Every finding on record at Charleston Rehab and Nursing

Based on interview and record review the facility failed to complete initial and weekly pressure ulcer assessments, initiate timely wound treatments, failed to provide pressure ulcer treatments, and failed to use the physician ordered treatment for one of three residents (R5) reviewed for Quality of Care on the sample list of five. These failures resulted in R5 developing one facility acquired pressure wound which deteriorated and became infected causing R5 to be hospitalized and treated for Sepsis related to a severe wound infection. Findings Include: The facility's Skin Prevention, Assessment and Treatment policy dated 5/2/25 documents the facility's policy is in place to promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown as well as to promote the healing of existing pressure ulcers. All residents should have their skin integrity examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. Findings from these weekly skin assessments should be documented on the skin progress notes. Upon identification of the development of a pressure wound, the wound assessment and treatments will be documented in the medical record and start the weekly wound log. The wound nurse should track the residents who have been identified as high risk and should create an assessment and documentation schedule. Residents with wounds should be reviewed during weekly risk management committee meetings for progress, interventions, and care plan revisions as appropriate. The Risk Management Committee should also monitor to ensure the facility's policies and protocols are followed. At the direction of the facility's Quality Assurance (QA) Committee, a weekly wound report should be completed by the Director of Nurses on a weekly basis for review and monitoring by the QA Committee to assure the objectives of the policy and protocol are being met. R5's Care Plan dated 3/6/26 documents R5 was admitted on [DATE] and is diagnosed with Paraplegia, Personal History of Infectious and Parasitic Diseases, Personal History of Methicillin Resistant, Staphylococcus Aureus Infections, and Need for Assistance with Personal Care. R5 has the potential for skin impairment due to immobility related to Paraplegia. R5 has current alterations to his skin due to a Pressure Ulcer. Staff are to conduct routine wound assessments, administer medications and apply treatments as ordered by the physician, monitor and document the location and size, and follow the facility's policies and protocols for skin breakdown. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively intact and was admitted with one stage three pressure ulcer. R5's Braden Scale for Predicting Pressure Sore risk dated 2/28/26 documents R5 was at high risk due to a slightly limited ability to respond meaningfully to pressure related discomfort, bedfast, very limited mobility, probable inadequate nutrition, and a potential problem for friction and shear. R5's Wound Log dated 2/28/26 documents upon admission R5 had one stage three pressure ulcer on his left buttock/coccyx area with some tunneling. This was the only completed Wound Log. R5's Weekly Nursing Skin Review dated 2/28/26 documents upon admission R5 had one open area to his coccyx/left inner buttock with tunneling. This was the only completed Weekly Nursing Skin Review. R5's Physician Order Sheet dated March 2026 documents an order for wound treatments for the pressure ulcer on R5's coccyx and one for a new wound on R5's Left lower buttock. Both wound treatment orders began on 3/7/26. No previous wound treatment orders were initiated from R5's admission on [DATE] through 3/7/26. R5's Treatment Administration Records dated March 2026 document staff did not complete wound/skin treatments for all of R5's wounds a total of 80 times. R5's Treatment Administration Records dated April 2026 document staff did not complete wound/skin treatments for all of R5's wounds a total of 54 times. R5's Wound Assessment and Plan dated 3/17/26 documents wound assessments completed by V13 Wound Nurse Practitioner. V13 documented R5 had a facility acquired left gluteal pressure ulcer on 3/6/26 which was unstageable due to the wound bed being 100% slough. On 3/17/26 this wound measured 4 centimeters (cm) length x 4 cm width x utd (unable to determine) depth. V13 ordered a wound treatment of nickel thick layer of Santyl (enzymatic wound debridement) followed by a dressing. R5's Wound Assessment and Plan dated 4/14/26 documents wound assessments completed by V13 Wound Nurse Practitioner. V13 documented R5's facility acquired left gluteal pressure ulcer measured 3.5 centimeters (cm) x 6 cm x utd (unable to determine) This wound had deteriorated and grown in size. V13 continued to order a wound treatment of nickel thick layer of Santyl (enzymatic wound debridement) followed by a dressing. V13 also ordered Bactrim for R5's wound due to signs of infection. R5's Nursing Progress Note dated 4/14/26 documents R5's wounds were leaking extensively and there were two new spots on right upper leg close to his scrotum. R5 was sent to the emergency room for evaluation. R5's Hospital Records dated 4/24/26 document R5 was admitted to the hospital on [DATE] for Sepsis secondary to an infected stage four left gluteal pressure ulcer which required a surgical debridement down to the bone. R5's wound was infected with MRSA, Morganella Morganii, E Coli, Klebsiella Pneumoniae, and Group B Streptococcus. R5 also had a perirectal abscess and Moisture Associated Skin Damage. On 5/8/26 at 1:55 PM, V5 Licensed Practical Nurse stated R5's wound treatment order was for Santyl on his left gluteal wound however because his insurance would not pay for it, she was told to use medical honey instead. V5 stated when doing R5's wound dressing changes, she thought the left gluteal wound appeared infected, had an odor and had deteriorated over a couple weeks. On 5/13/26 at 12:45 PM V12 Previous Assistant Director of Nurses (ADON) stated she completed R5's admission, is not sure why she only documented one wound, and it must've been a mistake. V12 stated she does not remember there being wound treatment orders for R5's wounds on admission and is not sure why none were ordered for him until 3/7/26 (8 days post admission). V12 stated R5 did acquire a new wound to the left gluteal on 3/6/25. V12 stated the left gluteal wound deteriorated. V12 confirmed V13 Wound Nurse Practitioner ordered Santyl for R5's wounds however R5's insurance did not cover the treatment, so she told the nursing staff to use medical honey instead. This was a PRN (as needed) order. V12 stated on 4/14/26, V12 and V13 noticed new areas where fluid was leaking from and V13 ordered an antibiotic for R5. On 5/13/26 at 1:35 PM V13 Wound Nurse Practitioner stated she started seeing R5 on 3/17/26 for multiple wounds. V13 confirmed she was told the left gluteal wound was facility acquired and began on 3/6/26. V13 stated overtime, the left gluteal wound deteriorated and eventually appeared to have tunneled into another wound with a possible abscess and was infected. V13 stated she ordered antibiotics but R5 went to the hospital the next day for his wound infection. V13 stated she was not aware that the facility nurses were using medical honey instead of the Santyl that she ordered for wound treatments. V13 stated she would expect the nursing staff to complete weekly skin and wound assessments, complete all treatment orders per physician order, and wounds should be fully documented upon admission and have treatment orders in place right away. On 5/13/26 at 12:00 PM V2 Director of Nurses confirmed R5's wounds were not completely documented upon his admission and subsequent wound assessments were not done completely. V2 also confirmed R5 did not have wound treatment orders in place until 3/7/26 which was eight days past his admission. V2 also confirmed nurses should be completing all treatments per physician order and should be documenting them in the residents' Treatment Administration Record. V2 confirmed a lack of wound prevention measures, including initial treatment, ongoing assessments and consistent wound treatments put R5 at risk for developing the facility acquired left gluteal wound. The lack of these things also put R5 at risk for developing a wound infection. V2 confirmed R5 was sent to the emergency room on 4/15/26 when his left gluteal wound appeared infected. R5 was admitted for a wound infection and did not return to the facility.

Based on interview and record review the facility failed to accurately document medication administration for one of three residents (R1) reviewed for pharmacy records on the sample list of five. Findings Include: R1's Physician Order dated 4/9/26 documents R1 was prescribed Ertapenem Sodium (antibiotic) one gram intramuscularly once per day for a Urinary Tract Infection for seven doses. R1's Medication Administration Record dated April 2026 documents R1 received the Ertapenem starting on 4/11/26 and ending on 4/18/26 for a total of eight documented doses. On 5/13/26 at 3:00 PM R1 stated he was not given one dose of his antibiotic back in April. He complained about it and the nurse on duty reported it. R1 stated he was told it had been confirmed by V2 Director of Nurses, after a medication count, that he had not received the dose on 4/13/26 and they would add a dose on the end and make sure he received all seven doses as prescribed.On 5/13/26 at 12:00 PM V2 Director of Nurses (DON) confirmed although the MAR documents eight doses were administered, it was found that staff had documented the dose was given when in fact it was not. V2 confirmed R1 had complained about not getting his dose on 4/13/26 and a medication count was completed that confirmed he had not received that day's dose. To provide R1 with the prescribed seven doses, a day was added at the end. V2 confirmed that R1 missed one dose on 4/13/26 but did receive seven total doses in all. V2 confirmed nurses need to document medication administration accurately and only document a medication as given if in fact the medication was administered to the resident as ordered.

Based on interview and record review the facility failed to accurately transcribe and administer multiple medications per physician order. This failure affected two of three residents (R1, R2) reviewed for pharmaceuticals on the sample list of nine. This failure included multiple missed doses of an antiepileptic medication resulting in R2 having a seizure and subsequently being sent to the emergency room. Findings Include:1. R2's Hospital Discharge Instructions dated 2/24/26 documents R2 was discharged to the facility on 2/24/26 after a hospital admission for elevated phenytoin level, altered mental status and urinary tract infection. R2's previous Phenytoin medication order was discontinued and R2 was to start taking Phenytoin 300 milligrams daily at bedtime. R2's Medical Diagnoses List dated March 2026 documents R2 is diagnosed with Epilepsy.R2's Physician Orders from her stay in the facility from 2/24/26 through 3/16/26 does not include an order for Phenytoin.R2's Nursing Progress Note dated 3/11/26 documents R2 was found in her wheelchair, shaking and foaming at the mouth with her eyes rolled back in her head. The seizure was observed for three to four minutes. After the seizure was over R2 began to react to verbal stimuli but was not yet back to baseline when she was taken by ambulance to the hospital.R2's Emergency Documentation dated 3/11/26 documents R2 presented to the emergency department from the facility with a breakthrough seizure. R2 does have a history of epilepsy. R2 was in the hospital a few weeks prior with supratherapeutic Dilantin levels and her dose of Dilantin decreased from 350 milligrams per day to 300 milligrams per day upon discharge to the facility. However, after reviewing R2's facility records, R2 was not taking Dilantin. It was noted that R2 did have a cluster of seizures and was slowly coming back to baseline. R2's Dilantin level on 3/11/26 resulted as 1.4 micrograms per milliliter (Low). Therapeutic levels are between 10-20 micrograms per milliliter.On 4/14/26 at 1:28 PM V3 Assistant Director of Nurses (ADON) stated she was the nurse who admitted R2 and confirmed she missed the new order to start Phenytoin 300 milligrams at bedtime and did not enter this order in R2's electronic medical record.On 4/14/26 at 1:28 PM V2 Director of Nurses (DON) confirmed V3 ADON had missed the Phenytoin order upon admission and R2 never received any Phenytoin while at the facility from admission to discharge. V2 DON confirmed she did phone the hospital to clarify medication orders but did not hear back from them and did not follow through with order clarification. V2 confirmed R2 did end up having a seizure on 3/11/26 in the facility and was transferred to the hospital for evaluation and treatment. V2 confirmed R2 had a history of seizures and was on Dilantin prior to admission and the dose was changed on the admission sheet from the hospital. The medication was important to the well-being of the R2 and should have been clarified if needed and physician orders should have been followed.On 4/22/26 at 1:45 PM V16 Physician Assistant (PA) stated he was unaware R2 had orders from the hospital to start a new dose of Phenytoin and was unaware the order was missed by V3 ADON. V16 confirmed the medication would be significant to the wellbeing of R2 who has Epilepsy. V16 stated if physician orders are confusing or nurses have questions, they need to clarify the orders and follow through until they are certain the resident is getting the correct medications. If an order is missed, or a resident dose not receive an ordered medication for one reason or another, the physician should be notified.2. R1's Medical Diagnoses List dated April 2026 documents Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Hypertension, Atrial Fibrillation, and Type II Diabetes Mellitus.R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Physician Medication Order Sheet dated April 2026 documents physician orders for Metformin (antihyperglycemic) Extended Release 500 milligrams twice daily, Apaxiban (blood thinner) five milligrams twice daily, and Empagliflozin (antidiabetic) 25 milligrams once daily. R1's Medication Administration Record (MAR) dated April 2026 documents R1 did not receive Apixaban on the evening of 4/10/26 or 4/11/26, and the morning of 4/12/26 due to the medication being unavailable. R1's MAR dated April 2026 documents R1 did not receive Empagliflozin and Metformin on 4/12/26, 4/14/26, or 4/15/26 due to the medications being unavailable.On 4/22/2026 at 1:05 PM, V3 Assistant Director of Nursing (ADON) stated the expectation when medications are missing during medication pass includes the nurse on duty to contact the pharmacy to obtain the medication, use the electronic medication back up system, notify the V2 DON or V3 ADON, and notify the physician. On 4/22/2026 at 2:36 PM, V17 Registered Nurse stated on 4/12/2026 she could not find R1's Empagliflozin, Metformin, and Apixaban in the medication cart and therefore they were not administered to R1. V17 confirmed she did not notify V2 DON, the Pharmacy or Physician.On 4/22/2026 at 2:40 PM, V14 Registered Nurse stated on 4/14/26 she could not find R1's empagliflozin, metformin, and apixaban in the medication cart and therefore they were not administered to R1. V14 confirmed she did not notify V2 DON, the Pharmacy or Physician.On 4/22/2026 at 3:12PM V18 Licensed Practical Nurse stated, on 4/10/26 and 4/11/26 the 8:00 PM of R1's Apixaban was not available and R1 did not receive either dose. V18 stated she did notify V2 DON. V18 stated a refill was requested with the pharmacy, however she did not call or speak to a pharmacist. V18 confirmed R1's physician was not notified of R1's missed medications.3. R1's Physician Progress Note dated 11/18/2025 documents an order change to increase R1's Dulaglutide (anti-hyperglycemia) dose from 1.5 milligrams (mg) subcutaneously every Friday to 3 milligrams. The order was not updated in R1's physician orders.R1's Electronic Medical Record documents an order was received via facsimile dated 3/20/2026 at 1:30 PM to increase the dose of R1's Dulaglutide from 1.5 mg to 3 mg, as ordered previously in November 2025. The order was still not updated in R1's physician orders.On 4/22/2026 at 2:35 PM, V24 (Endocrinology Nurse) stated the Dulaglutide order change had been sent with R1 after his appointment in November 2011 and was again sent via facsimile to the facility in March 2026.On 4/22/2026 at 1:08 PM, V22 (Facility Driver) stated that when residents are returned to the facility from a physician appointment, the physician orders and progress notes are copied and distributed to V2 (DON), V3 (ADON), V21 (Medical Data Set Nurse, MDS), V23 (Medical Records), and the nurse on duty. On 4/23/2026 at 11:45 AM, V3 (ADON) stated the expectation for medication change orders are to be entered in by the nurse on duty at the time the order is received. R1's MAR dated November 21, 2025, through April 17, 2026, documents administration of Dulaglutide 1.5mg subcutaneous one time every Friday.On 4/23/2026 at 2:00 PM, V3 (ADON) confirmed between November 21, 2025, and April 17, 2026, R1 had received the wrong dose of Dulaglutide.The facility's Medication Error policy dated 11/5/19 documents the facility shall ensure mediations will be administered according to physician's orders. Medication errors can include the wrong person, wrong drug, wrong dose, wrong time, and wrong route.

Based on interview and record review the facility failed to implement physician's orders for one of three residents (R1) reviewed for following plans of care on the sample list of nine. Findings Include:R1's Medical Diagnoses List dated April 2026 documents Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Hypertension, Atrial Fibrillation, and Type II Diabetes Mellitus.R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Physician Medication Order Sheet dated April 2026 documents a physician order for nursing to wrap R1's bilateral legs with elastic compression bandages from dorsum feet to below the knee every morning and remove at bedtime. R1's Treatment Administration Record (TAR) dated April 2026 documents between 4/1/26 - 4/23/26 there were seven missed treatments for R1's leg wraps. On 4/23/26 at 3:30 PM V2 Director of Nurses confirmed nurses need to document treatments on the TAR. V2 also confirmed nurses need to notify the doctor if residents are refusing treatments and document the refusal in the medical record. V2 confirmed R1's legs need to be wrapped daily per physician order.

Based on observation, interview, and record review, the facility failed to recognize and respond to a significant change in condition and delayed treatment for one resident (R1) with a known Covid diagnosis and a history of Atrial Fibrillation. This failure affects one (R1) of three residents reviewed for Resident/Patient/Client Neglect. As a result of the delayed response, R1 was sent to the local hospital and diagnosed with Acute Renal Failure, Elevated Troponin, Hyperkalemia, Dehydration, and Atrial Fibrillation with Rapid Ventricular Response. Findings include:On 3/11/26 at 9:39 a.m., R1 was observed lying in bed. R1 appeared thin and fragile, with oxygen tubing in place and the concentrator running at two liters per minute.R1's Electronic Health Record (EHR) dated 6/5/25 documents a diagnosis of Paroxysmal Atrial Fibrillation.R1's Minimum Data Set (MDS) dated [DATE] documents R1's cognition is intact.R1's Care Plan dated 6/18/25 documents R1 has a diagnosis of Atrial Fibrillation. An intervention for this focus area is that staff will notify physician of any abnormal readings. R1's progress notes dated 1/31/26 document R1 exhibiting tiredness, dry cough, and fever; a Covid test was performed and was positive.R1's vital sign flow sheet dated 2/8/26 at 9:52 a.m. and 11:03 a.m. documents that V7 Registered Nurse (RN) obtained R1's vital signs and noted a new onset irregular heart rate of 111 beats per minute.On 3/11/26 at 9:43 a.m., V6, Certified Nurse Assistant (CNA) stated R1 had been ill with Covid in February and that it hit him really hard. V6 stated R1 was not breathing well, not eating, and appeared significantly off the weekend prior to R1 being sent to the hospital. V6 stated that she, V8 CNA, and V9 CNA reported their concerns to V4 LPN over the weekend, but V4 told them she was too busy to assess R1.On 3/11/26 at 11:21 a.m., V8, CNA stated that V4 LPN and V7 RN were working the weekend in February when R1 experienced a significant decline. V8 stated R1 was extremely weak, had lost the ability to care for or feed himself, repeatedly said he did not feel well, and was short of breath the day before being sent to the emergency room. V8 stated she reported this to V4, who said she was too busy with a medication pass. V8 stated the next morning R1 appeared dazed and spoke little. V8 stated that when she reported this to V4, V4 said she would get to R1 when she could. V8 stated she then went directly to V2, DON, with concerns about R1's change in condition and V4's response to her concerns.On 3/11/26 at 11:29 a.m., V9, CNA stated R1 went downhill really fast when he had Covid in February. V9 stated R1 was extremely lethargic, complained of not feeling well, and was no longer able to assist with transfers as he had before. V9 stated she along with V6 and V8 repeatedly reported concerns to V4 LPN and V7 RN, asking what could be done for R1. V9 stated V4 repeatedly said she was too busy to assess R1. V9 stated she, V6, and V7 then brought their concerns to V2, DON.On 3/11/26 at 2:20 p.m., V4, LPN stated she did not remember the details surrounding R1's illness in February that required hospitalization. V4 stated that an assessment should be completed immediately when a CNA reports that a resident is not feeling well and not acting like themselves. On 3/12/26 at 10:47 a.m., V7, RN stated she was new to the facility in January and was still learning the residents. V7 stated she does not recall obtaining vital signs for R1 during his illness. V7 stated she does recall CNAs reporting a significant change in R1's condition the weekend before he was sent to the hospital, and that they told her they had reported it to V4 LPN, who did not act on their concerns.On 3/12/26 at 9:17 a.m., V2, DON stated R1 became very ill with Covid, and on the morning she assessed him and sent him to the emergency room he was very lethargic, alert and oriented only to self, which was not his baseline, and complained of generalized pain that worsened with movement, as evidenced by R1 moaning. V2 stated nurses should assess residents promptly when there are concerns regarding a change in the resident's condition. V2 stated that on the day R1's vital signs showed an elevated, irregular pulse with R1 having a history of Atrial Fibrillation, V4 LPN or V7 RN should have sent R1out for evaluation.On 3/12/26 at 9:36 a.m., V15, Physician Assistant (PA) stated that if a nurse obtained an irregular pulse of 111 that was not normal for R1, it should have been reported to the PA or R1 should have been sent to the emergency room for further evaluation. V15 stated R1's clinical picture warranted an X ray and EKG, and that had R1 been sent out sooner when the irregular pulse and change in cognition were identified, R1 probably would not have suffered from hypoxia, acute renal failure, dehydration, and Atrial Fibrillation with Rapid Ventricular Response. R1's hospital records dated 2/9/26 document that R1 was admitted to the local hospital with a diagnosis of Covid-19, Acute Renal Failure, Dementia, Elevated Troponin, Hyperkalemia, Dehydration and Atrial Fibrillation with Rapid Ventricular Response. The facility's Change in Condition Procedure dated 9/21/25 documents that the facility will provide guidelines for the appropriate handling of a resident's change in condition. This policy documents the following guidelines that will be utilized as appropriate to each situation and change in condition:1. Full Assessment by nursing staff including but not limited to:a. Full vitals (Temperature, Pulse, Respiration, Blood Pressure, and Oxygen Saturation)b. Level of consciousnessc. Respiratory status including lung soundsd. Abdomen including last bowel movement and urine propertiese. Functional statusf. Pain2. Staff should notify Medical Doctor of change and give assessment information.

