Every finding on record at Bridgeway Senior Living

Based on interview and record review, the facility failed to allow a long-term resident to return to the facility after being hospitalized and did not arrange for the disposition of her personal belongings.This applies to 1 of 4 residents (R5) reviewed for discharges in the sample of 8.The findings include:R5's EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE] and was a long-term resident with multiple diagnoses including Parkinson's disease with dyskinesia, chronic pain, psychotic disorder with hallucinations, bipolar disorder, schizophrenia, and anxiety. R5's MDS (Minimum Data Set) dated 7/15/2026 showed she had an unplanned discharge to the hospital, and the facility anticipated her return.On 8/12/2026 at 12 PM, V4 (R5's Power of Attorney/POA) said R5 had been a long-term resident at the facility since 2025 and was not allowed to return to the facility after she was discharged from an acute behavioral hospital on 7/31/2026. V4 said she was notified on 7/15/2026 of R5's emergency transfer because the facility had concerns regarding her behavior. V4 said that during R5's hospitalization, she had multiple discussions with the facility staff in-person and via telephone regarding R5's missed monthly antipsychotic injection and anticipated service needs upon her return to the facility, including an evaluation of a motorized wheelchair and transportation for her ECT (Electroconvulsive Therapy). V4 said her last contact with the facility was on 7/28/2026 and was never notified that R5 was not going to be allowed to return to the facility. V4 said then on 7/29/2026, the hospital's social worker notified her that R5 needed a new facility for long-term care placement because the facility decided not to allow her to return to the facility. V4 said she was shocked and worried because she needed to find a new facility for R5 within twenty-four (24) hours. V4 said after R5 was transferred to another long-term care facility, she contacted the facility for an explanation regarding R5's improper discharge and her belongings. V4 said she never received any response from the facility, and on 8/09/2026 she went to the facility and picked up R5's personal belongings, which remained in her vacant room.R5's progress note dated 7/15/2026 said R5 called 911 and Due to concerns for resident's safety and the need for emergency psychiatric evaluation and stabilization, resident is being transferred to the emergency department via EMS. (Emergency Medical Services)R5's progress notes did not show any further entries regarding the outcome of her transfer.On 8/12/2026 at 3 PM, V6 (Social Service Director) said she was unsure why R5 was not allowed to return to the facility. V6 said that during R5's hospitalization, she assisted V4 with her inquiries regarding R5's anticipated service needs upon her return to the facility.V6's Social Service Comprehensive Review assessment dated [DATE] said R5 had ongoing complex mood and behaviors including paranoid, have flight of ideas, became accusatorial, manic, talking to herself loudly and tearful. The facility had implemented multiple interventions, which remain appropriate, including one-to-one, at times are effective yet when in mania behavior is difficult to redirect and Psychiatry visits, LCSW (Licensed Clinical Social Worker) C referral, ECTs. The assessment also said, Resident's daughter is hopeful that [R5] can move to a supportive living when [R5's] mental health stabilizes. Social Services will assist with discharge planning as needed if discharge becomes a potential. Resident's daughter is very supportive.On 8/12/2026 at 3:30 PM, V3 (Assistant Director of Nursing/ADON) said she had met with V4 to discuss R5's missed antipsychotic injection and discuss her expected service needs upon her return from the hospital. V3 said the facility never discussed with her that R5 was not going to be allowed to return to the facility because they were expecting her return and resume her care at the facility. V3 further said she was unsure if V4 had picked up R5's personal belongings.On 8/13/2026 at 11 AM, V2 (Director of Nursing/DON) said he and V3 had met with V4 during R5's hospitalization and was not aware R5 was not going to be allowed to return to the facility. V2 said R5's room currently remained available, including on 7/31/2026 (at the time of her expected return), with her personal belongings.V4's (R5's POA) Concern Form dated 8/06/2026 showed V4 was concerned regarding the resident not being allowed to return to the facility. The facility's noted resolution said, Resident was transferred to another SNF (Skilled Nursing Facility). Per daughter request, daughter picked up belongings on 8/09/2026.On 8/12/2026 at 2:30 PM, V5 (Ombudsman) said she was familiar with R5, and that she was a long-term resident at that facility. V5 said the Ombudsman's office had no record of R5's permanent discharge from the facility, and she was not notified accordingly either. V5 said all residents have the right to a proper discharge unless it's an involuntary discharge that meets the state requirements. V5 said the facility was required to provide a thirty-day (30) discharge notification to the residents or their representative, including information regarding their right to appeal.On 8/12/2026 at 2:30 PM, V7 (Psychiatric Nurse Practitioner) said he was treating R5 at the facility and was expecting her to return to the facility after her hospitalization. V7 said the facility was able to manage her mental health illness safely in the facility and was unsure why she was not allowed to return to the facility.On 8/13/2026 at 12 PM, V1 (Assistant Administrator) said the facility received a call from the hospital on 7/29/2026 regarding R5's return to the facility, and during that time the facility decided to not accept her back as a long-term resident. V1 said the facility had not notified R5 or V4 of their decision. V1 confirmed that the facility made no attempts to contact V4 afterwards, as requested, to discuss their decision not to allow R5 to return and to make arrangements for her personal belongings. V1 said the facility's staff informed her on 8/10/2026 that V4 came to the facility on 8/09/2026 for R5's belongings. V1 said the facility was able to care for residents with mental illness service needs, including R5's behavioral needs. V1 was unable to provide further details regarding the facility's refusal to allow R5 to return to the facility on 7/31/2026.The facility's policy titled Transfer and Discharge Policy, undated, showed the facility's policy was to assure resident transfers and discharges would be conducted in accordance with residents' rights, physicians' orders, and in such a manner as to maintain continuity of care for the residents. The facility shall permit all residents to remain in the facility and not transfer or discharge except in those circumstances outlined in the Residents' Rights and in accordance with state-outlined involuntary relocation procedures. When the facility transfers or discharges a resident under any circumstances, the resident/authorized legal representative must be notified verbally and in writing at least thirty (30) days prior to intended discharge. The facility must also notify and receive an order from the resident's physician and include a written notice to the resident/authorized legal representative. The notice must include the following information: reason for transfer/discharge, effective date of transfer/discharge, location of transfer/discharge, a statement that the resident has the right to appeal the action to the State, the name, address, and telephone number of the State long-term care Ombudsman, and any other appropriate advocacy or protective services as required by the state. The facility must also document the provision of such notice in the resident's clinical record. The policy also noted that the relocation rights, including bed hold and readmission rights, would be maintained in all transfers. And, if the resident is transferred or discharged , their personal effects inventory record will be reviewed, corrected as necessary, and signed by the resident or authorized legal representative indicating what personal belongings they have received.

Based on the interview and record review, the facility failed to ensure a resident's monthly atypical antipsychotic injection and oral antibiotics were administered as ordered. This failure resulted in a resident experiencing unstable behaviors with a subsequent involuntary psychiatric admission.This applies to 1 of 4 residents (R4) reviewed for significant medication errors.On 07/21/2026 at 10:05 AM, V18 (R4's family member) stated that R4 receives Invega (atypical antipsychotic medication) injections on the 5th of each month, and in July she did not receive it. V18 said on 07/12/2026, R4 also received an order for an oral antibiotic treatment for a urinary tract infection, but R4 did not receive her antibiotic either. V18 said R4's psychiatric symptoms worsened and the facility petitioned and transferred R4 to the hospital on [DATE]. V18 stated R4 was admitted to the behavioral hospital and is still admitted .R4's Active Physician Orders as of 7/14/2026 showed an order for Invega Sustenna Intramuscular Suspension Prefilled Syringe 156 MG/ML (milligrams/milliliters) to inject one syringe intramuscularly one time a day starting on the 5th and ending on the 5th every month for mood stabilizer/antidepressant. R4's December 2025, January, March, April, May, and June 2026 Medication Administration Records (MAR) showed she has consistently received her monthly Invega Sustenna injections between the 3rd and the 5th of the month. R4's July 2026 MAR, printed on July 21st, does not have the medication checked off as administered in July and instead, a 9 was entered for other/see nursing notes on July 5th. R4's Minimum Data Set (MDS) dated [DATE] showed R4 was cognitively intact. R4's MDS dated [DATE], 04/07/2026, and 07/07/2026 showed R4 previously had no exhibition of hallucinations or delusions and no behavioral symptoms during the respective MDS lookback periods.R4's late entry nursing note effective 7/15/2026 (ten days after her missed Invega injection) showed Resident called 911 from the facility for the third time this week. Resident continues to exhibit manic behavior, agitation, poor judgement, and unsafe behaviors that cannot be safely managed in the facility including refusing to come inside from outdoors to receive prescribed medications despite repeated staff encouragement and redirection. She continued to come inside with [Emergency Medical Services] and police present. Due to concerns for the resident's safety and the need for emergency psychiatric evaluation and stabilization, resident is being transferred to the emergency department via EMS.On 07/23/2026 at 9:55 AM, V7 (Registered Nurse) said that on 07/12/2026, R4 wanted to go to the hospital for not feeling good and complaints of a sore bottom. V7 stated R4 returned with discharge paperwork that included an order for antibiotics for a urinary tract infection. V7 stated she overlooked it and did not endorse it to the incoming nurse. V7 said it's important to notify physicians and carry out medication orders, and administer the medications as ordered.R4's 7/12/2026 Emergency Department (ED) After Visit Summary showed a new order for an antibiotic. R4's Active Physician Orders as of 7/14/2026 do not include R4's antibiotic order from her 7/12/26 ED visit.On 7/21/2026 at 10:05 AM, V18 (R4's family member) continued and said that in the evening on 07/14/2026, she spoke with V5 (Licensed Practical Nurse/LPN) who told her R4 had severe psychiatric symptoms, and he also notified her R4 was getting antibiotics.On 07/21/2026 at 12:26 PM, V5 (LPN) said that when V18 called him, he told her that R4 was receiving antibiotics, but when he saw R4's Physician Orders, there was no order entered. V5 said nurses should notify the Physician for order clarification, call the pharmacy for medication, and administer the medications to residents.On 7/21/2026 at 10:05 AM, V18 continued that on 07/15/2026, she learned from V6 (LPN) that R4's Invega injection was not given on 07/05/2026. V18 said later the same day, V7 (RN) notified her that for safety, she might have to transfer R4 to the hospital for evaluation for her severe behavioral problems. V18 stated she also asked V7 about R4's antibiotic and V7 stated R4 never received any antibiotics. V18 said she was unaware of all the missing medications, and it was very frustrating.On 07/21/2026 at 11:40 AM, V14 (Registered Pharmacist) said the Invega Sustenna injectable medication was delivered on 07/06/2026 at 11:01 AM, and V21 (RN) received the medication. V14 said that upon the facility's request, if medication is required immediately, the pharmacy can make a special delivery. V14 said the manufacturer's recommendation to administer the medication on time to ensure its effectiveness. V14 also stated the facility never called the pharmacy to fill R4's antibiotic prescription.On 07/21/2026 at 4:05 PM, V21 (RN) said he received R4's Invega Sustenna medication on 07/06/2026 and did not realize that he needed to administer it to R4. V21 said the nurse should follow the Physician's orders and report any missed doses to the Physician.On 07/22/2026 at 01:11 PM, V13 (R4's Physician) stated that the facility notified him that medications were not given due to a pharmacy delay. V13 said he was not aware that R1 had a urinary tract infection, and no facility staff notified him about R4's antibiotic order or any clarification of the hospital emergency department orders. V13 reviewed the hospital emergency records and said R4's urine culture result showed R4 had Klebsiella, which often indicates a urinary tract infection (UTI), and an untreated UTI can cause issues such as sepsis or encephalopathy, and missing antipsychotic medications can relapse behavioral issues. V13 said the expectation is that any resident will receive their medications as ordered and that nurses should clarify any hospital medication orders with Physicians.R4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R4's diagnoses included psychotic disorder with hallucinations and bipolar disorder, recurrent urinary tract infections, and Parkinson's disease.R4's care plan dated 05/30/2026 showed R4 had a bipolar and psychotic disorder with hallucinations, with intervention to give antidepressant medications ordered by physicians. Care plans dated 11/03/2025 and 02/11/2026 indicated that R4 had a history of Urinary Tract Infection and had received antibiotic medications as ordered.On 07/21/2026 at 1:30 PM, V6 (LPN) said she worked with R4 often and has administered Invega a few times and was not aware of UTI or antibiotic treatment. V6 said the nurses should notify physicians of any new medication orders from the ED and carry out the orders to administer medications. V6 said that giving medication as ordered is very important for the effectiveness of the medication in treating symptoms.On 07/22/2026 at 2:10 PM, V3 (Assistant Director of Nursing) said the staff should refill the medication every month in advance before the administration of medication. V3 said the medication was ordered on 07/05/2026 and delivered on 07/06/2026, and the staff failed to administer it. V3 said the nurse is expected to check the hospital discharge summary, verify orders with the Physician, enter the orders, notify the pharmacy, and administer medications.On 07/22/2026 at 2:48 M, V2 (Director of Nursing) said Nursing staff should reconcile the medications upon return from the hospital, call the pharmacy, and administer as ordered. V2 said an untreated UTI can cause a worsening infection, and the Invega is given to control R4's mood and not giving it could relapse her conditions.The facility's Drug Order Policy (effective 3/1/2025) showed Policy: It is the policy of this facility to obtain a physician's order for all medications and treatments and to process medication orders to ensure the resident's medical plan of care is implemented, on a timely basis. The Policy further showed 5. All orders from a licensed practitioner for resident drugs are processed by a licensed nurse and entered in the resident's medical record. 6. The medication orders are processed timely, i.e. called/faxed to the selected pharmacy.14. Drug order shall be transcribed onto the medication record by the licensed nurse who received them as soon as practical after the physician's order is received.The facility's Medication and Treatment Incident Reporting Policy (effective 3/1/2022) showed 6. Medications not received from pharmacy and initiated within 24 hours of the time ordered to be administered will be considered a medication incident and require a Medication Incident Report to be recorded. Drugs with significant effect should be available within six hours.

Based on interview and record review the facility failed to ensure the safety of resident during care. This failure resulted in R1 falling from her bed during peri care, sustaining a scalp laceration, and needing transferred to a local hospital for sutures. This applies to one of three residents (R1) reviewed for safety in the sample of three. This past non-compliance occurred from 3/29/26 to 3/30/26.The findings include:The facility face sheet for R1 shows she was admitted to the facility with diagnoses to include conversion disorder with seizures, dementia, aphasia (communication disorder) and dysphagia (difficulty swallowing). The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and is dependent on staff for all care including bed mobility.The Facility Fall Report dated 3/29/26 shows that at 2:20 PM that day, R1 was being assisted with incontinence care by V3 Registered Nurse (RN) while R1 was lying in bed. R1 was lying on her right side when V3 was reaching over to grab a towel, R1 rolled out of the bed onto the floor. The report shows R1 was bleeding from a cut to her head and was sent to the local emergency room and received sutures.On 4/25/26 at 9:49AM, V3 said R1's daughter came to her on the afternoon of 3/29/26 stating her mother had been incontinent and needed to be cleaned up. V3 said R1 is nonverbal and is completely dependent on staff to care for her and turn her. V3 said she gathered the supplies she needed and proceeded to R1's room. V3 said the daughter left the room as she was providing care alone to R1. V3 said she was nearly done, and had R1 on her right side, and V3 said she reached to the left for a towel. V3 said she had a hand on R1 the whole time. V3 said at that moment, the bed alarm went off and R1 rolled out of the bed and fell to the floor. V3 said she observed blood coming from where a small cut was observed to the back of R1's head. V3 said she immediately assessed the resident, called the Physician, and sent R1 to the emergency room. V3 said she should have had another staff member present to assist with the care for R1.On 4/25/26 at 10:50 AM, V4 Certified Nursing Assistant (CNA) said R1 is totally dependent on the staff to move in her bed. R1 cannot assist with her care at all. V4 said R1 is always to be a two assist with her care.On 4/25/26 at 10:53 AM, V2 Director of Nursing (DON) said she investigated the fall for R1, and it seemed she just rolled off the bed during incontinent care. V2 said it was an unfortunate accident. V2 said R1 required the assistance of two staff for her care. V2 said after the fall, two bolster pillows were added to each side of R1's bed to prevent her from rolling out, all nursing staff were educated on having two staff present during all care with dependent residents. V2 said competency screening was completed for V3 and audits on staff completing care for dependent residents using two staff. V2 said this was all completed the next day on 3/30/26.The care plan for R1 for Activities of Daily Living shows an undated intervention for bed mobility, resident is totally dependent to roll left and right with two staff.The emergency room report dated. 3/29/26 shows R1 was seen after being rolled out of her bed onto the floor during care when the staff stepped away. A laceration measuring one centimeter was observed to the back of R1's head which required two staples.Prior to the survey of 4/25/26, the facility had taken the following action to correct the noncompliance:1. On 3/29/26, the facility added bolster pillows to R1's bed and in serviced staff on ensuring that there should be two staff present when performing perineal care for a dependent bed bound resident.2. On 3/30/26, all facility nursing staff were re-educated/in-serviced on ensuring that there should be two staff present when performing perineal care for a dependent bed bound resident.3. On 3/30/26, competency on transfers and repositioning was done for both nurses and CNAs.4. On 3/30/26, audits for ADL (Activities of Daily Living) provided for dependent residents using two staff was started.5. On 3/30/26, a QAA discussion was completed, and the facility implemented a performance Improvement Plan (PIP).

Based on interview and record review the facility failed to have orders in place to manage a resident's PICC (peripherally inserted central catheter) Line. This applies to 1 of 3 residents (R1) reviewed for intravenous lines in the sample of 3. The findings include:R1's Face Sheet shows that he was admitted to the facility on [DATE] with diagnoses including Nontraumatic Subarachnoid Hemorrhage, Acute and Subacute Infective Endocarditis, Pleural Effusion and Psychoactive Substance-induced Mood Disorder. R1's admission orders include the administration of 2 IV (intravenous) antibiotics to be administered through the PICC Line 2-3 times a day. R1's admission orders show no orders for the care, flushing or dressing changes for the PICC Line. On 3/27/26 at 12:35PM V4(RN-Registered Nurse) stated, We do routine flushes, dressing changes every 7 days, check to make sure there is a cap on the end, when we remove it, we measure it, check arm circumference. The night shift does all of that. Those orders are part of the batch orders that are put in on admission.On 3/27/26 at 1:05PM V2 (Director of Nursing) stated, Usually we change the dressing once a week on Sundays on PICC lines and midlines. It is part of our batch orders. Orders were not put in for R1.

Based on interview and record review the facility failed to administer antibiotics as ordered by the physician and notify the physician when those antibiotics were not administered. This applies to 1 of 3 residents (R1) reviewed for significant medication errors in the sample of 3. The findings include: R1's Face Sheet shows that he was admitted to the facility on [DATE] with diagnoses including Nontraumatic Subarachnoid Hemorrhage, Acute and Subacute Infective Endocarditis, Pleural Effusion, and Psychoactive Substance-induced Mood Disorder. R1's Medication Administration Record (MAR) dated February 2026 shows that R1 was scheduled to receive Vancomycin (Antibiotic) 1750mg/350ml every 12 hours for infection. This same document shows that R1's dose of Vancomycin was not administered on 2/26 at 9:00PM, 2/27 at 9:00PM, 2/28 at 9:00AM and 2/28 at 9:00PM. On 3/27/26 at 11:00AM V3 (LPN- Licensed Practical Nurse) stated, I don't know why I did not give the Vancomycin on those days. He came in on the 26th- it probably wasn't available. On the 27th he went to the hospital because he called 911 on himself and I don't know about the 28th. I think it was on hold that day. He has to have a blood test then the results are sent to the pharmacy then they send out the Vanco to us. Usually comes between 11PM and 1AM. On the 27th he called the ambulance on himself. He came out of his room and ran down the hall. The ambulance was already here. He said the PICC Line was out, but the PICC line was not out. He had said the medication was all over the floor, but me and a CNA went in there and there was nothing on the floor. The hospital said his PICC line was fine. He did not come back on my shift.R1's Vancomycin Trough drawn on 2/28/26 result shows it was an Alert Low of 3.6 (Normal 10-20). This lab was drawn at 10:10AM, Received at the lab at 1:25PM and reported to the staff at the facility at 2:52PM. On 3/27/26 V2 confirmed that from there the facility would notify the pharmacy. The next Progress Note in the R1's EMR (Electronic Medical Record) is from 3/1/26 at 3:19PM and states, Call from (Pharmacy) at 10:50AM with instructions to continue same dose of Vancomycin and check BMP (Basic Metabolic Panel) and Vanco Trough on 3/3/26. V2 also confirmed that R1's Vancomycin was administered on 3/1/26 at approximately 9:30AM prior to hearing from the pharmacy regarding the lab results/dose recommendation from 2/28/26. The Pharmacy Packing Slips dated 2/27/26 at 4:19 AM, 2/27/26 at 10:50AM and 3/1/26 at 5:34AM shows that there was a total of 8 doses of Vancomycin delivered to the facility during R1's stay from 2/26/28-3/3/26. R1's February and March 2026 MARs show that he only received 5 of those doses of Vancomycin. R1's Progress Notes dated 2/27- 3/1 do not document any notification to R1's physician regarding the missed doses of Vancomycin.

