Every finding on record at Elevate Care Windsor Park

Based on interview and record review, the facility failed to follow its policy to affirm the right of one resident (R2) to be free from abuse. On May 28, 2026, R2 was observed with left periorbital ecchymosis and reddish purple discoloration consistent with a 'black eye,' as well as bruising to the right temple extending toward the hairline, all were of unknown origin. R2 was subsequently admitted to the hospital with diagnoses of closed head injury and contusions to multiple sites of the head and neck. A total of four residents were reviewed for abuse or resident injury. Findings include:R2's face sheet and admission record show an initial admission date of 12/7/23 with diagnoses including, but not limited to, unspecified dementia, insomnia, gastroesophageal reflux disease, depression, history of falling, anemia, chronic kidney disease, hypertensive chronic kidney disease, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE] indicates that R2's cognition was severely impaired.R2's care plan dated 10/1/25 shows in part: The resident displays conflictual, difficult behavior as manifested by unprovoked expressions of anger toward staff and peers. These behaviors are related to DX: Dementia, Depression and mood distress.R6's face sheet and admission record show an initial admission date of 3/15/25 with diagnoses including, but not limited to, unspecified asthma, bipolar disorder, hyperlipidemia, chronic obstructive pulmonary disease, insomnia, anemia, essential (primary) hypertension, encounter for palliative care, malignant neoplasm of the colon, depression, Alzheimer's disease, and hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side. The Minimum Data Set (MDS) dated [DATE] indicates that R6's cognition is moderately impaired.R6's Care plan dated 3/23/26 shows in part: R6 presents with potential to display socially inappropriate and maladaptive behavior as manifested by (Confusion, Agitation, Restlessness, Anxiousness, Impulsive and/or Combative behavior. Scratching, Hitting, shouting). Symptoms are related to Dementia. On 7/31/26 at 10:09 a.m., R2 was observed sitting in a wheelchair in the dining room, alert and verbally responsive with confusion. She appeared comfortable and well groomed. R2 was unable to relay what occurred on 5/28/26. No bruising was noted around the eyes. On 7/31/26 at 10:44 a.m., the surveyor spoke with V8 (R2's daughter) via phone. V8 stated she was informed that R2 had bruising on her chin and cheeks/face area. V8 reported the incident occurred during the night shift at approximately 6:30 a.m. near the end of May 2026. She stated the bruising around R2's eyes, described as 'black eyes,' made it appear as though R2 had been punched. V8 stated R2 was transferred to the hospital and remained admitted for approximately four to five days. She stated R2 is confused due to her Dementia. On 7/31/26 at 11:32 am, R6 was observed sitting on the side of the bed, alert and verbally responsive. R6 was able to identify herself and stated that she has been living in the facility for more than a year and is aware that she resides in a nursing home. R6 stated that she punched R2 in the face because R2 was fighting with her and being mean to her. R6 reported that the incident occurred at nighttime and that no one witnessed the altercation between R2 and herself. She stated that she punched R2 and that R2 punched her back. R6 reported that R2 had a black eye because she punched R2 hard. She stated that R2 fell to the floor, face down, and that she helped R2 get up. R6 reiterated that she punched R2 in the face and stated that R2 punched her back, but she was not hurt. On 7/31/26 at 12:03 p.m., V12 (Licensed Practical Nurse/LPN) stated she has been working in the facility for about a year and regularly works with R2 and R6. She stated R6 is ambulatory and can be aggressive toward residents and staff at times. V12 stated R2 is alert with confusion and may resist care or become combative with staff. She identified physical contact or punching as physical abuse, and stated bruising of unknown origin is an abuse concern requiring investigation. V12 reported hearing that R2 woke up with two black eyes and stated she did not know the cause. She stated that when R2 returned from the hospital, the bruising was beginning to fade.On 7/31/26 at 12:21 p.m., V16 (Certified Nursing Assistant/CNA) stated she has been working in the facility for about 12 years and regularly works with R2 and R6. V16 stated R6 has a history of physical aggression toward staff and residents, including attacking a staff member. She stated R2 can be combative or aggressive with staff and residents and resistive to care. V16 stated physical contact or punching is physical abuse, and bruising of unknown origin should be reported immediately to the Administrator. She stated she observed fading bruising on R2's eye when R2 returned from the hospital.On 7/31/26 at 12:26 p.m., the surveyor requested V16 to accompany and witness the interview with R6. The surveyor observed R6 recognizing V16 and becoming more verbal. R6 stated that a couple of months ago, during the night, R2 was going through her belongings and fighting with her. R6 stated she punched R2 in the face, causing her to fall face down on the floor. She reported no staff witnessed the incident and that she helped R2 get up. R6 stated R2 punched her back but she was not hurt.The facility's final report dated 6/4/26 submitted to the state agency states: The CNA reported that during rounding, she observed R6 (R2's roommate) lying in the bed next to R2. Both R2 and R6 have a history of aggression when confused/agitated. R6 has a history of wandering into peers' beds when confused. Based on a complete and thorough investigation, it is likely that when R6 entered R2's bed, they made physical contact. R2 was relocated to another room.On 7/31/26 at 12:46 p.m., V1 (Administrator) stated the facility's policy and goal is to ensure all residents are free from abuse. He identified examples of physical abuse including punching, hitting, and physical contact. V1 stated that when physical contact occurs between residents, relocation to another room is required. He stated bruises of unknown origin must be thoroughly investigated to rule out abuse.On 7/31/26 at 1:33 p.m., V2 (Director of Nursing/DON) stated that staff notified her on the morning of 5/28/26 of bruising on R2's face. She observed a bruise on R2's eye area. During the investigation, staff reported no bruising earlier, no falls, and no witnessed altercation or physical contact. V2 stated bruising was noted when R2 was assisted up in the morning. V2 stated both R2 and R6 were interviewed but were unable to provide details due to impaired cognition. V2 stated she completed the final report submitted on 6/4/26. She stated that during the interview, staff reported that during rounding, R6 was found lying next to R2 in bed, and an assumption was made that physical contact may have occurred, leading to the conclusion documented in the final report. V2 stated black eyes had been noted on R2, and the origin of the bruising was unknown. She reported the bruise could have resulted from a fall or trauma but remained undetermined. V2 stated R2 has a history of entering other beds and going through roommates' clothing, and R6 has a history of aggressive behavior. She stated both residents were separated. V2 stated physical contact is abuse, and bruising of unknown origin is considered a type of abuse.On 8/4/26 at 12:06 p.m., R6 was observed resting in bed, alert and verbally responsive. R6 again stated she punched R2 in the face, R2 punched her back, R2 fell to the floor, and she assisted R2 to get up. She stated that she punched R2 because R2 was going through her clothes, was mean to her, and pushed her. She stated no staff witnessed the incident.On 8/4/26 at 12:53 p.m., V15 (LPN) reported observing bruising on R2's eyes, describing red marks or bruising under one eye and bruising under the eyebrow on the opposite side. She stated that R2 told her she did not know what had happened. V15 stated that R2 can be physically and verbally aggressive and combative with staff during care. V15 stated that R6 is alert with intermittent episodes of confusion and has had instances of pulling her own hair. She reported that R6 is ambulatory with guard assistance and may become aggressive toward other residents and staff if she does not get her way.On 8/5/26 at 10:40 a.m., V29 (Nurse Practitioner/NP) stated she was in the building on 5/28/26 and was notified by nursing staff. She observed discoloration to R2's left eye and bruising on the right temple. She stated R2, due to dementia, could not explain what happened. V29 notified the Administrator and ordered transfer to the hospital for further evaluation. She stated no falls were reported and the cause of the bruising was unknown, with potential for trauma or abuse given the injury of unknown origin.On 8/6/26 at 9:19 a.m., V17 (LPN) stated he has worked with R2 and R6. He reported R2's behaviors include resisting care and verbal aggression, and that R6 has a history of verbal and physical aggression. V17 stated that on 5/28/26, he observed bruising to R2's left eye when she got up in the morning. R2 replied, I don't know' when asked what happened. V17 stated he did not know the origin of the bruising.On 8/6/26 at 11:19 a.m., V2 (DON) reiterated she served as the abuse designee when the Administrator was unavailable and completed the final report submitted on 6/4/26. She stated the bruise was considered an injury of unknown origin and it is a type of abuse. She stated R2 has a history of aggression and that she explored every possible cause but could not determine the source. She reported no fall incident and confirmed R2 was not on blood thinners. She stated hitting, punching, or physical contact could potentially cause bruising.V29's (NP) notes dated 5/28/2026 shows in part: R2 was noted to have reddish-purple bruising around the left eye consistent with a periorbital ecchymosis. Additional bruising is present over the right temple extending toward the hairline and over the dorsal surface of the right hand near the thumb and index finger. The mechanism of injury is unknown. Skin: Ecchymosis noted to right hand dorsal surface near digits 1 and 2; skin intact without laceration or active bleeding. Left periorbital ecchymosis, reddish-purple discoloration consistent with black eye; bruising noted to right temple extending toward hairline. R2 has advanced dementia with unexplained multifocal ecchymosis including periorbital involvement, concerning for possible traumatic injury with unclear mechanism and inability to obtain reliable history. CONTUSION OF LEFT PERIORBITAL REGION. Unilateral periorbital ecchymosis raises concern for blunt facial trauma; given unclear history and cognitive impairment. Transferred to ED (Emergency Department) for urgent imaging and further evaluation. MULTIPLE CONTUSIONS - Bruising to right temple and right hand suggests multi-site trauma; differential includes unwitnessed fall versus other trauma.R2's Nurses notes dated 5/28/2026 show in part: R2 was noted skin discoloration to left eye region. R2 was transported to the hospital.R2's Nurses Notes dated 5/2926 show in part: R2 being admitted to the hospital for a closed head injury and contusion.R2's hospital records dated 5/28/26 shows in part: R2 has visual ecchymosis to the forehead and lateral temple lesion without lacerations. Contusion of multiple sites, closed head injury.Facility's abuse prevention and reporting policy dated 10/24/22 shows in part: This facility affirms the right of our residents to be free from abuse. Injuries of Unknown Source: For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury(e.g., the injury is located in an area not generally vulnerable to trauma) or the number ofinjuries observed at one particular point in time or the incidence of injuries over time. Residents' rights for people in long term care facilities dated 11/18 show in part: rights for safety. Must not be abused.

