Every finding on record at Centralia Manor

Based on observation, interview and record review the facility failed to ensure privacy was maintained for 1 (R1) of 3 residents reviewed for privacy in the sample of 6. Findings included:R1's Face Sheet documented an admission date to the facility on 7/26/2023 with the following diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, depression, unspecified, generalized anxiety disorder, other insomnia, and rapid eye movement sleep behavior disorder. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Score (BIMS) of 04 documenting R1 had severe cognitive impairment. Section I Active Diagnoses documented R1 has non-Alzheimer's dementia, anxiety, depression and psychotic disorder. R1's Care Plan documented a focus area of behavioral symptoms of depression and dementia without behavioral disturbances. R1 care plan documents R1 has delusions and becomes upset after family visits. R1 packs her belongings throughout the day and evening waiting for family to pick her up. In the past R1 has hid in her own and other resident's closets, bathrooms, and under beds stating that someone is going to kidnap her or she has been raped, hears gunshots, and thinks others are out to kidnap her with interventions that included reassure R1 that staff is here to make sure she is safe. On 5/12/2026 at 10:07 AM, V4 (Certified Nursing Assistant/CNA) stated she had recorded a video of R1 about a month ago when she was lying on her closet floor, sleeping. V4 stated, R1 is a relative of hers and she did not realize until just now that she should not have posted the video to her snap chat. V4 stated, she had been working with V12 (CNA) when they went to check on R1 around 6:00PM because she had not been out of her room in a while. V4 stated, she had been recording with her phone when she entered the room and when pulling back the closet door showing R1 lying on the floor covered up with a blanket then she stopped recording. V4 stated, she did not post the video until a week (around 5/1/2026) or so later when she was looking back over her memories in her phone. On 5/12/2026 at 11:01 AM this surveyor viewed V4's recording of opening a closet door and R1 lying on her closet floor covered up with a blanket posted to V4's social media account. This post contained the facility name with a recorded date 2 weeks prior from memories in V4's phone to posting the video. On 5/13/2026 at 12:02 PM, V1 (Administration) stated her expectation for all staff is to follow the policy and procedure for residents' privacy. The facility's Resident Rights Policy (revised 11/28/2017) documented under Privacy and Confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. The facility must respect the residents right to personal privacy,.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse by a staff member for 1 (R1) of 3 residents reviewed for abuse in the sample of 6. Findings included:R1's Face Sheet documented an admission date to the facility on 7/26/2023 with the following diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, depression, unspecified, generalized anxiety disorder, other insomnia, and rapid eye movement sleep behavior disorder. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Score (BIMS) of 04 documenting R1 had severe cognitive impairment. Section I Active Diagnoses documented R1 has non-Alzheimer's dementia, anxiety, depression and psychotic disorder. R1's Care Plan documented a focus area of behavioral symptoms of depression and dementia without behavioral disturbances. R1 care plan documents R1 has delusions and becomes upset after family visits. R1 packs her belongings throughout the day and evening waiting for family to pick her up. In the past R1 has hid in her own and other resident's closets, bathrooms, and under beds stating that someone is going to kidnap her or she has been raped, hears gunshots, and thinks others are out to kidnap her with interventions that included reassure R1 that staff is here to make sure she is safe. On 5/12/2026 at 10:07 AM, V4 (Certified Nursing Assistant/CNA) stated she had recorded a video of R1 about a month ago when she was lying on her closet floor, sleeping. V4 stated, R1 is a relative of hers and she did not realize until just now that she should not have posted the video to her snap chat. V4 stated, she had been working with V12 (CNA) when they went to check on R1 around 6:00PM because she had not been out of her room in a while. V4 stated, she had been recording with her phone when she entered the room and when pulling back the closet door showing R1 lying on the floor covered up with a blanket then she stopped recording. V4 stated, she did not post the video until a week (around 5/1/2026) or so later when she was looking back over her memories in her phone. On 5/12/2026 at 11:01 AM this surveyor viewed V4's recording of opening a closet door and R1 lying on her closet floor covered up with a blanket posted to V4's social media account. This post contained the facility name with a recorded date 2 weeks prior from memories in V4's phone to posting the video. On 5/12/2026 at 10:22 AM, V1 (Administration) she had not been aware of the incident of V4 recording R1 in her closet and posting it to social media. V1 stated she will start an investigation immediately. The Facility's Initial Reportable Event dated 5/12/2026 documented in part: R1 an [AGE] year-old female had been recorded sleeping on her closet floor by V4 (CNA) about a month ago. Notification of family/physician made. V4 contacted and suspended pending further investigation. Final follow up report to follow. The facility's Abuse Policy (revised 11/28/2019) documented under Policy: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat resident's symptoms. Under Purpose: to protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat resident's symptoms.

Based on interview and record review the facility failed to keep residents free from abuse for 2 (R1 and R3) of 3 residents reviewed for abuse in a sample of 5. This failure would cause a reasonable person to experience feelings of fear, anxiety and anger while residing in their home.Findings include:1. R2's Face Sheet documents an admission date of 12/11/25 with diagnoses including: displaced fracture of upper end of right humerus, dementia, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, candidiasis of skin and nail, pain, vitamin D deficiency, major depressive disorder, and essential hypertension. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03 indicating R2 has severe cognitive impairment.R1's Face Sheet documents an admission date of 05/15/25 with diagnoses including: Alzheimer's disease, hypokalemia, altered mental status, major depressive disorder, anxiety disorder, seizures, type 2 diabetes mellitus, dementia, and visual loss. R1's MDS dated [DATE] documents a BIMS score of 04 indicating R1 has severe cognitive impairment.R1's Care Plan documents a problem area of: behavioral symptoms with goals listed as: R1 will have a decrease in other behaviors by next review dated 03/12/26 with approaches listed as help R1 to call her friend when restless dated 06/16/25 and offer R1 a snack and drink in room or dining area dated 05/19/25, R1 will have a decrease in verbal, physical and rejection of care behaviors by next review dated 03/12/26 with an approach listed as offer independent activity supplies and setup dated 08/21/25, and R1 will have fewer episodes of exit seeking by next review dated 03/12/26 with an approach listed as invite R1 to activities of her interest dated 05/19/25.R2's Progress Note dated 1/20/26 at 10:18PM, authored by V10 (Licensed Practical Nurse/LPN) documents this writer was passing medication down the 200 hall when it was overheard from the resident next to (R2's) room saying 'get out of bed' (R2) was heard yelling. CNA went into room to find resident in her floor near the bathroom door. She stated, 'a man pulled me out of bed.' ROM is good except with her right arm. She doesn't want to move arm. This is the arm that she complains of often. Neuro checks were started. Resident was taken to day area and placed in a recliner. She was able to stand and pivot to get into the recliner. She was given PRN (as needed) pain medication.R2's Progress Note dated 01/22/26 at 10:23 AM documents: root cause analysis IDT (Interdisciplinary Team) met and discussed fall from 01/20 at 10:06 PM. R2 was previously in bed. Staff heard another resident (R1) in R2's room telling her to get up. R2 was then heard yelling out and observed on the floor. R2 stated, a man pulled me out of bed. Other resident (R1) was redirected back to her room. R2 was taken to the dayroom. The intervention was a room change for R1.R2's Event Report dated 01/20/26 at 10:06 PM documents event details: location of fall with resident's room marked, what was resident doing just prior to fall? documents was in her bed, why does resident think they fell? documents she said a man pulled me out of bed. The area titled, describe, if needed documents heard resident in room next to her's saying get out of bed. Then heard resident yelling. Advised CNA who went into room and resident was found in the floor by the bathroom door. The section titled, pain assessment contains: does resident exhibit or complain of pain related to the fall? If so, describe location with Yes marked and location as right arm, on a scale of 0-10, how does resident rate intensity of pain if able or indicate based on observation with '5' marked. The section titled, Body assessment contains: location of injury with mid back right side documented, note any injury to the head, extremities, or trunk with redness and range of motion with ROM (range of motion) painful/limited in upper extremity marked, describe, if necessary documents resident won't allow her right arm to be moved around. The section titled, Neurological Check notes: upper right extremity movement/grasps with other marked and documents won't grasp with right hand. The area titled, speech has clear-distinct, intelligible words marked. The section titled, possible contributing factors includes the question, are any the following factors present? with other marked and documents possible pulled out of bed by resident in room beside hers. The section titled, Interventions-immediate measures taken has marked: analgesics and other marked and documents placed resident in day area in recliner.R1's progress note dated 01/21/26 at 10:29 AM documents R1 is moving to room (number) due to going through the bathroom into another residents room disturbing her significantly.On 02/02/26 at 10:39 AM, R1 was interviewed and did not remember the incident with R2 and R1 started becoming agitated.On 02/09/26 at 11:20 AM, R2 was interviewed and did not remember the incident with R1.On 02/02/26 at 2:05 PM, V3 (Director of Memory Care) stated, R1's behaviors are sporadic, she can be physical, she tries to wake other residents up and almost forces them out of bed. V3 stated, R1 did pull R2 out of bed. R1 gets upset because R1 thinks other residents are in her bed so she either yells for them to get out or tries to force them out. V3 stated, R1's behaviors get the other residents frustrated and R1's behaviors get worse at night. V3 stated, R1 will tell residents to go play in traffic and to get out of her house. V3 stated, when you try to redirect R1 she will become more argumentative.On 02/02/26 at 2:33 PM, R3 stated R1 has a smart mouth.On 02/09/26 at 2:34 PM, V8 (Family) stated the facility called him and told him R2 was pulled out of bed by another resident. V8 stated, R2 fell at a different facility and fractured her arm and injured her shoulder and came to this facility for rehabilitation.On 02/09/26 at 2:45 PM, V4 (CNA) stated R2 has some verbal behaviors where she will yell out for her mother sometimes but that is about it. V4 stated, R1 has behaviors kind of all over the place but they are worse in the evening. R1 has tried to pull residents out of their beds. V4 stated, she was not working when the incident happened with R2, but she worked the shift right after and she was given report about it. V4 stated, R2 did complain she was hurting in the shoulder/arm area. V4 stated, they will try to redirect R1 but most of the time it does not work, you have to let her throw her fit and then she will go back to her room and be calmed down. V4 stated, sometimes redirection will just make the situation worse. V4 stated, R1 will sometimes swing on the staff but she has not seen her swing on any of the residents before. V4 stated, R1 has tried to pull more than one resident out of bed before. V4 stated, she caught R1 pulling R5 out of bed before, R1 had ahold of R5's ankles and was pulling her out of bed. V4 stated, V3 (Director of Memory Care) and V1 (Administrator) were aware of the situation, she reported the situation to them.On 02/09/26 at 3:07 PM, V7 (CNA) stated R1 has very triggering behaviors including: looking at her, talking with her, and R1 will come out of her room just to pick fights. R1 can be very aggressive towards staff and residents. V7 stated, V6 (CNA) was working when R1 pulled R2 out of bed. V7 stated, she has seen R1 get in bed with other residents and tell them to get out of bed. V7 stated, she will try to get R1 to go back to her room because she seems calmer there, sometimes they will have to get a nurse or someone else to help.On 02/09/26 at 3:18 PM, V8 (CNA) stated the shift R1 pulled R2 out of bed she was down in the dining room doing her charting and she heard R1 screaming and then she heard R2 scream. V8 stated, she ran down there and R2 was on the floor and R1 was standing next to her. V8 stated, R2 said, that guy pulled me out of bed. V8 stated, there are residents at the facility that think R1 is a guy. V8 stated, she was told by other coworkers, R1 had halfway pulled R5 out of bed. V8 stated, R1 will threaten other residents and they will try to take her to her room and give her space to calm down. V8 stated, R1's behaviors are all over the place, it's like a flip of a switch. V8 stated, R1 was pulling R5 out of bed by her feet, but she did not see how R1 pulled R2 out of bed, if it was by her feet or her arm but R2 did have a red spot on her back that was not there when she put R2 to bed.On 02/10/26 at 4:03 PM, V3 stated the intervention after R1 pulled R2 out of bed was a room change to a private room. V3 stated she reported the incidents R1 and R2 to the administrator. 2. R3's Face Sheet documents an admission date of 10/08/25 with diagnoses including: diabetes mellitus, diarrhea, fracture of unspecified carpal bone, vitamin D deficiency, pain, muscle spasm, end stage renal disease, dementia, metabolic encephalopathy, allergic rhinitis, gastro-esophageal reflux disease, muscle weakness, and depression. R3's MDS dated [DATE] documents a BIMS score of 03 indicating R3 has severe cognitive impairment.R3's final follow-up investigation report with a date of incident of 11/02/26 at 1:45 PM documents an incident description: On 11/02/26 at approximately 1:45 PM, (V1) was notified by staff member V3 that a resident-to-resident contact incident had occurred on the memory care unit in the dining room. According to staff report, two residents were seated at adjacent dining tables. One resident (Resident A) (R1) was repeatedly speaking loudly and asking the same question. The second resident (Resident B) (R3) became visibly frustrated and poured cold coffee onto resident A (R1). Staff immediately intervened and separated both residents.On 02/02/26 at 2:05 PM, V3 stated R3 did throw coffee, but it was cold coffee onto R1 because R1 agitated her, there was no injuries and R1 was taken to her room to clean up and calm down.On 02/02/26 at 2:40 PM, R1 was interviewed and did not remember the incident with R3.On 02/02/26 at 2:44 PM, R3 was interviewed and did not remember the incident with R1.On 02/10/26 at 4:06 PM, V1 stated in the report titled, Final Follow-up Investigation report the date should be 01/02/26 and resident A is R1 and resident B is R2.R1's Progress Note documents on 01/02/2026 at 1:53 PM coffee was thrown at R1, caught R1 in the face and the right side of head. The coffee was cold and there was no redness to right side of her face or neck. R1 offers no complaint of pain or discomfort.The facility policy dated 11/28/19 titled, Abuse Prohibition and Reporting documents: to protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms.

Based on interview and record review the facility failed to report alleged abuse for 1(R2) of 3 resident reviewed for abuse allegations in a sample of 5.Findings include:R2's Face Sheet documents an admission date of 12/11/25 with diagnoses including: displaced fracture of upper end of right humerus, dementia, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, candidiasis of skin and nail, pain, vitamin D deficiency, major depressive disorder, and essential hypertension. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03 indicating R2 has severe cognitive impairment.R1's Face Sheet documents an admission date of 05/15/25 with diagnoses including: Alzheimer's disease, hypokalemia, altered mental status, major depressive disorder, anxiety disorder, seizures, type 2 diabetes mellitus, dementia, and visual loss. R1's MDS dated [DATE] documents a BIMS score of 04 indicating R1 has severe cognitive impairment.R1's Care Plan documents a problem area of: behavioral symptoms with goals listed as: R1 will have a decrease in other behaviors by next review dated 03/12/26 with approaches listed as help R1 to call her friend when restless dated 06/16/25 and offer R1 a snack and drink in room or dining area dated 05/19/25, R1 will have a decrease in verbal, physical and rejection of care behaviors by next review dated 03/12/26 with an approach listed as offer independent activity supplies and setup dated 08/21/25, and R1 will have fewer episodes of exit seeking by next review dated 03/12/26 with an approach listed as invite R1 to activities of her interest dated 05/19/25.R2's Progress Note dated 1/20/26 at 10:18PM, authored by V10 (Licensed Practical Nurse/LPN) documents this writer was passing medication down the 200 hall when it was overheard from the resident next to (R2's) room saying 'get out of bed' (R2) was heard yelling. CNA went into room to find resident in her floor near the bathroom door. She stated, 'a man pulled me out of bed.' ROM is good except with her right arm. She doesn't want to move arm. This is the arm that she complains of often. Neuro checks were started. Resident was taken to day area and placed in a recliner. She was able to stand and pivot to get into the recliner. She was given PRN (as needed) pain medication.R2's progress note dated 01/22/26 at 10:23 AM documents: root cause analysis IDT (interdisciplinary team) met and discussed fall from 01/20 at 10:06 PM. R2 was previously in bed. Staff heard another resident (R1) in R2's room telling her to get up. R2 was then heard yelling out and observed on the floor. R2 stated, a man pulled me out of bed. Other resident (R1) was redirected back to her room. R2 was taken to the dayroom. The intervention was a room change for R1.R2's Event Report dated 01/20/26 at 10:06 PM documents event details: location of fall with resident's room marked, what was resident doing just prior to fall? documents was in her bed, why does resident think they fell? documents she said a man pulled me out of bed. The area titled, describe, if needed documents heard resident in room next to her's saying get out of bed. Then heard resident yelling. Advised CNA who went into room and resident was found in the floor by the bathroom door.On 02/10/26 at 4:06 PM V1 stated, the incident between R1 and R2 was discussed during the IDT meeting and decided since it was not witnessed and the resident could not give a description of the event, they did not consider it a resident to resident.On 02/02/26 at 2:05 PM, V3 (Director of Memory Care) stated R1's behaviors are sporadic, she can be physical, she tries to wake other residents up and almost forces them out of bed. V3 stated, R1 did pull R2 out of bed. R1 gets upset because R1 thinks other residents are in her bed so she either yells for them to get out or tries to force them out. V3 stated, R1's behaviors get the other residents frustrated and R1's behaviors get worse at night. V3 stated, R1 will tell residents to go play in traffic and to get out of her house. V3 stated, when you try to redirect R1 she will become more argumentative.On 02/09/26 at 2:34 PM, V8 (Family) stated, the facility called him and told him R2 was pulled out of bed by another resident.On 02/09/26 at 3:07 PM V7 (CNA) stated, R1 has very triggering behaviors including: looking at her, talking with her, and R1 will come out of her room just to pick fights. R1 can be very aggressive towards staff and residents. V7 stated, V6 (CNA) was working when R1 pulled R2 out of bed. V7 stated, she has seen R1 get in bed with other residents and tell them to get out of bed. V7 stated, she will try to get R1 to go back to her room because she seems calmer there, sometimes they will have to get a nurse or someone else to help.On 02/09/26 at 3:18 PM, V8 (CNA) stated the shift R1 pulled R2 out of bed she was down in the dining room doing her charting and she heard R1 screaming and then she heard R2 scream. V8 stated, she ran down there and R2 was on the floor and R1 was standing next to her. V8 stated, R2 said, that guy pulled me out of bed. V8 stated, there are residents at the facility that think R1 is a guy. V8 stated, she was told by other coworkers, R1 had halfway pulled R5 out of bed. V8 stated, R1 will threaten other residents and they will try to take her to her room and give her space to calm down. V8 stated, R1's behaviors are all over the place, it's like a flip of a switch. V8 stated, R1 was pulling R5 out of bed by her feet, but she did not see how R1 pulled R2 out of bed, if it was by her feet or her arm but R2 did have a red spot on her back that was not there when she put R2 to bed.As of 2/10/26, there has been no reports if resident to resident abuse reported to the Illinois Department of Public Health for R1 and R2 for the incident that occurred on 1/20/26.The facility policy dated 11/28/19 titled, Abuse Prohibition and Reporting documents: 2.if the matter involves alleged abuse or results in serious bodily injury, the administrator, or designee shall provide the Illinois Department of Public Health with initial notice of the alleged abuse or serious bodily injury as soon as possible, but not more than 2 hours after the matter becomes known or no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. 7. if the incident involves alleged abuse and substantiated evidence indicates that another resident of the facility is the perpetrator of the abuse, then the administrator shall take all steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated.

