Every finding on record at Bria of Woodriver

Based on interview and record review, the facility failed to prevent abuse for 1 of 3 residents (R2) reviewed for abuse in a sample of 8. Findings include:1. R2's Care Plan, dated 3/5/2023, documents that ABUSE: At risk for abuse and neglect r/t (related to) psychotropic meds, behaviors toward staff, dx (diagnosis) schizophrenia.R2's Minimum Data Set, dated [DATE], documents that R2 is moderate cognitive impaired and requires assistance with Activities of Daily Living (ADL).R2's Other Report, dated 6/4/2026, documents that Nursing Description I, (V5), LPN (Licensed Practical Nurse), was doing medication administration when I witnessed (R3) (resident) walk pass another resident using wheeled walker, he stepped on the foot of (R2). (R2) began yelling and stating his foot had been stepped on. R2 is oriented to person, confused/forgetful and unable to give a description of event.R2's Nurses Notes, dated 6/9/2026 12:19 PM, documents that Note Text: New order rec'd per (V8), NP (Nurse Practitioner), for STAT 2-view x-ray to Residents left foot R/T (related to) C/O (complaints of) pain, foot stomped on by another Resident. No edema to the left foot noted. States tender to touch on the top of his foot. Called (x-ray company) and spoke with [NAME]. Ordered x-ray STAT.R2's Left Foot X-Ray, dated 6/9/2026, documents reason Pain, and left foot stomped on. Findings: mild soft tissue swelling. No evidence of recent fracture. On 7/2/2026 at 9:20 AM V5, LPN, stated that she was passing her medication on the hall. V5 stated that R2 was sitting in the hall but against the wall. V5 stated that she looked up from the cart to see R3 with his leg raised and then stumped on R2's foot. V5 stated that she observed R3 come down with force on top of R2's foot. V5 stated that she separated them and R3 started laughing. V5 stated that she reported the incident to (V1) and made a police report.On 7/2/2026 at 9:29 AM R2 stated that he is blind and did not see what happen. R2 stated that he remembers the pain. R2 stated that he was in a lot of pain. R2 stated that he remembers having the x ray. R2 stated that he was not sure if he was safe at the facility. R2 stated that sometimes he feels safe and sometimes he doesn't.On 7/2/2026 at V7, Registered Nurse, stated that she was made aware of another resident stomping on R2's foot. V7 stated that they were monitoring it because R2 was complaining of pain in the foot and of it being tender to touch. V7 stated that she did not see a bruise but there was some slight swelling. V7 stated that she V8 were keeping an eye on it and when R2 continued to complain of pain V7 requested an x ray to make sure there was more of an injury.2. R3's Care Plan does not address R3's behaviors towards staff or residents. R3's MDS, dated [DATE], documents that R3 is cognitively intact.R3's Nurses Notes, dated 6/4/2026 7:14 PM, documents that Late Entry: Note Text: I, (V5), LPN (Licensed Practical Nurse), was doing medication administration when I witnessed (R3) (resident) walk pass another resident using wheeled walker, stomped on the resident's foot, and proceeded to laugh. I, (V5), Redirected (R3) away from the resident after the incident. Incident was reported to (V1), Administrator and a police report was made with Officer (V6).R3's Acute Care Note, dated 6/9/2026 at 11:36 AM, documents that Visit Type: Acute Care: I saw and examined this patient on rounds today for acute concern of: behavior. Resident is ambulating in halls, NAD. Resident denies any acute concerns, staff reports resident has been intoxicated for days now. Resident often leaves LOA (leave of absence) and returns with ETOH (alcohol) and/or after abusing it. Resident acts erratically when drinking and uses inappropriate language with staff. It was reported that resident stomped on another resident's foot the other day. Resident endorses this action however reports thinking 'it was funny'. The police were notified according to staff.The facility's Long-Term Care Facility & 110 - Serious Injury Incident and Communicable Disease Report, dated 6/10/2026, documents that Incident category Physical Altercation. It also documents that R3 is a long-term care resident of the facility. He has a BIMs (brief interview of mental status) of 15, he is able to ambulate throughout the facility and make his needs known. He has the following diagnosis: Osteonecrosis; weakness; muscle weakness; essential HTN; hyperkalemia; hidradenitis suppurative. R2 is a long-term care resident of the facility. He has a BIMs of 11, he is able to verbalize his needs and requires staff to propel him throughout the facility. He has the following diagnosis: COPD; hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side; schizophrenia; personal history of TBI; other epilepsy; dysphagia following cerebral infarction. R2 was sitting in his wheelchair in the 300 hall. He had pushed himself into the main walkway facing his room. Another resident was on the left side of the hall near resident R2. R3 was ambulating down the hall and was attempting to get around resident R2. When going past he picked his walker up and was going around and stepped on resident R2 foot. The investigation was conducted by staff and resident interviews. Care plans reviewed and updated. Resident R2 had x-ray to left foot. Both residents feel safe in the facility. Though this event did occur, it did not rise to the level of abuse. This incident is unsubstantiated.R3's 30-day Follow up Note, dated 6/3/2026 at 9:05 AM, documents that visit Type: 30-day Follow up. It also documents R3's F10.929 - Alcohol use, unspecified with intoxication, unspecified. Patient frequently leaves the facility and returns intoxicated, exhibiting belligerent and non-adherent behavior toward staff and residents.On 7/2/2026 at 7:52 AM R6, President of Resident Council, R6 stated that R3 has been yelling at other residents in the facility. R6 stated that she is not sure if he is drunk. R6 stated that R3 screams and curses at other residents in the facility. R6 stated that R3 has not approached her but has approached others. R6 stated that she does not always feel safe at the facility. R6 stated that at night there are yelling and screaming at times and there are minimal people to help you. R6 stated that the facility had her fill out a form asking if she feels safe and she put not all the time.The facility's Abuse policy, dated 9/2017, documents that Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. It also documents that This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on interview and record review the facility failed to implement effective fall interventions for 1 of 3 residents (R2) reviewed for accidents in the sample of 7. This failure resulted on R2 falling 4 times, requiring to be sent to the hospital and receiving a laceration to her head. This past non-compliance occurred from 3/11/2026- 3/20/2026. Findings include:R2's progress noted dated 3/9/2026 documents R2 was admitted to the facility from assisted living.R2's face sheet date 5/7/2026 documents a diagnosis in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting Right dominant side, cerebral infarction, muscle wasting and atrophy right and left lower leg, weakness, reduced mobility, and abnormalities of gait and mobility.R2's Fall risk assessment dated [DATE] documents a score of 12 (score of 10 or above indicates high risk for falls)R2's Fall risk assessment dated [DATE] documents a score of 26.R2's fall risk assessment dated [DATE] document a score of 20.R2's fall risk assessment dated [DATE] documents a score or 23.R2's fall risk assessment dated [DATE] documents a score of 26.R2's fall risk assessment dated [DATE] documents a score of 29. R2's Minimum data set (MDS) dated [DATE] does not document any score of mental status. R2's MDS documents R2 is dependent on staff for toiletin, hygiene, upper and lower body dressing and persona hygiene.R2's care plan dated 3/9/2026 documents R2 is high risk for falls r/t falls since admission, impaired balance and gait, use of psychotropic meds and incontinence, impaired safety awareness glaucoma. R2's care plan documents the following interventions: 3-11-26 offer to lay out her clothing on bed/or chair, 3-17-2026 frequent rounding, 3-19-26 do not leave in room when she is up in chair, 3-19-26 pillows for positioning in wheelchair (she will not leave in place), 3/19/2026 refer to therapy for wheelchair positioning, 3-20-26 assist with leg rests in wheelchair as needed, 3-22-26 keep in high traffic areas when up in wheelchair, 3/15/2026: Move resident room closer to nurses station, 3/9/2026 Encourage and offer rest periods when walking long distances, Fall risk assessment quarterly and as needed, : Monitor for any changes in condition, Notify MD and family of any new fall, Therapy to evaluate and treat as indicated.R2's fall incident reports documents that R4 has had 4 falls at the facility.R2's fall incident report dated 3/11/2026 13:45 documents R2 attempted to ambulate to her closet and fell into the door which resulted in a laceration to R2's forehead. R2's fall report documents R2 was bleeding and lying on the floor. 911 was called and R2 sent out for evaluation. R2's fall report documents R2 was admitted to the facility in the past 72 hours. Report document R2's mental status as confused/forgetful. R2's fall report documents Behavior Interview Mental Status (BIMS) 2 - severely cognitively impaired. Intervention: offer to lay out R2's clothing for her.R2's Fall incident report dated 3/17/2026 at 14:06 documents R2 was found on the floor by Certified Nursing Assistant (CNA). Report documents when the nurse arrived R2 was lying on her left side propping herself up on left elbow. Report documents no obvious injuries. R2's fall incident report documents predisposing factors; confused, gait imbalance, impaired mobility and weakness. Report does not identify an intervention in place.R2's fall incident report dated 3/15/2026 at 14:40 documents resident on floor in her room. Report documents R2 fell out of her chair. Report documents R2 was sent out 911 for evaluation. R2's fall incident report documents predisposing factors of confused incontinent, non-compliant with safety guidance gait imbalance and impaired memory. R2's report documents no injuries observed at time of incident. R2's report documents immediate action taken; interventions frequent rounding on resident and call before you fall sign. R2's fall incident report documents 3/18/2026 new intervention to move resident closer to the nures's station.R2's fall incident report dated 3/19/2026 at 18:30 documents R2 fell in the dining room during dinner and hit her head. Report documents when the nurse arrived R2 was lying on her back with a large bump to her forehead. Report documents 911 was called due to R2 being on anticoagulants, and lethargic. The report documents R2 fell forward out of wheelchair, when being taken to her room to lay down. R2's fall incident report documents mental status as confused. R2's report documents intervention: pillows for positioning in wheelchair. R2's fall incident report dated 3/22/2026 at 12:05 document R2 was found on the floor by roommates bed lying on her left side. Report documents no injuries at time. Report documents intervention: keep in high traffic areas when up in wheelchair. The facility policy Fall Prevention and Management dated, revised 1/2026 documents the facility is committed to maximizing each resident's physical, mental and psychosocial well-being. The policy documents 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. The policy documents all resident falls shall be reviewed, and the residents existing plan of care shall be evaluated and modified as needed. The policy documents upon admission a fall risk evaluation will be completed, readmission and quarterly, significant change and after each fall. The policy documents residents at risk for falls will have fall risks identified on the interim plan of care and the ISp with interventions implemented to minimize fall risk. ON 5/12/2026 at 12:35PM V10 Registered Nurse (RN) stated R2 was a sweet and confused lady. V10 stated R2 came from assisted living next door where she lived with her spouse. V10 stated R2 was admitted because she had a fall and was to receive therapy. V10 stated R2 was confused and acted like R2 did not know what to do. V10 stated R2 was a high fall risk on admission to the facility. V10 stated no interventions in place on admission except to remind R2 not to ambulate by herself. V10 stated R2 was eventually to be at nurses station because of falls. V10 stated she did not send R2 out to the hospital on 3/17/2026 after fall as no visible new injuries and R2 had a fall a couple of days before. V10 stated at that point it was determined R2 should be provided close observation. V10 stated R2 fell forward out of her wheelchair in the dining room on 3/19/2026. V10 stated R2's facial bruising got worse as R2 had another fall. V10 stated R2 had black eyes.On 5/12/2026 at 1:04PM V15, Assistant Director of Nursing (ADON) stated R2 had previously lived at assisted living with spouse and had a fall prior to admission V15 stated R2 was a known fall risk prior to admission to the facility. V15 stated R2 had 4 falls at the facility. V15 stated R2 was confused.On 5/13/2026 at 11:50AM V19, physician per telephone interview stated he would expect the facility to have interventions in place for R2 on admission, since R2 fell prior to admission. V19 stated he would expect the facility to identify and implement effective fall interventions. Prior to the survey dated 5/7/2026 the facility took the following actions to correct the non-compliance: Education on fall prevention policy provided 3/20/2026.R2 fall care plan reviewed and revised to meet resident needs on 3/20/2026.Director of Nursing (DON)/ Designee will audit falls facility activity reports daily for any residents who exhibit sexual behaviors 5 times weekly x 4 weeks, then 3x week for 4 weeks and then random thereafter to ensure root cause analysis and appropriate interventions are in place on 3/19/2026The Administrator/ADON/Designee will review all new admission fall risk assessments 5 times a week for 4 week, 3 times a week for 4 weeks and randomly thereafter to ensure appropriate measures are in place on 3/19/2026.A QAPI has been initiated to report the above monitoring and auditing procedures. All findings from the QAPI/PIP will be presented to the monthly QAA meeting. Monitoring/ auditing and reporting will continue for a minimum of three months Administrator/ Designee will conduct random staff and resident interviews 3x weekly x 4 weeks focusing on any reports of potential abuse.

Based on observation, interview, and record review the facility failed to initiate and implement progressive interventions to prevent falls for 3 of 10 residents (R2, R19, and R51) reviewed for falls in a sample of 41.Findings Include: 1)R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of reduced mobility, muscle weakness, difficulty in walking, dementia, abnormalities of gait and mobility, and repeated falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired, uses a wheelchair, needs substantial/maximal assistance with sitting to standing and chair/bed to chair transfers. R2's Care Plan Date Initiated 3/30/2025 documents Fall: R2 is at high risk for falls related to incontinence, weakness, history of fall, glaucoma, confusion, and use of psychotropic meds. Intervention Date Initiated 8/10/2025 documents out to er. Intervention Date Initiated 11/13/2025 documents brightly colored reminder on wheelchair to not stand up without assist. R2's Care Plan was reviewed in its entirety as viewed in R2's Electronic Health Record. R2's Care Plan Date Initiated 5/8/2025 Transferring: R2 has a self care deficit in transferring related to impaired balance, weakness. R2's Quarterly Fall Risk Evaluation Dated 7/22/2025 documents R2 is a high fall risk. R2's Nurses Notes dated 8/10/2025 at 11:33 PM documents patient sent to Local Hospital related to falling in room trying to take himself to the bathroom. Complaining of 10/10 pain, barely able to move around from the pain. Survival flight called for transportation and took patient to hospital. The Facility's Fall Investigation for R2's Fall dated 8/10/2025 contains R2's Face Sheet, Physician Orders, Care Plan, and Minimum Data Set Section O (Special Treatments, Procedures, and Program, Section C (Cognitive Patterns, Section GG (Functional Abilities (Admission), Section GG (Functional Abilities- Discharge). No root cause analysis or intervention noted. R2's Local Hospital XR Pelvis 1 or 2 views dated 8/11/2025 documents impression: intertrochanteric fracture of the right hip R2's Nurses Notes dated 8/13/2025 at 6:48 PM documents resident readmitted to facility at this time for post right hip fracture after fall, surgically replaced. R2's Nurses Notes dated 11/13/2025 at 10:48 AM documents 0902 Resident was in wheelchair sitting at nurses station with staff present. Resident continued to try and stand and was redirected to stay in his wheelchair. As staff member turned her back resident stood and fell into medication cart hitting the back of his head and shoulder on the wheel of the medication cart. Resident denies any pain associated with fall. Resident assisted back to wheelchair with use of gait belt and two assist transfer. Nurse Practitioner stated to send resident to hospital as resident hit head and is on blood thinner. R2's Nurses Notes dated 11/16/2025 at 5:36 PM documents the resident arrived at the facility at 14:00 on a stretcher, accompanied by Emergency Medical Technicians (EMTs) x2 from Local Hospital. The resident was alert and oriented x2, but exhibited some discomfort when moved, related to a fractured clavicle on the left side. The left arm is currently in a sling that should be worn while up. R2's Nurses Notes dated 11/17/2025 at 10:33 AM documents resident was sitting by nurses station, partially down hall. resident states that he was trying to go to the bathroom and fell while ambulating without assistance. Fall was unwitnessed. Resident is complaining of left hip pain. pain check, range of motion (rom), skin check, Neuro check, vital signs obtained. resident sent to local hospital. R2's Nurses Notes dated 11/17/2025 at 11:01 AM documents resident was sitting at nurses station, partially down 500 hall. resident then attempted to stand without assistance, was unwitnessed, resident then fell to the floor. resident complaining of left hip pain. resident sent to local hospital for evaluation. R2's Local Hospital XR Hip Left 2 or 2 views with pelvis dated 11/17/2025 documents Pelvis/left hip: there is a comminuted fractur of the intertrochanteric proximal left femur with moderate displacement of the lesser trochanter fragment and mild displacement of the main distal fracture fragment. R2's Nurses Notes dated 11/18/2025 at 10:20 AM documents This nurse called local hospital to get an update on this resident. Resident is currently awaiting surgery on hip. R2's Nurses Notes dated 11/20/2025 at 6:15 PM documents resident returned to facility at this time, alert and oriented to self, has visual hallucinations upon arrival. hospital states that he had visual hallucinations at hospital as well. he's returning with left l(t) hip fracture (fx) with surgical repair, also has a recent lt clavical fx, prior to this hospital stay. On 2/6/2026 at 9:33 AM R2 observed trying to stand up without assistance from his wheelchair in front of nurses station. No brightly colored reminder to not standup without assist noted to R2's wheelchair. On 2/13/2026 at V22, MDS Coordinator, stated after a resident experiences a fall, the facility will investigate the fall, determine a root cause analysis for the fall, and implement an intervention for the fall. V22 stated the resident's care plan is updated with an intervention after each resident fall. On 2/13/2026 at 9:18 AM V13, LPN, stated R2 is a high fall risk and use to always try to get up on his own and would fall. V13 stated R2 requires assistance with transferring. On 2/13/2026 at 9:29 AM V2, Director of Nursing, stated she expects the facility to implement a fall intervention and update the resident's care plan with the intervention after every fall. On 2/13/2026 at 9:51 AM V18, Nurse Practitioner, stated she expects the facility to follow their fall policy and implement interventions for residents to help with falls. On 2/13/2026 at 11:00 AM V23, Certified Nursing Assistant, stated R2 has had falls and requires assistance with getting up and transfers. 2. R51's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R51's EMR dated 3/27/24 documents a diagnosis of Cerebral Infarction, unspecified. R51's EMR dated 2/28/25 documents a diagnosis of Difficulty in walking, not elsewhere classified. R51's EMR dated 6/17/25 documents a diagnosis of Repeated Falls. R51's MDS 12/5/25 documents a BIMS score of 14 out of 15. The MDS documents that the resident requires supervision or touching assistance for roll left and right. The MDS documents that the resident requires partial/moderate assistance for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. R51's Care Plan dated 3/6/25 documents FALL: high risk for falls r/t (related to) incontinence, impaired balance, history of fall, psychotropic meds. Interventions: 3-12-25 - non-skid strips by bed. 3-22-25 - toileting pgm (program). 3-6-25 - low bed when arrives. 4-10-25 - assist with gripper socks. 4-14-25 - non-skid strips by toilet. 4-20-25 - keep in high traffic area. 5-17-25 - anti roll backs when arrives. 5-31-25 - dycem in wheelchair. 6-18-25 - gripper socks when up in chair. 6-22-25 - grab bars x's 2 assist with positioning and transfers dc'd (discontinued) 11-21-25 changed to half rail on right side. 7-13-25 - Keep frequently used items within reach. 7-14-25 - clinical evaluation. 7-26-25 - leave wheelchair in locked position by bed. 8-10-25 - no cloth pads in wheelchair. 8-22-25 - wheelchair seat modified. 8-25-25 - encourage participation in afternoon activities. 8-8-25 - bed against wall. 9-3-25 - Brightly colored visual aid on call light. 10-5-25 - remind to ask for assist with standing. 11-15-25 - brightly colored reminder on wheelchair not to stand without assist. 11-15-25 - therapy to eval. 11-24-25 - frequent observation and assist to have gripper socks in place. 11-27-25 - Staff to remind resident to sit up straight in wheelchair. 11-9-25 - Encourage AM diversional Activity, involve in activity of choice. 12-11-25 - toileting pgm to be modified. 12-30-25 - call before you fall sign by bed. 12-31-25 - redirect to hall as needed. 1-13-26 - re-educate on wheelchair positioning. 1-17-26 - dycem under resident in chair and under pad chair. 1-23-26 - during rounds staff to observe for covers to be straight. 1-26-26 - given reacher. 1-27-26 - therapy to eval for wheelchair saddle cushion. R51's Nurses Notes dated 3/6/25 at 9:33 PM documents Resident was put into his bed this evening. When the CNAs (Certified Nursing Aid) went to check on him, he had his diaper off, knees on the floor with the rest of his body lying on the bed. The CNAs got him off the floor and into his bed, and re-educated him to stay in bed, because it's nighttime. He then began to scoot his feet and legs back to the side of the bed. I retrieved a fall mat and placed it on the side of his bed. Plan of care ongoing. R51's intervention dated 3-12-25 documents non-skid strips by bed. On 2/10/26 at 1:13 PM, observation of R51's room. No non-skid strips noted by R51's bed. R51's Nurses Notes dated 4/10/25 at 4:21 PM documents res (resident) was found sitting on floor mat, no injury/pain noted at this time. Will continue to monitor. VS (Vital signs) WNL (Within Normal Limits). R51's intervention dated 4-14-25 documents non-skid strips by toilet. On 2/10/26 at 1:13 PM, observation of R51's room. No non-skid strips noted by R51's toilet. R51's Nurses Notes dated 7/26/25 at 2:12 PM documents Resident was trying to transfer from his bed to the chair in his room unaided and fell on his buttocks. This nurse along with other staff assisted him to his bed. Resident was assessed, no physical injuries noted. Vital signs checked BP (blood pressure) 126/68 P (pulse) 60. R51's Intervention dated 7-26-25 documents leave wheelchair in locked position by bed. On 2/10/26 at 1:13 PM, observation of R51's room. R51's wheelchair was noted to be across the room from resident's bed. R51's Nurses Notes dated 11/27/25 at 4:10 PM documents At 1555, this nurse observed Resident slide from his w/c (wheelchair) to the floor onto his buttocks. Did not hit his head. Assessment completed. Hand grips are strong and equal bilaterally. PERRL (Pupils Equal Round Reactive to Light). ROM (Range of Motion) WNL per baseline. Denies any pain or discomfort. VSS (Vital signs Stable). Assisted Resident using gait belt and two assists back to his w/c. Director of Nursing notified. R51's Intervention dated 11-15-25 documents brightly colored reminder on wheelchair not to stand without assist. On 2/10/26 at 1:13 PM, observation of R51's room. No brightly colored reminder noted on R51's wheelchair. R51's Nurses Notes dated 12/30/25 at 4:45 PM documents At 1625, CNA called this nurse to Residents room. Observed Resident sitting on the floor in front of his w/c next to his bed. Resident stated he was being stubborn and tried to transfer himself from his w/c to his bed. He denied hitting his head. Denied pain. Head to toe assessment completed. No apparent injuries. No changes in cognition. Hand Grips strong and equal bilaterally. ROM WNL per baseline. PERRL. Resident w/c was not locked. His call light was within his reach. Had on non-skid shoes. Y (temperature) 97.3HR (heart rate) 59 RR (respirations) 18 BP 129/50 SpO2 (oxygen saturation) 97% on RA (room air). Assisted back to his w/c. R51's Intervention dated 12-30-25 documents call before you fall sign by bed. On 2/10/26 at 1:13 PM, observation of R51's room. No call before you fall sign noted by resident's bed. R51's Nurses Notes dated 1/23/26 at 3:00 AM documents This nurse was notified by cna that resident was on the floor. When asked what happened? Resident stated he was tossing and turning in his sleep when he noticed he was on edge of the bed it was too late so he scooted to floor. VS T 98.6 bp 114/55 R 18 P 66 spo2 96% RA. ROM WNL. No injuries no c/o (compliant of) pain. Resident assisted back into bed via (mechanical lift) with assist of 2. Resident in bed at thus time resting. R51's Intervention dated 1/27/26 documents given reacher. On 2/10/26 at 1:13 PM, observation of R51's room. No reacher noted in resident's room. On 2/13/26 at 9:41 AM, V2, DON (Director of Nursing) stated that care plan interventions should be implemented after the facility determines the appropriate fall intervention for the resident. 3-02/05/2026 10:33 AM R19 stated she had just fell a day ago and her ankle still hurts. R19's POS dated January 2026 documents a diagnosis of Type 2 diabetes mellitus, weakness, unsteadiness on feet, cognitive communication deficit, acute kidney failure, chronic kidney disease stage 3, muscle weakness, heart failure, hypertension, generalized anxiety disorder, depression, anemia, insomnia. R19's MDS dated [DATE] document R19 was severely impaired for cognition for activities of daily living. R19's Progress Notes dated 2/3/2026 at 2:28 PM, Resident was trying to get into the bathroom in her wheelchair and fell to the floor. The resident claimed she landed on her right side and that her ankle hurt. This nurse assessed her and there were no open wounds or bruises. The hall CNA's (certified nursing assistants) aided the resident into the wheelchair. This nurse asked if there was any pain, and she claimed there was pain in her right ankle and right hip. Vital signs were within range. R19's Care Plan with a date initiated of 1/15/2025 documents under Fall: is at risk for falls r/t (related to) frequent falls, impaired safety awareness, impaired balance and gait, incontinence. R19's Care Plan dated 3/17/2025 documents, frequent rounding during the day. (No interventions were documented for R19's fall on 2/3/2026. On 2/6/2026 at 11:48 AM, R19's Fall Report and investigation was requested to V1, Administrator. On 2/6/2026 at 4:30 PM, R19's Fall report and investigation information was requested from V1, Administrator. On 2/7/2026 at 10:10 AM, R19's Fall report and investigation was requested from V1. On 2/7/2026 at 3:30 PM, a green folder with R19's POS, Care Plan and nurse's notes were provided by V2, Director of Nursing (DON). On 2/7/2026 at 3:35 PM, V2, Director of Nursing (DON) stated that was everything they had for R19's fall. R19's folder did not contain any interventions and/or anything addressing her fall other than the progress note for her fall on 2/3/2026. The Facility Fall Log documents R19 had a fall on 2/3/2026, No other falls were documented for R19 for the past six months. On 2/10/2026 at 12:44 PM, V1, Administrator stated policy she expects all fall interventions to be documented in the Resident's Care Plans. The Facility Fall Policy with a review date of 10/2018 documents, The 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 as 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. Evaluate the resident for any injury and notify the physician and emergency contact. Complete a fall incident report in the (Computer) risk management portal. Care plan to be updated with a new intervention based on root cause analysis after each all occurrence.

Based on observation, interview, and record review, the facility failed to provide catheter care, including irrigation, in 1 of 5 residents (R75) reviewed for bowel/bladder incontinence, catheter, and UTI (Urinary Tract Infection) in the sample of 41. This failure resulted in R75 being hospitalized for a UTI.Findings Include:On 2/5/26 at 1:43 PM, R75 was observed in his room with a suprapubic catheter draining clear tea colored urine. R75 stated he has a suprapubic catheter, he does not take care of it himself, the staff cleaned it two or more days ago and he has had a recent urine infection. On 2/10/26 at 12:25 PM, R75 stated he was sent to the hospital about a month ago because his catheter was clogged up and it had to be replaced. R75 stated the staff only clean his catheter site every 2-3 days. Catheter care was observed with V5, Wound Nurse, and R75 complained of penile pain and tenderness around the suprapubic catheter site. R75's Face Sheet, undated, documents R75 has the following diagnoses: UTI, Sepsis, and Obstructive/Reflux Uropathy. R75's MDS, dated [DATE], documents the following: R75 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R75 is cognitively intact, he requires partial/moderate assist with toileting, and has an indwelling urinary catheter. R75's Care Plan, dated 9/21/25, documents R75 has a suprapubic catheter. R75's (POS) Physician Order Sheet documents an order dated 1/30/26, to flush suprapubic catheter with 60cc (cubic centimeters) of sterile water every 12 hours. There were no orders for R75's catheter or catheter care. R75's Progress Note, dated 1/9/26 at 10:10 PM, documents R75's suprapubic catheter was changed. R75's Progress Note, dated 1/15/26 at 4:46 PM, documents the following: This nurse obtained the residents' vital signs and received a blood pressure of 200/152. This nurse attempted to contact telehealth with no answer. This nurse contacted the DON (Director of Nurses) who instructed this nurse to send the resident to the hospital. EMTs (Emergency Medical Technician) arrived at 4:40 PM and took the resident to the hospital. R75's Progress Note, dated 1/17/26 at 6:39 PM, documents the following: Resident arrived back to facility via ambulance accompanied by two on a stretcher. Resident arrived with a change in orders and some new orders, there are some follow-up appointments as well, which will be adjusted accordingly. Kitchen staff made aware of patients return to facility. No c/o (complains of) pain or discomfort. Resident is up, alert and oriented x4 to person, place, situation, and month. Resident in room with call light in reach awaiting food tray. Vital signs are as follows: 128/68; 97%; 98.9; 16; and 78. R75's Progress Note, dated 1/18/26 9:09 PM, documents the following: Resident currently on ABT (antibiotic) for UTI. Metronidazole 500 mg (milligrams) PO (by mouth) TID (three times daily) for 3 days, with the first dose being administered at bedtime, tolerated well. Foley catheter in place, patent draining yellow urine, and denies pain/discomfort at this time. R75's Progress Note by V18, Nurse Practitioner, dated 2/9/26 at 12:36 PM, documents the following: Obstructive and reflux uropathy, unspecified. Benign prostatic hyperplasia with lower urinary tract symptoms. Chronic indwelling suprapubic foley catheter for urinary retention. Foley, patent and draining. Oxybutynin ER (extended release) 5mg QAM (every morning) for overactive bladder, no current antibiotics, recent levofloxacin for UTI, now completed on 2/5/26. High risk for UTI: monitor for fever, confusion, dysuria, foul-smelling/dark urine.UA (urinalysis) ordered if symptoms arise. Regular assessment for pain (recent penile pain, managed with acetaminophen as needed). Nursing Care - Routine catheter care per protocol. Perineal hygiene reinforced. Foley care provided each shift. Catheter output and urine color monitored (recently straw-colored, no odor, no discomfort). Recent Complications - UTI treated with metronidazole and levofloxacin (Jan/[DATE]). No current signs of infection. Acetaminophen 500 mg PRN (as needed) for pain (recent penile pain episodes, responsive to medication). Notify provider for new/worsening confusion, pain/burning with urination, odorous/foul-smelling urine, or dark urine. R75's Progress Note, dated 2/9/26 at 5:53 PM, documents the following: Resident has had loose stool, brown in color, odor noted. Alert and oriented x3, confused about the day and time. Skin warm and dry, color pale. Lungs clear x4. Vitals obtained 113/64, pulse 98, Resp 19, non-labored. temp 98.0, o2 sat 96%. Unable to stand, unsteady, poor balance. Sitting up in bed head elevated. PO fluids encouraged. Suprapubic catheter intact, patent, amber urine. R75's Progress Note, dated 2/9/26 at 6:13 PM, documents the following: Collected the stool sample, placed in the refrigerator. Spoke with NP (Nurse Practitioner), new orders to collect a urine sample, r/t (related to) resident complaining of burning, and pain. NP will place order for antibiotic to be started after the UA is collected. R75's Progress Note, dated 2/9/26 at 7:57 PM, documents the following: Pinched off the suprapubic catheter for one hour, collected urine sample, cloudy yellow urine with no odor, placed in refrigerator. R75's Hospitalist History and Physical, dated 1/22/26, documents the following: Assessment: Catheter associated UTI. Urine culture: greater than 100,000 CFU (colony forming unit) of pseudomonas aeruginosa and enterococcus faecalis. R75's MAR/TAR (Medication Administration Record/Treatment Record) document R75's catheter was last changed on 1/9/26. There was no documentation of catheter care or irrigation of the catheter for January or February 2026. On 2/10/26 at 12:25 PM, catheter care was observed on R75 with V5, Wound Nurse, and during care R75 complained of penile pain and tenderness around the suprapubic catheter site. On 2/10/26 at 1:36 PM, V19, LPN (Licensed Practical Nurse), stated R75 is supposed to get his catheter irrigated every 12 hours and she believes it is done on evening shift, she doesn't do it on the day shift. On 2/10/26 at 12:25 PM, V5, Wound Nurse, stated catheter care should be done every shift. On 2/10/26 at 2:12 PM, V2, DON (Director of Nurses) stated catheter care/irrigation of the catheter would be documented on the MAR/TAR. On 2/13/26 at 9:40 AM, V2, DON, stated she would expect physician orders to be followed. On 2/13/26 at 9:53 AM, V18, Nurse Practitioner, stated in part she would expect the nurses to use their nursing judgement when following physician orders. The Foley Catheter Care Policy, dated 4/2019, documents daily and PRN catheter care will be done to promote comfort and cleanliness.

Based on observation, interview and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 76 residents living in the facility. Findings include: Facility [NAME], [NAME] (35156) - Kitchen On 2/5/2026 at 8:14 AM, in the walk-in refrigerator there was large industrial mesh bag of onions (50 pounds) sitting directly on the floor. In the corner was a large box of pasteurized eggs sitting directly on the floor. The eggs were next to a box of cupcakes and in the middle was a large industrial box of raw meat (chicken or pork) thawing. On 2/5/2026 at 8:15 AM, in the walk-in refrigerator on the metal shelf was a large industrial bowl of greens that was not dated and or labeled. Next to the bowl of greens was a bag of mozzarella cheese half opened and not covered sealed or labeled. The cheese was being exposed to the air. On 2/5/2026 at 8:16 AM, in the walk-in refrigerator on the metal shelf was a box of raw chicken that was thawing and dripping sitting next to a box with 12 heads of fresh cabbage inside the box. The boxes were next to each other. The chicken was not dated and or labeled. On 2/5/2026 at 8:18 AM, in the middle of the storage room there was a removable metal cart. On top of the cart was a large industrial size slab of beef thawing. The meat was not in a container but directly sitting on top of the cart. Underneath the cart was large industrial 4-quart container of a red substance with large noodles in it. The container sitting directly underneath the meat was not dated and or labeled. On 2/5/2026 at 8:20 AM, in the kitchen area is a large storage container and after opening the lid inside is a large industrial bag (25-pound bag) labeled breadcrumbs that was opened. The outside container was not dated and or labeled. On 2/5/2026 at 8:21 AM, in the kitchen area is large industrial container of food thickener that was not dated and or labeled. On 2/5/2026 at 8:24 AM, in the dry storage area is a large container of oatmeal sitting directly on the floor. The oatmeal is opened and exposed to the air. On 2/5/2026 at 1:03 PM, V7, Dietary Manager stated I would expect all items to be stored at least six inches off the floor and never stored directly on the floor. I expect all items to be dated and labeled and I expect meat to be stored alone and not near any other items to prevent food contamination and possible food borne illness. RR The Facility undated Food Storage Policy documents, Food stock and products are stored 6 inches of the floor (per state regulation) in the storeroom, walk-in cooler, and freezer. The Facility Labeling and Dating policy undated documents, Policy: Leftovers and opened foods shall be clearly labeled with. date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. (i.e. salad dressings, pickles, etc.) Name of food item if not clearly identified on container. Discard date [NAME].e. opened 4/30, discard 5/30). (Need meat policy). All protein items (i.e. meat, poultry, fish) are defrosted under ref bottom shelf.

Based on interview and record review the Facility failed to ensure call lights were being answered in a timely manner for 6 of 14 residents (R16, R17, R43, R67, R69 and R81) reviewed for call lights in the sample of 41. Findings include: 1-R67's MDS dated [DATE] document R67 is cognitively intact for decision making of activities of daily living. R67 uses a wheelchair and needs substantial/maximal assistance- Helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. During the Group Meeting on 2/5/2026 at 1:30 PM, R67 stated there were issues and have been complaints about the call lights not being answered in a timely manner. This is being brought up constantly at the Resident Council Meeting and does not seem to be getting any better. We typically wait for call lights at least 30 minutes if not more. 2-R16's MDS dated 11/2025 document R16 is cognitively intact for decision making of activities of daily living. During the Group Meeting on 2/5/2026 at 1:35 PM, R16 stated she was able to do most things by herself, but she attends the Resident Council Meetings regularly and this is something residents are constantly bringing up. We have issues with staff who really do not want to work and they are on their phones a lot and do not answer the call lights. It's a problem. 3-R43's MDS dated [DATE] document he was moderately impaired for cognition. During the group Meeting on 2/5/2026 at 1:39 PM, R16 stated there are times when he needs help with going to the bathroom and he feels embarrassed when he wets the bed and waits so long, he has an accident. Staff are not answering the call light fast enough when he needs to go to the bathroom. 4-R17's MDS dated [DATE] documents she is cognitively intact for decision making of activities of daily living. R67 uses a wheelchair and has impairment on her lower extremities and needs partial to moderate assistance with hygiene, dressing, showers and toileting. During the Group Meeting on 2/5/2026 at 1:42 PM, R17 stated that there are issues with staff not wanting to work and not answering the call lights. It's not uncommon for her to have to wait forty minutes for someone to answer her call light especially at night. 5-R69's MDS dated [DATE] document R69 was moderately impaired for cognition. On 2/5/2026 at 3:00 PM, R69 stated there are always issues with staff not wanting to work and not answering the call lights. It's a big problem here. 6-R81's MDS dated [DATE] document R81 was cognitively intact for decision making of activities of daily living. On 2/13/2026 at 3:00 PM, R81 stated that when she needs help, she does not always get help, and the staff are really bad about not answering call lights. She easily waits over an hour for staff to respond and sometimes that is way too long. This has caused her stress and when you need help you need help. On 2/13/2026 at 1:30 PM, V17, Ombudsman stated she had been getting a lot of complaints and has been out to the facility several times regarding call lights not being answered in a timely manner and it still seems to be a problem. The Resident Council Meeting Minutes dated 3/20/2025 documents, Call lights on for over an hour at time before being answered. The Resident Council Meeting Minutes dated 4/24/2025 documents, Call lights on for over an house at times before being severed. The Resident Council Meeting Minutes dated 11/20/2025 documents, Call lights are not being answered in a timely manner. Call lights are on for over an hour at times-All shifts. Grievance dated 8/5/2025 We see nurses and CNA's (certified nursing assistants) sitting at desk while call lights phone is ringing and doorbell is going off up front and they continue to sit there and talk. Grievance dated 3/20/2025 Call lights on for over an hour at times before being answered. Grievance dated 9/25/2025, Council believes nurses should help answer call lights when there are a lot of lights going off/doorbells ringing. Not just aides. Grievance dated 10/30/2025, Call lights are not being answered in a timely manner, Call lights are on for over an hour at times-All shifts. On 2/13/2026 at 2:41 PM, V2, Director of Nursing stated she expect all staff to answer call lights in a timely manner. She was aware of some complaints, but when we looked into it and we did find some call lights were not working properly. I expect call lights to be answered as quickly as possible less than 10-15 minutes.The Call Light Response Policy dated 9/2025 documents, To provide the staff with guidance on responding to resident's request and needs. Answer the patient or resident's call as soon as possible.

Based on observation and interview, the facility failed to properly label medications for an unknown number of residents due to medications not being labeled in a sample of 41.Findings include:On 02/05/2026 at 8:10 AM the 100 Hall Medication Cart was inspected with V8, Registered Nurse (RN). In the top right drawer of the medication cart, 2 Breztri Inhalers and 1 Airsupra Inhaler were observed with no resident name or date opened. 1 Breztri inhaler noted to have 1 inhalation left, 1 Breztri inhaler noted to have 8 inhalations left, and the Airsupra inhaler noted to have 10 inhalations left.On 2/5/2026 at 8:13 AM V8, RN, stated she did not know whose inhalers those were, and the inhalers looked like they have been used. V8 stated all inhalers should be labeled with a resident name and the date the inhaler was opened. V8 stated she is unsure who the inhalers belonged to and maybe the midnight nurse put them in the top drawer to figure out whose inhalers they were.On 2/13/2026 at 9:39 AM V2, Director of Nursing, stated she expects all medications including inhalers to be labeled with the resident's name and the date the medication was opened.The Facility's Medication Storage In The Facility Policy dated 12/2016 documents Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations.

Based on interview, observation, and record review, the facility failed to provide Ice Cream with meals as ordered for 5 of 5 residents (R6, R24, R74, and R81) reviewed for Nutrition in a sample of 41.Findings include:1.) R1's Face Sheet documents R1 was admitted to the facility on [DATE] and has a medical diagnosis of Dementia and Hypertension.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired and needs setup or clean-up assistance with eating.R1's Physician Order dated 1/9/2026 at 10:53 AM documents NAS (NO ADDED Salt) diet. Regular texture, THIN LIQUIDS consistency, Super cereal at breakfast with sugar. Vanilla ice cream at Lunch and dinner.R1's Meal Ticket dated 2/6/2026 documents Lunch Daily: VAN Ice Cream. Dinner DAILY: VAN Ice Cream.On 2/5/2026 at 1:00 PM R1 received her lunch tray which consisted of meatloaf, mashed potatoes and gravy, fruit, and cake. R1 did not receive her ice cream as ordered with her lunch tray.On 2/5/2026 at 1:10 PM R1 stated she did not receive her ice cream with her lunch today. R1 stated sometimes she will receive it and sometimes she does not.On 2/6/2026 at 12:30 PM R1 eating lunch tray. No ice cream noted on R1's tray. R1 stated she did not receive her ice cream again today.2.) R6's Undated Face Sheet documents R6 was admitted to the facility on [DATE] and has a medical diagnosis of Gastro-Esophageal Reflux Disease, Schizoaffective Disorder, and Dementia.R6's MDS dated [DATE] documents R6 is severely cognitively impaired and needs supervision or touching assistance with eating.R6's Physician Order dated 6/26/2025 at 2:35 PM documents Regular diet, PUREED texture, THIN LIQUIDS consistency, Divided plate, Super Cereal for breakfast; ice cream for Lunch and dinner.R6's Physician Order dated 10/21/2025 at 1:03 PM documents ice cream at lunch and supper.R6's Meal Ticket dated 2/6/2026 documents Lunch DAILY: Ice Cream. Dinner DAILY: Ice Cream.On 2/6/2026 at 1:51 PM R6 stated she did not receive ice cream with her lunch tray today and does not remember the last time she received ice cream with her meal trays.3.) R24's Undated Face Sheet documents R24 was admitted to the facility on [DATE] and has a diagnosis of Gastro-Esophageal Reflux Disease and Hypertension.R24's MDS dated [DATE] documents R24 is moderately cognitively impaired and needs setup or clean up assistance with eating.R24's Physician Order dated 1/12/2026 at 12:57 PM documents REGULAR diet, MECH/SOFT texture, THIN LIQUIDS consistency, Super cereal with breakfast. Ice cream with Lunch (Strawberry). Fortified pudding with dinner. Double portions at Breakfast & Dinner. Fortified potatoes at Lunch. Offer juice and milk at meals.R24's Meal Ticket dated 2/6/2026 documents Lunch DAILY: Milk Whole. Fortified Potatoes, Ice Cream.On 2/6/2026 at 1:54 PM R24 stated she has not been receiving her ice cream with her lunch for a couple days. R24 stated she will sometimes receive pudding with her tray but has not had her ice cream.4.) R45's Undated Face Sheet document R45 was admitted to the facility on [DATE] and has a medical diagnosis of Type 2 Diabetes Mellitus, Moderate Protein-Calorie Malnutrition, Hypertension, and Gastro-Esophageal Reflux Disease.R45's MDS dated [DATE] documents R45 is cognitively intact and needs setup or clean-up assistance with eating.R45's Physician Order dated 9/2/2025 at 9:14 AM documents LCS (low concentrated sweets) diet, REGULAR texture, REGULAR LIQUIDS consistence, 1 apple juice at breakfast; Ice cream with lunch and Dinner. Double portions all meals.R45's Meal Ticket dated 2/6/2026 documents Lunch DAILY: DOUBLE PORTIONS, Ice Cream. Dinner DAILY: DOUBLE PORTIONS, Ice Cream.On 2/6/2026 at 1:44 PM R45 stated she has not received ice cream with her lunch or dinner tray in a couple days. R45 stated she should not have to ask staff where her ice cream is since it is ordered for her to have it. R45 stated the ice cream was ordered for her to help her with her weight. R45 stated she has not received anything in place of the ice cream on her meal trays.5.) R74's Undated Face Sheet documents R74 was admitted to the facility on [DATE] and has a medical diagnosis of Dysphagia, Protein-Calorie Malnutrition, Hypertension, and Gastro-Esophageal Reflux Disease.R74's MDS dated [DATE] R74 is moderately cognitively impaired and needs partial/moderate assistance with eating.R74's Physician Order 11/20/2024 at 10:59 AM documents REGULAR diet, MECH/SOFT texture, THIN LIQUIDS consistency, Put each food item in a bowl. Double portions upon request; ice cream at Lunch.R74's Meal Ticket dated 2/6/2026 documents Lunch DAILY: DOUBLR PORTIONS Upon Request, Ice CreamOn 2/6/2026 at 1:48 PM R74 stated he has not received ice cream on his lunch tray for a few days. R74 stated he does not think he has received anything in place of the ice cream.6.) R81's Undated Face Sheet documents R81 was admitted to the facility on [DATE] and has a medical diagnosis of Type 2 Diabetes Mellitus and Gastro-Esophageal Reflux Disorder.R81's MDS dated [DATE] documents R81is cognitively intact and needs setup or clean-up assistance with eating.R81's Physician Order dated 2/3/2026 at 10:21 AM documents LCS diet, REGULAR texture, REGULAR LIQUID consistency, Double protein at breakfast, lunch and dinner. Whole milk at breakfast, Lunch and dinner. Ice cream at Lunch and dinner.R81's Meal Ticket dated 2/6/2026 documents Lunch DAILY: Milk Whole, DOUBLE PORTIONS, Ice Cream. Dinner DAILY: Milk Whole, DOUBLE PORTIONS, Ice Cream.On 2/6/2026 at 3:18 PM R81 stated it has been over 3 weeks since she has received ice cream with her lunch and dinner trays as ordered.On 2/6/2026 at 3:13 PM V15, Registered Dietitian, stated the facility has not notified her that they do not have ice cream available for residents as ordered. V15 stated she knows sometimes the facility will receive ice cream on the delivery trucks and sometimes they will not. V15 stated she expects the facility to be following the resident's diet as ordered.On 2/5/2026 at 8:14 AM, during the tour of the kitchen no ice cream was observed in the freezer.On 2/10/2026 at 2:30 PM, V16, [NAME] stated they had run out of ice cream. She was not sure when they ran out of ice cream, but they have been out of ice cream for just a few days.On 2/13/2026 at 9:29 AM V2, Director of Nursing, stated she expects staff to follow a resident's diet orders and the resident's physician orders.On 2/13/2026 at 9:51 AM V18, Nurse Practitioner, stated she expects the facility to follow a resident's physician ordered diet.The Facility's Dietary Preferences, Nutritional Requirements, and Portion Management Policy Date Last Reviewed 10/30/2025 documents Purpose: To ensure that all residents receive nourishing, palatable, and well-balanced meals that meet their assessed nutritional needs while honoring individual cultural, religious, and personal food preferences.

Based on observation, interview, and record review, the facility failed to perform infection prevention practices during medication administration, including hand hygiene and cleansing of the glucometer to prevent infections in 5 of 9 residents (R16, R52, R69, R75, R49) reviewed for infection prevention and control in the sample of 41.Findings Include:On 2/5/26 at 8:18 AM, Medication administration was observed with V9 LPN (Licensed Practical Nurse), with R52, V9 donned gloves, completed an accu-check and removed her gloves. V9 did not perform hand hygiene before or after donning and removing the gloves and did not clean the glucometer after use. A On 2/5/26 at 8:38 AM, V9 performed an accu-check on R16 with the glucometer used on R52 that had not been cleaned after use. V9 did not perform hand hygiene before or after glove use and did not clean the glucometer after use. V9 then administered R16 her medications and did not perform hand hygiene. On 2/5/26 at 8:55AM, V9 then into R69's room, administered her medications and did not perform hand hygiene before or after administration. On 2/5/26 at 9:05AM, V9 went into R75's room, touching R75 who was complaining of pain and vomiting. V9 did not perform hand hygiene before or after exiting the room. On 2/5/26 at 9:10AM, V9 went into R49's room, completed an accu-check, did not perform hand hygiene before or after glove removal and did not clean the glucometer before or after use. V9 then began to prepare R49's medication, V9 dropped R49's Lyrica on the floor, picked it up off of the floor and placed it into R49's medication cup and proceeded into R49's room and administered his medications, including the Lyrica that was dropped on the floor. V9 did not perform hand hygiene before or after administering R49's medications. On 2/10/26 at 9:25 AM V4, RN/ICP (Registered Nurse/Infection Control Preventionist), stated during medication administration, the nurse should perform hand hygiene each time the resident is touched, and the glucometers are to be cleaned after each use. V4 stated if the nurse drops a medication on the floor, the medication should be wasted, then they are to perform hand hygiene, retrieve a new pill and then administer the medication. V4 stated the nurse should not pick the pill up off of the floor, place it back in the medication cup and administer the medication. The Blood Glucose Machine Cleaning Policy, with a revision date of 4/4/20, documents the following: Obtain bleach or disinfectant wipes, apply gloves, take a pre-moistened disinfectant wipe and clean the entire surface of glucose monitor, allow product to remain on glucose meter according to manufacturer's recommendations, remove and discard gloves, sanitize hands, repeat process between resident use. The Hand Hygiene Policy, with a review date of 4/2024, documents the following: Proper hand hygiene is necessary for the prevention and the transmission of infectious disease. Hand hygiene is done before and after resident contact, before and after any procedure, before putting on gloves and after removing gloves. The Medication Administration Policy, with a review date of 4/2025, documents the following: Hand hygiene must be performed before and after any invasive procedure (i.e. blood glucose monitoring, injections, etc.).

