Every finding on record at Bria of Westmont

Based on observation, interview, and record review, the facility failed to ensure residents were receiving tube feeding as ordered.This failure resulted in R1 and R8 experiencing significant weight loss.This applies to 2 of 3 residents (R1 and R8) reviewed for tube feeding in the sample of 10.The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including epilepsy, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, dysphagia, bipolar disorder, dementia, and contractures of the left and right ankle, left wrist and left hand.R1's MDS (Minimum Data Set) dated July 9, 2026, showed R1 had severely impaired cognitive skills for daily decision making and was dependent on facility staff for all ADLs (Activities of Daily Living) and mobility. The MDS continued to show R1 had a significant weight loss and was not on a prescribed weight-loss regimen.R1's enteral feeding care plan dated January 30, 2026, showed Tube feeding: [R1] is at risk for complications related to nothing by mouth status and receiving enteral nutrition. The care plan continued to show multiple interventions dated January 30, 2026, including tube feeding as ordered.R1's nutrition care plan revised on July 11, 2026, showed [R1] is on tube feeding. Resident is dependent on tube feeding for adequate nutrition support. Low BMI (Body Mass Index). Significant weight loss times three, six months. Multiple hospitalizations. Tube feeding was adjusted. The care plan continued to show multiple interventions dated February 2, 2026, including Provide tube feeding as ordered; Registered Dietician to provide monthly nutrition assessment. Evaluate calorie, protein, and fluid needs and adequacy/appropriateness of current feeding regimen.R1's Weights and Vitals Summary dated August 13, 2026, showed R1 weighed 78.2 pounds on February 5, 2026, 74.4 pounds on May 13, 2026, and 64 pounds on August 11, 2026. R1 experienced an 18.16% (percent) weight loss in six months and a 13.98% weight loss in three months.On August 12, 2026, at 12:43 PM, R1 was lying in bed with tube feeding infusing at 55 ml (milliliter)/hour. R1 appeared cachectic with temporal muscle wasting. On August 12, 2026, at 4:20 PM, V18 (LPN/Licensed Practical Nurse) said she was caring for R1 on the evening shift and started at 3:00 PM. V18 said R1's tube feeding pump will show how much feeding R1 has received. V18 said R1's tube feeding was infusing at 55 ml/hour and the pump showed total feeding infused as 3661 ml. V18 said she cannot tell by looking at the pump how much feeding R1 has received. On August 13, 2026, at 8:46 AM, R1 was lying in bed. R1's tube feeding pump was alarming and the screen showed a message of low battery.On August 13, 2026, at 8:47 AM, V10 (LPN) said she was R1's nurse for the shift. V10 said she had previously been in R1's room about 30 minutes ago and the tube feeding was infusing. V10 entered R1's room and at 8:52 AM, V10 was able to get the tube feeding pump plugged into the outlet. V10 said the pump showed R1 has received 4525 ml of tube feeding. V10 said she keeps a note during her shift of the total volume R1 receives and then subtracts the end number from the beginning number. V10 said she discards the paper at the end of her shift in the shredding bin and does not document how much R1 received. V10 said she was R1's nurse yesterday for day shift from 7:00 AM to 3:00 PM. V10 said she does not remember how much tube feeding R1 received during her shift yesterday and she did not document it. V10 said she does not have to document how much tube feeding R1 receives because she is not on strict monitoring of her intake and output. V10 said R1's tube feeding is supposed to infuse over 22 hours. V10 said she usually turns it off towards the end of her shift and the next shift will restart the feeding after it is off for two hours.On August 13, 2026, at 11:56 AM, V12 (Dietitian) said the nurses should know when a resident's tube feeding should be infusing. V12 said she does not look at the nursing documentation to see if R1 is receiving her feeding. V12 said her tube feeding in exceeding R1's nutritional needs. V12 said she does not know why R1 is losing weight. V12 said it is the expectation the nurses are administering the tube feedings as ordered by the provider.R1's Order Summary Report dated August 13, 2026, showed an order dated June 30, 2026, for Enteral Feed Order, every shift, enteral feeding formula osmolyte 1.2, rate 55 ml (milliliter)/hour. Flush with 75 ml every eight hours. The report continued to show an order dated June 30, 2026, for Osmolite 1.2 at 55 ml/hour times 22 hours, total volume 1210 ml every shift for tube feeding.R1's June 2026 MAR (Medication Administration Record) showed on June 28, 29, and 30, every shift documented zero ml of tube feeding received.R1's July 2026 MAR showed 86 shifts out of 93 totals shifts for the month had a documentation of zero to 55 ml of tube feeding received.R1's August 2026 MAR for the period of August 1 to August 13, showed 35 of 37 total shifts had an intake of zero ml of tube feeding and two shifts had an intake of 25 ml. For the period of June 28, 2026, to August 13, 2026, the facility does not have documentation to show R1 received tube feeding as ordered by the provider. On August 13, 2026, at 4:46 PM, V15 (R1's Physician) said R1 should be receiving the tube feeding as ordered. V15 said facility staff should be documenting R1's intake to ensure the ordered amount is administered. V15 said R1 not receiving tube feeding as ordered can cause weight loss. V15 said R1 has dislodged her gastrostomy tube multiple times. V15 said facility staff notify him when the gastrostomy tube is dislodged but V15 does not receive a call with how long the gastrostomy tube was dislodged and how long R1 went without tube feeding. V15 said he was unaware R1 had dislodged her gastrostomy tube and was without tube feeding for about eight hours one day. V15 said staff should notify him of how long R1 is without tube feeding.A progress note dated July 10, 2026, at 2:14 PM, by V10 showed Abdominal binder in place for g-tube (gastrostomy tube) protection throughout shift. At noon resident pulled g-tube out. Physician notified, new order to place 16 French [indwelling urinary catheter] to keep area open per facility protocol, have [outside company] place new g-tube and have abdominal x-ray to verify placement. All orders noted and carried out. 16 French g-tube placed by [outside company], awaiting x-ray technician to arrive to verify placement. Writer endorsed to oncoming shift to not use g-tube until placement is verified per physician's order.The facility does not have documentation to show the gastrostomy tube placement was confirmed on July 10, 2026, and the physician was notified with the length of time R1's tube feeding was not infusing.A progress note dated July 11, 2026, at 9:01 PM, by V19 (RN/Registered Nurse) showed Resident sent to [local hospital] due to g-tube dislodgement. G-tube noted to be out, physician made aware, DON (Director of Nursing) made aware. All responsible notified.A progress note dated July 12, 2026, at 2:00 AM, by V20 (RN) showed Resident returned from [local hospital] via ambulance on a stretcher. New 16 French g-tube inserted. Tube flushed without difficulty. She remains with baseline confusion. Abdominal binder is in place. No signs/symptoms of pain or discomfort noted. Staff assisted with all ADLs (Activities of Daily Living).The facility does not have documentation to show R1's physician was notified of the length of time R1's tube feeding was not received on July 11 into July 12, 2026.A progress note dated July 27, 2026, at 4:40 PM, by V10 showed At 3:45 PM, writer observed resident with abdominal binder in place and resident hold g-tube in right hand. New orders to insert 16 French [indwelling urinary catheter] to maintain site, call [outside company] to reinsert 16 French g-tube, and have x-ray done confirm placement. Writer able to insert 16 French g-tube to maintain site. Writer called POA (Power of Attorney) and obtained consent for [outside company] to reinsert g-tube. [Outside company] notified, writer awaiting ETA (Estimated Time of Arrival). Once completed x-ray will be done.A progress note dated July 27, 2026, at 6:30 PM, by V10 showed [Outside Company] nurse arrived and inserted 16 French g-tube. Resident tolerated procedure well. Awaiting x-ray technician to do an abdominal x-ray to confirm placement of g-tube. Writer endorsed to oncoming shift accordingly.The facility does not have documentation to show R1's physician was notified of length of time R1 was not receiving tube feeding on July 27, 2026.A progress note dated July 31, 2026, at 2:59 PM, by V21 (LPN) showed Resident pulled out g-tube. I was not able to administer morning medication or feeding due to this. [Outside company] was called for reinsertion. DON and Doctor made aware.A progress note dated July 31, 2026, at 5:04 PM, by V22 (LPN) showed Resident pulled out her g-tube during the first shift. Per the morning nurse, she put in place a [indwelling urinary catheter] to keep it patent per physician orders. Resident has pulled it out same. Technicians were in facility to reinsert the g-tube, however the g-tube site was closed. Physician ordered resident to be transferred to the emergency room for reinsertion. POA notified.A progress note dated July 31, 2026, at 5:28 PM, by V22 showed [Ambulance Company] called for transfer.The facility does not have documentation to show how long R1 was without tube feeding on July 31, 2026, and notification of R1's physician regarding the tube feeding R1 missed. The EMR showed R1 was not admitted to the hospital, but the facility does not have documentation to show when R1 returned to the facility and when tube feeding was resumed.On August 17, 2026, at 1:57 PM, V13 (Restorative Nurse) said facility staff should be documenting the total amount of tube feeding a resident receives during a shift. V13 said staff should be clearing the total amount of tube feeding received on the pump at the beginning of their shift and then documenting the amount received at the end of their shift. V13 said staff need to document the total infused so staff know if a resident is receiving the ordered amount of tube feeding. V13 said by looking at R1's MARs, V13 cannot say how much tube feeding R1 receives every shift.2. R8's EMR showed R8 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, dependence on renal dialysis, end stage renal disease, megacolon, and epilepsy.R8's MDS dated [DATE], showed R8 had moderately impaired cognitive skills for daily decision making. The MDS continued to show R8 had a significant weight loss and was not on a prescribed weight-loss regimen.R8's nutrition care plan dated April 13, 2026, showed [R8] is dependent on tube feeding for nutritional support. Diagnosis: dysphagia, low BMI, significant weight loss, weight loss related to hospitalization, recent gastric tube placement related to dysphagia and fluid shifts (end stage renal disease on hemodialysis). The care plan continued to show multiple interventions dated April 13, 2026, including Provide tube feeding per physician order.R8's Order Summary Report dated August 13, 2026, showed an order dated July 27, 2026, for Enteral feed order, two times a day for enteral deeding, enteral feeding formula: osmolyte 1.2, rate: 70 cc (cubic centimeter) times 18 hours (on 4:00 PM, off 10:00 AM), flush 100 cc every eight hours.R8's Weights and Vitals Summary dated August 13, 2026, showed on May 6, 2026, R8 weighed 106.7 pounds, and on August 5, 2026, R8 weighed 94.2 pounds. The documentation showed R8 experienced an 11.72% weight loss in three months.On August 12, 2026, at 3:22 PM, R8 was lying in bed. R8 appeared cachectic with temporal muscle wasting. R8's tube feeding pump showed the feeding was infusing at 70 ml/hour. The pump showed a total amount infused of 340 ml. R8's tube feeding bottle was dated August 12, 2026, at 6:00 AM. The bottle showed the level of feeding in the bottle was at 900 ml out of a beginning amount of 1000 ml, for an approximate total of 100 ml infused from the bottle.On August 12, 2026, at 4:15 PM, V23 (LPN) said she had been caring for R8 since 7:00 AM. V23 said when she arrived on shift, R8 was already at dialysis, and his tube feeding was not infusing during dialysis. V23 said she restarted R8's tube feeding when R8 returned from dialysis. V23 could not remember what time R8 returned from dialysis, sometime around 10:00 AM to 11:00 AM. V23 said she did not clear the total infused on R8's tube feeding pump. V23 said the total infused amount on the pump is reset whenever a new bottle is started, which was on night shift. V23 said R8's tube feeding is held during care like showers, incontinence care, and during dialysis.On August 13, 2026, at 8:44 AM, R8 was lying in bed. R8's tube feeding pump showed the feeding was infusing at 70 ml/hour and a total infusion of 130.5 ml. R8's tube feeding bottle showed the bottle was started on August 13, 2026, at 12:00 AM.On August 13, 2026, at 9:00 AM, V24 (LPN) said she was R8's nurse. V24 said R8's tube feeding was started on the previous shift. V24 said she did not clear the amount infused on R8's tube feeding pump. V24 said the amount infused is cleared when the tube feeding is being started.On August 13, 2026, at 11:56 AM, V12 said she was unaware R8's scheduled tube feeding time was during R8's dialysis time and the tube feeding was being held while R8 was in dialysis. V12 said staff should be following the order for R8's tube feeding. V12 said her progress note showed R8 should be receiving a total of 1260 ml in a day and facility staff should be ensuring R8 receives the total amount in a day.R8's May 2026 MAR showed 76 out of 84 shifts had an intake amount of R8's tube feeding as zero to 60 ml infused in a shift.R8's June 2026 MAR showed 69 out of 90 shifts had an intake amount of R8's tube feeding as zero to 50 ml infused in a shift.R8's July 2026 MAR did not show the amount of tube feeding R8 received. The facility does not have documentation to show R8 received the ordered amount of tube feeding. R8's August 2026 MAR for the period of August 1, 2026, to August 13, 2026, did not show the amount of tube feeding R8 received. The facility does not have documentation to show R8 received the ordered amount of tube feeding.On August 13, 2026, at 4:09 PM, V16 (R8's Nurse Practitioner) said facility staff should administer R8's tube feeding as ordered. V16 said staff should be documenting how much tube feeding R8 receives in a shift. V16 said if R8 does not receive tube feeding as ordered it can cause weight loss. On August 17, 2026, at 2:06 PM, V13 said she cannot say how much tube feeding R8 receives in a shift because the documentation does not show how much tube feeding R8 is receiving in a shift. V13 said facility staff should be documenting how much tube feeding R8 receives in a shift.The facility's policy titled Tube Feeding dated October 2025, showed General: Nasogastric, gastrostomy, and jejunostomy tubes are used when an alternate method of nutrition is needed. Responsible Party: RN, LPN. Guideline: 1. Continues tube feedings are based on individual resident need per Registered Dietician assessment and delivered over a 24-hour period. 4. The Health Care Provider should be notified if tube-feeding amount is not infused as ordered.

Based on interview and record review, the facility failed to administer wound treatment as ordered by the provider. This applies to 1 of 3 residents (R2) reviewed for wound treatments in the sample of 10.The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including burns involving 10 to 19% (percent) of body surface area with 0 to 9% third degree burns, severe protein-calorie malnutrition, weakness, and chronic diastolic heart failure.R2's MDS (Minimum Data Set) dated July 28, 2026, showed R2 was cognitively intact. The MDS continued to show R2 required partial assistance from facility staff with personal hygiene.R2's skilled services care plan dated April 28, 2026, showed [R2] admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation and assessment of the patient's condition and/or teaching and training activities related to the reason for stay or in preparation to transition to a lesser care environment. The care plan continued to show multiple interventions dated April 28, 2026, including Provide skin treatments per physician order. Follow plan of care for skin management.R2's skin care plan dated April 29, 2026, showed [R2] has alteration in skin integrity as evidenced by burn wound to right axilla. She is at risk for further alteration in skin integrity related to low back pain, osteoarthritis, bradycardia, atrial fibrillation, congestive heart failure, and incontinence. The care plan continued to show multiple interventions dated April 29, 2026, including Assess and document of progress of areas weekly; Treatment as ordered to right axilla.On August 12, 2026, at 10:15 AM, R2 said facility staff do not clean her burn wound daily as it is ordered. R2's Order Summary Report dated August 13, 2026, showed an orders dated July 10, 2026, for Silver sulfadiazine cream 1%, apply to right upper arm-posterior topically every day shift to promote wound care healing, cleanse with normal saline then apply thin layer of Silvadene cream then cover with silicone super absorbent bordered dressing or (if itching) cover with [gauze pad] and secure with rolled gauze and surgilast net; Silver sulfadiazine cream 1 % apply to right arm topically as needed to promote wound care healing as needed if site becomes soiled or removed.R2's hospital documentation showed R2 was discharged back to the facility on June 2, 2026, with treatment orders to apply silver sulfadiazine topical, daily. The documentation continued to show the treatment was to begin on June 3, 2026. R2's June 2026 TAR (Treatment Administration Record) showed R2 did not receive treatment on June 3 and June 4. R2's July 2026 TAR showed R2 did not receive treatment as ordered for her right upper arm on July 12, 2026. The facility does not have documentation to show R2 refused the treatment on July 12, 2026. R2's August 2026 TAR showed R2 did not receive treatment as ordered on August 3, 2026. The facility does not have documentation to show R2 refused treatment on August 3, 2026.On August 17, 2026, at 1:53 PM, V13 (Restorative Nurse) said R2's wound treatments should be completed as ordered. V13 said staff should document the wound care at the time of treatment including if the resident refused treatment. V13 said R2 should have received treatment as ordered. The facility's policy titled Skin Management: Treatment/General Wound Treatment dated April 2026, showed General: The following treatment guidelines have been developed to serve as a general protocol for selecting the type of treatment or dressing to be used. However, the facility recognizes that the selection of treatment protocols is individualized based on the resident condition and Health Care Provider practice patterns. Therefore, these are only guidelines and not all-inclusive. An order is required for all treatment orders. Responsible Party: All nursing staff. General Treatment Guidelines: 1. Review the physicians order in the HER (Electronic Health Record) and place all necessary supplies in treatment cart. 8. Document routine and as needed treatments in the treatment administration record of the HER. Document all significant observations in the Nursing Progress Note.

Based on interview and record review, the facility failed to prevent a resident with increased confusion and identified as a high fall risk from being physically restrained. This failure resulted in the resident being barricaded in her bed surrounded by dressers.This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 5.The findings include:R1's face sheet showed multiple diagnoses that included unspecified fall, subsequent encounter, other abnormalities of gait and mobility, weakness, tremor, cognitive communication deficit, unspecified psychosis, bipolar disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, recurrent severe without psychotic features, abnormal posture, and osteoarthritis.R1's 5-day MDS (Minimum Data Set) dated July 24, 2026, showed that she was moderately impaired in cognition and needed partial assistance from staff for mobility. On July 31, 2026, at 9:50 AM, R1 was seated in her wheelchair and she had multiple bruises: on the left side of her face, under her eye, on her cheek near chin area and a faint bruise on the bridge of her nose. The middle of R1's lips were bruised with a cut and a reddish tint. When asked where she got the bruises from, R1 pointed to a 3-drawer dresser that was on the left side of the head of the bed and stated I fell by the dresser. I think a week ago. R1's right side of the bed was pushed against the wall. R1 also had two more dressers like the one at the head of the bed, that were placed side by side on the opposite side of the room. There was about 5 feet distance between these dressers and R1's bed. R1 was confused and had repetitive speech and appeared fearful and anxious and kept asking Are you done.On July 31, 2026, at 9:50 AM and 10:22 AM, V4 CNA (Certified Nursing Assistant) was seen with R1 and stated I am on 1:1 (supervision) with her today. When I came in on Wednesday (July 29, 2026) morning, I saw staff in the [R1's] room, and I went in to see what was happening and saw three dressers all around [R1's] bed, pushed up against the left side of the bed. They used the dresser as a restraint. Her lip and teeth were bloody. Her bedsheets were all bloody. Me and (V16) saw her that morning and changed the sheets and put them in the wash. She has fallen many times, and she has some old bruises from previous fall under her eyes, cheek, and chin on the left side of face that were fading. She tries to get out of bed and wander, so that is why they did that. [R1] said, 'They trapped me in here.' V4 said she told R1, I know they did. V4 pointed to the 3 dressers on R2's side of the room and stated that the dressers should be positioned as they currently were.On August 1, 2026, at 10:08 AM, V16 (CNA) verified that she had accompanied V4 to R1's room on July 29, 2026, morning at around 7:30-7:45 AM. V16 stated As I was getting prepared to start my shift, a CNA (V19) who was assigned to R1 that morning shift, was in the hallway, very upset and said, 'I just can't do this.' Apparently, he had walked into [R1's] room and he had seen something that made him irate. He showed me what he saw, and I saw three dressers lined up along R1's bed like a crib around the bed. Somebody took a picture of it. He said that she was being confined. That was deliberately done! You know that she could not move those heavy dressers by herself. The resident was putting her arms up and saying, 'help me, help me, I need to use the bathroom.' Without a doubt she was scared. She was shaking. I saw dried blood on her teeth and her lips and that made me curious about what happened. I looked into her mouth and she said it hurt. I noticed a line coming from her nostrils and saw some fresh blood coming down. [V4] and I saw some hold marks on both her arms. Her left eye had a bruise and her jaw was swollen. I noticed there was blood on her sheets and her dresser so that's where the concern came in. By the look of her face, it appeared and I assumed that she was abused and was beat up. I got the supervisors involved. I came to find out that she had fallen, and those bruises are from that.On August 1, 2026, at 10:56 AM V19 (CNA) stated that he worked Wednesday (July 29) on the 7 AM-3PM shift. V19 stated I was on the floor at 7:00 AM, and it was two CNA's that were standing at the nurse's station and asked if I would do 1:1 with (R1) until her assigned 1:1 came in. I went into the room at around 7:15 AM, I saw (R1) lying on the bed and she was reaching out to me. The furniture in the room was completely lined up around her bed, at side of the bed and she was boxed in so that she could not get out. She was reaching out and frightened and said, 'I need to go to the bathroom.' There was no way she could have moved that furniture by herself as it was heavy, and she tends to lose her balance when she stands. I yelled in the hallway for a nurse. That's when (V18) and (V21), both nurses came into the room.On July 31, 2026, at 10:49 AM and 12:33 PM, V8 (CNA) stated The day before (Tuesday, July 28, 2026) [R1's] face was fine and had no bruises. She had a bruise earlier under her eyes, but it had gone away on its own. I worked the morning shift after the incident. When I came into the room, I saw that she was barricaded as she had an object like a dresser at foot of bed and dressers on side of the bed. I bumped my leg and got a bruise on the dresser. Somebody had changed the sheets before we got here. There was some blood on the wall and blood was oozing from her mouth. I saw smears of blood on the dressers as if she was trying to move it. We get here at 7:00 o'clock and overnight leave at 7:15 AM. I was the second one who saw her as the CNA who had saw her first called me to the room. Her name was [V10]. The overnight nurses were aware when we got here. I don't know the staff that worked the night shift as sometimes its agency staff.On July 31, 2026, at 11:19 AM, V10 (CNA), stated This week Tuesday (July 28, 2026), I was with [R1] 1:1 and when I took her to the bathroom, I saw that she had a bruise on the right side of her face on her cheekbone that was faded way. She also had bruises on top of the arms and some on her front waist and both her knees. When I went in on Wednesday (July 29, 2026) morning at around 7:45 AM to check in on her, they were trying to fix her furniture as it was barricaded around her bed. I don't remember who was there, but I think it was (V11 CNA) and there was a housekeeper. The housekeeper was gathering the trash and the linen, and the room was a complete mess. There was blood on the wall and I called V8 (CNA) to the room.On July 31, 2026, at 10:06 AM and 11:13 AM, V11 (CNA) stated I was not here the previous days as I was on suspension. I was not here on Tuesday (July 28, 2026) or when the incident happened. I know that something happened as there are so many different rumors. When I came back Wednesday (7/29/2026) they say that she fell and hit her head on the nightstand. It's all hearsay. I saw bad bruises on her [R1's] eyes and lips. There was some blood on the walls and some blood stains on the floor. I am not sure if they are from the fall. I cleaned up the room, as it was in a mess. It was told to me that she [R1] was barricaded in bed by those dressers. V11 pointed to three dressers in R1's room.On July 31, 2026, at 9:15 AM and 12:55 PM, V1 (Administrator) stated that she is currently doing an investigation related to a resident's dresser found next to the bed by another staff member (V3 Restorative Nurse) in the morning, and that was unusual. The resident is [R1]. I am going to find out why the dresser was there and if it was an involuntary seclusion. I already talked to the staff member who was a night shift CNA. Her name is (V5) and she works here regularly. It happened within the last two days. I am investigating it. I sent an initial to IDPH (Illinois Department of Public Health) yesterday. This resident is not alert and oriented, and we have her on a 1:1 (supervision). She should be on a Dementia unit. We have had her on 1:1 for quite some time as she tends to grab things. V1 added that she reached out to another CNA (V6), and could not get a hold of V17 (Agency RN/Registered nurse), as both worked the night shift of the incident.Initial Report V1 referred to with date of incident July 29, 2026, included allegation of abuse: staff found dresser positioned against bed, creating a potential environmental hazard. On July 31, 2026, at 10:27 AM and 2:53 PM, V3 (Restorative Nurse) stated There were more than one dresser lined up on the side of her [R1's] bed, and it was unusual. I don't know how many there were. (V18 LPN/Licensed Practical Nurse) called me and notified me. [R1] was in bed and she was awake and we immediately moved the furniture. There were other staff present, the nurse and a CNA. I don't recall who the CNA was. I don't remember who else was in the room. I asked [R1] if she was okay and I looked at her skin and she was fine and no new injuries were noted. She had had some bruises from a previous fall and there was nothing new. She had her lip split from the inside that was from that fall. I had seen that. I did not see any blood anywhere. I did see some blood at the tip of her finger and the staff told me that she was picking at her nose. When I asked her, she did not say anything. Then I immediately spoke with (V1) and immediately started an investigation, and it was ongoing. We don't know who did it. When asked if the resident could have moved the furniture herself, V4 responded Probably not. V3 also stated that she did not make a written assessment of the resident after the incident and entered a late entry on July 31, 2026. On July 31, 2026, at 3:06 PM, V18 LPN (Licensed Practical Nurse) stated On Wednesday (July 29, 2026) I saw her [R1's] roommate (R5) in the hallway smelling of urine and I heard her [R1's] normal hollering through the doorway. It was before 7:00 AM as I always get to the building around 6:45 AM. As I walked into the room, I saw the dresser at the side of (R1's) bed blocking her in bed. I don't remember how many dressers there were as it was dark. She was upset and wanted to get out of her bed and was reaching out to me. She was all marked up and had bruises all over her face. She is 1:1 (supervision) and in her room most of the time, so I don't recall what her bruises from her fall were. I went immediately to the overnight nurse on duty (V17) and told her that it was a form of restraint and that you cannot put the dresser like that. She said she did not know anything about the situation and that she was from agency. I reported it to (V3) who came into the room to see it. It was a horrible situation.On July 31, 2026, at 1:27 PM, and at 1:37 PM, V5 (CNA) stated I worked on Tuesday 11PM-7AM (July 28, 2026 -July 29, 2026) shift. I wasn't her CNA but her 1:1 sitter. I was sitting in her room at the start of the 11PM to 7AM shift and in-between times. I stepped outside at times as her roommate was agitated. It is a behavior thing, so I did not want to frustrate her. I left at 6:30 AM, but before I left, I turned her care over to her CNA (V6) that worked 11-7. There was no furniture out of place when I left her. The dressers were in the usual position as they should be in the room. Her nurse was an agency nurse. She [R1] had a few bruises, her nose was bleeding, and she was picking at her nose, and she had a bruise under her eyes. They told me that she had had a fall the previous day or before that. I don't remember any bruises on her lips. I just remember her picking her nose and it was bleeding and I let the nurse know and she came in and did her assessment.On July 31, 2026, 2:38 AM, V6 (CNA) stated that she does not recall R1 having any bruises. V6 stated I worked from 11PM-7PM (July 28, 2026 -July 29, 2026). I was her (R1's) CNA. Her nose was bleeding and the nurse was aware of it. I don't recall any bruises to her lips. Some of the bleeding had gotten on to the pillowcase and I changed the pillowcase. She was picking at her nose. (V5) CNA was 1:1 with her and sat in room. I wasn't paying attention if she (V5) was in the room all the time. I left around 7:00 AM. When I last went into her room (did not recall when), the dresser was not against her bed as the facility had already called me about that. It was where it usually was. I don't know if the nurse went in there after I left.R1's nurse V17 (Registered Nurse) from Agency that worked July 28, 2026, to July 29, 2026, overnight 7PM-11AM shift did not respond to multiple calls. On August 1, 2026, at 11:21 AM, V20 (Physician) stated that he has never given an order for putting furniture around R1's bed and he has never heard about such a concept. V20 stated that it would restrict her movements if she was boxed in with the furniture. V20 stated that his nurse practitioner also takes calls on his behalf and he was not aware of this situation. R1's EMR showed late entry nurses progress notes dated July 31, 2026, for above incident of July 29, 2026, and included: Writer was called to [R1's] room at approximately 0700 (7 AM) by charge nurse. Writer noted a safety concern while [R1] was lying in the bed. Furniture is noted next to [R1's] bed. Writer immediately instructed staff to move the furniture. Writer assessed [R1]. Writer asked [R1] if she was ok (okay) and [R1] stated, Yes, I am ok. Skin assessment completed. No new injuries or bruising noted, no redness or swelling noted. R1 asked if she knew why furniture was beside her bed and resident stated, No I don't know why. Writer noted blood to [R1's] left pointer finger. Writer asked charge nurse if she was aware resident had blood on her finger and charge nurse stated [R1] had been picking her nose and had nosebleeds. No active bleeding noted at this time.Abuse care plan-initiated June 8, 2026, included that R1 is at risk for abuse and neglect related to currently in long term care facility with goal that R1 will have no episodes of abuse and neglect throughout next review. Interventions included to assure resident that he/she is in a safe and secure environment with caring professionals.Facility policy titled Abuse Policy and Prevention program 2022 included:Abuse policy: 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.This will be done by: .Assuring that physical restraints are used sparingly and properly.The following definitions are based on federal and state laws, regulations and interpretive guidelines.Abuse: Abuse means any physical or mental injury or sexual assault inflicted on a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain mental anguish to a resident (42 CFR 482.5).Facility policy for Physical Restraints/Devise (last revised July 2025) included:General: To provide guidance on the assessment for the use and documentation of physical devices including, but not limited to, position change alarms, bed rails, furniture positioning.A physical restraint is any manual method, physical or mechanical devise/equipment or material that limits a residents freedom of movement and cannot be removed by the resident in the same manner as it was applied by the staff.2.If it is deemed that the physical device is a restraint;a) A physician order will be obtained.4. The facility will use the least restrictive physical device if one is deemed necessary.

Based on observations and interviews, the facility failed to maintain a sanitary environment in its outside dumpster area. This applies to all 184 residents (R1-R184) currently residing in the facility.The findings include:As of 9:30 AM on June 8, 2026, the facility's census showed 184 residents residing in the facility. On June 8, 2026, at 9:55 AM, the facility's dumpsters located behind the building were open. There was a large bag of trash on the ground behind the dumpster, and several wet boxes lay next to it. There were pieces of paper, plastic bags, and face masks scattered on the ground around the dumpster. V4 (Housekeeping Director) said the area around the dumpster did not look good. V4 said the dumpster lid should be closed at all times, and there shouldn't be any trash on the ground for infection control reason and also to keep unwanted pests and rodents out of the facility building.On June 8, 2026, at 10:10 AM, V5 (Housekeeping Floor Tech) said he always leaves the facility's outside dumpster lid open when he begins his shift at 6:30 AM, and the second shift closes after they arrive at 2:30 PM.On June 8, 2026, V8 (Assistant Dietary Manager) said he sometimes sees the facility's outside dumpster open when he takes out the trash. V8 said there are no concerns for pests, rodents, or droppings in the facility kitchen.On June 8, 2026, at 3:30 PM, V1, Assistant Administrator, said the facility's outside dumpster lid should be closed at all times. V1 said there shouldn't be any trash left on the ground around the dumpster. V1 said anyone who puts trash in the dumpster is responsible for closing it. V1 said if trash is left on the ground around the dumpster and the dumpster lid is left open, it attracts unwanted pests, rodents, and vermin in the facility.

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and comfortable environment by allowing food and trash debris to remain on floors and tables and permitted hallways throughout the facility to become cluttered with equipment and supplies.This failure applies to 2 of 6 residents (R1 and R4) reviewed for physical environment in the sample of 6.The findings include:On May 28, 2026, at 10:15 AM, Unit B hallway was cluttered with two medication carts, folding wheelchairs, mechanical lifts and an electric wheelchair on the left side of the hallway and housekeeping carts and vital sign machines on the right side of the hall. Several residents were moving around the equipment trying to get down the hallway. On May 28, 2026, at 10:50 AM, Unit F hallway contained housekeeping carts, high back wheelchairs, linen carts, and medication carts on each side of the hallway. The F wing dining hall had soiled towels underneath table legs, there was a medicine cup with a resident's name on it inside of a 7oz clear drinking cup sitting on top of a stained table. There were several used coffee cups, syrup containers, and butter packets lying on various tables. Used tissue paper was noted on tables and floors as well. Used juice cups and open milk containers were noted on several tables. Food particles were observed on and underneath dining tables. In the adjoining living room area, there were food crumbs all over the floor and a used blanket was on the floor next to a chair. On May 28, 2026, at 11:00 AM, Unit E had several items on each side of the hallways making it hard for residents and staff members to navigate the halls. The items included high back wheelchairs, medication carts, housekeeping carts, folding wheelchairs, mechanical lifts, sit-to-stands, linen carts, and dining room chairs. On May 28, 2026, at 11:08 AM, the D wing dining hall was left unkempt. There were gloves scattered on a table on the left-hand side of the of the dining room. There was a breakfast tray sitting on top of the warming station with an open milk carton, coffee cup, and cereal bowl. A clear glass and soiled white washcloth was left under the paper towel dispenser. There was brown water left sitting in the warming bin. There were used tissue papers on the floor and open milk cartons left on top of several tables. At 3:38 PM, the D wing dining area had meal trays sitting on side table with two juice pitchers from lunch. There were food crumbs noted under several tables from the dessert option from lunch. On May 29, 2026, at 9:55 AM, activities aids were performing nail spa day for several residents in the F wing dining room, on several tables behind the activity there were used coffee mugs, used napkins, opened milk containers, cereal bowls, and used drinking cups from breakfast.The facility's dining schedule showed dining times for the first floor (Units A-C) breakfast 7:45 AM to 8:30 AM, lunch 12:00 PM to 12:45 PM, dinner 5:45 PM to 6:30 PM. The second-floor schedule (Units D-F) showed breakfast from 8:00 AM to 8:45 AM, lunch 11:45 AM to 12:30 PM, and dinner 5:30 PM to 6:15 PM.R1's face sheet showed R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including osteoarthritis, diabetes, dementia, major depressive disorder, epilepsy, obesity, anxiety and hypertension. R1's minimal data set (MDS) dated [DATE] showed R1 is cognitively intact and utilizes a walker for mobility. R1 requires supervision and moderate assistance to complete activities of daily living (ADLs). On May 29, 2026, at 1:03 PM, R1 was exiting the dining hall on the F wing. R1 said that the residents sometimes receive dirty dishes and silverware during mealtimes, and you can often see rings in the coffee when it is poured. R1 said that she has informed several staff members that the tables and chairs are wobbly and unsafe for the residents to sit in. R1 said that dinner trays are often left on the table and when residents come into the dining hall for breakfast in the morning, the dinner trays are still sitting on the tables and chairs. R1 said that she does feel that the halls can be hard to get through sometimes with everything in them. R4's face sheet showed R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including chronic respiratory failure, asthma, anxiety, obesity, depression, dependence on enabling machines, carpal tunnel syndrome, cardiomegaly, lymphedema, and osteoarthritis.R4's MDS dated [DATE], showed R4 is cognitively intact and utilizes a wheelchair for mobility. R4 requires supervision to complete ADLs. On May 29, 2026, at 10:28 AM, R4 was sitting in a wheelchair in his room. R4' s floor had shredded paper, dark brown spots, food crumbs, and plastic utensils all over the floor. R4 said that housekeeping was supposed to clean his room the day before, but they did not come. R4 said that he tries to clean up his own room because it does not get done as often as scheduled. R4 said that things are worse when V1 (Administrator) is not in the building. R4 said that when V1 is off nothing of importance gets done. R4 said the hallways can get quite cluttered at times with the equipment and especially when residents start to come down for smoke breaks. On May 29. 2026, at 1:19 PM, V3 (RN) said that after meals, the CNA's are supposed to pick up the meal trays and put them on the cart to be returned to the kitchen area. Housekeeping is supposed to then wipe down the tables and clean the floors. On May 29, 2026, at 1:40 PM, V10 (Dietary Aide) said that housekeeping is supposed to clean off the tables and clean the floors, but they don't do it. On May 29, 2026, at 3:35 PM, V11 (CNA) said that empty trays are put on the cart to be returned to the kitchen right after meals. V11 said that housekeeping is supposed to clean off the tables once everyone has completed their meals. V11 said that the hallways are often congested with equipment and that all equipment is supposed to be placed on the right hand side of the wall. On May 29, 2026, at 3:45 PM, V12 (CNA) said that after meals the CNA's are supposed to pick up meal trays and then housekeeping is supposed to wipe down the tables and clean the floors. V12 said all equipment is supposed to be on the right-hand side of the walls and that halls can get very crowded and congested at times. On May 29, 2026, at 1:15PM, V4 (Housekeeping Director) said that CNAs are responsible for picking up trays and dietary is responsible for cleaning tables after lunch. V4 said the dining room is cleaned immediately after meals and activities. V4 said housekeeping is responsible for cleaning the floors. On May 29, 2026, at 3:50 PM, V2 (Director of Nursing) said that dietary is supposed to clean the tables after CNA's remove trays. V2 said that housekeeping should then come in to clean the floors. V2 said that if equipment is being utilized it should be placed on one side of the hallway and wheelchairs should be folded up and placed in rooms. On May 29,2026, at 4:09 PM, V1 said that CNAs are supposed to pick up meal trays when residents are done eating and dietary is responsible for cleaning the tables in the dining halls. Housekeeping then cleans the floors and chairs. This should be done immediately following dining services. The facility's policy Cleaning Instructions: Dining Room Tables & Chairs showed Dining room tables and chairs will be cleaned as needed and according to the cleaning schedule.