Based on record review, and interview, the facility failed to identify appropriate targeted intervention post previous fall, for a resident (R1) with severe cognitive impairment, failed to maintain a mobility device within R1's reach to prevent an unwitnessed fall, failed to initiate neurological and physical assessments post the unwitnessed fall. These failures affected one of three residents (R1) reviewed for falls on the sample list of 18. These failures resulted in a severe head injury and untreated pain.Findings include:R1's most recent Diagnoses List included the following: Carcinoma of the left Bronchus in Situ; Senile Degeneration of the Brain; Chronic Respiratory failure with Hypoxia; Hypertensive Heart Disease with Heart Failure; Chronic Kidney Disease stage IV; disorder of muscle, unspecified; unsteadiness on feet; and other lack of coordination.R1's Minimum Data Set (MDS), dated [DATE] (prior to R1's three unwitnessed falls on 10/7/25, 10/28/25, and 12/06/25 described below), documents R1's Brief Interview of Mental Status score as five out of 15, indicating severe cognitive impairment. The same MDS documents R1 had no falls during the assessment look-back period, required supervision and contact assistance with toileting, and required a wheelchair for mobility.R1's Fall Investigation Report dated 10/7/25 at 10:30 p.m. documents R1 had an unwitnessed fall while getting up to go to the bathroom and fell over the recliner chair footrest. The same report documents that R1 hit her face on the floor and that V5, R1's Power of Attorney (POA), wanted R1 sent to the hospital.R1's corresponding Health Status Note dated 10/08/25 at 12:58 a.m. documents R1 returned with a small laceration to her head, no dressing, and no new orders.The facility's Fall Log/Analysis documents R1's fall intervention for 10/08/25 as: Make sure R1's call light was within reach and functioning. (R1 has severe cognitive impairment; V2, Director of Nursing, confirmed below this was not an appropriate intervention.) This intervention had already been in place since 03/10/25. There was no new targeted intervention to address toileting or the footrest documented after the fall of 10/7/25.R1's Fall Investigation Report dated 10/28/25 at 2:05 a.m. documents R1 had an unwitnessed fall and could not say what happened. The same report documents R1 was found on the floor. The intervention documented was to educate R1 to activate her call light when she needed help and wait for assistance (R1 has severe cognitive impairment, and V2 confirmed this was not an appropriate intervention).R1's Fall Incident Report dated 12/06/25 at 7:30 p.m. documents V11, Licensed Practical Nurse (LPN), as the person preparing the report.The same report documents:Nurse's Description: Resident was moving from one bed to the other in her room and fell on the floor. Resident has a small bump to her head by the right eye on forehead. Resident states she has no pain; head does not hurt. Vitals were taken.Resident Description: Resident stated she was trying to get to the other bed when she slipped and fell.Immediate Action Taken: Vital signs taken (completed by V31, Certified Nursing Assistant (CNA), according to interview below), resident assessed and helped back to bed, and instructed to use call light for help (R1 has severe cognitive impairment as noted above).V31's interview, documented below, stated V31 was the staff member who found R1 on the floor and that R1's wheelchair was across the room, out of R1's reach, when she was found.R1's Care Plan documents a fall intervention dated 3/10/25 stating assistive devices will be within reach of the resident.R1's Neurological Assessment Flow Sheet initiated 12/06/25 documents the following required checks:Every 15 minutes for one hourEvery hour for four hoursEvery four hours for 19 hoursThe same Neurological Assessment Flow Sheet documents the following for 12/06/25 at 7:30 p.m.:Level of Consciousness: S (stuporous, near unconsciousness)Pupil response: blank (not measured)Hand grips: blank (not measured)Motor function extremities: U (unable to follow directions)Pain: blank (not measured)Vital signs (blood pressure, temperature, pulse, respiration): blank (not measured)Observations: blankSignature: blank (nurse not identified)The same form documents that all assessment boxes were blank at the following times:7:45 p.m.8:00 p.m.8:15 p.m.9:15 p.m.10:15 p.m.11:15 p.m.3:15 a.m. on 12/07/25R1's Medication Administration Record (MAR) dated December 2025 documents the following medications were not administered to R1 on 12/06/25: Lorazepam Oral Concentrate 2 mg/mL, give 0.25 mL by mouth every four hours as needed for anxiety, agitation, or restlessness (hospice admission order), and Morphine Sulfate Concentrate Oral Solution 20 mg/mL, give 0.25 mL by mouth every two hours as needed for pain and dyspnea (hospice admission order).On 2/6/26 at 1:30 p.m., R1's family members/complainants V7 and V8 stated they had not been notified of R1's fall. V7 stated, We would have come in right away. It happened early evening (12/06/25). V7 and V8 also stated they had been told by an unidentified CNA that The nurse (V11, LPN) told two CNAs (V31 and V32) to get R1 up off the floor and put her back in bed without the nurse completing an assessment. The nurse told the CNAs she would give R1 morphine. I hope she did. When I saw her, she was moaning, and her face was swollen and bruised. She had to be in a great deal of pain.On 2/6/26 at 3:20 p.m., V10, LPN, stated that when she came to work on 12/07/25, V11 told her in report that R1 had fallen the evening of 12/06/25 at 7:30 p.m. V10 also stated there was no documentation that V11 had completed neurological assessments or contacted a physician, hospice, or family about R1's fall. V10 stated she tried to reach family and hospice, and both came into the facility right away. V10 also stated R1 was lethargic, could not talk, but moaned during her assessment.On 2/09/26 at 10:30 a.m., V5, Hospice Registered Nurse (RN), confirmed hospice was not notified of the 12/06/25 7:30 p.m. fall until 12/07/25 at approximately 8:00 a.m. V5 stated, It's protocol for hospice to be notified immediately of falls. We come out and do our own assessment. R1 was in decline prior, but she was still alert and could have conversations the day before. She was totally different when I came in on 12/7/25 to see her. She had obviously taken a serious fall and needed to be evaluated sooner. She could not hold a conversation. She was lethargic. V5 also stated, From my experience as a hospice nurse, R1 had a concussion and likely a brain bleed. She was comatose post-fall, had a change in swallowing and breathing, and showed no emotion. Had the facility called the night of 12/06/25, hospice staff would have been bedside to provide comfort and emotional support, as we did once we were notified.On 2/11/26 at 3:25 p.m., V2, Director of Nursing (not employed at the facility when R1 fell but experienced in investigating falls), reviewed investigations for R1's falls on 10/7/25, 10/28/25, and 12/06/25, along with care plans, assessments, neurological assessments, vital-sign documentation, interventions, and fall reports. V2 stated it is standard practice to thoroughly assess a resident post-fall. V2 confirmed the following: neurological assessments were not completed after the 12/06/25 fall; no appropriate notifications were made to family, physician, or hospice; no thorough investigation was conducted to determine root cause; reminding R1 to use the call light was not appropriate due to R1's cognitive impairment; and toileting should have been addressed after the 10/07/25 fall since R1 had been attempting to go to the bathroom independently.On 2/13/26 at 11:35 a.m., V31, CNA, stated she was R1's CNA the night R1 fell. V31 stated she heard R1 say, Help me, looked into R1's room, and saw her lying on the floor between her bed and the bathroom. V31 stated R1 could not speak words and was mumbling and groaning. V31 reported R1 appeared to be in pain and notified V11 immediately. V31 stated that when V11 came in, she did not assess R1 and told staff to get her up. V31 stated R1 had a large bump above her right eyebrow that swelled immediately and that R1 did not have her oxygen on. V31 stated they attempted to stand R1, but her legs gave out, and they dragged her to the bed. V31 stated V11 left the room immediately afterward. V32 then obtained vital signs. V31 stated R1 continued moaning and appeared in pain. V31 reported V11 later said she would give morphine but instead sat at the desk on her phone and reading.On 2/13/26 at 2:25 p.m., V11, LPN, stated it was a really hectic night when R1 fell and acknowledged she did not complete a full physical or neurological assessment. V11 confirmed R1 was moaning in pain at times throughout the night. Although R1's MAR does not document administration of morphine after the fall, V11 stated she was not sure whether she had given it.The facility's Policy and Procedure Fall Reduction Policy, revised 10/30/25, documents:4.a.ii. Evaluate/assess the resident for injury. Guidelines will be utilized as appropriate to each situation and change in condition.Notify the physicianNotify the responsible partyContact on-call nurseThe facility's Policy and Procedure Neurological Assessment, dated 11/05/25, states the purpose is to evaluate condition and provide professional nursing assessment and intervention for possible head injuries. General assessment guidelines include, but are not limited to: new onset changes in cognitive status; speech or communication changes; sensory changes; swallowing changes; balance and gait changes; headaches, dizziness, pupillary constriction, weakness, tremors, nausea, or vomiting; drowsiness or irritability; fluid or bleeding from ears; and changes in respiratory pattern.

Based on interview and record review the facility failed to complete a thorough investigation, by failing to interview other residents/staff (R16) resident (R17), and R3 and R4 alleged verbal abuse and failed to remove the alleged perpetrator (R16) from a resident shared dining room post witnessed verbal abuse. These failures affected three of four residents, ( R3, R4, and R17) reviewed for abuse, and two additional resident (R7 and R14) on the sample list of 18.Findings include:The facility-reported incident, final State Report, dated 01/16/26 documents that on 01/10/26 at 4:40 PM an allegation of verbal abuse was identified as follows: Resident (R16) to resident (R17) verbal exchange.The same facility-reported incident includes staff witness statements; however, it does not include interviews from other residents who may have been present at that end of the dining room.On 02/06/26 at 10:20 AM, R7 stated I was in the activity room by the dining room. I overheard (R16 and R17) one day in the dining room. (R16) yelled some pretty bad words at (R17). (R17) left crying. I can't repeat the words and can't pinpoint the day.On 02/06/26 at 11:00 AM, R14 stated There was a guy (R16) at my table (R14, R16, and R18 dine together). (R16) was cussing up a blue streak at another resident (R17) who was in the dining room to eat. It was not directed at me, but I thought the whole thing was uncalled for. That was a couple weeks ago, as I remember it.On 02/13/26 at 12:30 PM, R16 stated Hell yes, I put (R17) in his place. I yelled some harsh words because (R17) was talking to somebody in the kitchen and laughing. I thought he was laughing at me. I was with my girlfriend (R18), and we were in the dining room trying to eat. They were cutting up. (R17) came to me later crying and asked me if I was still his friend. I said yes we've been friends a long time. I just said yes because I wanted him to stop crying. (R18) and I finished eating our meals in the dining room and went down the hall to her room to visit. (R17) had been gone for probably 15 minutes before we left. I don't know if he came back to finish eating or not.On 02/13/26 at 12:40 PM, R18 stated: I was present when my fiance (R16) yelled at (R17). My fiance can get headstrong. He was really agitated because (R17) was laughing. He thought it was at him. He yelled some curse words. Staff talked to him about it already. Everything was okay after (R17) left the dining room and went into the activity room. I could see that (R17) was upset and crying as he left. We finished our lunch. About 15 or 20 minutes later we left the dining room and went down to my room to visit.R18 further stated the shared dining room had several other residents present who were spread throughout the room eating, but she was not sure of their names or who heard what.On 02/11/26 at 1:55 PM, V33, Dietary Assistant, stated she witnessed R16 verbally abuse R17 while other unidentified residents were present in the dining room.A second facility-reported incident, final State Report, dated 12/12/25 documents that on 12/08/25 at 11:20 AM an allegation of verbal abuse was identified as follows: Resident (R3) to resident (R4) verbal exchange.The same report documents the following disposition:Investigation initiated; final report to follow.Skin, pain, and trauma-informed care assessments were completed on both residents.Staff were educated on the Abuse, Prevention & Prohibition Policy.Statement from V50, Certified Nursing Assistant: While sitting at the nursing desk charting, (R3) was cursing out (R4). (R3) told him she hoped he chokes on his water and dies. (R4) asked if he heard her right. (R3) repeated it again and said, 'Yeah, I said it.' I told her that was not okay and removed her from the hall. I reported the incident to (V51), Assistant Director of Nursing, and (V1), Administrator/Abuse Prevention Coordinator.The report documents that R3 does not recall the incident.Statement from R4 I don't recall word for word what she said. I do know she wasn't very nice and cussed at me. I think she thought I was in her way or something.The same facility-reported incident does not include additional resident or staff interviews.On 02/11/26 at 3:05 PM, V1, Administrator/Abuse Prevention Coordinator, reviewed hard copies of the abuse allegation investigations and stated she observed that the investigations for R3/R4 and R16/R17 did not include witness statements from other residents, which is part of a thorough investigation. V1 also stated she thought R16 went directly to his room after the altercation. She further stated I was not in the building at the time. I had to go by what I heard when it was reported to me. I guess I just misunderstood. (R16) should not have been in the dining room at all after shouting profanities at (R17).

Based on interview and record review the facility failed repeatedly to provide the receiving supportive living facility complete and accurate personal identity, residents fund, Medicare and Social Security documents, and proof of purchase for a mobility device to ensure a resident continuity of care, and discharge occurred in a timely manner. This failure affected one of four residents (R2) reviewed for resident rights/discharge on the sample list of 18.Findings include:R2's most recent Diagnoses list documents the following:Diagnoses: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Foot Drop, Right Foot, Cerebral Infarction Unspecified, Aphasia Following Cerebral Infarction, Expressive Language Disorder, Major Depressive Disorder, Recurrent Pain Unspecified, and Unsteadiness on Feet.R2's Minimum Data Set (MDS) dated [DATE] documents R2 has no memory issues is marked (a Brief Interview of Mental Status assessment was not completed) The same MDS documents R2 and uses a manual wheelchair for mobility.R2's most recent Physician Order Sheet (POS) documents: Ok to d/c (discharge) to assisted living facility, will need wheelchair and cushion. No directions specified for order. Other 11/4/2025 (one month and 13 days before R2's discharge 12/17/25).R2's same POS documents the following: Discharge resident to assisted living facility. Resident requires a wheelchair for mobility due to Cerebral Infarction, Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side. Wheelchair size is 18 inches, x16 inches, x17 inches in height. Wheelchair cushions can be no thicker than 2 (two) inches. Bilateral swing away footrest. Order dated 11/7/2025 (one month and ten days before discharge). There is no documentation in R2's medical record to confirm a new wheelchair had or had not been ordered.R2's Discharge (D/C) Summary dated 12/17/2025 at 2:20 pm documents the following: Note Text: D/C education performed (sic) to res (resident R2), staff from (Local- Private Name, Supportive Care Facility) present and ready to transport res, res signed appropriate paperwork per facility protocol, meds (medication) sent w/res (with resident), res took w/c (wheelchair) (several years old, according to R2's interview below) and hemi-walker (specialized, assistive device for impaired cerebrovascular accident/CVA patients) on d/c as they belong to res, no further concerns at this time.On 1/22/26 at 2:10 pm this surveyor went to the local supportive living facility that R2 currently resides in. (R2) was in her apartment and answered her door in a wheelchair. The left arm of R2's wheelchair was visibly in disrepair. The plastic wall of the seat, holding the arm rest, was cracked in several pieces. There was an approximately two-inch section of the broken plastic wall that was bent inward. The end of the bent plastic was wrapped in a thin, elastic bandage tape and abutted R2's left hip. The same arm rest had an approximate five-inch chunk of plastic missing. The right arm rest was wrapped in a disposable thin, elastic bandage tape like wrap. R2's right arm was flaccid and laid across R2's lap. R2 stated I was not neglected, the issues I had with (Skilled Care Facility) was that they neglected to provide my paperwork, which delayed my discharge from (Skilled Care Facility) to (Supportive Care Facility) for months. They could not provide (Supportive Care Facility) with the paperwork needed for me to transfer. I waited months on end and asked (V1) the Administrator all the time. They also never got me my new wheelchair. R2 stated I asked, and I begged for a new wheelchair for months. Then in August, that is when I became eligible for Medicare, getting the facility (Skilled Care Facility) to submit my paperwork for the new wheelchair. It was supposedly in the works when I had Meridan Medicaid insurance. I continued to beg right up until I came here (Supportive Living Facility), (12/17/25). They ignored me. I talked to the (V1), Administrator, and she would say she would check into it. She never did. R2 then tugs at a very worn cushion in the wheelchair seat. You see, you see, this is bad, the cushion hurts my butt. The broken plastic here at the side of the wheelchair pokes me and hurts my hip. I have to be extra careful all the time, or I get jabbed. R2 then asked this surveyor to talk to (V21), Executive Director of (Supportive Living Facility). He will tell you how I waited and waited to get in here. He knows all about my chair problem too. (Skilled Care Facility) said at one time they were purchasing one and later said they did not. I hope you can sort this out. I am very uncomfortable in the one I am using. It is old and I have had it for years, since my stroke. R2 also stated (V22, Medicaid) my social worker has been involved with getting my wheelchair since October of 2023, I believe. She has been talking to (Skilled Care Facility), and no one seems to have the information. I had to come here with this broken-up wheelchair with the cracked-up, side panel. The cushion is worn tattered and flat. If you could talk to (V21) and (V22) they can give you all the updates. My chair has been the issue since early summer with Medicare (issues prior as documented below when on Medicaid), when they said they were ordering it again. I qualified to get one. I am still waiting. Just like I was put off for months to come to (Supportive Living) because (Skilled Care Facility) is not doing what they are supposed to do. I don't know how many times (V21) asked for the papers needed to come here. I believe it was back in January or February 2025. I asked a head (before) of August, when I was eligible (Medicare) and continued to ask the (V1) Administrator. She really ignored me.On 1/22/26 at 3:00 pm V21, Executive Director of (Supportive Living) stated We have experienced numerous delays by (Skilled Care Facility) in getting (R2's) documents in order for her to be admitted here in Supportive Living. (R2) turned 65, on 8/2/25. For months prior to that (8/2/25), we were attempting to get information from (Skilled Care Facility). They had no active Social Security card or the award letter for her. They couldn't figure out if she was Medicaid or private pay. Then when we asked for the balance of her funds that she had. The facility had no idea. (Skilled Care Facility) finally sent us a ledger with every resident on it. They blacked out the other residents' names on the ledger they were trying to send. Funds looked like they were all commingled with other residents' funds. They did not have separate documentation statement for their resident funds. It took months to put it all together. It was due to (Skilled Care Facility) not having the documents together to complete (R2's) admission packet that we had given them. We were very concerned. We weren't sure if (R2) had Medicare, Medicaid, Private Pay or what. V21 also stated She (R2) has mentioned the wheelchair since she got here (12/17/25), and before. Medicare will only cover one wheelchair every five years. The facility initially told us that they had initiated the purchase. We repeatedly asked prior to and before her admission on [DATE]. She could have been admitted on [DATE] had the facility provided the documents we requested. There were no care issues that we identified nor that (R2) had pointed out to us, other than the accommodating her need for a new wheelchair. It would be great to figure out if they have ordered it or if they have not, we are still trying to get the information from (Skilled Care Facility). We need to identify the next course of action. As you can see, (R2's) wheelchair is not appropriate. It is in serious disrepair. I have gone on (web-based store) and considered purchasing one for her. She admitted here last month. (Skilled Care Facility) has delayed information consistently, that they said would be provided. In the meantime, we have adjusted a cushion in the chair just to make the wheelchair she has somewhat more comfortable. It is not adequate. She has had a stroke and needs to be provided with the supportive cushion to adapts to her lean. As you can see, she has some kind of tape on the armrest. The plastic panel under the armrest is cracked and in part broken in pieces. (Skilled Care Facility) could not locate anything for her to use for the transition, while she is waiting on the new chair. She really wanted to be here, and she really qualified to be here. Had her documents been in order there (Skilled Care Facility), we could have made a smooth transition. The admission paperwork, Medicare and social security documents number, funds, and the wheelchair have been the issue.On 1/22/26 at 3:20 PM. V24, Director of Marketing/Sales Supportive Care facility and V23, Business Office Manager confirmed the Skilled care facility failed to provide R2's paperwork and purchase R2's wheelchair caused the delay in R2's admission to the Supportive Care facility since R2's eligibility 08/02/25.On 2/10/26 at 4:45 pm V1, Administrator confirmed R2's delay in discharge to the supportive living facility was due to paperwork, identification records and resident funds records had not been submitted to the supportive living facility by previous V28, Previous Skilled Care, Business Office Manager. V1, Administrator also confirmed the facility did not purchase R2's wheelchair and confirmed R2 requested repeatedly for the past year and had to discharge to the supportive living facility with R2's broken wheelchair.

