aide and again they started having problems with missing clothing, so she was terminated by the current laundry service and things are starting to get a little better.On 4/3/26 at 11:50 AM V20, Laundry Aide, stated if a resident reports missing clothing, they will get a description of the clothing item, check the lost and found first, then the residents' room, and if they still can't find it, he reports it to his manager.3. On 4/7/2026 at 9:04 AM V30, Certified Nursing Assistant (CNA), came into R13's room to answer R13's call light. V30 asked R13 what he needed, R13 asked V30 if she could apply his anti-itch cream to his back because he could not reach it. V30 stated staff are cleaning up breakfast, does not have time to do it, and she would come back later. R13 became tearful and stated every time he asks staff to help him do something they always say they will come back and they never do. R13 stated he sees staff take care of all the other residents, and when he asks for help, they never want to help him. R13 stated it makes him feel like he doesn't matter to staff. R13 stated if he could do certain things himself, he would, but he can't.The Facility's Resident Council Minutes dated 2/26/26 documents CNA: disrespectful.On 4/9/2026 at 2:37 PM V2, Director of Nursing, stated she expects staff to honor and follow the Facility's Resident Rights Policy.The Facility's Resident Rights Policy Date Reviewed 10/2025 documents General: The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. Procedure: The facility will assess and interview resident for the need to make reasonable accommodation such as protection of resident's personal items and supplies from loss or theft.

Based on interview and record review the facility failed to ensure residents were free from verbal abuse in 1 (R13) of 3 residents reviewed for abuse in a sample of 21.Findings Include:R13's Undated Face Sheet documents R13 was originally admitted to the facility on [DATE] and has a medical diagnosis of Metabolic Encephalopathy, Cognitive Communication Deficit, Hypertension, Spinal Stenosis Cervical Region, Cervicalgia, and End Stage Renal Disease.R13's Minimum Date Set (MDS) dated [DATE] documents R13 is cognitively intact, using a motorized wheelchair and/or scooter, and has an upper and lower extremity impairment on both sides.R13's Care Plan Last Reviewed 2/2/2026 documents Abuse: R13 is at risk for abuse and neglect related currently in long term care facility, 3/20/26: Allegation of abuse.The Facility's Final Investigation Report dated 3/20/2026 documents On 3/19/25 I received a call from V9, Licensed Practical Nurse (LPN), alleging inappropriate verbal interaction by a Dialysis Technician V31. Physician and family notified. Local Police notified. V9, LPN, reported that she witnessed dialysis tech V31 being verbally inappropriate with resident R13. Following the incident V31 left the area and returned to the Dialysis Den. V31, Dialysis Tech, denied the allegation. A full investigation was completed and based on witness statements it was determined that the allegation supported inappropriate behavior. Alert residents were interviewed and no other concerns were voiced. V31 was suspended pending the investigation. Dialyze Direct was contacted and informed of the allegation and outcome R13 denied any mental anguish regarding the incident.The Facility's Abuse Investigation Resident Questionnaire dated 3/20/2026 documents On 3/20 R13 reported that the dialysis tech which he later points out to be V31 was verbally abusive to him in dialysis as well as in the hall by the nurses station. R13 stated that he felt threatened by her and the nurse heard her say that she would mess him up. R13 said he thinks she was mad because he told on her for leaving the window open and was made to close the window.On 4/3/2026 at 12:00 PM V1, Administrator, stated she had an abuse investigation that involved a dialysis technician and a dialysis patient (R13), and she did substantiate that allegation.On 4/7/2026 at 9:04 AM R13 stated he had an incident with a Dialysis worker, where the Dialysis worker threaten him. R13 stated the Dialysis tech stated she was going to beat his a** when he complained it was cold in the Dialysis room. R13 stated he informed a nurse that the tech had threatened him and when the tech came out of the bathroom, she threatened him again and that nurse heard it. R13 stated staff are supposed to be professional and help the residents not threaten them. R13 stated when the Dialysis tech threaten him, it made him feel scared, threatened, and low.On 4/7/2026 at 9:52 AM V9, Licensed Practical Nurse (LPN), stated she was at the nurse's station when R13 stated he was going to Dialysis, and he asked the Dialysis nurse if the window could be closed in the Dialysis room. V9 stated R13 told her he was threatened by V31 when R13 asked about the window. V9 stated R13 told her that V31 stated she would f*** old people up. V9 stated R13 and herself were in the hallway by the bathroom when V31 came out of the bathroom and R13 told V31 that R13 used to be a cop and you can't say that to people. V9 stated V31 repeated what R13 had said and bent down to R13's ear and stated, I f*** old people up and V31 stated she knew the camera was there and did not care about the camera.On 4/7/2026 at 10:48 AM V31, Dialysis Technician, stated she was mopping part of the dialysis floor with bleach and cracked the window due to the smell and resident's receiving dialysis. V31 stated V33, Dialysis Nurse, informed her that R13 stated he would not do his dialysis treatment due to V31 refusing to close the window. V31 stated she never refused to close the window. V31 stated she was walking down the hall to go to the restroom when she saw R13 in the hallway and jokingly told R13 she was going to get him. V31 stated when she walked out of the restroom, R13 was standing in the hall with a nurse and R13 informed her that he used to be a cop and V31 stated, yea me too. V31 stated she told R13 I'm gonna get you again and was joking. V31 stated she continued to walk down the hallway and R13 yelled at her so you are going to beat my a**. V31 stated she never told R13 that she was going to beat his a**. On 4/9/2026 at 2:37 PM V2, Director of Nursing, stated she expects staff to follow the Facility's Abuse Policy.The Facility's Abuse Policy and Prevention Program Policy dated 10/2022 documents This facility affirms the right of our resident to be free from abuse, neglect, exploitation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.

Based on interview and record review the facility failed to appropriately document the administration of an opioid medication for 1 (R5) of 6 residents reviewed for pharmacy services in a sample of 21.Findings include:R5's Undated Face Sheet documents R5 was originally admitted to the facility on [DATE] and has a medical diagnosis of Type 2 Diabetes Mellitus, Altered Mental Status, End Stage Renal Disease, Osteomyelitis, and Hypertension.R5's Minimum Data Set, dated [DATE] documents R5 was moderately impaired.R5's Care Plan Last Review Date 3/9/2026 documents R5 has an alteration in comfort related to Advanced Disease Process, Hypoxic Ischemic Encephalopathy, Osteomyeltities, Pressure Ulcers, Gangrene.R5's Physician Order dated 1/10/2026 at 6:16 AM documents Oxycodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth every 4 hours as needed for Pain.R5's Medication Administration Record (MAR) dated 1/1/2026-1/31/2026 documents R5 received his ordered dose of Oxycodone-Acetaminophen 10-325 mg on 1/10/2026 at 7:15 PM and 1/12/2026 at 8:34 PM.R5's Oxycodone-Acetaminophen 10-325 mg Medication Monitoring/Control Record documents R5 received a dose of Oxycodone-Acetaminophen 10-325 mg on 1/10/2026 at 7:10 PM, 1/10/26 at 11:30 PM, 1/11 at 9:00 AM, 1/11 at 8:34 PM, 1/12, 1/13 at 8:00 PM, 1/14 at 5:00 AM, 1/14/2026 at 8:00 PM, 1/15/26 at 1:30 AM, 1/15/26 at 6:30 AM, and 1/15/26 at 3:20 PM.R5's Investigation Dated 1/16 documents R5 was administered his medication on 1/10 at 7:00 PM and 11:30 PM, on 1/11 at 9:00 AM and 8:30 PM, on 1/12 at 2:00 AM, on 1/13 at 8:00 PM, on 1/14 at 5:00 AM and 8:00 PM and on 1/15 at 6:30 AM and 3:20 PM.On 4/9/2026 at 10:15 AM V2, Director of Nursing, stated R5's MAR does not match R5's Oxycodone Medication Monitoring/Control Record, and R5's MAR does not document all dates the medication was administered. V2 stated nursing staff should document that a medication was administered on the resident's MAR. V40, Licensed Practical Nurse/Charge Nurse, stated if a medication is given, including a narcotic, it is documented on the resident's MAR. V2 stated she expects staff to document that a medication was given on the resident's MAR.The Facility's Medication Administration Policy Last Revised 5/2017 documents document as each medication is prepared on the MAR.

Based on interview and record review, the facility failed to complete indwelling urinary catheter changes as ordered, failed to follow urology physician orders as directed, and failed to verify hospital discharge orders for 1 of 3 residents (R2) reviewed for quality of care in the sample of 4. This failure resulted in R2 developing a urinary tract infection with sepsis that required hospitalization and IV (intravenous) antibiotics. Findings Include:R2's admission Record, print date of 1/22/26, documented R2 has diagnoses including cerebral infarction, osteomyelitis, diabetes mellitus, peripheral vascular disease, urinary tract infection, dysuria, stage 4 pressure ulcer, chronic kidney disease, congestive heart failure, and diabetic polyneuropathy. R2's MDS (Minimum Data Set) dated 12/2/25 documented R2 is cognitively intact, has an indwelling urinary catheter, and is dependent on staff for mobility.R2's Care Plan, initiation date of 12/9/25, documented R2 was diagnosed with a UTI (urinary tract infection) while at outside hospital. R2's urology consult progress notes and order, dated 7/8/25, documented [AGE] year old male with history of hypertension, hyperlipidemia, diabetes, neuropathy, peripheral vascular disease, neurogenic bladder managed with an indwelling urinary catheter, left AKA (above knee amputation), coccygeal wound with osteomyelitis, who presents today for follow-up following a hospitalization where urology was consulted for scrotal swelling. It continues, (R2) states that his indwelling urinary catheter has not been changed at his facility but that the facility is able to do that and just needs an order. It continues, Assessment/Plan: [AGE] year-old male with scrotal edema likely secondary to underlying comorbidities and a neurogenic bladder currently managed with an indwelling urinary catheter. We discussed his situation in some detail and recommended scrotal support for his scrotal edema. I do recommend he get his catheter changed every month at this facility. This can also be done on a PRN (as needed) basis if he has any issues with the catheter not draining. I plan on following up with him in 6 months for re-evaluation. Sooner, should he have any issues. Order for facility: (indwelling urinary) catheter change today and every month indefinitely.R2's progress note, dated 7/8/25 at 6:22 PM, documented resident went to urology appointment today, came back with a new order to change (indwelling urinary catheter) today and monthly after.R2's TAR (Treatment Administration Record), dated October 2025, documented change (indwelling) monthly every night shift starting on the 8th and ending on the 8th of every month. This TAR does not document R2's indwelling urinary catheter was changed as ordered on 10/8/25. R2's progress note, dated 10/9/25 at 3:15 PM, documented this writer was notified by aid that patient had bleeding from penis. Resident due yesterday for monthly (indwelling urinary) catheter change. This writer deposed of old (indwelling urinary catheter) extracting 30 cc (cubic centimeters) of water from balloon. Writer sterilized area and inserted new (indwelling urinary catheter) inputting 30 cc in balloon, met with urine return of clear yellow color. No complaints of pain or discomfort, patient thanked writer. R2's progress note dated 10/20/25 at 1:35 AM documented UA (urinalysis) collected. R2's progress noted dated 10/23/25 at 2:54 PM documented nitrofurantoin microcrystal capsule 100 MG (milligrams), give 1 capsule by mouth every 6 hours for UTI (urinary tract infection) for 7 days.R2's progress note dated 11/4/25 at 7:09 PM documented IM (intramuscular) ABT (antibiotic) continues r/t (related to) UTI. R2's TAR (Treatment Administration Record), dated November 2025, documented change (indwelling) monthly every night shift starting on the 8th and ending on the 8th of every month. This TAR does not document R2's indwelling urinary catheter was changed as ordered on 11/8/25. R2's progress note, dated 12/3/25 at 10:26 AM, documented upon entering resident's room to check morning BS (blood sugar) resident was observed to be shaky with elevated temperature and pulse. Vitals were taken and pulse was tachycardia at 134. Resident was alert and able to tell me that he was not feeling well. BS was 319, resident received 10 units of sliding scale insulin. Resident had emesis before EMS (emergency medical services) arrived. R2's progress note, dated 12/4/25 at 2:52 AM, documented Pt (patient) admitted to (local) hospital for sepsis. R2's hospital History and Physical, dated 12/3/25, documented patient presented from (facility) with complaint of abdominal pain to the lower abdomen with nausea and vomiting. Patient has an indwelling urinary catheter. He states he noticed sediment in his urine recently. He reports they just changed his indwelling urinary catheter 3 days ago, but it had been over 40 days since it had been changed, and the patient reports he had been telling them about it. This morning, he had a fever of 102.3, he also had shaking chills. He does not have much of an appetite and currently rates his abdominal pain at 3/10. He is having some discomfort to his left side. It continues, Assessment and Plan: Patient presented meeting sepsis criteria with a white blood cell count of 20500 with over 4+ leukocytes in urine and 50 white blood cells in his urine and 6-10 red blood cells. I ordered a lactate which is pending but he initially had a fever of 103 upon arrival as well as a heart rate of 110 and an increased respiratory rate at 22. This is a severe medical condition. R2's hospital after visit summary, dated 12/8/25, documented future appointment, follow up with (regional) urology on 4/29/26 with the same medical provider who ordered R2's indwelling urinary catheter to be changed every month. On 1/6/2026 at 3:45 PM R2 stated he's had an (indwelling urinary) catheter for years and prior to moving to the facility he used to have his catheter tubing and bag changed every month and he didn't get UTIs now the facility for whatever reason doesn't change his catheter bag or tubing and he stated he has a physician's order to change both tubing and bag every month. R2 stated he is very frustrated because he's been hospitalized twice within the last few months, and he received IV antibiotics, and the ER physician told him he is getting the really bad UTIs because the facility isn't changing the catheter monthly and the bugs are growing and that's why he's getting the UTIs that require IV antibiotics. R2 stated the UTI was uncomfortable and the second UTI he felt throbbing in his groin. R2 stated he wished the staff would follow physician's orders and change his foley catheter as they should monthly, because if not he is going to get another UTI and he doesn't want another one because it hurts and he hates having to go to the hospital. R2 stated he doesn't know why staff don't change his foley catheter monthly to prevent him from getting UTIs. R2 stated he felt this was neglect.On 1/22/26 at 9:55 AM V18 Case Manager at local hospital stated R2 was hospitalized in July of 2025, the Urology Department followed R2 and ordered his indwelling urinary catheter to be changed monthly. V18 stated R2 was hospitalized for a UTI in December 2025 and R2 stated the facility had not been changing his indwelling urinary catheter every month as ordered. V18 stated the physicians again ordered the catheter to be changed every month.On 1/22/26 at 10:25 AM V16 LPN (Licensed Practical Nurse) stated R2's indwelling urinary catheter is supposed to be changed every month because he was hospitalized in December 2025 with a UTI. On 1/22/26 at 12:10 PM V1 Administrator stated she assumes if an indwelling catheter change is not documented on the TAR then it wasn't completed but she would have to check with V2 DON (Director of Nursing).On 1/22/26 at 1:12 PM Surveyor requested the physician order for R2's indwelling urinary catheter to be changed PRN and not monthly as directed by R2's urologist on 7/8/25. V2 DON stated she must go through 600 pages of documents to find the order. Surveyor asked V2 if it is professional standard to follow the orders from R2's urologist. V2 stated the facility did not receive the order from R2's urologist dated 7/8/25 to change R2's indwelling urinary catheter every month and PRN indefinitely. Surveyor asked if it is standard practice for the facility nurses to call the doctor after a resident sees a specialist to clarify if there are any new orders. V2 replied the facility does not do indefinite physician orders and the urologist's orders are no longer in effect once a resident goes into the hospital.On 1/22/26 at 1:28 PM V2 DON stated she cannot find the order nor physician notification for R2's indwelling urinary catheter to be changed PRN instead of monthly. V2 stated R2's indwelling urinary catheter was not changed as ordered in October nor November of 2025.On 1/27/26 at 8:38 AM R2 stated the last time he was in the hospital the hospital nurse changed his indwelling urinary catheter, and the doctor informed him the catheter needs changed every month. R2 stated the facility does not clean around his catheter site every day and that he rarely gets it cleaned.On 1/27/26 at 10:07 AM V19 Wound Care Nurse stated R2's indwelling urinary catheter is ordered to be changed on night shift. V19 stated if it wasn't signed off then it wasn't documented so it wasn't done. V19 stated R2's urologist ordered R2's catheter to be changed monthly, when R2 was readmitted from the hospital the nurse should have restarted the orders so it should have been activated at that time. V19 stated the nurses restart the previous orders unless specified otherwise for consistency with the orders. The facility's Catheterization of Urinary Bladder policy, dated 6/2015, documented a catheter is placed in the bladder when it is needed to prevent urinary retention, when a resident needs to produce a sterile specimen, when a resident has a stage 3 or 4 pressure ulcer, for accurate intake and output or when the resident is at the end of life and moving them is uncomfortable. It continues, 21. The catheter is changed PRN when it is not draining. This policy does not address following physician orders for indwelling urinary catheter changes.

Based on observation and interview the facility failed to provide housekeeping services for 4 of 4 residents (R1, R2, R3, R4) reviewed for physical environment in the sample of 4. Findings include: On 1/6/2026 at 1:30 PM V11, Certified Nurse Assistant (CNA) stated no staff, including housekeepers clean the dining room floor between meals. On 1/6/2026 at 2:00 PM V6, Housekeeper stated the floor machine has been broken for over six weeks so they aren't cleaning the floors like they should. V6 stated she wasn't assigned to clean the dining room floor and hasn't ever cleaned it. On 1/6/2026 at 2:30 PM V7, Housekeeper stated she works five days a week and she tries to clean the dining room floor between meals, but she has a lot of resident's rooms to clean, and she can't clean the resident rooms and the dining room at the same time. V7 stated they have a floor technician, but he hasn't been able to use floor machine because it's been broken for over eight weeks. On 1/6/2026 at 2:40 PM V8, Dietary Aide and V9 Dietary Aide were observed cleaning off the dining room tables and stated they are responsible for cleaning the tables off, but they don't clean the floors, the housekeepers are supposed to do that. V8 and V9 stated no one is cleaning the dining room floor between meals because they don't have enough housekeepers to do it and the floor machine is broken. On 1/6/2026 at 1:50 PM V15, Housekeeper stated he works full time at the facility and doesn't know who cleans the dining room floor but he stated it wasn't on his assignment that day and he has never been assigned to clean the dining room floor. On 1/6/2026 at 4:00 PM V13, Housekeeper stated she cleans the dining room between meals but today she was running late getting to clean the dining room floor after lunch because she was cleaning other resident rooms. On 1/6/2026 at 3:05 PM V10, Housekeeping Supervisor stated the facility changed companies for housekeeping and multiple housekeepers quit and a few other housekeepers went on leave of absence and he was the only housekeeper for the month of December 2025 and although he worked over 40 hours a week he could only clean so much and the floor buffer machine has been broken for over eight weeks and he doesn't know when they are getting it fixed so they aren't able to clean the floors including the dining room floor properly. V10 stated he's not able to deep clean the floors because the floor machine isn't working. V10 stated he's hired several housekeepers since December 2025 but it's hard to keep staff that come to work.On 1/6/2026 at 2:45 PM the dining room floor had trash on it including milk cartons, napkins and straws. The floor also had multiple liquid spills and sticky residue.

Based on interview and record review the facility failed to prevent misappropriation of funds for two (R1 and R2) of three residents reviewed for misappropriation of funds in a sample of 3.Findings include:1.R1's admission record documents an admission date of 06/07/25 with diagnoses including: acidosis, hemorrhage of anus and rectum, paroxysmal atrial fibrillation, hypotension, cerebral infarction due to embolism of unspecified precerebral artery, altered mental status, major depressive disorder, diabetes mellitus with diabetic nephropathy, end stage renal disease, and transient cerebral ischemic attack. R1's Minimum Data Set, dated [DATE] documents a brief interview of mental status of 15 indicating cognitively intact. R1's care plan documents a focus area dated 07/11/25 of abuse: R1 is at risk for abuse and neglect related to currently being in a long term care facility with interventions listed as: alleged misappropriation of funds, will initiate additional financial monitoring dated 11/05/25 and assure the resident that staff members are available to help and department heads maintain an open door policy dated 07/11/25. R1's investigation contains transaction details for an ATM (automated teller machine) dated 07/08/25 for $800.00 dollars, on 07/21/25 for $800.00, on 07/28/25 for $800.00, on 08/05/25 for $800.00, on 08/14/25 for $800.00, on 08/18/25 for $800.00, and on 08/22/25 for $800.00. On 12/06/25 at 3:50 PM R1 stated, he noticed there was money missing from his account when he tried to order food and his card was declined. R1 stated, he logged into his account and seen all the ATM withdrawals for $800.00. R1 stated, he gave his debit card to V6 because she told him he owed $1000.00 on his account and needed to pay it. R1 stated he had no idea how he was going to get to an ATM and get the money for them. V6 stated she would take care of it for him. R1 stated, he contacted his bank and they told him to contact the police department. R1 stated, the police department was contacted and they are doing an investigation and he has not heard a resolution yet. R1 stated, he has asked staff what is going on with the investigation. R1 stated, he is just waiting for the investigation by the police to be completed. R1 stated, he did not necessarily want V6 fired, he would like the money back because he needs to pay for his stay at the facility. R1 stated, the facility did not state what happens, if they return the money or he has to see if V6 has to pay restitution.On 12/06/25 at 4:12 PM V2 (Director of Nursing) stated, R1 is missing money. The facility has terminated V6. The police department were notified and they have V6's picture using the ATMs at the time the transactions happened. This investigation was originally opened previously when they first knew about the incident and the police closed the investigation because they were under the impression they were speaking with V1 (Administrator) and it was V6, because V6 stated she was V1. V6 (previous Business Office Manager) was fired 11/05/25 when they figured out what happened with the police investigation and the confusion with it. The investigation has been reopened with a new officer and the investigation is still underway to her knowledge. V2 stated, R1 is the only resident she is aware of that V6 took any money from.The Employee Disciplinary Form documents employee name: with V6 (previous Business Office Manager) with a last day worked listed as 11/05/25 documents: describe what happened: (facility name) was made aware by several residents that they were missing money from their personal funds. An investigation revealed that V6 had misused resident's credit cards and also misappropriated cash payments for personal use. This is considered a violation of (facilities name) resident's rights, and abuse and neglect policy and therefore your employment is terminated effective immediately. R1's final report - alleged financial misappropriation dated 11/11/25 documents: investigation summary: upon notification, the facility initiated a thorough internal investigation following facility policy and IDPH (Illinois Department of Public Health) reporting requirements. The alleged staff members (V6-business office manager and V1-administrator) were suspended pending completion of the investigation. Resident and staff interviews were conducted, and a review of relevant documentation, bank statements, and financial logs was initiated. Although, the (local) Police Dept investigation remains ongoing. Based on information available to date, we were able to substantiate that V6 had misused the residents credit card and misappropriated cash payments for personal use. Additional documentation and verification from external financial institutions are pending to determine the outcome with the criminal charges from (local police department).V1 (Administrator) was unable to be reached during this survey. 2.R2's admission record documents an admission date of 03/27/24 with diagnoses including: aphasia following cerebral infarction, human immunodeficiency virus disease type 2 diabetes mellitus with hyperglycemia, severe protein calorie malnutrition, brain stem stroke syndrome, biliary cirrhosis, muscle weakness, schizoaffective disorder bipolar type, end stage renal disease, bipolar disorder, and sepsis. R2's MDS dated [DATE] documents a BIMS score of 13 indicating cognitively intact. On 12/06/25 at 4:28 PM R2 stated, he had his debit card taken from his room. R2 stated, they made $2000.00 worth of transactions. R2 stated, he reported the missing money after he checked his bank account and seen transactions that he was not aware of and there was money missing. R2 stated, his bank has put the money back into his account pending the police investigation. R2 stated, if the police find someone guilty, he thinks the bank prosecutes and the bank reimburses him. On 12/06/25 at 4:42 PM V2 stated, they have conducted an investigation into R2's missing money and it has been turned into the police. V2 stated, they interviewed residents and staff and watched the cameras. There are two staff members suspended pending the investigation. V2 stated, they have watched the cameras and believe they have it narrowed it down to two possible employees (V8 (CNA) or V9 (agency Housekeeping)). V2 stated, the two employees are still suspended.R2's check card statement had transactions marked with locations written in for the in question transactions. A letter from R2's bank dated 10/27/25 documents: we are writing to you about recent transactions you alerted us to on your account. While we review the transactions, we applied the following to your account on 10/27/25 a provisional credit for $1935.72. This letter documents a case ID (identification) number from the fraud division. R2's care plan documents a focus area of abuse: R2 is at risk for abuse and neglect relating to CVA (cerebrovascular accident), aphagia, cirrhosis, diabetes mellitus, and bipolar/schizophrenia dated 08/23/24 with an intervention listed as: alleged misappropriation of funds, will initiate additional financial monitoring dated 11/05/25. The facility policy dated 2022 titled, abuse policy and prevention program documents: this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment or residents.

Based on interview and record review the facility failed to provide appropriate services to 1 of 1 (R6) resident investigated for dementia care in a sample of 9. Findings include:R6's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R6's EMR dated 8/5/25 documents diagnose of unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.R6's MDS (Minimum Data Set) dated 11/11/25 documents a BIMS (Brief Interview for Mental Status) score of 3 out of 15. The MDS documents that the resident requires substantial/maximal assistance for roll left and right. The MDS documents that the resident is dependent for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R6's Nurses Notes dated 10/18/25 at 6:45 PM documents Resident was involved in abuse allegation. Head to toe assessment completed. Resident does not have any new open areas and is resting at this time. All V/S (vital signs) WNL (within normal limits). No s/s (signs/symptoms) of pain noted. MD (Medical Director), POA (Power of Attorney) and Administrator and DON (Director of Nursing) notified of allegation. Agency LPN (Licensed Practical Nurse) sent home, and investigation initiated.R6's Facility's Abuse Investigation dated 10/18/25 documents On 10/18/25 I received a call from (V28), C.N.A. (Certified Nurses Aid) and (V18), C.N.A. alleging verbal and physical inappropriate interaction by an agency LPN (V27). Physician and family notified. [NAME] Police notified. Risk completed including skin and body assessment. No injury identified. (R6) is a [AGE] year-old male resident who admitted to (facility) on 8/4/25. His diagnosis include hemiplegia and hemiparesis, L2 wedge compression fracture, moderate calorie malnutrition, aphasia, dysphagia, cerebral infarction, schizophrenia, malignant neoplasm of prostate, unspecified dementia, cognitive communication deficit. His BIMS score is 3. He is dependent for most ADL's (Activity of Daily Living). He ambulates with an unsteady gait and his primary mode of locomotion is by wheelchair. He is combative with staff and easily agitated. On 10/18/25 I received a call from (V28), and C.N.A. and (V18), C.N.A. alleging verbal and physical inappropriate interaction by an agency LPN (V27). Physician and family notified. [NAME] Police notified. Risk completed including skin and body assessment. No injury noted. (V18), (V20) reported that they witnessed Agency LPN (V27) being verbally inappropriate with resident (R6). (V20) approached (V27) and removed her from the situation while (V28) contacted management for assistance. The group kept (V27) out of resident area until the administrator called and had her sent home. (V27), LPN denied the allegation. A full investigation was completed and based on witness statements it was determined that the allegation supported inappropriate behavior. Alert residents were interviewed, and no other concerns were voiced. (V27) was suspended pending the investigation and had been blocked from being able to pick up shifts with the agency. The agency was contacted and informed of the allegation and outcome. (R6) does not appear to recall the incident.On 11/19/25 at 3:32 PM, V16, CNA stated that (R6) is her stepfather. She stated that she saw suspicious activity from the nurse on the camera that is in his room. She stated that one of the CNAs told her that this nurse was calling him a demon and that he beat women. She stated that CNA also told her that the nurse pointed her finger like gun and acted like she was shooting him. She stated that her stepfather is retired pastor.On 11/20/25 at 8:58 AM, V18, CNA stated that she saw and overheard the nurse talking inappropriately with (R6). She stated that (R6) was sitting in front of the nurse's station because he can become agitated and upset. She stated that the nurse was irritating (R6) on purpose for her own amusement and then laughing at him. She stated that does not remember the exact words, but the nurse said something about (R6) not being a pastor because he has the devil or a demon inside him.On 11/20/25 at 9:32 AM, V20, CNA stated that the incident between the nurse and (R6) lasted 15 to 30 minutes. She stated that she overheard the nurse tell (R6) that he was a woman beater. She overheard the nurse tell (R6) that he is not a pastor but a demon. She stated that the nurse was laughing at him. She stated that at one time the nurse and (R6) were having a finger gun shoot out. She stated that the nurse and (R6) were both shooting at each other. She stated that if the nurse would have left (R6) alone that he would have calmed down, but she kept messing with him. She stated that she told the nurse that one of the residents was having breathing issues. She stated that nurse did not go checked on the other resident and continue to mess with (R6). She stated that she had to go get the oxygen and got the SPO2 (oxygen saturation) reading and then found another nurse.

Based on interview, and record review, the facility failed to call emergency medical services, EMS, in a timely manner for 1 (R2) of 3 residents reviewed for delay in treatment in the sample of 10. This delay in treatment resulted in R2 experiencing a low oxygen level and later expiring at the the hospital from an unknown cause.Findings Include: R2's Face sheet documents an admission date of 7/30/2025. Diagnosis include Multiple Fractures of Ribs, Right Side, Wedge Compression Fracture of T11-T12 Vertebrae, Dysphagia, Severe Protein Calorie Malnutrition, Acute Thrombosis of Left Femoral Artery. R2's MDS dated [DATE] documents R2 is cognitively impaired.R2's care plan dated 7/31/2025 documents R2 is at risk for altered nutrition and hydration related to diagnosis of Pulmonary Embolism, Fracture of Thoracic Vertebra, Lumbar Fracture, Hyperlipidemia, Dementia.R2's progress notes dated 9/14/2025 at 3:12PM document Note Text: R2 sent to hospital due to possible aspiration and shortness of breath. Oxygen Saturation at 65%. R2 placed on Oxygen with rebreather mask until Emergency Medical Services, EMS, arrived. Blood Pressure cuff continued to read error, unable to obtain Blood Pressure. Emergency contact made aware of transfer.R2's progress notes dated 9/14/2025 at 5:30PM Telehealth Visit Chief Complaints: Emergency Department, ED, Transfer (R2 left building) Comments: R2 sent to ED at 3:12PM. Shortness of Breath, possible aspiration, Oxygen Saturation 65%, R2 placed on Oxygen. Lungs with audible crackles, unable to obtain vital signs. sent to hospital.No documentation of when change of condition began. No documentation of time EMS called. No SBAR, Situation, Background, Assessment, Recommendation, Assessment form completed. No documentation of notification of Physician during change of condition or before EMS being called.On 9/24/2025 at 12:10PM V2, Director of Nursing, DON, stated this happened on a Sunday. The nurse working said this was an acute change in condition. R2 had been fine all day and suddenly was having trouble breathing. R2 was immediately sent out. The nurse did not even call telehealth before calling Emergency Medical Services, EMS.On 9/24/2025 at 12:20PM V4, Certified Nursing Assistant, CNA, stated I was working the day (R2) was sent out to the hospital. When I came in the morning, I cleaned her up and fed her breakfast. (R2) ate all her breakfast and was not coughing or choking at all. She was on a pureed diet. I also fed her lunch. She took most of her lunch and drank all her drinks. I am not sure what time I checked on her next. I want to say 12:00PM-1:00PM. I noticed she was wheezing. I got (V5), Licensed Practical Nurse, LPN, and (V5) got (V3), Assistant Director of Nursing, ADON.On 9/30/2025 at 10:30AM V4, CNA, stated On 9/14/2025 I had started collecting the lunch trays after residents were finished with lunch. That is around the time I checked on (R2) and heard her breathing and rattling. It would've been 12:30PM to 1:00PM. When asked V4 if R2 was alert during the change in condition, V4 stated Her eyes were glazed over.On 9/24/2025 at 1:30PM V5, LPN, when asked about the change of condition on 9/14/2025 regarding R2, stated What about (R2)? (R2) had been fine all day. She ate fine. (V4), CNA, came and got me and told me (R2) was not the same. (R2) had shortness of breath and crackles that were audible. We got the oxygen tank, and I got (V3), ADON. We then called 911. It happened very fast, so I don't know the exact time everything happened. I was focusing on (R2). I don't know what time (V4) came and got me. I don't know what we called EMS or what time EMS got there.On 9/24/2025 at 1:50PM V3, ADON, stated V5, LPN, came to get me for a change in condition in R2. R2 had audible crackling. She was alert. We put her on 2 liters of Oxygen. We can't go past 4 liters. We called 911 from R2's room because her Oxygen would not stay up. She had been fine until then. We stayed with R2 the whole time. She was never left alone. V5 even called 911 from her personal cell phone. It all happened so fast that there was no change of condition to report to the Physician. EMS put a mask on R2 to help R2 breathe. I don't know the exact time everything took place or what time EMS were called.On 9/24/2025 at 3:00PM V6, Emergency Medical Technician, EMT, stated We were dispatched for a resident having a change in condition. Staff met us in the hallway. I didn't get the nurse's name, but the nurse said, The resident aspirated and now she isn't acting right. When we went in the room I saw the resident. She was unresponsive and very tachypneic in the 130s. She had vomited and it had pooled on her neck and gown. I had to wipe it away. The nurse told me all this started at 1:15PM and then everyone left the room. We put R2 on a high flow oxygen mask and loaded her in the ambulance. She was never responsive, and her lungs were full. I was in the room in the Emergency Department when she passed away.On 9/25/2025 at 11:50AM V2, DON, and V3, ADON, stated This is the time EMS was called for R2 on 9/14/2025. EMS was called at 1:51PM on 9/14/2025. These times are from V4's cell phone.On 9/30/2025 at 12:02PM V6, EMT, stated EMS was called from facility at 1:53PM and arrived at facility at 2:06PM.On 9/30/2025 at 12:30PM V12, Nurse Practitioner, stated I am Monday through Friday and the change of condition for (R2) occurred on a Sunday. I still would've expected one of the on-call Providers to be notified of a transfer to the hospital. I see there is no note saying telehealth was called until after the R2 was transferred. They should've called the on-call provider. When V12 was asked if he would've expected to be notified of R12's change in condition and for 1 hour to have gone by between R2's change of condition and EMS being called V12 stated They should've called the on call provider.Facility policy dated 9/2024 states It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. Nursing will notify the resident's physician or nurse practitioner when: There is a significant change in the resident's physical, mental or emotional status.

Based on interview and record review the Facility failed to ensure physical abuse did not occur for 2 of 3 residents (R1) and R3) reviewed for abuse in the sample of 7. 1-R1's Physician Order Sheet for August 2025 documents a diagnosis of nontraumatic subarachnoid hemorrhage, moderate protein calorie malnutrition, mucopurulent chronic bronchitis, weakness, major depression disorder, acute diastolic heart failure, pleurisy, anxiety disorder and spinal stenosis of the cervical region. R1's Minimum Data Set (MDS) dated [DATE] document R1 was cognitively intact for decision making of activities of daily living. No impairments on the upper or lower extremities and independent on most tasks and does not need assistance with some tasks. R1's Initial Incident Report dated 8/21/2025 at approximately 1:35 PM, there was an altercation between (R1) and (R3). There was no injury to either resident. The two were immediately separated. The Administrator was notified. A full investigation and a final report sent when complete. R1's Care Plan document under Abuse with the date initiated of 12/10/2024 documents, (R1) had verbal/physical altercation with another resident (no injuries) on 7/9/2025. The Care Plan does not address the resident-to-resident altercation on 8/21/2025. R1's Progress Notes do not address the resident-to-resident altercation on 8/21/2025. A Statement from V8, Certified Nursing Assistant (CNA) dated 8/21/2025 documents, I (V8) was bringing (R3) from the dining room pushing her to the room. Once there another resident was in her room. She asked (R1) to not move her curtain, then (R1) said 'wait Bitc*' to (R3) then (R3) rode down on (R1) and punched her in the back, then (R1) turned around and punched (R3) in the face, then I pulled (R3) back then everything was over. On 9/19/2025 at 2:11 PM, a phone message was left for V8, but she never returned the call during this survey. A statement from V7, Infection Control Preventionist (ICP) dated 8/21/2025 documents, Around 1:15 PM, I heard a CNA screaming while standing at the back nursing station. I turned around and saw CNA (V8) holding (R3) hand and resident punched (R3) in her face. Placed myself in between both residents. Calmly asked Resident (R1) to remove herself from the room. (R1) grabbed her walker and walked out. Called (R3) a bitc*. On 9/19/2025 at 11;21 AM, V7, Infection Control Preventionist stated, I had just got to the nurse's station, and I heard a staff yelling and I turned around and saw (V8, CNA) with (R3) and saw (R1) punch (R3) in the face. I put myself between the residents and tried to calm them down. I am not aware of either one of them being aggressive. All I know is that (R1) was going into (R3's) room because she is friends with (R3's) roommate. On 9/19/2025 at 11:39 AM, R1 stated, I was friends with (R7) and she shared a room with (R3). I liked to spend time with (R7) we are friends. (R3) was upset because she would pull the curtain, and she was upset with me because I was in her room, and she called me a name and hit me in the back, so I hit her back in the face. 2-R3's August POS 2025 documents a diagnosis of type 2 diabetes morbid obesity, chronic respiratory failure, major depression disorder, anemia, hyperparathyroidism and chronic kidney disease. R3's MDS dated [DATE] document R3 was cognitively intact for decision making of activities of daily living. R3 has impairment on both her upper and lower extremities, she uses a walker and wheelchair; She requires minimal assist to supervision for most ADL's (activities of daily living). R3's Care Plan: Abuse with a revision date of 8/28/2024 document, (R3) is at risk for abuse and neglect r/t (related to) DM (diabetes mellitus), neuropathy, morbid obesity, CKD3, cardiomegaly/HTN. R3's altercation on 8/21/2025 was not addressed on her care plan. On 9/19/2025 at 11:40 AM, R3 stated, I used to be in another room. I liked to have the curtain pulled all the way. At that time (R7) was my roommate and she was friends with (R1). (R1) liked to push (R7) in her wheelchair and every time she would come into the room she would move the curtain. I told her to stop moving the curtain and she would not listen and the next time she came in the room and moved the curtain I got mad and smacked her one because she would not listen. R3's Final Report document (R3) is a [AGE] year-old female resident. She admitted (Facility) on 8/26/2024. She is alert and oriented x 4. Her BIMS (brief interview for mental status) score is 15 (15/15). She is able to ambulate short distances with a walker, but primary mode of locomotion is a wheelchair. She requires minimal assist to supervision for most ADL's (activities of daily living). Her diagnosis includes type 2 diabetes morbid obesity, chronic respiratory failure, major depression disorder, anemia, hyperparathyroidism and chronic kidney disease. On 8/21/225 at approximately 1:35 PM residents were involved in a verbal disagreement which resulted in one resident making physical contact with the other residents. Staff intervened immediately, both residents were interviewed and assessed by staff. Neither resident had any injures and both stated they feel safe in the facility. (V8) reported that she was taking (R3) back to her room and there was another resident (R1) in the room. (R3) told (R1) not to move her curtain. (V7) stated that she heard a CNA hollering and she turned and saw (V8) holding back resident (R3). (V7) placed herself between the two residents and calmly asked (R1) to remove herself in the room. (R1) grabbed her walker and left the room. The Facility Abuse Policy 2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 Interpretive Guidelines). 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. (42 CFR 483.5).

Based on observation, interview, and record review, the facility failed to turn and reposition 1 (R14) of 8 residents investigated for pressure ulcers in the sample of 38. This failure resulted in R14 having re-opened pressure ulcers and new in house acquired pressure ulcers. Findings include: R14's Facesheet documents an admission date of 6/23/2024. Diagnosis include Syringomyelia and Syringobulbia, Ulcerative Colitis, Chronic Embolism, Crohn's Disease, Dorsalgia. R14's Minimum Data Set, MDS, dated [DATE] documents R14 has no cognitive deficits. R14 is dependent for mobility and transfers. R14's care plan with a revision date of 2/10/2025 documents R14 SKIN: R14 has developed a stage III pressure wound to his right back. Interventions include Assist and encourage resident to turn and reposition every one to two hours and PRN. Ensure proper body alignment. R14's admission Nursing assessment dated [DATE] documents R14's skin intact. No wounds documented. R14's progress notes dated 11/7/2024 at 1:08PM documents V19 (Wound Care Nurse Practitioner) present to assess right buttock with area having a stage II pressure wound with new order of cleanse right buttock with wound cleanser then apply collagen hydrogel mixed with collagen particles to wound bed and cover with calcium alginate then cover with dry dressing daily. R14's progress notes dated 2/10/2025 at 11:53AM Writer summoned to R14's room by CNA. Upon assessment, observed that R14 has developed an unstageable wound to his right back and an abrasion to his right buttock. Call placed to V19 with new orders of cleanse areas with wound cleanser then apply medi-honey to wound bed cover with calcium alginate and silicone bordered super absorbent dressing daily. R14 notified. R14's progress notes dated 4/2/2025 at 8:10AM documents V14 (Registered Nurse) was present to assess wound with no new orders yet did observe a re-opened stage III pressure wound to right buttock with new order of cleanse right buttock wound with wound cleanser then apply collagen hydrogel mixed with collagen particles then apply to wound bed cover with silicone boarded super absorbent dressing daily. R14 notified. R14's progress notes dated 5/6/2025 at 2:52PM documents V19 present to assess wound with new order of SSD cream to treatment. R14 notified. R14's Skin and Wound Evaluation dated 11/29/2024 documents pressure wound to right gluteal, unstageable, in house acquired. Exact date of discovery 11/7/2024. Slow to heal. R14's Skin and Wound Evaluation dated 3/6/2025 documents new stage 3 pressure ulcer to right gluteal. In house acquired. Exact date of discovery 2/10/2025. R14's Skin and Wound Evaluation dated 4/17/2025 documents new stage 3 pressure ulcer to right gluteal. In house acquired. Exact date of discovery 4/1/2025. R14's Skin and Wound Evaluation dated 5/13/2025 documents stage 3 pressure ulcer right lower back. In house acquired. Exact date of discovery 2/10/2025. On 5/14/2025 at 11:00AM R14 stated I am never turned or pulled up. I have been like this all morning. My care is poor. I haven't been up in a chair in months. I am afraid to get up because I am afraid, they will not put me back to bed and I will be stuck there in pain. My sore on my back was bleeding a lot last night. On 5/14/2025 at 1:55PM V9, Wound Nurse, provided wound care to R14 with assist of V21, Licensed Practical Nurse, LPN. R14's wound draining dark brown fluid and bright red fluid on bandage and on gauze used to clean wound. R14 in same position he was in at 11:00AM and was incontinent at this time. V9 stated R14 refuses a pressure reducing mattress. He can turn himself a little. His wound is healing slowly. The staff try to get him to turn. Facility policy with a revision date of 9/2023 states To prevent or reduce the incident of pressure injuries, standards of practice should be implemented. A pressure injury may be defined as any lesions cause by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injuries friction and shear are important contributing factors to the development of pressure injuries.

Based on observation, interview, and record review the facility failed to follow and implement progressive interventions and perform appropriate supervision to prevent falls for 1 (R24) of 6 residents in the sample of 38. This failure resulted R24 falling and R24 sustaining a fracture. Findings include: R24's Face sheet documents an admission date of 2/7/2024. Diagnosis include Metabolic Encephalopathy, Adult Hypertrophic Pyloric Stenosis, Hypertension, Radiculopathy. R24's Minimum Data Set, MDS, dated [DATE] documents R24 is severely cognitively impaired. R24 requires partial to moderate assist with mobility and transfers. R24's mode of transportation is walker and/or wheelchair. R24's care plan updated 3/28/2025 documents Fall: R24 is at risk for falls Cognitive deficits, Functional Deficits, History of Falls, Poor Balance. Interventions include: 1/10/25 prompt or assist for change in position, toileting, offer fluids, and ensure R24 is warm and dry. Encourage staff to anticipate needs. 6/28/24 Educate R24 to use the call light and wait for staff assist to walk to the bathroom. Fall risk assessment quarterly and as needed. R24's admission fall risk assessments dated 6/28/2024 documents R24 is at high risk for falls. R24's progress notes dated 6/28/2024 at 8:02PM document R24 was found in R24's bathroom on the floor at 7:11pm. This nurse and night nurse with CNA helped R24 up from floor to toilet. R24 had bowel movement. R24 stated I need to go to the bathroom this nurse asked what is hurting, R24 pointed to left side of head. R24 noted with red water left eye. this nurse contacted V28 (Physician) over telehealth, V28 recommended this nurse to ask family if they want R24 to be monitored. Contacted V27 (Family). V27 requested for bed alarms and for R24 to be closer to nurse's station. This nurse voiced concerns to V2 (Director of Nursing). Neuros started. R24's fall investigation dated 6/28/2024 at 7:38PM stated Interdisciplinary meeting to discuss fall from 6/28/2024. R24 alert and oriented x2-3. Brief Interview for Mental Status, BIMS, 00. R24 requires 1-2-person physical assist with ADLs and transfers. R24 is incontinent of bowel and bladder at times. RCA, root cause analysis: Attempted to self transfer to toilet and fell onto floor. All previous fall interventions in place adding reeducating R24 to call and await assistance. All parties agree with plan of care. Care Plan reviewed and updated. R24's progress notes dated 1/10/2025 at 6:22AM documents CNA came to this nurse stating that R24 was on the floor when she walked into R24's room to give R24 care and get R24 up for the day. This nurse assessed R24 and noted no open areas or any bleeding and R24 stated she was not in any pain. This nurse and CNA carefully got R24 up on the bed and after talking to R24 she stated she would like to get dressed and get into her chair. This nurse told CNA that R24 was able to get dressed and get into her chair. R24's family (V27), V1 (Administrator), V2, V3 (Assistant Director of Nursing), and V28 were notified. R24's progress notes dated 1/11/2025 at 9:48AM documents Continue monitoring related to fall. R24 x-ray of left hip came back new fracture of left inferior pubis ramus. Contacted V28. New order for outpatient ortho appointment related to fracture. Notified V27, V1, V2, V3. R24's 1/10/25's fall investigation dated 1/11/2025 at 6:22AM documents Root Cause Analysis, R24 got up to use the bathroom and R24 thought she should get up and get ready also. New inventions: Frequent rounding and prompt or assist R24 in position change, toileting, offer fluids and ensure R24 is warm or dry. Obtain labs to rule out acute change in condition. Neurology consults to monitor disease progression. Care plan updated as appropriate. R24's radiology report dated 1/10/2025 documents Fracture of the left inferior pubic ramus. On 5/14/2025 at 10:00AM R24 sitting at nurse's station. R24's room at end of the hall away from nurse's station. On 5/14/2025 at 2:00PM V20, Certified Nursing Assistant, CNA, assisted R24 from wheelchair to bed. R24 was not toileted prior to going to bed. R24 stated I wasn't working in January when R24 fell and hurt herself. She can stand but that's it. We try to have her at the nurse's desk during the day. She is in her room right now because she is ready for a nap. Facility policy with a revision date of 7/2024 states This facility is committed to maximizing each resident's physical, mental, and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All residents' falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, and distributed in a manner that prevents foodborne illness. This has the potential to affect all 108 residents living in the Facility. Findings include: On 5/13/25 at 8:10 AM, in the kitchen next to the oven there was a large tub containing light brown colored grains. The tub was not labeled or dated, and the scoop was lying directly on top of the grains inside. There was another large tub containing a white powdery substance that was not labeled or dated. V4, Dietary Manager (DM), stated that was sugar, and the brown grains were oats. She picked up the scoop from the oats and stated the handles always fall out into the grains. She stated she just washed both of the containers and refilled them but has not had a chance to label them. On 5/13/5 at 8:14 AM, in the walk in refrigerator there was a carton of milk and a carton of applesauce lying directly on the floor. There were two boxes of pasteurized shell eggs stored on a shelf directly above two boxes of (Nutritional Shakes). The (Nutritional Shakes) boxes read, Keep Frozen. On 5/15/25 at 8:18 AM, there was a rack next to the walk in freezer holding saucers stored upside down in stacks. Six of the stacks had crumbs and debris on the top plates. On 5/15/25 at 8:20 AM, the dish room floor was covered in food debris. On 5/15/25 at 8:22 AM, V10, Dietary Aid, stated the eggs should not be stored above the shakes, but some people do not know that. On 5/13/25 at 8:50 AM, V4, Dietary Manager, stated she put the eggs back on the bottom shelf where they were supposed to be and cleaned up the food on the floor of the walk in refrigerator. On 5/13/25 at 9:30 AM, the dish machine labeled ES 4000 was running. V4 stated it is a low temperature dish machine. After the cycle was complete, V4 dipped a test strip in the reservoir and pulled it out. The test strip did not change color at all. V4 checked the sanitizer bucket which was empty and stated that is why the test strip did not change colors. On 5/15/25 at 8:45 AM, V25, Registered Dietitian (RD), stated the purpose of storing animal products below other food items it to prevent them from dripping into other items and prevent foodborne illness. On 5/15/25 at 12:58 PM, V1, Administrator, stated she expects staff to adhere to the Facility's food service policies. The Facility's Undated Food Storage Policy documents food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. All containers must be legible and accurately labeled and dated. Scoops must be provided for bulk foods and are not to be stored in food containers but are kept covered in a protected area near the containers. For refrigerated foods, cooked foods must be stored above raw foods to prevent contamination. Raw animal foods will be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. All foods will be stored off the floor. Frozen foods must be maintained at a temperature to keep the food frozen solid. The Facility's Undated Warewashing Policy documents all dishware, serviceware, and utensils will be cleaned and sanitized after each use. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 5/14/25 documents there are 108 residents living in the Facility.

