Every finding on record at Countryside Care Center

Based on observation, interview, and record review the facility failed to promptly notify the physician and resident's representative to obtain treatment for an acute change in condition for one of three residents (R1) reviewed for a change in condition in the sample of four. These failures resulted in R1 lying in excruciating pain for seven hours, and experiencing nausea, chills and anxiety resulting in R1's Family Member (V5) calling 911 to transport R1 to the hospital after staff refused to send R1 to the emergency room for treatment. R1 was treated at the emergency room for excruciating pain, nausea, anxiety, and a Urinary Tract Infection/UTI and was later admitted to the hospital for Intravenous (I.V.) antibiotics to treat ESBL (Extended-Spectrum Beta-Lactamases) resistant UTI.Findings include:The facility's Change in Condition Procedure dated 9/21/25 documents, Policy Statement: This facility will provide guidelines for the appropriate handling of a resident's change in condition. We recognize that each situation is unique and must be handles in the manner that is most appropriate at the time and for the nature of the change in condition. The following guidelines 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. level of consciousness. c. Respiratory status including lung sounds. Abdomen including last bowel movement and urine properties. E. Functional status.f.Pain.2. Notify MD (Medical Doctor) of change and give assessment information. Receive orders, if any. 3.Nofity the family of change in condition and any change in MD orders. 4.Initiate vital signs every shift for a minimum of 72 hours or until condition stabilized or improves. 5.If not during normal business hours for provider, place call to provider to update on resident's condition if issue unresolved or there is a significant change. 6.If unable to reach provider, contact Medical Director or Medical Director Associate.R1's admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, history of Urinary Calculi, Obesity, Major Depressive Disorder (MDD), Fibromyalgia, and Restless Leg Syndrome.R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact.R1's current Care Plan documents, (R1) is at risk for pain related to Fibromyalgia, Osteoarthritis, MDD, Obesity, GERD (Gastroesophageal Reflux Disease), and Migraines. Goal: (R1) will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions: Administer medication and treatments as ordered by the medical doctor and monitor for side effects and effectiveness to current medication regimens. Monitor/record/report to the nurse any signs and symptoms of non-verbal pain. Report to nurse any change in usual activity attendance patterns or refuse to attend activities related to signs and symptoms of pain or discomfort.R1's current Order Summary Report documents, Pain assessment every shift. If there is pain do a progress noted. Acetaminophen Extra Strength 500 mg (milligrams) two capsules every 12 hours as needed for pain. Oxycodone HCL (Hydrochloride) five mg three times a day for left hip pain.R1's Progress Notes dated 8/11/26 at 3:31 AM and signed by V6 (LPN/Licensed Practical Nurse) documents R1 was nauseous and received promethazine. This same note documents R1 was having leg pain and back pain.R1's Progress Notes dated 8/11/2026 at 4:11 AM and signed by V6 document V6 called V10/Assistant Director of Nursing/ADON to inform V10 that R1 was requesting to go to the hospital and was crying and having pain in her legs and back, chills, and nausea. This same note documents V10 instructed V6 to inform R1 that R1 would be put on a list for the MD (Medical Doctor) to see R1 during rounds this week and if V5 (R1's Family Member) wanted to come and take R1 to hospital and ensure R1's way back that is entirely up to R1 and V5. These same notes document V6 made an effort to calm R1 down, but R1 wanted to argue with V6, so V6 stepped away from R1.R1's Progress Notes dated 8/11/26 at 5:05 AM and signed by V6 document, (V5) called and was asking about why we (facility staff) were not letting (R1) go to the hospital. This nurse tried to explain to (V5) that (R1's) vitals are stable, (R1) received her nausea med (medication), and (R1) stated she had relief. (V5) interrupted this nurse and stated (R1) is in severe pain and unable to move.R1's Progress Notes dated 8/11/26 at 5:10 AM and signed by V6 document, This nurse received a call from (local) hospital letting me know that the ambulance was on the way for (R1) in severe pain.R1's Progress Notes and Physician's Order dated 8/10/26 through 8/11/26 do not include documentation of V5 (R1's Family Member) or a physician being notified to obtain medical treatment for R1's complaints of excruciating pain, anxiety, nausea, or chills.R1's Emergency Department Note dated 8/11/26 at 7:06 AM and signed by V11 (Hospital Physician) documents, (R1) is a [AGE] year-old with a past medical history significant for Chronic Kidney Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, and OSA (Osteoarthritis) presenting with a chief complaint of abdominal pain. (R1's) pain started a few days ago, and (R1) states that if feels like recent kidney stones. (R1) complaining of severe pain on arrival. Denies any nausea or vomiting, denies and dysuria, but complain of frequency. (R1) states that (pain) starts in right flank and radiates into (R1's) abdomen. (R1) complaints of severe pain. Rates it at 10 out of 10 (excruciating pain). Assessment/Plan: Urinary Tract Infection, Polynephritis, and Dehydration. Orders: Culture Urine.R1's Emergency Department Discharge Orders dated 8/11/26 document, Cefdinir (antibiotic) 300 milligram one capsule every seven days for urinary tract infection, Oxycodone five milligrams every eight hours as needed for pain. Lorazepam 0.5 milligrams two times daily for anxiety. Drink fluids. Follow-up with primary care provider in three to five days.R1's Progress Notes dated 8/11/26 at 5:06 PM and signed by V7 (LPN) document, (R1) returned to facility with new orders for Cefdinir 300 mg every 12 hours for seven days for a UTI.R1's Progress Notes dated 8/16/26 at 12:19 PM and signed by V8 (LPN) document, (Hospital) emergency room called to report (R1) has ESBL resistant to Rocephin and would like to direct admit if symptomatic. (R1) is diaphoretic, has complaints of frequency and dysuria along with a temperature of 99.8 (tympanic). emergency room notified of symptoms and they do want to directly admit her. 911 called. (R1) sent to hospital.R1's History and Physical and Emergency Department Notes dated 8/16/26 document R1 was directly admitted to the hospital for I.V. antibiotics due to ESBL UTI that had resistance to Rocephin.On 8/19/26 at 9:30 AM R1 was lying in bed with an I.V. line inserted into her left upper arm. As R1 was talking to this surveyor she had visible tears and R1 stated, On (8/10/26) at 10:36 PM I recorded a conversation with my phone with me and (V6). At 10:30 PM I told (V6) that I was having excruciating pain in my legs that was starting in my back. I had kidney stones in the past and that is what the pain felt like. I knew I had an infection and was afraid I would become septic again. I started to get the chills and felt nauseated. All night I was having severe pain and (V6) kept telling me that she could not send me to the emergency room because the facility would not have transportation to bring me back. I suffered all night and (V6) did not do anything for my pain. I was begging and finally got ahold of (V5/R1's Family Member). (V5) called 911 for me around 5:00 AM and the ambulance finally took me to the hospital. I cannot go through that amount of pain ever again.On 8/19/26 at 10:30 AM V5 (R1's Family Member) stated, (R1) called me and said the nurse (V6) was refusing to let her go to the emergency room. (R1) was crying and saying she was having terrible back pain that she could not get to let up since 10:00 PM (8/10/26). I called the facility immediately and asked (V6) why (R1) was not able to go to the emergency room. (V6) said they (the facility) had no transportation to take her. (R1) was in terrible pain and I told (V6) it makes no f**king sense. I told (V6) that she is refusing (R1) medical service. It is ridiculous that they would refuse (R1) service. (R1) said she had been in pain all night and I was asleep and did not hear the phone. (R1) had tried to get ahold of me starting around 10:00 PM and I did not answer until 4:00 AM (8/11/26). I told (V6) that this was absurd and I called 911 myself. (R1) had to be treated for a terrible urinary tract infection and had to be admitted to the hospital for an I.V. antibiotic. I am (R1's) power of attorney for healthcare and (V6) did not even contact me when (R1) was having severe pain and asking to be sent to the ER (Emergency Room). I had to contact the facility myself after (R1) called me.On 8/19/26 at 11:10 AM V6 (LPN) stated, On 8/11/26 around midnight or 1:00 AM (R1) started to complain about nausea and I gave her a Zofran for nausea. (R1) said she knew she had a urinary tract infection and wanted to go to the emergency room. (R1) said I need to go now. (R1) said she was having pain with urination. I do not want to get sepsis. I told (R1) I would put her on the list to be seen by the doctor that week during rounds. (R1) was out of Ativan and was getting very anxious. I said to (R1) could this be anxiety? I tried to let (R1) calm down and 10 to 15 minutes later (R1) said (R1) was having leg pain and abdominal pain. (R1) was crying after I told (R1) I could not send (R1) out to the hospital. I called (V10/ADON/Assistant Director of Nursing) and (V10) said I could not send (R1) out and (R1) has a habit of this. (V10) said if (V5) wanted to take (R1) to the hospital he could. When I went back into (R1's) room, (R1) was crying to (V5) and was giving me evil looks and refused to talk to me. (R1) kept saying she needed to go to the emergency room now. (V5/R1's Family Member) called me and was telling me (R1) needed to go to the emergency room and I tried to explain we were trying to push fluids and have the physician see her that week.(V5) was screaming at me and saying (R1) called him and was crying and was in pain and needed to go to the emergency room. I went to see (R1) again and when (R1) saw me she started tearing up again. Somebody called 911 and the ambulance came to take (R1) to the emergency room. I have worked at the facility for two to three weeks. I did not call the on-call physician to report (R1's) concerns because I did not know how to call a physician to get orders and have no physician's phone numbers available and do not know how to find the physician's phone number. I felt like I needed a physician's order to send (R1) out and did not have any phone numbers to be able to reach a physician. It wasn't that I didn't want to send (R1) to the emergency room. I didn't have a phone number to call a physician. I would have rather sent (R1) in, but I was following what (V10) told me and that was not to send (R1) to the emergency room.On 8/20/26 at 9:55 AM V2 (Director of Nursing) stated, (V6) should have contacted the physician when (V6) was having an increase in pain to get (R1) treatment. (R1) should always have the right to go to the emergency room when she was asking.On 8/20/26 and 11:20 AM V13 (CNA/Certified Nursing Assistant) stated, I started working 6 PM to 6 AM on the night from 8/10/26 to 8/11/26. Around 5:00 AM (R1) told me she called her son because (V6) did not want to do anything for her pain and thought she was having kidney stones. (R1) was afraid she would become septic and (R1) was crying and saying she was having really bad pain. I felt really bad for (R1). (V6) told (R1) she did not have transportation to the emergency room or back. The ADON (V10) told (V6) (R1) needed her own transportation to be able to go to the emergency room. Around 10:00 PM (R1) told me she did not feel good and was having pain.On 8/21/26 at 10:00 AM V14 (Physician Assistant) stated, (R1) should not have been refused the right to go to the emergency room when she was asking. The nurses should have at the very least called the physician and gotten (R1) something for pain. (R1) should not have had to suffer in pain. I would have had (R1) sent to the emergency room immediately had I know she was having severe pain and requesting to go to the emergency room. We have physicians on staff 24 hours a day seven days a week to give orders. There is no excuse.

Based on observation, interview, and record review the facility failed to implement non-pharmacological or pharmacological pain relief interventions and conduct a comprehensive pain assessment for one of three residents (R1) reviewed for pain in the sample of four. These failures resulted in R1 crying and experiencing excruciating pain to the lower back and legs for over seven hours before being sent to the hospital emergency room for treatment. Findings include:The facility's Pain Management and Assessment policy and procedure dated 10/24 documents, To provide a broad spectrum of treatments for pain management as they apply specifically to older people and with specific recommendations to aid in decision making about pain management. To develop clinical practice guidelines for the management of acute or chronic pain. Evaluation and Assessment: Comprehensive pain assessment tool will be completed upon admission, transfer, or onset of new pain with includes: 1. Quality of pain. 2. Pain intensity. 3. Changes in mood state. 4. Locations and/or radiation of pain. 5. Factors that palliate or provoke pain, 6. Characteristics of pain. 7. Duration of pain. Interventions and Practices: 1. Chiropractic Treatment. 2. Acupuncture Nerve Stimulation. 3. Massage and the use of liniments and other topical agents. 4. Exercise, breathing techniques, relaxations, music therapy. 5. Emotional counseling. 6. Therapy department may administer heat and cold treatments. 7. Distraction and offering activities to keep busy. 8. Turning and repositioning. If non-pharmacological interventions are ineffective individually the provider may order medication based on the type, frequency, duration, and pain level.R1's admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, history of Urinary Calculi, Obesity, Major Depressive Disorder (MDD), Fibromyalgia, and Restless Leg Syndrome.R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact.R1's current Care Plan documents, (R1) is at risk for pain related to Fibromyalgia, Osteoarthritis, MDD, Obesity, GERD (Gastroesophageal Reflux Disease), and Migraines. Goal: (R1) will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions: Administer medication and treatments as ordered by the medical doctor and monitor for side effects and effectiveness to current medication regimens. Monitor/record/report to the nurse any signs and symptoms of non-verbal pain. Report to nurse any change in usual activity attendance patterns or refuse to attend activities related to signs and symptoms of pain or discomfort.R1's current Order Summary Report documents, Pain assessment every shift. If there is pain do a progress noted. Acetaminophen Extra Strength 500 mg (milligrams) two capsules every 12 hours as needed for pain. Oxycodone HCL (Hydrochloride) five mg three times a day for left hip pain.R1's Progress Notes dated 8/11/26 at 3:31 AM and signed by V6 (LPN/Licensed Practical Nurse) documents R1 was nauseous and received promethazine. This same note documents R1 was having leg pain and back pain.R1's Progress Notes dated 8/11/2026 at 4:11 AM and signed by V6 document V6 called V10/Assistant Director of Nursing/ADON to inform V10 that R1 was requesting to go to the hospital and was crying and having pain in her legs and back, chills, and nausea. This same note documents V10 instructed V6 to inform R1 that R1 would be put on a list for the MD (Medical Doctor) to see R1 during rounds this week and if V5 (R1's Family Member) wanted to come and take R1 to hospital and ensure R1's way back that is entirely up to R1 and V5. These same notes document V6 made an effort to calm R1 down, but R1 wanted to argue with V6, so V6 stepped away from R1.R1's Progress Notes dated 8/11/26 at 5:05 AM and signed by V6 document, (V5) called and was asking about why we (facility staff) were not letting (R1) go to the hospital. This nurse tried to explain to (V5) that (R1's) vitals are stable, (R1) received her nausea med (medication), and (R1) stated she had relief. (V5) interrupted this nurse and stated (R1) is in severe pain and unable to move.R1's Progress Notes dated 8/11/26 at 5:10 AM and signed by V6 document, This nurse received a call from (local) hospital letting me know that the ambulance was on the way for (R1) in severe pain.R1's Medication Administration Records (MARs) dated 8/1/26 through 8/31/26 document R1's pain assessment and pain level is to be documented every shift. These same MARs do not include a completed assessment of R1's pain level from 8/1/26 through 8/20/26 and do not include documentation of R1 receiving Tylenol as needed for pain during this timeframe.R1's Electronic Health Record does not include documentation of a comprehensive pain assessment being completed once R1 started to exhibit excruciating pain on 8/11/26.R1's Emergency Department Note dated 8/11/26 at 7:06 AM and signed by V11 (Hospital Physician) documents, (R1) is a [AGE] year-old with a past medical history significant for Chronic Kidney Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, and OSA (Osteoarthritis) presenting with a chief complaint of abdominal pain. (R1's) pain started a few days ago, and (R1) states that it feels like recent kidney stones. (R1) complaining of severe pain on arrival. Denies any nausea or vomiting, denies and dysuria, but complain of frequency. (R1) states that (pain) starts in right flank and radiates into (R1's) abdomen. (R1) complaints of severe pain. Rates it at 10 out of 10 (excruciating pain). Assessment/Plan: Urinary Tract Infection, Polynephritis, and Dehydration. Orders: Culture Urine.R1's Emergency Department Discharge Orders dated 8/11/26 document, Oxycodone five milligrams every eight hours as needed for pain.On 8/19/26 at 9:30 AM R1 was lying in bed with an I.V. (Intravenous) line inserted into her left upper arm. As R1 was talking to this surveyor she had visible tears and R1 stated, On (8/10/26) at 10:36 PM I recorded a conversation with my phone with me and (V6). At 10:30 PM I told (V6) that I was having excruciating pain in my legs that was starting in my back. I had kidney stones in the past and that is what the pain felt like. I knew I had an infection and was afraid I would become septic again. I started to get the chills and felt nauseated. All night I was having severe pain and (V6) kept telling me that she could not send me to the emergency room because the facility would not have transportation to bring me back. I suffered all night and (V6) did not do anything for my pain. I was begging and finally got ahold of (V5/R1's Family Member). (V5) called 911 for me around 5:00 AM and the ambulance finally took me to the hospital. I cannot go through that amount of pain ever again.On 8/19/26 at 9:40 AM R1 provided an electronic audio file that was dated 8/10/26 and time stamped as 10:36 PM. R1 stated she recorded the conversation between R1 and V6 because she wanted proof that V6 was not doing anything for her pain. During this audio file R1 could be heard moaning, crying, and repeatedly stating, Oh my god. Oh my god. Please. Please. Oh man. Oh man. R1 could be heard requesting to go to the emergency room for pain and V6 denying R1's request.On 8/19/26 at 10:30 AM V5 (R1's Family Member) stated, (R1) called me and said the nurse (V6) was refusing to let her go to the emergency room. (R1) was crying and saying she was having terrible back pain that she could not get to let up since 10:00 PM (8/10/26). I called the facility immediately and asked (V6) why (R1) was not able to go to the emergency room. (V6) said they (the facility) had no transportation to take her. (R1) was in terrible pain and I told (V6) it makes no f**king sense. I told (V6) that she is refusing (R1) medical service. It is ridiculous that they would refuse (R1) service. (R1) said she had been in pain all night and I was asleep and did not hear the phone. (R1) had tried to get ahold of me starting around 10:00 PM and I did not answer until 4:00 AM (8/11/26). I told (V6) that this was absurd and I called 911 myself.On 8/19/26 at 11:10 AM V6 (LPN) stated. On 8/11/26 around midnight or 1:00 AM (R1) started to complain about nausea and I gave her a Zofran for nausea. (R1) said she knew she had a urinary tract infection and wanted to go to the emergency room. (R1) said I need to go now. (R1) said she was having pain with urination. I told (R1) I would put her on the list to be seen by the doctor that week during rounds. I tried to let (R1) calm down and 10 to 15 minutes later (R1) said (R1) was having leg pain and abdominal pain. (R1) was crying after I told (R1) I could not send (R1) out to the hospital. I called (V10/ADON) and (V10) said I could not send (R1) out and (R1) has a habit of this. (V10) said if the son wanted to take (R1) to the hospital he could. When I went back into (R1's) room, (R1) was crying to (V5) and was giving me evil looks and refused to talk to me. (R1) kept saying she needed to go to the emergency room now. (V5/R1's Family Member) called me and was telling me (R1) needed to go to the emergency room and I tried to explain we were trying to push fluids and have the physician see her that week. (V5) was screaming at me and saying (R1) called him and was crying and was in pain and needed to go to the emergency room. I went to see (R1) again and when (R1) saw me she started tearing up again. Somebody called 911 and the ambulance came to take (R1) to the emergency room.On 8/20/26 at 9:55 AM V2 (Director of Nursing) stated, (V6) should have charted (R1's) pain level on the medication administration record and should have at least gave (R1) Tylenol for pain. (V6) should have contacted the physician when (V6) was having an increase in pain. (V6) should have completed a comprehensive pain assessment when (R1) was having excruciating pain.On 8/20/26 at 11:20 AM V13 (CNA/Certified Nursing Assistant) stated, I started working 6 PM to 6 AM on the night from 8/10/26 to 8/11/26. Around 5:00 AM R1 told me she called her son because (V6) did not want to do anything for (R1's) pain and thought (R1) was having kidney stones. (R1) was afraid she would become septic and (R1) was crying and saying she was having really bad pain. I felt really bad for (R1). (V6) told (R1) she did not have transportation to the emergency room or back. (R1) said she started to have pain sometime around 10:00 PM and was not feeling good.On 8/21/26 at 10:00 AM V14 (Physician Assistant) stated, (R1) should not have been refused the right to go to the emergency room when (R1) was asking. The nurses should have at the very least called the physician and gotten (R1) something for pain. (R1) should not have had to suffer in pain. I would have had (R1) sent to the emergency room immediately had I know (R1) was having severe pain and requesting to go to the emergency room.

Based on record review and interview the facility refused to allow a resident to exercise her rights to emergency room services when requested for one of three residents (R1) reviewed for resident rights in the sample of four.Findings include:The facility's Resident Rights policy dated 11/5/19 documents, It is the policy of this facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlines by the State Department of Public Health, Centers for Medicare and Medicaid, and the Joint Commission of Healthcare Organization. This facility supports the resident's right to knowledgably participate in decisions concerns their healthcare and medical treatment. This facility affirms the resident's right to accept/refuse medical treatment to the extent permitted by Illinois and federal laws. Resident rights will be observed and adhered to by all staff/physicians as outlined by facility policies and procedures.R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact.R1's Progress Notes dated 8/11/2026 at 4:11 AM and signed by V6 (LPN/Licensed Practical Nurse) document V6 called V10/Assistant Director of Nursing/ADON to inform V10 that R1 was requesting to go to the hospital and was crying and having pain in her legs and back, chills, and nausea. This same note documents V10 instructed V6 to inform R1 that R1 would be put on a list for the MD (Medical Doctor) to see R1 during rounds this week and if V5 (R1's Family Member) wanted to come and take R1 to hospital and ensure R1's way back that is entirely up to R1.R1's Progress Notes dated 8/11/26 at 5:05 AM and signed by V6 documents, (V5) called and was asking about why we (facility) staff were not letting (R1) go to the hospital. This nurse tried to explain to (V5) that (R1's) vitals were stable and (R1) received (R1's) nausea medication, and (R1) stated (R1) had relief. (V5) interrupted this nurse and stated (R1) s in severe pain and unable to move.On 8/19/26 at 9:30 AM R1 stated, On (8/10/26) at 10:36 PM I recorded a conversation with my phone with me and (V6). At 10:30 PM I told (V6) that I was having excruciating pain in my legs that was starting in my back. I had kidney stones in the past and that is what the pain felt like. I knew I had an infection and was afraid I would become septic again. I started to get the chills and felt nauseated. All night I was having severe pain and (V6) kept telling me that she could not send me to the emergency room because the facility would not have transportation to bring me back. I suffered all night and (V6) did not do anything for my pain. It is my right to go to the emergency room and should have been allowed to.On 8/19/26 at 10:18 AM V10 (ADON) stated, I did instruct (V6) not to send (R1) to the emergency room as I felt like it was not an emergency and we (the facility) do not have transportation at night.On 8/19/26 at 10:30 AM V5 (R1's Family Member) stated, (R1) called me and said the nurse (V6) was refusing to let her go to the emergency room. (R1) was crying and saying she was having terrible back pain that she could not get to let up since 10:00 PM (8/10/26). I called the facility immediately and asked (V6) why (R1) was not able to go to the emergency room. (V6) said they (the facility) had no transportation to take her. (R1) was in terrible pain and I told (V6) it makes no f**king sense. I told (V6) that she is refusing (R1) medical service. It is ridiculous that they would refuse (R1) service. I called 911 myself.On 8/19/26 at 11:10 AM V6 (LPN) verified R1 had asked several times to go to the emergency room, but V6 refused to call an ambulance and send R1 to the emergency room due to getting instructions from V10 (ADON) that the facility did not have transportation to bring R1 back to the facility.On 8/20/26 at 9:55 AM V2 (Director of Nursing) stated, (R1) should always have the right to go to the emergency room when (R1) was asking.On 8/20/26 and 11:20 AM V13 (CNA/Certified Nursing Assistant) stated, I started working 6 PM to 6 AM on the night from 8/10/26 to 8/11/26. Around 5:00 AM, (R1) told me she called her son because (V6) did not want to do anything for her pain and thought she was having kidney stones. (R1) was afraid she would become septic and (R1) was crying and saying she was having really bad pain. I felt really bad for (R1). (V6) told (R1) she did not have transportation to take (R1) to the emergency room and back. (R1) should have had the right to go to the emergency room.On 8/21/26 at 10:00 AM V14 (Physician Assistant) stated, (R1) should not have been refused the right to go to the emergency room when she was asking. I would have had (R1) sent to the emergency room immediately had I know she was having severe pain and requesting to go to the emergency room.

Based on record review and interview the facility failed to administer a resident's Anxiolytic (Anti-Anxiety) medication as ordered by the physician for one of three residents (R1) reviewed for significant medication errors in the sample of four. Findings include:The facility Medication Errors policy and procedure policy dated 11/5/26 documents, It is the policy of this facility to establish and follow a uniform process of medication error management, in regard to reporting medication errors and ensuring accurate and appropriate use of medications. The nurse that has noted the medication errors will contact the Director of Nursing, Physician, Resident/POA (Power of Attorney)/Guardian and the facility Pharmacy. It is the responsibility of every employee to report any known, suspected, or potential medication error.The facility's Physician Orders policy and procedure dated 02/14/23 documents To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. A monthly review of physician orders will be completed to assure appropriateness, accuracy, and completeness. Adherence to following physician orders will be reviewed quarterly by the Quality Assurance Committee for recommendations for sustaining professional standards.R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact.R1's current Order Summary Report documents, Ativan (anxiolytic) 0.5 mg (milligrams) two times a day related to Anxiety Disorder.R1's Medication Administration Records (MARs) and Controlled Substance Proof of Use Logs dated 8/1/26 through 8/20/26 document R1 did not receive Ativan 0.5 mg two times daily as ordered by the physician on 8/9/26 at 8:00 PM, 8/10/26 at 6:00 AM and 8:00 PM, 8/11/26 at 6:00 AM and 8:00 PM, 8/12/26 at 6:00 AM and 8:00 PM, and 8/13/26 at 8:00 PM.R1's Progress Notes and Physician Fax Notifications document R1's Physician (V4) and Physician Assistant (V14) were not notified of R1 being out of Ativan from 8/9/15 through 8/13/26.R1's Progress Notes dated 8/11/26 at 4:11 AM and signed by V6 (LPN/Licensed Practical Nurse) document, (R1) asked if (R1's) Ativan came in yet and was informed pharmacy has not showed up at this time. Resident started to cry and stated she is in pain in her legs and she knows it's not her legs it is from her back and she states she has chills now and nausea. Effort was made to calm (R1) down and (R1) wanted to argue with this nurse. This nurse informed (R1) she needed to calm down and encouraged (R1) to take slow deep breaths.On 8/20/26 at 11:30 AM V2 (Director of Nursing) stated, (R1) should not have missed any doses of Ativan. That is a significant medication error. V2 verified R1 did not receive eight doses of her scheduled Ativan.On 8/19/26 at 9:30 AM R1 stated, I was out of my Ativan for three to four days. I kept asking the nurses for it. I start to have withdrawals and get really anxious when I do not have my Ativan.On 8/21/26 at 10:00 AM V14 (Physician Assistant) stated, There is no reason why (R1) should have gone without her Ativan. After two to three days (R1) would have had significant anxiety and felt antsy. The nurses should have been calling me and the pharmacy daily to ensure (R1's) Ativan was ordered and delivered.

Based on record review and interview the facility failed to obtain a resident's Anxiolytic (Anti-Anxiety) medication from the pharmacy for one of three residents (R1) reviewed for pharmacy services in the sample of four.Findings include:The facility's Medication Ordering and Receiving from Pharmacy policy dated 11/21 documents, Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. If not automatically refilled by the pharmacy, repeat medication refills are called in, faxed, send electronically, or otherwise transmitted to the pharmacy.R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact.R1's current Order Summary Report documents, Ativan (anxiolytic) 0.5 mg (milligrams) two times a day related to Anxiety Disorder.R1's Medication Administration Records (MARs) and Controlled Substance Proof of Use Logs dated 8/1/26 through 8/20/26 document R1 did not receive Ativan 0.5 mg two times daily as ordered by the physician on 8/9/26 at 8:00 PM, 8/10/26 at 6:00 AM and 8:00 PM, 8/11/26 at 6:00 AM and 8:00 PM, 8/12/26 at 6:00 AM and 8:00 PM, and 8/13/26 at 8:00 PM.R1's Progress Notes and Physician Fax Notifications document R1's Physician (V4) and Physician Assistant (V14) were not notified of R1 being out of Ativan from 8/9/15 through 8/13/26.R1's Progress Notes dated 8/11/26 at 4:11 AM and signed by V6 (LPN/Licensed Practical Nurse) document, (R1) asked if (R1's) Ativan came in yet and was informed pharmacy has not showed up at this time. Resident started to cry and stated she is in pain in her legs and she knows it's not her legs it is from her back and she states she has chills now and nausea. Effort was made to calm (R1) down and (R1) wanted to argue with this nurse. This nurse informed (R1) she needed to calm down and encouraged (R1) to take slow deep breaths.On 8/20/26 at 11:30 AM V2 (Director of Nursing) stated, (R1) should not have missed any doses of Ativan. I am not sure why the pharmacy did not send (R1's) Ativan as a script was sent on 8/10/26. The nurses should have been calling the pharmacy every day until (R1's) Ativan was received. The nurses also should have called pharmacy to get a code to open the backup box to get (R1's) Ativan out.On 8/19/26 at 9:30 AM R1 stated, I was out of my Ativan for three to four days. I kept asking the nurses for it. I start to have withdrawals and get really anxious when I do not have my Ativan.On 8/21/26 at 10:00 AM V14 (Physician Assistant) stated, There is no reason why (R1) should have gone without her Ativan. After two to three days (R1) would have had significant anxiety and felt antsy. The nurses should have been calling me and the pharmacy daily to ensure (R1's) Ativan was ordered and delivered. Our team is available 24 hours a day seven days a week to electronically sign prescriptions.

Based on record review and interview the facility failed to ensure residents were assisted timely and safely with transportation from the emergency room to the facility for two of three residents (R1 and R2) reviewed for transfers/discharge in the sample of four.Findings include:The facility's Transportation of Residents policy dated 3/4/24 documents, It is the policy of this facility to safely transport residents to/from necessary appointments when needed. Per federal regulation, the facility's responsibility is to assist residents and representatives in locating and utilizing any available resources for the provision of the services the resident's needs. This includes assisting arranging transportation to obtain needed services. When deemed necessary and appropriate by the facility, the administrator may choose to allow certain exceptions for facility staff to provide transportation utilizing a facility vehicle. Only employees who have completed the facility training and are authorized by the administrator or director of nursing may operate a facility vehicle. The facility will allow employees to drive residents to appointments in facility-owned vehicles only.1. R1's admission Agreement signed by R1 on 10/8/25 documents, Services provided by the facility: The serviced provided for the daily basic rate are listed at Exhibit B. B. Physician and Ancillary Services: Assistance with transportation arrangements.On 8/19/26 at 9:30 AM R1 stated, This facility is terrible about letting you go to the emergency room and helping you get picked up from the emergency room. I was told someone was going to pick me up and I waited in a wheelchair for five hours before somebody showed up to pick me up. No one ever got back to me to let me know who was picking me up.On 8/21/26 at 1:40 PM V12 (CNA/Certified Nursing Assistant) stated, On 8/11/26 I was told I had to pick (R1) up from the emergency room in my own car. The facility does not have a vehicle to use. I did not get (R1) picked up until around 5:00 PM. (R1) had been waiting in the emergency room for five hours. I do not feel comfortable having to pick up residents in my own personal vehicle. I do not feel like it is safe.2.R2's admission Agreement signed by R2 on 7/28/26 documents, Services provided by the facility: The serviced provided for the daily basic rate are listed at Exhibit B. B. Physician and Ancillary Services: Assistance with transportation arrangements.R2's Progress Notes dated 7/25/26 at 7:24 AM document R2 was sent to the emergency room by ambulance.R2's Progress Notes dated 7/25/26 at 3:20 PM documents R2 returned to the facility by ambulance.On 8/21/26 at 3:30 PM V3 (Hospital Physician) stated, On 7/25/26 (R2) was sent to the emergency room. When we (hospital staff) were ready to discharge (R2) back to the facility, we called the facility to tell them (R2) was ready to be picked up. Hospital staff called the facility numerous times over a 6-hour period, and nobody ever got back to us or picked (R2) up. (R2) sat in the emergency room for over six hours before I decided to call an ambulance to take (R2) back to the facility. That facility leaves their residents in the emergency room without transportation and does nothing to help the residents figure out transportation.On 8/21/26 at 11:40 AM R2 stated, When I was sent to the hospital (7/25/26) I had to wait over six hours for someone to come and get me from the emergency room. It was miserable.On 8/22/26 at 10:45 AM V1 (Administrator-In-Training) stated, We (the facility) do not have a van or any other vehicle available to transport residents back and forth to appointments. I know staff should not be using their own vehicles to transport residents. I had no idea (R2) was waiting on being transported back to the facility. Someone should have told me so I could have worked on getting transportation for him.