Based on observations, interviews, and record review, the facility failed to ensure that the food preferences and individualized food choices of Indian residents were met, resulting in decreased nutritional intake and unplanned weight loss.This applies to 2 of 5 (R2 and R3) residents reviewed for food preferences in a sample of 5.1.R2's medical record showed that R2 was a [AGE] year-old with diagnoses including diabetes mellitus type 2, long-term use of insulin, heart disease, hemolytic anemia, and thrombocytopenia (Low platelet counts).The Minimum Data Set (MDS) quarterly assessment dated [DATE] showed R2's cognition was moderately intact and required supervision for touch-assisted activities of daily living. A review of the physician's order dated 04/10/2026 showed that R2 has a regular diet with a regular texture and consistency, prefers Indian food, and takes Glucerna twice daily. R2's dietary care plan showed to follow the physician's diet order and that R2 was well nourished in the current diet regimen.The facility did not have a menu for Indian cultural food; however, the lunch menu for a vegetarian diet (not cultural Indian diet) on 05/15/2026 showed Cheese Quesadilla (1 Each), Buttered Noodles, Normandy Blend Vegetables, Dinner Roll, Margarine, Chocolate Brownie, and Beverage of Choice.On 05/15/2026 at 12:30 PM, R2 was served a lunch tray with rice, a piece of plain bread, Normandy blend vegetables, chocolate brownies, lentil soup, and approximately 1.5 ounces of yogurt, which was different from what was listed on the weekly menu. At 1:00 PM, R2's food remained untouched and she was upset. R2 said that this happens every single day and she doesn't feel like eating it. On 05/15/2026 at 1:10 PM, V6 (Assistant Manager of Dietary) was in the hallway and was asked to see R2's meal tray. V6 checked R2's tray and said it was the Indian meal they were offering, and V6 did not offer any alternative menu to R2. V7 (Registered Nurse) also checked R2's tray and had not provided the Glucerna ordered for R2. V8 (Certified Nursing Assistant) who was removing the tray, did not notify anyone that R2 did not eat the meal, and R2's food intake at lunch was recorded as 75-100 percent.On 05/15/2026, V2 (Director of Nursing) was asked to weigh R2, and her weight was 105.6 pounds. R2's recorded weight on 05/01/2026 was 111 pounds, indicating 4.87% weight loss over 2 weeks. On 02/05/2026, R2 weighed 122 pounds. The percentage of weight loss in three months was 13.93.2.R3's medical record showed that R3 was [AGE] years old with diagnoses including diabetes mellitus type 2, long-term use of insulin, heart disease, chronic kidney disease, and gastroesophageal reflux disease.A review of the physician-revised order dated 02/24/2025 showed that R3 has a regular texture and a liquid consistency, with a double portion with all meals. R3's dietary care plan, revised on 05/13/2026, showed that it followed the physician's diet order and offered food alternatives based on their food preferences.On 05/15/2026 at 12:35 PM, R3 was served with a lunch tray with grilled cheese, rice, and green vegetables. At 1:05 PM, R3's tray was untouched, and R3 said she gets grilled cheese every single day, even though she doesn't like it. R3 said that because of the food's taste, her family tries to bring her food, and that they don't even offer any alternative. R3 said looking at their meal tray causes her frustration.On 05/15/2026 at 1:10 PM, the writer approached V6 (Assistant Manager of Dietary), who was in the hallway, and expressed R3's concerns. V6 checked R3's tray, and R3 voiced the same concern. V6 argued with her, saying, You eat everything the facility serves and did not offer any alternative menu for R3 to choose from. R3's food intake was recorded as 75-100 percent of lunch.On 05/15/2026 at 1:30 PM, V8 (Certified Nursing Assistant) said that if residents refuse to eat, they notify the nurses, and she had not yet had a chance to notify the nurse.On 05/17/2026, at 9:40 AM, V7 (Registered Nurse) said that when staff who monitor residents during meals notify nurses if residents refuse to eat or do not like their food, they call the kitchen supervisor for an alternative menu. V7 said two CNAs were assigned to tray distribution and monitoring, and V7 learned that another CNA went on break while V8 was doing everything and did not notify her. On 05/15/2026 at 3:00 PM, V9 (Registered Dietitian) said residents should have preferred meals and alternative meals, with a focus on daily intake of 6 ounces of protein. On 05/15/2026 at 3:30 PM, V3 (Regional Director of Operations - Vendor) said the facility kitchen should have an option menu and that the facility should inform dietary. V3 added that V6 (Assistant Manager of Dietary) should have offered an alternate menu. The Always Available Facility's Menu dated 05/15/2026 showed Hamburger (3 Oz), Egg Salad Sandwich (1 each), Chef's Salad (1 each), Grilled American Cheese Sandwich (1 each), and Deli Sandwich (1 each), and did not have an option for Indian cultural Menu.On 05/17/2026, V4 (Regional Chef-Vendor) said they have the Indian chef, who does the shopping for Indian grocers and prepares meals for them, and the facility monitors it. V4 said there are discrepancies in the menu. V4 said he won't be able to reach out to the chef who cooks Indian meals during his off-time per a union contract, and the writer was unable to interview.Policy & Procedure on menu alternative dated 05/31/2021 showed Nutritionally comparable menu items shall be available to accommodate resident food preferences. Alternate menu items are planned during the menu-planning process for protein sources, grains, fruits, and vegetables. Alternate menu items may be included on the cycle menu and/or included with the always available items. A By Request or Always Available menu will be written and available in all resident service areas. Various dining service areas may have slightly different versions of the By Request menu designed to meet resident needsThe facility policy Meal Service, titled Resident Meal Tickets - Food Preferences, Dislikes, and Allergies revise dated 05/14/2026 showed the facility ensure residents receive meals that honor their individual food preferences in a consistent, efficient, and regulatory-compliant manner, while promoting dignity, choice, and safety. The policy further showed the Dietary Manager / Dining Manager is responsible for ensuring all preferences are correctly entered and updated and Nursing and Dietary staff must review meal tickets before service.

Based on observation, interview, and record review, the facility failed to ensure that significant medications were administered to residents as indicated by physician orders. This applies to 7 of 7 residents (R8, R9, R10, R11, R12, R13, and R14) who were reviewed for medication administration in a sample of 14.On 02/17/2026 at 3:20 PM, after R8, R9, and R13 complained about receiving their morning medication in the afternoon, this writer asked V18 (Licensed Practical Nurse)-what time she administered medication to residents. V18 said that she was late in administering medications since she came to the facility after 10:00 AM due to some scheduling confusion, and she did not give the scheduled medications until after 11:00 AM and completed around 2:45 PM. V18 said the medications should be given as ordered, within a one-hour window before and after the ordered time.1. On 02/17/2026, at approximately 3:00 PM, R9 said she did not receive any of his insulin, water pill, or inhaler for his breathing conditions. A review of R9's EMR (Electronic Medical Records) showed R8 has diagnoses of diabetes mellitus, asthma, heart disease, and cardiac myopathy. R9's MDS (Minimum Data Set) dated 11/15.2025 showed his cognition was intact.R9's physician's order dated 01/31/2026 showed R9 to receive Humalog Solution 100 UNIT/ML (Insulin Lispro (Human)) 34 units subcutaneously three times a day for diabetes mellitus, 20 units sliding scale with meals subcutaneously with each meal, Insulin Glargine Solution 100 UNIT/ML 70 units subcutaneously every 12 hours for diabetes, order dated 06/13/2025 showed Advair HFA Solution one inhalation two times a day for chronic obstructive pulmonary disease, and the order dated 12/17/2025 showed Furosemide Tablet 40 MG one tablet by mouth two times a day for edema. The Medication Administration Audit report dated 2/17/2026 showed that the 7:30 AM and 9:00 AM ordered scheduled insulin, the 7:30 AM and 11:30 AM ordered sliding scale insulin, and the Advair HFA Solution and furosemide ordered at 9:00 AM, which were administered between 2:36 PM and 2:47 PM.2. On 02/17/2026 at approximately 3:40 PM, R10 was confused and not interviewable. R10's EMR showed R3 had diagnoses of aortic valve insufficiency, hypertensive diseases, bursitis of the left shoulder, facial cellulitis, and anxiety disorder. Physician orders dated 11/02/206 showed Gabapentin Oral Tablet 100 MG twice daily; 12/01/2025, Xanax Oral Tablet 0.25 MG twice daily; 12/07/2025, Amoxicillin-Pot Clavulanate Tablet 875-125 MG twice daily.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered between 12:37 PM and 1:07 PM.3. On 02/17/2026, at approximately 2:30 PM, R11 said she did not receive her morning medication until the afternoon. A review of R11's EMR showed R8 had diagnoses of hallucinations, anxiety, dementia, and MDS dated [DATE], showing R11's cognition was moderately intact. R11's physician's order dated 09/22/2025 showed Haloperidol Oral Tablet 0.5 MG three times a day, Divalproex Sodium Tablet Delayed Release 250 MG three times a day, and Memantine HCl Oral Tablet 10 MG two times a day.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered between 11:07 AM and 11:09 AM.4. On 02/18/2026, at approximately 10:00 AM, V26(Licensed Practical Nurse) said R12 was sent to the hospital from the dialysis unit for vomiting and was not available to interview. A review of R12's EMR showed R12 has diagnoses chronic pulmonary disease, end stage renal failure with dependence on dialysis, venous thrombosis and embolism.R12's physician's order dated 11/25/2025 showed Carvedilol 12.5 milligram; the 08/26/2025 order for Advair inhaler 12 hours; and Apixaban 2.5 tablet every 12 hours.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered at 2:57 PM. 5. On 02/17/2026, at approximately 3:10 PM, R13 said she did not get her 9:00 AM medication until 1:30 PM. A review of R12's EMR showed R12 had diagnoses of seizures, atrial fibrillation, hypotension, and chronic pain, and MDS dated 01/2026 showed R12's cognition was intact. R13's physician's order dated 09/21/2025 Apixaban 2.5 milligram every 12 hours for atrial fibrillation, Levetiracetam for seizure 750 by mouth twice a day, dated 11/18/2026, and Lyrica 25 milligram two times a day for pain.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered between 1:13 PM and 1:25 PM.6. On 02/17/2026, at approximately 3:55 PM, R14 said she did not get her 9:00 AM medication until 3:00 PM. A review of R14's EMR showed R14 had been diagnosed with heart failure, fibromyalgia, pulmonary embolism, anxiety disorder, and MDS dated [DATE], which showed R14's cognition was intact. R14's physician's order dated 02/11/2026 showed alprazolam 1 milligram two times a day, gabapentin 300 milligrams three times a day; order dated 10/07/2025: Losartan 50 milligrams for hypertensive heart disease with heart failure. Apixaban 5 mg, 2 times a day.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered between 3:03 PM and 3:37 PM.7. On 02/17/2026, at approximately 3:10 PM, R8 said she received her medication late. A review of R8's EMR showed diagnoses of chronic kidney disease and chronic obstructive pulmonary disease. R8's physician's order dated 05/04/2024 showed Fluticasone Propionate HFA Aerosol 110 MCG/ACT every 12 hours, and the order dated 02/18/2026 showed Fluticasone Propionate HFA Aerosol 110 MCG/ACT two times a day.The Medication Administration Audit report dated 2/17/2026 showed that R8's medications were ordered for 9:00 AM and administered at 1:45 PM.On 02/18/2026 at 10:31 PM, V2 (Director of Nursing) said the incident was very disappointing and that she was not aware until late in the afternoon that the medications were not administered on time. V2 said the nurses should follow the physician's orders and administer medications one hour before or after the scheduled time.On 02/18/2026 at 2:20 PM, V1(Administrator) said that administering medication too late was unacceptable, and it should not have happened. V1 further stated that it was disappointing and that the nurses should administer medication within a one-hour window before and after, per the physician's order.The facility policy Medication Administration, with a revised date of 11/2025, states, in part, that medication is to be administered at the proper time as ordered.

Based on observation, interview, and record review the facility failed to ensure the safety of a resident during a shower for 1 of 3 residents (R3) reviewed for accidents in the sample of 13. This failure resulted in R3 experiencing a fall from the shower chair and sustaining an acute comminuted and displaced distal femur fracture with large lipohemarthrosis (collection of fat and blood) and a subacute fracture proximal fibular diaphysis. R3 was admitted to the acute care hospital on [DATE] for surgical intervention and remained hospitalized until 12/4/25. The findings include:R3's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include multiple sclerosis, stiffness of right ankle, stiffness of left ankle, muscle wasting and atrophy, abnormalities of gait and mobility, weakness, major depressive disorder, iron deficiency anemia, paraplegia, peripheral vascular disease, and neuromuscular dysfunction of bladder. R3's facility assessment dated [DATE] showed she has no cognitive impairments and is dependent upon staff for most cares.On 1/24/26 at 11:02 AM, R3 was in her room sitting up in her electric powered wheelchair. R3 said, I fell the day after Thanksgiving. There were 2 people were in the room with me, neither one was paying attention and I slipped and broke my knee. They were putting lotion on my back, and I wasn't in the chair properly. I have MS (Multiple Sclerosis) so I am fully dependent for everything. I was in the shower chair but was completely done with my shower. The way I was positioned, I was leaning forward, I wasn't sitting up like I am now. They had me leaning further forward so they could lotion my back. [V21 CNA] said that I was slipping, and I had told them right from the start of the shower I wasn't sitting in it right. They either didn't hear me or they ignored me. I went down hard enough that I broke my leg. I have MS and it was my weaker leg, so I don't feel pain the same as I do in my other leg. The knee was swollen when they originally wanted to do the Xray. They came to do the Xray at around 11 PM. It still wasn't terribly painful at that time, but it was 3 times the size it usually is. They told me the next day that the Xray showed a fracture. Pain was at about a 5-6 so it wasn't that severe. I think my pain tolerance is high. They did a scan at the hospital, and we found out it was worse. R3 reported V21 CNA (Certified Nursing Assistant) and V7 CNA were performing her shower that day.R3's Care Plan initiated 6/11/2013 showed, [R3] is at risk for falls related to generalized weakness and immobility secondary to MS, paraplegia, PVD (peripheral vascular disease), obesity, and osteoarthritis. Interventions: . 11/28/25 Staff to ensure patient is sitting centered and assist with leaning forward. Education provided on patient to ensure to ask for assistance when unable to reach personal items. 11/28/25 Xray of right knee, right hip, right shoulder; 12/1/25 Send to ER for evaluation; 12/4/26 WBAT (weight bearing as tolerated) unlimited hip and knee motion. All above updates were documented as created on 1/24/26 while the surveyor was in the facility investigating R3's fall.R3's 11/28/25 Nurses Note entered at 11:59 AM showed, At 11:20 AM writer called to shower room by CNA (Certified Nursing Assistant). Resident observed laying on the ground in supine position with shower chair to the left of resident. Resident states, I started to slide out of the shower chair and the CNA, assisted me to the ground; then to lay down. Head to toe assessment completed, skin intact, no redness, bumps or bruising observed. Resident able to move all extremities. Resident states right knee feels sore, rating pain 3 out of 10, Physician notified, new order for x-ray to left knee/complete, 4 views. Order noted and carried out.R3's Follow up Investigation Report (Final Report) into R3's 11/28/25 Incident dated 12/5/25 showed, . after a thorough investigation, it was determined that the fall was an unavoidable incident. Patient was noted leaning forward to dry herself when she was observed sliding down from shower chair, the staff has attempted to catch her fall and lowered down patient slowly on the floor. The patient was educated on safety precaution focusing on following cues for safety such as looking at visual reminder to call staff for assistance, ensuring proper placement in shower chairs or chairs, and ensuring staff assist in hard-to-reach places. On 1/24/26 at 3:03 PM, V21 CNA (Certified Nursing Assistant) said, I was just assisting with the shower. I went in when she went into the shower. V7 (CNA) washed her up. At the time of the fall, she was putting her bra on for her. When she was leaning forward to snap the bra in the back, and she just slipped right on out of the chair. She wasn't saying anything that I heard during the shower. We went and got the nurse. The nurse asked her if she was hurting anywhere, and she complained of her right leg.On 1/26/25 at 4:41 PM, V7 (CNA) said she provided a statement to the facility regarding R3's fall from the shower chair and refused to provide any information to the facility. V7 said she is no longer employed at the facility. R3's 11/28/25 Fall Follow Up Note entered at 12:06 PM showed, Does the resident/care giver report change in pain status? Yes. Has there been a change in orders related to this event? X-ray to right knee/complete, 4 viewsR3's 11/28/25 Nurses Note entered at 8:58 PM showed, resident alert and orientated times three, able to make needs known. Resident began to complain of soreness to right upper extremity. Writer notified physician with new order to Xray right humorous and right shoulder. Order noted and carried out. Writer called [mobile Xray company] and updated on new order. Writer informed the technician will be in the building before midnight to x-ray resident's right knee, right shoulder and right humorous. Resident able to move all extremities and tolerated sit to stand transfer from wheelchair to bed. Skin intact, no redness, bumps or bruising noted. Writer endorsed to oncoming shift accordingly. R3's 11/28/25 Nurses Note entered at 10:53 PM showed, Technician arrived from [mobile xray company], x-ray of right shoulder, right humorous and right knee being performed. Results pending. Writer endorsed to oncoming shift to follow up on results. R3's 11/29/25 Nurses Note entered at 6:53 AM showed, Resident x-ray result reviewed and resident noted with right knee impacted supra condylar fracture of the distal femur. Relayed to [V2-DON (Director of Nursing)] per DON she will have to compare the current diagnosis with the existing one. Endorsed to AM (morning) nurse.R3's 11/30/25 Nurses Note entered at 9:07 PM showed, Writer observed swelling to right knee. Ice and heat alternated to site, PRN (as needed) Tylenol given and effective. BLE (bilateral lower extremity) positioned onto pillow for comfort. No changes in condition apparent. Resident reports increased pain to right knee when manipulated.R3's 12/1/25 Change of Condition report entered at 1:26 PM by V2 DON (Director of Nursing) showed, . Noted with Xray result of fracture of right femoral head. Primary Care Provider responded with the following feedback: . Send to ER for ortho follow up and plan of care. Immobilization R3's 12/1/25 Nurses Note entered at 2:15 PM showed, Director of Nursing obtained order from [Physician] to send resident to [acute care hospital emergency department] for further evaluation related to right knee impacted supra condylar fracture. ambulance arrived at 2PM and exited until with resident via stretcher at 2:16 PM.R3's Acute Care Hospital Documentation dated 12/1/25 at 2:43 PM showed, Patient arrived to Emergency Department via EMS (emergency medical services) from [the facility] with complaint of right knee injury. Patient had a slip and a fall in the shower on Friday last week. Patient was in shower chair and slipped off landed on right knee. Xray done at facility per patient and EMS showed right knee fracture. Alert and oriented x 4. a [AGE] year-old female with multiple sclerosis - mostly wheelchair bound, who presented with distal femur fracture. Right distal femur fracture; Subacute proximal fibular diaphysis fracture - after falling off the shower chair, ortho consult, anticipate surgery later today. pain control: Norco (opioid pain medication), Tylenol, morphine prn (as needed). R3's 12/4/25 Nurses Note entered at 2:00 PM showed, Resident readmitted to facility from [acute care hospital] following treatment right femur fracture. The facility's Nursing and CNA schedule with assignments showed V3 CNA was assigned to R3 for the overnight shift from 11PM on 11/28/25 through 7:15 Am on 11/29/25. On 1/25/26 at 10:55 AM, V3 CNA (Certified Nursing Assistant) said, When I came in to work and was doing my rounds, when I got to her room, she told me she was in a lot of pain because she fell out of the shower chair and said she wasn't all the way in the chair. I asked her what she meant, and she said her butt was not all the way in the hole in the shower chair. She said she didn't think her bottom was all the way in the shower chair seat. she said that she said something to them about it twice but they didn't fix her. When I started to check and change her, I noticed her leg was very swollen. She said they took an Xray of her knee. It was very swollen. She told me they iced her knee earlier that day. I noticed that she usually has spasms in her right leg. It usually tenses, stiffens up and shakes, there were no spasms in her leg. I told her I noticed there weren't spasms and asked her if she was sure her leg wasn't broke. She said no, she has a knee fracture. I continued to change her. when I was done, I asked her if she wanted me to get the nurse to get her something for pain. She said tell the nurse I would like two Tylenol. the second night I had her. I noticed her leg was twice the size it was the day before. I asked her about pain medicine. She asked for a nurse again. I noticed that day that also her leg wasn't responding still with the twitches and spasms. She told me she was going to be going to the hospital in the morning and that they were going to look at it. I said, I hope when they get you up in the morning, they don't put you on the sit-to-stand lift because that is what she uses to get up. I told her I'm afraid if they put you on the sit to stand with your leg broken, it can damage something more. I felt like it was more than a knee fracture. I felt like her getting up in that stand was going to provide too much pressure to that leg. Monday night (12/1/25) I found out that she was in the hospital, she went to surgery and her femur bone was fractured or broken. She went from Friday to Monday without knowing what the cause was of the swelling and pain.On 1/27/26 at 4:40 PM, V2 DON (Director of Nursing) said, I was notified her fall on Friday. Usually I ask what happened, how the fall happened. It happened in the shower room, they said she was leaning forward and slid out of her shower chair. I asked if she complained of pain and she said not at first but then she did after that. She told me she talked to the doctor, and I told her to let me know what happens after that. she had Xrays. It said there was a fracture.The facility's policy and procedure with review date of 9/2025 showed, Fall Prevention and Management. General: 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 resident 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 to ensure a physician was notified with Xray results for a resident with a confirmed fracture and failed to ensure prompt emergency care was provided for a resident with a confirmed fracture. This applies to 1 of 3 residents (R3) reviewed for change of condition in the sample of 13. This failure resulted in R3 experiencing a delay in emergency and surgical care after sustaining an acute comminuted and displaced distal femur fracture with large lipohemarthrosis (collection of fat and blood) and a subacute fracture of the proximal fibular diaphysis. The findings include:R3's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include multiple sclerosis, stiffness of right ankle, stiffness of left ankle, muscle wasting and atrophy, abnormalities of gait and mobility, weakness, major depressive disorder, iron deficiency anemia, paraplegia, peripheral vascular disease, and neuromuscular dysfunction of bladder. R3's facility assessment dated [DATE] showed she has no cognitive impairments and is dependent upon staff for most cares.On 1/24/26 at 11:02 AM, R3 was in her room sitting up in her electric powered wheelchair. R3 said, I fell the day after Thanksgiving. There were 2 people in the room with me, neither one was paying attention and I slipped and broke my knee. They were putting lotion on my back, and I wasn't in the chair properly. I have MS (Multiple Sclerosis), so I am fully dependent for everything. I was in the shower chair but was completely done with my shower. The way I was positioned, I was leaning forward, I wasn't sitting up like I am now. They had me leaning further forward so they could lotion my back. [V21 CNA (Certified Nursing Assistant)] said I was slipping, and I had told them right from the start of the shower I wasn't sitting in it right. They either didn't hear me or they ignored me. I went down hard enough that I broke my leg. I have MS and it was my weaker leg, so I don't feel pain the same as I do in my other leg. The knee was swollen when they originally wanted to do the Xray. They came to do the Xray at 11 PM. It still wasn't terribly painful at that time, but it was 3 times the size it usually is. The Xray showed my knee was fractured. They told me the next day that the Xray showed a fracture. I went to [the acute care hospital] . The day it happened they got me back up into my chair and I thought it was fine until that evening it really started to hurt. They gave me Tylenol. Pain was at about a 5-6 so it wasn't that severe. I think my pain tolerance is high. They did a scan at the hospital, and we found out it was worse.R3's 11/28/25 Nurses Note entered at 11:59 AM showed, At 11:20 AM writer called to shower room by CNA (Certified Nursing Assistant). Resident observed laying on the ground in supine position with shower chair to the left of resident. Resident states, I started to slide out of the shower chair and the CNA, assisted me to the ground; then to lay down. Head to toe assessment completed, skin intact, no redness, bumps or bruising observed. Resident able to move all extremities. Resident states right knee feels sore, rating pain 3 out of 10, Physician notified, new order for x-ray to left knee/complete, 4 views. Order noted and carried out, writer called order into [mobile Xray company] and faxed all appropriate paperwork. R3's 11/28/25 Fall Follow Up Note entered at 12:06 PM showed, Does the resident/care giver report change in pain status? Yes. Has there been a change in orders related to this event? X-ray to right knee/complete, 4 viewsR3's 11/28/25 Nurses Note entered at 8:58 PM showed, . Writer called [mobile Xray company] and updated on new order. Writer informed the technician will be in the building before midnight to x-ray resident's right knee, right shoulder and right humorous. Resident able to move all extremities and tolerated sit to stand transfer from wheelchair to bed. Skin intact, no redness, bumps or bruising noted. Writer endorsed to oncoming shift accordingly. R3's 11/28/25 Nurses Note entered at 10:53 PM showed, Technician arrived from [mobile Xray company], x-ray of right shoulder, right humorous and right knee being performed. Results pending. Writer endorsed to oncoming shift to follow up on results. R3's 11/29/25 Nurses Note entered at 6:53 AM by V18 showed, Resident x-ray result reviewed, and resident noted with right knee impacted supra condylar fracture of the distal femur. Relayed to [V2-DON (Director of Nursing)] per DON she will have to compare the current diagnosis with the existing one. Endorsed to AM (morning) nurse. R3's 11/30/25 Nurses Note entered at 9:07 PM by V23 LPN (Licensed Practical Nurse) showed, Writer observed swelling to right knee. Ice and heat alternated to site, PRN (as needed) Tylenol given and effective. BLE (bilateral lower extremity) positioned onto pillow for comfort. No changes in condition apparent. Resident reports increased pain to right knee when manipulated. R3's 12/1/25 Change of Condition report entered at 1:26 PM by V2 DON (Director of Nursing) showed, . Noted with Xray result of fracture of right femoral head. Primary Care Provider responded with the following feedback: Send to ER for ortho follow up and plan of care. Immobilization R3's 12/1/25 Nurses Note entered at 2:15 PM showed, Director of Nursing obtained order from [Physician] to send resident to [acute care hospital emergency department] for further evaluation related to right knee impacted supra condylar fracture. ambulance arrived at 2PM and exited with resident via stretcher at 2:16 PM.R3's complete medical record was reviewed and showed no evidence that R3's physician was notified of the Xray results until 12/1/25. R3's Acute Care Hospital Documentation dated 12/1/25 at 2:43 PM showed, Patient arrived to Emergency Department via EMS (emergency medical services) from [the facility] with complaint of right knee injury. Patient had a slip and a fall in the shower on Friday last week (11/28/25). Patient was in shower chair and slipped off landed on right knee. Xray done at facility per patient and EMS showed right knee fracture. Alert and oriented x 4. a [AGE] year-old female with multiple sclerosis - mostly wheelchair bound, who presented with distal femur fracture. Right distal femur fracture; Subacute proximal fibular diaphysis fracture - after falling off the shower chair, ortho consult, anticipate surgery later today. pain control: Norco (opioid pain medication), Tylenol, morphine prn (as needed) . On 1/25/26 at 3:23 PM, V18 LPN said she has taken care of R3 for a long time. V18 said R3 has MS and multiple other diagnoses. V18 said the night of 11/28 through 11/29, R3 didn't have much deviation from normal. V18 reviewed her 11/29/25 Nursing Note and said she was unsure of what the DON meant by comparing the current diagnosis with the existing one. V18 said she did not notify the physician of the fracture because she works nightshift, and the day nurse would relay the results to the physician. V18 said after a fall they do neuro checks and vitals for 72 hours and document them in the record. V18 said the nurses do a head-to-toe assessment at the time of a fall but not for the 72 hours follow up because on night shift residents don't like the lights turned on. V18 said she did not visualize R3's leg during her shift. V18 said R3 is verbal so if she had any pain after her fall, she could communicate that to the nursing staff. On 1/25/26 at 3:50 PM, V23 LPN (Licensed Practical Nurse) said, That weekend [R3] was in bed for the weekend. She didn't want to get out of bed, she was initially on a sit to stand. The X-rays happened before I was working. I monitored her and managed her pain throughout that weekend. When we get results back, we usually let the doctor know, not just the DON and a fracture you are also supposed report to the administrator as well. If there is a change of condition, we notify the physician so if we need new orders and to ensure resident safety. She was reporting pain to me during manipulation. When she was just sitting still, she was okay. I did see her knee because I documented swelling to the right knee. The facility's Nursing and CNA schedule with assignments showed V3 CNA was assigned to R3 for the overnight shift from 11PM on 11/28/25 through 7:15 AM on 11/29/25.On 1/25/26 at 10:55 AM, V3 CNA (Certified Nursing Assistant) said, When I came in to work and was doing my rounds, when I got to her room, she told me she was in a lot of pain because she fell out of the shower chair and said she wasn't all the way in the chair. I asked her what she meant, and she said her butt was not all the way in the hole in the shower chair. She said she didn't think her bottom was all the way in the shower chair seat. she said that she said something to them about it twice, but they didn't fix her. When I started to check and change her, I noticed her leg was very swollen. She said they took an Xray of her knee. It was very swollen. She told me they iced her knee earlier that day. I noticed that she usually has spasms in her right leg. It usually tenses, stiffens up and shakes, there were no spasms in her leg. I told her I noticed there weren't spasms and asked her if she was sure her leg wasn't broke. She said no, she has a knee fracture. I continued to change her. when I was done, I asked her if she wanted me to get the nurse to get her something for pain. She said tell the nurse I would like two Tylenol. the second night I had her, I noticed her leg was twice the size it was the day before. I asked her about pain medicine. She asked for a nurse again. I noticed that day that also her leg wasn't responding still with the twitches and spasms. She told me she was going to be going to the hospital in the morning and that they were going to look at it. I said, I hope when they get you up in the morning, they don't put you on the sit-to-stand lift because that is what she uses to get up. I told her I'm afraid if they put you on the sit-to-stand with your leg broken, it can damage something more. I felt like it was more than a knee fracture. I felt like her getting up in that stand was going to provide too much pressure to that leg. Monday night (12/1/25) I found out that she was in the hospital, she went to surgery and her femur bone was fractured or broken. She went from Friday to Monday without knowing what the cause was of the swelling and pain.The facility's Nursing and CNA schedule with assignments showed V15 CNA was assigned to R3 for the day shift from 7:00 AM to 3:15 PM on 11/29/25 (the day after her fall).On 1/27/26 at 8:45 AM, V15 said, On that day, [R3] was a little down that she fell, and she hurt her leg pretty bad, she was down about that. She seemed a little concerned about hurting her leg and if she would be able to go back the way she was. She was worried about what they were going to do about it but at this time she didn't know if she would need surgery or not. I saw her leg, it was swollen around the knee and looked like it really hurt. She told me it hurt to touch.On 1/27/26 at 4:40 PM, V2 DON (Director of Nursing) said, I was notified of her fall on Friday. Usually I ask what happened, how the fall happened. It happened in the shower room, they said she was leaning forward and slid out of her shower chair. I asked if she complained of pain, and she said not at first but then she did after that. She told me she talked to the doctor, and I told her to let me know what happens after that. she had Xray's. It said there was a fracture. I believe I spoke to [R3] on Monday because she didn't want to increase her pain medicine, but she wanted to know what the next plan for the fracture was, so I called [V20 (R3's Primary Care Physician)] and asked him what the plan was for the patient's leg. He asked what does she want to do? So, I asked [R3] if she wants to go to the hospital to see what the plan is for the leg. She said yes, so we got the order for her to go to emergency room. Talking to the doctor, the doctor wanted to know what she wanted to do because she wanted to go back to using the sit-to-stand. We had to be careful and use a Hoyer lift because of the fracture. Monday was the first time I spoke with [V20] about the fracture. I think the nurse's note that said Relayed to [V2-DON (Director of Nursing)] per DON she will have to compare the current diagnosis with the existing one. Endorsed to AM (morning) nurse was a misunderstanding because it is a reportable to Public Health that was what to compare. I would have expected her to notify the physician with the results of the Xray. My expectation is a standard head to toe assessment, neuro checks if needed, and pain assessments. If any change is noted on those assessments, they must let the doctor know . if a patient is not comfortable or not happy also, they should notify the doctor. They should notify the doctor for increased swelling and pain with manipulation that cannot be controlled. They are supposed to notify by phone, or they can use telehealth. I would expect them to document that they notified the physician in the resident's records. On 1/27/26 at 6:31 PM, V20 (R3's Primary Care Physician) said, I think the day of her admission to the hospital (12/1/25) the DON called me and told me the Xray was showing the fracture. She started having pain the day she had the fall. As soon as they called me and told me she had the fracture, I advised they send her to the hospital. I would absolutely expect to be notified of Xray results showing a fracture. I would have advised them to send her to the hospital on Friday.The facility's policy and procedure with review date of 09/2025 showed, Change in Resident Condition. 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 a change in condition. 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. Once the physician or nurse practitioner has been notified and a plan developed, the nursing r social service staff will alert the resident and family of the issue and any physician's orders. Communication with the resident and their responsible party well as the physician will be documented in the resident's medical record or other appropriate documents.The facility's policy and procedure with review date of 9/2025 showed, Fall Prevention and Management. General: 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 resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on observations, interview, and record review the facility failed to maintain an effective pest control program to support a sanitary environment and to enhance each residents' quality of life due to the continued presence of pests throughout the facility.The findings include:Review of Pest Control Sighting Log provided by V13 (Maintenance Director) indicated roach in room on 12/08/2025 and 12/23/2025 and mouse droppings were found in the kitchen on 12/23/2025.Review of pest control logs from October 2025 through January 2026 showed the following:Inspection report (#210445) dated 10/09/2025 documented, in addition to regular service, [V13] reports roach activity . and in kitchen dish room, 20-30 fruit flies were seen at time of service. Inspection report (#212938) dated 10/15/2025 documented, [V13] reports roach activity 2nd floor nurses' station .Inspection report (#210446) dated 10/24/2025 documented, 15 fruit flies in main kitchen area.Inspection report (#212222) dated 11/10/2025 documented, around 20 fruit flies were seen throughout the dish room area .Inspection report (#212223) dated 11/28/2025 documented, treated kitchen drains for fruit fly prevention. Fruit flies were present during time of service .Inspection report (#213979) dated 12/16/2025 documented, all visible fruit flies were eliminated during inspection, but cleaning is extremely crucial to completely eliminate his problem to remove any breeding material for their reproduction. Also, broken tiles and missing grout must be fixed to prevent stagnant water and food in between .On 01/24/2026 at 11:34 AM V6 (Certified Nursing Assistant) working on the second floor said yes there are roaches in the shower room up here. The E wing has terrible gnats and some of the rooms on D wing too, but I guess they said they fixed that today.On 01/24/2026 at 11:51 AM, R8 said, . gnats are always an issue. I have two gnat traps on that table over there. I would like to buy some groceries, and I like fresh fruit but I'm afraid to put any in here because the gnats are so bad. [V13 Maintenance Director] needs to come and put more liquid in those traps. The gnat traps are apple shaped and see through. There were several dead gnats observed in the bottom of both traps. On 01/24/2026 at 12:05 PM V22 (Certified Nursing Assistant) working on the second floor said there are roaches in the employee washroom, gnats in dining room and around the water container. I scrubbed out the water container this morning because there were gnats all over it.On 01/24/2026 at 12:11 PM V15 (Certified Nursing Assistant) working on the second floor said there are roaches in the shower rooms, all the time. They are bad and they are big. We all got our stuff in bags because we don't want to take any of these bugs home. Gnats are bad on the E wing.On 01/24/2026 at 1:00 PM, V13 (Maintenance Director) said we have a problem with gnats. We clean the area and when pest control comes in, they will spray. We did have issues with roaches that we reported to pest control. They came in and laid out traps and whenever a staff member reports seeing them, we go to the site but whenever we go, we don't see them. V13 added that roaches were reported at the nursing station, clean utility room and shower room on the second floor. On 01/24/2026 at 2:00 PM, surveyor observed 2 gnats flying around R5's room. R5 we get gnats sometimes. Last saw some a few days ago and informed the housekeeper. (R5's face sheet showed an admission date of 04/03/2024 and indicated resident resides on B wing.)On 01/24/2026 at 2:10 PM, V10 (Certified Nursing Assistant) escorted surveyor into the B wing shower room on the first floor. Surveyor observed approximately 30 gnats within the shower room that were either flying around the room, on the walls or on the shower curtains. V10 said Ewww, that's why I don't come in here because it's nasty. There's always some type of bug in here. V10 added that she takes her residents to the 100 unit spa shower room on their shower days. V10 also said when she was working on the second floor last week, she saw roaches at the nurse's station. On 01/24/2026 at 2:18 PM, R11 said she occasionally sees gnats flying in her room then said she will only shower in the spa shower room on the [100 unit] because the shower room on B wing is nasty and full of bugs. R11 added that she will refuse her shower if staff does not take her to the spa shower room. (R11's face sheet showed admission date of 02/27/2020 and indicated resident resides on B wing.)On 01/24/2026 at 2:30 PM, R10 also said she will only shower in the spa shower room on the [100 unit] because the shower room on B wing is nasty and full of bugs. R10 added that she will refuse her shower if staff does not take her to the spa shower room. (R10's face sheet showed admission date of 11/26/2023 and indicated resident resides on B wing.)On 01/24/2026 at 2:50 PM, surveyor entered B wing shower with V13 (Maintenance Director) and again observed approximately 30 gnats within the shower room that were either flying around the room, on the walls or on the shower curtains. V13 said he had no idea there were gnats in the room because no staff member informed him. He added that there should not be gnats in the shower room. V13 said he was in the shower room on Friday doing some repairs in the room and did not see any gnats present. V13 then said he believes the gnats are coming up from the drains so he will pour a chemical down the drains for a the next several days to help get rid of them. He said they previously used traps that were shaped like an apple but was told by management to discontinue use. At 3:01 PM, V13 said he will call pest control on Monday (01/26/2026) for an emergency visit to be done. On 01/24/2026 at 3:03 PM V21 (Certified Nursing Assistant) working on the second floor said he has not noticed any pests or bugs, then said I do know that staff seem to put their stuff in bags. I've heard about roaches, but I haven't seen them. I heard the E wing shower room on second floor has roaches.On 01/26/2026 at 12:24 PM, V24 (Scheduler) said the first floor consists of three wings: A, B, and C and wings D, E and F are on the second floor.Pest Control policy last reviewed 07/2025 provided by V13 (Maintenance Director) on 01/24/2026 reads in part: Facility shall maintain an effective pest control program. Responsible parties include maintenance and administrator. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Pest sightings will be reported to maintenance. Sightings are recorded in pest control log at reception desk. Maintenance services assist, when appropriate and necessary, in proving pest control services.