Based on interview, observation, and record review, the facility failed to prevent abuse in 1 of 3 residents (R31), reviewed for abuse in the sample of 38. Findings include: On 5/13/25 at 11:07 AM, R31 was observed in his room, alert to self only, pleasant and was unable to recall any details of the incident between him and R22. R31 and R22 are in rooms across the hall from one another. R31's Face Sheet, undated, documents R31 has the following diagnoses: Encephalopathy, Altered Mental Status, Slurred Speech, and a Cognitive Communication Deficit. R31's MDS (Minimum Data Set), dated 3/18/25, documents R31 has a BIMS (Brief Interview for Mental Status) score of 6, indicating R31 has severe cognitive impairment. R31's Care Plan, dated 12/23/24, documents R31 is at risk for abuse and neglect related to Encephalopathy and Cognitive Decline. R31 is at risk for complications due to occasional incontinence. He at times forgets where the bathroom is and wanders from room to room looking. R31's Progress Note, dated 5/8/2025 at 11:14 PM, documents the following: This nurse was informed by another res. (resident) that res. was pushed on the floor by another male resident. Upon arrival, res. noted to be trying to get himself off of the floor. ROM (Range of Motion) performed and WNL (Within Normal Limits), vital signs obtained and WNL, no bleeding, hematoma, or bruising noted at this time, res. assisted off the floor using a gait belt via two CNA's (Certified Nursing Assistant). All parties notified, Telehealth Doctor gave orders to monitor for pain and have in house NP (Nurse Practitioner) assess tomorrow morning. On 5/14/25 at 11:48 AM R22 was observed in room in bed with the door closed. R22 stated he didn't have any residents come into his room and he didn't push anyone down, he doesn't do that. R22 and R31 are in rooms right across the hall from one another. R22's Face Sheet, undated, documents R22 has the following diagnoses: Alzheimer's Disease, Traumatic Brain Injury due to Cerebral Infarction, Adjustment Disorder, and Intellectual Disabilities. R22's MDS, dated [DATE], documents R22 has a BIMS score of 15, which indicates R22 is cognitively intact. R22's Care Plan, dated 5/12/17, documents R22 is at risk for abuse, has a diagnosis of Alzheimer's Disease and may display moods/behaviors such as agitation, aggression, and refusal of care. On 5/8/25, R22 had a physical altercation with another resident. See Nurse's Notes, no injuries. R22's Progress Note, dated 3/17/25 at 6:05 PM, documents the following: Resident has been agitated with behaviors entire shift. Approaching staff members and other residents and cussing at them. Unable to redirect. Resident comes in and out of room constantly wandering halls. R22's Progress Note, dated 5/8/25 at 11:57 PM, documents the following: Nurse was informed that resident pushed another resident down, writer asked resident what was going on, resident stated that other resident entered his room looking for the bathroom. Resident's next of kin was called, no answer, VM (Voice Mail) left, all parties notified. R22's Behavior Tracking was reviewed with the following noted: 4/17/25 & 5/9/25, R22 displayed verbal aggression towards others. R22 and R31's Abuse Investigation Final Report, dated 5/14/25, documents the following: R95 alleged that she saw resident R31 enter R22's room and R22 pushed R31 down. R31 was assessed for injuries with none noted. On 5/8/25 at approximately 10:00 PM, R95 verbally stated that she was leaving the 300 hall shower room, she stopped outside the door of the shower room to take a break because she was getting winded. At that time, she saw the bigger man (R22) pushing the other taller guy (R31) out of his room and the other taller guy (R31) fell. She (R95) yelled for staff, they came running and looked at him (R31) and got him up. V26, LPN (Licensed Practical Nurse), documented and gave a verbal statement that R95 informed her that a resident was pushed by another resident onto the floor. Upon arrival she (V26) noted R31 on the floor in room [ROOM NUMBER] (R22's room). Upon assessment, range of motion was within normal limits, no bleeding, no hematomas or bruising was noted to R31. He (R31) was assisted off of the floor using a gait belt and two aides. The Administrator, DON, residents' responsible parties and Telehealth were notified. When R31 was asked what he was doing, he stated he was looking for the bathroom. When R22 was asked why he pushed R31, he stated The Lord made me do it. The local police were contacted, responded to the facility and took a report. The care plans were updated, and interventions were put into place in an attempt to prevent reoccurrence, including a toileting schedule for R31. There have been no further incidents and neither resident seems to recall the event. On 5/15/25 at 8:15 AM, V24, CNA, stated R31 wanders into other resident rooms and will get into their beds. V24 stated R22, is pretty much with it, stays to himself, sometimes he thinks he works here so he will clean, bark out orders, and says stuff under his breath, like f*** you. On 5/15/25 at 9:14 AM, R95 stated, last week, she was coming out of the shower room on the 300 hallways, was talking to her CNA, and observed the big guy (R22) push R31 and R31 hit the wall and then fell to the ground. R95 stated neither resident had said anything to one another prior to the incident or after the incident. R95 stated she was the only one that saw R22 push R31, her CNA did not witness the incident and she (R95) stated to staff are you going to get him, or do I need to? R95 stated R22 is big, and she thinks he is a bully. The Abuse Policy and Prevention Program, dated 10/2022, documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on interview and record review the facility failed to administer a seizure medication for 1 of 8 residents (R7) reviewed for significant medication errors in the sample of 9. This failure resulted in R7 having multiple seizures, requiring hospitalization . Findings include: On 1/28/25 at 1:20 PM, R7 stated she didn't get her seizure medication for two days, had four seizures and was admitted to the hospital. R7 stated this happens often but she has and is getting her medication now. R7's Face Sheet, undated, documents R1 has a diagnosis of Epilepsy. R7's MDS (Minimum Data Set), dated 12/2/24, documents R1 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R1 is cognitively intact. R7's Care Plan, dated 9/23/19, documents R7 requires healthcare monitoring related to a diagnosis of a seizure disorder. She is at risk for injury due to uncontrolled seizure activity. She is at risk for aspiration of respiratory secretions or vomiting during seizure and suffocation. She receives antispasmodic medication per physician orders. Intervention is to administer medications as ordered. R7's POS (Physicians Order Sheet) documents the following orders: 6/8/23 - Vimpat Oral Tablet 50 MG (Milligrams), Give 1 tablet by mouth two times a day for Epilepsy, Give with 200 mg to equal 250 mg two times a day. 7/19/22 - Vimpat Tablet 200 MG, Give 1 tablet by mouth two times a day related to Epilepsy. R7's Progress Notes, document the following: -11/18/2024 at 11:26 AM - This writer made aware that res stated she just had small seizure in room while sitting in wheelchair. Stated it only lasted a few seconds, no falls or injuries. Vitals 105/58, 69, 97.6, 98%. NP (Nurse Practitioner), admin (Administrator), and DON made aware. Resident also stated that she had a fall last night, assessed that left middle finger is swollen. Pain level 6 PRN (as needed) Norco given. Will continue to monitor. -1/1/2025 at 3:45 PM - Patient was noted to have seizure activity for 30 seconds, in her wheelchair, patient came out of the seizure. Patient v/s (vital signs) was taken 122/80, 81, 98.2, 18, 98%. Patient took all her meds after the episode, resident family, DON made aware, MD was made aware of the incident. Res Keppra (seizure medication) level reordered for tomorrow. Resident in a pleasant mood and cooperative to cares. -1/20/2025 10:45 PM - Medication Administration Note - Vimpat Oral Tablet 50 MG, Give 1 tablet by mouth two times a day for Epilepsy Give with 200 mg to equal 250 mg two times a day, Need a script. -1/20/2025 at 6:16 PM - Resident noted to have a seizure lasting approximately 1 minute NP made aware new order for labs resident and family aware. -1/21/2025 7:36 PM - This resident had a 2 minute witnessed seizure, resident was seizing in her chair and was sliding downward this nurse caught her in time and let her seizure take its course before assisting her correctly in her seat. This resident was a bit lethargic and confused once coming out of seizure after a few minutes this nurse asked her name, birthday, and place and she answered correctly. BP 142/69, P 63, R 18, T 97.9. This res was out of Vimpat, there wasn't any in the Cubic to pull from. Script was sent over around noon and when this nurse called for an update the pharmacy stated they never received it. This nurse resent the script and they stated it would be sent out tonight and that they are unable to send it to our backup pharmacy because they would want a separate script. (On-call MD) notified, POA (Power of Attorney) called n/a (not available) at this time, & DON notified. The doctor on call was also made aware that pharmacy was called and stated that meds will be sent out tonight she stated to monitor this resident until her medications arrive. Resident is now in her bed watching TV (television) at this time. Call light is in place. -1/21/2025 8:20 PM - This nurse called and spoke with (on call MD) about sending a stat script for this resident's Vimpat, she stated it has been sent over to our backup pharmacy and it should cover tonight's and tomorrow morning med pass. DON and Admin notified. -1/21/2025 at 10:46 PM - Medication Administration Note, Vimpat Tablet 200 MG, Give 1 tablet by mouth two times a day related to Epilepsy, Medication not available. -1/22/2025 6:03 PM - This resident had a seizure that lasted 59 seconds while lying down in her bed. Resident stating, she didn't feel well and said she felt like she was going to seize, this nurse stated to her that it is best she lie down instead of sitting in chair, so she does not fall, and she agreed, moments later resident started seizing and this nurse was a witness and turned her to her side and counted it to 59 seconds. Res VS are: b/p 120/64, P 63, T 97.3, O2 97, R 20, PAIN 0. Pupils are equal and reactive, POA has been notified and stated to this nurse Thanks and that she appreciates the call. DON & ADMIN notified, & (on call MD) notified to just keep an eye out on res throughout the night. There are NNO (No new orders) at this time. -1/22/2025 9:10 PM - This resident started having seizures back to back, M.D. stated to send this resident out. Resident has been sent to the hospital for observation. POA, Admin and DON notified. -1/23/2025 6:29 AM - Resident admitted to the hospital, room [ROOM NUMBER] with a Dx (diagnosis) of Seizures. -1/24/2025 at 2:35 PM - Resident arrived back at facility in wheelchair, assisted by 2 (facility) employees with NNO. R7's Medication Administration Record (MAR), dated 1/20/25, documents R7's Vimpat was not given as ordered on 1/19/25, 1/20/25, and 1/21/25. R7's Hospital Records, dated 1/22/25, R7 was admitted to the hospital with a diagnosis of Seizures. On 1/28/25 at 11:05 AM, V11, Family Nurse Practitioner, stated R7 not being given the Vimpat on 1/19/25, 1/20/25, 1/21/25, and 1/22/25, did contribute to R7 having seizures and subsequently being admitted to the hospital. V11 stated that medications are a big issue at this facility, there is no initiative from the nurses to make sure residents have prescriptions for their medications. V11 stated it is left on the DON (Director of Nurses) and ADON (Assistant Director of Nurses) to ensure this is happening. V11 stated he will check with the DON/ADON to see if any prescriptions are needed, if so, he will take care of it, give it to the DON/ADON to send to the pharmacy. V11 stated it's also a pharmacy issue because once they have sent a copy of the prescription to them and have confirmation that it was received, the facility still has to call them to get confirmation that they received it and find out when the medication is going to be arriving at the facility. V11 stated a lot of times, pharmacy will say that they didn't receive the prescription even though the facility has fax confirmation that it was sent. On 1/28/25 at 1:23 PM, V16, LPN (Licensed Practical Nurse), stated she sent R7 to the hospital for seizures. V16 stated R7 went for a couple of days without her Vimpat (seizure medication), and she can't go without it for one day and she has seizures. V16 stated normally they could get the medication from the emergency kit, but the Vimpat was not available. V16 stated pharmacy wouldn't send it and told the facility that they didn't receive the prescription for it, so they sent it again and finally received it. On 1/29/25 at 6:45 AM, V1, Administrator, stated they were unable to get R7's Vimpat due to the insurance not paying for the medication until 1/24/25, so when the DON was notified, unsure of the date, that R7 was out of the medication and pharmacy would not send it until 1/24/25, the medication order was sent to the local pharmacy and the facility paid for it and picked it up on 1/22/25. The Medication Administration Policy, dated 6/2015, documents if a medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. If a medication is ordered but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain from the contingency or convenience box. If the Physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the situation in the resident's medical record.

Based on interviews and record reviews the Facility failed to assess, monitor, and perform vital signs for 1 of 3 residents (R2) reviewed for change of condition in the sample of 6. This failure resulted in R2's low oxygen saturation level, hospitalization , and being put on a ventilator, unable to return to the facility. Findings include: On 10/4/2024 at 1:22 PM, V1, Administrator stated, (R2) was recently sent to the hospital for a change of condition, and when she got to the hospital, she tested positive for COVID, and they admitted her for COVID and pneumonia. (R2) had to go on a ventilator. We do not take any residents with ventilators (vents) so she was going to be sent to another facility that takes vents and will not be returning to us. R2's Physician Order Sheet (POS) for October 2024 documents a diagnosis of amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, hypertension, depression, chronic pain, and encounter for screening for COVID-19. R2's Minimum Data Set (MDS) dated [DATE] documents R2 was cognitively intact for decision making of activities of daily living. She has impairments on both sides of her upper and lower extremities, uses a wheelchair and was dependent on most activities of daily living. R2's Care Plan: Respiratory: (R2) has potential for difficulty in breathing related COPD acute respiratory, date initiated 11/15/2023. Interventions: Assess respiratory status rate, depth, pattern, skin color. Monitor O2 (oxygen) Sats (saturation). Monitor every shift for shallow respiration, diaphoresis, dyspnea, monitor vital signs and lung sounds, observe for change in breathing pattern. All of the interventions listed were documented with the date initiated of 11/15/2023. R2's Progress Notes dated 9/25/2024 at 11:35 AM, document Patient states she is not feeling good today and is very worried for her health situation. She reports her health concerns of being short of breath and unable to cough. Therapist notified nursing staff of patient concerns and nursing staff assessed patient. R2' s Progress Notes dated 9/25/2024 at 6:56 PM, Resident sent to (ED) (emergency department) via EMS (Emergency Medical Services) with c/o (complaint of) SOB (shortness of breath). O2 sats 79% during MD (Medical Doctor) consultation. MD instructed this nurse to raise O2 concentration to 5 L (liters), O2 sats improved to 91% but LOC remained unaffected. MD (Medical Doctor) instructed this nurse to send resident out due to change of condition. MD stated she would call report into (Hospital). On 10/8/2024 at 9:44 PM, V13, Physical Therapist stated he was familiar with (R2), and he remembered she was a total assist, and her ALS (Amyotrophic Lateral Sclerosis) was progressing. The last time she had any therapy was on 8/30/2024 and she received speech therapy. (R2) did not have any therapy treatment, speech, or physical therapy on 9/25/2024. I am not sure what you are referring to. I have checked our records, and (R2) did not see any therapist on 9/25/2024. On 10/8/2024 at 10:07 AM, V6, Licensed Practical Nurse (LPN), stated, I am fairly new in the facility. I am the Wound Nurse. Earlier in the day some staff told me (R2) was having some discomfort and I took (R2's) O2 (oxygen) sats and she was at 96%. I called the Telehealth doctor and sent her out later in the day. I recorded her vital signs in the progress notes and on the (electronic medical charting) under vitals. When I first checked on (R2) she was not in respiratory distress. I remember at that time COVID was in the building and I know I did not test her for COVID but did send her out. I did not write the entry for (R2) on 9/25/2024 at 11:35 AM. Someone did come and get me; I believe it was someone from therapy and let me know she was having breathing issues. On 10/8/2024 at 10:34 AM, V1, Administrator stated, The only way anyone could write a note for a nurse's note is if they have a password. Once they make a note, they have to enter their password again in order for the note to go through. More than likely, (V6) just forgot she had written the note. I find it hard to believe anyone else has her code. She is fairly new and learning so much stuff. R2's Electronic vital signs do not document any vital signs were being performed on R2. Oxygen, temperature, and pulse were not documented on her chart, everything was blank after 9/19/2024. No vital signs were documented for 9/25/2024 except for the oxygen levels on 9/25/2024 at 6:56 PM, no other O2 levels were documented when R2 stated she was having shortness of breath on 9/25/2024 at 11:35 AM. On 10/8/2024 at 1:57 PM, V18, Certified Nursing Assistant (CNA) stated, I remember (R2), her breathing was very rapid, and you could tell she was off. I immediately went and got the nurse, this was right before lunch, and let her know she was having issues with her breathing and said she did not feel good. If I charted anything, like her vitals it would be in PCC. I can't remember if I charted anything, but I did go and get (V6) and let her know what was going on. Then later that night (R2) was sent out to the hospital. The nurse was (V6, LPN). We can chart and/or the nurse can chart vitals. If we chart anything it will be in the (electronic charting system) On 10/8/2024 at 1:50 PM, V2, Corporate Nurse/Director of Nursing stated, I would expect all change of conditions to be charted in the charts and all vitals to either be in the Progress Notes and or (electronic charting system). On 10/8/2024 at 2:03 PM, V19, CNA stated, I remember the day (R2) went out to the hospital because she was not looking good. She could talk and she said she was having issues breathing. This was right before lunch. I remember telling the nurse and then later she was sent out to the hospital. The nurse was (V6), I believe. R2's Progress Notes dated 9/26/2024 4:18 AM, documents, Note Text: Resident was sent to (Hospital) for low 02 sats. I called (hospital) and they stated that (R2) is intubated at this time. On 10/9/2024 at 2:00 PM, V22, Nurse Practitioner stated, If a resident has a history of ALS and they tell staff they are not feeling well, and they were having issues with breathing I would expect to be notified. If a resident was complaining of SOB, then I would expect to be notified. I would expect the O2 stats to be monitored at least every shift but without knowing the vitals it makes it difficult because if (R2's) vitals were not within normal limits then I would expect to be contacted immediately and sent out. I would expect all vitals to be charted and documented in the patient's chart. If (R2's) oxygen situations were below 90 and I felt she was in distress I would have sent out her sooner to the hospital. R2's Hospital Notes dated 9/25/2024 documents, 7:00 PM, (R2) is a 58 y.o. (year old) female presenting to the ED (emergency department) c/o (complaint of) respiratory distress, EMS (Emergency Medical Services) reports they found the patient in significant respiratory distress. They immediate placed her on a non-rebreather with minor improvement. Impression: 9/26/2024 Patient presented to ED via EMS with respiratory distress, Patient intubated in ED. Plan includes respiratory, infection disease and medical management, isolation, ventilator, IV antibiotics, remdesivir and steroids. The Facility Change in Resident Condition Policy with a review date of September 2024 documents, It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician, and resident's responsible party of a change on condition. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and the family of the issues and any physician order. The communication with the resident and their responsible party as well as the physician will be documented in the resident medical record, or other appropriate documents.

Based on observation, interview, and record review, the facility failed to assess, monitor, and transfer a resident to the hospital in a timely manner for 1 of 3 residents (R2) reviewed for change in condition and complete treatments as ordered for 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for wounds in a sample of 6. This failure resulted in R2 being admitted to the hospital with the diagnoses of sepsis (a life-threatening complication of an infection) and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Findings include: 1. R2's Admission Record, with a print date of 08/27/24, documented R2 has diagnoses of but not limited to chronic respiratory failure with hypoxia, chronic pulmonary embolism, and non-pressure chronic ulcer of right calf limited to breakdown of skin. R2's Minimum Data Set (MDS), dated [DATE], documented R2 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 10 out of 15 and she required partial/moderate assistance with upper body dressing, some of bed mobility, substantial/maximal assistance with toileting hygiene, shower/bathe, lower body dressing, personal hygiene, lying to sitting position, transfers, and she was always incontinent of bowel and bladder. R2's MDS, M section dated 05/01/24 documented she did not have any skin issues at that time including no venous/arterial ulcers. R2's Care Plan, with an admitted [DATE], documented R2 is at risk for respiratory infections related to (r/t) COVID-19, chronic respiratory failure, and chronic pulmonary embolism. Interventions are but not limited to monitor for lower respiratory infection (LRI) and temperature. The Care Plan documented SKIN: R2 has developed what is presenting as a venous wound to her right lateral front lower leg. Interventions include but not limited to assess and document of progress of areas weekly, monitor area for signs and symptoms (s/s) of infection: odor, drainage, color, size, notify physician (MD) of abnormal findings, observe, and assess regularly, skin assessment weekly, and treatment as ordered to right lateral front lower leg. R2's Physician's Orders, dated 08/12/23 at 2:56 PM, documented weekly skin screen (complete skin form if new alteration is present) every day shift every Saturday for prophylaxis. R2's weekly skin screens for May 2024 were reviewed and documented R2 did not get her weekly skin screen on 05/25/24. R2's weekly skin screens for June 2024 were reviewed and documented R2 did not get her weekly skin screen on 06/22/24 and 06/29/24. R2's Wound Care Note, dated 06/18/2024 at 11:47 AM, documented writer notified by Certified Nursing Assistant (CNA) patient (Pt) had an open area to the right lower extremity (RLE) upon assessment it was observed the Pt had what was presenting as a ruptured blister wound. Wound bed had 100% granulation with no undermining or tunneling. The wound had moderate serous drainage, edges attached, peri wound was intact, no odor or pain, and RLE cool to touch and discolored. V8, Nurse Practitioner was called, and new orders received, and call placed to set up appointment for a doppler. R2's Skin & Wound Evaluation, dated 06/18/24, documented R2 had a new skin area (blister) to her front right (Rt.) lateral lower leg measuring area: 0.4 square centimeters (cm2), length: 0.9 centimeters (cm), and width: 0.7cm. R2's Physician's Orders, dated 06/20/24 at 8:25 AM, documented Cleanse right lateral calf with wound cleanser then apply collagen particles to wound bed then apply xeroform and cover with dry dressing daily. R2's Skin & Wound Evaluation, dated 06/25/24, documented R2's venous wound to her front Rt. Lateral lower leg was deteriorating and now measuring area 12.5cm2, length: 3.0cm, and width: 5.2cm. R2's Physician's Orders, 06/28/24 at 1:10 PM, documented R2's treatment was changed to the following: Triamcinolone (TMC) Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) Apply to Right anterior calf topically every day shift to Promote Wound Healing Cleanse right anterior calf wound with wound cleanser then apply TMC mixed with A&D ointment and collagen particles to wound bed cover with calcium alginate then apply abdominal (ABD) pad and Kling daily. R2's Treatment Administration Record (TAR) for the month of June 2024 was reviewed and had no documentation R2 received her daily wound treatments on 06/20/24, 06/23/24, 06/28/24, 06/29/24, and 06/30/24. R2's Skin & Wound Evaluation, dated 07/03/24, documented R2's venous wound to her front Rt. Lateral lower leg was stable and measuring area: 15.2cm2, length: 3.6cm, and width: 6.5cm. It also documents under evidence of infection there is increased drainage, increased pain, and warmth. R2's Skin & Wound Evaluation, dated 07/11/24, documented R2's venous wound to her front Rt. Lateral lower leg was improving and now measuring area: 19.7cm2, length: 5.7cm, and width: 4.9cm. R2's Skin & Wound Evaluation, dated 07/19/24, documented R2's venous wound to her front Rt. Lateral lower leg improving and measuring area: 15.6cm2, length: 3.4cm, and width: 6.5cm. R2's TAR for the month of July 2024 was reviewed and had no documentation R2 received her daily wound treatment on 07/02/24, 07/14/24, 07/18/24, 07/19/24, 07/20/24, 07/22/24, 07/24/24, 07/25/24, and 07/27/24. R2's Skin and Wound Note, dated 07/25/24, documented evaluation for venous wound to Right Lower Extremity (RLE) increased edema with erythema, warmth and pain, 2+ edema to RLE toes up to knee, 1+ edema to Left Lower Extremity (LLE). Wound assessment size 6 cm x 8.5 cm x 0.1 cm. Peri wound: fragile, edema, erythema, venous, denuded. Exudate: Heavy amount of serosanguineous drainage. Recommend STAT venous doppler to RLE to rule out deep vein thrombosis (DVT), if unable to obtain today then send to emergency room (ER) for evaluation. R2's Physician's Orders, dated 07/26/24, documented Keflex oral capsule 500mg (Cephalexin) give 1 capsule by mouth four times a day for skin redness for 7 days cellulitis to bilateral lower extremities. R2's Progress Notes, dated 07/27/2024 at 08:04 AM, documented Nurse's Notes Resident is shaking and very warm to touch. Resident is short of breath, oxygen (O2) saturation (sat) on room air is 85%. Place oxygen to 1 liter (L) and O2 sat is 90%. Place oxygen to 2 Liters (L) and O2 sat is 92%. Resident complains of shortness of breath. Emergency Medical Services (EMS) called at this time. Estimated Time of Arrival (ETA) is at 08:45. R2's Physician's Order, dated 10/02/23, documented Oxygen at 2L via nasal cannula at bedtime (HS) for sleep apnea. R2's Electronic Medical Record (EMR)/Vital Signs (v/s) were reviewed and documented on 07/27/24 at 8:11 AM, R2's blood pressure (B/P) was 130/48, temperature (T.) was 98.7, Respirations (resp) were 20, and R2's O2 saturation was 85%. There were no other v/s documented for 07/27/24. R2's Progress Notes, dated 07/27/2024 at 2:45 PM, documented Nurses Notes resident (Res) transported to the local hospital via ambulance at 2:15 PM. R2's Progress Notes, dated 07/27/2024 at 9:11 PM, documented Res admitted to local hospital for sepsis and hypoxia. R2's Electronic Medical Record (EMR) was reviewed and no documentation regarding continued monitoring of R2's condition including R2's oxygen saturation (SpO2). On 8/27/24 at 2:00 PM, V14, Licensed Practical Nurse (LPN) was contacted on the phone for an interview. V14 stated she had arrived at the facility at 5:38 AM and was working that morning to cover a few hours until the day nurse arrived. V14 said she was performing a check on her residents and a Certified Nursing Assistant (CNA) had told her R2 was acting different. V14 said she went into the room, and R2 was shaking, and her face was red. V14 stated she obtained R2's vital signs, her (R2) oxygen saturation was low so V14 obtained an oxygen tank and applied oxygen. V14 said she called the local ambulance with the number located on the sign at the nurse's station. She said the ambulance service told her they were on their way and about ten minutes later, the ambulance service called back and said they would be arriving about 8:45 AM. V14 said she let the oncoming nurse know she had called the ambulance and the estimated time of arrival. V14 then left as her partial shift was completed. On 08/27/24 at 2:45 PM, V15, LPN was called and asked if she could relay the events on 07/27/24, regarding her care of R2. V15 stated that she called the facility to let them know that she would be running a little late that day and they got the night nurse to stay over until she arrived. V15 stated V14, LPN had given her (V15) report and told her she had called the ambulance and was sending R2 out because she had the shakes. V15 said she looked in R2's room and staff were getting her dressed and preparing her for ambulance transfer. When V15 checked in the room later, she noted that R2 was eating her breakfast. V15 stated that it was time for the afternoon medications, and she called the ambulance service because they had not yet arrived. The ambulance service told her it would be another hour, so she cancelled the transport and said that if she assessed R2 and she needed to go out to the hospital, V15 would call herself. V15 said later on she assessed R2 and felt that R2 was behaving differently. V15 said she noted a change in R2's condition, and R2 hadn't eat lunch, so she called the emergency ambulance transport and they said they would arrive in five minutes. The ambulance arrived at 2:15 PM to transfer R2 to the hospital. V15 stated that she couldn't find the earlier transfer paperwork that had been prepared, she tried to reprint the paperwork, and had difficulty only receiving one or two of the papers. V15 said the hospital called back asking for the paperwork and once again she had difficulty, and she had the wrong fax number. V15 also stated the hospital staff asked her why she had waited so long to send R2 out. V15 was asked about any additional vital signs for R2 which she stated were not done because her assessment of change in condition did not occur until right before she called the ambulance. V15 stated her charting was in the progress notes regarding transfer by local ambulance at 2:15 PM. V15 stated that her charting again was done later when she charted the hospital admitting diagnosis of hypoxia and sepsis. On 09/05/24 at 12:16 PM, V20, CNA stated she was at the facility on the day R2 was being sent out to the hospital. V20 said when she first arrives at the facility, she will walk down her hallway and check on everyone and the night shift had told her something was wrong with R2 and R2 hadn't been acting right. V20 said R2 didn't eat breakfast that morning, she wouldn't get up out of bed, and that isn't like her at all. V20 stated night shift usually gets R2 up, but she was still in bed when she got to the facility that morning. V20 stated when she checked on R2 that morning she seen R2 was on oxygen, so she asked the nurse why and the nurse told her she was getting ready to send R2 out to the hospital. V20 stated she knew they were sending R2 out, so she kept a close eye on her throughout the day. V20 stated at 11:00 AM she noticed R2 wasn't looking good, so she went and talked with the nurse and asked her about R2 being sent out. On 09/05/24 at 12:29 PM, V15, LPN was contacted for a follow up interview regarding R2. V15 said she got to the facility about 8:00 to 8:15 AM on 07/27/24 and was told by the nurse covering for her she (V14) was sending R2 out to the hospital. V15 said V14, LPN told her she called the non-emergency ambulance number, and they would be here by 8:45 AM to pick up R2. V15 stated she went down to check on R2, but the CNAs were getting R2 cleaned up and changed so she could go out the hospital and she also seen her breakfast in her room. V15 stated she didn't do any vital signs at this time and R2 did not have any oxygen on, but she said R2 takes it off all the time. V15, said she didn't go down and check on R2 again until a couple of hours later around lunch time after she talked with a CNA. V15 said when she went down to R2's room to check on R2 and she wasn't acting like her normal self. She said she hadn't eaten any of her lunch, she was drowsy, and she was lying off the side of the bed. V15 stated she did do v/s on R2 at that time. She said she checked her b/p and her pulse but didn't check her O2 saturation, then she went and called 911, and they (EMS) arrived at the facility in about 5 to 10 minutes after she called them. When questioned about where this surveyor would find the documentation and v/s V15 stated she didn't document the v/s, but she did inform the Emergency Medical Technicians (EMTs) what they were when they came to pick up R2. On 09/12/24 at 11:13 AM, V15, LPN said she did not ask the CNAs that day to take R2's v/s because she likes to take her own vitals. R2's Patient Care Report from the local ambulance service, dated 07/27/24 at 2:24 PM, documented R2's chief complaint was altered consciousness: lethargic, R2's v/s were as follows: B/P 134/96, Pulse 88, Respirations 16, SpO2 was 86% ambient air (room air). The Report documents at 2:27 PM it documented R2's v/s as follows: B/P 137/68, Pulse 94, Respirations 21, and SpO2 87%. At 2:38 PM it documented R2's v/s as follows: B/P 103/52, Pulse 90, Respirations 13, and SpO2 94%. R2's Hospital Report, dated 07/27/24, documented Clinical Indicators/Treatments 90 y/o (year old) female presents from her extended care facility with shortness of breath. O2 sat upon arrival 86% on room air. O2 2L (Liters) NC (nasal canula) initially applied up to 6L NC. Patient's respiratory status continued to worsen and BIPAP (bilevel positive airway pressure) was applied. Currently on NC 4L with O2 sats 94-95%. It further documents Reason for visit, visit diagnoses sepsis, due to unspecified organism, acute on chronic hypoxic respiratory failure, cellulitis of right lower extremity, and acute on chronic CHF (congestive heart failure). It also documented Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following condition(s): unstable vital signs and end of life care/management/discussion, acute congestive heart failure exacerbation (CHF), hypoxic respiratory failure, and sepsis. It also documented critical care was time spent by providing the following: Continuous telemetry, continuous pulse oximetry, interpretation of bedside monitors, imaging, and arterial/venous lab draws and several patient bedside exams, supplemental oxygen, and non-invasive positive pressure ventilator management. It also documented some of R2's labs were abnormal. R2's Complete Blood Count (CBC) was high at 19.8 with the normal range being 3.8-9.9. R2's Brain Natriuretic Peptide (BNP) was high at 2,045 with the normal range being <=450 picograms per milliliter (pg/ML). (BNP is a test that gives your provider information about how your heart is working. When your heart must work harder to pump blood, it makes more BNP. Higher levels of BNP can be a sign of heart failure. ClevelandClinic.org) R2's Hospital Report, dated 08/05/24 at 6:20 PM, documented R2's final diagnoses were but not limited to Sepsis, unspecified organism, Acute on chronic CHF, Acute respiratory failure with hypoxia, and cellulitis of right lower limb. On 08/27/24 at 09:18 AM, V3, R2's daughter said when she arrived to the hospital R2 was in severe pain and looked like H***. V3 said later in the evening the doctor came up to check on R2 and told her (V3) he was surprised R2 made it because he wasn't sure if she was going to. V3 said R2 was on oxygen and having issues with breathing. They gave R2 some morphine to help with the pain and after that she was kind of out of it for a couple of days. V3 said R2's leg was swollen and looked like it was going to rot off. She said she (V3) talked with the facility, and they told her they take good care of their residents. On 08/27/24 at 12:15 PM, V9, LPN said if she had a resident who had a change in condition, she would assess the resident, obtain vital signs, and if abnormal would notify the physician for further evaluation and orders. She would then notify the family and if needed she would then call an ambulance. On 08/27/24 at 12:30 PM, V13, LPN/Infection control nurse stated if she had a resident who had a change in condition and shortness of breath, she would assess the resident and then phone the physician. She said if the resident was critical, she would immediately call 911. On 08/27/24 at 1:30 PM, V1, Administrator stated if there was a resident who complained of shortness of breath and had a change in condition, she would expect the nurses to contact the physician, they should chart the situation, background, assessment, and recommendation (SBAR) in the progress notes, and if the situation is urgent the staff should call 911. She said the response time of an ambulance varies and if the call is made on the non-urgent phone number you never know when the ambulance will arrive. V1 stated six hours is too long to wait for an ambulance. On 08/27/24 at 1:45 PM, V2, Director of Nursing (DON) stated if her nurses had a resident who complained of shortness of breath and had a change in condition, she would expect the nurses to first put oxygen on the resident, then call 911, and this should be documented in the progress notes. V2 said six hours is too long to wait for an ambulance. On 08/27/24 at 12:12 PM, V8, Nurse Practitioner (NP) stated she was not working the day of R2's incident. She said the nurses here at the facility would call the exchange and speak with the on-call provider to get any orders. V8 said the nurses will document in the resident's progress notes that they contacted the on-call provider. V8 said if the nurses were to have a resident who was complaining of being short of breath and their oxygen saturation (SpO2) was 85% she would expect the nurses to assess the resident, place oxygen (O2) on the resident if they didn't already have it on, contact the provider, then send them out. She would also expect them to continue to monitor the resident especially if the resident had interventions in place and there was no change in the resident. V8 was asked if R2 having to wait from 8:04 AM until 2:15 PM to be sent out to the hospital was an appropriate amount of time to which V8 responded No that was not an appropriate amount of time for a patient to be in distress if she was still in distress. On 09/05/24 at 10:30 AM, V16, Wound Care, NP stated she makes weekly rounds on Thursdays, she assesses the wounds, documents on the wounds, takes pictures of the wounds, and makes treatment recommendations for the wound care. She said it is then run past the Primary Care Physician (PCP) and they will say yes or no to the recommendation, but they will generally agree with it. V16 stated the last day she saw R2 she (R2) was having increased edema and showing signs of cellulitis to her wound. V16 stated her recommendation on that day for R2 was to get a stat doppler and if they were unable to get the doppler that day to send R2 out to the ER for further treatment. She said she would expect the nurses to put the order in the day it was received and start the order that day or at least within 24 hours of getting the order. V16 stated if she makes a recommendation, and the facility has the supplies in the building she will do the dressing and apply the treatment that day. V16 stated from her understanding V4, Wound Nurse/LPN is to do the dressing changes Monday through Friday unless he is pulled to work the floor and then the floor nurses are to do their own dressing changes. V16 stated when the nurse is changing the dressing, she would expect the nurse to assess the wound. Look for drainage, look at the wound bed, watch for increased warmth, increased pain, and report any signs that are abnormal. V16 said with R2's type of wound (venous) and if there wasn't a clot present the dressing doesn't necessarily have to be changed daily all the time but because of her (R2's) drainage it should have been changed daily as ordered. V16 stated with the signs of cellulitis and the amount of drainage R2 had it could have been detrimental to the wound. She said it was a perfect breeding ground for bacteria. V16 stated if R2's wound was determined to be the source of R2's infection then yes it could have caused the sepsis. 2. R1's Admission Record, print date of 08/27/24, documented R1 had diagnoses of but not limited to Type 2 diabetes, dysphagia, abnormalities of gait and mobility, end stage renal disease (ESRD), heart failure, dependence on renal dialysis, hypertension, chronic atrial fibrillation, and non-pressure chronic ulcer of heel. R1's MDS, dated [DATE], documented R1 was moderately cognitively impaired with a BIMS of 10 out of 15. It further documented she has impairment of both upper and lower extremities, treatment as ordered to left lateral mid foot and required use of a wheelchair. observe and assess regularly and protect heels. R1's Care Plan, last review date of 07/05/24, documented R1 is at risk for skin complications and has a problem listed as an arterial wound to her left lateral mid foot. The goal is that the area to her left lateral mid foot will remain stable/heal throughout the next review. Interventions include but not limited to assess and document progress of areas weekly, educate resident on MD orders for wound care, educate resident on the risks of infection and poor healing related to non-compliance, monitor area for signs and symptoms of infection, odor, drainage, color, and size, notify MD of abnormal findings, protect heals, skin assessment weekly and treatment as ordered to left lateral mid foot. R1's Physician's Orders, dated 07/04/2024, documented apply wound gel to left heel topically every day shift to promote wound healing. Cleanse left heel with wound cleanser then apply hydro gel mixed with collagen particles to wound bed then cover with calcium alginate then apply dry dressing daily. R1's TARs, for the month June 2024, shows no documentation that R1 received wound care on 06/13/24, 06/14/24, 06/22/24, 06/23/24, and 06/26/24. R1's TARs for the month of July 2024 shows no documentation for wound care on 07/02/24, 07/06/24, 07/18/24, 07/22/24, 07/27/24, and 70/29/24. R1's TARs for the month of August 2024 shows no documentation for wound care on 08/01/24, 08/02/24, 080/3/24, 08/09/24, 08/15/24, 08/17/24, 08/18/24, and 08/23/24. On 8/26/24 at 11:15 AM, R1 stated the floor nurses must change her dressing on the weekends because the wound nurse is off on the weekends. R1 stated that last Saturday (08/24/24) her wound care was performed while she was at in-house hemodialysis. During the same time V4, Wound Nurse was observed changing R1's dressing. The date on dressing was 8/24/24 (2 days prior to current observation date). V4 was asked what the date on the dressing was and he verified the date was 08/24/24. 3. R3's Admission Record, print date of 08/27/24, documented R3 had diagnoses of but not limited to non-pressure chronic ulcer of other part of right lower leg, lymphedema, osteoarthritis, schizophrenia, and heart failure. R3's MDS, dated [DATE], documented R3 has a moderate cognitive impairment with a BIMS score of 10 out of 15 and requires use of a wheelchair and a walker, is incontinent of bowel and bladder, and is at risk for developing pressure ulcers. R3's Care Plan, last review date of 06/04/2024, documented R3 has a problem with a venous wound to his right lateral calf with the goal that the wound will remain stable/heal throughout the next review. Interventions include but are not limited to assess and document progress of areas weekly, educate resident on the risks of infection and poor healing related to non-compliance, monitor areas for signs and symptoms of infection, odor, drainage, color, and size, notify MD of abnormal findings, observe, and assess regularly, skin assessment weekly, and treatment as ordered to right lateral calf. R3's Physician's Orders, dated 04/09/24, documented remove ace wraps from lower legs every night shift. Also, to cleanse bilateral lower extremities (BLE) with soap and water and apply A&D ointment and then wrap with ace wraps every day shift for edema control. R3's Physician's Orders, dated 08/01/24, documented cleanse right medial calf with wound cleanser and then apply TMC mixed with A&D to wound bed, cover with calcium alginate, ABD pad and Kling daily for 7 days. R3's Physician's Orders, dated 08/09/24, documented clean left medial calf with wound cleanser and apply TMC mixed with A&D and cover with calcium alginate and dry dressing daily for 10 days. R3's TARs for the month of June 2024 had no documentation for wound care on the following dates: 06/13/24, 06/22/24, 06/23/24, and 06/29/24. There is no documentation of ace wrap removal on 06/06/24 and 06/12/24. R3's TARs for the month of July 2024 had no documentation for wound care on the following dates: 07/06/24, 07/18/24, 07/20/24, 07/21/24, 07/22/24, 07/27/24, 07/28/24 and 07/29/24. There is no documentation of ace wrap removal on 07/05/25, 07/10/24, and 07/14/24. R3's TAR for the month of August 2024 had no documentation on wound care for 8/1/24, 8/2/24, 8/3/24, 8/17/24, 8/18/24, and 8/19/24. Ace wrap removal at bedtime was not documented on 8/7/24, 8/13/24 and 8/22/24. 4. R4's Admission Record, print date of 08/27/24, documented R4 had diagnoses of but not limited to multiple sclerosis, acute respiratory failure, metabolic encephalopathy, weakness, chronic pulmonary embolism, cellulitis, and dermatitis. R4's MDS, dated [DATE], documented R4 was moderately cognitively impaired with a BIMS of 12 out of 15, has impairment to both lower legs, is always incontinent of bowel and bladder, and is at risk for developing pressure ulcers. R4's Care Plan, last review date of 05/31/2024, documented R4 has a wound to his left great toe with the goal that the area to the left great toe will remain stable/heal throughout next review. Interventions include but not limited to assess and document the progress of areas weekly, educate resident on MD orders for wound care, educate resident on the risks of infection and poor healing related to non-compliance, monitor area for signs and symptoms of infection, odor, drainage, color, and size, notify MD of abnormal findings, skin assessment weekly and treatment as ordered to left great toe. R4's Physician's Orders, dated 05/20/24, documented apply Hydrocortisone (Topical) to buttocks and groin topically every day and night shift to Promote Wound Healing, Cleanse buttocks and groin with soap and water then apply Hydrocortisone, A&D ointment, Calamine lotion and nystatin twice daily. R4's Physician's Orders, dated 08/08/24 to 08/19/24, documented Triamcinolone Acetonide External Ointment 0.1% topical. Apply to left posterior calf topically every day shift to promote wound healing, cleanse left posterior calf wound with wound cleanser then apply TMC ointment mixed with A&D ointment to wound bed then cover with xeroform and cover with dry dressing daily. R4's Physician's Orders, dated 08/23/24, documented apply hydrogel to left lateral calf topically every day shift to promote wound healing. Cleanse left lateral calf wound with wound cleanser then apply Hydrogel mixed with collagen particles to wound bed cover with calcium alginate and dry dressing daily. R4's TARs for the month of June 2024 were reviewed and had no wound care documentation for the morning on 06/13/2024, 06/19/2024, 06/20/2024, 06/23/2024, 06/27/2024, and 06/30/2024 and in the evening on 06/18/2024 and 06/29/24. R4's TARs for the month of July 2024 had no wound care documentation on the mornings of 07/04/24, 07/16/24, 07/18/24, 07/19/24, 07/21/24, 07/22/24 and 07/28/24 and on the evenings of 07/12/24, 07/16/24, 07/17/24, 07/21/24 and 07/22/24. R4's TARs for the month of August 2024 were reviewed and had no wound care documentation for the mornings for 08/02/24, 08/15/24 and 08/22/24 and no evening documentation on 08/17/24. 5. R5's Admission Record, print date of 08/27/24, documented R5 had diagnoses of but not limited to aphasia following cerebral infarction, brain stem stroke, human immunodeficiency virus, (HIV), diabetes, acute and chronic respiratory failure, dysphagia, end stage renal disease, (ESRD), stage 4 pressure ulcer of sacral region, and pressure ulcer of left heel. R5's MDS, dated [DATE], documented R5 has moderate cognitive impairment with a BIMS of 8 out of 15, impairment on bilateral upper and lower extremities, has an indwelling catheter, is always incontinent of bowel, and it also documents R5 is at risk of developing pressure ulcers, and he has a pressure ulcer. R5's Care Plan, last review date of 08/09/24, documented R5 has a pressure injury to his left heel and sacrum with the goal that the areas will remain stable/heal throughout the next review. Interventions include but not limited to assess and document progress of areas weekly, educate R5 on MD orders for wound care, educate resident on the risks of infection and poor healing related to non-compliance, monitor area for signs and symptoms of infection, odor, drainage, color, and size, notify MD of abnormal findings, skin assessment weekly and to provide treatment as ordered to the left heel and sacrum. R5's Physician's Orders, dated 06/03/24, documented apply betadine to left heel, then apply ABD pad and secure with Kling daily. R5's Physician's Orders, dated 06/07/24 through 06/15/24, documented cleanse sacrum wound with wound cleanser then reconstitute 3 capsules of compound of Streptomycin 80mg, Flucytosine 50mg, and Meropenem 150mg and 1 capsule of Levaquin 400mg and 1 packet of collagen particles with 12 pumps of [NAME]-gel then apply to wound bed, cover with, and lightly pack with calcium alginate and then cover with dry dressing daily. R5's Physician's Orders, with a start date of 06/21/24 and discontinued on 07/26/24, documented Cleanse Sacrum wound with wound cleanser then reconstitute 3 capsules of compound of Streptomycin 80mg, Flucytosine 50mg, and Meropenem 150mg and 1 capsule of Levaquin 400mg and 1 packet of collagen particles with 12 pumps of [NAME]-gel then apply to wound bed cover with and lightly pack with calcium alginate. R5's Physician's Orders, dated 07/09/24, documented apply hydrogel to left heel topically every day shift. Cleanse left heel with wound cleanser then apply hydrogel mixed with collagen particles to wound bed and cover with calcium alginate and cover with ABD and Kling daily. R5's Physician's Orders, dated 7/26/24, state to apply wound gel to sacrum topically every day shift for to promote wound healing. Cleanse sacral wound with wound cleanser then apply Hydrogel mixed with collagen particles to wound bed cover with calcium alginate then dry dressing daily. R5's TARs for the month of June 2024 were reviewed and had no documentation of the sacrum wound treatment being completed on 06/22/24, 06/23/24, 06/27/24, and 06/30/24. R5's TARs for the month of July 2024 were reviewed and had no documentation of the sacral wound treatment being done on 07/04/24, 07/18/24, 07/22/24, 07/23/24, 07/25/24 and 07/26/24. The August 2024 TAR showed no documentation on the sacral wound on 8/2/24, 8/7/24, 8/12/24, 8/21/24 and 8/22/24. R5's July 2024 TAR showed no documentation his wound care was completed on the left heel wound on 7/14/24, 7/18/24, 7/22/24, 7/23/24. R5's August 2024 TAR showed no documentation R5's wound care was completed on the left heel on 8/2/24, 8/7/24, 8/12/24, 8/21, and 8/22/24. 6. R6's Admission Record, print date of 08/27/24, documented R6 had diagnoses of but not limited to type 2 diabetes, dependence on renal dialysis, congestive heart failure, (CHF), transient cerebral ischemic attack, (TIA), dependence on renal dialysis, essential hypertension, peripheral vascular disease, non-pressure chronic ulcer of other part of right foot with ot[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse/neglect, failed to ensure residents felt safe, and failed to ensure residents needs were met in a dignified manner in the facility for 2 of 24 residents (R16, R99) in the sample of 44. This failure resulted in R16 feeling sexually assaulted and fearful to endure a similar situation from occurring again. Findings include: 1. On 5/14/2024 at 11:20 AM, V1, Administrator (ADM) stated, I am working on a reportable (incident) right now. I am going to term (terminate) her. It sounds like she was under the influence of something. Her set (assigned hall) was a mess. One resident made an allegation that is considered abuse. I also interviewed the other residents on the hall. Social Services took over. I had another resident (R99) with a complaint. She stated she did not feel abused but had an episode of incontinence, which she usually doesn't, and the CNA (Certified Nursing Assistant) slammed a diaper down and told her to clean herself up. She (R99) said she would just hate to see her do that to someone who couldn't speak for themselves. V1 continued to state, Another resident (R16) said she told the CNA she needed a pain pill. The CNA started rubbing on her all over and saying how she loved her. When I asked her (the resident) if she felt sexually harassed, she said, 'yes' and became tearful and stated she was uncomfortable. Her roommate (R16's) (R64) was in the bathroom, came out and told the CNA to leave. (R16) has had customer service complaints before but she is not someone who wouldn't be credible. On 5/14/24 at 12:05 PM, two police officers were observed in the building walking towards (R64's) room. At this time, (V1) told (R16) the officers were there to interview her about what had happened. This surveyor was present for the interview. R16 stated, I hit my button (call light) for pain med at 2:30 (AM)and nobody came. I did it again about a quarter til 3. The CNA said she thought it was my roommate who called (pressed the call light). I told her I was the one and she got all in my face. I told her if you get in my face, I'm gonna deck ya then, all the sudden she started rubbing all over my breasts. I'm sorry, I'm not like that. R16 then became visibly upset and anxious. R16 continued, I told her to stay away from me, don't touch me, stop! She just kept rubbing on me, my boobs. I am just a person, and I don't like that. (R64) got her off me and sent her down the hall. I finally got my medicine about 6 (AM). The nurse said no one had told her I needed it. I've been in 3 different places (facilities) and never had anything like this happen. At this time, (V21, Police Officer) asked R16 if it made her upset and uncomfortable and R64 stated, Yes, I'm going to always wonder if someone is going to do it to me again. If that's the case, I want out of here and to go somewhere else. V21 also asked R16, Was she rubbing with a flat hand or was she grabbing your breasts? R16 replied, I was protecting myself and had my hands over them (breasts). She was aiming to grab. She was saying, We're going to be the best of friends. R16 continued, I don't want to worry about when I need changed again if that will happen. You don't expect to be molested. On 5/14/2024 at 12:19 PM, R64, who was present in the room during R16's interview, R64 stated she concurs with everything R16 said about the incident and that R64 witnessed it. R16's Minimum Data Set, dated dated dated [DATE] documents R16 is cognitively intact. At 12:30, V21 stated the police report would take 5-7 days to be completed. On 5/14/2024 at 10:31 AM, V15, CNA stated, I witnessed the one (incident) with (R99). Nothing was done on the set (hall). The nurse said the CNA left at 6 (AM). (R16) told me she was soaking wet. I asked her why she didn't ask for help, and she told me she didn't want her (V24) touching her because she 'violated' her. She said (V24) started rubbing her across her chest and it made her uncomfortable. On 5/14/24 at 12:45 PM, R64 was heard asking an unknown staff member, Is that situation that happened in my room last night going to be taken care of? The Facility's Reported Incident Form dated 5/14/2024 documents the incident category is Resident Abuse, and the Resident/victim/perpetrators are R16 and V24. It further documents, (R16) reported that she put on her call light around 3:00 AM to ask for a pain pill. Staff member (V24, CNA) responded again and when she came in (V16) stated, 'You know there are two of us in this room and it was me who had the light on'. She said at that time (V24) was leaning over the bed rail and getting really close to her face asking her what she needed. She told her that she needed a pain pill. She also asked her to get out of her face, that she was getting too close to her. (V24) told her that it was too soon she couldn't have a pain pill. At that time, (V24) began to rub on her (R16's) chest on the outside of her gown and tell her that she would be ok, she was going to take care of her and loves her. (R16) felt uncomfortable and was telling (V24) to leave her alone. At that time, (R64), who is (R16)'s roommate, came out of the bathroom and got the aide out of the room. (R16) reported the incident to the nurse in the morning. It continues to document V24 was suspended. 2. On 5/13/2024 at 10:45 AM, R99 stated, There are two bad staff. I reported it to the guy nurse (V17, Licensed Practical Nurse). They sent her home. I asked one of them to move me up in bed. I've had a stroke and can't move. It's very difficult. She told me to do it myself. On 5/14/2024 at 9:00 AM, R99 stated, The CNA last night told me to change myself., threw a diaper on the table and left. I did the best I could cleaning myself up. (V15) helped me the rest of the way this morning and there were still about 3 streaks of poop left. The Administrator was just in here talking to me and said the CNA will be fired and the police will be here later for a report. On 5/14/2024 at 10:31 AM, V15, Certified Nursing Assistant (CNA) stated, I witnessed the one (incident) with (R99). The lady (unknown CNA) came in (to work) mad about her set (hall assignment). She was slamming doors. She was yelling at (R99) 'You better get up!'. I was so shocked by it, my mouth dropped. I made eye contact with (R99), and she was in tears. She (R99) was so distressed. I told the nurse and he (V17, LPN) called (V1). (V17) sent her home. The next night (R99) said she had the same thing from another CNA. The CNA said, 'That lady (R99) don't want to do anything for herself!'. Some of these CNAs are 'nasty' (ill mannered). The Facility-Reported Incident Form dated 5/9/2024 documents, Interview of Alleged Victim documents, Resident (R99) reported that the CNA (Certified Nursing Assistant) (V16) 'threw' her shirt at her and then she only assisted her with putting her arms in sleeves and not in pulling it over her head. It further documents, Interview of Witness-(V15) CNA states that she witnessed CNA (V16) yelling and demanding resident in (room) to do things and to get up and get herself ready and that the yelling was really intense. She also stated the aide (V16) walked out of the room cussing and saying, 'It's a shame when you don't want to shower or do anything for yourself'. The Facility's Abuse Policy and Prevention Program 2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility id doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. It further documents this will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. This Policy defines Sexual Abuse as sexual harassment, sexual coercion, or sexual assault including non-consensual consent to sexual activity. This Policy defines Mental Abuse as humiliation, harassment, threats of punishment or deprivation.