Based on interview and record review the facility failed to prevent and investigate alleged abuse for 2 (R1 and R2) of 3 residents reviewed for abuse in a sample of 5.The findings include:R1's Face Sheet documents an admission date of 05/15/25 with diagnoses including: Alzheimer's disease, hypokalemia, altered mental status, major depressive disorder, anxiety disorder, seizures, type 2 diabetes mellitus, dementia, and visual loss. R1's MDS dated [DATE] documents a BIMS score of 04 indicating R1 has severe cognitive impairment.R1's Care Plan documents a problem area of: behavioral symptoms with goals listed as: R1 will have a decrease in other behaviors by next review dated 03/12/26 with approaches listed as help R1 to call her friend when restless dated 06/16/25 and offer R1 a snack and drink in room or dining area dated 05/19/25, R1 will have a decrease in verbal, physical and rejection of care behaviors by next review dated 03/12/26 with an approach listed as offer independent activity supplies and setup dated 08/21/25, and R1 will have fewer episodes of exit seeking by next review dated 03/12/26 with an approach listed as invite R1 to activities of her interest dated 05/19/25.R1's progress note dated 10/24/25 at 12:32 AM documents: R1 approaching staff and demanding that they go away. R1 attempting to pull other residents out of bed. R1 redirected to assigned room and covered up in bed. R1 tells this nurse to go away and get rid of the others.R1's progress note dated 01/14/26 at 12:00 AM documents: R1 was observed laying in another resident's bed with no shirt on and other resident sitting on side of her bed because R1 was telling her to get out of her bed. R1 continued to argue with staff telling them to get the other resident out of her bed and out of her room.R1's progress note dated 01/21/26 at 10:29 AM documents R1 is moving to room (number) due to going through the bathroom into another residents room disturbing her significantly.R1's progress note dated 01/22/26 at 6:05 PM documents: after dinner R1 was observed in another residents bed when assisting another resident to their room. R1 argued with staff and was difficult to redirect. R1 eventually got up and went back to her room.R2's Face Sheet documents an admission date of 12/11/25 with diagnoses including: displaced fracture of upper end of right humerus, dementia, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, candidiasis of skin and nail, pain, vitamin D deficiency, major depressive disorder, and essential hypertension. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03 indicating R2 has severe cognitive impairment.R2's Progress Note dated 1/20/26 at 10:18PM, authored by V10 (Licensed Practical Nurse/LPN) documents this writer was passing medication down the 200 hall when it was overheard from the resident next to (R2's) room saying 'get out of bed' (R2) was heard yelling. CNA went into room to find resident in her floor near the bathroom door. She stated, 'a man pulled me out of bed.' ROM is good except with her right arm. She doesn't want to move arm. This is the arm that she complains of often. Neuro checks were started. Resident was taken to day area and placed in a recliner. She was able to stand and pivot to get into the recliner. She was given PRN (as needed) pain medication.R2's Progress Note dated 01/22/26 at 10:23 AM documents: root cause analysis IDT (Interdisciplinary Team) met and discussed fall from 01/20 at 10:06 PM. R2 was previously in bed. Staff heard another resident (R1) in R2's room telling her to get up. R2 was then heard yelling out and observed on the floor. R2 stated, a man pulled me out of bed. Other resident (R1) was redirected back to her room. R2 was taken to the dayroom. The intervention was a room change for R1.On 02/09/26 at 2:45 PM, V4 (CNA) stated they will try to redirect R1 but most of the time it does not work, you have to let her throw her fit and then she will go back to her room and be calmed down. V4 stated, sometimes redirection will just make the situation worse. V4 stated, R1 will sometimes swing on the staff but she has not seen her swing on any of the residents before. V4 stated, R1 has tried to pull more than one resident out of bed before. V4 stated, she caught R1 pulling R5 out of bed before, R1 had ahold of R5's ankles and was pulling her out of bed. V4 stated, V3 (Director of Memory Care) and V1 (Administrator) were aware of the situation, she reported the situation to them.On 02/09/26 at 3:18 PM, V8 (CNA) stated the shift R1 pulled R2 out of bed she was down in the dining room doing her charting and she heard R1 screaming and then she heard R2 scream. V8 stated, she ran down there and R2 was on the floor and R1 was standing next to her. V8 stated, R2 said, that guy pulled me out of bed. V8 stated, there are residents at the facility that think R1 is a guy. V8 stated, she was told by other coworkers, R1 had halfway pulled R5 out of bed. V8 stated, R1 will threaten other residents and they will try to take her to her room and give her space to calm down. V8 stated, R1's behaviors are all over the place, it's like a flip of a switch. V8 stated, R1 was pulling R5 out of bed by her feet, but she did not see how R1 pulled R2 out of bed, if it was by her feet or her arm but R2 did have a red spot on her back that was not there when she put R2 to bed.On 02/10/26 at 4:06 PM, V1 (Administrator) stated the incident between R1 and R2 was discussed during the IDT meeting and decided since it was not witnessed and the resident could not give a description of the event, they did not consider it a resident to resident.On 02/10/26 at 4:03 PM, V3 (Director of Memory Care) stated she is not sure what the intervention was that was put in place after R1 was witnessed pulling R5 out of bed. V3 stated she reported the incidents between R1 and R5 and the incident with R1 and R2 to V1.The facility policy dated 11/28/19 titled, Abuse Prohibition and Reporting under Purpose documents To protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. Under C. Investigation step 1 documents interviews will all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least on interviewer shall take notes. Attachment 3 of this policy titled Abuse Investigation Checklist documents If there is reasonable cause to suspect that willful abuse, neglect, and misappropriation of property have occurred, use the following checklist during investigation to assure the necessary steps are completed.

Based on interview and record review the facility failed to answer alternative call lights for residents needing assistance in a timely manner to promote dignity for 5 residents of 13 residents (R1, R2, R4, R6, and R7) reviewed for call light response in a sample of 13. This failure resulted in R1, R2 and R4 having bowel and bladder accidents which lead to feelings of humiliation, embarrassment and shame. Findings include: 1. R1's Face Sheet dated 09/23/25 documents an admission date of 08/21/25 with diagnoses in part of fusion of the spine lumbar region, muscle weakness, other rupture of muscle, spinal stenosis lumbar region, other specified local infection of the skin and subcutaneous tissue, anxiety, rheumatoid arthritis, overactive bladder, and unspecified injury at unspecified level of cervical spinal cord.R1's MDS (Minimum Data Set) dated 08/28/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates R1 is cognitively intact. Section GG documents toileting as set-up and clean up help. R1's Care plan documents a problem area of R1 is at risk for falling r/t (Related to) HTN (Hypertension), depression, anemia, spinal stenosis an approach for this problem documents- therapy to use 2 assist with transfer to the toilet as tolerated and instruct R1 to call for assist before getting out of bed or transferring. Another Problem area documents Resident care information with an approach of - bowel and bladder continent and safe resident handling procedures transfer method sit to stand level of assistance x2 assist. On 09/22/25 at 9:32AM, R1 stated that the call light system on her hall has been down almost since she was admitted to the facility. R1 said they gave her a bike horn to be able to get a hold of staff when she needs help. R1 said she thinks that staff can hear the horn most of the time. R1 said that other times she doesn't know if they can hear it. R1 said one time it took them 45 minutes to answer her horn. R1 said that she has pissed all over herself a couple of times and she was so embarrassed that she must sit and lay in her own piss until someone finally comes and helped her get cleaned up. R1 said her roommate has jingle bells and when she needs something she will ring them, and staff doesn't hear her. R1 said that she will then honk her horn for her roommate so she can get help. R1 stated that staff told me that I don't need to honk my horn for my roommate that she has her own bells and needs to use them. R1 said that she tried to tell staff that her roommate has been ringing her jingle bells and no one was coming to help her. R1 said they have tried several different devices to be able to call for help and the horn seems to be the one that works the best. R1 stated her being at the end of the hall that it is harder for staff to hear her horn. 2. R2's Face Sheet dated 09/23/25 documents an admission date of 09/05/25 with diagnoses in part of aftercare following joint replacement surgery to right knee, paroxysmal atrial fibrillation, muscle spasm of calf, muscle weakness, chronic kidney disease, overactive bladder, irritable bowel syndrome, and type 2 diabetes mellitus.R2's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R2 is cognitively intact. Section GG documents toileting as supervision or touching assistance. R2's Care Plan documents a problem area of Resident Care Information with an approach of - continent of bowel and bladder, safe resident handling procedure transfer method stand aid level of assist: assist x1. On 09/22/25 at 12:45PM, R2 stated that the call light system has been down since she was admitted . R2 said that they give residents, bells, horns and whistles to use when they need help, and it is a joke. R2 said that staff is so loud or playing music and don't hear when we are using out devices to get help. R2 said she has a horn, and her roommate has bells, but it doesn't matter which one you have they don't hear any of them. R2 said she was supposed to wait for help from staff and she would honk her horn, and no one would come and answer her horn. R2 said she had had several accidents where she urinated on herself waiting on someone to come help. R2 said it was humiliating she said that she is [AGE] years old, and she does not want to be urinating all over herself if she doesn't have to. R2 said she did have to sit in her own urine for a while as she waited for a staff member to figure out who was honking or when they finally heard that she was honking for help. R2 said she finally got tired of waiting on staff to answer her horn and she just started taking herself to the bathroom instead of waiting on someone to help her. R2 said she has been working with therapy and she was supposed to be waiting on staff to assist her to the bathroom, but now she just does it on her own instead of waiting and urinating on herself. R2 said that this call system they have in place right now is a joke and they need to get the other system working so they can figure out who needs help and when they need help. 3. R4's Face Sheet dated 09/23/25 documents an admission date of 06/18/25 with diagnoses in part of periprosthetic fracture around other internal prosthetic joint, aftercare following joint replacement surgery, muscle weakness, other abnormalities of the gait and mobility, type 2 diabetes mellitus, and chronic kidney disease. R4's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates R4 is moderately cognitively impaired. Section GG documents toileting as dependent. R4's Care Plan documents a problem area of Resident Care Information with an approach of bowel and bladder continent, and safe resident handling procedure transfer method mechanical lift level of assistance x2.On 09/22/25 at 9:31AM, R4 stated that she has bells she is supposed to jingle when she needs help. R4 stated that staff doesn't really hear the bells when she is ringing them, and she has her roommate will honk her horn just so she can get someone to come take her to the bathroom or when she needs a bed pan. R4 said that she has had accidents and peed on herself waiting for staff to answer the bells or horn she said that it has taken staff over an hour she has had to wait, and it upset her so much. R4 said that she is usually able to control her urine most of the time and she doesn't like to wet herself it embarrasses her, and she hates it. R4 said she had one staff member who told her she had an incontinent brief and that she could pee in it that is what it is there for. R4 stated that one staff member told her that she needs to stop having her roommate honk her horn for her, if she needs something she needs to ring her bells herself. 4. R6's Face Sheet dated 09/23/25 documents an admission date of 09/05/25 with diagnoses in part of lumbago with sciatica, type 2 diabetes mellitus, muscle weakness, neuralgia, overactive bladder, and lower back pain. R6's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R6 is cognitively intact. Section GG documents toileting as partial/moderate assistance. R6's Care Plan documents a problem area of Resident Care Information an approach of- bowel and bladder continent and safe resident handling procedure transfer stand aid level of assistance assist x2. On 09/22/25 at 9:49AM, R6 stated that she has a whistle to blow on when she needs assistance. R6 stated she gets winded because she must keep blowing in the whistle until staff finally comes in and helps her. R6 stated is takes staff a while to come when she is blowing her whistle, because there are several residents that have whistles, and staff must try and figure out what hall and which residents whistle is being blown on. R6 said she has had an accident while she was waiting on staff to answer her whistle. R6 said she does get upset if she has an accident while waiting on staff to answer her whistle. 5. R7's Face Sheet dated 09/23/25 documents an admission date of 06/24/25 with diagnoses in part of acute on chronic diastolic heart failure, diabetes mellitus, parkinsonism, unsteadiness on feet, muscle weakness, overactive bladder, and other abnormalities of gait and mobility. R7's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R7 is cognitively intact. Section GG documents toileting as substantial/maximal assistance. R7's Care Plan document a problem area of Resident Care Information with an approach of bowel and bladder continent, continent toileting assist x2 and safe resident handling procedure transfer method stand pivot with walker level of assistance assist x 2. On 09/22/25 at 9:56AM, R7 stated that staff doesn't hear her horn when she squeezes it. R7 said that it takes the staff a long time before they do answer the horn when she is squeezing it. R7 said staff has told her to give them time to try and answer when she is squeezing her horn. R7 said she has had several incontinent episodes waiting on staff to answer her horn she said they have to figure out who is honking the horn first. R7 stated she doesn't know how long it had taken staff to assist her. R7 said she can't hold her urine long when she honks the horn. R7 said that she doesn't like when she has an incontinent episode on herself. On 09/22/25 at 2:36PM, V6 (Certified Nurse Assistant/CNA) stated that she usually works 300, 400, and 500 halls. V6 stated that she thinks the call light system for 300, 400, and 500 halls went out around the end of August. V6 stated that it is hard to figure out which hall the resident is whistling, honking or jingling the bells from. V6 said they go down every hall trying to figure out who needs help. V6 said the residents know to keep honking their horns, blowing their whistles, and jingling their bells until we figure out who it is. V6 said even from the nurses' station which is located between all the halls it is hard to figure out which direction the sound is coming from especially if they have staff and residents talking at the nurse's station. V6 said it is especially hard to hear the horns, whistles and bells when the residents are at the end of the hallway. V6 stated that yes some of the residents have had accidents while waiting on us to try and figure out what location the sounds are coming from. V6 said she did have a resident who was really embarrassed because she wet herself and she was really upset she said that resident was R2. On 09/22/25 at 2:37PM, V7 (CNA) stated that she usually works 300, 400, and 500 halls. V7 said that the call light system went down on those halls around the end of August. V7 said it is hard to head some of the bells, whistles, and horns especially if a resident is at the end of a hallway. V7 stated it is also hard to figure out who's whistles, horn, or bells are ringing. V7 said they must go down the halls and see what hall it is. V7 said it also makes it hard to hear those devices when a resident has their door closed. V7 said they did have a resident who kept trying to honk her horn and the horn wasn't working, and they did get the resident a new horn. V7 said that she has had several residents who were really embarrassed, and those residents were R1 and R2. V7 said that R1 and R2 both were really upset. On 09/23/25 at 9:00AM, V8 (CNA/Shift Coordinator) stated that the call light system on 300, 400, and 500 hallways quit working a couple of weeks ago. V8 said they gave the residents on those halls whistles, bike horns, and bells to be able to notify the staff when they need something. V8 said that it is very hard trying to figure out which hall or where the resident is honking, ringing or whistling from. V8 said they will go down the halls and yell out to tell the resident to keep honking, whistling, or ringing until they figure out who it is. V8 said that is does take longer for them to respond to the resident whistle, bells, or horn because they must figure out who it is that is making the noise first. V8 said when they hear a sound from the nurse's station, they get up right away and start checking all of the halls and see who it might be. V8 said that they do have resident who will honk their horns for other resident in the same room such as R1 for R4. V8 said that R4 did have a horn, but she was trying to use it the wrong way and kept trying to honk the horn, but it wasn't' making any noise so she ended up with bells. V8 said it is harder to hear some of the resident who are on the end of the halls. On 09/23/25 at 10:05AM, V4 (Licensed Practical Nurse/LPN) stated that the facility call light system on 300, 400, and 500 hallways went out around the end of August. V4 stated they gave the resident whistles, bells, and horns to be able to ring and notify staff that they need them. V4 said she thinks that staff can hear the whistles, bells, and horns but it is challenging trying to figure out where the sound is coming from. V4 said she does think it takes the staff long to be able to answer when the resident is ringing, whistling, or honking because they must figure out who it is. V4 stated that she does know there have been a couple of residents that complained that they had an incontinent episode, but she didn't know if it was because of the bells, whistles, or horns and staff not being able to find out who it was or if it is because they have a lot of resident to care for. V7 said that she thinks a lot of the residents wait till the last minute and then try to get staff to help them and staff might be in another room taking care of another residents. On 09/23/25 at 11:40AM, V1 (Administrator) stated that the call light system on 300, 400, and 500 hallways went out on 08/29/25. V1 stated she called someone right away to see what was wrong with the call light system on those halls, but the soonest someone could come look at it was on 09/03/25. V1 said they did come in and look at the call light system and they told her that the system has just out lived its life and that they need to replace the system on those halls. V1 said that when the system went down on 08/29/25 that they did get an alternative call system of whistles, horns, and bells for the residents, so they had a way to communicate when they need help from staff. V1 said that they did try different things with the residents to make sure that they could use the device they gave each resident. V1 said she is not aware of any resident that can't use the device they have been given. V1 said staff has told her that they do have a hard time hearing the devices if the resident has their doors closed or if the resident is at the end of the hall. V1 said she did have a resident complain to her since the call light system was down it was taking a long time for staff to respond to her device. V1 said that on 09/05/25 they gave them an estimate on the new call light system for 300, 400, and 500 hallways. V1 said on 09/08/25 they ordered the new system and then on 09/16/25 they sent in payment for the new call light system. V1 said the company who is installing the new call light system said it could take 2-3 weeks before they could install the new call light system. On 09/23/25 at 12:33PM, V2 (Director of Nursing/DON) stated that they did have a problem with the call light system on 300, 400, and 500 halls it went out around the end of August. V2 said they gave the residents an alternative method to be able to call for help like whistles, horns, and bells. V2 said the shift coordinators also said something about doing 15-minute checks on those residents as well. V2 stated that she didn't know how they were tracking it the 15-minute checks. V2 stated that they don't have any documentation stating that the 15-minute checks were done on those residents. V2 said she has heard resident complain that staff has been in places where it was hard for them to hear the whistle, bells, and horns and that they tell the residents to keep whistling, honking, or jingling the bells until they figure out who it was the was making the sound with their device. On 09/24/25 at 11:00AM, V1 stated that the facility does not have a policy on dignity. The facility policy titled Call Light with a revised date of 01/04 documents under objective: To respond to resident's request and needs. Equipment documents: Functioning call light.