Based on observation, interview, and record review the facility failed to ensure a resident's right to retain and use personal possessions by failing to maintain respect and dignity for the resident and their possessions and safeguard personal possessions for one resident (R4) out of a sample of four residents. Findings include: The facility's Safeguarding Resident Property Policy and Procedure documents its purpose is to ensure residents' personal possessions are properly safeguarded, while not limiting residents from using their personal items. This policy also documents the facility will follow an established process to inventory and document residents' personal property. On 6/11/2026 at 10:00 AM, R4 stated that recently housekeeping staff told her that she had to put some of her clothing in storage because the only closet in R4's room is to be shared by two residents and even though R4 does not have a roommate right now, she could in the future and the closet is too full. R4 stated I was told by V4 (Housekeeping Director) 'you can get your belongings packed up or I can do it, and you don't want me to do it'. R4 stated that eventually several plastic totes and cardboard boxes full of her belongings, mostly clothing, were taken to a storage shed but R4 is not sure exactly where the shed is, how many boxes of belongings she had and if her belongings or boxes were properly labeled with her name. On 6/11/2026 at 10:30 AM, V1 (Administrator) stated in April 2026 the facility had a Spring Clean Up and encouraged residents to go through belongings and decide if there was anything they would like to get rid of or have family pick up. V1 stated R4's belongings were boxed and taken by V4 (Housekeeping Director) to the Housekeeping Storage Shed in the back of the facility on the property. V1 stated the storage shed is not typically locked during the day because housekeeping staff goes out to the shed throughout their shift for housekeeping supplies, but the shed is always locked when they leave for the day. V1 stated he and V4 both have keys to the shed, but that other management staff should know where to find the key if needed. When asked if the boxes were inventoried and labeled with resident names, V1 stated he was not sure but V4 should have the answer to that question. On 6/11/2026 at 10:35 AM, observed the Housekeeping Storage Shed behind the facility accompanied by V1 (Administrator). The door to the shed was closed but unlocked. The shed was made of wood with plywood flooring. The shed is not climate controlled, no heating, cooling or humidity controlling appliances noted. Observed many storage boxes sitting on the floor of the shed stacked one on top of another. Some of the storage boxes were plastic, some were cardboard. Observed one cardboard box sitting directly on the floor with no other boxes on top of it with R4's name handwritten on the box. The box was not taped at the seams; the box flaps were folded in on each other to secure items inside but left a gap. On 6/11/2026 at 10:40 AM, V4 (Housekeeping Director) stated the boxes of resident belongings were organized in the shed by hall meaning the hall the resident's current room is in. V4 stated she has no digital or paper documentation of how many boxes R4 had or exactly what items and how many items were in each box. V4 stated she relies on her memory and knows R4 had three boxes that were full of mostly clothing. V1 (Administrator) then stated to V4 that they should probably make a list or inventory of resident boxes and items being stored in the shed.

Based on interview and record review, the facility failed to document the steps taken to investigate a grievance, summarize the pertinent findings or conclusions and what corrective action was taken by the facility for one resident (R4) out of a sample of four residents. Findings include: The facility's Resident and Family Concerns and Grievances Policy, dated 10/5/2023, documents its purpose is to provide for the prompt resolution of medical and non-medical grievances and that the facility will document all steps of the grievance resolution including whether or not the resident was satisfied with the resolution. The Grievance Form, dated 4/10/2026, documents staff have confiscated some of R4's belongings without informing her. The second page of this Grievance Form documents it's to be completed by the appropriate department head and returned within (5) business days. However, the sections to be completed on the second and third pages of this Grievance Form are not filled out. The Resident Council Meeting Minutes, dated 4/10/2026, document a resident says when staff takes things that the residents weren't supposed to have, the staff should notify the resident so they know it wasn't stolen. It is also documented in the meeting minutes that V1 (Administrator) is the Grievance Officer. On 6/11/2026 at 11:30 AM, R4 stated a grievance form concerning missing items was completed by V6 (Activity Director) on R4's behalf because she spoke about the missing items during a resident council meeting on 4/10/2026 that V6 attended. R4 states she never heard from V1 (Administrator/Grievance Officer) about the grievance form, the missing items, where they were stored or if she could return the items to the store she bought them for a refund. On 6/11/2026 at 11:40 AM, V1 (Administrator) looked at R4's Grievance Form, acknowledged page two and three of the grievance form were not filled in and stated he was unsure why he did not document the investigation, conclusions and what corrective action was taken by the facility for this grievance filed 4/10/2026.

Based on Observation, Interview and Record Review, the facility failed to ensure that direct resident care staffing was adequate to provide timely care and meet the needs of residents in the facility. This failure has the potential to affect all 44 residents residing in the facility.Findings include:The facility's Facility Assessment, dated 5/29/25, documents The facility must have sufficient staff with the appropriate competencies and skills sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.The facility's Resident Council minutes, dated 10/9/25, documents Residents want a night housekeeper. (Housekeeping addressed the staffing issue with residents. Telling them that they are short staffed and when they have enough people in the department (housekeeping) will training someone to go to nights.) Residents say that nurses and CNAs (Certified Nursing Assistants) are not responding to situations on time. Resident says she fell in the bathroom and yelled for help, but nobody came to help her.The facility's Resident Council minutes, dated 11/6/25, documents Multiple residents say that they're still not being assisted in the mornings. They are often left in bed past breakfast and the morning activity. Residents say they're still not being showered regularly. Some residents go a week without getting a bath or shower. Residents say the reason they aren't getting showered is due to lack of washcloths.The facility's Resident Council minutes, dated 12/11/25, documents Some residents go a week without getting a bath or shower, one resident stated they (staff) will put her down and forget about her. One resident stated she is not being showered properly during showers. Residents say it is still difficult to find a CNA willing to give them a shower. Some residents say the CNAs make them wait 20 minutes to get a response on their call lights.The facility's Resident Council minutes, dated 1/8/26, documents Residents say the kitchen isn't serving food on time and they are often waiting in the dining room for an hour before they are served.On 1/13/26 at 10:00 AM, a resident group meeting was held with R4, R6, R16, R19, R22, R26, R42, R46, and R47. During this meeting several residents stated it can take 45 minutes for call lights to be answered when the facility is short staffed. R22 stated Sometimes I wait 30 minutes to an hour for my call light to be answered. R16 stated Call lights take a long time. Sometimes 45 minutes and I have had incontinent accidents waiting to get help to the bathroom. I am incontinent some and wear a brief for it, but I still prefer to use the toilet. I can't hold it for that long. At this time, several residents stated that showers aren't being offered, and they believe it is usually due to the facility being short staffed. R6, R22 and R42 all stated they do not get a shower every week. R6 stated It's usually once every two weeks but I have gone three weeks without one. R22 stated I have to beg for a shower anymore. R6, R22 and R42 all stated that there is not laundry staff in the building at nights and on the weekends and sometimes the facility will run out of towels and washcloths. Several residents confirmed that CNAs will sometimes do laundry because if not then washcloths will run low and that takes the CNA's time away from being able to provide cares and answer call lights. During this same meeting, all residents in attendance confirmed that food in the dining room is often served cold because it will sit too long in the window waiting to be served and when delivered it is cold.On 1/13/26 at 9:30 AM, V9 (Certified Nursing Assistant/ CNA) stated that staff often do not give showers and if there is a shower aide, showers will only get done depending on staffing and call-ins.On 1/13/26 at 2:50 PM, V2 (Director of Nursing) confirmed that sometimes the facility has issues with adequate staffing. V2 stated When we are short staff it is typically because of CNA call offs. Retention is an issue and call offs are also an issue.On 1/14/26 at 3:00 PM, V1 (Administrator in Training) confirmed the facility does not have laundry services after 11:00 PM during the week and does not have laundry personnel in the facility at all on the weekends. V1 confirmed he has heard that CNAs will do laundry due to towels and washcloths running low and verified this could potentially affect their ability to provide required care to residents.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/12/26 and signed by V1 (Administrator in Training), documents 44 residents reside within the facility.

Based on observation, interview, and record review the facility failed to post the Daily Staffing Report for 1/14/26 and failed to keep copies of the Daily Staffing Reports. This failure has the potential to affect all 44 residents residing within the facility. Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/12/26 and signed by V1/Administrator documents 44 residents reside within the facility.On 1/14/26 at 9:10 AM, the Daily Staffing Report that was on the bulletin board was dated 1/13/26. As of 12:30 PM on 1/14/26 the Daily Staffing Report had not been updated. On 1/14/25 at 11:27 AM, V2/Director of Nursing/DON was asked for the last two weeks of the Daily Staffing Reports. V2 stated she does not have the Daily Staffing Reports and does not know what happens to the Daily Staffing Reports when they are taken down. V2 stated that the third shift nurse is supposed to fill out the Daily Staffing Report and post it on the bulletin board, but it doesn't always happen. V2 also stated if the nurse does not do the sheet V2 completes the posting at 8:00 AM when she arrives.On 1/14/26 at 1:01 PM, V1/Administrator in Training AIT stated that V2/DON is to be keep the Daily Staffing Reports for a couple of years. V1 also stated There is no reason (V2) doesn't have the previous days sheets immediately available. (V2) should not need to remake the sheets. V1 also stated that the Daily Staff Report should be posted in the morning by 6:00 AM.On 1/14/26 at 2:00 PM, V1/AIT stated that there is no policy about posting the Daily Staff Report.

Based on observation, interview, and record review, the facility failed to maintain sanitary food storage and preparation, failed to label and date opened and prepared food items, failed to ensure food items were free from expiration, failed to wear gloves when checking food temperatures and handling resident meals, and failed to maintain safe holding temperatures for prepared foods on the steam table after reheating. These failures have the potential to affect all 44 residents residing in the facility.Findings Include:The facility's Refrigerators and Freezers policy dated 12/30/2024 documents, Policy Statement, the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy interpretation and implementation, 6. All food shall be appropriately dated to ensure proper rotation. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Expiration dates on unopened food will be observed and a three-day expiration once food is opened.The facility's Food Storage Areas policy dated 12/30/2024 documents, Policy Statement, food storage areas shall be maintained in a clean, safe, and sanitary manner. Policy interpretation and implementation, 5. Prepared food stored in the refrigerator until service shall be dated.The facility's Food Temperatures policy dated 12/30/2024 documents, Policy Statement, food shall be stored in accordance with local, state, and federal guidelines. Policy interpretation and implementation, 1. Food will be stored in accordance with local, state, and federal guidelines. 5. Food will be cooked to the appropriate internal temperature per regulation. 9. Hot foods being reheated will be reheated to 165'F (Fahrenheit) or above for 15 seconds.On 1/12/2026 at 10:00 AM, during an initial kitchen visit with V16 (Dietary Manager), the following was observed in the freezer: 1/4 bag of frozen sugar cookies not labeled or dated. 1/2 bag of frozen fish patties not labeled or dated. 1/2 bag of frozen garlic bread slices not labeled or dated. 1/4 bag of hamburger patties not labeled or dated. In the refrigerator, the following was observed: One 10-ounce bar of opened margarine with no date, three ham and cheese sandwiches on a plate with saran wrap, no label, and no date, one diced pears tub, 1/2 full, made on 01/05/2026 with an expiration date of 01/09/2026, one medium-sized container with a brown substance covered with saran wrap, no label, and no date, one container with four cooked chicken breasts made on 12/29/2025 with an expiration date of 01/04/2026, one tub of mayonnaise, 3/4 full, not dated, 1/4 container of soy sauce not dated, Italian dressing tub, 1/4 full, not dated, a container with 15-20 slices of yellow square cheese, no label, and no date, a two-quart container full of pineapple chunks, not labeled or dated. In the dry storage room at 10:20 AM, the following was observed: A basket with five snack-size plastic bags of cereal and chocolate chips, not labeled or dated, a container of rolled oats, not dated, 1/2 bag of elbow macaroni, not dated, 1/2 loaf of raisin bread, not dated. On 1/12/2026 at 11:20 AM, during steam table temperature checks with V17 (Cook) V17 did not wear gloves and used the facility food thermometer to check the chicken tenders' temperature on the steam table, touching the chicken tender directly. V17 then picked up a roll with her bare hand and stated she could not take the temperature of the roll. V17 stated, I should be wearing gloves. V17 continued taking temperatures. When checking the mechanical chicken tenders, the thermometer read 112 F (Fahrenheit). V17 reheated the mechanical chicken, and the thermometer then read 140 F. V17 stated, It is supposed to be at 140 degrees Fahrenheit. V17 was going to serve the chicken tenders to residents until V16 (Dietary Manager) instructed V17 to discard the mechanical chicken. The chicken was not served to residents.On 1/12/2026 at 11:30 AM, V16 (Dietary Manager) stated all foods should be labeled and dated, all expired foods should be discarded, staff should always wear gloves when handling food, and when reheating food on the steam table, the temperature should be at least 165 degrees Fahrenheit.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/12/26 and signed by V1/Administrator documents 44 residents reside within the facility.

Based on interview and record review the facility failed to document the number of Registered Nurses/RNs, Licensed Practical Nurses/LPNs, and Certified Nursing Assistants/CNAs in the Facility Assessment needed to meet the needs of the residents. This failure has the potential to affect all 44 residents residing in the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/12/26 and signed by V1/Administrator documents 44 residents reside within the facility.The facility's Facility Assessment revised 5/29/25 by V1/Administrator in Training/AIT documents The Facility Assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day and emergency operations. The facility assessment identifies your capabilities as a skilled nursing service provider. The Facility Assessment will be the basis for surveyors to ascertain whether you are prepared to competently take care of the population you have identified that you serve. There are three components to the review: 3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems, a facility-based and community based risk assessment, and other information that you may choose. This same assessment lists the daily average census as 49. On page 21 of 32 it does not list the number of RNs or LPNs required to meet the needs of the residents and lists 0 (zero) CNAs needed. On 1/14/26 at 2:55 PM, V1/AIT verified that the staffing numbers needed for RNs, LPNs, and CNAs was not documented in the Facility Assessment but should have been.

Based on Interview and Record Review, the facility failed to record and track employee reported illnesses. This failure has the potential to affect all 44 residents residing in the facility.Findings include:The facility's Infection Prevention and Control Program policy, dated 10/28/24, documents An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. This same policy documents Monitoring Employee Health and Safety. The facility has established policies and procedures regarding infection control among employees, contractors, vendors, visitors, and volunteers, including: situations when these individuals should report their infections or avoid the facility (for example, draining skin wounds, active respiratory infections with considerable coughing and sneezing, or frequent diarrheal stools).On 1/14/26 at 11:00 AM, V3 (Licensed Practical Nurse/ Infection Preventionist/ Assistant Director of Nursing) confirmed the facility does not have any tracking or logs to monitor when an employee calls in sick. V3 stated I do not have any tracking of employee illness for call offs from infection or illness prior to January 2026.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/12/26 and signed by V1 (Administrator in Training), documents 44 residents reside within the facility.

Based on Interview and Record Review, the facility failed to offer COVID-19 immunizations to its employees. This failure has the potential to affect all 44 residents residing in the facility.Findings include:The facility's COVID-19 Vaccination policy, dated 7/15/21, documents It is the policy of this facility to have an infection control program that addresses a need to reduce the overall incidence of COVID-19 by offering to immunize all employees and residents. All residents and staff members are to be offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident or staff member has already been immunized. The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following: That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine.On 1/14/26 at 11:00 AM, V3 (Licensed Practical Nurse/ Infection Preventionist/ Assistant Director of Nursing) verified the facility does not have documentation to show that employees are offered the COVID-19 vaccine. V3 stated Employees are not being offered to the COVID-19 vaccine from the facility. I was not aware that it is a requirement.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/12/26 and signed by V1 (Administrator in Training), documents 44 residents reside within the facility.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) were provided and completed Dementia and Abuse training in a 12-month period. This failure has the potential to affect all 44 residents residing in the facility. Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 1/12/26 and signed by V1/Administrator documents 44 residents reside within the facility.The facility's Facility Assessment revised 5/29/25 by V1/Administrator in Training/AIT documents that Certified Nursing Assistants should receive training for Abuse and Dementia upon hire and annually.On 1/14/26 at 1:10 PM, V11/Human Resources/Business Office Manager stated that she could not provide the required training that the Certified Nursing Assistants received. V11 also stated she did not know what V15/Prior Director of Nursing did with the training information. V11 stated I can't say they (CNAs) have received training, but they should have. I have some in-services but not the required training. On 1/14/26 at 2:55 PM, V1/Administrator in Training verified that he could not provide the training records for the CNAs.

Based on observation, interview, and record review, the facility failed to provide showers as scheduled for six (R4, R6, R7, R22, R23, and R42) of six residents reviewed for Activities of Daily Living (ADL) care in the sample list of 28. Findings include:The facility's Shower Care policy revised 12/24/2020 documents it is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Showers/Baths/ Bed Baths are offered per regulation and taking into account personal preferences.The facility's Resident Council minutes, dated 11/6/25, documents Residents say they're still not being showered regularly. Some residents go a week without getting a bath or shower.The facility's Resident Council minutes, dated 12/11/25, documents Resident's say they're still not being showered regularly. Some residents go a week without getting a bath or shower, one resident stated they (staff) will put her down and forget about her. One resident stated she is not being showered properly during showers.1.On 1/13/26 at 10:15 AM, during a resident group meeting, R6, R22 and R42 all stated they do not get a shower every week. R6 stated It's usually once every two weeks but I have gone three weeks without one. R22 stated I have to beg for a shower anymore. 2.On 1/13/2026 at 9:15 AM, R23 stated, I do not get showers every week. Sometimes I get a shower every two weeks and sometimes it's longer. I will ask staff to shower me, and they say they will get to it, but they never come back.On 1/13/25 at 9:10 AM, R23 was lying in bed with his eyes open, R23 had a strong urine odor upon entering R23's room. R23's current care plan documents that R23 will receive a shower twice a week.R23's shower task dated 12/31/2025 through 1/13/2026 documents that R23 did not receive a shower during this period.R23's electronic medical record does not contain documentation as to why R23 did not receive a shower from 12/31/25-1/13/25.3.On 1/13/2026 at 9:18 AM, R4 stated she does not receive showers because she has an open area on her chest so staff say they cannot shower her.R4's shower task dated 12/17/2025 through 1/13/2026 documents that R4 did not receive a shower during this period.R4' electronic medical record does not contain documentation as to why R4 did not receive a shower from 12/17/25-1/13/25.On 1/13/2026 at 9:30 AM, V9 (Certified Nursing Assistant/ CNA) stated that staff often do not give showers and if there is a shower aide, showers will get done depending on staffing and call-ins. V7 stated that R4 had an offensive odor during morning cares on 1/13/25 and does not believe R4 has had a shower recently.4.R7's shower task dated 12/16/2025 through 01/13/2026 documents that R7 did not receive a shower during this period.R7's electronic medical record does not contain documentation as to why R7 did not receive a shower from 12/16/25-1/13/25.R7's Minimum Data Set, dated [DATE] documents that R7 is dependent on staff for showers and bathing. This same MDS documents R7 is cognitively impaired.On 1/13/25 at 1:30 PM, V2 (Director of Nursing) stated she was not aware residents were not receiving showers.

Based on observation, interview, and record review, the facility failed to ensure oxygen therapy equipment was maintained and labeled according to facility policy, and failed to ensure oxygen safety signage was posted for residents receiving oxygen therapy for five (R1, R6, R12, R17, and R34) of five residents reviewed for oxygen therapy in the sample list of 28. Findings include:The facility's Oxygen Administration and Storage Policy revised 3/8/2022 documents to ensure staff follow guidelines for storage and use of oxygen. Staff are to label the tubing connected to the oxygen concentrator with time and date and to place an Oxygen in Use sign on the resident's door/door frame.1.On 1/12/26 at 10:40 AM, R1 was sitting in her room wearing oxygen. There was no oxygen sign on R1's door. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses which included Chronic Respiratory Failure with Hypercapnia, Depression, Atrial Fibrillation, Panlobular Emphysema, Chronic Obstructive Pulmonary Disease, Anxiety, Chronic Kidney Disease (stage 3), and Essential (Primary) Hypertension.R1's Physician Orders printed 1/14/26 at 12:50 PM, document that R1 is to have oxygen at two to four liters per minute by nasal cannula every shift. Order date 9/26/25.R1's current Care Plan documents that R1 has an alteration to her respiratory system and requires oxygen at four liters. 2.On 1/12/26 at 10:30 AM, R6 was lying in bed wearing oxygen. There was no oxygen sign on R6's door.R6's admission Record documents that R6 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Bipolar Disorder and Obsessive- Compulsive Personality Disorder. On 1/21/25 R6 was diagnosed with Asthma.R6's Physician Orders printed 1/14/26 at 12:48 PM, document that R6 is to have oxygen at two liters per minute by nasal cannula as needed. Order date 12/30/25. R6's current Care Plan documents that R6 has an alteration to her Respiratory System and requires oxygen therapy. 3. On 1/12/26 at 10:47 AM, R7 was lying in bed wearing oxygen. There was no oxygen sign on R17's door.R17's admission Record documents that R17 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Chronic Obstructive Pulmonary Disease, Asthma, Shortness of Breath.R6's Physician Orders printed 1/14/26 at 13:11 PM, document that R17 is to have oxygen at two to four liters per minute by nasal cannula every shift. Order date 9/26/25. R17's current Care Plan documents that R17 is currently on oxygen related to Chronic Obstructive Pulmonary Disease and Asthma.4. On 1/12/26 at 10:30 AM, R12 was sitting on the edge of her bed with Oxygen on her face via nasal cannula. R12's Oxygen tubing and humidity bottle was not dated. R12 stated she does not think anyone checks the Oxygen and she does not know how they would be alerted if the tank ran out. On 1/13/26 at 2:50 PM, V2 (Director of Nursing) confirmed that Oxygen tubing and humidity bottles should have dates on them when they are changed. V2 stated They are supposed to be changed every Sunday night, and the staff should place a label with the date of change.5. R34's admission Record dated 1/14/2026 documents, R34 has a medical diagnosis of Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease, and Shortness of Breath.R34's Current Physicians Orders dated 1/14/2026 documents, R34 has an order for oxygen at 2L (liters) per nasal cannula as needed.On 1/12/2026 at 9:30 AM, R34 had an oxygen machine in her room next to her bed. Oxygen tubing was not labeled; R34's humidification bottle was labeled 1/2/2026.On 1/13/2026 at 10:30 AM, R34 had an oxygen machine in her room next to her bed. Oxygen tubing was not labeled; R3's humidification bottle was labeled 1/2/2026.On 1/13/2026 at 10:40 AM, V7 (Certified Nurse Assistant) confirmed that there was no label on R34's oxygen tubing, and R34's humidification was bottle was dated 1/2/2026.On 1/14/2026 at 10:45 AM, V3 (Assistant Director of Nursing) confirmed all oxygen tubing should be dated, and humidification bottles and tubing should be changed weekly.On 1/14/25 at 11:33 AM, V2 (Director of Nursing) stated that if a resident uses oxygen a sign should be posted on the door outside of the room. V2 confirmed that (R1, R6, and R17) did not have an oxygen sign outside of their door and should have one.

Based on observation, interview, and record review the facility failed to clean and disinfect a resident's wheelchair that had brown fecal matter smeared on the seat daily for one of four residents (R34) reviewed for dignity in a sample of 28. Findings Include:The facility's Resident Rights policy dated 11/5/2019 documents, It is the policy of this facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlined by the State Department of Public Health, Centers for Medicare and Medicaid (CMS) and Joint Commission of Healthcare Organization (JCAHO). Recognizing that society is dynamic, and the rights of residents are continually evolving; we will strive to improve the quality of our care through a multi-disciplinary approach recognizing that each resident is an individual with unique needs.The facility's Cleaning and Disinfection of Resident Care Equipment dated 3/24/2023 documents, Purpose: to provide guidelines for disinfection in accordance with manufacturer recommendations for reusable equipment used in resident care. Reusable resident care equipment includes wheelchairs. Procedure: 1. Reusable equipment will be cleaned and disinfected after use of one resident and before the use of another resident.R34's MDS (Minimum Data Set) section C dated 12/16/2025 documents R34 has BIMS (Brief Interview for Mental Status) score of 15, meaning cognitively intact.R34's MDS section C dated 12/16/2025 documents R34 uses a wheelchair.On 1/12/2026 at 9:30 AM, R34's wheelchair had a cotton pad cloth resting in her wheelchair with brown fecal matter smeared on the cotton pad cloth.On 1/13/2026 at 10:30 AM, R34's wheelchair had a cotton pad cloth resting in her wheelchair with brown fecal matter smeared on the cotton pad cloth.On 1/13/2026 at 10:40 AM, V7 (Certified Nurse Assistant) confirmed the brown fecal matter on R34's wheelchair.On 1/14/2026 at 10:20 AM, R34 was in her wheelchair, R34 got up and underneath her was a cotton pad cloth resting in her wheelchair with brown fecal matter smeared on the cotton pad cloth. R34 stated she always has brown fecal matter in her wheelchair and when she asks facility staff if they could change it they often tell me they ran out of pads cloths.On 1/14/2026 at 10:45 AM, V3 (Assistant Director of Nursing) stated staff should always change R34's cotton pad cloth, and that R34 should not have to sit in a dirty wheelchair with fecal matter in it.

Based on Interview and Record Review, the facility failed to ensure resident mail was delivered unopened for two of nine residents (R42, R47) reviewed for resident rights in the sample of 28.Finding include:The facility's Ombudsman Program Resident's Rights for People in Long Term Care pamphlet (undated), documents Your rights to privacy and confidentiality. Your facility must deliver and send your mail promptly. Your facility may not open your mail without your permission.On 1/13/26 at 10:20 AM, R42 and R47 both stated that sometimes mail is opened when delivered to them. R47 stated My mail was opened one time, and I went to (V1, Administrator in Training) about it. R42 stated They (staff) open my packages and envelopes all the time. They are not opened in front of me. R42 confirmed that she frequently gets packages that have been opened without her permission and that V8 (Social Service Director) is usually the one opening them. On 1/14/25 at 11:45 AM, V8 stated that she has opened mail with scissors prior to delivering the packages to resident rooms. V8 stated I do that, so I don't have to take scissors to resident rooms. V8 confirmed that when this has happened the resident(s) was not aware and was not with her to watch the package be opened.

Based on Interview and Record Review, the facility failed to implement their abuse policy when an allegation of staff to resident physical/sexual abuse was received for one of two residents (R12) reviewed for abuse in the sample of 28.Findings include:The facility's Resident Right to Freedom from Abuse, Neglect and Exploitation policy, dated 10/16/23, documents The 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). This same policy documents Associates must not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion against any resident. 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: Taking steps to prevent further potential abuse. Reporting the alleged violation and investigation within required timeframes. Conducting a thorough investigation of the alleged violation. The facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility shall: ensure all alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper timeframe pursuant to this policy. Have evidence that all alleged violations are thoroughly investigated.On 1/12/26 at 10:30 AM, R12 stated she recently had an incident with a male CNA (Certified Nursing Assistant, V12). R12 stated when V12 was assisting her with toileting he smacked her behind and she was very angry about it. R12 stated she did inform the facility staff about it, and she was very bothered by the incident. On 1/13/26 at 8:30 AM, V1 (Administrator in Training) stated he does not have any abuse investigations for the past six months. V1 stated I just started in May 2025, and I have none. If there have been any allegations or investigations prior to me starting, I am not sure where they are kept. I am not aware of any though prior to me working here.On 1/13/26 at 3:05 PM, V1 confirmed he is the facility's abuse coordinator and in December 2025, there was an incident between R12 and V12. V1 stated I don't have any interviews related to the allegation of (V12) hitting (R12) on the behind. I interviewed (V12) but it was related to the other staff issues, not the allegation from (R12). I did not record any interviews related to this allegation. I did not interview other residents about this employee. I do not have an investigation to provide or documentation to related to any investigation into the incident between (R12) and (V12).