Based on interviews and record review, the facility failed to ensure that a resident who was dependent on staff for incontinence care received the necessary assistance in a timely manner. This failure affected two (R1, R2) of four residents reviewed for activities of daily living (ADLs) in the sample of 13.The findings include:1. R1's face sheet documented an initial admission date of 09/20/2024 with a past medical history not limited to: generalized osteoarthritis, adult failure to thrive, chronic pain syndrome, and history of venous thrombosis and embolism. Minimum Data Set (MDS) Section C-Cognitive Functions dated 10/24/2025 indicated that R1 has no cognitive impairment. Section GG-Functional Abilities documented that R1 is dependent on staff for toileting hygiene, lower body dressing, and rolling side to side in bed. Section H-Bowel and Bladder indicated that R1 is always incontinent for both.R1's care plan last reviewed on 10/29/2025 reads in part: has an ADL functional performance deficit related to weakness and requires mechanical lift transfer with two-person assist; is at risk for alteration in skin integrity related to osteoarthritis, hemorrhoids, and incontinence; and is incontinent of bowel and bladder and is at risk for complications.R1's care planned ADL/skin interventions included but not limited to: provide skin care after each incontinent episode, provide incontinence care as needed; assist resident with ADLs; monitor skin integrity during routine care and report abnormal findings.On 01/24/2026 at 11:04 AM, observed R1 sitting on the side of her bed. R1 said the aides change her incontinence brief before she goes to bed around 10:30 -11:00 PM and she does not see any staff until about 5:00 AM when the nurse brings her meds than again at around 6:00 AM when the aide comes in and changes her brief. R1 added that this occurs nightly including last night, and she is still wearing the same brief from this morning when she was changed around 6:00 AM. R1 added that her brief is soiled and needs to be changed. 2. R2's face sheet documented an initial admission date of 07/19/2019 with a past medical history not limited to: encounter for palliative care, obesity, osteoarthritis and hypertension. Minimum Data Set (MDS) Section CC dated 12/03/2025 indicated that R2 has no cognitive impairment. Section GG-Functional Abilities indicated that R2 is dependent on staff for toileting hygiene, lower body dressing, and rolling side to side in bed. Section H-Bowel and Bladder indicated that R2 is always incontinent for both.Care plan report last reviewed 12/09/2025 indicated that R2 has a self-care deficit in bed mobility and requires assist with daily care needs related to weakness and impaired mobility, is at risk of alteration in skin integrity related to weakness, osteoarthritis, and incontinence. R2's care plan interventions included but not limited to: provide skin care after each incontinent episode, keep clean and dry after each incontinent episode; assist resident with ADLs; monitor skin integrity during routine care and report abnormal findings.On 01/24/2026 at 1:48 PM, R2 was observed lying in bed watching television. R2 said she receives hospice services and is seen 2-3 times weekly. At 2:00 PM, R2 said her incontinence brief is normally changed before going to sleep around 10:00 - 10:30 PM and is not changed again until about 5:00 or 6:00 in the morning. R2 indicated this occurs every night and that her brief is currently soiled, and she is waiting to be changed. R2 added that her brief has not been changed since early this morning around 5:30 AM.On 01/24/2026 at 4:25 PM, V2 (Director of Nursing) said staff are to reposition and change incontinent briefs at minimum every two hours for every resident to prevent infection and skin breakdown. V2 added that the floor nurses supervise to ensure this is being done. Activities of Daily Living (ADL) policy last revised 06/2025 provided by V1 (Administrator) on 01/24/2026 reads in part: a program for performing and assisting with hygiene, bathing, dressing, feeding, and elimination to prevent disability and maintain maximal functioning. A program of assistance and instructions in ADL skills is care planned and implemented. Elimination.adaptive equipment, assistance and instruction are given as required.

Based on observation, interview, and record review the facility failed to ensure a dependent resident's bed was functioning to meet his needs for 1 of 13 residents (R7) reviewed for equipment in the sample of 13. The findings include:R7's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, Type 2 Diabetes, quadriplegia, protein-calorie malnutrition, polyneuropathy, fusion of spine, cerebral atherosclerosis, and cervical disc disorder with myelopathy. R7's facility assessment dated [DATE] showed he has no cognitive impairment and is dependent upon staff for most cares. R7's Care Plan initiated 10/14/24 showed, [R7] has a self-care deficit in bed mobility related to cerebral infarction, Type 2 Diabetes, Traumatic subdural hemorrhage. 2 person assist with bed mobility. uses bilateral 1/2 rails to promote bed mobility.R7's Care Plan initiated 10/14/24 showed, [R7] requires assist with daily care needs related to cerebral infarction d/t stenosis of right posterior cerebral artery, Type 2 Diabetes, Traumatic subdural hemorrhage. Monitor for changes with daily care abilities and provide more or less assist if needed. On 1/24/26 at 12:11 PM, V15 Certified Nursing Assistant (CNA) said, Most of the beds in here are broken in some way or another. [R7's] is always broke. He can't put the head of the bed up when he wants to eat. On 1/24/26 at 2:15 PM, R7 was lying in his bed with the head of the bed flat with the television on. R7 said, My bed hasn't been working for a long time. I told the staff. In the past they came and worked on it, and it would be working for a little while, then it stops working again. I usually like to be sitting up. I can sit up on my own, but it is hard. I would like to use the bed remote to bring the bed up so I can sit up at least to eat. It is hard to eat with the bed down, but I try to sit up. I had a stroke, so it is difficult to keep myself sitting upright. I always eat in my room. My bed hasn't been working for about a month and a half this time.On 1/24/26 at 2:30 PM, V13 (Maintenance Director) came into R7's room with the surveyor. V13 crawled on the floor underneath R7's bed and was looking at the wires. V13 said, I wasn't aware his bed isn't working. We don't have extra beds to replace the beds, but we have beds we can take parts off to repair beds if we need to. We have had trouble with this bed, a lot of times, it's because the cord is pulled out a little bit under the bed. Sometimes I change the ring that holds the cord in. This time the power cord was pulled out of the box again. It happens because they twist the cord around the bedrail. The clip is gone on this one to hold it in. Maintenance requests are either given to me verbally or put into the binder at the nurse's station. On 1/24/26 at 2:38 PM, the Maintenance binder at the nursing station was reviewed. The earliest entry in the binder on the unit was 1/11/26 and none of the entries were regarding [R7's] bed. The previous maintenance logs were requested for review and showed no maintenance requests were recorded on the 2nd floor from 11/18/25 through 1/11/26. On 1/27/26 at 4:40 PM, V2 DON (Director of Nursing) said, If staff noted the bed was broken, I would expect them to report it to maintenance and I would expect that to be fixed. He does have the ability to sit up himself though, he is highly schizophrenic. He can sit up on the side of his bed because we caught him doing that before. He has attempted to get up before on his own. He has a cervical spinal cord injury so he can't get up. It is important for his equipment to function. The Illinois Long-Term Care Ombudsman Program titled Residents Rights for People Living in Long-Term Care Facilities showed, . Your facility must provide services to keep your physical and mental health at your highest practical levels.

Based on observations, interviews and record reviews the facility failed to provide assistance to dependent residents with ADL (activities of daily living) activities.This applies to 4 of 4 (R1, R2, R3, R4) residents reviewed for ADLs. The findings include: 1. R1 was admitted on [DATE], with multiple diagnoses including hemiplegia, malnutrition, difficulty walking, multiple fractures of the pelvis, hypertension, dementia, and orthostatic hypotension. R1's MDS dated [DATE], shows R1 is cognitively intact and is dependent on staff for toileting hygiene, bathing and dressing. R1's most recent care plan dated December 17, 2025, shows R1 is high risk for falls and has an alteration in skin integrity due to a sacral pressure ulcer. R1 is continent of bowel and bladder requiring substantial maximal assistance with toileting transfers. R1 is a stand pivot transfer with one person assist, gait belt, and front wheeled walker.On January 03, 2025, at 12:50PM V9 (Family member) and V10 (Family member) said they were unhappy with the care provided by the facility and lack of communication from administrative staff. V10 said that they visit R1 frequently and during visits, CNA's have not come in to check on R1 unless the button has been pushed. V10 said that when the call light is pushed it takes between forty-five minutes to two hours for staff to show up. V10 said she is certain about time frames because she has taken notes during each visit. V9 said that care associates informed them that R1 is using briefs because he is incontinent when in fact R1 is not incontinent. R1 can verbalize when he must use the rest room and V9 and V10 have requested the use of a urinal. V10 said facility nurse agreed that R1 can request a urinal and ask for it when needed, however the care associates continue to place briefs on R1. V10 said that on December 26, 2025, she waited for the head nurse for two hours to discuss concerns, and the head nurse never showed up. V10 said again she waited to discuss concerns with administration on December 31,2025 for one hour and forty-five minutes and no one showed up. V10 said that she eventually heard from administration but by this time it was to discuss discharge planning. V10 said that R1 was to be discharged later in the evening. 2. R2 was admitted [DATE], with multiple diagnoses including obesity, epilepsy, peripheral vascular disease, insomnia, neuromuscular dysfunction of the bladder, major depressive disorder, borderline personality disorder, anxiety, paraplegia, hemiplegia, pressure ulcer of the right buttocks, and incontinence without sensory awareness. R2's MDS dated [DATE], shows R2 is cognitively intact and dependent on staff for ADL care. R2's current care plan dated December 30, 2025, shows R2 is a high fall risk and at a high risk for abuse and neglect. R2 has a pressure wound to the ischium and is incontinent of bowel and bladder. Staff are expected to provide incontinence care as needed and ensure privacy and dignity are always maintained.On January 03, 2026, at 11:13AM R2 was crying in her room while lying in bed. R2 said that on the 3PM to 11PM shift on January 02, 2026, she was not checked or changed by the CNA (Certified Nurse Assistant) until 11:00PM. R2 said she saw V5 (wound nurse) earlier in the day but needed to be cleaned up before wound care. R2 said she informed V3 (CNA) at 7:00AM that she needed to be changed before the wound care nurse came. R2 said that V3 said she would come back but had not yet returned in over two hours. R2 said that she gets worried because she already has a sore on her bottom, and she knows that sitting in urine for an extended amount of time can lead to more sores or worsening of the sore that she has. R2 said that she had not been checked or changed since 6:00AM when the overnight shift did their last room rounds. R2 said that on weekends she feels hopeless because there is never a manager on duty.On January 03, 2026, at 1:43PM V3 said she saw R2 at the beginning of her shift and she seemed fine. R2 informed V3 that she would need to be cleaned before the wound nurse came in. V3 informed R2 that she would need to obtain assistance to help with her care. V3 said that R2 continued to push her call button while V3 was in neighboring rooms assisting other residents. V3 went in to check and clean R2 with the assistance of V4 at 11:15AM.On January 03, 2026, at 2:35PM V5 confirmed that she saw R2 between 7:30AM and 8:00AM. During this time R2 said she was not ready for wound care at that time because she was waiting for her CNA. V5 completed wound care with R2 at 11:30AM after care had been provided by V3 and V4.On January 3, 2026, at 2:53PM, V2 said that R2 constantly complains about staff and refuses care even though there are staff members there to help her. V2 said R2 has her favorite CNA's and only wants certain staff members to help her, and this is a known behavior. V2 confirmed that staff are to perform rounds every two hours and more frequently as need.Progress notes for December 1, 2025, through January 03, 2026, did not show any reports of behaviors or refusal of care from staff members.3. R3 was admitted [DATE], with multiple diagnoses including osteoarthritis of the knee, mild persistent asthma, type II diabetes with neuropathy, severe protein malnutrition, hypotension, difficulty walking, weakness, back pain, CHF, Renal Disease, falls, alcohol abuse, major depressive disorder, sleep apnea and dementia. R3's MDS dated [DATE], shows R3 is cognitively intact. R3's current care plan dated December 17, 2025, identifies R3 at high risk for falls. R3 requires total assistance from for toileting due to bowel and bladder incontinence. On January 03, 2026, at 3:33pm V8 (Family Member) said that she comes to visit R3 often because of the lack of care provided by the facility. V8 said she has had to supply her own briefs and disposable wipes for R3. V8 said that when she came in to visit R3 she smelled of feces. V8 turned on the call button and it took over an hour before a CNA came into the room to answer the call light. V8 said that she sometimes comes to the facility up to three times daily to ensure that R3 has been fed and changed. V8 said that the weekends are worse because there is no managerial staff present on the weekends. V8 said that she had been in communication with the admission coordinator regarding lack of care and miscommunication in the facility. V8 said she came to insist that R3 be sent to emergency room due to increased confusion and lack of care from staff. A concern form regarding call light response and toileting was completed by V8 on December 22, 2025, and shows a resolution date of December 26, 2025. V8 says the concerns have not been resolved and has only gotten worse. 4. R7 was admitted on [DATE], with multiple diagnoses including idiopathic peripheral autonomic neuropathy, morbid obesity, chronic obstructive pulmonary disease, cardiomyopathies, congestive heart failure, chronic kidney disease, sleep apnea, atrial flutter, cardiac and vascular implant, and pulmonary embolism. A current MDS assessment was not provided for R7 and a current care plan dated December 31, 2025, does not contain a plan of care for ADL'sA Physician's note dated January 1, 2026, shows R7 has severe back pain due to severe spondylosis. R7 is most comfortable lying flat on his back and has decreased mobility and ADL function.A Nurses 's note dated January 1, 2026, 10:25PM shows R7 requires assistance of one staff member to complete ADLS. On January 03, 2025, at 1:23PM R7 said that during the overnight shift he had a large bowel movement and was not completely wiped clean by V11 (CNA). R7 said that he informed V11 that he still felt dirty and asked to be washed. R7 said V11 informed him that the overnight shift does not give showers or wash up residents. R7 said that V11 told him he would have to wait to be cleaned by the next shift and would inform V7 (RN). V6 said she was not made aware by V11 or V7 that R7 would need to be showered. On January 03, 2025, at 4:00PM V6 said that she was not made aware that R7 needed to be cleaned or showered and had not tended to him. Attempts were made to contact V11 without response.On January 03, 2026, at 1:43PM V3 and V4 said that residents are to be rounded on every two hours and as needed. On January 03, 2026, at 2:53PM V2 said she expects the staff to answer call lights as soon as possible. If the assigned CNA is busy, they are to ask another CNA or nurse to respond to the resident. V2 said that residents are to be changed throughout the shift and residents should be rounded on every two hours and sooner if needed. It is the expectation that if a resident is soiled it is to be addressed right away even on the overnight shift. If a resident requested or needed to be washed on the overnight shift it should have occurred. On January 3, 2026, at 5:18PM V1 said residents' concerns are to be addressed right away. V1 said that anyone can answer call lights and tend to residents. V1 said as soon as a call light goes off a staff member should enter the room and address the concern. CNAs are expected to check on residents at the start of shift and at a minimum of every two hours.

Based on observation, interview and record review, the facility failed to serve coffee per the facility planned/approved menu. This applies to 5 of 9 residents (R6, R10, R14, R16, R17) reviewed or coffee in a sample of 29. The findings include: On 12/6/25 at 12:42 PM, V10 (CNA - Certified Nursing Assistant), stated during meals the coffee cart initially is placed in the second floor dining room. V10 stated by the time the coffee is served to the dining room residents and the residents receive seconds, there is no more coffee for the residents served in the hallway. V10 stated the staff can call food service for coffee if the coffee runs out on the second floor and will receive it. On 12/6/25 at 9:01 AM, R6 stated the prior week there was no coffee served and the facility runs out of coffee often. On 12/6/25 at 9:14 AM, R10 stated it was hard to get coffee at the facility during meals. V10 stated there was not enough coffee at the facility. On 12/6/25 at 9:18 AM, R14 stated, Sometimes we get coffee, sometimes we don't. On 12/6/25 at 9:25 AM, R16 stated she often did not receive coffee or other beverages during her meals. On 12/6/25 at 9:35 AM, R17 had her breakfast meal served but had no coffee. R17 stated, I drink coffee but I didn't get any. It's missing all the time. They sit it outside and it probably runs out. On 12/6/25 during breakfast service on the second floor at 9:37 AM, V16 (Dietary Aide) stated toward the end of the week the facility runs out coffee and the staff go to the store to by coffee. On 12/6/25 at 10:09 AM, V1 (Administrator) stated the facility should not run out of food because she is able to provide her credit card for food purchases if needed. On 12/6/25 at 3:45 PM with V1 (Administrator), V27 (Dietary Aide) stated the facility has run out of coffee for the residents at times. Facility menus, dated 11/2/25 to 12/14/25, showed coffee was to be served at every breakfast meal daily.

Based on observation, interview, and record review, the facility failed to provide transfer, toileting and dressing assistance to residents who were dependent on staff for ADLs (Activities of Daily Living). This applies to 7 of 7 residents (R5, R6, R10, R11, R12, R18 and R29) reviewed for assistance with ADLs in a sample of 29. The findings include:1.Face sheet, printed 12/6/25, shows R11's diagnoses included dementia, legally blind, anxiety, mood disorder, depression, and diabetes. MDS (Minimum Data Set), dated 10/15/25, shows R11's cognition was intact, R11 was dependent on staff for toileting hygiene and lower body dressing, required substantial/maximal assistance for showering/bathing, upper body dressing, and personal hygiene, and required partial/moderate assistance for toilet transfers. Review of R11's care plan shows R11 required hand over hand assistance with food and beverages due to a self care deficit in feeding related to visual and cognitive impairments, required substantial/maximum assistance from staff for upper / lower body dressing and personal hygiene, was incontinent of both bowel and blader, required total assist from staff for toileting hygiene, and required a staff to assist R11 to stand and pivot to transfer. On 12/6/25 at 3:01 PM, R11 was sitting in the dining room in his wheelchair with a gown on which was soiled with dried food down the front of the gown. V22 (Family) was standing next to R11 and stated she often arrived to see R11 not dressed. R11 had a very strong smell of urine around him. V22 checked R11's incontinence brief and the brief was bulging and appeared full of urine. V22 stated the brief was soaked with urine and the urine had soaked through to his blanket on the seat of his wheelchair. V23 (LPN- Licensed Practical Nurse) and V9 (CNA - Certified Nursing Assistant) took R1 to his room and V9 left after stating she would be back to help change R11. V22 stood R11 up and R11's incontinence brief appeared to be very heavy and was sliding down R11's waist and legs. There was a very strong and pungent smell of urine in the room when R11 stood up from his wheelchair. V23 stated R11's incontinence brief was soaked with urine and some stool was present in the brief. V9 never returned to assist with R11's care. On 12/6/25 at 3:15 PM, V24 (Assistant Director of Nursing) examined R11's wheelchair and the blanket on R11's wheelchair seat was wet with urine. On 12/6/25 at 3:18 PM, V27 (CNA) stated she last checked / changed R11's incontinence brief between 9:00 AM and 10:00 AM that morning. V27 stated she had not checked / changed his brief since that time because she was busy the whole day. On 12/6/25 at 9:46 AM, V17 (Director of Nursing) stated if a CNA can not assist a resident as requested, another staff should respond. V17 stated nurses are able to assist residents to transfer out of bed. On 12/6/25 at 10:09 AM, V1 (Administrator) stated staff were not to turn off resident call lights if the resident's concerns were not addressed. Facility document Call Light Response, reviewed 9/2025, shows 6. Answer the patient or resident's call as soon as possible. 9. Do what the resident asks of you, if permitted. If you are uncertain as to whether or not a request can be fulfilled or you cannot fulfill the patient/resident's request, ask for assistance. 10. If assistance is needed when you enter the room, summon help to the room. 11. After meeting the patient/resident's needs, turn off the call light. Facility document Incontinence Cand Perineal Care, reviewed 9/2025, shows Perineal care is provided to clean the perineum, prevent infection and odors, and provide comfort. 1. Perineal care is done daily and prn (as needed) for all residents requiring assistance and/or those residents with a foley catheter. 2. Face sheet, dated 12/6/25, shows R5's diagnoses included paraplegia, schizoaffective disorder, conduct disorder, and psychosis. MDS, dated [DATE], shows R5's cognition was intact and R5 required partial/moderate assistance from staff for upper body dressing and was dependent on staff for transfers, toileting, bathing, and lower body dressing. R5's care plan shows R5 transferred utilizing a mechanical lift. On 12/6/25 at 8:10 AM, R5's call light was on, R5 was in bed, and R5 was talking on the phone stating her call light was on for hours and no one was coming to get her out of bed. V8 (LPN) was standing at her medication cart in the hall a few doors from R5's door and R5's call light was on above the door of her room. On 12/6/25 at 8:23 AM, V36 (Transportation) walked into R5's room, turned off R5's call light and walked out of the room. R5 was still lying in her bed. At 8:28 AM, V36 stated she went in to see what R5 needed and turned off the call light before looking for a CNA to tell her R5 wanted to get out of bed. On 12/6/25 at 8:23 AM, R5 stated she originally put her call light on at 5:55 AM because she wanted to get out of bed but the staff turned it off and did not get out of bed. R5 re-activated her call light. On 12/6/25 at 8:26 AM V8 (LPN) was standing at her med cart a few rooms from R5's room and R5's call light was on. On 12/6/25 at 8:32 AM, R5's call light was off and R5 was still in bed. V9 (CNA) walked into R5's room with V10 (CNA) and V9 stated she did not start her shift until 8:00 AM and did not see R5's call light on prior. V9 stated R5 was rude to V9 when she came in her room to ask about her care at approximately 8:00 AM. V10 stated she was assigned to monitor a resident 1:1 during her shift. On 12/6/25 at 8:43 AM, V11 stated R5 was care planned to only have female caregivers. V11 stated he and V12 (CNA) and V13 (CNA) wee the three CNAs who started the shift at 7:00 AM. On 12/6/25 at 8:50 AM, V8 was standing at her med cart in the hallway and stated she was aware R5 was not to have male caregivers. V8 stated she did not look up and see R5's call light and she was not sure which CNA was assigned to R5 from 7:00 AM to 8:00 AM. On 12/6/25 at 8:51 AM, V12 (CNA) stated he was not sure who was assigned to R5's group of residents between 7:00 AM and 8:00 AM. On 12/6/25 at 8:56 AM, R5 was transferred from her bed to her wheelchair. On 12/6/25 at 8:57 AM, R13 stated, People wonder why we have behavior problems. It's because we are waiting for help! On 12/6/25 at 2:10 PM, V5 stated she was frequently left in soiled briefs at the facility. V5 stated if she got changed at 1:30 Pm the next time she got changed would be before going to bed because when she returns to the floor to ask to be changed they have to find help, staff are on break, staff are busy, and no staff come. V5 stated she tells the nurse first and waits but no staff come. V5 stated she and staff have attempted to set a schedule, but the schedule was not followed. On 12/6/25 at 10:52 AM, V24 (Assistant Director of Nursing) stated R5 told her she needed help at approximately 8:10 AM. V24 stated V19 (LPN), V10 (CNA), and V13 (CNA) were all working on the unit and able to assist R5 to transfer out of bed. On 12/6/25 at 11:09 AM, V19 (LPN) stated she was not aware V9 (CNA) was late to arrive for her shift and was not aware the working CNAs needed to cover V9's residents until she arrived. V19 stated she was not ware R5 was requesting help. On 12/6/25 at 12:42 PM, V10 (CNA) stated she arrived at 7:40 AM for her 7:00 AM shift and was told she needed to work 1:1 with one resident. V10 stated she was not informed a CNA was late to their shift or that any residents required assistance until the CNA arrived. V10 stated the night prior R5 was requesting assistance and could not find her assigned CNA. V10 stated the staff could not find the assigned CNA and R5 was upset. On 12/6/25 at 9:29 AM, V13 (CNA) stated she was not aware of any additional residents assigned to her between 7:00 AM and 8:00 AM and was only aware of her original resident assignment. V13 stated she was not aware a CNA had not yet started her shift. On 12/6/25 at 11:47 PM, V15 (CNA) stated she was not aware any CNAs were arriving late to work on the floor and was not told to cover any rooms for late CNAs at the beginning of her shift. On 12/6/25 at 9:27 AM, V14 (CNA) stated she was not aware who was assigned to R5 between 7:00 AM and 8:00 AM. On 12/6/25 at 2:50 PM, V21 (RN- Registered Nurse) stated he was not aware a CNA arrived late to her 7:00 AM shift and that R5 did not have an assigned CNA present at the facility. 3. Face sheet, dated 12/6/25, shows R10's diagnoses included weakness, atrial fibrillation, hypotension, syndrome of inappropriate secretion of antidiuretic hormone, chronic pain syndrome, seizures and dementia. MDS, dated [DATE], shows R10 was cognitively intact, was dependent on staff for toileting hygiene, showers/baths, and transfers and R10 was always incontinent of urine and bowel. Review of R10's care plan shows R10 required assistance from two staff with moving in bed, R10 was incontinent of bowl and bladder, requires substantial/maximum assistance for personal hygiene and upper body dressing, total assistance with lower body dressing, and requires a mechanical lift and two staff for transfers. On 12/6/25 at 2:53 PM, R10 stated she waited five hours for incontinence assistance. R10 stated she arrived to her room after bingo at 5:00 PM, asked to have her incontinence brief changed, and the CNA stated she would return to assist R10 but never returned. R10 stated she waited until 10:00 PM with her brief soaked with urine which soaked through her clothing. R10 stated she often waited an hour or more for staff to assist her with changing her incontinence briefs. R10 stated she was often told her CNA was on break or lunch and she needed to wait. R10 stated no other staff helped if her CNA was not available. R10 stated she sat in the hall for over three hours for assistance to get in bed because there was no one to help her. R10 stated she calls V1 (Administrator) to tell her she is in need of help when she does not receive it timely. 4. Face sheet, dated 12/8/25, shows R18's diagnoses included acute kidney failure, weakness, muscle wasting and atrophy, abnormal gait and mobility, polyneuropathy, dorsalgia, spinal stenosis, and urinary incontinence. MDS, dated [DATE], shows R18's cognition was intact, R18 was dependent on staff for toileting hygiene and lower body dressing, was dependent on staff for transfers, and was always incontinent of bowel. Review of R18's care plan shows R18 utilized an indwelling urinary catheter and was incontinent of bowel. The care plan shows R18 required the total assistance of staff for her catheter care and toileting hygiene and was dependent on two staff to assist her with transfers utilizing a mechanical lift. On 12/3/25 2:03 PM, R18 stated during the evening she waited four hours for staff to come and assist her. 5. Face sheet, dated 12/6/25, shows R6's diagnoses included chronic obstructive pulmonary disease, diabetes, basal cell carcinoma, neoplasm of bone, dependance on supplemental oxygen, chronic kidney disease, sleep apnea, and anxiety disorder. MDS, dated [DATE], shows R6 required supervision or touching assistance for toileting, transfers and baths. On 12/6/25 at 9:01 AM, R6 stated staff do not come when she presses her call light. R6 stated she felt like she waited forever for assistance and must wheel down to the nursing station for assistance. 6. Face sheet, dated 12/9/25, shows R12's diagnoses included hemiplegia and hemiparesis, pressure ulcer of sacral region, diabetes, aphasia, contractures of arms and legs, and chronic respiratory failure with hypoxia. MDS, dated [DATE], shows R12's cognition was severely impaired, R12 was totally dependent on staff for toileting hygiene, personal hygiene, oral hygiene, and upper/lower body dressing, and transfers, and R12 was always incontinent of bowel and bladder. Review of R12's care plan showed R12 was incontinent and required staff to check and change her incontinence brief, R12 required two staff for bed mobility, was totally dependent on staff for toileting hygiene and personal hygiene and dressing, and required two staff and a mechanical lift for transfers. Facility concern form, dated 11/3/25, shows family expressed concerns regarding R12's ADL and ostomy bag not being emptied of stool. The form shows staff were provided education on proper ADL performance and ostomy care. 7. MDS, dated [DATE], shows R29's cognition was moderately impaired, R29 required supervision or touching assistance for steadying for transfers and toileting hygiene, and was occasionally incontinent of bowel and bladder. Review of R29's care plan shows R29 required staff supervision with toileting transfers and toileting hygiene. Facility concern form, dated 10/6/25, showed R29 needed more assistance and to be checked regularly during the night. The form shows R29 was to be checked minimally every two hours. 8. Resident Council Meeting Minutes, dated 10/27/25, show resident expressed concerns some staff do not make themselves available to help others. The minutes show the residents expressed delays in call light response time.

Based on observation, interview and record review, the facility failed to serve palatable coffee during meals. This applies to 9 of 9 residents (R2, R4, R6, R10, R13, and R28) reviewed for coffee in a sample of 29. The findings include: On 12/3/25 at 2:20 PM, R4 and R28 both stated the coffee served at the facility was horrible and looked and tasted like brown water. There was a disposable cup on R4's dresser with translucent, light brown water in the cup. R4 and R28 both stated the liquid was served that morning at breakfast as the facility coffee. Concern form, dated 12/3/25, shows R4 and R28 reported the coffee was not prepared properly. The form shows V1 (Administrator) met with V28 (Food Service Manager) to review the preparation process, the coffee was observed at dinner on 12/3/25, and a food committee was held on 12/4/25. The form also shows dietary staff were retrained on proper preparation of coffee. On 12/6/25 at 8:29 AM with V8 (Licensed Practical Nurse) during breakfast service, coffee being served to residents at breakfast from the coffee cart was sampled. V8 looked at the coffee and stated, That's rough. Dark. Thicker than I have ever seen. Looks like sludge. On 12/6/25 at 8L55 AM, R2 stated the coffee served at the facility smelled rancid, nasty and burnt and she would not drink the coffee served. On 12/6/25 at 9:01 AM, R6 stated in the past week when they were served coffee, the coffee tasted horrible and you could not drink it if it were served. On 12/6/25 at 9:14 AM, R10 stated it was difficult to get coffee served at the facility and when it was served it tasted poor. On 12/6/25 at 8:57 AM, R13 stated the coffee at the facility did not taste good. On 12/6/25 at 9:37 AM after breakfast on the second floor, V17 (Dietary Aide) poured a sample of coffee from a coffee pot in the hallway used to serve coffee to residents. The color of the coffee was very light and translucent. On 12/6/25 with V1 (Administrator) in the kitchen, there were several packages of instant coffee sitting on the counter next to the coffee brewing machine. V27 (Dietary Aide) and V28 (Food Service Director) stated he used the instant coffee sitting on the counter to brew the coffee that morning for breakfast. On 12/6/25 at 10:09 AM, V1 (Administrator) stated after reports of poor coffee on 12/3/25, V1 stated she sampled the coffee and it did not smell or taste good. V1 stated the day prior the facility bought instant coffee and used the instant coffee from the store to brew the coffee. Facility policy Palatability and Nutritive Value, reviewed 3/9/23, shows, Food will be prepared, held, and served in a manner that preserves nutritive value and palatability.