Based on interview and record review, the facility failed to follow the facility policy for filing grievances or complaints, failed to ensure residents know how to file a grievance and failed to make the grievance forms readily available for residents to complete. This applies to 8 of 8 residents (R8, R15, R26, R61, R78, R120, R121, R175) who attended the resident meeting in the sample of 30. The findings include:On January 13, 2026, at 10:30 AM, R8, R15, R26, R61, R78, R120, R121, and R175 attended the Resident Meeting along with V38 (Ombudsman) as part of the annual survey. R15 was identified as the Resident Council President and all residents who attended the meeting identified themselves as regular attendees of the facility's Resident Council meetings. When all residents were asked if they were aware of how to file a concern or grievance with the facility, each attendee responded no. Each resident agreed they did not know where the grievance forms were kept or if they could file a grievance anonymously. In addition, the attendees stated there were recurring concerns identified during the resident council meetings that the residents did not feel the facility resolved or gave a response to, especially concerning food quality, lack of supplies including incontinence care items and meal service, both food served cold, and residents given only plastic utensils to eat with, and no condiments being served when needed. R15's face sheet showed R15 was admitted to the facility on [DATE]. R15's MDS (Minimum Data Set) dated October 2, 2025, showed R15's cognition was intact. R8's face sheet showed R8 was admitted to the facility on [DATE]. R8's MDS dated [DATE], showed R8 was cognitively intact. R26's face sheet showed R26 was admitted to the facility on [DATE]. R26's MDS dated [DATE], showed R26 was cognitively intact. R61's face sheet showed R61 was admitted to the facility on [DATE]. R61's MDS dated [DATE], showed R61 was cognitively intact. R78's face sheet showed R78 was admitted to the facility on [DATE]. R78's MDS dated [DATE], showed R78 was cognitively intact. R120's face sheet showed R120 was admitted to the facility on [DATE]. R120's MDS dated [DATE], showed R120 was cognitively intact. R121's face sheet showed R121 was admitted to the facility on [DATE]. R121's MDS dated [DATE], showed R121 was cognitively intact. R175's face sheet showed R175 was admitted to the facility on [DATE]. R175's MDS dated [DATE], showed R175 was cognitively intact. During the meeting on January 13, 2026, R78 complained of lack of incontinence supplies that occurred last weekend. R8 complained 5 days ago the facility was out of over the counter acetaminophen medication. R61 provided photo of being given only a plastic spoon to eat a salad, hamburger, and French fries with and no condiments provided on the meal tray. R8, R61, and R78 each stated they did not know where the grievance forms were or who they should bring their concerns to. On January 13, 2026, 10:30 AM, during the resident meeting, R15 and R175 both stated they had been requesting snacks that they considered to be healthier, such as fresh fruit and fresh vegetables instead of crackers and cookies and there had been no change in the snacks and no response from the facility staff. A review of the concern/grievance forms for the past 6 months showed there were no concern forms completed regarding the resident's request for more healthy snacks, residents served with plastic utensils, lack of supplies in January or lack of over the counter medication. On January 13, 2026, 3:59 PM, reviewed with R15 the facility provided food committee report. The reports showed for date Oct, Nov, Dec with no year indicated on the report. R15 reviewed the reports. R15 stated from the report there were still unresolved concerns or items just not addressed by the facility. R15 stated the concern from Oct report for more bananas to be served , and breakfast breads to include English muffins and bagels had not been addressed. R15 stated the concern identified on the Nov food report regarding spaghetti noodles being served watery remains a problem today. R15 stated for the months of Nov and Dec food committee report the request for more variety of snacks remain a concern today with no response from the facility. On January 13, 2026, at 11:41 AM, V43 (Activity Director) stated if a resident asks for a grievance form staff will give one to them. On January 13, 2026, at 11:44 AM, V2 (Assistant Administrator) stated grievance forms are available only at the reception desk. On January 13, 2026, at 4:35 PM, V44 (Receptionist) stated staff is at the reception desk from 8 AM until 8 PM. The facility policy title Filing Grievances/Complaints, dated December 2004, showed any resident visitor, or family member may file a complaint concerning treatment, medical care, behavior of other residents or staff members without the fear of reprisal in any form. The grievance and or complaint will be investigated within 5 working days of receiving the grievance or complaint. The resident or person filing the complaint will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems withing 5 working days of the filing of the grievance or complaint and a written summary of the report will also be provided to the resident and a copy filed in the business office.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with nail care and personal hygiene.This applies to 5 of 5 residents (R27, R49, R63, R92 and R133) reviewed for ADL (activities of daily living) in the sample of 30.The findings include:1. R92 had multiple diagnoses including, Parkinson's disease without dyskinesia with fluctuations and mild dementia with psychotic disturbance, based on the face sheet. R92's quarterly MDS (minimum data set) dated October 28, 2025, showed that the resident was cognitively impaired. The same MDS showed that the resident required total assistance from the staff with his ADLs, including personal hygiene. On January 12, 2026 at 10:37 AM, R92 was sitting in his reclining wheelchair inside the unit dining room. R92 was verbally responsive but confused. R92 had accumulation of long and unkempt facial hair, and his fingernails were long, jagged with black substances under some of the nails. V6 (RN (Registered Nurse)) was present during the observation. On January 13, 2026 at 9:58 AM, R92 was sitting in his reclining wheelchair inside the unit dining room. R92 was verbally responsive but confused. R92 had accumulation of long and unkempt facial hair, and his fingernails remained long, jagged with black substances under some of the nails. V5 (RN) and V4 (ADON (Assistant Director of Nursing)) were present during the observation. Both V4 and V5 stated that R92's facial hair needs to be shaven, and the resident needs his nails trimmed and cleaned. V4 and V5 stated that R92 required total assistance from the staff with grooming and personal hygiene including shaving and nail care. R92's active care plan initiated on May 5, 2025 showed that the resident is at risk for ADL self-care deficiency. The same care plan showed multiple interventions including total assistance from the staff with personal hygiene. 2. R27 had multiple diagnoses including, dementia without behavioral disturbance, based on the face sheet. R27's admission MDS dated [DATE], showed that the resident was cognitively intact. The same MDS showed that R27 required maximum assistance from the staff with personal hygiene. On January 12, 2026, at 11:21 AM, R27 was in bed, alert, oriented and verbally responsive. R27's fingernails were long, jagged with black substances under some of the nails. R27 stated that she needs the assistance of the staff to trim and clean her fingernails. On January 13, 2026, at 10:11 AM, R27 was in bed, alert and oriented. R27's fingernails remained long, jagged with black substances under some of the nails. V5 (RN) acknowledged that R27's fingernails needed trimming and cleaning. According to V5, R27 is dependent on the staff to provide nail care. R27's active care plan initiated on November 11, 2025, showed that the resident is at risk for ADL self-care deficiency. The same care plan showed multiple interventions including, Personal hygiene: Assist with or complete hygiene tasks as needed while encouraging participation. 3. R133 had multiple diagnoses including moderate dementia with other behavioral disturbance, based on the face sheet. R133's quarterly MDS dated [DATE], showed that the resident was moderately impaired with cognition. The same MDS showed that the resident required assistance from the staff with personal hygiene. On January 12, 2026, at 10:48 AM, R133 was sitting in her wheelchair inside the unit dining room. R133 was alert and able to answer questions. R133 had accumulation of long, curling facial hair on her chin area and her fingernails were uneven (some were long and some were short), some were jagged, and some had black substances under the nails. R133 stated that she wanted the staff to shave her and clean and trim her fingernails. On January 13, 2026, at 10:07 AM, R133 was sitting in her wheelchair inside the unit dining room. R133 had accumulation of long, curling facial hair on her chin area and her fingernails were uneven, some were jagged, and some had black substances under the nails. V4 (ADON) was present and acknowledged that R133's facial hair was long and curling and that the resident needs her fingernails trimmed and cleaned. V4 stated that R133 is dependent on staff with personal hygiene and grooming, including removal of unwanted facial hair and nail care. R133's active care plan initiated on November 1, 2025, showed that the resident is at risk for ADL self-care deficiency. The same care plan showed multiple interventions including provision of assistance with personal hygiene. 4. R63 had multiple diagnoses including, malignant neoplasm of unspecified kidney except renal pelvis, malignant neoplasm of the prostate and disorder of muscle, based on the face sheet. R63's admission MDS dated [DATE], showed that the resident was cognitively intact. The same MDS showed that R63 required assistance from staff with personal hygiene. On January 12, 2026, at 11:03 AM, R63 was in bed, alert, oriented with hard of hearing. R63 had accumulation of long, unkempt facial hair. R63 stated, it would be nice to be shaven. On January 13, 2026, at 10:14 AM, R63 was in bed, alert and oriented. R63 had accumulation of long, unkempt facial hair. V5 (RN) was present during the observation and stated that R63 needed shaving, and the resident nodded in agreement. V5 stated that R63 is dependent on staff with personal hygiene, including shaving. R63's active care plan initiated on December 19, 2025, showed that the resident is at risk for ADL self-care deficiency. The same care plan showed multiple interventions including, Personal Hygiene: Assist with or complete hygiene tasks as needed while encouraging participation. On January 13, 2026 at 3:50 PM, V3 (Director of Nursing) stated that it is part of the facility's nursing care and service to provide assistance to residents needing help with ADLs including shaving or removal of unwanted facial hair and nail care, to ensure that resident's hygiene and grooming are maintained. 5. According to the face sheet, R49 had multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes mellitus, abnormalities of gait and mobility, and lack of coordination. R49's MDS (Minimum Data Set) dated December 23, 2025, showed R49 had moderate cognitive impairment and required moderate assistance with personal hygiene and maximum staff assistance for showers or bathing. R49's ADL (Activity of Daily Living) care plan initiated on November 11, 2022, showed R49 was at risk for ADL Self-care deficiency due to increased weakness, diagnoses, and limited mobility. The same care plan showed multiple interventions, including provision of assistance with showers and personal hygiene. On January 12, 2026, at 12:49 PM, V7 (CNA/Certified Nursing Assistant) set up R49's lunch on R49's overbed table in her room, and R49 started eating. R49's fingernails were long with black substances under the fingernails on both hands. R49 picked up the meatballs with her left hand and ate them. On January 13, 2026, at 12:45 PM, R49 was eating lunch in her room. R49's fingernails were long with black substances under the fingernails on both hands. V7 said R49's fingernails on both hands were dirty and long. V7 said the CNAs are responsible for cleaning R49's fingernails during the scheduled showers and as needed when they are dirty.

Based on observation, interview, and record review, the facility failed to provide safe medication storage and labelling practices for residents receiving prescription and narcotic medications.This applies to one nursing unit and 7 of 7 residents (R3, R33, R88, R91, R106, R107, and R141) reviewed for medication storage in the sample of 30.The findings include:1. According to the face sheet, R88 had multiple diagnoses, including glaucoma, hypertension, and vascular dementia. R88's POS (Physician Order Summary) dated October 18, 2024, showed an active order for latanoprost ophthalmic solution 0.005 percent, and to instill one drop in both eyes at bedtime for decreased eye pressure. On January 14, 2026, at 10:35 AM, during a medication cart inspection with V22 (Nurse), R88's prescribed latanoprost eye drop solution was opened, and there was no open or discard date written on the eye drop bottle or box. V22 said the nurses administer the eye drop to R88 every night. 2. According to the face sheet, R3 had multiple diagnoses, including hypertension, cerebral infarction, multiple sclerosis, and transient cerebral ischemic attack. R3's POS dated May 18, 2025, showed an active order for latanoprost solution 0.005 percent, and to instill one drop in both eyes at bedtime for allergies. On January 14, 2026, at 10:35 AM, during a medication cart inspection with V22 (Nurse), R3 had two different opened bottles of latanoprost eye drop solution stored together in one box, and no open or discard dates were written on the eye drop bottles or the box. V22 said the nurses administer the eye drop to R3 at night. 3. According to the face sheet, R33 had multiple diagnoses, including hypertension, cerebral infarction, and type 2 diabetes mellitus. R33's POS dated September 17, 2025, showed an active order for latanoprost ophthalmic solution 0.005 percent, and to instill one drop in both eyes one time a day for the eye. The same POS also showed an active order for brimonidine tartrate ophthalmic solution 0.2 percent instill one drop in both eyes every eight hours for eye. On January 14, 2026, at 10:35 AM, during a medication cart inspection with V22 (Nurse), R33's prescribed latanoprost and brimonidine tartrate eye drops solution were both open, and there were no open or discard dates written on the eye drop bottles or boxes. V22 said the nurses are currently administering the eye drops to R33. 4. According to the face sheet, R91 had multiple diagnoses, including type 2 diabetes mellitus, hypertension, and hemiplegia, unspecified affecting the left dominant side. R91's POS dated September 18, 2025, showed an active order for latanoprost ophthalmic solution 0.005 percent, and to instill one drop in the left eye at bedtime for wellness. On January 14, 2026, at 10:35 AM, during a medication cart inspection with V22 (Nurse), R91 had two different opened bottles of latanoprost eye drop solution stored together in one box, and no open or discard dates were written on the eye drop bottles or the box. V22 said the nurses administer the eye drop to R91 at night. 5. According to the face sheet, R107 had multiple diagnoses, including hypertension, type 2 diabetes mellitus, and contracture of the right shoulder muscle. On January 14, 2026, R107's POS dated July 14, 2025, showed an active order for latanoprost ophthalmic solution 0.005 percent, instill 1 drop in both eyes at bedtime for ophthalmic. On January 14, 2026, at 11:40 AM, during a medication cart inspection with V16 (Nurse), R107's latanoprost eye drop solution box was open, dated with an open date of December 2, 2025. V16 said R107's eye drops should have been disposed of after 30 days, which should have been on January 1, 2026. 6. According to the face sheet, R106 had multiple diagnoses, including diffuse large B-cell lymphoma, Bell's palsy, and type 2 diabetes mellitus. On January 14, 2026, at 1:00 PM, R10's POS dated June 11, 2025, showed an active order for Norco Tablet 5-325 MG (milligram), and to give one tablet by mouth every 12 hours as needed for pain. On January 14, 2026, at 11:40 AM, during a medication cart inspection with V16 (Nurse), a narcotic medication card for Norco Tablet 5-325 MG, belonging to R106, was found in the facility's locked narcotic box. The medication card showed that one medication (pocket seven) had been opened and re-taped with clear plastic tape. 7. According to the face sheet, R141 had multiple diagnoses, including spinal stenosis, lumbar region, disorder of muscle, type 2 diabetes mellitus, and neuromuscular disorder of the bladder. R141's POS dated November 11, 2025, showed an active order for Norco Tablet 5-325 MG) controlled drug, and to give one tablet by mouth every six hours as needed for pain. On January 14, 2026, at 11:40 AM, during a medication cart inspection with V16 (Nurse), a narcotic medication card for Norco Tablet 5-325 MG, belonging to R141, was found in the facility's locked narcotic box. R141's medication card showed that one medication (pocket seven) had been opened and re-taped with a piece of yellow paper tape. On January 14, 2026, at 12:30 PM, V3 (DON/Director of Nursing) said the residents' prescribed eye drops should be dated for 30 days of use upon opening and discarded after 30 days to ensure the residents receive the eye drops within their efficacy period. V3 said the facility should have had two nurses witness and dispose of unused or punctured residents' narcotic medications appropriately. V3 also said that nurses should not return unused narcotic medication by applying tape to seal the medication cards for infection control and to ensure that the residents receive the correct medication as ordered, prepared, and packed by the pharmacy. The facility's Medication Administration Policy dated March 2024 stated, Policy Specifications: . 9. The cart will be locked when direct visual access is not possible. 10. No medications may be returned to its original container once removed from that container. The facility's undated Medication Labeling Policy stated, Policy: Is the policy of this facility to inspect all drug and biological labels for accuracy and complete information upon receipt and prior to administration. Policy Specifications: To ensure that only those medications properly labeled, in accordance with applicable laws be distributed or administered.

Based on interview and record review, the facility prevented a resident from utilizing their motorized wheelchair and failed to obtain the resident's consent before modifying a resident'smotorized wheelchair. This applies to 1 of 1 residents (R175) reviewed for resident rights in the sample of 30. The findings include:R175 admission record showed R175 was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia C5-C7 incomplete, chronic respiratory failure, malignant neoplasm of uterus, alcohol abuse, major depressive disorder, anxiety disorder and post-traumatic stress disorder. R175's MDS (Minimum Data Set) dated December 23, 2025, showed R175 was cognitively intact and required assistance with ADL's including set up assistance with eating and oral hygiene, supervision with personal hygiene, partial assistance with upper body dressing and rolling side to side in bed, substantial assistance with bathing and lower body dressing and dependent on staff assistance for toileting, footwear, and transfer. On January 13, 2026, at 11:50 AM, R175 stated that upon return from the hospital, the facility staff would not allow her to use her motorized wheelchair and had her sit in a manual wheelchair, which she was unable to propel herself. R175 stated she was told she would not be given her motorized wheelchair back until the facility was allowed to modify her own chair by changing the control unit to only the indoor speed. R175 stated the modification was unnecessary because her motorized wheelchair had a two speed controller, which was one for indoor speed and one for outdoor speed. R175 explained when sitting in the manual wheelchair she was unable to propel herself and lost her ability to be independent, due to left hand spasticity making it difficult to push the wheel and her left leg was immobile due to her spinal cord injury. When asked if R175 gave consent to facility staff to modify her motorized wheelchair, R175 stated she was told by V17 (Physical therapist) that he was instructed by administration that the modification of the wheelchair to lower the speed had to be done before giving it back to R175. R175 stated she wanted her motorized wheelchair back and wanted to be out of the standard manual chair, so she told V17 to do what he had to do in order to give her back her motorized wheelchair. R175 stated the new control does not fit the wheelchair as well as the original and she wants the original controller back. The census record showed R175 was discharged to the hospital on November 4, 2025, and returned to the facility on November 12, 2025. On January 13, 2026, at 2:09 PM, V17 stated R175's motorized wheelchair came with two speed controls one for inside use which was slower, and one for outside use which was faster. V17 stated he was unaware of any indoor accident R175 had with the motorized chair, but there was an incident outdoors with the wheelchair. V17 stated R175 used the fast speed while outdoors in the community and the facility administration instructed him to modify the wheelchair speed so it could not go fast anymore before giving her back her motorized wheelchair. V17 stated he removed the original controller and placed a different controller on the wheelchair that had only one slow speed. V17 stated when R175 returned from the hospital the wheelchair was in the facility, as he had seen the chair in the chapel activity room, even though staff were putting R175 in a manual wheelchair. V17 stated he evaluated R175 in the motorized wheelchair after the modification on November 19, 2025, and R175 scored 52/60 and was deemed safe to operate the motorized wheelchair both indoors and outdoors. On January 13, 2026, at 3:02 PM, V3 (Director of Nursing) stated she thought when R175 came back from the hospital on November 12, 2025, the motorized chair was not in the facility because the brother had taken the wheelchair home. V3 stated she is unsure of how V17 explained to R175 the need for modification to the wheelchair. V3 did explain the original controller had two speeds, a slower speed and a faster speed . V3 stated she instructed staff to use a manual wheelchair for R175 until the modification was made and the evaluation for safe use was completed on November 19, 2025. V3 stated on November 4, 2025, R175's brother had picked up the wheelchair because the wheelchair had run out of battery power at a nearby church parking lot but was unaware of when R175's wheelchair was returned to the facility. V3 also stated once a resident had a motorized wheelchair, we are not allowed to take the wheelchair away due to the result of decline in the residents quality of life. On January 14, 11:15 AM, V42 (R175's brother) stated he did not remove the wheelchair from the facility. V42 stated he was aware that R175 was very upset when the facility staff refused to give R175 her motorized wheelchair when she returned from the hospital. V42 stated no one from the family gave permission for the facility to change any part on R175's own wheelchair. On January 14, 1:44 PM, R175, explained her brother-in-law brought her motorized wheelchair to the hospital on November 5, 2025, and when she returned to the facility, he brought it back to the facility next day on November 13, 2025. R175 stated she knows that because a female peer (R26) told her she saw it in the chapel activity room the day after R175 returned to the facility. R175 stated she felt she was being punished by not being allowed to use her motorized wheelchair. On January 14, 2026, at 1:55 PM, R26 validated that she saw R175's wheelchair in the chapel activity room the day after R175 returned to the facility. The Facility's policy titled Resident Rights dated April 2007, showed employees shall treat all residents with kindness, respect and dignity and the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to complete the referral process to obtain a motorized wheelchair per a resident's request in order for the resident to gain more independence with mobility. This applies to 1 of 1 residents (R8) reviewed for accommodation of needs in the sample of 30. The findings include:R8's face sheet showed R8 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, type 2 diabetes, low back and left hip pain, chronic obstructive pulmonary disease, bipolar disorder, and unsteadiness on feet. R8's MDS dated [DATE], showed R8 was cognitively intact and required assistance with ADLs including set up assistance with eating, personal hygiene and bed mobility, supervision with oral hygiene, dressing and transfer. On January 12, 2026, at 1:40 PM, R8 stated there was a motorized wheelchair ordered by her physician because she was having increased pain while walking but was not delivered to the facility because V37 (Social Services Director) told V17 (Physical Therapist) that R8 did not need a motorized wheelchair. On January 13, 2026, at 11:30 AM, R8 stated she had a motorized wheelchair 10 years ago but stopped using it because her legs became stronger. R8 stated she had to stop fully participating in physical therapy due to increased pain and as a result, she is no longer able to walk as far as she used to. R8 reported she is being forced to walk despite her pain and on January 11, 2026, she required assistance to get up from the chair because her legs were too weak. R8 also reported that she had received phone calls and text messages from her insurance company that stated they had approved the purchase of the power/motorized wheelchair, however delivery of the power motorized wheelchair was being refused by the facility. On January 13, 2026, at 2:09 PM, V17 stated when R8 requested the motorized wheelchair he made a referral to the vendor who provided the motorized wheelchairs. V17 stated he had evaluated R8 for power/motorized wheelchair use. V17 stated his supervisor told him that administration instructed him not to proceed with the referral for R8's motorized wheelchair because R8 was not going to be allowed to have the power/motorized wheelchair. V17 was unsure of the date when he received that instruction from his supervisor. V17 provided email correspondence between V17 and the vendor that was dated October 7, 2025, and the subject line was titled face sheet for R8 needs a power wheelchair. The vendor replied to V17 by email that showed the vendor was working with R8's healthcare provider to get a face to face evaluation done. V17 provided summary of daily skilled services dated October 9, 2025, that showed R8 received training in wheelchair management including instruction in proper body alignment to facilitate independent ability to relieve pressure, training in locking and unlocking brakes, to facilitate safety and instruction in moving forward/backward and turning during outdoor mobility. R8's skilled therapy services note dated October 8, 2025, showed response to session interventions increased time spent to soothe R8 due to emotional instability and complaint of not receiving power/motorized wheelchair, collaborated with V17's supervisor who instructed V17 to tell R8 to speak to social services regarding not receiving requested wheelchair. On January 13, 2026, at 3:02 PM, V3 (Director of Nursing) stated R8 did not need a motorized wheelchair because she was able to walk with a walker from her room to the smoking area without the use of a wheelchair. On January 13, 2026, 10:30 AM, R8 arrived at the resident meeting while propelling herself in a manual wheelchair. On January 14, 2026, at 11:50 AM, R8 was observed in the smoking area seated in a manual wheelchair. During random observations during the survey from January 12, 13, and 14, 2026, R8 was observed using the manual wheelchair for mobility. On January 14, 2026, at 12:15 PM, V2 (Assistant Administrator) and V24 (Vice President) were asked about R8's concern regarding not receiving a motorized wheelchair. V2 stated the wheelchair vendor did not receive a referral regarding a power/motorized wheelchair. V2 did not provide documentation validating that statement, as requested. When told there was an email between therapy and the wheelchair vendor company, V24 stated doctors and nurse practitioners do not take orders for documentation from vendors. The facility was unable to provide a policy regarding accommodation of residents needs when requested. On January 14, 2025, 3:00 PM V3 stated there is no policy regarding accommodation of residents need and referred to the resident rights policy. The facility's policy titled Resident Rights dated April 2007, showed residents are entitled to exercise their rights to the fullest extent possible and our facility will make every effort to assist each resident in exercising their rights to assure the resident is always treated with respect, kindness, and dignity.

Based on observations, interviews, and record reviews, the facility failed to provide ongoing monitoring and reassessment of a physical restraint, implement restraint-reduction interventions, and ensure that a physical restraint was used only when medically necessary. This applies to 1 of 1 residents (R147) reviewed for physical restraints in the sample of 30. The findings include: R147 was admitted to the facility on [DATE], with multiple diagnoses, including intervertebral disc degeneration of the lumbar region. hypercholesterolemia, hypertension, osteoarthritis of the left hip and knee, dementia, chronic embolism and thrombosis, Alzheimer's Disease, anxiety disorders, varicose veins, and osteoporosis.On January 12, 2026, at 11:36 AM, R147 was seated in a wheelchair with a secured lap cushion on her lap, resting against the trunk of her body. R147's wheelchair was pushed up against a corner table in the dining room. R147 attempted to move the secured lap cushion but was unsuccessful. At 2:00 PM, R147 was still sitting in the dining room at the same table in the same position.On January 13, 2026, at 9:26 AM, R147 was sleeping in her wheelchair at the dining room table. R147 was positioned with the secured lap cushion on her lap and against her trunk, with her wheelchair pushed up against the table.On January 13, 2026, at 11:30 AM, R147 was seated in a wheelchair with a secured lap cushion on her lap, resting against the trunk of her body. R147's wheelchair was pushed up against a corner table in the dining room.On January 14, 2026, at 11:07 AM, R147 was seated in a wheelchair with a secured lap cushion on her lap, resting against the trunk of her body. R147's wheelchair was pushed up against a corner table in the dining room.On January 14, 2026, at 11:08 AM, V19 (Certified Nursing Assistant/CNA) said that R147 must always wear a secured lap cushion because she gets out of her wheelchair. V19 stated that there has been no in-service or further instruction regarding the secured lap cushion. V19 said that the staff were told only that she had to always wear it.On January 14, 2026, at 11:16 AM, V21 (CNA) stated that R147 has a secured lap cushion and that it is removed only during toileting, as she cannot be placed on the toilet with the device, and only at bedtime.On January 14, 2026, at 11:04 AM, V18 (Licensed Practical Nurse/LPN) stated that staff were not instructed to document the use of R147's secured lap cushion. The nurse ensures that the CNA has put the device on. Staff do not document the time at which it is placed or removed.The current Minimum Data Set (MDS), dated [DATE], shows R147 has severe cognitive impairment and is rarely understood. R147 utilizes a manual wheelchair operated by staff. MDS shows no physical or verbal behaviors or wanderingA physician's order dated August 25, 2025, reads Lap Buddy on wheelchair every shift. The physician's order does not note the release of the restraint. A signed restraint evaluation was completed on August 19, 2025, and lists the secured lap cushion as an enabler and restraint and cites the reason for use as a sliding-out wheelchair.There was no documentation of the use of a secured lap cushion in the resident's progress notes, and no evidence that a restraint observation had been performed. Staff did not document R147's response to restraint use for seventy-two hours following the initiation of the restraint. There were no skin assessments in the resident's medical record pertaining to the use of the restraint.R147's fall care plan, dated August 19, 2025, reads Provide lap buddy. There is no additional information in the care plan regarding the release of restraint, duration of restraint, reason for use, or interventions utilized to reduce restraint use.On January 14, 2026, at 10:20 AM, V4 (Assistant Director of Nursing) stated that when a resident is placed in a restraint, staff are responsible for assessing skin integrity. Staff should periodically monitor the restraint and, upon release, document this in the progress notes. V4 said the reason for use should be notated on the physician's order as well. V4 confirmed that documentation of physical restraint was not completed in the progress notes, and that appropriate assessments were not performed. V4 confirmed that the physician's order did not contain all the details needed for a restraint order.The facility's Physical Restraint Policy dated February 2014 states, the purpose is to achieve a restraint-free environment to improve or maintain quality of life, and processes are reimplemented to pursue this goal. Restraints shall not be used for the purpose of punishment or for staff convenience. Periodic assessments shall address the resident's status to reduce or eliminate restraints whenever possible and assure the least restrictive method is used, which allows the resident to function at their highest practicable level. The Policy Specifications state:1. Residents who are admitted with a physician's order for restraint use shall have a restraint observation performed. A physician order will be obtained for the release of the restraint with supervision during the assessment process, as appropriate, or an order to discontinue use. 4. A physician's order for a restraint will be valid for thirty days. After 30 days, the restraint observation must be completed to determine whether the restraint is required to continue. Physician orders for restraint shall be completed and specifically define the type, reason, duration, and justification for use. 7. The IDT is responsible for participating in care planning interventions that work toward restraint reduction and the use of the least restrictive devices. 8. When a new restraint is initiated, the resident's response to the use of the restraint will be documented in the progress notes each shift for 72 hours.13. Residents who are restrained will be temporarily released from the restraint at least every two hours and more often as necessary, such as for ADL care, activities, and meals.16. The care plan will reflect specific circumstances and medical symptoms for restraint use and time frames. In the event that restraint use is altered, the care plan will be revised.