Based on observation, interview and record review the facility failed to provide a functional call system for the 32 residents living on the 300, 400, and 500 halls.The findings include: 1. On 09/22/25 at 9:32AM, R1 stated that the call light system on her hall has been down almost since she was admitted to the facility. R1 said they gave her a bike horn to be able to get a hold of staff when she needs help. R1 said she thinks that staff can hear the horn most of the time. R1 said that other times she doesn't know if they can hear it. R1 said one time it took them 45 minutes to answer her horn. R1's MDS (Minimum Data Set) dated 08/28/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates R1 is cognitively intact. 2. On 09/22/25 at 12:45PM, R2 stated that the call light system has been down since she was admitted . R2 said that they give the residents, bells, horns and whistles to use when they need help, and it is a joke. R2 said that staff is so loud or playing music and don't hear when we are using out devices to get help. R2 said she has a horn, and her roommate has bells, but it doesn't matter which one you have they don't hear any of them. R2 said that this call system they have in place right now is a joke and they need to get the other system working so they can figure out who needs help and when they need help. R2's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R2 is cognitively intact.3. On 09/22/25 at 11:55AM, R3 stated that the call light system has been down since she was admitted to the facility. R3 said that staff gave them things like bells, whistles and horns to try and get staffs attention when they need something. R3 said that staff has a hard time trying to figure out who's whistle is going off. R3 said that staff will walk up and down the halls trying to figure out who is whistling, honking or ringing for help and they have several halls to go down to figure that out. R3's MDS dated [DATE] documents in Section C a BIMS score of 14 which indicates R3 is cognitively intact.4. On 09/22/25 at 9:31AM, R4 stated that she has bells she is supposed to jingle when she needs help. R4 stated that staff doesn't really hear the bells when she is ringing them, and she has her roommate will honk her horn just so she can get someone to come take her to the bathroom or when she needs a bed pan. R4's MDS dated [DATE] documents in Section C a BIMS score of 11 which indicates R4 has moderately impaired cognition.5. On 09/22/25 at 9:49AM, R6 stated that she has a whistle to blow on when she needs assistance. R6 stated she gets winded because she must keep blowing in the whistle until staff finally comes in and helps her. R6 stated is takes staff a while to come when she is blowing her whistle, because there are several residents that have whistles, and staff must try and figure out what hall and which residents whistle is being blown on. R6's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R6 is cognitively intact.6. On 09/23/25 at 8:57AM, R11 who was alert and oriented stated that when she needs assistance to go to the bathroom, she will just wheel over to the hallway and find a staff member. R11 stated that she didn't have a whistle, bells, or horn. R11 stated that she just must look for someone. R11 stated that she uses to hit the button on that white cord on the wall when she needed help, but it stopped working.On 09/23/25 at 8:58AM there were no whistles, bells, or horns observed in R11's room, that could be seen in plain sight. On 09/23/25 at 3:28PM observed V2 (Director of Nursing/DON) in R11's room looking for R11's alternative call light. V2 found R11's whistle in a bin on resident bedside table covered up under papers.On 09/23/25 at 3:32PM, R11 stated that she doesn't like to use the whistle it is too loud, she will just go and get someone in the hallway when she needs help.7. On 09/23/25 at 2:10PM observed R12 laying in bed. R12 had no bells, no whistle, and no horn next to her while she was laying in bed. Observed a bedside table next to the empty bed in R12's room that had bells laying on the table out of reach of the resident. On 09/22/25 at 2:34PM observed bells jingling from the nurses' station unable to locate if the jingling was coming from 400 hall or 500 hall. Observed staff going down the halls trying to figure out who was jingling the bells. During observation another resident was sitting by the nurses' station singing which was making it harder to hear the ring from the bells.On 09/22/25 at 2:36PM, V6 (Certified Nurse Assistant/CNA) stated that she usually works 300, 400, and 500 halls. V6 stated that she thinks the call light system for 300, 400, and 500 halls went out around the end of August. V6 stated that it is hard to figure out which hall the resident is whistling, honking or jingling the bells from. V6 said they go down every hall trying to figure out who needs help. V6 said the residents know to keep honking their horns, blowing their whistles, and jingling their bells until we figure out who it is. V6 said even from the nurses' station which is located between all the halls it is hard to figure out which direction the sound is coming from especially if they have staff and residents talking at the nurse's station. V6 said it is especially hard to hear the horns, whistles and bells when the residents are at the end of the hallway. On 09/22/25 at 2:37PM, V7 (CNA) stated that she usually works 300, 400, and 500 halls. V7 said that the call light system went down on those halls around the end of August. V7 said it is hard to head some of the bells, whistles, and horns especially if a resident is at the end of a hallway. V7 stated it is also hard to figure out who's whistles, horn, or bells are ringing. V7 said they must go down the halls and see what hall it is. V7 said it also makes it hard to hear those devices when a resident has their door closed. V7 said they did have a resident who kept trying to honk her horn and the horn wasn't working, and they did get the resident a new horn. On 09/23/25 at 9:00AM, V8 (CNA/Shift Coordinator) stated that the call light system on 300, 400, and 500 hallways quit working a couple of weeks ago. V8 said they gave the residents on those halls' whistles, bike horns, and bells to be able to notify the staff when they need something. V8 said that it is very hard trying to figure out which hall or where the resident is honking, ringing or whistling from. V8 said they will go down the halls and yell out to tell the resident to keep honking, whistling, or ringing until they figure out who it is. V8 said that is does take longer for them to respond to the resident whistle, bells, or horn because they must figure out who it is that is making the noise first. V8 said when they hear a sound from the nurses' station, they get up right away and start checking all of the halls and see who it might be. V8 said that they do have resident who will honk their horns for other resident in the same room such as R1 for R4. V8 said that R4 did have a horn, but she was trying to use it the wrong way and kept trying to honk the horn, but it wasn't' making any noise so she ended up with bells. V8 said it is harder to hear some of the resident who are on the end of the halls. On 09/23/25 at 10:05AM, V4 (Licensed Practical Nurse/LPN) stated that the facility call light system on 300, 400, and 500 hallways went out around the end of August. V4 stated they gave the resident whistles, bells, and horns to be able to ring and notify staff that they need them. V4 said she thinks that staff can hear the whistles, bells, and horns but it is challenging trying to figure out were the sound is coming from. V4 said she does think it takes the staff long to be able to answer when the resident is ringing, whistling or honking because they have to figure out who it is. On 09/23/25 at 11:40AM, V1 (Administrator) stated that the call light system on 300, 400, and 500 hallways went out on 08/29/25. V1 stated she called someone right away to see what was wrong with the call light system on those halls, but the soonest someone could come look at it was on 09/03/25. V1 said they did come in and look at the call light system and they told her that the system has just out lived its life and that they need to replace the system on those halls. V1 said that when the system went down on 08/29/25 that they did get an alternative call system of whistles, horns, and bells for the residents, so they had a way to communicate when they need help from staff. V1 said that they did try different things with the residents to make sure that they could use the device they gave each resident. V1 said she is not aware of any resident that can't use the device they have been given. V1 said staff has told her that they do have a hard time hearing the devices if the resident has their doors closed or if the resident is at the end of the hall. V1 said she did have a resident complain to her since the call light system was down it was taking a long time for staff to respond to her device. V1 said that on 09/05/25 they gave them an estimate on the new call light system for 300, 400, and 500 hallways. V1 said on 09/08/25 they ordered the new system and then on 09/16/25 they sent in payment for the new call light system. V1 said the company who is installing the new call light system said it could take 2-3 weeks before they could install the new call light system. On 09/23/25 at 12:33PM, V2 (Director of Nursing/DON) stated that they did have a problem with the call light system on 300, 400, and 500 halls it went out around the end of August. V2 said they gave the residents an alternative method to be able to call for help like whistles, horns, and bells. V2 said the shift coordinators also said something about doing 15-minute checks on those residents as well. V2 stated that she didn't know how they were tracking it the 15-minute checks. V2 stated that they don't have any documentation stating that the 15-minute checks were done on those residents. V2 said she has heard resident complain that staff has been in places where it was hard for them to hear the whistle, bells, and horns and that they tell the residents to keep whistling, honking, or jingling the bells until they figure out who it was the was making the sound with their device.The facility resident bed list report dated 09/22/25 documents 13 residents reside on 300 hall, 16 residents reside on 400 hall, and 3 residents reside on 500 hall. The facility policy titled Call Light with a revised date of 01/04 documents under objective: To respond to resident's request and needs. Equipment documents: Functioning call light.

Based on interview and record review the facility failed to initiate cardiopulmonary resuscitation (CPR) timely for 1 of 3 (R1) residents reviewed for death in the sample of 11. This failure resulted in facility staff not initiating CPR for 10-15 minutes after finding R1, who had chosen to be a full code with full treatment, in bed with no pulse and no respirations. CPR was not initiated until V11 (RN/Registered Nurse) was told by oncoming staff that R1 was a full code. After CPR was initiated, R1 was transferred via ambulance to the local hospital and pronounced dead.This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when facility staff failed to immediately initiate CPR after finding R1 with no pulse and no respirations. This failure resulted in R1 who was without pulse and respirations not receiving CPR for 10-20 minutes. After CPR was initiated R1 was transferred to the local hospital by emergency services and pronounced dead shortly after arrival at the hospital.V1 (Administrator) and V13 (Regional Nurse) were notified of the Immediate Jeopardy on [DATE] at 4:10 PM. This surveyor confirmed by interview and record review the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings Include:R1's undated Resident Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, acute respiratory disease, diabetes, chronic obstructive pulmonary disease, heart failure, pleural effusion, chronic kidney disease, and hypertension.R1's MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 was cognitively intact.R1's POLST (Practitioner Order for Life-Sustaining Treatment) form dated [DATE] documents under Orders for Patient in Cardiac Arrest a check mark next to Yes CPR: Attempt cardiopulmonary resuscitation (CPR). Utilize all indicated modalities per standard medical protocol. This same form documents under Orders for Patient Not in Cardiac Arrest a check mark next to, Full Treatment Primary goal is attempting to prevent cardiac arrest by using all indicated treatments. Utilize intubation, mechanical ventilation, cardioversion, and all other treatments as indicated. This indicates if R1 was found with no pulse and no respirations all treatments should be attempted to revive R1.R1's Physician Order Report dated [DATE] to [DATE] documents in bold print next to R1's name Full code.R1's current Care Plan documents the following header, Care Plan- (R1) (Full Code).R1's Vitals Report dated [DATE] documents the following vital signs 2:01 AM- blood pressure 137/75, oxygen saturation 96%, respirations 20 per minute, pulse 65 per minute; 2:47 AM - temperature 98.1 degrees Fahrenheit, pulse 74/per minute, respirations 20 per minute, blood pressure 112/54, oxygen saturation 98%.R1's Medication Administration History dated [DATE] documents R1's blood sugar was checked between 5 and 7 am with the result documented as 173.R1's Progress Notes document the following on [DATE]:2:48 AM, Continues on droplet precautions r/t (related to) Covid-19. Lungs diminished, no cough or SOB (shortness of breath) at this time. Vitals obtained Q (every) 4 hours. Will continue to monitor. Signed by V11 (Registered Nurse/RN)6:34 AM, CNA (Certified Nursing Assistant) came to signee stating resident not breathing and pulseless. CPR (cardiopulmonary resuscitation) initiated and 911 notified. Signed by V11 (RN)6:35 AM, signee entered facility and was informed of resident's passing. Signee then alerted staff that resident was a full code, and that CPR was needed STAT. crash cart taken to resident's room. 911 called per floor nurse. Signed by V3 (Licensed Practical Nurse/LPN).6:40 AM, (initials of ambulance service) here at this time x (times) 2 personnel. Attempted to reach both spouse, and daughter (name of daughter) with no answer.6:50 AM, attempted to reach (V7/Physician) at this time with no answer. EMS (emergency medical services) leaving with compressions given.7:10 AM, MD (physician) notified of resident condition.7:30 AM, POA (power of attorney) notified of resident condition.7:34 AM, Hospital called to notify resident expired. Time of death 0712 (7:12 AM).R1's local ambulance report documents on [DATE] at 6:36 AM the call was received, and the ambulance was dispatched to the facility and arrived at 6:41 AM. Under Patient Complaints the report documents Chief Complaint as Cardiac Arrest (Primary). Under Assessments and Comments the report documents R1 has no airway and no pulses. Under Narrative the report documents, Vehicle 44 dispatched Lights and Sirens to respond immediately to (initials of facility) for a male pt (patient) in arrest. Arrived on scene to find one staff member in pt's room performing CPR. Staff stated the pt was moving from his wheelchair to the bed and soon after went unresponsive.continued CPR for staff as EMS (Emergency Medical Services) placed pt on monitor showing asystole. Pt placed on EMS stretcher via 4-man sheet lift with strap x (times) 5.transfer initiated to (initials of local hospital) with radio report completed en route. EMS notes no changes in cardiac rhythm with meds (medications) or CPR. On arrival at (initials of local hospital) ER (emergency room), pt transported inside and placed in bed via 2-man sheet lift.R1's local hospital report dated [DATE] documents under ED (Emergency Department) Triage Notes, Patient from (name of facility) .Full arrest. CPR in progress by EMS. Code called, ACLS (advanced cardiac life support) initiated.7:12 AM. Time of death pronounced. The patient is a [AGE] year-old male who present to the ED in cardiac arrest. The patient was in the NH (nursing home) attempting to transfer from the wheelchair into his bed when he went unresponsive. The patient failed to awaken or respond to the staff, so EMS was called. The patient was found to be in asystole. An IO (intraosseous device) was established, and CPR was in progress. A laryngeal airway was placed, and two rounds of epi were given without return of circulation. The patient remained in asystole the whole 20 minutes he was in the care of EMS.On [DATE] at 2:16 PM, V9 (CNA) stated she worked night shift beginning on [DATE] and ending on the morning of [DATE]. V9 stated R1 put his call light on around 3:30 or 3:45 AM. V9 stated R1 had to go to the bathroom so she assisted him to the bathroom and onto the commode. V9 stated R1 put the light on when he was done, and she assisted him back to his room. V9 stated R1 wanted to stay up in his wheelchair so she asked him if he needed anything else and he said he didn't. V9 stated when she left his room he was sitting in his wheelchair with his walker beside him. V9 stated R1 was able to transfer from his wheelchair to his bed independently. V9 stated around 6 or 6:30 AM, she heard other staff yelling and asking if R1 was dead. V9 stated she went to R1's room and he was in bed and appeared dead. V9 stated during this time frame V11 (RN) stated twice R1 was a full code. V9 stated there were a lot of people with R1 so she finished taking care of other residents and was not involved in the care of R1.On [DATE] at 1:08 PM, V6 (CNA) stated she entered R1's room around 6:10 or 6:15 AM on the morning of [DATE]. V6 stated R1 usually got himself ready so she just went in to make sure he was awake and ask him if he needed anything before breakfast. V6 stated R1 appeared to be sleeping but his color was off, so she went closer to check on him. V6 stated R1 wasn't breathing so she called V4 (CNA) and V8 (CNA) to check him. V6 stated then she told the nurse (V11) they needed assistance. V4 stated V11 sat at the nurse's station and told them R1 was just fine. V6 stated V11 slowly came to R1's room and told them to get the nurse from the other hall. V6 stated as V11 entered the room she grabbed a stethoscope and checked R1's heart rate. V6 stated by the time V11 was done checking R1, V5 (RN) entered the room and checked for a heart rate and respirations. V6 stated they left the room after they verified R1 was not breathing and didn't have a pulse. V6 stated V3 (LPN) came in to work 10 or 15 minutes after she had first found R1 and asked if R1 was a full code or a DNR (Do Not Resuscitate) and she believed V11 answered and said R1 was a full code. V6 stated V3 said we have to do CPR. V4 stated V5 (RN) called for two people to go with her, and they went to R1's room to do CPR. V6 stated she continued getting other residents up since they had enough staff assisting with CPR. When asked if she had any concerns with the situation, V6 stated she thought V11 should have been on top of it and not so casual. V4 stated she thought it was more serious than V11 was acting. On [DATE] at 12:44 PM, V4 (CNA) stated she came to work at 5:30 AM on the morning of [DATE]. V4 stated they started getting residents up for breakfast on R1's hall about 6:00 AM. V4 stated they got up two residents and V6 (CNA) went to R1's room to wake him up. V4 stated V6 came to her and said she didn't think R1 was breathing. V4 stated she immediately went to R1's room and confirmed he wasn't breathing. V4 stated about 6:10 AM she yelled down the hall to V11, Hey, come here he isn't breathing. V4 stated V11 was moving very slowly so she yelled again, Hey, he isn't breathing. What do we do.? V4 stated V11 yelled back R1 was fine an hour ago when she checked his blood sugar. V4 stated V11 finally got to the room and got the stethoscope. V4 stated V5 (RN) arrived from the other side at that time and checked R1. V4 stated she thought they were going to call time of death since they hadn't started a code. V4 stated she was waiting on the nurse to tell her what to do. V4 stated V11 said he (R1) is gone. V4 stated V11 didn't say anything about R1's code status. V4 stated she started gathering supplies to clean R1 up for the funeral home to transport him. V4 stated she said, So we were getting ready to clean him up and prepare him for the funeral home until V3 walked in and asked the obvious question. V4 stated then V5 grabbed the crash cart, and V10 (LPN) started compressions, while V11 (RN) was doing the rescue breaths with the ambu bag. V4 stated she was standing on the side assisting as needed. V4 stated the plastic was still over the bag V11 was using so no air was getting to R1. V4 stated she told V11 the plastic was still over the bag and V11 laughed and removed the plastic. V4 stated V10 told V11 it wasn't funny. V4 stated the ambulance arrived quickly and the emergency personnel took over with the code. V4 stated she thought the failures were all V11. V4 stated V11 didn't know what she was doing, and she wasn't sure V4 checked R1 an hour before he coded. V4 stated the situation, woke me up and from now on she will look at the residents code status herself. V4 stated We literally had the linens in our hand ready to clean him up for the funeral home.On [DATE] at 2:11 PM, V8 (CNA) stated on [DATE] she came to work at 5:30 AM. V8 stated she was scheduled for a different hall but was on R1's unit asking a question when V6 (CNA) went into his room to wake him up. V8 stated V6 got her and V4 (CNA) to check R1 because she didn't think he was breathing. V8 stated they were running down the hall and saw V11 and told her they didn't think R1 was breathing. V8 stated V11 just stood there and stated R1 was fine she had just checked his blood sugar. V8 stated she did a sternum rub on R1 and he didn't respond. V8 stated she left because V11 (RN), V5 (RN), and V4 (CNA) were all in R1's room so she began taking care of the other residents. V8 stated she felt like it wasn't urgent for V11 (RN). V8 stated she thought V11 should have responded better, and she felt like they didn't have the help from V11 they needed.On [DATE] at 1:01 PM, V5 (RN) stated she was working on the other side of the facility when V12 (CNA) came to her and told her they needed her on the other side. V5 stated V12 didn't tell her why they needed her. V5 stated she walked to the other side and V11 was sitting behind the desk and told her a resident was dead and she thought he had expired a while ago. V5 stated V11 wanted her to look for signs of life. V5 stated she went to R1's room and donned PPE (personal protective equipment). V5 stated V11 was with her, and they listened for heart and lung sounds and there were none. V5 stated she started back to her side and V3 (LPN) walked up and told her R1 was a full code. V5 stated she got the crash cart and started CPR. V5 stated R1 was pale bluish, with no signs of respirations or a heartbeat. When asked if she had any concerns, V5 stated, Yes, I wish I would have started CPR earlier. When asked how long it was from the time R1 was found until they started CPR, V5 stated she wasn't sure.On [DATE] at 10:32 AM, V12 (CNA Shift Coordinator) stated she was working the day R1 passed away. V12 stated she got V5 (RN) for V11 (RN) and looked up R1's code status. V12 stated she was charting at the nurse's station when she heard V6 asking R1 if he was ready to get up. V12 stated she then heard them say they needed a nurse. V12 stated V11 asked them what they needed, and they said R1 wasn't breathing. V12 stated V11 got up and went to R1's room and told her to get the nurse from the other side of the facility. V12 stated she told V11, R1 was a full code and tried calling the nurse. V12 stated the nurse didn't answer so she ran to the other side and got V5 (RN). When asked if V11 was aware of R1's code status before entering his room the first time, V12 stated she was. V12 stated when she and V5 got to R1's hall they asked V11 if she started CPR and she stated she hadn't, he is cold. V12 stated V3 came in and said you must do CPR no matter what since he was a full code. V12 stated she took the crash cart to R1's room and left because they had plenty of staff in the room. When asked if she had any concerns with how the situation was handled. V12 stated her only concern was V11. V12 stated V11 wasn't a very good nurse. V12 stated V11 shouldn't have asked the CNA's why they needed her when they first asked for assistance, and she should have started CPR or instructed the CNA's to start CPR.On [DATE] at 12:32 PM, V3 (LPN) stated on [DATE] she clocked in for work about 6:30 AM. V3 stated she met V8 (CNA) in the hallway who seemed upset and told her they had lost R1. V3 asked V8 what she meant by lost and V8 told her R1 had passed away. V3 stated she asked if they were coding R1 and V8 stated they weren't. V3 stated she told V8, R1 was a full code, put her stuff down, grabbed the crash cart and went to R1's hall. V2 stated V5 (RN) and V11 (RN) were at the nurses station, and she asked V11 why they weren't doing CPR. V3 stated she put PPE on because R1 had tested positive for Covid previously and went to R1's room to assist with the code. V3 stated V11 called 911 and then relieved V3. V3 stated she didn't know why they hadn't started CPR immediately. V3 stated V11 made the comment R1 was cold. V3 stated she told V11 it didn't matter what color they are or what their temperature is if they are a full code they do CPR on them. V3 stated R1 had been diagnosed with Covid 19, had a cough and they had gotten a chest x-ray, but he was ok the last time she saw him. V3 stated she thought V11 should have immediately initiated CPR and called for assistance. On [DATE] at 2:25 PM, V10 (LPN) stated she arrived to work on the morning of [DATE], clocked in, and walked around the facility. V10 stated she saw chaos. V10 stated by the time she got to the area, she was told by staff R1 was unresponsive and they were getting ready to start CPR. V10 stated she went to help and started CPR. When asked what time it was V10 stated she clocked in about 6:30 AM. V10 stated she didn't have any concerns with the care R1 received after she arrived.On [DATE] at 2:21 PM, this surveyor attempted to contact V11 via telephone. There was no answer and no voicemail set up. On [DATE] at 11:10 AM, V2 (Director of Nurses/DON) stated on [DATE] she arrived at the facility around 8:00 AM. V2 stated she was told R1 had passed away and there were some questions about CPR being initiated immediately. V2 stated after she talked to staff and got the timelines in place, they determined there was a 10-20-minute time frame R1 went without having CPR initiated. V2 stated V3 came in around 6:30 AM on [DATE] and heard R1 had passed away, and they weren't doing CPR. V2 stated V3 started the process of coding R1 and called 911. When asked if during the investigation she was able to determine what happened and why they didn't initiate CPR immediately upon finding R1 with no respirations and no heartbeat, V2 stated it was a little hard with some time frames being off. V2 stated V11 (RN) placed the blame on everyone else. V2 stated she spoke with V11 (RN) on the phone and V11 admitted she didn't start CPR immediately and then hung up on V2. V2 stated she believed the issue was isolated to V11. V2 stated she knows a full code was called out by one of the CNA's and V11 didn't prompt any movement to begin CPR. V2 stated V11 said R1 was cold and gone and they weren't going to bring him back. V2 stated the CNA's were following V11's lead and had even gotten the supplies to clean R1 up for transfer to the funeral home. When asked what she did next, V2 stated they immediately started educating staff and it was completed with everyone working that day and all other staff when they returned to work or via telephone. V2 stated they educated on CPR, how to find code status, and what to do if a resident expires and is a full code. V2 stated they are doing continued education and auditing the training every week to ensure staff retain the training. V2 stated part of the training was also educating the CNA staff they could initiate a code without nurse guidance. V2 stated R1's code status was accurate and available for the staff to find. V2 denied any system failure related to this incident.On [DATE] at 3:47 PM, V1 (Administrator) stated right before she arrived at the facility on the morning of [DATE] she got a call from V3 (LPN). V1 stated V3 told her emergency medical services had been called for R1 and explained what happened to V1. V1 stated once she arrived at the facility she began talking to staff. V1 stated her investigation found V11 checked R1's blood sugar around 5:55 AM and R1 wanted to stay up in his wheelchair. V1 stated she spoke with CNA's, and they told her they went into R1's room around 6:10 or 6:15 AM and R1 appeared to be unresponsive. V1 stated they notified V11, and once code status was confirmed they got the crash cart and V3 and V10 started CPR. After reviewing the staff interviews with V1 this surveyor asked her what the outcome of her investigation was, V1 stated it should not have taken 15 minutes to initiate CPR. V1 stated she reached out to V11, and she wasn't very forthcoming. V1 stated V11 was supposed to come to the facility and talk and she didn't show up and couldn't be reached by phone. V1 stated V11 effectively terminated herself by not showing up.On [DATE] at 2:00 PM, V7 (Physician) stated he saw R1 the day before he passed away. When asked if he considered R1 to be end of life, V7 stated on [DATE] R1 seemed to be stable but had a lot of comorbidities including cardiac problems and Covid. When asked if the facility staff would have initiated CPR earlier if it would have changed the outcome, V7 stated, I doubt it. He (R1) had significant comorbid condition. You can never know for sure. When asked what his expectations as the physician would be if they found a resident with no pulse and no respirations who was a full code, V7 stated, Do CPR and send them to the hospital as soon as possible.The facility Policy 3.06 on Emergencies documents, It is the policy of the facility to provide emergency care to a resident in need of it. Emergency Care Procedure: 1. Nurse in charge of resident will evaluate resident's condition. If help is needed and there is more than one nurse available, the nurse assigned to resident will stay with resident and send another staff member to get another nurse. The staff member will also bring emergency equipment if needed. A nurse will notify resident's physician and follow orders received. Call ambulance, notify family, and complete transfer form. Call emergency room and let them know resident is on the way.Documentation of treatment and resident's response during emergency must be done in clinical record.I. Cardiac Arrest: When the facility has only one (1) employee on duty, that employee shall have been certified within the past twelve (12) months in the provision of basic life support by an American Heart Association or American Red Cross certified training program. When there is more than one (1) person on duty in the facility, at least one (1) person on duty shall be so certified. Any facility employee who is on duty may be utilized to assist in these medical emergencies. Signs and Symptoms: 1. Immediate loss of consciousness. 2. Absence of palpable carotidal or femoral pulse. 3. Absence of audible heart sounds. 4. Absence of breath sounds or air movement throughout the nose or mouth. 5. Convulsions (may or may not be present). 6. Dilation of pupils of eyes. 7. Ashen gray color. Treatment: 8. Note the time as soon as the cardiac arrest is determined. Summon help immediately. 9. Provide CPR if determine appropriate according to the POLST/DNR form. CPR should be performed in accordance with the guidelines set by American Heart Association or the American Red Cross. 10. Utilize AED (Automated External Defibrillator) according to instructions on machine for use.The Immediate Jeopardy that began on [DATE] was removed [DATE]. The deficient practice was corrected on [DATE] after the facility took the following action to correct the noncompliance: Facility administrator (V1) and DON (V2) were in-serviced by the regional nurse (V13) on [DATE] on the emergencies policy 3.06, specifically regarding cardiac arrest and CPR.DON (V2) initiated and completed in-servicing with all nursing staff on [DATE], on the emergencies policy 3.06 specifically regarding cardiac arrest and CPR.DON (V2) initiated and completed in-servicing with all nursing staff on [DATE] on location of code status/POLST for residents.V11 (RN) did not return to work after [DATE].Plan was added to the facility QA (Quality Assurance) program regarding CPR and code status on [DATE].The facility DON or designee will audit 10 employees per week for a month to ensure that location of code status/POLST is known and understanding of the emergencies policy.This will remain as part of the facility QA process for continued monitoring.Completion Date: [DATE].