Based on observation, interview and record review the facility repeatedly failed to ensure transportation and nursing preparation for dental appointments which resulted in a delay in dental extractions. These failures affected one of four residents (R7) reviewed for resident rights/quality of care on the sample list of 18.Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents that R7 has a Brief Interview of Mental Status score of 15 out of 15, indicating no cognitive impairment.R7's Care Plan dated 11/30/25 documents the following:Dental Care: R7 has poor dentition with obvious tooth decay and some broken teeth. He consumes regular-textured food without difficulty.Will be free from mouth pain for 90 days. Date initiated: 03/10/2023.Observe for complaints of mouth pain (e.g., difficulty chewing, refusal to eat or drink, grimacing, touching or rubbing affected area of face). Date initiated: 03/10/2023.Observe for unexplained weight loss that could be caused by mouth pain. Date initiated: 03/10/2023.Obtain dental consult PRN (as needed). Date initiated: 03/10/2023.Report any inflammation, swelling, or complaints of discomfort to the physician and family. Date initiated: 03/10/2023; revised 11/30/2025.R7's County Health Department Dental Clinic Medical Consultation Request, dated 5/12/25, documents: Hold Eliquis (blood-thinning medication) for 24 hours before extractions. The same consultation documents R7 will have multiple tooth extractions. Handwritten at the bottom of the consultation sheet documents a dental appointment scheduled for 9/3/25.On 2/06/26 at 10:20 a.m., R7 stated, I do have an issue with my dental appointments. (V26), the previous van driver-he still works here, but I don't know where-has had to reschedule appointments for my dental extractions so many times I can't count. As you see, I only have three teeth on the top. The other ones are all broken, and I only have three teeth on the bottom. The others are all broken off to my gums. R7 opened his mouth. He had multiple black and brown broken teeth that appeared as nubs at the gum level. R7 had three dark brown/black upper teeth and three brown/black lower teeth. The existing six teeth were chipped. R7 stated, I have learned how to eat with these bad teeth. I have little to no pain while I wait to have them all extracted and get my dentures.On 2/06/26 at 12:10 p.m., V26, Van Driver/Scheduler, stated, During the buyout, (Private Company) took over on 01/01/26. They are trying to research the insurance and title of the facility van. We have not been able to provide transportation for residents' appointments. I have visited residents and families and rescheduled appointments. All appointments have been rescheduled for the upcoming two, three, and four weeks. Some family members did take residents to appointments. (Local public transportation service) was supposed to meet with us last week. Weather dropped into low temperatures, and the roads were slick, and they closed. They have not met with us yet, but our plan is to use them. Part of the reason R7 missed dental appointments is because the county public health department had been remodeling around Christmas. We will be working with (Local public transportation service) to try to find him transportation to get his dental work completed. It has been on hold for a couple of months. He is not happy about that, but I'm doing the best I can to get it scheduled.V9, Regional Director, provided an email dated 02/16/26 at 3:46 p.m. documenting R7's dental appointments and reasons they were rescheduled.R7's dental appointments were documented as follows:5/12/25 - first visit (attended in person)9/3/25 - rescheduled because medications were not held10/1/25 - rescheduled because insurance was canceled2/10/26 - rescheduled because transportation was unavailable2/17/26 - appointment scheduled (see interview below; also rescheduled)On 2/17/26 at 12:25 p.m., V26, Van Driver/Scheduler, and V9, Regional Director/Acting Interim Administrator, entered the conference room together. V26 reviewed the appointment list provided by V9 and confirmed its accuracy. V26 stated the facility had to reschedule R7's dental appointment scheduled for that day (02/17/26) because he could not reach the local public transportation service for transportation. R7's appointment was rescheduled for March 5, 2026-10 months after the 5/12/25 visit when extractions were determined to be needed.V9 was present and confirmed R7's 9/3/25 appointment should have been kept, stating, The nurses should have been aware R7 was not to have the medications prior to the dental appointment. V9 also stated, About the 10/1/25 insurance issue, I will have (V49), Regional Business Office Manager, get back to you about this.On 2/17/26 at 1:05 p.m., V49, Regional Business Office Manager, stated, It was a mistake. R7 had active Medicaid coverage on 10/1/25, and he shouldn't have needed to reschedule that dental appointment.

Based on interview and record review, the facility failed to notify a resident's family, physician and Hospice after a change in residents' condition, post traumatic fall. This failure affected one of three residents (R1) reviewed for falls/change in conditon, on a sample list of 18.Findings include:R1's most recent diagnoses list includes the following: carcinoma of the left bronchus in situ, senile degeneration of the brain, chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, chronic kidney disease stage IV, unspecified muscle disorder, unsteadiness on feet, and lack of coordination.R1's most recent Physician Order Sheet documents: Admit to (private company) Hospice services related to adenocarcinoma of the left lung and bronchus. Prognosis: six months or less with normal disease progression. Start date: 7/15/25.R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status score was 5 out of 15, indicating severe cognitive impairment.R1's Fall Incident Report dated 12/06/25 at 7:30 p.m. documents V11, Licensed Practical Nurse (LPN), was R1's nurse and states, No notifications found.On 2/6/26 at 1:30 p.m., R1's family members, V7 and V8, stated neither of them had been notified of R1's fall on 12/06/25 until 12/07/25.On 2/06/26 at 2:45 p.m., V6, R1's Power of Attorney, stated she was not notified of R1's 12/06/25 fall until 12/07/25.On 2/6/26 at 3:20 p.m., V10, Licensed Practical Nurse (LPN), stated that when she arrived at work on 12/07/25, V11 reported during shift report that R1 had fallen the evening of 12/06/25 at 7:30 p.m. V11 also stated there was no documentation that she had notified a physician, hospice, or family member regarding R1's fall. V10 stated she attempted to reach family and hospice, and both arrived at the facility promptly. V10 also stated R1 was lethargic, unable to speak, and moaning during her 12/07/25 assessment.On 2/09/26 at 10:30 a.m., V5, Hospice Registered Nurse (RN), confirmed hospice was not notified of R1's fall that occurred on 12/06/25 at 7:30 p.m. until V10, LPN (day shift), notified hospice on 12/07/25 at approximately 8:00 a.m. V5 stated she then contacted R1's Power of Attorney (V6). V5 further stated, From my experience as a hospice nurse, (R1) had a concussion and likely a brain bleed. She was comatose post-fall and had changes in her swallowing and breathing. She showed no emotion. Had the facility called the night of the sixth (12/06/25), hospice staff would have been bedside to provide comfort and emotional support, as we did once we were notified.On 2/10/26 at 9:25 a.m., V2, Director of Nursing (DON), stated, R1's family should have been called immediately, as well as the provider and hospice. That is standard practice.On 2/13/26 at 2:25 p.m., V11, Licensed Practical Nurse (LPN), confirmed she was R1's nurse on 12/06/25 when R1 fell. V11 stated it was a hectic night, and she had not notified R1's family, physician, or hospice.The facility's Policy and Procedure: Fall Reduction Policy, revised 10/30/25, documents:4.) a. ii. Evaluate and assess the resident for injury. Guidelines will be utilized as appropriate to each situation and change in condition. Notify the physician Notify the responsible party Contact the on-call nurseThe (private company) Hospice Contract guidelines state: Services provided to the patient relating to the management of the terminal illness (CT scans, X-rays, lab work, additional procedures) may be provided to the hospice patient only with the express preauthorization of (private company) Hospice. Facility staff are to contact our Administrator on Call (AOC) for authorization. The AOC is available 24 hours a day, 7 days a week.

Based on interviews and record review, the facility failed to ensure R17 was free from witnessed resident to resident emotional and verbal abuse. R17 is one of four residents reviewed for abuse on the sample list of 18.Findings include:R16's Current Physician Order Sheet (POS) documents the following diagnoses and medication: Risperidone Oral Tablet 1 MG (milligram), Give 1 tablet by mouth at bedtime to take with 0.5 mg to equal 1.5 mg. Related to Undifferentiated Schizophrenia and Bipolar Disorder, Unspecified.R16's Minimum Data Set (MDS) dated [DATE] documents R16's Brief Interview of Mental Status (BIMS) score as 15 out of 15, indicating no cognitive impairment.R17's Current POS documents the following diagnoses and medications: Sertraline HCI Oral Tablet 50 MG, Give 1 tablet by mouth one time a day, Depression Unspecified, and Aripiprazole Oral Tablet 5 MG, Give 3 tablets by mouth one time a day for Antipsychotic - Unspecified Psychosis Not Due to a Substance Or Known Physiological Condition.R17's MDS dated [DATE] documents R17's BIMS score as 14 out of a possible 15, indicating no cognitive impairment.The facility-reported incident, final State Report dated 01/16/26 documents that on 01/10/26 at 4:40 pm an allegation of verbal abuse was identified as follows: Resident (R16) to resident (R17) verbal exchange.The same facility-reported incident, with witness statements, documents: Disposition:Skin and pain assessments were completed on both residents. 72-hour monitoring for s/s (signs and symptoms) of psychosocial distress was completed for both residents. All staff are educated on Resident Right to Be Free from Abuse, Neglect and Exploitation Policy.The same facility-reported incident documents the following typed (not handwritten) witness statements that omit some information this surveyor received in interviews and documented below. The facility-reported incident documents:Statement from (V35), Cook: Incident in the Dining Room. (V33, Dietary Assistant) and (R17) were joking with each other. (V16) became upset and yelled, shut the (F-expletive) up. I (V35) intervened. I informed (R17) that we cannot act like that in the dining room. I told him we all have to be nice. (R16) and (R18, R16's fiance) then decided to eat in their rooms.The same facility-reported incident documents:Statement from (V34, Dietary Assistant): I was doing my sub-list and I heard (R16) saying shut the (F-expletive) up when (R17) was laughing, and (R16) made (R17) upset, so he (R17) went back to his room and it (sic) calmed down and (sic) they wanted to eat in (R18's) room and (sic) they talked to the nurse, and I have no clue what happened after that because I was back to working and doing my sub-list.The same facility-reported incident documents:Statement from (V33, Dietary Assistant): At about 4:30 pm, (R17) came up for tea and (V35, Cook) said, 'Hey (R17), (V33) stinks,' then (R17) started laughing and we started to joke around with him. Then out of nowhere (R16) yelled, 'Shut the (F-expletive) up.' Originally I assumed this was directed at (R17), so I told him this is everyone's home, not just his. Then after that (V35) and other staff (unidentified) tried to de-escalate the situation.The same facility-reported incident documents:Statement from (R16): I did yell (sic) 'shut the (F-expletive) up.' I yelled because people were being loud and I had a headache. I didn't yell at anyone specifically, and it wasn't toward (R17) because he is my friend.The same facility-reported incident documents:Statement from (R17): I heard (R16) yell something. I don't know what it was. He was upset. He is my friend.The same facility-reported incident documents:(R16) is care planned for: (R16) has noted behavior of being aggressive with other residents. Known to yell or argue inappropriately with others. When others attempt to move (sic) from his behaviors, (R16) will, on occasion, follow them, continuing to be rude/inappropriate.Interventions in place: Staff will intervene when (R16) is having behaviors toward other residents. Staff will ensure that everyone is safe; staff will meet (R16's) nursing needs as needed, keeping (R16) safe; staff will monitor all inappropriate behaviors: type of behavior, time of day, what may have provoked behavior, staff present, how it was resolved, and whether it was effective.Both residents have been showing no s/s of psychosocial distress.On 2/06/26 at 10:20 am, R7 stated the following: I was in the activity room by the dining room. I overheard (R16 and R17) one day in the dining room. (R16) yelled some pretty bad words in there at (R17). (R17) left crying. I can't repeat the words and can't pinpoint the day.On 2/06/26 at 11:00 am, R14 stated, There was a guy (R16) at my (R14) table (R14, R16, and R18 dine together). (R16) was cussing up a blue streak at another resident (R17) who was in the dining room to eat. It was not directed at me, but I thought the whole thing was uncalled for. That was a couple weeks ago, as I remember it.On 2/10/26 at 9:25 am, V1, Administrator/Abuse Prevention, stated she had not had time to scan the investigation of the allegation that R16 verbally abused R17 in the dining room on 1/10/26. V1 stated, It happened, and I know you are waiting on the report.On 2/6/26 at 3:05 pm, R17 stated, It seems like I have talked to a lot of people about (R16) yelling at me in the dining room. I (R17) cried and went back to my room when he would not stop cussing at me. I thought he (R16) and I (R17) were friends. Friends don't use the F-word or tell you to shut up. I am not sure what his problem was that day. I was just hanging out in the dining room with the cooks while I waited on them to serve the food. I was overwhelmed at the time. I have depression. Yelling profanities at me does not help. I am tearing up (observed as he talked) now just talking about the ordeal.On 2/11/26 at 1:55 pm, V33, Dietary Assistant, stated, Yes, I witnessed (R16) verbally abuse (R17). It was awful. (R16) was in the dining room and started yelling (F-expletive) repeatedly. The dining room was half full. He was looking at (R17), who was engaged in conversation with one of the dietary staff. (R17) was laughing, and I think (R16) thought he was laughing at him. (R17) tried to go ahead and eat at his table. (R16) was sitting at his table eating. I told (R16) it was not okay for him to talk like that in the dining room around other people. I felt so bad for (R17). He (R17) started crying and ended up leaving the dining room about 5 minutes later.On 2/11/26 at 2:00 pm, V35, Cook, confirmed R16 yelled, Shut the (F-expletive) up, at R17, who left the dining room upset and crying.On 2/13/26 at 12:30 pm, R16 stated, Hell yes, I put (R17) in his place. I yelled some harsh words because (R17) was talking to somebody in the kitchen and he was laughing. I thought he was laughing at me. I was with my girlfriend (R18), and we were in the dining room trying to eat. They were cutting up. (R17) came to me later crying and asked me if I was still his friend. I said yes, we've been friends for a long time. I just said yes because I wanted him to stop crying. (R18) and I finished eating our meals in the dining room and went back down the hall to her room to visit. (R17) had been gone for probably 15 minutes before we left the dining room. I don't know if he came back down to finish eating or not.The facility policy Resident Right to Freedom from Abuse, Neglect and Exploitation dated 01/16/2023 documents the following:Policy StatementThe Facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility ( Associates).Policy Interpretation and ImplementationI. Associates must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion against any resident.II. The Facility will ensure that residents are free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.III. The Facility shall review altercations from resident to resident as a potential situation of abuse.A. Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to:a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating;b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects;c. Sexually aggressive behavior, such as saying sexual things, inappropriate touching/grabbing;d. Taking, touching, or rummaging through others' property; ande. Wandering into others' rooms/spaces.The same policy documents:IV. When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to:a. Taking steps to prevent further potential abuse;b. Reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations (see Elder Justice Act policy);c. Conducting a thorough investigation of the alleged violation; andd. Taking appropriate corrective action.