Based on interview and record review the Facility failed to monitor and treat acute medical conditions for two of seven Residents (R4 and R9) reviewed for quality of care in a sample of nine. This failure resulted in R4 and R9 requiring hospitalization.Findings include:The Facility Physician Orders Policy, revised 2/14/23, documents: to provide guidance to ensure physician orders are transcribed and implemented in accordance with the professional standards.The Facility Acute Respiratory Illness Policy, initiated 1/31/25, documents: the Facility follows current guidelines and recommendations for managing acute respiratory illness; and is defined by two of the following signs and symptoms (shortness of breath/difficulty breathing, which may manifest as increased fatigue and low oxygen saturation in the blood (normal levels are between 95 percent and 100 percent, but may vary for people with certain medical conditions).The Facility Registered Nurse Job Description, undated, documents: ability to work independently or part of a group; direct day-to-day functions of the nursing assistants in accordance with current rules, regulations and guidelines that govern long-term care; ensure that all nursing personnel assigned to you comply with the written policies and procedures established by the Facility; responsible for complying with Facility policies and procedures; cooperate with other Resident services when coordinating nursing services to ensure that Resident's total regimen of care is maintained; participate in the development, maintenance and implementation of the Facility's Quality Assurance Program; perform all tasks in accordance with established policies and procedures and as instructed by supervisor; sign and date all entries made in the Resident medical record; charts nurses' notes in an informative, relevant, concise and descriptive manner that reflects the care provided to the Resident, as well as Resident's response to the care; provides direct Resident care; review the Resident chart for specific treatment and medication orders as necessary; implement and maintain established nursing objectives and standards; educates the Resident through use of nursing knowledge and skills according to their needs and promote their mental and physical well-being; responsible for interpretation and execution of Physician orders and calling Physician as indicated; make periodic rounds to observe and evaluate Resident's physical and emotional status and to ensure the continuing quality Resident care; assess the total needs of the Residents and adjust care plans as needed; reviews care plan daily to ensure that appropriate care is being rendered; responsible for accurate observation, evaluation and reporting of Residents symptoms and change of condition reactions and progress to the Physician and shift supervisor; assures Resident care delivery is in accordance with the Facility policies and procedures; notifies Resident's attending Physician and family when the Resident is involved in an occurrence or change in condition; responsible for administering and documenting medications according to the Physician order and plan of care; responsible for competent administration of care and treatments according to the Physician orders and Facility policy and procedure at a minimum; responsible for administration and control of narcotics and controlled drugs according to state and federal regulations, Facility policies and procedures; ensure that Residents who are unable to call for help are checked frequently; make periodic checks to ensure that prescribed treatments are being properly administered by nursing assistants; Resident Rights in regards to psychosocial needs and caring for aged, ill, disabled and cognitively impaired, Communication/Personal skills and Medication rights; ensure that all Residents are treated fairly and with kindness, dignity and respect; knowledgeable to all Residents' Rights according to Facility policy and Regulations; and ensure that call lights are answered by all employees of the Facility, regardless of the department.The Facility Resident Council Notes, dated 7/2023, document Nursing Department issues with Residents stating, a male nurse on night shift (V8/Agency Registered Nurse/RN) is still missing wound treatments and that V8 (RN) told the Resident Council member that it is the day nurse's job to do the wound treatment, not his. Residents also have concerns that V8 (RN) skips their medication pass (med pass) every time he works.The Facility Concern/Grievance Form, dated 7/2025, documents a concern with male nurse on night shift (V8/RN-Registered Nurse). The review and action taken documents that the Facility quit using (employing) V8 (Agency RN).1.R9's Physician Order Sheet/POS, dated 8/30/25, documents R9's diagnoses including Generalized Anxiety, Hypertension, Congestive Heart Failure, Obesity, Mitral Valve Stenosis, Repeated Falls, Cardiomyopathy, Recurrent Moderate Chronic Obstructive Pulmonary Disease/COPD, Emphysema, Anemia, Cerebral Infarction, Chronic Kidney Disease Stage Three and Chronic Respiratory Failure with Hypercapnia.R9's POS, dated 8/30/25, also documents Physician Orders for a breathing machine (Bi-pap), keep head of bed elevated at 30 degrees as needed for shortness of breath, Oxygen therapy at four liters per nasal cannula, Nebulizer treatment (Proventil, Ipratropium and Albuterol) and medications (Apixaban, Spironolactone and Bumetanide for Congestive Heart Failure and Wellbutrin for Depression).R9's current Care Plan documents: to observe for presence of respiratory infection symptoms and shortness of breath that is unrelieved and report to Physician; Advance Directive status of Full Code; has alteration to ability to care for self and to report any declines to Physician; alteration to Respiratory System due to Chronic Respiratory failure and to monitor vital signs; administer medications and treatments ordered by Physician and monitor for side effects and effectiveness of current medication regimen; assess and monitor respirations and breath sounds noting rate and sounds; assist me to assume a position of comfort, educate me on breathing techniques; monitor for change in condition and notify the Physician; monitor for signs and symptoms of asthma attack; and monitor vital signs that they are in acceptable range.R9's Nursing Note, dated 7/3/25 at 6:24 am, documents an entry by V3 (Licensed Practical Nurse/LPN) stating when getting report from the night shift nurse (V8/RN), it was reported that (R9) was having trouble breathing and (R9's) pulse oximeter (SPO2) as at 78 percent. (V8) stated that (V8) gave (R9) two breathing treatments and now (R9) is in the 80's. (V3) went to assess (R9) and found (R9) lying in bed with a breathing treatment on and pulse ox/oxygen level at 82 percent and (R9) was mouth breathing and stomach breathing. (R9) was pale and clammy and complained of left arm pain. (V3/LPN) called Emergency Services/EMT and (R9) was transported to the local hospital Emergency Department for evaluation and treatment. The Nurses Note also document when EMTs arrived, they put (R9) on ten liters of oxygen on a re-breather bag and (R9's) oxygen saturation level increased to 92 percent. R9's Nursing Notes do not document entries from V8/RN for vital signs, breathing difficulties or nebulizer treatments.R9's Nursing Note, dated 7/3/25 at 9:56 am, documents R9 is admitted to Hospital Intensive Care Unit for fluid overload, exacerbation of COPD and Pneumonia.R9's Medication Administration Record, dated 7/3/25, does not document R9's respiratory status, medication therapy or administration of nebulizer treatments.R9's Hospital Summary, dated 7/6/25 through 7/16/25, document that R9 was admitted to the local hospital on 7/3/25 and transported to a larger hospital for diagnoses including Respiratory Distress, Pneumonia, COPD exacerbation, Congestive Heart Failure, Atrial Fibrillation, Acute Kidney Injury and Respiratory Failure with Hypoxia. R9 was admitted to the Intensive Care Unit, sedated and intubated with an endotracheal tube. The Hospital notes also document that R9 was placed on a feeding tube. 2.R4's Physician Order Summary Report/POS, dated 9/2/25, documents diagnoses including Schizophrenia, Bipolar Disorder, Hypertension, Borderline Personality Disorder, Depression, Insomnia, Generalized Anxiety Disorder, Congestive Heart Failure, Panic Disorder and Episodic Paroxysmal Anxiety. The POS also documents an order for the monitoring of Anti-Anxiety, Anti-Psychotic, Sedative/Hypnotic and Anti-Depression Medication.R4's Medication Administration Record, dated 7/8/25, documents V8's (RN) signature for administration of Depression medication (Fluvoxamine), Schizophrenia medication (Olanzapine) and Anxiety medication (Hydroxyzine Hydrochloride and Clonazepam) for the scheduled administration time of 6:00 am.R4's Medication Administration Audit Report, dated 8/30/25, documents that on 7/8/25, V8 (Registered Nurse/RN) signed out (administered) Depression medication (Fluvoxamine), Schizophrenia medication (Olanzapine) and Anxiety medication (Hydroxyzine Hydrochloride and Clonazepam).R4's current Care Plan documents: Advance Director of Full Code; dependent on staff for meeting emotional and physical needs and staff to converse while providing care; has self-care deficits and need assistance to complete quality of care and has shortness of breath with panic attacks, anxiety, educate on self-care needs; impaired physical mobility related to Congestive Heart Failure, COPD and increased weakness; check for breath sounds and monitor/document labored breathing; administer medications as ordered and monitor/document for side effects and effectiveness; maintain consistent routine to insure compliance and avoid confusion; uses anti-anxiety medication and monitor every shift for safety; unexpected side effects of medication (Hydroxyzine and Clonazepam) are mania, hostility, rage, aggressive or impulsive behavior and monitor/record occurrence document per protocol; uses anti-psychotic medications (Olanzapine) and administer as ordered by Physician and monitor/report adverse reactions and behavior symptoms; uses anti-depressant medication (Fluvoxamime) and administer per Physician order and monitor/document and report adverse and behavior symptom; and has chronic arthritis pain and monitor and observe for changes in usual routine.R4's Nursing Note, dated 7/8/25 at 6:19 am, documents an entry by V13 (Registered Nurse/RN) stating met in full blown anxiety, jittery, exasperated and sweating profusely at resumption (5:55 am). On checking the (electronic medical record), all 5:00 am medications were given, though (R4) kept asking for (R4's) medications that (R4) has not gotten them. The Nursing Note also documents it has been numerously stated by most Residents that the nurse in question (V8/Agency Registered Nurse/RN) rarely give them medications nor attends to needs by request if (V8's) assigned Certified Nursing Assistants ask him.R4's Nursing Note, dated 7/8/25 at 6:49 am, documents that R4 continues to be anxious and that no anti-anxiety medications can be given or are scheduled. Emergency Services was called and R4 was transported to the local hospital for evaluation.R4's Nursing Note, dated 7/8/25 at 2:38 pm, documents that R4 returned from the local hospital Emergency Department.R4's local hospital Emergency Department notes, dated 7/8/25, documents R4 is having shakiness, rapid breathing and wheezing. Per Emergency Medical Services, the Nursing Home (Facility) staff reported that usually once (R4) receives his medications all these symptoms resolve. The Medication Administration Record shows that (R4's) medications were given at 5:11 am but (R4) states that (R4) did not receive his medications.On 8/29/25 at 11:52 am, R7 stated, I did not always get my medication when (V8) worked.On 8/29/25 at 11:30 am, R4 stated, I did go the hospital when I did not get my medicine that morning. I get anxious and I need to get my medicine.On 8/29/25 at 2:13 pm, V22 (Insurance Representative) stated, I have to go to the Facility and check on my Residents and when I arrived that morning on 7/8/25, (R4) was sweating through (R4's) clothes and having a really hard time breathing. (R4) kept saying that (R4) did not get (R4's) medications. (R4) deserves more credit, even though (R4) has issues, but I truly believe that (R4) did not get the 6:00 am medications and (R4's) anxiety got out of control. They even sent him to the hospital because of it.On 8/31/25 at 6:55 am, V9 (Certified Nursing Assistant/CNA) stated, I would rarely see (V8/RN) down the hallways passing medications. I know that some nurses are faster than others, but if I did see (V8) passing medications, (V8) got done way quicker than the other nurses. I went to (V19/Former Director of Nursing) and (V5/Assistant Director of Nursing) multiple times complaining about (V8) not doing (V8's) job and nothing ever came of it. I was furious having to work with (V8/RN) and I told (V19) and (V5) that I will not work with (V8) anymore if (V8) was in the building. Also, (V8) would leave the premises and be gone for over an hour and on night shift, the nurse is not allowed to the leave the premises in the event of an emergency. I would tell (V8) that a Resident needed help from a nurse or something needed looked at, and (V8) would never follow up. I would work 1:00 am to 1:00 pm, when I worked and on 7/9/25, I came on to my shift, (R9) was having trouble breathing and gasping for air. (R9's) oxygen was down around 78 percent and it should be in the nineties. Even though (R9) had COPD (Chronic Obstructive Pulmonary Disease), I knew that (R9) was in distress. I went to (V8/RN) and told (V8) that (R9's) vital signs and pulse ox (oxygen level) was extremely low and (V8) did not even go look at (R9) and (V8) said 'she has COPD, she is going to have trouble breathing' and just shook it off. I even called one of the bosses (V19 and V5) but I could not get ahold of them because they were probably sleeping. At the end of our shift, around 6:00 am, I think he finally went down and gave (R9) a breathing treatment, but by the time the day shift nurse came on, they sent (R9) out immediately to the hospital and (R9) was admitted to the Intensive Care Unit at the hospital. My co-workers and I were furious, we heard (V8/RN) giving report to the day shift nurse and (V8) told them in report that (R9) had just started acting like this and I spoke up and told them that (V8) was lying because (R9) had been like that since I came on shift at 1:00 am. I would tell (V8) that someone would need a pain pill or that they needed something and (V8) would never follow up. All (V8) would do, was sit on (V8's) (electronic device) and watch movies.On 8/31/25 at 8:19 am, V24 (Certified Nursing Assistant/CNA) stated, I worked with (V8/RN) a lot on night shift and I would never see (V8/RN) doing a full medication pass or taking the medication cart down the hallways passing medications. When I work with other nurses, they always take the medication cart down the hallways. That 6:00 am medication pass usually takes the night shift nurse quite a long time to complete it, and I would never see (V8/RN) doing that medication pass. When (V8/RN) worked, I always had Residents tell me that they did not get their treatments or medication, (R1, R8, R11 and R12) were just the ones off of the top of my head that I can remember. Basically, (V8/RN) would sit at the nurse's desk and watch movies all night. The CNA's would go to him when a Resident needed something from him and (V8/RN) would never check on the Residents. I even asked (V8/RN) how (V8) got (V8's) stuff done and was always able to sit at the nurse's station and (V8) told me that (V8) pulls all of the medications at the beginning of (V8's) shift. I never even seen him do that or spend that much time at the medication cart. I know that a lot of us complained to management about (V8), but (V8) just kept coming back to work and nothing was done, until I think they fired him.On 8/29/25 at 9:40 am, V15 (Activity Assistant) stated The Resident Council does have specific complaints about several Residents complaining that the night shift male nurse (V8) does not do treatments and does not give medications. They have also complained that (V8) is not recording stuff right in their charts. I even had one Resident complain that (V8) told him that it is not my job to treat your wounds, it is day shift's job. I think that (V8) did lose (V8's) job here because of all of the complaints.On 8/29/25 at 9:46 am, V16 (Activity Director) stated I used to be in charge of the Grievances, but they took them away from a few months ago, but now I just got the Grievance Book back two days ago, and I am not sure what happened to my copies of Grievances from before. I am not sure who was doing them (Grievances) until now, but I do remember complaints from Resident's about the male night shift nurse (V8) not recording stuff right and not doing their job. I think they finally got rid of (V8).On 8/29/25 at 12:43 pm, V3 (Licensed Practical Nurse/LPN) stated, I was the day shift nurse that relieved (V8/RN) on night shift. I got so sick of coming onto shift and (V8/RN) not taking care of the Residents at night, I was always coming into a mess when I follow (V8). On 7/3/25, I came on shift and immediately found (R9) having a very hard time breathing. In Report (V8) told me that the breathing issues just started and the CNAs came up to me and told me that (R9) had been having breathing issues the entire night shift, and had me go look at (R9) right away. (R9) had a nebulizer mask on and (R9's) oxygen saturation was in the low 80's. I immediately sent (R9) out to the hospital and (R9) was admitted to the intensive care unit. I had reported (V8/RN) multiple times to management (V5/ADON) and (V1/Administrator) and nothing seemed to happen. Every time I followed (V8) I would have multiple Resident's complain about not getting medications or getting taken care of. From what I have heard, and I know it is only hearsay, but (V8) would sit at the Nurse's Station the entire shift and watch movies. I got so sick of Resident's complaining about (V8). Finally, staff were starting to want to call off if (V8) was working. I cannot tell you how many complaints I got from Residents that their blood sugars were not being checked (R7), treatments were not getting done and I even had a dialysis Resident (R10), tell me that (R10) did not get the right medications on the 6:00 am medication pass when (V8) worked. We did not have a DON (Director of Nursing) for some of that time, our former DON (V19) was no longer here, so no one was really in charge. (V8) was always sitting at the Nurse's Station when I got in to work and from what I hear on the morning of 7/3/25, the CNAs (V9) said the (V8) had been sitting at the Nurse's Station since 3:30 am. I would check the computer after I would get all these complaints from Resident's and (V8) had always signed everything out so it was hard to prove anything, although I could not find that (R9's) nebulizer treatment was signed out. When multiple staff members, get multiple complaints from Residents, over and over again on the same nurse (V8), I feel that it is warranted and needed checked in to.On 8/29/25 at 10:15 am, V13 (RN) stated, I work First Shift and (V8/RN) worked Third Shift, which means that I started my shift at 6:00 am and took report from (V8/RN). (V8/RN) was temporarily employed here for a few months through an Agency and was not one of our actual employees. On 7/8/25, when I came on to my shift, the CNAs were complaining that (R4) was having increased anxiety, sweating really bad and having trouble breathing. (R4) kept asking for (R4's) medication. I checked the electronic medical administration record and it was documented that (V8/RN) gave (R4's) medications, but (R4) kept asking for the medications and saying that (R4) did not get them. The nighttime staff would tell me that (V8/RN) was not helping (R4) on the Night Shift. (R4) does have psychological diagnoses but (R4) knows better if (R4) gets (R4's) medication or not. I knew that something was wrong with (R4) because he was sweating and having trouble breathing, so I immediately called Emergency Services (911) and sent R4 out for evaluation at the hospital for (R4's) anxiety. I believe that (R4) did not get (R4's medications that day, even though (V8/RN) signed them out. I have taken care of R4 for over three years, and I know that if (R4) gets (R4's) scheduled medication, that it is effective for (R4). Every time that I followed (V8/RN), multiple Residents would complain that they did not get their medications or treatments from (V8/RN) on night shift. The CNAs would complain to me that (V8/RN) would not take care of the Residents when they had to approach (V8/RN) with a nursing need for a particular Resident. They also complained that (V8/RN) would do nothing but sit at the nursing station and watch movies on (V8's) phone, and that they never saw (V8) take the medication cart up and down the hallway for the heavy 6:00 am medication pass or passing medications. I think that (V8) was very strategic with certain Resident's depending on their cognition as far as not giving medications. I told V1 (Administrator), V19 (Former Director of Nursing/DON), V5 (Assistant Director of Nursing/ADON) multiple times about (V8) not doing the job, then I would come on shift and have to clean everything up and deal with it. (V8) should have given medications and sent out (R4) and (R9) to the hospital way before us first shift nurses got in. Those poor Residents sat there for hours without (V8) monitoring or helping them.On 8/30/25 at 11:44 am, V8 (Agency Registered Nurse/RN) stated They came to me about (R9) not breathing well, but (R9) had COPD for gosh sakes, so (R9) was not going to be breathing well. I did give (R9) a nebulizer that morning, but I did not sign it out. (R4) was so confused, did anyone take into consideration that (R4) probably does not remember getting his medications. Honestly, does it really matter on medications if a dose, here or there, does get missed. As far as I am concerned, if I signed it, I gave it.On 9/2/25 at 9:54 am, V4 (Ombudsman) stated, I heard they had problems with a night shift nurse over there, from the Residents. Something with medications and not sending people out to the hospital.On 8/29/25 at 11:10 am, V5 (Assistant Director of Nursing/ADON) stated, I did hear the staff and Residents complaining about (V8) not doing his job. We needed our third shifts covered and needed him still to come in. I am not quite sure if (V19/Former DON) was still working here or not, so I am not sure who really took care of the issues. (V8) was in charge of the entire building on night shift, since there was only one nurse on duty. I would hear that he would leave sometimes for lunch and that definitely was not allowed. We ended up terminating (V8) through the Agency due to all of these issues.On 8/29/25 at 10:10 am, V1 (Administrator) stated, (V8) was employed through an Agency and because we were aware that (V8) was not performing the job duties, so we 'DNR'd/Do Not Rehire. (V8), so basically (V8) was terminated.

Based on observation, interview, and record review the facility failed to prevent an injury for one of three residents (R1) reviewed for accidents in a sample of nine. This failure resulted in R1 receiving a large hematoma under both eyes and across the bridge of R1's nose causing R1 pain and requiring R1 be sent to the Emergency Room.Findings include:Resident Rights Handbook documents Your rights to safety Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.The Fall Reduction Policy dated 10/30/24, documents Purpose: to provide an environment that remains as free of accident hazards as possible. Definition of Fall: A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. A near fall is a sudden loss of balance that does not result in a fall or other injury. This can include a person who slips, stumbles or trips but is able to regain control prior to falling. R1's computerized Medical Record documents that R1 is a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses which included Systemic Lupus Erythematosus, Organ and System Involved Unspecified, Personal History of Transient Ischemic Attack, and Cerebral Infarction without Residual Deficits, Chronic Kidney Disease, Stage 3, Age-Related Osteoporosis without Current Pathological Fracture, Essential (Primary) Hypertension, and Generalized Anxiety Disorder.R1's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) of 15, indicating (cognition intact). R1 has no upper or lower extremity impairment, uses no devices for mobility, is independent for activities of daily living, bed mobility, and transfers. R1's Care Plan printed 8/30/25 documents (R1) currently has an alteration to her Integumentary System d/t (due to) Bruising. Date Initiated: 8/5/2025.On 8/28/25 at 11:20 AM, R1 was sitting in the dining room. R1 had a purplish/green bruising under both eyes and across the bridge of her nose. R1 stated several weeks ago R1 was going to her room on C Hall after supper and tripped over a rug. R1 did not fall to the floor but her head hit a door. R1 did not tell anyone although she did have pain. When R1 got up the next morning a nurse (V13/Registered Nurse/RN) noticed bruising on R1's face. R1 was sent to the hospital to be evaluated. R1 is currently getting Tylenol for pain. R1 also stated The rug was starting to come up on one end. There have been other people to trip over it (the mat). We (R2/Resident Council President and R1) complained that someone was going to get hurt. They (the facility) removed the rug after I got hurt.R1's Nursing Note dated 8/5/25 at 6:30 AM, documents (R1) was ambulating towards nurses' desk, as staff noticed (R1) to have her left eye swollen and black, and continued from her left eyebrow up to her hairline. When staff questioned (R1) as to what had happened, (R1) replied that she had tripped over the corner of the rug that is in front of the back door and the break room door. (R1) stated that (R1) didn't fall, (R1) had caught herself and apparently hit her head on the doorway. (R1) did not report to any staff as she stated she didn't think it was that bad. Neuro checks initiated. R1's Telehealth Note dated 8/5/25 at 7:00 AM, documents that a nurse reported that R1 experienced a fall last night after tripping over a rug and struck her head. Swelling and bruising were noted around the left eye, extending from the left eyebrow to the hairline. R1 was referred to the emergency room for further evaluation and treatment.R1's Incident Report dated 8/5/25 at 6:30 AM, documents (R1) was walking by nurses' station and nurses noted (R1) had a black, swollen eye and a bruised area to the top of her left side of head. (R1) stated after supper on 8/4/25 at around 7:30 PM (R1) walked out of the dining room and down the hall, when (R1) walked through the doorway (R1) hit the corner of the rug and tripped over it, (R1) states (R1) tried to catch herself and hit her eye and head on the break room doorway and door frame. Action Taken - R1 was assessed and sent to the Emergency Department for evaluation and treatment. Injury type - left eye. Predisposing Environmental Factors- Rugs/CarpetingR1's Emergency Department Notes dated 8/5/25 at 11:23 AM, document History of Present Illness - R1 presents following a fall at (the facility) 16 hours ago. The fall was described as tripped (over floor mat). Location: Left head (forehead eye (s). The character of symptoms is pain and swelling. The degree at present is 7/10 (Severe pain). A CT/Computed Tomography of R1's head, cervical spine, and facial bones were done. Findings A prominent left frontal scalp hematoma hyper attenuating therefore acute measuring about 4 (four) by 1 (one) cm (centimeters). Prominent Soft Tissue Hematoma in the left supraorbital and frontal scalp. Therapy today: over the counter medications including Tylenol and Naproxen. Associated symptoms: headache. Plan - Follow up with primary care physician and continue prescribed Tylenol and Naproxen for pain. R1's Nursing Note dated 8/8/25 at 8:27 AM, documents (R1) up for breakfast, bilateral bruising to eyes from previous incident. (R1's) left eye has increased redness.R1's Wound Log printed 8/31/25 documents the following injuries were acquired in the facility. 8/8/25 - left eye 5 cm (centimeter) x (by) 3 cm bruise, right eye 6 cm x 4 cm bruise, bridge of nose 5 cm x 2 cm bruise, forehead 2 cm x 2 cm bruise. 8/15/25- left eye 4 cm x 3 cm bruise, right eye 5.5 cm x 3 cm bruise, bridge of nose 3 cm x 1 cm bruise, forehead 1 cm x 1 cm bruise. 8/22/25 - left eye 3 cm x 2 cm bruise, right eye 4 cm x 3 cm bruise, bridge of nose 3.5 cm x 1.5 cm bruise. 8/29/25- left eye 2.5 cm x 1.5 cm bruise, right eye 3 cm x 2 cm bruise, bridge of nose 3.5 cm x 1.5 cm bruise. Supply Invoice dated 8/4/25 documents that one Loop Edge Mat was ordered. The Fall Tracking Report dated August 2025 documents that R1 fell 8/5/25. On 8/28/25 at 12:22 PM, R2/Resident Council President stated (R1) tripped on a rug and messed her face up. (R1) looked rough. It was a mat coming from the hall into the TV (television) room. The mat was there to wipe feet on when you come in from outside. There was a section at the end of the rug that was turned up. It was sticking up enough to trip on just on the end. I believe I told (V1/Administrator) about the rug before (R1) fell. Whenever there is a complaint, I take it to (V1) to see what they will do about it. R2 also stated After (R1) fell they (the facility) took the rug up right away. Why did it take someone to get hurt before they took it up? It (the rug) had been bad for several weeks.On 8/28/28 at 1:40 PM, V3/Licensed Practical Nurse stated that prior to R1's fall, a residents family member (unidentified) came to take a resident out for the day, and the family member tripped on the mat but did not fall. Since it was a weekend V13/Registered Nurse/RN wrote a note and slipped it under the door of the office where Maintenance would see it. V3 also stated We knew the rug was a problem and reported it. The rug was not removed until (R1) tripped and hit her head. (R1's) accident should have never happened.On 8/28/25 at 1:56 PM, V13/RN stated that on 8/5/25 V13 was sitting at the nurse's desk around 6:30 AM and R1 walked past. V13 saw R1's eye was black. R1 told V13 that she (R1) tripped on the mat in front of the staff breakroom after supper on 8/4/25 and hit her head on the closed door. It hurt but R1 thought she was OK and did not report the incident. V13 assessed R1, R1 was complaining of pain and there was a bruise under R1's left eye. V13 gave R1 Tylenol and R1 was sent to the emergency room for evaluation. At first the bruising was grayish/black under the left eye then it was a dark purple under both eyes. The bruising continued to get worse and was eventually under both of R1's eyes and across R1's nose. V13 also stated That carpet has been a hazard. It was between seven to nine days before (R1) tripped that a visitor tripped. When the first incident happened, it was a weekend. I wrote a note and put it under the office door for the rug to be fixed or removed. Days later I talked to (V1/Administrator) and said that it (the rug) was a trip hazard. (V1) said he was going to tell corporate and get a new one. (Adhesive tape) was put on the corner of the mat to keep it flat. It lasted a couple of days then it rolled back up again.On 8/28/25 at 4:45 PM V4/Ombudsman stated that she had come into the facility and saw R1's face was bruised under both eyes and across R1's nose. R1 told V4 that she (R1) had tripped over a rug. V4 also stated that she was told by R2/Resident Council President that management was made aware of the rug being a trip hazard before R1 fell.On 8/29/25 at 10:05 AM, V1/Administrator stated that there was a nine foot long by four-foot-wide nonskid mat in front of the entry door. The mat extended past the front of the staff breakroom. The weekend before R1 fell on Tuesday 8/5/25 the residents had complained to V13/Registered Nurse that the rug was in disrepair and needed replaced. V13 told V1 about the residents' complaints. A new mat was ordered on 8/4/25 but the worn mat was not removed until after R1 tripped and hit her head on the staff breakroom door. After R1's injury on 8/5/25 the rug was removed to prevent any other accidents.On 8/29/25 at 11:36 AM, V14/Maintenance stated that a few days before R1 tripped they (staff) had talked about removing the rug. They were saying Someone is going to trip over it then (R1) did. I carried it (the mat) to the dumpster the same day that (R1) fell.