Based on interviews and record reviews the facility failed to ensure allegations of abuse were reported to the designated abuse coordinator and state agency. This failure applies to one of two residents (R175) reviewed for abuse in a total sample of 30 residents. Findings include:R175 was admitted to the facility 09/17/2025 with a diagnosis of Quadriplegia, Chronic Post Traumatic Stress Disorder, Recurrent Major Depressive Disorder, Anxiety Disorder, and Uterine Cancer On January 12, 2026, at 11:55 AM, R175 said some staff are really rough and that sometime last week V36 (Certified Nursing Assistant) gouged her during incontinence care and made her bleed. R175 reported this to a few aides including V35 (Certified Nursing Assistant). On January 12, 2026, at 1:35 PM, R175 said V35 (Certified Nursing Assistant) saw the scratch left on her from V36 (Certified Nursing Assistant) providing personal care the next day after it happened. On January 13, 2026, at 2:00 PM, V35 (Certified Nursing Aide) said R175 told her when V36 (Certified Nursing Assistant) was providing incontinence care she scratched R175. V35 said she did not report this to anyone and R175 told her she would report the incident to the director of nursing. V35 said R175 is really thick, and her legs are so tight you cannot really access her anal area easily to provide incontinence care and because of this you have to be gentle with R175 during care. V35 said R175 may have reported the incident to her because she and R175 have a good relationship with each other. R175 didn't sound like V36 scratched her intentionally. On January 14, 2026 at 1:35 PM, V2 (Administrator) said she is the abuse coordinator, if V35 (Certified Nursing Assistant) was informed that a resident was scratched she should inform the charge nurse and the charge nurse will assess and speak with the resident and depending on what the nurse finds or determines, the information will be reported to V2 if there is an allegation of abuse. V2 said if staff receive a report that another staff handled a resident roughly they should report this to the charge nurse or directly to V2; being handled roughly would be considered an allegation of abuse and if V2 received this information; immediately an investigation would be initiated, staff would be removed from the schedule, the resident would be assessed, and the physician and state agency would be notified. The facility filed an abuse investigation report on January 12, 2025, after notification by the survey team and not immediately after notification of the allegation. The facility's Abuse Prevention Policy received from the facility 01/14/2026 states: This facility affirms the right of our residents to be free from abuse and mistreatment. This facility therefore prohibits abuse and mistreatment. 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 it's control to prevent occurrences of abuse and mistreatment of residents. This will be done by:Identifying occurrences of potential mistreatment.Filing timely investigative reports. Employees are required to report any allegation or suspicion of potential abuse or mistreatment they hear about to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer.

Based on observation, interview, and record review, the facility failed to adequately assess a resident for discharge planning in accordance with their policy. This applies to 1 of 1 residents (R61) reviewed for discharge planning in the sample of 30. The findings include:R61 was admitted to the facility on [DATE], with multiple diagnoses including radiculopathy, type 2 diabetes, low back pain, benign prostatic hyperplasia without lower tract symptoms and acquired ichthyosis. R61's MDS (Minimum Data Set) dated December 19, 2025, showed R61 was cognitively intact and required set up assistance with eating and showering and was independent with all other ADLs including, grooming, toileting, dressing, bed mobility, transfer, and ambulation. On January 12, 2026, at 11:52 AM, R61 stated he wanted to be discharged from the facility and go to independent or supportive living, but staff are not assisting him to reach that goal. R61 stated he only receives his medication from the nurses, and he is independent in taking care of himself. R61 stated he even sweeps his own room. R61 was alert and oriented and stated he needed assistance getting his personal items from the facility he transferred from. R61 stated he had made these requests to V37 (Social Services Director) but stated he was not getting assistance with his requests. R61's Discharge Plan assessment dated [DATE], showed R61's placement was expected to be long term and the resident would have to wait 3 years in the current facility to be discharged to supportive living facility. On January 14, 2026, at 12:15 PM, V2 (Assistant Administrator) stated the reason for the 3 year wait was due to R61 not meeting the age requirement for their sister facility, a supportive living community. V2 stated other supportive or independent living facilities could be an option for R61's discharge. On January 14, 2026, at 12:49 PM, R61 was asked when he wanted to be discharged and R61 stated no more than 3 months, but as soon as it can be arranged. R61 stated he was given resources regarding potential places for discharge from V38 (Ombudsman) yesterday. R61 stated he did not remember discussing waiting 3 years for discharge and stated he has always stated he wanted to go to independent or supportive living since he was admitted to the facility. R61 asked rhetorically does it make sense for me to be here? All they do is give me my medication, and I am pretty sure I can do that myself too if they will let me, I take care of myself, and my room. During multiple observations on January 12, 13, and 14, 2026, R61 was observed ambulating independently throughout the facility, interacting with his peers, who were cognitively intact and had shared interests. On January 15, 2026, at 9:29 AM, V16 (RN) stated she had been R61's nurse since a week after admission when R61 moved to her unit. V16 stated R61 had been expressing his desire to be discharged to a facility where he could be more independent since she started taking care of R61. V16 stated she had discussed with R61's physician the anxiety and verbal aggression R61 displays with staff. V16 stated R61 frequently makes complaints regarding what he sees happening with his peers who are not able to care for themselves. V16 also stated R61 can be intimidating to the staff with his verbalizations of aggression. V16 reported that R61's physician discussed with V16 the current facility is not a good fit or R61. The facility's policy titled Discharge Planning Policy dated February 2014, showed the discharge planning process will begin at admission, the interdisciplinary team including the physician will identify potential needs after discharge, the resident's progress toward achieving identified goals and the discharge plan will be presented in terms understandable to the resident.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the use of a restraint and oxygen therapy.This applies to 2 of 2 residents (R9 and R147) reviewed for accuracy of assessments in a sample of 30. The findings include: 1. R147 was admitted to facility on July 28, 2024, with multiple diagnoses including intervertebral disc degeneration of lumbar region, hypercholesterolemia, hypertension, osteoarthritis of the left hip and knee, dementia, chronic embolism and thrombosis, Alzheimer's disease, anxiety disorders, varicose veins, and osteoporosis.R147's quarterly MDS dated [DATE], show R147 has severe cognitive impairment. Section P of the MDS shows R147 does not utilize a restraint. On January 12, 2026, at 11:36 AM R147 was in the dining room pushed up to a corner table with a secured lap cushion attached to her wheelchair. R147 was not able to move the lap cushion.On January 14, 2026, at 11:04 AM V18 (Licensed Practical Nurse) said that R147 utilizes a secured lap cushion because she always tries to get up. A restraint evaluation and consent form was signed on August 19, 2025. Section (Assessment Summary/ Determination) 1a. lists the device as an enabler and a restraint. On January 14, 2026, at 2:02 PM V30 (MDS Coordinator) said that R147 is the only resident utilizing a restraint. R147 is utilizing a secured lap cushion. V30 said that the use of the device should be documented under Section P of the MDS. V30 confirmed that no restraint was selected under section P of the November 04, 2025, MDS assessment. 2. R9 was admitted to facility on December 26, 2023, with multiple diagnoses including chronic obstructive pulmonary disorder, urinary tract disorder, emphysema, pneumonia, lack of coordination, disorder of the muscle, abnormalities of gait and mobility, cognitive communication deficit, Type II diabetes, Dementia, hypothyroidism, bipolar disorder, chronic viral hepatitis C, anxiety disorder, major depressive disorder according to face sheet. R9's physician's report dated December 30, 2025, shows Oxygen 3LPM (liters per minute) continuous O2 (oxygen) to keep saturation at 90% as needed for SOB (shortness of breath).R9's most recent MDS was dated November 18, 2025. An updated MDS was not completed to reflect the oxygen order. On January 13, 2026, at 1:20 PM R9 said that she uses her oxygen concentrator every night. R9's oxygen concentrator was located beside her bed against the wall. On January 13, 2026, at 1:17 PM V12 (Licensed Practical Nurse) said that R9 uses oxygen when she is feeling short of breath. On January 14, 2026, at 10:20 AM V3 (Assistant Director of Nursing) confirmed that an oxygen order for R9 was documented December 30, 2025, and should have been recorded in R9's MDS.

Based on observation, interview, and record review, the facility failed to off-load the heels of a resident, who has facility-acquired pressure ulcers. This applies to 1 of 3 residents (R176) reviewed for pressure ulcers in the sample of 30. The findings include:The EMR (Electronic Medical Records) shows R176 was admitted to the facility on [DATE], with multiple diagnoses including, congestive heart failure, other abnormities of gait and mobility, and dementia. R176's MDS (Minimum Data Set) dated December 31, 2025, shows R176 has severe cognitive impairment, requires substantial/maximal assistance for bed mobility and transfers. R176 is frequently incontinent of bowel and bladder. R176's MDS continues to show R176 is at risk of developing a pressure ulcer and did not have any pressure ulcers at the time of the MDS assessment. R176's initial wound evaluation dated January 8, 2026, shows R176 has unstageable DTI (Deep Tissue Injury) with intact skin on both left and right heels. R176's initial wound evaluation shows pressure as the cause of the wounds, with a duration greater than five days. Also, R176's initial wound evaluation shows the left heel wound measurement was 1.8 cm (centimeter) in length, 2.5 cm in width, and depth not measurable. Right heel measurement was 4.5 cm in length, 2.3 cm in width, and depth not measurable. R176's initial wound evaluation further shows V39's (Wound Physician) recommendation is to float heels in bed, off-load wounds, and pressure off-loading boot. R176's wound evaluation dated January 12, 2026, shows R176 has unstageable DTI to both heels. R176's wound evaluation shows the left heel wound measurement was 1.9 cm in length, 2.3 cm in width, and depth not measurable. R176's right heel wound measurement was 1.5 cm in length, 2.0 cm in width, and depth not measurable. V39's recommendation is to float heels in bed and off-load wounds. On January 13, 2026, at 9:21 AM, R176 was lying in bed with a pillow under each heel and both the heels were touching the pillows. This observation was done in the presence of V14 (Wound Nurse). On January 13, 2026, at 10:32 AM, R176 was lying in bed with both her heels touching the bed sheet. V14 did the wound treatment and placed a pillow under each heel. Both heels were touching the pillows. On January 13, 2026, at 11:37 AM, R176 was lying in bed with both heels touching the pillows. On January 14, 2026, at 8:42 AM, R176 was lying in bed with one pillow under her heels. Both heels were touching the pillow. V40 (Restorative Certified Nursing Assistant, CNA) and V41 (CNA) assisted R176 to the bathroom. At 9:08 AM, R176 was assisted back to bed and a pillow was placed under both heels and the head of the bed was raised. Both heels were directly touching the bed sheet.On January 14, 2026, at 9:38 AM, R176 was lying in bed and V3 (Director of Nursing, DON), stated R176's heels were touching the mattress. V3 also stated she expects staff to off-load residents' heels when there is a recommendation to do so for pressure ulcers. V3 stated R176 stays in bed due to her chronic pain so offloading is important. V3 further stated R176's current care plan does not address R176's pressure ulcers. Facility's policy titled Prevention of Pressure Ulcers revised on August 2008 shows when resident is in bed, every attempt should be made to float heels (keep both heels off the bed).

Based on observations, interviews and record reviews the facility failed to failed to provide adequate care and services to maintain adequate nutritional status by failing to monitor food intake and offer offering meal alternatives similar nutritive value, encourage resident intake of meals, and ordering and providing nutritional supplements as recommended by the dietitian for residents with low body weights and poor oral intake. This failure applies to three of six residents (R18, R49, and R105) reviewed for nutrition in a total sample of 30 residents. Findings include:1. According to the face sheet, R49 was admitted to the facility on [DATE], and had multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes mellitus, abnormalities of gait and mobility, and lack of coordination. R49's MDS (Minimum Data Set) dated December 23, 2025, showed R49 had moderate cognitive impairment and required supervision or touching assistance from the staff for eating. R49's Nutrition care plan initiated on November 20, 2025, showed R49 had potential for nutritional problems, and interventions included RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (as needed). R49's documented weight at the facility on June 20, 2025, was 135.6lbs (pounds), 131.9 lbs on July 16, 2025, 131.6 lbs on August 16, 2025, 130.9 lbs on September 18, 2025, 128.9 lbs on October 29, 2025, 106.8 lbs on December 6, 205, and 107.9 lbs on December 18, 2025. R49's weight documentation showed that all were obtained using a sitting scale. R49's quarterly weight assessment documented by V11 (RD/ Registered Dietitian) on December 23, 2025, showed R49's current weight is 107.9 lbs, height is 64 in [inches], and BMI [Body Mass Index] is 18.5, which is classified as underweight for age. Weight down 16.3 percent in two months (significant), weight down 17.6 percent in three months (significant), and weight down 20.4 percent in six months (significant). Recommend continuing the current diet and encourage intake. Recommend adding 120 milliliter (ML) MedPass [nutritional calorie and protein supplement] BID [twice daily]. Recommend weekly weights. On January 13, 2026, at 9:30 AM, R49's POS (Physician Order Summary) was reviewed, and the POS did not show orders for MedPass and weekly weights. On January 14, 2026, at 10:24 AM, R49 was weighed on a sitting scale by V8 (CNA/Certified Nursing Assistant) and V23 (Restorative Aide) in the presence of the surveyor, and R49's weight was 103 lbs. R49 lost 4.9 lbs, a 4.5 percent weight loss between December 18, 2025, and January 14, 2025. On January 13, 2026, at 12:50 PM, V3 (DON/Director of Nursing) said the RD usually sends the residents' dietitian recommendations to the facility's DON and ADON (Assistant Director of Nursing), and the DON or ADON notifies the residents' nurses. V3 said the nurses notify the residents' physician or NP (Nurse Practitioner) to obtain an order based on the dietician's recommendation. V3 also said the physicians and NPs usually agree with the dietician's recommendation, but R49's dietician's recommendation was missed, and no one followed up to obtain an order. On January 14, 2026, at 12:31 PM, V11 said she recommended 120 ML MedPass twice daily and weekly weights due to R49's significant weight loss at the facility. V11 said the facility's physicians and NPs usually agree with her recommendations for the residents. V11 said MedPass is a nutritional supplement recommended to help R49 with additional calories and protein, which could help stabilize her weight and help her regain some of the weight she had lost. V11 also said the weekly weights would help monitor R49's weight progress and determine whether additional interventions should be initiated. 2. R18 was admitted to the facility 11/16/2022 with a diagnosis of Dementia with Behavioral Disturbance, Chronic Congestive Heart Failure, Abnormalities of Gait and Mobility, Lack of Coordination, Repeated Falls, Anxiety Disorder, and Seizures. On January 12, 2026 at 12:35 PM, R18 was sitting in dining area not eating her lunch. R18's lunch meal was placed back onto the meal cart with most of the meal remaining on the tray. At 12:52 PM, V22 (Registered Nurse) said R18 just pushed her tray away and only ate a few bites. V22 said she didn't offer R18 any alternatives to her meal. V33 (Family Member) said R18 doesn't eat at times and during one visit she requested a burger for R18 because she didn't eat her meal. On January 12, 2026 at 1:10 PM, V33 (Family Member) said R18 has lost a lot of weight recently. On January 13, 2026 at 12:15 PM, R18 was sitting in the dining room with her meal tray lightly eating. On January 13, 2026 at 12:45 PM, V40 (Certified Nursing Assistant) said R18 only ate a portion of her meal and included a burger with her mashed potatoes and gravy, and broccoli, V40 said she did not offer R18 any alternatives. R18's remaining lunch meal was 25 - 30% eaten with most of her burger, potatoes, and broccoli remaining. R18's meal intake reports dated 01/12/26 and January 13, 2026, show that R18 consumed 51-75% of her lunch meals. On January 13, 2026, at 2:24 PM, R18's weight was measured by V25 (Registered Nurse) to be 117.1 pounds. R18's weight reports show her weight was measured at 123 pounds on 10/16/2025, 119 pounds 12/25/2025 and 117.2 pounds 01/13/2026 totaling a 5.8-pound weight loss in three months. R18's current active physician orders include an order effective an order effective 11/20/2024 for 120ml of a Nutritional Supplement to be given three times per day, and an order effective 01/23/2025 for weekly weights. R18's most recent Nutritional assessment dated [DATE] shows her nutritional goals are to consume 75% or more of her meals, her weights to remain stable with recommendations including encourage intake. R18's current care plan shows she has a nutritional problem or potential nutritional problem with interventions including weigh weekly and as needed. 3. Resident 105 was admitted to the facility 11/15/2025 with a diagnoses of Adult Failure to Thrive, Chronic Congestive Heart Failure, Bipolar Disorder, Dementia with Behavioral Disturbance, Cognitive Communication Deficit, and Hypovolemia who On January 14, 2026 at 9:39 AM, V32 (Family Member) said upon R105's admission she began gaining weight up to 90 pounds approximately and has lost weight and was down to 82 pounds, and there was no plan in place to address this; V32 sent an email yesterday asking for plan of care for R105's weight loss with no response from the facility. R105's current care plan does not include dietary/nutrition interventions. R105's Clinical assessments dated 11/15/2025, 11/19/2025, and 12/03/2025 show no diet or appetite concerns for R105. R105's Nutrition assessment dated [DATE] shows R105's eating patterns are between 50-100%, her weight was at 91 pounds, she was classified as underweight and nutritional goals included weights remaining stable or gradual weight gain with recommendations including encouraging intake. R105's current active physician orders include an order effective 11/19/2025 for a protein shake once daily and orders effective 01/06/2026 for 120ml of a nutritional shake once daily. R105's physician order history includes an order effective from 11/17/2025 to 12/15/2025 for weekly weights every Monday. R105's weight reports from admission to current show her weight was measured as 91 pounds on 11/17/2025 and as 82.6 pounds on 01/12/2026 totaling 8.4 pounds and 9% weight loss in two months; and does not include weekly weights at any time since admission. R105's progress note dated 11/23/2025 shows she needs encouragement to eat a little more than her normal amount. R105's dietary progress note dated 12/29/2025 shows she has an order for a protein shake, however, the protein shake is not available at the facility. Recommended adding 120 mL nutritional supplement once daily. R105's psychiatry progress note dated 1/7/2026 shows a chief complaint of anxiety and presents with fluctuating appetite. R105's progress note dated 1/12/2026 shows V32 (Family Member) called nursing station to discuss resident's diet and per nurse requested to discuss diet, plan of care. V32 is aware of the R105's recent weight loss and thinks pureed diet contributed to weight loss. She stated that R105 eats and enjoys food from home. R105's Lab Report dated 01/13/2026 shows abnormal blood urea nitrogen, albumin, and blood cell levels. Email communication from V32 (Family Member) to the facility dated 01/13/2026 shows V32 expressed concerns with serious gaps in communication regarding nutrition care regarding 105's sudden and serious weight loss and that R105's weight loss is not being adequately addressed. On January 15, 2026 at 1:15 PM, V3 (Director of Nursing) said R105 is not at risk for weight loss. On January 15, 2026 at 2:43 PM, V11 (Former Registered Dietitian) said R105 is fairly new so she is not as familiar with her as other residents, nutritional supplements are not sufficient by any means for long term use to maintain good nutritional status, V11 develops care plans with the assistance of the nursing department, if a resident is at risk for weight loss or has any nutrition risks they should have nutrition interventions, meal intakes should be monitored for anyone at risk for weight loss or has had significant weight loss and the information should be accurate because she uses this information to determine nutrition interventions such as encouragement at meals, if a resident has physician orders for weekly weights, these orders should be followed because this will help to catch weight loss earlier rather than weighting the whole month to determine weight loss status. On January 15, 2026 at 3:29 PM, V11 (Former Registered Dietitian) said yes said sometimes dehydration could be due to poor appetite and poor nutrition, R105's most recent lab report from January 13, 2026 could indicate poor hydration or intake, based on some of R105's diagnoses and weight loss she is at risk, and R105 was started on a supplement right away upon admission due to nutrition risk and low body weight. V11 said based on R105's diagnoses and diagnoses of adult failure to thrive she did need nutrition interventions of extra calories and nutrients until she was able to observe R105 more, she wasn't aware of R105's weight loss until her latest weight and the only weight measurement she has seen of R105 was 91 pounds from her November weight measurement. V11 said R18 does have a few diagnoses that could potentially put her at nutrition risk, if R18's meal intake is poor that would raise concerns for nutrition because at her last review R18's weights were stable and she had a good appetite, R18's weight is trending down, ideally R18 shouldn't be losing any weight and gaining weight would be beneficial for R18. The facility's Weight Assessment and Intervention Policy received from the facility 01/14/2026 states: Weights are monitored monthly or more often as recommended by the interdisciplinary team, the goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Weight data will be used as one step in determining if changes to the nutritional plan of care are needed to prevent or slow unintentional weight loss within the limits of the resident's clinical condition. Nursing staff will record the resident's weight the day they move in, the next day, and once a week for four weeks thereafter to establish a base weight and stability of weights. Care planning for undesirable weight loss or impaired nutrition shall be a multidisciplinary effort and will include the physician, nursing staff, Registered Dietitian, a member for the Food and Nutrition Department, consultant pharmacist, and the resident or the resident's legal surrogate. Individualized care plans shall address the following to whatever extent possible: Goals with measurable time frame for improvement. Interventions/approaches.