Based on interview, observation, and record review the facility failed to implement care plan interventions following resident falls for 1 of 10 (R51) residents investigated for falls in a sample of 41.Findings include:R51's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R51's EMR dated 3/27/24 documents a diagnosis of Cerebral Infarction, unspecified.R51's EMR dated 2/28/25 documents a diagnosis of Difficulty in walking, not elsewhere classified.R51's EMR dated 6/17/25 documents a diagnosis of Repeated Falls.R51's MDS (Minimum Data Set) 12/5/25 documents a BIMS (Brief Interview for Mental Status) score of 14 out of 15. The MDS documents that the resident requires supervision or touching assistance for roll left and right. The MDS documents that the resident requires partial/moderate assistance for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R51's Care Plan dated 3/6/25 documents FALL: high risk for falls r/t (related to) incontinence, impaired balance, history of fall, psychotropic meds.Interventions:3-12-25 - non-skid strips by bed.3-22-25 - toileting pgm (program).3-6-25 - low bed when arrives.4-10-25 - assist with gripper socks.4-14-25 - non-skid strips by toilet.4-20-25 - keep in high traffic area.5-17-25 - anti roll backs when arrives.5-31-25 - dycem in wheelchair.6-18-25 - gripper socks when up in chair.6-22-25 - grab bars x's 2 assist with positioning and transfers dc'd (discontinued) 11-21-25 changed to half rail on right side.7-13-25 - Keep frequently used items within reach.7-14-25 - clinical evaluation.7-26-25 - leave wheelchair in locked position by bed.8-10-25 - no cloth pads in wheelchair.8-22-25 - wheelchair seat modified.8-25-25 - encourage participation in afternoon activities.8-8-25 - bed against wall.9-3-25 - Brightly colored visual aid on call light.10-5-25 - remind to ask for assist with standing.11-15-25 - brightly colored reminder on wheelchair not to stand without assist.11-15-25 - therapy to eval.11-24-25 - frequent observation and assist to have gripper socks in place.11-27-25 - Staff to remind resident to sit up straight in wheelchair.11-9-25 - Encourage AM diversional Activity, involve in activity of choice.12-11-25 - toileting pgm to be modified.12-30-25 - call before you fall sign by bed.12-31-25 - redirect to hall as needed.1-13-26 - re-educate on wheelchair positioning.1-17-26 - dycem under resident in chair and under pad chair.1-23-26 - during rounds staff to observe for covers to be straight.1-26-26 - given reacher.1-27-26 - therapy to eval for wheelchair saddle cushion.R51's Nurses Notes dated 3/6/25 at 9:33 PM documents Resident was put into his bed this evening. When the CNAs (Certified Nursing Aid) went to check on him, he had his diaper off, knees on the floor with the rest of his body lying on the bed. The CNAs got him off the floor and into his bed, and re-educated him to stay in bed, because it's nighttime. He then began to scoot his feet and legs back to the side of the bed. I retrieved a fall mat and placed it on the side of his bed. Plan of care ongoing.R51's intervention dated 3-12-25 documents non-skid strips by bed.On 2/10/26 at 1:13 PM, observation of R51's room. No non-skid strips noted by R51's bed.R51's Nurses Notes dated 4/10/25 at 4:21 PM documents res (resident) was found sitting on floor mat, no injury/pain noted at this time. Will continue to monitor. VS (Vital signs) WNL (Within Normal Limits).R51's intervention dated 4-14-25 documents non-skid strips by toilet.On 2/10/26 at 1:13 PM, observation of R51's room. No non-skid strips noted by R51's toilet.R51's Nurses Notes dated 7/26/25 at 2:12 PM documents Resident was trying to transfer from his bed to the chair in his room unaided and fell on his buttocks. This nurse along with other staff assisted him to his bed. Resident was assessed, no physical injuries noted. Vital signs checked BP (blood pressure) 126/68 P (pulse) 60.R51's Intervention dated 7-26-25 documents leave wheelchair in locked position by bed.On 2/10/26 at 1:13 PM, observation of R51's room. R51's wheelchair was noted to be across the room from resident's bed.R51's Nurses Notes dated 11/27/25 at 4:10 PM documents At 1555, this nurse observed Resident slide from his w/c (wheelchair) to the floor onto his buttocks. Did not hit his head. Assessment completed. Hand grips are strong and equal bilaterally. PERRL (Pupils Equal Round Reactive to Light). ROM (Range of Motion) WNL per baseline. Denies any pain or discomfort. VSS (Vital signs Stable). Assisted Resident using gait belt and two assists back to his w/c. Director of Nursing notified.R51's Intervention dated 11-15-25 documents brightly colored reminder on wheelchair not to stand without assist.On 2/10/26 at 1:13 PM, observation of R51's room. No brightly colored reminder noted on R51's wheelchair.R51's Nurses Notes dated 12/30/25 at 4:45 PM documents At 1625, CNA called this nurse to Residents room. Observed Resident sitting on the floor in front of his w/c next to his bed. Resident stated he was being stubborn and tried to transfer himself from his w/c to his bed. He denied hitting his head. Denied pain. Head to toe assessment completed. No apparent injuries. No changes in cognition. Hand Grips strong and equal bilaterally. ROM WNL per baseline. PERRL. Resident w/c was not locked. His call light was within his reach. Had on non-skid shoes. Y (temperature) 97.3HR (heart rate) 59 RR (respirations) 18 BP 129/50 SpO2 (oxygen saturation) 97% on RA (room air). Assisted back to his w/c.R51's Intervention dated 12-30-25 documents call before you fall sign by bed.On 2/10/26 at 1:13 PM, observation of R51's room. No call before you fall sign noted by resident's bed.R51's Nurses Notes dated 1/23/26 at 3:00 AM documents This nurse was notified by cna that resident was on the floor. When asked what happened? Resident stated he was tossing and turning in his sleep when he noticed he was on edge of the bed it was too late so he scooted to floor. VS T 98.6 bp 114/55 R 18 P 66 spo2 96% RA. ROM WNL. No injuries no c/o (compliant of) pain. Resident assisted back into bed via (mechanical lift) with assist of 2. Resident in bed at thus time resting.R51's Intervention dated 1/27/26 documents given reacher.On 2/10/26 at 1:13 PM, observation of R51's room. No reacher noted in resident's room.On 2/13/26 at 9:41 AM, V2, DON (Director of Nursing) stated that care plan interventions should be implemented after the facility determines the appropriate fall intervention for the resident.Facility's Fall Prevention and Management policy dated 10/2018 documents This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All residents' falls shall be reviewed, and the residents' existing plan of care shall be evaluated and modified as needed. 4. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on record review and interview, the facility failed to evaluate and revise a resident's Care Plan with progressive interventions following falls for 3 of 10 residents (R2, R19, and R68) in a sample of 41.Findings Include:1.) R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of reduced mobility, muscle weakness, difficulty in walking, dementia, abnormalities of gait and mobility, and repeated falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired, uses a wheelchair, needs substantial/maximal assistance with sitting to standing and chair/bed to chair transfers. R2's Care Plan Date Initiated 3/30/2025 documents Fall: R2 is at high risk for falls related to incontinence, weakness, history of fall, glaucoma, confusion, and use of psychotropic meds. Intervention dated 8/10/2025 documents out to emergency room (er.) Intervention dated 11/13/2025 documents brightly colored reminder on wheelchair to not stand up without assist. R2's Care Plan Date Initiated 5/8/2025 Transferring: R2 has a self care deficit in transferring related to impaired balance, weakness. R2's Quarterly Fall Risk Evaluation Dated 7/22/2025 documents R2 is a high fall risk. R2's Nurses Notes dated 8/10/2025 at 11:33 PM documents patient sent to Local Hospital related to falling in room trying to take himself to the bathroom. Complaining of 10/10 pain, barely able to move around from the pain. Survival flight called for transportation and took patient to hospital. The Facility's Fall Investigation for R2's Fall dated 8/10/2025 contains R2's Face Sheet, Physician Orders, Care Plan, and Minimum Data Set Section O (Special Treatments, Procedures, and Program, Section C (Cognitive Patterns, Section GG (Functional Abilities (Admission), Section GG (Functional Abilities- Discharge). No root cause analysis or intervention noted. R2's Care Plan does not document a progressive intervention for R2's fall on 8/10/2025. 2.) R68's Undated Face Sheet documents R68 was admitted to the facility on [DATE] and has a diagnosis of Unsteadiness of Feet, Cerebral Palsy, Weakness, Abnormalities of Gait and Mobility, and Hypertension. R68's MDS dated [DATE] documents R68 is cognitively intact, uses a walker and wheelchair, needs supervision or touching assistance with sitting to standing, chair/bed to chair transfers, toilet transfers, and walking 50 feet with two turns. R68's Fall Risk Evaluation dated 2/4/2025 documents R68 is a high risk for falls. R68's Care Plan Date Initiated 6/16/2021 documents R68 is at high risk for falls related to balance/gait problems, diagnosis cerebral palsy, arthritis, incontinence, psychoactive drug use, history of falls, history of putting/throwing self on floor, non compliance with helmet and fall interventions. R68's Care Plan Date Initiated 2/17/2022 documents ambulation: R68 has a self care deficit in ambulation related to: weakness, CP & unsteady gait, dorsalgia, arthritis R68's Nurses Notes dated 2/14/2025 at 1:59 PM documents at 0615 Certified Nursing Assistants (CNA's) called this nurse into resident room to show what they observed. Resident was laying on the floor on the right side of her bed with blankets wrapped around her and a stuffed animal under her head. Resident stated she slept on the floor last night because she rolled off the bed around 1AM. Resident denies hitting head and denies any pain or discomfort. Resident was assessed for injury with none observed and assisted to sit in wheelchair with two assist. R68's Care Plan does not document a fall intervention for the fall on 2/14/2025. R68's Nurses Notes dated 2/23/2025 at 11:24 AM documents 400 Hall Nurse heard resident yell for help from resident bathroom. 400 Hall Nurse called this nurse to the room and this nurse observed resident sitting on her bottom on the floor of the bathroom. Resident verbally angry that we were in the bathroom assessing her and not immediately helping her off the floor. Resident stated I was trying to go to the bathroom and I just fell. R68's Care Plan does not document a fall intervention for the fall on 2/23/2025. R68's Nurses Notes dated 2/28/2025 at 11:00 AM documents resident found sitting on knees next to bed stating she fell. Upon nurse entering room she said I'm fine and got up and sat in bed without allowing further evaluation. no signs of discomfort. R68's Care Plan does not document a fall intervention for the fall on 2/28/2025. R68's Nurses Notes dated 2/28/2025 at 11:24 PM documents Resident found sitting on knees next to bed stating she fell, she got up and sat in bed independently and refused any assessment. R68's Nurses Notes dated 5/23/2025 at 10:06 PM documents resident in her room on the floor, refusing to be assessed by staff. Neuro checks initiated to continues to refuse vital signs and any further medical attention. Stated she is not going to the hospital after being educated on the risk and safety of possible injuries, but patient still refused. R68's Care Plan does not document a fall intervention for the fall on 5/23/2025. R68's Nurses Notes dated 10/11/2025 at 2:30 PM documents the resident was outside with activities when she fell forward face-first out of the wheelchair around 1:50 pm. This nurse was on lunch, and the covering nurse assessed and called 911 to send to the Hospital. R68's Care Plan does not document a fall intervention for the fall on 10/11/2025. On 2/6/2025 at 2:10 PM V2, Director of Nursing (DON), stated the facility does not have any fall investigations or interventions for R68's falls on 2/14/2025, 2/23/2025, 2/28/2025, 5/23/2025, and 10/11/2025. On 2/13/2026 at V22, MDS Coordinator, stated after a resident experiences a fall, the facility will investigate the fall, determine a root cause analysis for the fall, and implement an intervention for the fall. V22 stated the resident's care plan is updated with an intervention after each resident fall. On 2/13/2026 at 9:29 AM V2, Director of Nursing, stated she expects the facility to investigate every resident fall, implement a fall intervention and update the resident's care plan with the intervention after every fall. On 2/13/2026 at 9:51 AM V18, Nurse Practitioner, stated she accepts the facility to follow their fall policy and implement interventions for residents to help with falls. 3-R19's POS dated January 2026 documents a diagnosis of Type 2 diabetes mellitus, weakness, unsteadiness on feet, cognitive communication deficit, acute kidney failure, chronic kidney disease stage 3, muscle weakness, heart failure, hypertension, generalized anxiety disorder, depression, anemia, insomnia. R19's MDS dated [DATE] document R19 was severely impaired for cognition for activities of daily living. R19's Progress Notes dated 2/3/2026 at 2:28 PM, Resident was trying to get into the bathroom in her wheelchair and fell to the floor. The resident claimed she landed on her right side and that her ankle hurt. This nurse assessed her and there were no open wounds or bruises. The hall CNA's (certified nursing assistants) aided the resident into the wheelchair. This nurse asked if there was any pain, and she claimed there was pain in her right ankle and right hip. Vital signs were within range. R19's Care Plan with a date initiated of 1/15/2025 documents under Fall: is at risk for falls r/t (related to) frequent falls, impaired safety awareness, impaired balance and gait, incontinence. R19's Care Plan dated 3/17/2025 documents, frequent rounding during the day. (No interventions were documented for R19's fall on 2/3/2026. On 2/7/2026 at 3:30 PM, a green folder with R19's POS, Care Plan and nurse's notes were provided by V2, Director of Nursing (DON). On 2/7/2026 at 3:35 PM, V2, Director of Nursing (DON) stated that was everything they had for R19's fall. R19's folder did not contain any interventions and/or anything addressing her fall other than the progress note for her fall on 2/3/2026. The Facility Fall Log documents R19 had a fall on 2/3/2026, No other falls were documented for R19 for the past six months. On 2/10/2026 at 12:44 PM, V1, Administrator stated policy she expects all fall interventions to be documented in the Resident's Care Plans. (R19's Care Plan was not updated and does not document any interventions for her fall on 2/3/2026. The Facility Comprehensive Care Plan Policy with a review date of 3/2025 documents, The facility must develop a comprehensive person-centered care plan for each resident. The Care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental and psychosocial needs, the comprehensive care plan is reviewed quarterly, annually, and with any significant change.

Based on observation, interview, and record review, the facility failed to change soiled bed linens for a dependent resident in 1 of 2 residents (R10), reviewed for ADL (Activities of Daily Living) care provided for dependent residents in the sample of 41.Findings Include:On 2/5/26 at 10:00 AM, R10 was observed in her room lying on her left side. R10 has contractures noted to the left hand, left wrist, left elbow, and left shoulder. R10 was not able to move her left upper or left lower extremities. R10 is able to move her right arm but isn't able to make significant movements or position herself in the bed. On 2/5/26 at 12:13 PM, R10 was observed in her room in bed on her left side. R10 stated they delivered her lunch tray; she ate but made a mess. R10 had a liquid reddish colored substance, on her pillow and incontinence pad that appeared to be from a red colored drink. Surveyor asked R10 if staff were going to come in and change her bedding and R10 stated they already did, R10 then touched the incontinence pad with her right hand and stated it's wet referring to the red staining. On 2/5/26 at 2:17 PM, R10 was observed in bed on her left side with the red staining to the pillow and incontinence pad still there. R10 stated staff had not been in to change her bedding. R10's Face Sheet, undated, documents R10 has the following diagnoses: Hemiplegia/Hemiparesis following Cerebral Infarction involving the Left Non-Dominant Side, Muscle Weakness, and Age-Related Physical Debility.R10's MDS (Minimum Data Set), dated 1/12/26, documents the following: R10 has a BIMS (Brief Interview of Mental Status) score of 6, indicating R10 has severe cognitive impairment, she has limited ROM (Range of Motion) on the bilateral upper and lower extremities, and is dependent with hygiene. R10's Care Plan, dated 12/10/25, documents R10 has an ADL self-care deficit and requires assistance from staff.On 2/6/26 at 9:00 AM, V14, R10's Family, stated that she was very concerned about R10's care and she is wanting to pay for R10 to be sent to a facility closer to her so she can monitor her care. V14 stated she has to be an advocate for R10 because she isn't getting cared for. On 2/10/26 at 2:12 PM V2, DON (Director of Nurses), stated ADL care, including bedding changes, are provided every day and as needed. The Activities of Daily Living for Dependent Residents Policy, with a review date of 8/2024, documents it is a program of activities of daily living provided to prevent disability or to maintain residents at their maximal level of functioning based on their diagnosis.

Based on observation, interview, and record review, the facility failed to implement pressure relieving interventions for the prevention and treatment of pressure ulcers in 1 of 2 residents (R10) reviewed for treatment/services to prevent/heal pressure ulcers in the sample of 41.Findings Include:On 2/5/26 at 10:00 AM, R10 was observed in her room lying on her left side, a heel protector to the left foot, no pillow between her knees or under her heels and is very thin in appearance. R10 has contractures noted to the left hand, left wrist, left elbow, and left shoulder. R10 was not able to move her left upper or left lower extremities. R10 is able to move her right arm but isn't able to make significant movements or position herself in the bed. R10 stated she has several wounds that she had prior to admission to the facility. On 2/10/26 at 7:53 AM, R10 was observed in bed, on her back/left side, knees contracted up to her waist, nothing between her knees, ankles, nothing under her heels, the left ankle was touching the bed, and R10's pressure relieving boot was on the bed but was not on. R10 was complaining of pain and was anxious, surveyor told her that she would notify the nurse and R10 stated they haven't done anything for her.On 2/10/26 at 9:25 AM, R10 was observed in bed in the same position as the observation on 2/10/26 at 7:53 AM with no pressure relieving items/interventions in place. R10 stated she has not been repositioned.On 2/10/26 at 10:36 AM, R10 remained in the same position/conditions as she did on 2/10/26 at the 9:25 AM observation and R10 stated the staff hasn't done anything for her. R10's Face Sheet, undated, documents R10 has the following diagnoses: Hemiplegia/Hemiparesis following Cerebral Infarction involving the Left Non-Dominant Side, Moderate Protein-Calorie Malnutrition, Muscle Weakness, Age Related Physical Debility, Soft Tissue Disorders, and Skin Transplant Status.R10's MDS (Minimum Data Set), dated 1/12/26, documents the following: R10 has a BIMS (Brief Interview of Mental Status) score of 6, indicating R10 has severe cognitive impairment, she has limited ROM (Range of Motion) on the bilateral upper and lower extremities; is dependent with rolling in bed, has one stage two pressure ulcer not present upon admission, one stage three pressure ulcer present upon admission, and two DTI's (Deep Tissue Injuries) not present upon admission, and is not on a turning/repositioning program.R10's Care Plan, dated 12/10/25, documents R10 has an ADL (Activities of Daily Living) self-care deficit and requires staff assistance with ADLs, and has pressure ulcers to the left ankle (stage 3), left medial lower leg (stage 3), left great toe (DTI), and left 4th toe (DTI). R10 has an intervention to assist and encourage resident to turn and reposition frequently. R10's Progress Note, dated 12/10/25 at 3:53 PM, documents the following: Resident admitted to facility with osteomyelitis of the LLE (Left Lower Extremity), wounds to both medial and lateral ankle. Wound nurse notified of areas on skin. Resident is alert and oriented times 3-4 with moments of confusion. Left sided paralysis noted from past CVA (Cerebral Vascular Accident). Resident is incontinent of bowel and bladder. Transfers full mechanical lift and is a full code.R10's Progress Note, dated 12/24/25 at 1:03 PM, documents the following: Resident seen by the Wound NP (Nurse Practitioner) today. No new orders. Wound to left anterior ankle noted to be improving with a well-defined wound margin. No tunneling or undermining noted. Wound to resident's left medial lower leg noted to be improving with a flat and intact wound margin. No tunneling or undermining present. Resident tolerated treatments well.R10's Progress Note, dated 12/31/25 at 1:57 PM, documents the following: Resident seen by Wound NP. No new orders received. Wounds to left ankle and left medial leg noted to be improving.R10's Progress Note, dated 1/8/26 at 7:31 PM, documents the following: Resident seen by Wound NP. New areas noted during wound care. New area noted to the left fourth toe and left inner knee. New orders for the left great toe for area to be cleansed with wound cleanser and pat dry, skin prep applied daily and as needed. New orders for the left inner knee for area to be cleansed with wound cleanser, pat dry and cover with a bordered gauze. The area to the left medial leg is resolved. The wound to left anterior ankle noted to be improving with 40% epithelialization and 60% hyper granulation with measurements of: Length 2cm (centimeters); Width 2cm. Wound to left great toe noted to be a DTI with non-blanchable deep red area with measurements of: Length 7cm; Width 4cm. Wound to left fourth toe noted to be a DTI with non-blanchable deep red. Wound to left knee noted to be a stage 2 pressure injury with well-defined wound margin with measurements of: Length 3cm; width 1cm; Depth 0.1cm. Area noted with 20% epithelialization and 80% granulation.R10's Progress date, dated 1/15/2026 at 7:21 AM, documents the following: Resident seen by Wound NP. Wounds noted to be improving. The left ankle measuring 2cm x 1.5cm x 0.2cm. New orders for left ankle to be cleansed with wound cleanser, pat dry, apply honey gel and cover with a dry dressing. The left inner knee measuring 1.5cm x 2.5cm. New orders for wound to be cleansed with wound cleanser, pat dry, apply hydrogel to the wound bed and cover with a dry dressing. The left great toe area is improving, apply povidone iodine and leave open to air.R10's Progress note, dated 2/6/26 at 11:46 AM, documents the following: Care plan meeting held with R10's family and they are wanting to move her closer to them. Social Service Director will help with that when the decision is made. On 2/6/26 at 9:00 AM, V14, R10's Family, stated that she was very concerned about R10's care. V14 stated when R10 was admitted to the facility, she had several wounds because of her past stroke, but she doesn't think she is getting the care for her wounds or in general here. R10 stated she is wanting to pay for R10 to be sent to a facility closer to her so she can monitor her care. V14 stated she has to be an advocate for R10 because she isn't getting cared for. On 2/10/26 at 10:36 AM V5, Wound Nurse, stated R10 has a pressure injury to the left outer ankle, she also had one to the left medial leg, but it has resolved. V5 stated R10 was admitted to the facility with the pressure ulcer to the left outer ankle. V5 stated R10 should have her feet elevated and is to be T&R (Turned and Repositioned) as tolerated. On 2/10/26 at 2:12 PM V2, DON (Director or Nurses), stated they turn and reposition the residents for pressure relief every 2 hours. The Pressure Injuries Policy, with a review date of 9/2025, documents the following: The purpose of this policy is to prevent or reduce the incidence of pressure injuries, standards of practice should be implemented. A pressure injury may be defined as any lesions caused by unrelieved pressure that results in damage to the underlying tissue.

Based on observation, interview and record review the Facility to ensure staff were observing residents taking their medications and no medication was given to residents without supervision for 1 of 29 residents (R67) (reviewed for medications in the sample of 41. Findings include: R66's Physician Order Sheets (POS), document R66 has a diagnosis of Chronic Kidney Disease, Stage 4 (severe) and Hypokalemia and has an order for Potassium Chloride ER (extended release) Tablet Extended Release 10 MEQ (Milliequivalent). R66's Minimum Data Sets (MDS) dated [DATE] documents she is cognitively intact for decision making of activities of daily living. R66's Care Plan dated 3/9/2022 documents, meds as ordered. On 2/5/2026 at 8:39 AM, R66's table had a small clear cup of water sitting on it and next to it were two large pills left unattended. On 2/5/2026 at 8:39 AM, R66 was asked if she knew what those pills were, and she stated yes, they were her potassium chloride medications to help her with her potassium levels. The nurse had left them for her, and she planned on taking them later.The Facility Medication Administration Policy with a review date of 4/2025 documents, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. Explain procedure to resident and give the medication, remain with the resident to ensure that the resident swallows the medication.

Based on observation, interview and record review the facility failed to provide supervision to prevent elopement for 2 out of 2 residents (R2, R4). This failure resulted in R2 eloping through the front entrance at 2:05 AM unsupervised and the facility being notified of his location 4.4 miles away at 10:52 AM. This failure resulted in R4 eloping from the front door and being found across a busy two-lane road that borders the front of the facility approximately 500 feet away from the entrance at 1:27 PM. The Immediate Jeopardy began on 11/22/25 at 2:05 AM when R2 eloped through the facility's front door, R2 was not reported missing until six hours later at approximately 8:00 AM and found at 10:52 AM about 4.4 miles away from the facility in R2's wheelchair. On 1/15/26 at 3:40 PM, V1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 1/16/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:1.R2's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, aphasia, acute and chronic respiratory failure, dementia with agitation, major depressive disorder, schizophrenia, facial weakness following cerebral infarction and unsteadiness on feet. R2' Minimum Data Set (MDS) dated [DATE], documented R2 to be severely cognitively impaired, requiring partial/moderate assistance from staff to transfer from bed to chair/chair to bed. R2 also utilizes a wheelchair and requires supervision or touching assistance to wheel 50 feet and when making two turns. R2 was unable to be interviewed due to dementia diagnosis.R2's Care Plan dated 6/1/23 documented R2 is at risk for elopement with interventions for staff as follows: on 6/1/23 incorporate diversional activities, on 6/8/23 friendly approach and wander guard as ordered on 6/15/23 redirect from exit doors and show him his room. R2's Care Plan dated 5/31/23 documented wander guard placement with the following interventions for staff to complete: check function of wander guard as ordered, monitor every shift for placement and proper function of wander guard, replace wander guard every 90 days and document location of replacement as ordered. R2's Care Plan dated 6/13/23 documented he requires assistance with daily care needs with an intervention to provide assistance with ADLs (activities of daily living). R2's Care Plan dated 6/13/23 documented he is at high risk for falls related to impaired safety awareness, use of psychotropic medication, incontinence, impaired balance/coordination with right side weakness.R2's Elopement Risk Assessments dated 12/29/23, 3/12/24, 6/11/24, 8/3/24, 8/17/24, 9/10/24, 12/10/24, 1/28/25, 3/28/25, 4/25/25, 6/14/25, 6/26/25, and 9/25/25 all rated R2 to be at high risk. The local Fire Department's Incident Report dated 11/22/25 at 9:12 AM documented, V6 (Deputy Chief) received a text message from Capt. (captain) stating that the facility was requesting access to our department camera system due to a missing resident. V6 responded to the station and was given contact information for the ADON, V3, who V6 spoke with by phone. V3 stated that a male PT (patient) was last accounted for at 0230 (2:30 AM) this morning and is wheelchair bound. V6 reviewed the camera footage from 0230 to the present time and was unable to locate anything. V6 updated V3 with this information. V3 informed V6 that the facility now believes that R2 exited the facility at 0205 (2:05 AM). V6 was quickly able to locate footage on the front and west side cameras at 0206 (2:06 AM) showing R2 in a wheelchair moving east on the road to the facility to the entrance of a neighboring assisted living facility and stopping for about 10 minutes before moving west and out camera view at 0228 (2:28 AM), V6 called and updated V3 with this information and began checking the area.Employees of gas station (approximately 0.1 miles from facility's entrance) confirmed that R2 was sitting in his wheelchair in the neighboring lot at 0315 (3:15 AM) this morning. Shortly after while still driving the area, V3 called and stated that he was located at a residence in neighboring unincorporated community (approximately 4.1 miles away). All FD (fired department) units returned to service.The local Police Department Report dated 11/22/25 at 8:31 AM documented they responded to a report of a missing person from the facility. The report continued to document, V36 (assigned police officer) reviewed video footage from the facility and observed the following: 2:01am R2 sitting in his wheelchair in the front lounge area; 2:05am R2 exiting the front doors of the facility. The report documented V36 was informed at approximately 10:52 AM that R2 was located (at an address in a neighboring unincorporated community).R2's Nurses Notes dated 11/22/25 at 12:17 PM, documented, Writer noticed resident was not in the building at 0805 (8:05 AM) when trying to distribute medication to patient during morning medication pass. R2 was not in his room, dining room, or the front lobby. Writer and staff searched the building and discovered resident was not in the building. Writer then called Administrator at 0823 (8:23 AM) and was instructed to search building and surrounding areas and then to contact the police if resident was not located. Staff assisted writer and placed a call to the local police department at 0830 (8:30 AM) staff looked for R2 in surrounding areas. Staff nurses assisted writer by updating family at 0830 (8:30 AM). Police arrived and collected story data on events occurred.Global Positioning System (GPS) documented the address R2 was found 4.4 miles away and would take approximately one hour and 36 minutes for someone to walk to.R2's Incident Report dated 11/22/25 documented resident was reported to be missing from the facility. R2 stated he was hungry, predisposing physiological factors included gait imbalance and weakness/fainted. The report continued to document that R2 was in a wheelchair, and assessed on return with no concerns, placed on 1:1 (one on one) precaution. R2's Elopement Investigation of 11/22/25 did not include any interview statements from the night staff providing care for R2. The Investigation included a statement from V28 (Dietary Manager) stating she was called in on 11/22/25 and at 9:00 AM when R2 was reported missing. V28 documented she got to a business down the street and was told a man was pushing R2 in his wheelchair. The investigation also included a statement from V37 (R2's day shift CNA 11/22/25) stating she came into work to do her morning shift which is from 6AM-2PM. V37 stated she reported to 200 hall and started working. V37 stated as breakfast approached, the nurse asked her if R2 was in his room and he wasn't there to receive his breakfast tray, so they did a headcount and noticed he was missing. The Investigation included a statement from V16 (R2's day shift LPN 11/22/25) documenting she was notified that R2 was not in his room, bathroom, or common areas and reported to the administrator, DON and other staff that R2 was missing. V16 stated she went from room to room, and outside around the parameter to search for R2 and then notified R2's family.R2's Medication Administration Note dated 12/9/25 at 5:49 PM documented there was no wonder guard.R2's Medication Administration Note dated 12/11/25 at 6:00 AM documented his wander guard was not available.R2's Medication Administration Note dated 12/17/25 at 2:25 PM documented his wander guard was not in place.R2's Medication Administration Note dated 12/19/25 at 2:37 AM documented, resident is not wearing his wander guard ADON (assistant director of nursing) is to be at the facility in a couple of hours will request a new one from her as soon as she arrives, have informed all staff and will be monitoring resident closely.R2's Medication Administration Note dated 12/22/25 at 12:20 AM, documented no wander guard in place. R2's Medication Administration Note dated 12/23/25 at 12:51 AM, documented no wander guard in place.R2's Medication Administration Note dated 12/24/25 at 3:09 AM, wander guard attached to R2's wheelchair. R2's Medication Administration Note dated 12/27/25 3:04 PM documented his wander guard was not on person, DON (director of nursing) aware, resident refuses to wear.On 1/12/26 at 9:30 AM, V6 (Deputy Fire Chief) stated on 11/22/25 at 9:15 AM, the facility was needing access to our security cameras (the fire station is two buildings over from the facility and seen from entrance). V6 stated he wasn't sure what time to look at first but later was told around 2:00 AM and we were able to see the resident leave the facility in a wheelchair, and it was cold outside. V6 stated the resident wheeled himself next to the front entrance by the bushes of the apartments located between the facility and the fire station and sat there for about 15 minutes. V6 stated the resident then went west on the road and out of view. V6 stated the gas station down the street was able to confirm they saw a man in a wheelchair that night. V6 stated he couldn't remember what the resident was wearing or more details at this time. V6 stated the facility did have camera footage of the resident though because they confirmed the time he left the facility for us. On 1/12/26 at 1:58 PM, V1 (administrator) stated R2 eloped around 2:00 AM and by 10:30 AM he was brought back by police. V1 stated she wasn't sure if she requested the video footage but will look to see if they have it. V1 stated R2 got out the front door and his nurse that night said he'd been up in his wheelchair and last seen at the nurse's station around 1:30-2:00 AM. V1 stated she thinks his nurse that night was V8 licensed practical nurse (LPN).On 1/12/26 at 2:11 PM, V7, Registered Nurse (RN) stated she realized at 8:00 AM on 11/22/25 that R2 was missing, her shift started at 6:00 AM. V7 stated the nurse she received report from reported R2 was fine and had no concerns. V7 stated the CNA (certified nursing assistant) working with R2 did not report anything to her about R2's elopement. V7 stated she wasn't aware of R2 eloping prior to 11/22/25 and R2 was not at risk for elopement. V7 stated she checked the building first, got others to help, then about 15-20 minutes later called the administrator. V7 stated R2 had a wander guard, and it's supposed to sound when residents get close to the door. V7 stated R2 is alert and oriented times three but not safe to be off the premises without supervision. V7 stated everyone gets a wander guard if they move around independently. V7 stated R2 is typically cooperative, easy going and her main focus is getting R2 his medications.On 1/12/26 at 2:30 PM, V1, administrator stated another resident (R3) returned that night from a LOA (leave of absence) right before R2 got out the door. V1 stated R2 got out the front door before it could reset the alarm. V1 stated the wander guard also alarms when it gets within six feet of the exits, and we have eight total exits. V1 stated the wander guard alarm sounds only at the door. V1 stated R2 was not wearing his wander guard that night, he had removed it and it was found torn apart in his room. V1 stated R2 agreed to have his wander guard placed on the back of his wheelchair a week after the incident. V1 stated R2 would not be safe leaving the facility unsupervised without staff and on his own.On 1/12/26 at 2:43 PM, V11 (CNA working the night of 11/21/25-11/22/25), stated she didn't even know R2 was gone. V11 stated she overheard R2's aide tell R2's nurse they couldn't find him and his nurse responded saying she saw R2 going towards the vending machine not too long ago but neither one of them actually laid eyes and looked for R2 after that; they just continued working. V11 stated when she came back another day, she found out R2 had left that night right after another resident came back. V11 stated R2 was typically quiet, he'd get fussy if he doesn't get seconds of food, but he's cool just tends to himself and not a problem, likes to sit up front and stare out the window. V11 stated R2 was not an elopement risk. V11 stated R2 would not be safe by himself on the streets at night without supervision.On 1/13/26 at 2:06 PM, V8, Licensed Practical Nurse (LPN R2's night nurse on 11/22/25) stated she didn't question where R2 was that night because she saw him at the nurse's station at 2:30 AM and the building is completely alarmed, all the exits have alarms on them, and none went off. V8 stated R2 had just gotten up and came by the nurse's station at 2:30 AM, then went towards the back of the building. V8 stated R2's aide never brought concerns to her about his where abouts. V8 stated around 4:30 or 5:00 AM R2's aide asked her if she had seen him, and she told them that she had seen R2 at 2:30 AM then the aide went back down the hall and didn't say anything else. V8 stated R3 did return to the facility around 2:00 AM, we didn't let him in, he comes and goes all the time, so he has the code. V8 stated she rounds on residents every 2 hours but R2 doesn't like to be bothered and closes his door. V8 stated R2 is independent so she personally doesn't open it his door to his room and go in. V8 stated she probably saw R2 two or 3 times that shift. V8 stated R2 usually doesn't get up at night and he didn't say why he was up. V8 stated there is no way you can confirm someone's safety without seeing them with rounds. V8 stated R2 is not safe outside unsupervised. V8 stated she doesn't think R2 had a wander guard and doesn't remember him being at risk for elopement.On 1/13/26 at 11:01 AM, V10 (CNA), R2's assigned aide the night of 11/21/25-11/22/25), stated they didn't find out R2 eloped because the nurse assigned to R2 told them they had seen R2 that night. V10 stated they were told R2 was independent in report. V10 stated they were told after coming back from break around 2:00 AM that night that R2's nurse V8 had seen him 5 minutes prior up in the front lobby. V10 stated around 5:45-5:50 AM they asked the nurse again if she had seen R2 and she responded saying R2 had rolled up to breakfast. V10 stated they had rounded on R2 once that night and saw him in his bed but was later told by staff that it was actually R2's roommate in R2's bed. V10 stated they just assumed it was R2. V10 stated they were not informed R2 was at risk for elopement. V10 stated they saw R2 once during their first set of rounds and they do 4 rounds a shift. V10 stated they like to round on the residents every 2 hours or every hour and 30 minutes. V10 stated they were concerned they hadn't seen R2 that night but reported their concerns to the nurse and the nurse said she had seen R2. V10 stated they asked the nurse two times that night where R2 was. V10 stated the nurse would have had to pass R2 medications before leaving and never heard that he was missing. V10 stated R2 didn't have a wander guard on that night and nothing to indicated R2 was at risk for elopement. V10 stated no one informed them R2 was at risk for eloping either. V10 stated no one mentioned a binder of residents at risk for elopements that would be available. V10 stated R2's nurse assured them of R2's safety. V10 stated it would pose a safety risk for R2 to be out unsupervised. V10 stated it is protocol to do a head count if someone elopes or goes missing.On 1/13/26 at 11:15 AM, V19 (LPN) stated she worked 11/21/25 until 10:00 PM and gave report to V8, (LPN). V19 stated R2 appeared normal at the time, and not at risk for elopement that she was aware of. V19 stated she could find out who is at risk for elopements through the electronic health records and what residents wear wander guards. V19 stated R2 has been getting his wander guard off recently but can't remember if he was wearing one that night. V19 stated R2 went to bed before she left. V19 stated R2 is usually quiet, takes his medications, needs assistance with supervision, and set up assistance. V19 stated R2 would not be safe unsupervised outside mostly because he doesn't communicate well, doesn't comprehend well, and his cognitive state is concerning. V19 stated important things to prevent R2 from elopement is making sure R2's wander guard is on and that he gets his sleep, or he gets agitated, and rounding every two hours. V19 stated you would not be able to confirm someone's safety if they aren't rounded on. V19 stated she doesn't know the details of R2 elopement.On 1/13/26 at 1:12 PM, V3 (ADON) stated R2 was able to remove his wander guards before so they decided to place it on his wheelchair instead. At 1:25 PM, V3 stated R2 took off his wander guard in his room that night and that's where it was found.On 1/13/26 at 10:00 AM, V14 (Lead CNA) stated R2 is independent, stays to himself, and likes to go to the front lobby. V14 stated R2 eloped a couple months ago; he got out the front door at night, but she doesn't know details. V14 stated they have an elopement risk book at the nurse's station where she can find out who is at risk for elopement. V14 stated everyone was in-serviced on elopements. V14 stated she keeps an eye on R2 mostly as prevention for elopement. V14 stated R2 requires supervision assistance with ADLs, he always uses his wheelchair, never walks, he gets confused. V14 stated it would be concerning if she overheard other staff talking about not knowing where a resident was and didn't go find them. V14 stated if she overheard that, she would go look for the resident and find them. V14 stated she rounds every 2 hours and it is concerning if a resident didn't get rounded on for 6 hours, it poses a threat to their safety. V14 stated some precautions for elopements are having the risk book, in-services, and wander guards.On 1/13/26 a 10:09 AM, V15 (CNA) stated R2 is mostly quiet, stays to himself, and is up in the front lobby a lot. V15 stated R2 requires supervision assistance or set up and likes routine. V15 stated R2 eloped once a month ago but doesn't know details. V15 stated she makes rounds every 2 hours. V15 stated you cannot confirm a resident's safety without making rounds. V15 stated it would be concerning to overhear staff talk about not seeing a resident, then proceed back to work without laying eyes on that resident. V15 stated she would go find the resident if she overheard someone hadn't seen them and if not found start the process for elopement. V15 stated the wander guard is a bracelet that alarms if close to a door and you must disarm it to turn it off. V15 stated for elopements they do one on one supervision, frequent rounding, wander guard checks, and make sure you have an eye on the residents and inform others when you are leaving. V15 stated R2 would not be safe unsupervised outside. V15 stated there is an elopement risk book at the nurse's stations where she can find out who is at risk.On 1/13/26 at 10:35 AM, V17 (LPN) stated R2 has never eloped that she is aware of, and she isn't sure if he is at risk for elopement. V17 stated interventions set for elopement risks could include frequent monitoring, wander guards, and two-hour rounding. V17 stated you cannot confirm someone's safety without having eyes on them. V17 stated it would be concerning if she overheard staff talking about a resident they hadn't seen and didn't find them. V17 stated she would go and check for the resident. V17 stated in-servicing and signing off on rounds would be important to prevent elopements. V17 stated if a wander guard is in place, it will alarm when it gets too close to the door no matter what. V17 stated if the wander guard doesn't alarm it isn't working appropriately.On 1/13/26 at 10:42 AM, V18 Social Services Director (SSD) stated she was not working at the time of R2's elopement. V18 stated the MDS nurse does the elopement assessments and then we discuss concerns and everyone at risk gets a wander guard. V18 stated important interventions for elopement risks are putting eyes on the residents and following up on alarms. V18 stated R2 likes to sit up front a lot, eats in his room, is not too social, is confused, forgetful and sometimes needs redirecting especially when he gets agitated. V18 stated R2 is not safe to be outside in the middle of the night alone. V18 stated she heard R2 got out around 2:00 AM and everyone looked for him at about 4:00 or 5:00 AM and was found around 11:00 AM in a nearby village where he is from. V18 stated she is not sure why he got out. V18 stated you cannot confirm someone's safety without seeing and rounding on them. V18 stated they now have a receptionist up front 24hours a day in place.On 1/13/26 at 11:29 AM, V20 (Acting SSD) stated her involvement in R2's behavior management program is following the policy. V20 stated she would have to look to see if R2 has always been at risk for elopement. V20 stated she was the social services director working at the time of R2's elopement and continued until 1/6/26. V20 stated her concerns were with safety on R2. V20 stated she covers 7 facilities. V20 stated she is involved in care plans and updating risks and has been involved since she took over at the facility. V20 stated she would have to look up what R2's risk factors are for elopements. V20 stated interventions for elopement include wander guards and frequent rounding depending on the risk. V20 stated nothing comes to mind that is concerning R2. V20 stated all staff are responsible for reporting missing residents. V20 stated she does not know any of the details on R2's elopement. V20 stated they hold care plan meetings at the president's request and quarterly.On 1/13/26 at 12:01 PM, V4, RNC Registered Nurse Certified stated V20 (Acting SSD) should know details on what's going on in her building and everyone is supposed to be in-serviced.On 1/13/26 at 12:38 PM, V21 (Restorative CNA) stated R2 is pretty chill, struggles with communication and being understood, he can be argumentative and likes to hang out by the lobby looking outside. V21 stated R2 has been a high risk for elopement since he arrived. V21 stated R2 has not had an attempt to elope since 11/22/25 and never exit seeking. V21 stated R2 is a one assist with bathing, supervision mostly with ADLs, wheels himself around, is sometimes out of breath and has received breathing treatments. V21 stated R2 is not safe to be out unsupervised. V21 stated she rounds on residents every two hours. V21 stated R2 was found near his old house. V21 stated you cannot confirm someone's safety without rounding for 6 hours, and that is neglecting their safety.On 1/13/26 at 1:16 PM, V23 (Receptionist) stated R2 stays up front in lobby a lot, noted to get agitated if it's noisy. R2 keeps to himself and is quiet, V23 stated R2 doesn't display exit seeking behavior. V23 stated there is a nighttime receptionist at the front now but not when R2 eloped. V23 stated she was called that day and came in to look for R2. V23 stated R2 pulls his wander guard off and would refuse to wear it on his body so she decided to put it on his wheelchair instead. V23 stated R2 is always in his wheelchair, he can't walk. V23 stated R2 would not be safe outside unsupervised mostly because he gets confused easily with his dementia which is concerning.On 1/13/26 at 1:35 PM, V3 (ADON) stated that any time the door is opened the alarm will sound. V3 went to the front door to set off the alarm while this surveyor stayed at the nurse's station to hear the alarm. No alarm was activated or heard.On 1/13/26 at 1:37 PM, V24 (Maintenance Director) came to the nurse's station and adjusted the alarm box on the wall. Immediately two alarms went off, one for north exit and one for high corridor (neither one the front doors). The alarms were very loud and were turned off by pressing a button that is lit up. At 1:57 PM, V24 (Maintenance Director) stated the north door is an employee access door and smoke door so it has high traffic as well as the front lobby door, so they have different settings for the rest of the exits. V24 stated the front door and north door do not sound alarms at the nurse's stations like the rest of the doors or they'd be going off all the time. V24 stated both of those doors have been that way; it hasn't changed. V24 stated they are getting a new system soon. V24 stated R2 must have known if you hold down the door lever for 15 seconds it automatically unlocks and lets you out there's no other way he could have gotten out that night. V24 stated there is an alarm on the front lobby door if it opens but the sound will only go off up there. V24 stated the door has functioned appropriately to his knowledge. On 1/13/26 at 2:25 PM, V3 (ADON) stated the front lobby door doesn't alarm at the back where the nurse's stations are, V24 (Maintenance Director) just told her that it is a high traffic door, so we have someone up front all the time. V3 stated we did not have someone at the front the night R2 eloped. V3 stated she would find out when they started having the door supervised 24 hours a day. At 2:31 PM, V3 stated they started supervising the front door 11/22/25.On 1/14/26 at 9:06 AM, V22 Human Resources (HR) stated she did not know the front door wouldn't alarm at the nurse's stations.On 1/13/26 at 4:04 PM, V4 stated she would expect nursing staff to be rounding on the residents at minimum of every 2 hours and more if required. V4 stated rounding consists of knocking on the door, checking on the resident, checking if they are breathing, safe, checking on IV's or tube feedings, indwelling catheters, wounds, their comfort, positioning and making sure the resident is seen. V4 stated she could not confirm a resident was safe if they were not seen, which is why they round. V4 stated she was not aware the front door did not alarm to the nurse's stations. V4 stated she expects staff to do their jobs.On 1/14/26 at 12:28 PM, V2 (DON) stated R2 loves to be up in the front of the building by the birds, talking to V23 (receptionist), going to the vending machines, eating in his room but does not like when other people are with him while he eats. V2 state R2 needs touching/hands on assistance with his ADLs, cannot transfer himself alone, is always in his wheelchair, has never seen him walk. V2 stated R2 was rated high risk for elopements because when he first got here, he made attempts to get out. V2 stated they placed the wander guard on him when he had originally made those attempts. V2 stated he was always trying to remove the wander guard and is not compliant with it. V2 stated she expects staff to make 2-hour rounds, putting eyes on the residents, and if they are not seen staff will report to the nurse and continue to look and follow policy. V2 stated there are elopement binders now at the nurse's stations with pictures of the at-risk residents and their medical conditions, also they have been in-servicing on elopements with all the staff including agency but prior to R2's elopement she is not sure what was being done or in place. V2 stated the aide should lay eyes on a resident if they haven't seen them and were told the last where abouts were 5 minutes ago. V2 stated R2 was up all night that night when another resident came in the front door at 2:00 AM. V2 stated she saw the camera footage of R2 going to the door before it was able to reset and pushed it open. V2 stated R2 was not wearing his wander guard, and no alarms went off. V2 stated the resident that returned put in the code himself with no staff to let him in and residents are not supposed to have the code. V2 stated they've had to change the code many times. V2 stated she's not 100% sure how the front door alarm works, V24 tried to explain it to me, just know it's a high traffic door. V2 stated she would have expected someone to have noticed R2 was gone between the 6 hours of 2:00 AM and 8:00 AM. V2 stated they cannot confirm R2's safety while he eloped. V2 stated R2 was not safe to be outside unsupervised he could have gotten hit by a car, which could have led to serious harm or death. V2 stated R2 was found near his old house which is now torn down. V2 stated R2 had no injuries. At 1:26 PM, V2 stated she was the first to get to R2 along with V24 after R2's old neighbor recognized R2 and called the facility. V2 stated R2 was sitting outside, no injuries noted. V2 stated R2 didn't want to leave and told her he was going to stay. V2 stated R2 told her he went to a fast-food place to get food also. On 1/15/26 at 9:54 AM, V2 (DON) stated her expectations for frequent monitoring entails every two-hour rounding for those needing close supervision that R2 was.On 1/15/26 at 9:48 AM, V24 (Maintenance Director) stated R2 didn't want to come back when they found him. V24 stated R2 rode back to the facility with the police. V24 stated R2's old neighbors recognized him and called us when he got out. V24 was the first one to get to R2 and he didn't look hurt in any way, he was feeling good and said he was going to stay there. V24 stated R2 didn't mention how he was able to get to where he was found but there's no way he got there on his own in his wheelchair and he must have been on concrete, no way he could get through grass in his wheelchair either.On 1/15/26 at 8:22 AM, V1 Administrator, stated the wander guard is what is put in place as an intervention for residents with concerns of supervision. V1 stated she will have someone supervising the front door 24 hours a day and the front door alarm can be heard from the back nursing stations. V1 stated there is no policy for rounding but our expectations were added to the daily staffing sheets starting sometime in December she thinks which state every two-hour check/change/reposition for all rooms on assignment under CNA Duties. At 11:01 AM, V1 stated she wasn't at the facility during the initial investigation for R2 but the regional nurse at that time was in charge of it. V2 stated she didn't think to add interviews of any staff members that were working the night R2 eloped. V2 stated she did talk to the nurse on the phone but didn't type up the interview.On 1/13/26 at 3:44 PM, V26 Medical Director (MD) stated he cannot confirm someone's safety without seeing them. On 1/14/26 at 10:52 AM, V26 (Medical Directo) stated there's a safety risk for R2 while he eloped. V26 stated you could not make sure R2 was safe from harm during the time he eloped. V26 stated R2 was not a high risk for elopement prior to his elopement and when questioned about R2 having been rated high risk prior, V26 stated he would have to defer to the facility on their assessment scores. V26 stated given the facility's expectations of rounding being done, he would have expected them to have seen him during those 6 hours. V26 stated R2 being outside in the middle of the night is a safety concern and supervision is necessary to keep him safe from harm.On 1/12/26 at 1:45 PM, Surveyor observed R2 sitting in his wheelchair at the front lobby by the bird cage looking out the window. R2 had a wander guard strapped to the back of his wheelchair. R2 stated he usually hangs out here, they won't let him leave and he's never left the facility or gotten out. R2 is unable to answer questions appropriately about his care.On 1/13/26 at 1:11 PM, V4 and V3 (ADON) took R2 near the front door with his wander guard in place. The alarm went off when R2 was within 6 feet of the front door. V3 then went outside and put in the door code, walked inside and waited 10 seconds before attempting to open the front door again and was unable to, it was locked. On 1/15/26 at 12:07 PM, staff held down front door handle for 15 seconds, the door unlocked and opened, the alarm sounded until deactivated by receptionist.2.R4's Face sheet documented she was admitted on [DATE] with diagnosis of, in part, asthma, cognitive communication deficit, schizophrenia, and encounter for surgical aftercare following surgery on the digestive system. R4's MDS dated [DATE] documented her to be cognitively intact with hallucinations and delusions, requiring supervision with all transfers and walking.R4's Care Plan documented on 10/30/25 she was at risk for elopement related to her delusions, and stating intent to leave with interventions for staff as follow: on 10/30/25 1:1 with staff as needed, 15-30 min checks as needed, allow concerns to be expressed, check placement/function of wander guard every shift, replace wander guard every 90 day, may use wander guard to monitor resident for safety, encourage resident to keep busy with activities, MD notification PRN (as n