Based on observation, interview and record review, the facility failed follow their Abuse Policy and Prevention Program by ensuring residents were free from abuse/neglect as well as felt safe and needs were met in a dignified manner in the facility for 2 of 24 residents (R16, R99) in the sample of 44. This failure resulted in R16 feeling sexually assaulted and fearful to endure a similar situation occurring again. Findings include: The Facility's Abuse Policy and Prevention Program 2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of residents. It further documents this will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. This Policy defines Sexual Abuse as sexual harassment, sexual coercion, or sexual assault including non-consensual consent to sexual activity. This Policy defines Mental Abuse as humiliation, harassment, threats of punishment or deprivation. 1. On 5/14/2024 at 11:20 AM, V1, Administrator (ADM) stated, I am working on a reportable (incident) right now. I am going to term (terminate) her. It sounds like she was under the influence of something. Her set (assigned hall) was a mess. One resident made an allegation that is considered abuse. I also interviewed the other residents on the hall. Social Services took over. I had another resident (R99) with a complaint. She stated she did not feel abused but had an episode of incontinence, which she usually doesn't, and the CNA (Certified Nursing Assistant) slammed a diaper down and told her to clean herself up. She (R99) said she would just hate to see her do that to someone who couldn't speak for themselves. V1 continued to state, Another resident (R16) said she told the CNA she needed a pain pill. The CNA started rubbing on her all over and saying how she loved her. When I asked her (the resident) if she felt sexually harassed, she said, 'yes' and became tearful and stated she was uncomfortable. Her roommate (R16's) (R64) was in the bathroom, came out and told the CNA to leave. (R16) has had customer service complaints before but she is not someone who wouldn't be credible. On 5/14/24 at 12:05 PM two police officers were observed in the building walking towards (R64's) room. At this time, V1 told R16 the officers were there to interview her about what had happened. This surveyor was present for the interview. R16 stated, I hit my button (call light) for pain med at 2:30 (AM)and nobody came. I did it again about a quarter til 3. The CNA said she thought it was my roommate who called (pressed the call light). I told her I was the one and she got all in my face. I told her if you get in my face, I'm gonna deck ya then, all the sudden she started rubbing all over my breasts. I'm sorry, I'm not like that. R16 then became visibly upset and anxious. R16 continued, I told her to stay away from me, don't touch me, stop! She just kept rubbing on me, my boobs. I am just a person, and I don't like that. (R64) got her off me and sent her down the hall. I finally got my medicine about 6 (AM). The nurse said no one had told her I needed it. I've been in 3 different places (facilities) and never had anything like this happen. At this time, (V21, Police Officer) asked R16 if it made her upset and uncomfortable and R16 stated, Yes, I'm going to always wonder if someone is going to do it to me again. If that's the case, I want out of here and to go somewhere else. V21 also asked R16, Was she rubbing with a flat hand or was she grabbing your breasts? R16 replied, I was protecting myself and had my hands over them (breasts). She was aiming to grab. She was saying, We're doing to be the best of friends. R16 continued, I don't want to worry about when I need changed again if that will happen. You don't expect to be molested. On 5/14/2024 at 12:19 PM, R64, who was present in the room during R16's interview, R64 stated she concurs with everything R16 said about the incident and that R64 witnessed it. R16's Minimum Data Set, dated dated dated [DATE] documents R16 is cognitively intact. At 12:30, V21 stated the police report would take 5-7 days to be completed. On 5/14/2024 at 10:31 AM, V15, CNA stated, I witnessed the one (incident) with (R99). Nothing was done on the set (hall). The nurse said the CNA left at 6 (AM). (R16) told me she was soaking wet. I asked her why she didn't ask for help, and she told me she didn't want her (V24) touching her because she 'violated' her. She said (V24) started rubbing her across her chest and it made her uncomfortable. On 5/14/24 at 12:45 PM, R64 was heard asking an unknown staff member, Is that situation that happened in my room last night going to be taken care of? The Facility's Reported Incident Form dated 5/14/2024 documents the incident category is Resident Abuse, and the Resident/victim/perpetrators are R16 and V24. It further documents, (R16) reported that she put on her call light around 3:00 AM to ask for a pain pill. Staff member (V24, CNA) responded again and when she came in (R16) stated, 'You know there are two of us in this room and it was me who had the light on'. She said at that time (V24) was leaning over the bed rail and getting really close to her face asking her what she needed. She told her that she needed a pain pill. She also asked her to get out of her face, that she was getting too close to her. (V24) told her that it was too soon she couldn't have a pain pill. At that time, (V24) began to rub on her (R16's) chest on the outside of her gown and tell her that she would be ok, she was going to take care of her and loves her. (R16) felt uncomfortable and was telling (V24) to leave her alone. At that time, (R64), who is (R16)'s roommate, came out of the bathroom and got the aide out of the room. (V16) reported the incident to the nurse in the morning. It continues to document V24 was suspended. 2. On 5/13/2024 at 10:45 AM, R99 stated, There are two bad staff. I reported it to the guy nurse (V17, Licensed Practical Nurse). They sent her home. I asked one of them to move me up in bed. I've had a stroke and can't move. It's very difficult. She told me to do it myself. On 5/14/2024 at 9:00 AM, R99 stated, The CNA last night told me to change myself., threw a diaper on the table and left. I did the best I could cleaning myself up. (V15) helped me the rest of the way this morning and there were still about 3 streaks of poop left. The Administrator was just in here talking to me and said the CNA will be fired and the police will be here later for a report. On 5/14/2024 at 10:31 AM, V15, Certified Nursing Assistant (CNA) stated, I witnessed the one (incident) with (R99). The lady (unknown CNA) came in (to work) mad about her set (hall assignment). She was slamming doors. She was yelling at (R99) 'You better get up!'. I was so shocked by it, my mouth dropped. I made eye contact with (R99), and she was in tears. She (R99) was so distressed. I told the nurse and he (V17, LPN) called (V1). (V17) sent her home. The next night (R99) said she had the same thing from another CNA. The CNA said, 'That lady (R99) don't want to do anything for herself!'. Some of these CNAs are 'nasty' (ill mannered). The Facility-Reported Incident Form dated 5/9/2024 documents, Interview of Alleged Victim documents, Resident (R99) reported that the CNA (Certified Nursing Assistant) (V16) 'threw' her shirt at her and then she only assisted her with putting her arms in sleeves and not in pulling it over her head. It further documents, Interview of Witness-(V15) CNA states that she witnessed CNA (V16) yelling and demanding resident in (room) to do things and to get up and get herself ready and that the yelling was really intense. She also stated the aide (V16) walked out of the room cussing and saying, 'It's a shame when you don't want to shower or do anything for yourself'.

Based on interview, observation, and record review, the facility failed to provide proper wound care, and to turn and reposition a resident, for 1 of 1 resident (R270) reviewed for treatments and care to prevent pressure ulcers in the sample of 44. Findings include: R270's Face Sheet, undated, documents R270 was originally admitted to the facility on [DATE] with Diagnosis of Hypoxic Ischemic Encephalopathy, Type 2 Diabetes Mellitus (DM), Osteomyelitis, Dysphagia, Obesity, Dysarthria/Anarthria, Anemia, Major depressive disorder, Neuromuscular dysfunction of bladder, Gastrostomy, Dependence on renal dialysis, Gangrene, Pressure Ulcer of sacral region-stage 4, Sepsis, PVD, Metabolic Syndrome, Atherosclerotic Heart Disease (ASHD). R270's Care Plan states, R270 is at risk for skin complications related to Unspecified Severe Protein-Calorie Malnutrition. Interventions: Assist and encourage resident to turn and reposition every one to two hours and PRN (as needed), elevate HOB (head of bed) no more then 30-degrees, ensure proper body alignment, skin assessment weekly. It continues R270 was admitted with a DTPI (deep tissue pressure injury) to his left heel. Interventions: Assess and document of progress of areas weekly, Assist and encourage resident to turn and reposition every one to two hours and PRN, Elevate HOB (head of bed) no more then 30-degrees, ensure proper body alignment, maximal remobilization, monitor area for s/s (signs/symptoms) of infection: odor, drainage, color, size, observe and assess regularly, protect heels, treatment as ordered to left heel. It continues R270 was admitted with a DTPI to his left lateral malleolus. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, elevate HOB no more then 30-degrees, ensure proper body alignment, maximal remobilization, observe and assess regularly, protect heels, treatment as ordered to left malleolus. It continues R270 was admitted with a stage-III pressure wound to his left Ischium. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, elevate HOB no more then 30-degrees, ensure proper body alignment, maximal remobilization, observe and assess regularly, skin assessment weekly, treatment as ordered to left Ischium, wound-vac to aid in healing. It continues R270 was admitted with an unstageable wound to his right gluteus. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, elevate HOB no more then 30-degrees, ensure proper body alignment, maximal remobilization, monitor area for s/s of infection: odor, drainage, color, size, observe and assess regularly, skin assessment weekly, treatment as ordered to right gluteus, wound-vac to aid in healing. It continues R270 was admitted with a stage-IV pressure wound to his sacrum. Interventions: Assess and document of progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN, elevate HOB no more then 30-degrees, ensure proper body alignment, maximal remobilization, monitor area for s/s of infection: odor, drainage, color, size, observe and assess regularly, skin assessment weekly, wound-vac to aid in healing. R270's Minimum Data Set (MDS), dated [DATE], documents R270 has severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs). R270 has anuria and has a colostomy. On 5/13/24 at 10:45 AM, R270, was seen sitting in his recliner chair around the nurse's desk, right below knee amputation (RBKA), soft boot on left foot. R270 was just back from Dialysis. On 5/14/24 at 10:35 AM, V6, Licensed Practical Nurse (LPN)/Wound Care, stated that R270 has three stage-4 pressure ulcers and two unstageable ulcers. V6 stated that R270 came back from the hospital without the wound-vac and had no orders to continue it. V6 stated that he changes dressings and does wound care every day. On 5/14/24 at 10:20 AM, R270's wound-vac was seen in his closet in a plastic bag, along with its supplies. On 5/15/24 at 8:25 AM, R270 was seen sitting on his buttocks in his recliner in Dialysis. On 5/16/24 at 8:15 AM, R270 sitting in recliner on his buttocks during Dialysis. On 5/16/24 at 11:20 AM, R270 is still sitting in his recliner on his buttocks in Dialysis. On 5/15/24 at 12:45 PM, V6, LPN/Wound Nurse, stated All of (R270's) wounds are from the hospital. He was hospitalized for amputation of his leg and then sent here. He had all of these wounds when he arrived here. When (R270) pulled out his G-Tube, he was sent back to the hospital and for some reason, they kept him for 10 days. When he came back, he did not have his wound-vac in place and had no orders for it. I did not call the physician and ask about it but will check with the NP tomorrow when she comes to see him. I think that (R270) could benefit from having the wound-vac back on. On 5/15/24 at 12:50 PM, V6 began providing wound care to R270, Santyl spread on Xeroform and applied to wounds, then covered with occlusive dressing. Upon assessing R270, there were three new areas seen on R270 that V6 was not aware of. These seem to be blisters and was covered up by a band aid on one, and a small dressing on the other. Right upper/proximal flank 4 CM (centimeter) X 6.5 CM, Right mid-flank 0.9 CM X 0.9 CM, and Right distal flank - 1.5 CM X 1.5 CM. The proximal flank was still in a blister form, while the other two had blisters that popped and was oozing. V6 stated he was going to wipe them with betadine to dry them up and apply a dry dressing. V6 stated he knows what the physician will order, so he is going ahead and doing it before he calls, if the order is different, he will change it. On 5/15/24 at 1:15 PM, V6, LPN/Wound Nurse, continuing to work on R270's wounds. R270 rolled to his left side to assess his wounds on his sacrum/coccyx. R270 has three large open wounds/holes to his right ischium/sacral area. V6 stated that R270 came from hospital with them, and they were tunneled together but they are getting better. Wounds cleansed with wound cleanser and 4X4's, then packed with Santyl and Xeroform, then covered with large occlusive dressing. V6 stated that he changes R270's dressings every day and the days he is not working, it is the responsibility of the floor nurse to do. V6 took off R270's soft boot from his left foot to reveal an old dressing on his heel. The dressing was dated 5/8/24. V6 stated he is not sure why this dressing has not been changed since 5/8/24. On 5/15/24 at 1:30 PM, V6, LPN/Wound Nurse, stated (R270's) got a colostomy to help his wound heal because of his incontinence. (R270) sits in a recliner for most of the day. He gets up to his recliner early in the morning, eats a small breakfast, then I see him go by my office around 6:15 AM on his way to Dialysis. He is there for 3-4 hours and brought back to the floor in time for lunch. After lunch, which is usually around 1:00 to 2:00 PM, (R270) will be put into his bed and then I do his dressings. (R270) spends a lot of time sitting in his recliner and is not repositioned, which is making his wounds worse and hard to heal. I expected (R270) to come back from the hospital with his wound-vac in place and I am not sure why I didn't call and ask about it because he would probably benefit from having it. I think the new blisters he has is from sitting a long time in his recliner and it is rubbing on him somewhere. On 5/16/24 at 8:10 AM, V31, Nurse Practitioner (NP), stated that she sees R270, but does not take care of his wounds, that is a different NP. V31 stated that R270 definitely needs to get off his backside in order for his wounds to heal. On 5/16/24 at 8:15 AM, V32, Certified Hemodialysis Technician (CCHT), stated that R270 is scheduled for Dialysis every day from 7:00 AM until 10:00 to 10:30 AM, no later than 11:00 AM. V32 stated that the staff in Dialysis cannot turn and position the residents because they do not work for the facility. V32 stated they have to call the facility transport staff member to transfer R270 from their recliner to his recliner and then back to the floor. V32 stated she does not recall seeing any blisters on R270. On 5/16/24 at 11:00 AM, V1, Administrator, stated (R270) should not be sitting for those long periods of time. The facility's transporter is not that busy and could go and reposition (R270) as needed. I will consult OT/PT, and the care plan team for recommendations, and possibly have (R270) eat meals in bed rather than keep him sitting in his recliner. On 5/16/24 at 11:55 PM, V19, Wound Nurse Practitioner, stated that she saw R270 last on 4/16/24. V19 stated that R270 came back from the hospital without his wound-vac. V19 stated that R270 needs to be turned side to side every one to two hours in order for his wounds to heal and R270 sitting on his butt all day long are detrimental to his wounds. On 5/16/24 at 12:10 PM, V5, LPN, stated that R270 just came back from Dialysis because he had an adverse reaction to Vancomycin infusion and will be going to the hospital shortly. R270's Physician Order (PO), dated 4/9/24, documents Cleanse left ischium wound with wound cleanser then apply ABX (compound) mixed with Santyl to wound bed cover with Xeroform lightly pack with calcium alginate and 4x4s and cover with silicone boarded dressing daily. Everyday shift for To Promote Wound Healing. R270's PO, dated 4/9/24, documents Cleanse right ischium wound with wound cleanser then apply ABX (compound) mixed with Santyl to wound bed cover with Xeroform lightly pack with calcium alginate and 4x4s and cover with silicone boarded dressing daily. everyday shift for To Promote Wound Healing. R270's PO, dated 4/9/24, documents Cleanse sacral wound with wound cleanser then apply ABX (compound) mixed with Santyl to wound bed cover with Xeroform lightly pack with calcium alginate and 4x4s and cover with silicone boarded dressing daily. everyday shift for To Promote Wound Healing. R270's PO, dated 5/15/24, documents Apply betadine to right flank distal blister daily and cover with dry dressing daily. Everyday shift for To Promote Wound Healing. R270's PO, dated 5/15/24, documents Apply betadine to right flank medial blister and cover with dry dressing daily. everyday shift for To Promote Wound Healing. R270's PO, dated 5/15/24, documents Apply betadine to right flank proximal blister and cover with dry dressing daily. Everyday shift for To Promote Wound Healing. R270's PO, dated 5/14/24, documents Santyl External Ointment 250 UNIT/GM (Collagenase). Apply to Sacrum topically everyday shift for To Promote Wound Healing Cleanse sacrum with wound cleanser then apply Santyl to wound bed and cover with Xeroform and 4x4s and cover with silicone boarded dressing daily. R270's PO, dated 5/14/24, documents Santyl External Ointment 250 UNIT/GM (Collagenase). Apply to Left ischium topically everyday shift for To Promote Wound Healing Cleanse left ischium with wound cleanser then apply Santyl to wound bed and cover with Xeroform and 4x4s then apply silicone boarded dressing daily. R270's PO, dated 5/14/24, documents Apply betadine to left heel daily. Everyday shift for To Promote Wound Healing. R270's PO, dated 5/14/24, documents Apply betadine to left malleolus daily. Everyday shift for To Promote Wound Healing. R270's NP Note, dated 2/26/24, documents Patient being seen today for follow up care for pressure ulcer to sacral region, buttock and left gluteal fold, patient continues to be followed by wound care, patient examined while sitting in dialysis, patient expressed by nodding his head, continues to be followed by wound care, patient examined while sitting in dialysis, patient expressed by nodding his head his buttock is uncomfortable to sit on for long periods of time. R270's Skin Screen, dated 12/5/23, documents upon admission, Skin Evaluation: Sacrum: 5.1x5.4x3.0 with undermining from 11 to 4 o'clock. R270's Admission Observation, dated 12/31/23, documents R270's reason for admission was sepsis, wound-vac to coccyx. Skin Condition: Site - Coccyx, wound-vac in place. R270's last Skin and Wound Assessment located in the electronic medical record, is dated 3/12/24. V6, Wound Nurse, stated that he is doing them and has no idea why they are not showing up in the medical record. The facility's Pressure Injury Policy, dated 9/2022, documents To prevent or reduce the incidence of pressure injuries, standards of practice should be implemented. The facility's Skin Care Prevention Policy, dated 1/2023, documents All residents will receive appropriate care to decrease the risk of skin breakdown. 1. The Nursing Department will review all new admissions/readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 2. Dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching erythema), and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. 3. All residents will be evaluated for changes in their skin condition weekly. 5. All residents unable to reposition themselves will be repositioned as needed, based on a person-centered approach per the resident's plan of care. 6. Unless contraindicated, elevate heels off bed surface and avoid skin-to-skin contact.

Based on interview, observation, and record review the facility failed to provide adequate supervision and progressive interventions for 1 of 3 (R2) residents investigated for falls. This failure resulted in R2 having multiple falls and sustaining a Closed displaced fracture of medial malleolus of right tibia and closed avulsion fracture of lateral malleolus of right fibula. Findings include: R2's EMR, (Electronic Medical Records), undated documents, that the resident was admitted to the facility on [DATE]. R2's EMR dated 10/25/21, documents, a diagnosis of Cerebral Palsy, unspecified. R2's EMR dated 10/26/21, documents, a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's MDS, (Minimum Data Set), dated 09/05/23, documents, that resident has a BIMS, (Brief Interview for Mental Status), score of 14 out of 15. The MDS documents, that R2 is independent with setup help only for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, and toilet use. The MDS documents, that R2 requires supervision with setup help only for dressing and personal hygiene. The MDS documents, that R2 is not steady, but able to stabilize without staff assistance. R2's Fall Risk Evaluation dated 09/11/23, documents, a score of 15.0. Scoring a 10 or higher makes resident High Risk for falls. R2's Care Plan undated documents, Fall: (R2) is at high risk for falls cognitive deficits, functional deficits, history of falls, visual impairment r/t, (related to), weakness, recent falls, and decreased mobility. 10/07/23 fall with fracture, NWB, (Non-Weight Bearing), RLE, (right lower extremity). 10/20/23 ORIF, (Open Reduction and Internal Fixation), ankle. R2's Nurses Notes dated 01/16/23, at 5:20 PM documents, nurse was notified that res had fell to her knees in the hallway near 300-hall nurses' station, nurse came to assess res, (resident), and saw res just getting off the floor while holding on to walker, res stated, her legs buckled and gave out, she did not hit her head, nurse assessed res at this time, no injuries noted, res stated, she isn't in any pain at this time, nurse educated res on the importance of taking breaks when feeling tired, making sure to use wheelchair when can no longer walk, NP, (Nurse Practitioner) and POA, (Power of Attorney), has been made aware, no further concerns noted at this time, VS, (vital signs), 98.2 78 18 122/76 98 RA, (room air). Intervention dated 01/16/23 documents, encourage resident to use wheelchair. R2's Nurses Notes dated 02/06/23, at 11:25 AM documents, This nurse was notified by aid that res had a fall in the activity area. When I made it to the area res was up and sitting in a chair. Vitals was taken B/P (blood pressure):129/20, pulse:80, res (respirations) :18 temp, (temperature) :97.3, O2 97%RA, res stated, she tripped over the rug. ROM, (range of motion), was performed, and res complained of no pain and stated, she landed on her knees. Intervention dated 02/06/23 documents, Resident educated to be mindful of her environment and avoid tripping hazards. R2's Nurses Notes dated 02/28/23, at 2:56 PM documents, Resident fell backwards onto her bottom outside in the smoking area, resident's walker was in front of her when she fell . resident did not hit her head and the fall was visually seen by a staff member. Resident stated that she became dizzy and fell , Resident had no injuries noted at this time, no c/o, (Complaints of), pain or discomforts. Resident's BP was elevated 118/100, HR, (heart rate), was 95. This nurse had just administered morning medications 20 minutes prior to fall. NP notified of fall. Intervention dated 02/28/23, encourage resident to sit down in either w/c, (wheelchair), seat or on the seat on her rollator when she is smoking. R2's Nurses Notes dated 04/12/23, at 8:55 AM documents Res fell to her knees while ambulating in activity area. Res was able to get back up without assistance, denies pain and did not hit her head. VS are WNL, (within normal limits). no visible injuries noted. NP has been informed. NNO, (no new orders), have been given at this time. Intervention dated 04/12/23, documents, Monitor resident for tolerance and endurance. Schedule tasks accordingly. R2's Nurses Note dated 04/19/23, at 1:01 PM documents, Writer was informed that res had fallen in dining room and hit her head above her R, (right), eyebrow and has a skin tear to her L, (left), knee. VS are BP-194/86, P-73, R-20, T-97.3, o2- 98 on RA. Res is alert and able to move all extremities without complaints of pain/difficulty. Res was helped up from the floor by 2 staff members using a gait belt. She was able to walk from the dining room to her room without difficulty. Writer informed NP and was given order to send res to (local hospital) for further eval. Res guardian has been informed and has voiced no complaints or concerns. Intervention dated 04/19/23, documents, Therapy to evaluate for balancing and strengthening with recs for programming. R2's Nurses Notes dated 05/09/23, at 10:00 AM documents, Res fell during smoke break this am. Writer observed res sitting on her knees outside in the smoking area, with her wheeled walker in front of her. Res was assessed for pain and injury. Res denies pain, able to move both upper and lower extremities without difficulty. Res denies hitting her head. VS assessed, BP-78/56, P-103, R-18, T-97.9, o2-97% on RA. Res was helped from her knees onto and sat on the seat of her walker, then pushed to her room. Res is lying in bed, call light within reach, bed in the lowest position. Intervention dated 05/09/23, documents, Educated resident on taking her time while ambulating. R2's Nurses Notes dated 05/16/23, at 7:46 AM documents, Writer informed res was on the ground, Res was observed on her R knee, holding onto to wheeled walker while outside during smoke break. Res said she slipped in the rain. Res denies pain, denies hitting her head. Assessed for pain and injury, none noted. Res guardian has been informed and has voiced no complaints or concerns. VS BP-176/91, P-76, R-18, T-97.2, o2-98 on RA. Intervention dated 05/16/23, documents, encouraged (R2) to use wheelchair when going out to smoke, esp. in inclement weather. R2's Nurses Notes dated 05/24/23, at 9:56 AM documents, Writer alerted by staff to come to smoke break patio because there was a code blue. Writer observed res lying on the ground unresponsive, pulse faint and irregular. 911 call initiated, while this nurse stayed with res. Writer noticed res breathing was labored and res began to have uncontrollable body movements. EMT, (Emergency Medical Technician), arrived shortly after and res was transferred to stretcher and then to (local hospital). Guardian has been informed, no complaints or concerns have been voiced. No intervention noted for this fall. R2's Nurses Notes dated 05/25/23 at 1:46 PM documents, Writer informed by staff that res was on the floor in her room. Res assessed for injury and pain. No visible injury noted, res c/o pain to L hip when standing. VS assessed BP-167/93, P-71, R-18, T-97.1, o2-96 on RA. MD informed and gave order to DC Tegretol, order STAT, (Urgent or Rush), L hip XR (x-ray), CXR (chest x-ray), and labs CBC w/Diff (complete blood count with differential), UA (urinalysis) w/C&S (culture and sensitivity). Res and Guardian aware, no complaints or concerns voiced. Intervention dated 05/25/23, documents, Educated resident to rise slowly from her bed or wheelchair when she is feeling dizzy. R2's Nurses Notes dated 07/03/23, at 12:58 PM documents, Resident has been having unsteady ambulation this morning. This nurse provided pt education for ambulatory safety and referred a wheelchair, pt denied. Resident was witnessed going out the front lobby door and fell to her knees. Patient complained 5 out of 10 for pain in RLE. This nurse looked over pt no major signs of distress or discomfort. Resident is now using wheelchair and taking a rest from using walker. MD was notified but no answer. This nurse ordered 2 view X-ray on RLE, care ongoing. No intervention noted for this fall. R2's Nurses Notes dated 07/06/23, at 7:37 PM documents, resident at 6:54 reported to the CNA, (Certified Nursing Aide), that she broke her foot from a fall that happened in the shower at 2pm. this nurse asked resident what happened. Res stated, she fell in shower two time. resident complained of pain on the bottom of her right foot. small skin abrasion on right ankle. Vitals SPO2, (oxygen saturation), 96 RA, T 98.6, R 16, P 61, B/P 155/78. ROM was performed. V14 (Physician) notified, Guardian notified. resident is in bed with call light within reach. Intervention dated 07/06/23, documents, Encourage resident to use shower chair for safety. R2's Nurses Notes dated 07/08/23, at 10:41 AM documents, Writer informed by CNA that res fell in her room and got herself back up and into her bed. Res was assessed for visible injury, none noted. Res denies pain. VS BP-127/75, HR-58, o2-95% on RA, T-97.1, R-18. MD (V14) informed, gave order for orthostatic BP . Laying-BP-132/76, HR-63 Sitting-BP-170/110 HR-62 Standing-BP-191/116 HR-63. After reviewing results, MD gave order for res to have STAT CBC, CMP (complete metabolic panel, MAG, (magnesium), TSH, (thyroid stimulating hormone), and a UA. V15 (POA) has been informed, no complaints or concerns have been voiced. Intervention dated 07/08/23, documents, Ensure proper fitting footwear when up. R2's Nurses Notes dated 07/08/23, at 7:00 PM documents, Res came to the nurse station to report she had fallen in her bedroom while trying to go to the bathroom. She got herself up. She denied pain to writer, informed POA she was having pain and now could not walk. Writer left message with MD (V14); res being sent to (local hospital) for further eval. Intervention dated 07/08/23, documents, Encourage resident to ask for assistance when feeling weak. R2's Nurses Notes dated 07/14/23 at 11:00 AM documents, This nurse was standing at the nurse's station when (R2) literally came almost running up the hall towards the nurse's station. When (R2) got right up to the nurse's station she called for the nurse, while still almost running, and then abruptly stopped walking/running. When she stopped, she started to go forward, then went to turn and when she started to turn, she lost her balance, went down to left knee twisted herself around and sat on the floor. Advised (R2) to stay where she is while her nurse evaluated her. Able to move left and right legs straight out, pull her knees up to her chest and rotate her ankles without difficulty or c/o discomfort. Intervention dated 07/14/23, documents, Encourage (R2) to wear leg braces when getting up. R2's Nurses Notes dated 07/17/23, at 9:38 AM documents, resident found sitting on buttocks in front of wheelchair. Resident stated she was trying to pick up a towel off the floor. resident stated she did not hit her head. ROM performed x4 extremities without difficulty. Gait belt applied and resident assisted off floor back into wheelchair safely. This nurse escorted resident to her room and assisted her back to her bed safely. Nursing supervisor made aware. Intervention dated 07/17/23, documents, Encourage resident to lock wheelchair prior to leaning forward. R2's Nurses Notes dated 08/12/23 at 10:02 AM documents, Writer was informed that res had fallen out of bed and gotten herself up and laid back on the bed. Res said she tried to roll over and was on the edge of the bed, that caused her to fall and strike her back. She complains of pain to her back, a scratch is visible, the scratch is not bleeding. Writer ordered an XR to -cervical spine, dorsal spine, lumbar spine, sacrum and coccyx. Res POA has been informed. No complaints or concerns have been voiced. No intervention noted for fall on 08/12/23. R2's Nurses Notes dated 08/18/23 at 9:34 AM documents this nurse was informed by CNA that res was getting self-off the floor while CNA was entering the room, res stated that she thought she could make it to the restroom without her walker without falling, res stated that she did not use her walker because It was on the other side of the bed, res stated that she fell on her knees, res roommate witnessed the fall, res stated that she is ok and did not hurt herself, this nurse examined res, ROM WNL, res has bruising to the right knee that res stated it was old, res denies having any pain to legs at this time, will continue to monitor and update if condition changes. Res POA (V15) and sister-in-law made aware. Intervention dated 0818/23 documents Encourage resident to make sure she's using her wheeled walker when ambulating. R2's Nurses Notes dated 09/11/23 at 11:06 AM documents Aide reported to this nurse that resident had a fall. Resident stated she was throwing away a honey bun wrapper as she fell and hit her chin. Resident said she tried to get back into the bed but wasn't able to lift herself because of pain in Left knee. This nurse checked Vitals T 98.2 O2 97 RR 18 P 69 BP 137/110 and started neuro checks. Resident was provided a PRN (as needed) Narc for pain of chin and legs. Care ongoing. Intervention dated 09/11/23 documents Encourage resident not to bend forward when standing and to ask for assistance when the need is there. R2's Nurses Notes dated 10/07/23 at 11:32 AM documents Resident noted on floor in bedroom at 9:44am c/o pain 8.5/10 in right ankle. right ankle noted with bulges and swelling. right pedal pulse palpable. PRN hydrocodone administered. Vitals SPO2 95, T 99, P 94, B/P 120/62, R 22. notified NP and POA. sent resident to (local hospital) ER (emergency room ) for eval. Intervention dated 10/07/23 documents Encourage resident to reach behind her to feel for surface before attempting to sit. R2's Nurses Notes dated 10/07/23 at 3:39 PM documents resident arrived at facility at 3:30pm. With diagnosis for Closed displaced fracture of medial malleolus of right tibia and closed avulsion fracture of lateral malleolus of right fibula. referral to Orthopedic Surgery @ (local hospital group) Orthopedics and Sports medicine 4700 Memorial drive Suite 300 [NAME]. Orders to make appointment on Monday for a F/U (follow up). R2's Fall investigation dated 10/07/23 documents Resident was found by staff on floor in room. This nurse went over to her and ask what happened. Resident stated that her right ankle gave out while she was walking in her room. Right ankle noted with swelling and bulges around right ankle. Vitals SpO2 95, T 99, B/P 120/62, R 22. Resident was in extreme pain 8.5/10. PRN hydrocodone given right pedal pulse present. Resident unable to give description. Resident was taken to the hospital for extreme pain and suspected fracture or dislocation of right ankle. IDT (Interdisciplinary Team) meeting to discuss fall from 10/07/23. Resident alert and oriented x4. BIMS 14. Resident requires no physical assist with ADLs (activities of daily living) and transfers. Resident is continent of bowel and bladder. RCA: Walked to bed and turned to sit and sit to close to edge of bed and slid off onto floor. All previous fall interventions in place adding encourage resident to reach back with hands and feel before sitting that she's close enough. All parties agree with plan of care. Care plan reviewed and updated. On 11/21/23 at 11:05 AM, R2 observed sitting in her wheelchair in room which is located at the opposite end of the hall from the nurses' station. On 11/22/23 at 10:00 AM, V5, Care Plan Coordinator stated that R2 has interventions for all of her falls except for the falls on 07/03/23 and 08/12/23. On 11/28/23 at 10:15 am, V2, DON (Director of Nursing) stated that she would expect a resident to have an intervention put in place after every fall. She stated that she would expect a resident that has had multiple falls to be supervised closer and moved closer to the nurses' station. Facility policy Fall Prevention and Management dated 09/2022 documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well- being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. 4. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on interview, observation, and record review, the facility failed to assure bed rails were securely attached to the bed frame to maintain resident safety for 3 of 5 residents (R4, R7, R8) reviewed for resident safety in the sample of 16. This failure resulted in R4's bed rail falling off and R4 sustaining a fall out of bed with multiple facial fractures and being hospitalized . Findings include: 1. R4's Admission Record, undated, documents R4 was admitted to the facility on [DATE] and was discharged to the hospital on 6/29/23. R4's Electronic Medical Record documents R4's Diagnosis include Emphysema, Morbid Obesity, Type 2 Diabetes Mellitus, (DM), Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, (COPD), Osteoarthritis, Intestinal obstruction, Cognitive Communication Deficit, Dysphagia, Major Depressive Disorder, End Stage Renal Disease (ESRD)/chronic kidney disease, (CKD), Renal Dialysis, Malignant Neoplasm of Rectum, Fibromyalgia, Mixed incontinence, Hypertension, (HTN), and Hyperlipidemia. R4's Baseline Care Plan, dated 6/28/23, documents, (R4) is at risk for falls. Interventions: call light within reach, provide clutter-free environment, encourage use of assistive device, provide proper, well-maintained footwear. R4's Care Plan, dated 6/30/23, documents, entered 7/7/23: (R4) is at risk for falls related to, impaired mobility, poor safety awareness and DX, (diagnosis): DM II, Osteoarthritis, and HTN. Interventions: 6/29/23 Facility side rail audit completed. Educate resident on using call light to ask for help, encourage appropriate use of assistive device, evaluate multiple falls to determine commonalities or patterns, fall risk assessment quarterly and as needed, keep frequently used items within reach, promote placement of call light within reach and assess resident's ability to use, provide proper, well-maintained footwear. R4's Minimum Data Set, (MDS), dated [DATE], documents, R4 was cognitively intact with a Basic Interview for Mental Status, (BIMS), of 14. R4 required extensive assistance of one staff person for bed mobility, toilet use, transfers, and locomotion. R4 was occasionally incontinent of urine and has a colostomy. R4's Fall Risk Evaluation, dated 6/27/23 at 4:54 PM, documents, R4 was a High Risk for falls with a score of 11. Scoring a 10 or higher makes resident High Risk for Falls. R4's Nurses Note, dated 6/29/23 at 5:24 AM, documents Staff completed rounds this nurse and CNA, (Certified Nursing Assistant), were in hallway and heard resident yelling for help. Upon entering room res, (resident), found lying face first on the floor on top of her right-side rail. Res stated, I tried to roll over in bed. Res complaining of bilat, (bilateral), hip pain and has small abrasion to middle of forehead. Res made comfortable until EMS, (Emergency Medical Service), arrived. Res assisted from floor to stretcher via, (full body mechanical lift). Call placed to responsible party (V12) -no answer, voicemail left to call facility at earliest convenience. Call placed to Dr., (doctor), (V16) - voicemail left. Nurse manager made aware. Res alert and oriented, able to make needs known, continues on 3 L, (liters), 02, (oxygen). Transferred to (Local Hospital), ER, (emergency room ), for treatment and eval. VS, (vital signs), as follows 170/78-98-18-92%. R4's Nurses Note, dated 6/29/23 at 8:57 AM, documents, This nurse called for update on resident spoke with ER Nurse who is currently taking care of resident and was told resident has several fractures to whole face and currently awaiting results from CT, (cat scan), full body scan and will be transferred to, (Regional Hospital), for further evaluation and treatment. All parties notified. On 7/10/23 at 9:00 AM, R5 (R4's Roommate) stated, The nurse had just come in that night to check on us and shortly after she left, I heard a big bang and it sounded like the bedrail fell off, then I heard (R4) yelling for help. I couldn't see anything because of the wall between us. I heard the staff tell the ambulance guys that the bed rail fell off the bed. They were going to put another resident in that bed but, that resident wanted a warmer room, so they switched to a different room. I don't think they should use that bed until it is fixed. On 7/10/23 at 9:05 AM, room [ROOM NUMBER]-1, R4's bed, is currently empty. The bed appears to be an older bed with an air mattress on the bed frame. There is only one side rail on the left-side of the bed, (while lying in the bed), which is a metal rail with seven metal bars vertical on the rail. The bed rail is only secured by a black hand-turn knob that secures it to the bed by tightening it to the bedframe. The right-side bed rail is not on the bed. On 7/10/23 at 9:20 AM, V9, Maintenance Director, stated, If there is something that needs fixed in the facility, the staff can put it into the computer system and that will make a work order for me to do. I will usually send (V10, Maintenance Worker) to fix it. I don't recall any requests for bed rails to be fixed. We have a group text that sometimes, they use to put in a request for something to be fixed, but I don't see anything in the group text about bed rails. I did have a request on 6/21/23, to remove the bed from 110-1 to room [ROOM NUMBER], so that was done. I never know why; I just do what the work order says. We do inspections every week to all beds in the facility. We look at the power to the bed, the bed deflate/inflate as needed, and the bed rails to make sure they are secured. I don't really have a record of those inspections except for my last one on 6/29/23 after (R4) fell . On 7/10/23 at 9:25 AM, V10, Maintenance Worker, stated, There are a lot of times that the staff will catch me in the hallway and ask us to fix something and a work order isn't really done, we just go in and do it. I remember someone grabbed me one day and said that room [ROOM NUMBER]-1 needed a new bed rail for the resident to use as a support rail for turning. I made sure that the rails were secured to the bed before I left. I guess the only way a bed rail would fall off is if it wasn't put on properly or sometimes the resident uses it so much that it becomes loose. On 7/10/23 at 11:42 AM, V11, Social Worker at (Regional Hospital), stated, I'm the Social Worker helping (R4) and her husband at the hospital. They did not want to report it themselves because they felt they would have backlash. What they told me was that (R4) was admitted to the facility and immediately upon admission to her bed, she told the staff that her bed rail was loose and wiggly. They stated that they made it very clear to several staff members that it needed fixed, and no one did anything about it. (R4) stated, that while she was trying to reposition in bed, the bed rail fell off and she fell to the floor. (R4) is still in the ICU with multiple facial fractures and they are refusing to go back to that facility. On 7/10/23 at 11:49 AM, V12, R4's Husband, stated My wife (R4) got to the facility and upon putting her in her bed, she noticed that her bed rail was very loose and wiggly. She told and showed them how loose it was, and no one did anything to fix it. She was only there about a day or so, and I believe it was the nurse who called me around 4:00 AM and told me that my wife's bed rail fell off and she fell out of bed and was going to (Regional Hospital). They x-rayed just about everything, and it looks like she only has facial fractures. (R4) said it was the nurse who was working with her upon admission that she talked to about the bed rail. I went into the facility after she fell to collect all her belongings, and when I got to her room, they still had the same bed there with the rail sitting on the bed. I got down on the floor to look at how the rails are attached to the bed, and it is only attached by a hand knob that you hand tighten. All anyone had to do was to tighten the black knob and my wife would not be in this condition. Anyone could have done that. Their negligence is why my wife is like she is now. On 7/10/23 at 12:52 PM, V13, RN (Registered Nurse), stated, I was the one who admitted (R4). I am new to the facility and remember that I was very focused on the computer and my documentation. I vaguely remember someone in the room saying something about a bed rail, but without making something up or lying about it, that is about all I remember. When I came back to work, I heard that she fell out of bed. On 7/10/23 at 1:05 PM, room [ROOM NUMBER]-1's bed is empty, made up and ready for a new resident. The bed appears to have the same bed rails as R4's bed. Upon examination of the bed rails, both side rails have the same black hand turn knob that attaches it to the bed frame, and when examined, both knobs were loose and easily turned. On 7/12/23 at 10:45 AM, V20, CNA Supervisor, stated, I told the nurse the day before she fell that (R4) was leaning on that bed rail. The facility's Fall Investigation dated 6/29/23 at 4:45 AM, documents, Incident Description: Staff completed rounds at 4:45 AM, resident repositioned in bed and peri-care completed. This nurse and CNA, (Certified Nursing Assistant), were in hallway and heard a loud noise, heard resident screaming for help. Upon entering room, resident was laying face first on the floor on top of side rail. Resident has small abrasion to forehead and complaining of bilat hip pain. Resident stated, I was trying to turn over in bed. Predisposing Environmental Factors: Safety Device. Predisposing Situation Factors: Side Rails Up. The Facility's Sentinel Call Worksheet dated 6/29/23 at 9:30 AM, documents, the date of incident: 6/29/23, the time of incident: 5:15 AM, the location: Resident's Room. What occurred: Resident Rolled out of bed and rail came off. How it Occurred: The Railing came off the bed. Staff training - immediate needs? The whole house side rail audit was done. The Facility's Post Fall Huddle, dated 6/29/23 at 5:15 AM, documents, What did the resident say he/she was trying to do just before the fall? Rolled over. What appears to be the initial root cause of the fall? Rolled out of bed. Side rail off. Conclusion: Resident rolled out of bed. The Facility's Follow-Up Investigation Report, dated 7/6/23, documents R4 has frontal sinus facial fracture, mildly compressed skull fx, (fracture), with possible subdural hematoma. Interview of alleged victim: Resident (R4) reported she rolled out of bed repositioning herself. Medical record review: Resident is alert and oriented X 3 and was able to make all needs known. Transfer status assist of X 2 for ADLs (Activities of Daily Living) and transfers. Resident is continent of bowel and bladder. Conclusion page: Unsubstantiated. Conclusion: Following a complete and thorough review including interviews and resident record, this occurrence was determined to be unavoidable. Root cause analysis: Resident attempted to turn and reposition without assistance and fell off the bed onto the floor. This allegation cannot be substantiated. (Completed by V2, Director of Nursing/DON) The Facility's Side Rail Audit, completed by V9, dated 6/29/23, documents room [ROOM NUMBER]-1 Bed 1 empty bed with BW, (black and white), rail regular, Bed 2 hospital bed. R4's (Local Hospital) emergency room record, dated 6/29/23, documents Pt., (patient), arrives in ED, (Emergency Department), via EMS from, (Facility), SNF, (Skilled Nursing Facility), c/o, (complaint of), bilateral hip pain s/p, (status post), fall. Pt. AO, (alert and oriented), X 4 and in NAD, (no added distress). Per EMS pt was being moved or turned at SNF and one of the bed rails gave way and she fell from the bed to the floor. A CT, (cat scan), of R4's Cervical Spine, Thoracic and Lumbar Spine, Abdomen/Pelvis, Facial Bones, and Head were completed with R4's CT Results: Mildly depressed fracture of the left frontal bone involving the left frontal sinus. Subtle increased density along the left anterior cranial fossa deep to the site of fracture. This is non-specific for a tiny subdural hemorrhage. R4 was transferred to, (Regional Hospital), Geriatric Trauma Team. R4's (Regional Hospital) emergency room record, dated 6/29/23, documents, Female transfer from, (Local Hospital), following fall. Per EMS, pt. was being turned by staff at facility when the side railing of her bed broke off and pt. fell out of bed flat onto her front side. OSH (outside hospital) imaging showed several facial fx, (fractures), as well as possible underlying SDH, (subdural hematoma/hemorrhage). 2. R7's Admission Record, undated, documents R7 was admitted to the facility on [DATE]. R7's Electronic Medical Record, documents R7's Diagnosis include Cerebrovascular Accident, (CVA), Hemiplegia/Hemiparesis, Dysphagia, Morbid Obesity, DM, Visuospatial Deficit, Frontal lobe and Executive function deficit, Cognitive social or emotional deficit, Attention and concentration deficit, Anemia, ESRD/CKD, Dialysis, Anxiety disorder, HTN, Hyperlipidemia. R7's Care Plan, dated 6/6/23, documents, (R7) requires healthcare monitoring related to DX: CVA with Hemiparesis. She is at risk for impaired mobility and impaired communication related to effects of hemisphere damage on language or speech. It continues (R7) is at high risk for falls r/t, (related to), weakness d/t, (due to), hx, (history), /dx of CVA with hemiplegia, Dysphagia, Morbid Obesity, DM, CCD, (cognitive communication deficit), Osteomyelitis, Anxiety, HTN, Hyperlipidemia, ESRD and Anemia. Resident is an extensive assistance of two staff members for bed mobility. Resident is a total assistance of two staff members for toileting and transfers. Resident has weakness present. Resident utilizes Geri-chair. Interventions: 6/5/21 Bed moved against wall, fall mats placed by bed, fall risk assessment quarterly and as needed, promote placement of call light within reach and assess resident's ability to use. It continues (R7) has a self-care deficit in bed mobility r/t weakness and decreased mobility. Interventions: 2. Instruct and assist to cross leg over other towards the side turning to. 3.instruct to look towards the rail of the side turning to. 4.instuct to roll shoulders toward the side turning to. 5.Instruct to reach/grasp for rail of side turning to. 6. Instruct and assist to pull self toward side turning to. It continues (R7) requires assist with daily care needs r/t weakness d/t hx/dx of CVA with hemi, Dysphagia, Morbid Obesity, DM, CCD, Osteomyelitis, Anxiety, HTN, Hyperlipidemia, ESRD and Anemia. Resident is an extensive assistance of two staff members for bed mobility. Resident is a total assistance of two staff members for toileting and transfers. Resident has a (urinary catheter) and functional incontinence of bowel. Resident has a G (gastric)-tube present is NPO, (nothing by mouth). Resident is a total assistance of one staff member for meals. Resident has weakness present. Resident utilizes Geri-chair. She utilizes 1/2 side rails up X 2 to enhance mobility and transfer. Interventions: (full body mechanical lift), with two assists for transfers. R7's MDS, dated [DATE], documents, R7 has a moderate cognitive impairment with a BIMS of 12. R7 requires total dependence on two staff members for transfers, toilet use, and bathing. R7 requires extensive assistance from one to two staff members for all other ADLs. R7 is always incontinent of urine and frequently incontinent of bowel. R7's Physician Order, dated 7/10/23, documents, 1/2 Side rails up X 2 to enhance mobility and transfer. R7's Fall Risk Evaluation, dated 9/15/22, documents, R7 was a High Risk for falls with a score of 11. Scoring a 10 or higher makes resident High Risk for falls. On 7/10/23 at 1:38 PM, R7 was seen sitting in a recliner chair by her bed. R7 has the same bed rails as R4's bed had, and upon examination, the black hand turn knob on the right-side rail was loose and easily turned. The left side rail was against the wall and could not be examined. R7 stated that her rail is a little wobbly but has never fallen off. 3. R8's Admission Record, undated, documents R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents, R8's diagnosis include: CVA, Hemiplegia/Hemiparesis, Acute/Chronic Respiratory Failure, Type 2 DM, Aphasia, Dysphagia, Anemia, ESRD/CKD, Gastrostomy, HTN, Deep Vein Thrombosis, (DVT), and Dependence on Renal Dialysis. R8's Care Plan, dated 4/18/23, documents (R8) is at risk for developing an impairment in functional joint mobility/ (R8) has impaired functional mobility/ (R8) has contractures noted to (specify), r/t: weakness/ discomfort when moving/ spasm of affected area/ poor motivation/ inactivity resulting from impaired cognition/ inactivity resulting from (specify)/ neurological deficit. R8's MDS, dated [DATE], documents, R8 has a severe cognitive impairment and requires total dependence for all his ADLs. R8 is always incontinent of both bowel and bladder. R8's Fall Risk Evaluation, dated 6/27/23, documents, R8 is a High Fall Risk with a score of 13. Scoring a 10 or higher makes resident High Risk for falls. On 7/10/23 at 1:35 PM, R8 was seen lying in his bed with the same bed rails as R4's bed. Upon examination of the rails, both side rails had the black hand turn knob which was loose and easily turned. The rails appeared to be wobbly. R8 was not able to communicate. On 7/11/23 at 12:00 PM, V17, Regional Director of Operations, stated, I went and looked at the rooms you mentioned that had loose bed rails and I only found one of them, in room [ROOM NUMBER]-2 (R8's bed), that was loose. Someone must have tightened the other two. I have our maintenance guys going room to room and tightening all the bed rails. On 7/13/23 at 8:55 AM, V1, Administrator, stated, Anytime a staff member is notified or sees something that is broke, or in need of repair, I would expect them to report it to maintenance immediately. I would expect maintenance to make the repair as soon as possible. The Facility's Use of Bed Rail Policy, dated 10/2022, documents, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. 6. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes a. Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. b. Ensuring that the bed's dimensions are appropriate for the resident by: i. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed; ii. Installing bed rails using the manufacturer's instructions and specifications to ensure a proper fit; iii. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; iv. Ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. v. Checking bed rails regularly to make sure they are still installed correctly and have not shifted or loosened over time. c. Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. 8. Responsibilities of ongoing monitoring and supervision are specified as follows: d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails. The Facility's Fall Prevention and Management Policy, dated 9/2022, documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well- being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. 1. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. 2. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP with interventions implemented to minimize fall risk.