Based on observation, interview, and record review, the facility failed to ensure the resident received oxygen as prescribed. This applies to 3 of 4 resident (R7, R9, and R81) reviewed for oxygen administration in a sample of 30.The findings include: 1.R7 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, other pneumonia, heart failure, and COPD (chronic obstructive pulmonary disease) with acute exacerbation. R7's POS (Physician Order Sheet), dated 01/03/2026 shows an order for oxygen administration as oxygen at 7 LPM (liters per minute) per NC (nasal canula) every shift for COPD. On 1/12/2026 at 10:54 AM, R7 was lying in bed and was receiving between 8 to 8.5 LPM via NC. On 1/13/2026 at 12:15 PM, R7 was receiving between 8.5 to 9 LPM via NC, R7 was irritable and uncomfortable and was using accessory muscles to breathe. V16 (RN-Registered Nurse) verified that R7's oxygen rate was set between 8.5 to 9 LPM. V16 stated the oxygen rate should be set at 7 LPM. On 1/13/2026 at 3:48 PM, V16 stated R7 has an order for oxygen at 7LPM via NC and the order should be followed to avoid oxygen overload because R7 has COPD. 2. R9 was admitted to facility on December 26, 2023, with multiple diagnoses including chronic obstructive pulmonary disorder, urinary tract disorder, emphysema, pneumonia, lack of coordination, disorder of the muscle, abnormalities of gait and mobility, cognitive communication deficit, Type II diabetes, Dementia, hypothyroidism, bipolar disorder, chronic viral hepatitis C, anxiety disorder, major depressive disorder according to face sheet. R9's active summary report dated December 30, 2025, shows Oxygen 3LPM (liters per minute) continuous O2 (oxygen) to keep saturation at 90% as needed for SOB (shortness of breath). R9's most recent care plan dated December 01, 2025, acknowledges R9's COPD (Chronic Obstructive Pulmonary Disorder) status but states that she is not currently on oxygen. The most recently completed MDS (Minimum Data Set) does not reflect R9's use of oxygen. On January 12, 2026, at 11:46 AM, R9 was sitting in dining room for lunch without oxygen. On January 13, 2026, at 9:33 AM, R9 was sitting at breakfast table without oxygen. On January 13, 2026, at 11:20 AM, R9 was playing kickball in dining room without oxygen. On January 13, 2026, at 1:20 PM, R9 was sitting on her bed coloring with oxygen concentrator up against the wall. Oxygen was not utilized. R9 said that she uses her oxygen only during the night because the concentrator is too big to try to carry around. On January 13, 2026, at 1:17 PM, V12 (Licensed Practical Nurse) said that R9 uses the oxygen sometimes when she is short of breath. V12 confirmed that the physician's order reads 3L per minute continuously but that R9 only uses oxygen as needed. On January 13, 2026, at 11:08 AM, V19 (Certified Nursing Assistant) said that R9 is supposed to wear her oxygen whenever she is in her room. On January 13, 2026, at 1:35 PM, V3 (Director of Nursing) confirmed that according to current physician's order, R9 should be receiving 3L of continuous oxygen and that the directions listed contradict the order in place. 3. R81 had multiple diagnoses including, COPD (chronic obstructive pulmonary disease) and severe morbid obesity due to excess calories, based on the face sheet. R81's active order summary report showed an order dated January 6, 2026 for, Oxygen 2 liters/minute per NC (nasal canula) PRN (as needed) for SOB (shortness of breath) or SP02 (peripheral oxygen saturation) below 92% on room air. On January 12, 2026 at 11:32 AM, R81 was in bed, alert, oriented and verbally responsive. R81's head of bed was elevated. R81 had an ongoing continuous oxygen at 4 liters per minute via nasal canula using an oxygen concentrator. R81 stated that he was having shortness of breath. The resident was observed to be breathing normally, and no signs or symptoms of respiratory distress was noted. V6 (RN (Registered Nurse)) was informed of R81's complaint of shortness of breath. V6 checked R81's peripheral oxygen saturation and obtained 97%. V6 did not check how much oxygen R81 was receiving. While inside the room with V6, after his peripheral oxygen saturation was checked, R81 stated that he was not actually having shortness of breath. On January 13, 2026 at 10:21 AM, R81 was in bed, alert and oriented. R81's head of bed was elevated, and the resident had a continuous oxygen via nasal canula at 4.5 liters per minute using an oxygen concentrator as verified by V5 (RN)). R81 was breathing normally, and no signs or symptoms of SOB was noted. V5 checked R81's peripheral oxygen saturation and obtained 97%. V5 did not re-adjust R81's oxygen to ensure that the resident receives the oxygen as ordered by the physician. R81's MAR (medication administration record) dated January 12 and 13, 2026 showed documentation during the 7:00 AM - 3:00 PM shift that the resident received 2 liters per minute of oxygen PRN for shortness of breath or peripheral oxygen saturation below 92% on room air. The same MAR showed documentation that R81's oxygen saturation was 97% on January 12 and 13, 2026 during the 7:00 AM – 3:00 PM shift. R81's active care plan initiated on July 16, 2024 showed multiple interventions including, Give oxygen therapy as ordered by the physician. On January 14, 2026 at 1:30 PM, V3 (Director of Nursing) stated that the order for resident's oxygen rate should be followed as ordered by the physician. V3 stated that oxygen is considered medication and changing and/or increasing the rate should have an order from the physician, especially for residents with respiratory concerns, including COPD. The facility's policy and procedure regarding oxygen administration dated March 2024 showed under the preparation, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review the facility failed to ensure a resident with complaint of pain was reassessed and provided interventions to relieve pain in accordance with facility policy. This applies to 1 of 1 residents (R8) reviewed for pain management in the sample of 30. The findings include:R8's face sheet showed R8 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, type 2 diabetes, low back and left hip pain, chronic obstructive pulmonary disease, bipolar disorder, and unsteadiness on feet. R8's MDS dated [DATE], showed R8 was cognitively intact and required assistance with ADLs including set up assistance with eating, personal hygiene and bed mobility, supervision with oral hygiene, dressing and transfer. R8's care plan initiated on November 3, 2025, showed no non pharmacological interventions to address pain. R8's care plan initiated on November 22, 2025, showed R8 developed a behavior of calling 911 due to unrelieved pain with an intervention for R8 to see the pain doctor. On January 12, 2026, at 1:40 PM, R8 cried while stating walking hurts and there is no way she can do it. On January 13, 2026, at 11:30 AM, R8 stated five days ago the whole facility was out of Tylenol, on all the units and that is the only thing she has prescribed for pain. R8 explained last October she saw the facility pain doctor walking in the hallway and asked him to come to her room because she was having an increase in pain, especially during therapy and while walking or doing leg exercises. R8 stated the doctor prescribed a medication that helped but she had not seen the doctor again and the medication was discontinued. R8 stated V37 (Social Services Director) told her she did not need anything more for pain other than Tylenol, and that statement upset her. Review of R8's current pain medication regimen showed R8 is prescribed acetaminophen (Tylenol) 1000mg by mouth every 6 hours initiated on September 30, 2025, Lyrica 100 mg three times a day initiated on November 12,2025, and Lidocaine patch apply to right hip every 24 hours as needed initiated on September 11, 2025, and Lidocaine patch 4% to both knees two times a day initiated on October 7, 2025. Review of R8's previous medication orders showed R8 had been prescribed Tramadol 50 mg every 12 hours as needed from September 18, 2025, through September 28, 2025. R8's Physiatrist progress note dated October 24, 2025, showed a trial of prednisone was prescribed for brief time and R8 should be monitored closely. There was no additional pain assessment or further visit by the Physiatrist after that date. The physical therapy note dated October 30, 2025, showed R8 complained of pain in the groin and was upset due to the pain and the note showed nursing to address the pain. The physical therapy note dated October 28, 2025, showed R8 was with increased anxiety, was feeling upset, and complaining of increased pain and R8's daughter spoke to the therapist about sorting out pain medication to get back on track as well as speaking to the physician. The most recent pain assessment was dated September 3, 2025, and showed R8 was not experiencing any pain. There was no pain assessment completed when R8 began complaining of an increase in pain, and no modification of R8's pain regimen from October 30, 2025, when R8 complained of increasing pain, until January 12, 2025, when R8 complained her pain had increased and nothing was done. The facility's policy titled Pain -Clinical Protocol dated August 2008, showed Assessment and recognition, identify individuals who have pain or are at risk for having pain and assessments would occur whenever there is a significant change in condition or at any time pain is suspected, use an individualized pain assessment to identify the nature and severity of the pain, evaluate how pain is affecting mood, activities of daily living, sleep and selective quality of life measures, as part of the medical assessment, the physician will help identify the extent to which the underlying causes of pain can be addressed or reversed and with input from the resident establish goals of pain treatment the physician will order appropriate non pharmacological and medication interventions to address the individuals pain.

Based on observation, interview, and record review the facility failed to implement infection control practices including hand hygiene during dining and the use of personal protective equipment for residents on isolation and enhanced barrier precautions. This applies to 2 of 4 residents (R74, R92) reviewed for infection control in the sample of 30. The findings include: 1. R92 had multiple diagnoses including, oral phase dysphagia and adult failure to thrive, based on the face sheet. R92's active order summary report showed an order dated December 20, 2025, for a bolus tube feeding four times a day. On January 13, 2026, at 1:38 PM, an EBP (Enhanced Barrier Precaution) sign was posted on the door of R92's room. The EBP sign showed that providers and staff must wear gloves and gown during high-contact resident care activities, including during feeding tube device care or use. Inside the room, R92 was sitting in his reclining wheelchair. V5 (Registered Nurse) was inside the room to administer the bolus feeding of R92 via the gastrostomy tube. V5 administered the ordered initial water flushing and then the ordered tube feeding. After the said procedure, V5 removed her right glove, then with her bare right hand, held and moved R92's overbed table closer to her and the resident. V5 then got a new glove from the box of gloves using her right hand and put on a new glove on her right hand without performing hand hygiene and then proceeded to administer the final water flushing to R92's gastrostomy tube. During the entire gastrostomy tube feeding procedure, V5 was not wearing a gown as instructed on the EBP sign posted on the door. On January 13, 2026, at 1:50 PM, V5 acknowledged that she should have worn a gown during the gastrostomy tube feeding procedure as instructed on the EBP sign posted on the door. V5 also acknowledged that she should have performed hand hygiene, either hand washing or use of hand sanitizer, after removing her glove and before putting on a new glove. On January 13, 2026 at 3:53PM, V3 (Director of Nursing) stated that during gastrostomy tube feeding and care, the staff should wear the complete PPE (personal protective equipment), including gloves and gown, and hand hygiene either hand washing or use of alcohol rub should be used after removing glove/s and handling equipment, before putting on a new gloves. According to V3, the above-mentioned procedure should be followed to prevent cross contamination and to maintain infection control. The facility's policy and procedure regarding enhanced barrier precautions dated April 1, 2024, showed, It is the practice of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug resistant organisms. EBP are indicated during high contact activities for residents with infection or colonization with the CDC (Centers for Disease Control and Prevention) targeted [multidrug resistant organism] (when contact precautions do not apply) or for any resident who has a chronic wound and/or indwelling medical device. The same policy showed that high-contact resident activity included, feeding tube device and care. The facility's policy and procedure regarding gloves as personal protective equipment dated June 2005 showed that use of gloves, prevent the spread of infection. The same policy showed, 5. Wash hands after removing gloves (Note: Gloves do not replace handwashing). 2. R74 was admitted to the facility May 5, 2017, with a diagnoses of Partial Paralysis and COPD. R74's current active physician orders include an order for contact isolation for Klebsiella bacteria effective from 01/08/2026 to 01/18/2026. On January 12, 2026, at 12:10 PM R74's room door had a Contact Isolation sign and PPE (Personal Protective Equipment) bin outside the room. V34 (Certified Nursing Assistant) entered R74's room without donning PPE and touched R74's hand while delivering and setting up her meal tray. On January 15, 2026 at 2:24 PM V4 (Assistant Director of Nursing) said nursing staff should be wearing PPE (Personal Protective Equipment) when entering a resident's room who is on contact isolation because they may touch surfaces or come in contact with the resident, if staff have any physical contact with a resident who is on contact precautions while delivering meal trays, the nursing staff should be wearing PPE, R74 is on contact isolation for ESBL (Klebsiella) of urine and these precautions began 01/08/2026 and will end on 01/18/2026.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, and comfortable environment. This applies to 1 of 5 residents (R5) reviewed for environment in a sample of 5. The findings include:R5's face sheet shows multiple diagnoses, including Parkinson's disease, bipolar disorder, paranoid schizophrenia, unspecified dementia, hypertension, and chronic diastolic heart failure. R5's Minimum Data Set (MDS) shows impaired cognition, impaired mobility, poor safety awareness, and increased fall risk.On 12/26/2025 at 11:45 AM, two floor tiles were raised and uneven in the left corner of the R5's room, creating an unstable surface. V10 (Maintenance Director) acknowledged the tiles were uneven and stated they should have been repaired when it was initially identified. V5 added the uneven flooring contributed to instability of furniture placed on top of the tiles.The window in R5's room had rotting wood, peeling paint, and a non-functioning crank, preventing the window from opening or closing. A piece of wood had been placed on the sill as a makeshift seal, leaving a triangular-shaped gap that allowed cold air to enter the room. V10 stated the window was not repairable and that he had been aware of the condition since approximately September or October 2025, noting the window had been in this state for a couple of months. The room temperature measured 67 F at the time of observation. Additionally, the in-room refrigerator, which staff confirmed was provided by the facility, was observed with an internal temperature of 48 F, water accumulation in the freezer compartment, and moisture along the interior edges. V10 stated the water resulted from thawing due to the refrigerator's inability to maintain appropriate temperature.A Work Order Request Form No. 4623, dated 09/07/2025, showed a request submitted by V15 (R5's Certified Nursing Assistant) stating close window. V10 documented completion on 09/08/2025 with the notation repaired sill. A second Work Order Request Form, No. 4755, dated 09/26/2025, documented a request stating window won't open in R5's room; however, no completion date or corrective action was documented.On 12/27/2025 at 10:25 AM, V15 stated that she submitted the work order in early September 2025 when R5's window became stuck in the open position and could not be closed. V15 stated she attempted to push the window closed from the outside, but it remained stuck. V15 further stated that there had been a gap in the window since that time allowing air into the room, and that R5 was not relocated to another room while awaiting repair.On 12/26/2025 at 1:05 PM, V17 (R5's member) stated that during a visit, he observed the drawers from R5's television stand removed and, on the floor, with R5's personal belongings scattered. V17 reported that R5 told him the television nearly fell forward when she attempted to open a drawer, and that the drawers fell out due to the stand being unstable. V17 stated that when staff attempted to open the drawers themselves, the television and drawers again nearly tipped forward. V17 further stated that the uneven floor tiles beneath the stand contributed to the instability.On 12/26/2025 at 12:17 PM, V3 (Assistant Administrator) stated she was not aware of the uneven floor tiles, window condition, or refrigerator issues and these conditions pose a resident safety concern.The facility's Safety Policy (effective 01/01/2025) states that the facility will ensure a safe living environment for residents, conduct preventive inspections and maintenance, and maintain a system to communicate and address repair needs. The policy further states that part of their procedural guidelines includes preventive inspection and maintenance as well as a method to communicate repair needs.

Based on interview and record review, the facility failed to provide a safe environment and implement care plan interventions to prevent a fall that resulted in injury.This applies to 1 of 3 residents (R12) reviewed for falls in the sample of 14.This failure resulted in R12, experienced a fall that resulted in a right hip fracture and required hospitalization.The findings include:R12's EMR (Electronic Medical Record) showed R12 was admitted to the facility on [DATE], with multiple diagnoses including dementia, unspecified combined chronic diastolic and systolic congestive heart failure, history of falling and chronic kidney disease. R12 was transferred to the hospital on August 12, 2025.R12's MDS (Minimum Data Set) dated July 14, 2025, showed R12 was severely cognitively impaired, and needed assistance with ADLs including supervision with eating, partial assistance with oral hygiene and upper body dressing, substantial assistance with lower body dressing, bathing, bed mobility and transfer and dependent on staff for toileting. R12's fall prevention care plan, intervention added on February 14, 2025, showed R12 was at risk for falls and staff to get resident up early in the morning when awake and keep by the nurse's station. R12's fall care plan had an additional intervention added on May 21, 2025, that showed when observed awake keep her engaged in the common area until ready to go back to bed. On August 14, 2025, at 4:48 PM, V2 (DON) stated the intervention in February 2025, was added to R12's fall care plan as a result of a fall with no injury. V2 explained R12 liked to be active and move around and when she is awake it is best to keep her in an area where staff can see her. V2 explained R12 had experienced a fall in May 2025 that had resulted in a fracture wrist and the intervention was added that when R12 was observed awake to keep R12 engaged in the common area until ready to go to bed. V2 stated the post fall assessment was not done due to V17 (RN) had not started it at the time of the fall. The incident report dated August 12, 2025, at 5:25 AM, showed R12 was lying on the floor next to her bed and complaining of right hip pain and R12 stated she had hit her head. The report showed V16 (CNA) summoned V17 (RN) to report that R12 was lying on the floor. On August 14, 2025, at 4:36 PM, V17 stated she was the nurse assigned to R12 during the 11:00 PM, August 11, 2025, through 7:00AM on August 12, 2025, shift. V17 stated she was passing medications in the hallway around 5:25 AM, when V16 summoned her to R12's room because R12 was lying on the floor. V17 stated she assessed R12 and found she was complaining of right hip pain and R12 stated she had hit her head. V17 stated she called 911, the physician, and the family to notify them of the fall and R12's complaint of pain. V17 stated R12 went to the hospital via ambulance at 5:50 AM. V17 stated she saw a mat in use at the time of R12's fall.On August 15, 12:37 PM, V16 was interviewed by phone. V16 stated on August 11, 2025, at 11:15 PM on her first rounds, she found R12 sitting on a thick mat that was sitting next to the bed, the height of the mat was almost equal to the height of the bed. V16 stated she assisted R12 who was awake and alert, back into bed. V16 stated she then took the thick mat and propped it up, adjacent to the right side of the bed and the left side of the bed was against the heating unit which was attached to the wall with the window. V16 stated she had boxed R12 into the bed so she wouldn't get up and fall. V16 stated the next time she observed R12 was around 2:15-2:20 AM, and R12 was awake but was not moving around and the mat was still in place propped up against the right side of the bed. V16 stated she started her next rounds around 4:20 AM but started the rounds on the opposite end of the hall from where R12's room was. V16 stated she reached R12's room around 5:25 AM, on August 12, 2025, and found R12 lying on the floor on her right side in a fetal position with her head at the foot of the bed. V16 stated the propped-up mat was still in place and stated R12 must have crawled or scooted out of the end of the bed over the footboard and then fell on the floor. V16 stated she works on all the units in the facility. V16 stated she was not sure of what R12's care plan interventions to prevent falls were. V16 stated no facility staff had interviewed her as of yet as to how R12 had fallen.On August 15, 2025, at 4:12 PM, V2 stated she had not spoken to V16 regarding the cause of R12's fall and V2 stated she was unsure if the restorative nurse had spoken to V16.R12's Xray report from the hospital dated August 12, 2025, showed R12 sustained a mildly comminuted displaced right femoral intertrochanteric fracture, a right hip fracture.V11 (R12's Physician) stated on August 15, 2025, at 3:53 PM, that R12 having barriers on both sides of the bed would be an unsafe situation, especially due to R12 being cognitively impaired. V11 stated the likely cause of R12's hip fracture was the fall that occurred on August 12, 2025.The facility's policy titled Evaluating Falls and Their Causes, dated August 2008, showed, General Guidelines .5. Residents must be evaluated for potential causes of falls immediately. 6.Environmental issues must also be addressed immediately. Steps in the Procedure.3. Identifying Causes of a fall or fall Risk a. Within 24 hours of fall, the nursing staff will begin to try to identify possible or likely causes of the incident.b. Staff will evaluate the chain of events or circumstances proceeding a recent fall including.3. The activity the resident was engaged in. 6. whether the resident was responding to an urge to void. 7. Whether there were environmental factors involved (e.g. slippery floor, poor lighting, furniture, or objects in the way.c. The staff will continue to collect and evaluate information until they either identify a cause of falling or determine the cause cannot be found .