Based on observation, interview, and record review, the facility failed to maintain building temperatures within the regulated range to provide a homelike environment for residents and failed to obtain building humidity levels to accurately assess building temperatures. This failure affected all 198 residents residing in the facility.Findings include:On 6/30/26 at 10:54 AM, recorded facility temperatures with V4 (Maintenance Director). V4 stated, I have been assisting in this facility while their maintenance person was on leave. The temperature range should be between 75 - 81 degrees Fahrenheit. Approximately three weeks ago, the chiller that cools the building and provides air conditioning for the resident rooms and hallways, went down/malfunctioned and was repaired the same day. There are multiple air conditioning units for the facility. The HVAC (Heating, Ventilation, Air Conditioning) company came out the same day it malfunctioned and fixed it the same day. The portable air conditioning units, approximately 12 of them, were provided by an outside vendor. We are keeping them on for precaution. The HVAC company is back to install a temporary chiller and working on the ducts for air flow to the rooms. The chiller continues to malfunction, and we must reset it. After resetting it, it works for a period of time then needs to be reset again. It's monitored hourly by maintenance. It shows an alert when there is an issue with it.First floor temperatures (in degrees Fahrenheit) on 6/30/2026:Wing 1 hallway, 82.7,126 - 83.6, 83.1 fan, portable air conditioning unit133 - 87, 81.5 ventWing 2 hallway 2, 79.3, portable air conditioning unit117 - 81.8, 75.3 vent112 - 80.9, 78.8 vent113 - 81.5, 79.8 ventWing 3 hallway 78.2110 - 77.5 room and ventSpa/shower 78.6107 - 80.6, 77.7 vent104 - 80.4, 78.6 ventWing 4 hallway 81.5137 - 81.1, 79.5 vent104 - 81.1, 79.7 vent, dining room [ROOM NUMBER].8, 83.1, fanSecond floor temperatures (in degrees Fahrenheit) on 6/30/2026:Wing 1 hallway 83.4 fan, portable air conditioning unitDining room [ROOM NUMBER].0, 80 vent, fanSpa/shower 81.3233 - 82.2, 77 vent226 - 83.1, 80.9 vent221 - 84.7, 75 ventWing 2 hallway 81.5, portable air conditioning unit219 - 83.6, 78.6 vent, 81.6 room air/heat unit212 - 82.7, 78.6 vent, 72.5 room air/heat unit217 - 84.2Wing 3 hallway 77211 - 82, 79.5 vent204 - 84.0, 78.8 vent240 - 84.2, 78.6 ventWing 4 hallway238 - 86.7, 78.4 vent236 - 79.3, 78 vent234 - 82.9, 80.4 ventFloor three (in degrees Fahrenheit) on 6/30/2026:Wing 1 hallway 83.6, 85.4, portable air conditioning unitDining room [ROOM NUMBER].7, 78 vent, fanSpa/shower 82.0, 79.1 vent320 - 82.4, 78 vent327 - 82.9, 81.1Wing 2 hallway 81.3, portable air conditioning unit312 - 83.8, 77.7 vent312 - 82.4, 78.8Wing 3 hallway 77.3 portable air conditioning unit311 - 78.2, 77.1 ventSpa/shower 78.2, 77.5 vent341 - 78.9, 77.3 ventWing 4 hallway 81.6 portable air conditioning unit338 - 83.1, 90.6 vent334 - 79.3, 77.7 vent, 73.5 room air/heat unitOn 6/30/26 at 12:42 PM, V6 (Licensed Practical Nurse/LPN) stated, Saturday it was comfortable. It's a little warmer today. No residents are complaining. We are pushing fluids and taking vitals. There are no residents showing signs of complications related to heat. There have been no residents sent out related to heat. On 6/30/26 at 12:53 PM, V7 (LPN) stated, I worked yesterday and today. It was hot yesterday. It is better today. I was on the second floor yesterday. No residents on the second floor complained to me about it being too hot. No residents were sent out to the hospital due to the temperature/heat. I made sure they stayed hydrated and were provided with ice water. We passed out popsicles. Fans and portable air conditioners on each corner of the floor were provided. Maintenance was checking temperatures and said they were working on the issue yesterday. I observed the HVAC person in the building today.On 6/30/26 at 1:02 PM, R7 stated, I'm not hot. My room is not hot. It was hot yesterday. They gave me a fan, ice water, and popsicles yesterday. I did not get sick. It feels better today.On 6/30/26 at 1:05 PM, R8 stated, the temperature is okay and it is okay in my room. It was a little hot yesterday. I did not get sick because it was hot. It feels better today than yesterday.On 6/30/26 at 1:26 PM, V9 (Activities) stated, the temperature is not consistent. Sometimes it's hot, sometimes it's okay. Yesterday was hot. Last week it was warm but not hot. Today it's hot for me. The dining room/common area is hot. We kept pushing water and popsicles yesterday. We are pushing the water today.On 6/30/26 at 1:34 PM, R9 stated, the temperature is good.On 6/30/26 at 1:36 PM, R10 stated, it's been comfortable. It's not hot.On 6/30/26 at 1:53 PM, V10 (Certified Nursing Assistant/CNA) stated, it's been warm for a few weeks. I worked Saturday and Sunday. Staff worked short staffed, and it was hot. I have not observed residents go out or sick from the heat. We are keeping the residents hydrated.On 6/30/26 at 2:45 PM, V11 (Maintenance Supervisor) and V12 (HVAC, Heating, Ventilation, Air Conditioning Technician for private company) stated, the air conditioning chiller is partially, 60%, operational. Several aluminum coils are leaking freon. The leak is not repairable. We have a temporary chiller coming to the facility. It is being delivered today. The facility has chosen to replace the chiller unit and coils rather than replace only the coils and other components. It is more beneficial to replace the system. The facility has started to get bids to replace the unit. The temporary chiller will be in place through summer, until no longer needed, until heat is needed. We run hoses from the chiller unit outside into the building and connect to the exiting piping. We will install the temporary unit through the night. It should be running by the morning shift. I have been maintaining the old/current unit on the roof until the temporary is installed and running. There are four other HVAC techs prepping for the temporary unit already. I've been here since 7:00 AM. My boss was here overnight. It went down Thursday. My company has been here daily since then and we have been monitoring. The chiller keeps failing. We have to reset it and then the temperature has to get back to normal.On 6/30/26 at 3:14 PM, V1 (Administrator) stated, I have been Administrator here for four weeks. The air conditioning system/chiller is old and slated to be replaced. Corporate has agreed to purchase a new chiller. It takes 90 days to build a chiller. In the meantime, we are waiting for a rental, temporary chiller. It is supposed to be here this afternoon. Last update is it is on the way. There have been repairs on the current chiller for a couple weeks. It is still running but it's old and not efficient. Yesterday morning the chiller turned itself off. Maintenance got it back on. It was working. HVAC came out and made a repair so it would not shut off again. It ran the rest of the day. Monday night I got a call that it turned back off. Maintenance was here all night; HVAC came in at 4:00 AM and it is running again. We are making sure water is passed to the residents. We are passing popsicles to the residents. We have not had to send any residents out to the hospital for emergency.On 7/1/26, observed air conditioning units on each floor and multiple ice water dispensers.On 7/1/26 at 11:15 AM, R1 stated, It's warm. I feel okay and I am given water.On 7/1/26 at 11:32 AM, V13 (R12's family member) stated, they visit often. The temperature was okay on Monday. R12 nor other residents were showing signs of distress. R12 ate well.On 7/1/26 at 11:41 AM, observed R13 chewing on ice. R13 stated, the temperature feels good and they're okay.On 7/1/26 at 12:14 PM, V15 (Hospice Aide with an outside company) stated, their resident is showing no adverse signs due to heat.On 7/1/26 at 12:25 PM, V6 (LPN) stated, there have been no residents sent out to the hospital related to heat. No residents are complaining about the heat. We are taking vitals and pushing fluids. The 3rd floor is behavioral health and dementia. On 7/1/26 at 12:43 PM, R17 stated, I feel fine.On 7/1/26 at 12:45 PM, R18 stated, I feel good even though it's warm.On 7/2/26 at 9:10 AM, V12 (HVAC Technician) stated, the building lost power. There is no power to anything including the chiller. There is a generator/power supply coming. That will give power to everything, 460 volts including the chiller. The estimated time of arrival for the generator/power supply is 11:00 AM.On 7/2/26 at 9:13 AM, V18 (Regional Director of Operations) stated, at approximately 6:00 AM, we lost power. The maintenance director figured out it was a power issue and texted me at 6:30 AM. The maintenance director contacted the power company to report the power line issue. V17 (Corporate Director of Environmental Services) was contacted. A generator and private electrician are on the way to the facility. The power company reassured me that a crew has been assigned, gave me a ticket number and said the crew should be on sight at 11:00 AM. We have purchased more fluids for staff. We are continuously rounding and encouraging fluid intake for the residents. The corporate nurse practitioner who does IV (intravenous) hydration is aware while we continue to monitor resident vital signs. At this time there are no complaints from residents, and we have not received complaints from family members. We continue to round and are encouraging residents to keep windows closed. We have a preliminary evacuation action plan in place. We have checked bed availability as it relates to care needs. There are no issues with finding enough beds. We have plenty of bed availability in our 13 facilities. If need be, we will coordinate transportation with contracted ambulance services. No residents have been sent out to the hospital due to the temperatures. Nurses have not reported any residents showing signs of heat related effects. Evacuation is still on hold.On 7/2/26 at 9:57 AM, V18 (Regional Director of Operations) stated, the private electrician is in the building. He's working on connecting the generator to the chiller.On 7/2/26 at 9:34 AM, took temperatures with V19 (Maintenance Director). Temperatures are in degrees Fahrenheit.1st floor hallway 85136 - 84.7121 - 89.6206 - 84.3215 - 84.7337 - 85.83rd floor dining room [ROOM NUMBER].5, portable air conditioning unit and fan, popsicles being passed out to residents332 - 88.5 324-86.5316 -84.5309 -82.2On 7/2/26 at 12:05 PM, V18 (Regional Director of Operations) stated, at 6:00 AM the powerline went down. The power company is not on site. We have made repeated calls to the power company. The private electrician is on site. We have not initiated the emergency plan. We have ice, fluid with electrolytes, and are still encouraging fluid intake.On 7/2/26 at 12:10 PM, V20 (Vice President of Operations) stated, calls have been made to ambulance companies to make them aware that we may have a need.On 7/2/26 at 2:10 PM, V20 (Vice President of Operations) and V17 (Corporate Director of Environmental Services) stated, the power is on. We have to fill the pump with water and bleed the air out. The power company and HVAC are still on site. We are not using the generator. We are keeping it on site as precaution. The power line will connect the building to the chiller. The chiller is on a separate power line. On 7/2/26 at 3:24 PM, V21 (Chief Nursing Officer) stated, we are getting a final update from the environmental team in about 30 minutes. We have our emergency evacuation plan. It will be a planned partial relocation. We will utilize our own facilities to relocate. It is temporary. We will ensure everything is up and running prior to evaluating the residents return to the facility. We don't evacuate based on temperature alone. We consider the factors, how quickly the implementation of a fix and the residents' current conditions before evacuation. Our policy and the emergency preparedness plan, because of the increased risk to elderly with evacuations, makes evacuating the last resort. If evacuating, we will start on the third floor and then bring those portable air conditioning units down to the second floor and re-evaluate from there. On 7/2/26 at 4:15 PM, V21 (Chief Nursing Officer) stated, we are initiating our evacuation plan decided at 4:00 PM. CHUG (Collaborative Healthcare Urgency Group) has been notified. Ambulances have been notified and on their way. The Ombudsman was notified.On 7/2/26 at 4:25 PM, V18 (Regional Director of Operations) stated, the chiller is working but we are continuing with the evacuation. The third floor is first then the second and first floors will be reevaluated.On 7/2/26 at 7:30 PM, V21 (Chief Nursing Officer) stated, we started having issues on Tuesday. We started having issues again on Wednesday. The temporary unit blew the power line. We are providing portable air conditioning units and are encouraging hydration. No residents have had a change of condition until today. We kept waiting to evacuate the residents even though we had a meeting yesterday. Evacuation is the very last step due to the elderly population. Our plan now is to finish evacuating floor 3 and bring down the portable air condition units from floor 3 to floors 2 and 1. The original plan was to reevaluate after finishing the evacuation of floor 3. We have an IV hydration team. The third floor is the dementia floor. The residents are being placed in memory care units. If rooms run out at sister facilities, we have made arrangements with sister facilities.On 7/2/26 at 9:24 PM, V21 (Chief Nursing Officer) stated, the mayor's office wants the second floor evacuated.On 7/3/26 at 9:55 AM, V20 (Vice President of Operations) stated, all residents from floors 3 and 2 have been transferred. Residents on floor 1 remain in the facility. I have maintenance from other facilities working on cleaning the in-room air/heat units for better air flow. Although the city's temperatures this morning are still high in the 80-degree range, I do not anticipate and am not planning an evacuation of floor 1 at this time.On 7/3/26 at 12:15 PM, V2 (Director of Nursing) stated, we are evacuating floor 1.On 7/3/26 at 12:20 PM, V20 (Vice President of Operations) stated, the city wants me to evacuate as of 12:05 PM.Temperatures on 7/3/26 at 3:38 PM, in degrees Fahrenheit:114 - 73105 - 81.5136 - 72.6135 - 72.5Hallway - 75123 - 73.9On 7/3/26 at 3:45 PM, in degrees Fahrenheit:237 - 73.2206 - 75.9212 - 76.8Hallway - 77.9222 - 81.8231 - 80.9On 7/3/26 at 3:50 PM, in degrees Fahrenheit:338 - 77.3305 - 70.8312 - 72.6318 - 73.5330 - 73.7Hallway - 78.4321 - 81.8On 7/10/26 at 9:40 AM, V20 (Vice President of Operations), V1 (Administrator), V19 (Maintenance Director) stated, we have been cleared to bring patients back by state surveying agency Life Safety, and by the City of XXXXXX Department of Buildings. I plan to slowly bring residents back. I will bring floor one back on Monday. Tuesday I will bring back half of the second floor. Wednesday I will bring back the other half of the second floor. Thursday I will bring back half of the third floor and Friday I will bring back the other half of the third floor. The building has been deep cleaned. We went through the rooms, and all bed linen has been cleaned/changed. Rooms have been decluttered. We did not trash resident belongings. We wiped down and wiped-out dressers and drawers and closets. Every air conditioning/heat unit in each room has been cleaned, and motors have been replaced where needed. Only two rooms do not have working units. We have ordered the parts and are waiting for parts to arrive. Parts should be here in the next couple of days. We put a rush on them. Medication carts and nursing stations have been cleaned. The whole building has had a deep clean. The chiller is up and running 100%. The power company replaced the transformer with a bigger, more powerful one. The previous one was not powerful enough to handle the chiller. When we originally hooked up the temporary chiller it blew the transformer. The temporary chiller is here for the summer. The new chiller has been ordered. It is being built and it is expected to be here in four months, around November. The bad rooms with holes in the walls are being painted currently. We painted nine rooms. On 7/10/26 at 9:40 AM, V19 (Maintenance Director) stated, I did not have a thermometer to take humidity last week. I purchased one that takes humidity on Saturday. I was only taking temperatures. I am going to start to log temperatures with humidity daily. Prior to this, only temperatures were taken daily.Facility Building Temp Log Windsor Park for 6/29/26 - 7/2/26 indicate multiple building temperatures above the allowed regulated temperature range.Facility Building Temp Log Windsor Park for 6/29/26 - 7/2/26 indicate no building humidity levels were obtained.Facility Code [NAME] - Extreme Weather and Temperatures policy, 6/24/25, documents in part: The facility will follow federal requirement to maintain facility temperatures between 71-81 degrees Fahrenheit. The following measures should be taken during extreme heat and humidity: Monitoring of ambient temperatures and relative humidity in resident areas - refer to section at bottom of this document titled Monitoring of Facility Temperatures During Extreme Hot Weather and/or Cooling Outage. Monitoring of Facility Temperatures During Extreme Hot Weather and/or Cooling Outage: It is recommended that the temperature and relative humidity levels be measured at least every two hours between 8:00 a.m. and 10:00 p.m. in all areas occupied by residents during periods of extreme heat. Temperatures in resident areas should be at 71-81 Fahrenheit and relative humidity at 30-60%. The Heat Index should not exceed 80 degrees Fahrenheit. Note: The heat index, also known as apparent temperature, is determined by combining the actual air temperature and relative humidity to reflect how hot the conditions feel to the human body. It essentially represents the feels like temperature. This is because high humidity reduces the body's ability to cool itself through sweat evaporation, making the air feel hotter than the actual temperature. Facility Extreme Weather policy, no date, documents in part: It is the policy of this facility to protect our residents, staff and others who may be in our facility from harm during emergency events. To accomplish this, we have developed procedures for specific hazards which are built into our operations plan. The priority of this facility is to minimize the stress out residents could experience from extreme temperatures related to weather events. To mitigate this risk, we rigorously maintain our systems of heating, ventilation and air conditioning and generator. The facility follows federal and state guidelines related to maintenance, testing and inspections to ensure all systems are in working order. In the event of a disruption to our generator, heating, ventilation or air conditioning systems during extreme weather event, our facility will implement the following actions for extreme heat: 1. Activate extreme weather policy and procedure. 5. Follow state and federal guidelines to ensure internal temperature is adequate.

Based on observation, interview and record review the facility failed to evaluate its resident population to prioritize its most vulnerable residents prior to a facility emergency. This failure has the potential to affect all 198 residents that reside in the facility.Findings include:On 7/2/26 at 9:33 AM, V2 (Director of Nursing) stated, we are going to send residents to sister facilities. The high acuity/risk residents move first. On 7/2/26 at 12:00 PM, observed clinical team: V2 (Director of Nursing), V25 (Vice President of Clinical Services), V26 (Registered Nurse Consultant), V27 (Regional Respiratory Director) preparing the list of vulnerable residents. V2 stated they are currently identifying vulnerable residents. They are using the CHUG (Collaborative Healthcare Urgency Group) process to determine the vulnerable residents.On 7/2/26 at 3:24 PM, V21 (Chief Nursing Officer) stated, we are getting a final update from the environmental team in about 30 minutes. We have our emergency evacuation plan. It will be a planned partial relocation. We will utilize our own facilities to relocate. It is temporary. We will ensure everything is up and running prior to evaluating the residents return to the facility. We don't evacuate based on temperature alone. We consider the factors, like how quickly the implementation of a fix and the residents' current conditions before evacuation. Our policy and the emergency preparedness plan, and due to the increased risk to elderly with evacuations, makes evacuating the last resort. If evacuating, we will start on the third floor and then bring those portable air conditioning units down to the second floor and re-evaluate from there. On 7/2/26 at 7:30 PM, V21 (Chief Nursing Officer) stated, we started having issues on Tuesday. We started having issues again on Wednesday. The temporary unit blew the power line. We are providing portable air conditioning units and are encouraging hydration. No residents have had a change of condition until today. We kept waiting to evacuate the residents even though we had a meeting yesterday. Evacuation is the very last step due to the elderly population. Our plan now is to finish evacuating floor 3 and bring down the portable air condition units from floor 3 to floors 2 and 1. The original plan was to reevaluate after finishing the evacuation of floor 3. Floor 3 is the dementia floor. The residents are being placed in memory care units.On 7/2/26 at 9:24 PM, V21 (Chief Nursing Officer) stated, the mayor's office wants the second floor evacuated.On 7/9/26 at 3:16 PM, V2 (Director of Nursing) stated, the vulnerable resident list was not prepared prior to evacuation. It would have been beneficial if it were prepared prior to an incident such as this. The list is important in case of emergencies to know which residents to treat or evacuate first. The evacuation was by floor. Floors 3 and 2 were evacuated on Thursday and floor 1 was evacuated on Friday. Residents designated as Level 1 care are high acuity, so we tried to get them out first. We started evacuating on the third floor and then went by level designation. Not all level 1's from all floors were discharged first. It was done that way because the initial directive was to only evacuate the 3rd floor. I did not see a potential risk of not doing all level 1's from all floors for this instance. However, in future out of an extreme measure of caution I would do all level 1 from all floors first. Vulnerable residents should be identified prior to an incident. To my knowledge there was no reason the list was not prepared prior. The vulnerable list is created according to the CHUG (Collaborative Healthcare Urgency Group) outline. I would be concerned first with respiratory issues and cardiac issues as most vulnerable with the heat. All trach patients from all floors were not evacuated first. Trach patients were the first to be evacuated according to floor not according to level designation.According to the facilities list of vulnerable residents, R22 is designated as Level 1 level of care for gastrostomy tube, tracheostomy, and wounds.According to the facilities list of vulnerable residents, R23 is designated as Level 1 level of care for gastrostomy tube, tracheostomy.According to the facilities list of vulnerable residents, R24 is designated as Level 1 level of care for tracheostomy, as needed oxygen.According to a list that writer requested regarding the evacuation dates and times for R22, R23, R24; R22 was evacuated on 7/3/26 at 2:59 PM; R23 was evacuated on 7/3/26 at 2:42 PM, R24 was evacuated on 7/3/26 at 3:59 PM. The first day of evacuations was 7/2/26. R22, R23, R24, all level 1 care residents, were not among the first residents to be evacuated.Facility Extreme Weather policy, no date, documents in part: Identify residents whose fragile condition may require transfer.