Based on interview and record review, the Facility failed to ensure staff were knowledgeable and competent to provide emergent tracheostomy reinsertion for 1 of 1 resident (R2) in the sample of 1. This failure resulted in R2 being transported via EMS (Emergency Medical Services) for reinsertion of a trach after dislodgement after nursing staff on duty failed to attempt to reinsert the trach because they weren't properly trained and didn't feel comfortable/confident in doing so. R2 remains in the Intensive Care Unit following trach reinsertion. This has the potential to affect current and new admissions that require tracheostomy care. This resulted in an Immediate Jeopardy which began on 11/2/2025 at approximately 2:30 AM when R2 was sent to the hospital for reinsertion of trach replacement. On 11/14/2025 at 11:00 AM V2, Director of Nurses/Administrator in Training (AIT) and V3, Assistant Director of Nurses (ADON) were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on 11/18/2025 at 3:05 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:R2's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), trach, gastrostomy (G-Tube), supraventricular tachycardia (SVT), anemia, atrial fibrillation (A-Fib), pneumonia, sepsis, weakness, bilateral paralysis of vocal cords and larynx, hypoxemia, left ventricular failure, aneurysm of the ascending aorta without rupture, saddle embolus of pulmonary artery and congestive heart failure.R2's NRSG (Nursing) admission Assessment, dated 10/30/2025 documents reason for admission: rehabilitation. Other related illnesses and/or previous hospitalizations: acute respiratory failure, saddle PE, pneumonia, hypertension, high cholesterol, VT, A-Fib. Respiratory: regular unlabored, oxygen humification at 28%. Lung sounds: clear and diminished, resident has a trach which is size 6. The Facility's Staffing Pattern dated 11/1/2025 documents 2 agency LPNs (Licensed Practical Nurses) on night shift.R2's Late Entry Nurse's Note, dated 11/2/2025 at 2:30 AM V18, Licensed Practical Nurse (LPN) documents the resident's trach was out. No RN (Registered Nurse) was on duty, so resident was sent out to the emergency room. Resident was (sic) vital was monitored until EMS (Emergency Medical Services) arrived. On call staffing was also notified. No documentation staff attempted to reinsert R2's trach or what his vital signs including oxygen saturation was at that time. On 11/12/2025 at 1:25 PM V18, LPN stated she was an agency nurse. V18 stated V11, CNA (Certified Nurse's Assistant) reported to her that R2 fell out of bed at approximately 2:30 AM and his trach was out. V18 stated she assessed R2's head had a laceration at that time, and she used nursing judgement and called EMS to transport R2 to the local emergency room (ER.) V18 stated she didn't attempt to reinsert R2's trach at that time because she wasn't in-serviced on how to do that and she didn't feel comfortable or confident in attempting to reinsert a trach. V18 stated it was night shift and there was no RN in the building, and she felt R2 needed to be assessed by a physician. V18 stated there was only one other LPN working and she asked her if she knew how to reinsert a trach and she told her it isn't in the LPN nurse's scope of practice to reinsert trachs. V18 stated she didn't know what size R2's trach was or that trachs come in different sizes and she didn't know where to find that information. V18 stated she didn't know if there was a back up trach emergency kit in R2's room and didn't know where to locate a backup trach or supplies either. On 11/12/2025 at 3:50 PM V19, LPN stated she was an agency nurse and worked night shift on 11/1/2025 into 11/2/2025. V19 stated after V18 called EMS and R2 was transferred to the ER V18 asked her if she should have reinserted R2's trach and V19 told her that that's not in the LPN nurse's scope of practice and so she shouldn't do it. V19 stated at no time did V18 ask her to assist her to take care or assess R2 and she wouldn't have attempted to reinsert R2's trach after it was dislodged because she wasn't in-serviced on trach reinsertion prior to working at the facility and she didn't feel comfortable or confident in even attempting to reinsert a trach. V19 stated there were 2 nurses working the night shift and no RNs were in the building. V19 stated she's never been assigned to a resident with a trach so she doesn't know where the trach size is documented, or where or what supplies are needed to care for a trach.R2's Hospital Emergency Department (ED) Paperwork, dated 11/2/2025 documents principle problem: acute respiratory failure with hypoxia and hypercapnia. Pt (patient) presents to the ED via EMS. Patient is supposed to have a trach in place that is not present. Physical exam: trach site with no patency, unable to replace trach, decreased breath sounds bilaterally with shallow respirations, tachypneic. Clinical notes: will attempt to replace trach and evaluate for airway compromise. Diagnosis: trach complication. Disposition: transfer to larger hospital. General comments: Patient had trach placed for vocal cord paralysis. We were unable to replace trach here. Patient discussed with a larger hospital ENT (Ear, Nose Throat) and they will replace trach there. On 11/14/2025 at 8:56 AM V2, DON/AIT stated all nurses including agency nurses were in-serviced on emergency trach reinsertion in October 2025 and then again in November 2025. V2 stated to her knowledge all nurses, including agency nurses have been in-serviced on emergency trach reinsertion prior to working at the facility and no agency nurses have voiced that they don't feel confident or comfortable with reinserting a trach in an emergent situation. V2 stated when a resident's trach is dislodged for any reason she expects the nurse to reinsert the trach and document the trach reinsertion attempts in the resident's medical record and if the nurse is unsuccessful in trach reinsertion she expects the nurse to call for EMS to assist and if they can't reinsert the trach and stabilize the resident she expects EMS to transport the resident to the emergency room. V2 stated when a trach is dislodged the resident airway is compromised and the resident could experience respiratory distress and could cause respiratory failure and could lead to death. V2 stated she didn't know if reinserting a trach is within an LPNs scope of practice and that she'd have to look that up.On 11/14/2025 at 12:25 PM V3, ADON stated the facility's trach care policy doesn't document instructions on how to reinsert a trach if it is dislodged and they have been in-servicing nurses using a trach care skills checklist this week, but it also didn't include trach insertion instructions. V3 clarified the facility doesn't have a policy or skill checklist that covers trach reinsertion, so no staff have been in-serviced on trach reinsertion. V3 stated the facility is currently working on finding a trach skills checklist for trach reinsertion so they can in-service nurses on it. On 11/13/2025 at 11:05 AM V20, Nurse Practitioner (NP) stated she expected nurses including agency nurses to be in-serviced/educated on emergent trach care including trach reinsertion because when a resident has a trach it is considered medically necessary for breathing and when a trach is dislodged for any reason it should be reinserted immediately because without it could lead the resident to having respiratory distress which could lead to brain death. V20 stated an emergency trach reinsert kit should be in his room, and she expected there to be one in R2's room in case of dislodgement. V20 stated she expected staff to document resident's trach size in the resident's medical record so nurses would know what size to reinsert if the trach is dislodged.The Facility's Tracheostomy Care Policy revised 10/2024 documents, it is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway. No documentation regarding trach reinsertion is addressed in the facility policy. The Facility's Facility Assessment dated 6/18/2025 documents the Facility provides care for COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Specialized Rehabilitation Services include Respiratory. Special Care Needs include tracheostomy care and ventilator care.The facility took the following actions to remove the immediacy and prevent any additional residents from suffering an adverse outcome. Completion dated: 11/14/2025. R2 no longer resides at the facility. All new trach patients have the potential to be affected by alleged deficient practice. All nurses will be in-serviced by the DON/Designee on emergent and routine trach care initiated on 11/14/2025 & completed on 11/14/2025. Nurses will be in-serviced prior to the start of their next shift. Agency nurses will be in-serviced prior to the start of their next shift by the DON/Designee on emergent and routine trach care initiated on 11/14/2025 & completed on 11/14/2025. Nurses will be in-serviced prior to the start of their next shift.Actions to Prevent Occurrence/Recurrence: the facility took the following actions to prevent an adverse outcome from reoccurring. Trach in-servicing - completed once a month for 3 months starting 11/14/2025 by the DON/Designee. Audit logs: - 3 nurses will be observed on trach competency weekly for 4 weeks by DON/Designee initiated 11/14/2025. QAPI Review: Committee will access outcomes and adjust training as needed weekly during QA and initiate 11/14/2025.

Based on interview and record review, the facility failed to provide necessary emergent care and services for 1 of 1 resident (R2) with a tracheostomy in the sample of 1. This failure resulted in R2 being sent out urgently via EMS (Emergency Medical Services) for trach reinsertion after staff failed to attempt to reinsert R2's trach when it was found dislodged. R2 was admitted to the ICU (Intensive Care Unit) for respiratory distress. This has the potential to affect current and new admissions that require tracheostomy care.This Immediate Jeopardy began on 11/2/2025 at approximately 2:30 AM when R2 was sent to the hospital for reinsertion of trach replacement. On 11/14/2025 at 11:00 AM V2, Director of Nurses (DON)/Administrator in Training (AIT) and V3, Assistant Director of Nurses (ADON) were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on 11/18/2025 at 3:05 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), trach, gastrostomy (G-Tube), supraventricular tachycardia (SVT), anemia, atrial fibrillation (A-Fib), pneumonia, sepsis, weakness, bilateral paralysis of vocal cords and larynx, hypoxemia, left ventricular failure, aneurysm of the ascending aorta without rupture, saddle embolus of pulmonary artery and congestive heart failure.R2's NRSG (Nursing) admission Assessment, dated 10/30/2025 documents reason for admission: rehabilitation. Other related illnesses and/or previous hospitalizations: acute respiratory failure, saddle PE, pneumonia, hypertension, high cholesterol, VT, A-Fib. Respiratory: regular unlabored, Oxygen humification at 28%. Lung sounds: clear and diminished, resident has a trach which is size 6. R2's Late Entry Nurse's Note, dated 11/2/2025 at 2:30 AM V18, LPN (Licensed Practical Nurse) documents an unwitnessed fall for R2. R2 was found lying on the floor on the right side of his bed within reach of call light. R2 stated he was trying to get up. R2 was immediately assessed by this nurse. R2 was alert and oriented 2-3, denied any loss of consciousness but confirm his head hit the floor, vital was (sic) stable. Upon getting R2 back in bed, I noticed a small laceration to the right side of the forehead above the eyebrow and that trach was out. R2 complained of no pain or trouble breathing. No RN (Registered Nurse) was on duty, so R2 was sent out to the emergency room. R2 was vital was monitored until EMS (Emergency Medical Services) arrived. On call staffing was also notified. No documentation staff attempted to reinsert R2's trach or what his vital signs including oxygen saturation was at that time. On 11/12/2025 at 1:25 PM V18, LPN stated she was an agency nurse and was assigned to R2 on night shift on 11/1/2025 into 1/2/2025. V18 stated she got to the facility around 10:00 PM and did rounds at that time. V18 stated R2 was lying in bed and was resting. V18 stated R2 had a trach and it was in and connected to oxygen when she did the initial rounds that shift. V18 stated V11, CNA (Certified Nurse Assistant) reported to her that R2 fell out of bed at approximately 2:30 AM and she went and assessed him immediately. V18 stated during the assessment of R2 he was lying on the right side of his bed on the floor and his trach was out. V18 stated she assessed R2's head had a laceration at that time, and she used nursing judgement and called EMS to transport R2 to the local emergency room (ER.) V18 stated she assessed R2's oxygen and while he laid on the floor and it was low 90's and then staff transferred R2 back to bed and she placed oxygen via an oxygen mask, and his oxygen went to 95%-96%. V18 stated R2 didn't experience respiratory distress and EMS transported him to the ER. V18 stated she didn't attempt to reinsert R2's trach at that time because she wasn't in-serviced on how to do that and she didn't feel comfortable or confident in attempting to reinsert a trach. V18 stated it was night shift and there was no RN in the building, and she felt R2 needed to be assessed by a physician. V18 stated there was only one other LPN working and she asked her if she knew how to reinsert a trach and she told her it isn't in the LPN nurse's scope of practice to reinsert trachs. V18 stated she didn't know what size R2's trach was or that trachs come in different sizes and she didn't know where to find that information. V18 stated she didn't know if there was a back up trach emergency kit in R2's room and didn't know where to locate a backup trach either. On 11/12/2025 at 3:50 PM V19, LPN stated she was an agency nurse and worked night shift on 11/1/2025 into 11/2/2025. V19 stated she wasn't assigned to R2 and she didn't assist or assess R2 at anytime that shift. V19 stated after V18 called EMS and R2 was transferred to the ER V18 asked her if she should have reinserted R2's trach and V19 told her that that's not in the LPN nurse's scope of practice and so she shouldn't do it. V19 stated at no time did V18 ask her to assist her to take care or assess R2 and she wouldn't have attempted to reinsert R2's trach after it was dislodged because she wasn't in-serviced on trach reinsertion prior to working at the facility and she didn't feel comfortable or confident in even attempting to reinsert a trach. V19 stated she's never been assigned to a resident with a trach, so she doesn't know where the trach size is documented, or what supplies are needed to care for a trach.On 11/6/2025 at 10:45 AM V15, stated she is R2's POA (Power of Attorney) stated R2's trach fell out when he fell out of bed in the middle of the night on 11/2/2025 and he was transferred to the local emergency room. That hospital told her they didn't have proper staff to reinsert the trach so he had to be transferred to a larger hospital out of state. That hospital reinserted his trach and he was admitted to the intensive care unit (ICU) for respiratory distress and he is still in the ICU.R2's Hospital Emergency Department (ED) Paperwork, dated 11/2/2025 documents principle problem: acute respiratory failure with hypoxia and hypercapnia. Pt (patient) presents to the ED via EMS. Patient is supposed to have a trach in place that is not present. Physical exam: trach site with no patency, unable to replace trach, decreased breath sounds bilaterally with shallow respirations, tachypneic. Clinical notes: will attempt to replace trach and evaluate for airway compromise. Diagnosis: trach complication. Disposition: transfer to larger hospital. General comments: Patient had trach placed for vocal cord paralysis. We were unable to replace trach here. Patient discussed with a larger hospital ENT (Ear, Nose Throat Specialist) and they will replace trach there. On 11/14/2025 at 8:56 AM V2, DON/AIT stated all nurses including agency nurses were in-serviced on emergency trach reinsertion in October 2025 and then again in November 2025. V2 stated to her knowledge all nurses, including agency nurses have been in-serviced on emergency trach reinsertion prior to working at the facility and no agency nurses have voiced that they don't feel confident or comfortable with reinserting a trach in an emergent situation. V2 stated when a resident's trach is dislodged for any reason she expects the nurse to reinsert the trach and document the trach reinsertion attempts in the resident's medical record and if the nurse is unsuccessful in trach reinsertion she expects the nurse to call for EMS to assist and if they can't reinsert the trach and stabilize the resident she expects EMS to transport the resident to the emergency room. V2 stated when a trach is dislodged the resident airway is compromised and the resident could experience respiratory distress and could cause respiratory failure and could lead to death. V2 stated she didn't know if reinserting a trach is within an LPNs scope of practice and that she'd have to look that up. On 11/13/2025 at 11:05 AM V20, Nurse Practitioner (NP) stated she assessed R2 on 10/31/2025. He had a trach and it was clear and staff were providing trach care per physician's orders. V20 stated she expected nurses including agency nurses to be in-serviced/educated on emergent trach care including trach reinsertion because when a resident has a trach it is considered medically necessary for breathing and when a trach is dislodged for any reason it should be reinserted immediately because without it could lead the resident to having respiratory distress which could lead to brain death. V20 stated when she assessed R2 on 10/31/2025 she couldn't recall if there was an emergency trach reinsert kit in his room, but she expected there to be one in R2's room in case of dislodgement. V20 stated she expected staff to document resident's trach size in the resident's medical record so nurses would know what size to reinsert if the trach is dislodged. On 11/14/2025 at 12:25 PM V3, ADON stated the facility's trach care policy doesn't document instructions on how to reinsert a trach if it is dislodged and they have been in-servicing nurses using a trach care skills checklist this week, but it also didn't include trach insertion instructions. V3 clarified the facility doesn't have a policy or skill checklist that covers trach reinsertion, so no staff have been in-serviced on trach reinsertion. V3 stated the facility is currently working on finding a trach skills checklist for trach reinsertion so they can in-service nurses on it. The Facility's Tracheostomy Care Policy revised 10/2024 documents, it is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway. No documentation regarding trach reinsertion is addressed in the facility policy. The Facility's Facility Assessment dated 6/18/2025 documents the Facility provides care for COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Specialized Rehabilitation Services include Respiratory. Special Care Needs include tracheostomy care and ventilator care.The facility took the following actions to remove the immediacy and prevent any additional residents from suffering an adverse outcome. Completion dated: 11/14/2025. R2 no longer resides at the facility. All new trach patients have the potential to be affected by alleged deficient practice. All nurses will be in serviced by the DON/Designee on emergent and routine trach care initiated on 11/14/2025 & completed on 11/14/2025. Nurses will be inserviced prior to the start of their next shift. Agency nurses will be in serviced prior to the start of their next shift by the DON/Designee on emergent and routine trach care initiated on 11/14/2025 & completed on 11/14/2025.Actions to Prevent Occurrence/Recurrence: the facility took the following actions to prevent an adverse outcome from reoccurring. Trach inservicing - completed once a month for 3 months starting 11/14/2025 by the DON/Designee. Audit logs: - 3 nurses will be observed on trach competency weekly for 4 weeks by DON/Designee initiated 11/14/2025. QAPI Review: Committee will access outcomes and adjust training as needed weekly during QA and initiate 11/14/2025.

Based on observation, interview and record review the facility failed to ensure kitchen employees had food handling certificates for 4 staff, 3 cooks (V38, V39, V40) and a dietary aide (V31). This failure has the potential to affect all residents in the facility.Findings include:On 11/18/2025 at 8:40 AM V30, Dietary Manager stated she started working as the dietary manager 2 months ago and she spoke to corporate, and they told her they were aware there are multiple kitchen staff that haven't taken the food handlers certification class and corporate set it up for all kitchen staff to attend an in person class in August 2025 but no kitchen staff attended the class. V30 stated V31, Dietary Aide told her he took the class, but she wasn't sure if he had or not.The Facility's Employee Census documents V31 is a DA (Dietary Aide) and hire date: 5/1/2025.On 11/18/2025 at 8:47 AM V31, Dietary Aide stated he thought he took the required kitchen certification but perhaps he hadn't.On 11/18/2025 at 1:00 PM V2, Director of Nurse (DON)/Administrator in Training (AIT) stated she couldn't find V31's food handler certificate.On 11/19/2025 at 11:40 AM V30 stated 2 cooks and 1 dietary aide are taking the food handler certification class today.On 11/19/2025 at 11:41 AM V2, DON/AIT stated 3 kitchen staff are taking the food handler certification classes online today and they will not work until they have the classes completed. V2 stated she wasn't aware the kitchen staff didn't have the food handler certifications completed.On 11/19/2025 at 12:00 PM V2 DON/AIT stated all kitchen staff hire date is 5/1/2025 because the dietary department was contracted by another company and on 5/1/2025 the facility took over the dietary staff, and she doesn't know any of the dietary employee's original hire date due to this.The Facility's Employee Census documents V39 is a [NAME] and hire date: 5/1/2025.On 11/19/2025 at 12:19 PM V39, [NAME] stated her initial hire date was 9/9/2024 and she has had 6 dietary mangers since she's started working at the facility. V39 stated on 9/25/2025 the former dietary manager informed her she needs to take the food handlers class to work in the kitchen but no one told her how or when to take the class then that dietary manager left and V30 didn't notify her of when or how to take the class either.On 11/19/2025 at 12:48 V30 stated there is another cook that doesn't have the food handler course completed which is V38 and she is completing it today. V30 clarified there are 3 cooks and 1 dietary aide that hadn't completed the food handler's course.The Facility's Employee Census documents V38 is cook and hire date: 10/14/2025.On 11/19/2025 at 12:52 PM V38, [NAME] stated her initial hire date was 10/11/2025 and no one told her she needs to take a food handlers class prior to working as a cook. V38 stated she has been a cook many years and she's taken the food handler's class before but she couldn't recall where she took the course, so she has to retake it.On 11/19/2025 at 1:00 PM V30 stated she has 2 cooks V38 and V39 and the dietary aide V31 taking the food handler class online today and she can't get ahold of V40, [NAME] to let him know to take the course as well.The Facility's Employee Census documents V40 is a cook and hire date: 5/3/2025.On 11/19/2025 at 1:45 PM V2 DON/AIT stated the facility does not have a policy on kitchen employees having the food handler certification course being completed but she expected all kitchen employees to have the certification completed.The Facility Daily Census Form dated 11/6/2025 documents 80 residents in the facility.

Based on interview and record review, the Facility failed to ensure staff were educated and competent in providing the necessary care and services for tracheostomies for 4 of 4 residents (R2, R4, R5, R6) in the sample of 6. This failure resulted in R2, R4, R5, and R6 being sent out emergently for routine tracheostomy care. R2 was found unresponsive in the Facility and staff performed CPR that was not in accordance with professional standards using R2's primary airway because they did not know how to do so. R2 died in the Facility, and death certificate is pending.This Immediate Jeopardy began on [DATE] at approximately 10:44 PM when R5 was sent to the hospital for suctioning/removal of mucus plug and tracheostomy replacement. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 9:03 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan.Findings include:1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, respiratory failure, and tracheostomy status.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent for mobility, and received high concentration oxygen therapy and tracheostomy care.R2's Physician Order dated [DATE] documented R2 had a tracheostomy.R2's Care Plan initiated [DATE] documented R2 was at risk for breathing difficulty and complications related to tracheostomy placement.R2's Progress Note dated [DATE] at 8:20 AM documents R2 had two episodes of brown tube feeding colored fluid projecting from trach in a large amount. EMS was called for transport to hospital, and there was no documentation that R2's tracheostomy was suctioned.R2's emergency room (ER( Note dated [DATE] documents R2 came from Facility with tube feeding coming out of tracheostomy. R2 had no distress in the hospital and had been seen there frequently for the same issue.R2's Progress Note dated [DATE] at 1:00 PM documents R2 had increased secretions that changed from clear to brownish in a large amount. EMS was called for transport to hospital, and there was no documentation that R2's tracheostomy was suctioned.R2's ER Note dated [DATE] documents R2's tracheostomy tube was suctioned, cleaned, and monitored without any additional increased secretions. The cause of R2's symptoms was unclear with a plan to send him back to the nursing home. R2's Progress Note by V9, Licensed Practical Nurse (LPN), dated [DATE] at 6:00 PM documents, Aides were in room giving patient care when they grabbed nurse and alerted her that resident was unresponsive at 4:50pm, CPR started for 1q0 (10) minutes before EMTS (Emergency Medical Technicians) arrived and took over. EMT performed CPR until 5:30pm when they called timeof {sic} death.On [DATE] at 12:43 PM, V8, CNA, stated she helped perform CPR on R2 on [DATE]. V10, Registered Nurse (RN), started compressions while she placed the respiratory bag over R2's mouth because she was not aware it needed to be on the tracheostomy. She stated, I don't even know how to attach the thing. I have never bagged a trach before. I think that is something we need to be educated on. None of us in there knew. I even asked. (V10) gave me the oxygen and I just took the bag and went with the mouth because that's all I knew how to do. (V10) said she did not know how to attach it either.On [DATE] at 2:55 PM, V10 stated there was tube feeding coming out of R2's tracheostomy during CPR, so they just placed the respiratory bag over his face and turned the oxygen up.The (Local Fire Department) Incident Report dated [DATE] at 5:15 PM documents Fire Department arrived while staff were performing CPR on R2. Staff stated they were bagging the patient's mouth and not his tracheostomy tube due to secretions coming from the tube while CPR was being performed. On [DATE] at 2:37 PM, V22, (Local) Fire Department Chief, stated when his staff arrived to the facility on [DATE], Facility staff were bagging R2 with the BVM (Bag Valve Mask) over the naso-oral pharynx which is not the standard place for the BVM when the resident has a tracheostomy. The BVM should have been via tracheostomy. V22 stated over the past several months, the Fire Department has encountered multiple issues with tracheostomy residents at the Facility, making him question the care they receive, as far as keeping airways clear and patent so the residents can breathe. He stated they get calls for shortness of breath on a tracheostomy resident, and it is often something as simple as suctioning or cleaning of the tracheostomy tube or applicator. He stated these should be part of routine maintenance that he would expect from a facility that allows tracheostomies to be there.On [DATE] at 8:12 AM, V3, Local Fire Department Paramedic, stated R2 was sent to the hospital frequently for tracheostomy secretions and does not think the Facility has the staff they need to care for the residents with tracheostomies.On [DATE] at 9:30 AM, V4, Local Fire Department Paramedic, stated they get called to the Facility every day for suctioning or other non-emergent issues.2-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and tracheostomy status.R4's MDS dated [DATE] documented R4 was severely cognitively impaired, dependent with mobility and required tracheostomy care, suctioning and oxygen therapy.R4's Care Plan dated [DATE] documents R4 is at risk for complications due to tracheostomy. The interventions include performing tracheostomy care as ordered and as needed and suctioning mouth and tracheostomy as needed.R4's Progress Note dated [DATE] at 4:55 PM documented R4 had several episodes of emesis that day. R4 was found with agonal breathing, emesis and what appeared to be water coming out of his tracheostomy and mouth. EMS was contacted for transport, and there was no documentation that R4's tracheostomy was suctioned at that time.R4 Hospital Record dated [DATE] documents R4 has had multiple troubles with tracheostomy management and partial (mucus) plugs. On arrival to the hospital, R4 had a very dirty, partially plugged tracheostomy, but was breathing much better with no signs of distress after it was cleaned by respiratory therapy.On [DATE] at 11:59 AM, R4 was lying on stretcher in his room with Emergency Medical Services (EMS) present. EMS suctioned out clear, thick, frothy sputum that was bubbling from the tracheostomy. V4, Local Fire Department Paramedic, and V27, Local Fire Department Captain, both stated there was suction tubing in R4's room, but no yankeur (suction tip), so they used their own equipment to suction R4. R4 was transported from the Facility on stretcher at 12:02 PM.R4's Progress Note dated [DATE] at 12:02 PM documents blood was expelled through R4's trachea while being suctioned. There was a scant amount of red clotted blood, and R4 was sent out with EMS.R4's Hospital Record dated [DATE] documents R4 presents due to blood being noted in his tracheostomy at the Facility. Paramedics are highly skeptical as to this history given that when they arrived on scene there was no noted blood and the suction equipment that staff were reporting using was not hooked up to any mechanical suction. Paramedics got normal colored secretions and one small drop of blood from R4's tracheostomy. R4 was seen here 5 days ago after an episode of vomiting and perceived issues with his tracheostomy being obstructed after vomiting. His tracheostomy was suctioned copiously, and the X-ray was unrevealing. R4 has been seen in the ER several times in the last week and has had normal lab workups.3-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including COPD, chronic respiratory failure, and tracheostomy status.R5's MDS dated [DATE] documented R5 was cognitively intact, independent with bed mobility, required supervision with transfer, and required tracheostomy care, suctioning, and oxygen therapy.R5's Care Plan dated [DATE] documents R5 has potential for difficulty breathing related to bronchiectasis, COPD, chronic respiratory failure, obstructive sleep apnea, and dyspnea.R5's Progress Note dated [DATE] at 10:44 PM documents R5 was transferred to (Local Hospital) to have tracheostomy evaluated. R4 [NAME] EMS that her tracheostomy was supposed to have been replaced last month, but never was. V58, RN, was unable to change it in the Facility. R5's (Local) Fire Department Incident Report dated [DATE] documents, Upon arrival found pt (patient) sitting in a wheelchair at the nurses' station. The nurse advised that the pt was complaining of difficulty breathing and felt like something was in her airway. Pt was able to talk as normal, breathing was normal, and SPO2 (Peripheral Oxygen Saturation) was 94% on RA (Room Air). Visualized the trach opening and nothing noted to be obstructing; however, the area around it appeared to be pus, and the gauze was saturated with saliva and pus. Asked pt when was the last time the trach was last replaced. She advised it was supposed to be replaced over a month ago, and it's not been done yet. Asked the nurse if they have the proper supplies to switch out her trach, and she advised that she didn't know anything about it, she was agency. And just working her {sic} temporarily.R5's [DATE] Hospital Records document R5 was short of breath at Facility. Staff tried to suction her, but had trouble getting to the left (side) and she feels the left side is plugged. R5 was suctioned with removal of mucus plug, then saturations were fine with no further symptoms or distress. R5's [DATE] Hospital After Visit Summary documents R5 was seen for tracheostomy tube change.4-R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia.R6's MDS dated [DATE] documented R6 was severely cognitively impaired, required partial assistance with rolling from side to side, was dependent with transfer, and required oxygen therapy.R6's Care Plan does not contain any documentation regarding tracheostomy.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport to hospital when R6 removed his tracheostomy.R6's Hospital Records dated [DATE] document R6 pulled out tracheostomy in the Facility.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport when R6 pulled out his tracheostomy tube. Staff reported R6 was admitted to the Facility two days prior and had pulled out his tracheostomy every day since admission. R6's Hospital Records dated [DATE] document R5 removed his own tracheostomy and was just discharged from (Regional Hospital) earlier today for the same issue.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport when R6 removed his tracheostomy and feeding tube. R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport R6 removed his tracheostomy. This time, staff had replaced R6's tracheostomy, but still wanted him to be transported due to redness around the tracheostomy site.R6's Medical Record does not document any interventions to prevent R6 from removing tracheostomy.On [DATE] at 4:17 PM, V23, Licensed Practical Nurse (LPN), stated she did not receive any training at the Facility regarding tracheostomies.On [DATE] at 4:20 PM, V17, LPN, stated the Facility does not provide routine training on tracheostomy care.On [DATE] at 7:45 AM, V24, LPN, stated she has not had any training in the Facility regarding tracheostomy care. If a resident's tracheostomy ever came out and there was no RN at the Facility she would send the resident to the hospital.On [DATE] at 1:56 PM, V25, LPN, stated she has not had any inservices regarding tracheostomy care in the Facility.On [DATE] at 12:56 PM, V31, CNA, stated she has not had any training in the Facility on CPR for residents with tracheostomies and would always place the respiratory bag over the resident's mouth.On [DATE] at 1:00 PM, V32, LPN, stated she is not comfortable caring for residents with tracheostomies and did not know how to provide respiratory support to a resident with a tracheostomy needing CPR. She has not had any training regarding tracheostomies in the Facility.On [DATE] at 3:15 PM, V35, Assistant Director of Nursing (ADON), stated there has not been much staff education regarding tracheostomies, and there has been no formal training in the Facility.On [DATE] at 9:03 AM, V2, Director of Nursing (DON), stated she expects nursing staff to be proficient in providing routine tracheostomy care, including suctioning and cannula changes, and know what to do during emergencies.The Facility's Registered Nurse/Licensed Practical Nurse Job Description, Undated, documents, Under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Remain current in facility policies, procedures and nursing trends by participating in in-service and continuing education programs.The Facility's Facility Assessment reviewed [DATE] documents the Facility provides care for COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Specialized Rehabilitation Services include Respiratory. Special Care Needs include tracheostomy care and ventilator care.The Immediate Jeopardy and deficiency practice that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Tracheostomy in-service was completed on [DATE], and all nurses, including agency nurses, were educated prior to the start of their next scheduled shift. The abatement was validated with interviews with V15, V25, V48, V50, V56, and V57.

Based on interview, observation, and record review, the Facility failed to ensure nursing staff had the knowledge, skills, and necessary supplies to provide tracheostomy care for 5 of 5 residents (R1, R2, R4, R5, R6) reviewed for respiratory care in the sample of 6. This failure resulted in Cardiopulmonary Resuscitation (CPR) not being performed in accordance with professional standards on R1 and R2 and caused unnecessary emergency hospital transport for R4, R5 and R6. R1 and R2 died in the Facility, and death certificates are pending. This Immediate Jeopardy began on [DATE] at 10:44 PM when staff were unable to replace R5's tracheostomy and adequately suction R5 to ensure airway remains clear and patent. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 9:03 AM. The surveyor confirmed by record review, interview and observation that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan.Findings include:1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), asthma, and tracheostomy status. R1's MDS dated [DATE] documented R1 was cognitively intact and independent with mobility.R1's Care Plan initiated [DATE] documented R1 was a full code and was at risk for shortness of breath related to COPD, acute respiratory failure, and tracheostomy,R1's Progress Note by V34, Registered Nurse (RN), documents, (V11, CNA) informed this nurse that the resident appeared blue and to come assess.On [DATE] at 1:15 PM, V34 stated staff tried to provide ventilation for R1 over his tracheostomy, but did not have the correct tubing to attach the respiratory bag, so we just tried to cover the tracheostomy with a gloved hand and attempted bagging over his mouth. On [DATE] at 1:45 PM, V11, Certified Nursing Assistant (CNA), stated staff did not provide ventilation for R1 during CPR and only performed chest compressions. There were multiple respiratory bags in the room, but none would fit over his tracheostomy. The bag on the crash cart did not work either, so they continued with compressions and did not provide any ventilatory support.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, respiratory failure, and tracheostomy status.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent for mobility, and received high concentration oxygen therapy and tracheostomy care.R2's Physician Order dated [DATE] documented R2 had a tracheostomy.R2's Care Plan documented R2 was a full code and was at risk for complications related to tracheostomy placement.R2's Progress Note dated [DATE] at 8:20 AM documents R2 had two episodes of brown tube feeding colored fluid projecting from trach in a large amount. There was no documentation that R2 was suctioned, and EMS was called for transport to hospital.R2's emergency room (ER) Note dated [DATE] documents R2 came from Facility with tube feeding coming out of tracheostomy. R2 had no distress in the hospital and has been seen frequently for the same thing.R2's Progress Note dated [DATE] at 1:00 PM documents R2 had increased secretions that changed from clear to brownish and in large amount. There was no documentation that R2 was suctioned in the Facility, and R2 was transferred by EMS to the hospital. R2's ER Note dated [DATE] documents R2's trach tube was suctioned, cleaned, and monitored without any additional increased secretions. The cause of R2's symptoms was unclear and R2 would be sent back to the nursing facility.R2's Progress Note by V9, Licensed Practical Nurse (LPN), dated [DATE] at 6:00 PM documents, Aides were in room giving patient care when they grabbed nurse and alerted her that resident was unresponsive at 4:50pm, CPR started for 1q0 (10) minutes before EMTS (Emergency Medical Technicians) arrived and took over. EMT performed CPR until 5:30pm when they called timeof {sic} death.On [DATE] at 12:43 PM, V8, CNA, stated she helped perform CPR on R2 on [DATE]. V10 started compressions, and she placed the respiratory bag over R2's mouth because she was not aware it had to be on the tracheostomy. She stated, I don't even know how to attach the thing. I have never bagged a trach before. I think that is something we need to be educated on. None of us in there knew. I even asked. (V10) gave me the oxygen and I just took the bag and went with the mouth because that's all I knew how to do. (V10) said she did not know how to attach it either.On [DATE] at 2:55 PM, V10, Registered Nurse (RN), stated when CPR was performed on R2 on [DATE], there was tube feeding coming out of R2's tracheostomy, so they just placed the respiratory bag over his face and turned the oxygen up.The (Local) Fire Department Incident dated [DATE] at 5:15 PM documents Fire Department arrived while staff were performing CPR. Staff stated they were bagging the patients mouth and not his tracheostomy tube due to secretions coming from the tube while CPR was being performed. On [DATE] at 2:37 PM, V22, (Local) Fire Department Chief, stated when his staff arrived to the facility on [DATE], Facility staff were performing CPR with the BVM (Bag Valve Mask) over the naso-oral pharynx which is not the standard place for the BVM when the resident has a tracheostomy. The BVM should have been via tracheostomy. V22 stated over the past several months, the Fire Department has encountered multiple issues with tracheostomy residents at the Facility, making him question the care they receive, as far as keeping airways clear and patent so the residents can breathe. He stated they get calls for shortness of breath on a tracheostomy resident, and it is often something as simple as suctioning or cleaning of the tracheostomy tube or applicator. He stated these should be part of routine maintenance that he would expect from a facility that allows tracheostomies to be there.On [DATE] at 8:12 AM, V3, Local Fire Department Paramedic, stated R2 was sent to the hospital frequently for tracheostomy secretions and does not think the Facility has the staff they need to care for the residents with tracheostomies.On [DATE] at 9:30 AM, V4, Local Fire Department Paramedic, stated they get called to the Facility every day for suctioning and other non-emergent issues.3-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and tracheostomy status.R4's MDS dated [DATE] documented R4 was severely cognitively impaired, dependent with mobility and required tracheostomy care, suctioning and oxygen therapy.R4's Care Plan dated [DATE] documents R4 is at risk for complications due to tracheostomy. The interventions include performing tracheostomy care as ordered and as needed and suctioning mouth and tracheostomy as needed.R4's Progress Note dated [DATE] at 4:55 PM documented R4 had several episodes of emesis that day. R4 was found with agonal breathing, emesis and what appeared to be water coming out of his tracheostomy and mouth. There was no documentation that R4 was suctioned at that time, and R4 was sent to the hospital by EMS.R4 Hospital Record dated [DATE] documents R4 has had multiple troubles with tracheostomy management and partial (mucus) plugs. On arrival, R4 had a very dirty partially plugged tracheostomy, but was breathing much better with no distress after respiratory therapy cleaned it. On [DATE] at 11:59 AM, R4 was lying on stretcher in room with EMS present. EMS suctioned out clear, thick, frothy sputum that was bubbling from the tracheostomy. V4, Local Fire Department Paramedic, and V27, Local Fire Department Captain, stated there was suction tubing in the room, but no yankeur (suction tip), so they used their own equipment to suction R4. R4 was transported out on a stretcher at 12:02 PM.R4's Progress Note dated [DATE] at 12:02 PM documents blood was expelled through R4's trachea while being suctioned. There was a scant amount of red clotted blood, and R4 left with EMS.R4's Hospital Record dated [DATE] documents R4 presents due to blood being noted in his tracheostomy at the Facility. Paramedics are highly skeptical as to this history, given that when they arrived on scene there was no noted blood and the suction equipment that staff were reporting using was not hooked up to any mechanical suction. They got normal colored secretions and one small drop of blood from the tracheostomy. R4 was seen here 5 days ago after an episode of vomiting and perceived issues with his tracheostomy being obstructed after vomiting. His tracheostomy was suctioned copiously, and X-ray was unrevealing. R4 has been seen several times in the ER in the last week and has had normal lab workup.4-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including COPD, chronic respiratory failure, and tracheostomy status.R5's MDS dated [DATE] documented R5 was cognitively intact, independent with bed mobility, required supervision with transfer, and required tracheostomy care, suctioning, and oxygen therapy.R5's Care Plan dated [DATE] documents R5 has potential for difficulty breathing related to bronchiectasis, COPD, chronic respiratory failure, obstructive sleep apnea, and dyspnea.R5's Progress Note dated [DATE] at 10:44 PM documents R5 was transferred to (Local Hospital) to have tracheostomy evaluated. R4 told EMS that her trach was supposed to have been replaced last month, but never was. V58, RN, tried to locate a tracheostomy, but was unable to change it. R5's (Local) Fire Department Incident Report dated [DATE] documents, Upon arrival found pt (patient) sitting in a wheelchair at the nurses' station. The nurse advised that the pt was complaining of difficulty breathing and felt like something was in her airway. Pt was able to talk as normal, breathing was normal, and SPO2 (Peripheral Oxygen Saturation) was 94% on RA (Room Air). Visualized the trach opening and nothing noted to be obstructing; however, the area around it appeared to be pus, and the gauze was saturated with saliva and pus. Asked pt when was the last time the trach was last replaced. She advised it was supposed to be replaced over a month ago, and it's not been done yet. Asked the nurse if they have the proper supplies to switch out her trach, and she advised that she didn't know anything about it, she was agency. And just working her {sic} temporarily.R5's [DATE] Hospital Records document R5 was short of breath at Facility. Staff tried to suction her, but had trouble getting to the left (side) and feels the left side is plugged. R5 was suctioned with removal of mucus plug, then saturations were fine with no further symptoms or distress.R5's [DATE] After Visit Summary documents R5 was seen for tracheostomy tube change.5-R6's Face Sheet documents R6 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia.R6's MDS dated [DATE] documented R6 was severely cognitively impaired, required partial assistance with rolling from side to side, was dependent with transfer, and required oxygen therapy.R6's Care Plan does not contain documentation regarding tracheostomy.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport to hospital after R6 removed his tracheostomy.R6's Hospital Records dated [DATE] document R6 pulled out tracheostomy in the Facility.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport to hospital after R6 pulled out his tracheostomy tube. Staff reported R6 was admitted to the Facility two days prior and had pulled out his trach every day since admission. R6's Hospital Records dated [DATE] document R5 removed his own tracheostomy and was just discharged from (Regional Hospital) earlier today for the same issue.R6's Fire Department Incident Narrative dated [DATE] documents Fire Department responded for transport to hospital after R6 removed his tracheostomy and feeding tube.R6's Fire Department Incident Narrative dated [DATE] documents R6 removed his tracheostomy in the Facility. Staff replaced R6's tracheostomy, but want him to be transported due to redness around the tracheostomy site.R6's Medical Record does not document any interventions to prevent R6 from removing tracheostomy.On [DATE] at 4:17 PM, V23, Licensed Practical Nurse (LPN), stated she did not receive any training at the Facility regarding tracheostomies.On [DATE] at 4:20 PM, V17, LPN, stated the Facility does not provide routine training on tracheostomy care.On [DATE] at 7:45 AM, V24, LPN, stated she has not had any training in the Facility regarding tracheostomy care. If a resident's tracheostomy ever came out and there was no RN at the Facility, she would send the resident to the hospital.On [DATE] at 1:56 PM, V25, LPN, stated she has not had any education regarding tracheostomy care in the Facility.On [DATE] at 12:56 PM, V31, CNA, stated she has not had any training in the Facility on CPR for residents with tracheostomies and would always place the respiratory bag over a resident's mouth.On [DATE] at 1:00 PM, V32, LPN, stated she is not comfortable caring for residents with tracheostomies and does not know how to provide respiratory support to a resident with a tracheostomy needing CPR. She has not had any tracheostomy training in the Facility.On [DATE] at 2:00 PM, V16, CNA, stated she wishes CNAs were allowed to suction residents because sometimes nurses are so busy and she thinks it would cut back on sending residents out to the hospital and save a lot of people. On [DATE] at 3:15 PM, V35, Assistant Director of Nursing (ADON), stated there has not been much staff education regarding tracheostomies, and there has been no formal training in the Facility.On [DATE] at 9:03 AM, V2, Director of Nursing (DON), stated she expects nursing staff to be proficient in providing routine tracheostomy care, including suctioning and cannula changes, and know what to do during an emergency.The Facility's Tracheostomy Care Policy revised 10/2024 documents, It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway. Suction as needed. Cleanse stoma site. Document appropriately.The Facility's Facility Assessment reviewed [DATE] documents the Facility provides care for COPD, pneumonia, asthma, chronic lung disease, and respiratory failure. Specialized Rehabilitation Services include Respiratory. Special Care Needs include tracheostomy care and ventilator care.The Immediate Jeopardy and deficiency practice that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Tracheostomy in-service was completed on [DATE], and all nurses, including agency nurses, were educated prior to the start of their next scheduled shift. The abatement was validated with interviews with V15, V25, V48, V50, V56, and V57.

Based on interview and record review, the Facility failed to provide Cardiopulmonary Resuscitation (CPR) according to accepted professional standards for 2 of 2 residents (R2, R1) reviewed for CPR in the sample of 6. This failure resulted in R1 and R2 not receiving adequate respiratory ventilation when staff did not provide rescue breathing via R1 and R2's primary airway of tracheostomy. R1 and R2 both died while in the Facility, and death certificates are pending. This Immediate Jeopardy began on [DATE] at 6:40 PM when R1 was found unresponsive, and CPR was not performed in accordance with professional standards. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 11:37 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate implementation and effectiveness of the removal plan.Findings include:1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, and tracheostomy status. R1's MDS dated [DATE] documented R1 was cognitively intact and independent with mobility.R1's Physician Orders do not document supplemental oxygen orders.R1's Care Plan initiated [DATE] documented R1 was a full code.R1's Progress Note by V34, Registered Nurse (RN), on [DATE] at 10:27 PM documents V11, Certified Nursing Assistant, informed V34 that the R1 appeared blue and to come assess him. Staff initiated CPR and continued until Emergency Medical Services (EMS) arrived. EMS continued resuscitation efforts until (Local Hospital) cleared them to call time of death at 7:14 PM.On [DATE] at 1:15 PM, V34 stated we tried to do CPR for R1 over his tracheostomy, but we did not have the correct tubing to attach it, so we just tried to cover the tracheostomy with a gloved hand and attempted bagging (placing Bag Valve Mask, BVM) over his mouth. On [DATE] at 1:45 PM, V11 stated staff did not provide any ventilation for R1 during CPR and only did chest compressions. There were multiple (BVM) bags in the room, but none would fit over his tracheostomy. The one on the crash cart did not work either, so they continued with compressions, but did not provide any ventilation during the resuscitation.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, paraplegia, respiratory failure, and tracheostomy status.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent for mobility, and received high concentration oxygen therapy and tracheostomy care.R2's Physician Order dated [DATE] documented R2 was a full code.R2's Care Plan initiated [DATE] documents R2 is a full code and wishes will be honored.R2's Progress Note by V9, Licensed Practical Nurse (LPN), dated [DATE] at 6:00 PM documents, Aides were in room giving patient care when they grabbed nurse and alerted her that resident was unresponsive at 4:50pm, CPR started for 1q0 (10) minutes before EMTS (Emergency Medical Technicians) arrived and took over. EMT performed CPR until 5:30pm when they called timeof {sic} death.On [DATE] at 1:55 PM, V9 stated there were two CNAs whose names she was unable to recall in R2's room caring for him. V9 was standing outside in the hallway with the medication cart waiting for them to finish care so she could go in and give R2 his medications. V9 left for a break at 4:43 PM, and the CNAs let her know at that time R2 would probably need suctioning when they were finished. When V9 returned from break, EMS was in the Facility and had already stopped resuscitation efforts. On [DATE] at 12:43 PM, V8, CNA, stated she was working on another unit when a code was called on the 200 Hall. She ran to R2's room and could tell he was not breathing. V10, Registered Nurse (RN) started compressions, and V8 started bagging R2 by mouth. She was not aware the bag had to be on the tracheostomy and stated, I don't even know how to attach the thing. I have never bagged a trach before. I think that is something we need to be educated on. None of us in there knew. I even asked. (V10) gave me the oxygen and I just took the bag and went with the mouth because that's all I knew how to do. (V10) said she did not know how to attach it either. On [DATE] at 2:55 PM, V10 stated on [DATE] around 4:50 PM, a CNA whose name she cannot remember came and told her R2 was unresponsive. R2's nurse was on break at that time. R2 was a full code, and CPR was initiated. There was tube feeding coming out of R2's trach, so they just placed the respiratory bag over his face and turned the oxygen up. The (Local Fire Department) Incident Report dated [DATE] at 5:15 PM documents, FD (Fire Department) units arrived on scene and found staff bagging the patients mouth and performing CPR on the patient while he was still in bed. Staff states they were bagging the patients mouth and not his trach tube due to secretions coming from the tube while CPR was being performed. FD crew marked the patient was cold to the touch while attempting to find a femoral pulse, no pulse was found. FD crews moved the patient to the floor, continued CPR and ventilation. The BVM (Bag Valve Mask) was taken off the patients mouth, mask was removed, and the BVM was connected to the patients trach tube. Staff left the room and came back a few minutes later with paper work for the patient, showing the patients extensive medical history. The [NAME] and the defib pads were placed on the patient, showing an initial rhythm of asystole. FD crew gained IO access in the left tibial tuberosity. IO drew and flushed. First epi at 1723 (5:23 PM). ACLS protocols were followed with pulse checks every 2 minutes and Epi every 3-5. Initial end tidal reading was an 11. AMA crew arrived on scene and briefed on patient. Patient remained in asystole for the duration of the resuscitation attempt. AMA medic called medical control for directions. Medical control advised crews to terminate resuscitation efforts, per DM 153. FD gathered restock from the ambulance and returned to service.On [DATE] at 2:37 PM, V22, (Local Fire Department) Chief, stated when his staff arrived to the facility on [DATE], Facility staff were bagging R2 with the BVM over the naso-oral pharynx which is not the standard place for the BVM when a resident has a tracheostomy. The BVM should have been via tracheostomy. On [DATE] at 3:15 PM, V35, Assistant Director of Nursing (ADON), stated there is a bag that goes over the tracheostomy when you provide CPR. On [DATE] at 3:20 PM, V2, Director of Nursing (DON), stated there is a bag that goes on the trach, and those BVMs should be at bedside. She was not previously informed of any issues with staff getting the BVMs on the tracheostomy. On [DATE] at 3:33 PM, V1, Administrator, stated standard CPR protocol should be followed for residents with tracheostomies, but the respiratory bag should go over the tracheostomy site or the residents would not be getting air. On [DATE] at 3:50 PM, V33, Medical Director, stated he would expect staff to know how to perform CPR on residents with tracheostomies and would expect the Facility to have the necessary equipment and supplies for both maintenance and emergent situations. The Facility's Tracheostomy Care Policy reviewed 10/2024 documents, It is the policy of this facility that residents with tracheostomies receive care to maintain a patent airway.The Facility's Code Blue Policy reviewed 10/2024 documents, Breathing: provide 2 breaths via ambu or manually if ambu is not available. Continue CPR per BLS guidelines until EMS arrives and takes over CPR.The Facility provided CPR Certificates for Nursing Staff which document V19, V54, and V55, CNAs, did not have CPR certification from the American Red Cross or American Heart Association with hands on, in person training.The Facility's CPR Certification Policy revised [DATE] documents, Staff will have CPR certification from the American Red Cross or the American Heart Association The CPR Certification will be the CPR/BLS for Healthcare Providers level and include in-person training, hands on training.The Immediate Jeopardy and deficiency practice that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Clinical and agency staff were inserviced on performing CPR on residents with tracheostomies, CPR Policy was reviewed, CPR equipment was verified as available in the Facility, CPR audits were initiated, and QAPI Meeting was held. The abatement was validated by review of CPR policy and audits, observation of CPR/tracheostomy equipment and supplies, review of purchase orders for equipment and supplies, and interviews from V2, V6, V10, V13, V24, V25, V34, V39, V42, V44, V45, V47, V49, V51, V52, and V53.