Based on interview and record review the facility failed to identify a change in a resident condition, failed to provide frequent monitoring, failed to provide accurate information to the physician, and failed to transfer R2 to the hospital in a timely manner. This failure resulted in R2 experiencing a slow deterioration from the morning of [DATE], until she was transferred to the hospital at 12:30 PM on [DATE], in critical condition. R2 died at the hospital on [DATE] from septic shock. This applies to 1 of 3 residents (R2) reviewed for quality of care in the sample of 11. The Immediate Jeopardy began on [DATE] at 1:18 AM when V28 (LPN - Licensed Practical Nurse) failed to identify R2's change in condition, complete an assessment, obtain vital signs, and notify R2's physician. This failure continued when V19 (LPN) failed to provide frequent monitoring, provide accurate information to the physician, and transfer R2 to the hospital in a timely manner. V3 (DON - Director of Nursing) was notified of Immediate Jeopardy on [DATE] at 9:00 AM. The surveyor confirmed by 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 in-service training. The findings include: On [DATE] at 9:19 AM, V16 and V17 (R2's family members) said they had attempted to call R2 the evening of [DATE] and the morning of [DATE]. They said it was a routine for them to speak to R2 twice a day and it wasn't normal that she wasn't answering her phone. They said they contacted V19 (LPN) and asked her to check on R2. They said on [DATE] at 10:30 AM, V19 reported, that something was off and [R2] would probably be sent to the hospital. They said V19 reported that R2 screamed whenever she tried to touch her. V16 said she asked V19 if she was calling 911 and V19 replied, No I don't think so. V16 said she didn't understand why R2 was not picked up by the ambulance until 12:30 PM. V16 said she arrived at the emergency room to find R2 with an IV, indwelling catheter, and oxygen already on. V16 said R2 looked grey and was screaming in pain. V16 said R2 was admitted to the ICU (Intensive Care Unit) and was receiving IV blood pressure medications but was not doing well. V16 said R2 expired at the hospital on [DATE] due to septic shock. On [DATE] at 1:40 PM, V19 (LPN) said R2's wing was her regular assignment. V19 said she was familiar with R2 and was the nurse that sent her out on [DATE]. V19 said R2 was alert and preferred to use the bedpan and perform her own peri-care. V19 said R2 would usually turn on her call light when she needed us to grab her something or empty the bedpan, but otherwise she didn't want us bothering her. V29 said the night shift nurse did not report any issues with R2. V29 said on [DATE] R2 was a little confused, was having diarrhea, looked tired, and couldn't clean herself up, like she usually did. V19 said she had to send the CNA in to help R2 at least 2 times on [DATE]. V19 said that R2 wasn't acting like herself and was very weak. V19 said she called her family, the physician, and sent her to the hospital via non-emergent ambulance. R2's Face sheet printed [DATE] showed R2 had diagnoses to include, but not limited to: COPD (chronic obstructive pulmonary disease), heart failure, peripheral vascular disease, insomnia, atrial fibrillations, major depressive disorder, anemia, non-pressure chronic ulcer to left foot, dementia, and osteoarthritis. R2's facility assessment dated [DATE] showed R2 had moderate cognitive impairment; required partial to moderate assistance for personal hygiene and rolling in bed; required substantial to maximal assistance for toilet hygiene; and was always continent of stool. R2's Vital Signs showed on [DATE] at 9:35 AM her blood pressure (BP) was ,d+[DATE], heart rate (HR) was 62, respirations were 18, and her oxygen saturation (Sp02) was 95% on room air. There were no vital signs charted after [DATE] at 9:35 AM. R2's [DATE] MAR showed R2 received Tylenol at 1:18 AM on [DATE] and R2's ,d+[DATE] vital signs were not taken on [DATE]. R2 did not have progress notes from [DATE] until [DATE] at 11:58 AM. (R2's progress notes did not contain an assessment or entry on [DATE] by V28 (LPN) regarding R2's increased weakness, change in behavior, and complaints of vaginal pain. There were no vital signs taken on ,d+[DATE] shift and the physician was not notified of R2's change in condition.) R2's Progress Note dated [DATE] at 11:58 AM, by V19 (LPN) showed, Noticed resident weak and not doing her own peri-care as usual, said that she is weak and cannot do it and kept on removing her diaper. Also, c/o (complained of) vaginal pain. Called [V34 - R2's Physician], order given and carried out to - send resident to ER (emergency room to (local hospital) for eval and treat via regular ambulance. Called (non-emergent ambulance service), said ETA (estimated time of arrival) 30 minutes . Vital signs stable. Resident left with 2 Paramedics around 12:35 PM. Resident was alert, verbally responsive at the time of leaving. (This note does not contain any detail on the times the family or physician were notified, nor does it contain ongoing assessments and vital signs of R2 between 9:35 AM (identification of R2's change in condition) and 11:47 AM when the ambulance was notified.) R2's Physician Order Sheet printed [DATE] showed an order on [DATE] to send R2 to the emergency room via regular ambulance and an order to obtain vital signs every shift. R2's SNF/NF to Hospital Transfer Form dated [DATE] showed vital signs obtained at 9:35 AM. This form showed the date of transfer was [DATE] at 12:35 PM. R2's Ambulance Patient Care Report dated [DATE] showed the time of injury was 9:30 AM, dispatch was notified at 11:47 AM, and the ambulanced arrive to the patient at 12:23 PM. This report showed, Upon arrival patient was alert and oriented x 1, on room air, laying in bed in a lethargic sate. Patient is currently complaining of vaginal region pain and generalized weakness. (Nurse) on scene states they noticed patient lethargic this morning at 9:30 AM. (Nurse) on scene states patient's normal mental status is alert and oriented x ,d+[DATE]. (Nurse) states (R2's) last known normal is [DATE] . Patient pale, cold, and dry . This report showed initially R2's oxygen saturation was 86% on room air and she required hot packs on her hands and 100% oxygen, via a non-rebreather mask, to bring her oxygen level up. This report showed that R2's first BP was ,d+[DATE] (critically low). R2 had low blood pressure readings, unsuccessful IV attempts and the crew decided to divert to the closest hospital for critical care. R2's Death Certificate dated [DATE] showed the cause of death was Septic Shock due to a UTI (Urinary Tract Infection). On [DATE] at 1:48 PM, V35 (Restorative Aide) said they worked R2's wing the weekend of Memorial Day. V35 said on Saturday R2 complained of constipation and the nurse gave her a laxative. (R2's May MAR showed MiraLAX was administered on [DATE] at 8:34 AM). V35 said R2 was going poop all day on Sunday, she just kept going. V35 said R2 normally would clean herself up and rarely asked for help. V35 said on Sunday ([DATE]) R2 had poop everywhere and was actually letting me help her. V35 said that wasn't like R2, she was normally very independent with peri-care. On [DATE] at 12:47 PM, V30 (CNA - Certified Nursing Assistant) said she was working the overnight shift on [DATE]. V30 said R2 wasn't on her assignment, but she heard her screaming and went into her room. V30 said V29 (CNA) was R2's assigned CNA, but she was busy on another hall. V30 said R2 was screaming, so she went in to check on her. V30 said there was poop everywhere. V30 said R2 had spilled the bedpan on the floor and poop was smeared on the mattress, linens, and R2. V30 said R2 was grabbing at her vaginal area and yelling, It hurts! It burns! It itches! V30 said before she completed a full bed bath, she notified V28 that R2 wasn't acting right and was complaining of vaginal pain. V30 said V28 went in the room and gave R2 a Tylenol (R2's [DATE] MAR showed Tylenol was administered at 1:18 AM on [DATE]). V30 said V28 (LPN) never directed her to take R2's vital signs. V30 said she reported to V29 (R2's assigned CNA) that R2 wasn't acting like herself, and she would need to round on her. V30 said R2 can normally change and toilet herself, but not that night. On [DATE] at 3:06 PM, V29 (CNA) said normally R2 didn't want to be bothered at night. V29 said R2 wanted to do everything herself and usually used the bedpan and cleaned herself up. V29 said she didn't recall providing any care to R2 on the ,d+[DATE] shift on [DATE]. On [DATE] at 2:45 PM, V28 (LPN) said she worked ,d+[DATE] and ,d+[DATE] on [DATE]. V28 said she was familiar with R2. V28 said R2 was alert and oriented and able to make her needs known. V28 said R2 was very private related to peri-care and was normally independent with use of the bedpan and cleaning herself up. V28 said she didn't know anything about R2 having diarrhea, requiring assistance with cleaning up, and complaining of vaginal pain that night. The surveyor asked V28 why she gave Tylenol at 1:18 AM. V28 replied, Just to help her sleep or something. V28 said if R2 had weakness, required assistance with bedpan/peri-care, and was complaining of vaginal pain, then that would be a change in condition for her. V28 said with a change in condition she would complete an assessment, obtain vital signs, notify the physician, and complete any orders given. V28 said she did not do any of that for R2 because she wasn't aware there was an issue. V28 said frequent diarrhea causes dehydration and loss of electrolytes. On [DATE] at 10:58 AM, V19 said she found R2 like that in the morning, after breakfast. V19 said it was during morning medication pass when she did the assessment and took the vital signs. (Vital signs charted at 9:35 AM, morning medications due at 9:00 AM). V19 said during that time R2 was talking to her, but continued to have diarrhea, was complaining of vaginal pain, and kept removing her incontinence brief. The surveyor asked V19 what time she called the family, physician, and ambulance. V19 said she couldn't recall the exact times. The surveyor asked V19 if she took another set of vital signs before she called the physician. V19 stated, I don't remember if I took another BP after 9:35 AM. She was weak when I did her BP. The surveyor asked V19 to check her documentation in EMR and V19 replied, I don't see any more vital signs charted. The surveyor asked V19 if there was any documentation to show continued assessments between 9:35 AM (when she noted R2's condition change) and 11:47 AM (when the ambulance was notified, per Ambulance Patient Care Report). V19 said she didn't see anything specific in R2's progress notes. V19 said they don't complete a SBAR form when notifying the physician. V19 said the only form completed when she transfers a resident to the hospital is the Transfer Form. V19 was unable to explain why she used the 9:35 AM vital signs for the Transfer form completed dated [DATE] at 12:35 PM. On [DATE] at 12:01 PM, V25 (Agency CNA) said she was working ,d+[DATE] shift on [DATE]. V25 said she didn't recall the exact time, but she remembered R2 having diarrhea and not being able to clean herself up. V25 said she and the nurse thought something was up, and that she wasn't acting herself. V25 said R2 couldn't use the bedpan and clean herself up like normal. V25 said R2 declined quick and had to be sent to the hospital. On [DATE] at 2:06 PM, V34 (R2's physician) said she didn't recall what time the facility called her about R2 on [DATE]. V34 stated, Most of the residents at the facility are old and frail, so I usually just send them out 911. I remember they called and said she (R2) was a little confused. I usually ask for vital signs and what is going on. If the vital signs were stable, then I would follow the resident's wishes for transport. [R2's family member] preferred to send her to a specific hospital. V34 said she would expect the nurses to provide all pertinent information, regarding a resident's change in condition and a recent set of vital signs. V34 said this information is pertinent in determining the appropriate mode of transportation (911 vs. non-emergent transport). V34 said the vital signs were not stable, then she would have sent R2 out 911. On [DATE] at 2:04 PM, V3 (DON) said if a resident had frequent diarrhea, change in normal behavior/mentation, and complaints of vaginal pain that would be considered a change in condition. V3 said when the nurse identifies a change in condition then they should do an assessment, check vital signs, and discuss any concerns with the physician. The surveyor explained that R2 had frequent diarrhea, change in behavior, increased weakness, and complaints of vaginal pain on ,d+[DATE] shift on [DATE]. V3 said she would expect the nurse to notify the physician and document R2's vital signs, complaints, and pertinent assessments. V3 said when the nurse calls the physician, she should provide recent vital signs and accurate assessment information. V3 said it's important to provide the physician with an accurate picture of the resident's condition, so they can determine proper mode of transportation. The facility's Guidelines for Notifying Physicians of Clinical Problems (revised ,d+[DATE]) showed, These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medial record . When contacting the practitioner, especially at night and on weekends (when physician's not familiar with the residents may be on call), the nurse should have the following information available: 1. Detailed description of current issue or problem, including vital signs, symptoms, and results of physical assessment . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. The corrective action(s) taken for the resident(s) found to have been affected by the deficient practice: -V19 and V28 were in-serviced and educated on identification of a change in condition and continued monitoring. In-service/Education included: to ensure that assessments, monitoring and documentation is completed on residents with a change in condition, providing MD with accurate information regarding change of condition and transferring to emergency department in a timely manner. -Initiated in-service and education to nurses including agency nurses on identification of a change in condition and continued monitoring, documentation of assessments, and monitoring is completed on residents with a change in condition, providing MD with accurate information regarding change of condition and transferring to emergency department in a timely manner. In-service will be completed by [DATE]. 2. The corrective action(s) for other resident(s) having the potential to be affected by the same deficient practice: -All residents have the potential to be affected. None were identified. 3. The measures put into place and a systemic change made to ensure the deficient practice does not reoccur: -The Director of Nursing and MDS Coordinator in-serviced nurses on Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and documentation is completed on residents with a change of condition. In-servicing was [DATE]. V19 and V28 were already in-serviced and educated. Anyone who had not been in-serviced will be in-serviced in person or over the phone prior to their next shift by DON or designee prior to their next shift in this facility. This in-servicing includes nurses on FMLA & PRN and agency nurses. All new hires will be in-serviced during their orientation on the Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and documentation is completed on residents with a change of condition. 4. To ensure the deficient practice does not reoccur, the corrective actions(s) will be monitored by: -DON or designee will audit all residents with a change of condition daily x 6 weeks to ensure that all residents with a change of condition were properly assessed, monitored, and documented on, MD was notified with accurate information and transferred in a timely manner. -QAPI Committee have met and discussed the measures that were put in place to ensure that deficient practice does not occur. Medical Director is in agreement of the measures that were put in place and has approved it. 5. Completion date systemic changes will be completed: [DATE]

Based on interview and record review, the facility failed to have fall prevention interventions in place for a resident at risk for falls. This failure resulted in R1 falling out of bed and sustaining a subdural hematoma. This applies to 1 of 3 residents (R1) reviewed for accidents. The findings include: The facility's [DATE], Final Serious Injury Incident and Communicable Disease Report documented the following: CNA [Certified Nurse Assistant] notified the nurse on duty that R1 was noted on the floor by her bed. R1 stated that she was trying to get something off her table when she tipped over and fell from the bed. R1 was observed with a hematoma and bleeding to the left side of the head. Report showed, Root Cause: Per R1, she was trying to get something from her table when she tipped over and fell from her bed. R1 possibly hit her head on the bedside table causing the hematoma to left side of head. The Report did not mention that a fall mat was in use at the time of R1's fall. The facility's [DATE], Post Fall Evaluation Assessment from 4:00 AM which includes questions and checkboxes showed, Floor mat on floor? No. It also showed Was fall witnessed? No. and Was Resident wearing oxygen as prescribed at time of fall? No. R1's [DATE], Risk for Falls Assessment showed R1 was at risk for falls. On [DATE], at 10:52 AM, V4 (LPN/Licensed Practical Nurse) said she worked the 11 PM to 7 AM shift on [DATE], and was the nurse caring for R1. V4 said she was called to the room by the CNA (V5) and upon entering the room, saw R1 on the floor. V4 said there was blood all over the floor and the fall mat was either standing up or against the wall. V4 said she did not believe the fall mat was in place because there was blood on the floor and not on the fall mat. On [DATE], at 11:08 AM, V5 (CNA) was called, and a voicemail left requesting a return call. As of [DATE], at 9 AM, V5 had not return the surveyor's call. On February 28, 2024, at 08:28 AM, V17 (R1's Family Member) said that on [DATE], around 4 AM, R1 fell out of bed and hit her head and went to the hospital. V17 said there were supposed to be mattresses alongside the bed and if there were, she would not have hit her head and had a brain bleed. V17 said R1 needed surgery and ended up becoming unconscious and died on [DATE]. V17 said R1 had prior falls and was dependent on the staff to get her out of bed as she was bedridden. R1's [DATE], care plan showed R1 was at risk for falls related to impaired functional mobility due to weakness and contractures to bilateral lower extremities. R1's care plan goal showed R1 would have no injuries from a fall. R1's fall prevention interventions include on February 4, 2023, and [DATE], place floor bed with floor mat when resident is in bed and on [DATE], to keep needed items, water, etc. in reach. On [DATE], staff were to frequently check resident at night and on [DATE], to have the call light within reach. On [DATE], at 02:48 PM, V6 (R1's Physician) said R1 was an elderly woman with dementia, who was generally deconditioned. V6 said R1 was at a high risk for falls and measures including low bed with the mattress on the floor were initiated. V6 said the floor mat should have been there as she had previously had a fall in November of 2023. V6 said if R1 was bed bound, she should have had a fall mattress. R1's progress note dated [DATE], at 07:24 AM showed, At approximately 2:30 am, the resident was noted on the floor. R1's face sheet showed R1 was admitted with diagnoses including multiple sclerosis, generalized muscle weakness, lack of coordination, cognitive communication deficit, contracture of muscle, left lower leg and right lower leg, unsteadiness on feet, need for assistance with personal care, and abnormal posture. R1's MDS (Minimum Data Set) dated [DATE], showed R1 had moderate cognitive impairment. R1 required partial assistance from staff for bed mobility and was dependent on staff transfers. R1's MDS also showed R1 had no impairment with her upper extremities. R1's [DATE] [History and Physical] CT Brain or Head showed .Conclusion: Large acute on chronic left frontal, parietal and temporal subdural hematoma measuring up to 2.1 [centimeters]. R1's [Emergency Department] Provider Notes showed [Computed Tomography of Head] performed. I personally interpreted the images- Large [Left Subdural Hematoma] with midline shift. On exam, [R1's] mental status is similar, though slightly slower to respond. [Left] pupil now lightly larger than the [Right] . The facility's Falls- Clinical Protocol policy (revised [DATE]) showed Based on the preceding assessment, the staff and physician will identity pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .Causes refer to factors that are associated with or that directly result in a fall .Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.

Based on observation, record review and interview, the facility failed to provide supervision for a resident with wandering behaviors and Dementia. As a result, R1 left the secured unit and eloped from the facility without facility knowledge. R1 was found by a bystander on the grounds of neighboring independent living complex near a high traffic area and the bystander notified emergency services. As a result, R1 was transported to the local hospital and was noted with a head injury and nasal fracture and required emergency medical treatment. This failure resulted in Immediate Jeopardy. This applies to 6 of 6 residents (R1 through R6) who were reviewed for supervision and safety from a total sample of 10. The Immediate Jeopardy began on November 7, 2022, when R1 left the secured unit without facility staff being aware and then wandered out of the facility without being witnessed by facility staff. R1 got out from the East exit door of the facility and walked through the backyard, crossed a driveway and a parking lot which was located between the facility and the independent living complex before he reached the grounds of the independent living complex that is near a high traffic street. R1 was found on the grounds of the neighboring independent living facility about 199 yards from the nursing facility around 6:20 PM by a bystander. The bystander found R1 lying on the ground with a head injury and called 911 emergency services. The paramedics arrived, and R1 was taken to the nearest hospital. V1 (Assistant Administrator), V2 Director of Nursing/DON), and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on November 10, 2022, at 10:03AM. It was confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on November 14, 2022, at 9:03PM. The non-compliance remains at Level 2 because the additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: 1. Face sheet shows that R1 is [AGE] years-old who was admitted to the facility on [DATE]. R1 has multiple diagnoses which include maxillary fracture, left side, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, generalized muscle weakness, other abnormalities of gait and mobility. Minimum Data Set (MDS) dated [DATE] indicates that R1 is cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 2. The same MDS indicates that R1 requires extensive assistance with walking and transfer and is totally dependent with mobility outside the unit. R1 resides in the secured unit of the facility that houses cognitively impaired residents. On 11/9/22 at 11:25 AM, R1 was in the dining room, sitting, and waiting for lunch. R1 was awake but confused. R1 was able to respond to simple yes and no questions. R1's left periorbital area was swollen, with black, blue, and red discoloration, as well as his left cheek. The sclera or the white area of the eye was reddened from the trauma. R1 also showed the palm of his left hand at the base of his left thumb which was also bruised. R1 stood up and started to pace around the dining room. On 11/7/22, R1 was actively wandering. On 11/10/22 at 10:55 AM, V1 (Administrator) showed where R1 was approximately found by bystanders. The area is in the ground of the neighboring independent living and is near a high traffic street. This was measured by V4 (Maintenance Director) to be 199 yards from the nursing facility. V10 (Certified Nursing Assistant/CNA) stated on 11/9/22 at 1:46 PM that R1 has dementia and has the tendency to wander and attempts to exit open doors. V10 added that on 11/07/22 R1 was being given medications by V7 (Nurse) in the dining room around 6:00 PM. V10 stated that when he returned to the dining area about 6:15 PM after giving care to another resident, R1 was not in the dining room. According to V10, R1 could not be located after checking the unit, R1's room and the bathrooms. V10 then notified V7 about R1's status. V10 did not know how R1 was able to leave the secured unit without anyone knowing. According to V10, R1 frequently attempted to open exit doors, but since R1 wears wander guard and the alarm is activated when R1 tries to leave. The unit staff then started looking thoroughly for R1 in all the bedrooms, bathrooms, and other rooms of the secured unit. V7 notified V2 (Director of Nursing/DON), and everyone started looking for R1. V11 (the other CNA) went outside the building but did not find R1. They checked the other units; they couldn't find him. Around 8 PM that same night, V7 (Nurse) informed V10 and V11 that the local hospital called to report that R1 was in the hospital. On 11/9/22 at 3:35 PM, V7 (Nurse) stated that V7 started the shift by making rounds and doing head count to make sure that everyone was present. According to V7, R1 was in and out of the dayroom and bedroom. V7 added that R1's family is very involved and visit every day during mealtime. On 11/7/22 at around 5:30 to 6 PM, V7 started checking the blood glucose level of the diabetics and administering medications to all scheduled residents. V7's medication cart was just outside the dining area because she was passing medications (From observation, the dining area is in one of the inner corners of the secured unit. It has a short hallway and does not have a direct visual access to all the hallways and exit doors). V7 gave R1 his crushed medications, he spit it all out and walked away. V7 thought that R1 went back to his room which he usually does. R1's family left after dinner. Later, V7 looked for R1 to give him his uncrushed medications, and V10 approached and informed her that he couldn't find or locate R1. V7 stated that three of them (V7, V10, V11) started looking in the hallways, bathrooms, bedrooms, and other areas for R1 and called the supervisor. V7 added that since R1 could not be located, an amber alert was called, and all units were conducting a head count and searching for R1. V10 and V11 started to search for R1 outside of the facility but did not locate R1. V7 stated that R1 is a wanderer, he is a high risk for fall and elopement. He wears a wander guard in the right wrist. V7 could not explain how R1 was able to leave the unit without setting off the alarm. On 11/9/22 at 4:05 PM, V11 (Nurse Aide) stated that on 11/7/22, prior to R1's elopement incident, R1 was with his wife who was visiting at that time. Around 6 PM to 6:15 PM that same evening, V11 was giving a shower to his resident, while V7 (Nurse) was outside the dining room passing medications. Then V10 (the other CNA) approached V7 and V11 and told them that R1 was missing. They checked all the bedrooms, and other rooms. V11 went outside and around the building, but he couldn't find R1. V11 stated that he had no idea how R1 got out of the facility. V9 (Dietary Staff) was interviewed on 11/9/22 at 12:09 PM and stated that he and V15 (Dietary Staff) noted that R1 was outside the secure unit on 11/7/22 in the adjacent (unsecured) unit. V9 stated that R1 asked them for a cigarette. According to V9, V15 recognized R1 as being a resident from the secure unit so V9 and V15 notified two nurse aides that R1 was in their hallway. V9 added that the one nurse aide told him it was fine for R1 to be in unsecured unit as R1 was just going to sit there. V9 then stated as V9 and V15 were returning to the kitchen they heard the alarm. V15 (Dietary Staff) was interviewed on 11/14/22 at 9:30 AM and stated that on 11/7/22 between 6:15 to 6:30PM, the exit door to the secure unit was beeping. According to V15, the beeping means that someone passed through the door, and it did not close on time. V15 stated V15 put in the code for the door and opened the door to leave the secure unit and found R1 outside of the secure unit. V15 stated this was reported to the two nurse aides and a short time later the alarm went off. V15 added that one of the nurses came out and asked if anyone had seen a resident leave via the exit door. V6 (Nurse) was interviewed on 11/9/22 at 1:09PM and stated that on 11/7/22 while passing medications about 6:00PM she heard the door alarm. V6 stated she asked the staff if they saw anyone leave and then conducted a head count. V6 added that all the residents on her unit were accounted for, and she then went and reset the door alarm. V6 stated that a few minutes later she was instructed to do another head count since R1 was missing. V6 was not informed by staff that R1 had been seen on her unit off the secure unit. V6 stated that if she had been informed of R1's presence on her unit, she would have returned R1 to the secure unit and notify the nurse. On 11/9/22 at 4:21 PM, V12 (CNA in the unsecured unit) stated that she was never notified that R1 was in their unit, or else she would have done something. When the alarm sounded, she was at the nurses' station. V12 didn't see anyone that was not supposed to be there except for the kitchen staff who passed by leaving with the carts. V12 did not see R1 in the hallway of their unsecured unit. When the alarm sounded, they did head count, and nobody was missing. V12 never spoke to the kitchen staff that time. On 11/9/22 at 4:30 PM, V13 (CNA) stated that she was working in the unsecured unit when she heard that someone was missing (R1) from the secured unit. When they heard it, they immediately did a head count. Prior to the sound of alarm, one of the kitchen staff (V15), asked if she knew the person (man), she noticed that there were three of them in the hallway. V13 did not know the third person, she was not sure if the person was a visitor, a staff, or a resident. V13 told V15 that she does not know the man. V13 added, she was busy at that time picking up trays. V1 (Administrator), V2 (Director of Nursing), R1's family members and facility maintenance staff all returned to the facility to look for R1. V2 then received a phone call from the local hospital to identify a person the hospital thought was the missing resident. R1's family went to the hospital to identify R1. The EMS/911 (Emergency Medical Services) documentation dated 11/7/22 shows: The EMS paramedics was dispatched to respond to a call with regards to someone bleeding. The paramedics arrived on scene with law enforcement and met a man who has no identification and was placed under a name of John Doe (Who was later identified as R1). R1 was noted having a contusion above left eyebrow and with abrasions on both hands. The paramedics and the law enforcement were unable to find out what language R1 was speaking. There was no ID or information that could be gathered from R1. R1 made a motion to the paramedics which showed that he fell on the sidewalk. The paramedics also noticed a puddle of blood that R1 made a motion that it came from his nose. R1 was brought to the hospital for further evaluation. The EMS documentation of the timeline of service shows that they received a call on 11/7/22 at 6:26 PM. They arrived at the scene of incident at 6:35 PM. They begin to transport R1 to the hospital at 6:43 PM and arrived at 6:54 PM. Hospital Emergency Department (ED) record dated 11/7/22 shows that R1 was treated for Maxillary sinus fracture and injury of the head and left sinus with internal hemorrhage. Nursing Note dated 11/8/22 at 12:48 AM documents: R1 came back from the hospital at 11: 55 PM, after an elopement and a fall incident. The staff did a head-to-toe assessment and observed swelling and hematoma around the left periorbital area with abrasion and dressing on it. R1 had discoloration near to left side cheek above the left side lip measuring 1.5-centimeter (cm) X 1.0 cm. There were scratches on both knees without any deep injury. CT scan of the head results shows left periorbital hematoma and left maxillary sinus fracture. On 11/14/22 at 10:43 AM, V3 (Assistant Director of Nursing/ADON) said that if a staff saw someone wandering in their unit and not sure if it's a resident or a visitor and that someone is not familiar to them, they should approach the person and ask question and redirect where this person is supposed to be. On 11/9/22 at 4:41 PM, V2 (DON), stated that there were 3 staff in the secured unit who were working at the time of R1's elopement. These staff were V7 (Nurse), V10 (CNA), and V11 (CNA). On the day of the incident, V2 arrived at the facility approximately past 7 PM to help search for R1. V2 was searching outside the building, and at the same time communicating with V1(Administrator) who was also looking for R1. She later received a call from V1 and informed her that the assisted living received a call from the local hospital. R1's family was in the facility at that time, and they went to the hospital to identify R1. On 11/15/22 at 11:44 AM, V5 (R1's Physician) said that if a resident who is cognitively impaired is identified as a high risk for elopement and fall then he should be in a secured unit and be closely monitored for safety. Admission notes dated 10/12/22 documents, R1 has a history of dementia, he was unable to make needs known. According to family R1 wanders in the room and is a high fall risk. R1 was unable to use the bathroom, he needs 1:1 always monitoring. Nurse Practitioner notes dated 10/13/22 documents that R1 has dementia and has history of suicide attempt. R1 has decreased mobility, poor strength, muscle atrophy, all extremities examined. R1 with severe dementia, confuse. Social Service Note dated 10/19/2022 documents: R1 can express himself and understand in his native language and simple English phrases. R1 will push on unit door yet easily redirects. R1 wears wander guard as a precaution. Restorative Notes dated 10/27/22 documents: R1 is at risk for fall due to impaired functional mobility, unsteady gait, impaired cognition, and increased weakness. R1 will be assisted with activities of daily living (ADL) care as needed and all efforts will be praised. The protocol in monitoring high risk for elopement resident, is that a staff is supposed to be present in the hallway to monitor. To make sure no one goes to other people's room or try to escape through the exit door. When the nurses pass medications, they help monitor the hallway. The staff usually make unit rounds every 2 hours. R2 through R6 are residents who are on the list of the facility's elopement risk. Per documentation from the progress notes, assessments, MDS and care plan, R2 through R6 were identified as cognitively impaired, ambulatory, and displayed elopement risk behavior. These 6 residents can be potentially affected with the facility's failure of adequate supervision. Facility's Elopement and Search Policy and Procedure dated February 2014 indicates: Policy: To establish methods for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. Policy Specifications: 1. All nursing personnel are responsible for: a. Knowing the whereabouts of resident for which they are assigned. c. Staff are responsible for keeping the nurse informed of a resident's whereabouts. 7. All staff are responsible for promptly going to the location and determining the cause of the activated audible alarm. 14. All facility staff will be informed of residents at elopement risk. Through observation, interview and record review conducted on November 14, 2022, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: 1. The corrective action(s) taken for the resident(s) found to have been affected by the deficient practice: A head count was done immediately. All other residents were accounted for. All residents with wander guards were checked to make sure theirs were working. All were working as designed. The unit door alarm codes were changed. Visitors are not allowed to have the code and will be let on and off the locked unit by staff. Maintenance staff checked the wander guard system, and door alarms shortly after elopement. The systems were working as designed. 2. The corrective action(s) for other resident(s) having the potential to be affected by the same deficient practice: All residents have the potential to be affected. None were identified. 3. The measures put into place and a systemic change made to ensure the deficient practice does not reoccur: The Administrator or designee has in-serviced Nursing, CNA, Bed Maker, Housekeeping, Laundry, Maintenance, Dietary, Activity and Reception staff on the Elopement and Search Policy and Door Alarm Policy - in particular, to notify another staff member if you are unsure if it's a resident of that unit. In-servicing will be completed end of day 11/14/2022. Anyone who have not been in-serviced will be in-serviced in person or over the phone prior to their next shift by Medical Records, Nursing Scheduler, or designee prior to their next shift in this facility. This in-servicing includes staff on FMLA & PRN. All new hires will be in-serviced during their orientation on the Elopement and Search Policy and Door Alarm Policy - in particular, to notify another staff member if you are unsure if it's a resident of that unit. The Administrator or designee has in-serviced Agency Nurses and CNA staff on the Elopement and Search Policy and Door Alarm Policy - in particular, to notify another staff member if you are unsure if it's a resident of that unit. In-servicing will be completed end of day 11/14/2022. Agency staff who have not been in-serviced will be in-serviced in person or over the phone prior to their next shift by Medical Records, Nursing Scheduler, or designee prior to their next shift in this facility. Nursing, CNA, Bed Maker, Housekeeping, Laundry, Maintenance, Dietary, Activity and Reception staff were in-serviced on who is and how to identify a wanderer and an elopement risk resident. In-servicing will be completed end of day 11/14/2022. Anyone who have not been in-serviced will be in-serviced in person or over the phone prior to their next shift by Medical Records, Nursing Scheduler, or designee prior to their next shift in this facility. This in-servicing includes staff on FMLA & PRN. All new hires will be in-serviced during their orientation on how to identify residents at risk for elopement. Binders were placed by all unit nurse's stations, kitchen, therapy, and reception that contains the elopement policy and procedure and resident photos with their names. A Robo Call was sent out today on 11/14/2022 to all staff and current Agency staff on who is and how to identify a wanderer and an elopement risk resident, the Elopement and Search Policy, and Door Alarm Policy - in particular, to notify another staff member if you're unsure if it is a resident of that unit. Maintenance staff have installed motion censored lighting outside the exit door on 11/08/2022. Administrator, Maintenance Director, or designee has been auditing all door alarms, wander guards, wander guard systems daily to ensure they are working as designed. Daily checks started after the elopement on 11/7/2022. S. Electronic Services came out on 11/8/2022 to check the door alarms, magnetic locks, and wander guard system and it is working as designed. Nursing, CNA, Bed Maker, and Activity staff have been in-serviced to increase monitoring the hallway and other areas of the unit where residents who are confused and ambulatory tend to wander. In-servicing will be completed by end of day 11/14/2022. Anyone who has not been in-serviced will be in-serviced prior to their next shift. Facility will assign a bed maker daily for first (7-3) and second shift (3-11) to the locked unit to increase monitoring of the hallway and other areas of the unit where residents who are ambulatory tend to wander. 4. To ensure the deficient practice does not reoccur, the corrective actions(s) will be monitored by: Administrator, Maintenance Director, or designee will audit all door alarms, wander guards, wander guard systems daily x 4 weeks during first shift to ensure all are working as designed. The Quality Assurance Committee will monitor the facility's performance to ensure compliance and will reevaluate the duration after 4 weeks to either extend an additional 4 weeks or cease the auditing. This process will continue until compliance is achieved. The Quality Assurance Committee will meet 12/07/2022. 5. Completion date systemic changes will be completed: 11/14/2022