Based on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevents food borne illness.This applies to all 177 residents receiving dietary services.Findings include:On 11/21/2025 at 12:12 PM, V1 Administrator confirmed 177 residents were receiving dietary service on the survey start date of 11/18/25.On 11/18/2025 at 10:10 AM, the kitchen tour was conducted with V32 Dietary Manager and V33 Regional Dietary Director.The high temperature dishwasher was run. The testing strip used was labeled to indicated when 160-degree Fahrenheit was attained. The rinse gauge temperature reached 172-degree Fahrenheit.The walk-in cooler contained:Ham in plastic wrap dated 11/10.A box 31.75 lb. (pound) of raw chicken parts stored over three 5lb bags of scrambled egg product.A sliver facility pan with 11 cooked hamburger patties with an expiration date of 11/17.A 10lb box of wilted wrinkled jalapenos with black spotsA box with 14 rotten limes.The dry storage contained:A dented 6lb 12 oz. (ounce) can of kidney beansA dented 6lb 10oz. can of diced peachesA dented 6lb 9oz. marinara sauceA 50lb bag of rolled oats that was open to airA 25lb bag of corn meal that was open to air.A 32 oz bag of powdered sugar without any opened on or use by dates.The reach in cooler contained:6 bags with turkey sandwiches with out a label or dates.A facility container with unidentifiable contents dated 11/16/25.The general kitchen contained:Warming plates in a holding bin identified as being clean with debris.The trays on shelving holding brown cereal bowls were coated with a dark sticky substance.The silverware that was on service line identified as being clean had old food debris on them.The knives in the organizer on the wall above the three-compartment sink were soiled with bits of food debris on them.The cookware on storage shelving had grease and food debris on them.The microwave was splattered and dirty.The toaster oven had splatters of a dried brown substance and was covered in crumbs.The mixer not in use was crusty and uncovered.The reach in cooler in the dining room had 7 brown cups of fruit cocktail that were uncovered, unlabeled and undated.On 11/20/2025 at 3:14 PM, V32 Dietary Manager stated dented cans should be separated out of circulation because they could be contaminated. Food items should be properly to prevent contamination. Labeling and dating are important so everyone is aware when food items were delivered / prepared and when they should be discarded. V32 stated the refrigerators are checked twice per week on delivery days for spoiled or outdated items. Serving outdated items like the ham may cause illness. The raw chicken should not have been stored over the scrambled egg product because if it leaked it could contaminate the items underneath and cause illness. The dishwasher should assure the dishware is clean to the items are free of illness causing bacteria. The dishwasher is a high temperature dishwasher and should reach a rinse temperature of 180 degrees so illness causing bacteria are killed. The strips that only reached 160 degrees were not the correct strips to be used. Staff should be monitoring the strip and the temperature gauge to assure the correct temperature is attained and document the reading from the temperature gauge. If there is a problem with the dishwasher, I should be alerted so that I can contact a repair person. We have not been keeping a log for the red sanitizing buckets.The high temperature dish machine log for October and November had 23 days in which the final rinse temperature was less than 180-degrees Fahrenheit.The manufacturers instruction manual for the high temperature dish machine final rinse recommended is 180-195 degrees Fahrenheit.The undated facility policy Sanitizer Buckets states record ppm (Parts Per Million) on sanitation log.The undated facility policy Cleaning Standards states food contact surfaces, nonfood contact surfaces, equipment, pans and utensils must be kept clean at all times. This includes but not limited to free of grease deposits, food residue, dust and other soil accumulation / debris.The undated facility policy air drying tableware and utensils states once the tableware and utensils are sanitized, they are allowed to air dry.The undated facility policy Food Storage states all open products will be sealed to ensure quality and prevent contamination against pests or rodents. Open products are sealed, labeled and dated.The undated facility policy Labeling and Dating leftovers and opened foods shall be clearly labeled with the date food item is to be discarded. Some local health departments also require preparation date.

Based on interview and record review the facility failed to provide certification for the acting Dietary Manager.This applies to all 177 residents receiving dietary services.Findings include:On 11/21/2025 at 12:12 PM, V1 Administrator confirmed 177 residents were receiving dietary service on the survey start date of 11/18/25.On 11/20/2025 at 3:14 PM, V32 Dietary Manager stated he could not find his certification for Food Service Manager certification. V32 stated he must retake the class.On 11/20/2025 at 3:14 PM, V33 Regional Dietary Director stated they are under a new company and the previous company took V32 certificate during the company changeover.V32 provided a Food Handler certificate dated 8/15/2024 valid through 8/15/27.The facility did not have a policy regarding the certification of dietary staff.

Based on observation, interview, and record review, the facility failed to contain and secure resident medications. This applies to 4 of 4 residents (R1, R65, R84, R183) reviewed for medications in a sample of 36. The findings include: 1 1. On 11/18/2025 at 10:50 AM, R84 was not in the room. R84 had a medication cup on the bedside table that contained a white pill and a tan pill. R84's admission Record showed R84 was admitted to the facility on [DATE]. R84 had multiple diagnoses which included Wernicke's Encephalopathy, alcohol abuse, benign prostatic hyperplasia, and weakness. R84's MDS (Minimum Data Set) dated 10/07/25 showed R84 had moderate cognitive impairment. R84's EMR (Electronic Medical Record) showed no orders for medications to be left at the bedside. 2. On 11/18/25 at 2:28 PM, inside R65's drawer there was an Icy Hot original no-mess roll and Visine eye drops. On 11/20/25 at 1:50 PM, R65 stated the medications are always kept in her room because she doesn't want to bother the nurse each time her eyes are dry and whenever she has pain. Review of R1 and R65's POS (Physician Order Sheet) shows no orders for the medications to be at the bedside. OOn 1/20/2025 at 3:52 PM, V2 (DON—Director of Nursing) stated that medications should be locked up when there is no order for it to be at the bedside. She stated, It should be locked up in the medication cart so it can be secured. 3. On 11/18/25 at 10:39 AM, a bottle of Nyamyc Powder with R183's name was on the nightstand in the room. R183's admission Record showed R183 was admitted to the facility on [DATE]. R183 had multiple diagnoses which included major depressive disorder, morbid obesity, dysphagia, dementia, anxiety, and chronic kidney disease. R183's Order Summary Report for November 2025 showed Nystatin Powder, apply to abdominal folds, arms, and groin topically every day shift for wound prevention. R183's MDS dated [DATE], showed R183 had moderate cognitive impairment. R183's EMR showed no orders for medications to be left at the bedside. 4. On 11/18/25 at 2:03 PM, R1 was lying on her bed. R1 has a tracheostomy and is unable to verbalize. On top of dresser, there was a bottle of artificial tears. Facility's policy titled Medication Storage in the Facility titled 6/2025 shows: General: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview and record review, the facility failed to have interventions in place to prevent a resident from falling from bed. The facility also failed to store all smoking materials and failed to provide supervision to monitor residents for safe smoking. This affects 5 of 5 (R4, R53, R66, R106, R163) residents reviewed for falls and smoking in a sample of 36. The findings include: 1.On 11/20/2025 at 10:43 AM, R4 stated he had fallen out of the bed when he rolled himself over to his right side. R4 stated when he rolled there was nothing in place to keep him from rolling off right side of the bed. R4 stated he had been asking for a rail on the right side of his bed for a while, but none had been provided. On 11/20/2025 at 10:43 AM, V34 CNA (Certified Nursing Assistant) stated she was working the day R4 fell off the bed. V34 stated R4 fell face down on to the floor on the right side of the bed. V34 stated R4 had a right leg amputation prior to his fall. R4 only had a short rail on the left side of the bed. V34 stated the long rail was placed on the bed after the fall. V34 stated R4 did not have bolsters on his bed until today (11/20/25) when V10 Restorative Nurse asked for her assistance to put them on R4's bed. On 11/20/2025 at 10:56 AM, V35 LPN (Licensed Practical Nurse) stated when she was notified of R4's fall she found him face down on the right side of his bed. V35 stated R4 only had one short rail in place on the left side of his bed. V35 did not recall any other fall or positioning devices in place for R4 at the time of his fall. On 11/20/2025 at 11:06 AM, V25 RN (Registered Nurse) stated V10 Restorative Nurse added the bolsters to R4's bed that day (11/20/25). On 11/20/2025 at 2:47 PM, V10 Restorative Nurse stated she applied an overlay with bilateral bolster to R4's bed earlier in the day. V10 stated R4 was assessed in 8/14/25 to have the short rail on the left side prior to his amputation and prior to his fall. V10 stated R4 was not reassessed for bed safety after his right leg amputation in October 2025. V10 stated she did not do a new assessment for R4 until 11/10/25 after R4 fell out of the bed. V10 stated the post fall assessment done 11/10/25 included the long-left side bed rail and bed bolsters. The restorative side rail review dated 8/14/25 and 11/10/25 assessed for the use of 1/2 side rails to enable R4 to attain and maintain his practicable level. R4's 11/8/25 post fall event summary list contributing factors includes low air loss mattress not complimented with appropriate positioning devices. Lack of adequate use or securing of positioning supports (bolsters, alignment devices). R4's care plan for fall risk was updated on 11/08/25 to include wing tip overlay. The facility Policy Side Rails dated 9/2025 states individualized assessment for side rail usage should be completed as soon as possible after admission, readmission, quarterly and with a significant change in condition by the restorative nurse. 2. On 11/18/2025 at 10:22 AM, R53 he goes on smoke breaks. He had a pack of cigarettes with one stick of cigarette under his shirt on his right shoulder. On 11/18/25 at 8:45 AM R53 was in the patio and was smoking. He said he keeps his cigarettes and lighter on him. He said staff does not supervise them during smoking times. He said he does not know what the fire blanket is used for. R53's face sheet documents diagnoses of hemiplegia and hemiparesis, chronic obstructive pulmonary disease, depression, anxiety disorder, schizoaffective disorder, hyperlipidemia and hypertension. MDS (Minimum Data Sheet) dated 9/3/25 documents that he has intact cognitive functions. 3. On 11/19/25 at 1:00 PM, R66 was in her room. She said she was a smoker. R66's cigarette and lighter were in her pocket. On 11/20/25 at 8:45 AM, R66 was seen opening the patio door using a code. She said everyone knows the code but could not remember who gave it to her. She proceeded to light a cigarette. She said she always have her smoking materials with her. She said staff does not supervise them during smoking times. She said she does not know where the fire blanket was and what it is used for. R66's face sheet documents diagnoses of epilepsy, hypertension, depression, anxiety disorder, bipolar disorder, and obesity. MDS dated [DATE] documents she has intact cognitive functions. 4. On 11/18/25 at 12:20 PM, R106 said he is a smoker. He showed that he keeps his pipe and lighter in his pockets. On 11/19/25 at 9:56 AM, R106 was seen going to the patio to smoke. He was observed using a code to open the patio door. There was no staff observed monitoring the residents smoking in the patio. R106's face sheet documents diagnose of osteoarthritis, type II diabetes mellitus, chronic obstructive pulmonary, insomnia, anxiety disorder, depressive disorder, peripheral vascular disease, hyperlipidemia and hypertension. MDS dated [DATE] documents he has intact cognitive functions. Interview with V11 (SSD-Social Services Director) on 11/20/25 at 2:15 PM said there should be staff supervising residents during smoking times. She said staff should also be the one opening the doors with code. She said residents hold onto to their cigarettes but not their lighters. She is not sure if the facility does sweeps to look for lighters in the facility. Interview with V1 (Administrator) on 11/20/25 at 2:30 PM said residents should not have their cigarettes and lighters with them regardless of if they are safe smokers or not. She said they should be surrendered to staff after each smoking time. She said residents should not know the code to the door going to the smoking patio and does not know how residents got them. She said supervision during smoking times should be followed. Facility's Smoking Program Guidelines updated on 8/6/25 states the following: Smoking material will be stored in the Smoking Materials Container, which will be kept with the designated Smoking attendant during scheduled smoking breaks. Staff Responsibilities: Distribute smoking materials at scheduled times. Monitor for: safe smoking behavior, unsafe signs (e.g. burn marks, scavenging butts, inappropriate requests), overall treatment compliance. Prior to re-entry, staff must check patio for: any lingering residents, contraband or discarded materials. 5. On 11/18/2025 at 11:41 AM, R163 was sitting in a wheelchair in his room. R163 stated he was a smoker. R163 had two empty cigarette packs in his room. R163 stated he keeps his cigarettes in his possession. R163 had a red cigarette lighter in his pocket. R163 stated he steals cigarettes from his girlfriend's purse when she visits. On 11/20/25 at 11:29 AM, R163 stated he still had a cigarette lighter in his possession, but social services took all of his cigarettes from him the other day. R163 stated when he goes out to smoke, if he does not have any cigarettes, he borrows from other residents. R163 stated there are times when he loans cigarettes to other residents. R163's admission Record showed R163 was admitted to the facility on [DATE]. R163 had multiple diagnoses which included displaced comminuted fracture of shaft of left femur, diabetes, hemiplegia and hemiparesis, moderate protein calorie malnutrition, seizures. R163's MDS dated [DATE] showed R163 was cognitively intact. R163's Identified Smoker care plan revised date 11/06/25, showed R163 Had been made aware of the rules and guidelines of the smoking program. R163's Safe Smoking Risk assessment dated [DATE], showed Does individual have burn holes in clothes or burns on fingers/fingernails, with a score of yes.

Based on observation, interview, and record review the facility failed to use a two person assist to safely turn a resident requiring a two a person assist during cares. This applies to one (R2) of three residents reviewed for safety/supervision in the sample of seven. This failure resulted in R2 [NAME] off the bed and sustainting a laceration to the forehead requiring sutures. The findings include: On 5/22/2024 at 10:29AM, R2 was observed laying in bed in her room. R2 had approximately 1/2 to 3/4 inch scar in the hairline of her left eyebrow. R2 appeared to have limited range of motion to all four extremities. On 5/22/2024 at 11:21AM, V8 Certified Nursing Assistant (CNA) said on Sunday 4/28/2024 he was providing incontinence care for [R2] between 9:00PM and 10:00PM. V8 said he was providing care to [R2] alone without the assistance of other staff. V8 said he turned [R2] to her right side and because she was on an air mattress she began to slide out of bed. V8 said he was unable to stop [R2] from sliding out of bed and she fell out of bed and onto the floor. V8 said [R2] was sent to the hospital for treatment. V8 said [R2] is a 2 person assist with transfers and incontinence care. V8 said they use two people for safety reasons. V8 said residents can slide on the air mattresses. V8 said [R2] returned from the hospital later that night with sutures above her eye. On 5/22/2024 at 11:52AM, V10 Nurse Practitioner (NP) said [R2] was sent out to hospital following the fall. V10 said [R2] had sutures placed due to the fall and the laceration she sustained. On 5/22/2024 at 11:40AM, V2 Director of Nursing (DON) said [R2] is a two person assist with transfers and turning. V2 said they use two people for safety reasons, due to [R2's] limited mobility. V2 said [R2] is on an air mattress and they can be slippery. V2 said two people should be used if the resident is a 2 person assist. V2 said [R2] was sent to the hospital following the fall. V10's Progress Note dated 4/30/2024 notes physical exam other left side forehead 9 sutures - left cheek abrasion. R2's Progress Notes dated 4/28/2024 state the resident fell out of bed during a brief change and landed on the floor. R2 was sent to the hospital with emergency medical services. R2's Progress Notes dated 4/29/2024 state the resident hospital diagnosis was fall with laceration to the left forehead. Resident returned to the facility at 2:08AM on 4/29/2024 with sutures in place to the left forehead area. R2's Care Plan dated 4/23/2024 lists Bed Mobility as a focus with interventions including Dependent 2 person assist initiated on 4/24/2017. R2's Care Plan dated 4/23/2024 lists ADL (activities of daily living) toileting every two-hour dependent 2 assist.

Based on interview and record review, the facility failed to notify the physician of a change in the resident's condition in a timely manner. This failure resulted in a delay in treatment for R1, who experienced a decrease in activities of daily living and increased pain after sustaining a right hip fracture following a fall 4 days earlier. This applies to one of three residents (R1) reviewed for accidents in a sample of eight. The findings include: On April 24, 2024 at 09:47 AM, V9 (Insurance Agent) said R1 was in the facility and had a fall on February 22, 2024. V9 said R1 was sent to the ER (emergency room ) and was found to have a right wrist fracture. V9 said on February 27, 2024 she had right hip pain and it was unclear whether she fell again. V9 said an X-ray was done, which showed a right hip fracture. On April 23, 2024 at 01:36 PM, V3 (PT/Physical Therapist) said she evaluated R1 after her fall. V3 said R1 fell on [DATE], returned to the facility the same night, and she evaluated her on February 23, 2024. V3 said during her evaluation, R1 had a cast on her right arm and was non-weight bearing to the right arm. V3 said prior to the fall, R1 was independent with ambulation with or without an assistive device. V3 said after the fall, R1 was not able to get up. V3 said R1 can be confused, but when it comes to pain, she knows. V3 said when she tried to move R1's right leg, R1 started to exclaim ow! and was tapping her right hip. V3 said when she asked her where her pain was, R1 pointed to her right hip. V3 said she tried to get R1 to sit on the edge of the bed, but she was unable to do so because of her pain. V3 said R1 was in pain even during passive range of motion exercises. V3 said she spoke to the floor nurse about R1 and communicated the resident was not able to sit at the edge and even a little movement caused R1 to complain of pain. V3 said she discontinued treatment for R1 because she was unable to conduct the therapy and wanted to wait until diagnostics were completed for the resident. On April 23, 2024 at 2 PM, V4 (PTA/Physical Therapy Aide) said she worked with R1 on February 25, 2024 and February 26, 2024. V4 said on February 25, 2024, prior to starting treatment with R1, R1 was complaining of pain in the right leg and so she spoke with the nurse to ask if there were any restrictions for R1. V4 said she mainly did active range of motion exercises for the left leg because the right leg was painful, and when she tried to do passive range of motion exercises for the right leg, R1 complained of pain and was unable to tolerate it. V4 said on February 26, 2024, she spoke with the nurse and the NP (Nurse Practitioner) about R1's pain prior to the treatment. V4 said during her session with R1, R1 wanted to use the toilet so V4 attempted to sit R1 on the edge of the bed but was unable to do so because of R1's pain, grimacing, and guarding. On April 23, 2024 at 02:12 PM, V5 (LPN/Licensed Practical Nurse) said she worked on February 23, 2024 from 7 AM to 3 PM. V5 said on February 23, 2024, the PT had told her during therapy, R1 was complaining of pain in her hip. V5 said she assessed R1 to notify her physician of the hip pain but had to leave a message. V5 said she endorsed to the next shift nurse that she was waiting for a call back, and to follow up. V5 said she wrote a note in the EMR (Electronic Medical Record) and told the supervisor. On April 24, 2024 at 11:58 AM, V7 (RN/Registered Nurse) said the nurse did not ask her to call the doctor. V7 said sometimes the nurses chart something, but do not let the oncoming shift know. V7 said she would have called the doctor immediately, and if she was unable to reach the doctor, she would have told her supervisor and tried to reach the NP. On April 23, 2024 at 04:40 PM, V6 (RN) said she was the nurse on duty when R1 fell . V6 said she noticed R1's wrist was crackling, so she was sent out to the ER and returned with a fracture of the right wrist. V6 said when R1 returned, R1 was kind of bed bound. V6 said R1 would be crying if someone touched her, and when the CNA's (Certified Nurse Assistants) were trying to change her, she would scream. V6 said none of the nurse's had passed along to her that they were waiting for a call from the doctor. On April 25, 2024 at 01:09 PM, V8 (NP) said she was not made aware of R1's hip pain prior to February 26, 2024. V8 said the floor nurses never discussed with her about R1 being in pain, but it was her expectation the staff notify her of a change in condition. V8 said if she knew R1 was complaining of hip pain, she would have ordered an X-ray right away, which is what she did on February 26, 2024 when the staff notified her. The EMR (Electronic Medical Record) shows diagnoses including type 2 Diabetes Mellitus, difficulty in walking, weakness, repeated falls, dysphagia, fracture of right wrist and hand. Intertrochanteric fracture of right femur, psychosis, dementia, Alzheimer's disease, chronic kidney disease, hypertension, and osteoarthritis. R1's MDS (Minimum Data Set) dated March 28, 2024 showed R1 had severe cognitive impairment. R1 required supervision for eating, partial assistance for oral hygiene, upper body dressing, and substantial assistance for toileting hygiene, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. R1's progress notes documents the following: On February 22, 2024 at 06:17 PM, V6 wrote, Resident was witnessed by staff stumbling over and fell on her right side in the hallway. Staff immediately notified writer. Writer assessed resident and V/S (Vital Signs) were stable. During assessment writer noticed a lump above resident's right eye. No other bruising was noted. Resident complained of pain and discomfort on the right side of the face, right shoulder, right arm, and right leg. Writer immediately applied ice pack to right eye to decrease swelling. Staff helped assist resident to bed via [mechanical] lift. Residents' family, DON (Director of Nursing), and NP were notified. Resident is immediately being sent out to [Hospital] via ambulance with all paperwork. On February 22, 2024 at 10:42 AM, V6 wrote, Resident returned from [Hospital] with all paperwork. V/S were stable. Resident returned with a closed fracture of the right wrist. Resident will need assistance with ADLs (Activities of Daily Living). Resident returned with a new medication order of hydrocodone. Resident is currently in bed resting. will continue to monitor. On February 23, 2024 at 12:44 PM, V5 wrote, Writer received a script for residents signed by NP hydrocodone-acetaminophen (5-325), faxed to pharmacy, resident in stable conditions. resting in bed all needs attended to, no signs of distress or discomfort, PRN (As Needed) given r/t (Related To) pain in right hand d/t (Due To) fracture that occur d/t recent fall on 2/22/24. Resident kept comfortable. call light in reach care on going. On February 23, 2024 at 03:31 PM, V5 wrote, Writer informed that while resident was in PT/OT [Physical Therapy/Occupational Therapy] she verbalized complaints of pain in her right hip. R/T fall that occurred 2/22/2024. Writer called PCP (Primary Care Physician) [Doctor] to see if possible x-ray of resident right hip. Writer called message left to return call, Writer awaiting call back at this time Endorsed to next shift to follow up, resident did have a fall yesterday and was evaluated by doctors at hospital and returned this morning. Writer did call for PCP doctor to order hip x-ray endorse to 2nd shift nurses to follow up. V8's Progress Note written on February 26, 2024 showed, During therapy [Complaint Of] right hip and knee pain, X-rays ordered. On February 27, 2024, V8's Progress Note, Patient was seen today for right hip pain, [X-Ray] reviewed and shows right hip impacted intertrochanteric fracture. Discussed with DON likely occurred during previous fall. V3's Summary of Skill, written on February 23, 2024, showed Therapist initiated moving R LE (Right Lower Extremity) however patient c/o pain, refusing to move the leg. Patient unable to tolerate [PROM/Passive Range of Motion] and {AROM/Active Range of Motion] on RLE and pointed on [Right] anterior hip as location of pain, unable to roll and perform bed mobility. Nurse notified. V4's Summary of Skill, written on February 25, 2024 showed, [Patient] report of pain on [Right] knee during [Range of Motion], nothing on [Right] hip for today's session, initially only able to tolerate 5 reps during PROM on RLE however with repetition [Patient] was able to tolerate 10 [Times]. Nursing is aware regarding [Patient] report of pain. [Patient] was seen at bedside. On February 26, 2024, V4 wrote, Coordinated with NP and nursing regarding [Patient] report of pain and if therapy can continue, per NP and nursing [Patient] can continue with therapy. Attempted to work on sitting on [Edge of Bed] as [Patient] reporting of wanting to use the toilet during this attempt [Patient] started screaming despite not being able to move [Bilateral Lower Extremity], [Patient] reporting of R knee pain. The facility's Physician Notification policy reviewed in September 2023 showed In a non-emergent, but acute medical situation the physician will be paged and if there is no return call in 30 minutes, the physician will be notified again. If there is no return call in 30 additional minutes (30 minutes total), the Medical Director will be notified.

Based on interview and record review the facility failed to correctly transcribe and reconcile a resident's hospital discharge medication orders upon readmission to the facility for one resident (R1) of three residents reviewed for medications orders received upon admission/readmission to the facility in a sample of three. This failure resulted in R1 being prescribed and administered the wrong medication regimen, including an opioid, antibiotic and anticoagulant medications resulting in R1 having a change in condition that required transfer to the local hospital emergency room with subsequent hospital admission. The findings include: R1's EMR (Electronic Medical Record) showed R1 was [AGE] years old and admitted to the facility on [DATE], initially, and transferred to the hospital for psychiatric symptoms on March 21, 2024. R1 was readmitted to the facility on [DATE]. R1 had multiple diagnoses including spinal stenosis, Alzheimer's disease, protein calorie malnutrition, bipolar disorder, history of suicide ideation and suicide behavior. R1's MDS (Minimum Data Set) dated April 7, 2024, showed R1 with severe cognitive impairment, and required staff assistance with ADLs including dependent on staff for toilet hygiene, lower body dressing, required substantial assistance with transfer, upper body dressing and bathing and supervision/set up assistance with eating and bed mobility. On April 17, 2024, at 12:18 PM, V4 (Physician) stated R1's readmission medication orders were verified by an on-call Physician, however when V4 was approached on April 3, 2024, by the facility nurse to sign a prescription for Buprenorphine, an opioid medication for R1, V4 stated he refused to sign the prescription and instructed the nurse to contact the Psychiatrist at the hospital R1 was readmitted from. V4 stated R1 was not receiving that medication prior to hospitalization and V4 did not think the opioid medication was needed for R1. V4 stated he did not know the name of the facility nurse he had spoken to. On April 17, 2024, at 5:07 PM, V8, (RN (Registered Nurse)) stated she had processed R1's admission orders on April 1, 2024, and was working on April 3, 2024. V8 stated she prepared the prescription for Buprenorphine (opioid medication) for R1 and asked V3 (Nurse Practitioner) to sign the prescription for the opioid medication on April 3, 2024. V8 stated she had previously taken care of R1 prior to her hospitalization and readmission but did not realize that the discharge orders from the hospital had a different patient's name on the page and processed the orders for R1. On April 17, 2024, at 12:18 PM, V3 (Nurse Practitioner) stated she was presented a prescription form to sign on April 3, 2024, that had been prepared by a facility nurse. V3 stated she signed the prescription as a continuation of a medication that was initiated in the hospital and stated she was not starting the medication for R1. V3 stated at the time the prescription for Buprenorphine (opioid medication) was presented to her for signature, V3 was unaware of V4's objection to signing the prescription and was not aware that V4 had instructed the facility nurses to contact the Psychiatrist regarding the medication. V3 also stated she had not seen the discharge medication list for R1 from the hospital. On April 18, 2024, at 10:15 AM, V9 (Pharmacist, Director of Clinical Services for the Pharmacy) stated the only FDA (Federal Drug Administration) approved use for the opioid medication that R1 had been prescribed was for the treatment of opioid dependence. Davis's Drug Guide for Nurses, 14th edition show side effects including confusion, hallucination, and sedation for Buprenorphine HCL. R1's EMR did not contain a medical diagnosis of opioid dependence. On April 17, 2024, at 5:07 PM, V8 (RN) stated she observed a change in mental status, increased lethargy, of R1 on April 5, 2024, and reported the change to V3. V8 stated in response V3 ordered laboratory tests be done. V8 stated when she worked on April 7, 2024, R1 was observed to be more lethargic, would not open her eyes or take any food or fluids and contacted V4 who ordered R1 be sent to the hospital emergency room for evaluation. R1's medical records showed the medication orders for R1 on March 21, 2024, at the time of discharge to the hospital, compared to R1's medication orders implemented on April 1, 2024, were completely different medications. R1's MAR (Medication Administration Record) for April 2024 showed that R1 received the following medications while at the facility that had not been ordered for R1 prior to April 1, 2024. 1). Buprenorphine HCL (opioid) 2 mg was given once on April 4, April 5; and twice on April 6, 2024. 2). Apixaban tablet (anticoagulant) 5 mg was given two times a day on April 2, April 3, April 5, April 6, 2024 and once a day on April 1 and April 4, 2024. 3). Cephalexin (antibiotic) 500 mg was given 4 times per day on April 2, April 3, April 4, April 5, April 6, 2024; and 3 times on April 1, 2024. 4). Albuterol Sulfate HFA 108 mcg/ACT (inhaler) was given 4 times a day on April 2, April 3, April 5, April 6; 3 times a day on April 4 and twice a day on April 7. 5). Cardizem LA tablet extended release (Antihypertensive medication) 180 mg was given once on April 2, April 3, April 4, April 5, and April 6, 2024. 6). Metoprolol tartate (Antihypertensive medication) 25 mg was given two times a day on April 2, April 3, April 5, and April 6, 2024; once time a day on April 1 and April 4, 2024. 7). Venlafaxine HCL ER (antidepressant) 150 mg was given twice a day on April 2, April 3, April 5, April 6, 2024 and once a day on April 4, 2024. 8). Levothyroxine sodium (medication to treat hypothyroidism) 150 MCG was given once a day on April 2, April 3, April 4, April 5, and April 6, 2024. V2 (DON (Director of Nursing)) stated on April 17, 2024, at 10:46 AM, that she became aware of the medication error on April 7, 2024, when the hospital requested R1's medication orders be clarified. V2 stated it was on April 7, 2024, when V2 reviewed R1's discharge documents from the hospital that V2 recognized the documents had R1's name on them, but the discharge order summary had a different patient's name on them, and that patient did not reside in the facility. On April 7, 2024, at 11:30 AM, R1's ED (Emergency Department) note written by V12 (Physician Emergency Department) documented that R1 had received completely different medications than that were originally ordered upon discharge to the nursing facility. V12 documented since both hospitals were part of the same health system, V12 was able to access the records for R1 from the previous hospital. V12 documented R1 received anticoagulant medication that was not previously ordered, an antibiotic and opioid medication at a higher dose than would be expected for an [AGE] year-old. V12 documented R1's assessment at the time of transfer to the ED, showed R1 was lethargic, noncommunicative, and pupils were constricted but reactive. V12 documented that R1's urine test showed ketones +80 and V12 opined that the test results were indicative of R1 being too sedated to eat or drink while in the nursing facility. V12 documented that R1's progressive change in condition appeared pretty severe and was secondary to R1 receiving an aggressive overall med change. V12 admitted R1 to the hospital for further observation. R1's hospital record showed R1 remained in the hospital from April 7, 2024, through April 15, 2024, when R1 discharged to a different nursing facility. The facility's policy titled Admission/Re-admitted d reviewed April 2024, showed .g. All medications should be reconciled with the resident/resident representative and verified with the primary physician or nurse practitioner .h. Physician order sheet should reflect any standing orders specific to the resident as well as medications and treatments that are ordered throughout the stay.

Based on observation, interview and record review the facility failed to ensure residents were free from physical abuse. This applies to 4 of 4 residents (R3, R4, R14 and R15) reviewed for abuse in the sample of 17. This failure resulted in R3 being hospitalized with multiple facial fractures. The findings include: 1. On 1/10/24, R3 was sitting in his room. R3 had bilateral periorbital bruising and both of his eyes were red. On 1/10/24 at 10:45 AM, R3 said that he got punched multiple times by R4 and he now has an orbital fracture and nasal fracture. R3 said that his eyes were swollen shut for quite some time as well. R3 said that he now has daily headaches. R3 said that he went into R4's room to deliver him some things that he had purchased for him and R4 got upset with him. R3 said that at first they were both standing in the room yelling at each other and then R4 started punching him in the face. R3 said that he then started punching R4. R3 said that he eventually tripped over the edge of the bed and fell to the floor and R4 got on top of him and was punching him in the face multiple times. R3 said that he was sent to the hospital after the incident. R3 said that R16 was in the room and witnessed the incident. On 1/10/24 at 10:51 AM, R16 said that he was in the room when R3 and R4 had an altercation. R16 said that they first started arguing about money or something. R16 said then they started pushing each other and then they started punching each other. R16 said that R3 fell on the ground and R4 was on top of him and they were punching each other. On 1/10/24 at 1:39 PM, V3 (Nurse Practitioner) said that she saw R3 when he returned from the hospital. R3 received multiple facial fractures from the incident that happened. R3's Minimum Data Set assessment dated [DATE] shows that his cognition is intact. R3's Nursing Notes dated 1/1/24 at 3:45 PM shows, Writer walked into room [R4's previous room] and noted [R4] on top of a this resident that is from [R3's room number], this resident is face down on the floor and they have been fighting and resident is in a hold .noted this resident face swollen, and noted bleeding . R3's Hospital Notes dated 1/2/24 shows, Patient got punched in the face multiple times. Ended up sustaining left orbit fracture and bilateral nasal fractures. Patient's eyes quite swollen and difficult for him to see out of these. R3's After Visit Summary from the local hospital shows that R3 was admitted to the hospital on 1/1/24 with multiple facial fractures and discharged on [DATE]. R4's Minimum Data Set assessment dated [DATE] shows that his cognition is intact. R4's Nursing Notes dated 1/1/24 at 9:21 PM shows, Resident arrested by police. R3's Final Facility Reported Incident dated 1/8/24 shows, Interview of alleged victim: [R3] went to the store and upon return, brought items to the room .[R4] allegedly hit him in the face. R3 hit him back and fell to floor. [R4] got on top of him and hit him in face a few more times Interview of alleged perpetrator: .[R3] hit him in the face which started the fight. [R3] fell to ground and he got on top of him and hit him Police arrive and removed him from the facility . The facility's Abuse Policy and Prevention Program dated 10/2022 shows, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. 2. On 1/10/24 at 10:30 AM, R15 was sitting in his room. R15 said that the other day, his mother, his roommate (R17) and himself were in his room getting ready to go for a walk when R14 came into their room. R15 said that R17 asked him to leave and he did not. R15 said that then his mother told R14 that it was not his room and he needed to leave. R15 said that at that time, R14 'lunged at his mom and said, Who's going to make me?. R15 said that at that time he told R14 that he needed to leave since he was threatening his mother. R15 said that R14 then took a piece of a hard plastic cup that looked like a knife and cut him on the back of his head/neck area and punched him in the face/throat area. R15 said that at that time, he punched R14 and R14 fell down and he punched R14 him multiple times. R15 showed this surveyor a piece of paper that was a court document showing that R14 has a court hearing set for 1/29/24 for the charges of battery. On 1/10/24 at 10:30 AM, R17 said that R14 had walked into the room and he had told him to leave because it was not his room. R17 said that then R15's mother told him that he needed to leave and R14 started saying stuff to her so R15 started yelling at him. R17 said that he took R15's mother out of the room when R14 and R15 started hitting each other. R15's Minimum Data Set assessment dated [DATE] shows that his cognition is intact. R15's Nursing Notes dated 1/1/24 at 9:00 PM shows, Writer performing rounds at this time and observed resident in a physical altercation with another peer. Writer observed resident [R15] seated in wheelchair with right fist clenched striking resident [R14] while resident [R14] striking resident [R15] with clenched fists Resident [R15] states, he just walked into my room, I asked him to leave and he wouldn't. Then he started threatening me and my mom, then he tried to cut me with a sharp piece of plastic so I defended myself and I had to make sure my mom was ok. Police assistance requested .Staff observed sharpened plastic from drinking cup on resident [R14] persons. Item confiscated and given to PD (Police Department). Writer performed body gram, noted thin laceration to right side of back of head noted 10 cm (centimeters) in length, minimal bleeding observed. Swelling to left side of mandible, measured 6 cm R14's Minimum Data Set assessment dated [DATE] shows that his cognition is impaired. R14's Behavior Care Plan created on 1/8/24 shows, [R14] is observed by staff to be easily agitated due to confusion and cognitive deficits, becoming physically aggressive towards other staff and residents, along with being difficult to redirect. R14's Nursing Notes do not document anything about the incident on 1/1/24. The facility's Abuse Policy and Prevention Program dated 10/2022 shows, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.