Based on interview and record review the facility failed to ensure required in-service training for CNA's (Certified Nursing Assistants) was completed. This has the potential to affect all 66 residents currently residing at the facility. Findings Include:The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document specific the required annual in-service training for CNA's was completed. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation the required CNA training had been completed. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education opportunities and promote job satisfaction

Based on interview and record review the facility was unable to provide reproducible evidence staff were trained on compliance and ethics. This failure has the potential to affect all 66 residents residing at the facility. Findings Include:The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document specific compliance and ethics training for all staff. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation compliance and ethics training had been completed for all staff. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education opportunities and promote job satisfaction

Based on interview and record review the facility failed to ensure staff were trained on behavioral health services. This failure has the potential to affect all 66 residents currently residing at the facility. Findings Include:The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document behavioral health services training for all staff. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate staff were trained on behavioral health services. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education opportunities and promote job satisfaction

Based on interview and record review the facility failed to ensure all staff were trained on resident rights. This has the potential to affect all 66 residents residing at the facility. Findings Include:The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document staff were trained on resident rights. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation staff had been trained on resident rights. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education opportunities and promote job satisfaction

Based on interview and record review the facility failed to ensure staff were trained on effective communications. This has the potential to affect all 66 residents currently residing at the facility. Findings Include: The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document effective communication training for staff. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation effective communication training had been completed for all staff. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education opportunities and promote job satisfaction

Based on interview and record review the facility was unable to provide reproducible evidence annual training was completed for all staff. This failure has the potential to affect all 66 residents currently residing at the facility. Findings Include: The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document specific annual training for all staff. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation annual training had been completed for all staff.The facility Policy 1.10 on Inservice Training revised on 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education opportunities and promote job satisfaction

Based on interview, observation, and record review, the facility failed to consistently identify hazards/risks related to falls and ensure individualized, resident centered interventions were developed and implemented for prevention of falls for 4 of 7 residents (R13, R17, R28, R263) reviewed for accidents in a sample of 40. This failure resulted in R17 receiving a laceration to the back of the head, requiring emergency room treatment which included 3 staples to the back of R17's head. Findings include: 1. R17's Resident Face Sheet documented an admission date of 04/23/20 and included diagnoses of Alzheimer's disease, unspecified and difficulty in walking, not elsewhere classified. R17's MDS dated [DATE], documented a BIMS should not be completed, indicating R17 is rarely or never understood. Section GG-Functional Abilities documented that R17 requires partial/moderate assist with transferring. R17's Care Plan documented R17 is at risk for falls with interventions including emergency room evaluation on 03/01/25 and an antibiotic for 7 days related to a urinary tract infection with an initiation date of 03/02/2025. R17's Progress Note documented on 03/01/2025 at 9:02pm RN (Registered Nurse) heard screaming coming from unit. Upon entry into unit, CNA (Certified Nursing Assistant) in hallway stating, resident fell. Upon entry into resident room, resident laying supine on floor with head towards bathroom sink. CNA witnessed fall with resident, no loss of consciousness noted. Blood noted behind head. RN and CNA assisted resident into a sitting position, pressure applied to head. Laceration to back of head noted. 911 called and pressured applied until arrival. R17's Progress Note documented on 03/02/2025 at 02:14am RN took call from (name of RN) at (local hospital) with update on resident. CT (Computed Tomography) of abdomen/pelvis, brain and spine normal with no fractures noted. 3 staples to laceration to back of the head. Resident diagnosed with UTI (urinary tract infection), Ceftin 1 tab po daily X 7 days. Resident to return to facility. R17's Progress Note documented on 03/02/2025 at 5:59am, Resident was heard yelling help by RN. RN opened door into resident's room, resident laying supine on floor. Resident denies any pain. No injuries noted. Staples remained intact; no bleeding noted. Resident wearing non-skid socks. Resident positioned back in bed with RN and CNA. Resident refusing vitals and attempting to hit staff. Staff stepped away from resident. Resident's bed in lowest position. Resident laying in bed with eyes closed and respirations even and non-labored. R17's Progress Note documented on 03/02/2025 at 9:00pm CNA notified RN that resident was found sitting on floor between bathroom and resident room. Upon entry into room, resident in sitting position, pants were laying by bed. Resident denies no pain. No injuries noted. CNA and RN assisted resident back to bed. Resident bed in lowest position. Door to resident room open. R17's Progress Note documented on 03/03/2025 at 10:13am Root cause analysis: resident fell on ground when putting clothes on. Observed by the CNA who was in the room when incident happened. IDT met and intervention in place to provide safe resident handling education. R17's Progress Note documented on 03/03/2025 at 10:15am Root cause analysis: resident found laying supine on ground. Resident is unable to express what she was trying to do. Assisted back to bed and resident became combative with staff. Resident reapproached later. R17's Progress Note documented on 03/03/2025 at 10:17am Physical Therapy to eval resident. R17's Event Report for falls on 03/02/25 at 6:02am documented that R17 was observed by the nurse sleeping 10 minutes prior to the fall and was found lying supine (on her back) on the floor. Facility fall log with a run date of 06/25/25 documented for the month of March, R17 had a fall on 03/01/25 at 9:14pm and 03/02/25 at 5:10am. On 06/24/25 at 9:36am, V1 (Administrator) confirmed there was only one fall investigation for R17 on 03/02/25. On 06/26/25 at 2:03pm, V2 (Director of Nursing/DON) stated that if a resident were found sitting or lying in the floor it should be treated as a fall and investigated, unless it is a behavior they were care planned for. V2 stated if a resident was found laying supine on the floor and had fallen from their bed after having been previously witnessed sleeping, she would expect there to be more interventions than just an evaluation by physical therapy. V2 stated an evaluation by physical therapy is not going to hurt them, but it isn't going to do anything to address the cause of the fall or prevention. 2. R13's Resident Face Sheet documented an admission date of 03/12/25 and included diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, difficulty in walking, not elsewhere classified and unsteadiness on feet. R13's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 2, indicating R13 is severely cognitively impaired. Section GG-Functional Abilities documents that R13 requires substantial/maximum assist with transfers. R13's Care Plan documented R13 was at risk for falling with interventions including a touch pad call light with an initiation date of 03/18/25 and encourage resident to take wheelchair to bathroom with an initiation date of 03/24/25. R13's Event Report dated 03/18/25 documented the resident slid while transferring self to the bathroom. R13's Progress Note documents on 03/18/2025 at 10:10am, Resident's roommate came up to nurses station and stated resident (R13) was in the bathroom on floor. Signee observed resident sitting on floor with her feet towards the toilet and her back to wall. Resident stated she was taking herself to the bathroom, slid and fell onto her knees. Resident had no shoes on. Wheelchair was locked and next to toilet. Bathroom clear of clutter. ROM (range of motion) WNL's (within normal limits) performed per resident. No injuries observed at this time. No complaints of pain nor discomfort voiced at this time. R13's Progress Note documents on 03/18/2025 at 10:36am Soft touch call light switched out for resident for easier usage to call staff. On 06/26/25 at 2:03pm, V2 (Director of Nursing) stated if a resident fell in their bathroom attempting to toilet herself and she was barefoot and slid down, a soft call light would not be an appropriate intervention for the fall, it does not address the root cause of the fall. 3. R28's Resident Face Sheet documented an admission date of 08/02/22 and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, muscle weakness (generalized) and unsteadiness on feet. R28's MDS dated [DATE], documented a BIMS score of 10, indicating R28 has moderate cognitive impairment. Section GG-Functional Abilities documented that R28 requires partial/moderate assist with transferring. R28's Care Plan documented R28 was at risk for falls with corresponding interventions of; therapy screen with an initiation date of 02/27/25, touch pad call light with an initiation date of 03/03/25 and encourage leg bag as tolerated, with an initiation date of 03/26/25. R28's medical record contains Event reports for falls on 02/27/25, 03/01/25 and 03/26/25. R28's Progress Note documented on 02/27/2025 at 8:45am, Resident found laying in floor by CNA. Upon assessment, resident was laying on his left side with foley catheter tubing wrapped around ankle and bowel on his leg and brief. Resident said he was trying to get up and tripped on catheter tubing. c/o (complaint of) left shoulder and left knee pain. stated he hit his head. moving all extremities evenly and without difficulty. no bumps or redness to head. No obvious injuries. neuros initiated r/t (related to) unwitnessed fall . R28's Progress Note documented on 03/01/2025 at 9:44pm, Resident had unwitnessed fall in room. Observed wedged between recliner and bed facing TV with head against wall. Resident assessed and reported pain to left arm, left leg and back . (Name of physician) notified and order received to send resident to ER (Emergency Room) for evaluation. POA (Power of Attorney) called. Left message to call facility. DON (Director of Nursing) and Administrator notified. R28's Progress Note documented on 03/03/2025 at 10:10am, Root cause analysis: resident observed on floor when attempting to take himself to the bathroom. IDT met and interventions in place to provide touchpad call light and therapy to see resident. On 06/26/25 at 12:47pm, R28's room was observed. R28 had a regular call light, no soft touch call light was observed in place in his room. On 06/26/25 at 2:03pm, V2 (DON) stated if a resident had fallen due to being tangled in their catheter tubing and incontinence was present, an evaluation by physical therapy would not be an appropriate intervention. 4. R263's Resident Face Sheet documented an admission date of 06/21/24 and a discharge date of 05/10/25 with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, muscle weakness (generalized), difficulty in walking and multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing-right side. R263's MDS dated [DATE], documented a BIMS score of 11, indicating R263 is moderately cognitively impaired. Section GG-Functional Abilities documented R263 required supervision or touch assistance for transfers. R263's Care Plan documented R263 was at risk for falling with interventions including, therapy to evaluate with a start date of 05/05/25. R263's medical record contains an Event Report for falls on 03/01/25 and 05/04/25. R263's Progress note documented on 03/04/25 at 11:33am, As POA/dtr (name of daughter) was leaving 200 hall, she notified signee that she just saw res (resident) face plant onto her bed, stating that res had left her walker by the sink et (and) attempted to walk from there to her bed. Also stated she has noticed res leave her walker in D/R (dining room) et walk to table. Concerned since res had fall in room recently . R263's medical record does not contain any evaluation or further documentation regarding the 3/4/25 incident. Facility fall log with a run date of 06/25/25 documents for the month of March, R263 had a fall on 03/01/25 at 12:30pm. On 06/25/25 at 12:48pm, V21 (Certified Nursing Assistant/CNA) stated if she witnessed a resident sitting or lying on the floor, or if a family member reported seeing a resident faceplant their bed from a standing position, she would report it as a fall or change of plane to a nurse. On 06/26/25 at 12:43pm, V22 (Licensed Practical Nurse/LPN) stated if a visitor reported to her that they witnessed their family member faceplant their bed from a standing position, she would consider it a fall. She stated if it was reported to her or she witnessed a resident sitting or lying in the floor, she would consider it a fall and treat it as such. She stated she would assess the resident. On 06/26/25 at 1:36pm, V23 (LPN) stated if it had been reported to her by a visitor that they witnessed a resident face plant their bed from a standing position they would consider it a fall and assess the resident and open an investigation. On 06/26/25 at 2:03pm, V2 (DON) stated she would consider a resident face planting their bed as a change in plane. Facility document titled Observation Detail List Report found in R263's medical record dated 03/11/25 documented A fall is defined as an unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair or bedside mat). Facility Policy titled, Emergencies with a revision date of 04/03/18 documents under the section titled Falls: 1. Check the resident immediately for ability to move extremities; check for bruised areas and/or cuts. 2. Check resident's ability to explain what happened; evaluate resident's condition before the fall. 3.Check if, or with anyone who witnessed the accident. Determine, if possible, where, how, and when the accident occurred.