Based on interview and record review the facility failed to assess, identify, and intervene for a change in a resident's condition following a fall, resulting in a family member identifying resident's leg feeling cool to the touch and appearing swollen and insisting 911 be called. This failure resulted in a delayed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This applies to 1 of 3 residents (R2) reviewed for falls in the sample of 4. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE] and was discharged to the local hospital on June 13, 2022. R2 did not return to the facility. R2 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated May 7, 2022 shows R2 had moderate cognitive impairment, was totally dependent on facility staff for eating, required extensive assistance with personal hygiene and bathing, limited assistance with dressing, and supervision with all other ADLs (Activities of Daily Living), including, bed mobility, transfers between surfaces and walking in the room and corridor. R2 was always continent of bowel and bladder. On May 23, 2022 at 11:00 AM, V26 (LPN-Licensed Practical Nurse) documented, Notified by CNA (Certified Nursing Assistant), resident was on the floor. NOD (Nurse On Duty) immediately assessed. Resident was laying right side . Resident stated, I was just trying to get out of my room. On May 23, 2022 at 9:50 PM, V15 (LPN) documented R2 complained of pain in her left leg and agreed to have an X-ray at the facility. Facility documentation shows R2 received an X-ray of her sacrum, coccyx, and left hip on May 24, 2022 and no recent fracture or dislocation was identified. On May 28, 2022 at 7:10 AM, V13 (LPN) documented R2 was found lying on the floor in her room near her bed after attempting to self-ambulate. No injury was noted, R2 was able to move both upper and lower extremities without limitation and denied complaints of pain at the time. Prior to R2's falls on May 23, 2022 and May 28, 2022, V28 (PTA-Physical Therapy Assistant) documented on May 23, 2022 at 10:48 AM, R2 continues to ambulate with RW (Rolling Walker), navigating 150 ft, 200 ft. with CGA (Contact Guard Assist) for balance and safety. On May 25, 2022 at 1:11 PM, V28 (PTA) documented, R2 was only able to complete gentle active range of motion due to left lower extremity pain. On May 30, 2022 at 8:51 AM, V28 (PTA) documented, [R2] completed sitting and standing weight shifts to encourage WB (Weight Bearing) on LLE (Left Lower Extremity) and improve trunk control and balance recovery strategies. [R2] is perseverating on LLE pain, asking for [MEDICATION(S)] from nursing staff and hard to direct. [R2] attempted multiple times to perform SPT (Stand Pivot Transfer) with use of RW, however unable to gain WB stability on LLE or sequencing to pivot. Spoke with CNA [V4] regarding patient's transfer status. On May 31, 2022 at 9:57 AM, V28 documented, Patient completed supine RLE (Right Lower Extremity) exercises x 10 reps and seated BLE (Bilateral Lower Extremity) exercises x 10 reps with modification to LLE due pain from recent fall. V28 continued to document R2 had self-limiting WB on LLE due to pain and positioning LLE as toe touch instead of foot flat for WB due to pain. On June 2, 2022 at 9:47 AM, V28 documented, [R2] continues to c/o L hip pain with movement, modifications provided as needed. On June 28, 2022 at 1:34 PM, V28 (PTA) said, Prior to [R2's] first fall on May 23, 2022, the resident was able to ambulate approximately 150 to 200 feet using a walker and contact-guard assistance. After the first fall, we got the report the X-ray was negative, however, she experienced pain and it inhibited her movement and she leaned to her right side. After the second fall, between the pain and the fear of falling, she declined significantly and could not stand or ambulate anymore. Every day we would ask the nurse for pain medication because the pain was extraordinary. It was a constant thing that really affected her therapy. I spoke with [V4] (CNA) on May 30, because she was the CNA caring for [R2] that day. I told her the resident could no longer bear weight on her left leg and now required two facility staff members to transfer the resident. After we talk to the CNAs, we had meetings with [V23] (Rehab Director) to let him know what is going on. It was clearly communicated by me that this resident had declined significantly since her second fall. On June 28, 2022 at 1:19 PM, V23 (Rehab Director) said, We inform the nurse if there is a change in status and we have a meeting every Thursday to discuss every patient with the Director of Nursing, Social Work, and MDS Coordinator. The facility does not have documentation to show R2's decline during physical therapy was addressed with nursing. The facility does not have documentation to show R2's physician was notified of R2's decline or increased pain. The facility does not have documentation to show facility staff assessed R2 for a change in condition or decline following R2's fall on May 28, 2022 until June 13, 2022 when V27 (Daughter of R2) voiced concerns. On June 23, 2022 at 10:57 AM, V8 (LPN) said, I was [R2's] nurse on June 13, 2022. The daughter came in and wanted me to see the resident's left foot. There was 2+ pitting [CONDITION(S)]. Two weeks prior to that day, she had a fall. I called the hospice nurse, and she came, and we sent the resident to the hospital the same day. The daughter was upset we hadn't noticed the swelling or coolness in the resident's leg or sent her to the hospital. I did not call the physician about the [CONDITION(S)] in the resident's leg or the increased pain. I did contact the hospice nurse. Documentation by V29 (Hospice Nurse) dated June 14, 2022 shows, PRN (As Needed) visit provided by this RN D/T (Due To) increased/unmanaged pain and swelling to left foot. Upon arrival, patient lying in hospital bed with [V27] (Daughter) present at bedside. [V27] states that an ambulance service has been called to transport her mother to [local hospital] for evaluation/treatment. [V27] is visibly upset with her mother's condition. She states that her foot has been swollen for a week and nothing has been done about it. She also states that her mother's pain has not been appropriately addressed.She states that her mother has declined significantly since being at [the facility], that her mother is no longer able to walk due to pain to left leg.[R2] states pain is in left upper and lower leg. When attempting to reposition patient, patient moans in pain with facial grimacing noted. While patient is being repositioned, pain assessed at 6/10 (0 to 10 pain scale).+3 pitting [CONDITION(S)] noted to left foot. Left calf swollen, cool to touch, pedal pulse faint on left foot. No swelling or [CONDITION(S)] noted to right foot/calf, pedal pulse normal. Discussed possibility of DVT ([CONDITION(S)]) On June 14, 2022 at 7:28 AM, V30 (Orthopedic Surgeon) documented, R2 was brought into the emergency room of the local hospital. Imaging performed at that time showing evidence of a left intertrochanteric [CONDITION(S)] of unknown chronicity, but likely at least 1 to 2 weeks. V30 continued to document R2 received surgical intervention on June 14, 2022 to repair the [CONDITION(S)]. Hospital documentation shows R2 was discharged from the local hospital on June 18, 2022. On June 29, 2022 at 11:28 AM, V2 (DON-Director of Nursing) said, I found the 72-hour charting for R2's fall on May 28, 2022. There were only two neurological checks done on May 28, and then not another neurological check until May 30, 2022. There are gaps with the charting. The nursing documentation does not show if the resident complained of pain or had condition changes. On June 29, 2022 at 12:48 PM, V28 (Physician) said, If the facility would have notified me of [R2's] decline, I would have sent her out to the hospital. There is no question, if they would have let me know, I would have sent her out. It is safe to say the second fall caused the fracture. I would have expected them to contact me if the resident had a fall and a decline. I would have expected the facility staff to have ongoing assessment of the resident after a fall and notice if there was a decline or increased pain.

Based on record review and interview, the facility failed to provide two staff assistance during bed mobility while providing incontinence care. This applies to 1 of 3 residents (R9) reviewed for fall incidents in the sample of 11. This failure resulted in R9 rolling off her bed and hitting her head against bedside table sustaining laceration in the head which requires emergency care. The findings include: R9's face sheet showed that R9 is a [AGE] year-old who has multiple medical [DIAGNOSES REDACTED]. R9's risk management record showed: On 6/14/2020, V23 (Nurse) was informed by V24 (Certified Nursing Assistant/CNA) that R9 fell during provision of care. R9 rolled out of bed while V24 turned R9 on her side while providing peri-care and bumped her head on bedside table. Bleeding was observed from her head from a laceration about length (L) 2.0 centimeter (cm) x width (W) 0.1 cm, with a swollen soft bump about 3 inches in diameter. Hospital Record dated 6/14/20 showed: R9 was presented to the emergency department from her senior place of living where she was being rolled over and fell off the bed striking her head. R9 complained of headache and neck pain since falling. There was a laceration at the back of her head which measured 2 cm in length. The clinical impression was injury of the head with laceration of scalp. The wound was repaired/closed with staples. Wound Care Note dated 6/15/2020 at 3:38 PM showed: R9 had a (L) 2.0x (W) 0.1 cm laceration to right posterior scalp with 3 staples in placed which was applied from the hospital. There was a small amount of bruising to the wound site. On 1/12/21 at 11:45 AM, V23 (Nurse) stated that from what she remembered with R9's fall incident, V24 (CNA) was changing R9's incontinence brief and while turning R9 to her side, R9 was turned too much V24 was not able to catch R9 and she rolled from the bed and hit head to the side table causing head injury. R9's head was bleeding, V23 provided first aid care and sent R9 to the hospital per physician's orders [REDACTED].>On 1/12/21 at 12:59 PM, V24 (CNA) gave the following statement: V24 went to R9's room and provided incontinence care. V24 rolled R9 on her right side to apply incontinence brief, however she (V24) didn't have the incontinence brief within reached, it was on the seat of the chair. V24 turned to get the brief from the chair and within in 2 seconds R9 rolled out of bed hitting her head against the bedside table. V24 was alone during provisions of care. On 1/12/21 at 2:30 PM, V1 (Director of Nursing/DON) stated that from what she remembered from report, V24 rolled R9 on her side away from V24. R9 rolled out of bed and since V24 was on the opposite side of the bed she was not able to stop R9's fall. On 1/12/21 at 1:24 PM, V25 (R9's Physician) stated that he was aware that R9 was high risk for fall. V25 expected that facility would follow the assessment they had for R9 which was to provide extensive assistance by 2 staffs during provisions of care for prevention of fall or for safety. R9's Minimum Data Set ((MDS) dated [DATE] showed that R9 requires extensive assistance by 2 staffs for bed mobility and toileting.

Based on observation, record review, and interview, the facility failed to ensure that a resident with impaired mobility bed was positioned safely away from a room heating unit. This failure resulted in R9 sustaining a second degree burn to the arm when R9 was positioned on the heat radiator. This applied to 1 of 3 (R9) residents reviewed for mobility and safety from a total sample of 9. Findings include: The Face Sheet documents R9 is [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] shows R9 has cognitive impairment. R9 requires extensive assistance with bed mobility from two people. The facility's incident report to the State Surveying Agency documents R9 sustained [MEDICAL CONDITION] the right arm from a heater on 11/7/19 at 13:12 hours. The Nurse's Note read: 11/7/19, 13:25 : CNA (Certified Nursing Assistant) went into resident room to assist her with Lunch, noted resident right arm leaning on heater, immediately removed resident and called writer, assessed area, noted with redness extending from right posterior mid forearm to right shoulder with 1.2cm x0.3 cm opened blister proximal to the right elbow and another opened blister 1.3 cm x 0.5 cm proximal to the right elbow, intact blisters on right mid upper arm measuring 1.8 cm x 0.6 cm and another intact blister above it measuring 1.2cm x 0.8 cm. Asked resident what happened she responded my arm fell over the radiator. The Wound Note reads: 11/7/19, 16:53 Informed by nurse on duty that R9 sustained a burn on her right arm from the heater in her room. Assessed the area extending form mid forearm to her shoulder The area also noted with multiple fluid filled blisters on right mid upper arm measuring 1.8 cm x 0.6 cm and another intact blister above it measuring 1.2cm x 0.8 cm, 2 open blisters, one proximal to her right elbow measuring 1.2 x0.4x not measurable cm with light serous exudate the other opened blister measuring 1.3 cm x 0.5 cm with light serous on the right elbow. The Wound Evaluation from V21 (Wound Care Physician) dated 11/8/19 reads: R9 has a burn wound to the right arm with heavy serous exudate. On 11/12/19 at 3:30 PM, R9 was awake in the reclining chair in her room. There was a heating unit installed just below the window. Noted on R9's right upper arm was a large red and deep purple discoloration. There were also dry blisters on the outer part of the arm. Just above the elbow were 2 brown soft scabs. On 11/13/19 at 10:10, V8 stated she and V13 (Assistant Director of Nursing/ADON) pulled R9 up in bed on 11/7/19 between 8:30- 9:00 AM and the heater was a little too hot. V8 stated at that time she turned the heater down. V8 also stated R9 has a left [MEDICAL CONDITION] and can't move the left side of her body. R9 requires physical assistance from staff to turn in bed. R9 does not use the call light to call for assistance. V8 added R9 has confusion and does not always ask for help. V8 stated on 11/7/19 she heard V17 (Certified Nursing Assistant) calling for help. V8 stated when she entered the room V17 stated I found her like this. I smelled something burning. V8 stated when V17 turned R9, the arm was reddened from the shoulder to the elbow. There were blisters on the upper arm. Two of the blisters were open. V8 also stated R9 was in pain which she rated the pain 8/10. V8 stated the policy is for beds to be in the low position. On 11/13/19 at 1:54 PM, V13 (ADON) stated she and V8 pulled R9 up in bed between 8:30- 9:00 AM. V13 stated they raised the height of the bed to pull R9 up in bed. V13 stated the bed was against the heater when she entered the room. When asked why was R9's bed against the heater, V13 replied probably because she's a fall risk. Fall risk resident beds go against the wall. V13 stated the room was hot upon entering. V13 stated R9 cannot move. R9 can only move her right arm up and down. R9 can't turn herself and requires staff physical assistance. V13 also stated the policy is to place beds in the low position prior to exiting the room. On 11/13/19 at 2:15 PM, V22 (Wound Care Nurse) stated on 11/7/19 she was called to assess R9 after she was found with her arm on the heater. V22 stated R9's right arm had redness from the shoulder to the elbow. There were clusters of blisters, one near the elbow was leaking and the rest were fluid filled. V22 stated I saw her immediately after it happened. There was redness everywhere with blistering. On 11/13/19 at 4:04 PM, V17 (CNA) stated on 11/7/19 around 11:00 AM, she entered R9's room and noted R9 slumped in bed. As V17 got closer she smelled something burning. V17 stated it smelled like when you iron clothes. So V17 grabbed R9, pulled her next to her and called for help. When asked about the position of the bed, V17 replied it was not in the low position. It was definitely up. The policy is to place the bed in the low position. According to V17, the bed was against the heater. V17 added R9 is unable to turn in bed and can't move her left side. R9 does not use the call button, you must just go there. R9 was awake with tears in her eyes. She rated her pain 9/10 (Severe). V17 stated R9's arm was reddened with indentations from the vent on the heater. Then a couple of minutes later it started to bubble up. V17 stated she took R9's arm off the heater. V17 stated I touched her arm. It was definitely hot. That was the iron problem. On 11/14/19 at 2:50 PM, V2 (Director of Nursing/DON) stated on 11/7/19, upon entering R9's room she noted R9's right arm to be reddened with blisters. V2 stated first there were two, then there were four. V2 also stated the height of the bed should be in the low position. When asked what factors would place R9 at risk for harm, V2 stated R9 has immobility and impaired cognition. R9 requires physical assistance from staff for bed mobility. V2 stated new interventions is for staff to ensure R9's bed is away from the heater. On 11/14/19 at 3:05 PM, V17 clarified her previous statement and said R9's bed was in the highest position. Both the head of the bed and the bed itself were elevated. The vent shape from the top of the heater was indented in R9's arm. On 11/15/19 at 4:07 PM, V21 (Wound Care Physician) stated R9 sustained a burn from the heater. According to V21 the wound was big with first [MEDICAL CONDITION] approximately 20% second degree. The wound is almost healed. V21 stated R9 is confused and does not know what's going on. The facility needs to ensure she cannot touch the heater. V21 also stated the burn could've been prevented had the facility monitored R9 better. The Care Plan reads: 7/30/19 R9 has impaired cognitive function related to [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke). Goal: R9's needs will be anticipated by staff on a daily basis.