Based on record review and interview, the facility failed to check the temperature of a hot beverage before serving and failed to assist and supervise a resident dependent with eating for one of three residents (R1) reviewed for quality of care in the sample of three. These failures resulted in R1 spilling hot chocolate on herself and sustaining a second degree burn on her left hip/thigh causing R1 pain. Findings include: The Safety and Supervision of Residents policy dated 11/5/19 documents Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Facility-Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. 4. Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. Resident-Oriented Approach to Safety 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS (Minimum Data Set assessment). Systems Approach to Safety 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Resident Risk and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include h. Water Temperatures. The Serving Food policy dated 11/5/19 documents Food shall be prepared and served in a manner that meets the individual needs of each resident. Policy interpretation and implementation 2. Residents Requiring Full Assistance c. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. 3. Dining Room Residents: c. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. R1's electronic Medical Record documents R1 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Sequelae of Cerebral Infarction, Schizophrenia, Bipolar Disorder, Other Disorders of Physiological Development, Unspecified Focal Traumatic Brain Injury without Loss of Consciousness, Sequela, Heart Failure, Other Pulmonary Embolism without Acute or Cor Pulmonale, Pulmonary Hypertension, and Muscle Weakness (generalized). R1 was admitted to Hospice Care on 12/19/24 due to terminal diagnosis Unspecified Sequelae of Cerebral Infarction. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 had a Brief Interview for Mental Status/BIMS of 4 (severe cognitive impairment). R1 is Dependent on staff for eating. Helper does All of the effort. Resident does none of the effort to complete the activity. R1's current Care Plan documents R1 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to Schizophrenia, Traumatic Brain Injury, Bipolar Disorder, Developmental Delay, Cognitive Deficits. Date Initiated 5/20/24. R1 has self-care deficit and needs supervision and/or assist to complete quality care and or poorly motivated to complete activities of daily living. Related to poor motivation, poor regard for personal hygiene, and impaired mobility. Interventions: Assist with hands on feeding if R1 is unable or unwilling to complete the task. Date Initiated 5/20/24. R1 has risk factors that require monitoring and intervention to reduce potential for self-injury. R1 will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors. Intervention: Remind of safety precautions and limitations as necessary. Date Initiated 5/20/24. Interventions: R1 will have all drinks covered with a lid. Date initiated 3/17/25. R1 has reddened area from spilled hot chocolate noted to left hip with blistering. R1 to be served tepid, not hot drinks. Date Initiated 3/17/25. R1 currently has an infection due to wound infection of left hip. Date Initiated 3/28/25. R1's current diet is Regular, Dysphasia mechanical texture, regular thin liquids. Interventions: I (R1) will be fed by staff since I am unable to feed myself. Date Initiated 2/25/25. The Hospice Plan of Care signed by V10/Hospice Nurse dated 3/12/25 at 8:20 AM documents Interventions: Feed (R1) if visit is during a meal. Goals: Absence of injury, as evidenced by safe environment maintained to accommodate neurological deficits. (R1) will maintain a pain score of 4 (four) or less, per patient/family preference, on a scale of 0 (zero)-10. R1's Nursing Note written by V8/Licensed Practical Nurse/LPN dated 3/16/25 at 9:35 AM documents Observed (R1) in (high back wheelchair) with water pitcher tipped over on lap. (R1) stating that it was burning her. Water pitcher had hot chocolate in it. (R1) taken to room and skin assessment was complete. Writer (V8) noted red area to left hip. Area not raised or blistered at this time. The Accident statement of V14/Cook taken by V15/Dietary Manager not dated documents that on Sunday 3/16/25 a CNA/Certified Nursing Assistant requested hot chocolate for R1. V14 asked the nurse if it was OK, and the nurse said yes. V14 made the hot chocolate, put it in a cup, and put the lid on it. V14 set the drink on the counter but the CNA was no longer there so V14 took the drink to (R1) and set it on the table. R1's Nursing Note written by V2/Director of Nursing dated 3/17/25 at 9:54 AM documents Red areas with slight blistering noted to (R1's) left waist area and left upper thigh area. V11/R1's Primary Care Physician was notified of R1's blistering and Silvadene or alternate cream was requested to apply to R1. The Weekly Wound Log dated 3/17/25 documents there were four burn wounds to R1's left hip from spilled hot chocolate on 3/16/25. The wounds measured length 2.5 cm (centimeters) by width 0.5 cm, length 4.0 cm by width 3.0 cm, length 2.0 cm by width 1.0 cm, and length 15 cm by 3 cm. Pain was documented as slight discomfort. R1's Nursing Note written by V3/LPN dated 3/17/25 at 2:14 PM documents that V10/Hospice Nurse assessed R1, and new orders were given by V20/Hospice Physician for Silvadene two times a day to the blistered area on R1's left hip for seven days. The Hospice Certification of Terminal Illness signed by V20/Hospice Physician dated 3/17/25 at 3:48 PM documents (R1) is chair bound, and tends to lean forward, putting herself off balance. Speech is limited to a vocabulary of 6 (six) or less words in a conversation. Staff assist (R1) to eat, as she is unable to manage utensils. (R1) is totally dependent for bed mobility, dressing, grooming, toileting, eating, and transfers. The Hospice Visit Note signed by V10/Hospice Nurse dated 3/24/25 at 9:43 AM documents R1 has burns to left hip/thigh causing pain Soreness, Tender and pain is an active problem. Facility nurse called and stated that she believed that (R1's) burns were getting infected. (V10) completed PRN (as needed) visit. Burn areas look to be healing. Spoke with (V20/Hospice Physician) who gave orders to continue Silvadene cream 1% (percent) BID (twice a day) for 7 (seven) days. Cover area with (dressing) and secure with tape. RN (Registered Nurse) also ordered Norco 5/325 (milligrams) give one tab every 4 (four) hours PRN for pain. Discussed with facility nurse (V3/LPN) about giving Norco before dressing changes due to (R1) having pain during dressing change. R1's Medication Administration Record/MAR dated 3/1/25 - 3/31/25 documents Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligrams) to give one tablet by mouth every four hours as needed for pain related to burn on left hip/thigh. Start date 3/24/25. R1's Nursing Note written by V18/Registered Nurse/RN dated 3/24/25 at 12:23 AM documents (R1) has extensive burn to right hip. Order to clean with wound cleanser and apply Silvadene and cover. Areas are red and blistered with open areas covered in slough. R1's Nursing Note written by V3/LPN dated 3/24/25 at 4:13 PM documents that V10/Hospice RN was in to see R1. V20/Hospice Physician gave a new order to continue Silvadene to the burn on R1's left hip/thigh, cover with (dressing) and secure with tape twice a day for seven days. Give Norco 5-325 mg one tab by mouth every four hours as needed for pain related to R1's burn. The Hospice Skilled Visit Note signed by V10/Hospice Nurse dated 3/25/25 at 11:45 AM documents R1's wound is 18 cm (centimeters) by 9 cm, slough in wound bed with small amount of Serosanguinous drainage and mild odor. Visit Plan: Contacted doctor to obtain new order for antibiotic. R1's Nursing Note written by V8/LPN dated 3/25/25 at 12:04 PM documents that V10/Hospice Nurse was at the facility today to see R1. New order received for Clindamycin 300 mg twice a day for seven days for left hip wounds. R1's Nursing Note written by V18/RN dated 3/26/25 at 12:30 AM documents that R1 continues to have extensive burns to her left hip and buttocks. All areas are opaque and covered in slough with small black areas scattered throughout. V18 faxed a request to hospice requesting to change from Silvadene to Medi honey. R1's Dietary Note written by V21/Registered Dietician dated 3/31/25 at 8:28 AM documents that during an on-site visit on 3/31 V21 was notified that R1 had a skin issue being treated that was caused by a hot liquid spillage. V21 reviewed R1's diet due to R1's burn and weight loss. V21 recommended that all drinks are to have a lid. V21 noted poor intakes. (R1) needs supervision at meals. R1's Medical Record does not include a hot liquid risk assessment. R1's Medication Administration Record dated 3/1/25 - 3/31/25 documents Silvadene External Cream 1% (percent) (silver Sulfadiazine) Apply to left hip affected area topically every shift for blistered area. Start date 3/19/25. R1's Treatment Administration Record dated 3/1/25 - 3/31/25 documents Apply Silvadene cream BID (twice a day) to affected areas on left hip and cover with non-adherent pads for seven days every shift for blisters on skin. Start date 3/18/25 discontinue 3/23/25. R1's Treatment Administration Record dated 3/1/25 - 3/31/25 documents Apply Silvadene cream BID (twice a day) to affected areas on left hip and cover with non-adherent pads for seven days every shift for blisters on skin. Start date 3/24/25 discontinue 3/28/25. R1's Treatment Administration Record dated 3/1/25 - 3/31/25 documents Clean area to left hip with wound cleanser; apply Medi honey and cover with (dressing) and secure with tape daily until healed every day shift for wound healing. Start date 3/29/25. R1's Medication Administration Record dated 3/1/25 - 3/31/25 and 4/1/25 - 4/30/25 documents there is to be a pain assessment every shift on days and nights. Start date 12/8/24. (Pain is based on a 0 -10 scale) Pain was documented as follows; 3/17 both shifts 3 (three), 3/18 days 1 (one), nights 3, 3/22 days 7 (seven), 3/23 both shifts 5 (five), 3/24 both shifts 7, 3/26 both shifts 6 (six), 3/29 both shifts 6, 3/30 days 4 (four), 3/31 both shifts 5, 4/1 both shifts 4, 4/2 nights 3. (3/4/25 was the only time that pain was documented before the burn incident, and it was rated at a 3) The Food Temperature Chart for 3/16 to 3/22/25 does not document any temperatures for the Hot Coffee or Hot Tea. On 4/18/25 at 10:22 AM, V3/LPN stated I was not working the day of the accident, but I heard about it. (R1) was dependent on staff and should not have been handling a hot drink by herself. (R1) sits at the table where staff feed the residents. I was told that (R1) wanted hot [NAME]. The kitchen staff made it in the microwave. (V14/Cook) took it to the nurse's station to let it cool down and (V8/LPN) told (V14) to take it to (R1). (R1) was not able to hold her own cup or silverware. There were three burns, and they were large areas on (R1's) left hip in the front. They were nasty burns. They were painful for (R1). On 4/18/25 at 10:40 AM, V2/DON stated I was off and when I came in on Monday, I was told that (R1) spilled hot chocolate in her lap. There were four areas, three were pink and one had blisters. I did the assessment and called (V5/R1's Power of Attorney), the doctor, and talked to hospice. Staff had put the hot chocolate in a pitcher (large cup) that had a straw and a handle. (R1) could feed herself some but (R1) sits at a table to be assisted during meals. This was not at mealtime, and I don't know that anyone was there to help (R1) with the drink. I have no idea why it was so hot. They (kitchen staff) were not checking temperatures at that time. That process was not in place but evidently needed to be. On 4/18/25 at 10:50 AM, V4/Dietary Aide stated A CNA came to the kitchen and said that (R1) wanted some hot chocolate. We microwaved the water then added the ingredients. (V14/Cook) was who made the drink for (R1). (V14) took the drink to the nurse's station for it to cool down. (V14) was told to go ahead and take it to (R1). (V14) put the drink on the table in front of (R1). (R1) needed help with the drink because (R1) shakes. During meals (R1) sits at a table where staff can help (R1). Since this was not at mealtime, I don't think there were staff around to help (R1). On 4/18/25 at 11:23 AM, V5/R1's Power of Attorney stated (R1) was burned on 3/16/25 by spilling hot chocolate on herself. (R1) should have had someone help her with the drink. (R1) has Dementia, Bipolar, Schizophrenia, and physical limitations. (R1) is on hospice because of her declining health that required (R1) to have assistance or at least supervision. (V10/Hospice Nurse) told me the burns were not looking good with one of them being 19 cm by 9 cm in size and they were causing (R1) pain. I was upset because from what I was told by the facility the burns were minor, this does not seem minor to me. I know that accidents happen, but this is not acceptable. If there had been someone close by at least supervising (R1) they would have been able to quickly get the cup picked up so the burn area would not have been as large. I did not get good answers to how this accident happened and why there was no supervision. On 4/18/25 at 1:53 PM, V10/Hospice RN stated (R1) got a burn on her hip/thigh area from spilling hot chocolate on herself. When I saw the wound the areas had blistered then the blisters opened. There was slough in the wound bed. (R1) was started on a prophylactic antibiotic to prevent infection. The first treatment was Silvadene cream for seven days then it was changed to Medi honey. The burn was through the second layer of skin. (R1) was having pain due to the burn especially during dressing changes. Hydrocodone was ordered for pain relief and was to be given before dressing changes and as needed every 4 hours. V10 also stated (R1) needed supervision and help with all her activities of daily living including eating and drinking. On 4/18/25 at 2:04 PM, V11/R1's Primary Care Physician stated that R1's burn was a second degree burn and there is some degree of pain with any burn. The pain may range from moderate to severe. On 4/18/25 at 3:08 PM, V8/LPN stated I was at the nurse's desk when the kitchen brought out hot chocolate in a bedside cup for (R1). I told the kitchen staff to take the drink to (R1). Later I heard a commotion in the dining room. (R1) had spilled the hot chocolate on her leg. I took (R1) to her room and looked at her leg. It was just pink at the time. I called (V1/Administrator) and reported it. V8 also stated that at times R1 could eat and drink on her own. V8 was asked how it was determined if R1 was able to feed herself or needed assistance. V8 stated If there is a fork there and (R1) picks it up then she can feed herself. V8 also stated that she does not remember there being any staff in the dining room when R1 spilled the drink. On 4/18/25 at 3:19 PM V13/RN stated I was at the nurse's station when (R1) spilled the hot chocolate. It depends on the day if (R1) could feed herself. I don't remember there being any staff in the dining room with (R1). V13 also stated The wounds were not good; they were red then blistered and broke open. They were substantial. On 4/18/25 at 4:59 PM, V14/Cook stated I made the hot chocolate for (R1). I made it in the microwave. I don't know how hot it was. I did not take the temperature. That was not the protocol at the time. It was put in a blue cup with measurement lines on the side. The cup had a handle on it but no lid. I took the drink to the nurse's station and put it on the counter. The nurse said to give it to (R1). I did not know anything about how (R1) drinks, so I put it (hot chocolate) on the table instead of giving it to (R1). I don't remember there being any staff in the dining room. On 4/19/25 at 10:43 AM, V15/Previous Dietary Manager stated I was told that (R1) asked for hot chocolate. The kitchen staff asked the nurse if (R1) could have hot chocolate and the nurse said it was ok. The water for the drink was put in the microwave to get it hot. I don't know how hot it was. We were not temp testing the drinks or logging what the temp was. On 4/19/25 at 1:36 PM, V1/Administrator stated they did not have a hot liquid assessment for R1. On 4/19/25 at 1:42 PM, V17/CNA stated that she has worked at the facility for three years and was familiar with caring for R1. R1 ate at the assisted table and needed supervision when eating or drinking. Most days R1 was not with it enough to help herself and R1 was shaky.

Based on record review and interview the facility failed to ensure one of three residents (R1) reviewed for mechanically altered diets was served the Physician ordered diet. This failure resulted in R1 receiving the wrong texture of diet causing R1 choking on his food requiring back thrusts, the Heimlich maneuver and transfer to the local area hospital. This failure also put R1 at risk for death and/or brain damage from lack of oxygen due to choking. These failures resulted in an Immediate Jeopardy. Findings Include: The Immediate Jeopardy began on 6/23/24 at 5:50 PM when the facility failed to provide the proper mechanically soft diet with ground meat and gravy on all meats as ordered for R1. The immediacy was removed on 07/26/2024 and the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their In-service training and Quality Assessment oversight. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 7/26/24 at 10:30 AM. The Facility's Facility Reported Incident dated 6/23/24 documents (R1) was eating and began choking. CNA alerted nurse, she came to resident's side and told CNA to call 911. Resident transported to (Emergency Department) where received an x-ray. Investigation completed. R1's discharge papers dated 6/23/24 from the local hospital document that R1 was evaluated after a choking episode at the facility. The paperwork indicated that R1 had a chest x-ray done with no abnormalities and sent back to the facility. R1's admission diet order dated 5/22/24 documents Controlled Carbohydrate Diet, mechanical soft, thin liquids, ground up meat with gravy on all meats. R1's MDS (Minimum Data Set) dated 06/04/24 documents a BIMS (Brief Interview for Mental Status) score of 4 out of possible 15 indicating severe cognitive impairment. R1's MDS also documents inattention, disorganized thinking and altered level of consciousness. The MDS documents that R1 requires Extensive Assist of one person. On 7/24/24 at 11:30 AM V3 (Licensed Practical Nurse) stated the level of assistance R1 requires while eating varies depending on the day. Most days he will physically feed himself with a lot of verbal cueing. He does not like to be in the dining room so he will try to rush through meals and wheel himself out. Throughout the survey R1 did not answer any questions appropriately and did not seem to understand what was being said. On 7/24/24 at 11:00 AM V5 (Dietary Aide) stated I served (R1) a pork fritter type piece of meat. I did not grind it or put any gravy on it. When (V6/Certified Nurse Aid) requested gravy and chopped meat I cut up the meat with a knife and told her to use some other condiment on it to soften it up because I did not have any gravy. V5 stated I have not been trained on any of this, I am doing the best I can. I was in the kitchen by myself, so a housekeeper and a CNA came in to help sling trays. I do remember (V6/CNA) telling me that it was the wrong diet, I fixed it the best I knew how to. V5 stated that he did not know if a pork fritter/pork chop would be consistent with a mechanical soft diet. V5 stated I guess that means, so they (residents) don't have to chew up tough meat or something. V5 stated that he did not know who had altered diets in the facility until V4 (Dietary Manager) took over on 7/1/24. Once (V4) took over, I realized how wrong I was doing some stuff. I didn't mean to; I was just doing the best I knew. But (V4) follows the menus, gives me recipes to follow and showed me how to cook. (V7/Previous Dietary Manager) would not answer questions and didn't follow the menu or order the right groceries, so I came in on that night (6/23/24) and figured it out myself what I was making for supper. On 7/25/24 at 8:00 AM V1 (Administrator in Training) provided a dietary schedule for the night of 6/23/24 based on timecard punches. This information confirmed that V5 (Dietary Aide) was working alone on 6/23/24. On 7/24/24 at 10:30 AM V6 (Certified Nurse Aid) stated, (V5/Dietary Aid) gave me a regular diet for (R1) which I knew was wrong. (R1) was a mechanical soft diet with minced meat with gravy. I told (V5) that and he just cut up the meat and told me to use something else for the gravy. V5 had no idea what he was doing, and we were so short staffed and busy, I just took it. On 7/24/24 at 10:30 AM V6 (Certified Nurse Aid) stated I sat the tray in front of (R1) and continued to pass trays. All of us (Staff) were busy and not paying attention, when I happened to look over, he was putting a piece of meat in his mouth. He immediately began choking. V6 stated that R1 usually required supervision to eat. V6 stated, We had not even passed silverware yet, so I didn't think he would try to eat it. V6 confirmed that R1 very confused and can only follow simple instructions. On 7/24/24 at 11:30 AM V8 (Licensed Practical Nurse) stated On 6/23/24 (R1) was served the wrong diet. That is why he choked. He is supposed to have mechanical soft with ground meat and gravy on all meats. When he was choking, I smacked him on the back several times and then positioned him to do the Heimlich and he coughed up about 120 ccs (Cubic Centimeters) of chewed up meat. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 07/26/24. 1. On 7/26/24 at 10:45 AM V4 (Dietary Manager) stated she monitors all meals while she is in the facility and checks with second shift nurses and weekend managers to see how other meals are going. 2. Dietary Schedule for 07/01/24 - 07/31/24 documents at least two dietary staff on the schedule for every meal. 3. R1, R2 and R3 were the only residents in the facility to receive an altered texture diet. Their meal cards were correct and in the kitchen. Their dietary orders were posted next to the steam table/serving window. 4. V4 (Dietary Manager) provided a seating chart that had residents requiring assistance seated together in the middle of the dining room. There were no previous seating charts to compare to. 5. R1, R2 and R3's care plans all reflected the correct diet texture.

Based on observation, interview and record review, the facility failed to accurately administer physician ordered GlucaGen (injectable medication to increase blood sugar) according to the physician order for a resident with Type II Diabetes Mellitus and already elevated blood glucose (sugar) levels, for one of three residents (R1) reviewed for Medications in the sample of three. This failure resulted in R1's hyperglycemia worsening and requiring R1 to be transferred to the emergency room for treatment to lower her blood glucose. Findings Include: The facility's Adverse Drug Reactions and Medication Discrepancy policy, dated 10/2006, documents A medication discrepancy/error has been made when one of the following occurs: Wrong medication administered, Wrong dose administered, Medication administered by wrong route, Medications administered to wrong resident, Medication administered at wrong time, Medication not administered. R1's current Care Plan, dated 4/15/24, documents The resident has Diabetes Mellitus Type II. Monitor/document/report as needed any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, kussmaul (rapid, deep breaths) breathing, acetone breath (smells fruity), stupor, coma. R1's Current Physician Order sheet, dated 5/7/24 documents R1 has orders for Blood glucose monitoring four times a day. Novolog Regular (insulin) 100 units/ milliliter, inject seven units as needed four times daily if blood sugar greater than 350 (milligrams per deciliter, mg/dl). This same order sheet documents R1 has an order for GlucaGen one milligram (mg) injection, inject one mg intramuscularly one time as needed for low blood glucose. On 5/13/24 at 10:30 AM, R1 was laying in her bed in her room. R1 confirmed she was taken to the hospital recently. R1 recalled before she went to the hospital, she remembered feeling dizzy. R1 could not recall any other events that occurred that day before being sent to the hospital. R1's Nursing progress note, dated 5/5/24 at 6:40 PM and signed by V4 (Licensed Practical Nurse, LPN) document At 6:05 PM (R1) was acting off in the dining room, dropping liquids and seeming not quite right. Blood sugar assessed at 432 (mg/dl). Writer asked nurse on days (V8, Registered Nurse) and she stated she checked her sugar and gave sliding scale insulin per the doctor's order. 6:10 PM, resident non-responsive in the dining room. Blood glucose reading High. Intramuscular GlucaGen administered by writer and (emergency medical services) called. LPN (V4) administering medication realized the error and notified Medical Doctor (V9, R1's Physician). R1's Medication Discrepancy Report, dated 5/5/24 and signed by V4 documents GlucaGen injection was given to R1 and realized after injecting that it was an error. This report documents Possible effects to the resident: Elevating already high blood glucose. On 5/13/24 at 10:15 AM, V5 (Ambulance Paramedic) confirmed he responded to the facility for R1's transfer to the hospital. V5 stated The ambulance was called due to (R1) having increased blood sugar levels and being unresponsive. Our glucose meter reads up to 600 (mg/dl) and then it will just say high. Our reading of her blood sugar in the ambulance was high. The facility called us and initially said she was in the 500 (mg/dl) reading and then they got a high reading and they said they gave GlucaGen. I told them that GlucaGen raises the blood sugar and the nurse walked away and stated I messed up, I messed up several times. I did not catch the nurse's name. She (R1) became responsive to pain in the ambulance, but it was a moan and then back to unresponsive. She never woke up fully before arriving at the hospital. On 5/13/24 at 1:54 PM, V8 (Registered Nurse) stated I was working that day (5/5/24) and getting ready to leave. It was supper time. (R1) was having high blood sugar. She was tired and so I checked her blood sugar. I had to go back to see her again, she was almost asleep at the table. (R1) said she was dizzy. I checked her blood sugar and it said High. (V4) was already working and I didn't think (R1) was hypoglycemic (low blood sugar). I was trying to get staff to get her back to bed. (V4) checked her and said, Oh she is not feeling well and I said I know, and she is not low, she is showing signs of being septic. (V4) got GlucaGen and said, Sometimes you can show signs of high (blood sugar) when you're low. I think almost immediately she realized it was wrong because she came back to the nurse's station and said, I just made a rookie mistake. We didn't give any more insulin again. Initially (V4) was talking about giving orange juice and such, I said (R1) can't be low. I had just checked her blood sugar. After the GlucaGen was given, we then called the ambulance. (V4) realized it pretty quick. At that point we knew she would need to be sent to the hospital for care. R1's Emergency Department notes, dated 5/5/24, documents R1 was evaluated in the emergency room and later admitted to a tertiary hospital (higher level of care) for associated diagnoses of Septic shock, Urinary tract infection, Acute Kidney injury and Hyperglycemia. This note also documents on 5/5/24 at 6:49 PM in the emergency room , R1's laboratory value of blood glucose was 713 mg/dl. On 5/13/24 at 1:10 PM, V9 (R1's Physician) confirmed R1's blood sugar being over 350 mg/dl is high (hyperglycemia) and requires insulin medication to lower the level of glucose in the blood. V9 also confirmed that GlucaGen increases blood sugar and is meant for hypoglycemia (low blood sugar, below 60 mg/dl). V9 stated Once they (facility) gave her the extra injection of glucose (GlucaGen) it would cause the hyperglycemia to become worse and elevate the (R1's) blood sugar levels further. V9 confirmed R1 was sent to the hospital and treated for hyperglycemia as well as other medical conditions on 5/5/24.

Based on observation, interview, and record review, the facility failed to administer pain medication as ordered and assess pain on a daily basis following a fall that resulted in a fracture for one of one resident (R30) reviewed for pain in the sample of 23. These failures resulted in R30 having intractable pain related to a new rib fracture. Findings include: The facility's Pain Prevention & Treatment policy, dated 12/7/17, documents, 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. Assessment of pain will be completed with changes in the resident's condition, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to, date, rating, treatment, intervention and resident response. The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, diagnosis that may anticipate pain (i.e. arthritis, wounds, fractures, etc.). Information collected on the Pain Assessment Form will be used to formulate and implement a resident specific Pain Treatment Plan documented in the resident's care plan. On 10/15/23 at 11:10 AM, R30 was alert lying in bed with oxygen on at 4 L/min (Liters/minute). R30 stated, I fell a few days ago. I was walking with my walker to the bathroom, and my walker got caught on my oxygen tubing. It pulled me back and I fell on to my bed and the footboard of my bed. I instantly felt cracks and had lots of pain. I went to the ER (emergency room ) and they said I have rib fractures. R30 had to stop speaking several times due to the pain it was causing her to speak and each breath she took. Grimacing repeatedly R30 stated, The pain is awful. I'd say it's an '8' (on a scale of 0-10) right now. It's always sharp and stabbing. If I move my arms or my body, I can't take it the pain is so bad. On 10/18/23 at 10:45 AM, R30 was drowsy and falling asleep as she stated, I sleep a lot, but that doesn't mean I'm not in pain. I'm just always so drowsy especially since I came back from the hospital. They don't wake me up at night to give me any pills. I want to be woke up because I end up waking up in the morning, and my pain is awful. I can't take the pain. My pain is still at an '8' especially when I'm trying to talk to you. It's a constant sharp stabbing pain into my chest. R30's (Quarterly) Pain Assessment, dated 7/2/23, documents that R30 has occasional pain with the worst in the previous five days being a 4 on a scale of 0-10. R30's Hospital History and Physical, dated 10/8/23, documents, Chief Complaint: fell out of bed unwitnessed, (R30) states that she has right sided rib pain, unsure if she hit her head. History of present illness: (R30) states she was in her usual state of health today and had gotten up to use the bathroom with her walker. Unfortunately, her walker wheels were stuck in her oxygen tubing which resulted in a fall. She hit her right side of the chest and the hip. She could not get up and was in excruciating pain. She heard some crack according to (R30). She was brought to ER and work-up revealed right anterior ninth rib fracture. She was given Norco and fentanyl and was further admitted for intractable pain. A Facility Reported Incident, dated 10/13/23, documents, (R30) with a BIMS (Brief Interview of Mental Status) of 14 (Cognitively Intact) had an alleged fall. After interviewing the resident, it was determined that (R30) got out of bed to go to the toilet. She started ambulating with her walker towards the bathroom, as she approached the end of the bed. She tripped on her oxygen tubing resulting in her falling over the end of her bed and falling to the floor. Complaining of right sided pain she thought she heard a bone crack. Sent to ER x-ray results show a 9th rib fracture. She was admitted to the hospital for intractable pain. Returned to the facility on [DATE]. R30's Physician's orders, dated 10/9-10/31/23, documents that a new order was obtained on 10/11/23 for Norco (narcotic pain medication) 5/325 mg (milligrams) one tablet by mouth every four hours. The orders also document that R30 receives Norco 5/325 mg one tablet by mouth every six hours as needed for pain. R30's MAR, dated 10/9/23-present, documents that on 10/11/23 at 12:00 p.m., R30's scheduled every four hours Norco began. The MAR also documents that R30's 12:00 a.m. dose is circled as not given for each day 10/11-10/17/23. The MAR has no documentation of a daily pain assessment with the administration of R30's scheduled pain medication. R30's Quarterly Pain Assessment, dated 10/9/23, documents that R30 is having almost constant pain that makes it hard to sleep at night and limits her day-to-day activities. The assessment also documents that in the last five days the worst her pain was on a scale of 0-10 was a 10. On 10/18/23 at 10:25 AM, V4 (Registered Nurse) stated, The nurses are circling that they are not giving (R30) her 12:00 a.m. dose because she is sleeping at those times. She hasn't refused the Norco. We just don't want to wake her up to give her the medications since she is sleeping. V4 confirmed that R30 receives a scheduled pain narcotic, and when it is administered there is no formal pain assessment that is completed. On 10/18/23 at 12:22 PM, V2 (Director of Nursing) stated pain assessments are to be completed with every med pass and after each PRN administration. R30's pain assessment should be done before each scheduled Norco that they administer. I'm not sure where they should be documenting those pain assessments. The purpose of around the clock is to try and keep the pain down. V2 confirmed that R30's 12:00 a.m. dose of Norco has repeatedly not been given.