Based on interview, observation, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (R7 and R213) of 7 residents reviewed for nutrition in a sample of 40. This failure resulted in further contributing to continued harm for R7, who is documented to be severely underweight with a Body Mass Index of 16.66%. Findings include: R7's Resident Face Sheet documents an admission date of 01/30/2018 with diagnoses that included dementia, atherosclerotic heart disease, osteoarthritis, dysphagia, major depressive disorder, cachexia, pain in right arm, ventral hernia without obstruction or gangrene, abnormal weight loss, anxiety disorder, heartburn, vitamin deficiency, gastro-esophageal reflux disease without esophagitis, and vitamin B12 deficiency anemia. R7's Minimum Data Set (MDS) dated [DATE] documented no Brief Interview for Mental Status was performed due to resident is rarely/never understood. R7's eating ability is documented as setup or clean-up assistance needed. R7's Care Plan document a problem area of nutritional status dated: 09/17/2020 of R7 may be at risk for nutritional deficit related to decreased appetite related to dementia and an eating disorder with approaches dated 06/03/2025 of plastic plate with meals, 06/08/2024 provide supplement: regular diet with house supplements, 05/12/2022 shakes TID as tolerated, and 09/17/2020 staff assist with eating and drinking as tolerated. R7's vitals record documents a weight for R7 dated 06/04/2025 at 3:29 PM documents weights of 77 lbs (pounds), R7's weight dated 05/07/25 at 3:26 PM is documented as: 79 lbs, R7's weight dated 04/08/25 at 12:05 PM is documented as 81 lbs. R7's dietitian assessment dated [DATE] at 10:56 AM documents: R7 is on a Regular diet with house supplement at meals. Serve double meat or eggs at breakfas and dry cereal (sweet) at breakfast. R7's intakes are 25-75% and less at times. R7 has a Boost supplement 8 oz. TID (three times a day) between meals. R7's family does not want tube feeding. R7's weights: (6/4): 77 lbs, (5/7): 79 lbs, (3/6): 82 lbs, and (12/9): 84 lbs. R7's current weight trend is noted and she is below IBW (ideal body weight) range 89-115 lbs. R7's body mass index is 16.66% (Underweight). R7's dietitian quarterly assessment dated [DATE] at 11:39 AM documents: R7 is on a regular diet with house supplement at meals. Serve double meat or eggs at breakfast , and dry cereal (sweet) at breakfast. R7's intakes are 25-75% and less at times. R7 has a Boost supplement 8 oz. TID between meals. Family does not want tube feeding. R7's weights: (4/8): 81 lbs, (3/6): 82 lbs, (1/8): 86 lbs, and (10/15): 88 lbs. R7's current weight is down 7 lbs (8.0%) x/6 months. R7 is below IBW range 89-115 lbs. R7's body mass index is 17.53% (Underweight). R7's dietitian assessment dated [DATE] at 11:32 AM documents R7 is on a regular diet with house supplement at meals. Serve double meat or eggs at breakfast , and dry cereal (sweet) at breakfast. R7's intakes are 25-75% and less at times. R7 has a Boost supplement 8 oz. TID between meals. Family does not want tube feeding. R7's weights: (2/15): 81 lbs, (1/8): 86 lbs, (11/7): 86 lbs, and (8/6): 85 lbs. R7's current weight is down 5lbs (5.8%) x/1 month. R7 is below IBW Range 89-115 lbs. R7's body mass index is 17.53 (Underweight). R7's Physician Order Report dated 05/25/25-06/25/25 documented an order for house supplement with a start date of 06/08/24 an end date listed as open ended. R7's Dietary Card did not list a house supplement on the card. R7's dietary card documented: likes: ice cream. On 06/23/25 at 11:52 AM, R7's lunch tray was observed with no house supplement included on her tray. R7 sat with her lunch in front of her with no food eaten off of the plate and making no effort to eat. At 11:59 AM, R7 picked up her plate and was tilting it and almost dumped her food in her lap. At 12:00 PM, a staff member grabbed R7's plate, set it on the table and assisted R7 with one bite and walked away. At 12:07 PM, R7 still had not eaten any food or made any attempts to eat. At 12:08 PM, a staff member asked R7 if she wanted to try her dessert as she walked by, but R7 did not take any bites. At 12:10 PM, a staff member brought R7 some chocolate milk that she drank, but did not encourage her to eat any food. At 12:17 PM, R7 was yelling out and had still not eaten any of her food. At 12:22 PM, a staff member began encouraging R7 to eat and she ate approximately 0.25 percent of her food. On 06/24/25 at 11:56 AM, R7 received her lunch tray with ice cream but no health shake. At 11:59 AM, R7 did not make any effort to eat her food, but did pick up her ice cream and was licking it out of the cup. On 06/25/25 at 2:16 PM, V1 (Administrator) stated, if staff see a resident is not eating they should encourage or assist the resident within approximately five minutes or so. V1 stated, if the resident has an order for a supplement, they should receive the supplement. On 06/25/25 at 2:18 PM V2 (Director of Nursing/DON) stated, if staff see a resident is not eating they should encourage or assist the resident within approximately five minutes or so. V2 stated she would not consider R7 to be set up or clean up assistance only, R7 needs encouragement or assistance to total assistance at times. On 06/26/25 at 1:13 PM, V17 (Dietary Manager) stated, she does not know why R7 does not have her supplement listed on the dietary card. V7 said there must have been a breakdown in communication getting dietary the order, because as soon as she gets the orders she puts them in the program and the supplements are printed on the resident's dietary card. On 06/26/25 at 12:46 PM V24 (Registered Dietitian/RD) stated, R7 is underweight and she should have had the supplements that were ordered for her, she would expect her to receive them. The undated facility policy documents: 9. the weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to the RD as needed, 10. the dietician will review significant weight losses and any other residents referred by the weight committee, on a monthly basis, and make recommendations to physicians as necessary. 2. R213's Resident Face Sheet documents an admission date of 06/12/25 and included diagnoses of noninfective gastroenteritis and colitis, type 2 diabetes mellitus with diabetic chronic kidney disease, pain, muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, macular degeneration, severe protein calorie malnutrition, malaise, fatigue, vitamin deficiency, and cachexia. R213's Care Plan documented a problem area dated 06/18/25 of R213 has a BMI (body mass index) of 14.45, at risk for weight loss with interventions documented of regular diet with house supplement, Megase continues as ordered, notify physician and dietician as needed, and obtain weights dated 06/18/25. R213's problem area dated 06/12/25 of resident care information documents: snacks between meals as requested, regular diet with house supplement at meals dated 06/12/25. R213's Dietary Note dated 06/18/25 at 11:07 AM, documents: dietitian/admit (admission) assessment: [AGE] year old female admitted (6/12) on regular diet, intakes 25-75%, she has a diagnosis of malnutrition and on Megace to stimulate appetite. R213's diabetic preferences: offer reduced sugar condiments, beverages, and half portions of desserts. R213's weight (06/13) 84.2 (pounds) with a ideal body weight index of 14.45 (underweight). R213 has no edema, she is on an antibiotic for a urinary tract infection. R213's plan is to boost intakes 1) add house supplement at meals. R213's Physician Order Report documented an order for house supplement during meal time dated 06/19/25 with an end date of open ended listed. On 06/23/25 at 11:52 AM, R213's already had her lunch sitting in front of her with one or two bites taken from the mashed potatoes. R213 did not receive a house supplement. R213 did not answer any questions when asked. R213 was sitting in front of her food with her head slumped down making no effort to eat. At 12:02 PM, R213 still had not eaten any food and still had not received any encouragement or assistance. At 12:12 PM, R213 still had not made any effort to eat any of her food when V9 (Certified Nurse Assistant/CNA) sat down and began to assist R213 with her lunch. R213 ended up eating approximately 25% of her food. On 06/24/25 at 11:58 AM, R213 did not receive a house supplement with her meal. On 06/25/25 at 12:05 PM, R213 did not receive a house supplement with her meal. On 06/25/25 at 2:16 PM, V1 (Administrator) stated, if staff see a resident is not eating they should encourage or assist the resident within approximately five minutes or so and any resident that has an order for a supplement should receive it. On 06/25/25 at 2:18 PM, V2 (Director of Nursing/DON) stated, if staff see a resident is not eating they should encourage or assist the resident within approximately five minutes or so. The undated facility policy documents: 9. the weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to the RD as needed, 10. the dietician will review significant weight losses and any other residents referred by the weight committee, on a monthly basis, and make recommendations to physicians as necessary.

Based on interview, observation, and record review, the facility failed to ensure that pain management was provided for one (R53) of one resident reviewed for pain management in a sample of 40. This failure resulted in R53 experiencing prolonged severe pain without relief for several hours. Findings include: R53's Resident Face Sheet documented an admission date of 06/05/25 and included diagnoses of urinary tract infection, disorder of the skin and subcutaneous tissue, rash and other nonspecific skin eruption, muscle weakness, unilateral primary osteoarthritis in the left hip, pain, anxiety disorder, spinal stenosis in the lumbar region with neurogenic claudication, atrial fibrillation, and osteoarthritis. R53's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. R53's Care Plan documents a problem area with a start date of 06/05/25 of R53 has (or risk for) pain related to osteoarthritis and spinal stenosis with approaches listed as: administer pain medication as ordered and monitor for side effects and assist resident with non-pharmacological pain relief methods and reposition as tolerated. R53's Physician Order Sheet documents orders for: acetaminophen 500 mg (milligrams) every six hours PRN (as needed) with a start date of 06/18/25 and an end date of 'open ended,' morphine schedule II tablet immediate release 15 mg, 1 tablet twice a day with a start date of 06/05/25 and an end date of 'open ended,' and oxycodone - schedule II tablet 5 mg 1 tablet every 4 hours as needed for moderate to severe pain with a start date of 06/05/25 and an end date of 'open ended.' On 06/23/25 at 9:50 AM, R53's face was grimaced, she appeared agitated and kept trying to adjust herself in her wheelchair. R53 stated her back hurts really bad, she stated she is not supposed to stay in her chair that long and she has been in it since around 6:00 AM. R53 stated it hurts so bad she would rather be dead. R53 stated she was given some pain medication maybe an hour ago but it is not helping at all. R53 said she told the nurse and stated, sometimes it is better if she lays down. On 06/23/25 at 9:58 AM, V12 (Licensed Practical Nurse/LPN) stated she has given R53 some pain medication not too long ago. V12 stated, she is going to call the doctor to find out about medication. On 6/23/25 during continuous observations, R53 was sitting in her wheelchair at 9:55 AM, 10:02 AM, 10:10 AM, 10:18 AM, 10:20 AM, 10:26 AM, 10:42 AM, 10:45 AM, and 10:55 AM. On 06/23/25 at 11:05 AM, R53 stated her back and her hip really still hurt, it is just excruciating. On 6/23/25 at around 12:07 PM, R53 was laid down. R53's Medication Administration Record dated 06/01/25 - 06/24/2025 documents on 06/23/25 at 10:14 AM, acetaminophen 500 mg (milligrams) was administered, and oxycodone 5 mg was not given. On 06/23/25 at 1:10 PM, R53 stated now that she has laid down and has a heating pad it is starting to help, the pain is starting to feel some better. On 06/24/25 at 10:10 AM, R53 stated, the pain is not as bad today. R53 stated, the pain in her hip is always there but sometimes it will get so bad and then her back will also hurt where she can barely stand it and people do not understand until they feel pain like that. R53 stated sometimes a heating pad will help with the medication and sometimes the medication is not enough. When this surveyor asked R53 if she gets more pain medication or a heating pad, R53 asked, do I have to ask for that? R53's Medications Administration History dated 6/1/25-6/24/25 documents an order to assess pain every shift using the 0-10 pain scale or verbal descriptor scale with a start date of 6/5/25. R53's pain level is documented as the following: 6/7/25 on shift 3 pain level of a 4, 6/8/25 on shift 3 pain level of a 3, 6/10/25 on shift 2 there is no pain level documented, 6/14/25 on shift 1 pain level of a 4, 6/20/25 on shift 3 pain level of a 3, 6/21/25 on shift 3 pain level of a 5, 6/22/25 on shift 1 pain level of a 6, and on 6/24/25 on shift 1 a pain level of a 10. R53's pain level is documented as a 0 for all other entries. R53's Pain Management Observation dated 06/05/25 (date of admission) documents: Pain Interview: should pain assessment interview be conducted with 'not assessed' marked. The section titled, staff assessment of pain documents: should the staff assessment for pain be conducted? with 'not assessed' marked. The section titled, Pain Management documents: pain: received scheduled pain medication regimen; at any time in the last 5 days, has the resident received scheduled pain medication regimen with 'yes' marked, at any time in the last 5 days, has the resident received PRN (as needed) pain medications or was offered and declined with 'yes' marked, at any time in the last 5 days has the resident received non-medication intervention for pain with 'not assessed' marked. The section titled, Description of pain documents: if the resident answered yes to having had pain in the last 5 days, please ask the resident to rate their pain on a zero to ten scale, with zero being no pain and ten being the worst pain you can imagine with '8' being marked, what is the resident's stated acceptable level of pain with '2' marked. Under pain site; 'back pain' is marked. Under character of pain-how does the resident describe pain, with 'unable to describe' marked. Under onset of pain, 'early morning' is marked. Under duration of pain, 'constant/persistent' is marked. Under other expressions of pain, 'agitation/restlessness' is marked. The section titled, alleviating factors asks what alleviates or decreases pain with 'medication,' 'positioning/repositioning,' and 'rest/relaxation' marked. On 06/25/25 at 2:16 PM, V1 (Administrator) stated R53's pain level should be asked and documented for every shift because they do not want to wait until the pain gets so bad it makes it hard to get control of. V1 stated, if it helps for R53 to lay down when her back starts to hurt, then staff should lay her down quickly when she starts having pain. On 06/25/25 at 2:22 PM, V2 (Director of Nursing/DON) stated, knowing that R53 came to the facility with an order for Morphine and an as needed order for Oxycodone, a pain assessment should have been completed for her. R53's pain level should be assessed and documented every day. V2 stated, when R53 stated she had a high level of pain on the morning of 06/23/25, she should have been given the as needed Oxycodone instead of the Tylenol. If R53's pain was more like a three then she would have given Tylenol. The facility policy dated 03/03/22 titled, Pain Management documents: the facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. 3. Residents will be observed/asked about pain at a minimum of each shift by the nurse using a standardized 1-10 scale or verbal descriptor scale (VDS) to determine pain intensity. 6. If the resident's pain is not being controlled, an event will be initiated to track pain and response to medication and/or treatment. 7. Residents will be monitored until pain is resolved or is under control and periodically thereafter. 8. Licensed staff will document any complaints of pain and the resident's response to the medication/treatment in resident's record. 11. Alternative methods of pain control will also be attempted: for example: a repositioning, b. therapy evaluation (if ordered by physician), c. offering a back rub, d. hot packs, e. warm bath, and f. ice bags.