Based on interview and record review the facility failed to safely warm up food in the microwave for one resident (R4) out of four residents reviewed for accidents and supervision. This failure resulted in the resident sustaining a second degree burn measuring 15.0 cm (Centimeter) x 17.0 cm x 0.10 cm after hot noodles were spilled in her lap. Findings include: R4 was admitted to the facility with diagnosis not limited to Essential (Primary) Hypertension, Gastro-Esophageal Reflux Disease, Kyphosis, Cerebral Palsy, Burn of Second Degree of Right Thigh. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Progress note dated 04/14/26 2:34 PM document in part: Wound Care Note Text: R4 had a recent report of a new skin condition. There has been an additional report of a change in pain level since the event. Progress note dated 04/14/26 3:06 PM document in part: Wound Care Note Text: Wound care assessed resident post spill with a cup of noodles. R4 states that she was going to eat her lunch with other residents on another floor, and she had a spasm. Upon the spasm she spilled the noodles toward her. A burn was obtained to the Right Upper thigh where bunching of her pants was present. Resident was given pain medication; an ice pack and wound care/first aid was performed. Resident was seen by in-house NP (Nurse Practitioner) and orders obtained. Progress note dated 04/14/26 3:16 PM document in part: Visit Type: NP Initial Eval (evaluation). Evaluated today following a thermal injury sustained when she spilled a bowl of hot noodles onto her lap. She reports pain localized to the right thigh. Wound care evaluated the area; dressing remains intact. Image review and examination are consistent with a superficial burn to the right thigh. Review of Systems: Burn to right thigh Skin: Wound dressing intact. Assessment/Plan: Superficial Thermal Burn - Right Thigh Dressing intact and no signs of infection. (Superficial thermal burn is defined as a first-degree burn- the mildest form of traumatic tissue injury caused by heat. It is strictly confined to the outermost layer of the skin, the epidermis). Progress note dated 04/14/26 3:51 PM document in part: Nurses Notes Text: Resident states she was on the elevator going to the second floor and had an involuntary muscle spasm and her cup of noodles spilled out of her hand and fell onto her lap burning her right thigh. Progress note dated 04/14/26 6:54 PM document in part: Nurses Notes Text: writer called to room by resident's family, family requesting resident be sent to hospital for burn on her leg. Writer contacted MD (medical doctor), MD states send resident to hospital. Progress note dated 04/14/26 7:10 PM document in part: SBAR Summary for Providers Situation: The Change In Condition/s reported on this Evaluation are/were: Skin wound or ulcer - Skin Status Evaluation: Burn. Progress note dated 04/14/26 5:34 PM document in part: Nurses Notes Text: ambulance in facility to transport patient to emergency department per MD orders. Progress note dated 04/15/26 2:01 PM document in part: Nurses Notes Text: Resident returned to facility. Resident c/o (complain of) pain to her right leg. Right thigh burn is wrapped with gauze. Progress note dated 04/15/26 11:02 PM document in part: ER (emergency room) follow-up R4 is seen today for follow-up after ER evaluation last night due to increased right thigh pain related to prior thermal injury from hot noodles. R4 was diagnosed in the ER with a second-degree (partial thickness) burn and a new dressing was applied. Assessment/Plan: Superficial Thermal Burn - Right Thigh. Continue to coordinate with wound care for ongoing assessment. Progress note dated 04/17/26 3:19 PM document in part: Nurses Notes Text: Resident c/o of right leg thigh pain due to recent burn. Gabapentin 100mg administered at 9am. Resident c/o of pain at 12:30pm same site 5/10 pain on number scale. Informed resident she is due for another Gabapentin 100mg, and I can also give 1000mg Tylenol. Resident still c/o pain after a 30-minute f/u (follow-up). Resident stated, the pain did not go away in fact it got worse, and my leg is aching. Wound Assessment Detail Report document in part: Wound: Right thigh front. Assessment date: 04/14/26 01:17 PM. Type Burn. Classification: Thermal Heat. Source: Facility Acquired. Date identified 04/14/26. Clinical stage: Partial Thickness. Tissue Type: Blanchable Erythema -75%, Epithelial - 25%. Exudate: Amount-light. Type-Serosanguineous. Size: 15.0 cm (centimeters) x 17.0 cm x 0.10 cm (L x W x D) length by with by depth. Hospital Record dated 04/15/26 document in part: Chef Complaint/Reason For Consultation: Scald Burn. R4 sustained a 1% TBSA (Total Body Surface Area) burn injury on her right thigh. This injury occurred at a nursing facility from ramen noodles. Patient reports pain and well as numbness/tingling to the area. Notably, the patient expressed concern about going back to her nursing facility as she does not feel she receives adequate care there. Skin: burn along right thigh that appears mixed superficial and deep partial thickness. Wound base appears whitish pink in some areas, with sluggish blanching, ttp (Thrombotic Thrombocytopenic Purpura). Assessment and Plan: admitted to hospital for advanced wound care, pain control, possible operative intervention. History of Present illness: earlier today, patient was at nursing home and asked the nursing home staff to help make hot Ramen soup for her. When she received the noodles, she used power chair to go up in the elevator to a different floor. While in the elevator, she had a muscle spasm and spilled the hot liquid onto her right thigh. Endorses associated pain. Skin: Comments: Partial superficial and thick thickness burn on right thigh and with associated blistering. Wound base exposed, with blanching. On 06/09/26 at 11:32 AM Per telephone interview V6 (R4' Family Member) stated on 04/14/26 R4 was given hot noodles by a staff member. R4 got on the elevator, jerked or had a spasm. V2 (Director of Nursing) was on the elevator. They told R4 that everything was fine, they could take care of it, and they bandaged the leg. I told V18 (Licensed Practical Nurse) that R4 needs to be sent to the hospital. R4 said I had a cup of ramen noodles, and I was going to the second floor to hang out. V8 (Certified Nurse Assistant/CNA) warmed up my noodles and she was not aware I had muscle spasms. On 06/09/26 at 12:46 PM V8 (CNA) stated R4 came up, approached me and asked me to warm up some noodles. The aide put the noodles in the microwave, and I took the noodles to R4's room then placed them on the table on R4's wheelchair. R4 was in her room, in the wheelchair that has a table on top of it. R4 then asked for a fork, I went to get her a fork and when I went back to her room R4 was not in her room. The incident happened in the elevator. I was made aware of the incident later that day when I heard the noodles wasted on R4. I was not aware that R4 had muscle spasms. The burn was on R4's right thigh. On 06/09/26 at 12:37 PM V13 (Registered Nurse) stated I R4 had an incident with a burn on her leg. It was reported to me that R4 had a cup of noodles that spilled onto her leg. V8 (CNA) gave R4 the noodles. R4 provided her own noodles and asked V8 to warm them up for her. R4 was on the elevator going upstairs to see a resident, had a muscle spasm and the noodles spilled on her leg. I was not aware R4 had muscle spasms. When it happened, I did an assessment, followed up with wound care, spoke to the Nurse practitioner and documented. V2 (Director of Nursing) was on the elevator with R4. R4 was not sent out to the hospital that day but eventually yes. On 06/09/26 at 03:32 PM V18 (Licensed Practical Nurse) stated The incident when R4 got burned happened on 7am - 3 pm shift. I work 3 pm - 11 pm and they told me what happened. R4's family member wanted her to go to the hospital. I called V6 (R4's Family Member) and they wanted R4 sent to the hospital. On 06/10/26 at 12:19 PM V32 (Wound Care/Licensed Practical Nurse) stated On 04/14/26 I received a phone call from V2 (Director of Nursing) at approximately 1 pm. I met V2 at the room with R4. R4 spilled the noodles, and I removed her pants. The burn was on R4's right thigh and there was a lot of bunching of the legging type pants, clingy to the skin. It was still warm when I lifted the fabric and pulled it down. I asked what happened and R4 said she spilled a cup of noodles on her. R4 was in a motorized wheelchair with a stationary table tray and knocked the noodles in her lap when she had a spasm. It happened on the elevator and V2 (Director of Nursing) brushed off the noodles. V2 used the towel to remove some of the broth. I used saline and gauze to clean, I measured and put on proper dressing. R4's thigh was blistered with a big blister that ruptured. Initially the large blister was intact, I went to my cart and when I returned the blister had ruptured. I took xeroform, a dry dressing and wrapped it with gauze. I changed R4's pants and she remained in the wheelchair. I conferred with the V38 (Nurse Practitioner), and the wound doctor came in on Friday 04/17/26. Most of the areas that were blistered were very small lines. The Nurse Practitioner said it was ok and R4's pain was not terrible 3/10 rating which was addressed with Tylenol. The burn wound was identified on 04/14/26 that same day. I will have to go get the order and hospital records and I will come back. At 01:00 PM V2 (Director of Nursing) returned to the conference room with the documentation that the surveyor requested from V32 and stated V32 had left the facility. On 06/10/26 at 01:12 PM V38 (Nurse Practitioner) stated I am aware of R4's burn. R4 was in her room and the nurse mentioned she spilled a cup of noodles. R4 was on the elevator when she hit the bump, that is when the noodles wasted. When I saw R4 they had already changed her. I reviewed the image, and I ordered medicine for pain. I would not know how to classify a burn. I did not see the wound because it was covered by the wound care team. The wound care nurse said they could manage R4's burn and I went on what the wound care nurse said. V32 (Wound Nurse/Licensed Practical Nurse) did not report to me that a blister had ruptured. If we are not to do wound management knowing what I know now I would have sent R4 out to the hospital. I don't know what wound care did. My specialty is not burns or wounds. On 06/10/26 at 03:12 PM V39 (Alternate Physician) stated I was made aware of R4's burn and I saw R4 the next day after R4 was sent to the hospital. Based on the tissue description the nurse gave me, the burn went through more than one layer of skin and a blister formed as well, I would have sent R4 to the hospital. On 06/10/26 at 02:28 PM V2 (Director of Nursing) stated R4's burn happened on 04/14/26. I was getting on the elevator, R4 came out of her room with another resident. R4 and another resident entered the elevator. R4 had a game system and noodles on the wheelchair tray table, moved the game and she yelled. I had turned to put in the elevator code. The noodles on table spilled in R4's lap. We got off the elevator on the second floor, I asked the nurses to get towels and wiped R4 off. We got back on the elevator, went to the first floor and V32 (Wound Nurse/Licensed Practical Nurse) was outside the elevator. V32 took R4 to her room, got her undress and assessed the wound. I did not go into the room with them. I went to look for a [NAME] about what I need to do. I did not see R4's thigh until the next day. V32 did tell me R4 had a blister and a little area that had a skin tear. The template has to notify the doctor, wound care nurse, wound assessment notes and route cause analysis. I am assuming after V32 spoke to the doctor if they did not give an order, that is why R4 was not sent out to the hospital. I would have sent R4 out to the hospital based on the picture and measurements. That is something that would be reported to the state. I knew the day that I brought it to V25 (Former Administrator) and the consultant's attention, but the directive was to hold off on reporting the incident. It was reported 04/21/26. Surveyor asked V2 should the incident have been reported on 04/14/26 when the incident happened. V2 responded, Absolutely. R4 was sent to the hospital on [DATE] after sustaining a second degree burn to the right thigh after the family requested R4 be sent out. Burn Injury Checklist Evaluation: Burn Injury Investigation Checklist: undated, Date found and reported? Wound MD (Medical Doctor) notified, based on RCA (Root Cause Analysis) were appropriate interventions in place for prevention? Once you have completed the event's checklist and assessment, use the QAPI (Quality Assurance and Performance Improvement) Plan/Action plan to help address identified opportunities. Policy: Titled Wound Management dated 03/02/24 document in part: The facility will treat wounds according to physician's orders and current standards of clinical practice. IV. Optimizing Medical Conditions and General Systemic Function B. Medical conditions will be assessed and addressed to improve the resident's risk and/or ability to heal. Titled Etiology of the Wound dated 03/02/24 document in part: The facility will provide an aggressive skin care program following current standards of clinical practice. Management will be based upon the etiology of the wound. VI. Other wounds such as those caused by trauma or incontinence are managed using appropriate clinical practice guidelines and current standards of clinical practice.

Based on observation, interview, and record review the facility failed to maintain a safe, functional, sanitary, comfortable environment. The facility failed to maintain and repair water leaks in the kitchen timely. The facility also failed to maintain an adequate supply of dining ware resulted in residents being served meals using disposable Styrofoam items. These deficient practices have the potential to affect all 189 residents receiving food prepared in the facility's kitchen. Findings Include:1.) On 6/9/26 at 9:50AM, V7 (Dietary Manager) and surveyor toured the kitchen. Observed an active ceiling leak over the handwashing sink. There were no mold or discolored areas observed in the kitchen. Observed discolored area on the ceiling tile in the dishwashing area in the kitchen. On 6/9/10 at 9:58AM, V7 (Dietary Manager) stated, The discolored ceiling tile in the dishwashing area was from a leak over a month ago. The first-floor shower room was leaking down. The former administrator, housekeeping director and maintenance staff were made aware. The leak was leaking for about two weeks. The leak was repaired about two weeks ago. The ceiling leak over the handwashing sink started yesterday [6/8/26]. I made the administrator, director of nursing and maintenance aware yesterday. On 6/9/26 at 10:12AM, V10 (Dietary Aide) stated, There was a water ceiling leak in the dishwashing area a few weeks ago. The leak was recently fixed. The ceiling started leaking over the handwashing sink a day or two ago. On 6/9/26 at 10:50AM, V5 (Maintenance Assistant) stated, The maintenance director has been off work now for a month. I do not speak good English. Yes, the kitchen had a leak in May. The leak was fixed about a week ago. It took a while to find out where the leak was coming from. There is a new ceiling leak that should get fixed today. Yes, the ceiling tiles fell down from roof leak in R6's past room. The roof was repaired a couple days after the leak. On 6/10/26 at 2:44PM, V31 (Maintenance Supervisor) stated, There was ceiling leak in the kitchen in the dishwashing area about a month ago. The leak was repaired about two weeks ago. It took some time to figure out where the leak was coming from. At first, we thought the leak was coming from the first-floor shower room drainage, but that was not the source. Eventually a company came out and had to fill in concrete a space between the floors to stop the leak in the kitchen. We have a maintenance log for the nursing floor at the nursing station, but we do not have work orders for the basement, kitchen or laundry. I do not have any work slips regarding the leak in the kitchen. On 6/10/26 at 3:05 PM, V21 (Interim Maintenance Director) stated, I work at another sister facility. The Maintenance Director here is out on medical leave. The other sister facilities all take turns and come here to assist with repairs. I do not know anything about the kitchen leak over by the dish area. Today, I repaired the ceiling leak over the hand washing sink. The leak was from a toilet on the first-floor. The toilet was repaired and leak in kitchen stopped. I think the leak started a few days ago. When I got here today, I was made aware and completed the repair. I did not ask when the leak started. 2.) On 6/9/26 at 9:50AM, V7 (Dietary Manager) and surveyor toured the kitchen. Observed the return dishes from breakfast. There were some hardware plates, bowls, silver ware and Styrofoam plates, bowl and plastic forks, and spoons. On 6/9/10 at 9:58AM, V7 stated, We are short on dishes. I think some of the residents are hoarding the dishes. I made the former administrator aware a couple of months ago of the shortage. I use the hardware then I start using the Styrofoam dish ware. V25 (Former Administrator) ordered some dishes in May and June, but somehow the dishes are still missing and not enough for each meal tray. During meal try line I will think approximately half the residents received their food on the regular dining ware and the other half receive Styrofoam dish ware. Facility census on 6/9/26 was 197 residents. Eight are NPO. Total that eats from kitchen is 189. The dish washing machine is functioning properly. Facility order history:6/4/26: 9-inch plates 24 count per case. Two cases ordered. 9inch three compartment plates 12 count.5/5/26: [NAME] Ceramic ware 9inches 48 counts.3/27/26: 8 1/4 inch rim stoneware plate 36 count. On 6/10/26 at 3:30PM, V25 (Former Administrator) stated, I was told, the kitchen was only missing a few dishes, so I ordered a few dishes. The facility census is typically around 170 to 190. I was not made aware I needed to order more dishes. On 6/10/26 at 3:40 PM V1 (Administrator) stated, I been working here for five days. I was not aware of the shortage of the dining ware, I will order. The only times residents should eat on paper/Styrofoam plates, and bowl is if the dishwasher is down or infection control reasons. While some residents eat on dining plate and other eat on paper/Styrofoam, it's the resident rights to all eat on the hardware dishes. Water leaks in the kitchen should be repaired timely. If not it could potentially cause fall incidents, and cross contamination of food. R1, R2, R3, R6, and R10 all said they would like to eat on dining wear because styrofoam plates and bowls start to melt if you warm up the food in the microwave. Policies in part:Mechanical Ware WashingIf the dish machine is not working properly, may require disposable dishes to be used for the meal until it can be repaired. Kitchen Operation Policies, Sanitation and Food SafetyTo ensure the dietary department is maintained according to state and federal regulations as well as a clean, sanitary, and safe environment. Maintenance Job Description:Be prepared to handle emergencies as they come.Repair facility, resident property. In the event of inability to repair coordinate with outside vendors to make repair.