Based on observation, interview and record review, the facility failed to monitor and supervise a cognitively impaired resident (R1) with an identified elopement history from exiting the building during the deactivation of the facility door alarms. R1 was missing from the facility for hours and was found sleeping under a bush at a gas station on a busy street one mile from the facility. R1 was transported back to the facility by the local Police Department without injury. This failure has the potential to affect all eight Elopement Risk Residents residing in the Facility (R1, R2, R3, R4, R5, R6, R7 and R8). These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 8/23/23, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: Facility Elopement/Missing Resident Policy and Procedure, dated 7/2017, documents: it is the policy of the Facility that reasonable precautions are taken to prevent Resident Elopement; reasonable precautions include, but are not limited to, door alarms, wrist alarms and staff intervention; and all staff shall be trained and in-serviced on an annual basis in how to operate and respond to alarms, proper intervention and search techniques. Facility Missing Resident Policy, dated 7/2017, documents: it is the Facility policy to demand immediate response to elopement attempts, door alarm activation and participation in search attempts in the event that a resident is deemed missing; a Resident shall be defined as missing when initial reasonable search of the Facility interior and immediate grounds has not rendered physical evidence of the Resident's person; and no evidence of the Resident's whereabouts upon examination of documents including but not limited to the medical record, calendar of events and sign out books/sheets and after questioning of facility staff and Residents evidence of whereabouts remains uncertain; notify the Law Enforcement Officials; facilitate/coordinate staff assistance in investigation/search under direction of the Law; the Director of Nursing/DON's responsibility is to conduct a thorough investigation using the 'Investigative Report of Missing Resident: and report the findings to the Quality Assurance Committee with a time of occurrences, interventions and responses; prepare a summary of staff performance and policy/procedure strengths and weakness; and report as required by the State and Federal regulation to appropriate regulatory agencies. Facility Door Alarm Policy, dated 7/2017, documents: it is the policy of the Facility to ensure Resident safety and security through the use of door alarms; all doors leading to the outside, MUST meet these requirements; the alarm must only be disengaged at the door itself, either by push button code or key; no alarm may be disengaged from the nurses station or any other location without physical evidence gathered by a staff member or reason for trigger reported to the person silencing the alarm; the alarm must ring continuously until physically disengaging through key or code; testing, including actual activation, and documentation of testing will be completed weekly; and any malfunctions are to be reported to the Administrator and repaired as quickly as possible. The Facility Assessment Tool, dated 6/20/22, documents: the tool is organized in three parts, Resident Profile including diseases/conditions and physical/cognitive disabilities; services and care offered are based on Resident needs; and to provide competent care for Residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs; the Facility may accept Residents with Psychosis, Impaired Cognition, Mental Disorders, Anxiety and Behavior that needs interventions; and provide person centered/directed care to prevent abuse and neglect and identify hazards and risks for Residents. Facility Psychiatric Contracted Behavioral Health Source 6/23/22, documents: the purpose of this agreement services shall include psychiatric evaluation and medication management, psychological evaluation and testing therapy and counseling sessions; shall provide licensed Psychiatrists, Psychologists, Nurse Practitioners and other mental health care professionals; Facility shall provide the Contracted Behavioral Health Source with appropriate referrals for services; and each party shall comply with the Federal, State and Local laws, rules and regulations. R1's Physician Order Sheet/POS, dated 6/1/23 through 6/30/23, documents that R1 admitted to the facility on [DATE]. R1's POS documents that R1's medications include Buspar (Anti-Anxiety), Haloperidol (Psychosis), Chlorpromazine (Anti-Anxiety), Seroquel (Psychosis) and Trazadone (Anti-Anxiety). The POS also documents diagnoses including: Dementia, Psychosis, History of Alcohol Abuse, History of Encephalopathy, Elevated Hepatitis, Tardive Dyskinesia, Hallucinations, Paranoia and Anxiety. R1's Letter of Office/Guardian of Estate of Person Form, dated 3/16/23, documents that R1 is a disabled person and has a Court Appointed Guardian (V12/R1's Mother). 1. R1's Nursing Note, dated 6/15/23 at 2:00 am, documents that R1 climbed out the window and ran down the street and that R1 was unable to be redirected back to the Facility by staff and the Police were called and R1 taken to the emergency room (ER). R1's Nursing Note, dated 6/15/23 at 5:35 am, documents a telephone call from local Hospital Emergency Department that R1 was being discharged back to the Facility. R1's local Medical Hospital Emergency Department notes, dated 6/15/23 at 2:16 am, document: R1 presents from Facility due to a mental health evaluation with the local Police Department; staff (at the Facility) report that R1 removed a screen of the window and ran away; and that R1 is alert and not oriented at baseline. R1's Police Report, dated 6/15/23 at 1:30 am, documents V10's (Police Officer) Narrative and that V10 was dispatched and responded to a call for a [AGE] year old male (R1) that had jumped out of a window' (from the Facility). R1's Police Report/Report, dated 6/15/23, documents: at 1:31 am, R1 was identified at a nearby park; at 1:38 am, V10 (Police Officer) requested Emergency Medical Services/EMS for R1; at 2:06 am, R1 was taken to the local Hospital Emergency Department, R1 was confused and was left in the care of the Hospital Emergency staff for a mental evaluation. R1's local Hospital History and Physical/H&P, dated 6/15/23, documents that R1 admitted for a Mental Evaluation to the local Emergency Department at 3:16 am and was discharged back to the Facility at 6:57 am. The H&P documents that R1 was seen by a Behavioral Health Screener and deemed appropriate for return back to the Facility and that a Psychiatric follow-up is recommended. R1's Nursing Notes and Physician Order Sheets, dated 6/15/23 through 8/18/23, do not document a scheduled Psychiatric Evaluation appointment or screening order. On 8/18/23 at 10:40 am, V2 (Director of Nursing) stated, (R1) was identified upon his 4/24/23 admission to the Facility, as an Exit Seeker, and has continued throughout his stay. In the early morning of 6/15/23, (R1) climbed out of (R1's) window in (R1's) room and staff followed him down the road. They were unable to get him to come back to the Facility, so the local Police Department was called, and the Police took him the Hospital for an evaluation. On 8/23/23 at 2:48 pm, V2 (DON) stated, Our contact at our behavioral health psychiatric services (V13) has been out on medical leave for at least two months and that no contact person had been coming to the Facility in her place and I have no idea when (V13) is coming back. On 8/24/23 at 8:25 am, V17 (behavioral health psychiatric services) stated, We received a referral for (R1) but when we were going to do the initial screen, we did not have a signed Consent and (R1) was in the hospital and we never got another referral until 8/24/23, so (R1) has not been seen yet. (R1) is now scheduled for an initial assessment on either Monday (8/28/23) or Tuesday (8/29/23). We just received a signed Consent on 8/24/23, the Facility could never send us a signed Consent prior to this. R1's Nursing Note, dated 4/23/23 at 2:17 pm, documents that R1 admitted to the Facility and that R1 was placed on one-on-one observations. R1's Nursing Note, dated 4/25/23 at 1:00 am, documents that R1 has been exit seeking throughout the evening. R1's Nursing Note, dated 4/25/23 at 7:30 pm, documents that at 6:00 pm, R1 was exit seeking. R1's Nursing Note, dated 4/25/23 at 7:35 pm, documents that R1 exited the building eight times between 4:00 pm and 5:30 pm. and R1 believes R1 is residing in another town and became angry with staff and V12 (R1's Mother). R1's Nursing Note, dated 4/26/23 at 6:40 pm, documents that R1 has left the Facility three times and Facility staff has initiated one-on-ones with the Resident for the Resident's safety. The Nursing Note documents that V1 (Administrator) and V2 (Director of Nursing) were notified. R1's Nursing Note, dated 4/30/23 at 11:00 am, documents that R1 remained on one-on-one watch. R1's Nursing Note, dated 5/13/23 at 2:00 am, document R1 trying to find car and became agitated and argued with staff. R1's Nursing Note, dated 5/25/23 at 2:45 am, documents that R1 was trying to find car keys and go home. R1 was argumentative with staff and went out the back door. R1's Nursing Note, dated 6/2/23 at 7:30 am, documents that R1 was looking for his car keys and house keys and was hoarding cigarettes in pocket. R1's Nursing Note, dated 6/7/23 a 5:00 am, documents that R1 went to bed at this time and was up all night exit seeking. R1's Nursing Note, dated 6/8/23 at 5:00 am, documents that R1 went to bed at this time, was up all night, exit seeking. R1's Interdisciplinary Team/IDT Progress Notes, dated 6/15/23 at 9:00 am, document that the IDT team met to review R1's elopement attempt and that R1 was placed on one-on-one observations while awake for 24 hours until re-evaluation of elopement risk. R1's Interdisciplinary Team/IDT Progress Notes, dated 6/16/23 at 9:00 am, document that the IDT team met to review and re-evaluate R1's risk of elopement and that one-on-one observations were discontinued. 2. Facility local Health Department State Agency Notification Form/Notification Form, dated 6/17/23, documents that R1 has a Brief Interview for Mental Status (BIMS) score of 10/15 (cognitively impaired) and diagnoses including Dementia, Psychosis and Paranoia. The Notification Form documents that R1 was last seen, by staff on 6/16/23, during the hours of 10:00 pm and 6/17/23, at 1:00 am. The Notification Form documents that R1 exited the Facility unsupervised and was returned with no injuries. The local Police Department was notified. The Notification Form also documents In-Service Training forms to check door alarms were performed on 6/19/23. The Facility local Health Department State Agency Notification Form, dated 6/17/23, documents a written timeline statement from V6 (RN) stating, on 6/17/23, at 12:30 am, R1 was last seen by V6/RN sleeping on couch and R1 seen walking back to room. On 6/17/23, at 1:00 am, R1 was not in R1's room and V6 notified all staff in Facility to search all rooms, bathrooms and closets, and R1 was not in the Facility. V6 then notified the local Emergency (911), V1 (Administrator) and V2 (DON). On 6/17/23, at 1:40 am, V1 (Administrator) and V2 (DON) came to the Facility to help search for Resident. On 6/17/23, at 2:03 am, V10 (local Police Department) or V11 (local Police Department) called the Facility for R1's diagnosis, name and date of birth. On 6/17/23, at 3:00 am, all capable staff called into Facility to help search for Resident and at 4:15 am, R1 was still missing. Facility local Health Department State Agency Notification Form, dated 6/17/23, documents interviews with V6 (Registered Nurse/RN), V7 (Certified Nursing Assistant/CNA), V8 (Registered Nurse/RN) and V9 (Unit Aide). The Facility local Health Department State Agency Notification Form documents: that V7 stated, I was at the Nurses Station and (V6/RN) asked why the lights on the panel were blinking C Door, Front Door and Back Door. Saw they were off and (V9/Unit Aide) turned them back on. Around 11:30 pm, (on 6/16/23), (V6) asked where (R1) was, because (R1) was not in (R1's) assigned room. (V6) asked if (V9) and myself could check A Hall and B Hall while (V6) checks C Hall and (R1) was nowhere to be found. It had to be between 10:00 pm and 11:30 pm. (on 6/16/23); V8 (RN) stated, At 12:25 am (on 6/17/23), I went out to smoke and put in the code (door alarm code), and nothing happened. I said man, I can come in and out and alarm is not going off' and he (R1) heard it; V9 (Unit Aide) stated, (V6) was doing rounds and asked where (R1) was at. I told (V6) probably in room [ROOM NUMBER] or room [ROOM NUMBER] and (V6) said she had already checked them, so I said we will double check. Then I said we will check all single male beds, then I checked inside and outside the Facility. I checked for any broken screens but did not find any. (R1) is always trying to find his next escape route; V9 stated that V9 last saw R1 in the hallway between 10:30 pm and 11:30 pm.; a written timeline statement from V6 (RN) stating, on 6/17/23, at 12:30 am, R1 was last seen by V6 sleeping on couch and R1 was seen walking back to room.; on 6/17/23, at 1:00 am, R1 was not in R1's room and V6 notified all staff in Facility to search all rooms, bathrooms and closets, and R1 was not in the Facility. V6 then notified the local Emergency (911), V1 (Administrator) and V2 (DON).; on 6/17/23, at 1:40 am, V1 (Administrator) and V2 (DON) came to the Facility to help search for Resident. On 6/17/23, at 2:03 am, V10 (local Police Department Officer) or V11 (local Police Department Officer) called the Facility for R1's diagnosis, name and date of birth; on 6/17/23, at 3:00 am, all capable staff called into Facility to help search for Resident and at 4:15 am, R1 was still missing. R1's Police Report, dated 6/17/23 at 12:59 am, documents that the local Police Department was notified that R1 had left the building and was going west bound on Grant Street. On 6/17/23, during the hours of 1:05 am to 1:30 am, all Units checked area. On 6/17/23 at 1:45 am, R1 was entered into the system as a Missing Person and at 1:48 am, the Police Department contacted the local State Police (Illinois State Police) and requested a dog to search for R1. R1's Police Report, documents V10's (Police Officer) Narrative and that V10 was dispatched to the facility on [DATE] at 12:59 am. V10 went back to the Facility to talk with employees and was informed that the missing person was R1 who I am familiar with through previous contact of him running away from the Facility. V10 stated that staff was unsure of when R1 escaped the Facility and was last seen around 11:00 pm inside of the building. The staff were unsure how R1 was able to leave the building but did state that the alarm system had been disabled for several hours due to a death in the Facility. V10 stated that R1 had been placed into the system (LEADS) as a missing person and that Patrol Officers have continued to search area parks and high probability areas throughout the shift with negative results. On 6/17/23 at 8:09 am, V11's (Police Officer) Narrative documents that on 6/17/23 at approximately 6:30 am, V11 was dispatched to the possible location (200 block of North [NAME] Street, [NAME], Illinois) in search of R1. R1 was located at a gas station and stated he went for a walk to clear his mind and get some exercise. V11 brought R1 back to the Facility. Google Driving directions shows the distance from 200 N. [NAME] to the nursing home is 1.2 miles driving distance. R1's Nursing Note, dated 6/17/23 at 1:00 am, documents R1 not in his room or the room or the room he likes to sleep in and that staff immediately searched all rooms and (R1) not in Facility. R1's Interdisciplinary Team/IDT Progress Notes, dated 6/19/23 at 9:40 am, document that the IDT team reviewed R1's elopement from the weekend (6/17/23) and that one-on-one observations were immediately put into action and is on-going. R1's Behavior Tracking, dated 6/1/23 through 7/31/23, documents exit seeking behaviors and verbal aggression. The Facility could not provide Behavior Tracking Forms for April 24, 2023, through 5/31/23. R1's Care Plan documents that R1 has very poor memory, both short and long term, frequently exit seeks and wanders stating R1 is looking for various people or places and requires supervision. R1's Care Plan also documents that R1 is a High Elopement Risk and is known to wander and may seek to leave. R1's Care Plan also documents: an intervention on 5/14/23, that one-on-one observations and constant or continuous visual monitoring when R1 is agitated and not easily redirected from exits and wandering; R1 is known to wander and seek to leave the Facility due to diagnoses (Dementia, Psychosis, Hallucinations, Paranoia and Anxiety) and determine plan of care and need for location monitoring device and one-on-one and constant monitoring when R1 is agitated and not easily redirected from exits and wandering; and initiate behavior monitoring program to attempt to identify patterns, precursors and causes of behavior and attempt to understand the meaning of the behavior. R1's Sign Out/Acceptance of Responsibility for Leave of Absence does not document any signatures of R1 leaving the building or returning to the building. R1's Community Survival Skills Assessment, dated 4/25/23 and 8/2/23, documents: that R1 is not sufficiently oriented and coherent; is not able to navigate/negotiate safely on the community streets; does not know the Facility address, location or how to contact the Facility; is not able to refrain from self-harmful and/or socially inappropriate behavior; does not have knowledge of potentially dangerous situations, such as walking alone after dark, straying into alley, accepting rides from strangers or carrying valuable items; is not able to adhere to pass privilege, permission to leave, signing out or respecting time parameters and curfews; and is not able to behave with respect while in the community and there have been no problems/concerns with conduct over the past 30 days. R1's Elopement Evaluation, dated 4/23/23 and 6/15/23, documents: R1 is physically able to the leave the building; verbalized desire or plan to leave without proper supervision; level of agitation requires supervision; medical disorders which may lead to leaving unattended; attempts to leave undetected or without properly signing out; wandering in vicinity of exit doors; and is a high risk of elopement. On 8/18/23, at 9:00 am, the Facility Identified Resident Elopement Binder located at the Nurses Station, included documented Elopement Risk Evaluations for R1, R2, R3, R4, R5, R6, R7 and R8. On 8/18/23 at 2:00 pm, V5 (Maintenance Director) stated, (R1) got out of the building on 6/16/23 through the parking lot Exit Door. The Nurses had turned off the alarm system that night. After that, I added a momentary switch that can no longer shut it completely off, it just has like a 15 second delay. (R1) had gotten out a window right before this incident and I had to go to every exterior window in the entire building and screw the windows so that they can only open four inches. I also had to fix the [NAME] Patio Door because that door sensor needed replaced. Facility Maintenance Work Order, dated 6/19/23, documents that the East Patio door alarm sensor was not working and the wires are broken and the [NAME] Patio door alarm is not working due to wires are broken. Facility Maintenance Work Order, dated 7/5/23, documents a maintenance issue with the knobs on the door alarms and alarm toggles at the Nurses Station. Facility Maintenance Work Order, dated 7/28/23, document that the alarm toggles were replaced at the Nurses Station. On 8/18/23, 8/22/23 and 8/24/23, during the survey hours R1 had a staff member (V4) for one-on-one observations. On 8/18/23 at 9:48 am, R1, was lying in bed. R1 was talkative and moderately confused. R1 stated, I really do not remember why I left that night, but they brought me back here. I do not know how long I was gone. They did not take me to the hospital, they just checked me back in here. On 8/18/23 at 10:05 am, R2 stated, I did leave out of here, right after I came here. My daughters dumped me here about a month ago and I have not seen them since. I left out of the door, but they caught me at the picnic table and told me not to leave again. I did not know anyone here and I did not have any friends, but I am better now. I have not tried to get out since. On 8/18/23 at 9:18 am, R3 stated, There was one was one guy with a beard, named (R1), that got out of here a couple times. On 8/18/23 at 9:15 am, R9 stated, (R1) has gotten out of here more than once. I do not know where he went, but he gets out all of the time. On 8/18/23, at 9:09 am, V4 (Resident Aide) stated, I was hired to do one-on-one observations with (R1) because (R1) got out the door, over a month ago, and they ended up finding him sleeping under a bush at a gas station. From what I understand, the door alarm was off and (R1) got out of the door, so now we have to watch him all the time. We have to leave his door cracked, so I can see (R1), because before he got out the main door, he also climbed out of his bedroom window. On 8/18/23 at 9:50 am, V3 (Registered Nurse) stated, I was (R1's) nurse when (R1) was brought back by the Police that morning of 6/17/23. They found (R1) at a gas station about a mile from here and (R1) was sleeping under a bush. I did a complete body audit upon his return and (R1) did not have any injury. (R1) has gotten out of the building multiple times, now they have hired staff to watch him 24 hours a day, seven days a week. (R1) even got out of his window and was walking down the block, so now all the windows in the Facility only go up for inches because of him. On 8/18/23 at 10:40 am, V2 Director of Nursing (DON) stated, (R1) got out of the building on the night of 6/16/23, and was last seen about 10:30 pm, and the staff noticed (R1) missing on 6/17/23 around 1:00 am. My staff called me right away to tell me that they could not find (R1), and I immediately came to the building. V3 (Registered Nurse) and V8 (Registered Nurse) were working. V8 is no longer employed here now. We asked if there were any open windows, because (R1) had climbed out of a window recently and we had to get the police involved with the incident also. We looked all over the grounds and could not find him. We called the police and they found him sleeping under a bush at a gas station about 1.1 miles from here, right when it was starting to get daylight, then they brought him back here and we assessed him. We did not send (R1) to the hospital. We are not sure how (R1) got out, but the alarm was shut off at the panel or the door could have not been completely latched, and we think (R1) just pushed the door open and got out. We have cameras in the building, but most of them were not working that night and the one that was working did not record, but we have fixed all of them now. We have also fixed the door alarms to a push button, instead of a toggle, after (R1) got out the last time on 6/16/23. We now have hired staff that watch specifically (R1) with one-on-one's. V2 stated, The Elopement Binder at the nurses station has eight Residents that are elopement risks. On 8/22/23 at 9:00 am V2 (DON) stated, It was Care Planned that (R1's) intervention for the 6/15/23 elopement, was that (R1) be put on one-on-one observations, but I do not have any documentation of those one-on-one observations. After the 6/16/23 elopement, that is when we hired staff to specifically watch only (R1). The Immediate Jeopardy was identified to have started on 6/17/23, when R1, exited an unalarmed exit door and was missing from the Facility for hours. V2 (Director of Nursing/DON) was notified of the Immediate Jeopardy on 8/22/23 at 8:44 am. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. During the survey 8/18/23 through 8/24/23 R1 had an assigned staff member for the one-on-one observations. Facility Monitoring Logs, dated 6/17/23 through 8/23/23, were reviewed. 2. All Residents residing in the Facility had Elopement Risk Assessments completed. Residents were documented in the Elopement Risk Binder at the Nurse's Station. 3. The Facility Quality Assurance Team revised Care Plans for each at risk Elopement Resident. 4. Staff were in-serviced on Facility Exit Door Alarms, Elopement Policy and Procedures, Door Panel at Nurse's Station and doors that are inactivated or need repair. 5. Facility Maintenance Director is doing random door checks to ensure they are engaged and will do alarm checks.

Based on observation, interview, and record review the facility failed to honor residents' right of refusal of hospital transfer and failed to treat with dignity and respect for one (R23) of 43 residents reviewed for resident rights in the sample of 43. These failures resulted in R23 being distressed, feeling humiliated and exhibiting anxiety. Findings include: The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-term Care Facilities, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes you quality of life. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually. The facility must ensure that you are free from retaliation and discrimination, in exercising your rights. You may ask any visitor to leave your personal living area at any time. Your facility must try to keep your property from being lost or stolen. The undated Director of Nursing Job Description documents, Resident Rights: 1. Maintain the confidentiality of all resident care information. 2. Monitor nursing care to ensure that all residents are treated fairly and with kindness, dignity and respect. 3. Ensure that all nursing service personnel are knowledgeable of the residents' responsibilities and rights including the right to refuse treatment. 4. Review complaints and grievances made by the resident and make a written/oral report to the Administrator indicating what action(s) were taken to resolve the complaint or grievance. Follow facility's established procedures. 5. Maintain a written record of the resident's complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint. 6. Report and investigate all allegations of resident abuse and/or misappropriation of resident property. 7. Ensure that nursing staff personnel honor the resident's refusal of treatment request. Ensure that such requests are in accordance with the facility's policies governing advance directives. R23's Cognitive Assessment, dated 8/12/22 documents a score of 15 out of 15 which indicates R23 is cognitively intact, with no problems with short-term or long-term memory and no signs or symptoms of [CONDITION(S)]. R23's Behavior Tracking Record, does not document R23 with any behaviors prior to 9/20/22. On 9/20/22 V30 Housekeeping/Laundry Supervisor documented the only entry on R23's Behavior Tracking Record under Target Behavior: Physical Aggression/Throwing items when upset and interventions were successful in stopping the behavior. R23's current Care Plan documents R23 is to use a wheeled walker for ambulation. R45's Cognitive Assessment, dated 7/5/22, documents a score of 99 which indicates R45 is unable to complete the interview due to impairment and has severely impaired cognition. R45's Behavior Tracking Record documents a Target Behavior for R45 as Taking objects that belong to others (especially food) with Goal: Reduce wandering behavior to other residents rooms. This record documents 14 out of 20 days of continuous episodes of R45 wandering into other rooms and behavior increased with interventions. This record documents behavior on 9/20/22 with increased behaviors with attempted interventions. R45's current Care Plan documents R45 is known/has history of displaying inappropriate behavior and Resident known to take items that belong to others. R45 walks independently with a steady gain and Needs additional monitoring to insure respect of other resident rights. On 9/20/22 at 9:30 am, R23 was sitting on the side of her bed in front of her overbed table when R45 entered R23's room. R23 raised her voice and told R45 to get out of her room. V30 Housekeeping/Laundry Supervisor and V24 Activity Director entered R23's room and V31 Unknown Staff Member exited R23's room with R23's cane and V24 Activity Director sat in a chair just outside of R23's room. On 9/20/22 at 9:40 am, V24 Activity Director stated she was assigned to sit outside R23's for one-to-monitoring of R23. On 9/20/22 at 9:45 am, the local ambulance service arrived at the facility and entered R23's room with a stretcher. R23 began yelling profanities and asking Why the F*** do I have to go out? (R45) was the one who came into my room. I didn't F***ing do anything wrong. R23 was noticeably upset and angry. The local ambulance service staff assisted R23 onto the stretcher and exited the facility with R23. On 9/20/22 at 10:30 am, V3 RCC (Resident Care Coordinator) stated R45 was escorted out of R23's room, R23's cane was taken from her, and V24 Activity Director sat outside of R23's room and did one-to-one monitoring of R23 until the ambulance came to take R23 to the local hospital for an evaluation. V3 confirmed that R45 did not have any visible injuries. On 9/20/22 at 1:40 pm, R23 entered the conference room in acute distress with anguished facial expression and visible anxiety and asked to speak with surveyors. R23 stated she just got back from the hospital emergency room because the facility sent her there to be evaluated because she was yelling at R45 to get out of her room and tapped him with her cane to stop him from taking her cereal off her table and out of her room. R23 stated she has never had altercations with anyone at the facility. R23 stated they took my cane away, sent me to the hospital and did nothing with (R45) and they know he goes in other peoples' rooms. On 9/21/22 at 9:30 am, R23 stated she used to use a wheelchair but the facility took it away and she was using a walker, then they took that away and gave her a cane to use. R23 stated, They have not given me back my cane so now what do I use. R23 stated R45 still walks all over the place by himself and goes in and out of everyone's room and they know it and haven't done anything about it. R23 stated I feel so humiliated and made out to be the bad guy and I didn't do anything wrong. R23's Nurses Notes do not include documentation or an A.I.M. (Assess. Intercommunicate, Manage.) for Wellness form, documenting the 9/20/22 incident or that R23's Physician or Guardian were notified. The Nurses Note, dated 9/20/22 at 1:10 pm, documents Resident back to facility from mental health evaluation, no significant management care formulated or directed. We will continue to monitor, and all due care rendered. R23's Social Service Notes do not include any documentation regarding this incident. R23's Physician's Orders and Telephone Orders do not include a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's Nursing Notes do not include documentation or an AIM for Wellness form, documenting the 9/20/22 incident or that R45's Physician or Guardian were notified of the incident. R45's Social Service Notes do not include any documentation on 9/20/22 regarding this incident. On 9/21/22 at 2:30 pm, V1 AIT (Administrator in Training) stated she was aware of the incident with R23 and R45 and that R45 has been known to go into other resident rooms and try to take things.

Based on observation, interview, and record review the facility failed to complete new admission skin assessments (R150), failed to reposition a resident to prevent pressure ulcers, failed to complete pressure ulcer risk assessments, failed to notify a resident's physician of a pressure ulcer, failed to obtain and provide wound treatments, and failed to perform hand hygiene during wound assessment and dressing application for two (R41 and R150) of two residents reviewed for pressure ulcers in the sample of 43. These failures resulted in R41 obtaining pressure ulcers which worsened to R41's left lateral foot, left malleolus (ankle), left heel, left lateral bunion, and left elbow. Findings include: The facility's Preventative Skin Care policy and procedure, Revised 1/2018, documents Policy: It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. Responsibility: All nursing staff. Procedures: 1. All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly x 4 then will be reassessed at least quarterly and/or as needed. 2. Staff on every shift and as necessary will provide skin care . 5. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two (2) hours . 7. Pillows and/or bath blankets may be used between two (2) skin surfaces or to slightly elevate bony prominence's/pressure areas off the mattress. Pressure relieving devices may be used to protect heels and elbows. The facility Pressure Sore Prevention Guidelines policy and procedure, Revised 1/2018, documents It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale. After the four weeks of skin assessments the skin assessments must then be done with an annual. quarterly and significant change MDS (minimum data set) or in the event a pressure ulcer develops. Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse. The facility's Turning and Positioning Program policy and procedure, Reviewed 1/2018, documents To ensure residents at risk for pressure ulcers are turned and positioned per the plan of care in an organized system .1. Turning schedule will occur as indicated by the resident's plan of care. The facility's Decubitus Care/Pressure Areas policy and procedure, Revised 1/2018, documents 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 (Quality Assurance) 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. 30 Complete all areas of the Treatment Administration Record or Wound Documentation Record . 4) Notify the physician for treatment orders . 5) Documentation of the pressure area must occur upon identification and at least once each week on the TAR (treatment administration record) or Wound Documentation Form. The facility's Hand Hygiene policy and procedure, Revised 12/7/2018, documents, All staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions . If soap and water are not available alcohol gel/rub to clean your hands. The Shower Sheet for R41, dated 8/24/22, documents an open area to R41's right foot near the bunion area and signed off by V11 CNA and V26 LPN. The Shower Sheet, dated 8/31/22, documents open area to R41's left lateral foot and was signed off by V11 CNA but not a Nurse The Shower Sheet, dated 9/6/22, documents Has old small, scabbed area that is on top and sides of both feet and is signed off by V11 CNA and V33 LPN. The Shower Sheet, dated 9/7/22, documents open area on side of left foot and left ankle red area. This sheet is signed off by V11 CNA but not a Nurse. The Shower Sheet, dated 9/14/22, documents small open areas to left foot and red area on ankle. This form is signed off by V11 CNA but not a Nurse. R41's Cumulative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) R41's Physician Orders, dated 9/1/22 through 9/30/22 also lists Protein/Calorie Malnutrition as a diagnosis. On 09/18/22 at 6:24 am, 8:16 am, and 11:00 am, R41 was lying on his back with his left leg bent at the knee with his left leg underneath his extended right leg with his left foot near his right buttock cheek. R41's left foot, left leg and left elbow were lying directly on the mattress. There was no pressure relieving positioning devices noted under R41's legs, feet or under R41's left elbow. On 09/19/22 at 8:35 am, R41 was lying on his back with his left leg bent at the knee with his left leg and foot lying directly on the mattress underneath R41's extended right leg with his left foot near R41's buttock cheek. R41's left arm and elbow were also lying directly on the bed mattress. There were no pillows or other devices in place to help relieve pressure at this time. On 09/19/22 at 11:00 am R41 was lying on his back and his position was unchanged from 8:35 am as V5 LPN (Licensed Practical Nurse) donned gloves and performed a skin assessment of R41's left foot revealing open wounds to R41's left inner foot, left lateral malleolus, left lateral foot, and left heel. V6 and V7 CNA's (Certified Nursing Assistants) entered R41's room to assist with positioning during this assessment. During this skin assessment V5 LPN cleansed and measured each of R41's left foot wounds with the same pair of gloves on and used the same plastic measuring device to measure each of R41's left foot wounds. V5 LPN did not change her gloves, use hand sanitizer, or wash her hands during this task. On 9/19/22 at 11:05 am, V5 LPN stated she was concerned about R41's skin yesterday but didn't get a chance to assess him as it was her first day working at the facility. V5 LPN stated there are no treatment orders for the wounds on R41's left inner foot, left lateral malleolus, left lateral foot, or left heel. On 9/19/22 at 11:06 am, V6 CNA stated R41 is not able to move around in his bed by himself. On 9/19/22 at 12:00 pm V3 RCC (Resident Care Coordinator) and V8 CNA entered R41's room and turned R41 onto his right side to assess R41's back and buttocks, revealing very reddened and barely blanchable skin to R41's buttock and coccyx areas. V3 RCC and V8 CNA turned R41 onto his right side, revealing a large circular area to R41's left elbow that is covered with thick sloughing and unblanchable redness surrounding the open wound. During turning R41 hollered out that staff were killing him. R41 was positioned back onto to his back. On 9/19/22 at 12:00 pm, during R41's cares, V3 RCC stated R41 will be put back on the wound doctor list to be seen, R41's family will be notified, and treatment orders will be obtained. V3 RCC stated residents should be turned and repositioned every two hours. On 9/19/22 at 12:29 pm, R41 remained lying on his back with his left leg bent at the knee and underneath his extended right leg directly on the bed mattress and R41's left elbow remained lying directly on the bed mattress. On 9/19/22 at 1:19 pm, R41 remained lying on his back and position had not been changed. V9 and V10 CNA's provided R41 with incontinence care and when finished positioned R41 back onto his back and placed a pillow under R41's left leg raising left foot off the mattress. During positioning of R41's left leg an area to R41's left lateral bunion was noted that was burgundy and purple in color and did not blanch when touched. V10 CNA lifted R41's left arm to place a pillow under it and R41's left open elbow wound remained without a treatment or dressing covering it. V10 CNA then placed R41's left arm on top of a pillow with open area laying on the pillow. On 9/19/22 at 1:29 pm, V10 CNA stated R41 cannot turn and position himself, is dependent for all of his cares, and will holler out went positioned any other way than his back. V10 CNA stated R41 cannot move his left arm or left leg. On 9/19/22 at 1:11 pm, V3 RCC stated there is not a pressure ulcer risk assessment for R41, confirmed R41 is a high risk for skin breakdown, and will complete the pressure ulcer risk assessment for R41 and get it put in R41's chart. V3 also stated the facility does not currently have a wound nurse so the nurses should measure wounds. On 9/19/22 at 2:30 pm, R41 remained lying in bed on his back with his left leg bent at his knee underneath his extended right leg with his left foot near his right buttock cheek and still had no treatment or bandage to R41's left elbow. On 9/20/22 at 8:30 am, V11 CNA stated she does all the resident showers on day shift, unless she gets pulled to work the floor as a CNA. V11 stated she documented and reported R41's foot wounds on 8/24/22 to V26 (Licensed Practical Nurse) and to V33 (Agency LPN) on 8/31/22, 9/6/22, and 9/7/22. V11 stated V11 didn't report the wounds on 9/14/22 because she thought they already knew about them. V33 no longer works at the facility and is unable to be interviewed. As of 9/19/22 at 12:00 PM, R41's medical record did not document notification or orders for treatments to R41's physician regarding R41's pressure ulcers. On 9/21/22 at 2:30 pm, V1 AIT (Administrator in Training) stated she was not aware that R41 had any wounds to his left foot or elbow until 9/19/22 when V5 LPN found them and was not aware that the wounds had been documented by V11 CNA on R41's Shower Sheets. V1 AIT confirmed R41 should be turned and repositioned every two hours and treatment orders should have been obtained when R41's wounds were first identified. 2. The facility's Nursing Admission Assessment Policy, undated, states, Each resident upon initial assessment and re-admission to the facility will have a Nursing Admission Assessment completed. Responsibility: Admitting Nurse. Procedure: Nursing Assessment must be completed within 24 hours of admission. Complete all sections as indicated on the form. R150's Nursing Admission Assessment documents R150 was admitted to the facility on [DATE]. The remainder of this form is blank, including the area Skin Inspection. As of 9/20/22, R150's Pressure Ulcer Risk Assessment was located in R150's medical record and was blank. On 9/19/22 at 9:45 AM, V26 (Licensed Practical Nurse) stated that V26 was the admitting nurse for R150 on 9/7/22. V26 stated R150 was anxious upon arrival to the facility and went on an outing right away to help calm R150 down. V26 denied completing any of R150's admission paperwork, including an admission skin assessment or pressure ulcer risk assessment. V26 verified these forms should be completed upon admission.