Based on observation, interview, and record review the facility failed to ensure safety interventions were in place for a resident with a history of seizures for 1of 3 residents (R5) reviewed for safety in the sample of 17. This failure resulted in R5 having seizure like activity and falling from his wheelchair sustaining frontal skull fractures and a laceration. The findings include: On 1/8/24 at 12:00 PM, R5 was sitting up in a high back wheelchair in the dining room. R5 had a laceration on the right towards the middle his forehead, starting in R5's hairline and going down his forehead approximately one inch. R5's laceration was crusted with dried blood. R5 was alert but not able to answer any questions. V18 (R5's wife) said R5 fell out of his wheelchair on Friday morning (1/5/24) and had just returned from the hospital last night (1/7/24). V18 said the nurse said R5 had a big yawn and leaned over. V18 said the paramedics told her R5 had a seizure. V18 said R5 hit his head on the floor and has stitches in his forehead and sinus cavity fractures. V18 said the nurse could not tell her if R5 had the leg rests on in the wheelchair. V18 said R5 has had seizures before and staff is supposed to keep an eye on him and have his leg rests on the wheelchair for support. R5's Facility Reported Incident Report dated 1/8/24 shows R5 on 1/5/24 nurse noted resident had a fall; 911 notified; resident sent to hospital for evaluation and treatment; upon return 1/7/24, record review show resident sustained a depressed communicated fracture of the right frontal sinus. On 1/10/24 at 10:12 AM, V16 Licensed Practical Nurse (LPN) said she was working when R5 fell but was not the nurse assigned to R5. V16 said V23 LPN told her R5 fell and she went down the hall to see him. V16 said R5 was on the floor right outside his room. V16 said V23 told her R5 was sitting in the chair, yawned, jerked and then fell out of the chair. V16 said R5 had bleeding from his head and V23 said he hit the floor hard with his head. V16 said V23 called 911. V16 said she was not aware that R5 had epilepsy until she looked up R5's history. V16 said R5 was twitching on the floor and shaking uncontrollably. On 1/10/24 at 12:11 PM, V19 and V20 Certified Nursing Assistant (CNA) said they were working on other halls and heard the nurse call for help. V19 said she saw R5 on the floor and he was not alert or talking, and was bleeding but she was not sure where it was coming from. V20 said when she approached R5 on the floor he was twitching and was bleeding from the nose and the head. V20 said R5 was on the floor in the hall in front of the door to his room. V20 said R5's wheelchair did not have leg rests on. On 1/10/24 at 12:23 PM, V21 CNA said she was taking care of R5 that shift. V21 said R5 was trying to get out of bed, so her and another CNA transferred R5 to his wheelchair. V21 said R5 has a high back wheelchair and is supposed to have leg rests on but they were not in his room so she didn't put them on. V21 said she was pushing R5 out of his room and had just gotten out the door and into the hall when she stopped for a moment. V21 said R5 started to yawn and then leaned forward and fell . V21 said she tried to catch R5 but it happened so fast. V21 said she was directly behind R5's wheelchair and couldn't stop him. V21 said R5 hit the floor really hard and then started having a seizure. V21 said she was not aware of R5 having a history of seizures or any seizure precautions. V21 said R5 can't propel himself in the wheelchair and is supposed to have leg rests for stability. On 1/10/24 at 10:35 AM, V3 Nurse Practitioner (NP) said R5 fell out of his wheelchair face first and hit his face. V3 said R5 has a laceration on forehead with sutures and had facial fractures from his fall. V3 said R5 has had a couple seizures since admission. On 1/10/24 at 2:52 PM, V23 LPN said she was the nurse on duty for R5 when he fell . V23 said she was at the nurses station and saw V21 push R5 out of the room and then stop. V23 said R5 yawned loudly and then leaned forward like he was resting his head on his knees and then fell out the wheelchair. V23 said R5 hit his head hard on the floor. V23 said she went to R5 and he had blood on the right side of his forehead. V23 said R5 wasn't talking, was breathing, and then had some seizure like twitching behavior for less than a minute. V23 said she called 911. V23 said R5 was in a high back wheelchair with no leg rests prior to leaning forward. V23 said she didn't know R5 has history of seizures or what seizure precautions he was supposed to have. On 1/10/24 at 1:35 PM, V3 NP said R5 should have seizure precautions in place to keep him safe and prevent injury. V3 said it should be part of his Care Plan. V3 said leg rests on the wheelchair are for positioning and support and also a fall prevention to keep the legs from getting caught under [NAME] the wheelchair causing injury or causing the resident to fall forward. On 1/11/24 at 9:15 AM, V24 Restorative CNA said R5 can't his move legs on command due to cognition and can't propel himself in wheelchair. V24 said R5 has leg rests so that the doesn't put his feet down when you are pushing him and get his legs underneath making him fall forward. V24 said R5 should have leg rests on when in the wheelchair. On 1/11/24 at 9:30 AM, V25 Physical Therapy Director said leg rests on wheelchairs are for positioning and support. V25 said if a resident is unable to propel themselves the wheelchair should have leg rests on. V25 said R5 should be in a high back wheelchair with leg rests for positioning and support. R5's Hospital Encounter Notes dated 1/5/24 shows patient lives in a nursing home and was sitting in the chair, per Emergency Medical Service (EMS) fell forward and hit his head on the ground per EMS that was due to seizures. EMS noticed patient was post ictal on arrival. EMS brought patient to the emergency room (ER) and patient had another seizure in the ER. Also there is a laceration on the right forehead absorbable stitches were placed. CT head showed depressed commuted fracture involving the anterior wall of the right frontal sinus with fluid, hemorrhage and air extending into the right frontal sinus and right anterior ethmoidal air cells. Patient baseline is mostly bed bound and wheelchair bound at nursing home and the last seizure was about 2 or 3 moths ago per wife. R5's Nurse Practitioner Progress Note dated 1/8/24 shows R5 was hospitalized after he fell forward out of his wheelchair and his his head. R5 experienced a seizure in the ambulance as well as one in the emergency room . Sustained a laceration to his right forehead that required stitches in the emergency room . CT of the head showed a depressed commuted fracture of the anterior wall of the right frontal sinus with fluid. Depakote increased to 1000 mg twice daily. Monitor. Seizure precautions per protocol. R5's Face sheet shows R5 was admitted on [DATE] with diagnoses of unspecified psychosis, epileptic seizures related to external cause, dementia, depression and anxiety. On 1/10/24 at 11:21 AM, V2 Director of Nursing said R5 has a history of seizures but was not sure what seizure precautions R5 was supposed to have and if R5 had them in place. On 1/10/24 at 11:30 AM, V1 Administrator said the facility should have some sort of seizure precaution protocol or procedure to put in place for residents with seizures. R5's Fall Risk Evaluation dated 10/25/23 shows R5 is at high risk for falls related to: decreased mobility, predisposing conditions of hypertension, cerebral vascular accident, hypotension, and seizures, mentation-confused, impaired memory or judgement, and history of falls. R5's Minimum Data Set, dated dated dated [DATE] shows R5 has severely impaired cognition, uses a wheelchair, and is dependent on staff for mobility in wheelchair. R5's Care Plan shows R5 is at high risk for falls related to weakness, limited mobility, and cognitive impairment secondary to dementia, psychosis, and anxiety. This same Care Plan does not address R5's seizures or contain seizure precautions. R5's Physician Orders shows R5 is on divalporex twice daily for epileptic seizures but does not contain any orders for seizure precautions. R5's Nurse Practitioner Progress Note dated 10/31/23 shows called to patient's room as it was reported that he was experiencing a seizure. Staff witnessed that he became glassy eyed and then his extremities began shaking. May have lasted 1 minute. Witnessed seizure just occurred and now patient is post ictal but stable. Post seizure monitoring. Seizure precautions per protocol. R5's Progress Note dated 11/21/23 shows resident was in wheelchair complained of I cannot see anymore, Observed resident sitting in wheelchair eyes rolling to back of head and not responding to stimuli for 30 seconds. Resident then flinched and became responsive. The facility's Seizure Precaution Policy dated 10/2023 shows to put appropriate precautions in place for a resident who has a history of seizures. The care plan coordinator will be notified of the resident's seizure diagnosis and an appropriate care plan put into place. The facility's Fall Prevention and Management Policy dated 9/2023 shows while preventing 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.

Based on observation, interview and record review, the facility failed to provide care with two people assist during incontinent care and bed mobility. This failure resulted in R1 falling from the bed and sustaining a laceration on the top left part of her head requiring a staple and left femoral neck fracture. This applies to 1 of 9 residents (R1) reviewed for falls and accidents. Findings include: On 11/7/2023 at 10:09 AM, V2 (DON-Director of Nursing) said on 10/14/2023 around 1:30 AM, R1 fell from bed while V3 (CNA-Certified Nurse Assistant) and V4 (CNA) were providing incontinence care. He said while R1 was turned towards V4, R1 started coughing and shifted her weight on her air mattress causing her to fall off the bed. V4 was unable to break the fall. On 11/7/2023 at 11:03 AM, V3 (CNA) said on 10/14/2023 around 1:30 AM, she was providing incontinence care to R1. V3 said she was by herself and had no help. V3 said she provided care to R1 routinely by herself only. V3 said she was aware that R1's ISP (Individualized Service Care Plan) stated R1 was dependent on two people assist with bed mobility. V3 said on that day, while assisting R1 with incontinent care, V3 turned R1 away from her and V3 reached out for R1's incontinence brief at the foot part of the bed. R1 began to cough and suddenly. R1 went over the bed and fell on the floor. V3 said she went to get the nurse. The nurse called the paramedics immediately and R1 was sent to the hospital. V3 said she was traumatized by the incident and since that happened, she does not change R1 by herself. V3 said V4 was not there to help her when R1 fell . R1's Admission Records shows R1 was initially admitted to Facility on 6/9/2023. R1 was discharged to hospital on 10/14/2023 and was readmitted on [DATE]. Diagnoses include displaced fracture of base of neck, aphasia, laceration on part of head. R1's MDS (Minimum Data Sheet) dated 9/25/2023 documented R1's cognition was severely impaired. R1 was totally dependent on 2-person physical assist with bed mobility, transfers, dressing, and toilet use. On 11/7/2023 at 11:30 AM, R1 was observed hunched over on her right side in a fetal position due to contracture to both upper and lower extremities. On 11/7/2023 at 11:30 AM, V6 (LPN-Licensed Practical Nurse) said if there were two staff assisting R1 with bed mobility and incontinence care, R1 would not have fallen even if she started coughing. She said the air mattress might be slippery but if there is someone supporting R1 on both sides of the bed, she would not have fallen. On 11/7/2023 between 11:41 AM and 11:45 AM, V7 (CNA) and V8 (CNA) said if there are two staff assisting R1 with bed mobility and incontinence care, R1 would not have fallen even if she was coughing because both staff would support R1's upper and lower extremities. On 11/8/2023 at 10:00 AM, V13 (R1's Physician) said R1's left femoral neck fracture was because of fall she sustained from rolling out of her bed on 10/14/2023. V13 said he was informed that R1 fell while R1 was being changed by staff. He said if there were 2 or 3 staff assisting her during changing, the fall might not have happened, and she would not have a fracture. He said R1's fractured femoral neck's prognosis is not good because she is completely contracted and bed bound. The chances of healing will be poor and slow. R1's hospital records dated 10/14/2023 at 2:42 AM documented that due to fall, R1 had a laceration on top of her bed and was repaired with a single staple in the Emergency Department. R1's CT (Computed Tomography) scan of abdomen and pelvis done on 10/16/2023 showed a mildly displaced left femoral neck fracture that was new compared to CT done on 6/6/2023. Facility's Fall Prevention and Management Policy reviewed on 09/2023 stated the following: . General: The facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing 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.

Based on interview and record review, the facility failed to ensure one resident (R1) was free from a fall with serious injury out of 6 residents reviewed for falls. This failure resulted in R1 sustaining a pelvic fracture. This applies to 1 of 6 Residents (R1) reviews for falls Findings include: R1's Admission Record documents that R1 is a [AGE] year-old with diagnoses including but not limited to osteoarthritis and pain in left ankle and joints of the left foot. R1's original admitted is listed as July 24th 2017. R1's MDS (Minimum Data Set) section C for Cognitive Patterns dated May 4th 2023 documents that R1's cognition is severely impaired; Section G for Functional Status documents that for the ADL (Activities of Daily Living) tasks of bed mobility and transfers, R1 requires two-person physical assist; and Section GG for Functional Abilities and Goals documents that for the ability to roll left and right, R1 was coded as 01. Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required to complete the activity. On July 24th 2023 at 4:34 PM, the surveyor attempted to contact R1 at the hospital, however, R1's nurse stated that R1 was not alert enough to answer questions at that time. On July 25th 2023 at 11:07 AM, V18 (R1's Family Member) stated that when he asked R1 what happened, R1 told him that the CNA (Certified Nursing Assistant) was changing her (R1) and she (R1) fell down. V18 added, She was in tremendous pain and was screaming when the x-ray technician arrived to the facility and was placing the x-ray plate underneath R1. On July 24th 2023 at 2:33 PM, V4 (Agency CNA) stated that she (V4) was providing incontinence care by herself to R1 at the time of R1's fall out of the bed. V4 explained that after positioning R1 on her (R1) left side, she (V4) quickly ran into the bathroom inside of R1's room to get more supplies, leaving R1 unattended for no more than 10 seconds. V4 acknowledged that she (V4) witnessed R1 fall out of the bed as she (V4) stepped out of the bathroom. V4 stated that R1 landed onto her right side on the floor. On July 27th 2023 at 3:06 PM, inquired what position the bed was in. V4 stated, It wasn't that high. I'm 5'3 so it was at my waist length. On July 24th 2023 at 3:06 PM, V5 (RN/Registered Nurse), who was the nurse on duty at the time, stated that when she (V5) asked R1 what happened, R1 pointed at the CNA and told her (V5) to ask the CNA. V5 affirmed that V4 told her that while providing incontinence care, V4 went into the bathroom for more supplies. V4 stated that when she (V4) arrived to the room, R1 was lying on her back and had a spilled cup of water next to her (R1). V5 stated that R1 complained of pain to the right hip. On July 24th 2023 at 4:57 PM V3 (ADON/Assistant Director of Nursing) stated that she (V3) conducted the fall with serious injury investigation and submitted the Initial Report to the state agency on July 21st 2023 . V3 affirmed that based on V4's interview, V4 stepped away very quickly while providing incontinence care to R1. V3 added that she (V3) educated V4 on not leaving a resident unattended during incontinence care. V3 stated that she (V3) also told V4 to ensure that a resident is lying on his or her back in the center of the bed, if she (V4) ever needs to step away to get something or to use the call button for assistance if she's unable to step away. On July 24th 2023 at 3:52 PM, the surveyor inquired if a resident should be left unattended while being provided with incontinence care. V7 (Nurse Practitioner) replied, No, not until they're done. V7 added, Depending on how much they move, they could roll off the bed. They could break something. On July 26th 2023 at 10:21 AM, V18 (R1's Family Member) denied that R1 told him (V18) that she (R1) was reaching for water at the time of the fall. V18 stated, That kind of explanation does not make any sense. V18 stated that the only time R1 can reach for something is when it is placed directly in front of her (R1). V18 added, She (R1) cannot turn and pick it up. The surveyor inquired if R1 was capable of holding onto a side rail. V18 stated that R1's bed has never had side rails. V18 stated that if R1's bed had a side rail, there's a possibility she (R1) would have held onto it and not just the corner of the bed sheet. On July 26th 2023 at 12:28 PM, V19 (Restorative Director) acknowledged, Since, I've been here, I don't believe she's (R1) had rails. V19 stated that she (V19) has been at the facility since October 2022. R1's 8/8/22 Restorative: Side Rail Review documents, in part, The resident will not use side rails at this time. On July 26th 2023 at 1:09 PM, V21 (MDS Coordinator) explained that if a resident is coded as Dependent, then that resident would be considered a total assist and is unable to provide any assistance with that particular ADL. V21 stated, They're not able to maintain a side-lie, for example. V21 clarified that the resident would not be able to stay in a turned position on their own. V21 gave an example stating that the facility pretty much does not use side rails so if a resident does not have anything to hold onto and keeps falling back from a turned position then that resident would require a two-person assist, one to hold onto the resident and the other to provide the incontinence care. R1's 7/20/23 Right hip and pelvis x-rays done at the facility document, in part, Impression: Right hip pinning with fractures to the right superior and inferior pubic rami. R1's 7/20/23 ED (Emergency Department) Provider note authored by V20 (ED Physician) documents, in part, that R1 was diagnosed with a closed nondisplaced fracture of the right acetabulum and a closed fracture of the right pubis. R1's care plan initiated on 3/9/19 documents, in part, Fall: (R1) is at high risk for falls r/t (related to) weakness and limited mobility secondary to type 2 DM (Diabetes Mellitus), asthma, anxiety, osteoarthritis, hypertension and anemia. Interventions include but are not limited to Anticipate and meet the resident's care and safety needs. The 10/2021 Fall Prevention and Management facility policy 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 falls, plan for preventive strategies, and facilitate as safe an environment as possible.

Based on observation, interview, and record review, the facility failed to properly transfer a resident and failed to follow residents care plan. This failure resulted in the resident falling and obtaining a scalp hematoma, periorbital swelling, facial bruising, and pain and sent to hospital for treatment. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: On 5/11/23 at 10:02 AM, telephone interview was conducted with V4 (R1's POA/Power of Attorney). V4 stated the following: On Friday 5/5/23, an unknown female CNA (Certified Nursing Assistant) used a gait belt and tried to transfer (R1) from the bed to the wheelchair. R1 fell on to the floor. Her forehead had a raised area that was like 1/2 inch. She had some dark bruising and her left eye was swollen. There was some bruising up her left arm. There is a sign in her room that specifically says she is a mechanical lift. The CNA did not use the lift and transferred her by herself. There is always supposed to be two people. (R1) has weak legs. I heard that the CNA did not lock the wheelchair. (R1) was sent to the hospital. (R1) has pretty severe dementia. I tried asking (R1) what happened, but she doesn't remember the incident at all. On 5/12/23 at 9:42 AM, V4 met surveyor in the facility. V4 showed surveyor pictures from her cell phone of R1's face before and after her fall incident on 5/5/23. V4 also emailed surveyor the pictures. The pictures showed that R1 had a swollen left eye and there was purplish bruising on her left periorbital area, cheek, and forehead. There were all 3 small bruises (circular in size) to her left arm. V4 stated when she went to the ER (emergency room ) on 5/5/23, R1 had already been discharged back to the facility. The ER nurse at the hospital told her that that paramedics were told by the facility staff that R1 had a fall because the CNA (Certified Nursing Assistant) used a gait belt to transfer R1 from the bed to the wheelchair that was not locked. The CNA did not use a mechanical lift to transfer R1. On 5/12/23 at 10:32 AM, V3 (LPN/Licensed Practical Nurse/Unit Manager of 2nd Floor) stated the following: I was working on Friday 5/5/23, the day of the incident. I think it was around 10 AM. I heard someone say We need help. I believe it was V5 (Agency LPN/Licensed Practical Nurse) who said that. When I went to her room, I found (R1) lying on her back on the floor positioned diagonally to the bed and in between the dresser and bed. The CNA supervisor, V5, and V6 (CNA) were all next to (R1). (R1) had a hematoma above the left eye. There was no blood. There were little marks or bruises on her arm. I assessed (R1) and we also called V7 (Nurse Practitioner) to come assess her. I interviewed (V6) on what happened. (V6) transferred (R1) from the bed to the wheelchair by putting a gait belt on (R1), standing her up, then pivoting her by herself. (V6) and (R1) lost their balance and fell to the floor. I asked her why she transferred (R1) like that. She stated that she does it all the time with physical therapy like that in (R1's) room. (V6) got mixed up. She thought it was ok. I told her that therapy can do that, but as a CNA she can't do that. (V5) called 911 and I sent (V6) home immediately. She was suspended pending investigation. Every resident should have an ISP (Individualized Service Plan) hanging on their wall beside their bed. It has a confidentiality sheet over it. The ISP will tell staff what the transfer status is for the resident. (R1) also has a magnet that says H, which means Hoyer Lift. It's on the light fixture over the bed. We checked (R1)'s wheelchair and did an inspection of all the wheelchairs in the building. On 5/12/23 at 11:09 AM, surveyor went with V3 to the second floor. V4 was pushing R1's wheelchair in the hallway. Surveyor and V3 asked V4 if she would bring R1 back to her room so surveyor can evaluate and ask R1 some questions pertaining to the incident. R1 was brought back to her room. R1 was sitting in her wheelchair and her sling to the mechanical lift was under her. R1 had bruises to her left side of the forehead, periorbital area, and cheeks. The bruises were fading and the left side of her face had a yellowish tone to it. R1 was asked if she remembered anything about the fall. R1 stated, I don't remember the fall. I bumped my head three times. I don't know how it happened. They haven't been using the machine on me. It hasn't healed yet. Surveyor asked R1 if she had any pain and if she could rate it. R1 paused for several seconds and stated, It hurts on the left side of the face. It hurts a lot. I guess it would be a pain of 5 out of 10. Surveyor asked R1 if the pain is always there or when she touches it. R1 stated, I don't know. Surveyor asked R1 if she told anyone that she has pain. R1 stated she doesn't know. On R1's wall above the head of bed was her ISP (Individualized Service Plan) and there was a small laminated sign that says H. As per V3, the H stands for Hoyer Lift and is put up by the restorative nurse. V4 stated this is the first time she's seen that sign. R1's ISP documents the following: Transferring: 1. Explain procedure. 2. Lock wheelchair brakes. 3. Apply Hoyer sling. 4. Provide encouragement during transfer if becomes fearful. Attempt transferring daily. Transferring Hoyer Lift 2 Asssist. On 5/12/23 at 11:51 AM, telephone interview was conducted with V6 (CNA/Certified Nursing Assistant). V6 stated the following: I've been working as a CNA for [AGE] years. I'm assigned to (R1) five days a week. I know her very well. On 5/5/23, physical therapy came to the unit and told me that they need (R1) ready for her therapy session. So, I put a gait belt around her. Then, I did an extensive stand and pivot with (R1) by myself from the bed to the wheelchair. I tried to sit her in the chair, but the wheelchair moved. I locked the wheelchair and checked it twice. When I was turning (R1), her bottom thigh hit the wheelchair and then it started rolling away. I was like what's this? I tried to grab the wheelchair with my right leg, but then it was too late. We both fell and I was pinned under her. I never had a fall like this. We have been getting her up without a mechanical lift for quite a few days. We were just doing a stand and pivot technique. I got confused. I thought her transfer status got updated and we were not using the Hoyer lift anymore. On (R1's) head, there was knot and bruise on her upper frontal lobe. Surveyor asked V6 how she would find out the transfer status of a resident. V6 stated it would be either in the computer or on the wall in the resident's room. V6 stated she remembered R1 having the letter H above the head of her bed. V6 stated she was asked by V3 why she transferred R1 without a mechanical lift and another staff member. V6 stated because therapy was doing a stand to pivot on R1 and she just got confused. V6 said she was sent home until management finished their investigation. On 5/12/23 at 12:00 PM, V7 (Nurse Practitioner) stated the following: On 5/5/23, I was called into (R1's) room when she feel. I found her laying on her back on the floor. She had a lump on her forehead. There was a hematoma 3 x 4 inches on her left forehead. I did a trauma exam on her. She was complaining of neck pain, so we did not move her from the floor. We just waited for the ambulance and then she was sent to the hospital. This fall could have been have prevented if the CNA looked at the transfer status of the resident and used a mechanical lift. On 5/12/23 at 12:30 PM, V1 (Administrator) stated the following: I was working on 5/5/23. I think it was (V3) who brought it to my attention that (R1) had a fall. I immediately went up to (R1's) room and did an investigation. (V6) did a stand and pivot transfer of (R1) which resulted in (R1) falling. There was bruising and hematoma to her face and forehead. According to (V6), she and the physical therapist would do a stand and pivot transfer with (R1). (V6) got confused. She was not supposed to transfer (R1) using a gait belt. Instead, she was to look at the ISP, find out her transfer status, and then transfer (R1) with a Hoyer lift, which requires the assistance of two staff members. We did re-education with (V6) and sent her home. I had maintenance bring the wheelchair down to my office. We both inspected it. V2 (Assistant Administrator) and V3 (2nd Floor Unit Manager) checked it as well. There was nothing wrong with it. When we locked it, we couldn't move it. All the wheelchairs in the facility were inspected. There were no issues noted. On 5/12/23 at 1:12 PM, telephone interview was conducted with V5 (Agency LPN/Licensed Practical Nurse). V5 stated the following: On 5/5/23, I was (R1's) nurse. I never personally saw (R1) fall. I was called to the room by (V6). (V6) said she transferred (R1) by herself without using the Hoyer-lift. (R1) had a large contusion to the side of her face. (V7) was in the building, so we asked her to assess (R1). I called 911 and did the paper work. On 5/12/23 at 1:39 PM, V8 (CNA) stated, (R1) had complained of pain in her eye area today. Her face looks swollen and it's still sore. I told the nurse and I think he gave her some pain medication. On 5/12/23 at 2:09 PM, V9 (Agency LPN) stated, I'm (R1's) nurse today. (V8) told me she was complaining of pain, so I gave her Tylenol. R1's EMAR (Electronic Medication Administration Record) shows that R1 got Tylenol for pain (2/10) on 5/12/23 at 1:00 PM. R1's incident report dated 5/5/23 progress note dated 5/5/23 documents the following: This nurse was called to (R1's) room by (V6-CNA/Certified Nursing Assistant) who informed this nurse that she'd fallen with (R1) while transferring her from the bed to chair. (R1) was noted to be in a left side lying position at a 90 degree angle to her bed. (R1) stated, I don't know what happened by my head hurts. This nurse assessed (R1) noting a large contusion on the left side of (R1's) face with no other obvious injuries noted. Sent (R1) to the hospital for an evaluation. Notified nurse practitioner. Left a message for (R1's) POA (Power of Attorney) to call this nurse at the facility. Incident report also documents: (V6) was transferring (R1) to wheelchair when wheelchair shifted back and both (V6) and (R1) fell to the floor. Intervention: Inspected wheelchair for proper working function and re-educated (V6) on proper/safe transferring guidelines. Care plan in place. V7 (Nurse Practitioner)'s note dated 5/5/23 documents: Called to patient's room after she experienced a fall and sustained a head injury. Upon entering room, patient is laying on her back in the floor. Has a pillow under her head. She is awake and can answer questions. Denies any LOC (Loss Of Consciousness). Remembers falling but can't provide details. Has pain in left forehead, but no extremity/back pain. Initially did also complain of neck pain. Has 3 x 4 inches hematoma left forehead/above left eye. Skin: Hematoma left forehead as above. Small echymotic area just medial to left anticutibal area. Assessment and Plan: 1. Fall: Patient experienced a fall and sustained a head injury. Large hematoma above left eye on forehead. No LOC. Neuros at baseline. 911 called due to head injury. Initially, patient complains of neck pain, so made comfortable on floor. No transfer until paramedics present with equipment. Sat with patient until paramedics arrived. Ambulance left with patient at 10:15 AM. Primary care physician notified. Staff notified family. Patient taken to hospital ER (emergency room ) for further evaluation. EMS (Emergency Medical Services) report dated 5/5/23 documents the following: Called to above location for a fall. On arrival, found (R1) laying on the floor of her room with staff around her. Facility staff state they were assisting her from her bed to a wheelchair. Chair was not locked in place and rolled away as (R1) sat down. (R1) has a moderate hematoma to left forehead. Staff denies any loss of consciousness. (R1) denies any other injuries and has no other obvious sings of trauma. (R1) denies neck pain. (R1) lifted from floor and onto cot in a position of comfort. (R1) secured and moved to ambulance. (R1) transported to hospital and left in care of registered nurse. Hospital records dated 5/5/23 documents the following: ED (Emergency Department) Attending Note-[AGE] year old female with dementia was able to tell me she is here for a fall but could not give me any details. EMS (Emergency Medical Services) informed the nurse that patient was being transferred from the bed to the wheelchair and the wheelchair was not locked and the patient ended up falling on the ground in front of staff but did not lose consciousness. She does not have any complaints rights now. She has hematoma to her left forehead. No anticoagulation reported. Physical Exam: HENT (Head, Eyes/Ears, Nose, and Throat)-Comments: Left forehead and brow hematoma with superficial abrasions. Radiology Results CT (Computerized Tomography) Head Without Contrast Impression: 4. Large left frontal scalp hematoma and left periorbital soft tissue swelling. Left front scalp hematoma measures up to 1.3 CM (Centimeters) in thickness. Final diagnoses: Injury of head, initial encounter. Traumatic hematoma of forehead, initial encounter. R1's face sheet documents an admitted [DATE]. R1's face sheet documents the following diagnoses: paranoid personality disorder, visual hallucinations, auditory hallucinations, dementia in other diseases classified elsewhere, mild, with other behavioral disturbance, psychotic disorder with delusions due to known physiological condition, and weakness. R1's MDS (Minimum Data Set) dated 3/13/23 documents a BIMS (Brief Interview for Mental Status) score of 6, which is means she is severely cognitively impaired. R1's transfer score is a 4/3, which means she is total dependence with a two person physical assist. R1's fall risk assessment dated [DATE] during initial admission documents a score of 13, which means she is a high fall risk. R1's fall risk assessment dated [DATE] (after the fall) documents a score of 23, which means she is an extremely high fall risk. Both assessments show that R1 has unsteady gait and/or use of ambulatory device (cane, walker, wheelchair). R1's care plans document the following: Focus: (R1) is at risk for falls related to generalized weakness and decreased functional mobility secondary to CAD (Coronary Artery Disease), Dementia, HLD (Hypersensitivity Lung Disease), Hypertension, Psychosis, Chronic Kidney Disease, and Paranoid Personality Disorder. Goal: (R1) will remain free from falls through next review date. Interventions: 5/5/23-Inspect wheelchairs for proper working order and re-educate CNA's (Certified Nursing Assistant) on proper/safe transferring process. Focus: Hoyer Lift: (R1) has a self care deficit in transferring related to generalized weakness and decreased functional mobility. Goal: (R1) will be able to transfer safely with Hoyer and 2 staff assist daily through next review. Interventions: 1. Explain procedure. 2. Lock wheelchair brakes. 3. Apply Hoyer sling. 4. Provide encouragement during transfer if becomes fearful. 5. Attempt transferring daily. Facility's policy titled Transfer Status (9/2022) documents: 1. Upon admission to the facility, the restorative nurse will screen the patient/resident to determine transfer status. If the restorative nurse is unavailable, the admitting nurse will use the referral information to determine transfer status prior to discharge from the hospital or from previous location. 2. The transfer status will be entered into the EHR (Electronic Health Record) via the Admission Clinical Observation. Facility's policy titled Fall Prevention and Management (7/2022) documents: 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. 2. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP (Individualized Service Plan) with interventions implemented to minimize fall risk. Facility's policy titled Mechanical Lift-Hoyer (10/2022) documents: 6. One caregiver is to focus on the resident's head and body positioning while the other is operating the lift.

Based on interview and record review the facility failed to ensure a resident received follow-up/outpatient care from a urologist after being hospitalized with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R1 being hospitalized for [CONDITION(S)] secondary to a [CONDITION(S)]. The findings include: R1's Admission Record dated April 7, 2022 showed R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital records dated March 30, 2022-April 7, 2022 showed R1 was hospitalized with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The records showed R1 had a urinary catheter in place during the hospitalization . R1's hospital discharge instructions dated April 7, 2022 showed R1 was discharged back to the facility. R1's discharge instructions showed R1 was to make a follow-up appointment with a urologist in 4-6 weeks for a voiding trial (a trial to assess the ability of the bladder to empty). R1's facility physician note dated April 8, 2022 showed R1 should follow-up with Urology in 4-6 weeks for re-evaluation . R1's facility physician note dated May 2, 2022 showed R1 should see his urologist for an appoinment towards the end of May (2022). R1's medical records including progress notes, appointments, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These records showed no urology follow-up appointments for R1. R1's hospital records dated September 11, 2022 showed R1 was again admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital physician urology consult note dated September 12, 2022 showed R1 presented to the hospital with a complaint of abdominal pain and was diagnosed with [CONDITION(S)] related to a [CONDITION(S)]. The note showed R1 was seen by our service in April (2022) for [CONDITION(S)]. Failed a voiding trial prior to discharge (from the hospital). Did not follow up with us . On September 15, 2022 at 10:50 AM, V6 Physician Assistant (PA) stated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 stated, (R1's) hospital discharge instructions from April (2022) showed he was to follow-up with a urologist for a voiding trial. I just had the voiding trial done here (in the facility) in April and he failed it. We put the urinary catheter back in. No, I didn't notify the urologist that (R1) had failed the voiding trial. I haven't contacted (R1's) urologist to discuss any further cares or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On September 15, 2022 at 10:13 AM, V3 Assistant Director of Nursing stated, (R1) did not have a follow-up appointment with a urologist after his hospitalization in April (2022). On September 15, 2022 at 11:50 AM, V4 Infectious Disease Nurse Practitioner stated, I am not sure if (R1) has seen a urologist outside of being hospitalized . He needs follow-up with urology because of his history of [CONDITION(S)], frequent UTIs, [CONDITION(S)], and obstructive [CONDITION(S)]. On September 16, 2022 at 12:10 PM, V7 Urologist for R1 stated, I just saw (R1) in the hospital for a consult a few days ago Even if the facility did a voiding trial on him in April (2022), he still should have followed up with us (urology physician group). He has a very complicated urological history including recurrent UTIs resulting in [CONDITION(S)], obstructive [CONDITION(S)], [CONDITION(S)], and the need for a urinary catheter. That is why the follow-up with us was listed on his discharge instructions from April (2022).