Based on interview and record review the facility failed to report an incident of a resident burn to the state agency in a timely manner for one (R4) resident that sustained a second degree burn. Findings Include:R4 was admitted to the facility with diagnosis not limited to Essential (Primary) Hypertension, Gastro-Esophageal Reflux Disease, Kyphosis, Cerebral Palsy, Burn of Second Degree of Right Thigh. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Progress note dated 04/14/26 2:34 PM document in part: Wound Care Note Text: R4 had a recent report of a new skin condition. There has been an additional report of a change in pain level since the event. Progress note dated 04/14/26 3:06 PM document in part: Wound Care Note Text: Wound care assessed resident post spill with a cup of noodles. R4 states that she was going to eat her lunch with other residents on another floor, and she had a spasm. Upon the spasm she spilled the noodles toward her. A burn was obtained to the Right Upper thigh where bunching of her pants was present. Resident was given pain medication; an ice pack and wound care/first aid was performed. Resident was seen by in-house NP (Nurse Practitioner) and orders obtained. Progress note dated 04/14/26 3:16 PM document in part: Visit Type: NP Initial Eval (evaluation). Evaluated today following a thermal injury sustained when she spilled a bowl of hot noodles onto her lap. She reports pain localized to the right thigh. Wound care evaluated the area; dressing remains intact. Image review and examination are consistent with a superficial burn to the right thigh. Review of Systems: Burn to right thigh Skin: Wound dressing intact. Assessment/Plan: Superficial Thermal Burn - Right Thigh Dressing intact and no signs of infection. (Superficial thermal burn is defined as a first-degree burn- the mildest form of traumatic tissue injury caused by heat. It is strictly confined to the outermost layer of the skin, the epidermis). Progress note dated 04/14/26 3:51 PM document in part: Nurses Notes Text: Resident states she was on the elevator going to the second floor and had an involuntary muscle spasm and her cup of noodles spilled out of her hand and fell onto her lap burning her right thigh. Progress note dated 04/14/26 6:54 PM document in part: Nurses Notes Text: writer called to room by residents family, family requesting resident be sent to hospital for burn on her leg. Writer contacted MD (medical doctor), MD states send resident to hospital. Progress note dated 04/14/26 7:10 PM document in part: SBAR Summary for Providers Situation: The Change In Condition/s reported on this Evaluation are/were: Skin wound or ulcer - Skin Status Evaluation: Burn Progress note dated 04/14/26 7:34 PM document in part: Nurses Notes Text: ambulance in facility to transport patient to emergency department per MD orders. Progress note dated 04/15/26 2:01 PM document in part: Nurses Notes Text: Resident returned to facility. Resident c/o (complain of) pain to her right leg. Right thigh burn is wrapped with gauze. Progress note dated 04/15/26 11:02 PM document in part: ER (emergency room) follow-up R4 is seen today for follow-up after ER evaluation last night due to increased right thigh pain related to prior thermal injury from hot noodles. R4 was diagnosed in the ER with a second-degree (partial thickness) burn and a new dressing was applied. Assessment/Plan: Superficial Thermal Burn - Right Thigh. Continue to coordinate with wound care for ongoing assessment. Progress note dated 04/17/26 3:19 PM document in part: Nurses Notes Text: Resident c/o of right leg thigh pain due to recent burn. Gabapentin 100mg administered at 9am. Resident c/o of pain at 12:30pm same site 5/10 pain on number scale. Informed resident she is due for another Gabapentin 100mg, and I can also give 1000mg Tylenol. Resident still c/o pain after a 30-minute f/u (follow-up). Resident stated, the pain did not go away in fact it got worse, and my leg is aching. Wound Assessment Detail Report document in part: Wound: Right thigh front. Assessment date: 04/14/26 01:17 PM. Type Burn. Classification: Thermal Heat. Source: Facility Acquired. Date identified 04/14/26. Clinical stage: Partial Thickness. Tissue Type: Blanchable Erythema -75%, Epithelial - 25%. Exudate: Amount-light. Type-Serosanguineous. Size: 15.0 cm (centimeters) x 17.0 cm x 0.10 cm (L x W x D) length by with by depth. Hospital Record dated 04/15/26 document in part: Chef Complaint/Reason for Consultation: Scald Burn. R4 sustained a 1% TBSA (Total Body Surface Area) burn injury on her right thigh. This injury occurred at a nursing facility from ramen noodles. Patient reports pain and well as numbness /tingling to the area. Notably, the patient expressed concern about going back to her nursing facility as she does not feel she receives adequate care there. Skin: burn along right thigh that appears mixed superficial and deep partial thickness. Wound base appears whitish pink in some areas, with sluggish blanching, top (Thrombotic Thrombocytopenic Purpura). Assessment and Plan: admitted to hospital for advanced wound care, pain control, possible operative intervention. History of Present illness: earlier today, patient was at nursing home and asked the nursing home staff to help make hot Ramen soup for her. When she received the noodles, she used power chair to go up in the elevator to a different floor. While in the elevator, she had a muscle spasm and spilled the hot liquid onto her right thigh. Endorses are associated with pain. Skin: Comments: Partial superficial and thick thickness burn on right thigh and with associated blistering. Wound base exposed, with blanching. Long-Term Care Facility -Serious Injury Incident and Communicable Disease Report: document in part: Report Type: Initial. Date of Incident: 04/21/26. Report date: 04/21/26. Incident Category: Burn. Incident Description: Assessment/Test date: 04/21/26 Time: 12:35 PM. Detailed Incident Summary: R4 knocked her food into her lap. R4 was immediately cleaned and returned to her room for further thorough evaluation. R4 noted to have an open area to R (Right) upper thigh. R4 complained of pain 5/10 to site. Pain medication was given as indicated with relief noted. MD notified promptly, and treatment orders were received and implemented. Family was immediately notified regarding incident and new orders received from MD. Investigation initiated. Long-Term Care Facility and IID -Serious Injury Incident and Communicable Disease Report: document in part: Report Type: Final. Date of Incident: 04/21/26. Report date: 04/26/26. Incident Category: Burn. Upon further investigation by the interdisciplinary team (IDT), it is determined that R4 had warmed up her food and while returning to her room, she experienced leg spasms that caused her to spill the food onto her lap resulting in an open area to right upper thigh. R1 immediately received assistance from staff. Per CNA (Certified Nurse Assistant) I warmed up her food and I offered to bring the food back to her room: however, R4 declined. Per R4 I warm up my food all the time. This is the first time this happened. Despite current proactive interventions implemented, R4 remains at risk due to co-founding underlying factors identified such as weakness, decreased mobility and endurance, gait/balance problems, requires reinforcement of safety awareness, need for assistance with personal care and muscle spasms. On 06/09/26 at 11:32 AM Per telephone interview V6 (R4' Family Member) stated on 04/14/26 R4 was given hot noodles by a staff member. R4 got on the elevator, jerked or had a spasm. V2 (Director of Nursing) was on the elevator. They told R4 that everything was fine, they could take care of it, and they bandaged the leg. I told V18 (Licensed Practical Nurse) that R4 needs to be sent to the hospital. R4 said I had a cup of ramen noodles, and I was going to the second floor to hang out. V8 (Certified Nurse Assistant/CNA) warmed up my noodles and she was not aware I had muscle spasms. On 06/09/26 at 12:46 PM V8 (CNA) stated R4 came up, approached me and asked me to warm up some noodles. The aide put the noodles in the microwave, and I took the noodles to R4's room then placed them on the table on R4's wheelchair. R4 was in her room, in the wheelchair that has a table on top of it. R4 then asked for a fork, I went to get her a fork and when I went back to her room R4 was not in her room. The incident happened in the elevator. I was made aware of the incident later that day when I heard the noodles wasted on R4. I was not aware that R4 had muscle spasms. The burn was on R4's right thigh. On 06/09/26 at 12:37 PM V13 (Registered Nurse) stated I R4 had an incident with a burn on her leg. It was reported to me that R4 had a cup of noodles that spilled onto her leg. V8 (CNA) gave R4 the noodles. R4 provided her own noodles and asked V8 to warm them up for her. R4 was on the elevator going upstairs to see a resident, had a muscle spasm and the noodles spilled on her leg. I was not aware R4 had muscle spasms. When it happened, I did an assessment, followed up with wound care, spoke to the Nurse practitioner and documented. V2 (Director of Nursing) was on the elevator with R4. R4 was not sent out to the hospital that day but eventually yes. On 06/10/26 at 12:19 PM V32 (Wound Care/Licensed Practical Nurse) stated On 04/14/26 I received a phone call from V2 (Director of Nursing/DON) at approximately 1 pm. I met V2 at the room with R4. R4 spilled the noodles, and I removed her pants. The burn was on R4's right thigh and there was a lot of bunching of the legging type pants, clingy to the skin. It was still warm when I lifted the fabric and pulled it down. I asked what happened and R4 said she spilled a cup of noodles on her. R4 was in a motorized wheelchair with a stationary table tray and knocked the noodles in her lap when she had a spasm. It happened on the elevator and V2 (DON) brushed off the noodles. V2 used the towel to remove some of the broth. I used saline and gauze to clean, I measured and put on proper dressing. R4's thigh was blistered with a big blister that ruptured. Initially the large blister was intact, I went to my cart and when I returned the blister had ruptured. I took xeroform, a dry dressing and wrapped it with gauze. I changed R4's pants and she remained in the wheelchair. I conferred with the V38 (Nurse Practitioner), and the wound doctor came in on Friday 04/17/26. Most of the areas that were blistered were very small lines. The Nurse Practitioner said it was ok and R4's pain was not terrible 3/10 rating which was addressed with Tylenol. The burn wound was identified on 04/14/26 that same day. I will have to go get the order and hospital records and I will come back. At 01:00 PM V2 (DON) returned to the conference room with the documentation that the surveyor requested from V32 and stated V32 had left the facility. On 06/10/26 at 02:28 PM V2 (DON) stated R4's burn happened on 04/14/26. I was getting on the elevator, R4 came out of her room with another resident. R4 and another resident entered the elevator. R4 had a game system and noodles on the wheelchair tray table, moved the game and she yelled. I had turned to put in the elevator code. The noodles on table spilled in R4's lap. We got off the elevator on the second floor, I asked the nurses to get towels and wiped R4 off. We got back on the elevator, went to the first floor and V32 (Wound Nurse/Licensed Practical Nurse) was outside the elevator. V32 took R4 to her room, got her undress and assessed the wound. I did not go into the room with them. I went to look for a [NAME] about what I need to do. I did not see R4's thigh until the next day. V32 did tell me R4 had a blister and a little area that had a skin tear. The template has to notify the doctor, wound care nurse, wound assessment notes and route cause analysis. I am assuming after V32 spoke to the doctor if they did not give an order, that is why R4 was not sent out to the hospital. I would have sent R4 out to the hospital based on the picture and measurements. That is something that would be reported to the state. I knew the day that I brought it to V25 (Former Administrator) and the consultant's attention, but the directive was to hold off on reporting the incident. It was reported 04/21/26. Surveyor asked V2 should the incident have been reported on 04/14/26 when the incident happened. V2 responded, Absolutely. Burn Injury Checklist Evaluation: Burn Injury Investigation Checklist: undated, Date found and reported? Wound MD (Medical Doctor) notified, based on RCA (Root Cause Analysis) were appropriate interventions in place for prevention? Once you have completed the event's checklist and assessment, use the QAPI (Quality Assurance and Performance Improvement) Plan/Action plan to help address identified opportunities. Policy: Titled Documentation-Electronic Health Record revised 11/12/18 document in part: Entries made in the electronic health record shall be: Accurate. Identification of the author of a medical record entry by that author, and confirmation, that the contents are what the author intended and that the entry made is complete, accurate and final. Policy Titled Abuse Prevention and Reporting-Illinois revised 01/22/19 document in part: All alleged violations are reported immediately not later than 24 hours if the event that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency where the state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on observation, interview and record review, the facility failed to ensure a resident dependent on incontinent care was provided incontinent care in a timely manner for one (R9) of four residents reviewed for quality of care/treatment.Findings Include:R9's diagnoses include but not limited to History of Falling, Chronic Diastolic (Congestive) Heart Failure, Malignant Neoplasm of Prostate, Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Absolute Glaucoma, Right Eye, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, , Peripheral Vascular Disease, Gastro-Esophageal Reflux Disease, Diseases of Anus and Rectum, Pressure Ulcer of Sacral Region, Stage 3, Pressure Ulcer of left Buttock, Stage 2. R9's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R9's Care Plan document in part: Focus: R9 presents with a functional deficit in Bed Mobility related to: generalized weakness and musculoskeletal impairment. Focus: is at risk for alteration in skin integrity related to, Braden Scale Score of 15, Prostate Cancer, Diabetes, Immobility, Incontinence of Bowel, Fragile Skin, PVD (Peripheral Vascular Disease), Incontinence of Urine and Poor Skin Turgor. Interventions: Provide incontinence care as needed. Turn and reposition at least every 2 hours while in bed and as needed. Focus: New Onset Bowel Incontinence. Focus: New Onset Urinary Incontinence. Focus: R9 has alteration in skin integrity. Interventions: Keep skin clean and dry. Focus: R9 has an ADL Self Care Performance Deficit related to Impaired balance, Limited Mobility, and Musculoskeletal impairment. Focus: R9 has bowel/bladder incontinence related to Activity Intolerance, Dementia, Impaired Mobility, Physical limitations, and Poor toileting habits. Interventions: Incontinent: Check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Focus: R9 is at risk for falls d/t (due/to) confusion and gait/balance problems. Focus: R9 Has Gastrostomy Tube.MDS Section GG - Functional Abilities dated 04/01/26 document in part: Toileting Hygiene, Dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Roll left and right, Substantial/maximal assistance - Helper does more than half the effort.On 06/10/26 at 09:58 AM R9's call light was observed to be illuminated outside of his door. R9 began calling out, help. R11 came near R9's door and told R9 that he was just coming to check on him. In the meantime, R9's call light was illuminated outside of the door. R11 was observed at R9's door sitting in a wheelchair. R9 asked R11 was his call light on. R11 responded, yes the light is on. At 10:13 AM V13 (Registered Nurse) entered R9's room and said your call light is on. R9 said I'm wet. V13 responded, your aide is starting to do her rounds right now. R9's room and call light was turned off by V13 at 10:14 AM and V13 exited R9's room. At 10:18 AM this surveyor entered R9's room and said I see that you had your call light on. R9 stated the nurse came in. I am wet and need to be changed. I know they are making their rounds, and I need to be changed and repositioned. I have been wet since 07:30 AM. The nurse gave me my medications. R9 was observed lying in bed on a low air-loss mattress with a gastric tube in place. At 10:37 AM V40 (Certified Nursing Assistant/CNA) entered R9's room and said I came to get your mechanical lift pad. At 10:51 AM R9 called out six times, help, somebody help me please and turned the call light back on. R9 then called out three times, I cannot find my call light. At 10:53 AM V41 (CNA) entered R9's room and said you got your light on. V41 turned R9's call light off and said let me go get my cart. At 10:56 AM R9 said out loud, out of sight, out of mind. At 11:11 AM R9 called out four times, help me.On 06/10/26 at 11:13 AM This surveyor entered R9's room with V41 (CNA). Enhanced Barrier Precaution signage was posted on the wall to the right side of R9's door. V41 stated He thought I forgot about him. I get sidetracked when the lights go off. R9 said I am more wet. I urinated a couple of times. V41 stated I checked R9 this morning when I came about 07:30 AM. I make rounds 3 times a day, in the morning, noon and before I go home. At 11:16 AM V41 exited R9's room to get assistance. R9 stated I feel like I am being misused, and I don't like being wet. They will change me; I will urinate again and that starts the waiting process all over again. When people say that they are going to do something for you and leave the room you get out of sight and out of mind. They forget about you and start doing something else. At 11:23 AM V41 reentered R9's room with V42 (CNA) and began performing peri care with no gown in use. V41 removed R9's incontinence brief that was saturated with urine. R9's under pad, gown and top sheet were changed. At 11:25 AM V3 (Assistant Director of Nursing) knocked on R9's door, looked into the room then closed the door.On 06/10/26 at 01:00 PM V13 (Registered Nurse) stated I am R9's nurse. I did not hear R9 calling out for help. I saw R9's call light was on, I stopped and asked what he needed. R9 was wet, the aide started her rounds and would be to his room soon. I did not tell the aide R9 was wet. If I am being completely honest, I assist with (incontinent care) changes but have not initiated a change. The nurses can change residents. I do not know how long R9 was wet after I left the room, and I did not ask R9 how long he was wet. The residents are repositioned every 2-4 hours. I get overwhelmed with the task I have. I was trying to catch up with the doctor and I was not attentive to R9's needs. There was a failure to attend to R9's needs to be changed at that moment.On 06/10/26 at 02:08 PM V2 (Director of Nursing) stated My expectation is that the call light is answered promptly and to meet the residents' immediate needs as possible. Everyone is responsible for answering the call light. A nurse can change a resident if they complain about being wet. At 02:28 PM V2 (Director of Nursing) stated my expectation is staff are making rounds every 2 hours. The residents are checked and changed, not a check and I will be back. V2 was informed that V41 said that she makes rounds in the morning, at noon and before she leaves. V2 stated that would not be every 2 hours. If a resident is not changed and repositioned every 2 hours there is a risk for skin break down and not being changed there is a potential for a urinary tract infection.Job Description undated document in part: Registered Nurse (RN) Summary: The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. To ensure that the highest degree of quality care is maintained at all times. Fill out and complete accident/incident reports and submit to Director as required.Job Description undated document in part: Licensed Practical Nurse (LPN) Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. To ensure that the highest degree of quality care is maintained at all times. Fill out and complete accident/incident reports and submit to Director as required.Job Description undated document in part: Certified Nurse Assistant (CNA) Summary: The Certified Nurse Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensure the health, welfare and safety of all residents. Provide for resident comfort by utilizing resources and material, answering call lights and requests.Policy:Titled Call Light revised 02/02/18 document in part: Purpose: To respond to residents' request and needs in a timely courteous manner. 4. Requests shall be responded to in a courteous and professional manner. 5. Respond to request. If item is not available, or request questionable, get assistance from charge nurse. Return to resident with prompt reply.Titled Incontinence Care revised 04/20/21 document in part: Purpose: T prevent excoriation and skin breakdown, discomfort and maintain dignity. Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provide perineal and genital care after each episode.

Based on observation, interview and record review the facility failed to ensure staff wore the proper PPE (Personal Protective Equipment) while providing care for one (R9) resident on Enhanced Barrier Precautions. Findings Include:R9's diagnoses include but not limited to History of Falling, Chronic Diastolic (Congestive) Heart Failure, Malignant Neoplasm of Prostate, Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Absolute Glaucoma, Right Eye, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, , Peripheral Vascular Disease, Gastro-Esophageal Reflux Disease, Diseases of Anus and Rectum, Pressure Ulcer of Sacral Region, Stage 3, Pressure Ulcer of left Buttock, Stage 2. R9's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.Care Plan document in part: Focus: R9 Has Gastrostomy Tube.Physician order document in part: Enhanced Barrier Precautions. G-tube wounds every shift -Start Date-04/01/26.On 06/10/26 at 11:13 AM V41 (Certified Nursing Assistant/CNA) and this surveyor entered R9's room. Enhanced Barrier Precaution signage was posted on the wall to the right side of R9's door. R9 said I am more wet. I urinated a couple of times. At 11:16 Am V41 exited the room to get assistance. At 11:23 AM V41 reentered R9's room with V42 (CNA) and began performing peri care with no gown in use. V41 removed R9's incontinence brief that was saturated with urine. R9's under pad, gown and top sheet were changed. At 11:25 AM V3 (Assistant Director of Nursing) knocked on R9's door, looked into the room then closed the door.06/10/26 at 11:31 AM V42 (CNA) exited R9's room. This surveyor asked V42 to read the signage next to R9's door. V42 stated I should have put on a gown for barrier precautions. There is a potential the other residents can catch something.On 06/10/26 at 11:33 AM V41 (CNA) exited R9's room. This surveyor asked V42 to read the signage next to R9's door. V41 stated I should have put on a gown because R9 has a feeding tube. There is a potential I can bring something to them, myself and the other residents. R9 is a heavy wetter.On 06/10/26 at 02:08 PM While sitting in the conference room this surveyor asked V2 (Director of Nursing) to look outside the door at the wall next to R9's room. V2 stated the signage has enhanced barrier precautions. A gown and gloves should be worn for any high contact resident care. If the gown and gloves are not worn there is a potential for the spread of infection to the residents themselves and other residents in different rooms.Enhance Barrier Precaution Signage document in part: Providers and staff must also: Wear gloves and a gown for the following High-Contact resident care activities, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting. Policy: Titled Enhanced Barrier Precautions (EBP) reviewed 03/20/26 document in part: Purpose: To minimize the risk of acquiring, transmitting, or complications resulting from multi-drug-resistant organism (MDRO) colonization among residents in this setting. Population Affected: Residents with existing or colonized MDRO's where other transmission-based precautions are not warranted. Residents at increased risk of MDRO acquisition (Residents with wounds or indwelling medical devices). Equipment Needed: Gowns, Gloves. Guidelines: Residents Will require the use of personal protective equipment (PPE) for high-risk activities such as: Toileting, Linen Changes. Any situation where expected contact of blood, body fluids, skin breakdown or mucous membranes will be encountered. PPE required: Gowns, Gloves. Persons expected to encounter these circumstances are to don PPE (gowns and gloves) in accordance with the activity that will be encountered when caring for the resident.

Based on observation, interview, and record review, the facility failed to ensure there are no more than 14 hours between the evening meal and breakfast the following day with a substantial bedtime snack available/offered to everyone. These failures have the potential to affect all 190 residents receiving oral diets from the facility's kitchen. Findings include:On 03/31/26 during initial tour on units observed mealtime schedule posted which documented in part, 3rd floor dinner is served at 4:40 PM and breakfast is served at 7:40 AM, 2nd floor is served at 4:55 PM and breakfast is served at 7:55 AM, 1st floor is served at 5:20 PM and breakfast is served at 8:20 AM. On 04/01/26 at 11:51 PM, V28 (Food Service Director) stated each floor after the dinner meal a tray of evening snacks which consists of ten peanut butter and jelly sandwiches, ten meat sandwiches, four to five pieces of fresh fruit, 10-15 packages of graham crackers and four containers of applesauce or pudding. V28 stated the evening snacks are intended to be given out to the residents who have diabetes and whatever is left over can be given out to any resident who wants a snack. V28 stated the snacks sent up to each unit are not enough for every resident to receive a snack because it is primarily intended only to be offered to the residents with diabetes. V28 stated the kitchen closes at 8:30 PM and after this time none of the staff can get into the kitchen. V28 stated the evening snacks are already prepared for today.On 04/01/26 at 11:57 AM, observed in the walk-in refrigerator with three different trays and on each tray there were ten peanut butter and jelly sandwiches, eight graham cracker packages, five oranges. V28 stated ten cold cut sandwiches, and some containers of pudding or applesauce will be added to the trays before they are sent up to the unit after dinner. V28 stated the residents on pureed diets are offered pudding or applesauce as a snack, they do not prepare pureed sandwiches for them on the evening snack trays.On 04/01/26 at 10:27 AM, V35 (Certified Nursing Assistant) stated she sometimes works the 3-11 shift on the 1st floor. V35 stated the kitchen sends up a tray with sandwiches, graham crackers, and applesauce or pudding on it. V35 stated she asks if a resident wants a snack. V35 stated there are not enough snacks sent up for every resident. V35 stated if a resident is on a pureed diet she offers them pudding or applesauce.On 04/02/26 at 8:40 AM, V30 (Registered Dietitian) stated via telephone interview there can be no more than 14 hours between dinner and breakfast. V30 stated if they are serving dinner at 4:40 PM and breakfast at 7:40 AM that means there is 15 hours between dinner and breakfast which is too long of a distance. V30 stated if the facility is serving meals outside the 14 hours window, then all residents must have access to a substantial snack. V30 stated a substantial snack would be a sandwich but applesauce or pudding or a piece of fruit would not be a substantial snack. V30 stated evening snacks should not only be available for the residents who can walk independently to the nursing station to get snacks, they need to be passed out room by room so everyone is offered an evening snack. V30 stated for pureed diets applesauce or pudding would not be adequate but a pureed sandwich would be acceptable.R171's diagnosis includes but not limited to Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, Insomnia. R171's MDS dated [DATE] indicates R171 cognition is intact.On 04/02/26 at 10:05 AM, R171 stated he does not get offered a snack every night by staff and commented that they run out of snacks early. R171 stated if he wants a snack after dinner, he has to get himself out of his bed into his wheelchair and wheel himself down to the nursing station because the staff does come into his room to offer him a snack. R171 stated if he gets to the nursing station too late all the snacks are gone because the residents who can walk get to the nursing station first and take all the snacks. R171 thinks the time between dinner and breakfast is too long and wishes he could get an evening snack every day.R65's diagnosis includes but not limited to Type 2 Diabetes Mellitus. R65's Order Summary Record indicates R65 is receiving Trulicity and Metformin for diabetes. R65's [NAME] Data Set (MDS) dated [DATE] indicates R65's cognition is intact.On 04/02/26 at 10:11 AM, R65 stated he does not get offered a snack every night and he is a diabetic so he should be receiving something after dinner so his morning blood sugar readings are not low. V65 stated it is too long a time between dinner and breakfast and that is why he gets hungry at night.Facility provided document titled, Diet Roster - By Diet dated 03/31/26 listing residents with their diet orders. The report indicates there are 12 residents who receive nothing by mouth (NPO).Facility provided kitchen policy titled Snacks undated which documents in part, if meal services have more than 14 hours between dinner and breakfast, facility must provide a substantial snack to all residents, and intake must be recorded. If there are more than 14 hours between meals, a substantial snack must include a minimum of 2 food groups. Residents on texture-modified diets must also have an appropriate substantial snack offered.