Based on interview, observation, and record review, the facility failed to assure bed rails were securely attached to the bed frame to maintain resident safety for 3 of 5 residents (R4, R7, R8) reviewed for residents' safe environment in the sample of 16. This failure resulted in R4's bed rail falling off, R4 sustaining a fall out of bed and requiring hospitalization with multiple facial fractures. Findings include: 1. R4's Admission Record, undated, documents R4 was admitted to the facility on [DATE] and was discharged to the hospital on 6/29/23. R4's Electronic Medical Record documents R4's Diagnosis include Emphysema, Morbid Obesity, Type 2 Diabetes Mellitus, (DM), Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, (COPD), Osteoarthritis, Intestinal obstruction, Cognitive Communication Deficit, Dysphagia, Major Depressive Disorder, End Stage Renal Disease (ESRD)/chronic kidney disease, (CKD), Renal Dialysis, Malignant Neoplasm of Rectum, Fibromyalgia, Mixed incontinence, Hypertension, (HTN), and Hyperlipidemia. R4's Baseline Care Plan, dated 6/28/23, documents (R4) is at risk for falls. Interventions: call light within reach, provide clutter-free environment, encourage use of assistive device, provide proper, well-maintained footwear. R4's Care Plan, dated 6/30/23, documents Entered 7/7/23: (R4) is at risk for falls related to impaired mobility, poor safety awareness and DX, (diagnosis): DM II, Osteoarthritis, and HTN. Interventions: 6/29/23 Facility side rail audit completed. Educate resident on using call light to ask for help, encourage appropriate use of assistive device, evaluate multiple falls to determine commonalities or patterns, fall risk assessment quarterly and as needed, keep frequently used items within reach, promote placement of call light within reach and assess resident's ability to use, provide proper, well-maintained footwear. R4's Minimum Data Set, (MDS), dated [DATE], documents R4 was cognitively intact with a Basic Interview for Mental Status, (BIMS), of 14. R4 required extensive assistance of one staff person for bed mobility, toilet use, transfers, and locomotion. R4 was occasionally incontinent of urine and has a colostomy. R4's Fall Risk Evaluation, dated 6/27/23 at 4:54 PM, documents, R4 was a High Risk for falls with a score of 11. Scoring a 10 or higher makes resident High Risk for Falls. R4's Nurses Note, dated 6/29/23 at 5:24 AM, documents Staff completed rounds this nurse and CNA, (Certified Nursing Assistant), were in hallway and heard resident yelling for help. Upon entering room res, (resident), found lying face first on the floor on top of her right-side rail. Res stated, I tried to roll over in bed. Res complaining of bilat (bilateral) hip pain and has small abrasion to middle of forehead. Res made comfortable until EMS, (Emergency Medical Service), arrived. Res assisted from floor to stretcher via (full body mechanical lift). Call placed to responsible party (V12) -no answer, voicemail left to call facility at earliest convenience. Call placed to Dr., (Doctor), (V16) - voicemail left. Nurse manager made aware. Res alert and oriented, able to make needs known, continues on 3 L, (liters), 02, (oxygen). Transferred to (Local Hospital), ER, (emergency room ), for treatment and eval. VS, (vital signs), as follows 170/78-98-18-92%. R4's Nurses Note, dated 6/29/23 at 8:57 AM, documents, This nurse called for update on resident spoke with ER Nurse who is currently taking care of resident and was told resident has several fractures to whole face and currently awaiting results from CT, (cat scan), full body scan and will be transferred to (Regional Hospital), for further evaluation and treatment. All parties notified. On 7/10/23 at 9:00 AM, R5 (R4's Roommate) stated, The nurse had just come in that night to check on us and shortly after she left, I heard a big bang and it sounded like the bedrail fell off, then I heard (R4) yelling for help. I couldn't see anything because, of the wall between us. I heard the staff tell the ambulance guys that the bed rail fell off the bed. They were going to put another resident in that bed but, that resident wanted a warmer room, so they switched to a different room. I don't think they should use that bed until it is fixed. On 7/10/23 at 9:05 AM, room [ROOM NUMBER]-1, R4's bed, is currently empty. The bed appears to be an older bed with an air mattress on the bed frame. There is only one side rail on the left-side of the bed (while lying in the bed), which is a metal rail with seven metal bars vertical on the rail. The bed rail is only secured by a black hand-turn knob that secures it to the bed by tightening it to the bedframe. The right-side bed rail is not on the bed. On 7/10/23 at 9:20 AM, V9, Maintenance Director, stated, If there is something that needs fixed in the facility, the staff can put it into the computer system and that will make a work order for me to do. I will usually send (V10, Maintenance Worker) to fix it. I don't recall any requests for bed rails to be fixed. We have a group text that sometimes they use to put in a request for something to be fixed, but I don't see anything in the group text about bed rails. I did have a request on 6/21/23, to remove the bed from 110-1 to room [ROOM NUMBER], so that was done. I never know why; I just do what the work order says. We do inspections every week to all beds in the facility. We look at the power to the bed, the bed deflate/inflate as needed, and the bed rails to make sure they are secured. I don't really have a record of those inspections except for my last one on 6/29/23 after (R4) fell . On 7/10/23 at 9:25 AM, V10, Maintenance Worker, stated, There are a lot of times that the staff will catch me in the hallway and ask us to fix something and a work order isn't really done, we just go in and do it. I remember someone grabbed me one day and said that room [ROOM NUMBER]-1 needed a new bed rail for the resident to use as a support rail for turning. I made sure that the rails were secured to the bed before I left. I guess the only way a bed rail would fall off is if it wasn't put on properly or sometimes the resident uses it so much that it becomes loose. On 7/10/23 at 11:42 AM, V11, Social Worker at (Regional Hospital), stated I'm the Social Worker helping (R4) and her husband at the hospital. They did not want to report it themselves because they felt they would have backlash. What they told me was that (R4) was admitted to the facility and immediately upon admission to her bed, she told the staff that her bed rail was loose and wiggly. They stated that they made it very clear to several staff members that it needed fixed, and no one did anything about it. (R4) stated that while she was trying to reposition in bed, the bed rail fell off and she fell to the floor. (R4) is still in the ICU with multiple facial fractures and they are refusing to go back to that facility. On 7/10/23 at 11:49 AM, V12, R4's Husband, stated, My wife (R4) got to the facility and upon putting her in her bed, she noticed that her bed rail was very loose and wiggly. She told and showed them how loose it was, and no one did anything to fix it. She was only there about a day or so, and I believe it was the nurse who called me around 4:00 AM and told me that my wife's bed rail fell off and she fell out of bed and was going to (Regional Hospital). They x-rayed just about everything, and it looks like she only has facial fractures. (R4) said it was the nurse who was working with her upon admission that she talked to about the bed rail. I went into the facility after she fell to collect all her belongings, and when I got to her room, they still had the same bed there with the rail sitting on the bed. I got down on the floor to look at how the rails are attached to the bed, and it is only attached by a hand knob that you hand tighten. All anyone had to do was to tighten the black knob and my wife would not be in this condition. Anyone could have done that. Their negligence is why my wife is like she is now. On 7/10/23 at 12:52 PM, V13, RN, (Registered Nurse), stated, I was the one who admitted (R4). I am new to the facility and remember that I was very focused on the computer and my documentation. I vaguely remember someone in the room saying something about a bed rail, but without making something up or lying about it, that is about all I remember. When I came back to work, I heard that she fell out of bed. On 7/10/23 at 1:05 PM, room [ROOM NUMBER]-1's bed is empty, made up and ready for a new resident. The bed appears to have the same bed rails as R4's bed. Upon examination of the bed rails, both side rails have the same black hand turn knob that attaches it to the bed frame, and when examined, both knobs were loose and easily turned. On 7/12/23 at 10:45 AM, V20, CNA Supervisor, stated, I told the nurse the day before she fell that (R4) was leaning on that bed rail. The facility's Fall Investigation dated 6/29/23 at 4:45 AM, documents, Incident Description: Staff completed rounds at 4:45 AM, resident repositioned in bed and peri-care completed. This nurse and CNA, (Certified Nursing Assistant), were in hallway and heard a loud noise, heard resident screaming for help. Upon entering room, resident was laying face first on the floor on top of side rail. Resident has small abrasion to forehead and complaining of bilat hip pain. Resident stated, I was trying to turn over in bed. Predisposing Environmental Factors: Safety Device. Predisposing Situation Factors: Side Rails Up. The Facility's Sentinel Call Worksheet dated 6/29/23 at 9:30 AM, documents, the date of incident: 6/29/23, the time of incident: 5:15 AM, the location: Resident's Room. What occurred: Resident Rolled out of bed and rail came off. How it Occurred: The Railing came off the bed. Staff training - immediate needs? The whole house side rail audit was done. The Facility's Post Fall Huddle, dated 6/29/23 at 5:15 AM, documents What did the resident say he/she was trying to do just before the fall? Rolled over. What appears to be the initial root cause of the fall? Rolled out of bed. Side rail off. Conclusion: Resident rolled out of bed. The Facility's Follow-Up Investigation Report, dated 7/6/23, documents, R4 has frontal sinus facial fracture, mildly compressed skull fx, (fracture), with possible subdural hematoma. Interview of alleged victim: Resident (R4) reported she rolled out of bed repositioning herself. Medical record review: Resident is alert and oriented X 3 and was able to make all needs known. Transfer status assist of X 2 for ADLs, (Activities of Daily Living), and transfers. Resident is continent of bowel and bladder. Conclusion page: Unsubstantiated. Conclusion: Following a complete and thorough review including interviews and resident record, this occurrence was determined to be unavoidable. Root cause analysis: Resident attempted to turn and reposition without assistance and fell off the bed onto the floor. This allegation cannot be substantiated. (Completed by V2, Director of Nursing/DON) The Facility's Side Rail Audit, completed by V9, dated 6/29/23, documents room [ROOM NUMBER]-1, Bed 1 empty bed with BW, (black and white), rail regular, Bed 2 hospital bed. R4's (Local Hospital), emergency room record, dated 6/29/23, documents Pt. (patient) arrives in ED, (Emergency Department), via EMS from (Facility) SNF, (Skilled Nursing Facility), c/o, (complaint of), bilateral hip pain s/p, (status post), fall. Pt. AO, (alert and oriented), X 4 and in NAD, (no added distress). Per EMS pt was being moved or turned at SNF and one of the bed rails gave way and she fell from the bed to the floor. A CT, (cat scan), of R4's Cervical Spine, Thoracic and Lumbar Spine, Abdomen/Pelvis, Facial Bones, and Head were completed with R4's CT Results: Mildly depressed fracture of the left frontal bone involving the left frontal sinus. Subtle increased density along the left anterior cranial fossa deep to the site of fracture. This is non-specific for a tiny subdural hemorrhage. R4 was transferred to (Regional Hospital), Geriatric Trauma Team. R4's (Regional Hospital) emergency room record, dated 6/29/23, documents Female transfer from (Local Hospital), following fall. Per EMS, pt. was being turned by staff at facility when the side railing of her bed broke off and pt. fell out of bed flat onto her front side. OSH, (outside hospital), imaging showed several facial fx, (fractures), as well as possible underlying SDH, (subdural hematoma/hemorrhage). 2. R7's Admission Record, undated, documents R7 was admitted to the facility on [DATE]. R7's Electronic Medical Record, documents R7's Diagnosis include: Cerebrovascular Accident, (CVA), Hemiplegia/Hemiparesis, Dysphagia, Morbid Obesity, DM, Visuospatial Deficit, Frontal lobe and Executive function deficit, Cognitive social or emotional deficit, Attention and concentration deficit, Anemia, ESRD/CKD, Dialysis, Anxiety disorder, HTN, Hyperlipidemia. R7's Care Plan, dated 6/6/23, documents (R7) requires healthcare monitoring related to DX: CVA with Hemiparesis. She is at risk for impaired mobility and impaired communication related to effects of hemisphere damage on language or speech. It continues (R7) is at high risk for falls r/t, (related to), weakness d/t, (due to), hx, (history), /dx of CVA with hemiplegia, Dysphagia, Morbid Obesity, DM, CCD, (cognitive communication deficit), Osteomyelitis, Anxiety, HTN, Hyperlipidemia, ESRD and Anemia. Resident is an extensive assistance of two staff members for bed mobility. Resident is a total assistance of two staff members for toileting and transfers. Resident has weakness present. Resident utilizes Geri-chair. Interventions: 6/5/21 Bed moved against wall, fall mats placed by bed, fall risk assessment quarterly and as needed, promote placement of call light within reach and assess resident's ability to use. It continues (R7) has a self-care deficit in bed mobility r/t weakness and decreased mobility. Interventions: 2. Instruct and assist to cross leg over other towards the side turning to. 3.instruct to look towards the rail of the side turning to. 4.instuct to roll shoulders toward the side turning to. 5.Instruct to reach/grasp for rail of side turning to.6. Instruct and assist to pull self toward side turning to. It continues (R7) requires assist with daily care needs r/t weakness d/t hx/dx of CVA with hemi, Dysphagia, Morbid Obesity, DM, CCD, Osteomyelitis, Anxiety, HTN, Hyperlipidemia, ESRD and Anemia. Resident is an extensive assistance of two staff members for bed mobility. Resident is a total assistance of two staff members for toileting and transfers. Resident has a (urinary catheter), and functional incontinence of bowel. Resident has a G, (gastric)-tube present is NPO, (nothing by mouth). Resident is a total assistance of one staff member for meals. Resident has weakness present. Resident utilizes Geri-chair. She utilizes 1/2 side rails up X 2 to enhance mobility and transfer. Interventions: (full body mechanical lift), with two assists for transfers. R7's MDS, dated [DATE], documents R7 has a moderate cognitive impairment with a BIMS of 12. R7 requires total dependence on two staff members for transfers, toilet use, and bathing. R7 requires extensive assistance from one to two staff members for all other ADLs. R7 is always incontinent of urine and frequently incontinent of bowel. R7's Physician Order, dated 7/10/23, documents 1/2 Side rails up X 2 to enhance mobility and transfer. R7's Fall Risk Evaluation, dated 9/15/22, documents R7 was a High Risk for falls with a score of 11. Scoring a 10 or higher makes resident High Risk for falls. On 7/10/23 at 1:38 PM, R7 was seen sitting in a recliner chair by her bed. R7 has the same bed rails as R4's bed had, and upon examination, the black hand turn knob on the right-side rail was loose and easily turned. The left side rail was against the wall and could not be examined. R7 stated that her rail is a little wobbly. 3. R8's Admission Record, undated, documents R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents R8's diagnosis include: CVA, Hemiplegia/Hemiparesis, Acute/Chronic Respiratory Failure, Type 2 DM, Aphasia, Dysphagia, Anemia, ESRD/CKD, Gastrostomy, HTN, Deep Vein Thrombosis, (DVT), and Dependence on Renal Dialysis. R8's Care Plan, dated 4/18/23, documents (R8) is at risk for developing an impairment in functional joint mobility/ (R8) has impaired functional mobility/ (R8) has contractures noted to (specify) r/t: weakness/ discomfort when moving/ spasm of affected area/ poor motivation/ inactivity resulting from impaired cognition/ inactivity resulting from (specify)/ neurological deficit. R8's MDS, dated [DATE], documents R8 has a severe cognitive impairment and requires total dependence for all his ADLs. R8 is always incontinent of both bowel and bladder. R8's Fall Risk Evaluation, dated 6/27/23, documents R8 is a High Fall Risk with a score of 13. Scoring a 10 or higher makes resident High Risk for falls. On 7/10/23 at 1:35 PM, R8 was seen lying in his bed with the same bed rails as R4's bed. Upon examination of the rails, both side rails had the black hand turn knob which was loose and easily turned. The rails appeared to be wobbly. R8 was not able to communicate. On 7/11/23 at 12:00 PM, V17, Regional Director of Operations, stated I went and looked at the three rooms you mentioned that had loose bed rails and I only found one of them, in room [ROOM NUMBER]-2 (R8's bed), that was loose. Someone must have tightened the other two. I have our maintenance guys going room to room and tightening all the bed rails. On 7/13/23 at 8:55 AM, V1, Administrator, stated Anytime a staff member is notified or sees something that is broke or in need of repair, I would expect them to report it to maintenance immediately. I would expect maintenance to make the repair as soon as possible. The Facility's Use of Bed Rail Policy, dated 10/2022, documents It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. 6. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes a. Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. b. Ensuring that the bed's dimensions are appropriate for the resident by: i. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed; ii. Installing bed rails using the manufacturer's instructions and specifications to ensure a proper fit; iii. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; iv. Ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. v. Checking bed rails regularly to make sure they are still installed correctly and have not shifted or loosened over time. c. Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. 8. Responsibilities of ongoing monitoring and supervision are specified as follows: d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails.

Based on interview and record review, the facility failed to ensure adequate hydration for 1 of 4 residents (R3) reviewed for hydration in the sample of 10. This failure resulted in R3 being admitted to the hospital with severe dehydration. Findings include: R3's Face Sheet, undated, documents R3 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus, Gangrene, Kidney Disease, Non-Pressure Chronic Ulcer of the Left Lower Extremity, Right Below the Knee Amputation, Hypothyroidism and Other Symptoms Concerning Food and Fluid Intake. R3's Minimum Data Set (MDS), dated [DATE], documents R3 had moderate cognitive impairment and required supervision with eating. R3's Dehydration Risk Assessment, dated 9/28/22, documents R3 is at risk of dehydration. R3's Progress Notes, document the following: 1/11/2023 at 10:00 AM, Resident refused breakfast this am, writer offered to get resident something different from the kitchen, resident declined stating I just don't have an appetite. V10, R3's Sister has been informed, no complaints or concerns have been voiced. 1/11/2023 at 1:04 PM, Resident is alert and oriented times 3. Resident is able to verbally make her needs known. Resident does display symptoms of depression. Nursing staff noticed a decline in her health and inquired about hospice. Social Service Director (SSD) plans to reach out to family with updates. Lately the resident tends to self isolate, and she limits her socialization with others. It has been reported that resident refuses medications and food at times. 1/17/2023 at 11:19 AM, SSD discussed discharging with V10. V10 expressed she feels that R3 is on a decline and wants her out of the facility. V10 was informed that resident can be signed out against medical advice but strongly advised against it by medical staff. V10 reported wanting her to discharge back into the community but is concerned about the wound on her foot/toes. Nurse Practitioner and therapy were made aware, and both agree that it would not be a safe discharge. V10 states she agrees and understands that R3 will need 24 hour care if released. Resident remains in the facility; 1/19/2023 at 1:00 PM, Physician's Note: examined today, restless, anxious, confused: oxygen leave 74 on room air , heart rate 188, STAT (as soon as possible) nurse to start oxygen at 2-3 liters per nasal cannula with a goal of > 90 %, vital signs every shift and as needed. Stat urinalysis, Comprehensive Metabolic [NAME], Hemoglobin A1C, Complete Blood Count, Thyroid Stimulating Hormone, Chest X-ray, Electrocardiogram. Have Cardiology Nurse Practitioner consult with resident; 1/19/2023 at 6:04 PM, Resident taken off oxygen, saturation increased to 94% on room air. Resident is not showing signs of confusion at this time. Electrocardiogram resulted abnormal. Nurse Practitioner made aware, new order for cardiologist consult. Order entered. Vitals at this time are stable. Non stat eligible labs entered for routine draw on 1-20-22. Attempted to notify family, no answer, voice mail left; 1/19/2023 at 10:25 PM, Lab called in creatinine result of 16.5 (high) and blood urea nitrogen result of 291 (high). Called V16, R3's Physician and notified him of results, V16 instructed to send resident to the emergency room . 1/20/2023 at 4:17 AM, admitted to hospital with admitting diagnosis of Sepsis; 1/24/2023 at 10:48 AM, This nurse spoke with a nurse at the hospital intensive care unit. The nurse stated that resident has Cholecystitis and has plans to be taken to surgery for a splenectomy as well. There are no discharge plans at this time. R3's Hospital History and Physical, dated 1/19/23, documents R3 looks extremely dry, skin texture and turgor are markedly decreased, skin tense, oral mucosal membrane is extremely dry, tongue has an appearance of sandpaper. Skin texture and turgor are markedly decreased as noted, skin tense, lower extremities have pigmentation changes consistent with some previous, presumed, chronic venous stasis, toes and feet are almost withered, skin thickened, poor hygiene and long nails. Presents with very severe dehydration. R3's Blood Urea Nitrogen (BUN) was 306 (high) and her creatinine was 14.6 (high). On 3/29/23/ at 10:45 AM, V10, R3's Sister, stated R3 came to the facility for rehab after surgery. V10 stated she is not sure why R3 was there as long as she was because she had an apartment to go back to and was only here for rehab. V10 stated R3 was sent to the hospital because her vital signs were off and she didn't have any fluids in her. On 3/30/23 at 11:10 AM, V2, Administrator in Training, stated she would expect the nurses to put interventions in place for residents at risk for dehydration. On 3/31/23 at 9:15 AM, V16, Physician, stated if a resident is at risk for dehydration, she would expect the dietician to evaluate the patient, make recommendations and then the facility should consult with her for orders. V16 stated she would expect the facility to notify her of those recommendations and with any changes in a resident's condition. V16 stated a BUN/Creatinine of 306/14.6 is high, some patients can tolerate it that high but others cannot and it would be important to have them evaluated as soon as possible. V16 stated when those numbers (BUN/Creatinine) are elevated it means there is a problem with the kidneys and can be caused by kidney disease and dehydration, among other health conditions. The Hydration policy, dated 5/2015, documents this policy allows for each resident to be provided with sufficient fluid intake to maintain proper hydration and health. This is done through an evaluation to identify risk factors that may lead to dehydration, and, if present, a preventative care plan is developed.

Based on interview and record review, the facility failed to notify the Physician of change of condition including blood sugar levels in a timely manner for 1 of 3 residents (R2) reviewed for Physician notification in a sample of 14. This failure resulted in R2's condition changing without notification to R2's physician. R2 expired. Findings include: R2's Emergency Department to Hosp- Admission (Discharge) hospital record documents R2 was readmitted on [DATE] and was discharged to the facility on [DATE]. The Record documented Patient (R2) reports of occasional shortness of breath and reports of lower extremity [CONDITION(S)] and stated that she cannot put on her prosthetic leg due to increased swelling, patient was seen in emergency room where she was evaluated, she was found to be hyperkalemic with potassium of 7.0, and nephrology consult was requested for immediate [CONDITION(S)] to correct [CONDITION(S)]. The record documented Discharge medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject ,d+[DATE] Units under the skin 3 (three) times a day with meals Per sliding scale as directed by primary MD (Medical Doctor), [MEDICATION(S)] 100 unit/mL pen for injection. Inject 10 Units under the skin nightly. R2's Admission Record, print date of [DATE], documents R2 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 units; 201- 250= 2 units; 251- 300= 4 units; 301- 350=8 units; 351+ = 10 units; 351 and greater (>) give 10 units and notify MD, subcutaneously before meals related to Type 2 Diabetes Mellitus (DM), [MEDICATION(S)] Solution 100 UNIT/ML Solution (Insulin [MEDICATION(S)]), Inject 10 units subcutaneously at bedtime for diabetes mellitus. R2's Interim Baseline Care Plan, dated [DATE], documents monitor vital signs, assess lung fields/breath sounds. The Care Plan, documents Resident is at risk for hypo/[CONDITION(S)]. Resident blood sugar and other lab values will be within acceptable parameters according to physician, Accucheck as ordered, administer medications as ordered, monitor for [CONDITION(S)] signs and symptoms: sweating, tremors, increased heart rate, confusion, slurred speech, Monitor for [CONDITION(S)] signs and symptoms: increased thirst, increased appetite, increased urination, weight loss. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if less than 100 and not eating. [MEDICATION(S)] [MEDICATION(S)] 100 UNIT/ML Solution pen-injector. Inject 10 units subcutaneously at bedtime for DM Hold if blood sugar less than 100 and not eating. R2's [DATE] MAR, dated [DATE], does not document R2 received an 11:30 AM blood glucose monitoring. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation for this time in R2's Progress Note regarding the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] R2's [DATE] MAR's, blood glucose monitoring for [DATE] at 4:30 (1630) PM documented 9. There was nothing in the nurse's note regarding R2's 4:30 PM blood glucose monitoring or if R2 received insulin. R2's [DATE] MAR, dated [DATE], does not document R2 received a 9:00 (2100) PM blood glucose monitoring, or that R2 received her 10 Units of [MEDICATION(S)] as ordered. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's [DATE] MAR's blood glucose monitoring for [DATE] at 7:30 AM documented a blood glucose of 540, and 9. No documentation that physician was notified. R2's Progress Note, dated [DATE] at 8:07 AM, documented [MEDICATION(S)] Solution 100 UNIT/ML, Inject 5 units subcutaneously three times a day for DM, Hold if less than 100 and not eating. 15 units given per doctors' orders. There is no documentation in R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR, dated [DATE] at 4:30 PM, documents R2's blood glucose monitoring was 58, and 9. The Progress Note documented R2 was given apple juice. There was no documentation in the Progress Note V22, Nurse Practitioner, or V23, Primary Physician, was notified of R2's low blood glucose level of 58. R2's Progress Notes, dated [DATE] at 7:57 AM, documents that R2's blood sugar was too high to register on the blood glucose monitoring machine. V22, Nurse Practitioner (NP), was notified and ordered 15 units of [MEDICATION(S)] to be given. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 units; ,d+[DATE]= 2 units; ,d+[DATE]= 4 units; ,d+[DATE]= 8 units; 351+= 10 units; 351 and > give 10 units and notify MD, subcutaneously three times a day related to Type 2 Diabetes Mellitus. Give in addition to scheduled 5 units of [MEDICATION(S)] Three times daily (TID) with meals. Do not give lunch time insulin until after [CONDITION(S)], start date of [DATE]. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if less than 100 and not eating. [MEDICATION(S)] [MEDICATION(S)] 100 UNIT/ML Solution pen-injector. Inject 10 units subcutaneously at bedtime for DM Hold if blood sugar less than 100 and not eating, V23's orders on Hold Per [DATE] at 8:52 AM to [DATE] at 8:53 AM. R2's [DATE] MAR, dated [DATE] at 11:30 AM, documents R2's blood glucose monitoring was 418, and she was given 10 units of [MEDICATION(S)]. There is no documentation in R2's progress notes that the V22 or V23 was notified of R2's blood glucose level of 418. R2's [DATE] MAR, documents R2's blood glucose level on [DATE] at 4:30 PM was 136, and no insulin was given per sliding scale. From 4:30 PM-9:00 PM, on [DATE], there is no documentation in R2's medical record of assessment of condition, or if she was given an evening snack. R2's [DATE], MAR/Treatment Administration Record (TAR), on [DATE] at 9:00 PM, documented that V10, LPN, completed the blood glucose monitoring; however, there was no documentation of the results. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 10 units Subcutaneously at bedtime for DM. Hold if BS less than 100 and not eating. On hold from [DATE] at 8:54 AM to [DATE] at 8:53 AM. There is no documentation in R2's progress notes as to why the [MEDICATION(S)] was being put on hold. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:47 AM, V23, R2's Medical Doctor, stated that he was not aware of R2's [MEDICATION(S)] being put on hold. R2's Progress notes have no documentation between 9:00 PM on [DATE] through [DATE] at 10:23 AM, of any assessment or monitoring of R2 through the night. R2's MAR, dated [DATE], does not document that R2 received her 7:00 AM vital signs for that morning. R2's MAR, dated [DATE], does not document that R2's 7:30 AM Accucheck was done. R2's MAR, dated [DATE], does not document R2 received her 9:00 AM scheduled medications. R2's Progress Note, dated [DATE] at 10:23 AM, documents deceased . R2's Death Certificate, dated [DATE], documents manner of death, Natural causes. On [DATE] at 11:04 AM, V14, R2's sister, said the day before R2 passed away she (V14) tried to come and see R2 but was unable to get in to see her. V14 said she was able to talk too R2 on the phone though. V14 said R2 was upset, and R2 told her (V14) she (R2) was complaining about not feeling well. V14 said R2 told her the facility wasn't checking her blood sugars, not giving her (R2) her insulin, and not giving her [CONDITION(S)]. V14 stated R2 had told her (V14), her (R2's) blood sugars had been in the 600's when the nurses did check it. On [DATE] at 10:47 AM, V23, Medical Doctor (MD), stated that R2 was his patient (pt.) and had been for many years. V23 said that he is the one to recommend that she go to this facility for Rehab, and [CONDITION(S)]. V23 stated that R2 did have an extensive cardiac history and was a diabetic who was non-compliant. V23 said that R2 had just recently been in the hospital with diabetic ketoacidosis and was discharged to another facility. V23 stated that he was not made aware of any issues with R2. V23 said that no one called him about anything until they called and told him that R2 had expired. V23 said they gave him no kind of assessment on R2. V23 stated things could have possible been different if she had been monitored. The facility's Policy Change in Resident Condition, with a review date of ,d+[DATE], documents General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of change in condition. Responsible Party: RN, LPN, Social Services. Policy 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental or emotional status. It further document e. It is deemed necessary to appropriate in the best interest of the resident. 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 3. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents.