Based on observation, interview, and record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to follow the facility's policy for administering and documenting the total amount of tube feeding received by the residents. This failure resulted in R1 sustaining a significant weight loss of 6.38 percent in one month, developing a facility-acquired pressure ulcer, and being hospitalized for [CONDITION(S)] and dehydration. The Immediate Jeopardy began on July 5, 2022, when R1 was seen by V6 (NP-Nurse Practitioner) for abnormal lab values and appeared dry on examination after the facility failed to ensure R1 received enteral tube feedings and free water flushes as ordered by the physician. The Immediate Jeopardy was identified on August 2, 2022. V1 (Administrator), V2 (DON-Director of Nursing), V20 (Regional Nurse Consultant) and V21 (ADON-Assistant Director of Nursing) were notified of the Immediate Jeopardy on August 3, 2022 at 8:45 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on August 3, 2022 at 4:37 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff, documentation of enteral tube feedings, free water flushes, and administration and documentation of the total amount of tube feeding received by the residents. This applies to 5 of 5 residents (R1, R2, R4, R9, R12) reviewed for tube feeding and dehydration in the sample of 17. The findings include: The facility's 672 Question Detail report, dated August 1, 2022, shows six residents currently residing in the facility who receive gastrostomy tube feedings (R2, R4, R9, R12, R16, R17). 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was transferred to the local hospital on July 20, 2022 and did not return to the facility. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated May 15, 2022 shows R1 had moderately impaired cognition. R1 was totally dependent on facility staff for bathing, transfers between surfaces, and eating, R1 required extensive assistance with bed mobility, locomotion, dressing, toilet use and personal hygiene. R1 was always incontinent of bowel and bladder. R1's care plan, initiated May 19, 2022 for dietary, shows R1 is on a tube feeding related to disease process. R1's care plan goals, initiated May 19, 2022 show R1 will be well-nourished on present tube feed regimen as evidenced by stable weight through next review. Interventions initiated May 19, 2022 include monitoring monthly weights, one time a day [MEDICATION(S)] 1.2 80 ml/hour (milliliters per hour) until 1600 ml is infused, and four times a day water flush 400 ml. The EMR shows an order dated May 12, 2022 to July 15, 2022 for enteral feed order for [MEDICATION(S)] 1.2 at 72 ml/hour until 1440 is infused. R1's July 2022 MAR/TAR (Medication Administration Record/Treatment Administration Record) dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show the feeding was administered as ordered on June 17, 18, 25, 28, 30, 2022 and July 10, 11, and 13, 2022. The EMR shows an order dated July 15, 2022 to July 20, 2022 for [MEDICATION(S)] 1.2 at 80 ml/hour until 1600 ml is infused. R1's July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the feeding as ordered on July 15 and 17, 2022. The EMR shows an order dated May 12, 2022 to July 6, 2022 for 200 ml water flush, four times a day. R1's June and July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the water flushes as ordered on June 17, 18, 19, 20, 24, 25, 27, 28, 30, 2022, July 2, 4, and 6, 2022. The EMR shows an order dated July 6, 2022 for 400 ml water flush, four times a day. R1's July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the water flushes as ordered on July 6, 7, 8, 10, 11, 13, 14, 15, 16, 17, and 18, 2022. The EMR shows R1's weight on June 7, 2022 at 166.2 pounds. On July 6, 2022 R1's weight was 154.0 pounds. R1 was reweighed on July 7, 2022. R1's weight was 155.6 pounds, a 6.38 percent weight loss in one month. On July 20, 2022 at 7:37 PM V11 (ER physician) documented, This is an [AGE] year-old female with a history of dementia, ischemic stroke, hypertension, [CONDITION(S)], metabolic [CONDITION(S)], type 2 diabetes mellitus, [CONDITION(S)] heart disease, pulmonary embolism, recurrent urinary tract infection due to indwelling urinary catheter who was sent here from [nursing care facility] because of decreased level of consciousness. Evidently patient who is usually responsive is unresponsive today when nursing staff checked on her. Patient also appeared to have decreased urinary output, so she was transferred to the ED. On arrival to the emergency department the patient is definitely decreased responsiveness, she only responds to deep pain, she is tachypneic and [CONDITION(S)]. Patient is a DNR (Do Not Resuscitate), so was not intubated but rather placed on [CONDITION(S)] (Bilevel Positive Airway Pressure) for her respiratory rates. Her oxygen saturation was maintained at 100% in spite of her tachypnea. Unable to give any history. Patient with a large decubitus ulcer present on her sacrum, it is not very deep however there is a very wide area measuring about 8 to 9 mm (millimeters) that is affected. Patient's indwelling urinary catheter was changed out by nursing staff, and it was noted to not be completely in place, patient was urinating around it, and when it was removed a large amount of urine came out onto the bed. 8 French catheter was inserted, and a large amount of purulent and bloody urine immediately drained into the bag. Patient drained about 900 ml immediately and at this point her respiratory rate did drop down to 31 breaths/minute. Will be admitted for [CONDITION(S)]. The EMR shows R1's BUN (Blood Urea Nitrogen) blood level on July 5, 2022 was 32 mg/dL (milligrams/deciliter) (Normal range 7-28 mg/dL), and R1's creatinine level was 0.28 mg/dL (normal range 0.44 to 1.32 mg/dL). Upon admission to the hospital on July 20, 2022 at 7:52 PM, R1's BUN level was 81 and R1's creatinine level was 2.92. On July 28, 2022 at 11:47 AM, V4 (Dietitian) said, I increased [R1's] water flushes due to her lab results showing she had an elevated BUN level of 32 mg/dL. Increased levels of the BUN and creatinine can indicate dehydration. The tube feeding and water flush calculations, if given as ordered, should have prevented [R1] from becoming dehydrated. I ordered everything necessary to keep her hydrated and promote wound healing. But if the order was not administered the way it was intended, I would not know that. I was never told by facility staff there were any concerns regarding [R1] tolerating the tube feedings or water flushes or that she was not receiving the tube feedings as ordered. On July 28, 2022 at 12:03 PM, V9 (Wound Physician) said, I saw [R1] on July 7, 2022. The Stage 3 pressure ulcer of the coccyx was identified that day. Getting the correct amount of tube feeding and hydration is paramount to wound healing. This resident already had a wound on her buttocks, and the lack of nutrition played a role in a second wound developing. The EMR shows V6 (NP-Nurse Practitioner) documented the following for R1 on July 5, 2022 at 2:25 PM: [R1] seen today for new leukocytosis, [CONDITION(S)] (high sodium level) and ongoing debility. Sodium level elevated at 152, will increase FWF (Free Water Flushes) from 200 ml, four times a day to 400 ml four times a day. She does appear dry on exam . On August 1, 2022 at 10:40 AM, V6 (NP) said, I saw [R1] on July 5, 2022. She appeared dry to me, based on her labs. I had no idea the facility staff were not giving the water flushes as ordered. If that's an order, you are a licensed individual and you should carry out the orders and if it isn't able to be done, we should be notified. On August 1, 2022 at 4:19 PM, V12 (Physician) said, I cared for [R1] in the hospital. She had [CONDITION(S)] due to a [CONDITION(S)] (Urinary Tract Infection). I was not aware this resident was not receiving her tube feeding and free water flushes as ordered. She was admitted to the hospital with multiple concerns, including dehydration. Not receiving tube feedings and water flushes would definitely contribute to a resident becoming dehydrated. I expect facility staff to follow the orders for tube feedings and water flushes. 2. On August 1, 2022 at 11:26 AM, R2 was lying in bed in his room. R2 did not have tube feeding running at the time of the observation. A tube feeding bag was attached to the tube feeding pole labeled Glucerna, tube feeding was present in the dispensing bag, and the tube feeding tube was connected to R2's gastrostomy tube. The bag was dated August 1, 2022 at 5:00 AM. The tube feeding pump was in the off position. On August 1, 2022 at 12:12 PM, R2's tube feeding pump continued to be in the off position and R2 was not receiving the tube feeding. V13 (LPN-Licensed Practical Nurse) entered the room and said the tube feeding should be turned on. V13 turned the tube feeding machine to the on position and the tube feeding started to run at 60 ml/hour. V13 continued to check the status of R2's tube feeding pump. The pump showed a total amount infused as 9,577 ml. V13 said, Someone forgot to clear the pump when the tube feeding was started so we have no idea how much the resident is receiving. He should receive 700 ml. The nurse from the night shift forgot to start [R2's] tube feeding last night at 5:00 PM, so the tube feeding did not get started until 5:00 AM this morning. I have not given any water flushes yet to the resident. V13 went to the computer and checked the tube feeding order for R2 and said the order shows R2 should receive 720 ml not 700 ml as she previously stated. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS dated [DATE] shows R2 has severe cognitive impairment, requires extensive assistance with eating, dressing, personal hygiene, and transfers between surfaces and is totally dependent on facility staff for all other ADLs. The EMR shows an order dated May 22, 2022 for Glucerna 1.2 to run at 60ml/hour until 720 ml is infused, to start at 5:00 PM. R2's July 2022 MAR/TAR dated August 1, 2022 at 12:59 PM shows the facility does not have documentation to show R2 received the tube feeding as ordered on July 16 or 31, 2022. The EMR shows an order dated March 16, 2022 for free water flushes of 150 ml, three times a day. R2's July 2022 MAR/TAR dated August 1, 2022 at 12:59 PM shows the facility does not have documentation to show R2 received the water flushes as ordered on July 3, 7, 12, 16, 17, 23, and 31, 2022. 3. On August 1, 2022 at 11:31 AM, R4 was sitting up in the chair in his room. R4's tube feeding pole had a bottle of [MEDICATION(S)] 1.2 hanging from the pole and the tube feeding was running at a rate of 75 ml/hour via the feeding pump. V14 (LPN) used the controls on the front of the tube feeding pump to show 342 ml of tube feeding had infused thus far, and a total of 1428 ml was to be infused. V14 checked R4's physician order. The order in the EMR shows R4 should receive [MEDICATION(S)] 1.2 at 75 ml/hour until 1500 ml is infused. V14 said there was a discrepancy between the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS dated [DATE] shows R4 has severe cognitive impairment, and is totally dependent on facility staff for eating, transfers between surfaces, and bathing, and requires extensive assistance for all other ADLs. The EMR shows an order dated March 24, 2022 for [MEDICATION(S)] 12 at 70 ml/hour until 1400 ml is infused. The EMR also shows an order dated July 30, 2022 for [MEDICATION(S)] 1.2 at 75 ml/hour until 1500 ml is infused, to start at 5:00 PM daily. During review of the EMR on July 28, 2022, the facility did not have documentation to show R4 received the tube feeding as ordered on July 7, 12, 13, 14, 17, 17, 18, 19, or 21, 2022. The EMR shows an order dated March 24, 2022 for water flush of 150 ml, three times a day. During review of the EMR on July 28, 2022, the facility did not have documentation to show R4 received the water flushes as ordered on July 1, 7, 14, 15, 16, 17, 28, 19, 20, 21, 22, 24, and 27, 2022. On August 1, 2022 at 10:20 AM, V2 (DON-Director of Nursing) reviewed R4's documentation and said as of August 1, 2022, the medical record had been altered from observations on July 28, 2022 to show missing documentation of R4's tube feeding, and water flushes were now filled in for the month of July 2022. V2 said, I thought we had a grace period and could go back for the month and fill in the documentation that was missing. V15 (Regional Nurse Consultant) said nursing staff should document all medications administered, tube feedings, water flushes and wound treatments at the time of administration. 4. On July 28, 2022 at 9:11 AM, R9 was lying in bed. Tube feeding was infusing to R9's gastrostomy tube at a rate of 75 ml/hour, and 1,063 ml had infused, as shown on the tube feeding pump. The EMR shows R9 was admitted to the facility in June 2019 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's MDS dated [DATE] shows R9 is rarely/never understood and has moderate cognitive impairment. R9 is totally dependent on facility staff for eating, bed mobility, transfers between surfaces, toilet use, and bathing. The EMR shows an order dated May 29, 2022 for [MEDICATION(S)] 1.5 at 70 ml/hour to start at 6:00 PM for a total volume of 1260 ml/24 hours. R9's July 2022 MAR/TAR dated July 28, 2022 at 9:52 AM shows the facility does not have documentation to show R9 received the tube feeding as ordered on July 3, 7, 12, 14, 17, and 26, 2022. The EMR shows an order dated June 14, 2022 for 475 ml water flush every four hours. R9's July 2022 MAR/TAR dated July 28, 2022 at 9:52 AM shows the facility does not have documentation to show R9 received the water flushes as ordered on July 4, 5, 6, 7, 9, 10, 12, 15, 17, 18, or 26, 2022. 5. On July 28, 2022 at 9:15 AM. R12 was lying in bed. No tube feeding was running. An empty bag was hanging from the tube feeding pump and was attached to R12's gastrostomy tube. R12 was sleeping. The EMR shows R12 was admitted to the facility on [DATE] with [CONDITION(S)], gastrostomy, [CONDITION(S)], diabetes, respiratory failure with [CONDITION(S)], dysphagia, [CONDITION(S)], weakness, [CONDITION(S)], anxiety, and depression. R12's MDS dated [DATE] shows R12 is rarely understood and has moderate cognitive impairment. R12 is totally dependent on facility staff for eating and bathing and requires extensive assistance for all other ADLs. The EMR shows an order dated May 20, 2022 for [MEDICATION(S)] 1.5 via bolus 325 ml every six hours. R12's July 2022 MAR/TAR dated July 28, 2022 at 9:55 AM shows the facility does not have documentation to show R12 received the bolus tube feeding as ordered on July 7, 12, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 26, and 27, 2022. The EMR shows an order dated May 5, 2022 for water flushes of 300 ml, four times a day. R12's July 2022 MAR/TAR dated July 28, 2022 at 9:55 AM shows the facility does not have documentation to show R12 received the water flushes as ordered on July 7, 12, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 26, and 27, 2022. On August 1, 2022 at 1:29 PM, V2 (DON-Director of Nursing) and V15 (Regional Nurse Consultant) said facility staff should be following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 could not say what the facility policy shows or how long of a grace period facility staff should be allowed to go without documenting if physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy entitled Tube Feeding, reviewed on 9/2021 shows: Guideline: 1. Continuous tube feedings are based upon 22-hour consumption period or other time frame based on individual resident need per Registered Dietitian assessment and delivered over a 24-hour period. 2. Tube feedings are documented on the MAR and intake record. 6. The Health Care Provider should be notified if tube feeding amount not infused as ordered.9. Any tube feeding orders will include the formula, rate, time period, deliver method and flush. Feeding Pump: .4. Check residuals as ordered and alert Health Care Provider if there is more than 100 cc (cubic centimeters) or other order. 5. Pump should be cleared at the end of each shift. 6. Document tube feeding delivered. 7. Alert Health Care Provider of any issues or concerns. Through observation, interview, and record review conducted on August 4, 2022, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: All residents receiving enteral feeding were reviewed for appropriate orders. Education: On August 3, 2022 all nurses and CNAs (Certified Nursing Assistants) on duty were in-serviced by DON and Nurse Managers on the following: · Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] · Tube feeding, water flushes, gastric residual monitoring, notification, and documentation of tube feeding intake guideline/policy · Intake and output guideline/policy All remaining facility nurses, CNAs and agency staff will be in-serviced prior to the start of their next scheduled shift by DON, and Nurse Manager. New hire nurses and CNAs will be ins-serviced during orientation and/or prior to the start of their scheduled shift. Monitoring/Surveillance: · Audit input and residual amounts recorded on all residents receiving enteral feeding · Audit physician order [MEDICAL RECORD OR PHYSICIAN ORDER] All audits will be conducted daily for seven days, then three times a week for two weeks, then one time a week up to a total of six months. The results of the audits will then be taken to QAPI (Quality Assurance and Performance Improvement) to determine future frequency. The Administrator will be responsible for ensuring compliance with the staff in-servicing and audits. QAPI 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.

Based on observation, interview, and record review the facility failed to follow the facility's policy for monitoring urine output for residents with indwelling urinary catheters. The facility also failed to ensure residents with indwelling urinary catheters received catheter care. This failure resulted in R1 experiencing marked distension of the urinary bladder with urine retention of 900 ml (milliliters) of purulent, bloody urine and being admitted to the local hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy began on July 9, 2022, when the facility failed to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was identified on August 2, 2022. V1 (Administrator), V2 (DON-Director of Nursing), V20 (Regional Nurse Consultant) and V21 (ADON-Assistant Director of Nursing) were notified of the Immediate Jeopardy on August 3, 2022 at 8:45 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on August 3, 2022 at 4:37 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-service training of staff, documentation of catheter care, urine output, and initiation of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This applies to 10 of 10 residents (R1, R2, R3, R5, R6, R7, R8, R10, R11, R13) reviewed for indwelling urinary catheters in the sample of 17. The findings include: The facility's 672 Question Detail report, dated August 1, 2022, shows nine residents currently reside in the facility with indwelling urinary catheters (R2, R3, R5, R6, R7, R8, R10, R11, and R13). 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was transferred to the local hospital on July 20, 2022 and did not return to the facility. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated May 15, 2022 shows R1 had moderately impaired cognition. R1 was totally dependent on facility staff for bathing, transfers between surfaces, and eating, R1 required extensive assistance with bed mobility, locomotion, dressing, toilet use and personal hygiene. R1 was always incontinent of bowel and bladder. R1's care plan for [CONDITION(S)] related to [CONDITION(S)], initiated May 18, 2022 shows multiple interventions dated May 18, 2022 including Monitor/document/report for signs/symptoms of acute renal failure Oliguria (urine output less than 400 ml per 24 hours, increased BUN (Blood Urea Nitrogen) and creatinine. The EMR continues to show R1 was sent to the local hospital on July 9, 2022. R1 returned to the facility on [DATE] with an indwelling urinary catheter due to urine retention, pending urinalysis and urine culture results, and an order to ask your doctor about these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] ., take 1 tablet by mouth two times daily for 11 doses. Start tonight and continue 11 doses total with food. The facility does not have documentation to show nursing staff obtained an order from the physician to continue R1's indwelling urinary catheter or the physician's response to starting the [MEDICATION(S)] antibiotic. The facility does not have documentation to show nursing staff followed up on the urinalysis or urine culture results. The facility does not have documentation to show R1's urine output was measured or monitored every shift, or that R1 received daily indwelling urinary catheter care for the period of July 9, 2022 through July 20, 2022 when R1 was sent to the local hospital for unresponsiveness. On July 20, 2022 at 7:37 PM V11 (ER physician) documented, This is an [AGE] year-old female with a history of dementia, ischemic stroke, hypertension, [CONDITION(S)], metabolic [CONDITION(S)], type 2 diabetes mellitus, [CONDITION(S)] heart disease, pulmonary embolism, recurrent urinary tract infection due to indwelling urinary catheter who was sent here from [nursing care facility] because of decreased level of consciousness. Evidently patient who is usually responsive is unresponsive today when nursing staff checked on her. Patient also appeared to have decreased urinary output, so she was transferred to the ED. On arrival to the emergency department the patient is definitely decreased responsiveness, she only responds to deep pain, she is tachypneic and [CONDITION(S)]. Patient is a DNR (Do Not Resuscitate), so was not intubated but rather placed on [CONDITION(S)] (Bilevel Positive Airway Pressure) for her respiratory rates. Her oxygen saturation was maintained at 100% in spite of her tachypnea. Unable to give any history. Patient with a large decubitus ulcer present on her sacrum, it is not very deep however there is a very wide area measuring about 8 to 9 mm (millimeters) that is affected. Patient's indwelling urinary catheter was changed out by nursing staff, and it was noted to not be completely in place, patient was urinating around it, and when it was removed a large amount of urine came out onto the bed. 8 French catheter was inserted, and a large amount of purulent and bloody urine immediately drained into the bag. Patient drained about 900 ml immediately and at this point her respiratory rate did drop down to 31 breaths/minute. Will be admitted for [CONDITION(S)]. On July 28, 2022 at 12:29 PM, V5 (NP-Nurse Practitioner) said R1 was found unresponsive in her room on July 20, 2022. V5 said, [R1] was not responsive to painful stimuli, though she did have vital signs on July 20, 2022. We called an ambulance, and she was transported to the local hospital. A review of her hospital records shows [R1] was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Reviewing her hospital records further shows her indwelling urinary catheter was not draining urine properly upon arrival to the hospital and once the hospital personnel removed the malfunctioning catheter and inserted the new catheter, [R1] had 900 ml of bloody, purulent urine. Her labs drawn at the hospital further showed [R1] had a [CONDITION(S)] (Urinary Tract Infection). If a resident has an indwelling urinary catheter, facility staff should be monitoring the resident's urine output for the amount of urine output per shift, as well as the appearance of the urine including if the urine is cloudy, blood-tinged, or has an odor. I do not see any documentation to show [R1's] urine was being monitored for any of those things since the catheter was inserted in theER on [DATE]. Also, [V6] (NP) ordered an infectious disease consult, a urinalysis, and a urine culture for [R1] on July 5, 2022. Those labs were never obtained nor was the consult. A few days later, on July 9, [R1] went to the emergency room for hip pain and was diagnosed with urine retention of 900 ml of urine, and had an indwelling urinary catheter inserted in the ER, and also a urinalysis and urine culture were done. Those results were never followed up on by the nursing staff at the facility. [R1's] discharge paperwork from theER on [DATE] showed to check with the physician to see if an antibiotic ([MEDICATION(S)]) should be started. No facility staff informed me of those orders or asked if an antibiotic should be started for [R1]. All of those failures combined resulted in this resident ending up in the hospital with a [CONDITION(S)] and [CONDITION(S)] on July 20. On August 1, 2022 at 10:33 AM, V6 (NP) said, It has always been my experience while working at the facility, that when I see my residents and have orders, I write the information in my progress note and then tell the nurse and give verbal orders for what needs to be done, and it is the responsibility of the nurse to carry out those orders. On July 5, I was covering the entire facility, including my patients and [V5's] patients. I noticed [R1's] labs showed an elevated white blood cell count as well as elevated BUN, so I ordered additional hydration, and urinalysis and urine culture, as well as an infectious disease physician consult. On this particular day I very much remember verbally giving these orders to the nurse caring for [R1]. The resident appeared dry to me that day, and I increased her free water flushes in addition to the labs to be drawn. If that's an order, the nurse is a licensed individual and should carry out the orders, and if it isn't able to be done, notify either the NP or the physician. The facility does not have documentation to show V6's physician consult orders or laboratory orders were carried out as ordered. On August 1, 2022 at 4:19 PM, V12 (Physician) said, I cared for [R1] in the hospital. She had [CONDITION(S)] due to a [CONDITION(S)]. This resident also had a poor heart and [CONDITION(S)]. I expect the facility staff to follow the policy and document the resident's urine output every shift. The resident should also have received catheter care. The fact that she did not receive the urinalysis and urine culture on July 5, 2022, and the infectious disease consult, as well as the antibiotic following her ER visit on July 9, 2022, and monitoring of her urine output all led to this resident ending up in the hospital with [CONDITION(S)]. All of those things were really necessary to prevent this hospitalization . 2. On August 1, 2022 at 11:26 AM, R2 was lying in bed in his room. R2's indwelling urinary catheter was draining cloudy urine with sediment in the tubing. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS dated [DATE] shows R2 has severe cognitive impairment, requires extensive assistance with eating, dressing, personal hygiene, and transfers between surfaces and is totally dependent on facility staff for all other ADLs. The EMR shows an order dated April 2, 2020 for an indwelling urinary catheter. The EMR continues to show an order to Record Output every shift on output task. The facility does not have documentation to show R2 had urine output recorded every shift for the following dates: July 2, 6, 11, 12, 22, and 31, 2022. The facility does not have documentation to show R2 received daily catheter care on July 8, 20, 25 or 28, 2022. 3. On July 28, 2022 at 2:19 PM, R3 was observed sitting in the wheelchair. R3 had an indwelling urinary catheter bag suspended from the side of his wheelchair. The EMR shows R3 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS dated [DATE] shows R3 is cognitively intact, requires supervision with eating, and extensive assistance with all other ADLs. At the time of the MDS assessment, R3 had an indwelling urinary catheter and was always incontinent of stool. The EMR shows an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . As of July 28, 2022 at 2:19 PM, the facility did not have any documentation to show R3's urine output was recorded and monitored every shift for the period July 16, 2022 through July 28, 2022. As of July 28, 2022 at 2:19 PM, the facility did not have any documentation to show R3 was receiving daily urinary catheter care for the period July 16, 2022 through July 28, 2022. 4. On July 28, 2022 at 9:20 AM, R5 was lying in bed in her room. R5's indwelling urinary catheter was suspended from the side of the bed. The EMR shows R5 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR continues to show an order to record urine output. The facility does not have documentation to show R5's urine output was recorded every shift on July 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2022. For the period July 5, 2022 to July 31, 2022, the facility shows R5 received catheter care on July 23, 2022. The facility does not have documentation to show R5 received catheter care on any other days during the July 5 to July 31, 2022 period. 6. The EMR shows R6 was admitted to the facility on [DATE]. R6 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's MDS dated [DATE] shows R6 is cognitively intake, requires supervision with eating, limited assistance with locomotion and personal hygiene, and extensive assistance with all other ADLS. The EMR shows R6 has in indwelling urinary catheter and is always incontinent of stool. The EMR shows an order dated July 14, 2022 for a suprapubic urine catheter. The EMR shows an order dated August 18, 2020 to record urine output every shift. The facility does not have documentation to show R6's urine output was monitored and recorded on July 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2022. 7. On August 8, 2022 at 11:25 AM, R7 was lying in her bed. R7 said she has an indwelling urinary catheter in place. R7 was able to show the indwelling urine catheter had a dark brown substance caked on the catheter tubing near R7's genital area. R7 continued to say, I am a nurse, and I know it is important that I receive catheter care to prevent a [CONDITION(S)]. I now have a [CONDITION(S)]. I have not been receiving catheter care on a daily basis, and the other day I had to insist they change my catheter tubing because there was so much stool caked on the tubing after I received an enema and had multiple bowel movements. I have had an indwelling urinary catheter in place since I was admitted to the facility. They took it out for a few hours to see if I could urinate, but I was unable to, so they inserted it again the same day. The EMR shows R7 was admitted to the facility on [DATE] with an indwelling urinary catheter and multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Urine culture results dated July 25, 2022 shows Escherichia coli organism in R7's urine culture collected on July 21, 2022. The facility does not have documentation to show R7's urine output was measured prior to July 29, 2022. The facility does not have documentation to show R7 received indwelling urinary catheter care at the facility since her admission. 8. The EMR shows R8 was admitted to the facility in February 2022. R8 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows an order dated July 21, 2022 for an indwelling urinary catheter. The facility does not have documentation to show R8's urine output was measured every shift on July 21, 22, 23, 25, 26, 27, 28, 29, 30, 31, 2022. The facility does not have documentation to show R8 received daily catheter care on July 22, 28, and 29, 2022. 9. The EMR shows R10 was admitted to the facility in December 2021. R10 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows an order dated March 1, 2022 for an indwelling urinary catheter. The facility does not have documentation to show R10's urine output was measured every shift for the period July 4, 2022 to July 31, 2022. The facility does not have documentation to show R10 received catheter care for the period July 4, 2022 to July 29, 2022. 10. The EMR shows R11 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's MDS dated [DATE] shows R11 is cognitively intact, requires supervision with eating, is totally dependent on facility staff for bathing, and transfers between surfaces, and requires extensive assistance for all other ADLs. R11 has an indwelling urinary catheter and is always incontinent of stool. The EMR shows an order dated June 14, 2022 for an indwelling urinary catheter. The facility does not have documentation to show R11's urine output was monitored for the period July 4, 2022 to July 28, 2022. The facility does not have documentation to show R11 received urinary catheter care for the period July 4, 2022 to July 29, 2022. 11. On July 28, 2022 at 9:22 AM, R13 was lying in bed. An indwelling urinary catheter collection bag was suspended from the side of R13's bed. The urine in the collection back was dark yellow, and approximately 200 ml of urine was in the collection bag. The EMR shows R13 was admitted to the facility on [DATE]. R13 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows an order dated May 29, 2022 for an indwelling urinary catheter. Facility documentation shows R13's urine output was not measured every shift on July 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2022. The facility shows R13 received indwelling urinary catheter care on July 23, 2022. The facility does not have documentation to show R13 received catheter care from July 4, 2022 to July 22, 2022 and July 23 to July 31, 2022. The facility's policy entitled Indwelling Catheter Care, with a revision date of 3/2022 shows: Policy: Daily and PRN (As Needed) catheter care will be done to promote comfort and cleanliness. Procedure: .11. Cleanse area of catheter insertion site, using soap and water or pre-moistened wipes. Being careful not to pull on catheter or advance further into urethra. 12. Wash catheter itself by holding on to catheter at insertion site, wash with one stroke downward, using same procedure for rinsing.16. Catheter bag to be emptied at the end of every shift, and PRN. Make sure to record output. Through observation, interview, and record review conducted on August 4, 2022, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: All residents residing in the facility with an indwelling urinary catheter were reviewed for batch orders that apply, including change indwelling urinary catheter, catheter and balloon size, diagnosis, record output orders. Education: On August 3, 2022 all nurses and CNAs (Certified Nursing Assistants) on duty were in-serviced by the DON and Nurse Managers on the following: · Intake and output monitoring and documentation guideline/policy · Perineal care and indwelling catheter care guideline/policy and competency · Process on medication reconciliation and MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] · Process for residents with or return from the hospital with an indwelling urinary catheter · Process for laboratory orders and follow up for specimens obtained in and outside of the facility. Nurse manager to contact discharging facility for results on pending laboratory and diagnostic results. All remaining facility nurses, CNAs and agency staff will be in-serviced prior to the start of their next scheduled shift by DON, and Nurse Manager. New hire nurses and CNAs will be in-serviced during orientation and/or prior to the start of their scheduled shift. Monitoring/Surveillance: · Audit output documentation on all residents with an indwelling urinary catheter · Audit of new and readmissions medication reconciliation · Audit all new and readmissions identified with an indwelling urinary catheter · Audit laboratory results portal All audits will be conducted daily for seven days, then three times a week for two weeks, then one time a week up to six months. The results of the audits will then be taken to QAPI (Quality Assurance Performance Improvement) to determine future frequency. The Administrator will be responsible for ensuring compliance with the staff in-servicing and audits. QAPI 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.