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for 10 (R5, R23, R25, R28, R31, R39, R42, R45, R114, R166) of 19 residents reviewed for resident rights in the sample of 40. Findings include: 1. R114's Resident Face Sheet documents R114 was admitted to this facility on 6/21/2025 with diagnoses of orthopedic aftercare for right rotator cuff surgery, muscle weakness, hemiplegia and hemiparesis following cerebral vascular infarction affecting the left dominate side and abnormalities of gait/mobility. R114's Care Plan documents R114 has a focus problem area of decreased mobility r/t (related to) right shoulder fracture, anemia and vitamin deficiency. Interventions for this focus problem include, R114 will grab side rails to assist with turning and repositioning in bed with one assist. R114 also has a focus problem area of minimal risk for injury related to falls. Interventions for this focus area include, instruct R114 to call for assist before getting out of bed or transferring. R114 is alert, oriented and able to answer questions appropriately. On 6/24/2025 at 7:45am, R114 said she put on her call light at 5:00am that morning because she needed to go to the toilet to have a bowel movement. R114 said by 5:30am, no one had came to answer her call light. R114 said she did not want to mess the bed so she got herself up and out of bed without assistance to go to the toilet. R114 said she was scared to go to the bathroom by herself and needs staff assistance to transfer, but could not wait any longer. R114 said she had a stroke and it paralyzed her left side causing her to have difficulty walking and her left hand is flaccid. R114 said she just had rotator cuff surgery on her right shoulder and can't use her right arm very well yet and it's in a sling. R114 said staff did not answer her call light until 5:45am, but by then she had already gotten back into bed by herself. 2. R25's Resident Face Sheet documents R25 was admitted to this facility on 6/9/2021 with diagnoses of congestive heart failure, type 2 diabetes mellitus, abnormal posture and right sided sciatica. R25's Minimum Data Set (MDS) dated [DATE] documented R25 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R25 is cognitively intact. This same MDS documents R25 has impairment to both lower legs and is dependent of staff for toileting, showering and all transfers. On 6/24/2025 at 9:00am, R25 said around 3:00am that same morning, she had to wait over an hour for her call light to be answered by staff. R25 said she had urinated in the bed and needed to be changed. R25 said at 4:00am, staff finally answered her call light and changed her bed. R25 said she frequently has to wait long periods of time for her call light to be answered, especially during the evenings and at night. 3. R166's Resident Face Sheet documented R166 was admitted to this facility on 6/17/2025 with diagnoses of aftercare for surgical amputation of left leg above the knee, Abnormalities of gait and mobility, muscle weakness and type 2 diabetes mellitus among others. R166's Care Plan included a focus problem area of decreased mobility r/t above the knee amputee, kidney disease, heart disease and diabetes mellitus with neuropathy. Planned interventions for this focus problem area included R166 will grab side rails to assist with turning and positioning in bed with one assist. R166's Care Plan also has a focus problem area of R166 is at risk for falls r/t left above the knee amputee. Planned interventions included instruct R166 to call for assist before getting out of bed or transferring. R166 is alert oriented and able to answers questions appropriately. On 6/24/2025 at 9:05am, R166's call light was noted to already be activated. After a total of 34 minutes at 9:39am, staff responded to R166's request for assistance. At 9:45am, R166 said she activated her call light because she needed assistance from staff to urinate. R166 said sometimes it takes a very long time for the staff to answer her call light, but she has not been here very long and hopes the long wait times get better. On 6/24/2025 at 8:45am, V5 (Activities Director) said in April, May and June resident council meetings, the residents have repetitively complained about long call light response times. On 6/25/2025 at 8:45am, V16 (Local Ombudsman) said she attended the resident council meeting held on April 1, 2025. V16 said the residents who attended the meeting complained about having long call light wait times during the meeting and this has been an on-going problem for awhile. Resident Council meeting minutes for meeting date of 6/5/2025 documented residents still had concerns about long call light response times. Resident council meeting minutes for meeting date of 5/5/2025 documented long call light response times still needed improvement. Resident council meeting minutes for meeting date of 4/1/2024 documented a majority of the residents expressed prolonged call light wait times and the long wait times are interfering with resident needs and care. On 6/25/2025 at 1:00pm, V8 (Certified Nursing Assistant/CNA) said the facility trained her to answer call lights as quickly as possible which to her means within a minute or two of the call light being activated. V8 said call lights not being answered for over 30 minutes is way too long of a wait time. On 6/25/2025 at 1:03pm, V7 (CNA) said call lights are to be answered within 5 minutes or less. V7 said she would consider call light wait period of 30 minutes or more as not being very prompt and is too long of a wait period. On 6/25/2025 at 1:05pm, V9 (CNA) said call lights are to answered as soon as possible, which to her means within 5 minutes of resident activation. V9 said a call light response time of 30 minutes or more is too long for a resident to wait for assistance. On 6/25/2025 at 1:07pm, V10 (CNA) said call lights are to be answered as soon as possible, which to her means within 2 minutes of resident activation. V10 said a 30 minute or more call light response time is way too long. On 6/25/2025 at 3:45pm, V2 (Director of Nursing) said she expected her staff to answer call lights within 10-15 minutes. V2 said this is her definition of promptly answering a resident's call light. V2 said 30 minute response time is way to long for a resident to wait for staff assistance. On 6/25/2025 at 3:50pm, V1 (Administrator) said she expected the staff to answer resident call lights within 10-15 minutes. V1 said 30 minutes is too long for a resident to wait for staff assistance. Facility policy titled Call Light with revision date of 05/25 documented the objective of this policy is to respond to resident's request and needs. Procedure: answer call light promptly, knock before entering room, turn off call light, listen to resident's request and respond to request. 4. 4. On 06/23/25 at 11:45 AM, lunch service began to the main dining room. On 06/23/25 at 11:52 AM, R42 was served his lunch and was eating for 10 minutes before his tablemate R28 received his lunch tray at 12:02 PM. R42 was already finished eating before R28 received his meal. On 06/23/25 at 11:51 AM, R23's table began receiving lunch trays. R23's tablemate received her food and was eating for 12 minutes before R23 received her food at 12:03 PM. R23's tablemate was finishing up her lunch by the time R23 started eating. On 06/23/25 at 12:06 PM, R39 was observed to be almost done eating lunch when tablemate R5 just received her lunch tray. On 06/24/25 at 11:45 AM lunch service to the main dining room began. On 06/24/25 at 11:45 AM, R39 received her lunch, while her tablemate R5 waited approximately 13 minutes to receive her lunch tray. At 11:58 AM, R5 received her food, with eleven other residents served between. On 06/24/25 at 11:45 AM, R45 received her food and her tablemate, R31 waited 9 minutes before receiving her food at 11:54 AM, with other eight residents served between. On 06/26/25 at 10:56 AM, V2 (Director of Nursing) stated, residents sitting at the same table in the dining room should be served at similar times, not with several residents served in-between. V1 stated serving residents at the same time promotes dignity and a homelike environment for the residents. The facility policy dated 08/22 titled, Meal Service in Dining Room or Other Area documents: 15 Meals should only be served when residents are seated in the dining room. Staff shall serve meals to all residents at a table at the same time. All available Nursing staff and Department Heads shall assist in serving residents during meal times, if applicable.

Based on interview and record review, the facility failed to respect resident choices for one (R163) of one resident reviewed for self-determination in a sample of 40. Findings include: R163's Resident Face Sheet documented an admission date of 06/09/25 with diagnoses including: fracture of lower end of right ulna, atrial fibrillation, weakness, syncope and collapse, and elevated white blood cell count. R163's Care Plan documents a problem area of: resident care information dated 06/10/25 with an approach dated 06/10/25 listed as: preferred time up: 8:00 AM and bedtime 10:00 PM. On 06/23/25 at 10:15 AM, R163 was alert to person, place and time and stated she has told facility staff she does not like to get up early but lately they have been getting her up early again. R163 said today (06/23/25) they got her up at around 6:00 AM and that is before she wanted to be up. R163 said when she gets up that early, she then has to sit in her chair for two hours and wait for breakfast and that would not be her preference. On 06/25/25 at 10:05 AM, R163 stated they have still been getting her up around 6:00 AM and she just does not understand why. On 06/25/25 at 10:07 AM, V15 (Family) stated it has been around 6:00 AM that they have been getting R163 up lately and she does not like to get up that early. On 06/26/25 at 10:15 AM, V9 (Certified Nurse Aide/CNA) stated she works the hall R163 is on. V9 stated, she starts getting residents up shortly after she arrives to work, so at approximately 5:30 AM. V9 stated, there are no residents that she does not encourage to get up at that time. On 06/25/25 at 2:20 PM, V1 (Administrator) stated, residents should be woken up prior to breakfast or at any other time that they request. If a resident requests not to get up until right before breakfast, staff shouldn't wake them up at 6:00 AM, they should be woken up at 7:45 AM - 8:00 AM.

Based on observation, interview, and record review, the facility failed to provide the correct diet consistency to meet resident needs for 1 (R2) of 12 residents reviewed for menus and nutritional adequacy in the sample of 40. The findings include: 1. R2's Resident Face Sheet dated 06/26/25 documented an admission date of 08/06/24 (latest return) with diagnoses that included wedge compression fracture of third lumbar vertebra, chronic obstructive pulmonary disease, hypertension, osteoarthritis, and muscle weakness. R2's Minimum Data Set (MDS) dated [DATE], documented Brief Interview for Mental Status (BIMS) score of 08, indicating R2 has moderate cognitive impairment. Section GG, Functional Abilities and Goals documented under Eating that R2 requires setup and clean-up assistance. Section K, Swallowing and Nutritional Status documented R2 has a mechanically altered diet. R2's Care Plan with a revised date of 05/29/25, documented a problem area under resident care information with an approach listing Mechanical soft diet, Liquids: Regular, thin; Food Preferences: Dislikes- Eggs; feeds self: snacks as requested. R2's Physician Orders document an order for Diet: Mech (Mechanical) Soft continuous with a start date of 08/06/24 and a end date of open ended. On 06/23/25 at 12:12PM, R2 was in her room with her lunch tray. R2 had mechanical soft chicken with gravy, red roasted potatoes with peppers, apple crumble, milk, water and tea. While eating the red roasted potatoes, R2 appeared to have a difficult time trying to chew the potato skins and peppers that were in the red roasted potatoes. R2 was taking pieces of the potatoes and peppers out of her mouth and placing them on the side of her tray. At this time, R2 stated she was having a hard time trying to chew up the roasted red potatoes and the peppers that were in it. R2 said that she wasn't really a fan of the peppers anyway, but that she doesn't have a lot of teeth left to be able to chew the red roasted potato skins or the peppers up. R2 said that she did try to eat them, but probably wouldn't be able to eat anymore of them. On 06/30/25 at 9:10AM, V25 (Dietary Aide/Cook) stated that on 06/23/25, R2 should not have received roasted red potatoes. V25 stated that R2 is on a mechanically altered diet and she should have received mashed potatoes with gravy instead. V25 said that the diet spreadsheet for 06/23/25 shows that a mechanically altered diet should have received mashed potatoes with gravy. The facility diet spreadsheet with the date of 23 Monday documents under Mechanical Soft lunch as ground baked Caesar chicken with gravy, mashed potatoes with gravy, soft winter blend vegetables, bread/margarine, apple crumble, beverage, ground meatloaf with gravy and creamed spinach. The facility policy titled Liberalized Diets with a revised date of 06/2010 documents under purpose: Increase ability to maintain acceptable weight and nutritional status, and improve, quality of life for residents, improve residents' nutritional status, improve dietary compliance, enhance caloric and nutrient intake and ultimately increase resident satisfaction. Under Procedure: E Mechanical Soft Diet- the mechanical soft diet is designed to minimize the amount of chewing necessary for the ingestion of food. There are no restrictions of any type of soft regular foods if all are tolerated by the individual. The mechanical difficulties of each resident should be given consideration; foods may be chopped, ground, or pureed.

Based on interview, observation, and record review the facility failed to provide prescribed nutritional supplements and provide assistance with meals, and monitor intake for one of one resident (R20) reviewed for weight loss in a sample of 34. These failures resulted in R20 experiencing a severe and continuing weight loss (8.48%) within 3 months. The findings include: R20's Face Sheet, dated 07/11/24, documents R20 was admitted to the facility on [DATE] with diagnoses in part of chronic obstructive pulmonary disease, major depressive disorder, dysphagia, heartburn, dementia, cognitive communication deficit, dietary calcium deficiency, deficiency of other vitamins, pain, and hyperlipidemia. R20's Care Plan with a revised date of 05/16/24 documents under R20's Care information interventions of puree diet with super cereal at breakfast, fortified pudding at lunch/supper, and nutritional supplement at meals. There were no care areas listed for areas pertaining to nutrition or weight loss in the care plan. R20's Physician orders dated 06/25/24 documents diet pureed add house supplement (nutritional supplement) with meals with start date of 6/25/24. Prior diet order dated 08/23/23 documents pureed diet with high calorie high protein supplement. R20's Minimum Data Set (MDS), dated [DATE] documents in Section C a Brief interview for mental status (BIMS) score of 00 which indicates severely impaired cognition. Section GG document substantial/maximal assistance with eating. Section K documents no weight loss or gain of 5% or more in the last month or 10% or more in the last 6 months. R20's meal intake documents found in R20's Electronic Medical Record document no recent meal percentages. Last meal percentage that was documented was on 12/07/23 at lunch which R20 consumed 51-75% of her meal. R20's Vitals Report from 1/1/24-7/1/24 documents monthly weights as 1/1/24- 95.8 lbs (pounds), 2/1/24- 98.2 lbs, 3/1/24- 94.8 lbs, 4/1/24- 93.4 lbs, 5/1/24- 92 lbs, 6/1/24- 90 lbs, 7/1/24- 84.2 lbs. From 5/1/24 - 7/1/24 R20 experienced an 8.48% or severe weight loss within 3 months. R20's Dietitian assessment dated [DATE]: On a Pureed diet with House Supplement at meals. Fortified Pudding at lunch and supper. Super Cereal at breakfast. Intakes 25-75%. Weights: (7/5): 82.8, (7/4): 81.4, (6/28): 84, (6/21): 86.6, (6/14): 87, (6/5): 91, (4/6): 92, and (1/7): 93.4. Current weight is down 3# (pounds) (4.4%) x/14 day, down 4# (4.8%) x/21 days, down 8# (9.0%) x/1 month, down 9# (10.0%) x/3 months, and down 10#(11.3%) x/6 months. On daily weights. Below IBW (ideal body weight) Range 105-134. Body Mass Index: 14.67 (underweight). Had 3+ Left LE edema and 2+ Right LE edema, no reports of edema now, on Lasix. Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Has skin tear right LE. No new labs to review. On Multivitamin Supplement. Estimated Needs: 1330 calories (35 kilo-calories per kg), 1330 cc fluids (1 cc per kilo-calories), and 38-46 gram protein (1.0-1.2 injury factor). Expect weight changes as edema changes and with diuretic therapy. Continue with diet Rx and monitor. R20's Dietitian assessment dated [DATE]: On a Pureed diet with High Calorie High Protein Supplement. Fortified Pudding at lunch and supper. Super Cereal at breakfast and House Supplement with ice cream at meals. Intakes 25-75%. Weights:(6/11): 87.7, (6/10): 84.8, (6/4): 91, (5/28): 92, (5/22): 91.1, (3/13): 88.4, and (12/13): 98.8. Current weight is up 2# (3.4%) x/1 day, down 3# (3.6%) x/7 days, down 4# (4.7%) x/14 days, down 5#(5.7%) x/1 month and down 11#(11.2%) x/6 months. On daily weights. Below IBW Range 105-134. Body Mass Index: 15.53 (underweight). Had 3+ Left LE edema and 2+ Right LE edema, no reports of edema now, on Lasix. Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Has preventative treatment to Coccyx. No new labs to review. On Multivitamin Supplement. Estimated Needs: 1400 calories (35 kilo-calories per kg), 1400 cc fluids (1 cc per kilo-calories), and 40-48 gram protein (1.0-1.2 injury factor). Expect weight changes as edema changes and with diuretic therapy. PLAN: Clarify Supplements. 1). Discontinue High Calorie High Protein Supplement. 2). ADD: House Supplement at meals. R20's Dietitian Quarterly assessment dated [DATE]: On a Pureed diet with High Calorie High Protein Supplement. Fortified Pudding at lunch and supper. Super Cereal at breakfast and House Supplement with ice cream at meals. Intakes 25-75%. Weights: (5/8):92.5, (5/7): 95, (5/1): 92, (4/24): 93.8, (4/17): 90.5, (4/8): 93.1, (2/8): 101.8, and (11/10): 110.5. Current weight is down 9# (9.1%) x/3 months, and down 18#(16.3%) x/6 months. On daily weights. Below IBW Range 105-134. Body Mass Index: 16.38 (underweight). Had 3+ Left LE edema and 2+ Right LE edema, no reports of edema now, on Lasix. Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Has preventative treatment to Coccyx. Skin tear below right knee. No new labs to review. On Multivitamin Supplement. Estimated Needs: 1470 calories (35 kilo-calories per kg), 1470 cc fluids (1 cc per kilo-calories), and 42-50 gram protein (1.0-1.2 injury factor). Expect weight changes as edema changes and with diuretic therapy. PLAN: Clarify Supplements. 1). Discontinue High Calorie High Protein Supplement. 2). ADD: House Supplement at meals. On 07/08/24 at 11:57AM, R20 had her meal sitting in front of her. R20 appeared frail and thin in stature. R20 was not eating, and no staff was assisting her with eating. R20's tray had pureed beef tips, green beans, mashed potatoes with gravy, bread, nutritional supplement ice cream. No fortified pudding was noted on tray. R20's meal ticket listed fortified pudding, ice cream and nutritional supplement on her meal ticket. On 07/08/24 at 11:59AM, V27 (Certified Nurse Assistant/CNA) went over to R20 while standing she gave R20 a few bites of pureed beef tips. V27 then left and went back to assisting another resident with eating. After the few bites R20 was given R20 just sat at the table with her food in front of her not eating. Another staff member unknown name did walk up to the table while standing and gave R20 a couple more bites of food then left. On 07/08/24 at 12:01PM, V27 left another resident she was assisting again and while standing gave R20 one bite of her food then left again. On 07/08/24 at 12:03PM, V27 left the table and then another staff member V28 (CNA) sat down at the table across from R20 and started to assist another resident with eating. R20 sat at the table during this time with no assistance. On 07/08/24 at 12:36PM, R20 was taken out of the dining room. On 07/08/24 at 12:38PM it was noted that R20 had consumed less than 25% of the food on her tray. R20 mainly consumed her nutritional supplement ice cream. On 07/09/24 at 11:50AM, R20 was noted in the dining room. R20 had pureed polish sausage, sauerkraut, biscuit, noodles, nutritional supplement ice cream, fortified pudding, and two glasses of cranberry juice on her tray. R20 was feeding herself a few bites of her meal. R20 was not assisted by staff with eating during this meal. Only food consumed was the few bites she gave herself. On 07/09/24 at 12:20PM it was noted R20 had consumed less than 25% of the meal on her tray and was not assisted by staff. R20 had a few bites of her pureed polish sausage, sauerkraut, nutritional supplement ice cream, and a few bites of fortified pudding. On 07/11/24 at 11:04AM, R20 was in the dining room she was served pureed ham, mashed potatoes with gravy, mixed vegetables, cake, fortified pudding, nutritional supplement ice cream, and bread. R20 was being assisted by staff with her meal. On 07/11/24 at 11:45AM observed R20's tray she consumed around 50% of her tray. R20 consumed half of her nutritional supplement ice cream and half of her fortified pudding On 07/11/24 at 1:02PM, V8 (CNA) stated that R20 can feed herself at times, but if she doesn't eat on her own that staff must assist her with eating. V8 said they don't monitor the intake of all residents at the facility they only monitor residents who are at risk for weight loss. V8 said she doesn't know where the paper goes after they fill it out with the intakes of the resident they do monitor. V8 said she thought R20 was on the monitor intake list for weight loss and supplements. V8 stated that when she is in the dining room sometimes there isn't enough people to assist all the residents who need help with eating. V8 said she may have to give several residents a bite here and there to be able to assist all of them with eating. V8 said she does stand up and feed residents, because she is feeding several people at a times and will give a few bites and then go over to another resident and give them a few bites of their food. V8 said she has to do this often. On 07/11/24 at 1:19PM, V9 (CNA) stated that they don't monitor every resident's intake only people who have lost weight or on nutritional supplements. V9 said that she thought R20 is on the meal intake sheet for weight loss and nutritional supplement. V9 stated that R20 will mainly eat her nutritional supplement ice cream and her fortified pudding, she doesn't touch a lot of the main meal. V9 said that she does assist R20 at times with eating. V9 said R20 will feed herself at times, but they have to assist her at times. V9 said that if they notice someone isn't eating good, they let the nurse know. V9 said that she doesn't know who is responsible for putting people on the intake monitoring sheet or where the intake monitoring sheet goes after she fills it out. V9 stated that they are short of staff on second shift she said that there may be only one person in the dining room assisting all the residents that need help. V9 said there may be 2 people most of the time trying to help all the residents that need assistance with eating in the dining room. V9 said second shift doesn't have enough staff. On 07/11/24 at 1:55PM, V3 (Assistant Director of Nursing/ADON) stated that the only intakes they monitor are the ones that are ordered by a doctor. V3 said if a resident isn't eating well that the certified nurse assistant will usually let the nurse know. V3 said that they notify the doctor of any weight losses, and they will give an order to monitor the resident food intake. V3 said she didn't know who all they had orders to monitor intake for. V3 said that R20 can assist herself with eating, but if she doesn't eat then staff should be assisting her. V3 was unaware if R20 had a weight loss or not. V3 said that she has never seen the meal intake sheets that the certified nurse assistants had to write down the intake of certain people with weight loss. She thought R20 was on the list to be monitored. V3 said that R20's intakes should have been in the electronic medical record if they are monitoring it. V3 didn't know why R20 didn't have no intakes in her chart since 12/07/23. On 07/11/24 2:00PM, V4 (Dietary Supervisor) said that they monitor intakes of new admission times four weeks, and anyone that has a significant weight change. V4 said that she prints out a meal intake sheets daily for staff to write down intakes, but she doesn't know who gets it afterwards. V4 said that she thinks the nurses get it and then input the information into the electronic medical record. V4 said when they need to add someone to the intake sheet she usually gets an email. V4 said that she has no clue who gets the meal intakes sheets. V4 said that R20 was on the meal intake sheet for her nutritional supplement and weight loss. On 07/11/24 at 2:10PM, V10 (Licensed Practical Nurse/LPN) stated she hasn't seen a meal intake sheet in a while. V10 said that she does not receive the meal intake sheets and she has no clue where they go. V10 said it's been a while since she saw one. V10 was not sure if R20 was on the meal intake sheet or not. On 07/11/24 at 2:15PM, V11 (Registered Nurse/RN) stated that she hasn't seen a meal intake sheet in a long time for the other halls. V11 said they monitor all the resident on the memory care unit's meal intake, but she doesn't think they monitor the intake of the other residents. On 07/11/24 at 2:22PM, V26 (RN) stated that she doesn't get the meal intake sheets and she does not put any meal intakes in for any resident in the electronic medical record. V26 said the only monitoring they do is input fluid intake. V26 said that she has never seen the meal intake sheet. On 07/11/24 at 2:29PM, V2 (Director of Nursing/DON) stated that he has never seen the meal intake sheet that documents percentages of what food residents took in. V2 said that he is newer to the facility and is still trying to learn everything. V2 was unsure if R20 was on the meal intake sheet or if R20 has had a weight loss. V2 was unsure of R20's meal assistance needs. V2 did state that if a resident is not eating and needs assistance staff should be assisting any resident that needs help or not eating on their own. On 07/12/24 at 11:39AM, V28 (Registered Dietitian) stated that she believes that the facility does not monitor meal intakes because it is their policy. V28 said that meal intake recording is so subjective. V28 said that they pick and choose whose meal intakes to monitor. V8 said that she thinks it works out well. V8 said that she doesn't feel like she misses anyone even though she can't see what amount of food intake they have consumed. V28 said the certified nurse assistants are very good about letting them know if someone isn't eating well. V28 stated that even with the same staff not assisting the same resident daily they still monitor it well. V28 said that on her note on 07/05/24 that she wrote in R20's chart she obtained her meal intake percentages from some of the certified nurses assistants and the progress notes. V28 said there wasn't much about meal intakes in the notes. V28 stated that she didn't know if R20 required assistance with meals, but if R20 is supposed to get assistance with meal she expects staff to assist her. V28 said that she recommends supplements like ice cream, nutritional shake and would expect the staff to offer and make sure that the resident receive these supplements. V28 said that she usually is at the facility every other week and looks at the weights or looks at them remotely. V28 said that if R20 had a large weight loss she would have noticed it and put a new intervention in place. V28 was unsure if R20 required any assistance with meals. V28 said if they notified the doctor recently about R20 having a weight loss she will look at her weights and diet when she comes in next time or do it from home. R20's Progress Note dated 07/10/24 at 1:17PM Weight loss report received. R20 (resident) had a weight loss of 10.6% (96lbs-85lbs) over the last 180 days. R20 (resident) currently a daily weight. Puree diet with house supplement. Notified primary doctor, awaiting orders. The facility policy titled Weight Monitoring objective states to consistently assess residents for significant weight loss or gain. The Facility Policy Food Service with a revised date of 09/2010 documents in part under procedure the nursing staff shall be responsible for observing the resident's food acceptance and record the intake on the provided meal intake or documentation into POC (Point of Care for meal intake) only for those residents that are identified to be at risk.