Based on record review and interview the facility failed to monitor a pressure ulcer and failed to perform wound care as ordered on a pressure ulcer for three residents (R1, R2 and R3) of three residents reviewed for pressure ulcers in a total sample of three. These failures caused R1's wounds to deteriorate and increase in size and depth. R1's wounds required hospitalization due to extensive necrosis requiring emergent debridement. Initiation of vasopressor (elevates blood pressure) support due to septic shock secondary to infection from a severe breakdown of the debrided wound. Findings Include: The Facility's Decubitus Care/Pressure Areas Policy dated 01/2018 documents 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. The pressure area will be assessed ad documented on the Treatment Administration Record or the Wound Documentation Record. 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.) 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.) Characteristics (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii.) Treatment and response to treatment. 1. R1's Nursing Admission assessment dated [DATE] documents R1 was admitted to the facility with the following wounds: right outer big toe area 4 cm (centimeters) by 1.8 cm; under big toe area fluid filled blister 2.5 cm by 2 cm; left heel wound open with fluid filled blister to outer peri wound; right outer heel 2.5 cm by 2.2 cm; right outer foot area 2 cm by 1 cm. R1's Nurse's Notes dated 8/24/22 document sacrum wound measured 14 cm by 9 cm at the top, 5.5 cm at the bottom. Other sacrum wound: measured 8.5 cm by 5 cm. Resident refused measurements of legs. On 9/13/22 V3 (Assistant Director of Nursing) stated I don't know what the nurse meant by 5.5 cm on the bottom. V3 could not determine which sacrum wound was which with the measurements provided. R1's Nurse's Notes dated 8/25/22 documents left buttock .7 cm by 8 cm by 6.1 by 4 cm depth; right buttock 2 cm by 8 cm by 2 cm depth; outer big toe .5 cm by 2 cm; left heel 9 cm by 3 cm by .4 cm. R1's Nurse's Notes document R1 was admitted to the hospital on 9/8/2022 for a bowel obstruction. R1's Hospital Record shows on 9/9/22 V4 (Registered Nurse/Certified Wound Nurse) documents (R1) was seen by this nurse for wound vacuum placement on 8/22/22 and 8/24/22 and all wounds present have shown major deterioration. V4's documentation shows wounds on 9/9/22 to measure: left buttock 6 cm by 7 cm by .8 cm, coccyx/sacral wound 15 cm by 10.5 cm by 4.6 cm. R1's Treatment Administration Record for August 24-August 31 documents chair cushion at all times while sitting, flex protective boots at all times unless transferring. The treatment does not have any times assigned to sign it off. One nurse signed it off on 4 days in August. R1's Treatment Administration Record for August 24-August 31 documents moist saline gauze to left heel twice daily. The treatment does not have any times assigned to sign it off. One nurse signed it off on 4 days in August. R1's Treatment Administration Record for August 24-August 31 documents foam to all other wounds to bilateral feet and heels. The treatment does not have any times assigned to sign it off. One nurse signed it off on 4 days in August. On 9/13/22 V3 (Assistant Director of Nursing) confirmed that R1's treatments should all have a frequency to do the treatment and V3 also confirmed these treatments were not signed off as completed. R1's Treatment Administration Record for August 24-August 31 documents turn every 2 hours while in bed; alternating air pressure mattress at all times. The treatment does not have any times assigned to sign it off. One nurse signed it off on 4 days in August. R1's Treatment Administration Record for August 24-August 31 documents Limit one hour up before lying down. The treatment does not have times assigned to sign it off. On nurse signed it off on 4 days in August. On 9/13/22 V3 (Assistant Director of Nursing) could not provide September Treatment Administration Records for R1. They haven't even been put out yet. On 9/13/22 V3 (Assistant) Director of Nursing) stated (R1) was supposed to start seeing our wound doctor but the last time he came back from the hospital we saw that he had an appointment with a dermatologist so we figured they would handle his wounds. On 9/13/22 V6 (Dermatology Nurse Practitioner) stated We saw (R1) for a routine follow up regarding [CONDITION(S)], we do not address wounds in long term care, they usually have their own wound doctors who take care of that. R1's hospital record/Doctor Progress note from V6 (Surgeon) at hospital dated 9/9/22 documents Patient is a [AGE] year old male with multiple medical comorbidities on [MEDICATION(S)], (blood thinner) for history of Pulmonary Embolism, who is known to the surgery service. Patient has a stage 4 sacral decubitus ulcer that was debrided a couple of weeks ago due to necrosis, and now presents back to the hospital due to lethargy and altered mental status. When he arrived he was found to be [CONDITION(S)] and hypotensive, requiring initiation of vasopressor support due to septic shock secondary to infection from a severe breakdown of the debrided wound. After his last hospitalization he was discharged to (The Facility) and was supposed to have his wound managed with a wound vac. The wound vac was reportedly not being used and patient was not participating in any activity or physical therapy, and now has extensive necrosis requiring emergent debridement. On 9/14/22 V5 (RN/Case Manager at hospital) stated The condition (R1)'s wounds was visibly deteriorated. The dressing they (the nurses) took off of him in the emergency room wasn't even all the way on and it was rolled up and to the side and it had been that way for a while due to the amount of debris and drainage that was on the dressing. 2. R2's Nursing Admission assessment dated [DATE] documents 1/2 inch open area to right thigh. R2's Wound Doctor progress notes documents measurements of right thigh wound on 7/11/22, 7/18/22,7/25/22, and 8/8/22 show .5 cm (centimeters) by .4 cm by .2cm. R2's Treatment Administration Record for September 2022 documents Alginate Calcium with silver and border gauze to right groin. The Treatment Administration Record shows 6-2 shift responsible for this treatment. The treatment is not signed off as done for the month of September (9/1/22 until present 9/13/22.) 3. R3's Nursing Admission assessment dated [DATE] documents 3 cm (centimeters) by 4 cm reddened area to her coccyx. R3's Wound Doctor progress notes documents measurements of coccyx wound measurements to coccyx wound on 4/19/22 1.5 cm (centimeters) by .5 cm by .2 cm; 5/10/22 1.5 cm by 2cm by .3 cm; 5/24/22 2 cm by 2 cm by .3 cm; 6/7/22 2 cm by 2 cm by 2 cm; 6/14/22 2 cm by 2 cm by 2 cm; 7/11/22 1.7 cm by 2 cm by 5 cm; 7/18/22 1.7 cm by 2 cm by 5 cm, 7/25/22 1.5 cm by 1.8 cm by 2 cm; 8/8/22 1cm by .9 cm by 2 cm and 8/22/22 .7 by 1 by unmeasurable depth. On 9/13/22 V3 (Assistant Director of Nursing) could only provide July 2022 Treatment Administration Record which did not have any treatments to be done on it. On 9/13/22 V3 (Assistant Director of Nursing) stated (R3) has had this area since May it looks like, so there should be TARs for her with the treatment we are doing on it, but I cannot find them. On 9/13/22 V3 (Assistant Director of Nursing) stated We do not have a wound nurse, we go off of the wound doctors sizes and description of wounds. There have been holidays that the wound doctor does not come in, so we miss those weeks, or if she (Wound Doctor) could not come to the building for whatever reason, then we would not have measurements for those weeks. V3 confirmed that wounds were not measured and described in detail for all three residents (R1, R2 and R3) on a weekly basis. V3 also confirmed the lack of documentation regarding wound care treatments for all three residents.(R1, R2 and R3)

Based on interview and record review the facility failed to ensure physician ordered X-rays were obtained for one (R1) of three residents reviewed for falls in the sample of three. This failure resulted in continued pain for R1 and a four day delayed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility Fall Prevention policy and procedure, revised 11/10/18, documents Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. The A.I.M. for Wellness form for R1, dated 6/2/22 at 2:15 am, documents R1 fell going to the bathroom without using her wheeled walker and complained of pain to her left forearm and back. This form documents R1's PCP (Primary Care Physician) was notified and X-rays were requested for R1's left forearm and back. The Nurses Note for R1, dated 6/2/22 at 10:00 am, documents R1 refusing to stand or walk due to complaints of pain. R1's PCP was notified due to resident now complaining of left hip and left foot pain. The Nurses Note for R1, dated 6/3/22 at 12:00 pm, documents New order received for X-rays post fall. The POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurses Note for R1, dated 6/6/22 at 1:00 pm, four days after R1's fall, documents (diagnostic service) coming today to complete X-rays. The (diagnostic service) X-ray results dated 6/6/22 document results of left hip X-ray as Left femoral neck fracture and left forearm X-ray as Distal transverse radial fracture. The Nurses Note for R1, dated 6/6/22 at 9:05 pm, documents Results from X-ray came back shows left arm and left hip fracture. (R1) sent to local hospital by ambulance. The Nurses Note for R1, dated 6/7/22 at 2:15 am, documents follow up entry as R1 being transferred from local hospital to another local hospital for surgical intervention. The PRN (as needed) MAR (medication administration record) for R1, dated 6/2/22 through 6/6/22 documents R1 received two Tylenol 500 mg (milligrams) tabs every morning for complaints of generalized pain. There was no pain assessment documented and no other pain medications were ordered or administered during this time frame. On 6/10/22 at 9:02 am V10 (R1's) Family Member stated she received a call in the middle of the night on 6/2/22 that R1 had fallen, and they were going to get some X-rays then days later the facility called again telling V10 that they were sending (R1) to the hospital for a broken hip and then the hospital did surgery yesterday (6/09/22). V10 stated she doesn't know what took the facility so long to get the X-rays. On 6/10/22 at 8:32 am, V18 Paramedic stated he was called to the facility to transport (R1) to the (local hospital). V18 stated when he got to the facility and got report he was told R1 had fallen on 6/2/22 and the facility X-rays on 6/6/22 said (R1) had fractures to her hip and wrist. V18 stated the facility had the order for the X-rays on 6/3/22 and waited four days and R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . V18 stated It was very obvious to me that her wrist was broke and (R1) was in pain. It should have been obvious to the facility as well. V18 stated R1 moaned when she was moved onto the stretcher. V18 stated There is no excuse that they should have waited four days to get the X-rays. On 6/10/22 at 12:13 pm, V13 LPN stated she was R1's Nurse on 6/2/22 on night shift and was called down to R1's room because R1 had fallen in the bathroom. R1 was lying on the floor and complained about left arm and back pain. (R1) didn't have any visible signs of injury, there was no swelling or bruising and (R1) was able to move her arms and legs. V13 stated she wanted to send R1 to the hospital because she was crying in pain but when she called V2 DON, V2 told her to notify the doctor and get X-rays in house. V13 stated she faxed V14 (R1's) PCP to notify of R1's fall and requested X-rays. V13 stated when she came into work on 6/3/22 night shift R1 was still complaining about pain. The second shift Nurse reported to (V13 LPN) that R1 was now complaining of left hip and foot pain and the second shift Nurse had called to get more X-rays. V13 LPN stated she did not work the weekend but when she came in to work on 6/6/22 the diagnostic service had been at the facility and she was waiting for the X-ray results. V13 stated the results came in sometime between 8:00 pm and 9:00 pm and R1 had a left hip and left wrist fracture. V13 stated V13 sent R1 to (local hospital) for treatment. On 6/10/22 at 3:36 pm, V16 CNA stated she was working on 6/2/22 when R1 fell and was called down to the B hall bathroom to help V17 CNA and V13 LPN. V16 stated R1 is supposed to use her walker but didn't and fell . V16 stated R1 was hysterical, anxious, and crying at first and was complaining about her left wrist and back hurting. (R1) kept saying her wrist hurt. V16 stated R1's left wrist was a little red but didn't have any swelling and V13 LPN checked her and didn't feel anything out of the normal. V16 CNA stated after V13 LPN finished assessing R1 V16 CNA and V17 CNA assisted R1 up off the floor and V13 LPN pushed a wheelchair behind her because R1 wasn't able to stand. (R1) kept saying it hurt and wouldn't bear weight so (R1) just sat in the wheelchair or in her recliner. V16 stated V3 LPN/ADON worked over the weekend as one of the Nurses and she reported to her that R1 couldn't bear weight and was in pain but does not know what was done. On 6/10/22 at 9:18 am, V11 LPN stated she worked Thursday 6/2/22 from 6:00 am to 6:00 pm and was told in report that R1 had fallen and was complaining of pain and they were waiting for orders from V14 (R1's) PCP for X-rays. V11 stated she noticed a bump on R1's left forearm but nothing else and gave R1 Tylenol as per R1's usual request in the morning and that was all R1 received on 6/2/22 for pain. V11 stated she did call V14 (R1's) PCP (Primary Care Physician) prior to leaving her shift because R1 started complaining about foot and hip pain. V11 stated when she left that day she had not received an order back from V14. V11 LPN stated when she returned to work on 6/3/22 she found the orders for the X-rays had been received and she processed the orders and reported off to V5 Agency RN and told (V5) everything was done except calling (diagnostic service) to come and do the X-rays. V11 LPN stated she gave V5 Agency RN the 24 hour book that contained the (diagnostic service) phone number and reminded V5 Agency RN not to forget to call. On 6/9/22 at 1:40 pm, V5 Agency RN stated when she came into work on 6/2/22 at 10:00 am, V11 LPN had already processed the X-ray orders for R1 and had notified the (diagnostic service) to come and do the X-rays. V5 stated no one told her to call the diagnostic service to come and do the X-rays. V5 stated she did not call the (diagnostic service). On 6/10/22 at 4:12 pm, V3 LPN/ADON stated she did work the floor as a Nurse over the weekend and was (R1's) Nurse. V3 stated R1 was up in a wheelchair to the dining room for meals and fed herself. V3 stated she did not check for R1's X-ray results and stated It didn't trigger in me to check them because she hadn't complained of any pain. V3 stated she never saw R1's body or skin because R1 had a sweater on and none of the staff said anything to her about R1 complaining or having concerns. On 6/9/22 at 10:35 am V4 Agency RN stated she worked on 6/2/22 and 6/3/22 but was not R1's Nurse. V4 stated R1 is usually up walking around but on those two days R1 was sitting in a wheelchair. V4 stated when she returned to work on 6/6/22 R1 was still sitting in a wheelchair and (V4) assumed the X-rays for R1 had already been done. V4 stated she does not know how R1 was able to sit up in a wheelchair with a left femur fracture and left wrist fracture. On 6/9/22 at 1:48 pm, V6 CNA stated before R1's fall R1 could get up with supervision and would use her walker to walk, but after R1 fell it would take two to three of us to her up in a wheelchair or put her in her recliner. V6 stated R1 did complain of a lot of pain and finally got X-rays on 6/6/22 and R1 was sent to the hospital. On 6/9/22 at 1:51 pm, V7 CNA stated when she came into work on 6/2/22 at 6:00 am, she was told that R1 had fallen during the night and was in a lot of pain. V7 stated R1 complained of pain during her shift and didn't want to stand up. On 6/9/22 at 1:56 pm, V8 CNA stated she heard R1 complain of pain on 6/2/22 and (R1) was not walking anymore, and R1 was sitting in a wheelchair. On 6/9/22 at 2:15 pm, V9 CNA stated she just recently started working at the facility but remembers helping other CNA's to transfer R1 and R1 was complaining of pain. On 6/9/22 at 12:00 pm, V2 DON (Director of Nursing) stated R1 fell on [DATE] on third shift and V13 LPN (Licensed Practical Nurse) assessed her and R1 was complaining of left forearm and back pain but there were no visible injuries. V2 stated V13 LPN notified V14 (R1's) PCP (Primary Care Physician's) and requested X-ray orders. V2 stated later in the day R1 started complaining about of different pain and V11 LPN notified V14 (R1's) PCP and requested further X-rays. V2 stated the diagnostic service the facility uses was supposed to be called but wasn't. V2 stated V5 Agency RN was supposed to call but didn't. V2 stated she found out on Monday 6/6/22 that the X-rays weren't done for R1, and she had V11 LPN call and have the diagnostic service come out to do them. V2 stated the X-rays showed fractures to R1's left hip and left wrist and was sent to the (local hospital) for treatment. On 6/10/22 at 11:21 am, V12 HR (Human Resources) Manager for the diagnostic services the facility uses stated they received orders from the facility for X-rays of R1's left hip with pelvis, left forearm, left foot, and spine on 6/6/22 at 1:06 pm, the X-rays were completed on 6/6/22 around 4:45 pm, and the results were faxed to the facility on [DATE] at 8:51 pm, and called to the facility at 9:07 pm and results were verbally given to V13 RN. V12 HR Manager for diagnostic service stated they did not receive any orders from the facility for R1 prior to 6/6/22. On 6/10/22 at 12:55 pm, V15 RN stated she is V14 (R1's) PCP Nurse and V14 PCP received a fax from the facility on Thursday 6/2/22 at two something in the morning that R1 had fallen and was complaining of left forearm and back pain and the facility requested X-rays. V15 stated later in the day at 1:00 pm, V14 PCP received another request for additional X-rays because R1 started complaining of left hip and foot pain and at 5:07 pm. V14 PCP gave the facility the order for the X-rays. V15 RN stated on Monday 6/6/22 we received the X-ray results from the facility showing R1 had fractures and V14 PCP sent a message back asking for the cause of the four-day delay in obtaining X-rays and has still not received a response from the facility.

Based on observation, record review and interview, 1) the facility failed to ensure a resident assessed to be at high risk for falling was wearing proper footwear and 2) Based on record review and interview, the facility failed accurately summarize a written fall investigation and report all necessary findings to the State agency for one of three residents (R1) reviewed for falls, in a sample of three. 1) This failure resulted in R1 slipping on the floor as she was getting out of bed and experiencing a fall resulting in a fractured finger on her right hand and a laceration to the back of her head which required staples. Findings include: The facility Fall Prevention policy, revised 11/10/18, documents that the facility is responsible, 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. On 5/26/22 at 11:40 am, R1 was in the dining room being fed lunch by staff. R1's right and left forearms were in a hard cast, which is why R1 needed feeding assistance. A Fall Risk Assessment, dated 3/09/21, documents R1 scored a 17, which indicates a high risk for falling, related to occasional confusion, use of [CONDITION(S)], anti-[CONDITION(S)] and diuretic medication, and the diagnoses of [CONDITION(S)], [CONDITION(S)] Disorder, Mental Illness and Cognitive Deficit/Dementia. R1's Minimum Data Set assessment, dated 3/08/22, documents R1 has significant cognitive impairment, requires extensive assistance of one staff member to dress, and has experienced three or more falls since the last quarterly Minimum Data Set assessment. R1's current Plan of Care (no date), documents R1 is high risk for falling and instructs staff, Observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed and to have R1, wear non-skid socks during (hours of sleep). A Fall Investigation Report, dated 5/15/22, documents R1 was in the dining room at 3:00 pm and fell from her wheelchair attempting to reach for or transfer to a chair. Staff were present in the dining room, but unable to prevent R1's fall. R1 complained of left wrist pain on assessment and the Physician ordered a portable x-ray to be completed at the facility. The x-ray revealed R1 had sustained a fracture of the left distal radius and R1 was sent to the hospital. All of R1's falls over the last six months were reviewed. Documentation of a previous fall, on 5/01/22, indicates R1 fell in her room and broke a finger on her right hand. An A.I.M. for Wellness report, dated 5/01/22 (no time), documents R1 fell and, (R1) had a 2 cm (centimeter) laceration to back of (R1's) head on the left side. Pressure was held to area. (R1) is complaining of pain to her right hand. (R1) was sent to the ER (emergency room ) by ambulance for evaluation. A Hospital Diagnostic Radiology report, dated 5/02/22, documents R1 sustained the following: Fracture through the neck of the second metacarpal with slight displacement along the medial aspect. A Physician's Report, dated 5/11/22, documents R1's right hand and arm were placed in a hard cast during an Orthopedic Consult due to the right hand second metacarpal neck fracture. A Fax Worksheet (State Agency) Form, dated 5/01/22, documents at 11:45 pm, R1, reports when was getting out of bed to go to breakfast and slid, related to not having on proper footwear, nurse viewed resident on the floor on her back under the bedside table. Laceration noted to posterior scalp. Sent to ER for (evaluation and treatment). (R1) discharged from ER with 2 staples to posterior scalp and new orders to remove staples in 7-10 days. Monitor laceration for infection and keep clean and dry. Husband aware and agreeable to plan of care. (R1) encouraged to sleep in non-skid socks for safety and increase staff supervision during hours of sleep. This final notification of findings to the (State agency) fails to report that R1 sustained a right metacarpal neck fracture. On 5/29/22 at 3:02 pm, V6 (Licensed Practical Nurse) stated she was at the nurses station on 5/01/22 and heard a noise from the hallway. V6 stated she immediately started checking rooms and found R1 lying on the floor of her room. V6 stated R1 was bleeding from her head and was complaining of pain in her right hand, so she sent R1 to the emergency room . V6 indicated R1 should have had slipper socks put on before she was put in bed, because R1 is very unsteady on her feet and wants to be independent with ADLs (Activities of Daily Living). On 5/26/22 at 2:48 pm, V2 (Director of Nursing) stated she conducted the investigation into R1's 5/01/22 fall and confirmed that R1 sustained a scalp laceration and fractured finger as a result. V2 stated she determined that at the time of the fall, R1's feet were bare when she should have had slipper socks, as identified in her plan of care. V2 concluded that R1 requires assistance to dress and would have needed help from staff to put on non-skid socks before bed. V2 stated she did not inform the Regional Office in her reportable findings regarding R1's 5/01/22 fall that R1 sustained a fracture, even though that information was known on 5/02/22 upon R1's return from the emergency room , and that information should have been included in the report.

Based on observation, interview and record review the facility failed to honor a resident's preference for not receiving a shower resulting in staff forcing resident to take a shower against their will for one of three residents (R1) reviewed for abuse in a sample of six. This failure resulted in R1 feeling sexually violated and fearful of taking future showers while at the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 9/24/21, the facility remains out of compliance at Severity Level 2 due to the facility's ongoing monitoring of the their plan of correction and QA (Quality Assurance) team meeting to identify residents at risk for abuse who refuse cares to apply proper interventions of those refusals during the QA process. Findings Include: The facility's Abuse Prevention Program policy dated 3/5/2009, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: 2) orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect, and abuse immediately to supervisor personnel. 4) Identifying occurrences and patterns of potential mistreatment. R1's medical record documents that R1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's current Care Plan documents, Resident is known/has a history of displaying inappropriate behavior and/or resisting care/services. (A) If resident resisting cares. Ensure resident's safety. Allow time for resident to calm down and re-approach at a later time. Consider changing caregivers. Facility reported incident dated 9/16/21 documents (R1) who while receiving a shower, became combative with staff stated she was forcibly put in the shower and sexually assaulted. During the entire shower, three CNAs (Certified Nursing assistant), one LPN (Licensed Practical Nurse) and DON (Director of Nursing) were present. R1's medical record Social Service Director's (SSD) notes dated 9/16/21 document, Resident (R1) and I spoke about an incident that occurred while staff were trying to get resident to shower. Resident stated they 'staff' forced (R1) to shower and sexually assaulted (R1). (R1) and I spoke about the need for shower and how being physical with staff is inappropriate. I assured resident, management will take the proper steps to take care of the incident. Resident talked with me and calmed down before I walked (R1) back to his room. R1's medical record SSD notes dated 9/21/21 documents, Completed quarterly review with resident (R1). Resident has been self isolating and sleeping all day long. Resident kept falling back to sleep during assessment. R1's medical record Nurses' notes dated 9/19/21 documents, Resident exhibiting verbal behavior towards staff screaming (R1) is not safe and does not trust facility. When trying to calm resident and reassure (R1), resident (R1) stated that (R1's) been forced to get a shower and (R1) thinks it's an assault. R1's behavior tracking record dated September 2021 documents, Target Behavior: Refusing Personal Hygiene. Interventions: 1) Approach in a clam, non-threatening manner. 2) Allow resident time to express self and verbalize frustrations. 3) Ask another staff member to make attempt. R1's behavior tracking documents on 9/15/21 through 9/19/21, R1 refused personal hygiene with interventions 1-3 attempted with an outcome of an increase in behavior. On 9/22/21 at 11:13 am, R1 was lying in R1's bed. No odors of urine could be detected. R1 began to explain the incident that occurred with R1 in the shower room on 9/16/21 and while explaining the incident of the abuse allegation that took place on 9/16/21, R1 started crying, covered R1's body and face with blankets and stated I can't believe this has happened to me. I was sexually assaulted. I feel violated. I have rights. I told them 'no' and to stop. I thought when someone is told no and to stop that they're supposed to stop. They wouldn't stop. I kept asking them to stop but they just wouldn't stop. Why wouldn't they listen? I'm afraid of what's going to happen the next time I have to take a shower. Are they going to violate me again? I have rights and they should listen to me. On 9/22/21 at 11:20 AM, V1 Administrator, stated From what I investigated, (R1) was approached to have a shower because (R1) was soaked with urine and (R1) told the staff no. So they gave (R1) a timeline that day that they would be back to assist (R1) in getting a shower. Three CNAs (Certified Nursing Assistants) took (R1) to the shower room where (R1) became combative not wanting a shower. That's when (V2, Director of Nursing (DON)) and (V8, LPN (Licensed Practical Nurse) went into the shower room to help get (R1) into the shower. On 9/22/21 at 11:27 AM, V2, Director of Nursing (DON) stated, I walked into the shower room while three CNAs were in the process of undressing (R1). (R1) was throwing a fit and yelling for everyone to get out and saying that (R1) didn't want a shower, but we told (R1) that we need to do this because (R1) is soaked in urine. (R1) started to let the CNAs take (R1's) pants off, then decided (R1) didn't want a shower and didn't want them to undress (R1). (R1) was cooperative one second, then was telling us (R1) didn't want a shower the next. The CNAs finally got (R1) undressed and into the shower. When (R1) started washing (R1), I stepped out. (R1) kept repeating 'This is ridiculous, I don't need a shower, I don't have to take one' while I was in the shower room. On 9/22/21 at 11:44 AM, V4, CNA, verified R1 did not want to take a shower and stated The days leading up to 9/16/21, (R1) was completely soaked in urine along with (R1's) bed. We tried to get (R1) to take a shower but (R1) refused. On 9/16/21 at around 9:45 AM, (V8, LPN) told (R1) that (R1) needs to take a shower and that we were giving (R1) until 10:00 AM to go to the shower on (R1) own. When (R1) didn't shower, (V6, CNA, and V8, LPN) went into (R1)'s room and got (R1) out of bed and into the shower chair. R1 started becoming combative and fighting everyone yelling, 'I don't need a shower. This isn't right.' After we finally got (R1) into the shower room, (R1) started fighting me when I was taking trying to take (R1's) pants off saying, 'They are sexually assaulting me'. Once we got (R1) undressed, we got (R1) in the shower but (R1) refused to wash (R1). That's when I went ahead and washed (R1's) legs, armpits and private area. As I was washing (R1), (R1) kept saying, 'This isn't right. You're sexually assaulting me'. On 9/22/21 at 11:54 AM, V5, CNA stated, I was a shower aide the day of the incident. I was told to try and get (R1) in the shower. The nurse wound up giving (R1) 30 minutes to get into the shower. I left the room and to grab linen and when I got back, (V4, CNA and V6, CNA) were explaining to (R1) why (R1) needed to take a shower. We tried to get (R1) up, but (R1) started kicking, scratching, punching and biting at staff and refusing to shower. I left the room again to go down the hall to get a shower chair. When I returned, (V6, CNA, and V8, LPN) got (R1) out of bed, while (R1) was still fighting, and into the shower chair. (R1) is capable of walking on (R1's) own. The reason we used the shower chair was to transport (R1) to the shower room since (R1) wouldn't go on (R1's) own. Once we got (R1) into the shower room, (R1) let us take (R1's) shirt off without an issue, but then wouldn't let us take (R1's) pants off. (R1) crossed (R1's) legs and didn't want them removed. After we finally got (R1) undressed, (V4, CNA, and V6, CNA) started washing (R1). While they were washing (R1), (R1) kept saying. 'This isn't right. This is sexual assault.' After (R1) got showered, (R1) didn't fight us anymore. On 9/22/21 at 12:01 PM, V6, CNA, stated, On 9/16/21, (R1) was soaked in urine. We kept telling (R1) that (R1) had to shower, but (R1) refused. Then (R1) started yelling and screaming at us. (V8, LPN) and I put our arms under (R1) and stood (R1) up and transferred (R1) to the shower chair. Actually, we had to pull (R1) up because (R1) refused to get up. (R1) was biting, kicking, and punching us. (R1) started crying and kept repeating, 'This isn't right.' (R1) is ambulatory and able to go to the shower on (R1) own. We had to use the shower chair to transport (R1) to the shower room because (R1) refused to go. Once we got (R1) to the shower room, we undressed (R1) and got (R1) into the shower. (V4, CNA) and I had to wash (R1) because (R1) refused to wash (R1's) self. On 9/22/21 at 2:00 PM, V1, Administrator, verified forcing R1 into a shower was not an appropriate approach and stated, I'm not sure what the back story for (R1)'s [CONDITION(S)] (Post traumatic stress disorder) is. Looking back at the situation, we should have tried a re-approach or alternate methods to get (R1) to shower. If the residents continue shower refusals, we normally look at the care plan for the interventions. If the interventions listed for that particular resident don't work, we look at modifying the interventions or we try to get the family involved. On 9/22/21 at 2:17 PM, V7, Social Services Director (SSD), verified that R1 has [CONDITION(S)] (Post traumatic stress disorder) from a history of sexual abuse and stated, I spoke to (R1) after the incident and (R1) is very upset about what happened. (R1) started crying and telling me how it wasn't right what the staff members did. I'm sure (R1) being washed against (R1's) will triggered (R1's) experience of sexual abuse and (R1) had to relieve that pain. That had to be a traumatic experience for (R1). On 9/28/21 at 10:00 am, V1, Administrator, stated We use the Ombudsman's Resident Rights handbook for residents right to refusals. The Ombudsman Resident Rights handbook documents, You have the right to make your own choices. You have the right to request, refuse, and/or discontinue any treatment. The Immediate Jeopardy was identified on 9/23/21 The Immediate Jeopardy began on 9/16/21 when the facility failed to honor a R1's preference of not receiving a shower resulting in staff forcing R1 to take a shower against (R1's) will. V1, Administrator was notified of the Immediate Jeopardy on 9/23/21 at 12:39 PM. The surveyor confirmed through interview and record reviewed, that the facility took the following actions to remove the Immediate Jeopardy: On 9/24/21, V7, Social Service Director, provided all residents with a copy of Resident Rights On 9/24/21, V1, Administrator, provided education to all staff on de-escalating techniques for [CONDITION(S)], behavior in-service on [CONDITION(S)], Abuse prevention and reporting including reasonable suspicion of a crime to the facility Abuse coordinator. On 9/24/21, the Regional Director of Operations in-serviced V2 (Director of Nursing) on Abuse, de-escalation techniques for [CONDITION(S)], behavior in-service on [CONDITION(S)], Abuse prevention and reporting including reasonable suspicion of a crime to the facility Abuse coordinator. On 9/24/21, V2 (Director of Nursing) scheduled R1 a psychological evaluation on 9/24/21 with the facility psychiatrist.