Based on observation, interview and record review, the facility failed to (a) ensure a resident received the correct oxygen flow rate, (b) obtain physician order for oxygen use, (c) ensure oxygen in use signage was posted, (d) develop comprehensive care plan for oxygen use, (e) ensure oxygen nasal cannula was labeled and dated and (f) ensure nebulization tubing mask was properly stored. These failures affected five (R41, R89, R105, R173, R207) of seven residents reviewed for respiratory care in a sample of 35. The findings include: R173's face sheet/admission record shows admission date on 11/1/2010 with diagnoses not limited to Type 2 diabetes mellitus, Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, Dysphagia oropharyngeal phase, Essential (primary) hypertension, Hyperlipidemia, Benign prostatic hyperplasia, Gastro-esophageal reflux disease. MDS (Minimum Data Set) dated 1/27/26 shows R173's cognition is intact. On 3/31/26 At 12:20PM R173 was sitting up in a Geri chair, alert and responsive mouthing words. Appears comfortable and well groomed. Observed with oxygen inhalation via nasal cannula at 4L/min. No signage posted for oxygen in use outside R173's room. On 3/31/26 At 12:23PM V7 (Registered Nurse/RN) was requested in R173's room and she stated R173 is using Oxygen continuously. She stated there should be a signage by room entrance for oxygen in use for safety reasons, so staff and residents are aware that oxygen is being used inside the room. V7 said there was no signage posted for oxygen in use outside R173's room. V7 checked oxygen and stated it is on at 4L/min. V7 reviewed R173's EHR (electronic health record) and stated there was no order for oxygen use. On 4/2/26 At 10:59AM V2 (Director of Nursing/DON) stated there should be an order for oxygen use to ensure the proper amount of oxygen is administered to the residents. She said oxygen in use signage should be posted by room entrance to inform them that there is oxygen in use in the room and to make sure that there is no open flame nearby for safety reasons. V2 said care plan should be developed to make sure that staff would be able to know how to care for the residents. R173's EHR (electronic health record) reviewed no physician order and no care plan found for oxygen use. Facility's oxygen therapy policy (undated) shows in part: To deliver oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. It is the policy of this facility that oxygen shall be used in safe and effective manner in accordance with applicable rules and regulations and the standard of care. Verify physician's order. Attach the nasal cannula to the oxygen source and turn the flow meter to the ordered flow rate. Place Oxygen in use sign outside the room when in use. Facility's Comprehensive care plan policy dated 11/17/17 shows in part: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The facility will develop and implement a comprehensive person – centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing needs. 2. R89 has diagnosis not limited to Long Term (Current) use of Inhaled Steroids, Hypertensive Heart Disease with Heart Failure, Sleep Apnea, Chronic Obstructive Pulmonary Disease, Dependence on Supplemental Oxygen and Abnormal Finding of Lung Field. R89's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R89's Care plan document in part: Focus: R89 has oxygen therapy as ordered related to Chronic obstructive pulmonary disease. Change Oxygen Tubing and Humidifier as ordered per facility policy. R89's Care Plan document in part: Focus: R89 has risk for altered respiratory status/Difficulty Breathing related to COPD (chronic obstructive pulmonary disease)/Sleep Apnea. Focus: has oxygen therapy as ordered related to COPD. Interventions: Change Oxygen Tubing and Humidifier as ordered per facility policy. On 03/31/26 at 11:52 AM R89 was observed on 2 liters of oxygen per nasal cannula. Oxygen tubing is not labeled and dated. R89's Physician order document in part: Oxygen at 2 LPM (liters per minute) per Nasal Cannula/Mask continuously – Monitor. 3. R105 has diagnosis not limited to Essential (Primary) Hypertension, Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance, Hyperlipidemia, Vitamin D Deficiency, Anemia, Iron Deficiency Anemia, Long Term (Current) use of Aspirin, Moderate Protein-Calorie Malnutrition, Pressure Ulcer of Left Buttock, Unstageable and Pressure Ulcer of Sacral Region, Unstageable. R8's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate rarely/never understood. On 03/31/26 at 01:01 PM R105 was observed lying in bed on a low air loss mattress with oxygen at 2 liters per nasal cannula. R105's Care Plan document in part: Focus: R105 has oxygen therapy as ordered/see POS (Physician order summary) and MAR (medication administration record) for orders. There is no document order for R105's oxygen use with an oxygen flow rate of 2 liters. R105's Physician orders document in part: Check and ensure proper placement of ear cushion on oxygen tubing. Replace if needed every shift for Shortness of Breath and as needed. Policy: Titled Oxygen & Respiratory Equipment- Changing / Cleaning revised 01/07/19 document in part: Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: 2. Nasal Cannula. a. Nasal cannulas are to be changed once a week and PRN. c. A clean plastic bag with a zip loc or draw string, etc. will be provided to store the cannula when it is not in use. It will be dated with the date the tubing was changed. 4. R207's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (15) indicates he is cognitively intact. R207's Physician Order Sheet (POS) dated 03/31/26 noted an active diagnosis of chronic obstructive pulmonary disease, malignant neoplasm of esophagus, and essential hypertension. R207 has an active order for ipratropium-albuterol solution 0.5-2.5 (3) milligram/3mililiter inhale orally every 12 hours for shortness of breath/SOB or wheezing via nebulizer. On 03/31/26 at 12:19 PM, R207 stated that he received his nebulizer treatment every day, and he has received the nebulizer treatment this morning. Surveyor observed nebulizer tubing mask not inside the bag, but on his nightstand when not in use. On 03/31/26 at 2:32 PM, the surveyor and V7 (Registered Nurse) entered R207's room, observed nebulizer tubing mask on R207's nightstand. V7 stated that she has been at the facility since January 2026, the nebulizer tubing mask should have been stored in a bag when not in use to prevent infection. She also stated that she will immediately discard and replace it with a new nebulizer tubing mask in a bag. On 04/02/26 at 11:16 AM, V2 (Director of Nursing) stated that the nebulizer tubing mask should be stored inside a bag when not in use to prevent respiratory infection. Facility policy titled; Nebulizer Therapy dated 12/1/21documents in part: Store in a plastic bag. 5. R41 has diagnosis not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Chronic Pulmonary Embolism, Chronic Diastolic (Congestive) Heart Failure and Atherosclerotic Heart Disease of Native Coronary Artery. R41's Progress Note dated 03/31/2026 12:39:58 document in part: R41's oxygen was noted to be on 4 liters verified orders of 2 liters via nasal cannula, and the writer set oxygen on correct order. Writer made NP (Nurse Practitioner) aware. Resident shows no s/s (signs and symptoms) of respiratory distress or discomfort. R41's Progress Note dated 03/31/2026 13:28:59 document in part: R41 is lying in bed alert and verbally responsive no complaints of pain no s/s of SOB (Shortness of breath) or respiratory distress, Residents 02 (oxygen) saturation is 98% on 2 liters of oxygen. On 03/31/2026 at 11:59AM R41 was observed sitting in a wheelchair at the bedside asleep. R41 was observed using oxygen at 4 liters per nasal cannula. R41's physician order reads oxygen 2 liters. On 03/31/2026 at 12:02 R41 was arousable. V11 (Licensed Practical Nurse) stated I have been working here for 26 years. V11 checked R41's Blood Pressure to the left arm with a reading of 140/79 Heart Rate 70 Temperature 97.7. V11 stated it looks like R41's oxygen is on 4 liters. On 03/31/2026 at 12:08 PM V11 (Licensed Practical Nurse) checked the computer and said R41's oxygen order is supposed to be on 2 liters. Surveyor asked V11 what can potentially happen if the oxygen order is not followed. V11 stated there is a potential for hypoxia. V11 returned to R41's room to correct the oxygen setting. On 04/02/26 at 10:00 AM V2 (Director of Nursing) stated My expectation if a resident is admitted on oxygen that the orders are placed and are carried out, the resident is assessed, all the tubing is labeled and dated. The purpose of changing the oxygen tubing is for infection control to ensure the resident has clean and effective tubing. The nurse should have verified that R41 was at the correct oxygen flow rate. The nurse should have checked R41's oxygen setting at the beginning of the shift. My expectations for oxygen tubing are to be maintained, in infection control the line should be dated and changed out every 7 days. Every shift the nurse should monitor oxygen saturation, need to know if the oxygen is therapeutic then reassess to see if we need new orders and follow the physician orders. If the resident is not receiving enough oxygen, they can become hypoxic and if they receive too much oxygen, it can disturb the CO2 (carbon dioxide) drive which can be dangerous. If a resident has chronic obstructive pulmonary disease too much oxygen can be dangerous.

Based on observation, interview and record review the facility failed to ensure a) medications were discarded when expired, b) ensure medications were labeled with the resident's name and c.) ensure medications were dated when opened in 4 of 4 medication carts reviewed during the medications labeling and storage observation.Findings Include:On 04/01/26 at 09:34 PM V9 (Licensed Practical Nurse) handed the surveyor a zip lock bag containing Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT with 135-1 and the date of 03/18/26 written in marker on the inhaler. There was no label or resident name on the inhaler. V9 stated I don't know what happened to the box, I will order a new inhaler.On 04/01/26 at 12:11 PM the second-floor team 1 medication cart was reviewed with V11 (Licensed Practical Nurse). A bottle of Aspirin 325 mg was observed in the top drawer of the medication cart with an expiration date of 08/25.On 04/01/26 at 12:28 PM the third-floor medication cart #2 was reviewed with V25 (Licensed Practical Nurse). During review of the controlled substance a Controlled Substances Proof of Use sheet dated 03/19, amount received 15 ml (milliliter) was observed with no name documenting in part: Morphine Sulfate 100 mg (milligram) per 5 ml (milliliter). Take 0.25 ml (5mg) by mouth or under tongue every 2 hours as needed for shortness of breath. A box with R75's name was observed in the narcotic drawer. V25 stated the sheet has 15 ml but there is about 13 ml in the bottle. A Controlled Substances Proof of Use sheet, amount received 30 ml (milliliter) document in part: R75, Morphine Sulfate 20 mg/ml. Take 0.25 ml (5mg) by mouth or under tongue every 2 hours as needed for or every 1 hour as needed for SOB (Shortness of Breath). V25 stated the sheet has 29.5 ml and there is 30 ml in the bottle. I counted with the nurse this morning.On 04/01/26 at 12:52 PM the third-floor team 3 medication cart was reviewed with V15 (Licensed Practical Nurse). Surveyor asked V15 how long the inhalers were good to be used after opening. V15 stated I have to look it up. I googled it and it is good for 6 weeks or 42 days. R70's Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT 1 puff inhale orally two times a day was observed with no open date. R103's Proventil HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 4 hours as needed was observed with a dispensed date of 12/11/25 and no open date. R169'S Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT (microgram/actuation) inhale 1 puff daily was observed with no open date. Geri max antacid/antigas 12 fluid ounces was observed with an expiration date of 10/25.On 04/01/26 at 01:02 PM V15 (Licensed Practical Nurse) stated the expired medication should be discarded, and I am going to discard it. If a resident receives an expired medication, it can cause a bad reaction and side effects.On 04/01/26 at 01:18 PM the first-floor team one medication cart was reviewed with V8 (Registered Nurse). R2's Humalog Solution 100UNIT/ML 9 unit before meals were observed with no date opened. Epoetin Alfa Solution 10000 UNIT/ML was observed in the medication cart drawer with no name/label or date opened. R152's Ketorolac Tromethamine Ophthalmic Solution 0.4 % 1 drop in both eyes four times a day was observed with no open date. Sodium Chloride Hypertonicity Ophthalmic ointment 5% was observed with no name or label with a date of 01/16/26 written on the tube.On 04/02/26 at 10:00 AM V2 (Director of Nursing) stated Labeling and storage for the medication cart, medication room and multi dose medications we use an open date to make certain the medication required care date and whatever the expiration date should be listed on there as well. For the medication carts that is my same expectation for dating the medications with an open date, expiration and discard date. If the medication is used beyond the expiration date the efficacy of the medications can be affected and that is an infection control issue with the multi-use bottles. The inhaler date is an infection control issue even if they wipe the inhaler off and the inhaler is not good after the expiration date and that is something that they should get rid of. Symbicort is good for 90 days and Albuterol is good for 12 months. For the insulin, follow the sticker to date with an open date and store according to pharmacy guidelines. Potentially the efficacy of the drug can be affected. If medications are not stored in the box or separated out it can be a medication error, and the purpose is to keep down contamination. If a room number with no other identifier is written on a medication that can potentially be a medication error and that does not mean it is that resident's medication. There should be a two-patient identifier on the medication. Expired aspirin, the efficacy of that drug I nonexistent. The expired Geri max is not effective, and expired medications are not effective. The Epoetin should have been in the resident container and dated to prevent medication errors. The medications can be put in a zip lock bag and labeled. Narcotic accountability, I pulled R75 (Morphine) bottles and sheet. I instructed the nurses to label the bottles and number them if there is more than one bottle, number them to make sure the right bottle has the right strength. There was no name on the narcotic sheet so I would not know what I am supposed to be giving R75. Fill out the narcotic sheet appropriately. The nurses ordered multiple bottles of morphine and one of the bottles was from a different pharmacy. Whatever is on the medication label should be transferred to the narcotic sheet, stop, count and measure. V2 placed four narcotic sheets, one with no name, one unopened and three open morphine bottles on her desk expressing the narcotic count error and confusion of having multiple open bottles of the same medication.Policy:Titled Medication Storage revised 07/02/19 document in part: Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles. 4. Facility should ensure that medications and biologicals that (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guideline are stored separate from other medications until destroyed or returned to the supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 6. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels. 10. Facility should ensure that the medications and biologicals for each resident are stored in the container in which they were originally received.