Based on interview and record review, the facility failed to assess, monitor, and provide services to address the medical needs of a newly admitted resident (and/or address diabetic needs) for one of 3 residents (R2) reviewed for quality of care in the sample of 14. This failure resulted in R2 having not receiving medical monitoring for over 12 hours and was found expired. Findings include: R2's Emergency Department (ED) to Hospital record documented R2 arrived at emergency room (ER) on [DATE] and was admitted to hospital. The Record documented R2 was discharged on [DATE]. The Record documented Patient (R2) was seen in emergency room , she (R2) was evaluated, she was found to be hypotensive with blood pressure of ,d+[DATE], Blood Sugar (BS) was 528 and was found to be in diabetic ketoacidosis and was therefore admitted to intensive care unit under the consultation of the intensivist. R2's ED to Hosp- Admission (Discharge) hospital record documents R2 was readmitted on [DATE] and was discharged to the facility on [DATE]. The Record documented Patient (R2) reports of occasional shortness of breath and reports of lower extremity [CONDITION(S)] and stated that she cannot put on her prosthetic leg due to increased swelling, patient was seen in emergency room where she was evaluated, she was found to be hyperkalemic with potassium of 7.0, and nephrology consult was requested for immediate [CONDITION(S)] to correct [CONDITION(S)]. The record documented Discharge medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject ,d+[DATE] Units under the skin 3 (three) times a day with meals Per sliding scale as directed by primary MD (Medical Doctor), [MEDICATION(S)] 100 unit/mL pen for injection. Inject 10 Units under the skin nightly. R2's Admission Record, print date of [DATE], documents R2 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 units; 201- 250= 2 units; 251- 300= 4 units; 301- 350=8 units; 351+ = 10 units; 351 and greater (>) give 10 units and notify MD, subcutaneously before meals related to Type 2 Diabetes Mellitus (DM), [MEDICATION(S)] Solution 100 UNIT/ML Solution (Insulin [MEDICATION(S)]), Inject 10 units subcutaneously at bedtime for diabetes mellitus. R2's Interim Baseline Care Plan, dated [DATE], documents monitor vital signs, assess lung fields/breath sounds. The Care Plan, documents Resident is at risk for hypo/[CONDITION(S)]. Resident blood sugar and other lab values will be within acceptable parameters according to physician, Accucheck as ordered, administer medications as ordered, monitor for [CONDITION(S)] signs and symptoms: sweating, tremors, increased heart rate, confusion, slurred speech, Monitor for [CONDITION(S)] signs and symptoms: increased thirst, increased appetite, increased urination, weight loss. R2's PO, order date of [DATE], [MEDICATION(S)] Solution 100 UNIT/ML (Insulin [MEDICATION(S)]) Inject 5 units subcutaneously three times a day for DM. Hold if less than 100 and not eating. [MEDICATION(S)] [MEDICATION(S)] 100 UNIT/ML Solution pen-injector. Inject 10 units subcutaneously at bedtime for DM Hold if blood sugar less than 100 and not eating. R2's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation for this time in R2's Progress Note regarding the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] R2's [DATE] MAR's, blood glucose monitoring for [DATE] at 4:30 (1630) PM documented 9. There was nothing in the nurse's note regarding R2's 4:30 PM blood glucose monitoring or if R2 received insulin. R2's [DATE] MAR, dated [DATE], does not document R2 received a 9:00 (2100) PM blood glucose monitoring, or that R2 received her 10 Units of [MEDICATION(S)] as ordered. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's [DATE] MAR's blood glucose monitoring for [DATE] at 7:30 AM documented a blood glucose of 540, and 9. There was no documentation in R2's medical record that V23, R2's primary care physician was notified. R2's Progress Note, dated [DATE] at 8:07 AM, documented [MEDICATION(S)] Solution 100 UNIT/ML, inject 5 units subcutaneously three times a day for DM, hold if less than 100 and not eating. 15 units given per doctors' orders. There is no documentation in R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's [DATE] MAR, dated [DATE] at 4:30 PM, documents R2's blood glucose monitoring was 58, and 9. The Progress Note documented R2 was given apple juice. There was no documentation in the Progress Note V22, Nurse Practitioner, or V23 were notified of R2's low blood glucose level of 58. R2's Progress Notes, dated [DATE] at 7:57 AM, documents that R2's blood sugar was too high to register on the blood glucose monitoring machine. V22, Nurse Practitioner (NP), was notified and ordered 15 units of [MEDICATION(S)] to be given. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's [DATE] MAR, order date of [DATE], order time of 9:20 AM, documented R2 was given 15 units of [MEDICATION(S)] at 11:02 AM. R2's Progress Notes, dated [DATE] at 8:45 AM, documents R2 refused her breakfast. R2's Progress Note, dated [DATE] at 9:30 AM, documented R2's blood sugar levels were too high to register on the blood glucose monitoring device. The Progress Note documents call out to V22, NP, and she again ordered 15 units of [MEDICATION(S)], and to recheck blood sugar in one hour. There was only one order for 15 units of [MEDICATION(S)] although the Nurses Notes reflect the 15 Units of [MEDICATION(S)] was to be given twice on [DATE]. R2's Progress Note, dated [DATE] at 10:20 AM, documents R2's blood glucose level was 589 and V22 ordered 10 units of [MEDICATION(S)]. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's [DATE] MAR, order date of [DATE], order time of 10:27 AM, documented R2 was given 10 units of [MEDICATION(S)] at 11:03 AM. R2's Meal Record has no documentation R2 received supper on [DATE]. R2's Meal Documentation on [DATE], documents R2 refused breakfast, ate 26%-50% for lunch, and ate 26%-50% for supper. R2's Progress Notes, dated [DATE] at 9:09 AM, document R2's blood glucose level was 590, V22 made aware, stated to give R2 the max dose on sliding scale, and no additional orders at this time. The Progress note documents Will follow next sliding scale order. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 units; ,d+[DATE]= 2 units; ,d+[DATE]= 4 units; ,d+[DATE]= 8 units; 351+= 10 units; 351 and > give 10 units and notify MD, subcutaneously three times a day related to Type 2 Diabetes Mellitus. Give in addition to scheduled 5 units of [MEDICATION(S)] Three times daily (TID) with meals. Do not give lunch time insulin until after [CONDITION(S)], start date of [DATE]. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if less than 100 and not eating. [MEDICATION(S)] [MEDICATION(S)] 100 UNIT/ML Solution pen-injector. Inject 10 units subcutaneously at bedtime for DM Hold if blood sugar less than 100 and not eating, V23's orders on Hold Per [DATE] at 8:52 AM to [DATE] at 8:53 AM. R2's [DATE] MAR, dated [DATE] at 11:30 AM, documents R2's blood glucose monitoring was 418, and she was given 10 units of [MEDICATION(S)]. There is no documentation in R2's progress notes that the V22 or V23 was notified of the 418 blood glucose . R2's [DATE] MAR, documents R2's blood glucose on [DATE] at 4:30 PM was 136, and no insulin was given per sliding scale. On [DATE] from 4:30 PM-9:00 PM, there is no documentation in R2's medical record of assessment of condition, or if she was given an evening snack. R2's [DATE], MAR/Treatment Administration Record (TAR), on [DATE] at 9:00 PM, documented that V10, Licensed Practical Nurse (LPN), completed the blood glucose monitoring; however, there was no documentation of the results. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 10 units Subcutaneously at bedtime for DM. Hold if BS less than 100 and not eating. On hold from [DATE] at 8:54 AM to [DATE] at 8:53 AM. There is no documentation in R2's progress notes as to why the [MEDICATION(S)] was being put on hold. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:47 AM, V23, R2's Medical Doctor, stated that he was not aware of R2's [MEDICATION(S)] being put on hold. R2's Progress notes have no documentation between 9:00 PM on [DATE] through [DATE] at 10:23 AM, of any assessment or monitoring of R2 through the night. R2's [DATE] MAR, dated [DATE], does not document that R2 received her 7:00 AM vital signs for that morning. R2's [DATE] MAR, dated [DATE], does not document that R2's 7:30 AM Accucheck was done. R2's MAR, dated [DATE], does not document R2 received her 9:00 AM scheduled medications. There is no documentation that R2 received her breakfast that morning, and breakfast is usually served at 8:00 AM. V1, Administrator, provided handwritten meal pass times of 8:00 AM, 12:00 PM, and 6:00 PM, with signature of V1. R2's Progress Note, dated [DATE] at 10:23 AM, documents deceased . R2's Death Certificate, dated [DATE], documents manner of death, Natural causes. R2's Progress Note, dated [DATE] at 11:00 AM, documents res (resident) was found unresponsive with no breath sounds noted at 10:00 AM. Code was called and 911 notified; Fire Department arrived at 10:10 AM to assist with code and EMT (Emergency Medical Technician) arrived at 10:18 AM. Res was pronounced deceased at 10:22 AM. On [DATE] at 10:07 AM, V5, Registered Nurse (RN), said she was R2's nurse on [DATE]. She said at 10:00 AM or a little after, V8, Certified Nurse Assist (CNA), found R2 unresponsive. V5 stated that V8 hollered for help and she (V5) went down to see what was happening. V5 said she checked R2 for breath sounds, called code blue. V5 said the Emergency Medical Service arrived, and they are the ones that pronounced her death. V5 stated when she went to initiate CPR (Cardiopulmonary Resuscitation) on R2, that R2 was a little cold, a little stiff, and they couldn't turn R2 over. On [DATE] at 9:35 AM, V8, CNA, said she was passing trays, and that is when she found R2. V8 stated she doesn't remember the specific time R2 was found. V8 said she came into the room and placed R2's breakfast tray on the table, called R2's name, and R2 didn't respond. V8 said she then went around to the other side, because R2 was lying on her side facing the window. V8 said she bent down in front of R2's face, said R2's name again, and R2 still got no response from R2. V8 stated R2 was cold to the touch, discolored (purple), and when she (V8) touched R2's arm it was stiff. V8 stated when she saw her (R2's) face purple, arm and body cold, and stiff it shocked her. On [DATE] at 10:10 AM, V20, Licensed Practical Nurse (LPN), stated the CNA (V8) is the one who found R2 at about 10:00 AM. On [DATE] at 2:19 PM, V9, LPN (Agency Nurse), stated she was the nurse working the 100 hallway the day of the incident. V9 said it was approximately 10:10 AM on [DATE], and a code was called. She said she ran down to the 400 hall where the code was at. V9 said when they rolled R2 over, her (R2's) arm was stuck up in the air and wouldn't come down. She said Rigor mortis had already set in. Biologydictionary.net. documents, Rigor Mortis- Is one of the stages of death in which chemical changes that affect muscle fiber elasticity cause the muscles to stiffen. An indication of the time of death in Forensic science, rigor mortis usually initiates at two to three hours after death presents according to the position of the body at rigor mortis onset. On [DATE] at 11:04 AM, V14, R2's sister, said the day before R2 passed away she (V14) tried to come and see R2 but was unable to get in to see her. V14 said she was able to talk to R2 on the phone though. V14 said R2 was upset, and R2 told her (V14) she (R2) was complaining about not feeling well. V14 said R2 told her the facility wasn't checking her blood sugars, not giving her (R2) her insulin, and not giving her [CONDITION(S)]. V14 stated R2 had told her (V14), her (R2's) blood sugars had been in the 600's when the nurses did check it. On [DATE] at 11:54 AM, V13, CNA (Agency), stated she was working the 400 hallway on the night of [DATE]-[DATE]. She stated she was taking care of the front half that night, but she did answer R2's call light at around 11:00 PM. She said R2 complained she felt like her blood pressure was low. V13 stated she told the nurse (V12), and V12 went down to check R2's blood pressure. On [DATE] at 2:42 PM, V12, LPN, stated R2 put her call light on at about 11:10 PM, and she went down to answer it. V12 said R2 needed to use the commode. V12 stated that she assisted R2 on to the bedpan, R2 asked V12 if she could please leave the room for privacy, and that a CNA assisted R2 off the bedpan. V12 said she did not physically talk to R2 the rest of the night. V12 stated that no one said anything to her about R2 complaining about her blood pressure. V12 said R2 never complained to her, but she (R2) did complain to another nurse about feeling lightheaded. V12 said she did a walk through on her hall about 2:00 AM, and R2 was lying on her back. V12 also said she (V12) was down by R2's room at about 6:,d+[DATE]:00 AM passing medications, and R2 was on her left side sleeping. On [DATE] at 10:15 AM, V6, CNA, stated she checked on R2 at 8:00 AM on [DATE]. V6 said R2 was lying on her left side, facing the air conditioner, and she was sleeping. On [DATE] at 10: 07 AM, V5, Registered Nurse (RN), stated she had a lot going on that morning ([DATE]), so she hadn't get to see R2 yet, and that the CNAs had laid eyes on R2 at 8:00 AM. On [DATE] at 11:16 AM, V6, CNA, stated on [DATE] at 8:00 AM, she was standing at R2's door, said R2's name, and that R2 did not move. V6 stated she didn't check R2's respirations at that time. On [DATE] at 9:35 AM, V8, CNA, stated she was working the 400 hall the day of the incident ([DATE]). V8 said she was working the front set that day. V8 stated she starts work at 7:00 AM, and when she first comes on the floor, she will check the residents on her set. V8 stated she did not see R2 before breakfast. V8 stated she was passing trays when she found R2. On [DATE] at 10:10 AM, V20, LPN, stated the last time she seen R2 alive was on [DATE], when she was the nurse for the 400 hallway. V20, said R2's blood sugar was high (590), and she called the V22. On [DATE] at 9:10 AM, V22, Nurse Practitioner, stated she does not take call at night, and on the weekends. V22 stated that insulin should be given within 30 minutes of blood sugar being checked. V22 said that you shouldn't wait an hour to give it. V22 stated, I would say she (R2) was a brittle diabetic. My.clevelandclinic.org documents Brittle Diabetes- Brittle diabetes is also known as unstable diabetes or labile diabetes, meaning that the blood sugar swings can be severe and frequent. This version is rare and happens to mainly to people with Type I diabetes. It further documents Brittle diabetes is diabetes that's especially difficult to manage and often disrupts everyday life. People with brittle diabetes have severe swings in blood glucose (blood sugar). The swings can cause frequent episodes of [CONDITION(S)] (low blood sugar) or [CONDITION(S)] (high blood sugar). On [DATE] at 10:47 AM, V23, Medical Doctor (MD), stated that R2 was his patient (pt.) and had been for many years. V23 said that he is the one to recommend that she go to this facility for Rehab, and [CONDITION(S)]. V23 stated that R2 did have an extensive cardiac history and was a diabetic who was non-compliant. V23 said that R2 had just recently been in the hospital with diabetic ketoacidosis and was discharged to another facility. V23 stated that he was not made aware of any issues with R2. V23 said that no one called him about anything until they called and told him that R2 had expired. V23 said they gave him no kind of assessment on R2. V23 stated things could have possible been different if she had been monitored.

Based on observation, interview, and record review, the facility failed to provide treatment to pressure ulcers for 1 of 3 residents (R3) reviewed for pressure ulcers in the sample of 14. This failure resulted in R3 having maggots infest his left heel pressure ulcer causing him to have feelings of ongoing humiliation and embarrassment. Findings include: On 8/11/22 at 2:08 PM, V11, County Health Department Representative, stated she was contacted by the local health emergency hotline. She was told that when facility staff went to reposition R3 there were maggots on R3's foot and buttocks. R3's Admission Record, print date of 08/11/22, documents R3 has a Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS), dated [DATE], documents, R3 is cognitively intact, requires extensive assistance with two-person physical assistance with Activities of Daily Living (ADLs), and has Pressure Ulcers. R3's Care Plan, dated 7/8/2022, documents, R3 is at risk for skin complications related to (r/t) admitting with unstageable wounds to bilateral heels and left lateral leg, stage 4 wound to coccyx, refusal of turns, incontinence of stool, weakness and decreased mobility. R3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On, 8/10/2022 at 9:07AM, there were flies in R3's room. Multiple flies were sitting on R3's heel protectors that were on his feet. Two flies were sitting on R3's bed sheet that had bloody/whitish discharge coming from the bandages on his heel pressure ulcer. Flies were near R3's feet on the bed. R3 was sitting up in bed with head elevated R3 and was swatting at the flies flying around his head, and face. One fly landed on the top of his head, R3 then shooed the fly off his head, and stated, I should not have to live like this having flies in my room, landing on body and causing me to have maggots. R3 stated, These d*** flies landing on me, my bed, my feet, flying around my head. I know these maggots were from the flies. When the staff rolled me over and my boot was loose, and the maggots spilled out onto the bed sheets. They were moving and it was disgusting to think these maggots were on my pressure ulcers. These maggots have caused me to feel depressed, embarrassed, and humiliated, and this is happening where I live. I am a lawyer you know. There is no documentation in R3's medical record that maggots were found on/in R3's pressure ulcer. On 8/10/2022 at 1:15PM, V2, Clinical Support/RN stated, I was called by the Administrator. The Administrator came to facility the day maggots were found. V2 stated she was called on 8/6/22. On, 8/10/2022, at 1:24 PM, four flies sitting on R3's bed. Flies were flying around R3's head while eating his lunch. R3 swatted the fly away from his food and head. R3 stated, I know these flies landing on my feet, and boots caused the maggots on my wounds. It's nasty and does not help my pressure ulcer, wounds, and pain I have in my heels, the treatments don't get changed all the time. Weekends are the worst because nurses are lacking here. On, 8/10/22 at 1:32 PM, V1, Administrator, stated, I didn't get to see the maggots the staff had already cleaned up the maggots by giving (R3) a shower. V1 confirmed this incident occurred on 8/6/22. On, 8/10/2022 at 2:36PM, V5 Registered Nurse (RN) Hospice Nurse stated, I just came from (R3's) room I observed three flies in his room right now flying around his face and bed. A fly landed on (R3's) leg and he shews them away from his leg and face. V5 stated R3 asked her for a fly swatter. V5 stated to R3, What is going on with these flies? V5 stated that R3 is complaining of the flies bothering him and making him feel bad that maggots were found on his feet and backside. V5 stated R3 is alert and oriented and can make his needs known. On, 8/11/22 at 1:35PM V3, Licensed Practical Nurse (LPN) provided treatment to R3's pressure ulcers. During the treatment R3 stated Nobody does anything on the other shifts (evenings, and midnights), or the weekends. They don't do my treatments as they are supposed to do, they are very sporadic on day shift. Sick of them saying I refuse treatments, I hurt on my heels, and back. They just need to wait and not be so damn pushy. I need my pain medications and they need to wait till the meds kick in. R3 said, they don't offer later in the day on evenings, or midnights to give me the treatments. I am upset over the maggots, but they don't care, I feel so depressed, humiliated, and embarrassed over this issue. On 8/11/22 at 1:22 PM there were flies around R3s bed, and one landed on his forehead. R3 shooed the fly away. R3 stated, These d*** flies bother me when they land on me. When the staff turned me over on a Saturday maggot you know came out of my wounds on my heels, and back region. When I saw those maggots, it was disgusting, embarrassing, and made me feel bad. I shouldn't have to live like this with these maggots coming from my ulcers. They gave me a shower to clean my body from the maggots. I am tired of them thinking I refuse treatments when I'm in pain, they need to give me pain medications and wait till my pain is better to do my treatments, my heels hurt. On 8/17/2022 at 10:10AM, V17, Wound Physician stated, that non-medical maggots can increase in number, but the medical maggots cannot. V17 stated psychosocial in a patient is very difficult. He said that he could not evaluate R3 psych. He said it's going to differ from person to person. V17 stated that it depends on the person and how they feel. V17 stated that he is not going to say it's ok. V17 stated that he would expect to find dressings on the residents and that they do the orders that he ordered. V17 stated he knew about the maggots, but not about the flies. V7 stated that environmental needs to be asked what they can do to get rid of them (flies). V17 stated he would expect the nurses to ask again if the resident refuses the treatment. The Ncbi.nlm.nih.gov website documents Maggot infestation is a condition in which the fly maggots feed off and develop in the tissue of living organisms. Free myiasis results from flies deliberately laying eggs in or on the tissues. There are two forms of myiasis: obligate, in which it is necessary for the maggots to feed on living tissue and facultative, where flies opportunistic take advantage of wounds or [CONDITION(S)] necrotic conditions as a site to incubate their larvae. Female flies may visit wounds to feed or to lay eggs. They generally lay 50 - 300 eggs at a time and at skin temperature these hatch around 8 -12 hours later. The eggs are about 1.7 mm long and the emerging larvae are about the same but less easy to detect. Once emerged they grow rapidly within 24 hours at human skin temperature, they grow up to 7-8.5mm long and in only 50 - 60 hours they attain full growth.

Based on observation, interview and record review, the Facility failed to promote residents' dignity by not answering call lights in a timely manner to meet residents' needs for 2 of 7 residents (R4, R9) reviewed for improper nursing care in the sample of 16. This failure resulted in R9 activating her call light multiple times due to having multiple incontinent episodes. This made R9 feel demeaned. Findings include: 1. On 7/6/2020 at 9:30 AM, R4 and R9 were sharing a room and the call light was on. This surveyor entered the room. R9 was visibly upset. V19, Certified Nursing Assistant (CNA) entered the room, shut the call light off and began to attend to R9. V19 never asked R4 if she needed anything or had pressed the call light. At this time R4 stated to the surveyor that she had rang the bell and needed sugar and more tissues. R4 stated that there are times when she presses her call light, and it is not answered within 15-20 minutes. 2. On 7/6/2022 at 9:40 AM, R9 was still in bed and her breakfast was on the bedside table. R9 asked this surveyor what time it was. When informed R9 stated, I have been in this bed since 10 last night. I rang the bell several times. I should be up. I do get up to use the bathroom usually. I don't know the first time I peed in my depends last night. I told the CNA I am not getting up until I am cleaned up. It's despicable and demeaning. Mentally, this is not good. I can't even see a face around this place. During this above conversation, V19 was in the room but left, stating, I need to get towels and another person to help. At this time, R9 stated, Will you be back? V19 returned to R9's room with another staff member and began to provide incontinent care to R9. R9's adult brief was completely saturated in a dark colored urine. At this time V19 stated, I'd say that looks like about 5 pees (urination) worth. On 7/6/2022 at 10:00 AM R9 was up in a bedside chair and had eaten 100% of her breakfast. R9 stated she would have never waited until 10 AM to eat breakfast when she was at home. On 7/7/2022, V1, Administrator stated, I would expect call lights to be answered in a timely fashion, but I can't give a specific time frame, no longer than 10 minutes. I do not expect any resident to have to wait for an extended amount of time for their needs to be met.

Based on observation, interview and record review, the Facility failed to prevent the development of additional pressure ulcers and provide pressure ulcer care as prescribed by the physician to prevent the worsening of pressure ulcers for of 4 of 4 residents (R1, R2, R3, and R4) reviewed for pressure ulcers in the sample of 16. This failure resulted in R3 being hospitalized for [CONDITION(S)] and needing a surgical wound consult for worsening pressure ulcers. Findings include: 1.Upon arrival to the facility on [DATE], the Facility's Matrix, CMS 802, was reviewed and did not document that any residents at the Facility had current pressure ulcers. On 6/29/2022 at 10:45 AM, V2, Director of Nursing (DON) stated, We used to have a wound nurse, but she quit as wound nurse about 2 weeks ago. Now the floor nurses are responsible for the wounds. R3's Nursing Admission Observation, dated 5/21/22 documented R3 was admitted from an acute care hospital with a chronic wound. The Observation documents that R3 had a wound to her coccyx and knee. The Observation did not document the size of these wounds. R3's Care Plan, initiation date of 5/23/22, documented area to coccyx, left buttock and right knee will remain stable/healed throughout next review. R3's Care plan was updated on 6/7/22 and documented In-house Stage II on left buttock. R3's Facility's Skin & Wound Evaluation, dated 5/23/22, did not document R3 had a wound to her coccyx. R3's Minimum Data Set (MDS) dated [DATE] documents that R3 requires extensive assistance for bed mobility. It further documents that R3 was admitted with a stage 3 pressure area (does not indicate the location). R3's MDS does not reflect that R3 was on a turning and repositioning program. The Facility's Wound Line List for May and June 2022 did not document R3 had any wounds/pressure ulcers. R3's Facility's Skin/Wound Note dated 6/6/2022 documents that R3 was evaluated by (Wound Consultant Company) and it was noted that R3 had a New area to left buttock. There was no documented description of R3's pressure ulcer including size, wound bed description, peri-wound description and if exudate was present. R3's Treatment Administration Record (TAR) dated June 2022 documents, Start date 6/8/2022- cleanse wound to left buttock with wound cleanser. Apply Santyl and dry dressing daily and PRN (as needed). Monitor for s/s (signs and symptoms) of infection if present notify MD (medical doctor). R3's (Wound Consultant Company) Note, dated 6/13/22, documents location left buttock noted 6/6/22. The Note documents R3 had an unstageable pressure ulcer/injury measuring 4.5 centimeter (cm) x 1.5 cm x UTD (undetermined). The Note documented that 50% of the wound bed was necrotic. R3's Initial Would Evaluation and Management Summary from (Consultant Wound Physician) dated 6/20/2022 documents, Stage 4 wound of the left buttock-full thickness. Wound size 3 by 2 by 0.5 cm with moderate serous exudate. Dressing Treatment Plan- Alginate Calcium apply once daily for 30 days. Collagen powder apply once daily for 30 days. [MEDICATION(S)] apply once daily for 30 days. R3's June 2022 TAR does not include the treatment orders recommended on the Initial Would Evaluation and Management Summary dated 6/20/2022. There was no documentation R3 received this treatment. R3's Nursing Note dated 6/28/2022 documents, Resident admitted to (local hospital) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Hospital Evaluation-Suspected Abuse/Neglect Form, dated 6/28/2022, documents that R3 was admitted to the local hospital with multiple wounds. It further documents that the wound was a deep, stage four pressure ulcer to the mid-line sacrum and was described to have foul, purulent drainage and measured 8 centimeters (cm) in length, 3 cm in width, and 3 cm in depth. The Form documents also are eschar left buttock 9 (cm) x 3 (cm) x 0 with undermining all around, deepest at 7'oclock 6 cm. Eschar covering the wound bed at 100%. On 6/30/2022 at 12:20, V7 Licensed Practical Nurse (LPN) stated that she took care of R3 before she went to hospital for [CONDITION(S)]. V7 stated that R3 had a coccyx wound and as the treatment was to apply Santyl and pack the wound. V7 added that R3 was compliant with care. On 7/5/2022 at 1:35 PM, V13, Hospital Social Worker, stated, The odor was so bad, even though (V22's, Hospital Wound Nurse) masked she was still struggling not to vomit, and she is used to dealing with wounds. She (V22) couldn't believe no one at the facility had addressed it. The wound was unstageable and will require debridement surgery. 2. R2's Face Sheet dated 6/30/2022 documents that R2 was hospitalized from 6/14/2022 until 6/24/2022. R2's MDS, dated [DATE], documents that R2 has one stage 2 pressure ulcer and is totally dependent on staff for bed mobility. The Facility's Line List of wounds dated 4/2/2022-6/30/2022 documents R2's pressure ulcer to R2's coccyx was last evaluated 6/13/2022 and measured 9.3 centimeters (cm) by 8.1 cm by 0.2 cm in depth. R2's Order Summary Report dated 6/30/2022, documents Cleanse wound to coccyx with wound cleanser. Apply wound gel and dry dressing daily and PRN (as needed). R2's June 2022 Treatment Administration Record (TAR) documents that the treatment above was completed on 6/15/2022 and 6/16/2022, when R2 wasn't present at the facility. It further documents that this treatment to R2's coccyx was completed 6/24/2022, 6/25/2022, 6/26/2022, 6/27/2022, 6/28/2022, and 6/29/2022. On 6/29/2022 at 10:35 AM, V8, Certified Nursing Assistant (CNA) and V4, Licensed Practical Nurse (LPN) entered R2's room for a skin check. At this time V8 stated, I forgot to tell you, (R2) has a pressure area. At this time, a foam dressing was partially covering the pressure ulcer to R2's coccyx. The rest of the wound was not covered by the dressing and R2 had a small amount of feces present to the surrounding skin. The dressing was dated 6/24/22. This date was confirmed by V8. At this time V8 asked if she should remove the dressing and V4 stated, I don't know. I've been off for 5 days. I don't have anything to replace that one right now. At this time, V4 was asked to come and get this surveyor when she was going to replace the dressing. On 6/29/2022 at 3:30 PM, V4 still had not come to get this surveyor for the dressing change. 3. R1's Face Sheet dated 6/30/2022 documents R1 was admitted to the facility on [DATE]. R1's Admission Observation, dated 6/20/22, documents Sacrum Ulcer and does not include any measurements. R1's Care Plan dated 6/29/2022 documents, (R1) was admitted with a Stage IV to her coccyx, unstageable wound to her right heel and two scabbed areas behind both knees. R1's TAR and Order Summary Report dated June 2022, documents that treatments to R1's wounds were not initiated until 6/24/2022. This was four days after her admission. On 6/29/2022 at 1:11 PM, R1's coccyx dressing was observed to be completely saturated with drainage and falling off the wound. R1's adult brief also had drainage in it from the wound. On 6/30/2022 at 10:45 AM, V1, Director of Nursing (DON) stated, I would expect the dressing to be changed if saturated as ordered and as needed. On 6/30/2022 at 11:05 AM, V2, DON, stated, (R1) isn't on there on there (pressure log). She'll get on there. 4. On 6/30/2022 at 11:15 AM, R4 was observed to have two dressings to R4's bilateral thighs. R4's Skin Screen dated 6/30/2022 does not document any open areas. The Facility's Wound Log was reviewed and there was no documentation that R4 had a pressure ulcer. On 7/6/2022 at 10:15 AM, R4's skin was observed. R4 had an opened pressure ulcer to R4's left posterior gluteal fold. There was no dressing to this area. At this time, V19, Certified Nursing Assistant (CNA) stated, I would say the open area is about 1.5 inches. On 7/6/2022 at 12:15 PM, R4 stated, I have a sore down there. They ain't done nothing to it for about 5 days. They said they didn't have what they wanted to put on it. They talked about some kind of cream. R4's Progress Notes dated 7/6/2022 documents, New open area noted under residents R (right) gluteal fold. On 7/7/2022 at 11:07 AM V3, Assistant Director of Nursing (ADON) stated, Skin assessments should be completed the day of admission. It is included in the admission observation. Ideally Monday through Friday the wound nurse would do in house wound evaluation as soon as possible. If someone came to the facility with an open area, I would expect the hospital to send orders. I would expect if a resident had a skin issue that it be on the wound log. I would expect if a resident is seeing a wound specialist that those orders would be done as ordered. The Facility's Policy Skin Care Prevention dated 5/2015 documents, All residents will receive appropriate care to decrease the risk of skin breakdown. It further continues to document that the nursing department will review all new admission and put a plan in place for prevention. It further documents that all residents will be evaluated for changes in their skin condition and all residents unable to reposition themselves will be every two hours. It also documents that the skin should be cleaned at the time of soiling and at routine intervals.

Based on interview and record review the Facility failed to monitor a resident's medical condition after hospital discharge for 1 of 4 residents (R2) reviewed for quality of care in the sample of 12. This failure resulted in R2 not receiving diabetic and anti-[CONDITION(S)] medications, and blood glucose monitoring. R2 was sent to the hospital with a change of condition and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R2's Hospital Record documents R2 was admitted to the hospital on 12/1/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Record documented she was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge medications document [MEDICATION(S)] (used to treat type 2 diabetes), 2 milligrams (mg) daily also known as [MEDICATION(S)], [MEDICATION(S)] ([MEDICATION(S)]) 220 mg, 2x daily and [MEDICATION(S)] (an anti-[CONDITION(S)] medication), 2 mg daily. The Hospital Records Lab results 12/6/2021 documents a glucose level of 120 (normal range), ordered on 12/5/2021. R2's glucose levels were within normal limits when arriving at the facility. R2's Face Sheet documents R2 was admitted to the facility on [DATE] from the local hospital (acute care) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS also documents [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation for staff to monitor R2's blood glucose levels. R2's December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Interim Care Plan, effective date 12/6/21, documents R2 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interim Care Plan Interventions were as follows: Residents blood sugar and other lab values will be within acceptable parameters according to physician through next review; Accu check as ordered; Administer mediations as ordered; diet as ordered; Monitor for [CONDITION(S)] signs and symptoms; sweating, tremors, increased heart rate, confusion, slurred speech; and monitor for [CONDITION(S)] signs and symptoms, increased thirst, increased appetite, increased urination and weight loss. R2's Nurse's Notes dated 12/12/2021 at 10:12 AM, Note Text: Resident was lethargic, sweating and breathing very heavily when staff tried to wake her for breakfast. Resident's VS (vital signs) 150/92 (blood pressure 120/80 normal), 147 (pulse), 22 (respiration), 98.2 (temperature) 91% (oxygen saturation level) on RA (Room Air). Blood Sugar 332 (80-130 milligrams per deciliter (mg/dL)). Daughter was at bedside at this time. Resident is being sent to (local hospital) for evaluation. Report given to ER (emergency room ) charge nurse. On 12/15/2021 at 10:28 AM, V6, R2's sister, stated, My sister was supposed to be here for rehab to get better so she could come back home. She went out to the hospital and then came here to get better. She gets 2 [MEDICATION(S)] in the morning and 2 pills at night plus her diabetic pill in the morning. She was diabetic but she was not taking insulin it was a pill it was not [MEDICATION(S)]. V6 stated When I get here my sister looks really bad, she is sweating and not able to wake up, so I go and get the nurse. The nurse checks her sugar levels, and it was sky high. Then the nurse told me there was some type of a mix up she was sweating and running a fever. V6 stated She was admitted to the ICU (intensive care unit), but she just got out today of the ICU and she was also dehydrated when she got to the hospital. I just am shocked that she came here to get rehab and then they don't give her the current medications. On 12/15/2021 at 10:38 AM, V7, Daughter of R2 stated, My mom was in the facility for 7 days when my aunt came in to see my mom, she was all sweaty and unresponsive. My aunt went and got the nurse and she told her that (R2's) blood sugar was really high and there was glitch in the system and my mom had not been receiving her medications including her diabetic meds. My mom is diabetic, and she is not taking insulin, but she was taking a pill for her diabetes. My mom was living at home with her sister when she got sick and went out to the hospital and she had low potassium and a bladder infection. She was supposed to get rehab to get stronger and go home. V7 stated I just do not understand why she was not getting her medication. On 12/15/2021 at 1:21 PM, V8, Licensed Practical Nurse (LPN) stated, That particular day was my first day of taking care of (R2). I remember looking over her POS and she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I thought that was strange. But there were no orders for anything in the POS for her diabetes. That morning one of the CNA's (Certified Nursing assistant) went by me with (R2's) tray and it looked untouched. I asked the CNA if (R2) had eaten anything and she said no she did not eat anything today or yesterday. I then asked the other nurse on duty if (R2) was on hospice and she said no. I then went into her room and her sister was there and (R2) was all sweaty and lethargic and I took her vitals and checked her blood sugars and notified the doctor because I wanted her sent out immediately. Her blood sugar was over 300 almost 400. On 12/15/2021 at 1:21 PM. V9, Pharmacist stated, I would expect all hospital transfer records to be followed unless there was a reason why the Physician was discontinuing the order and I would expect that to be documented. I see from the transfer orders that (R2) did not receive the [MEDICATION(S)] 2 milligrams (mg), [MEDICATION(S)] sodium220 mg, 2x daily and [MEDICATION(S)] 2 mg daily. I see on 12/8/2021 they did a baseline labs glucose level and she was not elevated for blood glucose. This was the day after her admit. It's hard to know if there would be any harm but if her glucose level spiked then that would be harm. If she had an elevated blood sugar on 12/12/2021 at 332 then that would be high and would be a significant medication error. Yes, harm can occur if glucose increases or decreases. Without the facility monitoring and doing Accu checks it is hard to say what was or was not happening with (R2) and her blood glucose levels. (R2's) discharge hospital records document: [MEDICATION(S)] 2 milligrams (mg) daily also known as [MEDICATION(S)], [MEDICATION(S)] ([MEDICATION(S)]) 220 mg, 2x daily and [MEDICATION(S)] 2 mg daily. According to the facility records (R2) did not receive any of these medications. On 12/15/2021 at 2:35 PM, V1, Administrator stated, the nurse on duty is responsible for checking the medications and transfers for all new admits and then the nurse's management will do a triple check to ensure everything is correct. I am not sure what happened with (R2) or why her medications were overlooked and not transcribed correctly. On 12/16/2021 at 9:56 AM, V2, Director of Nurse's, stated, We did fail to transcribe (R2's) medications correctly upon admission. R2's Hospital Records dated 12/12/2021 at 11:02 AM, Chief complaint, (R2) is a [AGE] year old female presenting to the ED (Emergency Department) for altered mental status. Patient responsive only to painful stimuli. Recently came to (Facility) after hospitalization for [CONDITION(S)] (urinary tract infection) and [CONDITION(S)]. Sister now in ED assisting with history. Patient has decline in mental status starting yesterday, Patient has not had her diabetic or heart medication since coming to the new facility. Blood sugar 371 per EMS (emergency medical service). Patient [CONDITION(S)] and febrile at this time. Patient does have history of aggressive form of brain cancer per history. R2's Hospital Records General History and Physical dated 12/13/ at 2:06 PM, document, Patient has diabetes and was brought to the emergency room where she was found to be hyperglycemic with blood sugar of 371, she was [CONDITION(S)] and febrile. Patient was seen in emergency room where she was evaluated and was found to have leukocytosis of 23.7, potassium was 2.7, glucose of 305. On 12/17/2021 at 12:11 PM, V18, Physician stated, I saw (R2) before she came into the facility and was at the hospital. She was not eating and when an elderly person is not eating that in itself is going to affect their blood sugar levels. V18 stated that he was aware of what diabetic medication R2 was receiving but he would not have recommended that medication and would have more than likely taken R2 off of it. V18 stated Any diabetic should be monitored, and the facility should have been doing Accu checks on (R2) and monitoring her. I would expect the facility to be doing Accu checks on her. The Residents Right Policy undated documents, The facility strives to consistently and fully comply with the various laws and regulations, including but not limited to 42 CFR 483, pertaining to the treatment, services and needs of residents to attain or maintain residents' highest practicable physical, mental and psychosocial well-being.

Based on interview and record review the facility failed to initiate cardiopulmonary resuscitation (CPR) for R98. This failure resulted in staff not following standards of practice when finding R98 unresponsive and without vital signs. The staff did not initiate CPR, although R98 was a full code. R98 expired. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility failed to perform CPR on R98. This failure has the potential to effect 81 residents in the facility identified by the facility as Full Code Status. The following residents were identified as Full Code status in the sample of 50: R1, R2, R6, R9, R11, R12, R20, R23, R31,R32, R35, R41, R42, R43, R46, R48, R50, R52, R53, R54, R64, R66, R69, R72, R76, R80,R85, R93, R98. R147, R151, R152 and R153. The Immediate Jeopardy was identified on [DATE]. On [DATE], at 8:40 AM, V1, Administrator, and V3, Director of Nurses (DON), were notified of the Immediate Jeopardy. The surveyors confirmed by observations, record review and interviews that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Finding includes: R98's Face Sheet dated [DATE] documents R98 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R98's Care Plan dated [DATE] documents the family has chosen for R98 to be a full code. R98's Full code Care Plan intervention documents full treatment with the primary goal of sustaining life by medical means. R98's Illinois Department of Health Uniform Practitioner Order for Life Sustaining Treatment (POLST) Form documents that R98 Should have an Attempt Resuscitation/ CPR with the Full Treatment. R98's Electronic Health Record (EHR) Progress Note dated [DATE] at 6:02 PM documents CNA (Certified Nurse's Aide) requested RN (Registered Nurse) presence in the room resident not breathing. Resident's pupils were fixed and dilated. Resident had mottled or grayish discoloration of body and extremities. No response was noted to the sternal rub. (No response) to attempts at triggering reflexes. Resident had (indwelling catheter) in place draining dark colored urine to gravity and loss of bowel control. No pulse or respirations were noted. No blood pressure was able to be obtained by auscultation. The Note documented V26, Registered Nurse (RN) and V27 (RN) made the decision not to start CPR based on the above criteria. The Note documented V31, Physician, was notified at 6:30 PM. On [DATE] at 10:35 AM, V18, LPN, stated if she walked in on a resident who was not breathing, she would call a code and start CPR unless you know they are a DNR code status I would yell for someone to check their code status in the book that is kept on the crash cart as they are bringing the crash cart. On [DATE] at 10:26 AM, V10, LPN, stated, I would first check for pulse and make sure they are breathing and if not breathing start CPR. On [DATE] at 10:30 AM, V5, RN, states, If I found a resident that did not have a pulse, I would check for a pulse, check the code status and then initiate CPR. On [DATE] at 10:30 AM, V23, Licensed Practical Nurse (LPN), stated, If I found a resident without a pulse, I would call for help, check pulse. On [DATE] at 10:38 AM, V35, RN, stated if she came upon an unresponsive resident, she would immediately check for a pulse and call a code and yell for assistance and initiate CPR. She said she would holler at someone to check their code status as you are getting ready to start CPR. On [DATE] at 10:43 AM, V29, CNA, stated she would call for help and start CPR as soon as possible, if she walked into a room and a resident was not responsive. On [DATE] at 12:55 PM, V26, RN, stated, (R98) was not breathing and he had no pulse. He (R98) was kind of discolored bluish gray looking. No rigor mortis not initially. I'm not recalling clearly. He was on the 100 hall. It was clear he had passed. I checked his Code status and he was a full code. She (V27) said we have a policy. She (V27) pulled up the policy, and we went through the checklist (on the policy). Whatever was on the checklist, it all applied. On [DATE] at 1:06 PM, V27, RN, stated, I didn't see any signs of life. His (R98's) eyes were cloudy over. I checked his pulse. He was grayish looking. There were no signs of life in him and I went and got another nurse, his nurse (V26). He didn't necessarily have rigor mortis. There were no breath sounds, and no pulse. His chest was not going up and down. He wasn't that warm. The aide came and got me. I don't remember who the aide was. She said she thought he was gone because he wasn't responding to her. On [DATE] at 1:15 PM, V29, CNA, stated, I went in to check on him (R98) and he was unresponsive. He was dead. I called the nurse. She (V27) was literally right by the room. V29 stated she did not check to see if R98 had a pulse. On [DATE] at 2:30 PM, V31, Physician, stated he did agree with the American Heart Association's Guidelines regarding initiating CPR. The facility policy entitled Code Blue dated ,d+[DATE] documents, 1.Upon finding a person without respirations and or a pulse. Call for help and confirm presence or absence of advanced directives/ code status, if the resident is not a do not resuscitate (DNR), then a code blue should be announced and start CPR. The (AHA) American Heart Association urges all potential rescuers to initiate CPR unless a valid do not resuscitate order is in place or obvious clinical signs of irreversible death ( see presumed death policy) are present or initiating CPR could cause injury or peril to the rescuer. The American Heart Association's Guidelines for initiation of CPR document that CPR should be initiated unless there is a valid Do Not Resuscitate Order in place, obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present or CPR could cause injury or peril to the rescuer. The Facility's Guideline The facility's Guideline Presumed Death Criteria dated ,d+[DATE] documents, General: to provide guidance on emergency measures for patient/resident with an unwitnessed cardiac event The Guideline Procedure documents 1.) Cardiopulmonary Resuscitation (CPR) will not be performed after an unwitnessed cardiac arrest if ALL of the following are present: a.) pupils are fixed and dilated b.) mottled discoloration of the body c.) absence of reflexes d.) Loss of bowel and bladder sphincter control. e.) absence of vital signs (pulse, respirations, and blood pressure) with presence of other symptoms listed above. The Guideline documents 2.) Before a decision to not resuscitate is made, A through E must be verified by two licensed nurses one of which must be a registered nurse. 3.) The findings shall be documented in the medical record along with the signature of both licensed nurses. The attending physician will be notified. The facility's presumed Death Criteria does not address the clinical signs of irreversible death as defined by AHA. The Facility's Guideline Advance Directives and DNR, revised on [DATE], documented the following under section entitled Resident Presumed Dead: 1. CPR will not be performed after an unwitnessed cardiac arrest if the following are present: a. Pupils fixed and dilated; b. Mottled discoloration of body; c. Absence of reflexes; d. Bowel and bladder sphincter control absent; e. Absence of vital signs (blood pressure and pulse) with the presence of the other symptoms listed above. The Guideline documented Before a decision not to resuscitate is made, two licensed nurses must verify A to E. These finding must be documented in the nursing notes, along with the signatures of both nurses. The attending physician will be notified. This Guideline does not address clinical signs of irreversible death as defined by AHA. On [DATE], the facility provided a list Code Status Audit documenting that 81 residents in the facility had a Full Code Status. The surveyors verified through observation, interview and record review; the facility took the following actions to remove the Immediate Jeopardy: 1. Revision and review of all CODE BLUE policies, education with all licensed nurses and CNAs regarding facility policies on CPR. To be completed by V3, Director of Nurse on [DATE]. 2. All staff educated on location of crash cart and AED machine. All staff present have been educated and all remaining will be educated prior to start of next shift. To be completed by V3 and ongoing. 3. Whole house audit completed to determine all residents with Full Code Status. Completed by V1, Administrator on [DATE]. 4. All licensed nurses and CNAs have been educated on facility policies on CPR. Completed by V3 on [DATE]. 5. All staff present have been educated and all remaining will be educated prior to start of next shift. Education will be completed by V3 and will be ongoing. 6. Revision of the Advance Directive Policy was done on [DATE] by V1. Staff education completed by V3 on [DATE]. 7. Code status will be monitored upon admission using facility's triple check form. Nurse manager will monitor during the admission process. Ongoing 8. All episodes of resident being unresponsive will be reviewed by DON and RNC to ensure appropriate measure are taken. 9. All audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine if any further staff education or facility policy changes are need. Any deficiencies will be corrected immediately and reviewed again by the Quality Assurance Performance Improvement Committee monthly. All above measure will be subject to review, assess and modification.

Based on interview and record review the facility failed to answer call lights in a timely manner to promote residents' dignity for 5 of 5 residents (R1-R5) reviewed for dignity in the sample of 5. This failure resulted in R2 experiencing extreme anxiety and fear that she would not receive assistance; causing her to sign out of the facility against medical advice and R5 experiencing extreme anxiety and fear that she would not receive assistance if she became choked or, had a [CONDITION(S)]. Findings include: 1.R2's Minimum Data Set, (MDS), dated [DATE] documents diagnoses' of Medically Complex Conditions, Coronary Artery Disease; Diabetes Mellitus; Hypertrophied; [CONDITION(S)] Accident; Malnutrition. R2's MDS documents she is cognitively intact. R2's MDS documents that she has ability to independently toilet. R2's Progress Notes dated 4/7/2021 at 6:02 PM document, Resident arrived via ambulance with 2 emts (emergency medical technicians) from (local hospital). resident a&o (alert and oriented) x 3 calm and cooperative. Resident 1 assist with walker resident denies pain or discomfort call light in reach will cont (continue) to monitor. R2's Progress Notes dated 4/7/2021 at 10:32 PM document, Res (Resident) call her son that she wasn't change for an hour and call btn (button) taken away from her. Son came, wanted to see her and threaten he will call State. The writer and another nurse talked to son assured him will take care of it. DON was involved too. Res changed to (another room), maintenance reset call btns (buttons) on hall 100. Writer left voice message for son to notify him of room change. Will continue to monitor and check on her q2h (every two hours). There was no documentation in R2's medical records that R2 was checked every two hours. R2's Progress Notes dated 4/8/2021 at 3:04 PM document, resident left AMA (Against Medical Advice) with granddaughter. On 6/22/2021 at 3:40 PM, R2 stated that she was placed in a diaper and that she did not need to be put in a diaper that she could use a bedside commode. She also stated that when she put her call light on, they would not answer it and told her that she was not the only resident in the building to quit putting her call light on. R2 stated on 6/25/2021 at 10:00 AM, I was so upset and humiliated that they let me lay in a diaper when I didn't need one. It upset me so much that I called my son to come and get me. I was very afraid of the way they were treating me there. It was if I wasn't even human. R2 confirmed this was the reason why she left against medical advice. On 6/25/2021 at 2:31 PM, V1 Administrator, stated that the call lights at nurse's station on 100-200 halls can be turned off manually but not on 300-400 hall. V1 also stated that R2 was placed on the 100 hall but when the call light wasn't working R2 was moved to a special unit on the two hundred call. 2. R5's Electronic Medical Records documents R5 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/25/2021 the facility provided the facility provided a grievance report that R5 had filed for call lights not being answered. The facility grievance form dated 6/3/2021 documents that R5 filed a grievance on call lights and it was not witnessed but the second time this issue had been reported. On 6/25/2021 at 1:02 PM R5 stated, No it hasn't stopped. They turn the call lights off at the nurse's station. Sometimes I am up until 8 PM in this chair and I put my call light on, and they don't answer. I could be having a [CONDITION(S)], choking or anything else and they wouldn't come. I am afraid and it makes me feel horrible. 3. On 6/25/2021 at 11:45 AM R3 stated The regular ones are good but sometimes they have people work that are very poor with answering the lights and they just don't answer them at night. 4. On 6/25/2021 at 12:06 PM R1 stated They turn my light off when I put it on and do not answer it. 5. On 6/25/2021 at 1:19 PM R4 stated Most of the time they answer my lights but many times at night they turn it off and won't answer it. The facility's Call Light Policy dated 9/2017 documents in part, 6. Report all defective call lights to nurse supervisor or maintenance director promptly. 7. Answer the patient or residents call as soon as possible.