Based on observation, interview and record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R1 developing a facility-acquired pressure ulcer on her coccyx. This applies to 3 of 3 residents (R1, R4, and R5) reviewed for pressure ulcers in the sample of 17. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and transferred to the local hospital on July 20, 2022. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated May 15, 2022 shows R1 had moderately impaired cognition. R1 was totally dependent on facility staff for bathing, transfers between surfaces, and eating, R1 required extensive assistance with bed mobility, locomotion, dressing, toilet use and personal hygiene. R1 was always incontinent of bowel and bladder. The EMR shows an order dated July 7, 202 to cleanse R1's right buttocks wound with normal saline and apply medi-honey alginate, then cover with bordered foam dressing every day shift. R1's TAR (Treatment Administration Record) dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the physician-ordered wound treatment on July 11, 13, 16, 17, and 18, 2022. The EMR shows an order dated July 8, 2022 to July 14, 2022 for Wound/burn dressing paste, apply to coccyx wound topically every day shift to promote healing after cleansing with normal saline solution. Then cover with alginate and bordered foam dressing. R1's TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the physician-ordered wound treatment on July 11, and 13, 2022. The EMR shows the following order dated July 14, 2022: Santyl ointment 250 unit/gm (gram) apply to coccyx wound topically every day shift to promote wound healing after cleansing with normal saline, then cover with bordered foam dressing. Apply skin prep to surrounding skin every dressing change. R1's TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the physician-ordered wound treatment on July 16, and 17, 2022. The EMR shows an order dated May 12, 2022 to July 15, 2022 for enteral feed order for [MEDICATION(S)] 1.2 at 72 ml/hour until 1440 is infused. R1's July 2022 MAR (Medication Administration Record)/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show the feeding was administered as ordered on June 17, 18, 25, 28, 30, 2022 and July 10, 11, and 13, 2022. The EMR shows an order dated July 15, 2022 to July 20, 2022 for [MEDICATION(S)] 1.2 at 80 ml/hour until 1600 ml is infused. R1's July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the feeding as ordered on July 15 and 17, 2022. The EMR shows an order dated May 12, 2022 to July 6, 2022 for 200 ml water flush, four times a day. R1's June and July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the water flushes as ordered on June 17, 18, 19, 20, 24, 25, 27, 28, 30, 2022, July 2, 4, and 6, 2022. The EMR shows an order dated July 6, 2022 for 400 ml water flush, four times a day. R1's July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the water flushes as ordered on July 6, 7, 8, 10, 11, 13, 14, 15, 16, 17, and 18, 2022. The EMR shows R1's weight on June 7, 2022 was 166.2 pounds. On July 6, 2022 R1's weight was 154.0 pounds. R1 was reweighed on July 7, 2022. R1's weight was 155.6 pounds, which is a significant weight loss of 6.38 percent in one month. On July 20, 2022 at 7:37 PM V11 (ER physician) documented, This is an [AGE] year-old female with a history of dementia, ischemic stroke, hypertension, [CONDITION(S)], metabolic [CONDITION(S)], type 2 diabetes mellitus, [CONDITION(S)] heart disease, pulmonary embolism, recurrent urinary tract infection due to indwelling urinary catheter who was sent here from [nursing care facility] because of decreased level of consciousness. Patient with a large decubitus ulcer present on her sacrum, it is not very deep however there is a very wide area measuring about 8 to 9 mm (millimeters) that is affected. Patient's indwelling urinary catheter was changed out by nursing staff, and it was noted to not be completely in place, patient was urinating around it, and when it was removed a large amount of urine came out onto the bed. 8 French catheter was inserted, and a large amount of purulent and bloody urine immediately drained into the bag. Patient drained about 900 ml immediately and at this point her respiratory rate did drop down to 31 breaths/minute. Will be admitted for [CONDITION(S)]. On July 28, 2022 at 11:47 AM, V4 (Dietitian) said, I increased [R1's] water flushes due to her lab results showing she had an elevated BUN level of 32 mg/dL. Increased levels of the BUN and creatinine can indicate dehydration. The tube feeding and water flush calculations, if given as ordered, should have prevented [R1] from becoming dehydrated and losing weight. I ordered everything necessary to keep her hydrated and promote wound healing. But if the order was not administered the way it was intended, I would not know that. I was never told by facility staff there were any concerns regarding [R1] tolerating the tube feedings or water flushes or that she was not receiving the tube feedings as ordered. On July 28, 2022 at 12:03 PM, V9 (Wound Physician) said, I saw [R1] on July 7, 2022. The Stage 3 pressure ulcer of the coccyx was identified that day. Getting the correct amount of tube feeding and hydration is paramount to wound healing. This resident already had a wound on her buttocks, and the lack of nutrition played a role in a second wound developing. I expect facility staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On August 1, 2022 at 4:19 PM, V12 (Physician) said, I expect facility staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On August 1, 2022 at 11:31 AM, R4 was sitting up in the chair in his room. R4 was unable to answer questions due to his cognitive status. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS dated [DATE] shows R4 has severe cognitive impairment, and is totally dependent on facility staff for eating, transfers between surfaces, and bathing, and requires extensive assistance for all other ADLs. On July 7, 2022, V9 (Wound Physician) documented a Stage 4 pressure ulcer to R4's sacrum of greater than 108 days duration. V9 measured R4's wound as 3.9 x 2.7 x 0.8 cm. V9 documented: Goal of treatment is healing . The EMR shows an order dated March 19, 2022 for Medi-honey calcium alginate 4-inch x 5-inch pad. Apply to sacral wound topically every day shift to promote wound healing after cleansing with normal saline, then cover with bordered foam dressing. During review of the EMR on July 28, 2022, the facility did not have documentation to show R4 received the physician-ordered wound dressing changes on July 14, 15, 16, or 17, 2022. On July 28, 2022 at 10:25 AM, V3 (Wound Care Nurse) reviewed the documentation in the EMR and confirmed nursing did not document wound care for R4 on July 14 through 17, 2022. The EMR shows an order dated March 24, 2022 for [MEDICATION(S)] 12 at 70 ml/hour until 1400 ml is infused. The EMR also shows an order dated July 30, 2022 for [MEDICATION(S)] 1.2 at 75 ml/hour until 1500 ml is infused, to start at 5:00 PM daily. As of July 28, 2022 at 10:25 AM, the facility did not have documentation to show R4 received the tube feeding as ordered on July 7, 12, 13, 14, 17, 17, 18, 19, or 21, 2022. The EMR shows an order dated March 24, 2022 for water flush of 150 ml, three times a day. During review of the EMR on July 28, 2022 at 10:25 AM, the facility did not have documentation to show R4 received the water flushes as ordered on July 1, 7, 14, 15, 16, 17, 28, 19, 20, 21, 22, 24, and 27, 2022. On August 1, 2022 at 10:20 AM, V2 (DON-Director of Nursing) reviewed R4's documentation and said as of August 1, 2022, the medical record had been altered from observations on July 28, 2022 to show missing documentation of R4's wound treatments, tube feeding, and water flushes were now filled in for the month of July 2022. V2 said, I thought we had a grace period and could go back for the month and fill in the documentation that was missing. V15 (Regional Nurse Consultant) said nursing staff should document all medications administered, tube feedings, water flushes and wound treatments at the time of administration. 3. On July 28, 2022 at 9:13 AM. R5 was lying in bed. R5 had a low air loss mattress in place. On August 1, 2022 at 11:30 AM, R5 was in her room receiving wound care and refused to be observed. The EMR shows R5 was admitted to the facility on [DATE]. R5 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS dated [DATE] shows R5 is cognitively intact, is totally dependent on facility staff for transfers between surfaces, and bathing, requires supervision with eating, and extensive assistance with all other ADLs. V9's (Wound Physician) documentation for R5 dated July 21, 2022 shows the following four wounds and treatment plans: A Stage 4 pressure ulcer of the left ischium for greater than 46 days, measuring 6.5 x 17.5 x 3 cm. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Left ischium wound dressing orders dated July 15, 2022 show Cleanse wound with normal saline solution then apply calcium alginate and collagen then cover with bordered dressing every day shift. R5's July 2022 MAR/TAR dated August 2, 2022 at 10:14 AM shows the facility does not have documentation to show R5 received the wound treatments on July 15, and 16, 2022. A Stage 3 pressure ulcer of the right ischium for greater than 46 days, measuring 4 x 4.5 x 0.1 cm. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Right ischial tuberosity dressing orders dated June 25, 2022 show, Cleanse with normal saline then apply collagen and calcium alginate then cover with bordered form dressing every day shift. R5's July 2022 MAR/TAR dated August 2, 2022 at 10:14 AM shows the facility does not have documentation to show R5 received the wound dressing changes on July 1, 4, 5, 6, 11, 12, 14, 15, and 16, 2022. An unstageable left heel wound for greater than 46 days, measuring 3.5 x 3.6 x 0.1 cm. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Left heel wound dressing orders dated June 4, 2022 to July 21, 2022 show: Apply [MEDICATION(S)] and dry protective dressing daily. R5's July 2022 MAR/TAR dated August 2, 2022 at 10:14 AM shows the facility does not have documentation to show R5 received the dressing changes as ordered on July 1, 4, 5, 6, 11, 12, 14, 15, and 16, 2022. An unstageable right heel wound for greater than 46 days, measuring 2.5 x 3 x 0.3 cm. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Right heel wound dressing orders dated June 25, 2022 to July 14, 2022 show: Apply [MEDICATION(S)] and dry protective dressing every day shift, cleanse with normal saline solution and pat to dry. R5's July 2022 MAR/TAR dated August 2, 2022 at 10:14 AM shows the facility does not have documentation to show R5 received the wound dressing as ordered on July 1, 4, 5, 6, 11, and 12, 2022. On July 28, 2022 at 10:25 AM, V3 (Wound Care Nurse) said V9 (Wound Physician) comes to the facility on ce a week, though she just missed a week due to Covid-19. V19 (Treatment Nurse) is new to the facility and has been at the facility about a month. V18 (Wound Nurse) also helps with providing wound treatments. V3 said, If the wound nurse is not here, then the staff nurse is required to do the wound dressing changes for the residents. [V18] comes to the facility on Thursdays and Fridays or every other weekend. I was on vacation from July 4 to July 18, 2022 and I saw a lot of holes in the wound documentation when I returned, meaning there was no documentation to show the wound dressings were changed. The nursing staff is required to document on the TAR (Treatment Administration Record) after completing a wound treatment. We don't really have a way to let the nursing staff know there is no wound treatment nurse in the facility. The staff should check the TAR and if they see the wound treatment was not completed, then the staff nurse should complete the wound treatment. If they check the TAR and it hasn't been done then they should do it. The facility's policy entitled Skin Management: Pressure Injury Treatment/General Wound Treatment reviewed on 1/2022 shows: General: The following treatment guidelines have been developed to serve as a general protocol for selecting the type of treatment or dressing to be used. However, the facility recognizes that the selection of treatment protocols is individualized based on the resident condition and Health Care Provider practice patterns. Therefore, these are only guidelines and not all-inclusive. An order is required for all treatment orders. General Guidelines: Nutrition: dietary evaluation, monitor food intake, monitor fluid intake, provide protein supplements, provide vitamins as ordered, provide wound healing supplements as ordered, offer substitutes to meals, assist with feeding. General Treatment Guidelines: 1. Review the physicians order in the EHR (Electronic Health Record) and place all necessary supplies in treatment cart. 6. Perform the treatment as ordered using proper techniques of infection prevention and control. 7. When treatments are completed, discard disposables and return reusable items to proper locations. 8. Document routine and PRN treatments in the treatment administration record of the EHR. Document all significant observations in the Nursing Progress Note.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect when it failed to provide structures and processes to care for residents receiving tube feedings, and for residents with indwelling urinary catheters. The facility neglected to follow their policy for administering and documenting the total amount of tube feeding received by residents and administering tube feeding and free water flushes as ordered by the physician. This failure resulted in R1 sustaining a significant weight loss of 6.38 percent in one month, developing a facility-acquired pressure ulcer, and being hospitalized for [CONDITION(S)] and dehydration The facility neglected to follow their policy for monitoring urine output and providing catheter care for residents with indwelling urinary catheters. The facility also neglected to ensure all residents admitted or readmitted to the facility with indwelling urinary catheters had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This applies to 3 of 3 residents (R1, R2, and R3) reviewed for neglect in the sample of 17. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was transferred to the local hospital on July 20, 2022 and did not return to the facility. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated May 15, 2022 shows R1 had moderately impaired cognition. R1 was totally dependent on facility staff for bathing, transfers between surfaces, and eating, R1 required extensive assistance with bed mobility, locomotion, dressing, toilet use and personal hygiene. R1 was always incontinent of bowel and bladder. The EMR continues to show R1 was sent to the local hospital on July 9, 2022. R1 returned to the facility on [DATE] with an indwelling urinary catheter due to urine retention, pending urinalysis and urine culture results, and an order to ask your doctor about these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] ., take 1 tablet by mouth two times daily for 11 doses. Start tonight and continue 11 doses total with food. The facility does not have documentation to show nursing staff obtained an order from the physician to continue R1's indwelling urinary catheter or the physician's response to starting the [MEDICATION(S)] antibiotic. The facility does not have documentation to show nursing staff followed up on the urinalysis or urine culture results. The facility does not have documentation to show R1's urine output was measured or monitored every shift, or that R1 received daily indwelling urinary catheter care for the period of July 9, 2022 through July 20, 2022 when R1 was sent to the local hospital for unresponsiveness. The EMR shows an order dated May 12, 2022 to July 15, 2022 for enteral feed order for [MEDICATION(S)] 1.2 at 72 ml/hour until 1440 is infused. R1's July 2022 MAR/TAR (Medication Administration Record/Treatment Administration Record) dated July 27, 2022 at 12:43 PM show the facility does not have documentation to show the feeding was administered as ordered on June 17, 18, 25, 28, 30, 2022 and July 10, 11, and 13, 2022. The EMR shows an order dated July 15, 2022 to July 20, 2022 for [MEDICATION(S)] 1.2 at 80 ml/hour until 1600 ml is infused. R1's July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the feeding as ordered on July 15 and 17, 2022. The EMR shows an order dated May 12, 2022 to July 6, 2022 for 200 ml water flush, four times a day. R1's June and July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the water flushes as ordered on June 17, 18, 19, 20, 24, 25, 27, 28, 30, 2022, July 2, 4, and 6, 2022. The EMR shows an order dated July 6, 2022 for 400 ml water flush, four times a day. R1's July 2022 MAR/TAR dated July 27, 2022 at 12:43 PM shows the facility does not have documentation to show R1 received the water flushes as ordered on July 6, 7, 8, 10, 11, 13, 14, 15, 16, 17, and 18, 2022. The EMR shows R1's weight on June 7, 2022 at 166.2 pounds. On July 6, 2022 R1's weight was 154.0 pounds. R1 was reweighed on July 7, 2022. R1's weight was 155.6 pounds, a 6.38 percent weight loss in one month. On July 20, 2022 at 7:37 PM V11 (ER physician) documented, This is an [AGE] year-old female with a history of dementia, ischemic stroke, hypertension, [CONDITION(S)], metabolic [CONDITION(S)], type 2 diabetes mellitus, [CONDITION(S)] heart disease, pulmonary embolism, recurrent urinary tract infection due to indwelling urinary catheter who was sent here from [nursing care facility] because of decreased level of consciousness. Evidently patient who is usually responsive is unresponsive today when nursing staff checked on her. Patient also appeared to have decreased urinary output, so she was transferred to the ED. On arrival to the emergency department the patient is definitely decreased responsiveness, she only responds to deep pain, she is tachypneic and [CONDITION(S)]. Patient is a DNR (Do Not Resuscitate), so was not intubated but rather placed on [CONDITION(S)] (Bilevel Positive Airway Pressure) for her respiratory rates. Her oxygen saturation was maintained at 100% in spite of her tachypnea. Unable to give any history. Patient with a large decubitus ulcer present on her sacrum, it is not very deep however there is a very wide area measuring about 8 to 9 mm (millimeters) that is affected. Patient's indwelling urinary catheter was changed out by nursing staff, and it was noted to not be completely in place, patient was urinating around it, and when it was removed a large amount of urine came out onto the bed. 8 French catheter was inserted, and a large amount of purulent and bloody urine immediately drained into the bag. Patient drained about 900 ml immediately and at this point her respiratory rate did drop down to 31 breaths/minute. Will be admitted for [CONDITION(S)]. The EMR shows R1's BUN (Blood Urea Nitrogen) blood level on July 5, 2022 was 32 mg/dL (milligrams/deciliter) (Normal range 7-28 mg/dL), and R1's creatinine level was 0.28 mg/dL (normal range 0.44 to 1.32 mg/dL). Upon admission to the hospital on July 20, 2022 at 7:52 PM, R1's BUN level was 81 and R1's creatinine level was 2.92. On July 28, 2022 at 11:47 AM, V4 (Dietitian) said, I increased [R1's] water flushes due to her lab results showing she had an elevated BUN level of 32 mg/dL. Increased levels of the BUN and creatinine can indicate dehydration. The tube feeding and water flush calculations, if given as ordered, should have prevented [R1] from becoming dehydrated. I ordered everything necessary to keep her hydrated and promote wound healing. But if the order was not administered the way it was intended, I would not know that. I was never told by facility staff there were any concerns regarding [R1] tolerating the tube feedings or water flushes or that she was not receiving the tube feedings as ordered. On July 28, 2022 at 12:03 PM, V9 (Wound Physician) said, I saw [R1] on July 7, 2022. The Stage 3 pressure ulcer of the coccyx was identified that day. Getting the correct amount of tube feeding and hydration is paramount to wound healing. This resident already had a wound on her buttocks, and the lack of nutrition played a role in a second wound developing. On July 28, 2022 at 12:29 PM, V5 (NP-Nurse Practitioner) said R1 was found unresponsive in her room on July 20, 2022. V5 said, [R1] was not responsive to painful stimuli, though she did have vital signs on July 20, 2022. We called an ambulance, and she was transported to the local hospital. A review of her hospital records shows [R1] was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Reviewing her hospital records further shows her indwelling urinary catheter was not draining urine properly upon arrival to the hospital and once the hospital personnel removed the malfunctioning catheter and inserted the new catheter, [R1] had 900 ml of bloody, purulent urine. Her labs drawn at the hospital further showed [R1] had a [CONDITION(S)] (Urinary Tract Infection). If a resident has an indwelling urinary catheter, facility staff should be monitoring the resident's urine output for the amount of urine output per shift, as well as the appearance of the urine including if the urine is cloudy, blood-tinged, or has an odor. I do not see any documentation to show [R1's] urine was being monitored for any of those things since the catheter was inserted in theER on [DATE]. Also, [V6] (NP) ordered an infectious disease consult, a urinalysis, and a urine culture for [R1] on July 5, 2022. Those labs were never obtained nor was the consult. A few days later, on July 9, [R1] went to the emergency room for hip pain and was diagnosed with urine retention of 900 ml of urine, and had an indwelling urinary catheter inserted in the ER, and also a urinalysis and urine culture were done. Those results were never followed up on by the nursing staff at the facility. [R1's] discharge paperwork from theER on [DATE] showed to check with the physician to see if an antibiotic ([MEDICATION(S)]) should be started. No facility staff informed me of those orders or asked if an antibiotic should be started for [R1]. All of those failures combined resulted in this resident ending up in the hospital with a [CONDITION(S)] and [CONDITION(S)] on July 20. On August 1, 2022 at 10:33 AM, V6 (NP) said, It has always been my experience while working at the facility, that when I see my residents and have orders, I write the information in my progress note and then tell the nurse and give verbal orders for what needs to be done, and it is the responsibility of the nurse to carry out those orders. On July 5, I was covering the entire facility, including my patients and [V5's] patients. I noticed [R1's] labs showed an elevated white blood cell count as well as elevated BUN, so I ordered additional hydration, and urinalysis and urine culture, as well as an infectious disease physician consult. On this particular day I very much remember verbally giving these orders to the nurse caring for [R1]. The resident appeared dry to me that day, and I increased her free water flushes in addition to the labs to be drawn. If that's an order, the nurse is a licensed individual and should carry out the orders, and if it isn't able to be done, notify either the NP or the physician. The facility does not have documentation to show V6's physician consult orders or laboratory orders were carried out as ordered. On August 1, 2022 at 4:19 PM, V12 (Physician) said, I cared for [R1] in the hospital. She had [CONDITION(S)] due to a [CONDITION(S)]. This resident also had a poor heart and [CONDITION(S)]. I expect the facility staff to follow the policy and document the resident's urine output every shift. The resident should also have received catheter care. The fact that she did not receive the urinalysis and urine culture on July 5, 2022, and the infectious disease consult, as well as the antibiotic following her ER visit on July 9, 2022, and monitoring of her urine output all led to this resident ending up in the hospital with [CONDITION(S)]. All of those things were really necessary to prevent this hospitalization . 2. On August 1, 2022 at 11:26 AM, R2 was lying in bed in his room. R2's indwelling urinary catheter was draining cloudy urine with sediment in the tubing. R2 did not have tube feeding running at the time of the observation. A tube feeding bag was attached to the tube feeding pole labeled Glucerna, tube feeding was present in the dispensing bag, and the tube feeding tube was connected to R2's gastrostomy tube. The bag was dated August 1, 2022 at 5:00 AM. The tube feeding pump was in the off position. On August 1, 2022 at 12:12 PM, R2's tube feeding pump continued to be in the off position and R2 was not receiving the tube feeding. V13 (LPN-Licensed Practical Nurse) entered the room and said the tube feeding should be turned on. V13 turned the tube feeding machine to the on position and the tube feeding started to run at 60 ml/hour. V13 continued to check the status of R2's tube feeding pump. The pump showed a total amount infused as 9,577 ml. V13 said, Someone forgot to clear the pump when the tube feeding was started so we have no idea how much the resident is receiving. He should receive 700 ml. The nurse from the night shift forgot to start [R2's] tube feeding last night at 5:00 PM, so the tube feeding did not get started until 5:00 AM this morning. I have not given any water flushes yet to the resident. V13 went to the computer and checked the tube feeding order for R2 and said the order shows R2 should receive 720 ml not 700 ml as she previously stated. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS dated [DATE] shows R2 has severe cognitive impairment, requires extensive assistance with eating, dressing, personal hygiene, and transfers between surfaces and is totally dependent on facility staff for all other ADLs. The EMR shows an order dated May 22, 2022 for Glucerna 1.2 to run at 60ml/hour until 720 ml is infused, to start at 5:00 PM. R2's July 2022 MAR/TAR dated August 1, 2022 at 12:59 PM shows the facility does not have documentation to show R2 received the tube feeding as ordered on July 16 or 31, 2022. The EMR shows an order dated March 16, 2022 for free water flushes of 150 ml, three times a day. R2's July 2022 MAR/TAR dated August 1, 2022 at 12:59 PM shows the facility does not have documentation to show R2 received the water flushes as ordered on July 3, 7, 12, 16, 17, 23, and 31, 2022. The EMR shows an order dated April 2, 2020 for an indwelling urinary catheter. The EMR continues to show an order to Record Output every shift on output task. The facility does not have documentation to show R2 had urine output recorded every shift for the following dates: July 2, 6, 11, 12, 22, and 31, 2022. The facility does not have documentation to show R2 received daily catheter care on July 8, 20, 25 or 28, 2022. 3. On July 28, 2022 at 2:19 PM, R3 was observed sitting in the wheelchair. R3 had an indwelling urinary catheter bag suspended from the side of his wheelchair. The EMR shows R3 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . As of July 28, 2022 at 2:19 PM, the facility did not have any documentation to show R3's urine output was recorded and monitored every shift for the period July 16, 2022 through July 28, 2022. As of July 28, 2022 at 2:19 PM, the facility did not have any documentation to show R3 was receiving daily urinary catheter care for the period July 16, 2022 through July 28, 2022. The facility's policy entitled Tube Feeding, reviewed on 9/2021 shows: Guideline: 1. Continuous tube feedings are based upon 22-hour consumption period or other time frame based on individual resident need per Registered Dietitian assessment and delivered over a 24-hour period. 2. Tube feedings are documented on the MAR and intake record. 6. The Health Care Provider should be notified if tube feeding amount not infused as ordered.9. Any tube feeding orders will include the formula, rate, time period, deliver method and flush. Feeding Pump: .4. Check residuals as ordered and alert Health Care Provider if there is more than 100 cc (cubic centimeters) or other order. 5. Pump should be cleared at the end of each shift. 6. Document tube feeding delivered. 7. Alert Health Care Provider of any issues or concerns. The facility's policy entitled Indwelling Catheter Care, with a revision date of 3/2022 shows: Policy: Daily and PRN (As Needed) catheter care will be done to promote comfort and cleanliness. Procedure: .11. Cleanse area of catheter insertion site, using soap and water or pre-moistened wipes. Being careful not to pull on catheter or advance further into urethra. 12. Wash catheter itself by holding on to catheter at insertion site, wash with one stroke downward, using same procedure for rinsing.16. Catheter bag to be emptied at the end of every shift, and PRN. Make sure to record output.

Based on interview and record review, the facility failed to monitor [CONDITION(S)] catheter access site according to plan of care and the facility failed to communicate changes in the [CONDITION(S)] site between a facility based outside [CONDITION(S)] provider and nursing staff in the facility, for one of 3 residents (R1) reviewed for [CONDITION(S)] catheter access site. This failure resulted in a resident's (R1) death due to undetected infection and [CONDITION(S)] from the [CONDITION(S)] catheter access site. Findings include: R1's face sheet showed that R1was originally admitted to the facility on [DATE]. R1's multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated [DATE] with a review date on [DATE] showed: [CONDITION(S)]; (R1) has potential for impaired renal function secondary to [CONDITION(S)] (End Stage Renal Disease) and receiving [CONDITION(S)]. The intervention was to Observe access site for s/s (signs and symptoms) of infection: redness, drainage, swelling, pain and displacement every shift. On [DATE] at 11:15 AM, V8 ([CONDITION(S)] Nurse) stated that R1 was on [CONDITION(S)] treatment 3 times a week scheduled Mondays, Wednesdays and Fridays at 5:30 AM. V8 said that R1's [CONDITION(S)] access site was a central venous catheter on the intra jugular vein unto the right chest area. V8 added that on [DATE], during the [CONDITION(S)] treatment, R1 was observed with some redness, dry and flaky skin of the surrounding site of the [CONDITION(S)] access site. V8 added that she thinks it might be a skin irritation and so she decided to change the dressing to [MEDICATION(S)] ointment instead of the standard cleansing with Chlor Prep solution. V8 also said that the facility onsite [CONDITION(S)] center was the one changing the [CONDITION(S)] dressing. V8 further added that she did not inform and communicate to V5 (staff nurse/floor nurse) regarding R1's skin irritation and treatment was changed to the [CONDITION(S)] access site. V8 added that the access site will be checked again for the next [CONDITION(S)] treatment which would be [DATE]. As V8 continued to state, the dressing was only change during [CONDITION(S)] treatment. V8 said the access site was covered with pieces of gauze and secured with square type gauze tape. On [DATE] at 12:49 PM, V5 (Registered Nurse) stated that she did not check and visualize R1's dialyis catheter insertion site. V5 also said that when she sent R1 to the hopsital on [DATE], R1 was very lethargic and barely responsive. V5 added that she was not informed by V8 nor other nurses report to inspect the dialyis insertion site for possible infection. The Telehealth Notes dated [DATE] 18:56 (6:56 PM) telehealth evaluation Date of Service: [DATE] 4:26 PM CT Primary Chief Complaint: Altered Mental Status History of Present Illness: (R1)with [CONDITION(S)], DM2, [CONDITION(S)] (hypertension), [CONDITION(S)] secondary to [CONDITION(S)]. Patient has been lethargic for the past 2 days. (R1) is also not eating well. ( R1) has cough with coarse breath sounds, temperature was 99.9, given Tylenol. (R1) HR (Heart rate) elevated at 107. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . EGD (Esophagogastroduodenoscopy) showed acute pancreatitis and cholelithiasis Currently on HD (hemodialysis) 3 x/week. Patient seen today for follow up. According to nurse reports, (R1) was not able to get [CONDITION(S)] today, due to clogged port. Patient is not responding to verbal or tactile stimuli at this time. Ordered to send pt. (patient) out to ER(emergency room ) for further evaluation; pt. is full code .VS (Vital Signs): BP (Blood pressure): ,d+[DATE] mmHg (millimenters of mercury) Temperature: 99.6 F Pulse: 100 bpm (beats per minute) Respirations: 19 Breaths/min O2 (oxygen): 97 .Slowness and poor responsiveness. ER evaluation; nurse, MD and DON (Director of Nursing) at facility notified. The EHR (Electronic Health Record) dated from ,d+[DATE]-,d+[DATE] showed no documentation that the [CONDITION(S)] catheter access site was monitored and visually checked for signs of infection. On [DATE] at 10:54 A.M., V2 (Director of Nursing) was asked to make a chronological timeline regarding R1's [CONDITION(S)] catheter concern. The timeline showed: -[DATE], (R1) was sent to [CONDITION(S)]. Dressing was changed and slight redness noted at site. [CONDITION(S)] RN (V8) noted that (R1) had behavior of excessively touching site. No note of signs of infection. [CONDITION(S)] was uneventful. -[DATE], (R1) was noted as excessively sleeping since ,d+[DATE] and with altered mental status on ,d+[DATE] with abnormal vitals. Resident Temp 99 degrees. Heart rate 107. Change of condition initiated.MD notified. Labs ordered. -[DATE] at 2:55 am resident was noted with cough and respiratory symptoms. MD notified. Labs relayed. -[DATE] at 5:30 am during [CONDITION(S)] session the [CONDITION(S)] nurse is unable to access (R1's) port. Follows their protocol and uses Cathflo (drug used to restore patency to [CONDITION(S)] catheters) to clear catheter. No note of dressing stain or discoloration. Sent back to room for Cathflo to begin to work. -[DATE] at 11:40 am NP (Nurse Practitioner) saw (R1) in room and recommended to send out due to altered mental status. -[DATE]; Hospital staff notified (facility staff) that they needed clarification about the catheter ([CONDITION(S)] access catheter/port). Facility responded by placing (V8) in contact with the hospital social worker. On [DATE] at 10:54, V2 stated that V1 (Administrator) had received a call from V14 (Hospital Social worker) on [DATE] asking about the [CONDITION(S)] catheter and that V1 asked her to communicate with V14. V2 said that V14 had informed her of inappropriate nursing care due to infected [CONDITION(S)] catheter that was full of pus and will not missed it if it was monitored. V2 also said that the dressing was not removed to check the insertion site of the [CONDITION(S)] catheter since it is the [CONDITION(S)] nurse who change the dressing. V2 added that since R1's [CONDITION(S)] treatment was M-W-F, R1's catheter insertion site was not visualized and check for signs of infection since [DATE]. V2 added that the insertion site of the [CONDITION(S)] catheter was not visible because it was covered with gauzes and tape. V2 further said that staff nurse only look at the dressing but was not able to visualize the insertion site if there were signs of impending infection. On [DATE], V6 ([CONDITION(S)] technician) stated that he had changed R1's dressing of the [CONDITION(S)] catheter on [DATE] in the morning around 5:30 AM. V6 said he did not see signs of infection. On [DATE] at 2:35 PM, V14 stated that she informed the facility on [DATE] that R1's [CONDITION(S)] catheter on the right chest area was full of pus and was infected and there was no way that it was missed if they were monitoring it. On [DATE] at 5:30 P.M., V12 (Nephrologist) stated that standard of practice was for the [CONDITION(S)] nurse to change the dressing of the [CONDITION(S)] catheter during treatment. However, if there was a sign of skin irritation that could also most likely be an impending sign of skin/bacterial infection. The expectation was to open the dressing and visualize the [CONDITION(S)] insertion site for monitoring and check signs of infections before the situation become grave. The Cathflo, which is to clear clogged catheter will not backflow from the tunneled catheter and it will not backflow or seep through from the insertion site. If ER (emergency room ) had documented that purulent drainage from the insertion site, meaning there was pus around the insertion site. They (facility) should have monitor the insertion site by opening the dressing and visualizing the insertion site. The infection would not suddenly develop in few hours, but should the access site should have been monitored to provide prompt treatment. On [DATE] at 6:10 PM, V13 (R1's Attending Physician) stated that she had followed R1 for care at the hospital. V13 stated that R1 had expired on [DATE] due to [CONDITION(S)] and infection from the [CONDITION(S)] catheter. V13 also added that the [CONDITION(S)] catheter was sent to laboratory after it was removed for culture and determine microorganisms on [DATE]. V13 added that the [CONDITION(S)] catheter culture result had matched R1's microorganism found on R1's blood result. V13 added that when it was identified on [DATE], (R1's) skin irritation /dry/flaky around the [CONDITION(S)] catheter insertion site, there was already an impending skin infection building up that went through (R1's) [CONDITION(S)] catheter. I was not informed about the (R1's) skin irritation around the insertion site of her [CONDITION(S)] catheter, otherwise I would have ordered treatment such as antibiotic or send her out to the hospital. The ER documentation dated [DATE] showed (R1) on arrival, febrile (with fever), [CONDITION(S)] (elevated heart beat), and tachypneic (fast breathing). Septic work up initiated. She does have purulent drainage around the [CONDITION(S)] catheter site. The hospital record showed that R1 had expired at 3:16 A.M. on [DATE]. V14, hospital social worker notes dated [DATE] showed a call from V1 (Facility Administrator) and stated we do not deal with HD (Hemodialysis) catheter, this is managed by the [CONDITION(S)] nurse who are technically with a different company. V14 noted surely the bedside nurses at facility could keep an eye on catheter site and identify possible infection. (V1) stated they should be doing this but cited nursing shortage. V14 noted HD catheter very infected and looks like this was not address for some time. Facility policy for [CONDITION(S)] revised [DATE] documents, The [CONDITION(S)] site will be checked every shift for signs and symptoms of infection or bleeding. Under resident care the policy documents, Assessing, observing and documenting care of access site. Under the section Resident Care Facility Specific Guidelines documents, Assess, observing and documenting care of access site. Under the section Shared Communication between the facility and [CONDITION(S)] Facility the policy documents, The care of the resident receiving [CONDITION(S)] services will reflect ongoing communication, coordination between facility and [CONDITION(S)] staff. The communication process includes how the communication will occur, who is responsible for communicating, and where the responses will be documented in the medical record, including but not limited to . [CONDITION(S)] adverse reactions/complications and/or concerns related to the vascular access site/PD (peritoneal [CONDITION(S)]) catheter.

Based on record review and interview the facility failed to safely transfer a resident using two staff members and as a result, R2 sustained a fracture injury during an improper transfer. This applies to 1 of 3 residents (R2) reviewed for safe transfers in a sample of 8. Findings include: The Face Sheet documents R2 is a [AGE] year old resident with the following Diagnoses: [REDACTED]. The MDS (Minimum Data Set) dated 11/14/17 reads: BIMs (Brief Interview for Mental Status) score 1/15 indicating severe cognitive impairment. The MDS also documents R2 requires extensive physical assistance for transfers by 2 staff. Moving from seated to standing position and surface-to-surface transfer (transfer between bed and chair or wheelchair) -Not steady, only able to stabilize with staff assistance. Lower extremity- impairment on both sides. Mobility device- wheelchair. Nursing notes of (MONTH) 15, (YEAR) document that the V15 (nurse) was called into R2's room by the nurse aide to check R2's knee. V15 noted that that the right knee was swollen and warm to the touch. R2 was also noted with pain to the area. The physician was notified and an order was obtained for an X-ray. The Occurrence Report dated 12/15/17 reads: Resident expressed pain when staff member touched right lower extremity. The Facility Incident Report dated 12/16/17 reads: Resident was observed with swelling bruising to right lower leg. MD was contacted and order received for right tibia/fibula x-ray. X-ray completed and results revealed [MEDICAL CONDITION] tibia and neck of the fibula. MD notified and orders to send resident to the ER for further evaluation. The diagnostic report dated 12-15-17 reads, Impression: Fractures of the distal tibia and neck of fibula. On 3/6/18 at 1:23 PM, V14 (Certified Nursing Assistant/CNA) stated I transferred R2 by myself, which I shouldn't have because we are always short of staff. I picked R2 up because R2 is very light weight. I held R2 around the torso area. V14 stated I lifted R2 up totally. R2 is transferred with 1 person by a lot of people because R2 it's easy to do. I'm not the only one who would transfer R2 alone. I put R2 to bed and the second shift noted swelling. At the beginning of the job, they say (sic) we should always have a second person. I started in September. V14 stated she did not use a gait belt. On 3/6/18 at 2:53 PM, V5 (Licensed Practical Nurse/LPN) stated R2 is high risk for falls. V5 also stated the resident's transfer status is documented on care cards, printed, and put in the resident rooms. V5 stated the CNAs and nurses are then made aware of the resident's transfer status. V5 added there is also a code above the resident's bed. V5 added R2 was changed to a 2 person assist on 11/20/17. R2 can't pivot safely with 1 person. R2 is a 2 person assist. On 3/6/18 at 3:30 PM, V15 (Nurse) stated on 12/15/17 I was called by the CNA and noted R2's right knee swollen and warm. I called the doctor and he ordered an X-ray. On 3/7/18 at 3:22 PM, V2 (Director of Nursing) stated she was present when R2 was transferred to the hospital. V2 stated R2 had a bruise and R2's leg was swollen from the knee to the ankle and was warm, with a bruise by the ankle. R2 was exhibiting facial expressions of pain. V2 stated the X-ray showed fractures. V2 stated R2 was a mechanical lift/2 person transfer. The CNA transferred R2 by herself. She did not transfer R2 the way R2 was supposed to be transferred and the care card was right in front of her. V2 presented the facility's policy titled Transfer Status. The policy did not explain how to transfer residents with 1 or 2 person assist. On 3/7/18 at 3:54 PM,s V7 (Medical Doctor) stated he was informed R2 had a fall, not a transfer. However, V7 stated It caused R2 harm. R2 had to go to the hospital. There was deformity in the leg. It looked like a fracture. The Employee Report for V14 reads: The above employee failed to follow transfer policy which resulted in resident injury. The report was signed by V14 and V2.