Based on interview and record review, the facility failed to implement their Abuse policy by not removing an alleged perpetrator (V8/CNA/Certified Nursing Assistant) from direct resident care after an incident of verbal and mental abuse, not educating staff on resident behavioral management to prevent abuse, not educating staff on burnout, frustration, and stress, and not developing/implementing a care plan to address R1's behaviors that may lead to conflict/abuse for one of three residents (R1) reviewed for abuse in the sample of three. These failures resulted in V8 experiencing burnout and stress resulting in V8 abusing R1 several times verbally and mentally, and V8 having access to all residents within the building after abusing R1, potentially affecting all 38 residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6-3-21, the facility remains out of compliance at a Severity Level 2 as the facility continues to educate all staff on the Abuse Prohibition Policy including the protection of residents, behavioral management of residents to prevent abuse, and managing staff burnout, frustration, and stress. The facility also continues ongoing monitoring to ensure accurate implementation of this policy. Findings include: The facility's Abuse Prevention Program policy dated 02/2021 documents, Establishing a resident sensitive environment: This facility desires to prevent abuse, neglect, exploitation, and theft by establishing a resident sensitive and resident secure environment, This will be accomplished by a comprehensive quality management approach involving the following. Resident Assessment: As part of the resident's social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. Staff will continue monitor the goals and approaches on a regular basis. Protections of Residents: The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway. Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse, or misappropriation of resident property will be immediately removed from resident contact until the results of the investigations have been reviewed by the administrator or designee. Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics: Sensitivity to resident rights and resident needs; Dementia management and resident abuse preventions including how to assess, prevent and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protect both residents and staff; and how to recognize and deal with burnout, frustration, and stress that may lead to inappropriate responses or abuse reactions to residents. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672 dated 6-1-21 and signed by V1 (Administrator) documents 38 residents reside in the facility. This same form documents 34 residents have documented psychiatric diagnoses. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 has no behaviors, requires assistance of one-person physical assistance for eating and toileting, and has the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Medical Record dated 3-17-21 (date of admission) through 6-1-21 does not include a Care Plan addressing R1's increased vulnerabilities for abuse and needs/approaches to dealing with R1's behaviors that might lead to abuse/mistreatment. On 6-1-21 at 9:15 AM V5 (Registered Dietician) stated, On 5-19-21 I was in the business office and heard loud screaming in the dining room. (R1) was sitting in her wheelchair in the dining room. (R1) had thrown a plate at (V13/Dietary Aide). (V8/CNA) was in yelling at (V4/Minimum Data Set Coordinator), 'How long are you going to let this go on?' (V8) was in (R1's) face, yelling very aggressively and threatening at (R1), 'This is assault and you could go to jail.' (R1) was cussing at (V8) and (V8) was yelling back at (R1), 'Quit talking to me this way! I am sick of it!' (V8) was being very aggressive and loud with (R1). I approached (V8) and told her to take her concerns to V1. (V8) yelled at me, 'I am not going to.' (V8) proceeded to take (R1) to her room. I did not separate (V8) from (R1). I listened to (V8) from the nurse's desk, but no staff member directly monitored (V8) while (V8) proceeded to take (R1) to her room. (V8) and (R1) were left unattended at that time. On 6-1-21 at 10:08 AM V4 (Minimum Data Set Coordinator) stated, On 5-19-21 around 11:45 AM I was in my office and heard a plate crash on the ground. I went into the dining room and heard (V8/CNA) yelling at (R1) that (R1) cannot do that (throw a plate). (V8) yelled at (R1) that throwing a plate was assault and told (R1) that she could go to prison. (V8) then took (R1) towards her room and I could hear (V8) continuing to scold (R1). (V8) stopped with (R1) in front of the nurse's desk and was yelling at (R1), 'Do you know what they do to old people in prison? Do you know what prison is? (V8) was being very intimidating, inappropriate, and verbally abusive with (R1). (R1) was yelling back at (V8) 'F*** you! I do not care!' I then approached (V8) and told (V8) 'That is enough. Let it go and move on.' (V8) yelled at me 'No it is not enough.' I went to report the incident to (V1) while (V8) proceeded to take (R1) to her room. I did not separate (V8) from (R1). I probably should have. (V8) just kept escalating the situation with (R1), making (R1's) behaviors worse. (V8) seemed to be inappropriate with residents at times and would be sassy. I do not remember being trained on resident behavior management, or staff burnout. On 6-1-21 at 9:45 AM V1 (Administrator) stated, On 5-19-21 (V5) reported to me that (V8) was threatening and yelling at (R1) for over 30 minutes, and (V5) could not get (V8) to stop threatening (R1). Somebody should have separated (R1) from (V8). (V8) did not leave the facility until 12:45 PM and had access to all residents within the facility. This facility has not trained (V8) on de-escalating of resident behaviors. Nobody, including myself or V10 (Social Service Director) have been trained on de-escalating resident behaviors, or stress management/burnout. The facility does not have a behavior treatment policy and procedure. (R1) does not have a plan of care addressing her behaviors with interventions to prevent abuse. On 6-1-21 at 11:30 AM V8 (CNA) stated, That facility is very hectic and short staffed. The residents have a lot of behaviors and department heads do not help out. On 5-19-21 during lunchtime (R1) threw a glass plate and broke it. I told (R1) that she cannot be throwing glass plates as that could be considered assault and could lead (R1) to jail time. I am tired of the residents calling me racial slurs and throwing things at me. The residents never get disciplined for calling us staff names or for abusing the staff. What (R1) did is highly inappropriate. (R1) is not a baby and knows what she is doing. I am tired of (R1) abusing us (facility staff). (V4/MDS Coordinator) approached me and said I need to bring my concerns to (V1). I refused to talk to (V1). (V1) never helps us and we have no director of nursing to help us. I was not trained at that facility on de-escalation of resident behaviors. I have not had any training on dealing with stress. There is nobody to talk to anyway. Nobody helps. On 6-1-21 at 2:10 PM V10 (Social Service Director) stated, I am not aware of any staff being educated on de-escalation of resident behaviors, or staff burnout prevention. We (the facility) do not have a policy to manage resident behaviors. I have never been in-serviced at this facility on de-escalation of resident behaviors or burnout prevention. (R1) has not had a care plan developed regarding her behaviors with interventions to address those behaviors. (R1) has not been assessed for the risk of abuse. V8's Time Report dated 5-19-21 documents V8 worked from 5:56 AM through 12:43 PM on 5-19-21. The Immediate Jeopardy was identified on 6-1-21 at 2:00 PM. The Immediate Jeopardy began on 5-19-21 when V8 was experiencing burnout and stress resulting in V8 abusing R1 several times verbally and mentally, and V8 having access to all residents within the building after abusing R1. On 6-2-21 at 12:40 PM, V3 (Regional Supervisor) was notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The facility Social Service Director (V10) has provided all residents with a copy of the Resident Rights policy on 6/2/21. 2. A care plan was developed on 6-2-21 by the Regional Minimum Data Set Coordinator (V14) for R1's behaviors with appropriate interventions that address her behaviors that put her at risk for abuse. 3. V8 was terminated on 5/19/21. 4. Facility staff were trained by Administrator in Training (AIT/V15) and regional staff were trained by the Chief Risk Officer (V16) on the facility's behavior policy regarding de-escalation techniques to reduce behaviors, abuse prevention and reporting including reasonable suspicion of a crime to the facility abuse coordinator, as well as burnout, frustration and stress on 6/2/21 and 6/3/21.

Based on interview and record review, the facility failed to ensure a resident (R1) was free from verbal and mental abuse and failed to recognize these allegations as abuse for one of three residents (R1) reviewed for abuse in the sample of three. These failures resulted in R1 sustaining verbal and mental abuse from a staff member (V8/Certified Nursing Assistant), resulting in an escalation of R1's behaviors. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6-3-21, the facility remains out of compliance at a Severity Level 2 as the facility continues to educate all staff and all newly hired staff on de-escalation techniques to reduce behaviors, abuse prevention and the reporting reasonable suspicion of a crime to the facility abuse coordinator. Findings include: The facility's Abuse Prevention Program policy dated 04/2021 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms towards residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Example of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident. 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 residents, harassment, humiliation, and threats of punishment or deprivation. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 has no behaviors, requires assistance of one person physical assistance for eating and toileting, and has the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's (State Agency) Notification Reports dated 5-19-21 and signed by V1 (Administrator) documents, Staff (V4/MDS/Minimum Data Set Coordinator) and (V5/Registered Dietician) reported other staff member (V8/CNA/Certified Nursing Assistant) being verbally inappropriate in the dining area. Investigation concludes no type of abuse of any resident occurred. The facility's Abuse Inservice Log dated 5-10-21 and signed by V1 (Administrator) documents V8 was trained on the facility's Abuse Policy on 5-10-21. On 6-1-21 at 8:45 AM, R1 stated, (On 5-19-21) I was in the dining room and a black girl would not take me to the bathroom. I had to pee. I got upset and threw my plate. The girl started yelling at me and made me go to my room. She did not take me to the bathroom. On 6-1-21 at 9:15 AM V5 (Registered Dietician) stated, On 5-19-21, I was in the business office and heard loud screaming in the dining room. (R1) was sitting in her wheelchair in the dining room. (R1) had thrown a plate at (V13/ Dietary Aide). (V8) was in yelling at (V4/Minimum Data Set Coordinator), 'How long are you going to let this go on?' (V8) was in (R1's) face, yelling very aggressively and threatening at (R1). (V8) yelled at (R1) 'This is assault and you could go to jail.' (R1) was cussing at (V8) and (V8) was yelling back at (R1), 'Quit talking to me this way! I am sick of it!' (V8) was being very aggressive and loud with (R1). I reported the incident to (V1), and we brought (V8) into the office. (V8) was yelling at (V1), F*** you! Kiss my black a**! (V1) then terminated (V8) for insubordination and abuse of a resident. (V8) left the facility, yelling, 'Kiss my black a** you white bi**h!' On 6-1-21 at 10:08 AM V4 (Minimum Data Set Coordinator) stated, On 5-19-21 around 11:45 AM I was in my office and heard a plate crash on the ground. I went into the dining room and heard (V8/CNA) yelling at (R1) that (R1) cannot do that (throw a plate). (V8) yelled at (R1) that throwing a plate was assault and told (R1) that she could go to prison. (V8) then took (R1) towards her room and I could hear (V8) continuing to scold (R1). (V8) stopped with (R1) in front of the nurse's desk and was yelling at (R1), 'Do you know what they do to old people in prison? Do you know what prison is?' (V8) was being very intimidating, inappropriate, and verbally abusive with (R1). (R1) was yelling back at (V8), 'F*** you! I do not care!' I then approached (V8) and told (V8) 'That is enough. Let it go and move on.' (V8) yelled at me 'No it is not enough.' (V8) just kept escalating the situation with (R1), making (R1's) behaviors worse. (V8) seemed to be inappropriate with residents at times and would be sassy. On 6-1-21 at 11:30 AM V8 (CNA) stated, That facility is very hectic and short staffed. The residents have a lot of behaviors and department heads do not help out. On 5-19-21 during lunchtime (R1) threw a glass plate and broke it. I told (R1) that she cannot be throwing glass plates as that could be considered assault and could lead (R1) to jail time. I took a deep breath and asked (R1) why she threw the plate. (R1) stated that she needed to use the bathroom. (R1) continuously needs to use the bathroom. I am tired of the residents calling me racial slurs and throwing things at me. The residents never get disciplined for calling us (staff) names or for abusing the staff. What (R1) did is highly inappropriate. (R1) is not a baby and knows what she is doing. I am tired of (R1) abusing us (facility staff). (V4/MDS Coordinator) approached me and said I need to bring my concerns to (V1). I refused to talk to (V1). (V1) came into talk to me along with V5 (Registered Dietician). (V1) was trying to write me up for threatening (R1). I quit and walked out. On 6-1-21 at 9:45 AM V1 (Administrator) stated, On 5-19-21 (V5) reported to me that (V8) was threatening and yelling at (R1) for over 30 minutes, and (V5) could not get (V8) to stop threatening (R1). (V5) informed me that (V8) was yelling at (R1) that (R1) was going to have to go to prison for throwing a plate and was escalating (R1's) behaviors by getting in (R1's) face and yelling at (R1). (V8) was being intimidating and verbally abusive. I brought (V8) into the office and (V8) kept cussing at me and would not calm down. (V8) was telling me to kiss her a** and yelling f*** you! I was so upset that I finally terminated (V8). (V8) then went down the hallway to exit the facility and was yelling, 'Kiss my black a** you white b****! I did not conclude in my investigation that (V8) abused (R1). (V3/Regional Supervisor) instructed me document the allegations as not being abuse so that the facility does not get in trouble with (State agency). (V8) yelling at (R1) and threatening (R1) with going to jail is definitely abuse. The Immediate Jeopardy was identified on 6-1-21 at 2:00 PM. The Immediate Jeopardy began on 5-19-21 when R1 sustained verbal and mental abuse from a staff member (V8/Certified Nursing Assistant), resulting in an escalation of R1's behaviors. On 6-2-21 at 12:40 PM V3 (Regional Supervisor) was notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The facility Social Service Director (V10) has provided all residents with a copy of the Resident Rights policy on 6/2/21. 2. All staff were educated by the Regional Consultant (V3) and (V15) Administrator In Training before on 6/2/21 and 6/3/21, on de-escalation techniques to reduce behaviors, abuse prevention, and reporting including reasonable suspicion of a crime to the facility abuse coordinator. 3. V8 was terminated on 5/19/21.

Based on record review and interview the facility failed to protect a resident (R1) from sexual abuse by a staff member (V3/Licensed Practical Nurse) and failed to provide adequate supervision of a cognitively impaired resident (R4) to prevent abuse for two of four residents (R1, R4) reviewed for abuse in the sample of eight. These failures resulted in (R1) feeling uncomfortable and becoming severely depressed, which triggered (R1) to have a mental breakdown that required counseling and treatment. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1-28-21, the facility remains out of compliance at a severity level II as the facility continues to educate all staff and newly hired staff on the Abuse Prevention Policy and Sexual Harassment. Findings include: The facility's Abuse Prevention Program policy dated 11-28-16 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Sexual Abuse is non-consensual sexual contact of any type with a resident. This facility is committed to protecting our residents from abuse by anyone including facility staff, other residents, consultants, volunteers, and staff form other agencies providing services to the individual. R1's Pre-Admission Inpatient Psychiatry History and Physical Note dated 1-14-20 documents, (R1) has a history of [MEDICAL CONDITION]'s Disease (diagnosed on e year ago) and no previous psychiatric hospitalization s. (R1) was brought to the hospital due to worsening depression, hopelessness, and difficulties sleeping and functioning in his ADL's (Activities of Daily Living). (R1) reported having increased depression and suicidal ideation due to being [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is a [AGE] year-old who is cognitively intact and has [DIAGNOSES REDACTED]. This same MDS documents R1 was admitted to the facility on [DATE]. R1's Mood assessment dated [DATE] documents R1 was moderately depressed. R1's Mood assessment dated [DATE] documents R1's depression increased from R1 being moderately depressed on 1-21-20 to R1 being severely depressed on 3-20-20. V3's Personnel Record documents V3 signed an acknowledgement of receiving training on the facility's Abuse Prevention Program upon hire (1-20-20). R1's Investigation Notes dated 3-17-20 and signed by V11 (Previous Director of Nursing) document, (R1) states that multiple times the previous night (3-16-20), (V3) came to (R1's) room and engaged in inappropriate personal conversations. During one conversation (V3) stated that she had brought her dog to the facility and had to wait for management to leave so that she could bring her dog inside the building. During another conversation at some point (V3) stated she had purchased some underwear online and that she needed (R1's) opinion regarding them later. Later (V3) brought the dog in and laid down on (R1's) bed and continued the conversation in which she spoke of her personal relationships with others and being hurt by everyone in her life. During the end of the conversation, (V3) pulled down her scrub bottoms, exposed her underwear, and asked (R1's) opinion about them. (R1) stated the conversations made him very uncomfortable and he does not trust (V3) with his care any further. The facility's Reportable dated 4-1-20 to IDFPR (Illinois Department of Financial and Professional Regulation) documents, Your complaint is against: (V3/Licensed Practical Nurse/LPN). Description of complaint: (V3) is seen and heard on a video in (this facility) talking to (R1) in a sexual manner. (V3) appears to be inebriated in the video. At the very end of the video the nurse can be heard talking about underwear she has ordered and then is seen pulling down her pants and exposing her buttocks to (R1). (R1) is a resident at the facility. This is not the first time this nurse has had questionable moral turpitude. R1's Medical Record from admission 1-21-20 through discharge 4-11-20 does not include any documentation in R1's Social Service Notes, Progress Notes, or Care Plan of R1 consenting to V3's Sexual/Personal advances towards him (R1). On 1-25-21 at 9:40 AM V5 (Social Service Director) stated, I saw a video that (R1) showed me back in March 2020. V3 (LPN) was in (R1's) room and pulled her pants down to show (R1) her underwear. (R1) stated he videoed (V3) because (V3) always would go in his room and make (R1) feel uncomfortable. (R1) was not ok with what (V3) was doing and definitely was not consensual. (R1) recorded (V3) to show us what (V3) was doing. On 1-25-21 at 10:45 AM V4 (R1's Family Member) stated, I saw a video from March 2020 that (R1) had taken. (R1) told me that (V3) was inappropriate with him on several occasions. (V3) would talk to (R1) about her personal problems and would tell (R1) that she would do anything for him. In the video (V3) was walking around seductively and dropped her pants, showing her underwear to (R1). (V3) asked (R1) what he thought of her a**. (R1) was very upset by it. (R1) was upset that a nurse was doing this to him and did not trust her. (R1) has [MEDICAL CONDITION]'s Disease and was confused by what (V3) was doing. (R1) has been very traumatized since this and had been receiving counseling. (V3) made (R1) feel very uncomfortable. On 1-25-21 at 10:30 AM V3 (LPN) stated, I would talk to (R1) about my family thinking I am a b***h. I felt like (R1) and I were dating two weeks after (R1) got to the facility. I would talk to (R1) about my personal issues all the time. I did pull down my pants and show (R1) my underwear and I asked (R1) if I had a nice a**. I knew I should not have had a sexual relationship with (R1) while he was a resident at the facility. I do not know what I was thinking. I sent (R1) a picture of my breasts without any clothing on and several pictures of my butt with underwear on. I know what I was doing was wrong. The facility fired me because of what I did with (R1). Professional regulations sent me a letter that I need one hour of continuing education training on sexual harassment. I have not had sexual harassment training yet. On 1-25-21 at 11:10 AM R1 stated, (V3) would come into my room and talk about her personal issues and home-life a lot. (V3) would have alcohol on her breathe. On 3-13-20 around 3:00 PM (V3) sat on the end of my bed and said she had something to show me later. I left my phone on record because I felt uncomfortable with how (V3) was talking to me. Later on (V3) pulled her pants down and showed me her underwear and told me that I should leave my girlfriend for her. (V3) would tell me that I could go home with her and live instead of living at the nursing home. The situation kept getting weirder. (V3) had sent me a picture of her breasts without clothing on. (V3) would message my wife and tell my wife that I wanted (V3). (V3) brought liquor into my room once and drank it. My whole room wreaked of alcohol. (V3) knew I was a recovering alcoholic. I have [MEDICAL CONDITION]'s Disease and it is hard for me to cope with what (V3) has done to me. It triggered me and scared me. I have had to have counseling and treatment because of (V3). I had a mental breakdown. (V3) was obsessed with me and kept wanting me to live with her. I was not comfortable with (V3's) advances towards me. I think (V3) was obsessed with me because I was the only young resident at the facility and (V3) always seemed to be drunk. On 1-26-21 at 9:40 AM V11 (Previous Director of Nursing) stated, I terminated (V3) on 3-19-20 for inappropriate behavior and sexual abuse of (R1). (R1) recorded (V3) being inappropriate with him to prove to us what (V3) was doing to him. (R1) was alert and orientated at the time of the report. (R1) even told me that he had increased anxiety from (V3's) sexual advances towards him. (R1) said that (V3) made him uncomfortable living in the facility that was supposed to be giving him help. We (facility staff) suspected that (V3) had worked while under the influence of alcohol. 2. The Facility's Abuse Prevention Program dated 11/28/2016, states Resident Assessment. As part of a resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis. R4's Physician order [REDACTED]. R4's Minimum Data Set (MDS) assessment dated [DATE], documents R4 has moderately impaired cognition; ambulates with minimal assistance; exhibits behaviors that significantly intrude on privacy or activity of others; significantly disrupts care or living environment; and wanders. R4's most recent Care Plan, does not include any documentation about R4's wandering into other residents' rooms, putting him at risk for abuse, or any interventions to help prevent R4 from wandering into other residents' rooms. R2's MDS assessment dated [DATE], documents R2 is cognitively intact. R4's Incident Report dated 1/24/21 at 7:30 a.m., documents R4 wandered into R2's room and R2 kicked R4. R4 did not sustain any injuries. On 1/25/21 at 11:07 a.m., R2 stated R4 wandered into his room a total of four times the morning of 1/24/21. R2 stated I asked him (R4) nicely the first three times, not to come back into my room. The fourth time he came straight to my closet. I escorted him from my closet to the hallway. I kicked him in the butt. I know it was wrong but I warned him after three times of coming in my room. On 1/26/21 at 10:33 a.m., V2 (Director of Nursing) states R4 does frequently wander into other residents' rooms and tends to take their belongings or food. V2 stated R4's wandering and intruding on other residents privacy has worsened (as noted on R4's MDS assessment dated [DATE]). V2 stated R4's most recent Care Plan does not address R4's wandering, intruding on other resident's privacy, or the fact that R4 is at increased risk for abuse due to his wandering. V2 stated I am aware that we need to work on (R4's) care plan and interventions regarding his wandering into others rooms. (R4) is at increased risk for abuse due to his wandering. Staff have to keep a close eye on him when he's awake. On 1/25/21 at 10:30 a.m., V1 (Administrator) stated on 1/24/20 R2 admitted to kicking R4 in the butt because R4 had come into R2's room four times that morning. V1 stated the physical abuse was not witnessed by staff. V1 stated R4 is at high risk for abuse due to impaired cognition and wandering into other residents' rooms. The Immediate Jeopardy was identified on 1-26-21 to have begun on 3-16-20 when V3 sent R1 naked photos of her breasts and dropped her pants below her buttock to show R1 her underwear. V3 asked R1 if she had a nice a**. V3 also tried to persuade R1 to move in with her and would talk to R1 regarding her personal issues. On 1-27-21 at 12:30 PM V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1, V5 (Social Service Director), and V13 (Activity Director) conducted interviews of all residents and ensured all residents felt safe in their home, and were educated on whom they can report to should an employee or other resident makes them feel uncomfortable. 2. V1 completed a 100 percent audit of all employee records to ensure a background check had been completed on all current employees. 3. All staff were in-serviced by V1 on the Abuse Prevention Policy and Procedure. 4. All staff were in-serviced by V1 on Sexual Harassment. 5. All new hire staff will be in-serviced on the Abuse Prevention Policy and Procedure and Sexual Harassment prior to being placed on the schedules in their department. Completion Date 1-28-21

Based on observation, record review, and interview, the facility failed to readily identify an outbreak of rashes as a potential transmission of a communicable disease and failed to promptly initiate treatment of [REDACTED]. This failure has the potential to effect all 50 resident currently residing at the facility. This failure also resulted in compromised skin integrity due to scratching, a bacterial infection of the skin, extremity, pain, and hospitalization for one of three residents (R1) reviewed for skin rashes in a sample of three. Findings include: 1) On 1/17/17 at 1:48 p.m., E1 (Acting Administrator - License Pending) reported staff discovered (R1) had cellulitis and sent R1 to the hospital to be evaluated (on 12/27/16). E1 stated the facility received a phone call from the hospital physician (Z1 Physician - Hospitalist) reporting R1 had scabies (a contagious intensely itchy skin condition cause by a tiny, burrowing mite). E1 stated, I thanked (Z1 Physician -Hospitalist) and asked for confirmation for our records. I asked if any test was done. (Z1) said no we wouldn't get a positive reading because (Z1) was going to treat it. E1 indicated E1 had this conversation with Z1 the same day R1 was sent to the hospital (12/27/16). E1 reported after E1's conversation with Z1 the decision to treat the residents was made. E1 indicated all residents were then treated for [REDACTED]. E1 stated there are six residents that still have rash but all the rashes are improved. E1 reported in November (2016) there were residents with rash and E1 wanted to know what it was so E1 had them tested (laboratory skin scraping for detection of scabies) but there was nothing positive. E1 stated, Just a skin rash going on. On 1/17/17, E1 provided a handwritten note containing R1, R2, R3, R4, R5, and R6's names indicated theses were residents who still had rash on 1/17/17. Laboratory reports dated 11/04/16 show R2, R7, R10, R12, R14, R16, R20, R21, and, R22 had skin scrapings obtained for scabies examination with the results of each test stating Quantity Not Sufficient. A laboratory report dated 11/05/16 for scabies examination for R1 also states, Quantity Not Sufficient. A current resident roster shows the residents who had skin scrapings for scabies in November 2016 reside in all areas of the facility. Shower/Abnormal Skin Reports from 11/03/16 through 12/12/16 document skin rashes were reported for R1, R2, R4, R5, and R7 through R18. A current room roster shows the residents with reported skin rashes reside in all areas of the facility. On 1/18/17 at 12:25 p.m., Z3 (R2's Attending Physician) reported Z3 gave orders on 12/06/16 for R2 to be treated for [REDACTED]. R2's POS (Physician order [REDACTED]. This order is transcribed to R2's December 2016 TAR (Treatment Administration Record) however the word Hold is written on the order and there is no documentation in R2's records to indicate the order was completed. R2's December 2016 MAR (Medication Administration Record), TAR (Treatment Administration Record), and Nurses' notes contain no indication R2 was treated as Z3 ordered on [DATE] or on 12/13/16 one week later. R2's physician progress notes [REDACTED]. Launder all clothing worn recently in hot water. Start [MEDICATION NAME] Cream today. Apply from the neck down now, then repeat in one week. Apply TAC ([MEDICATION NAME] Cream - a topical steroid) 0.1 percent three times daily to affected areas for itching. Roommate or anyone in close contact should also be treated simultaneously. The wound clinic orders were not transcribed to R2's January 2017 POS, MAR or TAR. The only documentation to address these orders is a Nurses' Note for R2 written by E9 (LPN) after and 1/16/17 entry which states, Late entry 1/11/17 Ivermectin pills given to resident per orders. Laundry done and cream applied. R3 (R2's Roommate) also has a handwritten order by E9 (LPN) on his December 2016 POS from Z3 (R2's Attending Physician) stating, [MEDICATION NAME] Cream now and one week later. R3's December 2016 MAR, TAR, and Nurses' notes contain no indication R2 was treated as Z3 ordered on [DATE] or on 12/13/16 one week later. On 1/17/17 at 1:30 p.m., R2 and R3 stated they had both been treated for [REDACTED]. R2 indicated R2 had been treated before and even had seen a doctor who told him R2 was contagious. R2 believes the symptoms started about Six months ago but can't be sure of how long he's had the problem. R2 reports he still itches but It's not as bad as it was before. R2 reported his worst itching was on his legs and buttocks. R2 continues to have rash on his arms, torso and legs. R3 (R2's Roommate) also reports itching and rash. R3 has a red, circular, macule type rash areas on both upper arms and upper legs and a few areas scattered sparsely across the abdomen. R3 believes the rash is resolving since he received treatment. A POS (Physician order [REDACTED]. A policy dated 5/07 and titled Infection Control Surveillance and Monitoring states Monitoring of the day to day operation of the Infection Control Program will be conducted by the DON (Director of Nursing). Included in these duties are: a. Investigation and implementation of controls to prevent infections in the facility. b. Determine and direct the correct procedures necessary for the prevention of infections. On 1/18/17 at 1:05 p.m., E3 (DON - Director of Nursing) stated E3's first day of employment with the facility was 1/16/17. E3 reported E3 was made aware of scabies treatments occurring on 1/17/17 as staff were providing the second round of scabies treatment to the residents. On 1/18/17 at 2:00 p.m., E9 (LPN - Licensed Practical Nurse) reported the orders E13 (Past DON) received on 12/12/16 for scabies treatment of [REDACTED]. E9 (LPN) stated E13 (Past DON) didn't want to proceed with the scabies treat orders received on 12/12/16 until all the skin scrapings laboratory reports had come back. E9 reported staff proceeded with scabies treatment for [REDACTED]. So we went ahead. E9 (LPN) reported a second round of scabies treatment was provided to all the residents on 1/17/17. On 1/18/17 at 5:04 p.m., E4 (Medical Director) verified E4 gave orders for all the residents residing at the facility to have scabies treatment on 12/12/16. E4 stated, I am not certain how many had rash or who but if it's more than one resident and more than one room the whole facility should be treated. Clinically, a skin scraping alone, it's not based on that. If there's rashes that are spreading and not responding to other treatment it's worth going ahead and treating all. If it's not a good skin scraping or it's negative that doesn't mean you shouldn't treat. E4 (Medical Director) reported E4 was never notified the orders E4 gave to treat all residents on 12/12/16 were not carried out until 1/04/17. The CDC (Centers for Disease Control and Prevention) Internet site states, [DIAGNOSES REDACTED]. Whenever possible, the [DIAGNOSES REDACTED]. This can be done by carefully removing the mite form the end of it burrow using the tip of a needle or by obtaining a skin scraping to examine under a microscope for mites, eggs, or mite fecal matter. However, a person can still be infested even if mites, eggs, or fecal matter cannot be found; fewer than 10 to 15 mites may be present on an infested person who is otherwise healthy. This reference is dated 11/02/2010 and the content source is identified as Global Health (http://www.cdc.gov/globalhealth) - Division of Parasitic Diseases (/parasites/). A Facility Data Sheet dated 1/17/17 completed by E1 (Acting Administrator - License Pending) documents there are currently 50 residents residing at the facility. 2) On 1/17/17 at 1:00 p.m., R1 was transferred from a wheelchair to the bed and provided incontinence care by E5 (CNA - Certified Nursing Assistant). R1 had a red, blotchy rash covering R1's trunk, chest, and both arms as well as a light red blotchy rash around both ankles. R1 was confused and unable to give a history of the rash onset and treatment. E5 (CNA) reported R1 recently had a problem with cellulitis of both R1's arms. A Shower/Abnormal Skin Report sheet dated 11/03/16 stated R1 had Red marks on (R1's) breast. R1's Nurses' Notes from 10/15/16 through 11/15/16 contain no entries documenting R1 had skin rash or itching, however, a laboratory report dated 11/05/16 indicates R1 had a skin scraping for scabies (a contagious intensely itchy skin condition cause by a tiny, burrowing mite) examination on 11/05/16. The test results indicate there was a problem with the test specimen indicating, Quantity Not Sufficient. Shower/Abnormal Skin Reports for R1 dated 12/01/16, 12/12/16, and 1/02/17 document R1 had rash covering R1's entire body. R1's Nurses' Notes from 10/15/16 through 12/29/16 contain no entries documenting R1's rash or associated symptoms or notification of R1's Representative or Z4 (R1's Attending Physician). There are no entries in R1's Nurses' Notes after 11/28/16 at 10:00 a.m. until 12/27/16 at 9:00 a.m. A 12/27/16 Nurses' Note at 9:00 a.m. documents R1's right arm was red up to R1's neck and weeping clear fluid. A Communication Form dated 12/27/16 states R1's right arm is red, swollen, hot to touch with skin weeping clear fluid from the the top of (R1's) neck. A history and physical form from a local hospital completed by (Z1 Physician - Hospitalist) indicates R1 was admitted to the hospital on [DATE]. Z1's report states, Came to the ER (emergency room ) (12/27/16). (R1) says it started a few weeks ago. Per report (the Long Term Care facility) brought (R1) to the ER after complaining of right arm pain, swelling, and redness for three weeks. Right upper extremity painful, torso, upper extremities [DIAGNOSES REDACTED] (red) warm to touch, rash present. Areas on chest appear to be weeping. Assessment/Plan: 1. Scabies 2. Right arm cellulitis 3. Right arm pain. Z1 documents, During my assessment, (R1) is furiously scratching all over (R1's) body, arms, trunk and groin areas. (R1's) skin has widespread scratch marks with areas of redness, there is some weeping in (R1's) upper chest, there is groin redness and swelling in (R1's) right upper extremity/arm. I suspect (R1) may have scabies (a contagious intensely itchy skin condition cause by a tiny, burrowing mite) from the pattern of (R1's) dermatological issues and as such I will isolate (R1 and start [MEDICATION NAME] (a medicated cream to treat scabies). A hospital Discharge Summary dated 12/29/16, dictated by Z1 (Hospitalist) states, admitted following redness and swelling with pain on her right arm. In the ER there were concerns for cellulitis. On the medical floor we noted severe itching with subsequent scratching leading to burrows and scales and some ulcerations. Most intense regions appear to be groin, (under the breasts) as well as finger webs and torso. We washed her and used [MEDICATION NAME]. Today, she is not in any distress and is feeding herself, she is no longer scratching herself and denies itching. Yesterday, she had an area of weeping on her chest. This has resolved. Discharging her back to the Nursing Home. I have spoken to them about having such an infectious condition in their facility and suggest they take necessary precautions. I believe (R1's) skin breakdowns were secondary to her intense scratching.