Based on interview and record review, the facility failed to provide supervision and ambulation assistance to a resident identified as a high risk for fall and failed to keep common areas free of accident hazards. This failure resulted in 1) R1 sustaining a intertrochanteric fracture of right hip and 2) R2 sustaining a partial acute non-angulated distal radial fracture of left elbow-hand. This applies to 2 of 3 residents (R1 and R2) reviewed for falls/injuries in the sample. The findings include: 1. On 2/26/18 at 10:45am, R1 was observed sitting in the D wing dining area. There was no staff around supervising R1. R1 was dozing on and off, rubbing her right arm and right thigh area. R1 was alert and oriented to only her name. R1 stated she could not recall her fall but knew there is pain in the right thigh area where she was intermittently rubbing. R1 stated, I fell , but I can't remember what happened to me, You see my memory is bad. R1 was sitting in a wheelchair with her back turned to the television. On 2/26/18 at 4: 30pm, R1 was sitting in a wheelchair in her room with V10 and V11 (family members). R1 was half asleep. V10 stated R1 has not been the same since after her fall. V10 stated R1 has not been eating or drinking and has refused to do anything. V11 stated she flew in from another state when she heard R1 was not responding well. V11 stated it was difficult to even get R1 to take her medications in apple sauce. V11 stated R1 has refused to take even drinks from her. V10 stated he is concerned R1 is not eating or hydrating since after her fall and surgery. On 3/1/18 at 11:05am, V11 stated nothing has changed regarding R1's condition since hospitalization . That R1 has continued not to eat but drank little. V11 stated R1 was very agitated at the facility on 2/28/18 when she visited. On 2/26/18 at 4:50pm, both V10 and V11 spoke to V12 (Nurse Practitioner) about R1's decline in physical and mental status and reduced appetite since the fall. V12 stated R1's blood will be drawn the next day. At 4:50pm, V12 stated it is a big concern that R1 is barely eating. V12 stated she was present at R1's lunch and she barely ate. V12 stated since this is a new development for R1, she would recommend some testing for R1. The electronic medical record (EMR) showed R1 was admitted to the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. R1's minimum data set ((MDS) dated [DATE] showed R1 requiring limited assistance of one person physical assist with ambulation on and off the unit. R1's care plan dated 8/2/16 showed R1 is at risk for falls related to impaired cognition and impaired safety awareness. Interventions include: if resident appears tired, offer a nap. It also showed, resident is supervision with transfers. Facility's incident report dated 2/18/18 showed R1 had a fall on the way to main dining room while ambulating with the CNA. The report also showed, 'Nurse immediately assessed R1 and R1 complained of pain to right hip. Vitals taken and stable. MD notified with new order to send R1 to the ER for evaluation and treatment. 911 called. POA made aware. Called the hospital and R1 was admitted with intertrochanteric fracture of right hip. On 2/27/18 at 9:04am, V9 certified nursing assistant (CNA) stated she started working at the facility as a bed maker in (MONTH) (YEAR). She then completed her CNA course and started working on the floor as a CNA in mid (MONTH) (YEAR). V9 stated she usually worked on units A and E. V9 stated 2/18/18 was her first day to work on unit D, subsequently she was not familiar with the residents on unit D neither did she obtain report of the residents she took care of that day including R1. V9 stated she was instructed by one of the nurses on the unit to take R1 to the main dining area for dinner. V9 stated upon entering R1's room, R1 was sleeping so she woke R1 up and informed R1 she had to take R1 to the main dining room. V9 further stated R1 appeared 'woozy' when she got up. V9 stated when she got to the hallway with R1, R1 was pointing to the employee's lounge door, so V9 stated she asked R1 if she would like to be taken through the employee's lounge area (which is a short cut) to the main dining area. V9 stated R1 said yes and they proceeded. V9 stated she opened the employee's lounge door (fire door), held it for a few seconds and released the door. V9 stated R1 did not finish walking through the door before the door quickly slammed on R1's head and knocked R1 down to the floor. V9 stated she is seven months pregnant so she could not hold R1 back from falling. V9 also stated she did not use a gait belt while ambulating with R1. V9 stated while R1 was on the floor, R1 started crying. So V9 called the nurse. V9 started she has seen other staff taken residents through the employee's break room in the past. V9 stated she should have held on to the door longer for R1 to completely pass before letting go of the door. V9 stated there was no employee in the break room when the incident occurred. V9 stated on 2/20/18, she was informed by V14 (Human Resources Director) and V15 (scheduler) not to come back to work the next day. On 2/26/18 at 4:15pm, V8 (Nurse) stated he was the nurse on duty when R1's incident occurred on 2/18/18. V8 stated he was in another resident's room when he heard another staff calling his name. V8 stated he ran to where R1 was lying inside the employee's lounge crying and confused. V8 stated he called 911 and sent R1 to the hospital. V8 stated he regularly works on the D unit and is very familiar with R1. V8 stated R1 was always a happy, slightly confused but pleasant resident prior to the fall. On 2/26/18 at 11am, V4 CNA stated she is a regular CNA on D unit. V4 stated she knows R1 well. That R1 was sweet but confused and needs one person assist. V4 stated R1 used to walk around until after the fall. On 2/26/18 at 11:05am, V7 CNA stated R1 used to walk the unit by her self prior to the fall, she just needs to be supervised. On 2/26/18 at 11:30am, V5 CNA was supposed to care for R1 this morning but unfortunately she did not realize R1 was part of her assignment. V5 started working in the facility two weeks ago. V5 stated she did not get enough training prior to working so she did not know who to ask about her assignment. V5 stated she started her shift at 7am and has not performed any care for R1 and the other residents on the 5200 wing. On 2/26/18 at 11:40am, V6 (Nurse) stated it is a problem that V5 does not know her complete assignment. V6 stated she shared V5's assignment with her at the beginning of the shift. V6 stated R1 is a sweet lady that walks around the unit with supervision. On 2/27/18 at 9:50am, V3 (Restorative Nurse) stated taking R1 through the employee's lounge is not a normal route to the main dining area. V3 stated R1 should have been taken through the hallway to the main dining room. V3 stated the employee's break room is a non resident area. V3 further stated V9 should have used a gait belt prior to ambulating R1. On 3/1/18 at 10:40am, V3 stated R1 is automatically a high risk for falls due to previous fall history. On R1's fall risk assessment dated [DATE] where R1 received a score of 4.0. V3 stated the assessment did not reflect R1's status because R1 fell and should have received a higher score. On 2/27/18 at 12pm, V21 CNA, stated it is a requirement for staff to have gait belts on residents that requires supervision. V21 stated R1 was able to do a lot prior to fall and was always participating in activities. Review of R1's EMR showed V12's progress note on R1 dated 2/26/18 who suffered a mechanical fall at the facility prompting transfer to the hospital. R1 was with right intertrochantric fracture and underwent right intra medullary fixation of right hip 2/21/18. R1 was seen at lunch, 'not eating much', does not have appetite. Per nursing staff, R1 has been eating poorly. On On 3/1/18 at 11:05am V11 stated R1's appetite is still very Review of R1's X-ray report dated 2/18/18 after the fall showed, 4 part intertrochanteric [MEDICAL CONDITION] hip. R1's EMR also showed R1 with falls on: 7/25/17: R1 had slipped in the hallway while been escorted to the dining room- No injuries noted. On 3/2/17: R1 was observed sitting on the hallway floor next to her room. No injuries noted. On 12/27/17: R1 was observed on the activity floor against a chair. R1 stated she fell off the chair. No injuries noted. Review of R1's physical therapy discharge summary dated 2/8/18 showed, R1 performs ambulation 200 feet without assistive devices with standby assist On 3/1/18 at 11:24am, V22 (Rehabilitation Manager) stated R1 was recently discharged from rehab department 2weeks prior to the fall of 2/18/18. V22 stated residents that require a standby assist means someone has to be there to supervise their ambulation. The person must walk closely to the resident and have a gait belt on the resident to help catch the resident in case of a fall. 2. On 2/26/18 at 2:10pm, R2 was observed sitting at the nurses's station with the nurse. R2 has a left arm cast on. R2 stated she fell a few days ago but cannot remember how she fell . R2's EMR shows R2 was admitted to the facility 11/12/17 with [DIAGNOSES REDACTED]. Review of facility's fall incident dated 2/15/18, showed Around 5:15pm, R2 was walking dragging her walker on her side and she tripped over the weighing machine in the small dining room in unit E and fell on her left elbow hit the machine. The report also showed that R2 had a skin tear which was bleeding, skin tear measured 7cm length and 3cm wide and another skin tear on the middle finger of her left hand measuring 0.5cm length and 0.5cm wide. On 2/28/18 at 10:31am, V17 stated she was inside the E unit small dining area on 2/15/18 supervising about 10 residents including R2 when R2 fell . V17 stated R2 was done with her dinner, got up from her table and walked around other tables to socialize. V17 stated in the process, R2 had her walker side ways and she redirected R2 to put her walker in front of her. V17 stated she was standing by the door of the small dining area, putting the dirty dishes away when she noticed R2 falling over the weigh scale. V17 stated it was too late to catch R2 from falling into the weighing scale because it was quite a distance from her. R2 fell on to the weigh scale and landed on her left hand. V17 stated she called the nurse and it was noticed that R2's hand was bleeding. On 2/28/18 at 9:25am, V16 (Social service Director/Manager memory unit) stated R2 has moderate to severe cognition loss. V16 stated R2 is able to ambulate with her walker. When asked about weigh scale in the small dining area, V16 stated the scale was being used by restorative aides and has been removed from the dining area. On 2/28/18 at 1:23pm, V18 (Doctor) stated R2 always moves around confused. V18 stated R2' left wrist fracture was related to the latest fall she sustained. V18 stated R2 is high risk for falls that's why she is in the dementia unit. V18 stated she was not sure why weigh scale would be in the dining area. Review of R2's EMR showed R2 with multiple falls at the facility: 1/9/18 report showed=R2 was walking, got exhausted and fell . 1/3/18 report showed=R2 was seen lying on her right side on the floor of her room. The report showed resident thought she rolled out of bed bruises noted elbow and left knee. 12/6/17 report showed=R2 was found on the floor. The report showed R2 wanted some cool air. R2's fall risk assessment dated [DATE] and 2/15/18 scored R2 as 11.0-high risk. R2's care plan initiated 11/20/17 showed R2 enjoys walking in hallway yet does not seek exit and the intervention showed, keep hallways as free of items as possible to prevent risk of fall. R2's care plan also showed R2 is at risk for fall has dementia, gait is steady. The care plan also showed an intervention of: maintaining a clear pathway in room, free of obstacles. It also showed supervision when R2 is ambulating on the unit and in her room. On 2/26/18 at 2:10pm, an observation of the small dining area was made. There was no weigh scale in the small dining area. V3, Restorative Nurse stated the weighing scale has been removed by the facility, stored away in another room and only brought out for use. V3 stated the weighing scale should not have been in the dining room as it constituted a fall hazard for R2. R2's physician order [REDACTED]. Review of R2's medical diagnostic services dated 2/15/18 showed R2 with partial acute non-angulated distal radial fracture of left elbow-hand.

Based on observation, interview and record review, the facility failed to ensure a resident was free from mental abuse by coercing a resident into signing a behavior contract in order to return to the facility following hospitalization , and threatening the resident with involuntary discharge. These failures resulted in psycho-social harm when R1 appeared tearful and stated he felt afraid, on a daily basis, of being involuntarily discharged from the facility. This applies to 1 of 6 residents (R1) reviewed for residents rights and involuntary discharge in the sample of 7. The findings include: On (MONTH) 30, (YEAR) at 9:05 AM, R1 was sitting in bed eating breakfast. R1 said, About a week ago, around 5:00 AM, I was sitting in my room and got a bloody nose. There was blood everywhere and it wouldn't stop. I got aggravated because I felt like it was taking too long for the staff to address my concerns. I was screaming and then I threw my water pitcher across the room to get someone's attention. I was in a private room on that day. The water pitcher landed on the floor and slid out into the hallway. I never intentionally threw it at anyone, I was just trying to get someone's attention. Later they came and told me I was being sent out to a psych hospital. I had to stay there for three days. While I was at the psych hospital the facility made me sign a contract saying I wouldn't misbehave or they would kick me out. I also had to agree to return to a double room and not have my private room anymore. I didn't know my rights so I just signed the contract because I was afraid they wouldn't let me come back here. I felt very sad because I knew they didn't want to take me back. The facility did not give me a copy of the bed hold policy before they sent me to the psych hospital. I didn't know they had to take me back. I would never have signed the behavior contract if I knew they had to take me back. Now I lay here afraid every day that if I don't get dressed or don't go to physical therapy they are going to kick me out. I don't like to wear clothes when I lay in bed because they are restrictive and uncomfortable. I prefer to just wear the incontinence brief and cover myself with a sheet. I will get dressed if I go to therapy, but will remove the clothes as soon as I return to my room. R1 became tearful when discussing the possibility of being involuntarily discharged from the facility and being moved from his previous room. R1's previous room remained empty during the observation period of (MONTH) 30, 31 and (MONTH) 1, (YEAR). On (MONTH) 31, (YEAR) at 1:04 PM, R1 was laying in bed. R1 was wearing only an incontinence brief and covered himself with a sheet. R1 complained of right abdominal pain. R1 said, I refused to go to therapy today because of the pain I'm having. Now I'm worried they are going to kick me out because of that contract I signed. R1's physician was notified and orders were received and initiated. On (MONTH) 1, (YEAR) at 12:00 PM, R1 was laying in bed wearing only an incontinence brief and covered with a sheet. R1 said he continued to have abdominal pain and the previously ordered X-ray and urinalysis were negative for bowel obstruction and urinary tract infection. R1 said he refused therapy due to his abdominal pain. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 9, (YEAR) shows R1 is cognitively intact, feels down and depressed at times, has no behaviors, no rejection of care, requires extensive assistance with most ADLs (activities of daily living) and is occasionally incontinent of bladder, and always incontinent of bowel. The MDS shows R1 is totally dependent on facility staff for bed mobility and transfers. R1's care plan dated (MONTH) 2, (YEAR) shows: (R1) is resistive to care as noted by refusing to get out of bed, comply with therapy and eat meals. Becomes physically and verbally abusive to staff when encouraged to comply. Goal: (R1) will cooperate with care evidenced by not showing verbal or physically abusive behavior to staff through next review date. Interventions/Tasks: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Give clear explanation of all care activities prior to and as they occur during each contact. Praise (R1) when behavior is appropriate. Facility documentation shows a Petition for Involuntary/Judicial Admission for R1 dated (MONTH) 22, (YEAR). The petition shows: On 1/22/18 at 7:00 AM, (R1) became verbally and physically aggressive. (R1) is throwing water pitchers and personal objects at staff and peers. (R1) remains agitated and verbally abusive. (R1) is in need of immediate hospitalization to prevent harm to self or others. Per MD sent to hospital for psychiatric eval and placement. Facility documentation shows R1 was transferred to the local psychiatric hospital on (MONTH) 22, (YEAR) and returned to the facility on (MONTH) 26, (YEAR). The facility's Behavior Contract for R1 dated (MONTH) 26, (YEAR) shows: I (R1) will begin this contract upon my return to (the facility) to help in assuring my success and overall quality of care here at (the facility). This contract will be used to assist in determining my future at (the facility). I will follow all (facility) policies and procedure and behavior expectations, which include the following: 1. Refrain from being verbally and physically abusive toward staff and residents. 2. Comply with daily care as recommended by physician and IDT (interdisciplinary team). 3. Will comply with getting dressed and up in wheelchair daily. 4. Comply with restorative program and perform daily exercise program. If I fail to abide by the guidelines listed above, I understand that I will be liable for the following consequences: 1 Involuntary discharge from (the facility). By signing this contract all parties agree to the stipulations in the document and will follow accordingly. *Also discussed move to double room. The contract was signed by R1 and V14 (Marketing Director/Hospital Liaison) on (MONTH) 26, (YEAR). V17's (Psychiatrist) documentation dated (MONTH) 23, (YEAR) shows: Diagnostic Impressions: Major [MEDICAL CONDITION], recurrent, severe without [MEDICAL CONDITION]. (R1) is stable, not suicidal, not homicidal, able to care for self and not showing violent behavior . On (MONTH) 1, (YEAR) at 9:39 AM, V1 (Administrator) and V2 (DON-Director of Nursing) said R1 was not given a copy of the facility's bed hold policy prior to his discharge to the psychiatric hospital on (MONTH) 22, (YEAR). On (MONTH) 31, (YEAR) at 9:50 AM, V6 (LPN-Licensed Practical Nurse) said, On (MONTH) 22, (YEAR) at 5:45 AM I was right outside (R1's) room and I noticed he was bleeding. I had a towel and ice on my cart and I went in and cleaned him up. I told him I was going to get ice and more towels. He pulled the call light and yelled the F word. He threw a water pitcher towards me and it landed in the room across the hall. Usually that time of the day there is a resident who sits out in the hallway, but that morning the resident was not sitting there. No residents were near (R1) when he threw the water pitcher, though the spilled water worried the resident across the hall who was afraid it was close to the oxygen concentrator in his room. I've never had problem with him in the past. I had him Monday and he was nice to me. On (MONTH) 31, (YEAR) at 11:18 AM, V9 (Ombudsman) said the facility had not contacted her prior to (MONTH) 31, (YEAR) with any concerns, including behavior problems or alternative facility placement for R1. V9 said she was not contacted prior to R1 signing the behavior contract. V9 said she would have advised R1 not to sign the behavior contract. On (MONTH) 1, (YEAR) at 1:08 PM, V14 (Director of Marketing/Hospital Liaison) said, I told the social worker at (psychiatric hospital) that (R1) didn't fit into our community. (V15) (Caseworker) said she would try to find another facility that would take (R1). Two days later she called and said he was ready to come back. (R1) refused for her to send papers to other facilities, so we had to take him back. I went out and saw him. I gave him a copy of the behavior contract and read it out loud to him, and asked him if he had any questions. I told him if he wouldn't sign it and agree to these terms, he couldn't return to the facility. The behavior contract was a condition for him to come back and I believe he knew that. On (MONTH) 1, (YEAR) at 3:32 PM, V15 said, Initially the facility said they would prefer alternate placement for (R1). (R1) insisted he wanted to return to the facility. Everything they said that he was here for we never saw. They made him sign a contract in order to return to the facility. The facility's Abuse Prevention Program Policy dated (MONTH) (YEAR) shows: 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 [REDACTED]. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation (42 CFR 483.12 Interpretive Guidelines.)

Based on observation, record review and interview the facility failed to monitor and supervise a resident (R1) after administering antianxiety medication. The facility also failed to develop and implement specific and individualized interventions to prevent R1 from falling. As a result: R1, who was identified at risk for falling, had fallen on 4/12/13 after receiving antianxiety medication. R1 sustained intratrochanteric fracture of proximal left femur. This is for one of two residents (R1) in the sample of eight residents reviewed for falls. Findings include: On 5/2/13 at 10:20 am R1 was in her bed, the bed was not in lower position. R1 was hard of hearing, restless, and unable to carry on conversation. R1's 1/3/13 Fall Risk evaluation scored '10,' a total score of greater than '10' represents high risk for falling. The risk factors included problems with R1's balance, problem while standing and walking; has decreased muscle coordination; requires use of assistive devices (cane, wheel chair walker, furniture); takes medications including psychotropic medications that would place her at risk for falling. The 1/3/13 evaluation also showed R1 has predisposing disease conditions. The facility did not further evaluate these risk factors to develop and implement individualized specific interventions to prevent R1 from falling. R1's 4/5/13 Care Area Assessment (CAA) for falls also had no evaluation of the risk factors identified per 1/3/13 Fall Risk score. R1's 1/8/13 care plan indicated her gait, standing balance, decreased muscle strength, history of falls, use of wheel chair were the factors for falling as noted in 1/3/13 fall risk score. One of the interventions of 1/8/13 fall care plan was to keep call light within reach and answer promptly. It is not clear how the facility will ensure that R1 who has memory impairment and confused (per 4/5/13 minimum data set), would remember and use call light. On 5/14/13 after evening meal (from 5:50 pm to 7:30 pm) on 'A' wing where R1 used live had residents (R6, R7 and R8) their nurse call lights on for assistance. These residents are alert and oriented to time place and person. The staff did not answer call lights in timely manner. These residents made comments: 'I take care of my self, but some needs to remove box from the top of my bed, so I could go to sleep, the box is heavy;' 'I need ice water, we ate shrimp for dinner;' 'I put the light on to go to bath room, some one came and turned off my call light, did not come back to help.' R1's 4/22/13 fall care plan that was developed after her fall on 4/12/13. One of the interventions is to 'ensure bed is low position. The facility did not implement this intervention for R1 on 5/2/13. On 4/11/13 5:00 pm it R1's Nurses Notes showed, she manifested extreme agitation, confusion, low grade fever; which got worse since it started at 3:00 pm, and her mental status has changed. The Nurses Notes also showed at 1:00 am R1 received Lorazepam 0.5 mg. R1's April 2013 Medication Administration Record (MAR) showed Lorazepam was discontinued on 4/9/13. R1 also had an order on 4/11/13 to receive Lorazepam 0.5 mg twice daily. The MAR for April 2013 showed R1 did not receive any Lorazepam 0.5 mg on 4/11/13 or 4/12/13, but it was noted in her Nurses Notes and incident report that the Nurse gave Lorazepam 0.5 mg on 4/12/13. On 5/30/13 at 10:30 am E2 (Director of Nurses) said 'that means the nurse gave the medication, but did not sign out in MAR.' There was no specific plan with individualized interventions to administer or discontinue Lorazepam and or how to monitor R1 after she received the medication. R1's 4/12/13 4:20 am incident report showed at 4:20 am E7 (night shift nurse) heard bed alarm sound. When E7 responded, she found R1 on the floor lying next to her bathroom door. The facility did not analyze R1's 4/12/13 fall to rule out if, her change in mental status, toilet need, use of Lorazepam, environmental factors including proper functioning of bed and bed alarm, staff response time to provide assistance, have contributed to R1's falling. The investigation report also did not show, if the facility interviewed any staff or residents. R1's 4/12/13 hospital record indicated she sustained Intratrochanteric fracture of proximal left femur. E7 on 5/2/13 at 1:55 pm per phone interview, stated she heard R1's bed alarm sound, and by the time she went to R1's room, she found R1 on the floor lying next to her bath room. E7, stated she did not see how R1 reached to her bath room and landed on floor. R1's room is the first room (30 feet away) from the Nurses Station, and her bed is 6 feet away from her bed. E7 could not explain how R1 managed to get up from bed un noticed by staff, got up from bed, and made to bath room and landed on the floor. R1 had physical functional limitations including altered mental status, gait and standing problems, decreased muscle strength, confused, disoriented and wheel chair dependent for ambulation. E7, also stated she did not know where the Certified Nurse Aides were at the time of R1 falling on 4/12/13. On 5/15/13 at 2:35 pm interviewed physician (Z1), via telephone. Z1 stated, R1 was progressively getting worse with her Dementia, eating poorly, had change in condition (altered mental physical status) preceding her fall, receiving anxiolytic (Lorazepam) to keep her relaxed. Z1 also stated, he would expect the staff to monitor R1 closely after administering anxiolytic medication, which could cause dizziness.