Based on observation, interview and record review the facility failed to obtain and arrange for a wheelchair replacement for a dependent resident. This failure resulted in R2's prolonged use of a wheelchair in disrepair. R2 is one of three residents reviewed for quality care and service on the sample list of 18.Findings include:R2's most recent Diagnoses List documents the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominant side; foot drop, right foot; Cerebral Infarction, unspecified; Aphasia following Cerebral Infarction; expressive language disorder; Major Depressive Disorder; recurrent pain, unspecified; and unsteadiness on feet.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has no memory issues and is marked as not having had a Brief Interview of Mental Status assessment completed. The MDS also documents R2 uses a manual wheelchair for mobility.R2's Medication Administration Record (MAR), dated December 2025, documents R2 required the following pain medication to maintain comfort: Tylenol 8-Hour Arthritis (an arthritic analgesic similar to regular Tylenol but with extended pain relief), oral tablet extended-release 650 mg, give one tablet by mouth one time a day for pain, scheduled at 5:00 a.m., and give one tablet by mouth one time a day. R2's MAR documents R2 was administered the pain medication as ordered by the physician until R2's 12/17/25 discharge.R2's most recent Physician Order Sheet (POS) documents: Ok to d/c (discharge) to assisted living facility; will need wheelchair and cushion. No directions specified for order. Other 11/4/2025 (one month and 13 days before R2's discharge on [DATE]).R2's same POS documents the following: Discharge resident to assisted living facility. Resident requires a wheelchair for mobility due to cerebral infarction; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side. Wheelchair size is 18 inches x 16 inches x 17 inches in height. Wheelchair cushions can be no thicker than two inches. Bilateral swing-away footrests. Order dated 11/7/2025 (one month and ten days before discharge).R2's Discharge summary dated [DATE] at 2:20 p.m. documents the following: Note Text: D/C education performed (sic) to res (resident R2); staff from (Local Private Name Supportive Care Facility) present and ready to transport res; res signed appropriate paperwork per facility protocol; meds sent w/res; res took w/c (wheelchair) (several years old, according to R2's interview below) and hemi-walker (specialized assistive device for impaired CVA patients) on d/c, as they belong to res; no further concerns at this time.On 1/22/26 at 2:10 p.m., this surveyor went to the local supportive living facility where R2 currently resides. R2 was in her apartment and answered her door in a wheelchair. The left arm of R2's wheelchair was visibly in disrepair. The plastic wall of the seat holding the armrest was cracked into several pieces. There was an approximately two-inch section of broken plastic bent inward. The end of the bent plastic was wrapped in thin elastic bandage tape and abutted R2's left hip. The same armrest had an approximately five-inch section of plastic missing. The right armrest was wrapped in a disposable, thin elastic bandage-type wrap. R2's right arm was flaccid and rested across her lap.R2 stated, I was not neglected. The issues I had with (Skilled Care Facility) were that they neglected to provide my paperwork, which delayed my discharge from (Skilled Care Facility) to (Supportive Care Facility) for months. They could not provide (Supportive Care Facility) with the paperwork needed for me to transfer. I waited months on end and asked (V1), the Administrator, all the time. They also never got me my new wheelchair.R2 stated, I asked and begged for a new wheelchair for months. Then, in August, that is when I became eligible for Medicare. Getting the facility to submit my paperwork for the new wheelchair was supposedly in the works when I had Meridian Medicaid insurance. I continued to beg right up until I came here (Supportive Living Facility) on 12/17/25. They ignored me. I talked to (V1), the Administrator, and she would say she would check into it. She never did.R2 then tugged at a very worn cushion in the wheelchair seat and stated, You see, you see, this is bad. The cushion hurts my butt. The broken plastic here at the side of the wheelchair pokes me and hurts my hip. I have to be extra careful all the time, or I get jabbed. R2 then asked this surveyor to speak to (V21), Executive Director of (Supportive Living Facility), stating, He will tell you how I waited and waited to get in here. He knows all about my chair problem too. (Skilled Care Facility) said at one time they were purchasing one and later said they did not. I hope you can sort this out. I am very uncomfortable in the one I am using. It is old and I have had it for years, since my stroke.R2 also stated, (V22), my social worker from Meridian Medicaid, has been involved with getting my wheelchair since October of 2023, I believe. She has been talking to (Skilled Care Facility), and no one seems to have the information. I had to come here with this broken wheelchair with the cracked side panel. The cushion is worn, tattered, and flat. If you could talk to (V21) and (V22), they can give you all the updates. My chair has been the issue since early summer with Medicare (issues prior as documented below when on Medicaid), when they said they were ordering it again. I qualified to get one. I am still waiting. Just like I was put off for months to come to (Supportive Living) because (Skilled Care Facility) is not doing what they are supposed to do. I don't know how many times (V21) asked for the papers needed to come here. I believe it was back in January or February 2025. I asked ahead of August, when I was eligible for Medicare, and continued to ask (V1), the Administrator. She really ignored me.On 2/10/26 at 12:50 p.m., V22, Community/Social Worker for Meridian Medicaid, stated that although R2 is no longer under Meridian Health Care, V22 had been R2's case manager for years while R2 resided in the skilled care facility. V22 stated, I had been trying to get R2 a new wheelchair since 9/12/22 (three years and five months ago). I had asked (Skilled Care Facility) repeatedly for paperwork needed. They gave me the runaround. Finally, I talked to one of the nurse practitioners (unidentified), who gave the order for a new wheelchair. R2's wheelchair was in bad shape. The wheelchair was cutting into her side. R2 even tried taping the plastic side together. I was hoping the wheelchair would be provided by the time she went to (Supportive Living). I came into (Skilled Care Facility) multiple times asking about her wheelchair. The last time I was there, I was told since R2 was now on Medicare as of her birthday (8/2/25), I had no role in her case. Meridian was not her insurance any longer.V22 also stated, I really tried to work with the nursing home (Skilled Care Facility). At first, they kept saying they lost the paperwork due to the old ownership of the facility. Then they repeatedly said the same thing once new ownership was in place. They couldn't provide the papers needed. Medicaid would have provided the new wheelchair had they done their part.On 2/10/26 at 4:45 p.m., V1, Administrator, confirmed R2's delay in discharge to the supportive living facility was due to paperwork, identification records, and resident funds records not being submitted to the supportive living facility by the previous facility's V28, Business Office Manager. V1 also confirmed the facility did not purchase R2's wheelchair and confirmed R2 had requested one repeatedly over the past year.

Based on record review and interviews, the facility failed to maintain complete and accurate medical records for two of 18 residents (R7 and R17) reviewed for accuracy of medical records on the sample list of 18.Findings include:1. R17's Minimum Data Set (MDS) dated [DATE] documents R17's BIMS score as 14 out of a possible 15, indicating no cognitive impairment.The facility reported incident, final State Report dated 01/16/26 documents that on 01/10/26 at 4:40 pm an allegation of verbal abuse was identified as follows: Resident (R16) to resident (R17) verbal exchange.There is no documentation in R17's medical record of the above resident-to-resident altercation that occurred on 01/10/26. There is no documentation that R17's crying episodes/ emotional response were being monitored.On 2/6/26 at 3:05 pm R17 stated It seems like, I have talked to a lot of people about (R16) yelling at me in the dining room. I (R17) cried and went back to my room, when he would not stop cussing at me. I thought he (R16) and I (R17) were friends. Friends don't use the F- word or tell you to shut up. I am not sure what his problem was that day. I was just hanging out in the dining room with the cooks while I waited on them to serve the food. I was overwhelmed at the time. I have depression. That, yelling profanities at me does not help. I am tearing up (observed as he talked) now just talking about the ordeal.On 2/13/26 at 9:50 am V1, Administrator/ Abuse Prevention Coordinator said the resident to resident altercation between R16 and R17 that occurred on 1/10/26 should have been documented in both residents charts. V1 stated also stated she was not aware until this time that there was no documentation in R17's medical records. V1 stated R17 should have been monitored for anxiety, fear and increased depression. 2. R7's Minimum Data Set (MDS) dated 11.28.25 documents R7 has a Brief Interview of mental Status score of 15 out of a possible 15 indicating R7 has no cognitive impairment.R7's same MDS documents R7 has no Obvious or likely cavity or broken natural teeth.R7's Care Plan updated 11.30.25 documents the following: Dental Care: (R7) has poor dentation with obvious tooth decay.On 2/06/26 at 10:20 am R7 stated he has dental issues with a plan to have all his teeth extracted and get dentures. R7, opens his mouth. R7 had multiple black and brown broken teeth that looked like nubs at the gum level. R7 has three dark brown/black colored upper teeth, and three brown/black lower teeth. R7's existing six teeth are chipped.On 2/13/26 at 11:55 am V1, Administrator confirmed R7 MDS was coded incorrectly and is incongruent with R7 other medical records and current health status. (R7) obviously has broken teeth.

Based on observation, interview and record review the facility failed to assess, provide timely treatment, provide complete urinary catheter care, prevent cross contamination during wound care for one (R10) resident out of four residents reviewed for Urinary Tract Infections (UTI) in a sample list of 17 residents. These failures resulted in R10 obtained a Penile wound at facility which caused pain, additional medicated treatment and additional specialty physician appointments. Findings include:R10's undated Face Sheet documents R10 admitted to the facility on [DATE] with medical diagnoses documented as Metabolic Encephalopathy, Chronic Heart Failure, Muscle Wasting and Atrophy, Need for Assistance for Personal Care, Chronic Kidney Disease, Morbid Obesity, Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Alzheimer's Disease, Obstructive and Reflux Uropathy, Retention of Urine and Urinary Tract Infection (UTI). R10's Minimum Data Set (MDS) dated [DATE] documents R10 as moderately cognitively impaired. This same MDS documents R10 requires moderate assistance with bathing, personal hygiene, transfer, maximum assistance with dressing and is dependent on staff for toileting. R10's Care Plan revised 1/6/2025 instructs staff to anchor indwelling catheter tubing high on R10's thigh to reduce pulling/tethering on the penis. R10's catheter should not be pulled tight. This same care plan documents R10 has redness on the tip of penis. Staff will monitor and inform wound care of skin.R10's Physician Order Sheet (POS) dated July 2025, and August 2025 documents a physician order starting 7/25/25 to apply Zinc cream to R10's penis twice a day. R10's Skin Sweep assessment dated [DATE] documents No Findings. R10's Nurse Progress Note dated 6/30/25 at 6:47 AM documents R10's head of Penis was red and excoriated with no drainage. This note documents wound nurse was notified of reddened area. R10's Nurse Progress Note dated 7/15/25 at 1:49 PM documents R10 complained of pain to his Penis. This note documents R10's head of Penis was excoriated. This note documents wound nurse was notified of reddened area. R10's Urology Progress Note dated 7/16/25 documents (R10's) Catheter NOT anchored!! Catheter changed and anchored to (R10) thigh. Make sure (catheter) is anchored properly to (R10) thigh. R10's Shower Sheet dated 7/22/25 documents R10's perineal area is red. This same sheet documents R10 complained of his perineal area as 'itchy'. R10's Shower Sheet dated 7/24/25 documents R10 was Bleeding from Penis at catheter site. This same shower sheet documents R10 was complaining of bleeding in his urinary incontinence brief and in 'lots of' pain. R10's Nurse Progress Note dated 7/24/25 at 4:27 PM documents R10's tip of Penis was reddened. This same note documents an order for Zinc was requested. R10's Weekly Skin Check dated 7/26/25 documents R10 has excoriation to his Penis. This same skin check does not include measurement, drainage, nor assessment of wound.R10's Shower Sheet dated 7/29/25 documents R10 was complaining of irritation at the head of his Penis. R10's Nurse Progress Notes dated 8/16/25 at 4:33 PM, 8/17/25 at 1:02 AM, 8/17/25 at 5:22 PM and 8/18/25 at 5:24 AM documents R10's physician ordered Zinc cream was not available to apply to R10's Penile wound. On 8/27/25 at 11:35 AM, V16 Certified Nurse Assistant (CNA) completed indwelling urinary catheter care and perineal care for R10. V16 CNA did not fully retract R10's Penile Foreskin when cleaning R10's Perineal area. R10's proximal head of his Penis was red, open with a small amount of bleeding. R10's indwelling urinary catheter was not secured to prevent tethering. On 8/27/25 at 11:50 AM V17 Registered Nurse (RN) completed R10's Penile wound treatment. V17 RN did not change gloves nor perform hand hygiene between cleansing R10's Penile wound and applying R10's prescribed Zinc cream. V17 RN did not fully retract R10's Penile Foreskin to fully expose R10's filleted Penile wound. V17 RN applied R10's Zinc cream with contaminated glove used to cleanse blood from R10's filleted Penile wound. On 8/27/25 at 12:10 PM, V16 Certified Nurse Assistant (CNA) stated she did not fully retract R10's Penile Foreskin for cleansing due to R10's filleted Penile wound was bleeding. V16 CNA stated R10's entire area should have been cleansed including underneath R10's Penile Foreskin.On 8/27/25 at 12:15 PM, V17 Registered Nurse (RN) stated she forgot to wash her hands after cleansing R10's fillet Penile wound and prior to applying R10's Zinc treatment. V17 RN stated she should have not used her gloves to apply R10's cream. V17 RN stated she was unable to see R10's entire filleting of R10's Penis due to she did not fully retract R10's Penile Foreskin. On 8/29/25 at 1:40 PM, V2 Director of Nursing (DON) stated R10 did not admit to the facility with any Penile wounds. V2 DON stated R10 should have his catheter secured at all times to prevent tethering. V2 DON stated R10's Penile wound is directly caused by the constant pulling of his urinary catheter. V2 DON stated there is no reason the facility should be out of a commonly product such as Zinc Oxide. V2 DON stated R10's Zinc is a physician order and should be followed. V2 DON stated R10's Penile wound has worsened while R10 as stayed at this facility. V2 DON stated the facility is not able to provide any documentation of R10's Penile wound assessment and/or monitoring. R10's Physician Order Sheet (POS) dated July 2025, and August 2025 documents a physician order starting 7/25/25 to apply Zinc cream to R10's penis twice a day. The facility policy titled Urinary Catheter Care approved December 2024 documents staff are to secure the catheter after providing catheter care. This same policy instructs staff to ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. Catheter tubing should be strapped to the resident's inner thigh. The undated facility Skills Checklist for Changing Dressing/Treatment instructs staff to wash and dry hands thoroughly after cleansing wound and prior to applying new gloves to apply treatment.

Based on interview and record review the facility failed to ensure the dignity of one (R8) resident out of three residents reviewed for resident rights in a sample list of 17 residents. Findings include: R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. R8's Nurse Progress Note dated 8/17/2025 at 12:24 PM documents R8 was crying, stating staff was not listening, laughing at her (R8) and stated she (R8) wanted to leave Against Medical Advice (AMA). On 8/27/25 at 10:00 AM, R8 stated on 8/13/25 she was worried about R9 since R8 heard R9 screaming so loud. R8 stated she got herself up into her motorized wheelchair and went out to the hall. R8 stated V2 Director of Nursing (DON) was yelling and laughing at her (R8) because she was concerned about R9. R8 stated R8 had an abscessed tooth on the upper Left back side in her mouth. R8 stated she woke up one day (8/17/25) and 'the whole Left side of my face was swollen out to here' (pointing to Left cheek area). R8 stated R8 was telling the staff (V2 DON, V14 LPN and V20 LPN) about this and the staff yelled and laughed at her. R8 stated 'They (staff) were all laughing at me. It made me feel so sad.' On 8/27/25 at 1:50 PM, V1 Administrator stated staff should always treat residents with dignity and respect. V1 stated the staff should be more aware of residents. V1 stated R8 was not abused but the staff should be more aware of their conversations when residents are within earshot. The facility policy approved December 2024 documents each resident in this community has the right and will be afforded the right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. No staff member or contracted provider of care will hamper, compel, treat differently or retaliate against a resident for exercising Resident Rights.

Based on interview and record review the facility failed to protect the rights of the residents to be free from verbal/emotional abuse from staff and other residents. This failure affected seven of eight residents (R2, R4, R5, R6, R7, R9, R13) reviewed for abuse on the sample list of 17. Findings Include: 1. R2's Medical Diagnosis List dated August 2025 documents R2 is diagnosed with Epilepsy. R2's Care Plan dated 7/26/25 documents R2 has a diagnosis of Seizure Disorder. Staff are to administer medications, protect from onlookers, provide post seizure treatment, and take vital signs and do neuro checks post seizure. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact. On 8/29/25 at 12:15 PM, R2 stated V13 Licensed Practical Nurse (LPN) often tells others that he is faking his seizures. R2 stated this makes him feel upset and mad. R2 stated he (R2) does not fake his seizures, and it is embarrassing that the nurse doesn't believe that he (R2) is dealing with seizures. R2 stated he believes V13 hates his guts. R2 stated he is not stupid, and he knows V13 doesn't really care about him. The Incident Report Investigation dated 8/4/25 documents on 8/4/25 R2 alleged abuse by V13 Licensed Practical Nurse (LPN). On 8/29/25 at 10:34 AM, V9 Certified Nurse Assistant (CNA) stated on 8/4/25, she walked up to the nurse's station, R2 was sitting in a chair behind where V13 was standing. V13 Licensed Practical Nurse (LPN) asked V9 to get R2's vital signs because R2 was having a seizure, and his arms were shaking and moving. R2's head was down, and he was not responding. V9 stated V13 LPN turned around and bent down in front of R2. V13 picked up R2's head and opened his eyelid. V9 stated at that point V13 said R2 was fine, and he was faking it and if you look at his pupils you can tell. V13 claimed R2 was faking his seizures and repeated these many times in front of R2. On 8/29/25 at 12:40 PM, V1 Administrator confirmed staff should never be accuse a resident of faking a seizure. V1 confirmed this could be very upsetting for R2 and could be considered emotional abuse. 2. R4's Medical Diagnosis List dated August 2025 documents R4 is diagnosed with Neurocognitive Disorder with Lewy Bodies and Dementia with Psychotic Disturbance. R4's Care Plan dated 8/29/25 documents R4 has behavior concerns related to aggression towards staff and other residents. R4 is at risk for wandering. R4's Minimum Data Set, dated [DATE] documents R4 is severely cognitively impaired. 3. R5's Medical Diagnosis List dated August 2025 documents R5 is diagnosed with Surgical Aftercare for Left Femur Fracture. R5's Minimum Data Set, dated [DATE] documents R2 is cognitively intact. On 8/27/25 at 2:31, PM V11 Certified Nurse's Assistant (CNA) stated on 7/22/25 she was standing at the nurse's station when she heard R5 yell for someone to get out of her room. V11 stated she began to walk towards R5 and entered R5's room. R4 was in R5's room and R5 was telling R4 to get out. R4 responded by telling R5 she would whoop her a** (expletive). R5 responded by calling R4 a wench. On 8/29/25 at 12:40 PM, V1 Administrator confirmed R4 and R5 had a verbal altercation and required separation from staff. V1 confirmed the altercation could be considered verbal abuse. 4. R6's Medical Diagnosis List dated August 2025 documents R6 is diagnosed with Panic Disorder, Mild Cognitive Impairment, Psychotic Disturbance, Mood Disorder, and Anxiety. R6's Care Plan dated 7/3/25 documents R6 has a diagnoses of impaired cognitive function/dementia or impaired thought processes. R6's Minimum Data Set, dated [DATE] documents R6 is moderately cognitively impaired. The Incident Report Investigation dated 7/6/25 documents alleged abuse occurred involving V3 CNA and R6. On 8/27/25 at 2:31 PM, V11 Certified Nurse Assistant (CNA) stated R6 does not enjoy eating in the dining room and if she does agree to eat in the dining room, she likes to leave right after she is done eating. V11 stated on 7/6/25 V3 Certified Nurse's Assistant entered the dining room directly after R6 had finished eating and was about to leave the dining room. V3 proceeded to stop R6 from exiting and attempted to feed R6 more food. R6 refused and began to get agitated however V3 continued to agitate R6 and would not allow R6 to leave the dining room. V11 stated it seemed as though V3 wanted to agitate R6 and was trying to get a reaction from her. V11 stated she got up and attempted to help R6 move away from V3 however V3 told V11 that R6 could not leave and needed to stay in the dining room until everyone else was done eating. V11 stated at that moment V10 CNA approached R6 and told her she was needed in her room for an intravenous treatment. V3 then began to laugh and got up in R6's face and said, “Haha, you have to go get poked”. V11 stated R6 appeared visibly upset and irritated. V11 confirmed she believes V3 was mentally abusive to R6 by being intimidating and controlling. On 8/29/25 at 10:14 AM, V10 CNA stated on 7/6/25 she went to retrieve R6 from the dining room for an intravenous treatment. When V10 approached R6, V3 stated R6 needed to stay in the dining room until everyone else was done eating. V10 stated V3 had her feet up on R6's wheelchair as if she was keeping her there. V10 stated V3 was being very rude and when V10 told them why she was taking R6 to her room, V3 replied by getting inches away from R6's face and saying, “Haha, you have to go get poked”. V10 confirmed she believes this could be considered mental or emotionally abusive behavior by V3. On 8/29/25 at 12:40 PM, V1 Administrator confirmed V3 was suspended pending an investigation related to her mistreatment of R6. After the investigation it was determined V3 would be terminated. V1 confirmed the facility does not tolerate resident mistreatment. 5. R7's Medical Diagnosis List dated August 2025 documents R7 is diagnosed with Dementia with Behavioral Disturbances, Repeated Falls, Parkinson's Disease, Unsteadiness on Feet, and Need for Assistance with Personal Care. R7's Care Plan dated 7/3/25 documents R7 requires assistance with Activities of Daily Living and Self Care related to a self-care deficit. R7's Minimum Data Set, dated [DATE] documents R7 is severely cognitively impaired. The Incident Report Investigation dated 7/6/25 documents alleged abuse occurred involving V3 CNA and R7. On 8/29/25 at 10:34 AM, V9 Certified Nurse Assistant (CNA) stated on 7/6/25 she assisted R7 to the bathroom. V9 stated R7 seemed a bit more tired than usual so she asked for help from another CNA V3. V3 laughed in V9's face and asked why V9 toileted R7. V9 stated she always toilets R7 before bed. V3 came over to provide physical assistance and V9 and V3 assisted R7 in standing up. V9 stated R7 is slow moving, and V3 did not want to wait for him to move so she shoved him over to turn his hips so he could sit down. V9 stated she told V3 that she didn't want R7 to fall, and V3 replied she didn't give a f*** (expletive) if he falls because she won't get in trouble anyway. V9 stated V3 said this in front of R7. V9 confirmed this could be considered abuse. On 8/29/25 at 12:40 PM, V1 Administrator confirmed V3 was suspended pending an investigation related to her mistreatment of R7. After the investigation it was determined V3 would be terminated. V1 confirmed the facility does not tolerate resident mistreatment. The Employee Corrective Action Form dated 7/6/25 documents V3 was terminated for cursing near residents and providing discourteous care of residents. 6. R13's undated Face Sheet documents medical diagnoses as Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant side, Anxiety Disorder, Paroxysmal Tachycardia, Atrial Fibrillation, History of Falling and Dependence on Wheelchair. R13's Minimum Data Set (MDS) dated [DATE] documents R13 as cognitively intact. This same MDS documents R13 as requiring supervision with eating, maximum assistance with bathing, dressing, personal hygiene, bed mobility and is dependent on staff for toileting. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as severely cognitively impaired. This same MDS documents R9 requires supervision with eating and moderate assistance with transfers. R13's Initial Report to the State Agency dated 8/14/25 documents R9 cursed at R13 on 8/14/25. On 8/29/25 at 1:25 PM, R13 stated he resides on the same hall as R9. R13 stated the morning of 8/14/25 R9 was in the dining room ‘yelling and cussing at everyone'. R13 stated R9 then passed R13 in the hallway and R9 yelled ‘Stupid B****' (expletive) at R13. R13 stated R9 called him other curse words that morning and at other times also. R13 stated R13 is not afraid of R9 but does not like to be called bad names. R13 stated R9 also called R13 a ‘stupid b******' (expletive) that same morning. On 8/29/25 at 1:36 PM, V16 Certified Nurse Assistant (CNA) stated R9 cursed at R13 the morning of 8/14/25. V16 CNA stated R9 was having behaviors that morning when R9 was in the hallway as R13 yelled curse words at R9. On 8/29/25 at 11:00 AM, V1 Administrator stated R9 is known to have violent outbursts with yelling, cursing and throwing items. V1 Administrator stated on 8/14/25, R9 was upset because his pencil sharpener was missing. V1 Administrator stated R9 yells out regardless of who is around. V1 Administrator stated that morning (8/14/25) R9 intentionally yelled curse words at R13. The facility policy titled Abuse, Prevention & Prohibition Policy approved December 2024 documents each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate a person “in charge” in their absence to fulfill the role. This person would normally be the Director of Nursing. Resident to resident abuse includes the term “willful”. The work “willful” means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within the hearing distance regardless of their age, ability to comprehend, or disability. Mental abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Mental abuse includes but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident.