Based on observation, interview and record review, the facility failed to ensure residents receive treatment to maintain highest practicable physical well-being by assessing/monitoring new fractures/dislocations immobilized by splints/braces for three of three residents (R2, R21, R34) reviewed for treatment of [REDACTED]. These failures resulted in an Immediate Jeopardy which began on [DATE] when R2 was readmitted to the facility with a left femur fracture with soft immobilizer. The facility failed to assess/monitor the condition of R2's skin and newly fractured femur from [DATE] until [DATE]. On [DATE], the facility noted R2 had blood near her immobilizer and upon removal of the immobilizer found R2 had sustained an opened fracture, bone protruding through R2's left knee. The Facility sent R2 to the hospital for treatment and R2 required surgical intervention of an above the left knee amputation. Due to R2's comorbidities and vulnerabilities, this failure increased her risk for severe illness, injury and possible death. The IJ was identified to have begun on [DATE] when R2 was readmitted to the facility with a left femur fracture with soft immobilizer and the facility did not assess/monitor the condition of R2's leg under the immobilizer. The IJ was identified on [DATE] at 9:54 AM and facility staff, V1 (Administrator), V2 (Director of Nurse), V3 (Assistant Director of Nursing), V4 (Licensed Practical Nurse/Wound Care) and V38 (Regional Corporate Nurse) were notified. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1. R2's Admission Record, not dated, documents [DATE] as R2's initial admitted and lists the following Diagnoses: [REDACTED]. R2's Care Plan, dated [DATE], documents (R2) has impaired cognitive function r/t (related to) Alzheimer's Dementia. (R2) is at risk for falls r/t increased confusion and decreased mobility. She relies on staff assist with adl's (activities of daily living) and mobility. At risk for skin complications r/t decrease mobility, incontinent bowel and bladder and confusion. Interventions [DATE] ensure proper body alignment, monitor closely for sensory impairment. Observe and assess regularly. R2's Minimum Data Sets (MDS), dated [DATE] and [DATE], document R2 is severely cognitively impaired and is rarely/never understood. R2's Progress Note, dated [DATE] at 1:31 AM, documents CNA (Certified Nursing Assistant) told this RN (Registered Nurse) 'resident is on the floor,' went to room at 0105 to find resident on floor lying on her back with her head towards the foot of bed. Noted left leg was under roommate's bed. Obvious deformity to left knee/femur. Vital signs stable. Resident unable to verbalize how fall happened. Resident pointing to her knee leading this RN to assume she is in pain. (Ambulance) called for emergency transfer to a local hospital. Notifications made and documented. R2's Local Hospital left knee X-ray report, dated [DATE], documents R2 had a moderately comminuted (fracture producing multiple bone splinters), displaced, angulated, [MEDICAL CONDITION] 5th femoral shaft/metaphysis (long, straight part of the thighbone). R2's Local Hospital Discharge Summary, dated [DATE], documents R2's reason for admission was fractured femur. The Summary documented [AGE] year old female resident of a nursing home with a history of severe dementia and a past history of tibia and fibula fracture sustained a fall in the nursing home and was brought to the emergency room , xray of the left femur showed a fracture of femoral neck and patient has been seen/ evaluated by orthopedic but recommended non operative treatment for [REDACTED]. Patient has gait disorder and is mostly in a wheelchair. R2's Local Hospital Transfer Form (Physician Orders), dated [DATE], documents Recommend follow up x-ray in 6wks (weeks), bedrest for 6wks, wear knee immobilizer w/daily (with) skin checks for pressure injury. *has distal femur fracture w/o (without) intra-articular extension being treated with closed fracture care. R2's Facility Admission Observation, dated [DATE] at 12:58 AM, documents resident is unable to communicate needs. The Observation documents Skin is cool and dry with dressings to the coccyx, left thigh and right heel. Right heel skin peeling no dressing. R2's Daily Skilled Nurse's Note, dated [DATE] at 3:20 PM, documents Res. (resident) readmitted day 1. Res. total care per staff. Hand fed per staff. Appetite fair. Repositioned by staff. Pillows for support. Res. has soft cast to left leg. R2's Daily Skilled Nurse's Note, dated [DATE] at 1719, documents Res. total care per staff. Hand fed per staff. Appetite fair. Repositioned by staff. Pillows for support. Res. has soft cast to left leg. no s/s (signs/symptoms) of any distress or pain will continue to monitor. There is no documentation in R2's medical record including treatment records and daily assessments that the facility was visualizing, assessing/monitoring R2's left leg including daily skin checks from [DATE] through [DATE]. R2's Progress Note, dated [DATE] at 6:00 PM, documents During CNA rounds, this nurse was called to resident's room due to concern of small amount of blood on sheets near stabilizer. Resident assessed thoroughly, stabilizer noted to LLE (left lower extremity) intact throughout entire shift. During assessment, blood noted inside stabilizer. Deformity noted with bone protruding from left knee. Resident displayed no s/s (signs/symptoms) of verbal/nonverbal discomfort during assessment. Area cleaned and stabilized. CNA and another nurse remained at bedside while this nurse called EMS (emergency medical service), MD (medical doctor), DON (Director of Nursing), and report to (local) hospital ER (emergency room ). State guardian called and voicemail left for on-call to return call to facility. 6:15-EMS present to transport resident to ER. R2's Metropolitan Hospital Discharge Summary, from [DATE] hospitalization , documents Patient was sent back to (local hospital) on ,[DATE] when the facility was placing a knee brace on her leg, they noticed bleeding coming from the dressing. She was then transferred to a Metropolitan ED (emergency department), for further evaluation. In the ED, xray showed comminuted, displaced, extra-articular distal left femur fracture, low lying left patella suggestive of quadriceps tendon injury, intact proximal left femur. She was seen by the ortho (orthopedic) in ED. She was found to have a 2 cm (centimeter) wound with exposed bone and exudates. Ortho determined operative management was appropriate with left above the knee amputation due to chronic nature of the open wound with already degraded tissues around it and non-ambulatory status with the goal to provide definitive care. The review of the Facility's Injury of Unknown Origin Investigation, dated [DATE], did not provide documentation that the facility was visualizing, assessing/monitoring R2's left leg including daily skin checks from ,[DATE] through [DATE]. On [DATE] at 2:31PM V5 (Registered Nurse/RN) stated, (R2) was complete care. She was contracted. Not alert or responsive to environment. Not verbal. Not completely able to make needs known. Don't remember her having any bed rails. She needed 1 person assistance in bed. She fell out of the bed. She had an obvious deformity. Bent out at the knee in a way that was abnormal. No complaints of pain. But with her cognition she wouldn't be able to tell you she was in pain. On [DATE] at 11:00 AM V4 (Wound Nurse) stated, (R2) was alert to self. She was a feeder and had an ulcer to her feet. COVID+ (positive). No open area or pressure area to her left leg. I did not look under the brace. She didn't have any pressure areas under there. I looked under that brace when she first returned. Didn't have any wounds so I didn't look under there anymore. On [DATE] at 11:25 AM V6 (R2's Guardian) stated, (R2) has died . She had a fall at this facility and never recovered. She developed an infection related to the open wound. I was informed she slid in between the bed. That's all I got. She was frail and required repositioning. Once she was in the hospital and after her surgery, I didn't feel it was safe enough for her to return to this facility, so I had her transferred to another (facility). On [DATE] at 12:00 PM V7 (Licensed Practical Nurse/LPN) stated, Prior to her discharge she was a total care patient. She had a stabilizer to her leg. I had not checked under the brace because there was no order on how frequently to check or remove it. The CNA called me to the room. It was some blood on the sheet. The brace was on. I opened it and saw more blood to the inside of the brace. I could see the bone. She had her bone protruding from her leg. I sent her to the hospital. She didn't show any signs of pain, but her cognition is bad. She has no cognition to display grimacing or pain. On [DATE] 12:15 PM V8 (LPN) stated, I did take care of her. (R2) was alert to self. She did have the brace on. I didn't check under it. The CNA's wouldn't have moved it because she had a gown on. There would be no reason to remove it. On [DATE] at 10:27 AM V9 (Orthopedic) stated, I saw her, and she had fracture to her femur. I chose closed fracture care, nonsurgical treatment, because of her cognition; she doesn't walk, and it would not have maintained or improved her quality of life. The leg was to be looked at for pressure injury at least every day. I would expect the facility to monitor the area for problems. Checking for swelling, warmth, pulses, capillary refills and any changes. This would have required the staff to look at the leg under the brace. With her having the brace you have to keep an eye on it for any changes because she can't tell you. With her level of cognition, she would not be able to tell you that the changes are happening. This (open fracture) is not something that happens overnight. It happens over time. There would have been swelling, discoloration to the skin, warm to the touch, opening into the leg. Which is why it is important to monitor. If the facility would have been monitoring the area the infection could have been found earlier and prevented the injury from worsening. On [DATE] at 10:26 AM V10 (Orthopedic Surgeon) stated, (R2) was nonverbal. She did not communicate. She was cachectic (wasting of the body due to severe chronic illness), extremely thin and contracted when she got here, no padding. This amputation could have been prevented. When a fracture happens, the ends of the bone are sharp. As time goes on the tendons tighten and pull on the bone to help it pull into place. When it does this usually there is enough padding to prevent the pulling through the skin. She has no padding, so it puts her at a higher risk for this injury. My concern was how long had this wound been there. This had not just poked through. This was open for a few days prior to coming to (local hospital). She had an infection. The surrounding tissue had already started to try to heal itself. The surrounding tissue was dead and the bone as well. This injury would have been painful. She is nonverbal and not able to express her pain. If the facility would have been performing at least daily checks and monitoring the leg, this is something that could have been prevented. The amputation is a direct result of not monitoring the fracture. This would have been caught and things could have happened differently if she was being monitored. We could have gotten her in here and treated her. She would have had surgery, but she still would have her leg. On [DATE] at 11:15 AM V18 (Physical Therapist) stated, I have cared for (R2) and she had a severe cognitive decline. We (Physical Therapy) evaluated her and because of the bedrest order and her inability to follow commands we did not pick her up. We did the eval and the staff were able to demonstrate putting on the brace properly. On [DATE] at 12:55 PM V19 (LPN) stated, When performing an assessment, that information would be documented in the progress notes or in the daily skilled notes, if they are Med A. If a resident had a fracture, I would assess on my shift any redness or swelling. The assessment documentation would go in the daily skilled note or the progress note. It would be one of these two places if it was done. On [DATE] at 1:00 PM V16 (LPN) stated, We document our assessments in the daily skilled or the progress notes. What I do is, I document in the daily skilled first and if anything else happens during my shift, I would then document in the progress notes. On [DATE] at 1:09 PM V17 (LPN) stated, All of the assessments are either in daily skilled notes or if there is a specific assessment, that is in the computers under forms. This is where it would be completed under the forms tab. If needed, we can document in the progress notes but mostly it would be under that (forms) tab. On [DATE] at 1:03 PM V3 (Assistant Director of Nursing) stated, If a resident has an immobilizer, we check it depending upon the doctor's orders. Each nurse would look at the leg every shift and document it on the MAR indicated [REDACTED]. I don't know how that happened. There should be a place on the TAR that has check immobilizer and the nurse would document each shift at least. I would expect them (the nurses) to look under the brace and assess. Looking at the skin color and or any changes. If they were looking at the leg at least every shift, they would have found it and any other changes immediately. She did not return to the facility, so there was nothing put in place; there was nothing done. If she would have returned, then we would have put something in place. On [DATE] and [DATE] R2's Daily skilled notes, progress notes, Medication Administration Records, Treatment Records and Forms Tab were reviewed. There is no documentation in R2's medical record including treatment records and daily assessments that the facility was visualizing, assessing/monitoring R2's left leg including daily skin checks. The Facility's Splints/Devices Policy, dated [DATE], documents Guideline: 3. Devices will be removed each shift and prn (as needed) to assess the resident's skin and circulation under the device. On [DATE], the surveyors attempted to confirm through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: A. On [DATE], Restorative Nurse Manager completed a skin assessment on all residents with an order for [REDACTED]. B. On [DATE], Restorative Nurse Manager did a house audit to assure all residents that has a splint/brace has an order. C. On [DATE], Restorative Nurse Manager assured daily skin check orders were present on TAR. D. On [DATE], Restorative Nurse Manager assured all residents with splint/brace has a current order. Care plans updated as identified. E. On [DATE], education provided to Nurses and CNAs per facility Policy and Procedure by V4 (Wound Nurse Manager) or V2 (DON) on all shifts until complete and prior to working their next scheduled shift effective immediately. On [DATE], education was completed for appropriate nursing staff which included: Evaluate residents for use of a device based on their assessed deformity or contracture; A physician's orders [REDACTED]. of new skin alterations to physician and wound nurse; Reporting of resident refusal of skin observations and document accordingly. F. On [DATE], V1 and V2 developed Quality Assurance Tool with the following criteria and all admissions to facility will evaluated randomly as follows: 4 times per week for 3 weeks; 3 times a week for 3 weeks; 2 times per week for 3 weeks. To be performed by Nurse completing the Admission Audit Triple Check for new or re-admissions monitoring for splint/brace orders or needs. V1 and V2 were responsible for the process. Findings of this QA Tool will be submitted to the facilities QAPI committee for review and corrective action. G. All audit results will be reviewed by the facility Quality Assurance Committee to determine if any further staff education or facility policy changes are needed. Any deficiencies will be corrected immediately and reviewed again by the Quality Assurance Committee monthly. All above measures will be subject to review, assessment and modification. On [DATE], the surveyors confirmed through observation, interview and record review, the facility had not implemented some of the actions to remove the Immediate Jeopardy as stated above including failing to in-service staff and failing to ensure daily skin checks for R21 and R34. 2. R21's Admission Record/Face Sheet documented [DIAGNOSES REDACTED]. R21's Care Plan, dated initiated [DATE], documents (R21) requires the use of splint to r/t (related to) left wrist fracture and instability. Applies herself. Staff to provide assist for care and hygiene. The Care Plan Interventions, initiated on [DATE], documents Encourage resident to assist with applying and removing brace. Encourage resident to demonstrate ability to apply the brace and praise participation with program and improvements. Observe skin for complications r/t brace usage every shift and each time it is removed. Provide proper cleaning of brace on resident's specific shower days and PRN (when needed) when soiled. Provide verbal cues as to proper placement of brace when applying. R21's Care Plan Problem, dated [DATE], documented readmitted from hospital with Fx (fracture) left Radius, left hip hematoma. The Care Plan Intervention, dated [DATE], documents To wear left wrist splint @ all times, off for hygiene. R21's MDS, dated [DATE], documents R21 is cognitively intact. R21's TAR (Treatment Administration Record), dated [DATE], documents Left wrist splint, off for care, skin check Q (every) shift. Every day and night shift. On [DATE], [DATE], and [DATE] R21's TAR documents no skin check for day shift. On [DATE] at 10:30 AM R21 stated, I put my brace on myself. It only comes off when I take a shower. I take showers twice a week. V4 (Wound Nurse) comes in and looks at my leg but not my wrist. The nurses don't look at it at all. 3. R34's Care Plan, dated [DATE], documents SPLINT: (R34) requires the use of splint to r/t left knee instability secondary to TKA (Total Knee Arthroplasty) posterior dislocation. The Care Plan Intervention, dated [DATE], documented Encourage resident to assist with applying and removing brace. Encourage resident to demonstrate ability to apply the brace and praise participation with program and improvements. Observe skin for complications r/t brace usage every shift and each time it is removed. Provide proper cleaning of brace on resident's specific shower days and PRN when soiled. Provide verbal cues as to proper placement of brace when applying. The Care Plan Intervention dated [DATE], documents Splint to be on when up, off while in bed. R34's MDS, dated [DATE], documents R34 is cognitively intact. R34 TAR, dated [DATE], documents, WBAT (weight bearing as tolerated) with left knee brace on at all times when up (may remove when in bed). Skin check Q (every) shift. Every day and night shift. R34's TAR documents no skin checks for the following dates during the day shift: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. On [DATE] at 9:40 AM R34 stated, I put my brace on myself. I do put in on wrong sometimes. No one helps me. They do not look under my brace every shift. They don't look under it at all. On [DATE] at 1:40 PM, V33 (Nurse's Assistant) stated that she has not been in-serviced on policy and procedures regarding residents' braces or splints. On [DATE] at 1:41 PM, V14 (CNA) stated that she has not been in-serviced on policy and procedures regarding residents' braces or splints. On [DATE] at 1:43 PM, V81 (CNA) stated that she has not been in-serviced on policy and procedures regarding residents' braces or splints. On [DATE] at 1:49 PM, V13 (CNA) stated that she has not been in-serviced on policies and procedures regarding residents' braces or splints. On [DATE] at 2:25 PM, V67 (CNA) stated that she has not been in-serviced on policies and procedures regarding residents' braces or splints. On [DATE], the surveyors confirmed through observation, interview and record review, the facility took the following additional actions to remove the Immediate Jeopardy: H. On [DATE], all nurse managers completed a skin assessment on all residents with an order for [REDACTED]. I. On [DATE], V1, V2, V38 will be monitoring Q (every) shift 7 days per week every TAR for an immediate intervention for compliance with splint/brace policy and procedures. J. On [DATE], all Nurses and CNAs were re-in-serviced by V1, V2 and V3 on Policy and Procedures on splints/braces with each clinical staff member. All were required to read the policy and procedure in its entirety back to the educator to allow for maximum comprehension. All staff not present [DATE] will be educated via telephone call, receive the policy and procedure via text and respond via text to their completion of education and complete comprehension of policy and procedure. All staff identifying a missing brace/splint must report to the resident's nurse and Director of Nursing to address compliance and document accordingly. K. On [DATE], residents with splints/braces will be interviewed daily to verify staff compliance with splint/brace policy and procedure by Administrator or Director of Nursing.

Based on observation, interview and record review, the facility failed to assess residents for fall risk, provide supervision, progressive interventions, ensure fall interventions were implemented, complete fall investigation, and determine a root cause analysis of fall to prevent falls for 8 of 9 residents (R2, R3, R4, R11, R14, R16, R17, R21) reviewed for accidents and supervision in the sample of 56. These failures resulted in R2 sustaining fracture to her femur; R3 sustaining a fracture to right hip, right pelvis and right femur; R21 sustaining a large painful hematoma to her left hip area requiring hospitalization ; R11 having multiple falls in which he sustained a left [MEDICAL CONDITION] requiring surgical repair on one fall, a right [MEDICAL CONDITION] requiring surgical repair with another fall, and a laceration requiring 6 sutures on another fall; R14 sustaining a nasal fracture; R16 sustaining a fractured tooth; and R4 sustaining a 3 centimeter laceration to her head. Findings include: 1. R2's Care Plan, dated 3/27/2020, documents, (R2) is at risk for falls r/t (related to) increased confusion and decreased mobility. She relies on staff assist with adl's (activities of daily living) and mobility. At risk for skin complications r/t decreased mobility, incontinent of bowel and bladder, and confusion. R2's Care Plan does not document a new intervention based on root cause analysis for R2's fall on 4/4/2020. R2's Minimum Data Set (MDS), dated [DATE], documents R2 as totally dependent of 2 person physical assist for bed mobility. R2's Fall Risk Assessment, dated 3/9/2020, documents high risk for falls. R2's Nurses Notes, dated 4/4/2020 1:31 AM, document, Note Text: CNA (Certified Nursing Assistant) told this RN (Registered Nurse) 'resident is on the floor,' went to room at (1:05 AM) to find resident on floor lying on her back with her head towards the foot of bed. Noted left leg was under roommate's bed. Obvious deformity to left knee/femur. Vital signs stable. Resident unable to verbalize how fall happened. Resident pointing to her knee leading this RN to assume she is in pain. {Company name} called for emergency transfer to local hospital. Notifications made and documented. R2's Electronic Health Record does not document a fall assessment for 4/4/2020 fall. R2's Local Hospital left knee X-ray report, dated 4/4/2020, documents R2 had a moderately comminuted (fracture producing multiple bone splinters), displaced, angulated, [MEDICAL CONDITION] 5th femoral shaft/metaphysis (long, straight part of the thighbone). R2's Local Hospital Summary, documents R2's reason for admission was fractured femur. The Summary documented, [AGE] year old female resident of a nursing home with a history of severe dementia and a past history of tibia and fibula fracture sustained a fall in the nursing home and was brought to the emergency room , X-ray of the left femur showed a fracture of femoral neck and patient has been seen evaluated by orthopedic but recommended non operative treatment for [REDACTED]. Patient has gait disorder and is mostly in a wheelchair. R2's Local Hospital Transfer Form (Physician Orders), dated 4/10/2020, documents Recommend follow up x-ray in 6 wks (weeks), bedrest for 6 wks, wear knee immobilizer w/daily (with) skin checks for pressure injury. *has distal femur fracture w/o (without) intra-articular extension being treated with closed fracture care. R2's Fall Investigation Report, dated 4/4/2020, documents at 12:55 AM CNA reported resident was on the floor. Entered room Resident on back next to bed on floor with her head pointing towards the foot of the bed. Left leg under bed of roommate with obvious deformity to left femur/knee. Resident unable to give description. Immediate Action Taken: Gave pillow and blanket to resident and left on floor until EMS (emergency medical service) arrives. Called for emergency transport by (ambulance service); VSS (vital signs stable). Oriented to person. Predisposing Physiological Factors: Confused, Incontinent, Noncompliant with safety Guidance, Impaired Memory. 4/8/2020 Notes: IDT (interdisciplinary team) reviewed incident, investigation, and finding, documents in part RCA (Root Cause Analysis): According to cna while performing rounds found (R2) on floor by her bed with deformity noted to left leg. (R2) sent to ER (emergency room ) for further eval (R2) sustained fx (fracture) to left femur with no surgical interventions, remains in hospital at this time. All prior interventions were in place and appropriate time of fall. Based on investigation no abuse or neglect identified. R2's Fall Investigation Report does not document an effective or complete root cause analysis of fall and/or intervention put in place. On 11/10/2020 at 2:31 PM, V5 (Registered Nurse/RN) stated, She (R2) was complete care. She was contracted. Not alert or responsive to environment. Not verbal. Not completely able to make needs known. Don't remember her having any bed rails. She needed 1-person assistance in bed. She fell out of the bed. She had an obvious deformity. Bent out at the knee in a way that was abnormal. No complaints of pain. But with her cognition she wouldn't be able to tell you she was in pain. I'm not sure how she fell . She didn't move in the bed. It was a freak thing. I'm not sure how she fell . On 11/19/2020 at 9:17 AM V26 (Certified Nursing Assistant/CNA) stated, I worked with her (R2) before she fell . She was moved to a different hall after she fell . Before her fall she was a total care. Complete care. She didn't move. Once she was in the bed, she was just there. You had to move her. She didn't turn herself or move around in the bed. I don't know how she fell because she didn't move. It didn't make sense. On 11/19/2020 at 11:53 AM V27 (CNA) stated, She (R2) was total care. She had an air mattress. She didn't move at all. I found her on the floor. I believe it was her air mattress that caused her fall. Her mattress kept malfunctioning. It would deflate from time to time. I don't remember if it was deflated at the time because I was focused on her on the floor. I know that before the fall the mattress was messing up. On 11/30/20 at 1:03 PM, when asked about R2's falls, V3 (Assistant Director of Nursing/ADON) stated, Which time? I do remember one night, (V20) called me and told me she had found (R2) on the floor. I don't know how she fell . She was turned different. Her head was at the foot of the bed and her legs were at the top of the other bed. She didn't move in the bed. Wasn't very mobile at all. She didn't try to transfer self or nothing like that. I'm not sure how she fell . I was not in the building when she fell . I do believe she was one of the residents that had problems with her mattress. We have had air mattresses that have malfunctioned and deflated, but I don't remember if that was the issue. On 1/3/2020 at 3:23 PM, per phone interview, V54 (Physician) stated, When I saw her she was up in her chair. If her mattress was malfunctioning, the ideal solution would be to replace it. 2. R3's Care Plan, dated 3/20/20, documents, FALL: (R3) is at high risk for falls r/t weakness, recent hospitalization , and cognitive delay. Provide frequent visual checks on (R3) to ensure safety. Provide proper, well maintained footwear. (R3) is at risk for complications r/t incontinence secondary to cognitive delay. He requires frequent reminders to use the rest room and supervision to ensure that he is performing appropriately. R3's MDS, dated [DATE], documents, Severely impaired cognitively. Short and long-term memory problems. BIMS (Brief Interview for Mental Status) should not be performed because resident is rarely/never understood. Requires supervision with one person physical assist for transfers. R3's Incident Investigation Report, dated 3/26/2020, documents, Resident in therapy bathroom on toilet. Resident had fallen in bathroom and had a skin tear to Left elbow. No other skin issues noted. When asked how resident fell , resident stated he fell on his butt because the floor was wet. Resident then stated he fell on his legs. Resident aware of wet floor sign stating, 'they mopped it.' When asked why he came in this bathroom if the floor was wet, he stated he had to poop. When asked why he didn't use his room bathroom, he stated he didn't want to. R3's Nurses Notes Note, dated 3/27/2020 at 2:21 AM, documents, Text: X-ray results obtained. Resident has sustained fracture to right hip, right pelvis and right femur. Physician notified. New order received to send to emergency room . Call placed to resident's sister. No answer received. Voice message left instructing to call facility to speak with the nurse. Administrator notified. Call placed to EMS. Report called to local hospital. Resident resting quietly in bed at this time with eyes closed. Monitoring ongoing. R3's Nurses Notes, dated 3/27/2020 at 2:57 AM, documents, Note Text: Resident is leaving facility at this time transferred via EMS in route to local hospital. Transferred to stretcher via 2 person assist. Tolerated well. No s/s (signs/symptoms) of distress during transfer. Unable to reach family to notify of transfer. Will continue to attempt to reach family. Bed hold notification sent with resident. The facility provided a timeline, signed and dated 11/10/2020 by V1 (Administrator) which documents, in part, He (R3) approximately functions similar to a 4 to 5 year old. On 11/12/2020 at 11:30 AM, V1 stated, Residents returning from hospital are placed on the COVID hall and placed on isolation. There is one nurse and two CNA's to make sure the residents are cared for and supervised. On 11/30/2020 at 1:03 PM, V3 (ADON) stated, (R3) was challenging. He was on the COVID hall because of recent hospitalization . He had behaviors and difficult to redirect. He required supervision. Sometimes even one on one supervision. The staff would try to redirect. Sometimes it worked and sometimes it wouldn't. He needed a lot of supervision and staff interaction. When he fell in the bathroom, he was alone. Staff were not with him. On 11/18/2020 at 12:30 PM, V46 (R3's guardian) stated, I was told that he fell on a wet floor. They said that there was a wet floor sign, but he went into the bathroom anyway. (R3) can't read, so the sign wouldn't have done anything for him anyway. It wouldn't have stopped him. He couldn't read it. 3. R17's Care Plan, dated 9/23/2020 documents, FALL: (R17) is at risk for falls r/t history of Falls and poor balance. She has been noted to get up from her chair and attempt to sit on the floor. She requires redirection at times. Often restless at night, redirected to nurses' station when awake. Resident is an extensive assistance of two staff members for ADLs. Resident has incontinence present. Wheelchair used. 4/16/20 During night shift rounds, when restless, up and out with staff until breakfast, offer snack. R17's MDS, dated [DATE], documents, Frequently incontinent and requires extensive physical assist from two plus persons. R17's Incident Report Investigation, dated 6/9/2020 3:50 AM, documents, resident was found on the floor at the 300/400 hall nurses' station by the cna. R17's Incident Report Investigation, dated 6/26/2020 0:315, documents, CNA notified this nurse that resident was sitting on floor next to 300/400/500 hall nursing station. On 12/8/2020 at 1:30 PM, V24 (Restorative Nurse) stated, I did investigate (R17's) falls. She got up out of her chair. She gets up which is why she has to sit at the nurses' station when she is up at night as well. With her sitting at the nurses' station, it is the hope that she would be watched by the staff. With both of these falls, staff were not at the nurses' station where she was. They were down the hall providing care for another resident. When returned, they found her on the floor. This happened with both falls. On 12/23/2020 at 12:58 PM, V2 (Director of Nursing/DON) stated, Placing the resident at the nurses' station helps with supervision. If she was sitting at the nurses' station, I would expect (R17) to be supervised. 4. R21's Care Plan, dated 9/16/2019, documents, FALL: (R21) is at high risk for falls r/t (related to) functional deficits, non-compliance, poor balance; 9/14/20 x-rays result, no findings; 10/5/20 X-ray to left hip. Resident unrealistic about long term goal to return home unassisted, requires reeducation of need for assist and encouragement to use call light. Poor safety recall, believes therapy can strengthen her to go home; 11/16/20 Increased [MEDICAL CONDITION] activity, N.O. (new order) for med change; 11/22/20 Labs result - N.N.O. (no new order), CXR (chest X-ray) resulted no findings; 11/27/20 readmitted increased weakness, requires more assist, [MEDICAL CONDITION] medication changes made during hospitalization ; 12/1/20 Labs in house resulted, [MEDICAL CONDITION] meds adjusted; 10/5/2020 Bedside commode; 11/1/2020 Encourage to use bedside commode during night hours or use call light to ambulate to restroom. R21's MDS, dated [DATE], documents cognitively intact and extensive assist of one person physical assist for transfers. R21's Electronic Health Record documents R21 having 12 falls from July 7, 2020 to December 13, 2020. The November 15, 2020 fall resulted in a [DIAGNOSES REDACTED]. R21's Incident Report, dated 7/7/2020 3:46 PM, documents in part, res (resident) found on floor next to bed in room. RCA Poor balance, noncompliance. R21's Incident Report, dated 9/12/2020 9:30 PM, documents in part, Resident asked what happened; resident replies 'I was trying to pick up my bag off the floor and lost my balance.' Resident c/o (complained of) left ankle pain and bilateral hip pain. RCA: Poor balance, noncompliance. R21's Incident Report, dated 10/5/2020 8:30 AM, documents in part, Resident was ambulating to her bed in her room and fell on to the floor. No witness found. Resident stated she had pain in her L (left) ankle and L wrist. RCA: Poor balance, noncompliance. R21's Incident Report, dated 10/5/2020 1:30 PM, documents in part, Resident was found on floor in the bathroom doorway. Injury type: Hematoma to face. Resident transported to hospital for evaluation. RCA Poor balance, noncompliance. R21's Incident Report, dated 11/1/2020 4:00 AM, documents in part, Resident was ambulating in room to bathroom and fell on floor. No witness found. RCA Poor balance, weakness, noncompliance. R21's Incident Report, dated 11/15/2020 1:10 AM, documents in part, Heard crash from room. Went to find resident laying on her left side with her head resting on the floor. Resident has hematoma on left hip, however there is no internal or external rotation of the hip. CMST (circulation, movement, sensation, temperature) to right lower extremity wnl (within normal limits). No witness found. RCA weakness, noncompliance. R21's Incident Report, dated 11/16/2020 5:12 AM, documents in part, Resident roommate came to tell Nurse that res (resident) is on the floor. Went to room to find resident lying on her left side with her head resting on the floor. No injuries, only complaining of dizziness and pain level at 4. 'I was trying to get on my commode and fell .' RCA: [MEDICAL CONDITION]. R21's Incident Report, dated 11/22/2020 12:56 PM, documents in part, Nurse was in hallway passing meds when res roommate came in hallway and stated that resident was on the floor. Nurse went into room and saw res sitting in buttocks on floor next to roommate's bed. Res stated she was trying to go to the restroom at this time, lost her balance and her legs gave out. T99.1 Tylenol given to lower temp. RCA: increased weakness. R21's Incident Report, dated 11/23/2020 7:55 PM, documents in part, This nurse called to resident's room. Resident observed lying on floor next to bed on her back. Resident stated she fell . Injury type: fracture suspected/ruled out left trochanter (hip). Sent to hospital for evaluation. No witness found. RCA: [MEDICAL CONDITION], increased weakness. R21's Discharge Summary, dated 11/27/2020, documents in part, Reason for admission: hematoma, [MEDICAL CONDITION]. Patient developed hematoma of the left hip area associated with pain which happened when patient fell at the nursing home. X-ray did not show any evidence of fracture but patient has large hematoma of the left hip area which is causing severe pain. R21's Nurses Notes, dated 11/28/2020 7:21 AM, documents, Note Text: RN came onto hall and was called to resident room. Resident stated she was taking herself to the toilet and slid out of her chair landing on her buttock. Resident was seated on floor with her feet in bathroom doorway facing into bathroom. Resident c/o discomfort in left hip. A large hematoma was present from previous fall and a [MEDICATION NAME] was present. No deformation noted. Resident lifted into w/c (wheelchair). Resident stated she hit her head on w/c. no laceration or hematoma noted to head. R21's Incident Report, dated 11/28/2020 7:21 AM, documents, Resident Description: resident stated she was taking herself to the toilet and slid out of her chair landing on her buttocks. No witness found. RCA: Increased weakness and medication change per neuro during hospital stay. R21's Nurses Notes, dated 11/29/2020 2:32 PM, documents, Nurses Notes Note Text: Resident found in seated position on floor near bathroom with feet near bathroom and back towards doorway entering room. Resident denies pain or discomfort. No deformities noted. Resident returned to wc. R21's Incident Report, dated 11/29/2020 2:32 PM, documents in part, Resident Description: resident stated she was taking herself to the toilet and slid out of her chair landing on her buttocks. RCA: Increased weakness and medication change per neuro during hospital stay. On 12/9/2020 at 2:53 PM, R21 observed in her room. No bedside commode was present in room. On 12/9/2020 at 2:50 PM when asked about her falls, R21 stated, I fall a lot. I'm not sure why. I just keep falling. This last time, I used the call light and waited. Just like they said. It took forever. So I took myself. My wheelchair - it's broke. It rolled back when I tried to stand up. I went right onto the floor. I told (maintenance). They ain't did nothing about it yet. When asked if R21's bedside commode was in place, would she have used it. Resident stated Yes. R21's Incident Report, dated 12/13/2020 11:54, documents in part Res roommate came to nurses' station to inform nurse that res fell to the floor. Res was sitting on the floor by the bedside. Res stated she was trying to use the commode and slipped and fell . RCA: Weakness and unassisted transfer/ambulation. On 12/14/2020 at 10:30 AM, V30 (Nursing Assistant) assisted R21 with toileting. V30 applied the brakes to the wheels on R21's wheelchair. V30 then assisted R21 into the standing position. R21 pushed up, using arm rest from the wheelchair. The wheelchair right wheel rolled backwards. R21 began waving back and forth. R21 grabbed a hold of the wall. V30 then assisted R21 onto the toilet. R21 pointed to the wheelchair. V30 checked the wheelchair and verified the wheelchair brakes were on. V30 was able to roll the wheelchair, forwards and backwards, with the brakes on. On 12/14/2020 at 9:37 AM, V24 (Licensed Practical Nurse/LPN/Restorative Nurse) stated, (R21) has had a lot of falls. Her falls are because she doesn't listen and gets up. I am not aware of a wheelchair being involved in her falls. I am not aware of her wheelchair not working properly and have not checked the wheelchair. On 12/14/2020 at 10:35 AM, R21 stated, That damn wheelchair is raggedy. The brakes don't work. It don't work. I told them. On 12/14/2020 at 10:40 AM, V30 stated, The brake is broken. It doesn't lock in place. On 12/14/2020 at 11:30 AM, V31 (Maintenance Director) stated, If a resident has a fall and equipment is involved, the IDT (Interdisciplinary Team) tells me and I look at it and fix it if needed. I am not aware of (R21's) wheelchair not working properly. I have not worked on the wheelchair. On 12/16/2020 at 11:09 AM, V2 stated, If the resident slid out of the wheelchair, I would expect the wheelchair to be looked at as to why. If the resident says the wheelchair is broken, I would expect maintenance to look at the wheelchair and repair or replace it. Interventions that are put in place are expected to follow the resident with room move. On 1/3/2020 at 3:23 PM, V54 (Physician) stated, She has had a stroke with right sided paralysis, her balance is poor, and she attempts to walk. Trying to do things on her own. It is not uncommon that she would have these falls. They (facility) need to make it clear to her to make sure she calls for help. The facility has to make it clear to her. Of course, you would want to increase supervision. They could try frequent checks but with two CNAs to 20 to 30 people, that's not practical. 5. R11's Admission Record, print date 12/8/2020, documents R11 was admitted on [DATE] and has [DIAGNOSES REDACTED]. R11's MDS dated [DATE], documents R11 is severely cognitively impaired, requires supervision of 1 staff member for locomotion, and uses no mobility devices. R11's Fall Report, dated 3/30/2020, documents, Nursing Description: this nurse was informed that resident fell out on the patio while another resident stated that he lost his balance but did not hit his head. Resident Description: resident stated he lost his balance and fell while on the patio when he went out to smoke. Immediate Action Taken: resident assisted into a w/c to use. Injury Type: No injuries observed at time of incident. This Fall Report does not document new interventions or a Root Cause Analysis of the fall. R11's Fall Report, dated 5/29/2020 at 6:23 PM, documents, Nursing Description: Staff came to get nurse states resident fell in hallway and hit his head. Resident did not have wheelchair and tripped over scale and hit head on grab bars. Resident Description: Resident stated he fell out of wheelchair but did not have his wheelchair. Immediate Action Taken: Resident was immediately assessed for any fractures. Gauze applied to head gash and arm lacerations. Injuries Observed at Time of Incident: Injury type: Laceration. Injury Location: 15) Right antecubital. Injury type: Laceration. Injury Location: Face. Mental Status: Confused/Forgetful. Oriented to Person. Predisposing Physiological Factors: Confused, Gait imbalance, impaired memory and Weakness/Fainted. Notes: IDT review and investigation: Alert with confusion. Non-compliant with wheelchair use poor balance and BLE (bilateral lower extremity) weakness. Often ambulates without assist. Room located across hall from scale, walked out unassisted before staff could approach and tripped over scale and lost balance. Interventions: Halls clear and free of clutter, staff reeducated on monitoring ambulation in halls unassisted, encourage use (of) wheelchair. This fall report does not document the RCA of the fall. R11's Nurses Noted, dated 5/29/2020 at 4:21 PM, documents, Note Text: Resident fell in hallway while activities was taking residents to go on smoke break. Resident tripped over scale in hallway and hit his head on metal grab bars. Resident had a head gash, lacerations to right arm and elbow. Sent to local hospital for evaluation and treatment. R11's emergency room Visit report, dated 5/29/2020, documents, Review of Systems: Skin: Dry, warm, laceration 3 cm (centimeters) diagonal above right eye, other (superficial abrasions on right knee, superficial square shaped skin tear measuring 3 cm by 3 cm and located proximal to right elbow without significant bleeding). ED (Emergency Department) Procedures: Wound/Laceration Repair #1 wound location: above left eye. wound length (cm): 3. Skin sutures: 6. R11's Nurses Note, dated 5/30/2020, documents, Note Text: Late Entry 5/29/2020; resident discharged from Hospital. 7:04 PM resident returns to facility transported by ambulance via stretcher accompanied by 2 attendants; readmitted to assigned room (#). Upon returning resident has absorbable stitches to center forehead, bruising/swelling to right /left eye bruising and laceration to right arm. R11's Nurses Note, dated 6/2/2020, documents, Late Entry: Note Text: res noted to have 6 sutures to forehead from recent fall and 2 skin tears to right elbow and right upper arm. no pain noted. R11's MDS, dated [DATE], documents R11 is severely cognitively impaired, requires limited assistance of one staff member for walking in the corridor, supervision of one staff member for locomotion, R11 uses a wheelchair for locomotion and during walking is not steady, only able to stabilize with staff assistance. R11's Fall Report, dated 8/7/2020 at 5:24 PM, documents, Nursing Description: res was found on the floor in activities area. Resident Description: I was helping (another) put his shoe on, lost my balance and fell . Immediate Action Taken: Resident assisted back to w/c with assist of 2. Injuries Observed at Time of Incident: Injury Type: Skin Tear Injury Location 17) Right elbow. Mobility: Noncompliant with Ambulation Guidance. Mental Status: Oriented to Person, Orientated to Place. Predisposing Physiological Factors: Noncompliant with Safety Guidance, impaired memory. Notes: dated 8/10/2020, IDT review and investigation: Alert with confusion. Non-compliant with wheelchair use poor balance and BLE weakness. Often ambulates without assist. Leaning forward in wheelchair to help peer with shoes, poor balance and posture, fell forward. RCA: Weakness and manageable dehydration for poor fluid intake and insistence to go out to smoke. Seen in ER 8/4/2020, encourage fluids. Interventions: Tilted w/c seat to assist in positioning. R11's Fall Report, dated 8/23/2020 at 5:28 PM, documents, Nursing Description: CNA came and told nurse that res fell to the floor trying to go to the restroom. Resident Description: res stated he was trying to go to the restroom and he had fell to the floor. Immediate Action Taken: VS (vital signs) are stable at this time, nurse assisted res to bed, res has a skin tear to r (right) elbow which was treated with TAO (triple antibiotic ointment) and d/d (dry dressing), res now has a floor mat in place, res was instructed on how to use call light and ask for help. Mental Status: Confused/Forgetful. Notes, dated 8/25/2020, IDT Review and investigation: Alert with confusion. Non-compliant with wheelchair use poor balance and BLE weakness. Often ambulates without assist. Ambulating to restroom unassisted, poor balance and posture. RCA: Toileting unassisted. Interventions: Sent to ER to eval (evaluate) and treat, toileting program, bed in lowest position. R11's Nurses Note, dated 8/23/2020 at 5:33 PM, documents, res fell to the floor trying to go to restroom, res has skin tear to r elbow which was treated with tao and d/d, res also c. o. (complaint of) pain in right hip, X-ray has been ordered at this time, vs (vital signs) are stable, neuro (neurological) checks in place, no signs of distress noted, res has Tylenol given for pain, no signs of distress or discomfort noted at this time. R11's Nurses note, dated 8/24/2020 at 6:05 AM, documents, Right hip X-ray reported r/t fall, writer rec'd (received) orders to send to ER for further eval/tx (evaluation and treatment). Resident admitted with dx (diagnosis) of right hip fx (fracture). R11's Hospital Progress Note, dated 8/28/2020, documents, Patient admitted with [MEDICAL CONDITION], status [REDACTED]. R11's Hospital Patient Transfer Form, signed 8/28/2020, documents, Hospital admitting [DIAGNOSES REDACTED]. Ambulatory Status: Assist of 2 required with walker. R11's Nurses Note, dated 8/31/2020, documents, Note Text: re-admission skin assessment completed. res noted to have 3 incisions to right hip from surgery. incisions are well approximated with 18 staples noted. dry drsg (dressing) ordered to area daily. no pain noted. scab noted to left lower arm and scattered bruising to bilateral lower arms. res was pleasantly confused with assessment; does not remember having surgery to hip. will cont (continue) to monitor. R11's Fall Report, dated 9/3/2020 at 8:25 PM, documents, Nursing Description: Found res on his back on the floor in his room. Resident Description: I took a header. Injury type: Abrasion. Injury Location: Left scapula. Injury type: Skin tear. Injury Location: Right hand. Mental Status: Confused/Forgetful, Oriented to person, not oriented. Predisposing Physiological Factors: Noncompliant with Safety Guidance, Gait imbalance, Recent illness. Notes, dated 9/4/2020, IDT Review and investigation: Alert with confusion. Non-compliant with transfer need for assist, BLE weakness new right [MEDICAL CONDITION] and repair. Ambulating unassisted, poor balance and posture. RCA: Poor memory and decreased safety awareness. Interventions: In view of staff when restless. R11's Fall Report, dated 9/4/2020 at 6:00 PM, documents, Nursing Description: Writer was coming out of room (#) and heard resident yelling 'Help me, help me, help me.' Writer entered room to observed resident laying on the floor next to bed 1, legs stretched out in front of him stating 'Help me up.' Resident stated he was trying to get in bed 1 when his bed is bed 2, unassisted. Resident Description: Resident stated he was trying to get in bed. Immediate Action Taken: Head to toe assessment completed. Resident was noted with +ROM x 4 (positive range of motion for all 4 extremities) and noted with skin tears on his forearms from previous fall the night before. No abnormal deformity or rotation of extremities noted. Resident stated he was sore all over but refused Tylenol denying new pain. Resident was alert but confused. Resident was assisted off the floor after head to toe assessment performed and transferred back to his chair. Resident was placed in his wheelchair, face mask applied and was placed in the hallway outside of his room door for closer observation. (V54, Medical Doctor) called and informed of incident. No new orders received at this time in assessment. VS WNL (within normal limit) and resident attempted to finish his dinner but only ate a few bites. Staff also initiated q (every) 1 hr rounding on him and allowed him to self propel his wheelchair in hallway due to restlessness and frequently redirected when he attempted to leave unit. Injury Type: No injuries observed at this time. Mental Status: Confused/forgetful, Oriented to person and Oriented to situation. Predisposing Physiological Factors: Incontinent, Noncompliant with Safety Guidance, Gait imbalance, Impaired memory, recent illness and weakness/fainted. Predisposing Situation Factors: Improper footwear, ambulating without assist and during transfer. Notes, dated 9/9/2020, IDT Review and investigation: Alert with confusion. Non-compliant with transfer need for assist, BLE weakness new right [MEDICAL CONDITION] and repair. Ambulating unassisted, poor balance and posture. RCA: Poor memory and decreased safety awareness. Interventions: In site of staff from dinner to bedtime. R11's Nurses Note, dated 9/4/2020, documents, Note Text: Writer was coming out of room (#) and heard resident yelling 'Help me, help me, help, me.' Writer entered room to observe resident laying on the floor next to bed 1, legs stretched out in front of him stating 'Help me up.' Resident stated he was trying to get in bed 1 when his bed is bed 2, unassisted. Resident was noted with +ROM x 4 and noted with skin tears on his forearms from previous fall the night before. No abnormal deformity or rotation of extremities noted. Reside(TRUNCATED)

Based on observation, interview and record review, the facility failed to cleanse and monitor a Gastrostomy tube (G-tube) site, follow physician orders, check for placement using auscultation and residual checks, and turn off the tube feeding when the head of the bed is lowered to the flat position for 4 of 5 residents (R6, R14, R16, R20) reviewed for G-tubes in the sample of 56. This failure resulted in R6 requiring hospitalization for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. R6's Face Sheet documents she was first admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Hospital Records dated 6/25/20 to 7/17/20 document that she had a gastrostomy tube (g-tube) inserted on 6/30/20 for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per progress notes, R6 was admitted to the hospital on 8/23/20 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's hospital records dated 8/22/20 documents she was seen in the emergency roiagnom on [DATE] at 9:50 PM and subsequently admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These hospital records included physical exam findings of R6's abdomen: diffusely tender to palpation, worse around g-tube site; g-tube site with [CONDITION(S)] and purulent discharge. According to these hospital records, the pus from the g-tube site was cultured and the History and Physical report dated 8/27/20 identified the results of that culture as growing moderate mixed microorganisms including a few Pseudomonas aeruginosa, which was treated with 7 day course of antibiotic and antifungal treatment. The same hospital History and Physical report also included the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Order Summary Report dated 12/8/20 includes documentation of orders, dated 7/28/20 to auscultate g-tube for placement, flush her g-tube before and after medication administration, and to check residual through g-tube every shift. The Order Summary Report also included the order dated 7/28/20 for weekly skin checks on Wednesdays on night shift. R6's Order Summary Report did not include any orders for assessment or treatment to her g-tube site. R6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's TARs dated July 2020 and August 2020 document skin checks were performed on 7/17/20, 7/22/20, 7/29/20, 8/6/20, 8/12/20, and 8/19/20, but there was no documentation of assessment and/or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . May be done by nursing assistant if no open areas, every night shift for g-tube site. The start date for this order was 8/23/20, the day after R6 was sent to the emergency room and admitted for g-tube site infection. There were no other orders related to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's CNA (Certified Nursing Assistant) Skin Attention Form dated 8/22/20 but untimed, documents, No skin problems noted. R6's Care Plan, initiated 6/22/20 documents, (R6) is at risk for complications with weight and nutrition related to pancreatitis, chronic [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), severe underweight status, malnutrition, PEG-J (g-tube) status, poor intake, c-diff (bacterial infection), and history of not tolerating greater that 30 milliliters/hour of tube feeding formula. Another Care Plan focus, dated 7/20/20, was, Tube Feeding: (R6) is at risk for complications related to PEG-J (g-tube) need, intolerance to formula or rate, possible infection to enteral site, underweight status, and chronic pancreatitis. There were no interventions for either of these Care Plan focuses to monitor the g-tube for signs and symptoms of infection, or plan for treatment and assessment of R6's g-tube site. On 12/21/20 at 12:40 PM, V2 (Director of Nursing/DON) stated she did not know why or when R6 was sent to the hospital on 8/23/20. She stated she thought it might have been early in the morning on 8/23/20, but she was not sure if there were problems with her g-tube site or not. V2 stated the nurse should have filled out a transfer form detailing her assessment and reason for sending R6 to the hospital and would have included the date and time of the transfer. V2 stated that documentation was not done, and that nurse has since resigned from the facility. On 1/3/21 at 3:00 PM, V54 (Physician) stated, Normally a G-Tube site will have drainage around it. The nurses are not going to see redness or puss unless they manipulate the G-tube. If the G-tube was placed right, there should not have been a problem since this was a new G-tube. I do expect the nurse to chart if there is a problem and notify me. 2. R16's Admission Record, print date of 11/18/2020, documents R16 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R16's MAR, dated November 2020, documents, Enteral Feed Order every day and night shift Enteral Feeding Formula [MEDICATION(S)] 1.5 Rate 50 CC (cubic centimeters)/hr (Hour). Order date 6/12/2020. R16's November 2020 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Rate 50 cc/hr. Order date 6/12/2020. R16's Dietary Note, date 10/13/2020, documents, in part, TF (tube feed) [MEDICATION(S)] 1.5 at 50 ml (milliliters)/hr plus 200 ml water q (every) 6 hours via gastrostomy tube (G-tube). On 11/9/2020 at 11:15 AM, R16 was observed lying in bed with [MEDICATION(S)] 1.5 running at 65 ml/hr via G-Tube. During care provide by V32 (Certified Nurse Assistant/CNA) and V33 (Nurse Assistant/NA), the G -tube site had a dark brown crusty residue around the stoma site extending approximately 3/4th of an inch. The stoma site had no dressing around it. The CNAs put the head of the bed all the way down while performing incontinence care for R16 with the tube feeding still running. On 11/9/2020 at 3:15 PM, V17 (Licensed Practical Nurse/LPN) stated, I wash the G-tube site at least once a shift. V17 then confirmed R16's [MEDICATION(S)] 1.5 was running at 65 ml/hr. 3. R20's Admission Record, print date of 11/18/2020, documents R20 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R20's Care Plan, dated 1/6/2020, documents, Focus; Tube Feeding: (R20) is at risk for complications r/t (related to) new g- tube placement. She receives [MEDICATION(S)] 1.2 with a 100 ml water flush per MD (Medical Doctor) orders. Interventions: Check feeding tube residual as ordered. Keep HOB (head of bed) raised to 30 degrees. Tube feeding as ordered. R20's Order Summary, dated November 2020, documents, Check placement of G-tube using auscultation before administering food/medications/fluids. On 11/9/2020 at 11:58 AM, V16 (LPN) administered a 100 ml water flush via the G-tube. V16 failed to verify placement by auscultation. V16 exposed the G-tube stoma which had a buildup of crusty brown debris. On 11/9/2020 at 11:58 AM, V16 stated, I usually clean my G-tube sites at the end of my shift. 4. R14's Admission Record, dated 11/18/2020, documents R14 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Order Summary, dated November 2020, documents, Check placement of G-tube using auscultation before administering food/medications/fluids. On 11/9/2020 at 12:00 PM, V14 (LPN) administered a 150 ml water flush via the G-tube. V16 failed to verify placement by auscultation. On 12/15/2020 at 3:00 PM, V2 stated, I would expect the nursing staff to clean around the G-tube site if it is dirty. I expect the nurses to check G-tube placement by auscultation and checking for residual before administering anything through the G-tube. I expect the nurses to turn off the tube feeding if the resident's bed is going to be laid flat for care. The facility's Gastrostomy/Jejunostomy Tube Care and Maintenance policy and procedure, review date 9/2017, documents, Daily care of the gastrostomy/Jejunostomy tube and exit site will extend the life of the tube, prevent peristomal skin irritation, and assure appropriate hygiene of the tube exit site. The policy guidelines include, 4. Clean the tube site daily with mild soap and water, rinse (unless no rinse soap is used) and dry. 5. Observe the peristomal skin for redness, irritation or gastric leakage.