Based on observation, record review and interview the facility failed to provide a pressure relieving device for one resident (R4), resulting in the development of a Stage III pressure ulcer, and failed to maintain a physician ordered dressing in place for one resident (R5) with a pressure ulcer. R4 and R5 are two of two residents reviewed for pressure ulcers in the sample of 13. Findings include: A Preventative Skin Care Policy dated 10/2006, documents to provide preventative skin care through repositioning and careful washing, rinsing, drying and observation of the resident's skin condition to keep them clean, comfortable, well groomed and free from pressure ulcers. A Pressure Sore Prevention Guidelines Policy dated 11/2012, documents to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as High or Moderate risk for skin breakdown as determined by the Braden Scale. Interventions for a resident at moderate risk include turning and repositioning every two hours. 1. R4's Physician order [REDACTED]. R4's Initial Minimum (MDS) data set [DATE] documents R4 is cognitively impaired and requires extensive assistance of one with bed mobility and transfers and requires extensive assistance of two with ambulation. R4's Braden Scale for Predicting Pressure Ulcer Risk dated 4/16/15 documented R4 was a low risk for development of pressure ulcers. Nurses Notes dated 5/25/15 at 7:40 PM, document R4 as having a discolored area to the Left heel measuring 2.8 centimeters by 4.2 centimeters. Wound care clinic visit report dated 5/28/15 documents R4 was seen for an initial visit for a wound on the left ankle which resulted from pressure. Wound care clinic visit report dated 9/3/15 documents , (R4) left heel wound is a Stage three Pressure Ulcer measuring 0.6 centimeters long by 0.9 centimeters wide and 0.3 centimeters deep. On 9/15/15 at 1:15 PM, Z1(Physician's Assistant for R4) stated the wound on (R4's) left heel was pressure in origin and potentially preventable. Z1 stated R4 was to use a protective heel boot for the purpose of offloading. Z1 stated if R4 refused to wear the heel boot, pillows could be used under R4's left leg to prevent heel from coming in contact with the mattress. On 9/15/15 at 1:50 PM, E5, Licensed Practical Nurse removed the sock from R4's left foot. R4's left heel had an approximate 0.6 centimeter by 0.9 centimeter area of yellow tissue which appeared dry. On 9/14/15 at 10:55 AM, 2:03 PM and 2:57 PM, R4 was laying in bed without a protective heel boot on his left heel or a pillow under the legs. A Pressure Ulcer List provided by E1, Administrator on 9/14/15 documents R4 having a facility acquired Stage three pressure ulcer on the left heel. On 9/16/15 at 9:14 AM, E2, Director of Nursing (DON) stated (R4) did not have a wound on the left heel upon admission in April, 2015. E2 confirmed the wound on (R4's) left heel was facility acquired. E2 stated (R4's) pressure ulcer developed at the end of May. E2 stated (R4) developed the pressure ulcer due to(R4) crossing (R4's) legs while in bed. E4 stated (R4) should have the protective boot on at all times or have a pillow under the legs to offload. 2. A Pressure Ulcer List provided by E1, Administrator on 9/14/15 documents R5 having a facility acquired Stage two pressure ulcer on the coccyx. R5's Minimum (MDS) data set [DATE] documents R5 is cognitively impaired and requires limited assistance of one for transfers and ambulation. Braden Scale for Predicting Pressure Ulcer Risk dated 6/15/15, document R5 was a moderate risk for developing pressure ulcers. A Physician order [REDACTED]. On 9/14/15 at 11:22 AM and 12:03 PM, on 9/15/15 at 10:10 AM and 9/16/15 at 9:40 AM, R5 was sitting in a wheel chair in the television room. On 9/15/15 at 1:42 PM, E5, LPN stated R5 began sitting in a wheelchair following a fracture to the right leg. E5 stated R5 had never used a wheelchair before. R5's nurse notes dated 9/5/15 at 8:00 PM, document redness noted to coccyx and sacral area. Nurses note dated 9/7/15 at 9:00 AM document decreased redness to sacral and coccyx area. Nurse note dated 9/8/15 at 1:45 PM document coccyx now open. Nurses note dated 9/14/15 at 1:05 PM and 9/16/15 at 10:25 AM document coccyx wound open to air. 0n 9/16/15 at 11:50 AM, E2 Director of Nursing (DON) removed R5's adult brief. No dressing was noted to the coccyx area. On 9/16/15 at 11:50 AM, E2 confirmed there was an order for [REDACTED].

Facility noncompliance resulted in two deficient practices. A. Based on observation, interview, and record review, the facility failed to remove E3 (CNA/Certified Nursing Assistant) from having direct contact with residents after E3 alleged to have verbally abused R10. E3 was allowed to work in direct contact with all residents in the facility, following the alleged verbal abuse, resulting in E3 allegedly verbally and physically abusing R15. This had the potential to affect all 52 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 10/29/14 at 3:20 p.m., the facility remains out of compliance at a severity level two as the facility continues to in service all staff on the abuse policy, audit employee background checks, and implement interventions to protect the residents in the facility. Findings include: 1. The facility Abuse Prevention Program policy dated 11/11/11, documents: Abuse as any physical or mental injury or sexual assault infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. It is the right of our residents to be free from abuse. An environment will be established that promotes resident sensitivity, resident security, and prevention of mistreatment, neglect, and abuse of residents. This facility is committed to protecting our residents from abuse by anyone including facility staff and other residents. Employees of this facility who have been accused of abuse will be immediately removed from resident contact until an investigation has been reviewed by the Administrator. On 10-28-14 at 2:15 p.m., R15 was lying in a low bed and moving continuously in the bed. R15's legs were contracted. R15's Physician order [REDACTED]. R15's physician progress notes [REDACTED]. On 10-28-14 at 2:30 p.m., E4 (Certified Nursing Assistant/CNA) stated, "On 10-7-14 at around 5-5:30 p.m., (E3/CNA) and myself entered (R15's) room. (R15) had (R15's) hands in (R15's) pants. (E3) yelled at (R15), 'You nasty mother f*****r, get your hands out of your pants.' I then left (R15's) room and went and told the Director of Nursing (E2) what (E3) had yelled at (R15). (E2) did not remove (E3) from contact with (R15) at that time. (E3) was still in the room with (R15) when I went and told the Director of Nursing. I then went, got wash clothes, and returned to (R15's) room to help (E3) change, dress, and get (R15) up. (R15) was squirmy. (E3) was trying to put (R15's) pants on. (E3) grabbed (R15's) leg forcefully, to put the pants on. (E3) then grabbed (R15's) remote to the bed, and hit (R15) in the stomach a couple times, and hit (R15) on the knuckles a few times. (E3) then called (R15) a mother f****r and told me, 'Do not let the residents walk all over you. You have to show them some discipline.' I then left the room and told the nurse (E8). (E8) then notified the Administrator and the Administrator made (E3) leave the building." On 10-28-14 at 3:30 p.m., E2 (Director of Nursing) stated, "On 10-7-14, (E4) came in and reported to me that (E3) was cussing at (R15). I told (E3) to report it to the Administrator. I did not go to (R15's room) with (E4)." On 10-28-14 at 2:40 p.m., E8 (Registered Nurse) stated, "On 10-7-14 at around 5:00 p.m., (E4) told me that (E3) called (R15) a mother f****r, pulled on (R15's) leg, and hit (R15) on the knuckles and the abdomen with the remote. I did not call the Administrator. I told (E21/Registered Nurse) of the incident, during report, and (E21) called the Administrator. I assessed (R15) and (R15) had a red mark on the back of the hand. I filled out a SBAR (Situation Background Assessment Request), including (R15's) red area on the hand, and turned it into the Administrator. Around the end of September, 2014, (E3) would go on rounds with the other CNA's (Certified Nursing Assistants) and would say, "These mother f*****s (the residents) will pee themselves just to do it. (E3) would say it loud enough for residents to hear. It could be heard at the nurse's station. I was going to write (E3) up, but (E14/Licensed Practical Nurse) talked to (E3) regarding the cussing. (E3) also said, loud enough with residents present in the television/lobby room, 'It was j**k-off.' (E3) was talking about (R10). I did not report this to the Administrator. I thought (E14) would have." On 10-28-14 at 3:50 p.m., E21 (Registered Nurse) stated, "On 10-7-14, I had just came on shift at around 6:00 p.m., and right after report, (E8) reported to me that one of the certified nursing assistants had accused (E3) of abusing (R15). (E8) said (E3) struck (R15) with a remote and was verbal. I stopped (E8) right away, and told (E8) that we need to call the Administrator (E1). I removed (E3) from cares, called (E1), and reported (E3) was verbal and had struck (R15) with a remote." On 10-28-14 at 4:00 p.m., E1 (Administrator) stated, "The staff reported to me on 10-7-14 that (E3) flicked (R15's) hand. (E3) admitted to me that (E3) did flick (R15) , so that is physical abuse and (E3) was terminated. No allegations had been reported to me earlier about (E3) calling resident's names. (E3) should have been removed from the facility on the first instance of calling (R15) a mother f****r." On 10-30-14 at 10:00 a.m., E10 (Care Plan Coordinator) stated, "(E3) rotated and worked all resident halls." The CMS Centers for Medicare and Medicaid Services Resident Census and Conditions Report, dated 10/27/14 signed by E10 (Assistant Director of Nursing), documents that 52 residents reside in the facility. B. Based on observation, interview and record review the facility failed to protect two of two residents (R19 and R22) from sexual abuse by R10. R10 attempted to engage in inappropriate sexual behavior on two separate dates with R19 and R22. R10 was not restricted from access to other residents. R19 and R22 are two of eleven residents reviewed for abuse in the sample of thirteen. This has the potential to affect all fifty-two residents in the facility. This resulted in an immediate jeopardy. While the Immediate Jeopardy was removed on 10/29/14 at 3:20 p.m., the facility remains out of compliance at a severity level two as the facility continues to in service all staff on the abuse policy, audit employee background checks, and implement interventions to protect the residents in the facility. Findings include: 1. An Abuse Prevention Program Policy dated 11-11-11 documents, "This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual....sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault." R10's Physician order [REDACTED]. R10's MDS dated [DATE] documents, R10 is cognitively intake and has a BIMS Score of 12. On 10-27-14 at 2:54 p.m., E12 (Certified Nurse's Assistant /CNA) stated, around a couple weeks ago (R19) reported to me that (R10) has tried to feel (R19's) breast....(R19) is alert and oriented. On 10-27-14 at 3:35 p.m., R19 stated "(R10) came in my bathroom and asked me if I wanted to have some fun in the shower room on C Hall......the next day in the C Hall bathroom (R10) lifted up my shirt and went (whew)....I told him to get out you scuzz ball....I told the staff and the staff member (not sure who) said "Oh he does that"......no I don't like it, he touched my privates.....this happened about ...two or three weeks ago....I am afraid he will do it again." R19's room is located diagonal from R10's room on the same hall. R19's MDS (Minimum Data Set) dated 6-9-14 documents, R19 is cognitively intake and has a Brief Interview Mental Status (BIMS) of 14. 10-27-14 at 2:42 p.m. E7 (CNA) stated, "(R10) was found with (R22) On trying to undo (R22's) pants...R10 was found doing this in (R22's) room." On 10-29-14 at 9:48 a.m. E21 (CNA) stated, "I was told in morning report that (R10) tried to unfasten (R22's) belt and tried to get under (R22's) pants....this happened just the other day." On 10-29-14 at 10:28 a.m. E22 (RN /Registered Nurse) stated, we have to constantly re-direct (R10) from females.....I heard in report (R10) was found trying to take off R22's belt...this happened about one week ago...if I find (R10) going down B Hall, I won't let him....(R22) is on that hall." On 10-29-14 at 11:38 a.m. E20 (CNA/Certified Nursing Assistant) stated, "I caught (R10) touching (R22's) breast in the dining room.....I told (R10) not to touch (R22) anymore.....I reported it to the Nurse last week or so,.....I can't remember which Nurse it was....this happened a few days ago." R22's Physician order [REDACTED]. R22's MDS dated [DATE] documents, long term/short term memory problems, cognitive as "severely impaired" and totally dependent with Activities of Daily Living. According to R22's Activities of Daily Living Care Plan R22 requires two person mechanical lift for transfers and is not a candidate for Restorative Programming......can not move self. On 10-27-14 at 2:30 p.m. E15 CNA (Certified Nursing Assistant) stated, "(R10) does have inappropriate sexual behavior....(R10) wanders in other residents rooms and (R10) was playing with (R10's) self in the television room around other residents....(R10) was exposed at the time." R10's Behavior Care Plan dated 7-16-14, documents (R10) has inappropriate sexual behaviors. According to the care plan R10 was on fifteen minute checks, however E10 CPC (Care Plan Coordinator) stated, "(R10) has been on five minute checks for at least all of October." On 10-27-14 at 3:09 p.m. E1 (Administrator) stated, "If incidents happen they are to be reported to me....I should have been informed of (R19's) and (R22's) incidents....we are trying to find placement for (R10) because (R10) may need a locked unit." On 10-29-14 at 11:50 a.m., E1 (Administrator) stated, "no reports of (R10) touching (R22)....I have reports of (R10) going towards (R22's) room, but not touching (R22)....if (R10) has touched any residents it should have been reported to me so I can investigate....I did not know about (R10) and (R19) until E12 reported it during the interview with Public Health." E1 verified on 10-29-14 at 12:27 p.m. that (E1) found out about the alleged sexual abuse between (R10) and (R19) on 10-27-14 at 2:54 p.m...... and did not do any interventions to keep the residents safe until 10-28-14 at 5:50 p.m. when (R10) was sent out of the building for a psych evaluation." On 10/29/14 at 12:45 p.m., an Immediate Jeopardy was identified to have begun on 10/7/14. E1 (Administrator) was notified of the Immediate Jeopardy on 10/29/14 at 12:45 p.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. Every employee, before starting their next shift was in-serviced on the Abuse policy by E1, E2 (Director of Nursing, and E23 (Assistant Director of Nursing) on 10/29/14. This included a test that was required before starting their next shift on 10/29/14. All employees would remain suspended until completion and proof of 100 percent knowledge regarding the facilities abuse policy. The in-service and test would include the seven types of abuse, the proper step by step actions needed upon suspicion of abuse including protecting the resident, and the steps to abuse prevention. 2. E3 (Certified Nursing Assistant) who was involved in the abuse allegation was suspended upon report of the incident and terminated upon completion of the investigation by E1 on 10/14/14. 3. R10 and all residents involved in alleged abuse cases will immediately have an intervention put in place to protect the residents in the facility. This was done on 10/29/14 by the Quality Assurance team.

Facility noncompliance resulted in two deficient practices. A. Based on interview and record review the facility failed to report an allegation of abuse immediately to the Administrator, failed to remove the alleged perpetrator from direct contact with residents, failed to report an allegation of abuse to the state agency, nurse aid registry, and police, and failed to initiate a fingerprint background check on the alleged perpetrator (E3). R15 was subjected to threatening verbal abuse by E3 (C.N.A./Certified Nurse Aide), which was not reported to the Administrator immediately. E3 was allowed to continue to work and not removed from resident care, which resulted in R15 being subjected to further verbal and physical abuse. This failure has the potential to affect all 52 residents in the facility and resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 10/29/14 at 3:20 p.m., the facility remains out of compliance at a severity level two as the facility continues to in service all staff on the abuse policy, audit employee background checks, and implement interventions to protect the residents in the facility. Findings include: On 10-28-14 at 2:30 p.m., E4 (Certified Nursing Assistant/CNA) stated, "On 10-7-14 at around 5-5:30 p.m., (E3/CNA) and myself entered (R15's) room. (E3) yelled at (R15), 'You nasty mother f*****r, get your hands out of your pants.' I then left (R15's) room and went and told the Director of Nursing (E2) what (E3) had yelled at (R15). (E2) did not remove (E3) from contact with (R15) at that time. (E3) was still in the room with (R15) when I went and told the Director of Nursing. I then went, got wash clothes, and returned to (R15's) room to help (E3) change, dress, and get (R15) up. (E3) grabbed (R15's) leg forcefully, to put the pants on. (E3) then grabbed (R15's) remote to the bed, and hit (R15) in the stomach a couple times, and hit (R15) on the knuckles a few times. (E3) then called (R15) a mother f****r and told me, 'Do not the let the residents walk all over you. You have to show them some discipline.' I then left the room and told the nurse (E8)." On 10-28-14 at 2:40 p.m., E8 (Registered Nurse) stated, "On 10-7-14 at around 5:00 p.m., (E4) told me that (E3) called (R15) a mother f****r, pulled on (R15's) leg, and hit (R15) on the knuckles and the abdomen with the remote. I did not call the Administrator. I told (E21/Registered Nurse) of the incident, during report, and (E21) called the Administrator. Around the end of September, 2014, (E3) would go on rounds with the other CNA's (Certified Nursing Assistants) and would say, "These mother f*****s (the residents) will pee themselves just to do it. (E3) would say it loud enough for residents to hear. I did not report this to the Administrator. " On 10-28-14 at 3:30 p.m., E2 (Director of Nursing) stated, "On 10-7-14, (E4) came in and reported to me that (E3) was cussing at (R15). I told (E3) to report it to the Administrator. I did not go to (R15's room) with (E4)." On 10-28-14 at 4:00 p.m., E1 (Administrator) stated, "No allegations had been reported to me earlier about (E3) calling resident's names, so those allegations were not investigated or reported to the state agency. (E3) should have been removed from the facility on the first instance of calling (R15) a mother f****r, and prior to hitting (R15) on 10-7-14. " On 10-28-14 at 12:55 p.m., E1 stated, "When employees are hired a finger print back ground check is to be done if the employee has not had one." On 10-28-14 at 1:20 p.m., E1 stated, "(E3's) employee file does not contain a finger print background check. (E3) was hired prior to me working here, so I am guessing it was not done. I checked (E3's) registry now, and it does not show that a finger print check has been done." On 10-29-14 at 1:05 p.m., E1 stated, "I did not report to the nurse aide registry that (E3) was fired for abuse on 10-7-14." On 10-30-14 at 10:00 a.m., E10 (Care Plan Coordinator) stated, "(E3) rotated and worked all resident halls." On 10-30-14 at 1:30 p.m., E1 stated, "I have not notified the police regarding the incident regarding (E3) and (R15)." On 10-30-14 at 10:00 a.m., E10 (Care Plan Coordinator) stated, "(E3) rotated and worked all resident halls." On 10-28-14 at 1:00 p.m., E3's personnel file did not include a finger print check. On 10-29-14, abuse allegations were reviewed from 8-1-14 to 10-19-14, and did not contain an investigation regarding the verbal abuse allegations E8 had stated E3 had made against the residents. The CMS Centers for Medicare and Medicaid Services Resident Census and Conditions Report, dated 10/27/14 signed by E10 (Assistant Director of Nursing), documents that 52 residents reside in the facility. B. Based on observation, interview, and record review the facility failed to investigate allegations of sexual abuse, notify the Administrator of potential sexual abuse, and to protect the residents after the allegations were reported for two of eleven residents (R19, R22) reviewed for abuse in the sample of thirteen. This has the potential to affect all fifty-two residents in the facility. These failures resulted in an immediate Jeopardy. While the Immediate Jeopardy was removed on 10/29/14 at 3:20 p.m., the facility remains out of compliance at a severity level two as the facility continues to in service all staff on the abuse policy, audit employee background checks, and implement interventions to protect the residents in the facility. Findings include: 1. R10's Physician order [REDACTED]. R10's MDS (Minimum Data Set) dated 10-13-14 documents that R10 is cognitively intake and has a BIMS Score of 12 out of 15, indicating cognitive ability. On 10-27-14 at 2:54 p.m., E12 CNA (Certified Nursing Assistant) stated, around a couple weeks ago (R19) reported to me that (R10) has tried to feel (R19's) breast....(R19) is alert and oriented.... I don't know if I reported it to anyone.....I assumed staff was aware." On 10-27-14 at 3:35 p.m., R19 stated "(R10) came in my bathroom and asked me if I wanted to have some fun in the shower room on C Hall......the next day in the C Hall bathroom (R10) lifted up my shirt and went (whew)....I told him to get out you scuzz ball....I told the staff and the staff member (unknown) said "Oh he does that"......no I don't like it, he touched my privates.....this happened about ...two or three weeks ago....I am afraid he will do it again." R19's room is located diagonal from R10's room on the same hall. R19's MDS (Minimum Data Set) dated 6-9-14 documents that R19 is cognitively intact and has a Brief Interview Mental Status (BIMS) of 14 out of 15. On 10-27-14 at 2:42 p.m. E7 CNA stated, "(R10) was found with (R22) trying to undo (R22's) pants...R10 was found doing this in (R22's) room." On 10-29-14 at 9:48 a.m. E21 CNA stated, "I was told in morning report that (R10) tried to unfasten (R22's) belt and tried to get under (R22's) pants....this happened just the other day." On 10-29-14 at 11:38 a.m. E20 (CNA/Certified Nursing Assistant) stated, "I caught (R10) touching (R22's) breast in the dining room.....I reported it to the Nurse last week or so,.....I can't remember which Nurse it was....this happened a few days ago." R22's Physician order [REDACTED]. R22's MDS dated [DATE] documents long term/short term memory problems, cognitive ability as "severely impaired" and totally dependent with Activities of Daily Living. According to R22's Activities of Daily Living Care Plan, R22 requires two person cradle lift for transfers and is not a candidate for Restorative Programming. R22 can not move herself. R10's Behavior Care Plan dated 7-16-14, documents (R10) has inappropriate sexual behaviors. According to the care plan R10 was on fifteen minute checks, however E10 CPC (Care Plan Coordinator) stated on 10-28-14 at 10:23 a.m., "(R10) has been on five minute checks for at least all of October." On 10-27-14 at 3:09 p.m. E1 (Administrator) stated, "If incidents happen they are to be reported to me....I should have been informed of (R19's) and (R22's) incidents....we are trying to find placement for (R10) because (R10) may need a locked unit." On 10-29-14 at 11:50 a.m., E1 (Administrator) stated, "no reports of (R10) touching (R22)....I have reports of (R10) going towards (R22's) room, but not touching (R22)....if (R10) has touched any residents it should have been reported to me so I can investigate....I did not know about (R10) and (R19) until E12 reported it during the interview with Public Health." E1 verified on 10-29-14 at 12:27 p.m. that (E1) found out about the alleged sexual abuse between (R10) and (R19) on 10-27-14 at 2:54 p.m...... and did not do any interventions to keep the residents safe until 10-28-14 at 5:50 p.m. when (R10) was sent out of the building for a psych evaluation." On 10/29/14 at 12:45 p.m., an Immediate Jeopardy was identified to have begun on 10/7/14. E1 (Administrator) was notified of the Immediate Jeopardy on 10/29/14 at 12:45 p.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. Every employee, before starting their next shift was in-serviced on the Abuse policy by E1, E2 (Director of Nursing, and E23 (Assistant Director of Nursing) on 10/29/14. This included a test that was required before starting their next shift on 10/29/14. All employees would remain suspended until completion and proof of 100 percent knowledge regarding the facilities abuse policy. The in-service and test would include the seven types of abuse, the proper step by step actions needed upon suspicion of abuse including protecting the resident, and the steps to abuse prevention. 2. All employee background checks were audited by E1 and E24 (Business Office Manager) on 10/29/14 to ensure that the correct background checks were completed. Upon audit if an employee was found to not have the correct background check that employee would not be allowed to return to work until it had been done. 3. E3 (Certified Nursing Assistant) who was involved in the abuse allegation was suspended upon report of the incident and terminated upon completion of the investigation by E1 on 10/14/14. 4. R10 and all residents involved in alleged abuse cases will immediately have an intervention put in place to protect the residents in the facility. This was done on 10/29/14 by the Quality Assurance team.

Facility noncompliance resulted in two deficient practices. A. Based on interview and record review the facility failed to follow their Abuse policy by failing to report an allegation of abuse immediately to the Administrator, failing to remove the alleged perpetrator from direct contact with residents, failing to report an allegation of abuse to the state agency, nurse aid registry, and police, and failing to initiate a fingerprint background check on the alleged perpetrator (E3). R15 was subjected to threatening verbal abuse by E3 (C.N.A./Certified Nurse Aide), which was not reported to the Administrator immediately. E3 was allowed to continue to work and not removed from resident care, which resulted in R15 being subjected to further verbal and physical abuse. This failure has the potential to affect all 52 residents in the facility and resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 10/29/14 at 3:20 p.m., the facility remains out of compliance at a severity level two as the facility continues to in service all staff on the abuse policy, audit employee background checks, and implement interventions to protect the residents in the facility. Findings include: 1. The Abuse Prevention Program policy dated 11-11-2011, documents: Employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect, and abuse of residents to a supervisor and the administrator. Upon learning of the report, the administrator or designee shall initiate an investigation. Employees of this facility who have been accused of neglect or abuse will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator. Employees accused of abuse shall not complete their shift as a direct care provider to the residents. The facility must ensure that all alleged violation involving neglect, abuse, or suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with stated law. A report must be sent to IDPH (Illinois Department of Public Health) no later than 24 hours after forming the suspicion of abuse. It there is "any reasonable suspicion of a crime," defined by local law, the administrator shall immediately notify local law enforcement as soon as possible, but no later than 24 hours, when physical abuse involving physical injury is inflicted on a resident by a staff member or visitor. The facility is required to request a fingerprint based criminal history records check for all non licensed employees. On 10-28-14 at 2:30 p.m., E4 (Certified Nursing Assistant/CNA) verified on 10-7-14 at around 5-5:30 p.m., E3 (Alleged Perpetrator/CNA) verbally abused R15. E4 left E3 in R15's room, and reported the abuse to E2 (Director of Nursing), who did not remove E3 from R15's room. E4 verified E4 re-entered R15's room where E3 was still present, and E3 continued to verbally and physically abuse R15. E4 verified E4 did not report the abuse to the administrator (E1), but had told E8 (Registered Nurse). On 10-28-14 at 2:40 p.m., E8 (Registered Nurse) verified E4 reported E3's verbal and physical abuse towards R15. E8 verified E8 did not call the Administrator or remove E3 from resident cares, but did report the abuse to E21 (Registered Nurse). E8 verified also, around the end of September, 2014, E3 would go on rounds with the other CNA's (Certified Nursing Assistants) and verbally curse the residents, in the hallway, loud enough for residents to hear. E8 verified E8 did not report this to the Administrator. On 10-28-14 at 3:50 p.m., E21 (Registered Nurse) verified on 10-7-14 around 6:00 p.m., and right after nurse report, E8 reported to E21 that E3 had verbally and physically abused R15 around that shift. E21 verified, E21 removed E3 from resident cares at that time, and called the administrator. On 10-28-14 at 3:30 p.m., E2 (Director of Nursing) verified E2 did not remove E3 from resident cares after the verbal abuse towards R15 on 10-7-14. On 10-28-14 at 4:00 p.m., E1 (Administrator) verified no allegations had been reported to E1 earlier about E3 calling resident's names, so those allegations were not investigated or reported to the state agency. E1 verified E3 should have been removed from the facility on the first instance of verbal abuse towards R15 on 10-7-14. On 10-28-14 at 12:55 p.m., E1 stated, "When employees are hired a finger print back ground check is to be done if the employee has not had one." On 10-28-14 at 1:20 p.m., E1 stated, "(E3's) employee file does not contain a finger print background check. (E3) was hired prior to me working here, so I am guessing it was not done. I checked (E3's) registry now, and it does not show that a finger print check has been done." On 10-29-14 at 1:05 p.m., E1 stated, "I did not report to the nurse aide registry that (E3) was fired for abuse on 10-7-14." On 10-30-14 at 10:00 a.m., E10 (Care Plan Coordinator) stated, "(E3) rotated and worked all resident halls." On 10-30-14 at 1:30 p.m., E1 stated, "I have not notified the police regarding the incident regarding (E3) and (R15)." On 10-30-14 at 10:00 a.m., E10 (Care Plan Coordinator) stated, "(E3) rotated and worked all resident halls." On 10-28-14 at 1:00 p.m., E3's personnel file was reviewed and did not include a finger print check. E3's Hire Form documents E3 was hired on 2-7-14. On 10-29-14, abuse allegations were reviewed from 8-1-14 to 10-19-14, and did not contain an investigation regarding the verbal abuse allegations E8 had stated E3 had made against the residents. The CMS Centers for Medicare and Medicaid Services Resident Census and Conditions Report, dated 10/27/14 signed by E10 (Assistant Director of Nursing), documents that 52 residents reside in the facility. B. Based on observation, interview, and record review the facility failed to follow the Abuse Prevention Program Policy by notifying the Administrator of alleged sexual abuse and to protect the residents after reports of alleged sexual abuse for two of eleven residents (R19, R22) in a sample of thirteen. This had the potential to affect all fifty-two residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 10/29/14 at 3:20 p.m., the facility remains out of compliance at a severity level two as the facility continues to in service all staff on the abuse policy, audit employee background checks, and implement interventions to protect the residents in the facility. Findings include: 1. The facility Abuse Prevention Program Policy dated 11-11-11 documents, "This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents,......Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault..... Sexual abuse of a resident by a staff member, another resident, or a visitor;........As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict.......The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with Sate law through established procedures.....Employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator.......Residents who allegedly mistreat or abuse another resident or misappropriation of resident property will be removed from contact with that resident during the course of investigation." On 10-27-14 at 2:54 p.m. E12 (CNA/Certified Nursing Assistant) stated, "(R19) reported to me that (R10) pulled (R19's) gown up and tried to feel (R19's) breast...this happened a few weeks ago...I assumed staff was aware." E1 (Administrator) was present during the interview. On 10-27-14 at 3:30 p.m. R19 stated, (R10) came in my bathroom and asked me if I wanted to have some fun. R19 also said the next day (R10) came into the shower room and lifted up my gown and said "whew", (R10) touched my privates and I am afraid (R10) will do it again. R19 stated, "This happened around two or three weeks ago....I told staff (unknown) and the staff member said "Oh (R10) does that." On 10-29-14 at 11:38 a.m. E20/CNA stated that (E20) caught (R10) touching (R22's) breast in the dining room a few days ago last week. E20 stated "I reported it to the Nurse (unknown)." On 10-29-14 at 11:50 a.m. E1/Administrator stated, "I did not know about the alleged sexual abuse involving (R19) until the interview with E12/CNA and Public Health....I had no reports of (R10) touching (R22)....I have had reports of (R10) going towards (R22's) room but not touching (R22)." E1 also stated, "If (R10) has touched any residents it should have been reported to me so I can investigate." On 10-29-14 at 12:27 p.m. E1/Administrator stated, "We called the doctor to get a psych evaluation....It takes some time for the doctor to come in and see him." R10's Nurse's Note dated 10-28-14 documents that at 5:50 p.m. R10 was sent out of the facility (29 hours and 20 minutes after reported allegation. R19's room is located diagonal from R10's room on the same hall. On 10/29/14 at 12:45 p.m., an Immediate Jeopardy was identified to have begun on 10/7/14. E1 (Administrator) was notified of the Immediate Jeopardy on 10/29/14 at 12:45 p.m. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. Every employee, before starting their next shift was in-serviced on the Abuse policy by E1, E2 (Director of Nursing, and E23 (Assistant Director of Nursing) on 10/29/14. This included a test that was required before starting their next shift on 10/29/14. All employees would remain suspended until completion and proof of 100 percent knowledge regarding the facilities abuse policy. The in-service and test would include the seven types of abuse, the proper step by step actions needed upon suspicion of abuse including protecting the resident, and the steps to abuse prevention. 2. All employee background checks were audited by E1 and E24 (Business Office Manager) on 10/29/14 to ensure that the correct background checks were completed. Upon audit if an employee was found to not have the correct background check that employee would not be allowed to return to work until it had been done. 3. E3 (Certified Nursing Assistant) who was involved in the abuse allegation was suspended upon report of the incident and terminated upon completion of the investigation by E1 on 10/14/14. 4. R10 and all residents involved in alleged abuse cases will immediately have an intervention put in place to protect the residents in the facility. This was done on 10/29/14 by the Quality Assurance team.