Based on interview and record review the facility failed to report allegations of mental abuse on two separate occasions affecting one (R8) resident from staff interactions to the State Agency timely out of three residents reviewed for Abuse in a sample list of 17 residents. Findings include:R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. R8's Nurse Progress Note dated 8/17/2025 at 12:24 PM documents R8 was crying, stating staff was not listening, laughing at her and states she wanted to leave Against Medical Advice (AMA). On 8/26/25 at 12:10 PM, V1 Administrator was informed of an allegation of mental abuse of R8 from staff V2 Director of Nursing (DON), V14 Licensed Practical Nurse (LPN) and V20 LPN on 8/13/25. V1 stated this allegation was never reported to the State Agency. On 8/27/25 at 1:40 PM, V1 Administrator stated she was not made aware of R8's allegation of mental abuse from staff on 8/13/25 nor 8/17/25. V1 stated she was made aware through her own record review of R8 on 8/27/25. V1 Administrator stated staff should always report any allegation of abuse directly to the Administrator. The facility policy titled Abuse, Prevention & Prohibition Policy approved December 2024 documents each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available to address this role, the Administrator will designate a person in charge in their absence to fulfill the role. This person would normally be the Director of Nursing. Resident abuse must be reported immediately to the Administrator. The Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action.

Based on observation, interview, and record review, the facility failed to effectively supervise an unalarmed and unlocked facility exit door. This failure resulted in R3, a resident with a diagnosis of Dementia, eloping unnoticed from the facility and exiting through the facility courtyard towards the facility parking lot area. The facility also failed to identify and document any root-cause for R3's elopement in their elopement investigation. R3 is one of three residents reviewed for supervision in the sample of 17. Findings include: R3's Medical Diagnosis sheet (8/27/2025) documents R3's diagnoses including Dementia, Weakness, Muscle Wasting and Atrophy, and Unsteadiness on Feet. R3's Orders sheet (8/27/2025) documents the order May be up ad-lib (at liberty) per plan of care. R3's Elopement Assessment (6/4/2025) documents R3 is cognitively impaired, independently mobile, and has the elopement risk factor of a recent mental status change. R3's Resident Assessment (6/10/2025) documents R3 has severe cognitive impairment.R3's Care Plan (8/27/2025) documents R3 only requires a minimal level of staff assistance as needed for ambulation.The facility incident report (8/8/2025) documents V5 (Certified Nursing Assistant) noticed R3 walking on a sidewalk outside of the facility on 8/2/2025 and retrieved R3 back into the facility and to R3's bedroom. On 8/27/2025 at 1:45PM, V5 reported being in R15's room on 8/2/2025 providing care to R15 and when V5 looked through R15's window, R3 was visible outside of the facility walking down a sidewalk along the side of the building with R3's walker. V5 reported immediately going outside to retrieve R3 back inside of the facility with R3 stating to V5 at the time it's a beautiful day outside and I just got turned around and need to go home. V5 reported turning R3 around to go back into the facility and R3 then stated Oh, there's my home. V5 denied any door alarms were sounding when R3 eloped from the facility. V5 reported R3 must have exited the building through an exit door located in the hallway near R3's room leading to a courtyard and then out of the courtyard to the sidewalk where V5 found R3. V5 reported the courtyard has a swinging gate that leads to a sidewalk located along the exterior building perimeter and the gate was unlocked and open the day R3 eloped due to the facility mowing contractor being in and out of the courtyard area to [NAME] grass. V3 reported R3 ambulates independently and R3's cognition is so-so and hit or miss. V5 reported the hallway exit door to the courtyard was always kept unlocked and unalarmed so residents who smoke independently could access the facility smoking area located inside of the courtyard without staff supervision. On 8/29/2025 at 10:48AM, the swinging gate leading from the above courtyard to the sidewalk and building exterior was closed but unlocked and easily opened by the surveyor. The facility Elopement policy (June 2025) documents It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible and Should an elopement occur, the facility's QAPI Committee shall determine the root cause of the elopement and review the facility's systems, policies and procedures, and responses to elopements to identify areas of opportunity for improvement.The facility's Elopement investigation related to R3's 8/2/2025 elopement does not identify or document any root cause for R3's elopement occurring on 8/2/2025 and does not document the hallway exit door above was unsupervised, unlocked, and unalarmed when R3 eloped from the facility. The same investigation fails to document the courtyard exit gate was unlocked at the time of R3's elopement.

Based on interview and record review, the facility failed to document a resident (R3) elopement and subsequent investigation in the resident's medical record. This failure affects one resident (R3) of three reviewed for elopement in the sample of 17.Findings include:R3's Medical Diagnosis sheet (8/27/2025) documents R3's diagnoses including Dementia, Weakness, Muscle Wasting and Atrophy, and Unsteadiness on Feet. R3's Orders sheet (8/27/2025) documents the order May be up ad-lib (at liberty) per plan of care. R3's Elopement Assessment (6/4/2025) documents R3 is cognitively impaired, independently mobile, and has the elopement risk factor of a recent mental status change.R3's Resident Assessment (6/10/2025) documents R3 has severe cognitive impairment.R3's Care Plan (8/27/2025) documents R3 only requires a minimal level of staff assistance as needed for ambulation.The facility incident report (8/8/2025) documents V5 (Certified Nursing Assistant) noticed R3 walking on a sidewalk outside of the facility on 8/2/2025 and retrieved R3 back into the facility and to R3's bedroom. On 8/27/2025 at 1:45PM, V5 reported being in R15's room on 8/2/2025 providing care to R15 and when V5 looked through R15's window, R3 was visible outside of the facility walking down a sidewalk along the side of the building with R3's walker. V5 reported immediately going outside to retrieve R3 back inside of the facility with R3 stating to V5 at the time it's a beautiful day outside and I just got turned around and need to go home. V5 reported turning R3 around to go back into the facility and R3 then stated Oh, there's my home. V5 denied any door alarms were sounding when R3 eloped from the facility. V5 reported R3 must have exited the building through an exit door located in the hallway near R3's room leading to a courtyard and then out of the courtyard to the sidewalk where V5 found R3. V5 reported the courtyard has a swinging gate that leads to a sidewalk located along the exterior building perimeter and the gate was unlocked and open the day R3 eloped due to the facility mowing contractor being in and out of the courtyard area to [NAME] grass. V3 reported R3 ambulates independently and R3's cognition is so-so and hit or miss. V5 reported the hallway exit door to the courtyard was always kept unlocked and unalarmed so residents who smoke independently could access the facility smoking area located inside of the courtyard without staff supervision. On 8/29/2025 at 10:48AM, the swinging gate leading from the above courtyard to the sidewalk and building exterior was closed but unlocked and easily opened by the surveyor. The facility Elopement policy (June 2025) documents It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible and Should an elopement occur, the facility's QAPI Committee shall determine the root cause of the elopement and review the facility's systems, policies and procedures, and responses to elopements to identify areas of opportunity for improvement.The facility's Elopement investigation related to R3's 8/2/2025 elopement does not identify or document any root cause for R3's elopement occurring on 8/2/2025 and does not document the hallway exit door above was unsupervised, unlocked, and unalarmed when R3 eloped from the facility. The same investigation fails to document the unlocked courtyard exit gate was unlocked at the time of R3's elopement.On 8/29/2025 at 1:23PM, V2 (Director of Nursing) reported being unsure if R3's medical record in the facility documented R3's elopement occurring on 8/2/2025.R3's nursing progress notes (August 2025) do not document R3's elopement.R3's electronic medical record (undated/accessed 9/2/2025) does not document R3's elopement incident on 8/2/2025.On 9/2/2025 at 1:32PM, V2 reported V2 would look again in R3's medical record for documentation of the elopement and V2 reported being unsure if the elopement was documented anywhere except in the Risk section of R3's electronic medical record (a portion of R3's EMR not normally accessible to medical staff or nursing staff).

Based on observation, interview and record review the facility failed to wear the proper Personal Protective Equipment (PPE) for one (R8) resident on Enhanced Barrier Precautions (EBP) out of three residents reviewed for Urinary Tract Infections (UTI) in a sample list of 17 residents. Findings include:R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. This same MDS documents R8 as requiring maximum assistance for toileting and moderate assistance for dressing, personal hygiene and bathing.R8's Electronic Medical Record (EMR) documents R8 is on Enhanced Barrier Precautions (EBP) due to R8 having a history of a Multi Drug Resistant Organism (MDRO) and currently has an indwelling urinary catheter. On 8/27/25 at 2:00 PM, V15 and V16 Certified Nurse Assistants (CNA) provided indwelling urinary catheter care and perineal care for R8. R8 had a sign on the wall outside her door next to the floor that read 'Enhanced Barrier Precautions' (EBP). V15 and V16 did not wear gowns when providing direct catheter care and perineal care for R8. V16 CNA emptied R8's urinary drainage bag which contained 450 milliliters (ml) of dark orange, hazy urine without wearing a gown. R8's room did not contain any disposal bins for contaminated Personal Protective Equipment (PPE). R8's garbage cans inside her room did not contain any PPE that had been disposed of. On 8/27/25 at 2:20 PM, V15 and V16 Certified Nurse Assistants (CNA) both stated they should have worn gowns when providing direct cares for R8. V16 CNA stated not wearing the proper PPE could result in cross contamination to other residents. On 8/29/25 at 10:45 AM, V21 Assistant Director of Nursing (ADON)/Infection Preventionist (IP)/Registered Nurse (RN) stated staff should wear the appropriate Personal Protective Equipment (PPE) when providing direct cares such as indwelling urinary catheter care, perineal care and emptying of a resident's urinary drainage bag. V21 stated the purpose behind a resident being placed on EBP is due to that resident has had a history of a Multi Drug Resistant Organism (MDRO) and/or has an indwelling device. V21 stated R8 has both a history of MDRO and has an indwelling urinary catheter. V21 stated R8 is high risk for obtaining another infection which could be spread if the staff do not wear the proper PPE. The undated facility policy titled Infection Prevention and Control Manual-Enhanced Barrier Precautions (EBP) documents EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a Multi Drug Resistant Organism (MDRO) as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). High-contact resident care activities where a gown and gloves should be used include providing hygiene, caring for or using an indwelling medical device and performing wound care.

Based on interview and record review the facility failed to notify the physician of pressure ulcers present on admission for one resident (R1) of three residents reviewed for pressure ulcers in a sample list of three residents. This failure caused one resident (R1) to suffer due to untreated deep tissue injury and Stage three pressure ulcer for 19 days. Findings include: The facility's policy Notification for change in resident's condition or status revised [DATE] states The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etc) of changes in the resident's medical/mental condition and/or status. 1 The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: o. Onset of pressure ulcers or stasis ulcers. R1's Order Summary Report dated [DATE] includes the following diagnoses: Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Major Depression, Type II Diabetes, Heart Disease, Melanoma, Lung Cancer, and Peripheral Vascular Disease. R1's Braden Scale dated [DATE] documents R1 was at high risk for skin breakdown and was admitted to facility with deep tissue injury of Right buttock. R1's Dietary Note dated [DATE] documents R1 was admitted with a Stage III (pressure ulcer) left heel. There is no documentation to support R1's skin issues were ever reported to the doctor or treatment was initiated. R1's Treatment Administration Record (TAR) for January or February 2023 does not document any treatment was administered for R1's two pressure ulcers - left heel and right buttock. R1's consultation report dated [DATE] by V9, Infectious Disease Physician upon admission to the hospital documents (R1) was admitted with Decubitus Ulcers to Sacrococcygeal area and Left heel Stage III or stage IV and a Deep Tissue injury to right foot On [DATE] at 2:00PM V4, R1's family member stated (R1) had pressure sores since before (R1) went to the hospital. (R1) was at another nursing home owned by the same company. After (R1) went to the hospital that facility couldn't do the intravenous (IV) fluids so (R1) came here temporarily to get the IV. (R1) was supposed to go back to the other facility once he got the IVs. (R1) got the pressure sores at the other nursing home. (R1) went to the hospital from this facility on [DATE]. (R1) died on [DATE] at the hospital. I think he died of a respiratory infection. On [DATE] at 10:00AM V2, Director of Nursing (DON) stated When (R1) came back to us (R1) was positive for COVID-19 and he was on contact precautions. Also (R1) had systemic Inflammatory Response Syndrome (SIRS). (R1) needed IV antibiotics. (R1) came to us from our sister facility. (R1) was to go back there after his IV antibiotic was complete. It wasn't on the hospital transfer that (R1) had any skin issues or pressure ulcer treatments. I see where it is documented in the dietary notes [DATE] (R1) had a Stage III pressure ulcer to (R1's) heel and I see (R1's) Braden [DATE] documents a Deep Tissue Injury to (R1's) Buttocks. V2 stated (R1) was never seen by the wound doctor. The wound doctor was not notified of (R1's) wounds. On [DATE] at 3:25PM V7, Corporate Nurse verified the Stage III pressure area on R1's left heel and the Deep tissue injury on R1's right buttocks were documented upon admission. However, there is no documentation that the wound were ever assessed or measured or a treatment was ever initiated or that a physician was notified. On [DATE] at 3:30 V8, Attending Physician stated As far as I know the Nurse Practitioner or me were not notified of the pressure ulcers (R1) was admitted with. I would expect to be notified or the Nurse Practitioner so we could order appropriate treatment. I would say if the wounds were not treated from [DATE] until [DATE] they would have deteriorated. It is the standard of practice wounds are assessed and treated and reassessed.

Based on observation, interview, and record review the facility failed to assess, treat, and initiate interventions for a resident having pressure ulcers. This failure affects one (R1) of three residents reviewed for pressure ulcers in a sample list of three residents. This failure caused R1 to suffer from an untreated Deep Tissue Injury and Stage Three Pressure Ulcer for 19 days. Findings include: The facility's policy Decubitus Care/Pressure Areas revised [DATE] states Policy: It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Responsibility: Licensed Nursing Personnel. Procedure: 1) Upon notification of skin breakdown, the QA form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses. 2) The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record. 3) Complete all areas of the Treatment Administration Record or Wound Documentation Record. I) Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician) ii) Document the stages of the pressure ulcer as follows: (a) Suspected deep tissue injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. (B) Stage I: redness, which does not resolve 30 minutes after pressure is relieved, no broken skin (c) Stage II: broken skin, an abrasion, blister or shallow crater (d) Stage III: broken skin, affects full thickness and presents as a deep crater (e) Stage IV: broken skin, muscle and/or bone exposed iii) Document the color according to the following: (a) Red: pale pink to beefy red with or without healthy granulation tissue (b) Yellow: whitish yellow, creamy-yellow, yellow-green, or beige (c) Black: black, stringy gray or gray scab 4) Notify the physician for treatment orders. The physician ' s orders should include: i) Type of treatment ii) Frequency treatment is to be performed iii) How to cleanse, if needed iv) Site of application v) No PRN order is acceptable for a pressure ulcer. The order must have specific frequencies. vi) Initiate physician order on treatment sheet 5) Documentation of the pressure area must occur upon identification and at least once each week on the TAR or Wound Documentation Form. The assessment must include: i) Characteristic (i.e., size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) Treatment and response to treatment 6) Reevaluate the treatment for response at least every two (2) to four (4) weeks. Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order. 7) Nursing personnel are to notify dietary personnel of any pressure areas to seek nutritional support and monthly reviews by the Registered Dietician. 8) When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers. R1's Order Summary Report dated [DATE] includes the following diagnoses: Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Major Depression, Type II Diabetes, Heart Disease, Melanoma, Lung Cancer, and Peripheral Vascular Disease. R1's Braden Scale dated [DATE] documents R1 was at high risk for skin breakdown was admitted to facility with deep tissue injury of Right buttock. R1's Dietary Note dated [DATE] documents R1 was admitted with Stage III (pressure ulcer) left heel. Surveyor notes no skin/wound assessments or measurements are documented for R1 during his stay at the facility. The facility's Admission/discharge summary for the past three months document R1 was admitted to the facility [DATE] and discharged [DATE]. He was then taken to the emergency room at the local hospital. There is no documentation to support R's skin issues were ever reported to the doctor or treatment was initiated. R1's Treatment Administration Record (TAR) for January or February document any treatment was administered for the two pressure ulcers-left heel and right buttock. R1's consultation report dated [DATE] by V9, Infectious Disease Physician upon admission to the hospital documents (R1) was admitted with Decubitus Ulcers to Sacrococcygeal area and Left heel Stage III or stage IV and a Deep Tissue injury to right foot On [DATE] at 2:00PM V4, R1's family member stated (R1) had pressure sore since before (R1) went to the hospital. (R1) was at another nursing home owned by the same company. After (R1) went to the hospital that facility couldn't do the intravenous (IV) fluids so (R1) came here temporarily to get the IV. R1) was supposed to go back to the other facility once he got the IVs. (R1) got the pressure sores at the other nursing home. (R1) went to the hospital from this facility on [DATE]. (R1) died on [DATE] at the hospital. I think he died of a respiratory infection. On [DATE] at 10:00AM V2, Director of Nursing (DON) stated When (R1) came back to us (R1) was positive for COVID-19 and he was on contact precautions. (R1) had systemic Inflammatory Response Syndrome (SIRS). (R1) needed IV antibiotics. (R1) came to us from our sister facility. (R1) was to go back there after his antibiotic IV was complete. It wasn't on the hospital transfer that (R1) had any skin issues or pressure ulcer treatments. I see where it is documented in the dietary notes [DATE] (R1) had a Stage III pressure ulcer to (R1's) heel and I see (R1's) Braden [DATE] documents a Deep Tissue Injury to (R1's) Buttocks. V2 stated (R1) was never seen by the wound doctor. On [DATE] at 3:20PM V3 Registered Nurse (RN) Care Plan Coordinator stated I did the Braden Scale (Skin assessment) on [DATE]. I documented (R1) had a deep tissue injury to (R1's) right buttocks. I wasn't aware of the heel area. When I did the skin assessment, I talked to the charge nurse, but I don't remember who was working that day. On [DATE] at 3:25PM V7, Corporate Nurse verified the Stage III pressure area on R1's left heel and the Deep Tissue Injury on R1's right buttocks were documented upon admission. However, there is no documentation that the wound was ever assessed or measured, or a treatment was ever initiated. On [DATE] at 3:30 V8, Attending Physician stated As far as I know the Nurse Practitioner or me were not notified of the pressure ulcers (R1) was admitted with. I would expect to be notified or the Nurse Practitioner so we could order appropriate treatment. I would say if the wounds were not treated from [DATE] until [DATE] they would have deteriorated. It is the standard of practice wounds are assessed and treated and reassessed.