Based on observation, interview and record review the facility failed to provide timely treatment to gangrenous toes for 1 of 4 residents (R3) reviewed for nonpressure wounds in the sample of 15. This failure resulted in no treatment to the changes on the right 2nd toe and right great toe when first observed, and progression of gangrenous changes to the 1st, 2nd and 3rd toes of the right foot. Findings include: R3's Care Plan dated 10/18/19 documents, At risk for skin complications r/t recent amputation of left leg and decreased mobility. (R3) had abrasions to right foot 2nd and 3rd toes. 11/15/19 sutures and staples removed to left above knee amputation. Interventions (in part): Observe and assess regularly. Inspect feet during routine care for open areas, pressure areas, blisters, [MEDICAL CONDITION] or redness. R3's Skin/Wound Note dated 11/14/19 documents, 11:41 AM. Resident noted to have abrasion to top of right foot 2nd and 3rd toe. Minimal pain to touch. Areas are scabbed and no drainage noted. Skin prep order received. Resident made aware of new order. Will continue to monitor. R3's Skin/Wound Note dated 11/15/19 documents, 10:09 AM. Sutures and staples removed from left above knee amputation (LAKA). Incision is healed. V16 (R3's Primary Physician) gave orders for removal last weekend. Little pain noted with removal. Resident has abrasion to top of right foot 2nd and 3rd toe. This writer noted that bottom of 2nd toe is black. (V9) Medical records made aware to call vascular MD (V5) for sooner appointment. Next follow up appointment with (V5) is on 12/4/19. Awaiting answer from MD. R3's Skin/Wound Note dated 12/2/19 documents, 10:54 AM. Therapy called this nurse into therapy office to look at resident's right great toe. Dry blood noted to the base of toenail, area cleansed and area noted to be purple in color. Minimal pain noted. V17 (Nurse Practitioner) made aware and V6 (R3's Power of Attorney for Healthcare) made aware. Follow up appointment with (V5) on 12/4. There was no documentation of any changes to R3's 3rd toe prior to his vascular clinic visit on 12/4/19. R3's Physician order [REDACTED]. R3's PO dated 11/14/19 documents, Wipe skin prep to abrasion to right foot 2nd and 3rd toe daily and PRN (as needed). R3's PO dated 12/5/19 documents, Wipe right great toe, 2nd and 3rd toe with [MEDICATION NAME] daily and place ABD (abdominal dressing), wrap with kling every day shift to necrotic toes. R3's Treatment Administration Record (TAR) for 11/2019 documents, Wipe skin prep to abrasion to right foot 2nd and 3rd toe daily and as needed (PRN) everyday shift for abrasions, start date 11/15/19. discontinue date 12/11/19. R3's TAR dated 12/2019 documents, Wipe skin prep to abrasion to right foot 2nd and 3rd toe daily and as needed (PRN) everyday shift for abrasions, start date 11/15/19. discontinue date 12/11/19. R3's TAR dated 12/2019 documents, Wipe right great, 2nd and 3rd toe with [MEDICATION NAME] daily and place abdominal pad, wrap with kling (elastic gauze wrap), start date 12/06/19. Both the PO and TAR have no documentation addressing the black discolored bottom of the 2nd right toe noted on 11/15/19 and the discolored great toe noted on 12/2/19. On 12/12/19 at 8:35 AM, V4 (Treatment Nurse) provided wound care to R3 in bed. R3 had a left above knee amputation. R3 wore a pressure-relieving boot on the right foot which V4 removed. The bottom of R3's 2nd and 3rd toes were black and the great toe was purple. V4 wiped the 3 toes with [MEDICATION NAME], covered with ABD pad and secured with elastic gauze wrap. On 12/12/19 at 9:25 AM, V4 stated she noted the abrasion on top of R3's 2nd and 3rd toes on 11/14/19 and notified V16 (Facility Physician) about it. V4 stated skin prep was ordered to be applied daily. V4 stated she noted the bottom of R3's 2nd toe was black the next day (11/15/19) during treatment and she asked V9 to call V5's office to move up R3's 12/4 appointment sooner. V4 stated she noted the bleeding and discoloration of the great toe on 12/2/19 and notified V17 about it with no new orders. On 12/18/19 at 12:35 PM, V4 stated she only did skin prep treatment to the abrasions on top of the 2nd and 3rd toes. V4 stated there was no order for treatment to the blackened bottom of the 2nd toe until R3 returned from seeing V5 on 12/4/19. On 12/12/19 at 9:49 AM, V9 stated she is in charge of setting up residents' appointments outside the facility. V9 stated she was notified by V4 to call V5's office to request for R3's appointment be moved sooner. V9 stated R3 had a 12/4 follow up appointment with V5 but she was told by the office that there was no opening, nothing available before 12/4. On 12/12/19 at 1:00 PM, V2 (Regional Nurse) stated it is usual practice for V9 to make the calls to set up outside appointments so that was what happened with R3's appointment. V2 stated V9 made the call and was not able to move the appointment to an earlier date. V2 stated R3 went on 12/4 and was seen by V5. On 12/12/19 at 1:09 PM, V5 (Vascular Surgeon) stated prior to the 12/4/19 visit, he had not seen R3 since R3's last follow up visit to his clinic on 10/23/19. V5 stated his clinic always has a record of all calls from his patients or facility staff who called for change in condition and there was no record his office was notified of R3's black 2nd toe or discolored great toe. V5 stated he was not aware the facility called his office regarding R3's toe on 11/15/19 or on 12/2/19 for the changes on the great toe. V5 stated he expected the facility to call him for changes in R3's foot. V5 stated if the facility notified him of the black 2nd toe on 11/15/19, he would have wanted to see R3 within that week with the one black toe rather than when it progressed to multiple black toes when he saw R3 on 12/4/19. V5 stated when he saw R3 on 12/4/19, R3 had gangrene of the great toe, 2nd and 3rd toes. V5 stated gangrene usually does not appear as gangrene right away but starts as discoloration as purple-like a few days earlier and should have been referred to him right away. V5 stated the treatment of [REDACTED]. V5 stated R3 has some developmental issues and is not able to help himself; somebody has to look/take care of him. V5 stated if the facility did daily diabetic foot checks on R3 they would have noted initial gangrenous changes on R3's right toes before 11/15/19. V5 stated it is not hard to look at toes specially when R3 has only the right foot left. V5 stated there was some harm caused by the delay and the facility should have reported to him as soon as they saw the second toe turned black. V5 stated if it is the facility policy to do daily diabetic foot checks they were not doing it even if they say they were doing it. R3's Clinic Note written by V5 dated 12/4/19 documents, (R3) is a [AGE] year old gentleman status [REDACTED]. He denies any trauma. He is a poor historian. He has been living at (Facility) following his amputation. He has no complaints with respect to the left above knee amputation. His sutures have already been removed from the above knee amputation stump. R3's Clinic Note further documents, Physical Exam: Pulses - (R3) has 3 out of 4 bilateral brachial pulses, 2-3 out of 4 bilateral radial pulses, 2-3 out of 4 bilateral femoral pulses. He has non-palpable right popliteal and foot pulses. Extremities - He has left above knee amputation stump with some eschar at the mid portion of the incision. He has dry gangrenous changes to the 1st, 2nd, and 3rd toes on the dorsal aspect of the right foot. There is no purulence. There is no maceration. Studies: Previous arterial studies on (MONTH) 9, 2019 demonstrated a right ankle/brachial index of 0.40 consistent with severe degree of [MEDICAL CONDITION]. [MEDICATION NAME] on (MONTH) 22, 2019 demonstrated the right superficial femoral artery had moderate multi-focal disease. The right above knee and below knee popliteal artery demonstrated severe multi-focal disease. The right tibial turnoff was not well seen. Impression: Right 1st through 3rd toe dry gangrene with known history of severe [MEDICAL CONDITION]. Plan: He is to be scheduled to a right lower extremity angiogram with intervention. He is to undergo dressing changes using [MEDICATION NAME] paint and Kerlix roll for gangrenous areas. He will likely need a right 1st through 3rd to amputation after the successful intervention. The Facility Policy on Change in Resident Condition dated 9/20/17 documents, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician, and residents responsible party of a change in condition. Responsible Party: RN (Registered Nurse), LPN (Licensed Practical Nurse), Social Services. Policy: 1. Nursing will notify the resident, resident's physician or nurse practitioner when: a) the resident is involved in an accident or incident. b) there is significant change in the residents' physical, mental or emotional status. The Policy further documents, 3. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents. 4. The care Plan Coordinator will be notified so that changes in the care plan can be made if needed.

Based on interview and record review the facility failed to address a change in condition in a timely manner by failing to ensure the attending practitioner was notified of the change in condition of a resident's toe for 1 of 4 residents (R3) reviewed for management of change in condition in the sample of 15. This failure resulted in no treatment to the changes on the right 2nd toe and right great toe when first observed and progression of gangrenous changes to the 1st, 2nd and 3rd toes of the right foot. Findings include: R3's Minimum Data Set ((MDS) dated [DATE] documents R3 has severely impaired decision-making skills and needs 50 to 75% help from staff to complete tasks of daily living. R3's Medical [DIAGNOSES REDACTED]. R3's Skin/Wound Note dated 11/14/19 documents, 11:41 AM. Resident noted to have abrasion to top of right foot 2nd and 3rd toe. Minimal pain to touch. Areas are scabbed and no drainage noted. Skin prep order received. Resident made aware of new order. Will continue to monitor. R3's Skin/Wound Note dated 11/15/19 documents, 10:09 AM. Sutures and staples removed from left above knee amputation (LAKA). Incision is healed. V16 (R3's Primary Physician) gave orders for removal last weekend. Little pain noted with removal. Resident has abrasion to top of right foot 2nd and 3rd toe. This writer noted that bottom of 2nd toe is black. (V9) Medical records made aware to call vascular MD (V5) for sooner appointment. Next follow up appointment with (V5) is on 12/4/19. Awaiting answer from MD. R3's Skin/Wound Note dated 12/2/19 documents, 10:54 AM. Therapy called this nurse into therapy office to look at resident's right great toe. Dry blood noted to the base of toenail, area cleansed, and area noted to be purple in color. Minimal pain noted. V17 (Nurse Practitioner) made aware and V6 (R3's Power of Attorney for Healthcare) made aware. Follow up appointment with (V5) on 12/4. There was no documentation of any changes to R3's 3rd toe prior to his vascular clinic visit on 12/4/19. R3's Physician order [REDACTED]. R3's PO dated 11/14/19 documents, Wipe skin prep to abrasion to right foot 2nd and 3rd toe daily and PRN (as needed). R3's PO dated 12/5/19 documents, Wipe right great toe, 2nd and 3rd toe with [MEDICATION NAME] daily and place ABD (abdominal dressing), wrap with kling every day shift to necrotic toes. R3's Treatment Administration Record (TAR) for 11/2019 documents, Wipe skin prep to abrasion to right foot 2nd and 3rd toe daily and as needed (PRN) everyday shift for abrasions, start date 11/15/19. discontinue date 12/11/19. R3's TAR dated 12/2019 documents, Wipe skin prep to abrasion to right foot 2nd and 3rd toe daily and as needed (PRN) everyday shift for abrasions, start date 11/15/19. discontinue date 12/11/19. R3's TAR dated 12/2019 documents, Wipe right great, 2nd and 3rd toe with [MEDICATION NAME] daily and place abdominal pad, wrap with kling (elastic gauze wrap), start date 12/06/19. Both the PO and TAR have no documentation addressing the black discolored bottom of the 2nd right toe noted on 11/15/19 and the discolored great toe noted on 12/2/19. On 12/12/19 at 8:35 AM, V4 (Treatment Nurse) provided wound care to R3 in bed. R3 had a left above knee amputation. R3 wore a pressure-relieving boot on the right foot which V4 removed. The bottom of R3's 2nd and 3rd toes were black, and the great toe was purple. V4 wiped the 3 toes with [MEDICATION NAME], covered with abdominal pad and secured with elastic gauze wrap. On 12/12/19 at 9:25 AM, V4 stated she noted the abrasion on top of R3's 2nd and 3rd toes on 11/14/19 and notified V16 (Facility Physician) about it. V4 stated skin prep was ordered to be applied daily. V4 stated she noted the bottom of R3's 2nd toe was black the next day, 11/15/19 during treatment and she asked V9 (Scheduler/Medical Records) to call V5's office to move up R3's 12/4 appointment sooner. V4 stated she noted the bleeding and discoloration of the great toe on 12/2/19 and notified V17 about it with no new orders. On 12/12/19 at 9:49 AM, V9 stated she is in charge of setting up residents' appointments outside the facility. V9 stated she was notified by V4 to call V5's office to request for R3's appointment be moved sooner. V9 stated R3 had a 12/4 follow up appointment with V5 but she was told by the office that there was no opening, nothing available before 12/4. On 12/12/19 at 1:00 PM, V2 (Regional Nurse) stated it is usual practice for V9 to make the calls to set up outside appointments so that was what happened with R3's appointment. V2 stated V9 made the call and was not able to move the appointment to an earlier date. V2 stated R3 went on 12/4 and was seen by V5. On 12/12/19 at 1:09 PM, V5 (Vascular Surgeon) stated prior to the 12/4/19 visit, he has not seen R3 since R3's last follow up visit to his clinic on 10/23/19. V5 stated his clinic always has a record of all calls from his patients or facility staff who called for change in condition and there was no record his office was notified of R3's black 2nd toe or discolored great toe. V5 stated he was not aware the facility called his office regarding R3's toe on 11/15/19 or on 12/2/19 for the changes on the great toe. V5 stated he expected the facility to call him for changes in R3's foot. V5 stated if the facility notified him of the black 2nd toe on 11/15/19, he would have wanted to see R3 within that week with the one black toe rather than when it progressed to multiple black toes when he saw R3 on 12/4/19. V5 stated when he saw R3 on 12/4/19, R3 had gangrene of the right great toe, 2nd and 3rd toes. V5 stated gangrene usually does not appear as gangrene right away but starts as discoloration as purple-like a few days earlier and should have been referred to him right away. V5 stated the treatment of [REDACTED]. V5 stated R3 has some developmental issues and is not able to help himself; somebody has to look/take care of him. V5 stated if the facility did daily diabetic foot checks on R3 they would have noted initial gangrenous changes on R3's right toes before 11/15/19. V5 stated it is not hard to look at toes specially when R3 has only the right foot left. V5 stated there was some harm caused by the delay and the facility should have reported to him as soon as they saw the second toe turned black. V5 stated if it is the facility policy to do daily diabetic foot checks they were not doing it even if they say they were doing it. R3's Clinic Note written by V5 dated 12/4/19 documents, (R3) is a [AGE] year old gentleman status [REDACTED]. He denies any trauma. He is a poor historian. He has been living at (Facility) following his amputation. He has no complaints with respect to the left above knee amputation. His sutures have already been removed from the above knee amputation stump. R3's Clinic Note further documents, Physical Exam: Pulses - (R3) has 3 out of 4 bilateral brachial pulses, 2-3 out of 4 bilateral radial pulses, 2-3 out of 4 bilateral femoral pulses. He has non-palpable right popliteal and foot pulses. Extremities - He has left above knee amputation stump with some eschar at the mid portion of the incision. He has dry gangrenous changes to the 1st, 2nd, and 3rd toes on the dorsal aspect of the right foot. There is no purulence. There is no maceration. Studies: Previous arterial studies on (MONTH) 9, 2019 demonstrated a right ankle/brachial index of 0.40 consistent with severe degree of [MEDICAL CONDITION]. [MEDICATION NAME] on (MONTH) 22, 2019 demonstrated the right superficial femoral artery had moderate multi-focal disease. The right above knee and below knee popliteal artery demonstrated severe multi-focal disease. The right tibial turnoff was not well seen. Impression: Right 1st through 3rd toe dry gangrene with known history of severe [MEDICAL CONDITION]. Plan: He is to be scheduled to a right lower extremity angiogram with intervention. He is to undergo dressing changes using [MEDICATION NAME] paint and Kerlix roll for gangrenous areas. He will likely need a right 1st through 3rd to amputation after the successful intervention. The Facility Policy on Change in Resident Condition dated 9/20/17 documents, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician, and residents responsible party of a change in condition. Responsible Party: RN (Registered Nurse), LPN (Licensed Practical Nurse), Social Services. Policy: 1. Nursing will notify the resident, resident's physician or nurse practitioner when: a) the resident is involved in an accident or incident. b) there is significant change in the residents' physical, mental or emotional status. The Policy further documents, 3. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents. 4. The Care Plan Coordinator will be notified so that changes in the care plan can be made if needed.

Based on record review and interview the facility failed to prevent significant medications errors for one of 3 residents (R2) reviewed for medication errors in the sample of 11. This failure resulted in R2 not receiving Human Immunodeficiency Virus ,[MEDICAL CONDITION]. medication as ordered. R2'[MEDICAL CONDITION] progressed to the point of causing R2 neurological defects. Findings include: R2's Hospital Patient Medication Schedule discharge medication list, dated 7/29/19 current as of 4:36 PM documents the following medications and time of last dose: Dolutegravir (HIV integrase inhibitor which decreases the amount [MEDICAL CONDITION] blood and increasing the number of immune cells that help fight infections in body), 50 milligram (MG) tablet - take one tablet by mouth once daily. Last dose was given at 9:00 AM and 30 tablets were dispensed. [MEDICATION NAME]-[MEDICATION NAME] (antibiotic), 800-160 mg tablet - take one tablet by mouth every Monday Wednesday and Friday. Hold 2 days prior to planned admission for [MEDICAL CONDITION]. Last dose was given at 9:00 AM and 30 tablets were dispensed. R2's Progress Note, dated 7/30/19, documented Resident arrived with anti [MEDICAL CONDITION] meds r/t (related to)[MEDICAL CONDITION] nurse placed in med cart for safe keeping. R2's Care Plan Goal, initiated on 7/30/19, documents (R2) is at risk for rapid physical or mental decline r/t (related to) disease process [MEDICAL CONDITION].He receives long term antibiotic and [MEDICAL CONDITION] medication per MD (Medical Doctor) orders. An intervention for this goal was Medication as ordered. R2's Medication Administration Records for (MONTH) 2019 and (MONTH) 2019 failed to list Dolutegravir 50 mg tablet take one tablet by mouth once daily. R2 missed 10 doses of this medication. R2's MAR indicated [REDACTED]. The Facility Nursing Admission Observation dated 7/29/2019 at 11:49 PM documents in the section Medication Drug Regimen Review the nurse reviewed, compared, and reconciled discharge medications/orders with the physicians new admitting order. The Admission Observation documents the nurse interviewed the resident's representative and confirmed medications/orders the resident was taking for his/her condition, and as a result of this collected and communicated information the nurse determined there are no identified potential or actual clinical medication issues. R2's Nursing Notes dated 8/9/2019 at 6:26 PM documents that R2 was discharged to the hospital for his [MEDICAL CONDITION]. On 8/20/19 at 1:00 PM V2 (Director of Nursing/DON) stated that she would expect medications to be given as ordered by the physician. V2 did state that the medication Dolutegravir had been sent to the facility and the medication had not been administered. V2 did not state why the medications had not been administered as ordered. On 8/21/2019 at 3:23 PM V11 (Oncology nurse for V12 Oncologist) stated that R2 missing 5 days of Dolutegravir caused harm to R2. V11 stated that due to R2 not receiving medications as ordered, R2'[MEDICAL CONDITION] progressed and he had some brain swelling. V11 stated that the progression of R2'[MEDICAL CONDITION] causing R2 to have neurological deficits. The Facility Policy Medication Orders Accepted dated 6/2015 documents, prior to admission, medications are reviewed to ensure that the facility is able to administer the medications. The Policy documents any questions regarding medications will be directed to the DON who will also consult the pharmacy and physician. The policy documents all medications for new admissions will be reviewed by the admitting nurse and Physician will be notified upon arrival of all new orders. The Physician will give order to continue current medications or change upon discretion. The Facility Policy Medication Administration dated 6/2015 documents, if the physician's orders [REDACTED].

Based on observation, interview, and record review, the Facility failed to provide timely turning and repositioning for 2 of 11 residents (R72 and R309) reviewed for pressure ulcers in the sample of 54. This failure resulted in R309 developing three new deep tissue injuries; one on both of R309's heels and one on R309's medial left foot. Findings include: 1. On 05/28/19 at 9:37 AM, R309 had a [DEVICE] (negative pressure wound therapy) in place to a pressure ulcer on R309's right thigh, and a dry dressing to a pressure ulcer to R309's left ischium. R309 had pressure relieving boots on bilateral lower legs. The right boot was turned to the side, with R309's heel pressing into the side of the boot instead of cradled in the heel area of the boot. V16, Certified Nurse's Aide (CNA) removed the boots to conduct a check of R309's skin. R309 had dark maroon colored, deep tissue injuries to both heels and the top medial left foot, each one about the size of a nickel. R309 stated the pressure areas on R309's heels and left foot are new today. R309 stated (V17, Wound Nurse), came in early this morning and changed the dressing on R309's left buttock around 6:00 AM, and R309 had not been turned and repositioned since then (about 3 and 1/2 hours). R309 stated sometimes staff will turn R309 when R309 asks, but other times they answer R309's call light and R309 asks to be turned. R309 reported staff say they will be right back, but then don't return. On 05/29/19 at 9:30 AM, R309 was heard stating, I think I need to be turned to the other side now. Upon entering R309's room V14, CNA, was getting ready to turn R309 from R309's left side to right side. R309 stated R309 had been turned at about 2:00 AM, then again at about 6:30 AM when V17 changed R309's dressing. R309 had been incontinent of soft brown bowel movement (BM) and R309's dressing to left ischial wound was soiled. V14 removed it and went to let the nurse know R309 would need a new one. V14 cleaned R309's rectum and buttocks, then V17 came in and applied a new dressing to the pressure ulcer on R309's left ischium. V17 stated R309 has new DTIs (deep tissue injury) to R309's bilateral heels and left medial foot. V17 confirmed V17 had changed R309's dressing at about 6:30 AM this morning. R309 stated R309 had been lying in the same position since V17 had changed R309's dressing. After V17 completed R309's dressing change, V14 turned and repositioned R309 onto R309's right side. On 05/29/19 at 12:00 PM, R309 remained on R309's right side. R309 confirmed that R309 had not been turned and repositioned since V14 turned R309 after R309's dressing was changed. On 05/29/19 at 1:04 PM, R309 was still lying on R309's right side. R309 stated, I wish they would turn me again. I'm getting uncomfortable. On 05/29/19 at 1:57 PM R309 continued to lay on R309's right side. On 05/29/19 at 2:20 PM, R309 was sitting up in bed. R309 stated V14 had come in and turned R309 at 2:00 PM. R309 had been lying on R309's right side for four hours. On 05/30/19 at 3:25 PM, R309 verbalized concern due to new pressure areas on heels. R309 stated R309's feet/heels are supposed to be floated, but they are laying on the pillow, not floating. Both of R309's feet were noted to be on top of a pillow, including heels, with no part of feet or heels floating. Pillow was flattened by the weight of R309's feet. R309 stated R309 has been a paraplegic since 1993, and R309 and caregivers at home have always taken very good care of R309's feet because R309 knows R309 is at risk for more skin breakdown. R309 stated R309 did not have pressure areas on R309's feet before R309 was admitted to this facility. R309's Minimum Data Set ((MDS) dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15, indicating R309 is cognitively intact. The same MDS also documents R309 requires extensive assist of staff for turning and positioning in bed. The MDS documents R309 was admitted to the facility on [DATE] and had two stage 4 pressure ulcers that were present on admission, and documents R309 did not have any deep tissue injuries present on admission. R309's Face Sheet documents R309's [DIAGNOSES REDACTED]. A Progress Note by V17, dated 05/6/2019 at 11:20 AM, documents, Skin/Wound Note Text: new admission skin assessment completed. Res (resident) noted to have a stage 4 to right hip and stage 4 to left ischium. wound vac (vacuum) applied to right hip as ordered. (Sodium Hypochlorite moistened gauze) applied to left ischium. Res is noted to be a paraplegic. Res is incont. (incontinent) of B&B (Bowel and Bladder). 16F (French)30cc (indwelling urinary catheter) in place. Res to be in a bariatric bed with air mattress. RUE PICC (Right Upper Extremity Peripherally Inserted Central Catheter) noted. All wound orders reviewed with resident. A Progress Note dated 05/29/2019 at 10:31 AM, documents, Skin/Wound Note Text: during skin assessment this am res noted to have 3 new DTI (deep tissue injury) to lower extremities. Res made aware. Pressure relieving boots) in place at all times. Res is T&R (Turned and Repositioned) Q (every) 2 hours. MD (Medical Doctor) made aware and skin prep to areas noted. (Special Wound consultant) will assess on 5/30. R309's Skin and Wound Report dated 05/29/19, documents, #3- Pressure-Deep Tissue Injury Right Heel; Status New-1 day old: Acquired: In-House Acquired; #4- Pressure- Deep Tissue Injury Left Heel; Status New-1 day old; Acquired: In-House Acquired; #5- Pressure- Deep Tissue Injury Medial Left Foot; Status New- 1 day old; Acquired; In-House Acquired. The Skin and Wound Report dated 05/30/19 documents: #6-Pressure- Deep Tissue Injury Right Calf (Lateral); Status New-2 hours old; Acquired: Acquired In-House. A Progress Note by V17 on 05/30/19 at 12:44 PM documents, Res evaluated by (special wound consultant) this am and noted res to have another DTI to right lower leg caused from (pressure relieving boot). NP (Nurse Practitioner) ordered for resident's feet to float on pillows while in bed and with every turn and re-position. New order to have therapy consult to suggest proper cushion/boot that would be appropriate to prevent further injuries. Res made aware and MD of new orders. Res got shower this shift. R309's Physician order [REDACTED]. for proper type of boot/cushion for bilateral feet to prevent further injuries and keep bilateral feet floating on pillow with every turn and re-position. R309's undated Care Plan documents the Focus of Skin: (R309) is at risk for skin complications related to history of [DIAGNOSES REDACTED] to right hip, history of pressure area to left ischium, incontinence and decreased mobility. The interventions for this focus do not include turning and repositioning R309 routinely. On 05/30/19 at 3:41 PM, V17 stated floating R309's heels means R309's heels should not be touching anything. V17 stated R309's feet should be propped up on two or three pillows to keep feet off the bed. V17 stated R309 should be turned and repositioned at least every two hours, and V17 had been in servicing staff regarding this. On 06/5/19 at 9:07 AM, R309 stated that R309 had been turned at 12:00 AM last night, then R309's call light had come unplugged from the wall, and someone finally came in around 5:00 AM and turned R309 when R309 yelled for help. R309 stated R309 needs to be turned now because R309 was starting to have pain from lying in one position for too long. R309 put R309's call light on to call for assist, and V23, Restorative Aide came to assist R309. On 06/6/19 at 12:30 PM V2, Director of Nursing (DON), stated V2 would expect a resident who has pressure ulcers or is at risk for pressure ulcers to have a low air loss mattress, pressure relieving boots, and they should be turned and repositioned at least every two hours. The Facility's undated policy, Skin and Wound Management Guidelines documents, in part, New Facility Acquired Wounds: 3. Ensure immediate interventions to relieve pressure from the area are in place. This policy also documents: Additional Oversight and Management: 9. During rounds, ensure resident are positioned correctly and heels are off loaded. and 10. Coordinate with Administrator for facility cues to remind staff to turn and reposition residents every 2 hours. 2. R72's MDS, dated [DATE], documents R72 requires total assistance from two staff for bed mobility and transfers. The MDS documents R72 is at risk for pressure ulcers. R72's Braden Scale (scale to determine risk for skin breakdown) documented a score of 11, indicating R72 was at high risk. On 05/29/19 at 09:29 AM, R72 was up in R72's geriatric chair at nurse's station. R72 remained up in R72's geriatric chair from 10:02 AM to 1:13 PM without changes of position. On 05/29/19 at 1:29 PM, V22 and V25, CNAs, transferred R72 from R72's geriatric chair to bed via the mechanical lift. V22 stated V22 got R72 up around 8:00 AM.

A. Based on observation, interview, and record review, the facility failed to provide supervision and implement interventions to prevent falls for two of two residents (R72 and R93) reviewed for falls/supervision in the sample of 54. This failure resulted in R72 rolling out of bed and sustaining a large skin tear/wound requiring 14 staples. Findings includes: 1. On 05/28/19 at 12:20 PM, R72 was in bed. The bed was not in a low position and there was no bolster mattress in place. R72 had a dressing to the scalp/top of R72's head. On 05/29/19 09:41 AM R72 was picking at the large opened wound to R72's head while at the nurse's station. The facility's pressure ulcer /wound log, dated 05/23/19, documented R72 had a wound to R72's scalp measuring 2.6 centimeters (cm) by 1.2 cm by 0.2 cm. R72's Fall Risk Evaluation, dated 10/3/18, documented a score of 12, 10 or more indicating a high risk for falls. R72's Minimum Data Set (MDS), dated [DATE], documents R72 was severely cognitively impaired. The MDS documented R72 was totally dependent with two plus person physical assist for bed mobility. The MDS documents R72 has limited range of motion on both sides of lower and upper extremities. R72's Care Plan, with an undated goal, documented R72 was at risk for falls due to increased confusion and decreased mobility. The Care Plan documented R72 relies on staff assistance with Activities of Daily Living and mobility. The Care plan did not document R72 required two-person assistance with bed mobility although she had been assessed as requiring two persons. R72's Care Plan Interventions, dated 09/17/19 documented R72 should have a bolster mattress in place and a low bed. On 05/30/19 at 10:11 AM, V2, Director of Nurse's, DON provided an incident report regarding the incident which occurred on 4/12/19. V2 stated a CNA turned around to do something while R72 was in bed, and R72 rolled out of bed. The Facility's Fall Report, dated 04/12/19, documented, Writer called to resident's room to find resident lying in assigned bed bleeding from the top of head. States CNA (Certified Nurse's Aide) told her she was performing care R72 rolled out bed onto the floor beside. The report documented the CNA turned around to get a towel, and the resident rolled out of bed. The report documented the CNA was unable to prevent resident from falling at that time. The report documented 911 was called, and R72 was sent to the local hospital for treatment. The report documented only one CNA was providing care when this incident occurred. R72's Nurse's Note, dated 04/12/2019 at 11:21 AM documents, This nurse spoke with (Hospital Registered Nurse) at (local hospital). (Local Hospital RN) reported to this nurse that resident is in stable condition and had a CT (Computed tomography) of head and was clear. The Nurse's Note documented R72 had a 7-centimeter laceration which was closed by staples. The Hospital Report, dated 04/12/19, documented R72 sustained a laceration to R72's head requiring 14 staples. On 06/6/19 at 10:45 AM, V17, Licensed Practical Nurse (LPN)/Wound Nurse, stated R72 returned from the hospital with multiple staples to R72's head. R72 said after the staples were removed, R72 because to pick at the area and that is what caused the wound. 2. On 05/28/19 at 2:25 PM, R93 was outside smoking on the patio. There were no staff present. On 05/28/19 4:05 PM, R93 was walking down the hallway with a wheeled walker. R93's gait was shuffled. R93's MDS, dated [DATE], documented R93 required staff supervision with one physical assistance during off unit locomotion. R93's Nurse's Note, dated 10/12/18 documented R93 fell outside while out on the smoking patio. R93's Care Plan, undated intervention, documents (R93) re-educated on smoking supervision, and that R93 is not to go out to smoking patio without a staff member. R93's Nurse's Note dated 02/2/19, documented Alerted that res (resident) fell out on smoking patio. Found res in sitting position with walker near him. R93 states, 'I just lost my balance.' Assisted R93 back into building. Small abrasion to left elbow. The Note documented Res reminded that a staff member needs to be with R93 when R93 goes out to smoke. R93's Nurse's Note, dated 02/10/2019, documented This nurse was made aware that res had fell outside while coming in from smoking. Res stated that R93 was ok and unharmed. R93's Nurse's Note, dated 02/10/19, This nurse made aware that resident fell while coming in from smoking. Per care plan R93 should not be outside by self because R93 falls. R93's Care Plan, with intervention dated 02/10/19, documents (R93) will remain on supervised smoking with assistance. 05/30/19 10:00 AM, V29, Activity Director, noted that R93 can smoke independently but needs to be watched because R93 fell out there. The facility's Fall Prevention and Management policy, revision dated 10/2018, documented Care Plan to be undated with a new intervention based on root cause analysis after each fall occurrence. B. Based on interview and record review, the facility failed to assess, monitor, and implement interventions to address a resident with verbalization of self-injurious behavior for one of one resident (R9) reviewed for self-injurious behavior in the sample of 54. Finding includes: R9's Admission Record, undated, documented R9 has [DIAGNOSES REDACTED]. R9's Minimum Data Set (MDS), dated [DATE], did not document R9 made statements of self-harm or being better off dead. R9's Nurse's Note dated 02/12/2019 at 4:24 PM documented This nurse was informed that res spoke with (V30, Contracted Licensed Social Worker) who stated that res wanted to kill himself. Res exact words were, 'I want to kill myself and I have a plan.' Res would not state what the plan was. DON, Administrator, and MD all made aware of incident. N.O. (New Order) received to send res to (Local City Hospital) for a psych (psychiatric) eval (evaluation). R9's Nurse's notes documented R9 returned to the facility on [DATE]. R9's Consulting Psych Service Note, dated 02/19/19, stated R9 returned from the hospital. The Note documented that R9 had no risk issues noted. The note documented R9 returned from the hospital with a change of medications but there were no other comments regarding monitoring R9 for suicide ideations. R9's MDS dated [DATE] did not document R9 wanted to harm self. There was no documentation in R9's medical record that a further assessment was conducted to address R9's verbalizing [MEDICAL CONDITION] or how the facility was going to monitor R9 for this behavior. R9's Care Plan, undated, does not address that R9 wanted to kill self or how staff should monitor R9. R9's (MONTH) 2019 Behavior Tracking does not address R9 made these statements regarding self-harm. On 05/31/19 at 10:14 AM, V8, Social Service stated V8 didn't write a note because (V30) went directly to nursing. V30 told nurses R9 wanted to kill himself because of eye pain. V8 stated I usually make notes regarding these issues but because (V30) went to nursing first, that is where the note is. I'm not sure why this isn't in the care plan. On 06/6/19, at 10:30 AM, V2 stated that V2 would expect staff to monitor residents if they have [MEDICAL CONDITION]. V2 was unsure if the facility had a policy regarding [MEDICAL CONDITION]/self-injurious behavior. On 06/6/19, at 1:30 PM, V2 stated V2 did not implement the facility policy regarding [MEDICAL CONDITION] because R9 didn't have a history of [MEDICAL CONDITION] and didn't express R9 wanted to commit suicide after R9 returned from the hospital. The facility's Procedure/Practice Guidelines for Suicide Ideations, undated, documented 1. Resident's that have a history of suicide ideations/attempt and are a risk for self-harmful behaviors due to history will be assessed upon admission, quarterly, annually and as needed. The Guidelines did not address how the staff should monitor residents who express suicide ideations and for how long. C. Based on observation, interview, and record review, the facility failed to assess and implement interventions to ensure safe smoking for one of five residents (R9) review for safe smoking in the sample of 54. Finding include: R9's Smoking Assessment completed in the Electronic Medical Record (EMR), dated 05/22/19, documented R9 had burn holes in R9's clothing, but R9 may independently handle smoking materials. The Assessment did not address how to keep R9 from burning R9 or R9's clothing while smoking. On 05/28/19 at 11:56 AM, R9 was outside smoking without staff supervision. R9 was wearing a red shirt and had multiple burn holes in the shirt. At 2:24 PM, R9 was again outside smoking unsupervised . R9's Care Plan, dated 04/29/19, documents R9 is at risk for injury related to smoking. The Care Plan goal was for R9 to be unsupervised with no incidents. There were no interventions related to the burn holes in R9's clothing or how to protect R9 from burning R9 or R9's clothing. On 06/5/19, at 10:00 AM, V1 Administrator stated V1 was aware of the burn holes in R9's clothing. D. Based on interview and record review the Facility failed to assess the side rails for an accident hazard for 1 of 12 residents (R39) reviewed for side rails in the sample of 54. Findings include: R39's Physician order [REDACTED]. R39's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (cognitively intact). R39's MDS documents lower extremity impairment on both sides and bed mobility with limited assistance of one staff. R39's Side Rail Review, dated 05/14/2019 at 3:24 PM, documents in part, The resident will utilize side rails that are not considered a restraint and will be utilized to enable the resident to attain and maintain R39's practicable level. R39's Nurses Notes, dated 02/23/2019 at 2:32 PM, documents in part, Resident remains on follow up related to self-reported fall. No injuries noted or reported. Maintenance man in facility and fixed side rail related to safety. R39's Incident Report Notes dated 02/25/2019, documents, Interdisciplinary Team reviewed incident, investigation and findings. (R39) attempted to pull self-up in bed using the side rail, side rail broke causing (R39) to fall. New intervention: maintenance call in to the facility to assess side rail. Care Plan reviewed and updated. R39's Care Plan, revised on 04/11/2019 documents, in part, Requires assistance with daily care and needs related to weakness and cardiovascular disease. Requires assistance and supervision with transfer and bed mobility. R39's Care Plan also documents on 2/23/2019 maintenance call in to facility to assess side rails.' On 05/30/2019 at 10:34 AM, V2, Director of Nursing stated, Yes, (R39's) side rails broke, and it caused R39 to fall. I don't know what was wrong. The side rails malfunctioned, and our maintenance man came and fixed it. I am not sure who oversaw the side rails inspections. I know our new maintenance man does assessments now. Siderails Inspections were requested for R39 on 05/30/2019 and were not provided by the facility for R39. On 06/05/2019 at 3;26 PM, V1, Administrator stated there was no policy on side rail inspections. The Facility Fall Prevention and Management Policy with a revision date of 10/2018 documents in part, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for fall, plan for preventive strategies, and facilitate as safe an environment as possible. All residents' falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on interview and record review, the facility failed ensure sexual abuse did not occur for 1 of 12 residents (R1) reviewed for abuse in the sample of 12. This failure resulted in R1 being scared with emotional distress and continued emotional distress when seeing the alleged perpetrator in the facility after the initial incident. Finding includes: R1's Facility Incident Report dated 04/12/2019 at 1:45 PM, documents the following: (R1) reported to her CNA (Certified Nurse's Assistant) that her roommate's husband was patting her on the shoulder and moved his arm lower making her feel uncomfortable. V8 (spouse of R11 - roommate) stated that he was just visiting as usual and patted (R1) on the shoulder and was just checking to see how she was doing. Local Police were notified of the allegation. (R1) was offered a room move, (R1) stated that she would move instead to avoid any inconvenience. R1's Incident Report Occurrence Resolution, dated 4/12/19, document Interdisciplinary team met, reviewed investigation, chart and findings. Staff and residents were interviewed. Based on the results of the investigation, the facility was unable to substantiate abuse. Resident has carried out her normal routine with no signs of mental anguish. On 05/03/2019 at 10:24 AM, V1 (Administrator) stated, A resident (R1) reported that she was inappropriately touched by roommate's husband about 3 weeks ago. I immediately restricted (V8's) visits to 3 times a week and visits have to be in the lobby and supervised by the receptionist. V1 also stated, There was another incident previously but no investigation was done and completed on R3 even though it was documented in the final report. R1's electronic Physician order [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] a Brief Interview for Mental Status (MDS) score of 15 out of 15 (cognitively intact). R1's Care Plan with a date initiated of 03/06/2019 document (R1) has a [DIAGNOSES REDACTED]. She is currently alert and orientated to person, place and time, with no apparent symptoms of cognitive deficits. On 05/01/2019 at 9:30 AM, R1 stated, About 3 weeks ago it was during the day about 4:00 PM that evening (V8, husband of R11, my roommate) came up behind me in my wheelchair. (V8) put his right hand on my right shoulder and asked if I was feeling okay then he lowered his hand to the top of my right breast and cupped my breast. I was not wearing a bra. (V8) then asked if I was feeling okay and I said 'Yes' and I stopped it and turned towards (V8) and said, 'Don't do that'. (V8) then went to the doorway, looked around, closed the door. (V8) came back to me and placed his hand again on my right shoulder and he reached down and cupped my breast and again I told him, 'Don't do that.' I felt scared, terrified and uncomfortable. I told him to stop it and he went and sat in the corner where his wife (my roommate) was. His wife was sleeping at the time and snoring when this started happening. I was sharing the room with her. I called my husband and told him what happened. I did not tell staff until the next day. After the incident I was moved to another room. I did not feel safe sharing a room where (V8) was. I did see (V8) in the lobby and it makes me feel scared all over again like it was all happening all over again. I was in shock, running into him again. I wish they would have told me he was in the building. When I saw him it was awful. Why didn't they prepare me because when I saw him it was like it was happening again. R1's Nurse's Notes do not document any allegation of abuse or being touched inappropriately. V4 (Certified Nursing Assistant/CNA) statement dated 04/19/2019 (no time) document (R1) came to me and told me she didn't like being in her room because of (V8). When I asked, she told me that he came behind her and started to rub her shoulders. While doing that his hands kept getting lower and he grabbed her breast. She told him to stop and he did it again. First I reported it to the Director of Nursing and then the Administrator. On 05/02/2019 at 2:38 PM, V4 stated, (R1) came to me and told me she didn't like being in her room because of (V8). When I asked why, she told me that (V8) came up behind her and started to rub her shoulders. While doing that (V8's) hands kept getting lower until he grabbed her breast. (R1) said she told him to stop and then he did it again. I first I reported it to the (DON) and then my administrator. V11's (Licensed Practical Nurse/LPN) nurses' note dated 4/11/19, untimed documented, To Whom it may Concern: It was brought to my attention that a complaint was made against (R11's) husband. The complaint was he felt (R1's) breast. (R1) states he felt my breast and I told him to not do that and he then went to the door to see if anyone saw him then he came back and felt my breast again. She goes on to tell me that she spoke with staff about the incident. This is very upsetting to hear from a resident's mouth. We are to protect all of our residents at this facility. Please take action, our residents need to be safe. This is the second resident that I have heard to become a victim. R1's Final Investigation Report, undated documents, On 04/12/2019 it was reported that (R11's) husband touched (R1) inappropriately. Based on the known facts, the following conclusions have been determined about the original allegation. (R1) stated that (V8) came to the side of the room, he usually said hi and greeted her daily, often patting or rubbing her shoulder. She felt that he was putting his hand near her breast and she asked him to stop, she stated that he walked over to the door to close it. She stated that he came and walked back over to her and continued to rub on her shoulder and towards her breast. She stated she told him to stop and he did. She stated she had never felt threatened by him before and that she had a good relationship with his wife which is her roommate. She said she had discussed this with her husband and that her husband had spoken with (V8) about the incident. Skin assessments done by the administrator showed no signs of abuse. Resident stated that she just wouldn't feel comfortable around (V8) anymore. We planned a room move for the roommate and (R1) asks me if she could just move. Room move completed. Police called, report made. Alleged visitor (V8) was interviewed and stated that he always checks on (R1). He admitted to rubbing on her shoulder but never touching her inappropriately. He stated that this accusation was devastating to him and denies closing the door or going back over to (R1) and touching her again. I discussed to (V8) that I was going to have to have him visit his wife supervised in the lobby or front conference room, not allowing him to go past the double doors until the investigation was completed by the police department. (V4) interviewed and stated that (R1) informed him of this incident while he was caring for her. He stated that he has never seen any activity suspicious between (V8) and (R1) but does recall an incident a month back that involved suspicious activity between (V8) and another resident. Resident and staff interviewed with no new negative findings. Based on staff interviews, resident interviews, and the review of medical records the facility is unable to substantiate sexual abuse. There was no additional witnesses or evidence of abuse. On 05/08/2019 at 8:10 AM, V18 (CNA) stated, (R1) is alert and oriented and able to answer questions. She is reliable, does not exaggerate and is credible. On 05/08/2019 at 8:12 AM, V19 (CNA) stated, (R1) is credible and reliable. She does not have a history of making things up that I am aware of. On 05/08/2019 at 8:13 AM, V6 (Supervisor CNA) stated, (R1) is alert, interviewable, credible and able to recall and answer things. V1's Investigation Notes interview, dated 4/12/2019 with R1 documents, (R1) interviewed states (V8) greeted her, put his hand on her shoulder, moved it lower. Went to the door, closed it. Came back and continued to move his hand down lower. She mentioned this had happened in the past to another resident. On 05/03/2019 at 12:45 PM V1 stated, Police are called in for any kind of abuse (sexual, theft, physical) depending on our policy. Once I started taking statements I learned (R1's) breast was touched. I sent my initial report based on staff. I am not sure if I mentioned (V8) grabbing her breast. I think it was in the final report. The initial report does not document the breast touching. I think the breast touching is in the final report. On 05/03/2019 at 1:55 PM, V16 (spouse of R1) stated, Yes, my wife called me that night and told me (V8) had touched her breast. She was traumatized. I never talked to him about it or saw him. He is lucky I never saw him. It's just not right; how would he feel if someone did this to his wife. He should not be touching anybody's wife but his own. The Final Report documents V16 talked to V8. On 05/01/2019 at 1:00 PM, V7 (Police Officer) stated, Yes we were notified of an incident with (R1). When I interviewed (R1) she told me (V8) grabbed her breast. This is currently under investigation.