Based on record review and interview, the facility failed to: 1) initiate cardiopulmonary resuscitation (CPR) and access the emergency life support system (EMS) in a timely manner. 2) follow the facility policy for Code Response for one (R1) of three residents sampled for neglect. 3) ensure that an emergency protocol for life threatening situations was in place, and emergency equipment was readily available on all units for life threatening emergencies. 4) ensure staff are familiar with identifying the code status of the resident; and 5) initiate emergency procedures such as the application of resuscitative (ambu) oxygen mask and to continue with CPR until the emergency medical personnel arrived. On [DATE] at 5:00 AM, R1 was found unresponsive, not breathing and without pulse. The facility failed to identify R1's code status, who was a Full Code. The facility failed to initiate CPR and access the emergency medical system in a timely manner. R1 expired on [DATE] in the hospital. These failures of staff to initiate timely emergency medical care and follow the Code Response policy placed other residents in the facility at risk. The facility was informed of the Immediate Jeopardy on [DATE] at 10:25 AM. The Immediate Jeopardy began on [DATE] when the facility did not initiate timely CPR on R1 who was a full code. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures, education of staff for emergency preparedness. Findings include: Review of closed clinical record indicated, R1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was alert with periods of confusion, forgetfulness and lethargy. R1 was on continuous oxygen therapy at 2 - 3 liters per minute thru nasal cannula. The admitting face sheet reflected that R1 was a Full Code Status. The Initial Incident Investigation Report dated [DATE] at 5:15 PM, documented that E6 (Certified Nursing Assistant -CNA) found R1 in bed at 5:00 AM on [DATE] unresponsive, without pulse and respiration and with emesis on R1's gown. No CPR record was found. At 5:15 AM, the paramedics arrived at the facility and transported R1 to the hospital. The Summary of the Investigation of Unanticipated of Death for R1 indicated the following: 3:40 AM - Resident found sleeping by E6 (CNA). 5:05 AM - E6 found resident with vomit on the gown, unresponsive, no respirations/pulse, color pale. Immediately summoned the nurse. E3 (Nurse on Duty) listened for heartbeat with stethoscope - no pulse and no respirations noted. E6 cleaned the emesis and gown of the resident. 5:07 AM - E3 called E5 (B Unit Nurse) who said she would come over and get E4 (C Unit Nurse) to come. 5:10 AM - E3 tried to call Unit E Nurse to page overhead for Code Blue - no answer. E4 & E5 got the crash cart and went to the room. 5:11 AM - E3 tried to call Unit E again - no answer. E3 went back to the room and noted E4 doing chest compressions. E5 went to copy medical records for paramedics. 5:12 AM - E3 called 911 and went back to the room. E4 left the room and instructed E3 to do chest compressions. 5:15 AM - Paramedics arrived. E4 handed paramedics the medical records. Paramedics took over care of the resident. 5:30 AM - Resident transported to the hospital. The local Fire Protection District Patient Care Report dated [DATE] documented the following: EMS (Emergency Medical System) called to the scene for full arrest. EMS was directed to the D Wing instead of B Wing as originally stated to the Dispatch. EMS found patient (PT) lying supine on bed with caretaker (E6) standing over patient. Caretaker stated that she found patient unresponsive about 15 - 20 minutes before calling EMS. Caretaker stated she thought PT was a full code. Caretaker stated she did not start CPR because PT was gone. EMS noted no pulse or respirations. EMS started CPR. E3 stated during phone interview on [DATE] at 2:25 PM, E6 found R1 to be dead at 5:00 AM. E6 summoned E3 to check the resident. E3 went to the room and found R1 unresponsive, without pulse and respiration. E3 stated that she then left the room to check R1's code status in the clinical record at approximately 5:10 AM. When E3 determined that R1 was a Full Code, she called Unit E to announce code blue. According to E3, it is only in Unit E that has the capability to page an overhead code during the night shift. E3 stated no one answered the phone in Unit E. E3 then called Unit B and asked for help at approximately 5:15 AM. E3 sent the other CNA to Unit E to announce Code Blue ([MEDICAL CONDITION]). E3 saw E5 (Unit B Nurse) going to R1's room and so E3 grabbed the crash cart and brought it to R1's room. E3 saw that E4 (Unit C Nurse) was already in the room performing chest compressions on R1. E3 then left the room and called 911 (approximately 15 minutes after R1 was found unresponsive, breathless & pulseless). E3 stated that she did not document anything in the CPR record. On [DATE] at 2:55 PM during a phone interview, E4 stated that E5 called her to go to Unit D. E4 went directly to R1's room and started chest compressions after placing the cardiac board with assistance from E5. E4 said that the ambu (resuscitative) bag did not have the face mask so she applied the non rebreathing mask instead. E4 also stated that E6 was in the room with the resident. When E3 came back to the room, E4 told E3 to continue chest compressions and E4 left the room. On [DATE] at 3:20 PM during a phone interview, E5 stated that E3 called on [DATE] in the morning to ask what procedure to follow when a resident expire. E3 told E5 that she did not find a DNR (Do Not Resuscitate) form in the clinical record. E5 instructed E3 to call for Code Blue overhead by calling Unit E. E5 then proceeded to Unit D and requested E4 (Unit C Nurse) to assist. E5 and E4 arrived in R1's room and did not observe any staff in the room. E5 also stated that she brought the crash cart to the room and applied the cardiac board with E4. The ambu bag (resuscitative) face mask was not in the cart so E4 applied a non rebreathing or simple mask. E5 stated that E4 started chest compressions so E5 left the room. On [DATE] at 8:10 AM, E6 stated that she saw R1 in bed on [DATE] at 12:00 AM, sleeping. At 2:00 AM, she responded to R1's call light. R1 verbalized that she wanted to go home. E6 reassured R1 and informed her that she will call R1's family at 7:00 AM. E6 repositioned R1 in bed and left the room. At 2:30 AM, R1 called and verbalized again wanting to go home. E6 reassured R1 again and left the room. E6 responded to other call lights and checked on R1 at 3:40 AM. The resident appeared to be asleep in bed. Between 5:00 AM and 5:05 AM, E6 went to R1's room and smelled an unpleasant odor. E6 turned on the lights and called R1's name. R1 did not respond and observed vomit on her face and gown. E6 touched and shook R1 who did not respond. E6 notified E3 to check R1 at approximately 5:10 AM. Both nurses from Unit B & C arrived and brought the crash cart in the room. E6 left the room to attend to another resident while both E4 & E5 were in the room. E6 stated the paramedics and police department arrived between 5:17 AM & 5:18 AM. E6 did not know R1's code status. E6 also said that she did not start CPR because her certificate has expired. E6 stated that she did not observe E3 start CPR. The facility policy titled, "Code Response," dated [DATE] requires, "If a resident is a full code and stops breathing and/or has no pulse, the first staff member on the scene remains with the resident and summons help by announcing "CODE BLUE" until qualified staff arrives to the location of the resident. 5. Staff with CPR credentials is expected to respond. EMS/911 will be activated. 6. The first CPR certified staff member on the scene initiates cardiopulmonary resuscitation after assessing resident for lack of pulse and/or respiration. 7. The licensed staff members on the scene is responsible for documenting all pertinent information related to the event such as time, resident response,etc. 8. CPR is continued until EMS staff arrives." The facility policy was not followed, therefore there was delay in initiating CPR. The lack of protocol for calling emergencies during the third shift, lack of staff knowledge of emergency protocol, and lack of availability of emergency equipment on the unit resulted in delay for provision of effective oxygenation and continued CPR until the paramedics arrived on the scene. Surveyor confirmed that the facility took the following actions to remove the Immediate Jeopardy: A. Licensed nurses were re-educated on the Code Response Policy. The in-service was conducted on [DATE],19 and 22, 2012 and covered when staff observe a patient unresponsive. If a full code, a license nurse will initiate CPR. A licensed direct care nurse directs code blue (crash cart, paging code blue, calling 911). The license nurse assigns a code blue recorder. CPR is continued until EMS staff arrives. B. The night shift licensed nurses are responsible for checking the stock of the crash cart nightly. Crash carts were inspected for appropriate supplies and equipment. The content to be included: airway, BP cuff, cardiac board, clipboard with paperwork, gloves, gowns, masks, oxygen cylinder, venti mask, tubing, nasal cannula, ambu bag, stethoscope, suction machine, suction catheter, saline for suction, cups and tape. C. Third shift nurses were educated on checking crash carts with the above mentioned equipment and must sign that they have checked on a checklist that is attached to the cart nightly. The in-service was completed on [DATE] and 22, 2012. D. Random audits of the crash carts were completed on [DATE] and [DATE], 10, and 12, 2012 and will continue weekly. The completion of the check lists are reviewed by the Administrator of Clinical Services during daily rounds. E. A new process of identification of DNR (Do Not Resuscitate) patients was completed. Upon admission, the Social Service staff review's a resident DNR status and places a red sticker on the name tag on the resident's medical record. Social Service will maintain a master list of all residents with DNR. Licensed nurses and social services were educated regarding this process on [DATE] and 19, 2012. F. Social services applied red stickers on spine of charts of DNR patients on [DATE]. G. The Administrator of Clinical Services is responsible for managing a Mock Code. The purpose is to simulate a Code Blue situation and provide continuous QA and QI. Mock Codes were completed on [DATE] and [DATE] and will continue monthly for 3 months and quarterly thereafter until deemed necessary by the Quality Assurance committee. H. Education on the Code Response policy will be held annually and as a part of orientation for licensed nurses. All in-service attendance and audits will be reviewed at the Quality Assurance committee meetings monthly for the next 3 months and annually to assure compliance is maintained. Director of Clinical Compliance will be responsible to monitor and report to the committee.

Based on record review and staff interview, the facility failed to ensure an allegation of neglect toward 1 resident (R28) by a CNA (E11) was reported and investigated immediately. R28 alleged that E11 refused to provide incontinence care multiple times. This is for one resident (R28) in the supplemental sample of 13. This failure resulted in E11 continuing to work in the facility for 5 1/2 weeks, having the potential to affect all 163 residents in the facility. An Immediate Jeopardy was identified on 11/16/11 and facility Administrator (E1) was notified. The Immediate Jeopardy was determined to have begun on 10/09/11 when facility staff reported verbally and in writing an allegation of neglect and abuse, which was not investigated due to failure of supervisor not reporting allegations to abuse coordinator. The Immediate Jeopardy was removed on 11/16/11 but facility remains out of compliance at a severity level 2. Additional time is needed to monitor and evaluate the effectiveness of the Quality Assurance tool and to complete inservices to all staff on the abuse policy. Findings include: On 11/16/11, during routine record review of the clinical record for R16 a folded paper was found in the record that recounted an incident of a completely different resident from R16. The subject of the note dated 10/9/11, was R28, a resident who has since been discharged from the facility. The note was written by a certified nurse aide (CNA), E10, who works on the 3-11 shift on the B unit. In the note E 10 recounts that R28 had told her that she had asked another CNA from the 7-3 shift to change her and was told by that CNA, E11 that she would have to wait for the next shift to come on duty because she was going home. The note further states that this was not the first time. "Everyday when I work behind E11, R28 has her call light on to be changed. E11 literally runs out of here!" "R28 has also stated previously that E11 is overall rough." There was no indication that these allegations had been addressed or investigated or why it was found in another residents file. The facility abuse investigations had been reviewed and none were found related to this resident or the incidents noted. E10 was scheduled to work at 3:00pm on 11/16/11, so an interview was done with her when she came on duty. E10 was interviewed at 3:05pm on the B unit. E10 was asked if she had ever received any allegations of abuse from residents or reported anyone for abusive or negligent acts. E10 stated that she had reported someone in the past. She further explained that a resident, R28 was discharged shortly after the allegation was made; that she had told her that another CNA, E11 was rough with her and that she had refused to change her and told her she would have to wait for the next shift to come on duty. E10 was asked to whom she had reported the incident, and stated that she had told the nurse on duty for the 3-11 shift and that she had also written a note recounting the allegation. At this time the note that was found in the chart of R16 was shown to E10. E10 stated that this was the note that she had written. She further explained that she had let the nurse read it to be sure that she had included all the necessary details. The nurse to whom she reported and who helped her with the note was identified as E12, an RN (registered nurse). When the note was finished it was slipped under the supervisor's door according to E10. During the interview, E10 was asked whether any other residents had ever commented to her about E11 and her care of them. She stated that other residents had also found E11 to be rough in rendering care to them. When asked whether the nurses were aware of this, E10 stated that: "all the nursing staff here are aware of her behavior." E10 was also asked whether she knew if there had been any action taken regarding E11 such as inservicing or discipline. E10 stated that there has not been any action taken as far as she knows. The staffing for the timeframe of 10/9/11 was obtained and the nursing staff for that date was identified. E12 was working on 10/9/11 from 3-11pm and was also working 11/16/11. E12 was interviewed about her knowledge of the allegations made. On 11/16/11 at 4:00pm, E12 said that an aide, E10 had reported to her about a resident that was upset with the care of E11. R28 reported to E11 that she did not want her (E11) taking care of her, did not want her in the room. She was rough. E11 said that E10 wrote up the paper and they read it. The supervisor (E3) knew about the incident because she was the one to tell them to write a report about the allegations. When the report was completed, it was slipped under the door of E3. E12 stated that she was not aware if E11 had ever been approached by E3 or anyone else regarding her behavior. E3, the nursing supervisor for the B unit, was also interviewed on 11/16/11 at 3:45pm. During the interview, E3 denied any knowledge of any allegations of rough care, abuse or neglect of a resident. E3 stated that she had been in the position of supervisor since August when the previous supervisor resigned. She stated that since that time: "I don't remember anyone reporting anything to me regarding this situation." The minimum data set (MDS) for R28 indicated that R28 was cognitively intact and also functionally incontinent due to impaired mobility. The careplan reflects that she is able to verbalize the need for toileting, but has poor bladder control. She is totally dependent on staff for all toileting needs including pericare and diaper application. Careplan approaches direct staff to offer toileting at regular intervals, and respond to call light promptly. Provide good pericare. The facility "Protocol for Abuse Prevention" summarizes that "It is the policy of the facility that each resident has the right not to be subjected to abuse by anyone....It is everyone's responsibility to report suspicions of neglect or abuse... immediately." Under the section titled Prevention it reads that the facility will identify, correct and intervene in situations in which abuse, neglect...is more likely to occur. This is not limited to "supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while giving care." Reporting/Investigation indicates that anyone who suspects abuse is obligated to to report this immediately so that "the matter can be investigated and the resident be safe guarded against further threats to safety and well-being." The facility policy was not followed in this case allowing the alleged staff member to remain working in the facility another 6 weeks potentially effecting all residents with whom she came in contact. The supervisor did not take the allegation further and report to the abuse prevention coordinator and an investigation was not initiated. The facility took the following actions to remove the Immediate Jeopardy. 1. Immediate suspension of staff member E3 and E11 per facility policy pending our investigation. 2. All residents have the potential to be affected by the alleged abuse. Interview of all residents, beginning with Unit B, to ensure no further allegations of abuse or neglect utilizing QIS scripted questions. Residents identified as at risk for abuse, care plans immediately updated. 3. Inservicing all staff will begin immediately reviewing facility abuse policy. Those that are not currently working, will receive the inservice prior to being allowed to deliver any resident care. Nurse managers and department heads of BCV will all receive a directed inservice on abuse policy and regulation. 4. A new Quality Assurance check list will be initiated and completed upon any and all allegations of abuse. Quality Assurance check list will be reviewed by the Quality Assurance committee monthly for six months and quarterly thereafter. Executive Director and/or Administrator will monitor for compliance. (See attachment) 5. This will be completed at by 11:59 pm on 11/16/11.

A. Based on record review and staff interview, the facility failed to ensure an allegation of rough treatment of [REDACTED]. This is for 1 resident (R28) out of a supplemental sample of 13. This failure resulted in E11 continuing to work in the facility for 5 1/2 weeks having the potential to affect all 163 residents in the facility. An Immediate Jeopardy was identified on 11/16/11 and facility Administrator (E1) was notified. The Immediate Jeopardy was determined to have begun on 10/09/11 when facility staff reported verbally and in writing an allegation of neglect and abuse, which was then not investigated due to failure of supervisor not reporting allegations to abuse coordinator. The Immediate Jeopardy was removed on 11/16/11 but facility remains out of compliance at a severity level 2. Additional time is needed to monitor and evaluate the effectiveness of the Quality Assurance tool and to complete inservices to all staff on the abuse policy. Findings include: On 11/16/11, during routine record review of the clinical record for R16 a folded paper was found in the record that recounted an incident of a completely different resident from R16. The subject of the note dated 10/9/11, was R28, a resident who has since been discharged from the facility. The note was written by a certified nurse aide (CNA), E10, who works on the 3-11 shift on the B unit. In the note E 10 recounts that R28 had told her that she had asked another CNA from the 7-3 shift to change her and was told by that CNA, E11 that she would have to wait for the next shift to come on duty because she was going home. The note further states that this was not the first time. "Everyday when I work behind E11, R28 has her call light on to be changed. E11 literally runs out of here!" "R28 has also stated previously that E11 is overall rough." There was no indication that these allegations had been addressed or investigated or why it was found in another residents file. The facility abuse investigations had been reviewed and none were found related to this resident or the incidents noted. E10 was scheduled to work at 3:00pm on 11/16/11, so an interview was done with her when she came on duty. E10 was interviewed at 3:05pm on the B unit. E10 was asked if she had ever received any allegations of abuse from residents or reported anyone for abusive or negligent acts. E10 stated that she had reported someone in the past. She further explained that a resident, R28 was discharged shortly after the allegation was made; that she had told her that another CNA, E11 was rough with her and that she had refused to change her and told her she would have to wait for the next shift to come on duty. E10 was asked to whom she had reported the incident, and stated that she had told the nurse on duty for the 3-11 shift and that she had also written a note recounting the allegation. At this time the note that was found in the chart of R16 was shown to E10. E10 stated that this was the note that she had written. She further explained that she had let the nurse read it to be sure that she had included all the necessary details. The nurse to whom she reported and who helped her with the note was identified as E12, an RN (registered nurse). When the note was finished it was slipped under the supervisor's door according to E10. During the interview, E10 was asked whether any other residents had ever commented to her about E11 and her care of them. She stated that other residents had also found E11 to be rough in rendering care to them. When asked whether the nurses were aware of this, E10 stated that: "all the nursing staff here are aware of her behavior." E10 was also asked whether she knew if there had been any action taken regarding E11 such as inservicing or discipline. E10 stated that there has not been any action taken as far as she knows. The staffing for the timeframe of 10/9/11 was obtained and the nursing staff for that date was identified. E12 was working on 10/9/11 from 3-11pm and was also working 11/16/11. E12 was interviewed about her knowledge of the allegations made. On 11/16/11 at 4:00pm, E12 said that an aide, E10 had reported to her about a resident that was upset with the care of E11. R28 reported to E11 that she did not want her (E11) taking care of her, did not want her in the room. She was rough. E11 said that E10 wrote up the paper and they read it. The supervisor (E3) knew about the incident because she was the one to tell them to write a report about the allegations. When the report was completed, it was slipped under the door of E3. E12 stated that she was not aware if E11 had ever been approached by E3 or anyone else regarding her behavior. E3, the nursing supervisor for the B unit, was also interviewed on 11/16/11 at 3:45pm. During the interview, E3 denied any knowledge of any allegations of rough care, abuse or neglect of a resident. E3 stated that she had been in the position of supervisor since August when the previous supervisor resigned. She stated that since that time: "I don't remember anyone reporting anything to me regarding this situation." The minimum data set (MDS) for R28 indicated that R28 was cognitively intact and also functionally incontinent due to impaired mobility. The careplan reflects that she is able to verbalize the need for toileting, but has poor bladder control. She is totally dependent on staff for all toileting needs including pericare and diaper application. Careplan approaches direct staff to offer toileting at regular intervals, and respond to call light promptly. Provide good pericare. The facility "Protocol for Abuse Prevention" summarizes that "It is the policy of the facility that each resident has the right not to be subjected to abuse by anyone....It is everyone's responsibility to report suspicions of neglect or abuse... immediately." Under the section titled Prevention it reads that the facility will identify, correct and intervene in situations in which abuse, neglect...is more likely to occur. This is not limited to "supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while giving care." Reporting/Investigation indicates that anyone who suspects abuse is obligated to to report this immediately so that "the matter can be investigated and the resident be safe guarded against further threats to safety and well-being." The facility policy was not followed in this case allowing the alleged staff member to remain working in the facility another 6 weeks potentially effecting all residents with whom she came in contact. The supervisor did not take the allegation further and report to the abuse prevention coordinator and an investigation was not initiated. The facility took the following actions to remove the Immediate Jeopardy. 1. Immediate suspension of staff member E3 and E11 per facility policy pending our investigation. 2. All residents have the potential to be affected by the alleged abuse. Interview of all residents, beginning with Unit B, to ensure no further allegations of abuse or neglect utilizing QIS scripted questions. Residents identified as at risk for abuse, care plans immediately updated. 3. Inservicing all staff will begin immediately reviewing facility abuse policy. Those that are not currently working, will receive the inservice prior to being allowed to deliver any resident care. Nurse managers and department heads of BCV will all receive a directed inservice on abuse policy and regulation. 4. A new Quality Assurance check list will be initiated and completed upon any and all allegations of abuse. Quality Assurance check list will be reviewed by the Quality Assurance committee monthly for six months and quarterly thereafter. Executive Director and/or Administrator will monitor for compliance. (See attachment) 5. This will be completed at by 11:59 pm on 11/16/11. B. Based on observation, record review and interview the facility failed to ensure that allegations of abuse (including injuries of unknown or are thoroughly investigated. This is for 2 residents in a sample of 25. (R14) Findings include: R14 is a [AGE] year-old resident with [DIAGNOSES REDACTED]. R14 is totally dependent on staff for all Activities of Daily Living per the 9/2/11 MDS. R14 has a history of hip and shoulder fractures according to documentation in the care plan. R14 sustained a bruise to the left anterior hand (no measurement documented) according to the nursing notes and accident/incident report dated 8/17/11. The Investigation Conclusion form (undated and unsigned) documents the following "A comprehensive investigation including interviews of staff involved in her care state that (R14) moves her upper extremities during repositioning to assist in mobility." A request was made to the facility to provide the documentation of the staff interviews that were referred to in the Investigation Conclusion report. The facility provided one interview statement. The statement was written by E23 (CNA). E23 was the CNA who identified and reported the bruise. According to the statement, R14 told E23 that 'it happened yesterday while the lady was changing my diaper. I was turned and my hand hit the side rail.' On 11/17/11 at 10:15 AM, E2 (Director of Clinical Services) confirmed that no other interviews were conducted. E2 stated that she didn't investigate the hand bruise because there was no verbal allegation of abuse and it had already been determined how the bruise occurred. E2 was not able to identify the staff who was taking care of R14 when the bruise occurred. On 11/16/11 at 11:10 AM, R14 said that staff have been rough with her in the past. R14 said that her family has requested that a certain CNA not take care of her anymore.

Based on interview and record review the facility failed to transfer, one of three residents sampled, (R3), with a gait belt and two staff members, as assessed. As a result of this facility failure, R3 sustained a tibia and fibula fracture. Additionally, the facility failed to follow their Fall Prevention Policy and Procedure. Findings include: The 3-31-2009 Fall Prevention Policy and Procedure is: "Policy - It is the policy, (Name of facility), to provide each resident with an appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. Procedures - Residents will be assessed for risk of falls on admission, quarterly, and as clinically indicated." According to the Facility Face Sheet R3 was admitted to the facility on [DATE]. Admission Fall Risk Assessment contains documentation that R3 was "High Risk" for falls. The 3-11-2011 MDS, (Minimum Data Set) documents R3 requires "Extensive two plus staff member assistance" with transfers." On 5-25-2011 at 10:25am. E5, (MDS/Care Plan Coordinator) stated, "The Restorative Nurse assesses the residents for transfer assist and inputs that information in the residents MDS. Then I do the Care Plan every quarter. Yes (R3) is assessed as extensive two plus staff member assistance with transfers." R3's 4-1-20-11 through 4-30-2011 Care Plan Flow Sheet contains the following documentation: "Approach: Transfer: Provide extensive assist of 2 with transfers, use gait belt. Start Date: 11-30-2009." The 4-28-2011 at 9:45am. Nursing Note is, "(R3) lowered to floor by staff during transfer from bed to wheelchair. CNA, (Certified Nursing Assistant/E6), stated she set her on the floor and called for assistance. (R3) transferred from floor to wheelchair by two assist. 3:00pm. (R3) sitting in wheelchair in doorway. (R3) complained of severe pain to left lower extremity, (knee and down to ankle), left lower extremity swollen....Described the pain as severe, on scale zero no pain, ten severe. Rated (pain) as 10 and constant pain. Unable to recall what happened and when. 4:40pm. X-ray to left knee, tibia, ankle, and fibula. 7:30pm. Dr on call, (Z2), called back, relayed to (Z2), x-ray of left lower extremity report. (Z2's) order, send (R3) to emergency room ." Hospital History and Physical Report of 4-29-2011 contains the following information: "R3 after a fall at the facility sustained a nondisplaced fracture of her left tibia/fibula. (R3) does not walk, but does pivot transfer with her right leg. She has a rather significant left hemiparesis, since cerebral vascular accident two years ago. It is not clear how this happened exactly at the nursing facility. She does have severe osteoporosis and it may have been just a matter of transferring, she had some weightbearing and the bone gave way." On 5-25-2011 at 11:25am. E3, (DON/Director of Nursing Long-Term Care) provided the following information: E9, (LPN/Licensed Practical Nurse) worked 4-28-2011 on the 3pm. to 11pm. shift and was upset that it had not been reported to her, at shift change, that R3 had a fall or injury on day shift. E3 immediately went and assessed R3. R3 had swelling and definite pain. E3 instructed E9 to call R3's physician, (Z1), order a portable x-ray, elevate the leg, and apply ice. Day and pm. shift did not notify E3, (DON) of the fall/incident. The day nurse, (E10/LPN), thought she wrote the Accident/Incident Report and left it for E6, (CNA), involed in transferring R3, to fill out. E10 had not done so and E6, (CNA) had not filled out the report. E3, (DON) told E9, (LPN) to come in and fill out the Accident/Incident Report. E3, (DON) began an investigation of the fall/incident. E7, (CNA) on interview verbalized E6, (CNA) had not used a gait belt and was transferring R3 without another staff member's assistance. "(R3) was assessed as an extensive 2 plus staff member assist transfer on her MDS. The (Resident's) care is in the CNA book. (E6/CNA) had access and would have known (R3) was a two plus person extensive assist. (E2/Administrator of Clinical Services), and I interviewed (E6/CNA). (E2/Administrator of Clinical Services) asked (E6/CNA) why she transferred (R3) alone and without a gait belt and (E6) said she didn't know what type of transfer (R3) was. (E6/CNA) had access, she has been here long enough to know where the Care Plan is." Review of E6, (CNAs) personnel file contains documentation that E6 was hired in March of 2008. E6's annual 3-14-2009 Employee Performance Review documents, "Has required reminders to use gait belt with transfers, to follow CNA Assignment Sheets to provide residents care." E6's 3-14-2010 Annual Employee Performance Review documents her overall performance rating as "Needs Improvement." E6's personnel file contained the following Disciplinary Reports: Disciplinary Report of 3-3-2010 contains documentation that E6, "Failure to follow instructions, procedures, and violation of safety rules: "Went with (E6/CNA) to assist, I had to remind (E6) to use her gait belt for standing resident. (E6) did not have gait belt with her, she had to get it." Disciplinary Report of 5-2-2011 is, "Failure to follow procedures: A resident entrusted to your care asked that you reposition her leg and the resident stated that you dropped her leg causing her pain. You were observed by your supervisor using the stander lift for a resident without the assistance of a second staff member as required." Disciplinary Report of 5-5-2011 contains documentation that E6, (CNA) "Failed to follow procedures and was disciplined for not using a gait belt and transferring a resident independently..."Since the resident, (R3) is paralyzed on one side of her body and does not bear weight." The 5-9-2011 Employee Separation Report documents E6's Nature of Separation as "Unsatisfactory Work Performance and Violation of Company Policy."