Based on observation, interview, and record review, the facility failed to ensure a) food items were properly labeled and dated, b.) food is rotated using First In, First Out (FIFO) guidelines, c.) kitchen equipment is sanitized based on manufacturers' procedure directions. These failures have the potential to affect all 190 residents receiving food prepared in the facility's kitchen. Findings include:On 03/31/26 at 9:38 AM, V28 (Food Service Director) stated all opened items in the refrigerator and freezer should be labeled with a delivery date, an opened date and a use by date. V28 stated different food items have different use-by dates. V28 pointed to a posted chart on the wall in between the refrigerator and freezer and said the staff follow that use by-date chart. V28 stated labeling the opened food items with an open and use-by date is important so the staff knows when to discard an item, so a spoiled item does not get served to a resident(s) and potentially make them sick.On 03/31/26 at 9:40 AM, observed the following items in the Walk-In Refrigerator:Opened 5-pound container of sour cream labeled with a delivery date of 02/24/26, an opened date of 03/02/26 and a use-by date of 03/09/26.Unopened case of whole milk ricotta cheese consisting of four 5-pound containers labeled with a delivery date of 02/03/26 and marked on each container by the manufacturer best if use by date of 03/26/26.On 03/31/26 at 9:45 AM, V28 went outside the walk-in refrigerator and checked the use-by chart posted on the wall. V28 stated the sour cream should be discarded seven days after it is opened. V28 stated therefore if the sour cream was opened on 03/02/26, it should have been used by or discarded on or before 03/08/26. V28 stated the expired sour cream has the potential to cause a food-borne illness which could harm the residents. V28 stated the ricotta cheese was going to be used this week to make lasagna which is on the menu later in the week. V28 had not realized the ricotta cheese best by date had expired last week.On 03/31/26 at 10:00 AM, V28 stated items are stored and organized in the dry storage room using FIFO which means the newest or most recently delivered items are stored in the back, the oldest items are stored in the front so that the older items are used first. Observed in the dry storage room [ROOM NUMBER]-pound cans of chocolate pudding labeled 03/07/26 in front of other 7-pound cans of chocolate pudding labeled 01/20/26. V28 stated the cans labeled 01/20/26 should be in front of the cans labeled 03/07/26 so that the older dated cans are used first.On 04/01/26 at 10:31 AM, during pureed food preparation observations observed V28 take a dirty blender container, blade and lid to the three-compartment sink and wash, rinse and quickly dip each piece into the sanitizing solution in the third sink (surveyor counted 2 seconds per item).On 04/01/26 at 10:51 AM, V28 stated kitchen equipment items being hand washed in the three-compartment sink only need to be dipped into the sanitizing solution in the third sink, they do not have to be fully submerged. V28 stated the purpose of sanitizing the kitchen equipment is to make sure the item is disinfected and clean to prevent cross-contamination. V28 stated they are using a commercial quat-based sanitizing solution.On 04/01/26 at 10:52 AM, observed V31 (Cook) take a dirty blender container, blade and lid to the three-compartment sink and wash, rinse and quickly dip each piece into the sanitizing solution in the third sink (surveyor counted 2 seconds per item).On 04/01/26 at 10:53 AM, V32 (Pot Washer) stated each item being cleaned in the three-compartment sink needs to be submerged in the sanitizing solution for at least 30 seconds and then allowed to air dried fully before use.On 04/01/26 at 10:54 AM, surveyor observed two posters above the three-compartment sink which had a picture and written diagram of washing procedure. V28 viewed the posters and confirmed that those posters are guidelines from the company the kitchen uses for the quat-based sanitizing solution.Facility provided document titled, Diet Roster - By Diet dated 03/31/26 listing residents with their diet orders. The report indicates there are 12 residents who receive nothing by mouth (NPO).Facility provided kitchen policy untitled, undated which documents in part, under the heading Refrigerator - items that have exceeded the manufacturer's expiration date or use by date should be discarded.Facility provided document titled, Use-By (UB) Guidelines undated which documents in part, sour cream should be used with seven day from opening.Facility provided kitchen policy titled, Storage Labeling & Dating undated which documents in part, purpose - to ensure inventory is stored in a safe, sanitary manner to provide the best food quality and safety and all stored products will be labeled with the name, appropriate dates and rotated following the First-In, First-Out method (FIFO).Facility provided document titled, Labeling, Dating and FIFO undated which documents in part, food and beverages should be dated upon receipt and stocked rotating using the first-in, first-out (FIFO) method. The item delivered first should be used first.Facility provided kitchen policy titled Sinks, Three and Two Compartment undated which documents in part, purpose - to ensure food safety and sanitizing items in the 3rd sink. Submerge items for at least 60 seconds if using quat, or per the manufacturer's guidelines.Facility provided copy of posters above the three-compartment sink. The poster titled Pot & Pan Wash Procedure documented in part, submerge in sanitizer sink for one minute or as specified by product label and/or local guidelines. The other posted titled Multi-Quat Sanitizer documents in part, Directions for Use - Expose all surfaces of equipment, ware or utensils for the sanitizing solution for a period of not less than one minute.

Based on observation, interview and record review the facility failed to (a) ensure staff cleaned and disinfected reusable equipment between resident use, (b) perform hand hygiene during medication administration for five (R53, R56, R112, R119, R215) residents, (c) ensure proper Personal Protective Equipment (PPE) were worn during wound care treatment, (d) ensure Enhanced Barrier Precautions (EBP) signage was posted, (e) develop comprehensive care plan for one (R7) resident on Enhanced Barrier Precautions (EBP). These failures have the potential to affect six (R7, R53, R56, R112, R119, R215) residents reviewed for infection control in a sample of 35. The findings include: R7's face sheet/admission record shows initial admit date on 10/31/2025 with diagnoses not limited to Spinal stenosis lumbar region with neurogenic claudication, Unspecified injury to unspecified level of lumbar spinal cord, Pressure ulcer of sacral region stage 4, Peripheral vascular disease, Unspecified atrial fibrillation, Type 2 diabetes mellitus, Hypertensive heart disease with heart failure, Non-pressure chronic ulcer of other part of left foot, Heart failure, Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction, Neuromuscular dysfunction of bladder, Nontoxic diffuse goiter, Anemia, Neurogenic bowel. MDS (Minimum Data Set) dated 2/24/2026 shows R7's cognition is intact. He needed Supervision or touching assistance with oral hygiene, upper body dressing; Partial/moderate assistance with toileting and personal hygiene, shower/bathe self, chair/bed and toilet transfer; Substantial/maximal assistance with lower body dressing. R7's MDS shows 1 Stage IV pressure ulcer that was present on admission. On 4/2/26 at 9:46AM Wound care observation conducted with V14 (Wound Care Director, LPN/Licensed Practical Nurse) assisted by V38 (Certified Nursing Assistant/CNA). V14 stated R7 has Stage IV pressure ulcer to Sacral area. V14 and V38 observed wearing gloves but not gown. Observed V14 removed soiled dressing to R7's sacral area. Observed wound bed 100% beefy red, no signs and symptoms of wound infection. V14 cleanse sacral area with NS (normal saline) then applied hydro [NAME] blue to wound bed and covered with dry dressing. V14 and V38 not wearing proper PPE (Personal Protective Equipment) during wound care observation. R7's room with no EBP (Enhanced Barrier Precautions) signage posted. PPE (gown) supplies not accessible for staff to use. On 4/2/26 At 10:59AM V2 (Director of Nursing/DON) stated EBP (Enhanced Barrier Precautions) is used when residents have medical indwelling line or devices or open wound or colonized infection. She said residents with open wounds or stage IV pressure ulcer should be on EBP, signage should be posted, PPE should be accessible and proper PPE (personal protective equipment) such as gown, mask, gloves should be worn during wound care treatment to decrease the spread of infection. She said residents on EBP should have a care plan so staff would be able to know how to care for the residents. R7's POS (Physician Order Sheet) dated 4/2/26 shows active order not limited to: Wound Care: Sacrum Cleanse site with NSS, Pat dry with gauze, apply hydrofera blue to wound bed and cover with a dry dressing everyday shift for Wound Care AND as needed for soiled or compromised dressings. Reviewed R7's care plan, no care plan found for EBP (Enhanced Barrier Precautions). Facility's Enhanced Barrier Precautions (EBP) policy dated 3/20/26 shows in part: to minimize the risk of acquiring, transmitting, or complications resulting to multi-drug resistant organism (MDRO) colonization among residents n this setting. Populations affected: Residents with wounds. Residents will require the use of personal protective equipment (PPE) for high-risk activities such as wound care. PPE required: Gowns, gloves. Persons expected to encounter these circumstances are to don PPE (gown and gloves) in accordance with the activity that will be encountered when caring for the resident. Facility's EBP signage shows in part: providers and staff must wear gloves and a gown for the following high-contact resident care activities – wound care: any skin opening requiring a dressing. Facility's Comprehensive care plan policy dated 11/17/17 shows in part: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The facility will develop and implement a comprehensive person – centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing needs. 2. On 03/31/26 at 09:21 AM V9 (Licensed Practical Nurse) requested that a staff member remove the blood pressure machine from R215's room with Enhanced Barrier Precaution signage observed posted on the door. V9 proceeded down the hall with the blood pressure machine to R53's room. On 03/31/26 at 09:25 AM V9 (Licensed Practical Nurse) entered R53's room with Enhanced Barrier Precaution signage observed posted on the door. V9 failed to clean and disinfect the blood pressure machine and pulse oximeter prior to placing the blood pressure cuff on R53's right arm and pulse oximeter on R53's right index finger, obtaining a blood pressure reading of 114/64, pulse 82 and oxygen saturation 98%. V9 then exited the room with the blood pressure machine without cleaning and disinfecting it. On 03/31/26 at 09:32 AM V9 (Licensed Practical Nurse) entered R56's room with the blood pressure machine, applied the blood pressure cuff to R56's right arm with the pulse oximeter on the right middle finger obtaining a blood pressure reading of125/64, pulse 85 and oxygen saturation 94%. At 09:35 AM V9 exited R56's room with the blood pressure machine without cleaning and disinfecting it then prepared R56's medication. On 03/31/26 at 09:47 AM V9 (Licensed Practical Nurse) entered R112's room, applied the blood pressure cuff to R112's right arm and pulse oximeter to the right index finger obtaining a blood pressure reading of 101/41 pulse 41. V9 exited R112's room then said the blood pressure machine is getting a low reading check. At 09:52 AM V9 retrieved a portable blood pressure machine from the bottom drawer of the medication cart then reentered R112's room. V9 applied the blood pressure cuff to R112's right arm and obtained a blood pressure reading of 112/67. V9 returned to the medication cart and placed the blood pressure cuff on top of the medication cart without cleaning and disinfecting it. On 03/31/26 at 09:53 AM V9 (Licensed Practical Nurse) returned to the medication cart without performing hand hygiene then V9 began preparing R112's medications. V9 entered R112's room and administered R112's oral medications. At 10:09 AM V9 exited R112's room without performing hand hygiene then proceeded down the hallway with the medication cart and blood pressure machine. On 03/31/26 at 10:11 AM V9 (Licensed Practical Nurse) entered R119's room with Enhanced Barrier Precaution signage observed posted on R119's door without performing hand hygiene. V9 placed the blood pressure on R119's right arm and could not get a reading. V9 returned to the medication cart and retrieved the portable blood pressure cuff from the top of the medication cart then reentered R119's room and placed the blood pressure cuff on R119's right arm obtaining a blood pressure reading of 123/77 pulse 77. On 03/31/26 at 10:18 AM surveyor asked V9 (Licensed Practical Nurse) the procedure for cleaning the reusable blood pressure machine and portable blood pressure cuff. V9 responded we are supposed to wipe it down when it is used between two residents. It is sanitized to decrease infection, bacteria and contamination to the next resident. We are supposed to use sanitizer or wash our hands between residents to keep down infection and bacteria. On 04/02/26 at 10:00 AM V2 (Director of Nursing) stated When taking a resident's blood pressure, perform hand hygiene, clean the blood pressure cuff between each resident for infection control, not to transfer bacteria or anything on the blood pressure cuff from one resident skin to another. Policy: Titled Cleaning and Sanitizing -Wheelchairs and other Medical Equipment revised 01/25/18 document in part: Purpose: To ensure that devices are cleaned and sanitized on a regular or as needed basis. Equipment/devices used by more than one resident will be cleaned and sanitized between each use. 4. All surfaces shall be thoroughly cleaned with a sanitizing agent which prohibits the growth of bacteria and microorganisms. 5. Devices/equipment used for more than one resident shall be cleaned between each resident. Titled Hand Hygiene/Handwashing revised 01/10/18 document in part: Hand hygiene means cleaning your hands by using either handwashing, antiseptic hand wash, or antiseptic hand rub. Examples of when to perform hand hygiene (either alcohol-based hand sanitizer or handwashing): Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure). After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Titled Medication Administration dated 10/25/14 document in part: Procedures: 2. Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming in direct contact with a resident.

Based on observation, interview and record review, the facility failed to ensure the call light was within reach for two (R1 and R13) of two residents reviewed for reasonable accommodation of needs in a sample of 35. The findings include: 1.) R1's face sheet/admission record shows admission date on 9/12/25 with diagnoses not limited to Pneumonitis due to inhalation of food and vomit, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Essential (primary) hypertension, Nontraumatic subdural hemorrhage, Chronic embolism and thrombosis of unspecified deep veins of left lower extremity, Conversion disorder with seizures or convulsions, Dysphagia, Adult failure to thrive. R1's MDS (Minimum Data Set) dated 2/4/2026 shows R1's cognition is intact. He needed Supervision or touching assistance with eating, chair/bed and toilet transfer, Partial/moderate assistance with oral, toileting and personal hygiene, shower/bathe self, upper and lower body dressing. R1's Care plan dated 11/25/2025 shows in part: R1 is at risk for falls due to Deconditioning, Gait/balance problems, and Paralysis. Be sure call light is within reach and encourage R1 to use it for assistance as needed. On 3/31/26 At 11:44AM R1 was sitting up in a wheelchair at the bedside, alert and verbally responsive. R1's left hand is contracted with splint/device on left arm. R1's call light on the other side of the bed on the floor not accessible to R1. R1 stated he can't reach the call light. He said he uses call light when he needs something from the staff. On 3/31/2026 At 11:49AM V6 (Certified Nursing Assistant/CNA) requested in R1's room and picked up the call light on the floor and kept it by R1's side accessible to him. V6 stated call light should always be within reach. On 4/2/26 At 10:59AM V2 (Director of Nursing/DON) stated call light is used for safety, and alert staff regarding needs of the residents. She said call light should always be placed within physical reach of the resident, so safety and personal needs are met. Facility's Call light policy dated 2/2/18 shows in part: All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2.) R13's has diagnosis including and not limited to Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy, Primary Generalized (Osteo)Arthritis, History of Falling and Peripheral Vascular Disease. R13's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 09 indicating moderate impairment. R13's Care Plan document in part: Focus: R13 is at risk for falls Deconditioning, History of falling and, Gait/balance problems. Interventions: Keep needed items, water, etc. in reach. Be sure call light is within reach and encourage R13 to use it for assistance as needed. On 03/31/26 at 12:51 PM R13 was observed lying in bed. Surveyor asked R13 did he used the call light. R13 stated I would use the call light if I knew where it was. I don't even know where it is. R13's call light was observed on the floor under the left side of R13's bed out of reach. On 03/31/26 at 12:54 PM V12 (CNA) entered R13's room. Surveyor asked V12 the location of R13's call light. V12 proceeded to pick up R13's call light and clipped it to R13's sheet. Surveyor asked V12 was the call light on the floor. V12 responded, yes ma'am it was under R13's bed. R13 knows how to use the call light, and it should have been attached to R13's bed. I made my rounds, and I thought R13's call light was on his bed. If the call light is not in the residents' reach it could have been something R13 really needed. On 04/02/26 at 10:00 AM V2 (Director of Nursing) stated The call light is put in the resident reach and assessed if the resident can reach the call light. It should be within physical reach and place it with the resident's preference. If the call light is not within the residents' reach, there is a potential that they will not get the assistance they need or get anyone's attention. The call light placement should be checked when rounding.

Based on interview and record review, the facility failed to obtain a physician order for a code status for two (R10, and R12) out of eight residents reviewed for advance directive in a total sample of thirty-five. Findings Include: R10's Minimum Data Set (MDS) dated [DATE] noted she is moderately cognitively impaired. R10's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. She is [AGE] years old with diagnoses not limited to type 2 diabetes mellitus without complications, dementia, obstructive and reflux uropathy, myocardial infarction, and chronic kidney disease. 2. R12's Minimum Data Set (MDS) dated [DATE] noted she is cognitively intact. R12's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. She is [AGE] years old with diagnoses not limited to type 2 diabetes mellitus with neuropathy, heart failure, end stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease, cervicalgia, and adult failure to thrive. On 04/01/26 at 10:16 AM, V20 (Assistant Social Services Coordinator) stated that she oversees the care plan section of the code status. The code status should be in the Physician Order Sheet (POS) to ensure the residents' wishes are documented and honored. The surveyor and V20 reviewed R10 and R12's POS, but the code status was not documented at this time. On 04/01/26 at 10:43 AM, V21 (Licensed Practical Nurse) stated that she has been in the facility for one year six months. The code status, either Do Not Resuscitate/DNR or Full Code should be documented in the POS upon admission to prevent wrong intervention during an emergency. On 04/02/2 at 11:16 AM, V2 (Director of Nursing) stated that it is her expectation that nurses will document residents' code status in the POS upon admission, and a corresponding care plan should be completed by the social worker. R10's full code status care plan initiated on 01/30/26, R10's late POS with a date stamped 04/01/26 at 11:32 AM. R12's full code status care plan initiated on 07/24/25, R12's late POS with a date stamped 04/01/26 at 20:56 (8:56 PM). Facility Advance Directives Policy dated 02/12/25, documents in part; (9) A written physician's order is required in response to the resident's Advance Directive(s). Physician's order shall be specific and address each Advanced Directive(s).