Based on observation, record review and interview the facility failed to provide antibiotic treatment for [REDACTED]. This failure resulted in R2 being admitted to the hospital with [REDACTED]. Findings Include: R2's Electronic Medical Record Medical [DIAGNOSES REDACTED]. R2's Wound Report, dated 11/17/16, documents R2 has an unstageable pressure ulcer on her left lateral foot measuring 0.80 centimeters (cm) length and 1.5 cm width. R2's Culture and Sensitivity Laboratory Form, dated 11/17/16, documents R2 has heavy growth of Proteus Mirabilis in her left lateral foot wound. R2's Physician order [REDACTED]. R2's POS, dated 11/17/16, documents the order from Z3, Nurse Practitioner for Z4, R2's Primary Physician, to discontinue the [MEDICATION NAME] was ordered by Z2. R2's POS, dated 11/18/16, documents the order from Z3 for Ertapenem (an antibiotic) 1 gram (GM) intramuscularly (IM) once daily for 14 days. R2's physician progress notes [REDACTED]. The Note also documents We will begin Ertapenem 1 Gram daily for 14 days due to poor absorption and deconditioning. R2's Nurses Note, dated 11/20/16, documents a call was received from pharmacy stating Ertapenem is not available in the back up pharmacy and medication will be available tomorrow through regular pharmacy. R2's Nurses Note, dated 11/20/16, documents that Z5, Nurse Practitioner for Z4, was notified the Ertapenem was not available until 11/21/16. There is no documentation that Z2, Wound Physician, was ever notified that there was a change in antibiotics or that R2 was not receiving any antibiotics for the infection of the pressure ulcer since 11/17/16. There is no documentation that Z3, who originally ordered the Ertapenem, was notified that it was not available. R2's 11/2016 Medication Administration Record [REDACTED]. R2's 11/2016 MAR indicated [REDACTED]. R2's 11/2016 MAR indicated [REDACTED]. R2's Nurses Note, dated 11/20/16, documents R2 has decreased appetite, and medication administration was unsuccessful. Stat labs were ordered bmp (basic metabolic panel) and cbc (complete blood count) was ordered. (Z5) was notified of lab results. (Z5) was notified medications will start tomorrow. R2's Nurses Note, dated 11/22/16 at 10:44 AM, documents R2 has not been eating, when assisted with feeding and R2 will not take in fluids or medication. R2's Nurses Note, dated 11/22/16 at 1:37 PM, documents R2 is displaying poor appetite, decreased [MEDICATION NAME]. (R2) is less responsive then her usual, alert to her name. New orders were received send R2 to (local Hospital). R2's local hospital History and Physical, dated 11/22/16, documents R2 was found to be unresponsive with decreased gag reflex, minimal response to painful stimuli, and R2's temperature was 99. The skin examination on the above form documents an ulceration to the left lateral foot is 3 x 4 cm and 0.4 cm in depth. R2'[MEDICAL CONDITION] Assessment documents [MEDICAL CONDITION] signs and symptoms plus organ dysfunction. It also documents R2 has septic shock severe with low blood pressure and low fluid. It documents the possible source of the septic shock as the left lateral foot ulcer. It documents R2 was given [MEDICATION NAME] upon arrival and R2 was also placed on Meropenem and [MEDICATION NAME]. On 11/30/16 at 8:06 AM, when asked if she was aware that R2 did not receive Ertapenem, Z2 stated No, I didn't know she didn't receive her Ertapenem, but I didn't order the medication. I haven't seen a wound cause septic shock, but I can't say whether or not her foot wound contributed to septic shock. On 11/30/16 at 10:48 AM, E7, Licensed Practical Nurse (LPN), stated I don't remember the date, but I faxed the order off. The medication was to begin on the evening shift. I didn't know anything about the pharmacy not having the medication. In an interview on 11/30/16 at 2:00 PM, E6, Minimum Data Set Coordinator, stated (R2) [MEDICATION NAME] the 18th, and she was suppose to start Ertapenem on the 19th. (Z5) was notified the medication was not available. The Facility Pressure Ulcer Policy, dated 06/2015, documents to prevent or reduce the incidence of pressure ulcers with pressure ulcer defined as any [MEDICAL CONDITION] caused by unrelieved pressure.

Based on observation, interview and record review, the facility failed to provide treatment and services to maintain and/or increase range of motion for 1 of 5 residents (R6) reviewed for range of motion in the sample of 24. This failure resulted in R6 becoming contracted and no longer ambulating. Findings include: 1. R6's Electronic Medical Record, undated, documents R6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact and requires extensive assistance of one staff member for Activities of Daily Living (ADLs). The MDS further documents R6's Functional Limitation in Range of Motion as no impairment for upper and lower extremities. The MDS documents R6's Functional Rehabilitation Potential as follows: Resident believes he or she is capable of increased independence at least some ADLs: 1-Yes. Direct Care staff believe resident is capable of increased independence in at least some ADLs: 1-Yes R6's Physical Therapy Progress and Discharge Summary notes, dated 4/15/15, document Analysis of Functional Outcome/clinical Impression: Patient participates well in skilled PT. Patient discharge this time as he has completed the 12 treatments that his family has agreed to private pay for. Patient demonstrates improved gait and transfer. Patient continues with some balance deficits. Believe patient is safe to ambulate short distances with FWW (Front wheeled walker), which was private goal of patient. Patient provided with restorative nursing program. Pt performed Omnicycle x (times) 15 minutes on level 2 to increase strength and activity tolerance with max verbal cues to hold head in neutral position. Pt ambulates with FWW on even surfaces x 450 feet. The document further states Short Term Goals History: Ambulation specific: Pt will ambulate extended facility distance safely with front wheeled walker and stand by assist (supervision) on even surfaces. End of Goal status as of 4/15/15: Goal Met- DC'd (discontinued) on 4/15/15. Pt ambulates 400 feet safely with front wheeled walker and stand by assist (supervision) on even surfaces. R6's current Care Plan, dated 4/6/16, documents AROM (Active Range of Motion): (R6) has weakness noted to all extremities and decreased mobility. Will maintain/improve with current ROM (Range of Motion) strength through next review. 3. Instruct to do AROM to BUE (bilateral upper extremities) and BLE (bilateral lower extremities). May perform standing and seated LE (lower extremity) strengthening with ankle weights, 30 reps (repetitions) per muscle group. Perform seated/standing marching, calf raises, toe raises, hamstring curls, sit to stand, 20 reps each. The Care Plan further documents ADL: (R6) is nonambulatory. Restorative program as appropriate. R6's Fall Investigation, dated 12/9/15, documents under Immediate Action taken in part: due to the fact that (R6) is severely contracted and very stiff jointed. R6's Rehabilitation Screen, dated 5/17/16, documents Dietician consulted with therapist regarding (R6's) request to ambulate with physical therapy. Screen was performed and due to severity of hip and knee flexion contractor, (R6) is not a candidate for PT for ambulation and is a (mechanical) lift for transfer. On 5/17/16 at 11:15AM, R6 stated he wanted to speak with his nurse about walking. R6 stated he shouldn't have any reason why he can't walk if he moves all his extremities on command. R6 stated he did not have any pain. R6 stated he has been at the facility for about a year and was walking when he came in. R6 stated he was doing therapy for about 1 month and then it was going to cost him $1000 a month for therapy and he could not afford that. R6 states the facility has never helped him try and get therapy services after that. R6 stated No one does any kind of exercises or range of motion with me. R6 was noted to have contractures to bilateral knees and could not straighten bilateral knees with staff cueing during care. R6 was also noted to have upper extremities contractures. On 5/18/16 at 9:05 AM, R6 was in the Dining room. R6 stated at this time that he talked to an aide yesterday and they tried to do some exercises but he had just received pain medication and couldn't do them. On 5/19/16 at 12:06 PM, E13, Restorative Certified Nurse Assistant, CNA, and E23, CNA provided R6 with Active Range of Motion (AROM). E23 did AROM bilateral arm curls with 3# weights x 20 reps. E23 then cued R6 for Flexion/extension of bilateral shoulder and elbow joints with 3 # weights. E13 then then cued R6 to do AROM to BLE. R6 was seated in his high back wheelchair and E13 cued him to do 20 reps of leg marches in seated position. E13 cued R6 to do 20 knee flexions/extensions. E13 cued R6 to do 20 hip adductions/adductions. E13 cued R6 for 10 reps of flexions/extensions of wrist, 2 reps of opposition of bilateral hands, 10 reps of flexions/extensions of fingers, 10 reps of flexions/extensions of neck and 10 reps of eversions/inversions of R6 neck. R6 had very minimal movement during neck exercises, approximately 30 degrees to the left and 15 degrees to the right. R6 was compliant with all task requested by E13 and E23. At this time, R6 stated he can't self propel himself in his wheelchair because his feet don't touch the ground. R6 further stated he used to walk while at the facility and doesn't know why he stopped walking. R6 further stated that staff really hasn't been doing any exercising since being at the facility. E23 stated at this time that she remembers when R6 could walk in the facility. E23 stated R6 was in a restorative program but had gotten sick and hasn't been going to groups that are offered 4-5 x a week. E23 further stated since R6 has been on oxygen he hasn't had range of motion either. E23 stated R6 hasn't walked since the very beginning of R6's stay at facility. E23 further stated that R6 is not on a walking program but they want us to start standing R6. On 5/19/16 at 9:15 AM, E29, Licensed Practical Nurse, LPN stated R6 was on hospice for end stage liver disease at one time. E29 stated R6 did have therapy services and the restorative CNA's provide restorative care for R6. E29 further stated restorative staff does walk R6 with gait belt and R6 hunches with walking but R6 requires a 2 man transfer or mechanical lift. On 5/19/16 at 9:25 AM, E3, Assistant Director of Nursing (ADON) stated R6 has come a long way since being here. E3 stated R6 was very ill and was on Hospice but has recovered greatly. E3 stated The other day he asked 'When am I going to be walking?' E3 stated R6 was not walking when he first came to the facility. E3 stated R6's ammonia levels were being monitored closely and he was really bad [MEDICAL CONDITION]. E3 stated R6 did therapy in the beginning and I don't think he progressed very well and often refused. E3 stated she could not answer if he was contracted when R6 first came to the facility. E3 stated R6 was mainly in bed and transferred with 2 people. E3 stated R6 was in a restorative program. On 5/23/16 at 11:22 AM, E15, LPN, stated R6 is not on a walking program. E15 stated the facility will pay for therapy if needed, regardless of payer source. On 5/24/16 at 1:30 PM, E19, Restorative LPN, stated she has only been at the facility for 2 months and E15 would be able to answer questions regarding R6 history and care. On 5/25/16 at 10:30 AM, E15 stated R6 was walking when he was admitted [DATE] through approximately June 2015. E15 stated R6 had a decline in medical conditions and staff expected him to pass each day. E15 stated that when R6 was discharged from PT services, he started gradually declining and had a Urinary Tract Infection, hepatic encephalapathy, and the facility was watching R6's labs. E15 stated during this time, R6 was not medically able to participate in therapy. E15 stated R6 went on Hospice in June of 2016 and the restorative walking program documentation shows a decline in R6's participation. E15 stated R6 got better and was able to be discharged from Hospice 2/4/16. E15 stated R6 was more cognitively better than physically. The Facility's Policy Restorative Program Review dated 12/15, documents: To provide direction on the completion of the program review 3. The Restorative Program Review will evaluate the appropriateness of their goals and the program.

Based on interview and record review the facility failed to follow it's policy to call a Code Blue and call for 911 Emergency Services for 1 of 3 residents (R2) reviewed for emergency care in the sample of 3. This failure resulted in the facility not adequately providing Cardio [MEDICAL CONDITION] Resuscitation (CPR), and R2 being pronounced expired. Findings include: A review of R2's Admission Record dated [DATE], documented the following [DIAGNOSES REDACTED]. The Admission Record documents "Advanced Directive - Full Code". R2's nurses notes dated [DATE], by E4, Licensed Practical Nurse ( LPN), documented; [DATE], at 5:52 AM, resident was noted unresponsive with color pale, lips and finger tips were blue, lying on her back with her mouth open. CPR was started with no return pulse or heartbeat. A second nurse confirmed absence of pulse, resident was expired. Z1, Physician of R2, and Coroner and Funeral Home were notified. Call placed to Director of Nursing to make her aware. On [DATE] at 11:30 AM, in a phone interview with E5, Certified Nurses Aide, she stated, "On [DATE], R2 was fine all night. I saw her at 2:00 AM and 4:00 AM on rounds, we changed her. R2 was alert and could talk to you. The nurses were in there around 5:00 AM, and I heard the resident talking to E6, LPN, when she was doing accuchecks. Some time between 5:30 AM and 5:40 AM, I went to R2's room to get her up and called her name twice, but she did not respond. I walked over to R2's bed and touched her hand and arm because she looked asleep. She had her eyes closed, and her lips were slightly open, and she was still warm to touch. She did not respond so I went and told E4, LPN. E4 came down to the room, she did not ask me to get the crash cart, and I don't know what happened after that because I went on to get the other residents up for the day. I think E4 went to get the other nurse. I don't think 911 was called. Later E4 told me she did try CPR, but R2 was gone." On [DATE] at 12:27 PM, in a phone interview E4, LPN, she stated " I saw R2 alive at about 5:10 AM, when I was passing medications. She was alert, spoke to me and did not have any complaints of feeling ill. I think around 5:40 or so, E5 came and told me that R2 looked like she had passed. I was passing medications, and went down to R2's room to check her. At 5:52 AM, R2 was lying on the bed with her mouth slightly open, and her lips were bluish. I pulled back the bed covers and R2's finger tips were bluish and felt cool to touch. I felt her carotid and did not find a pulse, I tried to listen for a breath with my ear, and I listened to R2's heart with my ear also, but did not hear any thing. I thought R2 looked like she had been dead long enough if we tried CPR, she probably wouldn't come back. E5 had left the room, but I thought I should try CPR, and did it by myself. I think after 15 minutes or so I stopped. I did not call for the crash cart or call anyone to help with CPR. I think now, I was wrong not to call 911, but I did not know R2 was a Full Code when I first got there. I probably should have called 911 first, or asked someone else to call 911 while I did CPR. I'm not sure what the facility policy is for 911. I had E6, LPN, verify R2 was dead, then I called the doctor and told him she had passed, and then I called the coroner, funeral home, and family." On [DATE] at 1:15 PM, in a phone interview with E6, she stated "On [DATE] at 5:05 AM, I saw R2, and she was fine, alert and talking. I know E4, saw her shortly after me because she was passing medications that morning behind me on the hall, and they were talking. I went on to the other side of the building to do my work, and returned at 6:15 AM. At that time E4 told me that R2 had passed away around 5:53 AM. E4 said she had tried CPR but was not successful. E4 said she had not called 911 because wasn't sure if R2 was a Full Code or not, and R2 was already gone. E4 said she had already called Z1 and the coroner. I was surprised that E4 didn't call 911, especially since we had just seen R2 alive about 30 minutes earlier. I told E4 to call the DON and ask if we needed to call 911 or what else if anything E4 needed to do. I wish E4 would have called for help or called a Code Blue, but she didn't. I did not confirm R2's death until 6:15 AM, after E4 had called Z1 and the coroner. On [DATE] at 1:35 PM, Z2, Coroner's assistant, verified that the Coroners office had been called on [DATE] at 6:07 AM, and informed of R2's death. Z2 stated that the coroner did not come out to verify the death. On [DATE] at 1:52 PM, Z1, Physician of R2, stated "I signed the death certificate, and noted the cause of death as "Sudden Death". I was called early in the morning, not sure of time, on [DATE] and informed of R2's death. I asked E4, what had been done for R2, and she told me "she did not do anything for her". I asked E4, Did you try CPR, and she told me no she did not. I asked E4 if R2 was a Full Code or a DNR, and E4 told "I do not know". I told E4 she had to check the resident's chart immediately and find out what her code status was and do what is necessary, that is, call 911 if full code, or call the coroner if a DNR. I did not know if R2 was a full code or not, but upon finding her unresponsive, I would expect the nurse to immediately check the chart and find out. Any resident found unresponsive, I would expect the nurse would call 911 and try to revive as long as indicated in the facility policy. No one from the facility called back regarding R2's status, and I assumed everything was done according to policy. On [DATE] a copy of R2's Death Certificate dated [DATE], documented; Cause of Death - 1. Sudden Death, 2. Hypertension. Approximate interval between onset and death, unknown. On [DATE] at 11:20 AM, in a second interview with E4, she stated "I did not know R2 was a Full Code when I saw her, and I did not call a Code Blue. I did try CPR by myself but quit after 15 minutes as R2 looked like she would not come back. When I called Z1 he asked if I had done CPR and I told him I tried but was unsuccessful, then he told me to call the Coroner. No, Z1 didn't say anything else." The signs of death E4 described were that R2 had no palpable pulse, and no respirations, had blue lips and blue finger tips, and was "cool, not cold to touch". During these interviews, E4 was asked if she found or noticed any other other presumptive signs of death (e.g.: no response to painful stimuli, corneal reflexes, absence of eye movement, no blood pressure, profound cyanosis) and E4 said she did not think so. E4 stated she did not confirm R2's death with another nurse until after she had called the Coroner and Funeral Home, sometime around or after 6:15 AM, but not at the time of actual death or after CPR was stopped. E4 stated she called E3, Acting DON, at 6:30 AM to inform her of R2's passing. Review of R2's nurse's notes dated [DATE] at 5:52 AM by E4, found no documentation that R2 had been checked for presumptive signs of death except for; "no pulse or respirations, color pale, lips and finger tips blue". On [DATE] at 11:30 AM, A review of the facility policy Cardiopulmonary Resuscitation and Emergency Response Notification, documented; 1. If an individual is observed unresponsive, with no pulse and cessation of breathing, a licensed staff person who is certified in CPR/BLS shall initiate CPR, call "code blue", designate a staff person to call 911 and make the crash cart available at the site unless: The individual has a Do Not Resuscitate / DNR order that specifically prohibits CPR and or external defibrillation for that individual. There are obvious signs of irreversible death, e.g.: absence of respiration, absence of blood pressure, absence of pulse, rigor mortis, algor mortis, livor mortis, fixed/dilated pupils. 2. Emergency Medical Response (911) is not necessary to be contacted when a resident death has occurred by natural disease process and there are obvious signs of irreversible death. On [DATE], at 12:00 PM, E1, Administrator stated that the above facility policy for Cardiopulmonary Resuscitation was not in the facility at the time of R2's death, but sent to E1, by electronic delivery from the corporate office on [DATE]. On [DATE], at 11:25 AM, in a phone interview with E3, Acting DON, she stated on [DATE] she was called early in the morning and told by E4 that R2 had passed, that CPR was tried, and that R2 was not able to be revived. E4 told E3 that R2 was a full code, and 911 had not been called as E4 described R2 as not having respirations, pulse, and some blood pooling on her backside when found. On [DATE] at 11:50 AM, in a phone interview, E1 stated that E4 had been interviewed about R2's death, and had told the facility that R2 had signs of obvious death, and therefore 911 was not called. E1 stated she had no written documentation of this interview and no documentation from E4. .

Based on record review and interview, the facility failed to assess risk factors, fluid intake and output and monitor the fluid needs for 1 of 4 residents (R1) reviewed to be at risk for dehydration in a sample of 13. This failure resulted in a low fluid intake, dehydration and hospitalization for R1. R1 expired on [DATE]. The findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of bladder and [MEDICAL CONDITIONS] and chronic pain. R1 was receiving Hospice services. E3, Licensed Practical Nurse, stated in an interview on [DATE] at 12:40 PM that R1 was vomiting small amounts of clear liquid during the 6 AM to 2 PM shift. E3 stated she did not call the physician due to the small amount. E3 stated the family of R1 gave R1 water and he did vomit the water. E3 stated she asked the family not to give him any more fluids. E3 stated R1 did not complain of nausea so she didn't give him any anti-nausea medication. E3 stated R1`kept asking for water and was voiding "OK". E3 stated the urine was not concentrated. The nurses notes by E3, dated [DATE] documented "fluids given as tolerated, asks for water constantly, Foley patent and draining dark amber urine to gravity...". The nurses notes by E3 and dated [DATE] at 3:44 PM documented "asks for water continuously, water given, total care given, denies pain or discomfort, no s/s (signs/symptoms) of distress noted. Resident had moderate amount of clear emesis, RP (family) here and was giving him water, nurse did ask RP (family not to give anymore water for now)...". E5, Registered Nurse, stated in an interview on [DATE] at 11:05 AM that she did not recall R1 asking for water. E5 stated she was told R1 had an emesis and they were reluctant to give R1 any fluids due to aspiration. E5 stated she did not give R1 anything for nausea nor did she call the physician. E5 stated the family had called hospice and the hospice nurse came in to check on him. E5 stated R1 was incontinent of a large bowel movement also. E5 stated there was about ,[DATE] cc's (cubic Centimeters) in the catheter bag and she was not sure if it had been emptied before that. E5 stated she thought Z3 sent R1 to the hospice because she was not sure of the urinary output. E5 stated she was not sure if the intake and output sheet was done. The nurses notes dated [DATE] at 12:03 AM documented "Resident continues on hospice care...Advised to hold fluids, as resident had emesis of liquids, water," and "Spoke to (Z3) hospice nurse, following call from (family). Advised that medications given 1 mg [MEDICATION NAME], and 0.5 ml liquid [MEDICATION NAME] but holding liquids". The "Intake and Output" sheet for September, 2011 documented no fluid intake for [DATE] or [DATE]. The urine output for [DATE] was documented as 500 for Days, 300 for Evenings, and 300 for Nights. The only documentation of output for [DATE] was on days with 350 documented. There was no documentation for bowel or emesis output for [DATE]. Fluid needs are estimated for R1's weight of 104 kilograms at 2614 to 3120 cc's (cubic centimeters) per day. The "Initial Care Plan" dated [DATE] documented R1 was at risk for dehydration due to [MEDICATION NAME] administration. The Initial Care Plan documented to maintain adequate hydration, R1 would be "assessed for dehydration", "follow hydration protocol", "I & O (intake and output)", "offer fluids", and "monitor skin turgor". E8, Certified Nurse Aide (CNA), stated in an interview on [DATE] at 1:15 PM that R1 asked for water a lot. E8 stated he worked the 6 AM to 2 PM shift on [DATE] and R1 had not vomited but didn't eat a lot. E8 stated R1 seemed uncomfortable. E21, CNA, stated in an interview on [DATE] at 11:40 AM that he worked from 2 PM to 11 PM on [DATE]. E21 stated R1 was calling out for water. E21 stated the nurse, E5, said to stop giving fluids because R1 was throwing up the water all day. E21 stated the family kept giving him water. E21 stated he stopped giving water around 5:30 PM. E9, CNA, stated in an interview on [DATE] at 11:10 AM that he worked the 6 AM to 2 PM shift on [DATE]. E9 stated they didn't give R1 fluids on Sunday because the nurses were afraid to give him too much water. E9 stated the nurse, E3, told him not to give fluids. E9 stated R1 always wanted water and would call out all the time. E7, CNA, stated in an interview on [DATE] at 8:25 AM stated R1 was calling out for water. E7 stated she worked the 11 PM to 6 AM shift that started on [DATE]. E7 stated the hospice nurse was there when she came in. R1 had a huge bowel movement that went all over the bed. E7 stated R1 kept asking for water and she gave him some. No one said not to and he had not vomited on her shift. Z1, Primary Care Physician, stated in an interview on [DATE] at 1:00 PM that she did not receive a call regarding R1 that weekend. Z6, Physician Assistant for Z1, stated in an interview on [DATE] at 9:45 AM that at no time was she contacted regarding R1 vomiting until Z3 contacted her on the evening of [DATE]. Z3 stated in an interview on [DATE] that she was on call the weekend of [DATE] and [DATE] and had not been contacted regarding R1's vomiting by the Facility. Z3 stated the family of R1 called her on the evening of [DATE] due to concerns with his condition and she went to the facility about 11:00 PM. Z3 stated when she arrived, R1 was "begging" for water, had a large indentation on his left leg due to the side rail, was very agitated, had a low blood pressure and was vomiting. Z3 stated the facility staff told her they had not given R1 any fluids due to the vomiting. Z3 stated she gave R1 some anti-nausea medications and he calmed down. Z3 stated she called Z2, Hospice Physician, who ordered to send R1 to the emergency room . The hospice progress notes dated [DATE] at 8:30 PM documented Z3 called the facility and talked to E5. The note states E5 reported to her that R1 was "the same as he was last night when I was here, just hollering out, begging for water, but he has been throwing up so we haven't given him anything to drink". The note also states E5 was asked if R1 had been given sips of water or at least swabbing his mouth and E5 stated "no". Z3 asked E5 if R1 had been eating and she stated "he hasn't been eating". Z3 then called Z2, Hospice Physician, and was told to make a visit to the facility. The hospice progress note dated [DATE] at 10:00 PM documented that Z3 found R1 "literally begging for water stating "water, ice water, I need water, please, help me". The urine was dark yellow. Z3 provided toothettes, ice water sips, Tylenol and [MEDICATION NAME] suppositories. Z3 gave R1 a drink and he vomited. Z3 called Z2 who immediately ordered to send R1 to the emergency room "for pain and symptom control related to the N/V (nausea/vomiting) and his restless state and condition a the LTCF (long term care facility)". The "Triage Assessment" emergency room notes dated [DATE] documented "(Hospice) nurse was visiting patient per family request. Patient has not been given anything to drink all day. The amount of urine in catheter is output for the day..." . There was no amount documented. The assessment documented the urine as "yellow" and "concentrated". According to the hospital notes by Z2, Hospice Physician, R1 was admitted for acute on [MEDICAL CONDITIONS], nausea and vomiting possibly due to uremia. R1's blood urea nitrogen was elevated at 126 (,[DATE] mg/dl)(milligram/deciliter) and creatinine was 2.71 (0XXX,[DATE].20 mg/dl). Z2 documented in the hospital progress notes that R1's family had called Z3. Z2 noted that she spoke to Z1 and she had not been contacted by the facility. Z2 noted that R1's creatinine level was 1.7 on [DATE]. R1 expired on [DATE].

Based on record review and interview the facility failed to provide pain medications as ordered by the physician to 1 of 4 residents (R1) reviewed for pain medication in a sample of 13. The findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of bladder and [MEDICAL CONDITIONS] and chronic pain. On admission R1 had physician orders [REDACTED]. R1 also had orders for [MEDICATION NAME] Concentrate 10 milligrams every three hours routinely and every 1 hour as needed for severe pain. The hospital "Medication Reconciliation Discharge" noted R1 had a [MEDICATION NAME] placed on 9/7/11 and would require a new patch on 9/10/11. The "Admission Nursing Assessment" dated 9/10/11 documented R1 had pain daily with the intensity of the pain noted "Times when pain is horrible or excruciating". The "Pain Assessment" dated 9/10/11 documented R1's pain as "severe" with limitations in sleeping and activities due to the pain. The facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There is no documentation that any PRN (as needed) [MEDICATION NAME] was given to R1. E5, Registered Nurse, stated on 10/18/11 at 11:05 AM that she only gave R1 his scheduled [MEDICATION NAME] and she did not recall giving R1 any PRN [MEDICATION NAME]. E5 could not recall the [MEDICATION NAME] for R1. E5 stated R1 was "agitated" and "restless" during sleep. E5 stated R1 was "thrashing around" before the hospice nurse came that evening. The nurses notes dated 9/12/11 at 12:03 AM by E5 documented "Resident admitted previous night on hospice with Foley catheter, hematuria, in [MEDICAL CONDITION].Cries out with movement or while stationary. Medicated on 0.5 ml liquid [MEDICATION NAME] q (every) 3 hrs (hours). Resident sleeping but has restless movements @ (at) times". On 9/12/11 R1 was sent to the hospital emergency room for vomiting according to the emergency room record. The hospital emergency department noted a patch was on R1's shoulder dated 9/7/11. Z2, Hospice Physician, documented in the "Progress Notes" "Unclear if pt (patient) had rec'd (received) meds (medication) as ordered @ (at) NH (nursing home)-[MEDICATION NAME] never changed (due 9/10 and changed today (at) hosp (hospital). PRN (As Needed) meds (medication) not being given." E2, Director of Nursing, stated in an interview on 10/11/11 at 10:30 AM, that R1 did not get the [MEDICATION NAME] or PRN [MEDICATION NAME] because the pharmacy didn't send the patches or the [MEDICATION NAME]. E2 stated it was the weekend and they couldn't get the physician authorization for the pharmacy to send the medications. E2 stated she was not aware he didn't get the patch until after the fact. E2 stated staff got the [MEDICATION NAME] out of the emergency kit and R1 received the scheduled [MEDICATION NAME] but not the PRN [MEDICATION NAME]. On 10/13/11 the packing slip from the pharmacy was obtained. The slip shows "1.0 [MEDICATION NAME] Dis (disc) 12 mcg/hr" was sent for R1. The packing slip also documented "30.0 [MEDICATION NAME] Sul (Sulfate) Sol (Solution) 20 mg/ml (milligrams/milliliter)" was sent to the facility. The medications were received by E5, Registered Nurse, on 9/10/11. No time was documented. Z1, Primary Care Physician, stated in an interview on 10/11/11 at 1:00 PM, that R1 came in to the facility on a Friday evening, 9/9/11. Z1 stated there was some confusion with the medication and Z6, Physician Assistant, had taken the call that weekend. Z1 stated she did talk to Z2, Hospice Physician, after R1 was admitted to the hospital on [DATE]. R1 was having more pain than before his admission to the facility and Z2 was concerned about pain management. Z1 stated if R1 did not get the [MEDICATION NAME] as ordered or the PRN medication then his pain could have increased. Z6, Physician Assistant for Z1, stated in an interview on 10/12/11 at 9:45 AM that she received a call from the facility staff on Friday that they were having problems getting R1's pain medication. Z6 stated she called the pharmacy Friday evening about 11 PM and spent an hour trying to get them to send the medication. On Saturday Z6 also received a call from the facility that they could not get the medication. Both times Z6 stated she told the facility staff to call Hospice to get the medications. Z6 stated R1 was in pain and the staff were trying to get the pain medication. Z6 stated she did talk to the Hospice nurse, Z3, on Sunday evening and Z3 stated no one from the facility had called her about the pain medication. Z3, Hospice Nurse, stated in an interview on 10/12/11 at 9:05 AM that she did not receive any calls from the facility regarding R1's pain medications. Z3 stated that the family of R1 called her on the evening of 9/11/11 regarding R1's change of condition.

A.) Based on record review and interview, the facility failed to initiate CPR for a resident whose code status was Full Code for 1 of 24 residents (R23) reviewed for code status in the sample of 24. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. Findings include: 1. R23 was hospitalized on [DATE]. The hospital's History and Physical (H & P) dated [DATE] documented in part that R23 was admitted to Acute Rehabilitation Ward following an extended hospitalization for exacerbation of [MEDICAL CONDITION], pneumonia. The H & P documented, "The patient is a full code at this time." R23 was admitted to the facility on [DATE]. E9, Social Services Director, documented (in part) in R23's Social Service Note dated [DATE], that R23 was admitted to the facility as a short-term admission. E9's note stated that R23 was, "Alert and oriented times three, able to make needs known. Res has w/c (wheelchair) to propel self...Res states here for aftercare to d/c (discharge) home.....". On [DATE], at 3:00 PM, E9 stated, "She (R23) was a young woman, planning to go home. She never was a DNR (Do not resuscitate). I keep the Code Status list for all residents. The DNR sheet would have to be signed and in the chart.". E10, Licensed Practical Nurse (LPN), documented in Nursing Notes dated [DATE], "Called to room per CNA (certified nursing assistant). Res lying in bed unresponsive to painful stimuli. Page over head all nurses to Room ,[DATE] stat with crash cart....Ambulance call ....02 started per n/c (nasal cannula). Skin warm and dry....continue to remain unresponsive...Amb. here to assess res and Dr at (local hospital) called res death 20:57. Z1, physician, called to inform that res have no sign of life." On [DATE] at 10:06 PM, E10 documented in the Nurses Notes, "Z1....called, inform unable to obtain vital sign. New orders to discharge res to funeral home of family choice." The ambulance Patient Report Form dated [DATE] documented, "Crew dispatched to scene urgent. Staff states, 'Pt was sitting in her wheelchair in the hallway, laughing & talking. A couple of the girls helped her to the bathroom, where she was fine, and they helped her lie down in bed. As soon as she did, she went. She is a DNR so we didn't start CPR. I can't find the DNR papers at the moment'. Pt presents to crew as 61 y/o female lying in bed unconscious/unresponsive, pulseless & apneic. Crew unable to obtain carotid or radial pulse. Pt's pupils dialated, unresponsive to light. Crew place pt on cardiac monitor - asystole. R/O sudden [MEDICAL CONDITION]." The ambulance Patient Mobility Report dated [DATE] documented the statement, "Pt is DNR/DOA (dead on arrival)". The form is signed by E10. On [DATE] at 8:45 AM, E10, stated that she, "didn't initiate CPR at first because she (R23) was still breathing. When other nurses came in, she was still breathing. When I got back to the Nurse's Station to call the doctor and the ambulance, I looked on the face sheet and saw DNR (Do Not Resuscitate) written on the face sheet. I learned later that the DNR paper was supposed to be signed." E10 verified that she did not perform CPR on R23. E10 stated, "When I got back into the room, the other nurses told me she had passed away. The ambulance arrived after she passed. The ambulance attendants asked what her code status was. I told them she was DNR. The ambulance people checked her out. They called a doctor in the emergency room , told the doctor what they had found. The doctor pronounced her dead". The Facility's Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) Policy revised [DATE], documented (in part), "Sudden [MEDICAL CONDITION] is a leading cause of death in adults.....Depending on the underlying cause, the chances of surviving arrest may be increased if CPR is initiated immediately on collapse....The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives....If an individual is found unresponsive and without a pulse, a licensed staff person who is certified in CPR...shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR....exists for that individual; or there are obvious signs of irreversible death (i.e. rigor mortis)." E5, Corporate Registered Nurse, and E2, Director of Nursing, DON, were notified of the Immediate Jeopardy on [DATE] at 3:00 PM. The surveyor confirmed through record review and interview that the facility took the following actions to remove the Immediate Jeopardy. 1.) On [DATE] an audit of all DNR forms and physicians orders has been completed for all residents to verify their code status. 2.) On [DATE] a resident with a code status of DNR will have an executed DNR on orange paper in the front of the resident paper record. 3.) On [DATE] all face sheets have been reviewed to ensure code status is accurate. 4.) On [DATE] the code status will be updated by Social Service when their is a changes in a resident's code status 5.) On [DATE] the Charge Nurse will update order/face sheet when and if change of code status order is received. 6.) On [DATE] all Nurses have been in-serviced related to facility policy on: a. DNR - Do not resuscitate b. What to do when a CODE is called c. When to do CPR and when not to do CPR d. In the event Code status is unclear the resident is considered a FULL CODE and CPR must be initiated. e. Where to look in chart for code status 7.) On [DATE] a DNR sticker has been placed on every face sheet of residents that have DNR orders. B.) Based on record review, and interview, the facility failed to assess and provide pain relief for one of eight residents (R3) reviewed for pain control needs in the sample of 24. Findings include: According to an INCIDENT REPORT dated [DATE] at 11:20am, R3 was found on the floor by her wheelchair. The report documents that R3 "c/o (complained of) pain to lt (left) hip area down to her toes after." The nurses notes dated [DATE] document R3 was sent to the emergency room at 2:55pm, and had "no evidence of pain unless when being moved." An Xray was done and was negative for fracture. R3 returned to the facility on [DATE] at 6:19pm. The nurses notes dated [DATE] at 10:56pm document "resi (resident) continues to c/o pain when turn and position for comfort", and on [DATE] at 2:43am document "resident does continue to c/o pain to left hip especially when being assisted with changing positions." There is no evidence the facility assessed R3's pain at the time for the cause and/or severity. On [DATE] at 3:14am, nurses notes document R3's complaints of pain continued when "turned et (and) repositioned but rests quietly without c/o when task is completed." No assessment for the cause of pain and/or the intensity/severity was completed. The February 2011 physician's orders [REDACTED]. There is no evidence that R3's physician was notified of R3's continued complaints pf pain. On [DATE] at 10:31pm, the nurses notes document that R3 voiced no complaints, and fails to include any assessment for pain with movement. On [DATE] at 2:09am, the nurses note entry fails to reflect pain at all. There is no further nurses notes written until [DATE], 12 days later. The nurses notes dated [DATE] at 2:58pm document "resident c/o knee, femur, and left hip pain. Resident stated It hurts when she moves." The notes continue that family was present and wanted an Xray. An INCIDENT REPORT FOR ILLINOIS DEPARTMENT OF PUBLIC HEALTH dated [DATE] confirms the facility's nurse was told of R3's complaints of pain by the family, and that the physician was then notified. There is no evidence the nurses were consistently monitoring R3's pain on movement following her fall on [DATE]. A mobile Xray was done which doumented a subcapital [MEDICAL CONDITION] femur with coxa were deformity and moderate arthritis of left knee with [MEDICAL CONDITION] changes. The physician was notified of the results. an order for [REDACTED]. On [DATE] at 12:36pm, E2, DON, confirmed the nurses notes did not include any documentation toward consistent monitoring and/or assessments following R3's complaints of pain on movement following her fall on [DATE]. E2 also stated she had no nurses notes from [DATE] through [DATE], but stated there was an assessment done following her return to the facility on [DATE]. R3 was r-eadmitted to the facility on [DATE] at 5:37pm. No repair was done for the fracture per family request. A nurse assessment including a pain assessment was done following this readmission on [DATE] and identifies R3's pain as "mild" "hip", "less than daily." No pain assessment was provided or evident following the fall on [DATE] when her complaints began. The next entry into the nurses notes is identified as a "late entry" at 10am on [DATE], and describes R3 as "restless" and trying to get out of bed. Tylenol #3 was given. There is no evidence that R3's pain was assessed using a scale, etc. The next entry into the nurses notes did not occurred until [DATE]/11 and documents "This resident complained of pain in her leg." Tylenol #3 pain medication was given, but no assessment was completed to determine the severity of the pain. The Care Plan fails to reflect an effective pain management plan that ensures she is comfortable during transfers and mobility times. The facility's policy on Pain Management documents that it is the responsibility of the caregiver to report any changes in behaviors that might indicate pain and assess it considering pain as the "fifth" vital sign. Under IMPACT OF PAIN ON FUNTIONAL STATUS, assessments should/may include impaired ability to perform Activities of Daily Living (ADL's) when moving. The policy documents that on re-admission and/or a change in condition, a Pain Screening will be done along with a flow sheet.

Based on observation, interview, and record review, the facility failed to develop and implement effective interventions for repeated falls for two of six residents (R3 and R1) reviewed for falls in the sample of 24. This failure resulted in R3 falling from her wheelchair, and sustaining a fractured femur. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents R3 as having short/long term memory deficits with severe cognitive impairment and requires extensive assist of one staff for bed mobility and totally dependent for transfers. The MDS indicates she has balance deficits. The care plan dated 11/17/10 identifies R3 at risk for falls due to history of falls. According to an INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS report, R3 was "observed on the floor by her wheelchair in" her room on 1/30/10 at 11:20am. The investigation reports that R3 has a history of leaning forward in her wheelchair and that she had a release belt on to prevent her from falling forward. The investigation continues to document that a Certified Nurses Aide (CNA) failed to fasten the seat belt and R3 leaned forward falling from her chair. The INCIDENT REPORT documented R3 complained of left hip pain following the fall and the physician was notified. R3 was sent to the emergency room where Xray's were negative for a fracture. However, nurses notes written between 1/30/11 and 2/2/11 indicate R3 continued to complain of pain and on 2/14/11, another Xray was done which was positive for a subcapital fracture of the left femur. On 8/2/11, E1, Acting Administrator, stated the facility attributed the fracture to the fall on 1/30/11. R3's Care Plan dated 5/23/11 documents that R3 to be at risk for further falls. Interventions include personal alarm per facility policy on chair and/or bed, proper positioning in chair when up, ensure bed/chair alarm in functioning properly, assist resident in a timely manner, mechanical lift for all transfers, and high/low bed in low position when resident is in bed. According to INCIDENT REPORTS, R3 fell on [DATE] when her alarm went off and staff were unable to reach her before she fell to the floor as she was sitting in activities, and on 6/27/11 at 450am, R3's alarm was sounding and staff found her on the floor in her room. The report of 6/27/11 documents family will be encouraged to allow a low bed. There is no indication as to why staff were unable to respond in a timely manner to prevent R3 from falling. On 7/3/11 at 5:35am, another INCIDENT REPORT documents that R3 was found sitting on the floor beside her chair in the activity area and had removed her alarm. The report suggestions include "maybe a chair sensor or other device she could not remove." The facility failed to aggressively address R3's repeated falls. On 7/27/11 and 7/29/11, R3 was observed in bed and chair with a clip alarm on and not a sensor. 2. R1's Care Plan initiated on 5/29/10 documented "Resident is at high risk for falls r/t altered mobility, functional limitations in range of motion, balance problem and gait disturbance related to CVA (Cerebral Vascular Accident)" On 7/28/11, at 10:50 AM, R1 was sitting in his room in an electric wheelchair. During an interview with R1, he stated he needed asssistance getting in and out of his wheelchair. He stated he was very unsteady and his feet and legs "give out on me." R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS form, dated 9/6/10, documented "The res (resident) was found on the floor at the bedside by the nurse. He stated he was attempting to get up from bed and rolled over to floor." This form documented "What would you suggest to prevent future occurrences of this nature: Reinforce the instruction of using call light to ask for assistance before getting up." R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS form, dated 9/24/10, documented "Res rolled out of bed". This form documented "What would you suggest to prevent future occurrences of this nature: Res to lay in middle of bed - Scoop mattress for resident." R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS form, dated 9/26/10, documented " Res lost balance and fell transferring from w/c (wheelchair) to bed." this form documented "What would you suggest to prevent future occurrences of this nature: Have Res ask for help or use call bell- Use of PSA (Personal Safety Alarm)." R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS form, dated 10/4/10, documented "CNA (Certified Nurse's Aide) came to this nurse stating res was found on floor next to bed." The report documented R1 rolled out of bed. This form documented "What would you suggest to prevent future occurrences of this nature: Bed alarm placed on res bed. Res re-educated on need to use call light." This was the same interventions documented on the previous fall, 9/26/10. R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS form, dated 10/22/10, at 9:00 PM, documented "Attempting to transfer self to bed." The form documented "found res on floor - res states slipped and fell trying to get in bed." This form documented "What would you suggest to prevent future occurrences of this nature: Enc (Encourage) res to use call bell and keep electric w/c in hallway so res has to call for help." R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS form, dated 11/13/10, at 11:10 AM, documented "Res found on floor next to bed. No shoes on. Floor dry. PA (Personal Alarm) on and functioning." This form documented "What would you suggest to prevent future occurrence of this nature: Bed alarm and chair alarm on and functioning." R1's care plan, updated on 11/13/10, documented "Found on floor, alarm on and working. Resident self transfers and will not call for assit. Resident turns alarm off. Review residents needs and time of fall and alert staff to anticipate need for assist." R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS form, dated 1/27/11, at 7:30 AM, documented "Resident observed by nurse on the floor by the side of his bed on his left side stating 'I rolled out of bed'. " The form documented interventions to prevent future occurrences as "Monitor resident. Wing mattress." R1's care plan, updated on 1/27/11, documented "Scoop mattress on bed." The scoop mattress was listed as a intervention when he fell on [DATE], four months prior. R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS form, dated 3/28/11, at 3:00 AM, documented "Resident was found lying on the floor beside bed." The form documented intervention to prevent future occurrences as "Psych evaluation, remove chair from room when in bed, PVC bed with alarm." R1's care plan, revised on 3/28/11, did document he was to receive a PVC bed; however, the care plan did not address the removal of his chair from his room. The intervention regarding staff removing his wheelchair from his room was documented as a previous intervention for his fall on 10/22/10. R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS FORM, dated 4/17/11, at 9:15 AM, documented "CNA was entering resident's room and resident was noted to be transferring self to mobilized chair and resident slid to floor." Again the intervention listed to prevent future occurrences of falls was "Resident has alarm in his new chair. POA (Power of Attorney) called this nurse advised to keep his mobilized wheelchair in the hallway when not in use. Resident educated on using his call light." R1's care plan, revised on 4/19/11, documented "Educate resident R/T (Related To) ambulating (without) assistance c (with) walker, remove w/c from room and ensure call light in place." R1's INCIDENT INVESTIGATION QUALITY IMPROVEMENT PROCESS FORM, dated 5/26/11, at 10:55 PM, noted "Resident found standing beside w/c in his room. Stated 'I fell over my chair.' No c/o (complaints of) pain ROM (Range Of Motion) of exts (extremities)." Although the facility documented staff were to remove his wheelchair from his room to prevent future falls, the report did not indicate why R1's wheechair was left in his room at the time of the fall. There was no interventions documented to prevent future occurrences of falls. The facility did not update R1's care plan did not revise R1's care plan after this fall.