Based on observations, interviews and record reviews the facility failed to follow their policy for medication administration and failed to ensure that ophthalmic eye drops were re-ordered as needed. This failure led to R5 received the incorrect medication resulting in an overdose of medication with resulting lethargy, decreased blood pressure and hospitalization . This applies to 7 of 7 residents (R1, R3, R4, R5, R6, R7 and R8) reviewed for medications in a sample of 8. Findings include: 1). The Face Sheet reads R5 is [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The face sheet reads R3 was admitted to the facility on [DATE]. The POS/MAR physician's orders [REDACTED]. [MEDICATION NAME] 5mg, give 1 tablet by mouth one time a day related to hypertension; Losartan 25mg, give 1 tablet by mouth two times a day related to hypertension; Duloxetine 60mg give 1 capsule by mouth one time a day; [MEDICATION NAME] 300mg, give 1 capsule by mouth three times a day; [MEDICATION NAME] 100mg, give 1 capsule by mouth two times a day; Aspirin 81mg, give 1 tablet by mouth one time a day; Montelukast 10mg, give 1 tablet by mouth one time a day; The Nurse's Notes by V6 (Registered Nurse/RN) read: 12/8/17 14:28, nurse entered residents room to administer medication. After administration of medication nurse relies (sic) that she had administered wrong residents (sic) medication. NP (Nurse Practitioner) and DON (Director of Nursing) were notified. Daughter was notified at bedside. Ordered to monitor resident and take vitals every 15 minutes for the remainder of shift. 12/8/17 at 1530pm, R5 was noted with low blood pressure and R5 was discharged to the hospital for treatment. The Employee Report for V6 dated 12/12/17 reads: Date of incident 12/11/17 Above employee administered incorrect medication to a resident resulting in hospitalization . The report was signed by V2(Director of Nursing), V4 (Assistant Director of Nursing) and V6. On 3/7/18 at 9:19 AM during interview, V6 stated she gave R3's medication to R5 during the morning of 12/8/17. V6 stated I pulled R3's medication, and instead of going to R3's room I went to R5's. R5's daughter recognized ASA (Aspirin) and was questioning it so I held the ASA and gave R5 the rest of the medication. R5 went to the hospital for low blood pressure. When asked the process for administering medication and identifying the resident, V6 stated make sure I enter the right room. I know all the residents. V6 stated she knew R3 and thought she was in R3's room. When asked how she identified the resident prior to administering the medication, R5 replied the family was there and I just introduced myself like I always do. On 3/7/18 at 9:45 AM, V2 (Director of Nursing) stated V6 had given the wrong medications to a resident. V2 stated the medication error was identified because the family of R5 had asked about the ASA. V2 stated the policy is to verify the 5 rights (right patient, route, dose, drug, and time) prior to administering medication. V2 stated if family is there, the policy is to identify the resident's name. V2 also stated We have pictures on the MAR. All MARs have pictures. V2 then pointed to the printed MAR indicated [REDACTED] On 3/7/18 at 3:45 PM, V7 (Medical Doctor) stated R5 was hospitalized because R5 was given the wrong medication and R5's blood pressure didn't come up. We sent R5 to the hospital. The medication definitely caused R5's blood pressure to drop and required hospital treatment. You have to be very careful. V7 stated R5 was admitted to the hospital. The facility's policy for Medication Administration reads: -Check Medication Administration Record [REDACTED]. -Read each order entirely. -Identify resident using two resident identifiers. The facility's policy for Medication Error Prevention reads: All residents will be identified for medication pass with two identifiers. If these are both not present, the nurse will take a time out and assure they are present before proceeding. The ALS (Advance Life Support) report dated 12/8/17 reads: lethargic, given wrong medication at Nursing Home at 9:00 AM. The emergency room documentation reads: Visit Reason- Unintentional ingestion- Overdose; Acuity- lethargic. -Admit to Cardiac/Neuro unit. The report also documented the hospital received a list of the above medications that were administered to R5. 2). The Face Sheet for R1 documents the following Diagnoses: [REDACTED]. The MDS (Minimum Data Set) dated 12/11/17 reads R1 has a BIMs (Brief Interview for Mental Status) score of 15/15 indicating no cognitive impairment. R1 stated on (MONTH) 6, (YEAR) at 12:24PM, I am not getting my medication. I am not getting my [MEDICAL CONDITION] eye drops. R1 stated they just got somebody's bottle and it is not mine. I haven't had [MEDICATION NAME] since Sunday. They told me it was too early to order. The POS/MAR documented the following orders for R1: [MEDICATION NAME] Solution 0.2%, Instill 1 drop in both eyes 3 times a day related to residual stage of angle-closure [MEDICAL CONDITION]; Dorzolamide HCL-[MEDICATION NAME] Solution 22.3-6.8 mg/ml, Instill 1 drop in both eyes two times a day related to residual stage of angle-closure [MEDICAL CONDITION]. [MEDICATION NAME] tablet 20mg, give 1 tablet by mouth one time a day related to major [MEDICAL CONDITION]; [MEDICATION NAME] HCL 50mg, give 1 tablet by mouth every 12 hours as needed for pain On 3/6/18 at 12:30 PM, V8 (Licensed Practical Nurse/LPN) was asked to review R1's medication. V8 pulled out an empty bottle of Dorzolomide-[MEDICATION NAME] from the top drawer of the cart. V8 stated I just tried to give it and nothing came out but air. The plastic bag the [MEDICATION NAME] was stored in read Dispense 10/29/17. There was also a bottle of [MEDICATION NAME] on the cart. The label containing the patient's name had been peeled off the bottle. The [MEDICATION NAME] and [MEDICATION NAME] were both missing. V8 looked for the medication and did not find them. V8 stated the policy is to reorder medication prior to it running out. V8 stated R1's eye drops were ordered on [DATE], but the facility lost them and attempted to reorder on 2/25/18 but the pharmacy stated order too soon. When asked who signed for the medication on 2/21/18, V8 stated V4 (Assistant Director of Nursing/ADON) has everything. You have to talk to her. On 3/6/18 at 12:47 PM, V4 (ADON) stated the policy is to reorder medication prior to it running out. V4 stated medication should be reordered within 48-72 hours of them running out. V4 stated we just switched to V9 (Pharmacy) and R1's eye drops were delivered on 2/21/18. I was just told the [MEDICATION NAME] just ran out this morning and all the other eye drops are in the cart. V4 stated R1's informed her this morning that R1 was improperly administering eye drops and was pouring too much from the bottle. V4 stated R1 was self administering the medication with supervision from the nurses. V4 stated The nurse was supervising R1, it was supervised. When asked what the nurse's response was while R1 was pouring out the medication, V4 stated the medication was to be kept on the med carts since January. But now the nurse's administer the medication. V4 was informed that V8 stated the eye drops were lost in (MONTH) and the facility attempted reorder. V4 stated I just told you R1 poured out the medication. Those are the bottles on the medication cart that were sent 2/21/18. On 3/6/18 at 1:55 PM, V10 (Pharmacy Supervisor) stated R1's eye drops were delivered on 2/21/18, and then the facility attempted to reorder them on 2/25/18 but was informed of reorder to soon. V10 stated the facility has not called again in relation to the eye drops. V10 was provided with the prescription number (RX) on the bottle of eye drops for R1 which began with #1. V10 stated That's not a prescription from our pharmacy. Our numbers begin with #9. We took over as the facility's pharmacy on 12/1/17. On 3/7/18 at 11:00 AM, R1 came to the conference room window and was waving to the surveyor. Upon being invited inside, R1 stated I still don't have my eye drops. It really makes me angry. I'm concerned with my eye drops because I have [MEDICAL CONDITION] and my eyes hurt. At times I can't see. 3). On 3/6/18 at 4:23 PM, V11 (Registered Nurse/RN) was asked to see R6's eye drops. The POS/MAR for R6 read: [MEDICATION NAME]-[MEDICATION NAME] 0.2-0.5%, Instill 1 drop in both eyes every 12 hours related to acute angle-closure [MEDICAL CONDITION]; Latanoprost Solution 0.005%, Instill 1 drop in both eyes at bedtime related to acute angle-closure [MEDICAL CONDITION] There was an empty bottle of [MEDICATION NAME] on the cart for R6 dated 1/18/18. The Latanoprost was 1/3 full and dated 1/8/18. V11 stated The [MEDICATION NAME] is empty. It should've been reordered. 4). On 3/6/18 at 4:29 PM, V12 (RN) was asked to see the eye drops for R7. The POS/MAR read: [MEDICATION NAME] Solution 0.2-0.5% ([MEDICATION NAME]-[MEDICATION NAME]), Instill 1 drop in both eyes two times a day; Dorzolamide HCL Solution 2%, Instill 1 drop in both eyes two times a day related to borderline [MEDICAL CONDITION] with ocular hypertension. V12 searched through the medication cart and did not locate either bottle of eye drops. V12 stated They must've run out. It should be in here in the top drawer. On 3/7/18 at 12:10 PM R7 had yellow crusty secretions in the eyes. R7's right eye was sticking together at the edge of the lids. R7 stated That's because I didn't get my eye drops. I don't get my eye drops every day. 5). On 3/6/18 at 4:34 PM, V13 was asked to see the eye drops for R4 and R8. The POS/MAR for R4 read: [MEDICATION NAME] Solution 0.2%, Instill 1 drop in both eyes 1 time a day for [MEDICAL CONDITION]; Latanoprost Solution 0.005%, Instill 1 drop in both eyes at bedtime related to [MEDICAL CONDITION]. V13 checked the cart and stated I don't see anything. V13 then checked the other 2 carts on the unit and stated 'I don't see them, if it's not here- it's not here. The POS for R8 read: Latanoprost Solution 0.005%, Instill 1 drop in both eyes at bedtime related to open angle with borderline findings; [MEDICATION NAME] Solution 0.5%, Instill 1 drop in both eyes two times a day related to open angle. The [MEDICATION NAME] packaging was dated 9/19/17; the bottle read opened 9/20/17. The bottle was full. The Latanoprost read sent 10/12/17. The bottle was not opened. The cap remained with the plastic safety seal in place. On 3/7/18 at 1:11 PM, R4 had dried yellow secretions in the eyes. On 3/7/18 at 1:38 PM, V2 (Director of Nursing) stated I went through the carts last night. R4's eye drops still are not here. We are reordering all of the medication. The policy titled Medication Administration read: If medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication.

Based on observation, interview and record review the facility failed to follow their Fall Prevenion Policy and failed to provide and implement Post Fall identified interventions for residents identified as High Risk for falls. This failure affects 2 of 3 residents (R4, R5) reviewed for falls. This failure resulted in R4 sustaining a scalp laceration requiring surgical glue repair. Findings include: R4 was admitted to the facility 12/1/17 with [DIAGNOSES REDACTED]. Incident Reports dated 2/3/18, 2/25/18 and 2/27/18 indicate R4 fell out of bed on each of those dates. Fall Incident Report dated 2/3/18 at 5:00pm indicates R4 was found on the floor next to his bed on the side opposite the bed's one siderail. Report indicates R4 was repositioned away from the non-reinforced side. Report does not indicate Root Cause of fall only that R4 has limited range of motion to bilateral upper and lower extremities. Post Fall Intervention was identified as (R4) benefiting from bed bolsters and floor mat for safety. Fall Incident Report dated 2/25/18 at 12:25pm indicates R4 was found lying on his back towards right side, between bed and window with covers and wedge also on the floor. Report indicates R4 with an air mattress on bed. Witness Statement indicates R4 was last provided care at 11:00am, was positioned to the left facing window and that wedges were placed left and right side of R4. Report indicates R4 sustained a laceration on scalp and was transferred to the hospital. Report Root Cause indicates R4 has behavior of pulling at (indwelling urinary catheter) and that (R4) has unstable bed mobility when behavior occurs. Post Fall Intervention was identified as (R4) would benefit from winged mattress to aid in safety when behavior occurs. Nurse Progress Note dated 2/25/18 at 6:33pm indicates R4 returned from the hospital. Hospital Discharge records dated 2/25/18 indicate R4 received treatment for [REDACTED]. Wound Note dated 3/1/18 at 2:00pm indicates R4 received a laceration (fall 2/25/18) top right side of head/scalp. Note indicates wound measures 0.9cm (centimeter) with surgical glue in place. R4 was seen in bed at that time and noted with purplish/red small left eyebrow bruise from fall 2/27/18. Fall Incident report dated 2/27/18 at 11:30am indicates that R4 was noted on the floor next to the bed and closet and that the blankets and wedge were also on the floor. Report indicates that R4 sustained redness and slight bruising to left eyebrow. Report indicates R4 sent to the hospital for evaluation. On 2/27/18 at 1:30pm, the bed in R4's room noted to be a flat air mattress, not winged. R4 was not in the bed at that time as he had been transferred to the hospital due to fall earlier that day. Observation on 2/27/18 and 2/28/18 found R4 on a non-winged air mattress. On 2/28/18 at 9:45am V2, DON (Director of Nursing) confirmed that R4 did not have a winged mattress on her bed. On 2/28/18 at 2:10pm V10, Restorative Nurse stated that she did not check to see that the winged mattress was in place on R4's bed before she put it on the care plan. V10 stated That's totally on me. On 2/28/18 at 9:40am, R4 was observed in a bariatric bed with a flat type air mattress. On 2/28/18 at 9:45am, V2, DON (Director of Nursing) stated that the mattress on R4's bed was not a winged type mattress. On 2/28/18 at 2:15pm, V10, Restorative Nurse stated R4 was always pulling at his (urinary) catheter but it recently became more of a problem behavior. V10 stated that she ordered the winged mattress (on 2/25/18) but didn't check to see if it had been placed on the bed before she put it on the care plan. V10 stated R4 should have had the winged mattress from 2/25/18 to 2/27/18 and that the bariatric mattress would have been replaced by the winged mattress on 2/27/18 when R4 returned from the hospital. Behavior identified post fall 2/25/18 was not identified on the care plan and no interventions were initiated to attempt to prevent the behavior causing unstable bed mobility. Winged mattress was identified to aid in safety when behavior already occurring, however winged mattress was never implemented and R4 fell out of bed again two days later on 2/27/18 sustaining a scalp laceration requiring hospital treatment. 2) MDS/BIMS (Minimum Data Set/Brief Interview for Mental Status) dated 12/18/17 indicates R5 scored 12/15. On 2/27/18 at 1:40pm, R5 stated that the siderails were removed from her bed. R5 stated I need my siderails. They said I don't need them anymore. At that time R5 stated that she spends most of her time in bed and used the siderails to help move from side to side and keep her from falling out of the bed. It was noted at that time that R5's bed was against the wall on right side, that R5 had an air mattress and that R5's bed had no siderails. On 2/28/18 at 9:30am, R5 stated that she wasn't trying to sit up or get out of the bed when she fell and stated I just rolled out toward the wall. R5 stated that her bed was not against the wall at that time and they didn't put the bed against the wall until she fell out of bed. (Most recent) Side Rail assessment dated [DATE] at 11:15am indicates R5 has difficulty with poor balance or trunk control; that R5 currently uses siderail for positioning, mobility or support; R5 expressed a desire to have siderails raised while in bed and that Half side rails are indicated and currently used as an enabler to provide assitance with bed mobility. Incident Report dated 2/25/18 at 1:45pm indicates that staff heard R5 calling for help from her room and upon entering the room found R5 on the floor on the right side of the bed. Report indicates R5 stated that she slid out of bed. Report indicates air mattress at medium pressure and that R5 sustained a bruise and redness in right occipital area. Report indicates R5 was oriented to person, place, time and situation. Report Post Fall Inervention indicates R5 will be given a winged mattress to aid in bed mobility and that therapy will assist resident with new mattress. Observation on 2/27/18 found R5 on a non-winged air mattress. On 2/28/18 at 9:45am V2, DON (Director of Nursing) confirmed that R5 did not have a winged mattress on her bed. Facility Policy/Fall Prevention dated 9/2017 indicates: Care Plan to be updated with new intervention based on root cause analysis after each fall occurrence.

Based on record review and interview the facility failed to assess and monitor 1 resident (R3) per facility policy after a fall. As a result of this failure R3 remained in the facility for 3 days after the fall before x-rays were taken. The x-rays revealed a [MEDICAL CONDITION] which required hospitalization for surgical repair. This is for 1 of 3 residents reviewed for falls. (R3) The findings include: 1. Review of R3's closed record admission face sheet showed R3 was admitted to the facility for Respite Care on 10/27/12. R3's admission [DIAGNOSES REDACTED]. Nursing note documentation dated 10/27/12 at 1:05 p.m. showed R3 was ambulatory upon admission to the facility. Interviews with E2 (Director of Nurses) on 2/27/13 at 12:15 p.m. and E3 (Restorative Coor/Occupational Rehab Aide) on 2/28/13 at 1:00 p.m. verified that R3 was ambulatory on admission to the facility. Nursing note documentation dated 10/28/12 at 2:06 a.m. and Fall Occurrence report documentation dated 10/28/12 at 2:00 a.m. showed R3 was confused, pacing, and wandering. R3 was placed at the nurses staion, was observed ambulating from chair to chair, and attempted to sit on the floor and fell . Nursing documentation showed an assessment was done on R3 at this time with no noted injury. Nursing documentation the same day (10/28/12) at 2:43 p.m. showed "R3 is calm today sitting in his wheel chair..." On 2/27/13 at 12:15 p.m. E2 (Director of Nurses) stated R3 was placed in a wheel chair on the same day of his fall even though he was not injured. E2 stated, "R3 was put in a wheel chair due to his cognition. He was so confused." As mentioned above, R3 was admitted with a [DIAGNOSES REDACTED]. Review of restorative intervention post fall for R3 included, "Wheel chair with alarm." Review of the facility's policy on documentation post falls showed, "All residents who had a fall incident will be monitored every shift for the next 72 hours and documented on..." Further interview with E2 on 2/28/12 at 12:15 p.m. noted E2 to say, "After a resident falls the nurses are supposed to assess/examine the resident for any further injury, pain, swelling, etc... and document this information on the resident on every shift for the next 72 hours. Review of the 72 hour nursing documentation showed nursing documentation was not done per facility policy or per instructions by E2. Nursing documentation showed there was 2 shifts that did not document at all on R3 during the 72 hour post fall (10/29/12 11:00 p.m - 7:00 a.m. and 10/30/12 - 3:00 p.m. to 11:00 p.m.). Three nurses notes were signed very late. The nurses note entry dated 10/28/12 - 3:52 a.m. was signed on 11/6/12 (9 days after R3's fall). The nurses note dated 10/29/12 - 2:28 p.m. was signed 11/5/12 (7 days after R3's fall), and the nurses note dated 10/30/12 2:45 p.m. was dated 10/31/12 (1 day after being written). None of the nurses notes showed R3 had been assessed and/or examined for bruising, redness, swelling, or range of motion. On 10/31/12 at 8:00 a.m. nursing documentation showed R3 still remained in the wheel chair. Ten O'clock documentation for the same day showed R3 had facial grimacing and complained of pain upon movement of the right lower extremity. Upon nursing examination of R3's right hip a 4.8 cm x 5.2 cm greenish/purple bruise was noted. R3 was sent to a nearby hospital where he was admitted with a [DIAGNOSES REDACTED]." Hospital Operative Report dated 11/2/12 showed R3 had to have surgical intervention for repair of the right femoral neck fracture.

Based on observation, record review, resident, facility staff and other interviews the facility failed to monitor, assess and evaluate 1 of 3 sampled residents R1 who complained of pain in the right shoulder and experienced swelling and decreased range of motion, failed to follow the physicians orders to keep the the right shoulder immobilized with shoulder immobilizer after a fracture occurred to promote healing, failed to follow the facility's policy and procedure for pain management and failed to notify the physician of the seriousness of the injury to R1's right shoulder to avoid delay in treatment. Findings include: R1 was admitted to the facility on [DATE]. R1 has no prior history of falls since admission. Cognitively assessed on 6/6/11 by use of the Minimum Data Set as usually understands and comprehends most conversations, short attention span, requires extensive assistance in mobility, transfer,continent of bowel and bladder, complains of pain. R1 was independent in ambulation before the fall on 5/26/11. R1 was sent to the hospital on [DATE] at 3:15 a.m. after receiving x-ray results, that R1 had sustained a [MEDICAL CONDITION] shoulder from a fall that occurred around 5:30 p.m. on 5/26/11 stated E10 (nurse). E10 did not witness the fall. E10 was interviewed on 6/14/11 regarding the occurrences involving R1's accident. E10 stated on 6/14/11, he and E13 (p..m. nurse supervisor) assessed R1 for injuries after the fall and felt, "it was not serious." E10 stated R1 was able to follow directions when asked to, "wiggle fingers and flex and extend her right arm." E10 asked if the right shoulder was assessed. E10 said, "no" because we evaluated the fingers and arm and everything was ok." The nurses notes completed by E10 on 5/26/11 document , (range of motion) "ROM tested with new limitation on right shoulder, verbalized pain when moving the shoulder, no limitation of the elbow and fingers, no bruising, redness or visible injury noted.. E10 stated he and E13 (pm supervisor) agreed that R1's pain probably came from the hit she took on the floor or was a dislocation. E10 stated they did not feel it warranted R1's being transferred to the hospital. E10 stated Z1 did not give directions to send to the hospital, just stat x-ray. " E10 stated R1 was, " complaining of pain and was medicated" at that time. E10 stated R1 was observed around 6 p.m. by him after the fall walking by herself to the dining room and then went to her room to bed and and did not get up anymore." E10 stated R1 "remained in her room." E10 said when queried that he did not assess R1 after the fall, it was not until E12 CNA reported to him around 9 p.m. that R1's right shoulder looked swollen 9 p.m we he went to see her. E12 stated on 6/14/11 that he saw R1 around 8 p.m. and reported the swollen right shoulder to E10 at that time. E12 stated that R1 is usually very active and she was not on this night, she sleeping a lot. When he went in to see her, he noticed her right shoulder looking swollen. E10 said on 6/14/11 we usually don't disturb her, because she has behaviors when we do. E10 notified Z1 around 9 or 10 p.m. ( time could not be determined). Z1 gave orders for "stat" right shoulder x-ray. The nurses notes document that (Z2) the portable x-ray provider arrived around 11p.m. and the results were received on morning of 5/27/11 around 3 a.m.. This was approximately more 5 hours after the stat order for x-ray was obtained and nine hours after the incident occurred. E10 and E3 (assistant director of nurses were queried on 6/14/11 as to the length of time for a, " stat" order to be completed and results reported. Both agreed the length of time should be 1 to 2 hours. E10 was unable to provide information, show documentation or explain how, R1's right shoulder was continually monitored, assessed, evaluated for pain or changes in range of motion, swelling or other injuries after the fall had occurred at 5:30 p.m. This information was not provided upon request or was available for review or documented in R1's nurses notes or Unusual occurrence Report. Z1 stated on 6/16/11 that the facility did not thoroughly communicate the extent of injuries and changes in the condition of R1's right shoulder (type and how much pain and swelling and limitation in movement). Z1 stated the clinical assessments information received from E10 on 5/26/11 of R1's right shoulder did not warrant an emergency or a decision to send to the emergency room . Z1 said she was unaware of the swelling and R1's shoulder or the type, intensity or location of the pain. Z1 stated that the communication between the facility was not through and complete enough to determine whether R1 should be sent out to the emergency room for further treatment and evaluation. Z1 stated a different decision would have been made if more information was provided by E10. Z1 stated the stat x-ray order was given on 5/26/11 and thought the results would be back within one to two hours of the call from E10 around 9-10 p.m. Z1 stated not able to give the direct time the call was received from E10; however Z1 said was called in in the morning and notified that R1's shoulder was fractured. Z1 stated being surprised of this injury due to the information received from E10 earlier. The results of the x-ray (impacted [MEDICATION NAME] of the Right Humerus) was telephoned to the facility by Z2. Z1 ordered, R1 be sent out to the hospital for evaluation and treatment. R1 left at 3:15 a.m as documented in R1's nurses notes. R1 stated that her right arm/shoulder hurt and it took them (nurses) to long to care for her shoulder and take her to the hospital after she fell . R1 stated that the medication she received Tylenol after the fall did not help her pain, and needed something stronger. R1 when queried stated she was not offered anymore pain medications by the nurses. There was no documentation that R1 received any further pain medication from E10 on 5/26/11. The medication regimen and physicians orders were reviewed. Tylenol was the only pain medication ordered for R1. The medication record notes(5/26) from E10 was lacking whether the medication was given and effective. The nurses notes document on 5/26/11 at 23:13, Tylenol two tabs given to R1 by E10, the time given was not documented or the effectiveness of the medication. There was no further assessment of R1's pain documented after the pain medication was given. E10 when queried on 6/14/11 stated he and E13 decided that R1's had no serious injuries from the fall, that the pain was probably from the hit (fall on the shoulder) or it was dislocated. This is why E10 did not make a request to Z1 to send to the emergency room for an evaluation. R1 was observed on 6/14/11 in bed alert and oriented with limited recall of events that happened on 5/26/11. R1 was observed with E4(day nurse), E3 (quality nurse) and E5 (CNA) on the afternoon of 6/14/11 in bed in room E15. R1 was alert and oriented and wearing a right arm/shoulder immobilizer. The immobilizer has two straps, one to secure the wrist to the waist and one for the humerus to secure the right arm to the chest. There is a waist belt that secures the immobilizer to the body. When queried R1, stated she could not remember the accident or what happened exactly was too long ago. Stated she was seated in a chair and remembers falling; however said it took them to long on that day to take care of me. Stated in pain now and always in pain. The Tylenol they give me does not work but they still give it to me. Stated the nurses donot ask her whether she has pain or if the medication works. R1 stated she [MEDICATION NAME] something stronger. E4 who was present said she medicates R1 with tylenol and a stronger pain medication [MEDICATION NAME] whenever R1 complains about pain. Review of the record show that E10 documented on 5/26/11 that a full body assessment was done and range of motion for R1 tested with new limitation on right shoulder, verbalizing pain when moving the shoulder. Tylenol was given for pain (time given unknown) and this was not documented in the record. E10's documentation does not include the rating/intensity, specific location of R1'a pain. The medication record and nurses notes lack information if the pain medication was effective or if continued monitoring of the pain was done after the fall occurred. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The record showed scoring of zero for all shifts and days from 5/24/11-6/13/11. E4 was requested to explain the pain protocol on 6/14/11. E4 stated zero does not mean that R1 had no pain. E4 stated a score of zero is documented at the end of th shift and R1 has no pain at that time it does not mean that the resident did not receive pain medication or complained of pain only pain free if pain at the end of shift. A review of the facility's policy and procedure for pain reflects the facility's policy is different and is not being followed. The policy and procedure requires a pain scale be used and to assess the residents before and after medication, to reevaluate the effectiveness of pain medication and document accordingly. This policy and procedure was not followed consistently. The accident investigation report faxed to the Illinois Dept of Public health was reviewed with E3 (assistant director of nurses/investigation of accidents/incidents) on 6/14/11 in the conference room. The report documented that R1 is alert and oriented, able to ambulate on her own, lost her balance and fell to the floor on her right shoulder, sent to the hospital and found to have a fractured right shoulder. E3 was queried about the surrounding events leading up to the fall, whether witness were present and what was resident doing prior to fall. E10 stated E4 (nurse) was at the desk, stayed late. This information was not contained in the report given. E3 stated there was another report available for surveyors review. Review of this report dated 5/26/11 document no injuries at time of assessment (5:30 p.m.); although E10 documented the right shoulder had new range of motion limitations and pain. The nurses notes lacked documentation of assessment and evaluation for the cause of the limitation of R1's right shoulder. R1 stated she fell from the chair on 6/14/11 when interviewed. The, "Unusual Occurrence Report Form" completed by E10 (nurse), dated 5/27/11 for R1, and the, "IDPH INITIAL REPORT" documented, " alert and oriented, but has confusion, able to ambulate on her own, lost balance and fell to the floor on right shoulder" at 5:30 p.m. This occurred on the 2nd floor E unit across from nurses station. E10 documented R1 said she fell , tripped from wheelchair, no injuries at the time, refused ice pack be applied, Tylenol 2 tabs given for pain. The Unusual Occurrence Report Form completed by E10 documented that E8 witnessed the accident involving R1 on 5/26/11 at 5:30 p.m. Review of the investigative interviews conducted by E3 did not include an interview from E8. Z3 (family) was at the facility on 6/14/11 and stated being notified by the facility E10 on 5/26/11 that R1 had fallen while walking in the hallway and tripped on a wheelchair. E8 stated this in the interview on 6/14/11. Upon E3's hearing of the inconsistent events from E4, E8 and E10 surrounding the accident to R1, E3 said she would reinterview E4 and E10 together and requested surveyor not be present. A meeting was held on 6/14/11 in the presence of E2 (director of nurses), E3, E4, E10. E4 repeated the events as documented in the , "Witness Interview Form" and E10 was queried as to not actually witnessing the event. The facility decided that E4's description was accurate. Z1 voiced reservations about how the accident occurred due to the different descriptions told to her by facility staff. Z1 on 6/15/11 stated not knowing exactly how the accident occurred. Z1 stated the distance of the fall is important to know in order to determine the impact and possible injuries. Z1 stated not exactly knowing how the fall occurred as inconsistent occurrences of the accident was told to her. Z2 (x-ray department) was notified on 6/15/11 and 6/22/11 for clarification of time interval for when the stat x-ray order was given to the x-ray department and performed and results obtained. It was learned that the x-ray department received the order on 5/27/11 at 9:20 p.m. and results ( Impacted [MEDICATION NAME] of the right Humerus) called to the facility at 1:53 a.m. stated Z4. The nurses notes document R1 did not leave the facility until 3:15 a.m. for the hospital. On 6/14/11 Z3 (family) stated that on occasions, 6/5/11 and 6/6/11, 6/9/11 and 6/10/11. R1's was not wearing the shoulder immobilizer prescribed to be worn at all times for the treatment of [REDACTED]. Z3 stated there was a conversation with E4, about this. R1 was seen walking down the hall with a nurse with her arm to the side and no immobilizer on 6/9/11. This was verified with E4 (nurse) on 6/14/11. Z1 stated R1 was seated in a armless chair in the dining room with her arms to the side not wearing the immobilizer when she came for a visit on 6/8/11. Z1 stated she met with the facility's administrators about R1 not having it on and none being available for her use. . E4 stated the facility staff has removed the immobilizer for wash and its during these times when R1 is without the immobilizer stated E4. E4 was queried on 6/14/11, whether Z1 had given permission for the removal. E4 stated she used a sling and a ace wrap to replace the shoulder immobilizer when it was removed. Z1 was not notified of this. Interview with Z1 revealed that the sling and ace wrap could not replace the shoulder immobilizer as the immobilizer should not have been removed by the facility staff without Z1'a knowledge. Z1 stated she was not made aware by the facility staff that they were removing R1's shoulder immobilizer. Z1 said the immobilzer is to be worn continously 24 hours a day for 6 weeks. Interview with E6 (physical therapy director) on 6/14/11 revealed that she purchased two shoulder immobilizers on 6/10/11 from a pharmacy. E6 stated she found out on last Tuesday 6/7/11 that R1 needed them and none were available in the facility for replacement. E4 stated R1 becomes incontinent of urine and the shoulder immobilizer becomes soiled with urine. R1 Minimum Data Set ((MDS) dated [DATE] and 6/6/11 scored zeros and documented R1 as being continent of bowel and bladder. R1's MDS read no trial voiding was done 6/6/11. The facility has a toileting program for residents assessed as being incontinent of urine. A list of those residents was reviewed with E3 on 6/14/11. R1's name did not appear on the scheduled toileting list.

Based on observation, interview and record review the facility failed to: 1) provide supervision to ensure safety of the residents for 1 out of 3 residents in the sample (R5). The incident resulted in an injury to R5 receiving a hematoma on the back of his head after being pushed by R2. 2) provide safe equipments causing accident/injury on 1 out of 3 sampled resident.(R8) Findings include: 1) Review of record showed that R2 has [DIAGNOSES REDACTED]. Nurses notes dated 01/03/11 document: At or about 3AM R2 aggressively came out of his room yelling to be changed. He (R2) approached CNA ( Certified Nursing Assistant E8) at the nursing station who was not assigned to R2 and preceded to attack him with his fists myself ( E7 nurse) and the other nurse on night shift, grab the resident telling him to let go of E8 and to sit down. However the aide's necklace was broken during the encounter. Nurses notes dated 01/14/11 08:00 showed R2 has been violent towards other residents this noc (night) shift. R2 was observed beating another resident and pushing him to the floor. Earlier, R2 was observed pulling on the feet of another resident who was on Gastrostomy tube ([DEVICE]), for no apparent reason. Nurses notes dated 01/17/11 late entry for 01/14/11 document: At 6:45 AM, resident (R5) was observed on the floor in supine position. Upon physical assessment, writer ( E13 nurse) noted hematoma to the back of resident's head. No changes were noted in resident's level of consciousness, as usual he requested juice and cookies which were given. Ice pack was applied to the back of head. Tylenol 650mg administered. R2's documentations also showed that he was verbally abusive and showed aggression to staff and residents as charted on 12/02/20 nurse's note and 11/5/10 social service note. Since admitted on [DATE] R2 has had 7 room changes because of his behaviors and not getting along with roommate. R2 was sent to hospital for aggressive behavior for further evaluation on 01/14/11. Review of unusual occurrence report form dated 01/14/11 at 6:45 AM documents that R5 was observed on the floor in supine position at 6:45 AM. Upon physical assessment noted hematoma at the back of R5's head occipital bone. When interviewed on 04/19/11 at 3:25 PM E9 (nurse) stated " I was 7-3 nurse for R2. R2 is alert and oriented X3 and R2 explained to me what happened. I remembered that R2 pushed R5 (roommate) on 01/14/11. R2 keep asking me if I will call police or going to jail for pushing R2. R2 told me that R5 was touching R2's feet and pulling R5 and R2 asked R5 to stop. R5 has issues with cognition. R5 sat on bed on R2's feet and got upset pushed R5 to the floor. R2 can ambulate, gets verbally abusive, swear to others residents, impatient and always wants to be first. If R2 is in wheel chair and a resident is on R2's way R2 pushes them away. I asked R2 why he does that. R2 said he is in a hurry and want them out the way. R2 is very impatient. R2 was bad and other residents in first floor who are alert wants to pushed R2 and does not like R2. R2 could be violent and been to several rooms cause can not get along with other residents and roommate." E10 indicated on interview on 04/19/11 at 3 PM that R2 was verbally aggressive, belligerent, impatient, uncooperative and very demanding. When R2 is in a wheelchair, he is very impatient, he will overrun any person on his way or push them away. E11, nurse on the F wing indicated on interview on 04/19/11 at 2:55 PM that R2 is agitated, restless, aggressive, screaming going around the hallway, not polite, verbally abusing staff and residents. E11 indicated that R2 had pushed another resident in the past. The facility did not make an incident report and investigate the incident in which R2 caused injury to R5. With his history of aggressive behaviors, care plan was not updated to ensure proper safety of other residents and staff. The facility did not have any behavior management plan to deal with his aggression and he was allowed with unacceptable behaviors with no intervention planned or documented. This resulted in an injury to another resident which was avoidable. 2) During tour of the facility on 05/08/11 at 11AM, R8 was observed in bed with bruises of the left upper arm. E4 ( Nurse) was asked to checked on R8's bruises with R8's permission. R8 was observed with another huge bruise on the lateral aspect of left lower leg. E4 was asked to measure the bruises. R8's bruise measures 13 1/2 inches in length and 9 inches in width with edematous/swollen hard, size of a tennis ball and with bluish discoloration extending to the calf, very sensitive to touch. R8 was observed grimacing when site is touched. Left upper arm bruise measures 7 1/2 inches x 3 inches with bluish discoloration. R8 bruises was observed with E3 ADON (Assistant Director of Nursing) and E4. R8 left leg bruise was observed as R8 was observed grimacing when R8's leg was touch. Per R8 she bump her leg and arm on the side rails. When interviewed, E4 stated that R8 bumped leg on the side rails. R8's side rails tube was observed with no cap and with sharp edges and this was pointed to E4 and E5 QA nurse (Quality Assurance Nurse ) and acknowledge the condition of the side rails. On 05/10 11 side rails were checked randomly with E5 and found 2 other side rails with rough edges and no cap. Progress notes dated 05/02/11 documents " Patient c/o left leg pain. She apparently injured leg over the weekend. It got stuck in the side rails". E6 DON ( Director of Nursing) was asked on 05/10/11 at 11:55 AM if there's incident report for R8's bruises and if this incident was reported to IDPH ( Illinois Department of Public Health ). E6 stated "no incident report was done on R8's big bruise on left outer aspect of the leg so it was not reported to IDPH. I checked with E5 and no incident report were done. There should been an incident report filled out for this particular incident. E6 further stated that he asked R8 before ( E6 can not specify exact date and time) how she got the bruise. Per R8 made contact with the side rails when getting up. Bed and side rails is the same as before the incident happened". Review of R8's care plan does not reflect intervention to prevent further injury. The facility did not investigate the incident and did not provide any preventive measures.