Based on observation, interview and record review, the facility failed to provide a clinical contraindication for gradual dose reduction (GDR) for residents receiving psychotropic medications. This failure resulted in three residents (R3, R11, R70) not having a gradual dose reduction (GDR) attempted/completed for medications they receive. Findings include: 1. R3's electronic health record (EHR) documents in part a diagnosis of Dementia with Moderate Mood Disturbance, Schizophrenia, Bipolar Disorder, Brief Psychotic Disorder. R3's Minimum Data Set (MDS) dated [DATE] documents in part, R3 receives antipsychotic medications on a routine basis, a GDR has not been attempted, and the physician has not documented GDR as clinically contraindicated.R3's Order Summary Report review of physician orders documents in part, R3 has an active order for the following medications: Depakote 500 mg two times a day for agitation (start date 12/13/24), Haloperidol 10 mg give 0.5 tablet by mouth two times a day for bipolar (start date 06/07/25), Lithium Carbonate extended release 450 mg one time a day (start date 11/12/24), Melatonin give 9 mg at bedtime (start date 11/11/24), Trazodone HCL tablet 50 mg give 1 tablet at bedtime related to Schizophrenia (start date 06/08/24).Review of R3's Psychiatry/Mental Health progress notes dated 09/18/25, 10/08/25, 11/08/25, 12/06/25, 01/11/26, 02/25/26 reveals that there was no recommendation for a GDR and there was no description of a clinical contraindication to attempt a GDR. Also, note R3's Psychiatry/Mental Health progress notes indicate R3 is receiving Depakote 500 mg daily however actual active order R3 is receiving is Depakote 500 mg two times a day.2. R11's EHR documents in part a diagnosis of Vascular Dementia with Other Behavioral Disturbance, Unspecified Psychosis Due To a Substance or Known Physiological Condition, Cognitive Communication Deficit. R11's MDS dated [DATE] documents in part, R11 receives antipsychotics on a routine basis, and a GDR has not been attempted, and the physician has not documented GDR as clinically contraindicated.R11's Order Summary Report review of physician orders documents in part, R11 has an active order for Quetiapine Fumarate 50 mg every 12 hours (start date 11/27/25). Note R11 was hospitalized from [DATE] to 11/26/25. Prior to hospitalization R11 had been receiving Quetiapine Fumarate 25 mg tablet with orders to give 50 mg two times a day for dementia with behavioral disturbance with psychotic features (start date 06/11/25, end date 11/25/25).Review of R11's Psychiatry/Mental Health progress notes dated 09/18/25, 10/08/25, 11/05/25, 12/06/25, 01/11/26, 02/06/26, 03/04/26 reviewed reveals that there was no recommendation for a GDR for Quetiapine Fumarate and there was no description of a clinical contraindication to attempt a GDR for Quetiapine Fumarate.3. R70's electronic health record (EHR) documents in part a diagnosis of Major Depressive Disorder, Paranoid Schizophrenia, Other Psychoactive Substance Abuse with Psychoactive Substance Induced Persisting Dementia. R70's Minimum Data Set (MDS) dated [DATE] documents in part, R3 receives antipsychotic medications on a routine basis.R70's Order Summary Report review of physician orders documents in part, R3 has an active order for Trazodone HCL 50 mg at bedtime (start date 04/02/25).Review of R70's Psychiatry/Mental Health progress notes dated 09/18/25, 10/08/25, 11/08/25, 12/06/25, 01/11/26, 02/25/26 reveals that there was no recommendation for a GDR for Trazodone and there was no description of a clinical contraindication to attempt a GDR for Trazodone. Note on the Psychiatry/Mental Health progress note dated 03/02/26, 12:38 Late Entry which documented GDR contraindicated. Patient needs this meds and dosage for stabilization is time stamped as being created on 04/02/26, 12:40:48.On 04/02/26 at 12:37 PM, V2 (Director of Nursing) stated GDR is gradual dose reduction for psychotropic medications (antidepressants, antipsychotics, hypnotics) and GDR should be considered every six months to determine what is the lowest dosage of that medication the resident can be on to give the optimal therapeutic result. V2 stated it is the prescribing providers responsibility to consider GDR and document reasoning if contraindicated. V2 stated the pharmacy consultant will send V2 recommendations for residents to consider GDR on and these pharmacy recommendations are then emailed to the Psych Nurse Practitioner. V2 stated it is then up to the Psych Nurse Practitioner to review the pharmacy form and decide if he wants to proceed with the recommendation or not and this should be indicated on the pharmacy recommendation form. V2 stated pharmacy recommendations do not become part of the resident's EHR. V2 started working at the facility in February 2026 she has not received any signed pharmacy recommendations back from the Psych Nurse Practitioner to date. V2 stated if the pharmacy recommendation is not signed, then it is not done. V2 stated the Psych Nurse Practitioner sees all of the residents on psychotropic medications monthly and puts all of his documentation in the resident's EHR under the progress note section. V2 stated the Psych Nurse Practitioner reviews the medications but does not specifically address GDR. V2 stated his notes do not have anything saying the GDR is contraindicated or provide a reasoning why. V2 stated the Psych Nurse Practitioner's progress notes only say to continue with the psychotropic medication or that the resident is stable. V2 stated this does not mean GDR is contraindicated because a resident could be stable but on a lower dose of the medication. V2 stated there needs to be an attempt to decrease the medication dosage to see if there is a negative outcome and this needs to be documented.V2 stated this issue also came up on the last annual survey and the regional nurse consultant did education with the Psych Nurse Practitioner when this occurred last year. V2 stated she had a conversation with the Psych Nurse Practitioner in February 2026 about the GDR and that he needed to document rationale if GDR was contraindicated because she could see that they were not being done. V2 stated the Psych Nurse Practitioner said, okay, I'll get it done. V2 stated since taking to the Psych Nurse Practitioner in February 2026, V2 has not noticed any change in his monthly documentation, he is continuing to list out the medications the resident is receiving, and then commenting that the resident is stable and to continue with the medication as ordered.On 04/02/26 at 2:27 PM, V2 stated the situation has been escalated and the Psych Nurse Practitioner will be terminated.Facility policy titled, Psychotropic Medication- Gradual Dose Reduction dated 02/01/28 documents in part, Purpose: To ensure that residents are not given psychotropic drugs unless drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions and residents who use psychotropic drugs shall receive gradual dose reductions and behavior interventions, uncles clinically contraindicated, in an effort to discontinue or reduce the medication. A gradual dose reduction shall be encouraged at least twice yearly unless previous attempts at reduction have been unsuccessful or reduction is clinically contraindicated.

Based on interviews and record reviews, the facility failed to refer a resident (R11) who was later identified with a mental disorder to the appropriate state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for one out of a total sample of 35 residents. Findings include:R11's Notice of PASRR Level I Screen Outcome dated 10/31/22 documents in part PASSR Level I Determination: No Level II Required - No SMI/ID/RC.R11's PASRR Outcome Explanation Notice of No PASRR Level II Required which documents in part, Your Level I screen does not show that you have a mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs.R11's admission Record documents in part an initial/original admit date of 11/04/22. It documents in part a diagnosis of Unspecified Psychosis (added 03/06/25).R11's admission Minimum Data Set (MDS) dated [DATE] indicates R11 did not have a Psychiatric/Mood Disorder.R11's MDS dated [DATE] indicates R11 has a Psychiatric/Mood Disorder with specific diagnosis of psychotic disorder.R11's Order Summary Report dated 04/02/26 indicates in part, R11 is receiving Citalopram, Quetiapine Fumarate and Divalproex Sodium.R11's care plan a care plan for R11 use of psychotropic medications related to behavior management dated 09/13/23.On 04/01/26 at 12:42 PM, V17 (Assistant Social Service Consultant) stated PASSR is to make sure residents are appropriate placed in a skilled nursing facility and not inappropriately placed if they have severe mental illness (SMI) such as depression, schizoaffective disorder, schizophrenia, bipolar, psychosis, delusional disorder, paranoid disorder. V17 stated a PASRR Level I screen gets completed prior to admission at the hospital to make sure the resident is appropriate for admission to the facility. V17 stated if a resident is initially admitted without a SMI diagnosis but then one is added after their initial admission then the facility would resubmit for a PASRR level I/II re-screen. V17 stated this is important to do to make sure the facility is providing the appropriate care for their diagnosis and the facility is still an appropriate placement for the resident. V17 stated for newly acquired SMI diagnosis it is the Social Service Departments responsibility to resubmit for another PASRR I/II screening to be completed. V17 stated R11 has a diagnosis of psychosis which was added after his initial admission and therefore R11 should have been referred to have a PASRR level I/II re-screen completed.Facility provided policy titled, Pre-admission Screening and Resident Review (PASRR) dated 11/17/17 which documents in part, the facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the state PASRR representative.

Based on interview and record review, the facility failed to refer a resident to the appropriate state-designated authority for a PASARR Level II Screen evaluation and determination with known mental illness for one (R35) out of eight residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35.Findings include:R35's electronic health records (EHR) indicate R35 was admitted to the facility on [DATE] with diagnosis including but not limited to Delusional Disorders upon admission.R35's Order Summary Report dated 04/01/26 includes but not limited to Seroquel 50 mg two times a day for delusional disorder.R35's MDS (Minimum Data Set) dated 03/09/26 documents in part, R97's active diagnoses include but not limited to Psychiatric/Mood Disorder including Psychotic Disorder.R35's Notice of PASRR I Screen Outcome dated 11/30/22 documents in part, PASRR Level I Determination: No Level II Required - No SMI/ID/RC.R35's PASRR Outcome Explanation Notice of No PASRR Level II Required document in part, Your Level I screen does not show that you have a mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have r may have a serious mental illness or an IDD and experience a significant change in treatment needs.On 04/01/26 at 12:42 PM, V17 (Assistant Social Service Consultant) stated PASSR is to make sure residents are appropriate placed in a skilled nursing facility and not inappropriately placed if they have severe mental illness (SMI) such as depression, schizoaffective disorder, schizophrenia, bipolar, psychosis, delusional disorder, paranoid disorder. V17 stated a PASRR Level I screen gets completed prior to admission at the hospital to make sure the resident is appropriate for admission to the facility. V17 stated if the resident has a SMI they are referred to for a PASRR Level II screen unless the resident has exemptions such as dementia, terminal illness, vent dependency, neuro cognitive. V17 stated collectively it is the facility responsibility to make sure that the information submitted by the hospital for the PASRR Level I is accurate. V17 stated R35 PASRR Level I screen was completed 11/30/22. V17 stated R35 was admitted to the facility with a diagnosis of delusional disorder which is a SMI but it was not included on the initial PASRR Level I Screen and it should have been. V17 stated R35 needs to have a PASRR level II screening completed.Facility provided policy titled, Pre-admission Screening and Resident Review (PASRR) dated 11/17/17 which documents in part, it is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability or related condition. Based upon the Level I screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed.

Based on observation, interview, and record review, the facility failed to ensure nail care was provided for one (R126) resident who requires supervision in grooming reviewed for Activities of Daily Living (ADL) out of eight residents in total sample of thirty-five. Findings Include: R126's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (15) indicates he is cognitively intact. R126 Electronic Health Record/EHR noted an active diagnosis of hemiplegia and hemiparesis affecting right dominant side, contracture of right hand, acquired absence of left leg below knee, acquired absence of other right toes, chronic kidney disease, and type 2 diabetes mellitus with diabetic nephropathy.R126's Minimum Data Set (MDS) dated [DATE] functional abilities assessment noted R126 requires partial/moderate assistance with personal hygiene.On 03/31/26 at 1:24 PM, R126 was observed up in a wheelchair in his room. R126's right hand was contracted with very long fingernails that overgrown the tips of his fingers. He also stated that no one ever offered to cut his long nail, but he wants his fingernails cut. On 4/1/26 at 10:45 AM, R126 was in his room still with very long fingernails, and stated no staff have come to cut his fingernails.On 04/01/26 at 10:47 AM, Surveyor and V22 (Licensed Practical Nurse) observed R126's fingernails, she stated that the fingernails are surely long! The Certified Nursing Assistant (CNA) should be providing nail care during daily grooming and as needed, but she will inform the CNA to cut R126's long fingernails now.On 04/01/26 at 10:52 AM, V23 (CNA) stated that she has been working at the facility for five years, fingernail clipping is part of grooming which should be done daily and as needed by the CNA. She also stated that having long fingernails could be a dignity issue.On 04/02/26 at 11:16 AM, V2 (Director of Nursing) stated that the CNAs should be providing nail clipping care during shower twice a week and as needed. She also stated that R126 could scratch himself, his long fingernails could cause indentation into the palm of his hand which could lead to skin breakdown and infection. The facility policy for Nail Care dated 1/25/18, documents in part: (1) Observe condition of resident nails during each time of bathing, note cleanliness, length uneven edges, hypertrophied nails.

Based on observation, interview, and record review, the facility failed to assist a resident (R78) out of bed for 1 out of a total sample of 35 residents reviewed for Activities of Daily Living (ADLs).Findings include: R78's admission Record documents in part diagnoses of pathological fracture of right femur, malignant neoplasm of prostate, secondary malignant neoplasm of bone, adult failure to thrive, hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke) affecting the left non-dominant side, absolute glaucoma in the right eye, and history of falling. R78's 2/27/2026 MDS (Minimum Data Set) assessment documents in part that R78 is cognitively intact, has functional limitations to upper extremity on one side, and is dependent on staff to transfer from bed to chair. R78's Care Plan Report documents in part that R78 presents with functional deficit in bed mobility related to generalized weakness and musculoskeletal impairment (revised 10/14/2024). R78 has an ADL (Activities of Daily Living) self-care performance deficit related to impaired balance, limited mobility, and musculoskeletal impairment (revised 12/05/2025). R78 is dependent on staff to transfer between the bed and chair (revised 2/04/2025). R78 uses wheelchair for locomotion (revised 2/04/2025). On 3/31/2026 at 12:59 PM, R78 laid in bed. R78 was oriented to person, place, and date. R78 stated wanting to get up out of bed because he has not gotten up to wheelchair in a while. R78 stated it feels like months since [R78] sat on the wheelchair. R78 stated can only tolerate wheelchair for a couple of hours due to right hip pain but would still like to get up out of bed. R78 stated [R78] does not have a schedule for facility to get R78 out of bed. During interview, R78 turned on call light at 1:02 PM stating I'm gonna call them now and see what they say. V10 (Certified Nursing Assistant/CNA) answered the call at 1:03 PM. R78 asked to get up out of bed. V10 stated you can get up today. I'll get you up. On 3/31/2026 at 1:59 PM, R78 remained in bed. R78 stated CNAs came into the room a couple of times stating they were going to get R78 up but has not done so. R78 stated I told you I knew it wasn't going to happen. I'm still in bed. On 3/31/2026 at 2:01 PM, surveyor observed V10 with another CNA down the hall assisting another resident. On 3/31/2026 at 2:27 PM, R78 remained in bed. On 3/31/2026 at 2:45 PM, V8 (Nurse) stated R78 did not have a get up out of bed schedule. On 3/31/2026 at 2:47 PM, V10 stated R78 did not have a get up out of bed schedule and can get up when R78 wants to. When asked if R78 will get up today, V10 stated not knowing that R78 wanted to get up (despite earlier observations). V10 asked V8, who was sitting nearby, if R78 could get up out of bed. V8 stated it should be fine if it's in R78's chair. After a couple of minutes, V10 pushed the mechanical lift near R78's room. On 3/31/2026 at 3:04 PM, V10 was at the nurses' station. R78 remained in bed and the mechanical lift outside R78's room. R78 stated V10 came into the room about five minutes ago asking where R78's high-back wheelchair was. R78 stated hasn't seen it since being moved to the current room for isolation. R78 stated V10 was going to look for it. On 3/31/2026 at 3:45 PM, R78 remained lying in bed. R78 stated staff have not been back to give R78 an update about getting out of bed or finding R78's wheelchair. R78 stated still wanting to get out of bed. On 4/01/2026 at 1:41 PM, R78 was lying in bed. R78 was oriented to person, place, date, and recalled surveyor and surveyor's roll. R78 stated facility did not get R78 out of bed yesterday. R78 stated facility brought in a high-back wheelchair this morning. R78 stated informing V10 that [R78] wanted to get up today. R78 stated wanting to be up in the wheelchair for two hours sometime after lunch and back in bed before dinner. On 4/01/2026 at 1:51 PM, V8 stated that staff including V10 are aware that R78 wants to get up to wheelchair. On 4/02/2026 (following day) at 10:11 AM, R78 stated staff did not assist R78 out of bed yesterday. R78 stated informing the morning staff and the evening staff that [R78] wanted to get out of bed, but they did not do so. On 4/02/2026 at 9:22 AM, V2 (Director of Nursing) stated R78 is alert and oriented and able to make needs known. V2 stated there are no contraindications as to why R78 cannot get up out of bed. V2 stated staff should have gotten R78 up out of bed into a high-back wheelchair. Facility's ADL Care policy documents in part: Activity of Daily Living will be performed according to resident needs and preferences. ADL will include bathing, dressing, grooming, toileting/incontinent care, eating, bed mobility, transfer, and restorative exercises. Facility's Resident Rights policy (effective 8/23/17) documents in part: Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement.