Based on interview and record review, the Facility failed to ensure changes in condition were reported for timely assessment and intervention for 1 of 3 residents (R2) reviewed for change in condition in the sample of 6. This failure resulted in R2 showing a change in condition with dilated pupils, hand to touch cool body temperature and decreased baseline response to care on [DATE] when V11 and V12 were providing care to R2. V11 and V12 stated they did not inform R2's nurse of R2's changes. Approximately 15-20 minutes later, V12 returned to check on R2 and R2 was found unresponsive and Cardiopulmonary Resuscitation (CPR) was initiated. R2 died in the Facility, and death certificate is pending.This Immediate Jeopardy began on [DATE] at approximately 5:00 PM when R2 displayed changes from his baseline that were not reported to his nurse. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 2:12 PM. The surveyor confirmed by interview, observation, and record review Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan.Findings include:1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, paraplegia, respiratory failure, and tracheostomy status.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent for mobility, and received high concentration oxygen therapy and tracheostomy care.R2's Physician Order dated [DATE] documented R2 was a full code.On [DATE] at 1:45 PM, V11, Certified Nursing Assistant (CNA), stated she was helping another aide clean R2 on [DATE]. She noticed R2's skin was cool, and he seemed more relaxed than normal. She said usually R2's eyes are wide open and moving from side to side, but this day they were more droopy and he just seemed calmer than normal. V11 did not tell the nurse about these changes and went on to help another resident.On [DATE] at 3:13 PM, V12 (CNA) stated, I've done nursing homes for 30 years. I could tell by (R2)'s eyes that his pupils had dilated a little bit. Around 5:00 PM another young lady helped me clean him up. I said, 'His pupils are dilated a little.' He was still breathing and everything. We cleaned him up. I couldn't wash his arm because it was really stiff. Usually (R2) tries to bat us away with his little arm that is all curled up, but he was stiff, and we had to lift his arm to wash his armpit. V12 said she did not convey these changes to the nurse and went on to care for another resident. V12 checked back on R2 15-20 minutes later and he was not responding. She told the nurse she thought R2 expired and she needed to go check on him. She said the nurse was moving too slow and it took her one or two minutes to get down to R2's room. When the nurse got there, CPR was initiated.On [DATE] at 1:55 PM, V9, Licensed Practical Nurse (LPN), stated there were two CNAs whose names she cannot remember caring for R2 right before he was found unresponsive. V9 was right outside R2's room with the medication cart waiting them to finish with R2 so she could give him his medications. These CNAs did not tell her R2 had any changes from his baseline, so V9 left for a break. When she returned from break, EMS (Emergency Medical Services) was in the building and had already called R2's death.On [DATE] at 2:55 PM, V10, Registered Nurse (RN), stated a CNA whose name she cannot remember told her R2 was unresponsive. R2's nurse was on break at that time. CPR was performed for 15-20 minutes, then EMS arrived and took over. V10 was checking vital signs and was never able to get anything, like he was already gone.The (Local) Fire Department Incident dated [DATE] at 5:15 PM documents Fire Department arrived on scene while staff was performing CPR on R2. Fire Department Crew attempted to find a femoral pulse and noted R2 was cold to the touch.On [DATE] at 9:30 AM, V4, Local Fire Department Paramedic, stated staff were performing CPR on R2 when they arrived at the Facility. R2 had no femoral pulse and was cold to the touch, so he questioned when R2 was last known to be well.On [DATE] at 11:00 AM, V8, CNA, stated R2 was already starting to stiffen up during CPR. On [DATE] at 1:48 PM, V19, CNA, stated R2 was already cold when CPR was being performed. On [DATE] at 2:09 PM, V20, CNA, stated she helped perform CPR on R2 and he was already cold.On [DATE] at 3:50 PM, V33, Medical Director, stated he would expect staff to report any changes in condition to the nurse on duty. On [DATE] at 1:40 PM, V2, Director of Nursing (DON) stated if a resident experiences a change in condition, staff should report it to the nurse. If the resident's nurse is not available, they should report it to another nurse that is available. R2's change of condition was not reported to her, and she had no idea why they would not have reported those changes to the nurse on duty.The Facility's Change In Resident Condition Policy reviewed 10/2024 documents, It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. The policy does not contain documentation pertaining to communication between nurse aids and licensed nurse staff.The Immediate Jeopardy that began on [DATE] was corrected/removed on [DATE] after the Facility took the following actions to correct the noncompliance: Clinical and agency staff were in-serviced on timely assessments, Notification of Change Policy was reviewed, QAPI meeting was held on [DATE], 24 hour reports were reviewed for change in condition. The abatement was validated through review of 24 hour nursing reports and Notification of Change Policy and interviews with V2, V6, V10, V13, V24, V25, V34, V39, V42, V44, V45, V47, V49, V51, V52, and V53.

Based on interviews and record reviews the facility failed to follow written orders for wound care treatment for 1 out of 4 residents, (R2); reviewed for quality of care in a sample of 5. This failure resulted in R2 being admitted to the hospital with wounds declining. Findings include: R2's face sheet documented he was admitted to the facility on [DATE] and discharged on [DATE]. R2's face sheet documented his diagnoses were, in part, burn of third degree of right foot, type two diabetes mellitus and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. R2's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact. R2's Care Plan dated 4/25/25 documented R2 was at risk for skin complications (entered on 5/4/25) with interventions, in part, to provide treatment as ordered (entered on 5/4/25). R2's discharge summary was faxed from hospital on 4/23/25 to the facility, it included his wound care orders. The discharge summary wound care orders documented the following: Donor site location: left thigh, Xeroform/bacitracin: leave adherent xeroform on donor site. Wash it daily with soap/water to remove any debris/old ointment. Reapply new bacitracin over adherent xeroform then leave it open to air. Trim loose xeroform as it lifts up. Once donor site is heeled (usually 2 weeks after surgery) xeroform should be able to be easily removed to reveal healed pink/dry donor site skin. Graft location: bilateral feet: bacitracin, xeroform and gauze daily to foot burns-separate toes with gauze. f/u (follow up) in 1 week with burn/plastic surgery clinic. R2's hospital discharge paperwork dated 4/23/25 documented to start bacitracin 500 unit/gram ointment on 4/24/25; apply to affected area daily. R2's Progress notes dated 4/28/25 documented V3, Wound Nurse Practitioner, wrote out the same wound care orders as mentioned in the discharge summary. R2's Orders documented on 4/25/2025 at 6:48 AM, are as follow: Left upper leg clean with soap and water cover old xeroform with bacitracin cover with either wrapped gauze or bordered dressing every day shift every Mon, Tue, Wed, Thu, Fri for wound care management. R2's Orders documented on 4/25/2025 at 6:00 AM, are as follow: Left upper leg clean with wound cleanser cover wound with xeroform cover with either wrapped gauze or bordered dressing every day shift every Mon, Tue, Wed, Thu, Fri for wound care management. R2's Orders documented on 4/24/2025 at 1:36 PM are as follow: right foot clean with wound with wound cleanser cover with xeroform wrap with gauze every day shift every Mon, Tue, Wed, Thu, Fri for wound care management. R2's Orders documented on 4/24/2025 at 1:33 PM, left foot clean with wound cleanser cover with xeroform cover with wrapped gauze every day shift every Mon, Tue, Wed, Thu, Fri for wound care management. R2's Progress note dated 4/25/2025 at 9:33 AM, documented V4 (Wound Nurse) charted she received a call back from surgeon's nurse and was informed by the nurse that the area where the skin graft was taken from was not to be changed. V4 continued to document We are to wash the area with soap and water and cover the xeroform that is on the area with bacitracin and leave open to air. I explain the clothing sticking to the clothing. Nurse stated that we can wrap it in gauze. I informed the nurse of removing one strip of the xeroform from the area do to what I read from the first set of orders. Nurse question if I covered it back up with xeroform, which I inform her that I did. Nurse stated that it is ok but not to do it again. R2's April Treatment Administration Record documented no wound care was signed off on 4/26/25 or 4/27/25 and there is no PRN (as needed) order for wound care on R2 in the TAR. R2's Progress note dated 4/30/25 at 3:43 PM documented R2 had a temperature of 100.8 degrees but asymptomatic and received new orders for labs. R2's labs collected on 4/25/25 resulted on 4/26/25 with a WBC of 17.10 where the normal range is documented to be between 3.4 - 10.8. On 4/30/25 R2's labs were done again and resulted with a WBC of 15.25. R2's orders documented Doxycycline Monohydrate Tablet 100 mg (milligram), give 1 tablet by mouth two times a day for infection for 7 Days with a start dated of 4/30/25 at 8:00 PM. Post-op paperwork documented R2 was admitted with diagnosis of wound cellulitis on 5/5/25. R2's Hospitalist Progress note dated 5/6/25 at 2:28 PM, documented under Assessment and Plan: Burn involving 5% of body surface status post grafting 4/16 and full-thickness third degree burns on feet with management per burn primary. Status post-split-thickness skin grafts on 5/5 with bilateral wound VAC (vacuum-assisted closure) in place. Wound cultures from 5/2 positive for Escherichia coli, Enterobacter cloacae, Staphylococcus aureus, Proteus mirabilis and Corynebacterium species. Continue ceftazidime for cellulitis. On 5/12/25 at 9:35 AM, R2 stated his stay at the facility was horrible, the treatment he was supposed to have, he didn't get. R2 stated they rarely changed his wound dressings or washed his feet. R2 stated the day or two right before he was going in for his follow up at the burn clinic, they did the dressing changes completely, out of nowhere. R2 stated he was concerned about getting an infection because it was so dirty at the facility, and they did wound care on the floor of his room not in a cleaned room or on his bed. R2 stated he asked the Director of Nursing (DON) if there was a more sanitary way to clean his feet but was told they'll just do it on his floor. R2 stated when he first arrived, the nurse just started to rip off the dressing from his thigh. R2 stated the nurse came back later and told him she didn't look at the second page of instructions where it said to leave the dressing in place on his thigh. R2 stated one nurse tried giving him wound care and told him she couldn't do it after she completed one of his feet and just left him sitting in his room for an hour with his foot undressed. R2 stated he can only remember the facility changing his wound dressings three times while he was there, his pain increased over time, and the wounds started to smell bad. R2 stated his surgeon asked him what the facility didn't do to his wounds because they shouldn't look the way they did. R2 stated his surgeon told him it pushed his recovery back but hopefully not too far and that his feet aren't as good as they would have hoped. R2 stated because of his stay at the facility he went backwards in recovery from the care they provided and had to undergo another surgery; now he is back in the hospital instead of home. On 5/8/25 at 2:41 PM, V13, R2's daughter in law, stated she arrived on 5/2/25 with R2. V13 stated she handed R2's discharge paperwork to the staff member that helped them get situated and emphasized how important it was because it has everything the facility needs to know on how to take care of R2 including his wound care. V13 stated the next day she went to the facility, and they had no idea what happened to it and said they didn't have any of R2's orders. V13 stated on 4/25/25 she talked to the wound care nurse who was rude to her, she said she had already done R2's wound care but later that day we received a phone call saying she removed R2's thigh dressing that was supposed to stay in place, so she obviously hadn't done his wound care yet or looked at the orders from the surgeon. V13 stated on 4/27/25 the facility was placing R2 on bedrest because when he walks around his bandages get dirty. V13 stated on 5/2/25 she took R2 to his follow up appointment with the surgeon at the burn clinic and he told them he was very sorry, R2's wounds are not supposed to look like this, they have gone backwards from when he was initially admitted with the burns, and he would like to admit R2 right away. V13 stated the surgeon said they could do another skin graft from the other thigh and redo it all. V13 stated on Monday 5/5/25, R2 had both of his feet skin grafted again and they also skin grafted the left thigh donor site from the skin loss that occurred there also. V13 stated all R2's wounds were infected on admission to the hospital. V13 started to cry and stated she thought we were sending R2 somewhere to get taken care of, she just hopes this doesn't happen to anyone else. On 5/8/25 at 10:26 AM, V12, R2's son, stated when R2 first got to the facility he dropped off the discharge paperwork with all the care instructions in it at the nurse's station. V12 stated the wound care nurse must not have looked at the packet because the first day she ripped off a strip of xeroform from R2's donor site that was supposed to stay in place for 2 weeks. V12 stated the facility barely did wound care to R2 and they weren't ambulating him like his surgeon instructed to. V12 stated all the wounds were to be done daily. V12 stated when he took R2 to his follow up appointment with the surgeon, you could smell the infection coming off R2's feet. V12 stated the surgeon said at the follow up all R2's sites failed, and they will probably need to do a skin graft to the donor site, redo his feet and use the other thigh for the skin graft. V12 stated the doctor said all R2's wounds were infected, and he was admitted to the Burn Unit ICU. On 5/7/25 at 10:30 AM, V4, Wound Care Nurse, stated that R2 came to the facility after burning his feet with tea, he was transferred from the hospital with 5% burns to his body. V4 stated R2's orders initially were to cleanse the sites, apply xeroform and wrap them up. V4 stated when she went to remove the xeroform from R2's thigh, he was in a lot of pain and later found out it was not supposed to be removed. V4 stated because R2 was in so much pain she only removed one strip and stopped. V4 stated she found the wound care orders several hours after she removed the one strip from R2's thigh. V4 stated there was supposed to be bacitracin applied to the thigh, but didn't have that at the facility. V4 stated she notified the surgeon's office and was told to leave the remaining xeroform on and apply more, cover with A&D ointment because the facility did not have bacitracin, and cover the area. V4 stated R2's feet were to be changed daily and PRN (as needed). V4 stated she wasn't concerned about R2's wounds until 2 days prior to him leaving the facility and notified the surgeon and sent pictures. V4 stated she was concerned about R2's wounds the entire time he was at the facility especially because he constantly dropped things on his dressings like urine from his urinal and juice. V4 stated she told the nurses to tell her anytime R2's dressing were wet. V4 stated she wanted to try to keep R2 in bed more to keep his feet safe but was told we couldn't do that. V4 stated two days prior to him leaving, parts were coming off his wound and reported it to the surgeon's nurse. On 5/8/25 at 10:05 AM, V4 stated that V3 (Wound Care NP) told her she could make R2's dressing changes Monday through Friday and PRN (as needed). V4 stated the surgeon's nurse also said R2's dressings could be done as needed. V4 stated she sent a picture of just one of R2's feet when she saw concerns but did not look at the other foot because it had a new dressing on it applied by another nurse. V4 stated the facility did not have bacitracin so she used A&D ointment on the thigh but did not see the discharge orders had instructions to apply bacitracin to the feet also. V4 stated the office only mentioned the xeroform on the phone. V4 stated the PRN wound care orders were not in the TAR, so that is why it does not document R2 had wound care over the weekend, and she had to make Progress notes instead for the treatment administration. V4 stated she had to enter those progress notes late because her computer wasn't working. On 5/7/25 at 2:35 PM, V4 stated wound care is documented as being completed on the treatment administration record (TAR) and should be completed there unless there is a question about the order, then hold doing it until clarifying. V4 stated wounds are supposed to be changed as needed when she is not at the facility by the staff nurses. V4 stated the TAR will show when the last dressing was done. On 5/8/25 at 9:44 AM, V7 Licensed Practical Nurse (LPN) stated when she took care of R2 over the weekend once and she remembered he spilled on his dressing but did not have to change them, she didn't feel comfortable changing his wounds because of how severe they were. On 5/7/25 at 2:56 PM, V11 (LPN) stated wound care is to be done according to the doctor's order. V11 stated she was concerned from the start with R2's wounds because of how severe they were but had never done his wound care. On 5/7/25 at 2:41 PM V9 (LPN) stated the Treatment Administration Record (TAR) will tell you what the wound care orders are, and will follow those when doing dressing changes. On 5/7/25 at 12:58 PM V3, Wound Nurse Practitioner (NP), stated V4 sent her a picture of R2's wound and it looked like it was failing. V3 stated V4 removed the donor site dressing and told said she didn't see the orders to leave it in place. V3 stated she was not told the facility did not have bacitracin to use on R2. V3 stated she would recommend following orders from the surgeon. On 5/8/25 at 10:52 AM, V3 stated her recommendations were to follow the surgeon's orders on R2 and she did not want to change anything. V3 stated she only put in orders as written by the surgeon. V3 stated she thinks they were supposed to be daily but would have to check the chart to make sure. V3 stated she did not put in for R2's wound care to be done on Monday through Friday and PRN because he was treated by a surgeon and would follow their recommendations. On 5/8/25 at 1:56 PM, V15, Facility's NP, stated she was concerned about infection for R2 after a nurse reported a low-grade fever on Thursday (5/1/25) and thought it could be related to his wounds, so she started him on a broad-spectrum antibiotic. V15 stated not administering the bacitracin ointment as ordered could have contributed to R2's wounds declining, it is an antibiotic ointment. On 5/12/25 at 10:06 AM, V14, Burn Unit Social Worker, stated upon discharge, she notifies the facilities of what patients need for aftercare and they never told her they didn't have bacitracin because if that was the case she would have sent some with R2 before he left. V14 stated the providers did not change any of their discharge orders for R2's wound care after he left and never said to use A & D ointment or to give dressing care Monday through Friday and PRN (as needed). V14 stated the wound care is very particular for burns and skin grafts. On 5/12/25 at 2:25 PM V2 (DON) stated R2 came with a donor site and skin graft wounds. V2 stated she started to have concerns about his wounds when he had an elevated temp and WBC (white blood cell). V2 stated V4 told her she notified the surgeon of this and provided updates on the wounds, but they wanted to hold off on doing anything until they saw him at his follow up appointment which was in the next day or two at that time. V2 stated she expects nurses to follow orders as written from the discharge paperwork and to only put in orders as a provider instructs to do so. V2 stated she was never notified that bacitracin wasn't available, she thought it was being applied to R2 the entire time. V2 stated no one made concerns to her that R2 wasn't getting wound care as ordered. The facility's Treatment/General Wound Treatment Policy dated 4/2024, documented under treatment guidelines to document routine and PRN treatments in the treatment administration record of the EHR (electronic health record) and to document all significant observations in the Nursing Progress Note. The facility's Skin and Wound Management Guidelines revised on 1/3/22 documented on admission or readmission to ensure the treatment order is in place and appropriate. The wound care nurse is to obtain or ensure appropriate treatment order is in place.

Based on interviews and record reviews the facility failed to follow wound care orders for 1 out of 4 residents, (R2) reviewed for quality of care in a sample of 5. This failure resulted in R2's experiencing severe pain. Findings include: R2's face sheet documented he was admitted to the facility on [DATE] and discharged on [DATE]. R2's face sheet documented his diagnoses were, in part, burn of third degree of right foot, type two diabetes mellitus and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. R2's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact. R2's Care Plan dated 4/25/25 documented R2 was at risk for skin complications (entered on 5/4/25) with interventions, in part, to provide treatment as ordered (entered on 5/4/25). R2's orders documented acetaminophen 650 mg (milligram) tablet to be started 4/23/25 as needed for pain/fever/headache and oxycodone 5 mg tablet to be started 4/23/25 as needed for pain. R2's Medication Administration Record documented the first dose of acetaminophen he was given was on 4/24/25 at 8:53 AM and the first dose of oxycodone was administered on 4/24/25 at 11:25 AM. R2's discharge summary was faxed from hospital on 4/23/25 to the facility, it included his wound care orders. The discharge summary wound care orders documented the following: Donor site location: left thigh, Xeroform/bacitracin: leave adherent xeroform on donor site. Wash it daily with soap/water to remove any debris/old ointment. Reapply new bacitracin over adherent xeroform then leave it open to air. Trim loose xeroform as it lifts up. Once donor site is heeled (usually 2 weeks after surgery) xeroform should be able to be easily removed to reveal healed pink/dry donor site skin. Graft location: bilateral feet: bacitracin, xeroform and gauze daily to foot burns-separate toes with gauze. f/u (follow up) in 1 week with burn/plastic surgery clinic. Progress note dated 4/24/25 at 2:38 PM, V4 documented that R2 refused wound care treatment due to pain. After given pain pill and waiting 35 to 40 mins. Went back to resident to try to do wound care. R2 was still in a lot of pain. Resident agreed to let me cover the wound back up. Spoke with facility NP about resident's pain. NP increased frequency of pain medicine given. Called the wound NP and went over different ideas and how to help resident with dressing change and if she wanted to change any of the orders. The only change was to wrap or put a bordered dressing over graft area. Went over plan with R2 about changing dressings tomorrow. R2 did not want dressing change but stated that he will try. R2's son came into voice concerns about treatments. V4 explained R2's pain level and what she discussed with R2. Also went over that surgeon was called and left a voice message to see if anything needs to be changed with wound care due to the pain. R2's son was upset that the wound care was not completed and was worried about R2's mental status. NP called and orders for labs and urine to be collected by tomorrow. R2's Progress note dated 4/25/2025 at 9:33 AM, documented V4 (Wound Nurse) charted she received a call back from surgeon's nurse and was informed by the nurse that the area where the skin graft was taken from was not to be changed. V4 continued to document We are to wash the area with soap and water and cover the xeroform that is on the area with bacitracin and leave open to air. I explain the clothing sticking to the clothing. Nurse stated that we can wrap it in gauze. I informed the nurse of removing one strip of the xeroform from the area do to what I read from the first set of orders. Nurse question if I covered it back up with xeroform, which I inform her that I did. Nurse stated that it is ok but not to do it again. On 5/12/25 at 9:35 AM, R2 stated his stay at the facility was horrible, the treatment he was supposed to have, he didn't get. R2 stated when he first arrived, the nurse just started to rip off the dressing from his thigh, she didn't try to wet it down or peel it back slowly the way the hospital would do. R2 stated it felt like a strip of skin was ripped off his thigh. R2 stated he was screaming in pain, and they didn't give him medication before doing it; the nurse kept telling him It needed to be done until he finally told her to stop, he couldn't take the pain anymore. R2 stated he looked down at his leg after she ripped of the dressing, and it was bleeding. R2 stated they put in the charts that he refused care and ignored that it was causing him so much pain. R2 stated he's cut off a finger in his past and was treated better for that, they made sure his pain was managed first before providing the wound care but at the facility they didn't do any of that. R2 stated he was in severe pain screaming and she put him through hell. R2 stated the nurse came back later and told him she didn't look at the second page of instructions where it said to leave the dressing in place on his thigh. R2 stated because of his stay at the facility he went backwards in recovery from the care they provided and had to undergo another surgery; now he is back in the hospital instead of home. On 5/7/25 at 10:30 AM, V4, Wound Care Nurse, stated that R2 came to the facility after burning his feet with tea, he was transferred from the hospital with 5% burns to his body. V4 stated when she went to remove the xeroform from R2's thigh, he was in a lot of pain and later found out it was not supposed to be removed. V4 stated because R2 was in so much pain she only removed one strip and stopped. V4 stated she found the wound care orders several hours after she removed the one strip from R2's thigh. On 5/8/25 at 10:05 AM, V4 stated the initial time she took off the dressing from R2's thigh, R2 was in extreme pain. V4 stated we would pre-medicate R2 for wound care after that. On 5/8/25 at 9:44 AM, V7 Licensed Practical Nurse (LPN) stated R2 would complain of his wounds causing him pain. V7 stated the day V4 took the dressing off R2's thigh, he was bleeding, and she had to give him oxycodone after because he was in pain and wouldn't let anyone touch it afterward. On 5/13/25 at 9:53 AM, V16 (LPN) stated she would review orders first and see if there is pain medication to administer to the residents at least 30 minutes prior to providing wound care. V16 stated if the resident was in severe pain, then something is wrong and would stop. V16 stated she would soak the dressing first before removing it if it was dried to the skin. On 5/13/25 at 9:55 AM, V17 registered nurse (RN) stated she would pre-medicate if there were orders to do so prior to wound care. V17 stated she would not continue with wound care if it was causing the resident severe pain especially if it was sensitive. V17 stated she would wet the dressing first if it was dried to the skin before removing only if she had orders to remove it. On 5/13/25 at 10:56 AM, V2 (DON) stated she would expect the nurses to provide pain management if the resident is having complaints of pain. The facility's Pain Management Policy dated 1/2025 documented it will facilitate and provide guidance on pain observations and management. The policy continues to document the pain management program is based on a facility-wide commitment to resident comfort and pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. The policy further documented pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals.

Based on interview and record review, the facility failed assess, monitor, and treat a change of condition for 1 of 4 resident (R6) reviewed for quality of care in the sample of 15. This failure resulted in a delay of treatment for a significant change in condition resulting in R6's hospitalization . Findings include: R6's Face Sheet, print date of 2/19/25, documents that R6 was admitted on [DATE] and has diagnoses of Alzheimer's Disease and Dementia. R6's Minimum Data Set, dated dated [DATE], documents that R6 is moderately cognitively impaired and is independent with eating. R6's Nurses Note, dated 1/13/25, documents, Resident returned to the facility via (hospital) ambulance accompanied by EMS (Emergency Medical Services). The resident is alert and denies pain. The resident was a total assist into her bed and is 1.5 L (liters) of oxygen per nasal canula. Call light is within her reach. The resident is on droplet / contact isolation for influenza. R6's Nurses Note, dated 1/14/25, documents, Resident refused to leave O2 NC (oxygen) (nasal canula) on, repeatedly attempted to place NC on and resident takes it off. Resident educated on the importance of using her supplemental oxygen and resident still refuses. R6's Nurses Note, dated 1/15/25, documents, 'Resident refuses to keep on O2. Resident has been redirected several times. Resident is currently sitting in bed resting with nasal canal (cannula) on will continue to monitor. R6's Note Text, dated 1/15/25 9:53 PM, documents R6 received a DRIPT IV Therapy infusion per provider order with post infusion vital signs of 136/84 blood pressure and a heart rate of 82. R6's Progress Note, written by V12, Medical Nurse Practitioner, dated 1/17/25, documents, Patient seen and examined today for routine 30 day follow up. Patient reports good appetite. Is sleeping well overnight. Denies acute medical conditions. It continues, resident requires assistance with ADL's (activities of daily living) and mobility. Patient recently hospitalized for Influenza A. Continues to refuse to wear supplemental oxygen. R6's vital signs, dated 1/18/25, documents R6's blood pressure of 102/68, heart rate of 51, temperature of 98.2, respirations of 18, and oxygen saturation of 88%. R6's Meal Intake, dated 1/23/25, documents R6 at 75 to 100% of her meal at 11:15 AM and 12:45 PM. R6 has no other meal intakes documented before R6's discharge to the hospital on 1/27/25. The facility Weekly Weeks documents the week of 1/13 R6 weighed 173 pounds, the week of 1/20 R6 weighed 162.5 pounds. The facility Communication for Daily Facility Discharges documents R6 was sent to the hospital on 1/27/25 because of AMS (Altered Mental Status), Hypotension, and Dehydration. R6's Electronic Medical Record fails to document any other Nursing Notes, Vital Signs, Nursing Assessments, Doctor Notification, Change of Condition, or Hospital Transfer documentation between 1/13/25 and 1/27/25. R6's Emergency Department Disposition, dated 1/27/25, documents Hospital Problems present upon admission Pneumonia of right lower lobe, Acute on chronic hypoxic respiratory failure, Hypernatremia, Moderate malnutrition, SIRS (systemic inflammatory response syndrome) UTI (urinary tract infection). A/P (assessment and plan): lab's significant for leukocytosis 14.6, lab's look like hemo-concentrate. Hypernatremia 155 (high normal is 145) AKI (acute kidney injury), cre (creatine) 1.94 baseline 1.1, UA (urinalysis) showed 4 plus leukocyte estrase, 4 plus bacteria. CXR (chest x-ray) noted opacities right lower lobe concern for pneumonia, no pleural effusion, no pneumothorax. In the ED (Emergency Department), she was given ceftriaxone/azithromycin for pneumonia and UTI. 1 L of fluid and continuous fluid. Plan: Hypernatremia AKI cre 1.94 baseline 1.1 Free water deficit: 2.7 L. repeat labs, sodium q6h (every 6 hours) These fluid and electrolyte abnormalities are being treated, evaluated, or monitored. Dehydration - IVF's (Intravenous Fluids) and repeat electrolytes. On 2/20/25 at 11:43 AM, V2, Director of Nurses, stated, (R6) just came off of our NAR (Nutrition At Risk) watch on 1/6/25. The way that the weekly weights work is as long as the weight is done that week, I enter the weight on Friday, and then on Tuesday when the Dietitian comes, we talk about putting new interventions in place. (R6) was 173 the week of 1/13/25 and the week of 1/20/25 she was 162.5. I entered the (R6's) weight of 162.5 on the 24th which was a Friday. I had planned on talking to the Dietitian about her on Tuesday, but she was sent to the hospital on Monday (1/27/25) and did not return. We already had her on fortified pudding and supplements. We can put things in place but if she is not eating it is not going to help. I am not sure if the Doctor was notified of (R6) not eating. I did educate the staff to push fluids and encourage her to eat. The staff should have been charting on her decline, a note about her going to the hospital, meal intake, and notifying the doctor if they did. On 2/20/25 at 1:48 PM, V12, Medical Nurse Practitioner, stated, I saw (R6) on 1/17/25. I knew she had just come back from the hospital with Influenza. I was not notified that she had a decline, she was not eating, and had weight loss. I should have been. On 2/19/25 at 12:30 PM, V3, Assistant Director of Nurses, stated I took care of (R6) on 1/26/25 going into the 27th. I did hear she was not feeling well, wasn't eating, and didn't want to get her hair cut. She hadn't been herself after she came back from the hospital with the flu. She was not eating or drinking like before. She would go to the dining room for meals. Before she was independent with dining, after that sometimes we would have to help her and encourage her to eat. There should be nurse's notes of her decline and why when she was transferred to the hospital. On 2/19/25 at 2:30 PM, V16, Licensed Practical Nurse (LPN) stated R6 really did decline fast after she got the flu. On 2/19/25 at 2:45 PM, V17, Certified Nurse Aide (CNA), stated The last two weeks she was probably eating 25% of her meal. It came to where we had to feed her. She used to be able to eat. I would say she totally stopped eating 2 to 3 days before she went to the hospital. The nurses knew. It should be documented in our charting of the intakes. On 2/20/25 at 11:00 AM, V1, Administrator, stated that V24, agency LPN is the nurse that sent R6 out to the hospital. On 2/20/25 at 11:05 AM, V2, Director of Nurses, stated I was in the building the evening that (R6) went out to the hospital because I told (V24) to send her out. The aides came out and said that (R6) wasn't acting right. She was acting very sluggish just not herself. She had low blood pressure. On 2/20/25 at 11:07 AM, V22, CNA, stated, The last time I worked with her (R6) it was 2 days before she went out. She was really tired. I was able to get her eat a few bites. I had to fed her. I even tried to get her to take some bites of her fortified pudding, but she wasn't having it. She was ok just really really tired. She was still urinating like normal. I did chart her intakes. I let the nurse know that she did not have an appetite that day. On 2/20/25 at 11:39 AM, V24 stated, I haven't worked there often but I didn't send anyone out to the hospital while I was there. On 2/20/25 at 12:26 PM, V25, CNA, stated, I took care of (R6) the evening before she went to the hospital (1/26/25). Before she would talk to me. She was confused but she would talk. The last night I cared for her, she was completely out of it. She looked horrible. She would go ew ew ew she couldn't even talk anymore. I tried to get her to drink her water, but she couldn't even swallow it just sat in her mouth. The nurse was going in and giving her meds (medications). I asked what was going on and she said she has had a decline. On 2/20/25 at 1:20 PM, V8, Registered Nurse, stated, (R6) was more tired and less talkative but about her normal self. She would always sit in her doorway in her wheelchair wanting to go to her room which she was in her room. She wasn't doing that. As far as I know, she was eating and drinking just fine. I did not see anything alarming about her. The policy Change in Resident Condition, dated 9/2024, documents, Nursing will notify the resident's physician or nurse practitioner when: b. There is a significant change in the resident's physical, mental or emotional status. c. There is a pattern of refusing treatment or medication. It continues, e. It is deemed necessary or appropriate in the best interest of the resident. The Weight Change Policy, dated 9/22, documents, 1. Review weights and vitals dashboard for significant weight changes. 2. upon identification of a newly significant weight change, complete NARs weekly review tool. 3. Notify Dietician, Physician, and resident representative. The Policy Documentation by Exception, dated 9/2024, documents, 2. documentation should include any unusual event or change of condition of the resident. 3. Any communication with the physician, nurse practitioner, or consulting physician should be documented.

Based on observation, interview, and record review, the facility failed to identify, assess, and monitor pressure ulcers, and provide the Physician prescribed treatment for 4 of 5 residents (R1, R2, R4, R5) reviewed for pressure ulcers in the sample of 15. The failure resulted in R5 developing a pressure ulcer of unknown stage while at the facility, not receiving treatment for a pressure ulcer for 23 days at which time it was unstageable, and R4 developing 3 pressure ulcers while at the facility and a sacral pressure ulcer that became infected. Findings include: 1. R5's Face Sheet, print date of 2/20/25, documents R5 was admitted on [DATE] with diagnoses of Severe Protein Calorie Malnutrition, Delusional disorder, Schizophrenia, and Heart Failure. R5's Minimum Data Set (MDS), dated [DATE], documents R5 is moderately cognitively impaired, dependent on staff for dressing, toileting, and hygiene, frequently incontinent for urine and bowel, and R5 has 2 unstageable pressure ulcers. R5's Braden Scale for predicting Pressure Sore Risk, dated 1/8/25, documents that R5 is a high risk for pressure ulcers. R5's Electronic Medical Record fails to document a Braden Scale before 1/8/25. R5's Nurse's Note, dated 12/1/2024 11:12 AM, documents, Resident has 2 open wounds. 1 is on his right hip, and the other is on his inner left knee. I put TAO (Triple Antibiotic Ointment) and bandages on both of the wounds. His right heel on the left side is also becoming soft. I had CNA (Certified Nurse Assistant) put a pillow in between his knees and feet to take the pressure off. Plan of care ongoing. R5's Weekly Skin Assessments, dated 11/14/24 - 12/23/24 fails to document any pressure areas noted on R5. R5's Electronic Medical Record fails to document a pressure ulcer wound assessment for the pressure ulcer found on 12/1/24, Physician Notification, or Physician Orders for treatment for the pressure ulcer. There are no progress notes regarding the monitoring, assessment, or treatment of R5's pressure ulcer from 12/1/24 to 12/24/24 for the pressure ulcer to R5's right hip. R5's Nurse's Note, dated 12/24/24, documents, Was informed by CNA (Certified Nurse Aide) that resident has a bad wound on his right hip/ butt. Check wound with wound NP (Nurse Practitioner) and found an unstageable wound. Resident stated that its fine don't touch it. Resident stated that it is not a wound, its clothing. Did wound care on wound with resident upset with wound care being done. Resident stated that he would pull it off when I am gone. R5's Treatment Administration Record (TAR) for December 2024, documents, Start date 12/19/24 Discontinue date of 1/5/25, right buttock, cleanse wound with wound cleaner and apply Silvadene, calcium alginate, collagen and cover with gauze dressing. every day shift for wound care. This TAR documents R5 refused dressing changes 5 of the 24 ordered changes. R5's Skin and Wound Note, dated 12/24/24, documents, Patient seen today for a new unstageable PI (Pressure Injury) to his right hip. Per staff, patient refuses to roll to left side, always laying on right side causing pressure. Wound: 3 Location: Right hip Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: New. Size: 5.5 cm (centimeters) x 3 cm x 0.2 cm. Wound Base: 100% eschar Wound Edges: Attached Periwound: Intact, Fragile Exposed Tissues: Epithelium Exudate: None amount of None. Wound # 3 Right hip Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Hydrogel to base of the wound. 3. secure with Bordered gauze. 4. change Daily, and PRN (as needed). NEW RECOMMENDATIONS: The resident has a treatment change listed above. Please reference the recommended orders for updated treatments. R5's December 2024 Physician Orders or TAR failed to document a right hip pressure ulcer treatment recommendation, written on 12/24/24 of cleanse with wound cleanser, apply hydrogel to base of the wound, secure with bordered gauze, change daily and PRN (as needed). R5's Skin and Wound Note, 1/3/25, documents, Wound: 3 Location: Right hip Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: Improving with delayed wound closure Size: 4 cm x 4 cm x 0.2 cm. Wound Base: 100% eschar Exposed Tissues: Epithelium Wound Edges: Attached Periwound: Intact, Fragile Exudate: None amount of None. Wound # 3 Right hip Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Hydrogel to base of the wound. 3. secure with Bordered gauze. 4. change Daily, and PRN. NEW RECOMMENDATIONS: The resident has a treatment change listed above. Please reference the recommended orders for updated treatments. R5's January 2025 TAR, documents, Start date of 1/6/25 Discontinue date of 1/16/25, right buttock, cleanse wound with wound cleanser cover with hydrogel cover with boarder dressing every shift for wound care. This TAR documents that R5 refused 1 of the 10 dressing changes. R5's January 2025 TAR documents, right buttock cleanse wound with betadine and cover slough with silver alginate cover with boarder dressing every day shift for wound care. Start date of 1/17/25 Discontinue date of 2/4/25. This TAR documents that R5 refused the dressing change 2 of the 11 dressing changes. R5's January 2025 TAR documents, left hip clean with wound cleanser cover with silver alginate cover with boarder dressing every day shift for wound care. Start date of 1/17/25 Discontinue date of 2/4/25. 2. R4's Face Sheet, print date of 2/10/25, documents R4 was admitted on [DATE] with a diagnosis of compression fracture of T (thoracic) 11-T12. R4's MDS, dated [DATE], document that R4 was cognitively intact, required moderate to partial assistance for bed mobility, and totally dependent on staff for transfers, and was frequently incontinent of bowel. R4's Braden Pressure Ulcer Risk, dated 1/2/24 documents R4 is a high pressure risk. R4's Skin Condition Assessment, dated 1/2/25, fails to document a skin condition or pressure ulcer. R4's Electronic Medical Record fails to document an Admission Assessment for R4 on 1/2/25. R4's Physician Order, dated 1/3/25, documents Cleanse sacrum with wound cleanser &/or NS (normal saline), apply dry dressing daily until wound MD (Medical Doctor) sees for new ordered. R4's TAR, dated 1/3/25, documents Cleanse sacrum with wound cleanser &/or NS (normal saline), apply dry dressing daily until wound MD (Medical Doctor) sees for new ordered. R4's TAR, dated 1/3/25, documents apply zinc oxide to buttocks every shift for redness and open area. R4's Nurses Note, dated 1/5/25, documents, called to resident room, resident is not responding to verbal or physical stimulation, breathing normally, vital signs at this time 99.7, 68/48, 129 hr (heart rate), 22 resp (respirations). It continues, Call placed to 911 for transport to hospital for eval (evaluation) and treatment. R4's Nurse's Note, dated 1/9/25, documents, Resident came from (local hospital). It continues, Resident has an open wound on her bottom, hospital said wound was not open; however, the area is open. R4's Nursing Admission Observation, dated 1/9/25, documents R4 has Pressure Ulcers. This document fails to document the location, appearance, or measurements of the pressure ulcer (s). R4's Skin Note, dated 1/9/25, documents, No new skin issues noted. R4's Physician Order, dated 1/9/25, documents Apply Zinc Oxide to buttocks every shift for redness, open area. R4's TAR, start date of 1/9/25 end date of 2/5/25, documents apply zinc oxide to buttocks every shift for redness and open area. R4's Skin and Wound Evaluation, dated 1/10/25, documents, Wound Measurements Length 3.4 cm Width 1.1 cm. This Skin and Wound Evaluation fails to document the type of wound, location, appearance of the wound, or notification of the Physician of the wound. R4's Skin Screen dated 1/9/25 and 1/16/25 fails to document R5 having skin conditions or pressure ulcers. R4's Skin and Wound Note, dated 1/15/25, documents Wound: 1 Location: right buttock Primary Etiology: Pressure Stage/Severity: DTI (Deep Tissue Injury) Wound Status: Present on Admission Size: 3 cm x 5 cm x 0 cm. Wound: 2 Location: sacrum Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: Present on Admission Size: 4.5 cm x 2 cm x 0.2 cm. Wound Base: 10% granulation, 90% slough Wound Edges: Attached Periwound: Fragile, Erythema Exudate: Scant amount of Serous Wound: 3 Location: left buttock Primary Etiology: Pressure Stage/Severity: DTI Wound Status: Present on Admission Size: 7.5 cm x 4 cm x 0 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Intact, Fragile PLAN: Wound # 1 right buttock Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Zinc Oxide Paste to base of the wound. 3. secure with Leave open to air. 4. change Q Shift. Wound # 2 sacrum Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Medical grade honey to base of the wound. 3. secure with Bordered gauze. 4. change Daily. Wound # 3 left buttock Pressure. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Zinc Oxide Paste to base of the wound. 3. secure with Leave open to air. 4.change Q Shift. The above dressing(s) was selected to promote autolytic debridement and moist wound healing within the wound bed. R4's Physician Order, dated 1/17/25, documents sacrum clean with wound cleanser cover open wound with medihoney cover with sacrum comfort foam dressing every day shift for wound care management. R4's TAR documents, Start date of 1/17/5 Discontinue date of 2/4/25, clean with wound cleanser cover open wound with medihoney cover with sacrum comfort foam dressing every day shift for wound care management. R4's TAR, start date of 1/9/25 end date of 2/5/25, documents apply zinc oxide to buttocks every shift for redness and open area. R4's Skin and Wound note, dated 1/21/25 WOUND ASSESSMENT: Wound: 1 Location: right buttock Primary Etiology: Pressure Stage/Severity: DTI Wound Status: Worsening Size: 5 cm x 5 cm x 0 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Fragile Wound Pain at Rest: 5 Wound: 2 Location: sacrum Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: Improving without complications Size: 4.1 cm x 2 cm x 0.4 cm. Wound Base: 30% granulation, 70% slough Wound Edges: Attached Periwound: Fragile, Erythema Exudate: Scant amount of Serous Wound Pain at Rest: 5 Wound: 3 Location: left buttock Primary Etiology: Pressure Stage/Severity: DTI Wound Status: Improving without complications Size: 6.5 cm x 3 cm x 0 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Intact, Fragile Exudate: None amount of None. R4's Skin and Wound Note, dated 1/28/25 documents WOUND ASSESSMENT: Wound: 1 Location: right buttock Primary Etiology: Pressure Ulcer/Injury Stage/Severity: Stage 2 Wound Status: Improving without complications. Size: 4 cm x 2.5 cm x 0 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Fragile Exudate: Scant amount of Serosanguineous Wound Pain at Rest: 5. Wound: 2 Location: sacrum Primary Etiology: Pressure Ulcer/Injury Stage/Severity: Stage 4 Wound Status: Worsening Size: 3.8 cm x 3.5 cm x 0.5 cm. Wound Base: 60% granulation, 40% slough Wound Edges: Unattached Periwound: Fragile, Erythema Exposed Tissues: Muscle/Fascia, Subcutaneous, Dermis Exudate: Heavy amount of Purulent, Serosanguineous. Wound: 3 Location: left buttock Primary Etiology: Pressure Stage/Severity: Stage 2 Wound Status: Improving without complications Size: 2 cm x 1 cm x 0.1 cm. Wound Base: 100% epithelial Wound Edges: Attached Periwound: Intact, Fragile Exudate: Scant amount of Serosanguineous Wound Pain at Rest: 5 PLAN: Wound # 2 sacrum Pressure Ulcer/Injury Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Silver alginate to base of the wound. 3. secure with Bordered gauze. 4. change Daily. R4's 1/2025 Physician Orders or TAR fails to document R4 being ordered or treated the change in sacrum pressure ulcer treatment of cleanse with wound cleanser, apply silver alginate to base of wound, secure with bordered gauze, and change daily that was ordered on 1/28/25. R4's Emergency Department document, dated 2/3/24 4:07 PM, documents Was called into the room by (Hospital Registered Nurse) when changing the patient's diaper, she has a deep sacral ulcer with purulent drainage present. (Hospital Physician) updated on wound and CT (computed tomography scan) abdomen and pelvis, sed (sedimentation) rate, CRP (C- Reactive Protein), vancomycin, and cefepime ordered. R4's Emergency Department Record, dated 2/3/25, documents Wound of sacral region initial encounter, Mental status has improved. Son at beside. Explained the wound will likely not heal at all given the advancement and bone involvement If there is any chance to heal this will require a diverting ostomy. Risks/benefits discussed. Code status has been addressed. Discussions with palliative hospice ongoing. As soon as determination is made, we can discuss further. R4's Hospital Record, dated 2/3/25, documents Sacral wound with infection, present on admission, s/p (symptom / plan) debridement. -Wound present on prior discharge but has certainly progressed and now with concerns of infection. - CT 5.8 x 1.6 x 2cm sacral ulceration extending from S (sacral)4-S6 containing gas and fluid and/or debris. Thin tract of gas along left side of sacrum with possible fistula and/or osteomyelitis - General surgery consulted - Continue Vanc (vancomycin)/Cefepime/Flagyl - Wound would likely require diverting ostomy for optimal healing - 2/5: Family opting to proceed with surgical intervention and hospice will follow for discussion postoperatively - 2/6: general surgery for sacral debridement and possible diverting ostomy - Wound culture with MSSA (Methicillin- resistant staphylococcus aureus), pseudomonas, continue vanc/cefepime/flagyl today. can likely de-escalate postoperatively pending findings. 3. R1's Face Sheet, print date of 2/10/25, documents R1 was readmitted on [DATE] and has diagnoses of Type 2 Diabetes Mellitus and Dementia. R1's MDS, dated [DATE], documents that R1 is mildly cognitively impaired, requires substantial maximal assist with rolling in bed, dependent on staff for transfers, has an indwelling urinary catheter, and is always incontinent of bowel. R1's Skin and Wound Note, dated 2/5/25, documents Patient seen today for a healing stage 4 PI to his right buttock. Location: right buttock Primary Etiology: Pressure Stage/Severity: Stage 4 Wound Status: Stable Size: 0.8 cm x 0.5 cm x 0.2 cm. Wound Base: 70% epithelial, 30% granulation, 0% slough, 0% eschar. Wound # 5 right buttock Pressure Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Collagen Particles to base of the wound. 3. secure with Bordered gauze. 4. change Daily, and PRN. NEW RECOMMENDATIONS: The resident has a treatment change listed above. Please reference the recommended orders for updated treatments 2/5. On 2/8/25 at 9:18 AM, V4, Certified Nurse's Aide (CNA) and V5, CNA, entered R1's room to provide incontinent care. V4 removed R1's covers. R1 is not wearing heel protectors. R1 had a large liquid bowel movement that has leaked out of R1's incontinent brief. R1's brief was removed. V4 provided incontinent care. R1 did not have a dressing on the right buttock pressure ulcer. V4 confirmed R1 did not have a pressure ulcer dressing on the right buttock. The pressure ulcer was actively bleeding. While providing the incontinent care V4 wiped a stool soiled pre-moistened cloth over the pressure ulcer. V4 and V5 both stated that R1 should have on his heel protectors, and they placed them on him. On 2/8/25 at 10:34 AM, V9, Licensed Practical Nurse, LPN entered R1's room to provide R1's right buttock pressure ulcer treatment. V9 cleansed the wound with wound cleaner. The wound bed is red with white edges at the top. V9 measured the wound 3.2 centimeters (cm) long x 1.4 cm wide. V9 applied Hydrogel, Collagen Particles, (Silver Sulfadiazine) SSD cream, calcium alginate and a superabsorbant gauze, and then taped it securely. R1's February 2025 TAR documents, Clean with wound cleanser on right buttock hydrogel, collagen particles, SSD, calcium alginate rope, Cover with super absorbent gauze every day shift for wound care management start date of 1/8/25. This TAR fails to document and order from 2/5/25 of cleanse with wound cleanser, apply collagen particles to base of the wound, secure with bordered gauze. 4. R2's Face Sheet, Print date of 2/10/25, documents R2 was admitted on [DATE] and has diagnoses of Type 1 Diabetes and Paraplegia. R2's MDS, dated [DATE], documents that R2 is cognitively intact, requires partial to moderate assistance for bed mobility, is dependent on staff for transfers, has an indwelling urinary catheter, and an ostomy. R2's Physician Orders, dated 2/7/25, documents, SSD (Silver sulfADIAZINE) External Cream 1 % (Silver Sulfadiazine) Apply to right buttock topically in the morning for wound care management. R2's Physician Orders, dated 2/6/25, documents right buttock clean wound with wound cleanser cover wound with mixture of SSD, collagen filler and hydrogel cover with calcium alginate cover with bordered gauze every day shift for wound care management AND as needed for whenever the wound dressing comes off or dirty. R2's Physician Orders, dated 2/6/25, documents sacrum clean wound with wound cleanser cover with zinc ointment leave open to air every day shift for wound care management AND as needed after bowl movements. On 2/8/25 at 10:52 AM, V8, Registered Nurse, RN entered R2's to provide pressure ulcer treatments. V8 cleansed the sacrum pressure ulcer with wound cleanser, applied a mixture of SSD, hydrogel, collagen particles, calcium alginate, and covered the pressure ulcer with border gauze. The pressure ulcers were 5.5 cm x 4.5 cm. The wound bed was red. The upper left side of the pressure ulcer had scabs. V8 then cleansed the right buttock pressure ulcer with wound cleanser, applied a mixture of hydrogel, collagen particles, calcium alginate, and covered the pressure ulcer with border gauze. The pressure ulcer measured 3 x 1.5. There is a stitch in the middle of the pressure ulcer. The middle is indented, and the wound bed color is dark pink. V8 stated she just may have done the wrong order on the sacrum. V8 did not remove the applied a mixture of SSD, hydrogel, collagen particles, calcium alginate, and covered the pressure ulcer with border gauze. On 2/8/25 at 11:15 AM, R2 stated that she just returned from the hospital because one of the wounds needed to be cauterized because it would not stop bleeding. On 2/8/25 at 2:30 PM, V8 stated she did not use the SSD cream on the right buttock is because R2 was out. On 2/10/25 at 2:30 PM, V2, Director of Nurses, stated that she is unsure why the orders that the Wound Nurse Practitioner are not put in as orders. A pressure ulcer assessment should be done at admission, readmission, or when a pressure ulcer is found. On 2/13/25 at 11:49 AM, V13, LPN/Wound Nurse, stated a skin assessment should be done within the first two hours of admission. If a pressure ulcer is new, it will get a dressing over it, and I notify the Nurse Practitioner or the Doctor to get orders for it. I then put the order in and do the treatment. I do rounds with the Wound Nurse Practitioner. the Nurse Practitioner will go over the pressure ulcer and then what order she wants. If I am not here the floor nurse will go with the Wound Nurse Practitioner. When she changes an order, I put it in right then that way it gets put in the Physician Orders and to the Treatment Administration Record. The Wound Nurse Practitioner will send an email with the wound information and what order she wants. Sometimes it is the same and sometimes it is different. If a dressing is missing it should be replaced as soon as possible. The dressings should be done as they are ordered. On 2/19/25 at 10:48 AM, V14, Wound Nurse Practitioner, stated We are a contracted company, so we are not allowed to put in orders. The nurses here do it. I have 48 hours to turn in my report with the recommendations which are the orders, but they are called recommendations. Once they get that report, the recommendations should be entered as orders and then carried out. If a new pressure ulcer or wound develops the facility should be calling the Medical Doctor for orders. I am only here once a week so when I come next, I will then look at it. The nurses should be putting on the treatments as they are ordered. The policy Skin Management: Pressure Injury Treatment/ General Wound Treatment, dated 4/2024, documents, General Treatment Guidelines; 1. Review the physician order in the EHR (Electronic Health Record) and place all necessary supplies in treatment care. It continues, 6. Perform the treatment as ordered using proper techniques of infection prevention and control. 9. Pressure Injuries will be evaluated, and the following areas documented weekly (minimum every 7 days). Location. Size: Perpendicular measurement of the greatest extent of length and width of the injury using a disposable measuring device. Depth: insert a swab in wound and gloved finer at end, then measure in centimeters. Presence and location (based on the clock) of undermining/ tunneling/ sinus tract. exudate: type, color, odor, and appropriate amount. pain: Nature and frequency. Wound bed: color and type of tissue / character including evidence of healing (granulation tissue) or necrosis. Description of wound edges and surrounding tissue (rolled edges, redness, maceration, etc.) 10. The staff nurse will notify the Wound Nurse upon identification of skin impairment. If the Wound Nurse is not available, the staff nurse should document the open area on a Skin Screen Form and alert the health Care Provider for treatment orders. 11. When the Wound Care Team assesses the resident, they will take a picture, measure the wounds, review the orders, and update any notes and care plans as appropriate.