Based on interview and record review, the facility failed to provide post-operative pain medication as ordered to a newly admitted resident (R1). This failure resulted in R1 sustaining prolonged severe pain with nausea, vomiting and verbalizing a desire to die. Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Post Left Shoulder Replacement, Left Shoulder Pain, Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure and Congestive Heart Failure. R1's Hospital Discharge Orders dated 2/12/23 at 11:27 am documents the following order for pain medication: Percocet 10 milligrams (mg) with 325 mg of acetaminophen (Percocet 10/325 mg) every 4 (four) hours as needed for pain. R1's Medication Administration Record (MAR) dated 2/12 and 2/13/23 does not document R1 receiving any Percocet 10/325 mg pain medication. On 2/17/23 at 10:50 am, V2 Director of Nursing confirmed that R1 was admitted to the facility a little before noon on 2/12/23 and R1 was alert and oriented to person, place, and time. V2 stated that R1 came with orders for Percocet (oxycodone 10 mg with 325 mg of acetaminophen). V2 stated none of R1's medications came from the facility's pharmacy, and the facility did not have the correct dosage of Percocet in the facility. V2 confirmed that V2 did not call V3 Medical Director to get a new prescription for pain medication. On 2/21/23 at 10:50 am, V3 confirmed that V3 did not receive a call from the facility to let V3 know that R1's medications had not been delivered. V3 stated absolutely (R1) would have severe pain that would require a Schedule II pain narcotic. The facility needed to have (R1's) pain medication on hand when (R1) arrived at the facility so that (R1's) pain did not get out of control. V3 confirmed had the facility notified V3, the pain medication could have been ordered and delivered from a local pharmacy. On 2/21/23 at 11:10 am V7 Licensed Practical Nurse (admitting nurse) confirmed that R1 did not receive any pain medication from the pharmacy and the facility did not have the Percocet dosage ordered for R1 in house. V7 stated R1 was assessed during the day on 2/12/23 for pain and R1 rated R1's pain at an 8 (eight) (on a pain scale of 1 to 10, 10 being the worst pain experienced). V7 confirmed R1 was in a lot of pain and V7 should have called V3 about R1's pain and the lack of R1's medications. V2 also present at this time, confirmed that R1's pain level was high. V2 documented an assessment at 3:00 am on 2/13/23 with R1 rating R1's pain at a 7 (seven). On 2/21/23 at 12:10 pm, R1 (residing in a different facility) was sitting upright in a recliner with oxygen at 2 liters per nasal cannula. R1 confirmed R1 was in so much pain by the late afternoon of 2/12/23 and the facility never gave R1 any pain medication. R1 stated the pain was so severe and debilitating that R1 became nauseated and was vomiting and became short of breath and did not have any inhaler medication. R1 stated this went on through the evening and the night and R1 did not sleep. R1 stated I called my daughter and told her to come and get me and take me somewhere else because I could not stand the pain in my shoulder any longer. The pain radiated across my neck and back, and down my arm. It was so bad it just made me want to die. R1 stated R1's pain was between an 8 and 10 on the pain scale and R1 had told both nurses (V7 and V2) at the facility of R1's severe pain level. The facility policy titled Pain Prevention & Management dated 12/7/17 documents the following: It is the facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (Activities of Daily Living) functioning and enhance quality of life. Pain - an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms of such damage. Pain is subjective and should be documented as perceived by the resident. Pain Management - the assessment of pain and if appropriate, treatment in order to assure the needs of residents who experience problem with pain are met.

Based on record review, observation, and interview, the facility failed to develop and implement interventions to prevent falls, failed to complete fall risk assessments, and failed to ensure equipment was functioning correctly to prevent falls for three of four residents (R3, R2 and R4) reviewed for falls in the sample list of five residents. As a result of these failures, R3 fell and suffered an intraventricular (brain) hemorrhage and a femur fracture, R2 fell and suffered a laceration requiring sutures, and R4 fell and suffered a laceration requiring sutures. Findings include: 1. R3's Physician Order Sheet (POS), dated April 1-30, 2022, documents medical diagnoses of Subdural Hemorrhage Following Injury, Trauma, Traumatic Intracerebral Hemorrhage with Loss of Consciousness, Closed Displaced Fracture of Right Femoral Neck and history of Diabetes Mellitus, Unspecified Visual Loss, [CONDITION(S)] [CONDITION(S)] and [CONDITION(S)]. This same POS documents a Physician order of 'May have siderails on bed.' R3's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 4 out of 15 possible points, indicating R3 is severely cognitively impaired. This same MDS documents R3 as requiring extensive assistance of one person for bed mobility and total assistance for transfers. R3's Care Plan, dated 9/28/21, documents a fall intervention of, Use body pillow at edge of bed to remind resident (R3) of boundaries. This same Care Plan has a separate fall intervention, dated 9/28/22, documenting, When pillow is being washed, place other pillows at edge of bed. R3's Medical Record did not include a Fall Risk Assessment. R3's Final Incident Report to Illinois Department of Public Health (IDPH), dated 4/7/22, documents Conclusion: (R3) was sent to the hospital and then transferred to another hospital on 4/3/22 for an unwitnessed fall in room. Computerized Tomography (CT) scan revealed Intraventricular Hemorrhage and Closed Displaced Fracture of Right Femoral Neck. (R3) admitted to hospital. Facility believes that the root cause of the alleged fall on 4/3/22 was a result of (R3) rolling out of bed due to restlessness. R3's CT Brain Without Contrast results, dated 4/3/22, documents, Impression: Acute hemorrhage has developed in the dependent portion of the occipital horn of the lateral ventricles. There are two small parenchymal hematomas in the genu of the corpus callosum on the left, each measuring less than seven millimeters (mm). R3's X Ray Report results, dated 4/3/22, document, Impression: Subcapital Fracture Right Femur with mild impaction and dorsal cortical overlap. Non-displaced fracture through the Greater Trochanter also suggested. On 4/16/22 at 4:40 AM, V13, Licensed Practical Nurse (LPN), stated, (R3) was found laying on the floor next to bed, laying on back on floor mat. We (staff) think (R3) must have hit head on waste basket during fall. (R3) did not have a side rail on (R3) bed. (R3) used to have siderails, but (R3) hadn't had the side rails on since (R3) moved back into this room after having COVID-19. I (V13) do not think there was a body pillow in place. (R3) did not have it with (R3) on the floor, and it wasn't on the bed. V13, LPN, stated (R3) used that body pillow when (R3) rolled over. (R3) would hug it and that is how (R3) knew to stop rolling. Since (R3) didn't have the pillow and siderails, (R3) just kept rolling and rolled out of bed. On 4/16/22 at 5:40 AM, V15, Certified Nurse Assitant (CNA), stated, I saw (R3) about 30 minutes prior to fall on 4/3/22. We (staff) heard the fall. (R3) must have fallen hard for how loud the crash was. (R3) was laying on the floor on and off the floor mat. (R3) had a knot on (R3) head. The nurse assessed and called for 911. We (staff) did not move him because of the injuries. You could tell (R3) was hurt bad. (R3) did not have the body pillow in (R3) room. (R3) did not have siderails on the bed. (R3) did have a regular pillow between (R3) knees, but there was no body pillow. On 4/18/22 at 11:05 AM, V2, Director of Nursing, stated, We (facility) are not able to find the Fall Risk Assessments for (R3). I (V2) have looked everywhere and cannot find them. The Fall Risk Assessments provide a score that relates to the resident level of risk for falls. This should be a part of the Care Plan. This should be a part of their care processes. The Fall Risk Assessment score determines what interventions should be placed on the Care Plan. It is very important and we (facility) either did not do them or we (facility) simply can't find them. Those assessments should be a part of the hard chart. They (staff) should be following the Physician orders. Since (R3) had the order for siderails, they should been in place. Between the body pillow and the siderails, those could have prevented this fall. 2. R2's undated Face Sheet documents medical diagnoses of Facial Laceration, Fall, Arthritis of Right Knee, [CONDITION(S)], Cataract Left Eye, and Left [CONDITION(S)] Stenosis. R2's Minimum Data Set (MDS), dated [DATE], documents R2's Brief Interview for Mental Status score of 11 out of 15 possible points, indicating moderate cognitive impairment. This same MDS documents R2 as requiring one assist for transfers, walking in room, locomotion on unit, and toileting. R2's Care Plan documents a fall intervention, dated 3/13/22, of pressure alarm on bed. R2's Medical Record did not include a completed Fall Risk Assessment. R2's Final Incident Report to Illinois Department of Public Health (IDPH), dated 3/31/22, documents, Conclusion: Facility believes that the alleged fall on 3/24/22 was a result of the resident (R2) getting up and walking to bathroom on his (R2) own. (R2) stated 'I fell while attempting to go to the bathroom.' (R2) returned same day from emergency room with seven sutures above Right Eye. This same report also documents, (R2) entered room across the hall of his bedroom. (R2) was unaware that was not his room. R2's Hospital Records, dated 3/24/22, document (R2) diagnoses of Facial Laceration and Fall. This same record documents R2 received seven sutures to above Right Eye due to laceration received from fall. On 4/15/22 at 10:00 AM, R2's call light had been activated, and was making an intermittent buzzing sound. (R2) walked out of bathroom and sat on side of bed independently. Bed alarm was not sounding. At 10:04 AM, V6, Certified Nurse Assistant (CNA), entered room asking (R2) if R2 needed assistance to bathroom. (R2) responded, I have already done that. You are too late. V6 assisted (R2) back in bed. V6, CNA, stated, 'Why isn't your bed alarm sounding? It should be going off right now and it is not. On 4/15/22 at 10:05 AM, V6, Certified Nurse Assistant (CNA), stated, (R2) is a nice gentlemen and he (R2) forgets everything. (R2) is supposed to be one assist but sometimes (R2) just gets up on his (R2) own. Sometimes (R2) turns off the alarms on the bed or chair, but this time the alarm just didn't sound on its own. It (alarm) was plugged in and set up ok, it just didn't sound. That alarm lets us (staff) know when (R2) is getting up on (R2) own. (R2) could fall and get hurt again if the alarm doesn't sound. On 4/16/22 at 5:30 AM, V12, Housekeeper, stated, I (V12) was the first one to find (R2) (on 3/24/22). I (V12) heard someone yelling so went to find out what was going on. (R2) was laying on the floor inside the room across the hall from (R2) room. The outside door was closed. (R2) had blood all over his face. (R2) is supposed to have a bed alarm but it was not sounding. On 4/16/22 at 6:05 AM, V16, Certified Nurse Assistant (CNA), stated, When I (V16) checked on (R2) early that morning before (R2) fall, (R2) was still in room with alarm on bed. (V16) don't know if it was working or not because I (V16) didn't check it then. These alarms don't work half the time. On 4/16/22 at 10:00 AM, V1, Administrator, stated, Alarms do not stop residents from falling. Alarms let the staff know when a high fall risk person is trying to get out of bed or chair. The staff can then go assist the resident before a fall happens. (R2) got up on his own and the alarm didn't sound so the staff couldn't have known that (R2) was up. (R2) ended up falling and receiving stitches over (R2) eye. V1, Administrator, confirmed R2's personal bed alarm was care planned prior to R2's fall on 3/24/22, and was not functioning properly at time of fall. 3. R4's undated Face Sheet documents an admitted [DATE]. R4's Minimum Data Set (MDS), dated [DATE], documents R4's decision making ability as severely impaired. This same MDS documents R4 as requiring extensive assistance of one person to transfer. R4's Physician Order Sheet (POS), dated January 1-31, 2022, documents medical diagnoses of Dementia, History of Falls and Recent history of [MEDICATION(S)] Head Injury, Facial Contusion, Intertrochanteric Left Femur Fracture and Fracture of Neck of Left Humerus. R4's Medical Record did not include a Baseline Care Plan. R4's Comprehensive Care Plan did not include fall focus area, goal, nor fall interventions prior to R4's 1/29/22 fall. R4's Medical Record did not include a Fall Risk Assessment. R4's Assess, Intercommunicate, and Manage Report, dated 1/29/22, documents, (R4) found in room laying next to closet on Left side. Skin tear to Left Shoulder. Laceration to Left Ear. (R4) stated hit head. No signs of bruising or injury on top of head. Steri strips applied to skin tear. Bleeding stopped. R4's Final Incident Report to Illinois Department of Public Health (IDPH), dated 1/31/22, documents, Summary: (R4) Alert and oriented x 1 and full assist had an unwitnessed fall hitting Left Shoulder and Left Ear on floor. Was sent to emergency room for evaluation. Laceration on inner Left Ear was sutured. (R4) had a previous Left Humerus Fracture prior to admission. R4's Hospital Record, dated 1/29/22, documents a 1.5 centimeter (cm) laceration to Preauricular Area, 1.5 cm laceration to [NAME] area, 8 millimeter (mm) laceration to edge of Antihelix area and 6.0 cm x 4.0 cm skin tear to Left Upper Extremity. Four sutures were applied to [NAME] and Antihelix area. On 4/18/22 at 11:15 AM, V2, DON, stated, (R4) admitted with fractures from a fall in another facility. We (facility) should have been aware that (R4) was a high fall risk, (R4) fall history should have been on the baseline care plan and then on the comprehensive care plan and it wasn't. We (facility) can't find the Baseline Care Plan or the Fall Risk Assessment and the Comprehensive Care Plan does not include any information about falls until (R4)'s fall on 1/29/22. I (V2) have looked everywhere and cannot find them. The Fall Risk Assessments provide a score that relates to the resident level of risk for falls. This should be a part of the Care Plan. This should be a part of their care processes. The Fall Risk Assessment score determines what interventions should be placed on the Care Plan. It is very important and we (facility) either did not do them or we (facility) simply can't find them. Those assessments should be a part of the hard chart. The staff did not have any interventions in place to guide them in trying to prevent falls for (R4). On 4/18/22 at 2:35 PM, V19, Medical Director, stated, The facility is responsible for determining the risk for someone to fall. This is the responsibility of the staff. The fall risk is determined and should be a part of the plan of care. When this facility did not complete the Fall Risk Assessments and Care Plan, they (facility) have not thoroughly reviewed the residents needs and therefore sets that resident up for injury from falls. They (facility) should have completed all of the assessments to provide thorough care and try to prevent falls. The facility policy titled 'Fall Prevention', revised 11/10/18, documents the following: Policy: to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Procedure: 1. Conduct fall assessments on the day of admission, quarterly and with a change in condition. 2. Identify on admission the resident's risk for falls. 3. Assessments of Fall Risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. 4. Assignment of the final risk category will be determined by the Interdisciplinary team (IDT) at their conferences based on: Fall Risk Score, History of Falls, Medical condition which directly impacts on equilibrium and/or ambulation. And Discussion of individual circumstances. The facility policy titled 'Baseline Care Planning', revised 11/1/17, documents the following: A plan of care (Baseline Care Plan) shall be developed to include instructions needed to provide effective person-centered care to each resident, based on his/her initial assessment and the professional standards of quality of care, to serve as a functional guide in delivery of care until such time as a comprehensive plan is developed. The Baseline Care Plan shall be completed within 48 hours of admission by the admitting nurse or designee.