Based on interview, observation, and record review the facility failed to provide prescribed nutritional supplements and weight loss interventions for 1 of 7 residents (R18) reviewed for weight loss in a sample of 37. The failure resulted in R18 experiencing a 14.3% weight loss in 5 months. Findings Include: R18's Face Sheet documents R18 is a [AGE] year old female with an admitted [DATE] and the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Minimum Data Set (MDS) dated [DATE], documents R18 has a Brief Interview for Mental Status (BIMS) score of 00 denoting R18's cognitive status as: severely impaired. Section G documents R18's Eating status as: independent with set up help only. R18's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Care plan dated 06/10/21 and last reviewed 3/25/22 documents: Category: Nutritional Status: R18 may be at risk for nutritional deficit related to decreased appetite related to dementia, eating disorder, with a problem start date of 09/17/2020. A goal target date of 03/09/2022 documents a goal of; R18 will not have any significant weight changes through review. An Approach Start Date of 01/27/22 documents: provide Supplement: High Calorie High Protein, an Approach Start Date of 02/12/21 documents: House Shakes BID (twice a day), an Approach start date of 09/17/2020 documents: Staff assist with eating/drinking as needed. On 05/02/22 at 11:45 AM, R18 received her lunch tray which contained her meal and her beverage, no fortified milk shake or fortified pudding was given. R18 ate less than 10% of her lunch with no encouragement or cueing noted from staff. On 05/03/22 at 11:42 AM, R18 received her lunch tray which contained her meal and her beverage, no fortified milk shake or fortified pudding was given. R18 ate less than 10% of her lunch with no encouragement or cueing noted from staff. On 05/04/22 at 11:06 AM, R18 received her lunch tray which contained her meal and her beverage, no fortified milk shake or fortified pudding was given. R18 ate less than 10% of her lunch with no encouragement or cueing noted from staff. R18's Lunch card dated 05/04/22 documents: Fortified Pudding - 1 each, Fortified Milkshake - 1 each with Notes: HCHP (High Calorie High Protein) Pudding and HCHP Milk Shake. On 05/04/22 at 4:40 PM, R18 received her supper tray which contained her meal and her beverage, no fortified milk shake or fortified pudding was given. R18 ate less than 10% of her lunch with no encouragement or cueing noted from staff. The Facility document titled, Vitals Report documents: on 12/02/2021 at 10:23 AM R18's weight was documented as 92 pounds. On 01/04/22 at 2:56 PM R18's weight is documented as 91 pounds. On 02/04/22 at 10:50 AM R18's weight is documented as 88 pounds. On 03/07/22 at 10:06 AM R18's weight is documented as 77 pounds. On 04/07/22 at 2:20 PM R18's weight is documented as 80 pounds. On 05/04/22 at 8:56 AM R18's weight is documented as 78.8 pounds. When calculated this shows R18 had a 14.3 % weight loss in 5 months. R18's Progress Notes document on 03/09/2022 at 11:23 AM, titled,Dietary Assessment by V15 (Licensed Dietician Nutritionist): On a Regular diet with High Calorie High Protein Supplement. Prefers Fortified milk at breakfast only. Also gets fortified pudding at lunch and supper. Fortified Milk Shakes at lunch and supper. Intakes 50-70%. Weights: (3/7): 77 (pounds), (2/24): 80, (2/16): 82(pounds), (2/9): 85(pounds), (2/7): 88(pounds), (12/2): 92(pounds), and (9/2): 90 (pounds), . Current weight is down 3# (pounds), (3.8%) x 11days, down 5# (pounds), (6.1%) x 19 days, down 8# (pounds), (9.4%) x26/days, down 11# (pounds), (12.5%) x /1 month, down 15# (pounds), (16.3%) x /3months, and down 13# (pounds), (14.4%) x /6 months. Below IBW Range 90-110 (pounds). Body Mass Index:16.09 (Underweight). Awaiting M.D. orders for U.A. results. Skin free of open areas. Labs (2/17/22): Glucose 80, Sodium 145, Potassium 3.4(L), Blood Urea Nitrogen 10, Creatin 0.6, Total Protein 4.9(L), and [MEDICATION(S)] 2.8(L) Plan: to stabilize weights. 1). Add: Butterball at breakfast 2). Add: Double meat at breakfast. R18's Progress Notes document on 04/13/2022 at 12:02 PM, titled, Dietary Assessment by V15 (Licensed Dietician Nutritionist): On a Regular diet with High Calorie High Protein Supplement. Prefers Fortified milk, Butterball, and Double meat at breakfast. Also gets fortified pudding at lunch and supper. Fortified Milk Shakes at lunch and supper Monitor. R18's Progress Notes document on 04/27/2022 at 5:23 PM, titled, Dietary Assessment by V15 (Licensed Dietician Nutritionist): On a Regular diet with High Calorie High Protein Supplement. Prefers Fortified milk, Butterball, and Double meat at breakfast. Also gets fortified pudding at lunch and supper. Fortified Milk Shakes at lunch and supper Monitor. The Facility document titled, Observation Detail List Report Nutritional assessment dated [DATE] documents R18's current diet order as: Regular diet with High Calorie High Protein Supplement. Prefers Fortified milk at breakfast only. Also gets fortified pudding at lunch and supper. Fortified Milk Shakes at lunch. House Shakes BID (twice a day). The category titled, Nutritional Risk Indicator documents weight status as: no weight change, Feeding Capabilities as: Independent, Supervised and Vision impaired and Oral/Nutritional Intake is documented as 50-75% intake. The section titled, Notes by V15 (Licensed Dietitian Nutritionist) documents: Dietitian/Readmit Assessment: [AGE] year old female readmitted (12/31) On a Regular diet. Dietary Intakes 50-75%. Resides on Garden Court, additional snacks available between meals. Weights: (1/4): 91, (12/31): 90.8, (12/2) 92, (10/04): 91, and (7/6): 91. WNL of IBW Range 90-110. Body Mass Index: 19.02 (Normal/Healthy weight). On antibiotics for [CONDITION(S)]. Has enlarged gallbladder but so wants no further treatment. Skin free of open areas and no new labs to review. Estimated Needs: 1230 calories (30 kilo-calories per kg), 1230 cc fluids (1 cc per kilo-calories), and 41-49 gram protein (1.0-1.2 injury factor). Plan; restart Supplements. 1). High calorie High Protein Supplement. 2). Prefers Fortified milk at breakfast only. Also gets fortified pudding at lunch and supper. Fortified Milk Shakes at lunch. House Shakes BID (twice a day). The Facility document titled, Observation Detail List Report Nutritional assessment dated [DATE] documents R18's current diet order as: Regular diet with High Calorie High Protein Supplement. Prefers Fortified milk, Butterball and Double meat at breakfast. Also gets fortified pudding at lunch and supper. Fortified Milk Shakes at lunch and supper. Reason for Assessment is documented as: Quarterly. Body Mass Index is documented as: 16.51 (Underweight). Weight status is documented as 7.5% weight change in 90 days and 10% Weight change in 6 months. Oral/Nutritional Intake - Food as: Intake Meets 26-50% of Estimated Needs. R18's Feeding capabilities are documented as Independent and Assisted. On 05/05/22 at 1:05 PM, V5 (Dietary Manager) stated, residents that are supposed to be given supplements including fortified puddings or health shakes, should receive them. R18 is supposed to receive nutritional supplements, they are listed on her meal card. On 05/05/22 at 12:30 PM V16 (Dietary Assistant) stated, the nutritional supplements are listed on the meal cards and are put on the resident's trays by the kitchen staff that is serving at that time. On 05/05/22 1:20 PM V15 (Licensed Dietitian Nutritionist) stated, R18 has had weight loss, she is to receive fortified pudding and fortified milk shakes. The Facility policy titled, Supplementation with a revised date of 07/18 documents: Procedure: 6. The Food Service Supervisor or designee will update resident's meal tray ticket to include supplementation.