Based on observation, interview, and record review the facility failed to prevent pressure ulcer development and failed to provide resident centered interventions, monitoring and orders for residents who were identified to be at risk for pressure ulcers and for residents with pressure ulcers for 2 of 3 residents (R1, R2) reviewed for skin impairment. This failure resulted in R1 acquiring an unstageable pressure ulcer to his/her left heel and stage 3 pressure ulcer to right buttock; R2 requiring debridement of an unstagable pressure ulcer during a hosptial stay to R2's coccyx. Findings include: 1. R1's face sheet with a print date of 10/21/2024 documented R1 has diagnoses of type 2 diabetes mellitus, sepsis, cognitive communication deficit, contracture of left knee, dementia, osteoarthritis, hypertension, and paroxysmal atrial fibrillation. R1's MDS (Minimum Data Set) dated 10/9/24 documented R1 has moderately impaired cognition. R1's MDS dated [DATE] documented R1 requires substantial to maximal assistance with bed mobility and is dependent on staff for all other mobility. R1's care plan, undated, documented R1 is at risk for pressure ulcers related to impaired mobility and incontinence. This care plan documented R1's interventions include assist and encourage resident to turn and reposition frequently, document signs and symptoms of skin break down, low air loss mattress, notify nurse of signs and symptoms of skin breakdown noted during routine care, weekly and prn (as needed) skin assessment. R1's progress note dated 8/30/24 at 10:40 AM by V10 NP (Nurse Practitioner) documented R1 developed a new stage 2 pressure ulcer to left heel. V10 documented wound size 2.5 cm x 4 cm x 0 cm, wound base 100% epithelial, wound edges attached, and exposed tissues: epithelium and dermis. R1's progress note dated 9/5/24 at 9:17 am by V10 NP documented wound left heel, primary etiology: pressure, stage/severity: stage 2, wound status: worsening, size 3 cm x 5 cm x 0 cm, wound base: 100% eschar. R1's progress note dated 9/12/24 at 10:10 AM by V10 NP documented R1's stage 2 pressure ulcer on left heel as worsening and new measurements of 4.6 cm x 4.5 cm x 0 cm. This progress note documented that R1 was experiencing pain in the heel at rest and that V10 surgically debrided that pressure ulcer during this visit. V10 documented post-debridement measurement of 4.6 cm x 4.5 cm x 0 cm. R1's progress noted dated 9/20/24 at 9:40 am by V10 NP documented R1's stage 2 pressure ulcer on left heel as unstageable. On 10/17/24 at 8:35 am R1 was observed in bed on a regular mattress lying on his back. On 10/17/24 at 11:35 am V8 LPN (Licensed Practical Nurse)/Wound Nurse and V9 LPN/former Wound Nurse were observed as they performed wound care to R1's heel. V9 stated R1's heel started out as what appeared as a bruise and that the pressure ulcer worsened and developed tunneling in the wound. V9 stated she would consider the pressure ulcer on R1's heel to be a stage 4 since it has the tunneling but she must document what the Nurse Practitioner stages the wound as, so she documented a stage 2 on the EMR (Electronic Medical Record) wound evaluation with a picture dated 9/12/24 at 3:07 pm. V9 stated that R1 is supposed to be on a low air loss mattress and she doesn't know why he isn't unless it didn't get moved when he changed rooms about a week ago. V9 stated that R1's only pressure ulcer is on R1's left heel and that R1 does not have any pressure ulcers on his backside. Surveyor then requested to observe R1's buttock region. V8 and V9 then turned R1 onto his right side revealing a large undated dressing covering R1's coccyx and partially covering R1's left buttock. V9 stated to V8 he has a wound on his bottom and a dressing over it. V8 replied no one told me. V9 then removed the dressing from R1's buttock/coccyx region revealing a large area of detached skin approximately 6 cm x 6 cm on left buttocks from what appeared to have been a fluid filled blister that had drained and an approximate 1 cm x 1 cm open area to R1's coccyx. V9 stated that R1's EMR does not document anything regarding these open areas to R1's buttock and coccyx. V9 stated that R1 does not have a treatment order for these wounds and that she would have expected the nurse to notify R1's doctor about the new pressure ulcers and get orders for a treatment. V9 stated that she expects the staff to turn and reposition R1 at least every two hours. On 10/17/24 at 11:55 am R1 stated that the staff do not turn him very often and that he was on his back all morning until the nurses changed his dressing. R1's progress note dated 10/17/24 with time of service at 12:14 pm V10 NP documented left heel stage 3 pressure ulcer, right buttock new stage 2 pressure ulcer 6 cm x 6.1 cm, and coccyx new DTI (deep tissue injury) with primary etiology as pressure measuring 1 cm x 0.6 cm. R1's progress notes orders do not documented anything regarding the pressure wounds on R1's buttock and coccyx region until V8 and V9 discovered the wounds upon the surveyor's request to observe R1's skin on R1's buttock region. R1's TAR (Treatment Administration Record) documented a new order to cleanse buttock with wound cleanser, apply calcium alginate, collagen, Silvadene, cover with bordered gauze everyday shift to promote wound healing dated 10/18/24. This treatment is not signed off as completed on 10/20/24 as ordered. R1's TAR documented an order to apply calcium alginate, collagen, Silvadene, and rolled gauze to R1's left heel daily dated 10/17/24. This treatment is not signed off as completed on 10/20/24. On 10/21/24 at 11:32 AM V2 DON (Director of Nursing) stated that she would have expected the nurse that placed the dressing on R1 to call R1's doctor and get a treatment for the pressure ulcers that were found but were not documented on R1's coccyx and buttock. V2 stated that she would have expected R1 to be on a low air loss mattress as is on his care plan. On 10/21/24 at 3:45 pm V1 Administrator stated that she would expect interventions to be in place as care planned and that R1 should have been on a low air loss mattress. V1 stated that if a treatment is not signed off on the TAR, then it was not completed as ordered. 2. R2's face sheet with a print date of 10/21/24 documented R2 has diagnoses of metabolic encephalopathy, type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema, diabetic neuropathy, dysphagia following cerebral infarction, depression, schizoaffective disorder, delusional disorders, dementia, cerebrovascular disease, Alzheimer's disease with early onset, hypertension, atherosclerotic heart disease, and chronic kidney disease. R2's MDS dated [DATE] documented R2 is severely cognitively impaired and is dependent on staff for bed mobility. R2's progress note dated 8/9/24 at 11:30 AM documented R2 has a new skin condition. Please see skin condition observation for details. R2's skin condition report dated 8/9/24 at 12:06 PM documented left buttocks open area, Kennedy ulcer in appearance. R2's skin and wound progress note dated 8/22/24 at 9:55 AM by NP V10 documented reason for visit: new skin and wound consult on current resident. It continues, wound assessment: Wound 1, location: coccyx, primary etiology: pressure, stage/severity: unstageable, wound status: new. R2's skin and wound progress note dated 9/5/24 at 8:16 AM by NP V10 documented wound 1, location: coccyx, primary etiology: pressure, stage/severity: unstageable. It continues, wound 2, location: right heel, primary etiology: pressure, stage/severity: DTI (deep tissue injury), size 1.5 cm x 2 cm x 0 cm. It continues, wound #2 right heel pressure treatment recommendations: 1. Cleanse with wound cleanser. 2. Apply skin prep to base of the wound. 3. Leave open to air. 4. Daily treatment. R2's skin and wound progress note dated 9/16/24 at 2:41 PM by NP V10 documented wound 1, location: coccyx, primary etiology: pressure, stage/severity: unstageable, size: 1.5 cm x 3 cm x 0.5 cm, wound status: stable. It continues, wound 2, location: right heel, primary etiology: pressure, stage/severity: DTI (deep tissue injury, size 1.5 cm x 2 cm x 0 cm. R2's skin and wound progress note dated 10/3/24 at 8:47 AM by NP V10 documented wound 1, location: coccyx, size 1.5 cm x 2.6 cm x 0.7 cm. Undermining from 12 o'clock to 1 o'clock, 3 cm. It continues, wound #1 coccyx pressure treatment recommendations: 1. Cleanse with wound cleanser. 2. Apply Dakins moistened fluffed gauze to base of the wound. 3. Secure the bordered gauze. 4. Change daily, and PRN (as needed). R2's skin and wound progress note dated 10/11/24 at 11:12 AM by NP V10 documented wound 1, location: coccyx, primary etiology: pressure, stage/severity: unstageable, size 3 cm x 3.2 cm x 0.7 cm, undermining from 10 o'clock to 3 o'clock. It continues, wound 2, location: right heel, primary etiology: pressure, stage/severity: stage 3, wound status: worsening, size: 0.5 cm x 0.3 cm x 0.1 cm. R2's TAR dated October 2024 documented a treatment order for R2's coccyx to cleanse with wound cleanser and apply Dakins moistened fluffed gauze everyday and night shift for wound care management. R2's October 2024 TAR does not document that this treatment was performed as ordered on the following day shifts: 10/4/24, 10/5/24, and 10/9/24. R2's TAR dated October 2024 documented a treatment order to R2's right heel to be cleansed with wound cleanser and to apply skin prep everyday shift for wound care management. R2's October 2024 does not document that this treatment was completed on 10/2/24, 10/4/24, and on 10/5/24 as ordered by R2's physician and as recommended by V10 NP for wound consultant company. R2's wound progress notes by NP V10 were reviewed and none of the progress notes by V10 documented a diagnosis of a Kennedy ulcer on R2's coccyx. R2's EMR does not document a diagnosis of a Kennedy ulcer by a Physician nor by a Nurse Practitioner. R2's progress note dated 10/12/24 at 1:20 PM documented that R2 was transferred to a local hospital. R2's hospital progress note dated 10/16/24 at 7:33 PM documented Plan #3. Left buttock decubitus ulcer. This is a deep ulcer. Doctor V15 has debrided it. Wet to dry dressing should be continued and the patient will need frequent repositioning. R2's hospital records were reviewed, and these records do not document that R2's pressure ulcer is a Kennedy ulcer. On 10/17/24 at 12:06 PM V9 stated that R2's pressure ulcer looked like it was the start of a Kennedy ulcer when it started and that is what she documented on R2's wound evaluation form. On 10/21/24 at 11:32 AM V2 DON stated that she is not sure where R2's diagnosis on a Kennedy ulcer came from. The facility's Skin Management: Monitoring of Wounds and Documentation policy dated 1/2022 documented it is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. Responsible Party: All nursing staff. General Guidelines: An evaluation of the PU/PI (pressure ulcer/pressure injury), in no dressing is present; an evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); the status of the area surround the PU/PI; the presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection; and whether pain, if present, is being adequately controlled. The facility's Skin Management: Pressure Injury Treatment/General Wound Treatment Policy dated 6/2015 documented 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. It continues, an order is required for all treatment orders. Responsible Party: All nursing staff. General Guidelines: implement prevention protocol according to resident needs, sensory perception risk factor: watch for nonverbal cues, assess areas of the body that do not feel pain for openings or redness, Moisture: avoid prolonged periods of wetness, apply moisture barrier with each incontinent episode, choose treatments that do not cause skin maceration, Activity: turn and reposition as needed using a person-centered approach (minimum of every 2 hours). It continues 10. The staff nurse will notify the Wound Nurse upon identification of skin impairment. If the Wound Nurse is not available, the staff nurse should document the open area on a skin screen form and alert the health care provider for treatment orders.

Based on observation, interview and record review, the facility failed to prevent employee to resident abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4. This failure resulted in R2 being physically and mentally abused, causing her to feel scared and not safe in the facility. Findings include: On 6/14/24 at 6:10 AM, R2 was in her room, sitting up on the side of the bed, with purplish green bruising noted under both eyes and a bruise to her left forearm. R2 was tearful and stated that the bruising under her eyes was caused by a fall, she was feeling scared after what happened, and she was pulling a wet pad out from underneath her and when she went to put it on the floor she fell forward out of the bed. R2 stated prior to that she was sitting up in her wheelchair in her room and V12, LPN (Licensed Practical Nurse), wanted her to go to bed. R2 stated she was having pain in her feet, doesn't need much sleep and wasn't ready to go to bed. R2 stated V12 and an unknown female employee (later identified as V15, CNA, Certified Nursing Assistant), came into her room, grabbed her on the left forearm and was fighting with her in a back-and-forth motion. R2 stated V15 got into her ear and loudly yelled something like you're going to get up and get in bed. R2 stated it hurt her ear when V15 yelled in it. R2 stated then they went and grabbed the mechanical lift, put her in it and then put her in bed. R2 stated she was yelling out for someone to help her, save her. R2 stated this made her feel low class and scared. R2 stated anytime V12 wants something done, she gets V15 to help her do it. R2 stated in one way she doesn't feel safe in the facility because she was yelling for someone to help her, and no one did. R2 stated this happened last Thursday (6/6/24), she isn't sure exactly what time, but it would have been after everyone goes to bed around 10:00 PM. R2 stated she reported it to V13, LPN, either the next day or the following day. R2 stated the police came to the facility and talked to her about what happened. R2 stated she has not seen V12 or V15 since she told V13 about what happened. R2 stated she still feels scared and if she would have known something like this could happen here, she wouldn't have come here. R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteoarthritis, Weakness, Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder, Type 2 Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease, Pain in Bilateral Knees, Lumbago, Chronic Kidney Disease, Dorsalgia and Insomnia. R2's Minimum Data Set, MDS, dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status) of 15, which means R2 is cognitively intact. R2's Care Plan, dated 2/16/24, documents R2 is at risk for abuse/neglect. R2's Progress Notes by V13, LPN, document the following: 6/10/2024 9:39 PM - Resident initially said to me that she wanted to tell me something, but didn't want to if someone would get in trouble or if I would have to report it. I said depending on what it is I would have to report it. She said never mind, but eventually told me that one of the CNA's was being abusive to her. She said she was in her chair and the CNA wanted her to get up into bed, but demanded it, so she wasn't cooperating with her. The abuser tried to pull her up by her wrists and put a bruise and small cut on her left wrist. (R2) also said that the abuser yelled 3 times in her ear, you're going to get up. The resident was clearly scared to divulge the information to me. After she told me about it, I immediately notified my DON (Director of Nursing) and HR (Human Resources) manager, who notified the local Police. The police officer took both mine and (R2's) statement and left a card with the case number on it. I put the card under the DON's office door; 6/10/2024 9:42 PM - I did a skin assessment on her and she has a bruise and a small cut on her left forearm. There are no other skin issues. Will continue to monitor. The Police Report by V17, Police Officer, documents the following: Report for Incident 2024-012193, Possible Abuse, document created on 6/11/2024 @ (at) 03:59:02. On 06/10/2024, at approximately 2018 hours, I, responded to (the facility) in reference to a possible abuse complaint. On arrival, I met and spoke with (V13). (V13) advised that a resident brought an incident up to her that was concerning. (V13) stated that (R2) informed her that she has a large bruise on her left arm that she obtained from the Nurse or CNA working on the night before she went into the hospital on Friday night (06/06/2024). (R2) informed (V13) that the bruise was attained when the worker attempted to pull her up by her arms. (V13) stated that (R2) told her she was scared to talk to her about the incident and she did not want to get anyone into trouble. (V13) informed (R2) that due to the nature of the complaint, she was going to have to speak to her supervisor to report the incident. (V13) advised that after speaking with (R2), she contacted her supervisor, (V2, DON). (V13) informed (V2) of the complaint made by (R2) and (V2) then contacted the police department for a report to be created. (R2) said that she does not know the name of the Nurse or CNA working on the night of the incident, but it happened the night before she went into the hospital. (R2) stated that the nurse came into the room and told her to get up, but she did not feel like getting up at that moment, so she did not try to help the aide and the nurse in moving her. (R2) said that this made the nurse angry, so she went to get the bigger, bully, female CNA to make (R2) get up. (R2) advised that the CNA yelled into her ear 3 times that she was going to get up and this scared her. (R2) then held her left arm out and I observed a large bruise on her left arm, above her wrist, and a small cut on her wrist. (R2) advised this happened when the CNA placed one arm on top of the other and attempted to pull her up. (R2) then stated that it could have happened when the CNA grabbed her arm with her hand to pull her up. It should be noted that I observed face was due to her falling out of bed and due to falling out of bed, she was in the hospital on Friday (06/07/2024). (R2) stated that she is scared due to the situation. I took photos of the injury; they were later attached to the report. I provided (R2) with my department issued business card and told her to call the police, if a situation like the one she told me about, happened again. (V13) informed me that at this time, they did not know who was working but (V2) was working on figuring that out at this time. (V13) advised, if any additional information was obtained, the police department would be contacted. I provided (V13) with my department issued business card and report number. R2's Follow-Up Investigation Report, dated 6/14/24, documents the following: Resident was scared to report the issue but is now feeling better that she did. Resident claims that a tall woman grabbed her by the wrist and yelled in her ear that she was going to bed now - resident couldn't remember the exact date, but it happened on night shift. Resident claims she stayed up late because she doesn't sleep much, and staff kept telling her she needed to go to bed. She told them she wasn't tired yet and she just keeps requiring less and less sleep the older she gets. Then, they came in the room and forced her in bed. One grabbed her arm and yelled in her ear that she was going to bed now. Resident appeared scared to tell what happened. (V12) claims that she, (V15, CNA), and (V16, Agency CNA), put the resident to bed. She stated that they got the sit to stand and kept telling the resident she needed to go to bed because of her wound and she needed to put her legs up and get out of the wheelchair. V15 claims that she put the resident to bed in the sit to stand. (V16), states that (V15) put resident to bed while she was fighting because she didn't want too yet. (V15), told R2 she was going to bed and got the sit to stand and forced her, the nurse was in the room. The conclusion was the allegation of abuse was substantiated due to evidence collected during the investigation. The investigative evidence contains the following information: On 6/10/24, Resident claims a tall white woman grabbed her arm and yelled into her ear that she was going to bed now but she didn't know what date it happened - either 6/6 or 6/7. Resident had a bruise and small cut on her left forearm - skin assessment completed. A review of camera footage showed that (V12) and (V15, CNA) went into residents' room with a sit to stand to put resident to bed on 6/6/24 at 11:32 PM. (V12) claims that she informed resident that she needed to go to bed to put her legs up due to her wound. (V15) claims that she put resident to bed in the sit to stand. (V16) claims that the resident was fighting by kicking, hitting, and biting but (V15) still made her go to bed with the sit to stand. Resident claims she kept telling them that she didn't want to go to bed yet because she wasn't tired, and she doesn't need much sleep anymore. (V12) and (V15) were suspended immediately. (V12) was terminated on 6/13/24 on an unrelated issue. (V15), was terminated on 6/14/24 for violating resident rights to choose what time to go to bed. On 6/14/24 at 7:10AM - V3, Human Resources, stated that V12 was being terminated today for a HIPPA violation and due to an abuse investigation. On 6/17/24 at 7:55 AM, V2, Director of Nursing, DON, stated V12 and V15 were terminated due to forcing R2 into bed. The Abuse Policy, dated 10/2022, documents the facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.

Based on observation, interview and record review, the facility failed to obtain orders to treat a new pressure ulcer, to prevent deterioration of the pressure ulcer, and failed to have appropriate interventions in place to prevent new pressure ulcers from developing and keep existing pressure ulcers from getting worse for 2 of 4 residents (R3 and R4) reviewed for pressure ulcers in the sample of 11. This failure resulted in R4 developing a Stage 4 Pressure Ulcer on his right buttock. Findings include: 1. On 2/22/24 at 9:15 AM V4 (Wound Nurse) provided pressure ulcer treatment to R4's Stage 4 pressure ulcer on his right buttock. V4 stated that the wound was just discovered on 2/20/24. She stated that she has ordered a cushion for his wheelchair (w/c), and he is on an air mattress. She stated R4's pressure ulcer is on the side affected by his stroke, and he cannot feel it and she think this contributed to his not being aware he was getting a sore and not letting anyone know about it. V4 unfastened R4's adult diaper and removed the dressing from the pressure ulcer on his right buttock. The pressure ulcer was larger than a quarter and the wound base was completely covered with yellow slough. There was a moderate amount of drainage noted on the soiled dressing. R4's Face Sheet, undated, documents his diagnoses to include Cerebral Vascular Accident (CVA); Flaccid Hemiplegia Affecting Right Dominant Side; Chronic Obstructive Pulmonary Disease (COPD); Neuropathy; Aphasia; Bipolar Disorder; Schizoaffective Disorder; Major Depressive Disorder; Hypertension (HTN); and Alcohol Dependence in Remission. R4's Minimum Data Set (MDS), dated [DATE], documented that R4 was severely cognitively impaired, and he uses w/c for mobility and propels self independently. This assessment documented that R4 requires substantial to maximal assist with most Activities of Daily Living (ADLs) including transferring and toileting hygiene and requires supervision with eating and turning and positioning. According to this assessment, R4 is always incontinent of bladder and frequently incontinent of bowel. At the time of this assessment, on 1/2/24, R4 had no unhealed pressure ulcers. R4's Care Plan, dated 6/12/22, documented, Pressure Ulcer: (R4) has potential for pressure ulcers related to decreased independent mobility. Dx (Diagnosis): CVA w/right hemiplegia, incontinence. Interventions for this Care Plan include doc s/s skin breakdown, Notify MD & family prn of changes in skin status, notify nurse of any new areas of skin breakdown, redness, blisters, bruises or discoloration observed during routine care, Remind/assist as needed to reposition frequently, utilize pressure-reducing mattress, and weekly body assessment. R4's Care Plan, dated 2/15/24, documented, Skin: At risk for skin complications r/t (related to) open area on right buttocks. This Care Plan was revised on 2/21/24, documented, Skin: At risk for skin complications r/t wound on right buttock. Interventions for this care plan include: 2-22-24 (brand name protein drink) as ordered, 2-21-24 air mattress as ordered, assist and encourage resident to turn and reposition frequently, educate resident on MD (Medical Doctor) orders for wound care, educate resident on the risks of infection and poor healing r/t non-compliance, monitor area for s/s of infection: odor, drainage, color, size, observe and assess regularly, provide skin care after each incontinent episode, RD (Registered Dietician) to assess and recommend, serve diet as ordered, skin check weekly, treatment as ordered, (Wound Physician) to follow. R4's Progress Note, dated 2/14/2024 at 8:47 PM, documented, Resident has open pressure sore on right buttock. It's roughly 4cm (centimeters) x 3cm. I cleansed it with wound cleaner and put a dressing with TAO (Triple Antibiotic Ointment) on it. R4's progress notes were reviewed for 2/1/24 through 2/14/24 and there was no documentation of R4 having a pressure wound to his right buttock until 2/14/24. R4's Wound Physician Progress Note, dated 2/20/24, incorrectly documented that the Stage 4 Pressure Ulcer as a skin tear and documents and the measurements of his wound as 4cm x 1.5 cm x 0.2 cm. R4's Wound Physician Progress Note, dated 2/22/24, documented, Non-visit Progress Note: Stage 4 pressure ulcer on Right buttock, not left buttock. R4's Physician Orders, dated 2/22/24, documented, Silver Sulfadiazine External Cream 1 % (Silver Sulfadiazine). Apply to Left buttock topically every day shift for Stage 4 pressure ulcer Cleanse stage 4 pressure ulcer to left buttock with wound cleanser, apply silver sulfadiazine cream, collagen, calcium alginate, cover with boarder dressing daily until clear. There was no order for a treatment to R4's pressure ulcer before 2/20/24, after R4 was evaluated by V9 (Wound Physician) for treatment of R4's facility acquired pressure ulcer that was discovered on 2/14/24, indicating R4's pressure was untreated for 6 days. R4's Braden Scale for Predicting Pressure Sore Risk, dated 1/2/24, documented a score of 13 indicating he is at moderate risk for developing pressure ulcers. On 2/22/24 at 11:20 AM V4 (Wound Nurse) stated that she was not aware of R4's Pressure Ulcer until 2/20/24 which was the first time she observed it, along with V9 (Wound Physician). V4 stated no staff had reported to her that R4 had a pressure ulcer before that. She stated that was the first time she received orders for the treatment of the pressure ulcer. V4 confirmed the pressure ulcer is a stage 4 pressure ulcer on R4's right buttock. V4 stated she had seen the discrepancy in the physician orders and with the wound physician's progress note and stated he had documented the wrong wound location and type of wound on R4's progress note. V4 confirmed the stage 4 pressure ulcer is on R4's right buttock and it is not a skin tear. She stated she had spoken to V9 (Wound Physician), and he is going to send her a revised progress note with the correct information. On 2/22/24 at 11:25 AM V2 (Director of Nursing/DON), stated that any staff who find a pressure ulcer or other skin impairment should notify the physician immediately and have a treatment order in place, and then notify V4 (Wound Nurse), of the new wound so she can follow-up and get the resident on the list to be seen by V9 (Wound Physician). V2 stated that R4 was very resistant to care and often the Certified Nursing Assistants (CNAs) provide incontinent care over the toilet because he refuses to lay down, and that might be why they missed the pressure ulcer on his buttock. V2 stated that she does not know why the pressure ulcer was not found on his weekly skin checks before it became a Stage 4. On 2/23/24 at 10:05 AM, V2 stated that there was no documentation of weekly skin being done for R4 prior to the observation of his pressure ulcer on 2/14/24. She stated she does not know when his pressure ulcer started but does not think it would have started a Stage 4 pressure ulcer. On 2/23/24 at 12:33 PM, during phone interview, V13 (Registered Nurse/RN) stated that she received a report on 2/14/24 from a CNA who was putting R4 to bed and providing him with incontinent care that he had an open area on his buttock. V13 stated she went down to assess the wound and put a treatment on it and notified V17 (Nurse Practitioner) via a text message of the new area. V13 stated she did not receive any new orders that evening regarding R4's pressure ulcer. V13 stated that she did not notify the V2 (DON) or V3 (Assistant Director of Nursing/ADON) or V4 (Wound Nurse) of the new pressure ulcer, but did document it in his progress notes. V13 stated she has taken care of R4 again and cannot remember seeing an actual order for a pressure ulcer treatment, but stated she did put some cream on it the other day. V13 stated R4's pressure ulcer looks much worse now than when she first saw it. She stated on 2/14/24 when she first identified the pressure ulcer, it was barely a Stage 1. She stated it was an open wound but didn't look that bad. V13 stated the wound is larger and deeper now and just looks a lot worse. V13 stated she believes the protocol if you find a new pressure ulcer is to document it, put a treatment on it and notify the doctor or nurse practitioner. V13 stated she did not notify anyone else of R4's new pressure ulcer. 2. On 2/21/24 at 10:05 AM, R3 was lying in her bed on her back. She stated that she was here for rehab because she broke her ankle when she fell at home. R3 stated nobody comes to turn and reposition her in bed. She stated they did turn her one time because she put on her call light and asked them to, otherwise she does not get turned and she knows she needs to or the sore on her bottom will get worse. R3 stated that she worked in the health field for a long time and knows it is important to get pressure off her backside if she wants it to heal, but they just don't have enough staff. R3 stated that she has never told staff she does not want to be turned because she knows how important it is, but they just don't do it and she hates to bother them. She stated they got her out of bed yesterday for therapy but then put her right back in bed because the wound doctor came. R3 stated that yesterday was the first time she got out of bed since she's been here because therapy was delayed with insurance problems. On 2/21/24 at 12:05 PM R3 was laying on her back in her bed. She stated that nobody has turned her. On 2/21/24 at 1:50 PM V4 (Wound Nurse) provided pressure ulcer care for R3. Upon entering R3's room, she was lying on her back. R3 stated they had just cleaned her up because she knew V4 was going to come in and do her treatment. R3 stated she has been on her back all day except for when they turned her and cleaned her up. R3 stated her butt does hurt from lying on her back all day. She stated she has not been out of bed since yesterday when therapy got her up for a short time. V4 cleansed the stage 2 pressure ulcer on R3's left buttock. The wound was irregular shaped with dark red base. There was no treatment in place when V4 rolled R3 onto her left side to do the treatment. R3 stated, They just cleaned me up. V4 applied silver sulfadiazine cream, collagen, and calcium alginate and covered it with a foam dressing. R3 complained that the bed was very uncomfortable to lay on and felt like she had things sticking her in the back and buttocks. V4 stated they would get her an air mattress because she should have one anyway because she has a wound. V4 stated R3 was on a regular mattress right now. V4 stated when the air mattress is put on R3's bed, that will be the pressure relieving device on the bed. V4 stated R3 did not have any type of pressure relieving device on her bed right now and stated R3 should be turned and repositioned every two hours to relieve pressure off her bottom. R3 stated to V4 that she has been on her back all day except during incontinent care. V4 placed a wedge cushion under R3's left hip to relieve pressure and R3 stated that felt a lot better. On 2/21/24 at 2:05 PM, V4 asked V8 (CNA) if R3's pressure ulcer dressing came off during incontinent care and V8 stated that it had come off because R3 had been incontinent of bowel and bladder and the dressing was soiled. V8 stated R3 is not turned and repositioned every two hours because of her fractured ankle and it being so uncomfortable when she is moved for incontinent care. V4 informed her it is still important for R3 to be turned and repositioned every two hours to help her pressure ulcer heal and prevent any other pressure ulcers. R3's Face Sheet, printed 2/22/24, documented her diagnoses to include Displaced Bimalleolar Fracture of Right Lower Leg, Asthma, Type 2 Diabetes Mellitus, Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems, Non-Displaced Fracture of Neck of Left Talus, Unspecified Fall, Other Reduced Mobility, and Generalized Edema. R3's MDS, dated [DATE], documented that she was alert and oriented and she required substantial/maximal assist for turning and repositioning. The assessment further documented that R3 was dependent for all transfers and was incontinent of bowel and bladder. It continued to document that R3 was admitted with one Stage 2 pressure ulcer and has a pressure reducing device for her bed and application of nonsurgical dressings other than to feet. It documents she is not on a turning and repositioning program. R3's Care Plan, initiated 2/18/24 documented, The focus: Bed Mobility: has a self-care deficit in bed mobility r/t decreased ability to position or reposition self in bed/turn from side to side/ use side rails to move in bed/move from lying to sitting or sitting to lying position. Interventions for this care plan include Position and reposition resident in bed for comfort, joint support, and skin integrity. R3's Care Plan, initiated 2/16/24 documented, Skin: At risk for skin complication r/t blister right ankle, left gluteus present on admission pressure per wound nurse. Interventions for this care plan include Therapeutic mattress in bed and cushion in chair as appropriate. R3's Skin and Wound Evaluation, dated 2/16/24, documented that she has a stage 2 pressure ulcer on her left gluteus, middle that was present on admission. Under Additional Care this evaluation documented that R3 was to have incontinence management, mattress with a pump, moisture barrier, moisture control, positioning wedge, and turning/repositioning program. R3's Braden Scale for Predicting Pressure Sore Risk, dated 2/9/24, documented a score of 16, indicating she is at risk for developing pressure ulcers. The facility's policy, Pressure Injuries, reviewed 9/2022, documented, To prevent or reduce the incidence of pressure injuries, standards of practice should be implemented. A pressure injury may be defined as any lesions caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are important contributing factors to the development of pressure injuries. The facility's policy, Skin Management: Pressure Injury, reviewed 1/2023, documented, 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 treatments. General Guidelines: Implement prevention protocol according to resident needs. Sensory Perception risk factor: watch for nonverbal cues, assess areas of body that do not feel pain for openings or redness. Activity: turn and reposition as needed using a person-centered approach (minimum every 2 hours), reposition in chair, provide appropriate pressure redistribution devices, teach resident to weight shift if appropriate, ensure proper body alignment. Mobility: turn and reposition as needed using a person-centered approach (minimum every 2 hours), provide appropriate pressure reducing devices. It continues, Under General Treatment Guidelines: 10. The staff nurse will notify the Wound Nurse upon identification of skin impairment. If Wound Nurse is not available, the staff nurse should document the open area on a Skin Screen Form and alert the Health Care Provider for treatment orders. Treatment Guidelines for Stage 2 Pressure Injuries: Turn and reposition as needed using a person-centered approach (minimum of every 2 hours).

Based on interview and record review the facility to monitor and prevent weight loss for one of two residents (R48) reviewed for weight loss in the sample of 33. This failure resulted in R48 having a slow insidious weight loss from March 2023 through July 2023 and a 12% weight loss since January 2023. Findings include: R48's Admission Record Sheet, printed on 8/1/23, documented R48 had diagnoses of Dysphagia following other Cerebrovascular Disease, Moderate Protein-calorie Malnutrition, Cerebral Infarction. R48's Care Plan initiated on 10/12/22, documented Tube feeding: Resident is a risk for complications of g-tube r/t dysphagia from CVA (stroke). R48's Care Plan Intervention, dated 10/19/22 documented monitor weights and labs as ordered and notify dr (doctor) of sig (significant) wt (weight) changes. R48's Electronic Health Record (EHR) documented R48 weighed 264.5 pounds (lbs.) on 11/25/22. R48's Physician Order, dated 12/15/22 documents Every shift Osmolite 1.2, 68ml (milliliter)/hr (hour). R48's EHR documented R48 weighed 255 pounds (lbs.) on 12/27/22, a 9 lb. weight loss in one month. R48's Dietary Nutrition at Risk Follow up dated 1/24/23 documents increase tube feeding to 68ml. R48's currently tube feeding order was Osmolite 1.2 68ml/hr and did not change. R48's EHR documented R48 weighed 245.5 lbs. on 1/31/23, a 9.5 weight loss in one month and 19 lbs. in two months. R48's Physician Order dated 2/21/23 documents Osmolite 1.2 320ml bolus every 4 hours. R48 remained NPO (nothing by mouth) at the time. R48's Nurses Note 2/21/23 Pt (patient) has had no issues with her g-tube. All medications, feedings, and flushes have flushed well. R48's EHR documented R48 weighed 248 lbs. on 2/28/23. R48's Dietary Nutrition at Risk Follow up dated 2/28/23 discontinue continuous feeding and started bolus. R48's Physician Orders dated 3/1/23 documented Osmolite 1.2, 320ml bolus q 4 hours. R48's March and April 2023 Physician's Order Sheet documents Osmolite 320ml Q 4hrs. R48's POS dated 5/5/23 documents Regular diet mechanical soft texture nectar thick liquids. R48's Physician Order Sheet (POS) dated 5/5/23 documents Enteral Feed Osmolite 1.2 320ml TID if resident eats less than 50% Enteral Feed. R48's Dietary Nutrition at Risk Follow up dated 5/5/23 Patient wants to eat will inquire about speech therapy. R48's Care Plan, revised 5/6/23, documented Tube feeding dc'd (discontinued) tube for free water flushes has been upgrade to mech altered diet and thickened liquids, wt. loss. The Interventions dated 5/5/23 documented diet as ordered mech altered with thickened liquids 5/5/23. R48's EHR documented R48 weighed 249.4 lbs. on 5/19/23. R48's Physician Order Sheet (POS) dated 6/1/23 documents regular diet puree texture nectar thick liquids. R48's EHR documented R48 weighed 237.4 lbs. on 6/5/23 which was over a 10 lb. weight loss in one month. There was no documented assessment to address R48's weight loss and there were no interventions to address this weight loss. On 7/26/23 documentation was requested as to how the facility was documenting if R48 was eating less than 50%. This was never provided. R48's EHR documented R48 weighed 235.6 lbs. 7/6/23 and then 215.8 lbs. on 7/27/23 which is a 20 lb. weight loss. R48's Nurse's Note dated 7/25/23 documents R48 noted with a 20-pound weight loss, and she remains on a pureed diet with nectar thick liquids. On 7/26/23 at 1:00 PM V24 Director of Nursing (DON) from another facility stated We reviewed her chart on 7/25/23, and a note was sent to the dietician for her case to be reviewed. She (R48) has had a 20-pound weight loss from January to July. R48's Dietary Evaluation dated 11/15/22 documents Current ht (height): 63 and wt. (weight): 264.5#; BMI 46.8 Wt. hx: 11/9 and 11/11 264.5# 10/19 277# 9/26- 296# 9/6- 292# 8/25- 290.5# 7/15- 268# 6/16- 251# 5/18- 246.5. Tube feeding Osmolite 1.5 continuous feeds at 55ml/hr provides total of 1320ml of feeding: 1980kcalorie (cal)/day and 82.8 g protein (PRO)/day. EEN: Calories: 2400-2770kcal/day (20-23kcal/kg (kilograms) BW body weight)) for weight moderation/maintenance Protein: 96-120g pro/day (0.8-1.0g/kg BW). Significant change of status/Readmission assessment. hospitalized ,d+[DATE]-[DATE] following CVA; returned on tube feeding d/t difficulty swallowing while in hospital. hospitalized again 10/24-11/9/22. Current ht: 63 and wt: 264.5#; BMI( basic metabolic index) 46.8. Resident had been triggering for significant weight gains just prior to CVA; now triggering for loss. Current tube feeding order: Osmolite 1.5 continuous feeds at 55ml/hr provides total of 1320ml of feeding; 1980kcal/day and 82.8 g pro/day. This order meets needs for weight moderation, as resident had previously displayed multiple triggers of significant weight gains. Resident tolerating tube feeding well at this time. Speech therapy will be working with resident to reinstate PO intake. Will continue on weekly weights while on tube feeding. Will continue to monitor and adjust tube feeding as necessary. On 8/1/23 at 1:45 PM V26 Registered Dietician stated, You know I'm trying to recall we had a different company now. I took over in March. She was a tube feeding then. I don't have access to her stuff. I think she lost weight from her hospitalization s. I usually put my recommendations in forms. The facility Policy entitled Weight Change Policy 9/2022 documents it is the policy of this facility to monitor the nutritional status of all residents, including all significant or trending patterns of weight change.