Based on record review, observation, and interview, the facility failed to implement an Occupational Therapy recommended fall prevention intervention to provide wheelchair foot rests for one (R2) of three residents reviewed for falls. This failure resulted in harm to R2 as evidenced by facial bruising, contusion, hematoma, and closed head injury without loss of consciousness, resulting in a three day hospital stay where R2 was monitored for any possible internal bleeding. R2 is one of seven sampled residents. Findings include: R2's undated Face Sheet documents an original admitted [DATE], and a re-admitted from hospital stay of 6/11/21. R2's Physician Order Sheet (POS), dated June 1-30, 2021, documents diagnoses of: Aortic Insufficiency, Chronic Anti-Coagulation, Chronic Diastolic Heart Failure, History of [CONDITION(S)] (DVT) in Right Lower Extremity, Restless Leg Syndrome and Chronic Venous Insufficiency. This same POS documents R2 is to be up with assist and a Physician order for [MEDICATION(S)] (blood thinner) 5 milligram (mg) tablet to be taken twice per day. R2's Minimum Data Set (MDS), dated [DATE], documents R2 requires extensive assist of one person for transfers and locomotion on unit. This same MDS documents a Brief Interview for Mental Status score of 15 out of 15 possible points, indicating R2 is cognitively intact. R2's Care Plan intervention, dated 4/23/21, documents R2 requires a wheelchair for mobility and needs assist to propel wheel chair. R2's Fall Risk Assessment, dated 4/21/21, documents a score of 19, indicating R2 is at a high risk for falls. R2's Occupational Daily Treatment Note dated: 2/8/21-V17 Occupational Therapy Assistant (OTA) documents R2 was assessed in new wheelchair. OTA documented Once in the wheelchair with patient cushion, patient continues to be on her tip toes. Once therapist put on patient foot pedals, patient is able to assist with scooting back in the wheelchair. 2/12/21-V17 OTA documented Patient was complaining about her wheelchair being to high, therapist educated patient on putting her feet up on pedals and that would help so her feet aren't dangling. R2's AIM for Wellness Report, dated 6/9/21, documents R2 fell on [DATE], which was witnessed V19, Certified Nurse Aide (CNA). Resident stated that her (R2) feet hit the floor and she (R2) went forward in the chair. R2 landed on right side of body and hit face on the floor. Bruise and contusion noted on upper right forehead. Abrasion to bridge of nose due to glasses hitting face. R2 on [MEDICATION(S)] 5 mg BID. R2 sent to emergency room and admitted to hospital at 6:00 PM due to chest pain. This same report documents R2 had new and worsening of chronic pain to upper right forehead. R2's Hospital Discharge Documentation, dated 6/11/21, documents admitted [DATE], and admitting diagnosis of [CONDITION(S)] and Fall. This same discharge report documents R2 as having a small pleural effusion and atelectasis which could be secondary to fall. This same report documents R2 as having an abrasion and swelling to forehead and abrasion to nose and a discharge diagnosis of Closed Head Injury without Loss of Consciousness. On 6/2421 at 9:50 AM, R2 was sitting in wheelchair in room with no skid socks on feet. Wheelchair foot rests were not in place. R2's upper half of face including both cheeks, nose, both eyes and entire forehead is bruised and discolored (grey/green/purple) with 2 inch round dry scabbed area on upper mid forehead. On 6/25/21 at 9:00 AM, R2 was sitting in room in wheelchair. Wheelchair foot rests were not on R2's wheelchair. R2 wearing shoes on both feet. R2 having difficulty trying to maneuver wheelchair in room to place a newspaper on table. On 6/24/21 at 9:51 AM, R2 stated, They took me to the bathroom and on the way back, my feet caught and I fell out of my wheelchair and landed right on my face. If they would have put my foot pedals on, I probably wouldn't have fallen out of my wheelchair. On 6/25/21 at 9:05 AM, R2 stated, If they (staff) would just remember to put on my pedals, I wouldn't have to struggle so much. I don't want to fall again. On 6/24/21 at 3:30 PM, V2, Director of Nursing (DON), stated on 6/9/21, R2 was being transported out of R2's bathroom back into interior room. V2 stated wheelchair did not have foot pedals on it 'because it (R2's wheelchair) was too new'. V2 stated nursing staff should monitor resident's feet during transporting, even for short distances. On 6/25/21 at 11:50 AM, V17, Occupational Therapist Aide (OTA), stated R2 was assessed by Occupational Therapy in February 2021, after receiving a new wheelchair. V17 stated R2 was unable to place both feet flat on floor in new wheelchair, and was noted during therapy sessions dangling feet. V17 recommended at that time for wheelchair foot rests to be provided. V17, OTA, stated R2 should have had wheelchair footrests in place on 6/9/21, and should have been in place since 2/8/21. V17 stated V17 had witnessed R2 without wheelchair footrests in place on multiple occasions since that time, and would provide footrests and re-educate nursing staff each time. On 6/25/21 at 1:30 PM, V18, Nurse Practitioner (N.P.), stated R2 is at greater risk of injury such as bruising, [CONDITION(S)] or even death due to being on blood thinner and falling. V18 stated part of why R2 is considered a high risk for falling is due to previous falls, and R2 being on an anticoagulant. V18 stated any resident who is considered a high fall risk and on an anticoagulant should be monitored closely and should have fall prevention interventions in place to help prevent falls and/or injury. The facility policy titled 'Fall Prevention', revised 11/10/18, documents the following: All falls will be discussed in the morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on interview and record review, the facility failed to physically stabilize a high fall risk resident (R1). This failure resulted in R1 sustaining a [MEDICAL CONDITION] shoulder after falling out of a standard shower chair. R1 was one of three residents reviewed for falls in the sample of three. Findings include: On 1/2/19, V1 Administrator presented a Final Report Regarding Injury to resident (R1) which documents R1 experienced a fall on 12/15/18 in the shower room and sustained a [MEDICAL CONDITION] humeral head. This report also documents R1 was transferred by staff from wheelchair to shower chair by mechanical lift. R1 was unhooked from the mechanical lift and began sliding in the shower chair and was gently lowered to the floor when R1's left arm got hung up on the armrest of the shower chair. R1s [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE], documents R1 as not cognitively intact, totally dependent on two plus staff for transfers and showers, is not able to walk, is not steady, can only stabilize with staff assistance with surface to surface transfer between bed, chair and wheelchair, totally dependent with all ADL's (activities of daily living) including a mechanical lift for transfers, and uses a wheelchair with total staff assistance for locomotion. R1's Care Plan dated 12/15/18, documents R1 is unaware of R1's safety needs related to [MEDICAL CONDITION] and advanced dementia. R1's care plan also documents R1 has current interventions that include reclining wheelchair for positioning due to lack of trunk control. This care plan documents R1 is unable to safely transfer or ambulate by self. This same Care Plan also states R1 is nonverbal and unable to follow verbal cues or directions, and ensure R1 is in an upright position and proper alignment while out of bed. R1's Fall Risk assessment dated [DATE], documents R1 is a high fall risk having decreased muscle coordination and loss of sitting balance. R1's Range of Motion assessment dated [DATE], documents R1 as serious for mobility, functional ability, and mentation. On 1/3/19 at 12:00 PM, V5 MDS Coordinator stated serious means R1 is fully dependent on staff for care, cannot move self in wheelchair, and can't do anything for herself. R1's Nurse's Notes dated 12/15/18, documents notified MD (medical doctor) V11 of left shoulder being swollen. V11 gave order for x-ray, results came back stating a humeral fracture and V11 gave a new order to put arm in a sling. R1's portable x-ray report, dated 12/15/18 and electronically signed by V12, Medical Doctor documents the reason for the x-ray as: swelling, patient slid in the shower, and the impression is confirmed as a humeral head [MEDICAL CONDITION] shoulder. On 1/3/19 at 10:00 AM, V3 Certified Nursing Assistant (CNA) stated R1 was in a regular shower chair and there were no foot rests on the shower chair when R1 slipped out. V3 stated when R1 was sliding out of the shower chair, R1's left arm got caught between the left arm rest and the seat and V3 had to lift R1 up some to get R1's arm from being caught in the shower chair. V3 also stated R1 leans to the side when sitting up in the shower chair. V3 stated there is no specific chair care planned for R1's use in the shower. V3 stated R1 now has a shower chair that tilts back, has foot rests, is more narrow and there are grips in the shower chair. On 1/3/19 at 10:51 AM, V4 Physical Therapy Assistant (PTA), stated no one in therapy assesses residents for shower chair use and R1 has never been assessed by PT for a shower chair. On 1/3/19 at 1:00 PM, V5 Licensed Practical Nurse (LPN)/ MDS Coordinator (previous floor nurse) stated V5 is not sure the exact date R1 started using the tilt back wheelchair, but it was before V5 started as MDS Coordinator so it had to be the middle of (YEAR). V5 stated the tilt back chair was a nursing intervention. V5 confirmed R1 is in the tilt back wheelchair due to poor trunk control. V5 stated also stated, (R1) would need a tilt back shower chair as well. On 1/3/19 at 2:51 PM V2 Director of Nursing (DON), stated R1 should have been ordered a tilt back shower chair at the same time R1 was ordered a tilt back wheel chair.

Based on interview and record review the facility failed to ensure a safe transfer using assessed needed equipment to avoid a serious injury for one of three residents (R3) reviewed for falls in the sample of four. This failure resulted in an avoidable fall for R3 that caused a Tibial Fracture. Findings include: The facility's form Situation Background Assessment and Recommendation (SBAR) Communication Form dated 1-27-17 documents R3 was being inappropriately transferred and was lowered to the floor. When assessed resident (R3) (complained of right) knee pain. (Medical Director) called (and) ordered x-ray. On 2-28-17 at 1:35pm E2, Resident Care Coordinator, stated (R3's) Fall Investigation documents (R3) was being inappropriately transferred by (E4), Certified Nursing Aide (CNA), when she used a gait belt and one assist for the transfer for this resident (R3) when (E4) was actually going into transfer (R4), the roommate. The document identifies (R3) is a lift transfer (sit to stand) and (E4) used the gait belt to help ease (R3) down to the floor.(E4) transferred (R3) with the wrong lift. (E4) was confused as to the resident and what she was to use to transfer (R3). On 3-1-17 at 1:24pm Z1, R3's Physician stated (R3's) fracture was the result of the fall. not pathological. On 3-1-17 at 12:38pm E4 CNA, stated she went into R3's room on 1-27-17 to transfer R4, (R3's roommate) from bed to wheelchair using a gait belt. E4 stated she spoke to the resident and called her R4's first name saying Good Morning. Then after they had a little conversation she continued with the gait belt transfer (without the use of a mechanical lift). E4 stated with the gait belt on R3 she was able to slowly lower R3 down to the floor when she started going down. E4 stated she was not aware she had the wrong resident until E6, Licensed Practical Nurse (LPN) came in and said you've got the wrong resident. On 2-28-17 at 1:16pm E3, LPN stated before the fall of 1-27-17 R3 would cooperate with staff during transfers and staff were using a sit to stand lift for all transfers. The Radiology Report of 1-27-17 of R3's right knee shows acute fracture proximal right tibia. R3's Fall Risk assessment dated [DATE] documents R3 is a high fall risk. On 12-19-16 the Rehabilitation Screen Rehab Care form for R3 documents .Resident requires sit to stand lift due to no lift policy here. As she is a heavy lift of 2. R3's Minimum (MDS) data set [DATE] documents R3 being assessed as needing extensive assistance of 2 person physical assist. R3's Care Plan dated 1-3-17 documents (R3) is a sit to stand (mechanical lift) for all transfers.

Based on interview and record review the facility failed to to ensure a planned fall intervention (motion sensor alarm) was in place and functioning for one of five residents (R1) reviewed for falls in the sample of five. This failure contributed to R1 falling and sustaining a fractured wrist. Findings include: The Minimum (MDS) data set [DATE] documents that R1 requires extensive assistance with bed mobility and is cognitively impaired. The Fall Risk assessment dated [DATE] documents that R1 is at a high risk of falling. Z1's (Orthopedic Physician) Consult Note dated 12/26/15 documents (R1) found down (at previous nursing home) after a fall .head CT (computed tomography) scan revealed a left thalamic (brain) area hemorrhage .distal femur fracture of the right lower extremity. The Admission Nurses Note dated 12/30/15 documents that R1 was admitted to the facility on that date with history of a fall and a right femur fracture. R1's Care Plan dated 12/30/15 documents that R1 is at high risk for falling related to confusion, gait and balance issues, weakness issues, history of falls resulting in Fx (fracture) and a TBI (traumatic brain injury). R1's Care Plan dated 12/30/15 documents an intervention of personal alarm while in bed. Check position with cares and function each shift. E8's Licensed Practical Nurse (LPN) Nurses Notes dated 1/1/16 at 4:15 AM document this writer noted (R1) on floor with blood on arm. (R1) was laying on right side with head towards foot of bed. (R1) stated I slid out of bed while I was trying to get up Noted was two skin tears to right elbow and one to right inner wrist. MD (medical doctor) notified .send to ER (emergency room ). On 2/29/16 at 2:40 PM E8 stated that (on 1/1/16) R1 was attempting to get out of bed when R1 fell . E8 stated that at that time R1 was to be non weight bearing on her right leg. E8 stated that when she found R1 on the floor no alarm was sounding and an alarm was not present on R1's bed. E8 stated a pressure pad alarm was placed on R1's bed after R1 fell (on 1/1/16). On 3/1/16 at 8:50 AM E7 Care Plan Coordinator stated that a personal alarm on R1's bed should have been initiated as a fall intervention on 12/30/15. On 3/1/16 at 9:00 AM E2 Director of Nurses reviewed R1's Care Plan dated 12/30/15 and stated that R1 should have had an alarm on her bed when she fell on [DATE]. E9's Situation, Background, Assessment, Request Communication Form dated 2/13/16 documents (R1) noted laying on left side with left arm pinned under body, hematoma over left eye .ST (skin tear) to left elbow . The Final Report dated 2/20/16 documents that after R1 fell on [DATE] R1 was transported to the hospital for evaluation and treatment and returned to the facility with [DIAGNOSES REDACTED]. Z2's (Emergency Department Physician) Note dated 2/13/16 documents (R1) fell striking the left side of her face and putting her left arm out to catch her fall. The Radiology Report dated 2/13/16 documents Indications: fall on outstretched hand .Impression acute on chronic appearing distal radius fracture. On 3/1/16 at 5:10 AM E10 Certified Nurses Aide (CNA) stated that on 2/13/16 at approximately 5:00 AM E10 heard R1 calling for help and found R1 laying on the floor in R1's room with R1's left arm under R1's body. E10 stated that R1 told her she was trying to get out of bed. E10 stated when she arrived in R1's room R1's bed alarm was on her bed but the alarm was not sounding. E10 stated she does not know why R1's alarm did not sound when R1 began trying to get out of bed. On 3/1/16 at 11:05 AM E2 stated that an alarm device was put in place for R1 to alert staff if R1 is trying to get up. E2 stated CNA staff should check alarms at the beginning of each shift to ensure they are functioning. At that time E2 could not provide documentation that R1's bed alarm had been checked on 2/13/16 prior to her fall. On 3/1/16 at 1:15 pm E2 stated that R1 fractured her left wrist when R1 fell on [DATE]. On 3/1/16 at 12:50 PM E1 Administrator stated the facility does not have a policy directing staff on the use or monitoring of pressure alarms.

Based on record review and interview, the facility failed to supervise a resident (R18) while on a bedside commode. This failure resulted in R18 falling and sustaining a Right Hip Fracture. R18 is one of four residents reviewed for falls in the sample of 15. Findings include: R18's Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R18 as moderately cognitively impaired and requires extensive assist with staff providing weight bearing support during toileting and transfers. The same MDS documents that R18 is not steady without staff assistance. A facility Fall Risk assessment dated [DATE] documents R18 as high risk for falls with a history of multiple falls. R18's Plan of Care dated December 2014 documents that R18 has risk factors for falls that require monitoring related to, mental status and weakness as evidenced by a decline in activities of daily living. A facility report titled Fall Log dated February 2015 documents R18 with falls on 2/4/15 and 2/26/15. A Facility Incident Report sent to the State Agency dated 2/26/15 documents the following on R18: On February 26, 2015 at approximately 1:35 am, (Certified Nursing Assistant), (E10) heard a noise coming from (R18's) room. (R18) was observed on the floor, in a right side-lying position. The (Licensed Practical Nurse/Charge Nurse), E3 was notified and assessed (R18) immediately. The report documents that R18 was sent to the hospital and admitted with a Right Femoral Neck Fracture (Hip Fracture). Nursing Notes for this 2/26/15 incident/fall document that R18's fall was unwitnessed and was last seen sitting on the commode. R18 complained of right hip and leg pain and was sent to the hospital and was admitted . Nursing Notes on 3/2/15 document R18 returning to the facility status [REDACTED]. On 10/22/15 at 1:30 pm E1, Administrator confirmed that R18 was left unsupervised on the toilet and stated (R18) should not have been left unattended on the toilet. On 10/22/15 at 4:40 pm Z2, Primary Care Physician for R18 stated that R18 should never have been left on the commode by herself. Z2 stated that R18 had not walked in several years due to a Spinal Infarct and R18's dementia has steadily gotten worse. Z1 stated (R18) has been totally dependent upon staff in all her personal care .it's upsetting that they left (R18) unattended, causing a hip fracture. On 10/23/15 at 8:55 am E3 Licensed Practical Nurse acknowledged that E3 was the Charge Nurse on duty the night of 2/26/15. E3 stated that R18 was left unattended on a bedside commode, not the toilet. E3 stated I am not sure why (R18) had a bedside commode, but (R18) was a full assist and there is no excuse for (R18) being left alone on the bedside commode. On 10/23/15 at 10:55 am E10 acknowledged that E10 was the Certified Nursing Assistant (CNA) that left R18 on the bedside commode unattended. E10 stated It was dumb, I know better. I was the only CNA on the hall at the time and I thought I heard another resident yelling for help and I left (R18) alone. I should never have done that. I knew (R18) was not to be left alone and (R18) had fallen before. I feel really bad (R18) fell and got a broken hip.