Based on interview and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the development and worsening of pressure ulcers for 1 of 3 residents (R17) reviewed for pressure ulcers in a sample of 37. This failure resulted in R17 developing an infected and painful stage 3 pressure ulcer to his coccyx requiring debridement on three occasions. Findings include: According to R17's admission face sheet printed 5/4/22, R17 was admitted to this facility for short term rehab services after a hospital stay at the local hospital. R17's Face Sheet documents R17 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per R17's admission nurses note dated 2/5/2022, R17's wished to return home where he lived with his wife and has daily family support to help with daily needs. The Admission Observation Report, dated 2/05/2022, shows R17's skin was assessed, and the coccyx was pink in color and blanches. An assessment for predicting pressure sore risk was completed for R17 on 02/05/2022 in which R17 scored a 14 indicating R17 was at moderate level of risk for developing pressure related complication to his skin. Factors listed on this assessment which contributed to R17's risk of pressure sore development included: Slightly Limited Sensory Perception-responds to verbal commands but cannot always communicate discomfort or need to be turned, and has some sensory impairment which limits the ability to feel pain in 1 or 2 extremities, Moisture-Occasionally skin is moist and requires extra linen changes, Mobility, Very Limited, makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently, Adequate Nutrition eats about 1/2 food offered, eats a total of 4 servings of protein each day, occasionally will refuse a meal, but will usually take a supplement when offered, and Friction/Shearing due to requires moderate to maximum assistance with moving, complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assist. [CONDITION(S)], contractures, or agitation leads to almost constant friction. R17's MDS (Minimum Data Set), dated 2/12/2022, under section C, BIMS (Brief Interview Mental Status) score is 13, cognitively intact, under section G, Functional Status, R17 requires extensive assistance x 2 person physical assist with bed mobility, transfers, and toileting. R17's Current Care Plan documents,R17 is at increased risk for pressure injury R/T (related to) decreased mobility, dementia and [CONDITION(S)] .Unstageable area noted to coccyx. Infection to coccyx wound. With a problem start date of 2/5/22. Approaches include: Assist resident with turning and repositioning, Start Date: 02/05/2022, Pressure reducing device in wheelchair and bed, Start Date: 02/05/2022, Provide incontinent care after each incontinence episode, Start Date: 02/05/2022, Side rails/enablers to assist with turning and repositioning, Start Date: 02/05/2022, therapy as ordered, Start Date: 02/05/2022, High Calorie, High Protein Supplements (HCHPS), Start Date: 2/10/2022, Administer treatment to coccyx until resolved, Start Date: 03/11/2022, Air mattress, Start Date: 03/18/2022. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Discontinue when healed., 02/23/2022-3/11/2022, Cleanse wound on coccyx with [MEDICATION(S)] wound cleanser, pat dry, apply antifungal/barrier cream to coccyx and apply [MEDICATION(S)] at bedtime; 7:00 p.m. - 11:00 p.m., 03/11/2022-03/25/2022, Cleanse wound on coccyx with [MEDICATION(S)] wound cleanser, pat dry, apply [MEDICATION(S)] to wound bed/gauze, cover with bordered foam dressing at bedtime; 7:00 p.m. - 11:00 p.m., 03/11/2022 - 03/28/2022, Cleanse wound on coccyx with [MEDICATION(S)] wound cleanser, pat dry, apply [MEDICATION(S)] to wound bed/gauze, cover with bordered foam dressing once a day as needed., 03/11/2022 - open ended, measure wound to coccyx and update wound management., 03/25/2022 - 03/28/2022, Cleanse wound on coccyx with wound cleanser or normal saline (NS), pat dry, apply [MEDICATION(S)] to wound bed/gauze, cover with bordered foam dressing at bedtime; 3:00 p.m. - 11:00 p.m., 03/28/2022- 03/29/2022, Cleanse wound on coccyx with wound cleanser or NS, pat dry, apply [MEDICATION(S)] to wound bed/gauze, cover with bordered foam dressing. Special Instructions: continue [MEDICATION(S)] until santyl arrives, then discontinue order at bedtime; 3:00 p.m.- 11:00 p.m., 03/28/2022- 04/22/2022, Cleanse wound to coccyx, pat dry, apply nickel thick layer of santyl to wound bed; if wound has low moisture/drainage follow with normal saline moist to dry gauze, cover with foam border dressing daily as needed., 04/22/2022-04/28/2022, Cleanse wound to coccyx, pat dry, apply nickel thick layer of santyl/[MEDICATION(S)] to wound bed. If wound has low moisture/drainage follow with normal saline moist to dry gauze, cover with foam border dressing daily as needed., 04/28/2022-Open ended, Cleanse wound to coccyx, pat dry, apply nickel thick layer of santyl to wound bed. If wound has low moisture/drainage follow with normal saline moist to dry gauze, cover with foam border dressing daily as needed. On 5/2/2022, at 9:00 a.m., R17 stated that he did not have a wound on his bottom when he got admitted to the facility. R17 stated that his wound on his bottom has gotten worse and has caused a lot of pain. R17 stated that he has been going to a wound clinic and his son helps transport him to and from his appointments. On 5/4/2022, at 1:45 p.m., R17's coccyx's wound treatment was performed by V6 (Registered Nurse) with assistance from V11 (Certified Nursing Assistant). Dressing was removed and was saturated with light yellow colored drainage. Wound looked like a deep, crater-like hole into the skin. Area in the crater-like hole was noted to have light yellow slough at the bottom with redness to tissue surrounding the inside of the wound. A Resident Progress Note dated 02/05/2022, at 11:37 a.m. and entered into R17's EHR (Electronic Health Record) by V14, (Licensed Practical Nurse), documents Body Assessment: Heels intact, toenails thick, no [CONDITION(S)] to BLEs (Bilateral Lower Extremities), multiple moles to mid/upper back, skin warm/dry. Bruising from needlesticks to RFA (right forearm) & LFA (left forearm). Coccyx has preventative bordered foam dressing, coccyx pink and not open. A nurses note dated 2/5/2022 in R17's medical record documents R17 developed MASD (Moisture -Associated Skin Damage) to his coccyx and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurses note in R17's medical record dated 2/14/2022 at 3:03pm documented antifungal cream applied to coccyx wound. Redness still noted. A nurses noted in R17's medical record dated 2/19/2022 at 10:47am, documented resident has been yelling, upon inspection, resident has a 1cm (centimeter) deep bedsore on his bottom. 1.5 cm width, 3.5cm in length on his coccyx. Wound had slight yellow slough noted. Cleansed and applied dried [MEDICATION(S)] (dressing) will pass on to inform POA (Power of Attorney) and doctor related to time. A nurses note in R17's medical record dated 2/20/2022 at 8:40pm documented dressing change to bottom area, slight non odorous drainage noted to dressing very little yellow/white slough noted to wound site, wound edges seemed very macerated. Cleansed wound patted dried. Zinc applied to peri-wound new Opti foam dressing applied. A nurse's note in R17's medical record dated 2/22/2022 at 9:05pm documented slight white/yellowish slough noted to wound, applied new [MEDICATION(S)] (dressing) and antifungal/barrier cream to coccyx. A nurse's note in R17's medical record dated 2/23/2022 at 8:42pm documented made new treatment order. (doctor) okayed on 2/20/2022 when rounding was informed of what we were doing and okayed it. A nurse's note in R17s medical record dated 2/28/2022 at 9:22pm documented cleansed area to bottom and patted dry. Zinc/antifungal cream mixture applied to buttocks and coccyx and covered with [MEDICATION(S)] (dressing). A nurse's note in R17's medical record dated 3/4/2022 at 10:11pm, dressing changed to bottom at this time, scant amount of drainage noted, wound bed has whitish look to it, peri-wound is not macerated. A nurse's note in R17's medical record dated 3/10/2022 at 9:13pm documented wound to bottom treated at this time, wound bed is completely covered in white stiff slough, peri-area around the wound looked dark in color, slightly macerated and slightly curled, applied zinc/antifungal mixture to peri-wound to help prevent maceration and covered. A nurse's note in R17's medical record dated 3/17/2022 at 3:45pm documented wound to buttock shows some sign of decline. Wound edges are red/purplish in color with some maceration. Darker yellow, immovable slough noted to wound bed. Updated (doctor's) office and asked for referral to wound clinic. Stated would call back with orders. A nurse's note in R17's medical record dated 3/17/2022 at 4:01pm documented signee assessed unstageable wound to coccyx. Slough to wound bed has decreased however still obscuring wound bed. Resident complains of mild pain with cleansing. Edges have appearance that resembles DTI (Deep Tissue Injury). Son in room. Signee explained meaning of unstageable wound and that facility would like to make referral to wound clinic. Signee spoke with resident about having cushion in recliner when he is sitting and will have staff place air mattress for bed at this time. A nurse's note in R17's medical record dated 3/18/2022 at 2:59pm documented appointment at wound clinic is on 3/28/2022 at 11:00am . A facility document printed from R17's EHR (Electronic Health Record) titled Wound Management Detail Report created on 3/11/2022 documents the following: Wound type: Unspecified Ulcer, Wound location: Coccyx, Date/Time identified: 003/11/22 10:30 am, Present on Admission/Re-entry: No. Observation History: On 5/4/2022 at 2:10PM, Length 5cm (centimeters), Width 3cm, Depth 1.5cm, Exudate: Moderate, Exudate color and consistency: Serosanguineous (pale red to pink, thin and watery), Wound odor present: Yes. Tissue type: Slough, Percent of wound cover by slough tissue: 20, Wound edges/margin: Macerated/soft. On 4/29/2022 at 10:36 PM, Length 5.5cm, Width 2cm, Depth 1.5cm. Exudate: Moderate, Exudate color and consistency: Seropurulent (yellow or tan, cloudy and thick), Wound odor present: No. Tissue type: Slough, Percent of wound cover by granulation tissue: 25, Percent of wound covered by slough tissue, 75. Wound healing status: Declining. On 4/20/2022 at 2:05 PM, Length 5cm, Width 3cm, Depth 1.5cm. Exudate: None, Wound odor present: No. Tissue type: Slough, Percent of wound covered by slough tissue, 90.Wound healing status: Stable. On 4/15/2022 at 10:27 AM, Length 3.5cm, Width 2cm, Depth 1.6cm. Exudate: Light, Exudate color and consistency: Serous (clear, amber, thin and water), Wound odor present: No. Tissue type: Slough, Wound healing status: Stable. On 3/30/2022 at 9:28 PM, Length 4cm, Width 2.2cm, Depth 1.8cm. Exudate: Moderate, Exudate color and consistency: Serosanguineous (pale red to pink, thin and watery), Wound odor present: No. Tissue type: Slough, Tissue type: Slough, Percent of wound cover by granulation tissue: 10, Percent of wound covered by slough tissue, 90. Wound healing status: Stable. On 3/25/2022 at 8:56 PM, Length 3.7cm, Width 2cm, Depth 1.2cm. Exudate: None, Wound odor present: Yes. Describe: foul, Tissue type: Slough, Tissue type: Slough, Percent of wound cover by granulation tissue: 10, Percent of wound covered by slough tissue, 50. Percent of wound covered by eschar tissue: 40, Wound healing status: Declining. On 3/16/2022 at 9:54 PM, Length 3.5cm, Width 1.2cm, Depth: could not be measured. Exudate: None, Wound odor present: No. Tissue type: Slough, Tissue type: Slough, Percent of wound cover by granulation tissue: 10, Percent of wound covered by slough tissue, 90. Wound healing status: Stable. On 3/11/2022 at 10:31 AM, Length 3.2cm, Width 1cm, Depth: could not be measured. Exudate: None, Wound odor present: No. Tissue type: Slough, Tissue type: Slough, Percent of wound cover by granulation tissue: 10, Percent of wound covered by slough tissue, 90. The bottom of R17's Wound Detail Management Report documents: Wound type: Abrasion, Wound location: Coccyx, Date/Time Identified: 2/19/2022 11:44 AM, Present on admission/Re-entry: No, Healed/Discontinued Date/Time: 3/11/22 at 10:29 AM. A nurse's note in R17's EHR dated 4/8/2022 at 4:23pm documented Received orders from the wound clinic for [MEDICATION(S)] 800-160mg BID (twice per day) x 10 days r/t (related to) green drainage from wound A nurse's note in R17's EHR dated 4/30/2022 at 9:45pm documented Changed wound dressing to coccyx per order. Noted yellowish saturation to old dressing, strong odor noted. Noted wound bed 25% slough, wound depth 2.5cm, 3cm width and 5.5cm length. Wound edges macerated. Surrounding wound tissue irritated and red res voiced pain to site. A nurse's note in R17's EHR dated 5/5/2022 at 1:31pm documented dressing to coccyx soiled and removed at this time .some purulent (pus) drainage noted . On 5/05/2022 at 12:30pm, V2, (Director of Nursing) said R17 should have had an air mattress applied to his bed and chair before 3/17/2022 when she asked staff to apply it and documented her request. V2 said it should have been applied when R17 was assessed to be at moderate risk for developing pressure wounds. V2 said she could not find where R17's care plan had been updated when R17 developed the open area on his coccyx. V2 said the nursing staff are responsible for the weekly assessment of wounds and are responsible for measuring and pursuing new treatments if current wound treatments were not working. V2 said per the facility's pressure injury prevention and treatment protocol if the pressure injury is showing no improvement, the physician will be notified so change of treatment may be obtained. When V2 was asked when R17's coccyx ulcer did not show improvement after several weeks of decline, would she expect her nursing staff or R17's physician to try a different treatment then antifungal cream, V2 would not give an answer. On 5/10/2022 at 10:16am, V17 (Advanced Practice Wound Nurse) said she has been treating R17 since R17 was referred to the local wound clinic. V17 said AF (antifungal) cream is not an appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V17 said R17 reported to her that the nursing home was not limiting his time up in his wheelchair so V17 wrote orders for R17 to only be out of bed for meals. V17 said on 3/28/2022 R17's coccyx wound measured 4.2cm (Centimeters) long by 2.4cm wide and 1cm deep and adipose (fat) tissue was visible, pain was rated by R17 as 5 on a scale of 10 and was surgically debrided. V17 said on 4/8/2022 she saw R17 at his weekly wound clinic appointment where R17 reported a pain rating of 5 on a scale of 10. V17 said R17's wound again was debrided and now measured 5cm long by 2.4 cm wide and 1.3cm deep, had green drainage so a wound culture was obtained and a broad spectrum antibiotic was ordered for the green wound drainage because the wound was now infected. V17 said at R17's 4/15/2022 appointment, R17 reported pain of 5 on a scale of 10, R17's wound was debrided again and post debridement wound measurements were 5cm long by 2.4cm wide and 2.2cm deep.V17 said when R17 came to his next wound clinic appointment on 4/28/2022, R17 did not have any dressing on his coccyx wound and wore an adult diaper without any underwear on. V17 said R17's coccyx wound was making great progress but that no longer was the case. V17 said R17's wound had turned black and no longer looked as good as it had previously. V17 said R17's stage 3 coccyx pressure ulcer remained unchanged in size and developed slough. R17's Progress Note Details report by V17 dated 3/28/22 documents in part, Wound Assessment(s) Wound #1 Coccyx is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received status of Not Healed. Initial wound encounter measurements are 4.2 cm length x 2.4cm width, x 1cm depth, with an area of 10.08 sq (square) cim and a volume of 10.08 cubic cm .Procedures: Wound #1.A skin/subcutaneous tissue level excisional/surgical debridement with a total area debrided of 10.5 sq com was performed by V17. Subcutaneous was removed along with devitalized tissue: biofilm and slough .Post debridement measurements: 4.7 cm length x 2.5 cm width x 1.1 cm depth, with an area of 10.5 sq cm and a volume of 11.55 cubic cm. R17's Progress Note Details report by V17 dated 4/8/22 documents in part, Wound Assessment(s) Wound #1 Coccyx is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received status of Not Healed. Subsequent wound encounter measurements are 5 cm length x 2.4cm width, x 1.3 cm depth, with an area of 12 sq cm and a volume of 15.6 cubic cm. Wound covered with a thick layer of slough, with greenish-drainage. Procedures: Wound #1.A skin/subcutaneous tissue level excisional/surgical debridement with a total area debrided of 12 sq com was performed by V17. Subcutaneous was removed along with devitalized tissue: slough .Post debridement measurements: 5 cm length x 2.4 cm width x 1.3 cm depth, with an area of 12 sq cm and a volume of 15.6 cubic cm. R17's Progress Note Details report by V17 dated 4/15/22 documents in part, Wound Assessment(s) Wound #1 Coccyx is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received status of Not Healed. Subsequent wound encounter measurements are 5 cm length x 2.4cm width, x 1.3 cm depth, with an area of 12 sq cm and a volume of 15.6 cubic cm. Procedures: Wound #1.A skin/subcutaneous tissue level excisional/surgical debridement with a total area debrided of 12 sq com was performed by V17. Subcutaneous was removed along with devitalized tissue: biofilm and slough .Post debridement measurements: 5 cm length x 2.4 cm width x 2.2 cm depth, with an area of 12 sq cm and a volume of 26.4 cubic cm. R17's Progress Note Details report by V17 dated 4/28/22 documents in part, When he (R17) arrived today from Nursing Home he had no dressing in wound or on wound. Son report he doesn't feel they are limiting his time in chair .30 day follow up visit for Stage 3 pressure ulcer to coccyx. We have been treating wound with Santyl daily. We added [MEDICATION(S)] at last week visit as well for added coverage from positive tissue culture from 4/8/22. He has been making good progress with wound healing until this week. He arrived today to visit with no dressing inside of wound base or cover dressing to wound. Increase in slough with some induration noted to edge of ulcer. Santyl ointment sent with patient from (Facility) was dated 4/22/22 and had never been open. I called and spoke with his nurse from nursing home. She told me she did not know why wound was not covered with dressing. Sharp debridement performed at the beside to remove devitalized tissue . Will consider general surgery consult next week if ulcer shows no improvement. A facility policy titled Pressure Injury Prevention and Treatment Protocol (revision date of 07/16) documents A skin risk assessment is completed on all residents upon admission and weekly for the first four weeks after admission . An individualized plan of care will be developed for the resident following the guidelines of the assessment . All high and moderate risk residents may have the following and if so, they will be addressed on the care plan. a. Special mattress and wheelchair cushions b. PROMS (Passive Range of Motion) c. Protein and/or nutritional supplements d. Turning and repositioning schedule e. Skin checks f. Elbow and heel protectors When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: Assess the pressure injury for location, size, wound bed, drainage, odor, tunneling, undermining or sinus tract, wound edges/surrounding tissue and pain at the site. Notify physician of assessment and obtain orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure injury will be care planned. For pressure injury with drainage the physician will be notified, and culture obtained.

Based on interview and record review the facility failed to use a gait belt when transferring a resident, which required the assistance of two staff persons and a gait belt for 1 of 1 resident (R3) reviewed for falls in the sample of 3. This failure resulted in R3 falling and sustaining a right hip fracture. The findings include: R3's February 2015 physician's orders [REDACTED]. R3's Minimum (MDS) data set [DATE] states in Section G; Line B that R3 is Extensive assist of two for transfers and R3's undated Fall Risk Evaluation stated that R3 was High Risk for falls. The facility's policy dated ,[DATE] on "Gait Belt" use stated under "Policy"; It is the policy of the facility that all direct care staff shall use a gait belt when transferring or ambulation residents. The Gait Belt policy states under "Procedures"; Line 2: No resident will be transferred or ambulated without the use of a gait belt, unless to do so is contraindicated and this would be indentified on residents plan of care. R3's Resident Progress Note dated [DATE] at 10:48 stated that CNA staff reported a controlled sit down with resident in 400 shower room. Upon entering shower room, R3 was observed sitting on buttocks with Right leg bent beneath her and left leg extended straight in front of resident. CNA staff stated, "We were transferring her from wheel chair to shower chair and her right leg started to bend behind her so we helped her sit on the floor." R3 extended her right leg in front of her and range of motion was within normal limits. R3 was assisted to the shower chair with 3 staff. R3 had a purple bruise on the right lateral breast and right arm with no swelling to the site. Z2 (Patient's Primary Physician) was notified as well as Z1 (Family Member). On [DATE] at 12:27 PM, R3's Nurses Notes stated that CNAs brought R3 back to nurses station from lunch and she was lethargic and was in her wheel chair with her head down, skin yellow, cool and clammy. R3's respirations were even and unlabored, and her lungs clear. R3 had 3+ pitting edema to both of her lower extremities and no warmth to the site. R3 was complaining of severe pain in both lower extremities and her blood pressure was 106/ 62, pulse weak and thready and E5 (RN) was unable to palpate pulse radially. Z2 was notified, and at 2:18 PM, Z2 returned call and gave orders to send R3 to the hospital. On [DATE] at 9:45 AM, Z1 (Patient's Family Member) stated that he was told that R3 had to get a shower, and while she was being transferred from her wheel chair to the shower chair, R3 had what the staff called a "controlled fall", and there were no problems related to the fall. Z1 stated that he thought the nurse did her best, but didn't identify a broken bone. Z1 also stated that R3 did have a bruise on her right breast and right ribs and realized that R3 was on a blood thinner and bruising can happen with that. Z1 did not mention R3 having fractured ribs. Z1 also stated that Z4 (Family Member) was there to be with R3 around 12:30 PM on [DATE], and Z4 told Z1 that R3 was put back in bed and wasn't responding but was turning her head back and forth. Z1 stated that was when the facility called Z2 (Physician) to have R3 taken to the hospital. Z1 stated that it took a long time to get R3 sent out because they were waiting on Z2 to call and give orders. Z1 stated that R3's Death Certificate stated that R3 died from Cardiopulmonary Arrest, Congestive Heart Failure and Chronic Kidney secondary to Disease and that R3 had a Fractured hip and Peripheral Vascular Disease. On [DATE] at 11:20 AM, E7 (Certified Nursing Assistant) stated that she came in after R3's fall and was told that R3's legs buckled under her and they lowered R3 to the floor. E7 stated that E6 (Certified Nursing Assistant) and a Nursing Assistant student from the High School was also involved in the transfer, but doesn't know her name. E7 also stated that R3 was transferred to the shower chair after E5 (Registered Nurse) did an assessment of R3 and that R3 wasn't complaining of pain during the transfer and was not complaining of pain while being showered or when R3 was transferred back into her wheel chair. E7 stated that R3 had a bruise on her right breast and her right rib area, but no briusing on her right hip. E7 stated that R3's legs were swollen and draining, but R3 had that condition prior to the fall. On [DATE] at 11:30 AM, E6 stated that she and a student (couldn't recall her name) from the high school Certified Nursing Assistant (CNA) program that was helping her with R3 because R3 was covered in bowel movement (BM) and needed a shower. E6 stated that she did not use a gait belt to transfer R3 from the wheel chair to the shower chair because R3 was completely covered with BM and didn't want to get the BM on the gait belt. E6 stated that when she and the CNA student stood R3 to transfer her to the shower chair, E6 stated that R3's right leg went behind her left leg and her knees were bending and E6 stated that she and the CNA student lowered E6 to the floor and while R3 was on the floor, her right leg was underneath her. E6 stated that she had her arm under R3's right arm when R3 was lowered to the floor, and that R3 was not complaining of pain but was complaining about being on the floor and wanted to be gotten up and put in the shower chair. E6 also said that R3 did not have a bruise on her breast on right side before the transfer, and E6 also stated that R3 didn't have a bruise after the fall. On [DATE] at 11:45 AM, E5 (RN) stated that the CNAs came and got her and they said that R3 had a "controlled fall". (lowered R3 to the floor). E5 stated that when she got into the shower room, R3 had her left leg extended out in front of her and the right leg was bent underneath her. E5 stated that when R3 extended the right leg out in front of her, R3 didn't complain of pain and there was no noticeable shortening or rotation of the right leg. E5 stated that she asked R3 two or three times if she was in pain and R3 kept saying "no". E5 stated that she also assessed R3 to see if she had feeling in the right leg and when performing range of motion to R3's right hip, she was not complaining of pain. E5 stated that R3 always had ,[DATE]+ pitting edema in both lower extremities and she couldn't determine if there was an injury to the right leg or hip. E5 stated that around lunch time on [DATE], the CNAs brought R3 up to the nurses station and she was lethargic, pale, and her pulse was weak and her blood pressure was low. E5 stated that they put R3 into bed and she called Z2 and didn't get an answer. E5 stated that she tried to call Z2 (Patient's Physician) again with no answer, and then around 1:00 PM she called the Z3 (Medical Director). E5 stated that Z4 was with R3 around 12:30 PM and Z4 stated that she believed R3 was not in a lot of distress and to wait and see what Z2 would say. E5 stated that Z2 (Patient's Primary Physician) finally called and gave the order to have R3 sent to the local hospital around 2:18 PM. On [DATE] at 2:45 PM, Z2 stated via telephone that R3 had a lot of medical problems including Congesstive Heart Failure, Atrial Fibrillation, Deep Vein Thrombosis, Bruising, Stroke and Dementia and that R3 was a DNR (Do Not Resuscitate). Z2 stated that R3's cause of death was Cardiopulmonary arrest and Congestive Heart Failure and did not believe that the hip fracture was the cause of death, but was a contributing factor. Z2 stated that he knew the family and they wanted to keep her comfortable. On [DATE] at 3:30 PM, E1 (Administrator) stated that E6 was counselled on the proper use of gait belts and that the CNAs would be retrained on use of gait belts as well as monitored by the Director of Nursing, Assistant Director of Nursing and Nursing staff. R3's Certification of Death Record dated [DATE]th, 2015 stated that the immediate "Cause of Death" Part I; line a.) Cardiopulmonary Arrest line b.) Congestive Heart Failure line c.) Chronic Kidney Disease Part 2 (Significant conditions contributing to death but not resulting in the underlying cause given in Part I); Fracture hip and PAD (Peripheral Artery Disease)