Based on observation, interview, and record review, the facility failed to notify a resident's family representative and physician of changes in condition for 2 of 3 residents (R40, R71) reviewed for changes in condition in the sample of 36. This failure resulted in R40's psychiatric decline and R71's exacerbation of heart and lung issues resulting in hospitalization . Findings include: 1. On 9/6/22 at 10:54 AM, R40 was sitting in the recliner in her room with her eyes closed. R40 was able to state her name but then had slurred, mumbled speech when answering questions, and was very difficult to understand. She stated she has only been in the facility a couple of days and had moved here because the last facility she lived in told her she had to leave because the administrator didn't want her there. R40 kept nodding off to sleep but would wake to try to answer questions. She appeared very lethargic and drowsy. Her hair was uncombed and general appearance disheveled. R40's Face Sheet documents her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's Minimum Data Set (MDS) dated [DATE] documents she was admitted to the facility on [DATE] and is alert and oriented. It also documents she did not have any delusions , hallucinations, or behaviors during that assessment period. R40's Care Plan dated 4/14/21 documents, Medication: (R40) uses antianxiety medications related to anxiety disorder. Is at risk for side effects. Interventions for this Care Plan include anti-anxiety medication as ordered. R40's Care Plan dated 4/16/21 documents, Behavior: (R40) has a history of anxiety and self-isolation. At risk for alteration in mood. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions for this care plan include medications as ordered. R40's Care Plan dated 9/3/22 documents: Elopement: At this time (R40) is experiencing delusions and hallucinations related to her mental illness. Interventions for this care plan include: 1:1 with staff as needed; 15-30 minute checks as needed; allow concerns to be expressed; encourage resident to keep busy with activities; MD notification as needed. R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (antipsychotic medication) 100 mg by mouth at bedtime with start date 6/8/21 and [MEDICATION(S)] 50 mg by mouth in the morning with a start date of 9/3/22. R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's Progress Notes dated 6/1/22 to 9/7/22 document she missed 18 doses of [MEDICATION(S)] 0.5 mg which was ordered to be given twice a day for anxiety. All the missed doses of [MEDICATION(S)] occurred between 6/20/22 and 7/26/22. On R40's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's Progress Notes document she did not receive her [MEDICATION(S)] 100 mg which was ordered to be given at 8:00 PM every night, on 8/6/22, 8/19/22 or 8/20/22. R40's Drug Record Book dated 6/1/22 to 9/30/2022 documents her [MEDICATION(S)] 100 mg was reordered on 8/27/22 and notes on that date, out, please send asap (as soon as possible). Review of R40's Progress Notes dated 6/1/22 to 9/7/22 does not document any behaviors until 9/4/22 at 4:46 AM when it documents, most of evening and night, resident up yelling and screaming. Very confused and talking about people and things from the past. no distress noted. Will continue to monitor. There was no documentation that family or physician was notified of R40's change in condition. R40's Progress note dated 9/3/22 at 8:52 AM documents, Resident very restless, walking from her room to nurses station to front lobby. Voicing delusional thoughts and difficult to redirect. Told this nurse, You are a bad nurse, you don't have any facts. I no longer live here. I was in Australia all last week. Resident's family reports that resident refusing to take their phone calls and denied knowing who her sister is when she came to see her this AM. V24 (Psychiatric Nurse Practitioner) aware of above. New order received. Resident placed on 15-minute checks for safety. On 9/8/22 at 9:30 AM, V2 (Director of Nurses/DON) provided R40's psychiatric progress notes dated 4/27/21, 2/4/22 and 5/25/22. She included a handwritten note that documents, (R40) verified with NP (Nurse Practitioner) 9/7 at 5:28 PM that R40 was last seen May 2022 and was not seen in June or July (did not mention August). The note documents she will see this month. May call (V24) to discuss. On 9/7/22 at 2:36 PM, V18 (LPN) stated R40 was moved yesterday. She stated R40 had been having some kind of [CONDITION(S)] V18 stated on the past Thursday, September 1st, R40 was delusional and saying that she needed to go to Washington DC, and she thought her sister had committed suicide and that her roommate had gotten inside her head and stolen all her memories and deleted them. V18 stated she did not know anything about R40 having fallen recently. On 9/7/22 at 2:38 PM, V19 (LPN) stated she was here last Thursday (September 1st) and saw changes in R40's behaviors. She stated R40 had missed one of medications for a couple of days because of problems with pharmacy, something about them not getting the order, or it was outdated. V19 stated today R40 was doing a lot better, but last night when she worked R40 was still not the same but did finally remember V19's name. V19 stated if they don't have a resident's medication, they notify the pharmacy to see what is going on. V19 stated if the medication is not a psych med, they notify the MD's nurse practitioner, but if it is a psych med, they notify V24 (psych nurse practitioner). On 9/7/22 at 2:45 PM, R40 was sitting in her room. Her speech was clear, and she was awake and alert. R40 stated, I couldn't sleep because I didn't have my medicine. They kept telling me it didn't come in from pharmacy. I haven't been sleeping good for 4 or 5 weeks, and I wasn't getting enough to eat. I felt like they were punishing me because (V1) doesn't want us to have Resident Council meetings and it's our right. I felt bullied by her. I am the resident council president and I have to look out for the residents here. She stated her parents are not her guardians, her husband is . She stated, You know, he is Hawkeye on MASH. She stated she goes out on Saturdays with her sister to eat and shop. She stated they wouldn't let her husband take her out. R40 stated she talks to her brother a lot on the phone, but he doesn't live around here. On 9/7/22 at 3:05 PM, V2 (DON), stated the facility had some problems with the pharmacy at the beginning of August when they went to a new system. She stated they went from the card system to having medications in individual plastic rolls, except high acuity medications, which were still on cards. V2 stated the first couple of weeks after the change they had a lot of problems because the pharmacy thought they still had the high acuity medication cards, but they had sent everything to the pharmacy and then did not get the high acuity meds back with the other meds. V2 stated R40 did miss her [MEDICATION(S)] 50 mg on September 3 but did get it as soon as it came in on September 4. V2 stated R40 had started getting a little manic, and the psychiatric nurse practitioner had ordered her to have [MEDICATION(S)] 50 mg every morning in addition to her current dose of [MEDICATION(S)] 100 mg at HS. V2 stated R40's brother had called and asked about her missing some medication. V2 stated he talked to V1 (Administrator) but she was unable to give him any information because he was not on R40's contact list. V2 stated when R40 had behaviors last week she had contacted R40's parents and sister on Thursday, August 1st and asked them to come and see her and help figure out what was going on with R40. V2 stated they came to see R40 on Saturday. V2 stated R40's sister does not see her often; she has only seen her visit a couple of times in the last year. V2 stated R40's parents are her guardians, but they are elderly and don't hear well so when staff call them, if they can't hear what is being said, they hang up. V2 stated R40's parents and sister have left specific instructions that they are not to give her brother any information regarding R40; he is to call either her parents or sister and they will let him know what they want him to know. V2 stated I called R40's sister and parents to inform them of her behaviors last week. I can show you on my cell phone where I called them. V2 then looked through her cell phone and stated, I must have used (V1's) cell phone because I can't find it on my phone. V2 stated when a medication is missed, if it is a psych med, they notify the psychiatrist because the medical doctor and his nurse practitioner will not do anything with psych meds. She stated the nurse usually notifies V24, the psychiatric nurse practitioner, with any psyche issues. She stated she does not think the psychiatrist has been in the facility for several months. On 9/7/22 at 3:50 PM, V16 (R40's brother) during phone interview, stated he had not talked to R40 about her missing medications, because he was on a zoom call when she tried to call him, but R40 had notified his niece, who is in medical school, by text, stating that she had missed some of her medication and was not sleeping. V16 stated R40, in her text message to his niece, stated the facility was giving her [MEDICATION(S)] and it was not helping her to sleep, and was asking if there was anything else that would help. V16 stated he called and tried to ask the administrator (V1) about R40 having missed medications, and she told him she is dealing with a state survey and has a funeral to attend and did not have time to talk to him. V16 stated he tried to set up a better time to discuss R40 but (V1) told him he was not on her contact list so she would not be able to talk to him. V16 stated he then asked if his sister (V17) could call and make the appointment and was told yes, she could. V16 stated R40's text to his niece indicated she had missed her medication for about a week. He stated R40 had been doing very well with no psychiatric setbacks for about [AGE] years and was usually very alert and oriented and well organized. V16 stated he had called and informed his sister about the text message R40 had sent to her niece about missing medication, so she went to see her on Saturday, which was the usual routine, and R40 was not her normal self. V16 stated he did not know of any falls or injuries that had occurred as a result of R40 not receiving all her medication, but he feels she has had a mental set back as noted by her change in behaviors and her lack of sleep. V16 stated he is worried about the facility retaliating against R40 because the family is complaining, but he stated he just wants to know what medication was missed, why it was missed and what is being done about it, so it doesn't keep happening because he knows her medications are very important to her stability mentally. On 9/7/22 at 5:15 PM, V17 (R40's sister) during a phone interview, stated she comes in every Saturday and takes R40 out of the facility for the day and they usually have lunch or dinner with their parents. V17 stated R40 is very alert and oriented and runs the Resident Council at the facility, and if she feels like she or any of the other residents are being mistreated, she will say something about it. V17 stated R40 usually calls her during the week to talk about what they are going to do on the Saturday when she comes to get her, but R40 did not call her last week, which was very unusual for R40. V17 stated nobody from the facility called her last week to tell her about R40 having behaviors, but when she arrived at the facility that Saturday morning, September 3, a staff met her at the door and stated she had meant to call her and warn her that R40 was having a lot of behaviors and was not acting like herself. V17 stated they told her R40 was yelling and cursing at the staff. She stated she went to R40's room and R40 yelled for her to get the f*#% out. V17 stated nobody from the facility had notified her or R40's parents that R40 was not receiving all of her medications. V17 stated her brother had called her with concerns because their niece had received a text message from R40 last week, telling her R40 was not getting her medications and could not sleep and wanted to know if she could tell her something that would help her because the [MEDICATION(S)] the facility was giving her was not working. V17 stated R40 knew her own medication very well and sometimes when she went on home visits, R40 would catch that they had forgotten to send one of her medications and would call up and tell them she needed it. V17 stated no one had given any directive to the facility to not release any information to R40's brother regarding her care. V17 stated he is not on her list because he lives out of state and it is easier to get in touch with her or her parents, but there is no reason he cannot call with concerns about her care. She stated R40 speaks to her brother on the phone often. V17 stated she feels the facility owes them an apology and an explanation of why some of R40's medications were missed and why they had not been informed of this or R40's change in behaviors and overall condition. V17 stated R40 has not had a psychotic break like this since 2005, and when it happened back then, it caused her to have to be institutionalized. V17 stated she knows R40 not receiving her medications could be very detrimental to her mental health. On 9/8/22 at 10:35 AM, V2 (DON), stated, I don't do medication error reports when medications are missed, only when the wrong medication is given. We don't do a medication error report, but we notify the doctor when a medication is missed. If the doctor was notified of the missed medication it is documented in the eMAR (Electronic Medication Administration Record) documentation progress notes. V2 stated she would expect physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/8/22 at 2:00 PM, V24 (Psychiatric Nurse Practitioner) stated the facility does sometimes send a fax or calls the office when a resident's medication is not available. V24 stated she was surprised when the nursing staff called about R40 having behaviors this past weekend. V24 stated staff reported to her that R40 was in the midst of the delusion of having a famous husband and was trying to run out of the facility to meet him. V24 stated she does not recall anyone reporting R40 missing 18 doses of [MEDICATION(S)] in July 2022 because that would have been pretty significant. V24 stated she would think the facility would contact the pharmacy right away and figure out what was going on so R40 would get her medications as ordered. V24 stated there is no reason R40 should have missed 18 doses of her [MEDICATION(S)] without the facility doing something about it. V24 stated she does not think that is related to R40's behaviors this past weekend, as R40 had been complaining of being tired and her [MEDICATION(S)] would have made her drowsier, not caused her to have behaviors. V24 stated they had been decreasing R40's [MEDICATION(S)] gradually over the past year, so missing a dose may cause her to have changes in her behaviors for a couple of days following the missed dose, but the missed dose a couple of weeks ago probably would not have affected R40's behaviors this past weekend. V24 stated she knows R40 very well and has been treating her for the past 5 years and stated R40 is normally very alert and oriented and is aware of her own care. V24 stated she would not be surprised if R40 remembers meetings she had 2 or 3 years ago. V24 stated she does not know what would have caused R40's behaviors last weekend but she did give an order to add [MEDICATION(S)] 50 mg QAM because they had decreased her dose quite a bit. On 9/8/22 at 7:00 PM, R40 was sitting in her room waiting on her medication and snacks. R40 stated she is feeling a lot better. R40 was noticeably more alert, and her speech was clearer than during previous encounters with her during the survey. She remembered this surveyors name. She stated she had missed her nighttime dose of [MEDICATION(S)] 3 nights last week and it was horrible. R40 stated, The didn't give me my [MEDICATION(S)] for 3 days and I couldn't sleep. I begged them to give me my meds and they told me pharmacy didn't bring them yet. I asked them to call my doctor and they told me they couldn't because he was on vacation. It was terrible. I felt like my eyelids wouldn't close. I cried because I knew I wasn't right, but I didn't know what to do. On 9/8/22 at 7:20 PM, during an off-hours portion of the survey, V19 (Licensed Practical Nurse/LPN) stated the facility is still using the same pharmacy since changing owners, but they reorder residents' medications differently. V19 stated they reorder a resident's medication through the electronic medical record but several times the medication has been reordered it doesn't show up with the delivery. V19 stated this has happened with R40's [MEDICATION(S)] more than once, but she knows she missed some doses last week, but doesn't know how many because she doesn't always work on the same hall. V19 stated she felt very bad about what R40 went through last week and the beginning of this week. V19 stated R40 got so bad mentally that she did not even know V19's name, and she stated R40 usually recognizes all the staff and her fell ow residents. V19 stated R40 was upset because she was afraid her changes were part of her illness and was afraid, she was getting worse, but V19 stated she reassured R40, when she was able to understand again, that her mental changes and behaviors were not her fault, and that it was the facility's fault because they did not get her [MEDICATION(S)] ordered on time. V19 stated she has worked with R40 for over a year, and this is the first time she has seen her have behaviors like these, and not recognize staff. V19 stated when R40 had missed doses of her [MEDICATION(S)] in the past it did not affect her this bad. V19 stated she talked to R40's sister when she came in and she told V19 that R40 had behaviors similar to these back in 2009 and that is what caused her to be institutionalized. On 9/9/22 at 8:45 AM, V31 (Pharmacist) stated R40's [MEDICATION(S)] 50 mg was ordered and processed on 9/2/22 and should have been delivered on 9/3/22. V31 stated she could not tell when R40's [MEDICATION(S)] 100 mg was ordered, but all the orders she has are old. V31 stated she could not tell exactly when the last [MEDICATION(S)] 100 mg was last sent to the facility and would have to check with someone else and will return call. On 9/9/22 at 12:00 PM, V31 (Pharmacist) stated they did receive the facility's request for a refill of her [MEDICATION(S)] on 8/27/22 but it was not sent because they needed a lab that is required before they can send [MEDICATION(S)]. V31 stated her records show the pharmacy has not refilled R40's [MEDICATION(S)] 100 mg since April 2022. V31 stated since April 2022, the only [MEDICATION(S)] that has been sent to facility for R40 was [MEDICATION(S)] 50 mg for her new order received on 9/2/22 for [MEDICATION(S)] 50 mg one every morning. On 9/9/22 at 12:15 PM, V2 (DON) and V23 (ADON) stated they were not aware R40 did not receive her [MEDICATION(S)] 100 mg from 8/27/22 until her [MEDICATION(S)] 50 mg was delivered on 9/4/22. V23 stated, I am the one who wrote on the order that we were out of (R40's) [MEDICATION(S)] and to please send it out. Both V2 and V23 stated they have given R40 her medications when they have worked the floor since April 2022, and they feel like she had her [MEDICATION(S)] 100 mg when they gave her medications. On 9/9/22 at 1:37 PM, V24 (Psychiatric Nurse Practitioner) during phone interview, stated R40 having missed her [MEDICATION(S)] 100 mg QHS would have directly caused her to have experience her changes in mental status resulting in her [CONDITION(S)] she experienced starting on 9/2/22 and she is continuing to have some [CONDITION(S)]. V24 stated R40 will most likely require a higher dose of [MEDICATION(S)] to get back to her baseline and it might take a while. V24 stated she will be assessing R40 next week and will be contacting the DON to get an update on R40. V24 stated it is very sad that R40 is going through this because she was doing so well and was very active in the facility before last week. 2. R71's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R71's Progress Notes dated 8/24/2022 at 4:36 PM documents, resident admitted to (local hospital) with dx (diagnosis) of exacerbation of [CONDITION(S)] and acute CHF. R71 had an additional Progress Note dated 8/24/2022 at 4:36 PM which documents, resident sats (saturates) at 95% on 2.5L (liters) O2 (oxygen) states she feels SOB (short of breath), abdominal breathing observed, wheezing auscultated. pulmonologist NP (Nurse Practitioner) here to see and assess resident, new orders received of [MEDICATION(S)] 500 mcg ( micrograms) and [MEDICATION(S)] inhaler that were just ordered and not available from pharmacy at this time. medical NP here to see and assess resident ordered to be sent to ER (emergency room ) per 911 for respiratory distress. EMS (Emergency Medical Services) arrived approx (approximately) 1305 (1:05 PM) to take over tx (treatment). Review of R71's Progress Notes dated 8/16/22 to current (9/9/22) includes documentation of R71's medications that were not available on these dates. There is no documentation that the facility notified the physician or nurse practitioner of the missed doses of medications on these dates: 8/17/22: [MEDICATION(S)], [MEDICATION(S)], Potassium Chloride, and [MEDICATION(S)] were not available 8/18/22: [MEDICATION(S)] and [MEDICATION(S)] were not available 8/19/22: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Guaifenesin, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Potassium Chloride, Vitamin D, and [MEDICATION(S)] were not available. 8/21/22: [MEDICATION(S)] was not available 8/22/22: [MEDICATION(S)] was not available (R71 was hospitalized at local hospital 8/24/22 to 8/25/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 8/26/22: Guaifenesin, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] was not available 8/29/22: [MEDICATION(S)] was not available 8/31/22: [MEDICATION(S)] was not available 9/1/22: Incruse Ellipta not available 9/3/22: [MEDICATION(S)] not available 9/7/22: Incruse Ellipta not available. R71's Hospital Discharge Summary dated 8/25/22 documents her admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/9/22 at 12:37 PM R71 stated she does not know why she did not get her medications when she was first admitted and thinks that was the reason she had to go back to the hospital. R71 stated it scares her when she doesn't get her medications because she has heart and breathing problems. She stated the nurses said it was not their fault that her medications were not here; it was because of pharmacy. On 9/9/22 at 12:40 PM, V38 (Pulmonary Nurse Practitioner) stated she was not notified by the facility that R71 was not receiving her medications as ordered. After reviewing the medications R71 had missed since her admission on 8/16/22 until 9/7/22, V38 stated R71 having missed those medications definitely would have caused her to have an exacerbation of her [CONDITION(S)] and CHF and caused her to be sent to the hospital. V38 stated she had seen R71 on 8/24/22, the day she was sent to the hospital, and noted she was short of breath, but she had just finished with therapy, so she thought R71 was just needing to recover from that. V38 stated the Primary Nurse Practitioner called her later that day and told her R71 was continuing to be short of breath and lethargic and they made the decision to send her to the emergency room for evaluation. V38 stated the facility did not notify her that R71 was not receiving all of her medications and that would have absolutely been something they should have reported to her so she could follow up with the pharmacy to determine the estimated time of delivery of the medications. She stated R71's diuretics and inhalers are very important medications for her to receive because of her [CONDITION(S)] and CHF diagnoses. The facility's policy, Change in Resident's Condition with the review date of 9/2022, it documents, General: It is the policy of the facility, except in medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: it continues, b. There is a significant change in the resident's physical, mental, or emotional status. and e. It is deemed necessary or appropriate in the best interest of the resident.

A. Based on observation, interview and record review the facility failed to provide adequate supervision, assess, and investigate for the root cause of falls, and implement progressive interventions to prevent further falls for 1 of 4 residents (R42) reviewed for accidents in the sample of 36. This failure resulted in R42 having 32 falls from 1/2022 through 9/8/2022, 6 of which required R42 to be transported to the emergency room for right knee fracture, right hand fracture, staples to R42's head, and 2 concussions. B. Based on observation, interview and record review the facility failed utilize safe equipment to propel residents for 1 of 4 residents (R2) reviewed for safe equipment to provide locomotion in the sample of 36. Findings include: A. R42's Undated Face Sheet documents she was admitted to the facility on [DATE]. R42's Face Sheet documents diagnoses of history of falling, [CONDITION(S)], difficulty walking, seizures, [CONDITION(S)] disorder and [CONDITION(S)] disorder. R42's Referral form from a local group home, dated 6/7/2021 documents she was at risk for falls. The referral form documents R42 ambulated with a wheeled walker with minimum assist of 2 staff for balance, weakness, and safety. The Referral Form documented R42 needed assistance with ADLs (activities of daily living). The Referral Form documented interventions in place included call light within reach, bed in lowest position, bed wheels locked and a bed alarm. The Referral Form documented the group home staff documented R42 whereabouts every 2 hours. R42's Admission Fall Risk Assessment, dated 6/15/2021 documents she was high risk for falls. The Fall Risk Assessment documented she had 3 or more falls in the last 3 months, assess the resident's gait/balance, have him or her stand on both feet without holding onto anything; walk straight forward; walk through a doorway; and make a turn: N/A not able to perform function adequate vision and intermittent confusion. R42's medical record documented R42 had falls on following dates with no major injuries: 1/20/2022 no injury, 2/4/2022 no injury, 2/11/2022 no injury, 2/4/2022 laceration to nose, 2/16/2022 no injury, 2/22/2022 abrasion right knee, 2/23/2022 no injury, 2/26/2022 no injury, 3/6/2022 no injury, 3/8/2022 no injury, 3/9/2022 no injury, 3/10/2022 no injury, 3/13/2022 no injury, 3/15/2022 no injury, 3/18/2022 no injury, 3/19/2022 blood coming from her nose, large hematoma to left eye, bruise on right wrist, 3/31/2022 no injury, 5/20/2022 no injury, 5/22/2022 no injury, 5/23/2022 no injury, 5/28/2022 no injury, 6/5/2022 steri-strips right forehead, 6/14/2022 no injury, 6/22/2022 no injury, 6/23/2022 no injury, 6/29/2022 no injury, 7/26/2022 no injury, 7/28/2022 no injury, 7/30/2022 no injury, 8/21/2022 abrasion to left knee and elbow and 8/23/2022 bruise right side of face and lump on right forehead. R42's Quarterly Minimum Data Set (MDS), dated [DATE] documents she is alert and needs supervision/setup help only with bed mobility, transfers, personal hygiene and walk in room. Independent/setup help only with locomotion on and off unit. R42's MDS documents R42 requires staff dressing limited assist with one-person physical assist for dressing, and extensive assistance one-person physical assist with toileting. R42's MDS documents R42 is not steady, but able to stabilize without staff assistance for moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet, surface-to-surface transfer (transfer between bed and chair or wheelchair). R42's MDS documents R42 utilizes a walker and wheelchair. R42's MDS documents R42 had 4 falls including 2 with no injury and 2 with injuries except major. R42's Nurse's Note, dated 1/11/2022 at 6:26 AM documents R42 fell in room between bed and dresser. The Nurse's Note documented R42 busted her head-on right-side ear level. R42's Nurse's Note documented she was able to move extremities and sat herself up. The Nurse's Note documented R42 stated she don't want to be on this covid unit and wait until her family hears about her being on unit. R42's Nurse's Note documented at 6:45 AM Emergency Medical service (EMS) called and R42 left facility to local hospital via ambulance at 7:00 AM. The Nurse's Note documented R42's sister was called, and the Assistant Director of Nurses (ADON) was notified and called report to local hospital. R42's Hospital Paperwork, dated 1/11/2022, documents reason for visit was a fall. R42's Hospital Record documented R42 had diagnoses of fall, closed nondisplaced fracture of right patella (knee), concussion with loss of consciousness of 30 minutes or less and acute [MEDICATION(S)] (inflammation of the bladder) without hematuria (bloody urine.) R42's Care Plan, dated 1/11/2022 documents post fall intervention cardiologist consultation as she allows. The Care Plan did not document any staff interventions to provide R42 with increased supervision. R42's Nurse's Note, dated 1/15/2022 at 5:11 PM, documents took residents out to smoke at 4:00 PM. The Note documented Upon entering building heard resident scream. 4:05 PM entered room resident lying face down on floor. Assessed resident she has hematoma on right eye, laceration on nose, and swollen right wrist. Resident was laughing and stated she was upset over TV not working. 4:15 PM Called 911. B/P (blood pressure) 158/92, T (temperature) 97.8, P (pulse) 94, O2 (oxygen saturation) 98% RA (room air), R (respiration) 24. 4:35 PM EMS arrives and picks up resident going to local hospital. 4:40 PM DON (Director of Nurses) called, 4:45 PM NP (nurse practitioner) called, 4:50 PM POA (power of attorney) called. R42's Nurse's Note, dated 1/15/2022 at 8:19 PM documents, R42 returned to facility from local hospital. The Note documented Resident RT (right) orbital/eye swollen shut, purple in color. Sutures noted to RT eyebrow. RT hand had splint and wrapped. Resident has nasal fracture, metacarpal bone fracture, metacarpal neck, 2nd thru 5th. Eyebrow laceration which was sutured. Orders to f/u (follow up) with physicians Resident was alert and not complaining of any pain. Resident assisted into her bed and instructed her to use call light for assistance. R42's Hospital Paperwork, dated 1/15/2022, documents reason for visit, fall. The Hospital records documented Diagnoses metacarpal (hand) bone fracture, metacarpal neck, 2nd through 5th, nasal fracture and facial laceration. R42's Care Plan, dated 1/15/2022 documents post fall intervention discuss behaviors with her as she allows, moved closer to the nurse's station, referred for cardiologist re-visit and seen by cardiologist. R42's Medical Practitioner Late Entry Note (Physician/NP), dated 1/18/2022 at 9:51 AM documents Will continue to monitor falls and attempt to gather additional information from the patient about the falls. Will order tilt table test to assess for [CONDITION(S)] Continue to monitor. R42's Medical Practitioner Late Entry Note (Physician/NP), dated 2/22/2022 at 7:18 AM, documents Tilt table test for [CONDITION(S)] pending, most recent fall occurred on 2/20/2022, no loss of consciousness reported. Continue to monitor. R42's Medical Practitioner Late Entry (Physician/NP), dated 3/8/2022 at 10:53 AM, documents Unable to obtain tilt table test due to no local hospitals performing them. R42's Nurse's Note, dated 4/12/2022 at 12:04 PM documents Call to local hospital ER (emergency room ) to check up on res. Received info that res has closed nasal FX (fracture) but stable. Blood work pending and res to be discharged back to facility at that time. R42's Hospital After Visit Summary, dated 4/12/2022 documents R42 fell and sustained closed fracture of nasal bone. R42's Hospital Paperwork, dated 4/12/2022, document diagnoses of fall, closed fracture of nasal bone and [CONDITION(S)]. R42's Nurse's Note, dated 4/12/2022 has no documentation R42 fell or that she was transferred to the hospital. R42's Care Plan, dated 4/12/2022 documents post fall intervention out to ER for evaluation. Referred to ENT (ear/nose and throat physician). R42's Medical Practitioner (Physician/NP) Late Entry Note, dated 4/19/2022 at 5:29 AM documents Since last visit, patient has had an additional fall which required hospitalization and surgery for a nasal fracture. R42's Nurse's Note, dated 4/19/2022 at 6:15 PM documents R42 was found face down in room by bed. The Note documents R42 was bleeding from nose and lump to front mid forehead. The Note documented Resident c/o (complaint of) pain to right arm during ROM (range of motion). NP notified and ordered resident to be sent to ER for eval and tx (treatment.) Resident agreed to go to ER after three attempts. Family called to make aware with no answer. Message left to call facility back. EMT arrived at approximately 6:10 PM to transport resident. R42's Hospital After Visit Summary, dated 4/19/2022, documents she sustained a closed fracture of nasal bone and a right forearm contusion. R42's Hospital Paperwork, dated 4/27/2022 documents chart review pt (patient) presented to hospital on 4/19/2022 for evaluation after a fall. Imaging showed bilateral mildly displaced nasal bone fractures. R42's Care Plan, dated 4/19/2022 documents post fall intervention ER visit with f/u (follow up) radiology as indicated. No injuries noted. The Care Plan documented Camera review completed. Resident stood fell forward bending at knees prior to falling to floor. No hazards or issues observed. Lost balance when she stood up quickly from seated position on bed. Education provided on carefully/slowly changing positions. Resident agreed to allow staff to attempt to set up neurology apt (appointment). Resident agrees to hospital. R42's Nurse's Note, dated 4/27/2022 at 12:20 PM documents Heard res yelling out and noted her laying face down in her BR (bathroom) in front of her toilet with her pants halfway up. Large pool of blood under res head. Pressure held to laceration to R (right) hairline and position safely maintained. Call to 911. NP, DON and res family notified of above. R42's Hospital ED report, dated 4/27/2022 documents Resident arrived via EMS from nursing home for evaluation after a fall today. Pt (patient) states she was using the bathroom and when she was trying to pull up her pants, she had a syncopal (to faint) episode in which she fell forward, hitting her head on the ground. Pt states she 'blacked out' for 2-3 seconds. She notes a laceration to the anterior aspect of her scalp and states she noted blood on the floor of her home. She states her roommate called EMS (emergency medical services). The Record documented R42 received 6 staples to scalp. R42's Care Plan, dated 4/27/2022 documents post fall intervention out to ER laceration to forehead treated. Refused therapy screen and orthostatic v/s (vital signs) refused. Continue at risk interventions, evaluate cause of falls, neuro checks per policy and staples to right scalp. The Care Plan did not address R42's need for increased supervision. R42's Nurse's Note, dated 5/7/2022 at 4:38 PM documents Called to room by CNA (Certified Nurse's Aide). Resident noted on floor beside bed in prone position bleeding noted from scalp wound above middle of forehead. states 'don't know what happened I blacked out.' Pressure dressing applied refused vitals to be taken refused neuro checks ambulance called. R42's Nurse's Note, dated 5/7/2022 at 9:25 PM documents Hospital ER called resident is returning dx concussion and with staples. R42's Hospital Paperwork, dated 5/7/2022 documents Patient presenting via EMS for [CONDITION(S)] and ground level fall. Prior to presentation patient states that she got up, lost consciousness and woke up on the ground. Per EMS report patient fell down on her knees then fell headfirst into the tile floor. Patient regained consciousness within seconds. Was alert oriented immediately afterwards. Apparently, patient has a long history of [CONDITION(S)]. Additionally, patient had staples removed from her forehead today no which were used to fix an injury due to a similar event about a week ago. She lacerated her head in the same place. Hemostatis noted. ED provider notes documents there is a vertical laceration on the right side in the hairline extending into the forehead measuring approximately 7 cm (centimeters.) 6 staples were used to suture the laceration. R42's Nurse's Note, dated 5/7/2022 at 10:50 PM documents Resident returned from hospital via ambulance. Ambulated to bed with 2 assist. Resident refused to have vital signs taken. Staples intact to left upper forehead. Small trickle of blood noted. Paramedics stated they attempted to wipe her face, but she refused. She also refused from me. Resident denies headache or dizziness. Resident is able to move all extremities. Call light within reach. R42's Care Plan, dated 5/7/2022 documents post fall intervention IDT (interdisciplinary team) review completed and w/c seat dumped to provide for safety. The Care Plan documents the following interventions: Encourage her to leave her door open so we can observe her, neuro checks as she allows, out to ER, review camera footage for cause of fall and wheelchair dumped. R42's Medical Practitioner (Physician/NP) Late Entry Note, dated 5/17/2022 at 12:41 PM documents patient continues to have falls, cardiac work-up has been negative, continue to monitor. R42's Medical Practitioner (Physician/NP) Late Entry Note, dated 6/14/2022 at 7:53 PM documents Patient continues to have falls, cardiac work-up has been negative, continue with [MEDICATION(S)] 5 mg (milligrams) PO (by mouth) 3 times a daily to prevent orthostatic [CONDITION(S)] and continue to monitor. Observation of R42's room on 9/8/2022 at 2:00 PM showed quarter side rails on her bed, nonskid strips on the side of the bed located toward the door. On 9/7/2022 at 3:30 PM R42 stated she doesn't know why she keeps falling, she just blacks out. R42 stated she lets staff assist her with care and she doesn't ambulate on her own. R42 stated she walks with a walker with assistance of staff. R42 stated she goes to the bathroom in her room independently. R42 stated she hasn't changed rooms or wheelchairs recently. She wears a padded headband to protect her head when she falls. R42 stated she's never fell out of bed. On 9/7/2022 at 1:00 PM V19 (Licensed Practical Nurse/LPN) stated (R42) just keeps falling and there is nothing we can do about it. She refuses assistance. On 9/8/2022 at 12:20 PM V5, (Registered Nurse/RN) stated (R42) has probably set a record for falls. (R42) seems to fall a lot in her bathroom after having a large bowel movement and she has educated her to stand up slowly and hold onto the grab bar after when getting up. (R42) has no safety awareness. She recalled she removed staples from (R42's) forehead in May 2022 and the same day she fell again and had to get staples again in the same place. On 9/9/2022 at 9:52 AM V33 (Nurse Practitioner/NP) stated she wouldn't answer questions regarding why R42 has had so many falls. V33 stated to talk to V32, R42's Physician. V33 stated she expected the facility to follow the fall policy and to have progressive interventions after each fall because that is the expectation. On 9/9/2022 at 10:07 AM V32 stated he have to look at (R42's) medical record to see what the medical reason why she is falling so much. V32 stated he was aware (R42) having a lot of falls, he expected staff to document the falls and to follow the facility's fall policy and to have progressive interventions in place after each fall. On 9/9/2022 at 11:40 AM V36 (Physical Therapist/PT) stated she started working at the facility in March 2022. V36 stated (R42) is a very difficult resident because she falls a lot, and no one knows what the medical cause. (R42) is alert and propels herself in her wheelchair. Her understanding was (R42) falls in her bathroom a lot. (R42) has received PT and occupational therapy (OT) when she is willing to participate. On 9/7/2022 at 2:00 AM V2 (Director of Nursing/DON) stated she has a line listing of all R42's fall with interventions the facility put in place after each fall. V2 stated (R42) has fell 32 times in 2022. V2 stated she doesn't know why R42 falls so much; it could be behavioral she may throw herself out of her wheelchair. V2 stated (R42) refuses ADL care from staff and she doesn't want assist with anything. She self-propels about the facility in a wheelchair. She falls a lot in her bathroom. Staff placed a camera in her room, and she reviews it for post fall assessment (R42) often stands up and falls. On 9/8/2022 at 2:00 PM V1 (Administrator) stated she knew R42 called 911 many times and had multiple times prior to being admitted to the facility. V1 stated staff have done everything they felt they can for R42. She didn't know what else to do to stop R42 from falling. The facility's Fall Prevention and Management Policy, revised 10/2018, documents This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Upon admission a fall risk evaluation will be completed on admission, readmission and quarterly, significant change and after each fall. 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. Evaluate the resident for any injury and notify the physician and emergency contact. Complete a fall incident report in the PCC (Point Click Care) risk management portal. A fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less than 10 indicates at risk for fall. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. Complete the follow-up monitoring from every shift for 72 hours. All incident and accident with serious physical injury will be reported to IDPH (Illinois Department of Public Health) within 24 hours. A full written investigative report is required by IDPH within five (5) days of the incident. B. R2's Face sheet documents on 9/6/2022 a weight of 288 pounds. On 9/7/2022 at 10:32 AM, R2 was in a large shower chair on the VVV hall and was being pushed by V22 (Certified Nursing Assistant/CNA), and V27 (Maintenance Director). V27 was bending over and was grabbing the bottom of the chair and was pulling R2 down the hallways while bending down the entire time all the way down from the VVV-hall to the end of the YYY-hall. The large shower chair did not have any wheels in the front of the chair and the white pipes where the wheels had detached were brown in color and there were two wheels on the back of the chair. On 9/7/2022 at 10:39 AM, V27 stated, The wheels are no longer on the chair because they rusted out or rather the bolt broke. I am looking into fixing it. On 9/27/2022 at 11:01 AM, R2 stated, The shower chair has been broken for several weeks and it has been like that for a while now with the missing wheels. On 9/8/2022 at 4:02 PM, V2 (Director of Nursing) stated, I would not expect any staff to transfer residents in shower chairs down the hall with no wheels in the front or not in working order. I heard about the chair not having wheels yesterday. The Fall Prevention Policy dated May 2015 documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible.

Based on observations, record review, and interviews, the facility failed to assess, monitor, and implement progressive interventions to prevent weight loss for one of one resident (R62) reviewed for nutritional needs and the sample of 36. This failure resulted in R62 having a significant weight loss of 24 pounds (lbs. and/or 12.9%) in six months. Findings include: On 09/06/2022 at 12:23 PM R62's head of bed was up 30 degrees for lunch. V14 (Certified Nurse Assistant/CNA) did not raise the head of the bed up any further for R62 to eat his lunch. R62 was frail, thin, and pale. R62's bedside table was approximately six feet away from his bed. A water cup and the lunch meal were sitting on the bedside table. The bedside table was out his reach. R62's lunch consisted of two hamburgers on a bun, potato chips, brownie, and milk in a carton with a straw. V14 handed R62 his hamburger which she had broken apart in quarter sizes. V14 handed R62 a quarter size of his hamburger each time she handed the hamburger to R62 until R62 consumed both hamburgers. V14 gave him a drink of milk. V14 stated, He won't eat his chips. R62 stated, I will eat my chips. V14 handed him his chips, and she laid some chips on his bed where he picked the chips up and ate them. V14 handed the milk to R62, and he drank 100% of his milk. V14 stated He won't eat the brownie he doesn't like the consistency or texture. Immediately R62 stated, I will eat my brownie. I like brownies. V14 then handed him his brownie and he ate the brownies. No fluids were offered after R62 ate his brownie. There were no noted house supplements, or ice cream on his meal tray. R62 stated Thank you each time he was handed his hamburger, chips, and milk. At the end of the meal V14 stated, I better raise the head of the bed up more. She then raised the head of bed to 45 degrees. On 9/08/2022, at 11:30 AM R62 was up in his tilted back wheelchair sitting in the dining room for lunch. R62's meal tray consisted of two hamburgers, potato chips, brownie, ice cream, 8-ounce glass of water. R62 was not given his house supplements, health shake, or milk that was documented on his meal ticket. V14 tore one hamburger apart and handed the torn hamburger to R62. He proceeded to eat the hamburger and ate 100% of the first hamburger, then R62 picked up the second hamburger that had not been torn or cut apart. R62 ate 100% of his hamburger. V14 handed him a cup of water. R62 drank 100% of his water. R62 then picked up his potato chips and started to eat the chips. He ate 100% of the chips. V14 went to get R62 a glass of (flavored drink) then handed him his (flavored drink) he drank 100% of his (flavored drink) without a straw. V14 fed R62's ice cream at times to him. At times, R62 would feed himself the ice cream, he was using a plastic spoon which he had difficultly scooping up the ice cream from the cup, he ate 100% of his ice cream. R62 stated, I am still hungry, he was supposed to have gotten hot dogs for lunch. (R62) stated, I would like to have hot dogs. V14 stated, we are out of hot dogs, she offered a peanut butter and jelly sandwich. They brought him a peanut butter and jelly sandwich. R62 picked up the sandwich and ate 100% of his sandwich. No other fluids were offered after he ate the peanut butter and jelly sandwich. No house supplements, health shake was noted on the meal tray. V14 stated, We are done, and wheeled R62 out of the dining room. R62's weights were reviewed and documents on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .), 1/6/2022 at 182 lbs., 2/4/2022 at 174 lbs., 3/7/2022 at 175 lbs., 5/1/2022 at 161 lbs., and 9/6/2022 at 158 lbs. There were no weights for R62 documented for the following months 04/2022, 06/2022, 07/2022, and 08/2022. From 12/2021 through 5/1/22, R62 experienced a 24 lbs. (12.9%) weight loss. R62's Minimum Data Set (MDS) dated [DATE], documents a BIMS score of 99, severely impaired cognition. R62's MDS documents he is totally dependent upon staff for eating. The MDS did not document R62 had a weight loss. The MDS documented R62's weight as 161 lbs. R62's Note Text Nutrition Assessment Weight Warning written by V40 (Registered Dietician), dated, 03/07/2022, document R62's current body weight was 175 lbs. The Note documented R62's weight indicates stability in the last two months, but overall loss as previously noted. The Note documented the following dates and weight history: 2/4/2022 176 lbs. 12/6/2021 185 lbs., and 9/3/2021 200 lbs. indicating a 12% loss of weight. The Note documented R62 remains on regular thin liquids with milk all meals, ice cream with lunch/dinner. Intake >/=50% now, improved. The Note documented a (nutritional supplement ice cream) and (nutritional supplement drink) previous added, but reported to refuse (nutritional supplement drink), appropriate to discontinue. The Note documented reported improved intake and self-assist when finger type foods offered, stability at current weight desired. The Note documented to recommend discontinue (nutritional supplement ice cream) as ordered, continue ice cream for lunch/dinner, discontinue (nutritional supplement drink) as ordered refusing and overall, with improved intake at meals, offer finger type foods, when possible, monitor weight, will follow. There was no documentation a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R62's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . GI soft, house supplement with all meals for diet order. R62's form, (Requests for Diet Change) dated, 05/04/2022, documents add super cereal and fortified pudding at lunch. Will follow. There was no documentation noted in Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R62's Dietary Notes dated 08/01/2022, documents Nutrition assessment: Resident with unintentional weight loss related to hospitalization s, inadequate oral intake, as evidenced by 15 lbs. weight loss in 6 months, 8.5 %. Recommend: continue soft diet as tolerated, monitor swallowing, add house supplement with meals, obtain a new weight (last weight taken 5/1/2022), encourage PO (by mouth) intake and offer snacks, will monitor tolerance to supplements, PO intakes, and weight. R62's Care Plan dated 09/06/2022, documents (R62) is at risk for complications with weight and nutrition r/t (related to) need max assist -total assist with eating most of the time now. R62's Care Plan Goal documented R62 will consume adequate nutrition and weight to remain stable throughout next review. R62's Care Plan interventions, dated 9/6/22, document assist feed resident with meals as needed, document signs and symptoms of chewing/swallowing problems, monitor weight and labs, notify MD, RD, of any significant weight changes, offer substitutes for uneaten foods, RD to assess and recommend as needed, serve diet as ordered. R62's Meal ticket dated, 09/09/2022, documents, breakfast diet regular, diet texture regular, needs up for all meals NAS (No added salt), high protein meals. Soft food, resident has no teeth. Adaptive equipment paper products. Lunch diet regular, diet texture regular, needs up for all meals NAS high protein meals. Soft foods, resident has no teeth. Supper documents diet regular, diet texture regular, needs up for all meals NAS high protein meals, soft foods, resident has no teeth. On 09/09/2022 at 9: 04 AM, V4 (Dietary Manager) stated, (R62) was asked what he wanted for lunch this morning for 09/09/2022. V4 said, (R62) requested two grilled cheese sandwiches. (R62) wants what is on the regular menu for supper V4 (Dietary Manager) stated, (R62) did not get his hot dogs yesterday for lunch that he requested because we ran out of hot dogs and it will be several days before the hot dogs will be delivered, so, we just gave him hamburgers. V4 stated, (R62) told me during lunch he really wanted the hot dogs. On 09/09/2022 at 9:10 AM V4 gave surveyor another meal ticket that R62 did not have on his table yesterday for 09/08/2022 that did not match up with the meal ticket given to surveyor this morning. meal ticket. R62's meal ticket documented on 9/8/2022 needs up for all meals, NAS, House Supplements with all meals, Health Shake 8 fl ounces, Milk 8 fluid ounces, and Ice Cream for lunch and dinner. V4 stated, They changed these meal tickets last night in the office. On, 09/06/2022 at 10:02 AM, V3 (Registered Nurse/RN), stated, We feed (R62) in his room we don't get him up because he fights the staff, and curses staff. On 09/06/2022 at 10:30AM, V2 (Director of Nursing/DON), stated, We had (R62) losing weight because he was too big. On 09/08/2022 at 2:00PM, V2 stated, Not sure why (R62's) weights were not done during the months of April, June, July, and August of 2022. V2 stated, not sure what happened. On 09/08/2022 at 2:10PM, V2 said, I would expect the staff to be checking the meal tickets before giving the tray to the resident to make sure the correct diet was being served. V2 stated, I would expect the staff to give what is ordered, or on the meal tickets for any supplements. On 09/09/2022 at 11:48 AM V40 (Dietician) said, (R62's) weight loss was significant. V40 stated she not aware that four months of weights were not gotten. V40 stated that she would expect what is recommended on the nutrition assessment and signed off by the MD to be followed. V40 stated she would expect the meal tickets to be correct based on the diet orders, and any supplements be given and on the meal tickets. V40 stated she expect R62 having a weight loss a monthly weight be gotten, and sometimes more often. V40 stated I haven't been to that facility since July 2022. Weight Change Policy review date, 09/2022 documents General: It is the policy of this facility to monitor the nutritional status of all residents, including all significant or trending patterns of weight change.