Based on record review, observation and interview, the facility failed to follow their Intravenous (IV) Policy and Infection Control Policy by not providing nursing services for IV maintenance, monitoring, dressing changes, IV flushes, hand hygiene, and Physician notification. These failures resulted in a 27 hour and 59 minute delay in treatment of [REDACTED]. Findings include: R21's Physician order [REDACTED]. This Physician order [REDACTED]. The facility policy Infusion Maintenance Table dated 2007, documents the following: PICC, five ml, normal saline (Sodium Chloride) flush, infuse medication then five ml normal saline Transparent Dressing Changes, 24 hours post insertion, on admission then every week and as needed. Measure upper arm circumference and external catheter length . Monitor IV site every shift R21's Assessment Discharge, from the local hospital, dated 10/19/15 at 10:50 am, documents the following: scattered bruising at the right hip surgical incision and redness on the buttock and perineal area. There is no indication on the body map, of redness to the left upper arm, PICC site. R21's Nurses Note, dated 10/19/15 at 4:10 pm, documents the following: Resident returned to the facility alert and oriented . see Nursing Assessment. R21's Nursing Admission assessment dated [DATE], without a time, documents on the body map, the following: Left upper arm PICC, red, possible PICC infiltration. There is no documentation that the Physician was notified per nursing standard of practice and R21's Care Plan. R21's Treatment Administration Record (TAR), dated 10/19/15 - 10/31/15, documents the following: Change PICC line dressing weekly. The same TAR documents no nurse signature / initials on the PICC line dressing treatment order. There is no entry on the TAR to monitor the insertion site or measure the AC (arm circumference) and ECL (external catheter length), of the upper arm, for adverse signs and symptoms every shift, as the IV protocol and Care Plan document. R21's Care Plan, dated 10/19/15, documents the following: Maintain IV for the duration of treatment. Monitor site every shift for infection (pain, drainage, redness and swelling). Monitor every shift and as needed for infiltration (redness, swelling, pain, boggy appearance). Report signs or symptoms of infiltration or infection to the doctor for treatment and follow up recommendations. On 10/20/15 at 11:50 am, E5, Registered Nurse (RN), entered the medication room after taking the keys out of her pocket. Without washing her hands or using hand sanitizer, E5 set up supplies for R21's IV flush and medication administration on top of a visibly soiled (dry,white milky substance and white crumbs) treatment cart. Without washing her hands or using hand sanitizer, E5 prepared the bottle of [MEDICATION NAME] (name brand for [MEDICATION NAME]) and IV tubing, then placed a pair of latex gloves in her pocket. Without washing her hands or using hand sanitizer, E5, exited the medication room with the IV medication and supplies. E5 went down the hallway, entered R21's room, partially closed R21's the door (there was no privacy curtain in R21's room), laid two alcohol prep pads and two 10 ml syringes (one out of the sterile package and one still in the sterile package) which contained Sodium Chloride, on a newspaper. With contaminated hands, E5 set up the IV pump and primed the IV tubing. Without washing her hands or using hand sanitizer, E5 assisted R21 with the removal of R21's long sleeve shirt. E5, touched R21's hair and shoulder while E5 assisted an unknown Certified Nursing Assistant (CNA) with draping R21's left shoulder and left breast with a hospital gown. R21's hospital gown remained untied. With contaminated hands, E5, put on the latex gloves from her pocket and attempted to set the dose and rate on the IV pump, three times. With the same contaminated gloves, E5, touched R21's, left upper arm PICC site as R21 flinched. R21's PICC line transparent dressing was not labeled with the date, time or the nurses initials to show the last time it was changed. R21's inner, upper left arm was red and swollen, approximately five inches long by three inches wide. E5 stated I think that redness and swelling is from a previous IV. E1, Administrator/RN entered the room and reiterated that is from an IV that infiltrated at the hospital. At 12:12pm, E5, wearing the same contaminated gloves, picked up an alcohol pad and a syringe from off the newspaper, removed the heplock (IV tubing connection site) cap, wiped the heplock with the alcohol pad, flushed the PICC line with 10 ml's of Sodium Chloride (the facility IV protocol, documents that 5 ml's are to be used before and after the administration of medication), attached the medication tubing and started the IV medication pump infusion. (nurse standard of practice is to notify the physician before administering medication through an IV that presents with signs and symptoms of infection or infiltration). E5, removed the gloves, washed her hands and donned new gloves. With the clean gloves, E5 adjusted the contaminated IV pump to set the dose and rate to deliver the medication. With the same contaminated gloves, E5 removed a tight bandage from R21 left wrist. R21's wrist and bandage were soiled with a moderate amount of dried blood. With the same soiled gloves, E5 picks up the second syringe from on top of the newspaper and puts the syringe in her pocket. The soiled bandage remained in E5's opposite hand as she exited R21's room. E5 carried the bloody bandage to the medication cart trash before removal of the soiled gloves and hand hygiene. At 12:45pm, E5 entered R21's room to turn off the beeping IV pump. E5, did not wash her hands or use hand sanitizer before E5 reached into her pocket and pulled out a pair of latex gloves and the syringe of normal saline. E5 flushed R21's IV with 10 ml of normal saline. R21's Medication Administration Record [REDACTED]. There was no documentation of the PICC line location on the MAR. R21's Nurses Note dated 10/20/15 at 3:50 am, documents the following: Alert and confused, would yell freq (frequently), up until mid shift. Was pleasant but anxious. No complaint of pain. The same Nurses Note does not document an assessment of the PICC site nor that the Physician was notified for a change in cognition or mention R21's left upper arm PICC site. On 10/20/15 at 1:45 pm (27 hours and 59 minutes after the first signs of PICC complications were identified on the admission assessment), E5, RN documents in R21's Nurses Note, the following: . (R21's) Left upper extremity with ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising), fading with [MEDICAL CONDITION] (swelling) related to previous PICC line displacement . The same Nurses Note has no mention of Physician notification. On 10/20/15 at 2:30 pm, E5, Registered Nurse (RN) documents in R21's Nurses Note, the following: See SBAR (Situation Background Assessment Recommendation) for details related to an unwitnessed fall. The facility's SBAR dated 10/20/15 is not timed and documents the following: Unwitnessed fall related to confusion. Resident (R21) sent to ER (emergency room ) by ambulance as ordered by Doctor (Z5, Primary Care Physician). There is no documentation related to left arm PICC site swelling and redness. The Hospital's emergency room Report dated 10/20/15 at 2:49 pm, documents the following: (R21) is found to have swelling and redness to the medial aspect of (R21) left upper extremity (arm) distal to her PICC line extending down the arm across the medial aspect of the elbow and to the proximal (nearest) aspect of her forearm. There is some slight increased warmth in this area . Left upper extremity venous Doppler ultrasound was done, reviewed and did show evidence of [MEDICAL CONDITION] ([MEDICAL CONDITION] .Impression Left upper extremity [MEDICAL CONDITION], suspected catheter induced. The Hospital's Ultrasound Report dated 10/20/15, untimed, documents the following: (R21) Left upper extremity .There is a partial [MEDICAL CONDITION] of the axillary (armpit) vein to the [MEDICATION NAME] (under the collar bone) vein. On 10/22/15 at 10:00 am, Z3, Medical Director stated the nursing home should follow the standards of practice. The nurses should have monitored (R21's) left arm every shift, as needed and before infusing any medication. I expect the nursing home to look for any signs of infiltration or infection and report any abnormal findings to me. They should follow their protocol. I was not notified of any abnormal signs or symptoms, absolutely not. I would have immediately ordered an ultrasound to rule out any complications with the (R21) PICC. I should have been notified earlier. On 10/23/15 at 10:45 am, Z5, Primary Care Physician (PCP) for R21, stated A nurse called and reported a fall and did not mention anything about (R21's) arm swelling. I sent (R21) to the ER to evaluate the fall. I am very upset about this. I should have been notified immediately of the PICC site changes. On 10/23/15 at 4:15 pm, E2, Director of Nursing (admitted R21 on 10/19/15) stated I thought the redness and swelling was from a PICC line that infiltrated in the hospital. I did not notify her (R21) doctor (Z5) because her arm was only red and swollen a little bit, about three or four inches. I didn't actually measure it. I didn't change the dressing and did not question when the dressing on her PICC was last changed. No it (PICC dressing) was not dated or signed but it should have been. I needed to question it or change it (PICC dressing) myself when I admitted (R21). The facility policy Infection Control, Surveillance and Monitoring dated 5/07 documents the following: IV site purulent drainage or [MEDICAL CONDITION] from the site of any invasive venous or arterial line, with or without positive culture results [MEDICAL CONDITION] confirmed by clinical judgement, i.e. with heat, swelling, [DIAGNOSES REDACTED] (redness), and or tenderness. The same policy documents the following: All staff will wash their hands, promptly and as thoroughly as possible after each resident contact. Wash hands after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them. Hand washing is an important component of the infection control precautions.

Based on observation, record review and interview the facility staff failed to remove a liquid oxygen tank, and cannula from R1 prior to allowing R1 to smoke. This resulted in R1's oxygen cannula igniting causing complex facial burns to R1's face, and placing the other residents present (R2, R3 and R4) at risk of injury. R1, R2, R3, and R4 are 4 residents reviewed for smoking safety in the sample of six. This failure resulted in an Immediate Jeopardy. The facility removed the immediate jeopardy on 11-29-11, but remains out of compliance at a severity level 2. The facility continues to monitor for the effectiveness of staff inservice re-education and revised policy implementation related to smoking safety and oxygen use. The findings include: On 11/10/11 the facility faxed an initial incident report to the State Survey and Certification Agency Regional Office which stated "Resident outside to smoke with oxygen on, cigarette lit causing a flash burn November 19, 2011. Investigation initiated and final report to follow." The Admission record shows R1 was admitted to the facility on [DATE] for a short stay. Social Service History and Admission note documented that R1 was [AGE] years old and was admitted from his apartment in the community. Notes document "resident says he needs nursing care and wants to come (to the facility) to get better. Resident has trouble breathing and gets winded easily". R1's admitting [DIAGNOSES REDACTED]. R1 had 11/08/11 orders for Physical and Occupational therapy for 30 days. R1 had an admitting physicians order for Oxygen at 2 liters per minute by nasal cannula PRN (as needed). R1's Minimum Data Set ((MDS) dated [DATE] documented R1 was cognitively intact, required limited assistance of one staff for transfers and ambulation, and was independent in wheelchair mobility. The assessment documented goal was resident expected to be discharged to the community and the careplan team had also deemed discharge feasible for R1. R1's Nurses notes dated 11/19/11 6:40 pm documents "Nurse on duty notified that (resident) acquired facial burns when outside smoking with O2 (oxygen) tank. On call nurse (E3) instructed nurse to transfer resident to (local hospital) via 911." Notes of 11/19/11 9:00 pm documented R1 was on a ventilator and was being transferred via helicopter. The hospital nurse reported the resident was intubated, and put on ventilator for soot accumulation in naso/oral pharynx, R1 had acquired 2nd and 3rd degree facial burns and 2nd degree burns to right hand. The resident was transferred to a Springfield burn unit. The local Hospital emergency room Report dated 11/19/11 documents R1's past medical history with [DIAGNOSES REDACTED]. The report documents R1 had burns to mid face and nose area and upper lip with soot noted diffusely to area, broken blisters over nose tip to about three quarters of nose..soot and singed burns to nasal passages...broken blisters to upper lip, pale in appearance and insensitive to touch to entire upper lip consistent with possible full thickness burn..deep swelling in nasal passages". The report documented R1 had a nasopharyngeal scope of the airway by (Z2) ENT (Ear Nose Throat) physician. The report documented there was "some edema about the tracheal level " The residents airway was protected with intubation and the resident was given medication for pain relief and sedation. The clinical impression was "Complex Facial Burns with Suspected Full Thickness Upper Lip Burn. Partial Thickness Burns to the right index, third and fourth finger and left index finger and Suspected Inhalation Injury." The facility final incident report summary dated 11/23/11 documented "staff member, (E7) escorted resident to smoking area. E7 did not have nurse remove oxygen before exiting facility. Resident attempted to relight cigarette and ash caused flash burn." The report documented the resident was assessed and sent to (local hospital) and then was transferred to a Springfield hospital. The report documented "During interviews it was determined (E7) was aware oxygen was to be removed prior to resident smoking and this did not occur. Resident is alert and oriented." Administrator, E1 stated on 11/28/11 at 10:10 am that R1 was still in the Burn Unit of the hospital. E1 confirmed that R1 had gotten burned on 11/19/11 while out in the courtyard smoking. E1 stated that other residents outside at the time of the incident included R2 and R3 who she stated were non interviewable. E1 during the same interview, all of the resident smoking is done outside of the building, and is supervised by staff with a smoking schedule. The residents are taken outside to the outdoor courtyard to smoke. E1 demonstrated that the courtyard was located between the West and Northwest wings of the facility. A side walk from each wing leads to a covered gazebo in the center of of the courtyard approximately 25 feet from the building. The exterior doors to the courtyard on the West and Northwest wings were equipped with a keyed alarmed lock. E1 stated that the staff had to use a key to shut off the alarm and open the door before letting residents outside to smoke. A large sign was taped to the door which said "NO OXYGEN BEYOND THIS POINT NURSING MUST REMOVE OXYGEN". On 11-28-11 at 10:20 a.m. E1 stated that this sign had been posted on both doors after R1's accident. The Smoking Schedule was posted on the wall by the exterior doors to the courtyard. The schedules listed smoking times every two hours from 6:30 am until 8:30 pm. Laundry staff, Housekeeping staff, Social Services, or Dietary staff were assigned to supervise smoking for all smoke times except 4:00 pm and 8:30 pm when a Certified Nurse Aide (CNA) supervises the smoking. The sign stated "Resident smoking is ONLY permitted during the above designated times. ALL residents must be at the door waiting for staff to assist them outside. Residents are allowed one cigarette per smoke break." E1 provided E7's written statement dated 11/20/11 (error on date) 6:31 pm which stated "I took (R1, R4, R3, and R2) out to smoke. (R1) was smoking and his oxygen tubes caught on fire because he took a drag off of his cigarette and it just sparked and went up in flames. I tried to get the flames out and off his tubes and then I ...told the closest CNA to go find her (nurse)...At the time he was attempting to relight his own cigarette". On 11-28-11 at 10:10 a.m. E1 stated that she had interviewed E7 and asked why she had not removed R1's oxygen tank before she took him out to smoke. E1 stated E7 stated that she was aware of the policy (oxygen safety) but was "busy thinking of other things." E1 stated that's why E7's employment was terminated. Nurse, E3 stated on 11/28/11 at 11:00 am that she was the nurse on call and was notified by Nurse, E10 that R1 had been injured. E3 stated when she arrived at the facility about five minutes later, R1 was at the the nurse's station in his wheelchair with an ice pack on his face and mouth. E3 stated she interviewed Laundry staff E7, who was the assigned smoking monitor. E7 kept saying that the nurse had not taken off the oxygen. E3 stated she told E7 "But you were the one who lit the cigarette". E3 said she did confirm that E7 had taken the residents out to the courtyard to smoke, that R1 was wearing the oxygen when E7 took him out to smoke and that E7 had lit R1's cigarette. E3 stated the Smoking Protocol was the nurse keeps the cigarettes at the nurse's station. The Nurse hands out the cigarettes when the assigned staff member is ready to take out the resident to smoke. According to E3 the nurse is to remove any oxygen from the resident before the resident is taken out to smoke. E3 stated on 11/29/11 at 11:00 am when she arrived at the facility R1 was inside the facility and the oxygen tank was outside in the courtyard, and the oxygen tubing was all burnt. R2 stated on 11/28/11 at 12:15 pm that she was present when R1 had been burned. R2 stated the laundry girl, E7 had taken her, R3, R4 and R1 out to the courtyard, the nurse wasn't at the desk at the time around 6:15 pm. R2 said E7 had the cigarettes and they were all sitting pretty close together around a round metal table in the gazebo. R2 stated she was across the table from R1 and R3 was seated right next to R1. R2 stated E7 had lit our cigarettes, and (R1's) cigarette hadn't lit all the way, he took a drag and it sparked, and caught the tubing on fire. R1 yelled and started slapping his face. R2 stated " I told (E7) someone needed to get a nurse!" E7 said a CNA got the West Wing nurse and they took the oxygen tank off of him. On 11/28/11 at 12:45pm R3 stated "He (R1) was lighting up a cigarette when it kind of flared up. He was sitting right next to me. I felt the heat but I didn't get burned." R3 said he saw the blaze and he felt the heat on his wrist and face. R3 stated he has smoked with "that guy" before and "they always took the tank and everything off before but this time they didn't." On 11/28/11 at 1:30 pm. R4 confirmed he was present when R1 got hurt. R4 stated that R1 had a cigarette and when he lit the cigarette, he got burned. R4 said his face was burned and he's in the hospital. R4 stated that they don't carry their own lighters the escort lights the cigarette. Nurse, E11 stated on 11/28/11 at 2:00 pm that on 11/19/11 she was the Nurse for the Northwest Wing. E11 stated she had been in a patient room when she was notified by CNA E8 that R1 had been burned while smoking outside with oxygen. E12, the other nurse had already responded and was with R1. E11 said R1's face was blackened from nose to chin, he had a good level of consciousness and was complaining of pain to face and his hand. E11 stated R1's physician had been paged several times with no response and 911 was then called. E11 stated that she was not present when the residents R1, R2, R3 and R4 were taken out to smoke. E11 had handed R3 and R4 their cigarettes, which were locked in her medication cart after supper while they were waiting to go out to smoke. E11 stated she did not give R1 any cigarettes as he was in the hall by his room, not at the desk. E11 stated R1 hand rolls his cigarettes and the machine and tobacco and filters are kept in the unlocked CNA (Certified Nurse Aide) room. E11stated that R1 utilizes a mini portable liquid oxygen tank. If she had been there when the residents were taken out to smoke, she would have removed the whole thing (tank and cannula) from the wheelchair before they went outside. Nurse, E10 stated on 11/28/11, at 2:10 pm she had been in the dining room on 11/19/11 after supper when CNA E8 had come to her saying there was an emergency, that the oxygen tank hand blown up in R1's face, that the laundry girl had taken residents out to smoke and had not removed the oxygen tank. E10 went out to the courtyard to assess R1. E10 stated R1 was conscious, the staff had turned off the oxygen tank and the cannula was burnt and R1's face was black. E10 stated it was dark outside it was after 6:00 pm. E10 the other nurse then took over and she went inside to call. E10 stated Nurses don't take the residents outside to smoke. If the residents have oxygen the nurse it to take the oxygen tank off before they go outside. E10 stated on 11/29/11 at 2:30 pm when she saw R1 in the courtyard (on 11/19/11) the staff had asked her what to do with R1's oxygen tank, E10 told them to get it away from him and the chair. E10 didn't recall if the tank was still on the residents chair, E10 stated the oxygen cannula had burnt up and there was a piece of stuck to R1's face. CNA, E8 stated on 11/28/11 at 4:15 pm that he had brought R1 back to the North West wing after supper on 11/19/11. E8 said laundry staff takes the residents out to smoke while the CNA's are putting people to bed. E8 stated that E7 had told him what happened, she said that R1 was smoking and there was a poof and the plastic tubing was on fire so she pulled the tubing off of R1. E7 stated he shut the oxygen tank off . E7 stated he grabbed the nurse (E10) and they rushed outside. The undated facility "Safe Smoking Policy" outlined conducting a smoking safety risk assessment for residents that smoke, having a Smoking Contract completed by the Social Service Designee and resident and listed rules to follow for smoking. There was no discussion of safety concerns for residents who utilize oxygen that smoke in the policy. Care Plan Coordinator, E4 stated on 11/28/11 at 11:00 am that R1 did not have a smoking assessment or smoking contract completed. R1 only had an Interim Care Plan that only stated "O2 (oxygen) per N/C (nasal cannula), Smokes". E4 stated she didn't include any safety information for removing the oxygen tank before smoking because it was facility policy. At the bottom of the page E4 had written "11/19/11 Sent to ER for eval and tx, will re-eval for safety upon readmit. All inservice on O2 safety." The facility "Oxygen Safety General Standards" states "Safety standards for oxygen are designed to ensure the safety of all persons involved in the transport, storage and use of oxygen. Oxygen is a non -flammable gas. In the presence of an ignition source and a fuel oxygen will vigorously accelerate combustion." The policy states "A. No Smoking: Smoking is prohibited in all areas where oxygen is stored, transported, or used... F. Residents, nursing agency personnel/caregivers and families must be educated regarding the safe use of oxygen. They must be informed of the hazards and all regulations associated with use." On 11-28-11 the facility Administrator, E1 was notified that an Immediate Jeopardy had been identified. The Immediate Jeopardy began on 11/19/11 when E7 failed to ensure that R1's oxygen was removed before smoking. The surveyor confirmed though interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: On 11/19/11 Staff member extinguished flames, removed oxygen, moved resident to safety, assessed and sent R1 out for Emergency Medical Treatment. On 11/19/11 The facility initiated all staff inservice on Oxygen Safety which is on going until all staff are inserviced. Staff are being inserviced prior to starting their scheduled shift. Signs were posted on doors leading to the designated smoking area to have nurse remove oxygen prior to exiting. On 11/19/11 1:1 (one to one) education on Oxygen Safety was provided to residents who smoke and are on oxygen. On 11/21/11 the Quality Assurance Committee initiated Nursing Oxygen Safety monitoring in the facility which was conducted by Administrator E1. On 11/29/11 Safe smoking policy was reviewed and revised to include precautions for residents with oxygen.

Based on observation, record review, and interview, the facility failed to provide pain control to 1 (R10) of 6 residents on the sample of 15 by not giving any pain medication prior to a dressing change. This caused R10 to cry out in pain during the dressing change. Findings include: The admission record for R10 shows R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment of 8/7/11 and documentation in the nurses notes dated 8/8/11 shows that R10 had a Stage II pressure ulcer 2.0 centimeters (cm) X 3.0 cm on the right buttock, an unstageable 5.0 centimeters (cm) X 3.5 cm black area on the right buttock, and on the left buttock a stage II measuring 1.0 cm X 1.0 cm, and another measuring 0.6 cm X 1.0 cm. E8, Treatment Nurse stated on 9/22/11 at 11:45am, that R10 had the area on his coccyx/buttock area and that the black tissue was debrided on 9/15/11. On 9/22/11 at 11:45am E8 stated that R10's open area on the coccyx/ right buttock area had a deep opening that had tunneling in 3 areas and moving away from this area was raw tissue where more of the blackened area had been removed. During this dressing change on 9/22/11 at 11:45 am E8 prepared her equipment on a clean surface, washed her hands and put on gloves. E8 cleansed the area and irrigated the deep open area with normal saline. E8 then proceeded to pack the tunneled areas with gauze each one at a time. R10 cried out in pain and moaned as E8 was packing these tunneled areas. E8 finished the procedure and when asked if R10 had anything for pain, E8 said no she did not think so. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R10 stated on 9/22/11 at 1:15pm that when he has his dressings changed he squeezes the bed rails with his hands and waits until the pain goes away. R10 said that some days it hurts worse than others. When asked if he would like something for pain before his treatment so his pain would not be as bad while they change his dressing, R10 stated, "you mean they could do that?"