Based on observation, interview and record review, the facility failed to ensure residents are free from significant medication errors for two of 7 residents (R40, R71) reviewed for medication in the sample of 36. This failure resulted in R40 experiencing acute psychotic episode due to not receiving her antipsychotic medication as ordered, and R71 being hospitalized with an exacerbation of her [CONDITION(S)] ([CONDITION(S)]) and CHF (Congestive Heart Failure) after not receiving her cardiac and respiratory medications. Findings include: 1. On 9/6/22 at 10:54 AM, R40 was sitting in the recliner in her room with her eyes closed. R40 was able to state her name but then had slurred, mumbled speech when answering questions, and was very difficult to understand. She stated she has only been in the facility a couple of days and had moved here because the last facility she lived in told her she had to leave because the administrator didn't want her there. R40 kept nodding off to sleep but would wake to try to answer questions. She appeared very lethargic and drowsy. Her hair was uncombed and general appearance disheveled. R40's Face Sheet documents her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's Minimum Data Set (MDS) dated [DATE] documents she was admitted to the facility on [DATE] and is alert and oriented. It also documents she did not have any delusions, hallucinations, or behaviors during that assessment period. R40's Care Plan dated 4/14/21 documents, Medication: (R40) uses antianxiety medications related to anxiety disorder. Is at risk for side effects. Interventions for this Care Plan include anti-anxiety medication as ordered. R40's Care Plan dated 4/16/21 documents, Behavior: (R40) has a history of anxiety and self-isolation. At risk for alteration in mood. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions for this care plan include medications as ordered. R40's Care Plan dated 9/3/22 documents: Elopement: At this time (R40) is experiencing delusions and hallucinations related to her mental illness. Interventions for this care plan include: 1:1 with staff as needed; 15-30 minute checks as needed; allow concerns to be expressed; encourage resident to keep busy with activities; MD (medical doctor) notification as needed. R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (antipsychotic medication) 100 mg by mouth at bedtime with start date 6/8/21 and [MEDICATION(S)] 50 mg by mouth in the morning with a start date of 9/3/22. R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's Progress Notes dated 6/1/22 to 9/7/22 document she missed 18 doses of [MEDICATION(S)] 0.5 mg which was ordered to be given twice a day for anxiety. All the missed doses of [MEDICATION(S)] occurred between 6/20/22 and 7/26/22. On R40's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's Progress Notes document she did not receive her [MEDICATION(S)] 100 mg which was ordered to be given at 8:00 PM every night, on 8/6/22, 8/19/22 or 8/20/22. R40's Drug Record Book dated 6/1/22 to 9/30/2022 documents her [MEDICATION(S)] 100 mg was reordered on 8/27/22 and notes on that date, out, please send asap (as soon as possible). Review of R40's Progress Notes dated 6/1/22 to 9/7/22 does not document any behaviors until 9/4/22 at 4:46 AM when it documents, most of evening and night, resident up yelling and screaming. Very confused and talking about people and things from the past. no distress noted. Will continue to monitor. There was no documentation that family or physician was notified of R40's change in condition. R40's Progress note dated 9/3/22 at 8:52 AM documents, Resident very restless, walking from her room to nurses station to front lobby. Voicing delusional thoughts and difficult to redirect. Told this nurse, You are a bad nurse, you don't have any facts. I no longer live here. I was in Australia all last week. Resident family reports that resident refusing to take their phone calls and denied knowing who her sister is when she came to see her this AM. (V24 Psychiatric Nurse Practitioner) aware of above. New order received. Resident placed on 15-minute checks for safety. On 9/8/22 at 9:30 AM, V2 (Director of Nursing/DON) provided R40's psychiatric progress notes dated 4/27/21, 2/4/22 and 5/25/22. She included a handwritten note that documents, (R40) verified with NP (Nurse Practitioner) 9/7 at 5:28 PM that (R40) was last seen May 2022 and was not seen in June or July (did not mention August). The note documents she will see this month. May call (V24) to discuss. On 9/7/22 at 2:36 PM, V18 (Licensed Practical Nurse/LPN) stated R40 was moved yesterday. V18 stated R40 had been having some kind of [CONDITION(S)]. V18 stated on the past Thursday, September 1st, R40 was delusional and saying that she needed to go to Washington DC, and she thought her sister had committed suicide and that her roommate had gotten inside her head and stolen all her memories and deleted them. V18 stated she did not know anything about R40 having fallen recently. On 9/7/22 at 2:38 PM, V19, LPN, stated she was here last Thursday (September 1st) and saw changes in R40's behaviors. V19 stated R40 had missed one of medications for a couple of days because of problems with pharmacy, something about them not getting the order, or it was outdated. V19 stated today R40 was doing a lot better, but last night when she worked R40 was still not the same but did finally remember V19's name. V19 stated if they don't have a resident's medication, they notify the pharmacy to see what is going on. V19 stated if the medication is not a psych med, they notify the MD's nurse practitioner, but if it is a psych med, they notify V24 (psychiatric nurse practitioner.) On 9/7/22 at 2:45 PM, R40 was sitting in her room. Her speech was clear, and she was awake and alert. R40 stated, I couldn't sleep because I didn't have my medicine. They kept telling me it didn't come in from pharmacy. I haven't been sleeping good for 4 or 5 weeks, and I wasn't getting enough to eat. I felt like they were punishing me because V1 (Administrator) doesn't want us to have Resident Council meetings and it's our right. I felt bullied by her. I am the Resident Council President and I have to look out for the residents here. She stated her parents are not her guardians, her husband, (television actor) is. She stated, You know, he is Hawkeye on MASH. She stated she goes out on Saturdays with her sister to eat and shop. She stated they wouldn't let her husband take her out. R40 stated she talks to her brother a lot on the phone, but he doesn't live around here. On 9/7/22 at 3:05 PM, V2 (Director of Nursing /DON), stated the facility had some problems with the pharmacy at the beginning of August when they went to a new system. V2 stated they went from the card system to having medications in individual plastic rolls, except high acuity medications, which were still on cards. V2 stated the first couple of weeks after the change they had a lot of problems because the pharmacy thought they still had the high acuity medication cards, but they had sent everything to the pharmacy and then did not get the high acuity meds back with the other meds. V2 stated R40 did miss her [MEDICATION(S)] 50 mg on September 3 but did get it as soon as it came in on September 4. V2 stated R40 had started getting a little manic, and the psychiatric nurse practitioner had ordered her to have [MEDICATION(S)] 50 mg every morning in addition to her current dose of [MEDICATION(S)] 100 mg at HS. V2 stated R40's brother had called and asked about her missing some medication. V2 stated he talked to V1 (Administrator), but she was unable to give him any information because he was not on R40's contact list. V2 stated when R40 had behaviors last week, she had contacted R40's parents and sister on Thursday, August 1st and asked them to come and see her and help figure out what was going on with R40. V2 stated they came to see R40 on Saturday. V2 stated R40's sister does not see her often; she has only seen her visit a couple of times in the last year. V2 stated R40's parents are her guardians, but they are elderly and don't hear well so when staff call them, if they can't hear what is being said, they hang up. V2 stated R40's parents and sister have left specific instructions that they are not to give her brother any information regarding R40; he is to call either her parents or sister and they will let him know what they want him to know. V2 stated, I called (R40's) sister and parents to inform them of her behaviors last week. I can show you on my cell phone where I called them. V2 then looked through her cell phone and stated, I must have used (V1's) cell phone because I can't find it on my phone. V2 stated when a medication is missed, if it is a psych med, they notify the psychiatrist because the medical doctor and his nurse practitioner will not do anything with psych meds. V2 stated the nurse usually notifies V24 (psychiatric nurse practitioner) with any psych issues. V2 stated she does not think the psychiatrist has been in the facility for several months. On 9/7/22 at 3:50 PM, V16 (R40's brother) during phone interview, stated he had not talked to R40 about her missing medications, because he was on a zoom call when she tried to call him, but R40 had notified his niece, who is in medical school, by text, stating that she had missed some of her medication and was not sleeping. V16 stated R40, in her text message to his niece, stated the facility was giving her [MEDICATION(S)] and it was not helping her to sleep, and was asking if there was anything else that would help. V16 stated he called and tried to ask the Administrator (V1) about R40 having missed medications, and she told him she is dealing with a state survey and has a funeral to attend and did not have time to talk to him. V16 stated he tried to set up a better time to discuss R40 but (V1) told him he was not on her contact list so she would not be able to talk to him. V16 stated he then asked if his sister (V17) could call and make the appointment and was told yes, she could. V16 stated R40's text to his niece indicated she had missed her medication for about a week. V16 stated R40 had been doing very well with no psychiatric setbacks for about [AGE] years and was usually very alert and oriented and well organized. V16 stated he had called and informed his sister about the text message R40 had sent to her niece about missing medication, so she went to see her on Saturday, which was the usual routine, and R40 was not her normal self. V16 stated he did not know of any falls or injuries that had occurred as a result of R40 not receiving all her medication, but he feels she has had a mental set back as noted by her change in behaviors and her lack of sleep. V16 stated he is worried about the facility retaliating against R40 because the family is complaining, but he stated he just wants to know what medication was missed, why it was missed and what is being done about it, so it doesn't keep happening because he knows her medications are very important to her stability mentally. On 9/7/22 at 5:15 PM, V17 (R40's sister) during a phone interview, stated she comes in every Saturday and takes R40 out of the facility for the day and they usually have lunch or dinner with their parents. V17 stated R40 is very alert and oriented and runs the Resident Council at the facility, and if R40 feels like she or any of the other residents are being mistreated, she will say something about it. V17 stated R40 usually calls her during the week to talk about what they are going to do on the Saturday when she comes to get her, but R40 did not call her last week, which was very unusual for R40. V17 stated nobody from the facility called her last week to tell her about R40 having behaviors, but when she arrived at the facility that Saturday morning, September 3, a staff met her at the door and stated she had meant to call her and warn her that R40 was having a lot of behaviors and was not acting like herself. V17 stated they told her R40 was yelling and cursing at the staff. V17 stated she went to R40's room and R40 yelled for her to get the f*#% out. V17 stated nobody from the facility had notified her or R40's parents that R40 was not receiving all of her medications. V17 stated her brother had called her with concerns because their niece had received a text message from R40 last week, telling her R40 was not getting her medications and could not sleep and wanted to know if she could tell her something that would help her because the [MEDICATION(S)] the facility was giving her was not working. V17 stated R40 knew her own medication very well and sometimes when she went on home visits, R40 would catch that they had forgotten to send one of her medications and would call up and tell them she needed it. V17 stated no one had given any directive to the facility to not release any information to R40's brother regarding her care. V17 stated he is not on her list because he lives out of state and it is easier to get in touch with her or her parents, but there is no reason he cannot call with concerns about her care. She stated R40 speaks to her brother on the phone often. V17 stated she feels the facility owes them an apology and an explanation of why some of R40's medications were missed and why they had not been informed of this or R40's change in behaviors and overall condition. V17 stated R40 has not had a psychotic break like this since 2005, and when it happened back then, it caused her to have to be institutionalized. V17 stated she knows R40 not receiving her medications could be very detrimental to her mental health. On 9/8/22 at 10:35 AM, V2 (DON) stated, I don't do medication error reports when medications are missed, only when the wrong medication is given. We don't do a medication error report, but we notify the doctor when a medication is missed. If the doctor was notified of the missed medication it is documented in the eMAR (Electronic Medication Administration Record) documentation progress notes. V2 stated she would expect physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 9/8/22 at 2:00 PM, V24 (Psychiatric Nurse Practitioner) stated the facility does sometimes send a fax or calls the office when a resident's medication is not available. V24 stated she was surprised when the nursing staff called about R40 having behaviors this past weekend. She stated staff reported to her that R40 was in the midst of the delusion of having a famous husband and was trying to run out of the facility to meet him. She stated she does not recall anyone reporting R40 missing 18 doses of [MEDICATION(S)] in July 2022 because that would have been pretty significant. She stated she would think the facility would contact the pharmacy right away and figure out what was going on so R40 would get her medications as ordered. V24 stated there is no reason R40 should have missed 18 doses of her [MEDICATION(S)] without the facility doing something about it. She stated she does not think that is related to R40's behaviors this past weekend, as R40 had been complaining of being tired and her [MEDICATION(S)] would have made her more drowsy, not caused her to have behaviors. V24 stated they had been decreasing R40's [MEDICATION(S)] gradually over the past year, so missing a dose may cause her to have changes in her behaviors for a couple of days following the missed dose, but the missed dose a couple of weeks ago probably would not have affected R40's behaviors this past weekend. V24 stated she knows R40 very well and has been treating her for the past 5 years and stated R40 is normally very alert and oriented and is aware of her own care. V24 stated she would not be surprised if R40 remembers meetings she had 2 or 3 years ago. V24 stated she does not know what would have caused R40's behaviors last weekend but she did give an order to add [MEDICATION(S)] 50 mg QAM because they had decreased her dose quite a bit. On 9/8/22 at 7:00 PM, R40 was sitting in her room waiting on her medication and snacks. R40 stated she is feeling a lot better. R40 was noticeably more alert, and her speech was clearer than during previous encounters with her during the survey. She remembered this surveyors name. She stated she had missed her nighttime dose of [MEDICATION(S)] 3 nights last week and it was horrible. R40 stated, The didn't give me my [MEDICATION(S)] for 3 days and I couldn't sleep. I begged them to give me my meds and they told me pharmacy didn't bring them yet. I asked them to call my doctor and they told me they couldn't because he was on vacation. It was terrible. I felt like my eyelids wouldn't close. I cried because I knew I wasn't right, but I didn't know what to do. On 9/8/22 at 7:20 PM, during an off-hours portion of the survey, V19 (Licensed Practical Nurse/LPN) stated the facility is still using the same pharmacy since changing owners, but they reorder residents' medications differently. V19 stated they reorder a resident's medication through the electronic medical record but several times the medication has been reordered it doesn't show up with the delivery. V19 stated this has happened with R40's [MEDICATION(S)] more than once, but she knows she missed some doses last week, but doesn't know how many because she doesn't always work on the same hall. V19 stated she felt very bad about what R40 went through last week and the beginning of this week. V19 stated R40 got so bad mentally that she did not even know V19's name, and she stated R40 usually recognizes all the staff and her fell ow residents. V19 stated R40 was upset because she was afraid her changes were part of her illness and was afraid, she was getting worse, but V19 stated she reassured R40, when she was able to understand again, that her mental changes and behaviors were not her fault, and that it was the facility's fault because they did not get her [MEDICATION(S)] ordered on time. V19 stated she has worked with R40 for over a year, and this is the first time she has seen her have behaviors like these, and not recognize staff. V19 stated when R40 had missed doses of her [MEDICATION(S)] in the past it did not affect her this bad. V19 stated she talked to R40's sister when she came in and she told V19 that R40 had behaviors similar to these back in 2009 and that is what caused her to be institutionalized. On 9/9/22 at 8:45 AM, V31 (Pharmacist) stated R40's [MEDICATION(S)] 50 mg was ordered and processed on 9/2/22 and should have been delivered on 9/3/22. She stated she could not tell when R40's [MEDICATION(S)] 100 mg was ordered, but all the orders she has are old. She stated she could not tell exactly when the last [MEDICATION(S)] 100 mg was last sent to the facility and would have to check with someone else and will return call. On 9/9/22 at 12:00 PM, V31 stated they did receive the facility's request for a refill of her [MEDICATION(S)] on 8/27/22 but it was not sent because they needed a lab that is required before they can send [MEDICATION(S)]. V31 stated her records show the pharmacy has not refilled R40's [MEDICATION(S)] 100 mg since April 2022. V31 stated since April 2022, the only [MEDICATION(S)] that has been sent to facility for R40 was [MEDICATION(S)] 50 mg for her new order received on 9/2/22 for [MEDICATION(S)] 50 mg every morning. On 9/9/22 at 12:15 PM, V2 (DON) and V23 (ADON) stated they were not aware R40 did not receive her [MEDICATION(S)] 100 mg from 8/27/22 until her [MEDICATION(S)] 50 mg was delivered on 9/4/22. V23 stated, I am the one who wrote on the order that we were out of (R40's) [MEDICATION(S)] and to please send it out. Both V2 and V23 stated they have given R40 her medications when they have worked the floor since April 2022, and they feel like she had her [MEDICATION(S)] 100 mg when they gave her medications. On 9/9/22 at 1:37 PM, V24 (Psychiatric Nurse Practitioner) during phone interview, stated R40 having missed her [MEDICATION(S)] 100 mg QHS would have directly caused her to have experience her changes in mental status resulting in her [CONDITION(S)] she experienced starting on 9/2/22 and she is continuing to have some [CONDITION(S)]. V24 stated R40 will most likely require a higher dose of [MEDICATION(S)] to get back to her baseline and it might take a while. V24 stated she will be assessing R40 next week and will be contacting the DON to get an update on R40. V24 stated it is very sad that R40 is going through this because she was doing so well and was very active in the facility before last week. 2. R71's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R71's Progress Notes dated 8/24/2022 at 4:36 PM documents, resident admitted to (local hospital) with dx of exacerbation of [CONDITION(S)] and acute CHF. R71 had an additional Progress Note dated 8/24/2022 at 4:36 PM which documents, resident sats (saturates) at 95% on 2.5L (liters) O2 (oxygen) states she feels SOB (short of breath), abdominal breathing observed, wheezing auscultated. pulmonologist NP (Nurse Practitioner) here to see and assess resident, new orders received of [MEDICATION(S)] 500 mcg ( micrograms) and [MEDICATION(S)] inhaler that were just ordered and not available from pharmacy at this time. medical NP here to see and assess resident ordered to be sent to ER (emergency room ) per 911 for respiratory distress. EMS (Emergency Medical Services) arrived approx (approximately) 1305 (1:05 PM) to take over tx. Review of R71's Progress Notes dated 8/16/22 to current (9/9/22) includes documentation of R71's medications that were not available on these dates. There is no documentation that the facility notified the physician or nurse practitioner of the missed doses of medications on these dates: 8/17/22: [MEDICATION(S)], [MEDICATION(S)], Potassium Chloride, and [MEDICATION(S)] were not available 8/18/22: [MEDICATION(S)] and [MEDICATION(S)] were not available 8/19/22: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Guaifenesin, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Potassium Chloride, Vitamin D, and [MEDICATION(S)] was not available. 8/21/22: [MEDICATION(S)] was not available 8/22/22: [MEDICATION(S)] was not available (R71 was hospitalized at local hospital 8/24/22 to 8/25/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 8/26/22: Guaifenesin, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] was not available 8/29/22: [MEDICATION(S)] was not available 8/31/22: [MEDICATION(S)] was not available 9/1/22: Incruse Ellipta not availabel 9/3/22: [MEDICATION(S)] not available 9/7/22: Incruse Ellipta not available. R71's Hospital Discharge Summary dated 8/25/22 documents her admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/9/22 at 12:37 PM, R71 stated she does not know why she did not get her medications when she was first admitted and thinks that was the reason she had to go back to the hospital. R71 stated it scares her when she doesn't get her medications because she has heart and breathing problems. She stated the nurses said it was not their fault that her medications were not here; it was because of pharmacy. On 9/9/22 at 12:40 PM, V38, Pulmonary Nurse Practitioner, stated she was not notified by the facility that R71 was not receiving her medications as ordered. After reviewing the medications R71 had missed since her admission on 8/16/22 until 9/7/22, V38 stated R71 having missed those medications definitely would have caused her to have an exacerbation of her [CONDITION(S)] and CHF and caused her to be sent to the hospital. V38 stated she had seen R71 on 8/24/22, the day she was sent to the hospital, and noted she was short of breath, but she had just finished with therapy, so she thought R71 was just needing to recover from that. V38 stated the Primary Nurse Practitioner called her later that day and told her R71 was continuing to be short of breath and lethargic and they made the decision to send her to the emergency room for evaluation. V38 stated the facility did not notify her that R71 was not receiving all of her medications and that would have absolutely been something they should have reported to her so she could follow up with the pharmacy to determine the estimated time of delivery of the medications. She stated R71's diuretics and inhalers are very important medications for her to receive because of her [CONDITION(S)] and CHF diagnoses. The facility's policy, Medication Administration with date reviewed of 3/2022, documents, General: All medications are administered safely and appropriately to aid residents to overcome illnesses, relieve and prevent symptoms and help in diagnosis. It continues, 26. If medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain from the contingency or convenience box. 27. If the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, observation and record review, the facility failed to prevent a decline in range of motion (ROM) by providing adequate services including Passive Range of Motion and splints for one of 4 residents (R5) reviewed for range of motion services in a sample of 34. This failure resulted in R5 developing a contracture left hand and declining range of motion bilateral lower extremities. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents R5 to have severe cognitive impairment with a Brief Interview of Mental Status score of 4. The MDS documents R5 to have range of motion limitations bilaterally upper and lower extremities and receives Passive Range of Motion 6 days a week. On 9/26/18 at 11:10am, R5 was sitting in her reclining wheelchair. Both knees were contracted and laid over the side of a platform on the bottom of the wheelchair. R5's left hand appeared to have some limitations also. On 9/27/18 at 11:11am, V18, R5's daughter, said the stiffness had just started using a sling which she picked up off a chest of drawers next to the bed. V18 stated she hadn't noticed her Mom's decline in her left hand until the CNA (certified nurse aide) told her. V18 identified the CNA as V12 who notice the decline and it was mentioned to therapy who asked if she minded if they tried the sling. V18 stated her mothers fingers had started to curl in and she also has contractures of both legs which she thought had gotten worse also. She doesn't think they do any exercises with her adding none that she's aware of or that they've talked about. V18 stated the newly developed hand contractures inhibit her mothers ability to feed herself and get her own drinks. V18 stated R5 can feed herself finger foods and drink from glasses if they are small enough to fit in her hand and have a straw. The Progress Notes written by V12 CNA on 9/19/18 at 11:39am documents Splint was placed after PROM was done. Wanted off after breakfast so splint was removed. The Care Plan 7/4/18 documents under Focus PROM: Dorothy is at risk for decline in functional mobility/ has contractures noted to BUE/BLE. The goal documents R5 will maintain current level in range of motion without further decline through next review. Interventions include: Explain each procedure, Maintain good body alignment and assess skin, Provide Passive Range of Motion exercises 5-10 repetitions to BUE/BLE during AM/PM care, Perform repetitions in a slow and smooth motion, Stop range at point of pain or resistance, Inform resident when procedure is complete and Notify nurse of signs and symptoms of pain during activity. (CNA,RNA,NURS). This care plan does not include any information regarding splint use. An occupational evaluation dated 7/10/18 documents the reason for referral as The pt (patient) has mild stiffness in the lt (left) digits and the contractures of the LE (lower extremities) have increased. It is difficult to place pt in the w/c (wheelchair) due to contractures. The pt will benefit from skilled OT program to establish exercises to decrease contractures. The Initial assessment also documents R5 to have pain with movement scoring an 8/10 with 10 being the worse documenting pain limits the following functional activities: proper positioning in w/c, difficulty in repositioning in bed and in w.c identifying remaining still as what relieves pain. Under Long Term Goals, it documents The pt will demonstrate ability to wear the lt resting splint in functional position for 2 hours w.o (without) s/s (signs/symptoms) of discomfort to prevent contractures in the left hand from getting worse. On 10/2/18 at 11:15am, V32 Certified Occupational Therapy Assistant (COTA) stated R5 did show decline in range of motion for her legs bilaterally and a newly developed contracture in her left hand which they ordered a splint for. V32 stated R5 does refuse the splint at times and will refuse range of motion. V32 stated R5 will wear the splint some days for only 15min and at times, 1-2 hours. V32 stated it is the CNA's responsibility to do the ROM currently because she is no longer getting skilled therapy. V32 couldn't say why R5 developed contractures of her hand and decline in her legs if the ROM services were provided appropriately. On 10/2/18 at 10:30am, V12 Restorative Certified Nurse Aide (CNA) confirmed that she was the restorative aide and does all the ROM in the building on a daily basis. However, V12 stated she would not be doing ROM today since she'd been scheduled to do the monthly weights instead. V12 was unable to provide any progress notes written that gives information such as R5's compliance or lack of with the PROM's but did provide daily documentation that PROM were done 15 minutes daily. V12 stated R5 does remove her own splint at times making it difficult to meet the time frames suggested by OT. On 10/3/18 at 10am, V12 Restorative Certified Nurses Aides (CNA) was asked to do PROM's on R5 and couldn't recall whether R5 got ROM on all four extremities but thought she just got them on her lower with the splint on her one wrist/hand. On 10/3/18 at 1:21pm, V12 entered R5's room and explained that she was going to do her exercises. R5 was laying in bed, her legs were bent with knees laying to the left. V12 did 5 repetitions on the joints she ranged. V12 failed to do flexion/extension, abduction/adduction, and opposition of her thumb, failed to do flexion/extension of her finger joints, failed to do internal/external rotation and hyperextension of the hip joints, abduction/adduction of the toe joints (did range of motion while R5's socks were on,) failed to do supination/pronation of the elbow joint, and internal/external rotation and hyperextension of the shoulder joint. V12 stated R5 had her splints on from 6:05am until right before lunch around 11:10am or so. R5 resisted a little during some of the exercises which caused V12 to move to the next joint. A care plan dated 10/19/17 documents R5's risk for debility and limited range of motion to Bilateral Lower Extremities but fails to address her upper extremities. The care plan documents R5 was to receive PROM's am and pm 5 repetitions per joint. A revised care plan was provided on 10/3/18 which identifies R5's focus area as requires the use of splint to left hand rt contractures and immobility but fails to address her refusal or ability/history of removing the splint at times. The revised focus area for PROM's also failed to identify her refusals for ROM to be done fully and on all joints. The facility failed to develop a effective functional plan that address R5's needs in an effort to ensure that ROM services are provided to prevent further contractures and limitations. The facility's policy/procedure entitled Resident Mobility and Range of Motion dated 7/2017 documents the resident with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. The policy interpretation and implementation documents During the resident's assessment, the facility will attempt to identify any underlying factors that contribute to his or her range of motion or mobility problems. The policy also documents Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs.

Based on interview, observation and record review, the facility failed to develop an appropriate resident focused plan to prevent further weight loss and failed to provide adequate supervision and assistance to prevent weight loss for 3 of 6 residents (R4,R5,R44) reviewed for weight loss in a sample of 34. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents R5 to have severe cognitive impairment with a Brief Interview of Mental Status score of 4. The MDS dated [DATE] documents a decline in eating from set up with minimal assist of one on 10/23/17 to extensive assist of one staff currently. On 9/26/19, R5 was propelled to the dining room table at 11:30am. R5 remained in her reclining wheelchair at a 45 degree angle back as she sat at the table awaiting her meal. R5 was served at 12:20pm. No set up assistance was provided when the tray was delivered by V5. R5 was served one cup of coffee, no straws R5 was served spaghetti/meatballs, bread, a bowl of cut up peaches, and broccoli stems. R5's tray also had a carton of chocolate health shake. R5 remained in a reclining position when V5 CNA sat R5 up to approximately 30 degree. V5 then sat down to assist her to eat. R5 lifting her head to take sips. R5 was given a cup of coffee but no water with her meal. There was no conversation between V5 and R5 as V5 slowly gave R5 bites of food. At 12:35pm, V5 got up from feeding R5 and went to the other side of the table to assist her tablemate. At 12:38pm, V5 again got up and walked to the kitchen. At 12:50pm, V5 gave R5 a bite of peaches and at 12:56pm, V5 got up and left R5's table. R5 had only eaten bites of spaghetti, no bread, 50% of her broccoli and only sips of her chocolate health shake. No further assistance was given R5 before taking her back to her room nor were any substitutions offered for foods uneaten prior to her leaving the table. Tables were observed being cleared without meal intake recorded. R5 was not offered/encouraged any substitutes for foods uneaten before removing her from the table. On 9/27/18 at 11:40am, R5 was assisted with her lunch meal by V18, daughter. R5's plate had plate guard on it which was not on it the day before. R5 was served tea and a health shake which she drank well with a straw independently. R5 was handed a buttered piece of bread which she fed herself with no problems. R5 ate approximately 50% of her total meal. The monthly weight records documents a gradual weight loss for R5 whose weight was recorded as 112.8 pounds 2/2/18 and on 9/10/2018, it was recorded as 102.5 Lbs. On 9/27/2018 at 2:03pm, the Nurses Notes document Dietary recommendation received to add super cereal to breakfast tray. POA and Dietary notified, after a discussion regarding R5's difficulty in eating. On 9/25/2018 11:14 Dietary Note documents Weight progress note: resident has been noted to eat bites of her food and dietary manager is concerned that family bringing in candy and other snack foods is causing her to get too full for meals. CBW 102.5#, down 4.3# x 3 weeks. Weight normally runs in upper 110s. BMI 20.7-lower than optimum for age. Staff reports that resident gets a health shake at meals. Physician order [REDACTED]. RD went to resident's room to help offer some suggestions to resident but she was asleep and did not stir when name was called. RD will suggest adding super cereal at breakfast. RD will monitor for additional weight changes. The Dietary Slip provided by V7, Dietary Manager on 10/2/18, documents R5 receives as General Mechanical Soft diet with adaptive equipment (plate guard) and for lunch is to receive a house shake 4 ounces, plate guard and may offer finger foods. Drink of choice is identified as tea. On 09/27/18 at 11:08 AM, V18, R5's daughter, stated she comes almost daily to visit and was here last night to feed her. V18 stated her mom is able to feed herself if she is positioned properly and given some finger foods. V18 also said R5 needs straws in her fluids. V18 stated R5 has lost weight this past month so she tries to come feed her when she can as she thinks staff don't take enough time with her during meals. The facility failed to identify R5's gradual weight loss over the past 7 months and failed to develop a plan based on her needs and ability to feed herself to prevent further weight loss. The current care plan fails to reflect the weight loss, her need for finger foods and straws. Nor does the care plan identify the need to properly position R5 at the table to maximize her ability to feed herself or for staff to take time for R5 to eat. The facility provides the health shake but fails to document it's consumption amount. Meal Intake records provided on 10/2/18 fails to document intake for all three meals daily. For example, R5 has only one meal documented on 9/8/18 at 17:15 (5:15pm), two meals documented on 9/10/18, one at 10:23am and the other at 17:15 (5:15pm.) Incomplete intake records also occurred on 9/12, 9/13, 9/15, 9/16, 9/20, 9/22, 9/24-9/28 (no documentation for 9/25, 9/26 at all), and only included one meal documented on 9/27/18. Of the days documented, R5 consumed 0-25% for 13 of 60 days and 25-50% for 27 of those days. There is no evidence the dietician fully assessed R5's needs and addressed them. The current care plan dated 7/6/18 fails to document R5's current needs including her need for finger foods, straws and being fed. The current care plan documents as a focus R5 takes her meals in the dining room. Is assisted with meals, with set up and supervision. She is on a Mech (mechanical) Soft Diet. Appetite poor-fair, eats 25-50% of most meals. Family chooses meals from a selective menu for her. The goal is documented as Alb. ([MEDICATION NAME]) level will be WNL (within normal limits), R5 will eat 50% or more of meals and Wt. (weight) will remain within 2# (pounds) of present wt (weight.) Interventions include Assist with tray set up and encourage her to eat 50% or more of meals. Assist with feeding as needed. Offer alternates for foods uneaten. Allow ample time for her to eat each meal. Record % eaten at meals.(CNA (certified Nurses aide,)ALL,DIET,NURS, Plate guard at meal time(DIET,NURS), Provide with Regular diet per orders. Honor food pref (preferences) and dislikes. Offer selective menu to family to assist in choosing her meals.(DIET) , Refer to RD for possible dietary supplement.(FSS (Food service supervisor),Diet), Weigh monthly and per facility protocol. If wt. loss is determined, weigh weekly and re evaluate. Notify Dr. and responsible party of any sign of wt. changes. Record wt. in chart. There is no evidence the facilty fully assessed R5 current needs which included her decline in eating ability, need to be fed, have straws/finger foods, and the need for proper positioning and developed a plan to meet these needs in an effort to prevent further weight loss. 2. The MDS dated [DATE] documents R44 to be cognitively intact with a BIMS score of 14. The MDS documents she requires set up and supervision to eat. The Physician order [REDACTED]. On 9/26/18 at 11:27am, R44 exited her room with her wheeled walker to go to Dining room for lunch R44 sat at the table waiting to be served until 11:50am when she was served chicken rice (single portion), bread, broccoli stems and a health shake. The broccoli was pale and overcooked. R44 was independent in eating and had no staff approach after her meal was delivered. At 12:45pm, R44 left the dining room with no staff intervention. R44 had eaten only a few bites of her meal. R44 had given her health shake to her table mate who drank it. There were no offers of substitutions for food uneaten. On 9/27/18 at 11:45am, R44 received her noon meal which was salisbury steak, carrots and potatoes and gravy. R44 ate only bites of her meal. R44 gave her health shake away to her tablemate who drank it and handed back the carton. R44 had a cup of coffee. On 09/27/18 at 2:26 PM, V 16 LPN stated R44 does not eat at times and sometimes she does. A telephone order dated 9/27/18 documents R44's house shake as discontinued. The POS for (MONTH) (YEAR) documents R44 receives a regular diet, high cal snacks every 4 hours while awake and [MEDICATION NAME] 7.5mg at HS added 8/7/18 and [MEDICATION NAME] as an appetite stimulant. The last Registered Dietician note dated 8/7/18 documents R44's weight loss could be due to depression, refuses snacks offered, going to try [MEDICATION NAME], maybe adjusting [MEDICATION NAME], RD suggests weekly weight times one month but there is no evidence the facility further identified/assessed and monitored R44's weight loss. The monthly weight logs document a gradual weight loss for R44 from 12/6/17 at 122.8 pounds to 111.5 pounds on 9/10/2018. R44's care plan dated 8/29/18 only documents R44 requires set up and supervision for eating under Activities of daily care and fails to identify R44's gradual weight loss and her increased risk for more weight loss. The care plan also fails to address her giving food away off her plate. A telephone order dated 9/27/18 documents R44's health shake was discontinued. POS regular diet, high cal snacks every 4 hours while awake, [MEDICATION NAME] 7.5mg at HS added 8/7/18. The diet slip documents R44 is to get tea for lunch and double portions which she received neither on 9/26/18 or 9/27/19. Meal Intake Records for (MONTH) (YEAR) document R44 ate 50-75% of her lunch meal on 9/26/18 and 9/27/18 which conflicted with observations made of the actual meal. On 10/3/18 at 9:35am, R44 was standing in the doorway of the dining room with her room mate, R15. The dining room lights were off and a barrier was in front of the door to prevent residents from going onto the wet floor. R44 was asked if she had breakfast and responded no, I'm waiting for it. R15 stated well, we've already had breakfast. There is no evidence the facility developed a plan to prevent further weight loss that included accurate assessment, monitoring and effective interventions. The facility's policy/procedure entitles Nutrition/unplanned weight loss policy dated 1/2016 documents under Assessment and Recognition, documents As part of the initial assessment, the staff and physician will define the individual's current nutritional status and identify individuals who are at risk for impaired nutrition. Under Cause Identification, it documents The physician will review possible causes of weight loss with the nursing staff and/or Dietician before ordering interventions. a. The Dietician will estimate calorie, nutrition and fluid needs and, with the physician, will identify whether the resident's current intake is adequate to meet his or her nutritional needs. The policy continues The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. Under Monitoring, the policy documents Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals will be done. 3. On 09/26/18 11:10 AM, R4 was observed seated in a wheelchair in the dining room. At 11:50 AM, R4 told another surveyor If she didn't get her lunch tray she was going to leave. The surveyor then went to V15, CNA who then told the kitchen staff. At 12:00 PM, R4 still didn't have her tray and propelled herself toward the exit. V15, CNA asked her where she was going and said you haven't eaten yet and took her back to her table. At 12:15 PM, R4 did not have her tray and propelled herself out saying I'm full. V5, CNA removed her clothing protector and R4 left. R4 appeared lethargic and unable to focus or speak clearly. There was no tray taken to her in her room. There was a glass of water at her table, no health shake was observed. On 09/27/18 at 9:00 AM, R4 was observed propelling herself slowly down the hallway from the dining room. When her plate was observed, R4 had dropped a lot of her food on the floor and had not touched her health shake. R4 had eaten approximately 25% of her meal, and no fluids. The POS, dated 09/01/18, documented R4 had the following diagnoses, in part as, Dementia, [MEDICAL CONDITION], history of [MEDICAL CONDITION], right side [MEDICAL CONDITION] and recurrent Urinary Tract Infection. It also documented R4 was on a regular general diet. The MDS, dated [DATE], documented R4 had a BIMS of 5 out of 15, moderate cognitively impaired and required extensive assist of one staff for bed mobility, transfers, dressing, toilet use, hygiene and bathing. It also documented R4 required assist of two for ambulation and required supervision during meals. On 09/11/18 at 1:38 PM, a dietary note documented Dietary manager weighed resident yesterday (09/10/18) at her Current Body Weight (CBW) and reports that her CBW is in line with her (MONTH) weight 105.1 lbs., and does not believe the 105.1 lbs. weight to be accurate. Intake continues to vary between 0-50% at meals with few consumed greater than 50%. She is on a regular diet, NAS restriction was d/c per RD request last month. Will ask physician to d/c NAS from order sheet. Continue snacks bid and health shakes tid. RD will continue to monitor for hospice. The weight for R4 on 03/06/18 was 115.8 lbs. and R4's weight for 09/10/18 was 100.1 lbs. The Care Plan dated, 09/28/18, documented R4's Height 62 in. and Weight 105.3 lbs. R4's Ideal Body Weight Range (IBWR) ranges from 131.0-159.0 BMI of 19.3. R4's appetite is usually poor 25% or less at meals. It documented R4 required some assistance with feeding self in the main dining area and is able to make likes and dislikes known. No noted difficulty swallowing. No noted difficulty chewing a regular consistency diet. She gets health shakes 3 times a day and snacks 3 times a day to help with weight loss and maintain weight. She was placed on hospice care per change in condition. She uses a divided plate at meals. Assist with tray set up as needed or requested. Encourage her to eat a well balance diet and to eat 75% or more of meals. Offer alternates for foods uneaten. Record % eaten at each meal. Also, Honor food preferences and dislikes. Offer selective menu. Refer to Registered Dietician for weight loss and possible interventions. Weigh monthly and per facility protocol. If significant weight loss is determined, weigh weekly x's 4 weeks and re eval. Notify Dr. and responsible party of any significant weight loss. Record weight in chart. The intake record for (MONTH) was reviewed and on 09/26/18 documented R4 scored a 3 meaning 51% to 75% was consumed at 12:45 PM. R4 was observed at 12:15 PM to leave the dining room and at 12:45 PM, R4 was observed in her wheelchair propelling down the 500 hall. On 09/27/18, the intake record had nothing marked for the 0745 or 1245 meals. There was a 10% weight loss in one month with no weekly weights or re-evaluation documented. On 09/06/18, 09/16/18 and 09/20/18, there were missing intake numbers for 0745, 1245 or 1715.

Based on interview and record review, the facility failed to recognize, assess and treat a change of condition for 1 of 7 residents (R2) reviewed for a change of condition in the sample of 26. This failure resulted in R2 being found in bed unresponsive with a temperature of 104.1 degrees and being admitted to the hospital with [REDACTED]. Finding includes: R2's current Electronic Medical Record (EMR) documented, R2 was admitted on [DATE] with [DIAGNOSES REDACTED]. R2's Minimum Data Set ((MDS) dated [DATE] documented R2 had a Brief Interview of Mental Status (BIMS) of 00 which indicated R2 was severely cognitively impaired. This same MDS documented R2 required extensive assistance of 2 staff members for bed mobility, limited assistance of 1 staff member for transfers, supervision of 1 staff member for locomotion on the unit in wheelchair, supervision with set up help only with dining and R2 was frequently incontinent of bowel and bladder. R2's Health Status Note, dated 11/22/17 at 9:43 PM, documented Resident transfers around in wheelchair, but redirection is needed as resident displays much confusion. Resident becomes irritable when redirected. Gait unsteady although he attempts to ambulate to the bathroom. R2's Health Status Note, dated 11/24/17 at 10:29 AM, documented Resident confused. Resident requires much attention and redirection. (Electronic monitoring bracelet) in place and functioning properly. Resident been sitting at nurses station. R2's Nurse's Note written byV8, Licensed Practical Nurse (LPN), dated 12/24/17 at 12:00 PM, documented Resident in room resting. Upon entering room Resident was easily aroused. Resident vital signs were taken blood pressure was 148/64 pulse 68 temperature was 98.9. Residents O2 (oxygen) sats (saturation) were fluctuating from 94% - 96%. Residents blood sugar was taken results were 108. O2 applied for comfort to resident at 2 Liters. CNA (Certified Nurse's Aide) noted to this nurse that resident was very sleepy so resident was assessed. This nurse completed an assessment residents pupils were Perrla (pupils equal, round, react to light, accommodation) Resident has good equal grips skin was warm pink and intact this nurse and 2 CNA's assisted resident out of bed with gait belt resident was offered water but drank very little. Resident was alert but sleepy this nurse and 2 CNA's assisted Resident with a gait belt back to bed family came to visit stated they would come back when resident was awake resident currently in bed resting w/ (with) HOB (head of bed) elevated w/ call light in place will cont (continue) to monitor. R2's Health Status Note, dated 12/25/17 at 11:10 AM, written by, V6 (LPN), documented Resident in lethargic state unable to administer medication resident spits it back out. VSS (vital signs stable) O2 on 2L (liters) per nasal cannula for comfort O2 sat 96%. R2's Health Status Note dated 12/25/17 at 12:55 PM written by, V5 LPN, documented CNA reported that resident doesn't look right. Resident laying in bed resting with eyes closed. Skin hot and dry. Resident nonresponsive to verbal and physical stimulation. SPO2 (peripheral capillary oxygen saturation) at 82% on 2 liter of O2 via nasal cannula. Changed O2 to 3 litters via nasal cannula SPO2 99%. Call placed to (V4 Physician) with new orders to send resident to emergency department for evaluation and treatment. R2's VS (vital signs) sheet, dated 12/19/17 shift 2-10, documented Temp (temperature) 98.7, Resp (respiration) 18, Pulse 78, B/P 102/68. R2's Vital Signs dated 12/25/17 at 12:53 PM documented Blood Pressure 116/58 mmHg (millimeter of Mercury), Temperature 104.1 Fahrenheit Axilla, Pulse 68 bpm (beats per minute) Respiration 24 breaths/minute. R2's local FIRE DEPARTMENT INCIDENT REPORT dated 12/25/17 at 12:55 PM documented, Upon patient contact, found an [AGE] year old male supine in bed with his head elevated. PT (patient) is unresponsive with snoring respirations at 30/min (minute). Patient is hot to the touch, pale and dry, PERRLA with heavy discharge noted in and around both eyes. BP (blood pressure) 155/64, P (pulse) 93, R (respirations) 30, 89% O2 on 4 L by nasal cannula, blood sugar 242. Nurse (V5 LPN) arrived and stated that this was not her patient and she was not familiar with him. Chart reviewed, showing history of [MEDICAL CONDITIONS], behavioral disorder, diabetes and hypertension. The nurse then remarked that the patient has been in this condition 'Since Wednesday.' The nurse was asked to clarify and told that Wednesday would have been 5 days ago. She again stated that this was not her patient but that the aides on this hall all agreed no one has seen him awake since Wednesday of last week. She also advised that his normal mental status was alert and responsive but occasionally combative. R2's local hospital Emergency Department Arrival Information dated 12/25/17 at 1:33 PM documented Arrival Complaint unresponsive [DIAGNOSES REDACTED]. Arrival vitals Temp (temperature) 101.8 Fahrenheit, Pulse 110, Resp (respirations) 23, BP 59/39, SpO2 85%. Assessment/Plan Septic Shock due to right lower lobe pneumonia. R2's Medication Administration Record (MAR) documented R2 received [MEDICATION NAME] 5 mg by mouth on 12/3/17, 12/13/17 and 12/14/17. R2's MAR documented 12/19/17 all meds held 4p & 8p. lethargic. R2's MAR documented 12/21/17 Resident lethargic 4p & 8p med pass. R2's MAR documented 12/22/17 Resident refused medication at 4p MD notified. R2's MAR documented 12/24/17 Resident lethargic refused 4p meds. R2's telephone order dated 12/24/17 documented, O2 2 liters for comfort. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/21/17 evening shift 2 pm - 10 pm written by, V6 (LPN), documented Lethargic all shift. 4 p (pm) & 8 p (pm) meds held MD (Medical Doctor) aware. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/22/17 night shift (this shift starts on 12/21/17 and ends on 12/22/17) 10 pm - 6 am documented ok. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/22/17 day shift 6 am - 2 pm documented ok. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/22/17 evening shift 2 pm - 10 pm has no documentation of R2's condition. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/23/17 night shift (this shift starts on 12/22/17 and ends on 12/23/17) 10 pm - 6 am has no documentation of R2's condition. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/23/17 day shift 6 am - 2 pm documented ok. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/23/17 evening shift 2 pm - 10 pm has no documentation of R2's condition. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/24/17 night shift (this shift starts on 12/23/17 and ends on 12/24/17) 10 pm - 6 am written by, V7 (LPN), documents, Crush meds (medications), not swallowing. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/24/17 day shift 6 am - 2 pm documents, has no documentation of R2's condition. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/24/17 evening shift 2 pm - 10 pm has no documentation of R2's condition. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/25/17 night shift (this shift starts on 12/24/17 and ends on 12/25/17) 10 pm - 6 am written by, V9 (Registered Nurse/RN), documented O2 per Nasal cannula snoring wet respiration has never awaken this shift. R2's SHIFT TO SHIFT 24 HOUR COMMUNICATION SHEET SOUTH / 200 dated 12/25/17 day shift 6 am - 2 pm written by, V6 (LPN), documented Lethargic hard to arouse 0 (zero) meds given change in condition. On 1/29/18 at 11:28 AM, V2, Director of Nurse's confirmed there was no other documentation regarding R2 for the shifts of 12/22/18 evening shift, 12/23/17 nights shift, 12/23/17 evening shift or12/24/17 evening shift. On 1/3/18 at 3:10 PM, V17, Certified Nurse's Aide (CNA), stated, On 12/20/17 (R2) was sleeping in the hall. He wasn't responding by waking up so we laid him back down. A week before Christmas he was very sleepy which was a change because he would propel himself in the wheelchair, be combative and try to get up. On 1/3/18 at 12:00 PM, V6, Licensed Practical Nurse (LPN), stated, Usually (R2) is up all night and sleeps in the morning. On the 19th (R2) was lethargic. I held his medications on the evening shift. On 1/4/18 at 11:20 AM, V11 (CNA) stated, I worked the evening shift on 12/21/17. I came in at 6 pm. (R2) was up in bed. He slept through the shift after dinner. This was unusual because usually he is up roaming propelling himself in his wheelchair. On 1/4/18 at 10:08 AM, V12 (CNA) stated, On Thursday (12/21/17) day shift I worked another hall but I did see him in the dining room for lunch and he just finger painted in his food. Normally he would propel himself and feed himself but this day had to be pushed in his wheelchair and I assisted him with feeding. He didn't eat lunch. I came back and I worked with (R2) on 12/21/17 midnight shift and he slept all night. I changed him three times. He would tense up but never fully aroused or spoke to me. I did get report from evening shift that he was asleep all shift. On 1/29/18 at 2:00 PM, V30, RN, stated, (R2) was not responsive enough to give him his medications safely on 12/22/17 at 4:00 PM. (R2) was sleepy/lethargic. I left a voicemail on (V4's, R2's Physician) answering service that the medications were held. I never did hear back from (V4). On 1/4/18 at 10:08 AM, V12 (CNA) stated, I worked with (R2) on 12/22/17 the midnight shift. He was incontinent 1 time throughout the night. He did not respond to me during incontinent care. I thought he was in a deep sleep. This sleeping at night was abnormal for him usually he would be up all night. I was not concerned because he did void. On 1/3/18 at 2:00 PM, V10 (CNA/day shift) stated that on 12/23/17, R2 was asleep and snoring and he wasn't responding. V10 stated this was odd because he was usually up and dozing in his chair. V10 further stated, On 12/22/17 and 12/23/17 (R2) slept on my shift and I told the nurse (V8/LPN). I don't know if she did anything. So for 3 days he was sleeping and not eating or drinking. (R2) would not respond during incontinent care. I didn't even try to get him up because it wouldn't have been safe. On 12/28/17 at 2:20 PM, V8 (LPN), stated, On 12/24/17 (R2) slept through breakfast. At approximately 11:00 AM/12:00 PM, (R2's) family came in we tried to get him up but he was sleeping. He would respond to me. The family requested I lay him back down. He has a history of staying up all night. I have worked the midnight shift and he is up. He will sleep through breakfast or get up and go back to sleep. Sometimes the same thing with lunch. If he gets his injection he is a heavy sleeper. I got vitals and O2 sats everything was normal. Nothing was out of the ordinary. Nothing was a red flag. On 1/2/18 at 1:44 PM, V35, R2's daughter -in -law, stated, My husband and I went down to see (R2) on Christmas Eve around lunch time. He was in bed asleep with the door shut. (R2) was in a gown and a diaper. There were half dissolved pills in his mouth. The nurse (V8) came in and said he was up earlier and took his pills. She tried to get him up or drink. She had to brush his teeth to try and get the pills out and to get his mouth cleaned out. She tried to get him to take some applesauce. Then she said Lets get him dressed. While they were putting him in the wheelchair the applesauce came drooling out of his mouth and onto his shirt. She got his pulse ox and his numbers were low, she put oxygen on him, layed him back down and raised the head of his bed. I am unsure what the oxygen level was. When we went to the emergency room the next day he still had on the same shirt he had on Christmas Eve because it had the applesauce stain in the same place. On 1/2/18 at 2:25 PM, V36, R2's son, stated, My wife and I went to see my dad on Christmas Eve around lunch. (V8/LPN) told me (R2) probably wouldn't get up. He was up this morning and he must have chewed up his pills he must have been pocketing them. I helped raise him up, she tried to brush his teeth and give him something to drink. She took his oxygen level which she said was 82 to 84% and she put oxygen on him. They layed him back down and raised the head of his bed. Once he had the oxygen on his color did come back. She told me his days and nights are messed up. My dad only said a few things nothing that was coherent. He never did really wake up. I believed her and that he was ok. She is the medical professional. On 1/3/18 at 3:10 PM, V17 (CNA) stated, On 12/24/17 he was asleep for the shift me and (V18/CNA) tried to get him up for dinner but he just layed there asleep. We brought his tray (to his room) he took a couple sips. After dinner he slept through all his care. This was the evening shift. This was unusual for him. I did not tell the nurse. I assumed the nurse saw what I saw so they would know, I did not get vital signs I don't know if someone else did. I did not get report from the CNA or the nurse. All of this behavior was unusual for him. On 1/3/18 at 1:25 PM, V13, CNA, stated, The week before he went out, on Monday or Tuesday he was asleep. I cleaned him up and he didn't wake up. I did tell the nurse about it. On 1/3/18 at 1:20 PM, V14 (CNA) stated, I don't honestly remember when but he wouldn't wake up in the dining room, he wasn't eating. Usually he would feed himself. The nurses or anyone that was in the dining room would try and feed him and he wouldn't eat. On 1/4/18 at 3:30 PM, V9, RN, stated, Usually (R2) is up all night. When I came in on Sunday night (12/24/17), I was surprised because he had O2 and he was sleeping when I came on. I asked the CNA's why he was sleeping, why O2. They said he was sleeping and they said he had been sleeping all day. I related his sleeping to maybe he got his [MEDICATION NAME]. I meant to look into why he was on O2 but I didn't. I was concerned about him. I was waiting for him to 'get busy' because he is up at night with me at the nurse station. His vital signs were normal. I don't think I charted them. He had no food or drink this shift and I started around 8:00 PM. In the morning (12/25/17) he would arouse to touch and repositioning. I told (V6/LPN) on 12/25/17 day shift to watch him because I was concerned about him. On 1/3/18 at 12:00 PM, V6 (LPN) stated, On Christmas day I couldn't get him to take his medications. He wouldn't open his eyes. He would open his mouth but would not swallow. Those were his 8:00 AM medications. I took his vital signs and they were stable. I think I charted them in the 24 hour chart. O2 was on. When I went to his room nothing was alarming that something was wrong. (R2's) skin was not hot not shivering. (R2) stayed in bed all morning. He did not get up. The CNA's didn't report that he didn't eat. The protocol is if a resident doesn't eat to let the nurses know. I gave report to (V23/RN) before I left around 12:00 PM. I thought maybe he had gotten his prn (as needed) [MEDICATION NAME] injection or by mouth because when he gets that he goes into a deeper slumber. I did check his MAR and he had not been given a prn. On 1/29/18 at 11:25 AM, V6 (LPN) stated that she left a message with the doctors answering service on 12/25/17 in regards to R2 not taking his medication. On 1/3/18 at 2:00 PM, V10, CNA, stated On 12/25/17 my shift started at 6 AM. (R2) was still asleep and unresponsive. I told (V6/LPN) to go look at him around 9:00 AM - 9:30 AM. I didn't receive any feedback from her. Right after (V6/LPN) left I went in and (R2) was shaking and trembling. I touched his hand and he was hot. I went and got (V5/LPN). On 1/3/18 at 10:35 AM, V15, CNA, stated, On 12/25/17 day shift he was asleep. We went to change him and he was running a fever. He was warm to touch. Another CNA got vital signs and got the nurse. The dayshift starts a 6 AM. I only saw him right before he went to the hospital. On 12/25/17 no one told me anything was wrong with (R2). I was working with (V16/CNA). On 1/3/18 at 9:45 AM, V5 (LPN) stated, I normally don't have him. That day on 12/25/17 the aides just came and got me. (V6/LPN) gave report (V23/RN) not to me. (R2's) O2 was down to lower 80% on 2L/NC (nasal cannula). I bumped up his oxygen to 3L/NC and that increase to 99%. (R2's) temperature was 104.1. I called (V4/Physician) and received an order to send him to the emergency room . I called 911 and called his daughter. When I found him he was totally unresponsive. I had no prior knowledge that he had had a change of condition. On 1/3/18 at 10:45 AM, V23, RN, stated, On 12/25/17 (V6) gave the medications then left. I did not get report on him (R2). Usually at shift change we will do a report. To my knowledge I was not in charge of (R2). If the CNA's needed us they could come to us. I did not lay eyes on (R2) before (V5) came and got me to come and assess (R2) with her because (V5) and I were just covering for a short time. I agreed with (V5) that (R2) needed to be sent out to the hospital. On 1/3/18 at 3:40 PM, V2, Director of Nurses (DON), stated, On 12/25/17 (V5/LPN) called me and told me about (R2's) temperature and that he did not want to get up. I told her to send him out which is what she wanted to do. I was not aware that he had been lethargic prior to this. Every time I send someone out I do an investigation. I looked at his MAR. I talked to staff. I and (V1/Administrator) determined that he was up all night. I was told he wasn't drinking or eating well because he was up all night. None of the night staff told me he was sleeping a few days before Christmas on nights. The day staff stated that he was up at night. I do expect staff to notify me if a resident has a change of condition. I do agree that the 24 hour reports and MAR documents that (R2) was lethargic. (R2) was private pay he is charted on for the first 72 hours after that only with behaviors or a change of condition. On 1/4/18 at 1:00 PM, V2, stated, I expect that (V9/RN) should have notified the doctor and myself regarding (R2's) wet respirations and that he had never awakened that shift (12/24/17 into 12/25/17). On 12/24/17, I was in building and on the phone with (V8/LPN) and she never mentioned a change of condition for (R2) the need for oxygen. I expect staff to notify me of a need for oxygen. (V8) should have notified me and the doctor of his change of condition on 12/25/17. I would expect an aide to notify me if a nurse is not addressing a situation. On 1/11/18 at 2:40 PM, V1, Administrator, stated, The nurse on duty on 12/25/17 that the fire department mentioned was (V5). (V10) was the CNA. In my investigation, I questioned (V10) and she stated that is not what she said she said that he had been sleeping more the last 5 days. My investigation concluded that his appetite was poor. V1 further stated, (V8) told me she did not feel he was sleeping more. My investigation is kinda incomplete because (V8) is no longer employed here, she left voluntarily and I need to talk to her more. On 1/17/18 at 10:20 AM, V4, Physician, stated, I do know that he (R2) does refuse medications at times. From a respiratory stand point with wet respirations the man sounded like a very sick man. He at least deserved a phone call to notify me of change of condition. A change in sleeping patterns is also is a change of condition that I should have been notified of. A delay to notify me of his change of condition contributed to his death because it delayed his treatment. On 1/18/18 at 8:51 AM, V4, Physician, stated, I believe I was notified of the use of the oxygen. It is common practice that the nurses will apply oxygen and then notify me. I expect them to monitor O2 saturations and the resident while a resident is on oxygen. When his respirations became wet I should have been notified. I would have sent him out. The facility policy and procedure Change in a Resident's Condition or Status dated December 2016 documented Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The Policy documented 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d: significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; g. need to transfer the resident to a hospital/treatment center. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standards disease related clinical interventions. b. Impacts more than one area of the resident's health status.

Based on interview and record review the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) in a timely manner for 1 of 32 residents (R4) reviewed for Advanced Directives/CPR in the sample of 35. Facility staff failed to follow R4's Advanced Directives by not initiating CPR for R4, who subsequently expired. This past non compliance occurred on [DATE]. This failure resulted in an Immediate Jeopardy. This failure had the potential to affect 30 of 34 residents (R2, R6, R7, R8, R10, R11, R13-R37) whose Advanced Directives indicated Full Code Status. The immediacy was removed on [DATE] when the facility completed the following: The facility completed a facility wide audit on all Advanced Directives assuring documentation was in all medical records with full code records identified for quick reference, care plans reviewed and revised accordingly. The facility reviewed and revised the Emergency Procedure- Cardiopulmonary Resuscitation procedure and internal processes. The facility completed in-servicing for all staff on Emergency Procedure-Cardiopulmonary Resuscitation including code status during an emergency, pulling the medical record simultaneously with the crash cart, checking POLST, initiating CPR, calling 911, continuing to follow the instructions of the nurse in charge until EMS personnel arrive. The facility initiated Emergency Procedure education for all new hires and this remain ongoing. Findings include: The facility's undated Emergency Procedure-Cardiopulmonary Resuscitation policy documents, in part, 1) If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. Check code status, initiate CPR if appropriate: a) Instruct a staff member to call 911. b) Initiate the CPR. i. Chest compressions ii. Airway iii. Breathing 2) All rescuers, trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. Trained rescuers should also provide ventilations. 3) Continue with CPR until emergency medical personnel arrive. The undated Electronic Medical Record for R4 under Medical [DIAGNOSES REDACTED]. R4's Minimum Data Set (MDS), dated [DATE], documents R4's Brief Interview for Mental Status (BIMS) score as 13, indicating R4 was cognitively intact. R4's post hospital Physician order [REDACTED]. R4's Practitioner Order for Life Sustaining Treatment (POLST) form, dated [DATE], documents, Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment described in Selective Treatment and Comfort Focused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated. R4's Social Service Admission Progress Note, dated [DATE] at 11:24 AM, documents, Resident has a POLST where resident has chosen to be full code status. R4's Care Plan, dated [DATE], documents, (R4)'s Advanced Directives are in effect, and her wishes and directions will be carried out in accordance with her Advanced Directives on an ongoing basis. R4's Nurse's Notes, dated [DATE], document, 6:32 (AM) Resident reported to be unresponsive other nurse assessing pt (patient). 6:37 (AM) Ambulance service here. 7:10 AM Coroner called gave okay to release body. 10:50 AM Funeral home staff here to pick up body. The Local police department Incident Report, dated [DATE], regarding 911 call from facility on [DATE] documents the police received 911 call at 6:44 AM on [DATE]. Incident report documents E6, Certified Nurse Aide (CNA), was the first staff to find R4 unresponsive. E6 then went to find E5, CNA, to have her come to R4's room to confirm R4 was deceased before E6 reported this to Z2, Agency Licensed Practical Nurse (LPN). Per incident report, Z2 informed E6 that this was Z2's first day and told E6 to get E4, LPN. E6 went outside of building to get E4, and then E4 went to R4's room and confirmed she thought R4 was deceased and that she could not get a pulse on R4. E6 mentioned getting R4's chart to determine if R4 was to be resuscitated, and it stated R4 was a full code. 911 was contacted at that time. Per this police incident report, no one ever attempted CPR or life saving efforts. The Local fire department Incident Report, dated [DATE], documents, 911 call received at 6:44 AM and fire department arrived on scene at 6:47 AM. Per report, post patient evaluation it was determined no CPR was performed by facility staff at any time during this incident, and could not explain why. Per report, it did not appear this was related to patient assessment by employees. On [DATE] at 1:25 PM, E4, LPN, stated that on [DATE], E6, CNA, came to tell her R4 was unresponsive and Z2, Agency Nurse, had instructed E6 to come get E4. E4 stated she went and looked at R4 and asked what her code status was. E4 stated she then got R4's chart and determined R4 was a full code. E4 said she instructed E6 to call 911. E4 stated by the time she headed back to R4's room, the Fire Department personnel were headed down the hall. E4 stated no CPR was initiated by staff prior to arrival of the fire department staff. E4 stated she is able to tell in R4's chart if R4 was a full code by looking at color of paper the POLST is printed on, green paper indicated that R4 was a full code. E4 said if paper was red or orange, it would have indicated a do not resuscitate status. On [DATE] at 1:38 PM, E5, CNA, stated that on [DATE], E6 came and told her to come to R4's room. E5 said R4 was unresponsive, E6 yelled for Z2 that she was needed in R4's room, and then E6 ran to get E4. E5 stated she then went back to her hall and did not see anyone initiate CPR. On [DATE] at 1:43 PM, E3, CNA, stated she was working down the ,[DATE] Hall on [DATE] when E6 was doing her rounds on her hall and found R4 unresponsive. E3 stated E6 got Z2 and Z2 went to R4's room, then E4 went to R4's room while Z2 was looking at R4's chart to check R4's code status. On [DATE] at 9:25 AM, E6, CNA, stated that on [DATE] at 6:30 AM, she found R4 unresponsive in her room. E6 stated R4 looked pale and E6 could not tell if R4 was breathing, but E6 felt a faint pulse in R4's neck. E6 stated she went to Z2 to let her know about R4's condition, and Z2 told her to go get E4. E6 stated she went and got E5, and E5 agreed that R4 was gone. E6 stated she went outside of building at 6:40 AM to get E4 to come check R4. E6 stated E4 came to R4's room and directed E6 to call 911. E6 stated she did not know when they determined R4 was a full code because E6 was down the hall to let fire department in. E6 stated that she knew R4 was a full code because E6 works as social service staff and had completed R4's paperwork just a couple days before this incident of unresponsiveness. E6 stated she had completed an audit regarding residents code status. E6 stated she is aware if a resident is a full code and becomes unresponsive, CPR should be initiated immediately, but E6 thought a nurse needed to evaluate the situation before E6 took over. E6 stated after E4 went in to evaluate R4, E6 let E4 know that R4 was a full code. On [DATE] at 2:30 PM, E1, Administrator, stated if staff found a resident unresponsive, she would expect staff to grab the chart and the crash cart, and determine resident's code status, and if resident is a full code, immediately initiate CPR. E1 stated this should occur within one to three minutes. E1 stated the facility does not have a specific policy regarding Advanced Directives, but she would expect staff to follow what the resident's POLST states and follow the resident's wishes. On [DATE] at 2:40 PM, Z1, R4's physician, stated if a resident has a full code status, he would expect CPR to be initiated immediately. In the case of R4, he would have expected E6 to yell for help and initiate CPR. Z1 also stated that initiating CPR would probably not have changed the outcome for R4, but if resident was a full code, it should have been initiated. On [DATE] at 10:15 AM, E2, Director of Nursing (DON), provided a document titled Midnight Census Report, dated [DATE], which had R2's, R3's, R6's, R7's, R8's, R10's, and R12's through R35's names highlighted in green to indicate their code status as Full Code. On [DATE], an Immediate Jeopardy was identified. E1, Administrator, and E2, Director of Nursing, were notified of the Immediate Jeopardy Past Noncompliance on [DATE] at 8:54 AM. The immediacy jeopardy past noncompliance began on [DATE] when the facility failed to initiate CPR for R4 who was a full code status. On [DATE], the surveyor determined through observation, interview, and record review, the facility took the following action to remove the Immediacy: On [DATE], the following was initiated/completed: 1. The Social Service Designee, Minimum Data Set Coordinator, and Restorative Licensed Practical Nurse completed a facility wide audit on all Advanced Directives assuring documentation was in all medical records with full code records identified for quick reference, care plans reviewed and revised accordingly. 2. The Vice President of Clinical Operations and Administrator reviewed and revised the Emergency Procedure- Cardiopulmonary Resuscitation procedure and internal processes. 3. The Administrator, Minimum Data Set Coordinator, and Restorative Licensed Practical Nurse completed inservicing for all staff on Emergency Procedures- Cardiopulmonary Resuscitation including code status during an emergency, pulling the medical record simultaneously with the crash cart, checking POLST, initiating CPR, calling 911, continuing to follow the instructions of the nurse in charge until EMS personnel arrive. 4. The Administrator initiated Emergency Procedure education for all new hires and this remains ongoing. On [DATE] and [DATE], the following was initiated/completed: 1. All residents will have Advanced Directives choices clearly identified at the front of each medical record- ongoing. 2. The Administrator/Designee or DON/Designee will perform random procedure observation and record reviews 2 times a week for 8 weeks, then weekly times 4 weeks to ensure appropriate emergency procedures and Advance Directives are being followed. 3. Resident's Advanced Directives will be reviewed with the resident and/or responsible party upon Admission, Readmission, as needed, Quarterly and Significant Change. 4. Results of all reviews will be discussed in the Quarterly QA Meeting time 3 Quarters with educational needs discussed as needed.

Based on interview and record review, the Facility neglected to monitor a resident in severe respiratory distress and neglected to provide timely medical treatment for 1 of 4 residents (R1) reviewed for medical treatment in the sample of 4. This neglect resulted in R1 having a decline in her condition. She requied Cardio [MEDICAL CONDITION] Resuscitation and was transported to the hospital. R1 expired upon her arrival to the hospital. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to provide ongoing monitoring of resident's for changes in condition, evaluate the effectiveness of the Facility policies and procedures and their system of investigations regarding allegations of neglect. Findings include: E4, Licensed Practical Nurse (LPN), was interviewed on [DATE] at 11:38 AM. E4 said that she was R1's nurse on [DATE] when R1 was sent out to the hospital. E4 said that R1 seemed fine in the morning and had a non-productive cough. E4 stated "the Certified Nurses Aides (CNA's) were getting R1 up for lunch and they came and got me as she wasn't sounding good. I did her vitals and O2 Sat was 80% so I put O2 on her. I met Z1, R1's Physician, at the door as he was coming into the Facility and I said "come with me now". Z1 went and assessed R1 and asked if I had called her family. I called her family member and Z3 said definitely send her out to the ER (emergency room ). I called the ambulance and the hospital and got the paperwork ready. I did not call 911 - I just called for a transport. I didn't think R1 was that bad, that quick. I put the head of her bed up and put O2 on her. By the time Z1 came down to see her, she wasn't coughing anymore. I didn't think she was that bad off - I had no clue it was that bad. Z1 didn't tell me to send her out STAT - he told me to see what the family wanted to do". E4 went on to say that she did not remember if she took R1's vital signs. E4 said that she checked on R1 before she went to lunch "but, I don't remember when". E4 confirmed that no vital signs had been documented for R1 after 9:32 AM on [DATE]. R1's nurses notes dated [DATE] document the following: "9:33 AM, Resident continues on antibiotic follow-up day 2 for upper respiratory infection with no adverse reaction noted. No respiratory distress noted. Noted non-productive couch still at this time. 12:08 PM, At approximately 11:45 AM, this nurse was called to resident room, resident was gurgling and unresponsive. This nurse checked resident oxygen saturation levels (O2 Sat) and it was 80%, this nurse put oxygen (O2) at 2 liters per nasal cannula per nursing judgement, raised the head of her bed. Z1, R1's Physician was here and assessed R1. Called family to see if they wanted to send her to the ER. Family wanted her sent to ER. This nurse gathered paperwork, called ambulance and gave report to the ER. 1:15 PM, ambulance here to transport resident to ER. Resident not doing well. This nurse called family and informed the family that they need to get to the hospital as soon as possible." Z1's Physician's Progress Note, dated [DATE], and signed by Z1 documents "I was asked to see patient in acute respiratory distress of sudden onset". R1's "general appearance" is documented as "severe respiratory distress-saturation 80%, respirations 24". Z1 documented in the area on the bottom of the form entitled "Assessment/Plan: Severe Respiratory Distress, pending [MEDICAL CONDITION], acute [MEDICAL CONDITIONS], send to ER STAT." (Stedman's Illustrated Medical Dictionary, 24 th Edition, documents that stat or statim is defined as "at once, immediately".) Z1 was interviewed by telephone on [DATE] at 1:45 PM. Z1 said that E4 met him at the door as he was coming into the facility on [DATE] and asked him to look at R1. Z1 said that he told E4 to call R1's family to see if they were in agreement to send her out to the ER - "that means it's out of my hands". Z1 said that it sounded like R1 was in [MEDICAL CONDITIONS] or had pneumonia. "I said send her out As soon As Possible (ASAP). Z1 said that "STAT" means to send out ASAP. Z1 said that he would have expected R1 to get to the ER within a half-hour - "I can judge that". Z1 said "I would have moved faster if it had totally been in my hands". E9, CNA was assigned to work with R1 on [DATE]. E9 was interviewed on [DATE] at 2:10 PM. E9 said that R1's hall is her "permanent"hall and she was very familiar with R1. E9 said that R1 was "OK" in the morning, just a little bit congested. R1 "ate fine" at breakfast. "After breakfast, after laying her down, I looked in on her and she was having a hard time breathing. I got the nurse and she hooked her up to the oxygen machine and took her vitals. R1 wouldn't eat lunch, she was awake but having a hard time breathing - her chest was rattling". E9 said that she stayed on the 100 hall while the resident's were served lunch in the dining room. E9 said that she did not stay with R1 nor did she see E4 go into R1's room between 11:45 and 12:38, when EMS arrived. E9 said that she would look in at R1 when she passed R1's room and her condition appeared to be "the same". E4 said "They (EMS) were trying keep her alive with the Ambu bag. The ambulance people said that her blood pressure was extremely low". E10, CNA, was interviewed on the telephone on [DATE] at 9:00 AM. E10 said that she was working on a "different" hallway on [DATE] but, went to help transfer R1 when the paramedics showed up. E10 said that R1 was still breathing when she entered R1's room. E10 said "after I helped transfer her to the stretcher, it looked like her soul left her. She became unresponsive. They gave her oxygen, hooked up the heart rate monitor and then started bagging her". Z2, Emergency Medical Technician, stated in a telephone interview on [DATE], at 10:30 AM that the Facility did not seem to be aware of R1's medical status or "know that she was really blue" when they entered R1's room to transport her on [DATE]. Z2 said "I had initiated breathing for the patient prior to looking at the DNR form. Meanwhile, I was looking for a pulse. After looking at the DNR form and saw her code status I began CPR". The Facility had called for a "transfer only, which means no lights or sirens. Thank goodness we were close by". Emergency Medical System (EMS) Patient Care Report for R1 documents that at 12:15 PM on [DATE], the ambulance company was contacted to transfer R1 to the hospital emergency room . The Report documents that the ambulance arrived at the Facility at 12:34 PM and was at R1's bedside at 12:38 PM. The Narrative on the Report documents the following: "Requested to respond non-emergent to Facility for a patient with cardiac problems. Upon arrival at Facility, looked around for a nurse to obtain paperwork and report. After a couple of minutes a staff member came up to the nurses station and gave me paperwork. I asked her what is going on with the patient and she told me that patient just finished a Z-pack antibiotics for an upper respiratory infection but her lungs still sound bad. She stated the doctor was here and wants her sent to the emergency room (ER) because he believed that patient is going into [MEDICAL CONDITIONS]. I asked how long had it been since the doctor saw the patient and I was told today, but she couldn't give me a time because she wasn't the nurse for that hall, that nurse was at lunch. Staff member then showed EMS where patients room was. Once at patients side noted patient was on 2 liters of oxygen via nasal cannula, patient is dark blue in face. Assessed Loss of Consciousness (LOC) and patient is unresponsive to painful stimuli, with a respiratory rate of 4 showing agonal respirations, deep, gurgling breaths. Moved patient to stretcher, started high flow oxygen with Bag-Valve-Mask ventilation (BVM), placed on cardiac monitor showing an idioventricular rate of 44. Unable to feel radial pulses or palpate a carotid pulse. Obtained an automatic blood pressure via cardiac monitor showing ,[DATE]. I asked the staff member that gave me the paperwork if patient was a full code or not, she went and grabbed patients code status advising that she is a Do Not Resuscitate (DNR). I asked to see the DNR and the DNR stated that if patient is still breathing or has a pulse to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR). At that time I told the nurse to give us a few minutes and call the family and let them know that this has turned into an emergency and they may want to get to the hospital. We took patient to unit, placed combo pads on patient, and started CPR. Attempted assessment for possible intubation and found clumps of food in patients mouth, in turn I suctioned a large amount of yellowish/orange thickened liquid and clumps from oral Pharynx and out of airway. Continued to ventilate patient via BVM and CPR, glucose assessed, 18 gauge intravenous line (IV) location established in patients left elbow joint and flushed. 5 [MEDICATION NAME] of [MEDICATION NAME] given throughout transport. My partner called in report while I continued with CPR. On arrival at hospital advised to take patient to ER 4 with staff entering room with EMS. Patient moved to ER bed. Patient asystolic without CPR. Showed ER doctor the DNR form and the specific comments about initiating CPR. Shortly after ER Doctor pronounced the patient at 1314 as deceased ". E2, Director of Nursing (DON) and E3, Assistant Director of Nursing (ADON) were interviewed on [DATE] at 1:25 PM concerning the incident with R1 on [DATE]. Both E2 and E3 confirmed that 30 minutes had elapsed between R1's onset of symptoms and when the telephone call was placed for R1's non-emergent transfer to the hospital. Both also confirmed that there is no documentation showing that anyone in the Facility checked on R1 while she was waiting to be transported to the hospital. During an interview with E1, Administrator, on [DATE] at 11:15 AM, she stated that the Facility did not begin investigating the incident involving R1 until after it was brought to their attention by the surveyor on [DATE]. The Facility's policy entitled "Investigating Allegations of Neglect" documents that "All reported incident's of neglect will be promptly and thoroughly investigated. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a Resident's physical or mental condition. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death". The Immediate Jeopardy was identified to have begun on [DATE], when staff neglected to monitor R1 who was in severe respiratory distress and failed to provide timely medical treatment. E1 was informed of the Immediate Jeopardy on [DATE] at 11:20 AM. Based on interview and record review, the Facility took the following actions to remove the Immediate Jeopardy: 1. The DON and/or ADON began and continue to provide ongoing monitoring of resident's for changes in condition. Began on [DATE] and continues. 2. Risk Manager (RM) investigated incident concerning R1, including staff interviews. Completed [DATE]. 3. Staff Development Coordinator (SDC) began inservicing licensed staff on readmission to hospital, changes in resident's condition, assessment of resident's, notification of physician, documentation, code status, when to initiate CPR, CPR training, potential neglect and what STAT means for nursing orders. SDC began inservicing Certified Nurses Aides (CNA's) on changes in resident's condition, assessment of resident's and documentation, all which could lead to a potential for neglect. Completed [DATE]. 4. RM reviewed all resident's clinical records for code status and care planned accordingly. Completed [DATE]. 5. Quality Assessment Committee reviewed systems, and policies and procedures. No changes were necessary. Completed [DATE].

Based on interview and record review, the Facility failed to monitor and treat a resident in [MEDICAL CONDITION], and failed to immediately call for an ambulance as ordered by the physician for 1 of 4 resident's (R1) reviewed for changes in condition in the sample of 4. This failure resulted in R1 expiring upon arrival at the hospital emergency room . This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to provide ongoing monitoring of resident's for changes in condition and evaluate the effectiveness of the Facility policies and procedures. Findings include: R1 was originally admitted to the facility on [DATE], with diagnoses, in part, of [MEDICAL CONDITION], Alzheimer's Dementia and Depression. R1's Minimum Data Set (MDS), dated [DATE], documents that she is cognitively impaired and requires extensive staff assistance with all activities of daily living. R1's plan of care, dated [DATE] with an original date of [DATE], documents "resident has the following Advanced Directives on record: Health Care Surrogate; DNR of [DATE]. Resident is not capable of making informed consent regarding their health care decisions". R1's computerized vital signs record documents that at 9:32 AM on [DATE] her vital signs were as follows: Blood Pressure-,[DATE]; Temperature-97.4; Pulse-89, Respirations-24. There are no further vital signs documented for R1 on [DATE]. R1's nurses notes dated [DATE] document the following: "9:33 AM, Resident continues on antibiotic follow-up day 2 for upper respiratory infection with no adverse reaction noted. No respiratory distress noted. Noted non-productive couch still at this time. 12:08 PM, At approximately 11:45 AM, this nurse was called to resident room, resident was gurgling and unresponsive. This nurse checked resident oxygen saturation levels (O2 Sat) and it was 80%, this nurse put oxygen (O2) at 2 liters per nasal cannula per nursing judgement, raised the head of her bed. Z1, R1's physician was here and assessed R1. Called family to see if they wanted to send her to the ER. Family wanted her sent to ER. This nurse gathered paperwork, called ambulance and gave report to the ER. 1:15 PM, ambulance here to transport resident to ER. Resident not doing well. This nurse called family and informed the family that they need to get to the hospital as soon as possible." Emergency Medical System (EMS) Patient Care Report for R1 documents that at 12:15 PM on [DATE], the ambulance company was contacted to transfer R1 to the hospital emergency room . The Report documents that the ambulance arrived at the Facility at 12:34 PM and was at R1's bedside at 12:38 PM. The Narrative on the Report documents the following: "Requested to respond non-emergent to Facility for a patient with cardiac problems. Upon arrival at Facility, looked around for a nurse to obtain paperwork and report. After a couple of minutes a staff member came up to the nurses station and gave me paperwork. I asked her what is going on with the patient and she told me that patient just finished a Z-pack antibiotics for an upper respiratory infection but her lungs still sound bad. She stated the doctor was here and wants her sent to the emergency room (ER) because he believed that patient is going into [MEDICAL CONDITIONS]. I asked how long had it been since the doctor saw the patient and I was told today, but she couldn't give me a time because she wasn't the nurse for that hall, that nurse was at lunch. Staff member then showed EMS where patients room was. Once at patients side noted patient was on 2 liters of oxygen via nasal cannula, patient is dark blue in face. Assessed Loss of Consciousness (LOC) and patient is unresponsive to painful stimuli, with a respiratory rate of 4 showing agonal respirations, deep, gurgling breaths. Moved patient to stretcher, started high flow oxygen with Bag-Valve-Mask ventilation (BVM), placed on cardiac monitor showing an idioventricular rate of 44. Unable to feel radial pulses or palpate a carotid pulse. Obtained an automatic blood pressure via cardiac monitor showing ,[DATE]. I asked the staff member that gave me the paperwork if patient was a full code or not, she went and grabbed patients code status advising that she is a Do Not Resuscitate (DNR). I asked to see the DNR and the DNR stated that if patient is still breathing or has a pulse to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR). At that time I told the nurse to give us a few minutes and call the family and let them know that this has turned into an emergency and they may want to get to the hospital. We took patient to unit, placed combo pads on patient, and started CPR. Attempted assessment for possible intubation and found clumps of food in patients mouth, in turn I suctioned a large amount of yellowish/orange thickened liquid and clumps from oral Pharynx and out of airway. Continued to ventilate patient via BVM and CPR, glucose assessed, 18 gauge intravenous line (IV) location established in patients left elbow joint and flushed. 5 [MEDICATION NAME] of [MEDICATION NAME] given throughout transport. My partner called in report while I continued with CPR. On arrival at hospital advised to take patient to ER 4 with staff entering room with EMS. Patient moved to ER bed. Patient asystolic without CPR. Showed ER doctor the DNR form and the specific comments about initiating CPR. Shortly after ER Doctor pronounced the patient at 1314 as deceased ". Z2, Emergency Medical Technician, stated in a telephone interview on [DATE], at 10:30 AM that the Facility did not seem to be aware of R1's medical status or "know that she was really blue" when they entered R1's room to transport her on [DATE]. Z2 said that she asked R1's DNR status and no one from the Facility knew what it was. Z2 said that they brought her the DNR form after she started "bagging" R1. Z2 said that the nurse said R1 was a DNR. Z2 asked to look at the form and noted that it said to initiate CPR if R1 had a pulse or blood pressure. Z2 told the staff that R1 is not a DNR. Z2 said "I had initiated breathing for the patient prior to looking at the DNR form. Meanwhile, I was looking for a pulse. After looking at the DNR form and saw her code status I began CPR". The Facility called for a "transfer only, which means no lights or sirens. Thank goodness we were close by". E4, Licensed Practical Nurse (LPN), was interviewed on [DATE] at 11:38 AM. E4 said that she was R1's nurse on [DATE] when R1 was sent out to the hospital. E4 said that R1 seemed fine in the morning and had a non-productive cough. E4 stated "the Certified Nurses Aides (CNA's) were getting R1 up for lunch and they came and got me as she wasn't sounding good. I did her vitals and O2 Sat was 80% so I put O2 on her. I met Z1, R1's physician, at the door as he was coming into the Facility and I said "come with me now". Z1 went and assessed R1 and asked if I had called her family. I called her family member and she said definitely send her out to the ER. I called the ambulance and the hospital and got the paperwork ready. I did not call 911 - I just called for a transport. I didn't think she was that bad, that quick. I put the head of her bed up and put O2 on her. By the time Z1 came down to see her, she wasn't coughing anymore. I didn't think she was that bad off - I had no clue it was that bad. Z1 didn't tell me to send her out STAT - he told me to see what the family wanted to do". E4 went on to say that she did not remember if she took R1's vital signs. E4 said that she checked on R1 before she went to lunch "but, I don't remember when". E4 confirmed that no vital signs had been documented for R1 after 9:32 AM on [DATE]. Z1's Physician's Progress Note, dated [DATE], and signed by Z1 documents "I was asked to see patient in acute respiratory distress of sudden onset". R1's "general appearance" is documented as "severe respiratory distress-saturation 80%, respirations 24". Z1 documented in the area on the bottom of the form entitled "Assessment/Plan: Severe Respiratory Distress, pending [MEDICAL CONDITION], acute [MEDICAL CONDITIONS], send to ER STAT." (Stedman's Illustrated Medical Dictionary, 24 th Edition, documents that the word stat or statim is defined as "at once, immediately".) Z1 was interviewed by telephone on [DATE] at 1:45 PM. Z1 said that E4 met him at the door as he was coming into the facility on [DATE] and asked him to look at R1. Z1 said that he told E4 to call R1's family to see if they were in agreement to send her out to the ER - "that means it's out of my hands". Z1 said that it sounded like R1 was in [MEDICAL CONDITIONS] or had pneumonia. "I said send her out As soon As Possible (ASAP). Z1 said that "STAT" means to send out ASAP. Z1 said that he would have expected R1 to get to the ER within a half-hour - "I can judge that". Z1 said "I would have moved faster if it had totally been in my hands". E9, CNA, was assigned to work with R1 on [DATE]. E9 was interviewed on [DATE] at 2:10 PM. E9 said that R1's hall is her "permanent"hall and she was very familiar with R1. E9 said that R1 was "O.K." in the morning, just a little bit congested. R1 "ate fine" at breakfast. "After breakfast, after laying her down, I looked in on her and she was having a hard time breathing. I got the nurse and she hooked her up to the oxygen machine and took her vitals. R1 wouldn't eat lunch, she was awake but having a hard time breathing - her chest was rattling". E9 said that she stayed on the 100 hall while the resident's were served lunch in the dining room. E9 said that she did not stay with R1 nor did she see E4 go into R1's room between 11:45 and 12:38, when EMS arrived. E9 said that she would look in at R1 when she passed R1's room and her condition appeared to be "the same". E4 said "They (EMS) were trying keep her alive with the Ambu bag. The ambulance people said that her blood pressure was extremely low". E10, CNA, was interviewed on the telephone on [DATE] at 9:00 AM. E10 said that she was working on a "different" hallway on [DATE] but, went to help transfer R1 when the paramedics showed up. E10 said that R1 was still breathing when she entered R1's room. E10 said "after I helped transfer her to the stretcher, it looked like her soul left her. She became unresponsive. They gave her oxygen, hooked up the heart rate monitor and then started bagging her". E5, Care Plan Coordinator, stated in an interview on [DATE] at 12:10 PM, that she was working at the Facility on [DATE] but, not on R1's hallway. E5 said that E4 told her that R1 was going out to the hospital and had been seen by Z1 - "that was it". E5 had been gone to lunch about 5 minutes when the EMT's arrived. "We went down to R1's room, put her on the stretcher and they started working on her". E5 said that the EMT's started R1 on a heart rate monitor, did a oxygen saturation reading and listened to her lungs. E5 said that the EMT said "she's not doing well" and began "bagging" her. As the EMT's were leaving they said to call R1's family. "Her heart rate was maybe in the 40's". E5 said that she had not seen R1 on [DATE] prior to assisting in her transfer. E2, Director of Nursing (DON) and E3, Assistant Director of Nursing (ADON) were interviewed on [DATE] at 1:25 PM, concerning R1's transfer on [DATE]. Both E2 and E3 confirmed that 30 minutes had elapsed between R1's onset of symptoms and when the telephone call was placed for R1's non-emergent transfer to the hospital. Both also confirmed that there is no documentation showing that anyone in the Facility checked on R1 while she was waiting to be transported to the hospital. Both E2 and E3 stated that the Facility does not have a policy defining a medical emergency. E2 said that nurses should use "good nursing judgement" in a situation such as occurred with R1. The Immediate Jeopardy was identified to have begun on [DATE], when staff failed to monitor a resident in respiratory distress and failed to immediately call for an ambulance as ordered by the physician. E1 was informed of the Immediate Jeopardy on [DATE] at 11:20 AM. Based on interview and record review, the Facility took the following actions to remove the Immediate Jeopardy: 1. The DON and/or ADON began and continue to provide ongoing monitoring of resident's for changes in condition. Began on [DATE] and continues. 2. Risk Manager (RM) investigated incident concerning R1, including staff interviews. Completed [DATE]. 3. Staff Development Coordinator (SDC) began inservicing licensed staff on readmission to hospital, changes in resident's condition, assessment of resident's, notification of Physician, documentation, code status, when to initiate CPR, CPR training, potential neglect and what STAT means for nursing orders. SDC began inservicing Certified Nurses Aides (CNA's) on changes in resident's condition, assessment of resident's and documentation, all which could lead to a potential for neglect. Completed [DATE]. 4. RM reviewed all resident's clinical records for code status and care planned accordingly. Completed [DATE]. 5. Quality Assessment Committee reviewed systems, and policies and procedures. No changes were necessary. Completed [DATE].

Based on observation, interview and record review, the facility failed to provide appropriate treatment for [REDACTED]. This failure resulted in R29 developing [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED] and having her left great toe amputated. Findings include: 1. R29's Physician order [REDACTED]. R29 has a Physician order [REDACTED]. Cleanse area and apply [MEDICATION NAME] ointment and dry dressing q (every) day and PRN (as needed). POS documents an order of 7-19-11 "May send res (resident) to ER (emergency room ). POS shows an order of 7-19-11 for Bactrin DS BID (twice a day) po (by mouth) x 10 days. It is documented on 7-21-11 on the POS to refer to a vascular surgeon to evaluate and treat left great toe. POS documents an order on 7-22-11 to send R29 to the ER for evaluation per family demand. R29's Wound Culture of left great toe on 7-19-11 [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus) which was resistive to Bactrim DS. The culture does not identify sensitivity to Keflex. NURSE/PHYSICIAN COMMUNICATION RECORD of 7-17-11 has documentation that reason for calling the physician is left great toe very red, swollen , hot to touch , nail bed above nail red and top of the toe is purple. Temperature is 99 degrees, pulse is 90, blood pressure is 110/68. Pain is 3 out of 5. Pain medication given for comfort. Physician called and gave order for [MEDICATION NAME] 1 gm IM qd x 2 days then start Keflex 500mg every 6 hours x 8 days. Record also shows the above order for cleaning and treating the wound. Note at 2PM states R29 states foot and even her leg hurt half way up her calf. No drainage. NURSE/PHYSICIAN COMMUNICATION RECORD of 7-19-11 documents, "L (left) great toe declining". Time of Physician response states 12 noon with orders to send R29 to the ER for evaluation. Note at 10AM documents, "CNA (Certified Nurse Aide) came & told this nurse L toe looks worse very red & swollen hot to touch mushy on bottom & purple has yellow drainage coming out. Res was started on ABt (antibiotic) 7/17/11. Call placed to Dr. (Doctor) awaiting call back." Note at 12 noon documents, "Dr states send res to ER for eval. DON (Director of Nursing) states call Dr. back ask for culture order & ? about IV antibiotics. awaiting call back." (POS review shows no order was obtained for IV antibiotics.) Note at 3:20PM documents, "Spoke with Dr.-- at length re (regarding) res cond (condition), states to send res to ER if res chooses to go. This Nurse evaluated L great toe et (and) noted 0 increase in redness or swelling noted from eval on Sunday evening, res (resident) reassured and states does not want to go to ER..." It is documented on 7-20-11 Nurses Notes that R29 left the facility with a family member at 8:30AM for a Doctor appointment. E1, Administrator, stated on 10-21-11 at 11AM, she could not find any information as to where R29 went on 7-20-11. She stated it is suppose to be documented in the Nurses Notes but it is not. E1 suggested to call R29's sister and she may know. On 7-20-11 at 12:40PM, Z4, R29's sister, stated she took R29 to the plastic surgeon who operated on her buttock wound and the Surgeon did not look at R29's toe. It is documented in the Nurses Notes on 7-20-11 that R29's left toe continues to be swollen, red and purple with large amount of yellow slough noted, continues to have scant amount of serosanguinous drainage. R29 ambulates and full weight bearing to left lower extremity without difficulty. Left foot slight swollen inner arch and slight red in color. (Facility WEEKLY WOUND OR SKIN ABNORMALITY TRACKING LOG of 7-22-11 identifies left toe wound with treatment of [REDACTED]. ".2 slit on nail bed. 0 toenail. Just starting to grow from bottom of toe nail bed. There is no mention of color, swelling, slough or drainage.) Z5, Nurse Practioner, documented on a progress note of 7-21-11, that R29 was seen to follow up on a Vascular Ulcer to great left toe. Onset 5-7 days ago on antibiotic therapy. Denuded skin up to 1st knuckle. A large piece debrided off with slight bleeding. Wound base white. Rest of toe mushy under skin. Plan to send to Vascular Surgeon. Nurses Note 7-20-11 states R29 propels self around facility in wheel chair. Note of 7-22-11 states R29 has pain in left leg, 3 plus [MEDICAL CONDITION] noted in left leg and foot. It is documented on 7-22-11 at 12 noon, Z4 was called to tell her of appointment for vascular surgeon. Z4 stated, "I demand my sister be sent to hospital now!" It is documented at 6:25PM R29 was admitted to the hospital for IV antibiotic [MEDICAL CONDITION] to R (right) great toe. (Yet above medical records show it was the left great toe.) It is documented in R29's Hospital History and Physical of 7-23-11, that R29 came to the hospital with chief complaint of having noted left toe pain and redness and swelling ongoing for a few days. She had broken her toe nail and started noticing that there was some redness in the beginning but no purulence or bleeding. Later on the toe started to swell and she had severe pain. Physical examine showed left foot great toe has significant [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. No open wounds or ulcers. No purulent discharge noted at this time. It is documented under Assessment and Plan: Left foot diabetic ulcer with [MEDICAL CONDITION] associated with leukocytosis, subjective fever. Culture is positive [MEDICAL CONDITION]. Continue [MEDICATION NAME], obtain podiatry on consult, wound care on consult. Arterial Doppler negative for evidence for [MEDICAL CONDITION]. Continue [MEDICATION NAME] topically. Obtain X-ray of the foot for signs of osteo[DIAGNOSES REDACTED]... It is documented on the Hospital X ray of R29's left foot, on 7-22-11, Soft tissue swelling of the great toe is seen. Irregularity of the tuft of the distal phalanx of the great toe. This may be due to bony erosion as a result of osteo[DIAGNOSES REDACTED]. This could be due to prior trauma. A small linear lucency in the area, possibly a more recent fracture. Mild [MEDICAL CONDITION] osteoarthritic changes. Small posterior calcaneal spur. It is documented on R29's Consultation Report of 7-24-11 by Z3, Podiatrist, R29 does have a large ulceration distal tip of the left hallux. There is exposed bone of the distal phalanx tip present. It is somewhat fibrotic and necrotic. X ray results are suspicious for osteo[DIAGNOSES REDACTED] . There does appear to be some destruction about the distal tip of the distal phalanx...Assessment: Osteo[DIAGNOSES REDACTED] of the left hallux distal phalanx with associated [MEDICAL CONDITION] and foot ulceration. Plan includes, in part, treat with amputation of the distal phalanx of the hallux...continue on current IV antibiotics... Hospital Discharge Summary of 7-27-11 states discharge diagnoses, in part: Osteo[DIAGNOSES REDACTED] of the distal phalanx of the left great toe; status [REDACTED]. Hospital Course: R29 came to the ER and admitted with severe pain in her right great toe and was admitted to the hospital She has a left [MEDICAL CONDITION] and was diagnosed to have cellulites of the foot, and was started on IV antibiotics because of the wound and the leukocytosis and fever. R29 was diagnosed as having osteo[DIAGNOSES REDACTED] and underwent amputation of the distal phalanx of the left great toe for the osteo[DIAGNOSES REDACTED]. During interview with E20, Licensed Practical Nurse (LPN) on 10-14-11 at 11:45AM, E20 stated on 10-19-11 she was told by a CNA that R29's toe was getting worse. E20 stated she had not seen the toe before. It was really big very swollen purple on bottom and the top was cracked with yellow drainage. It was crusty. E20 thought R29 needed to go to the hospital. She had been on antibiotic's for 2 days. It must not have been working. E20 called Z2, R29's Physician and told him of her concerns and he ordered for her to be sent to the hospital. E20 stated they have to let, E2, Director of Nursing (DON) know when they are sending a resident to the hospital. E20 stated she told E2 and E2 stated to call Z2 back and see if they could treat the toe at the facility. R29 was not refusing to go to the hospital. It was the end of the shift so E21, Registered Nurse (RN) took over. On 10-19-11, E21 stated she was the Nurse who initially saw R29's toe on 7-19-11. Her great toe was red and swollen and real purple on the end with yellow drainage. It looked like a blister area on the end of the toe. She called Z2 and got an order for [REDACTED]. and Procedure to check with E2 or the Nurse on call, before sending residents to the hospital. E21 stated she thought E2 went and looked at the toe and thought they could treat it at the facility with IV antibiotics. E21 stated she was the one who had to call Z2 back and tell him E2 wanted to treat R29 in house. E21 stated Z2 was very upset. He wanted her sent to the hospital. He felt he was being seconded guessed. He asked E21 if she had seen the toe that day and she told him "NO", she had just come on duty. Z2 told her he did not understand why they did not want to send R29 out and said if she wants to go send her. E21 said she then looked at R29's toe and talked to R29. The toe didn't look any worse. Her accu check was good. E21 stated she told R29 the antibiotics had not had a chance to work. E21 states she felt she convinced R29 she didn't need to go the the ER. E21 stated she felt pressured not to send R29 to the hospital. E21 stated after R29 went to the hospital she talked to E1 and E2 of concerns of not doing what Z2 wanted. Facility Policy got in the way of good patient care. Z2 did not give an order to not send R29. He said she had just had 2 days of IM [MEDICATION NAME]. He wanted her to go to the hospital based on what the Nurse told him that morning. E21 stated at the time, there was no written order to send R29 to the ER. It was written on the Nurse communication record but not on the POS. On 10-19-11 at 2:15PM, Z2 stated he had gotten a report from a Nurse that R29's wound on her toe was worse. He wasn't at the facility at the time. If the wound is not getting better in 2 days and is worse, someone needs to look at it. He ordered for R29 to be sent to the hospital. If he over reacted then the worse thing that happens is they send her back. If needed they would admit her. They called Z2 back and said E2 wanted to treat R29 at the facility. Z2 stated he had concerns and thought R29 should go to the hospital. Z2 stated he did not rescind the order to send R29 to the ER. The only reason not to send her is if she refused to go. Z2 stated if the toe was becoming gangrenous then waiting 2 days would not have made a difference. She probably would have lost the toe anyway. (There is nothing in hospital records that show R29's toe was gangrenous.) E2 stated on 10-21-11 at 10:45 AM, she was not aware Z2 had ordered for R29 to go to the hospital. E20 had told her she was sending R29 out to the hospital and E2 told her she should ask for a culture and antibiotics and treat at the facility. E2 denied she told E20 not to send R29 to the ER. "If someone wants to go to the hospital it's her right." E2 stated she did not look at R29's toe before telling E20 to call Z2 and see if she could be treated at the facility. She stated there was no written Policy and Procedure that she or a charge Nurse had to approve before a resident was sent out to the hospital. On 10-21-11 at 10:55PM, E22, LPN, stated it had been the rule around the facility that you had to get approval to send a resident to the hospital. They wanted residents to be treated in the facility unless it was an emergency. On 10-21-11 at 11AM, E1, Administrator, stated there was no written Policy and Procedure to not send a resident to the hospital unless the DON or charge Nurse approves. The do want the Nurses to run it through the DON before sending out unless it's an emergency due to some Nurses getting carried away and sending a resident out when they could be treated at the facility. On 10-20-11 at 3:05PM, Z3, R29's Surgeon/Podiatrist, stated trauma could have caused injury to R29's left great toe. Even rubbing shoe on toe could have caused the injury. She doesn't have much feeling in the toe and she could be doing damage without knowing it. Z3 stated they possibly could have saved the toe if it was treated earlier. When he saw it, bone was exposed and it was too late. Once bone is exposed it has to be amputated. Possibly with IV antibiotics and staying off her feet, the toe may have been saved. It could have healed. Two days could make a difference. 2. R8 was observed on 10-12-11 at 12:30PM, to have two ulcerated areas on her right foot and one on her left foot. E7, Treatment Nurse, was present and confirmed the areas and stated they were not pressure sores. Record review of R8's Medical Record and Treatment Administration Record (TAR) show R8's ulcerated areas on her feet were not assessed. At 1:20PM, E1, Administrator, stated she had just looked at R8's feet and stated it looks arterial and R8 needs a doppler study. E1 was informed there was a treatment order on the TAR for treatment to the left lower extremity but no assessment. At 1:50PM, E1 stated she could not find an assessment on R8's feet. E1 stated the policy is to do an initial assessment and document and then assess and document weekly. 3. The Admission sheet identifies R14 as being readmitted to the facility on [DATE]. According to the Minimum Data Set ((MDS) dated [DATE], R14 receives [MEDICAL TREATMENT] services. There are no orders for [MEDICAL TREATMENT] services and no orders for the [MEDICAL TREATMENT] catheter or shunt site on the physician's orders [REDACTED]. A "[MEDICAL TREATMENT] Communication Form" dated 10/11/11 indicates R14 goes to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The care plan dated 8/5/11 has [MEDICAL TREATMENT] identified only under Dehydration for fluids restriction. There are no directions and/or care interventions toward monitoring the catheter or shunt site or for intake/output regarding the fluid restriction in the care plan. On 10/13/11 at 10:35am, R14 was in her room eating lunch. R14 stated she eats before she goes to [MEDICAL TREATMENT] and is leaving for that around 11am. R13 had a dressing upper left arm. R14 stated she was on a special diet. On 10/13/11 at 11:05am, E9, Licensed Practical nurse identified R14's shunt site as the left arm and stated "yea" when asked if she checked the site including Bruit/Thrill. E9 was unsure as to where the nurses charted the assessment then stated she thought they charted it on the daily [MEDICAL TREATMENT] sheet. When asked how often, she hesitated and stated "daily." E9 also identified R14 as being on 1500cc fluid restriction but could find no order for it on the current physician's orders [REDACTED]. [MEDICAL TREATMENT] Communication Reports are sent home with R14 and have a section to be completed post [MEDICAL TREATMENT] by the facility. The report is blank for "Vascular Access Condition" for her 10/11/11 visit. The only other daily sheets are dated 10/1/11, 9/29/11, 9/22/11, and 9/27/11. The Treatment Administration Records, Medication Administration Records and the nurses notes were all reviewed and found to be void of any information regarding R14's catheter or shunt site and/or Bruit/Thrill. According to the facility's policy on [MEDICAL TREATMENT] dated 11/1/07, residents receiving [MEDICAL TREATMENT] treatments will be appropriately assessed for complications and will together, with the [MEDICAL TREATMENT] treatment center, communicate and collaborate to assess, implement, evaluate, and revise the resident's plan of care. Under care of the shunt, it states care will be provided by a licensed nurse and include leaving dressing in place for 24 hours, closely inspect dressing for drainage and bleeding, sites are checked for patency and condition daily an upon return from [MEDICAL TREATMENT] "If a bruit changes in regularity or depth or if thrill is not able to be palpated, notify the physician immediately." The policy also indicates blood pressures or venous punctures will be not performed on the extremity where the shunt is located. In addition, the policy states the residents plan of care will include the following: [MEDICAL TREATMENT] order - There are no orders on the POS for [MEDICAL TREATMENT]. Monitor Intake and Output (I&0) - review of the I&0 sheet since her return from the hospital on [DATE] is incomplete. The COMPREHENSIVE INTAKE & OUTPUT RECORD (8 HOUR SHIFTS) has no 24 hour totals recorded and only 6 of 11 shifts completed. The policy also indicates common nursing practice will be implemented that includes shunt assessment and monitoring. The Contract for Outpatient [MEDICAL TREATMENT] Services indicates they will provide information on all aspects of the management of the residents care related to the provision of [MEDICAL TREATMENT] services including but not limited to bleeding/hemorrhage, infection/bacteria, and care of the [MEDICAL TREATMENT] site and disinfection of [MEDICAL TREATMENT].

Based on record review, observation and interview, the facility failed to provide timely turning and repositioning and pressure sore identification, monitoring and treatment for 1 of 7 residents (R16) in the sample of 21 and 1 resident (R28) in the supplemental sample reviewed for turning and reposition and pressure sore prevention. This failure resulted in R28 developing an unstageable left heel pressure sore. Findings include: 1. R16's Minimum Data Set (MDS), dated [DATE], documented severe cognitive impairment, total dependence of two plus persons physical assistance with mobility and transfers, bilateral upper and lower extremity impairment and two Stage II pressure sores. R16's Care Plan, goal date 11-17-11, documented R16 was to be turned and repositioned every 2 hours and as needed. During observation of R16's turning and repositioning, on 10-12-11 from 9:25a.m. to 12:20p.m., R16 was not timely turned and repositioned. Interview of E14, Registered Nurse (RN), on 10-12-11 at 9:25a.m., E14 stated R16 was"pulled up and switched her sides." R16's position was observed the same before and after her positioning with coccyx and buttock pressure remaining and unrelieved with being pulled up and sides switched. E13, Certified Nursing Assistant (CNA) and E5 (CNA), were observed checking R16 adult diaper for incontinence, on 10-12-11 at 11:40a.m., E5 and E13 did not reposition R16. 2. R28's MDS, dated [DATE],documented severe cognitive impairment, total dependence of one person physical assist with mobility and transfer, bilateral upper and lower extremity impairment and at risk for pressure sore development. The facility's Weekly Wound or Skin Abnormality Tracking Log, week ending date 8-5-11, documented a 5.0cm x 4.0cm unstageable area was found on R28's left heel on 8-1-11. Interview of E7, Treatment Nurse, on 10-13-11 at 1:40p.m., E7 stated she started as the Treatment Nurse on 8-5-11 and R28's entire left heel was very, very deep purple and boggy, mushy, when she saw it. E7 also stated she documented the measurements of R28's left heel on the Tracking Log, week ending date 8-5-11 and future Tracking Logs. R28's Weekly Wound or Skin Abnormality Tracking Log, week ending 8-12-11, documented R28's left heel as an unstageable 5.0cm x 4.0cm "escar (eschar)" area. Review of R28's chart did not document R28's left heel was monitored for pressure sore development until it was found on 8-1-11 as a 5.0cm x 4.0cm unstageable area. R28's MDS, dated [DATE], document she was at high risk for pressure sore development. R2's Skin Risk Evaluation and Plan of Care, goal date 12-25-11, documented R28 was at risk for skin breakdown. It was also noted R28's left heel pressure sore was not documented on her Care Plan with goals identified and/or interventions for her left heel. The facility's Wound Prevention/Skin and Wound Treatment policy and procedure, dated 10-1-08,documented, in part, residents will exhibit no evidence of sign breakdown or will regain skin integrity. It was also documented that all residents at risk will have skin condition checked and documented daily. Interview of E16, Medical Records, on 10-14-1 at 1:15p.m., E16 stated she was not finding Weekly Skin Condition Evaluation sheets for 7-11, 8-11 and 9-11. E16 then provided, on 10-14-1 at 1:50p.m., Weekly Skin Condition Evaluations, dated 2-11 to 10-11, which did not document skin breakdown of R2's left heel until 8-15-11.

Based on record review, interview and observation, the facility failed to provide a safe transfer for a resident with a history of falls; failed to ensure a resident's siderail was properly functioning; and failed to provide timely supervision, care planning and fall prevention for residents 4 of 10 residents ( R2, R3, R8 and R15) reviewed for falls in a sample of 21. This failure resulted in R2 fall and fracturing his left hip. This failure also resulted in R15 falling and fracturing her right hip. Findings include: 1. R2's Investigation Report, dated 5-23-11, documented R2 was found, on 5-20-11, sitting on the floor, bedside. It was also noted R2 had a [DIAGNOSES REDACTED]. R2 complained of right ankle pain and edema. R2's Investigation Report, dated 6-17-121, documented R2 was found sitting on the floor in a puddle of urine. It was also noted R2 was attempting to ambulate unassisted. R2's Investigation Report, dated 7-11-11, documented R2 was found sitting on the floor in his room. It was also documented R2 was a risk factor for weakness and Dementia. R2's Investigation Report,dated 10-3-11, documented R2 was found, on 7-11-11, leaning up against his roommates bed. It was also noted R2 sustained a left hip fracture. R2's Fall Risk Assessments, dated 5-11 and 6-11, documented R2 was a high risk for falls. It was also noted R2 had a history of [REDACTED]. R2's Plan of Care, current, did not document R2's falls or interventions to prevent further falls. R2's Behavioral Tracking, dated 7-11, 8-11 and 9-11,documented "Continuously getting out of wheel chair" with documented interventions. R2's Care Plan did not document R2's behavior or interventions documented on R2's Behavior tracking Sheet. The facility's Fall Management policy and procedures, dated 11-07, documented "the facility will identify residents at risk for falls and implement interventions to minimize fall occurrences and injury real ted to falls." It was also noted A Fall Risk Evaluation and Care Plan will be completed when the resident is identified to be at risk for fall or has had a fall to ensure that appropriate interventions are put into place." 2. According to the Minimum Data Set ((MDS) dated [DATE], R15 requires extensive assist of one staff for mobility, transfers, toilet use, hygiene and ambulation. The MDS also indicates that R15 has a moderate cognitive impairment and has sitting and standing balance deficits. The care plan dated 05/05/11 identifies R15 at high risk for falls requiring ADL assistance and supervision. A goal listed on the care plan dated 05/05/11 was listed as "resident will have fewer episodes of trying to get out of wheelchair." On 06/08/11, a "Nurse/Physician Communication Record" indicated that R15 had "fallen forward from her wheelchair to the floor." The document indicated that R15 sustained a hematoma to the right side of the forehead. Further notations indicated that the physician was notified with no new orders. The care plan dated 06/08/11 listed interventions, in part as, "give verbal cues and offer to lay down after meals or when noted sleeping in wheelchair." On 06/25/11 a "Resident Occurrence Report" indicated that R15 was found on the floor in her room next to her bed. It further indicated that R15 was complaining of right hip pain and pain to the right lower extremity. R15 was sent to the hospital where x-ray results showed a right subcapital femoral fracture resulting from trauma from a fall. Hospital records also indicated that a urine sample was obtained in the emergency department upon arrival indicating R15 also had an urinary tract infection. The only new intervention put into place was "Increase monitoring as needed." On 07/18/11, documentation indicated that R15 had an unwitnessed fall from her bed with no injury noted. New interventions on R15's care plan, dated 07/18/11 were, in part as, "chair or bed alarm." On 10/13/11 at 11:00 am, R15 was observed standing in front of wheelchair at nurses station and took two steps forward. R15 was quickly assisted back to sitting position in wheelchair. There was no chair alarm that sounded. E7 was asked if R15 had a chair alarm, and her response was that she wasn't sure. There is no documentation in the medical record to indicate if a chair alarm was ever applied or in use as of this survey date. 3. R8's Physician order [REDACTED]. R8's most current Care Plan dated May 2010 identifies R8 as needing assistance of 1 staff for transfer using a gait belt. R8's MDS of 9-1-11 identifies R8 as having disorganized thinking and a history of falls with injury. R8's Care Plan of May 2010 identifies R8 as being at risk for falls and having a history of a fracture of left hip. Care Plan approach includes in part, chair and bed alarm and remind to request assistance with transfers and toileting. Care plan also documents R8 is to be transferred with a gait belt. On 10-12-11, at 12:30PM was observed to be transferred from her wheel chair to her bed by E17, CNA and Z1, Hospice CNA. E17 and Z1 failed to use a gait belt when transferring R8. R8 did not have a chair or bed alarm. Facility Occurrence Report shows R8 had 7 falls between February 2011 and October 2011. Interventions for the falls include, in part; Provide safety education, ensure call light within reach, remind resident to request assist with toileting and transfer as needed. R8's current MDS shows disorganized thinking. Occurrence Report of 8-17-11 documents R8 obtained a large hematoma to the right side of the forehead, abrasion to the bridge of the nose with a large amount bleeding from the nares and edema to nose/face and was sent to the hospital for evaluation. Occurrence Report of 10-9-11 reflects R8 fell out of her wheel chair and landed on her face. Recommendation is to increase monitoring as needed. Antibiotic, 3 day bladder tracking to be initiated on 10-17-11 when antibiotic completed. R8 was observed on 10-11-11 at 11:30AM to have a black and blue bruised face. 4. During the initial tour conducted on 10/11/11 of the 500 hall at 10:45 AM an air mattress was observed on the second bed in room 510 with side rails on both sides. The bed was occupied by R3. The head of the bed was elevated and there was a gap under the side rails of 4 inches at the point of where the bed was bent. When pressure was applied to the mattress edges where the bed bent a gap of 8 inches was measured. It was brought to the attention of E1, Administrator, at 10:55 AM on 10/11/11. An attempt was made to adjust the height of the side rails to eliminate the gap and it was determined the side rails could not be adjusted. At 11:30 AM the side rails were observed again and were found to have been replaced with adjustable side rails that could be adjusted to eliminate the gaps under the side rails.