Based on interview and record review the facility failed to follow their fall prevention policy and safely transfer for one resident (R4). The facility failed to check the mechanical lift sling to ensure that the sling was safe for resident transfers. This failure resulted in R4 falling to the ground from a mechanical lift, causing R4 pain and being frightened every time the staff have to transfer R4. This failure affected one resident (R4) reviewed for falls. This past noncompliance occurred from 10/26/25 to 11/4/25. Findings include:R4's medical diagnoses include but are not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, essential hypertension, type 2 diabetes mellitus, obesity, peripheral vascular disease.R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, indicating R4's cognition is intact.R4's progress notes dated 10/26/25 at 5:20pm documents in part, CNA (Certified Nursing Assistant) called out for assistance to complete transfer from shower bed to bedroom. Resident fell on back side during transfer. Resident was alert and talking immediately after incident. Resident able to express pain and discomfort. Writer requested resident to hold steal (sic) while more assistance could be gathered. Aide stayed with resident while writer gathered assistance. Resident relocated to stretcher by the assistance of staff and EMT's (Emergency Medical Technician). Resident transferred to hospital for observation.R4's progress note dated 10/28/25 at 3:17pm documents in part, 10/26/25 - The resident had a documented fall today from an elevated surface. EMS was contacted due to the impact of the fall.On 01/26/26 at 11:17am V7 (Licensed Practical Nurse/LPN) stated that she was R4's nurse the day that R4 fell. V7 stated that she had seen V12 (Certified Nursing Assistant) struggling to adjust R4 in the mechanical lift and went to offer assistance. V7 stated that R4 was already on the mechanical lift when she went to assist V12. V7 stated that they were right at the door of R4's bedroom when R4 fell from the mechanical lift. V7 stated that they were trying to take R4 to R4's bed, the strap from the mechanical lift sling broke and R4 fell to the ground. V7 stated that R4 complained of some discomfort at the time of the fall. V7 stated that she instructed R4 not to move and instructed V12 to stay with R4 while she went to call 911. V7 stated that R4 was already on the mechanical lift when she went to assist V12 and she is unsure if V12 assessed the mechanical lift sling for wear and tear before placing it under R4.On 01/26/26 at 1:05pm R4 stated that after V12 (CNA) gave her a shower, V12 placed R4 in the hallway outside the door of R4's room. R4 stated that V12 then transferred R4 from the shower bed onto the mechanical lift. R4 stated that she was told by V12 that R4's room was too congested and would do the transfer to the lift in the hallway. R4 stated that after V12 lifted her up in the mechanical lift, V12 stated that something didn't feel right and started looking for help. R4 stated that V7 (Licensed Practical Nurse/LPN) came to assist with the transfer. R4 stated that at that time, the strap from the mechanical lift sling broke and R4 fell to the floor. R4 stated that when she fell to the ground, it felt like she fell on one leg and her butt cheek. R4 stated that after the fall, her left leg began to swell, and she has been having pain since the fall. R4 stated that she is frightened every time the staff have to transfer her. R4 stated that since she fell, she has been receiving bed baths because she is paranoid to get in the shower and fall again. On 01/26/26 at 2:55pm V12 (CNA) stated that R4 was already up and in the dining area when she arrived at work at 3pm. V12 stated that she did not know that the staff on the shift before hers had placed R4 on a defective sling. V12 stated that she showered R4 with the mechanical lift pad still under R4. V12 stated that with the assistance from V7 (LPN), they attempted to transfer R4 to bed with the mechanical lift. V12 stated that while R4 was in the air on the mechanical lift, the mechanical lift strap broke and R4 fell to the floor. V12 stated that she did not notice the worn-out strap before she tried to transfer R4. V12 stated that the feet straps of the mechanical lift sling snapped and R4 fell to the ground on R4's buttocks. V12 stated that R4 was in pain after the fall. V12 stated that she took pictures of the broken mechanical sling strap after R4's fall.On 01/26/26 at 3:00pm surveyor reviewed four photos of a broken and frayed strap in V12's (CNA) cellular phone dated 10/26/25.On 01/27/26 at 10:32am V17 (Restorative Nurse) stated that all staff are trained to use the mechanical lift. V17 stated that the staff are trained to inspect for wear and tear of the mechanical lift sling. V17 stated that if a mechanical lift sling is worn out, the staff have been instructed to give it to her so that it can be replaced. V17 stated that staff should not use a sling with worn hooks to transfer a resident. V17 stated that a mechanical sling with worn hooks may result in the hooks tearing during transfer, causing injury to the resident and/or staff. V17 stated that being dropped from the mechanical lift can cause fear of it happening again. V17 stated that the sling should have been inspected prior to R4's transfer and even prior to the staff putting it under R4. V17 stated that transfers should not be done in the hallway unless absolutely necessary. V17 stated that the mechanical lift is for transfers and is not a transport device. V17 stated that R4 was dropped from midair in the hallway. V17 stated that R4 never made it to R4's room.On 01/27/26 at 11:13am V1 (Administrator) stated that after R4's fall from the mechanical lift, they believed that the sling may have had a defect. V1 stated that the sling that was used for R4's transfer was sent to the manufacturer for inspection. V1 stated that the manufacturer stated that there were no manufacturer defects with the sling. On 01/27/26 at 12:53pm V18 (Nurse Practitioner/NP) stated that after R4's fall, R4 had some increased swelling to R4's legs. V18 stated that R4 complained of pain after the fall. V18 stated that R4' nervousness and anxiety is something that can be anticipated after a fall.On 01/27/26 at 2:24pm V2 (Director of Nursing/DON) stated that a quick inspection of the mechanical lift sling could have prevented R4's fall. V2 stated that from a reasonable person's perspective, she would absolutely be in fear of being transported after a fall. V2 stated that the mechanical lift should be used for transferring residents and not to transport them. V2 stated that transferring R4 from the hallway to R4's bed would be considered as transporting.On 01/27/26 at 3:45pm V3 (LPN) stated that R4 has been refusing showers since R4's fall. V3 stated that since R4 has been refusing to shower, she has instructed the CNAs to give R4 a bed bath. V3 stated that she does R4's skin assessment that is supposed to be done during showers while the CNA is giving R4 a bed bath.R4's care plan dated 12/31/25 documents in part, R4 requires use of full body lift for transfer. Diagnosis includes hemiplegia/hemiparesis. R4 will have no complications using the full body lift to next evaluation.R4's care plan dated 12/31/25 documents in part, R4 is at risk for falls related to hemiplegia/hemiparesis and gait/balance problems. R4 will be free of minor related to injury through the review date.Update: Resident was being transferred via (mechanical) lift when (mechanical) lift strap broke bringing resident down to the floor. Laundry and CNA staff was in-serviced on recognizing deteriorating (mechanical) lift pads and the proper procedure of removing them from circulation.Facility's policy titled Fall Prevention Program revision date 11/21/17 documents in part, Purpose: to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guideline: The Fall Prevention Program includes the following components: Methods to identify risk factors. Use and implementation of professional standards of practice. Adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. Standards:.Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service.Facility's policy titled Transfers - Manual Gait Belt and Mechanical Lifts revision date 01/19/18 documents in part, Purpose: In order to protect the safety and well-being of the staff and resident, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of residents. Guidelines:. 4. Mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to ensure that equipment remains in good working order.Facility's mechanical lift operator's manual titled Manual/Electric Portable patient Lift dated 2013 documents in part, Using the Sling: Warning. After each laundering (in accordance with instruction on the sling), inspect sling(s) for wear, tears, and loose stitching, bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. Lifting the Patient: Warning. When elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hander bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem. Adjustments for safety and comfort should be made before moving the patient. Prior to the start of this survey on 01/26/2026, the facility has taken the following actions to correct the noncompliance:On 10/27/2025, V12(CNA/Certified Nursing Assistant) received formal one on one training on mechanical lift transfers, sling functions, sit to stand transfers, and one person transfers.On 10/27/2025, a facility wide audit was done to inspect all mechanical lift pads for damage.On 10/26/2025 to 11/04/2025, all certified nursing assistants were in-serviced on the proper technique and transfer mechanics for the use of the mechanical lifts, and sit to stand transfers, with competency return demonstrations. Also, in-serviced on the inspection of the mechanical lift pads for damage.The Director of Nursing or designee to conduct random observations during different shifts of five residents three times a week for four weeks and monthly thereafter. Any issues or concerns identified were to be addressed/ corrected immediately. Audits started 10/27/2025 for four weeks and are ongoing monthly after the four weeks.The Administrator or designee to conduct random observations during different shifts of two laundry staff members three times a week for four weeks and monthly thereafter. Audits started 10/27/2025 for four weeks and are ongoing monthly after the four weeks.A QA meetings were held on 11/25/2025 and 01/20/2026 with the facility Medical Director, Facility Administrator, and Director of Nursing to review the plan of correction of 10/26/2025.

Based on observation, interview and record review, the facility failed to provide wound care treatment and change wound dressing as ordered by physician to one (R1) resident identified as a high risk for development of pressure ulcer. This failure affected one (R1) out of three residents reviewed for improper nursing care. As a result of this failure, R1 had worsening/deterioration and infection of pressure ulcer. The findings include: R1's admission record showed admission date of 5/12/2025 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Essential (primary) hypertension, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Acute respiratory failure with hypoxia, Pneumonitis due to inhalation of food and vomit, Encounter for attention to gastrostomy, Pressure ulcer of sacral region unstageable. R1's MDS (Minimum Data Set) dated 5/20/2025 showed R1 was rarely or never understood. R1 needed total assistance or dependent with oral, toileting and personal hygiene, shower/bathe self, upper and lower body dressing, chair/bed and toilet transfer. Always incontinent of bowel and bladder. MDS showed unstageable pressure ulcer that was present upon admission. R1's risk assessment/Braden Score was assessed on 5/14/25, 5/26/25, 6/2/25 and 6/11/25 and documented as 12 (high risk for acquiring pressure wounds). On 6/22/25 at 11:18AM Wound care observation conducted with V4 (Wound Care Director, Registered Nurse/RN) assisted by V8 (Restorative Aide, Certified Nursing Assistant/CNA). R1 was observed lying in bed, alert but nonverbal with enteral feeding infusing. R1 observed with wound dressing to sacral area dated 6/18/25, soaked with yellowish and some pinkish discharges. V4 stated wound dressing was dated 6/18/25 and the wound treatment order is daily. V4 said R1 has an unstageable pressure ulcer to sacrum extending to the buttocks. Observed wound bed pinkish with yellowish slough. V4 cleansed the wound with normal saline and pat dry with gauze. V4 applied skin prep on surrounding wound area. V4 applied Gentamycin ointment to wound bed then Santyl ointment to slough area and metronidazole cream to surrounding area prevent contamination per V4 then covered with dry gauze and foam dressing and dated 6/22/25. On 6/22/25 at 11:54AM V24 (Inhouse Nurse Practitioner/NP) stated she is following R1 and aware of the sacral wound and the wound care team is following/evaluating it. V24 stated there was a concern of wound infection so a wound culture was taken, and the result came out yesterday and read as positive for Proteus Mirabilis, A. Baumanii, CRE (Carbapenem-resistant Enterobacteriaceae). V24 stated R1 is currently on antibiotic treatment for wound infection. V24 said as a standard nursing practice, the wound dressing is dated when the dressing is changed to know when it was done or for communication purposes. She stated if the wound treatment or dressing is not changed as ordered it could potentially cause infection or wound deterioration. On 6/22/25 At 1:03pm V4 (Wound Care Director, RN) stated she has been working in the facility for almost a year. She stated the Wound MD (medical doctor) or NP is coming to facility weekly to follow up/evaluate resident's wound/pressure ulcer. V4 said wound treatments should be done and dressing should be changed as ordered by physician. She said the dressing is dated on the day of the treatment to know when it was done. V4 stated it is the facility's policy that the wound dressing should be dated. She said all treatment orders should be done and sign in the TAR (treatment administration record) once treatment was provided. V4 said nursing standard of practice when it was not signed, it was not done. She said when wound treatment was not done or dressing was not changed as ordered, potentially it can lead to decline or worsening of wound or infection. R1's EHR (electronic heath record) reviewed with V4 and stated R1's was admitted with unstageable pressure ulcer to sacrum, measured 2 x 1.3cm x unknown depth. V4 said on 5/27/25 sacrum pressure wound extended to the right buttock. On 6/17/25 wound assessment: Unstageable to sacrum extending to the right buttock, measurement: 8 x 8 cm x unknown. V4 said wound has worsened or declined due to increase of wound size. She said wound treatment order is Santyl and gentamicin to necrotic tissue, metronidazole cream for contamination and zinc to peri area then cover with dry dressing daily. V4 said sacral wound was observed getting bigger in size and ordered for wound culture. She said wound culture result dated 6/21/25 showed light growth proteus mirabilis and light growth CRE. V4 said R1 is on oral antibiotic for wound infection. V4 stated R1 has an order for moisture barrier cream with zinc to protect skin and prevent further breakout. On 6/22/25 At 2:54PM V2 (Director of Nursing/DON) stated he has been working in the facility for over a year now. He said staff is expected to do wound treatment and changed dressing as ordered. He said wound dressings should be dated on the day that it was done. V2 said moisture barrier cream with zinc oxide if it is ordered for the resident, should be done and signed in TAR (Treatment Administration Record). V2 said the standard nursing practice, if it was not signed or documented, then it was not done. He stated the purpose of moisture barrier cream is to prevent skin breakdown. V2 said he is aware of R1's wound culture. The result was received yesterday and showed CRE. He said R1 is currently on antibiotic for wound infection. V2 said if dressing was not changed or treatment was done as ordered, it could potentially lead to worsening/deterioration of the wound or infection. On 6/23/25 at 10:44AM V26 (Wound Doctor) was interviewed via phone and stated he has been a Wound MD for 30 years and servicing the facility for over a year. He said he comes to the facility once a week to see/evaluate resident's wounds/pressure ulcers. V26 said wound treatment should be done and dressing should be changed as ordered. If the staff is not providing wound care or treatment or if the dressing not changed as ordered, it could lead to worsening of wound or infection. V26 said moisture barrier cream with zinc is to prevent skin breakdown. He said he is following R1 and aware of sacral wound culture result with current order of antibiotic for wound infection. Skin/Wound Notes dated 5/27/2025 showed in part: R1's sacral wound now extends to right buttock. R1's May and June 2025 TAR (Treatment Administration Record) showed treatment order not limited to: Moisture Barrier with Zinc 10% Apply to buttocks topically every shift for Skin Care. Treatment order was not signed as treatment was provided on the following dates: 5/13/25 to 5/27/25, 5/30/25, 6/7/28 to 6/9/25, 6/12/25 and 6/16/25 to 6/21/25. V24's (NP) notes dated 6/21/2025 documented in part: R1 was seen by a wound care team, concerned about infection. Culture was collected and started on doxycycline. V26 (Wound Doctor) notes dated 5/15/25 showed in part: R1 with unstageable pressure on sacral measured 2.5 x 1.5 x 0.1cm. V26's notes dated 6/19/25 showed Unstageable pressure on sacral measured 9 x 7 x 0.3cm. Recommended: Doxycycline for wound infection. R1's wound assessment report dated 5/13/25 showed in part: Sacrum - Unstageable pressure. Size: 2 x 1.3 cm x unknown depth. Wound assessment dated [DATE] showed in part: Sacrum extending to right buttock. Size: 8 x 8 cm x unknown depth. R1's laboratory final result dated 6/21/25 showed in part: culture, wound: 1. Proteus mirabilis. 2. Ac. Baumanii - CRE. Isolation precautions may be required. R1's POS (Physician Order Sheet) dated 6/22/25 showed active order not limited to: -Doxycycline Hyclate Oral Tablet 100 MG (Doxycycline Hyclate) Give 1 tablet via G-Tube every 12 hours for Wound infection for 10 Days. Date ordered: 6/21/25. -Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth every 12 hours for Wound Infection for 7 Days. Date ordered 6/21/25. -Gentamicin Sulfate External Ointment 0.1 % (Gentamicin Sulfate (Topical) Apply to sacrum to R buttocks topically every day shift for wound care cleanse with NS, apply zinc oxide on peri-wound, apply Gentamicin to wound bed, calcium alginate cover with a foam dressing AND apply to sacrum to R buttocks topically as needed for wound care. Date ordered 6/12/25. -Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to sacrum to R buttocks topically every day shift for unstageable pressure injury Cleanse with normal saline. Pat dry with gauze. Skin Prep to periwound. Apply treatment and cover with foam dressing. AND apply to sacrum to R buttocks topically as needed for wound care. Date ordered: 6/12/25. -Moisture Barrier with Zinc 10% Apply to buttocks topically every shift for Skin Care. Date ordered 5/12/25. Care plan dated 5/14/25 showed in part: R1 has Pressure Injury to Sacrum, is at risk for delayed wound healing, and is at risk for further alteration in skin integrity related to: Cerebral Vascular Accident, History of Pressure Ulcers, Hypertension, Immobility, Incontinence of Bowel, and Incontinence of Urine. Care plan interventions included but not limited to: Moisture barrier cream/ointment after each incontinent episode. Treatment as ordered by provider. Facility's pressure injury and skin condition assessment policy dated 1/17/18 showed in part: Dressings which are applied to pressure ulcers, wounds shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness and signs and symptoms of infection. Physician ordered treatments shall be initialed by the staff on the electronic treatment administration record after each administration.

Based on observation, interviews and record review, the facility failed to make prescribed anticonvulsant medication (Dilantin/ Phenytoin) available for one a resident (R444), who is diagnosed with seizure disorder, had sub- therapeutic (low levels) of Dilantin in his blood according to lab-work, and missed a dose of his anticonvulsant medication; the facility failed to administer medication for one resident (R15) who has seizure disorder. This failure has affected R444, who had two episodes of seizures within five minutes of each other and resulted in R15 having sub- therapeutic levels Dilantin medication in the blood. Findings include: R444 is a [AGE] year old with diagnosis including but not limited to: Conversion disorder with seizures or convulsions, personal history of transient ischemic attack, congestive heart failure, hypertensive heart and chronic kidney disease with heart failure. R444's BIMS (Brief Interview of Mental Status) score as of 2/25/25 is 15, which indicates cognitively intact. On 3/3/25 at 11:53 AM, R444 was observed in hallway and complained of not having his seizure medication on 3/1/25, which resulted in two seizures on 3/2/25 in the morning. R444 said, they (facility) ran out of my seizure medication and I went without a dose on that night (3/1/25). The next morning, I had the seizures. I can't go without my medication. I'm epileptic. On 3/4/2025 at 12:11 PM, Surveyor observed emergency medication supply in the first-floor medication room with V14 (LPN). At that time, V14 accessed the emergency medication supply computer and affirmed that six doses of Dilantin 100 MG were noted in the emergency medication supply. On 3/4/2025 at 12:11 PM, V14 stated if medications are not available, the nurses are to call the pharmacy to pull from the emergency supply. If emergency supply is not available, the nurse should tell the pharmacy to send the medication STAT (as soon as possible). On 3/4/2025 at 1:34 PM, V20 (Nurse Supervisor) said, If the therapeutic levels are low, I would advocate for increased dose or one time dose. The therapeutic levels are to keep a resident from having seizures or reduce seizures. It indicates the effectiveness of a medication in the body. On 3/4/2025 at 1:34 PM, V20 (Nurse Supervisor) said that medication should be reordered once there are five tablets left on the dispensing card. This is to give them enough time to get the medication and not run out. We have an emergency medication dispenser that all nurses are aware of. Agency nurses have to get access to emergency medication from a staff nurse, but all nurses are able to get medication from the emergency box. On 3/6/25 at 11:01 AM, V45 (MD/Medical Doctor) said, The labs indicate the amount of medication that is in the blood. For the therapeutic range of Dilantin, as long as it is within 10-20 ug/ml (microgram per milliliter), the resident is at decreased risk for seizure. With a sub-therapeutic Dilantin level and a missed dose, that could be the reason for a seizure. The dosage needed to be increased. Surveyor inquired about the adverse effects of continued low levels of Dilantin in the blood and a missed dose of Dilantin, V45 (MD) said that the resident could end up having more seizures. On 3/6/25 at 11:01 AM, V45 (MD) said that a complication from seizures is possible aspiration which could result in death. On 3/6/25 at 3:10 PM, V44 (LPN/ Licensed Practical Nurse) said, R444 was out of his medication (Dilantin) on 3/1/25 and the pharmacy was out delivering R444's medication on that day. Surveyor inquired about the emergency medication dispenser, V44 (LPN) said that she (V44) does not have access to the emergency medication dispenser and don't believe that any nurse in the facility on 3/1/25 had access to the emergency medication dispenser. MAR (Medication Administration Record) for the period of 3/1/25- 3/31/25 documents, R444's anticonvulsant medication N/A (not available) per V44 (LPN). Progress note dated 3/2/25 documents, R444 experienced two mild seizures. The first one occurred approximately at 06:42 and it lasted for one minute. The second seizure occurred two minutes after the first lasting for one more minute. R444's Care plan dated 2/18/25 documents, R444 has seizure disorder; give medication as ordered. R444's Order Recap report documents, Dilantin Oral capsule; give two tablets by mouth two times a day for seizure activity starting 2/19/25 and ending 3/4/25. R444's Laboratory Report dated 2/19/25, documents Phenytoin (Dilantin) level as 2.4 L (Low) with a reference range of 10-20 ug/ml (microgram per milliliter). R444's progress note dated 2/21/25 documents, Phenytoin level 2.4. New order to repeat level in one week. R444's progress note dated 2/26/25 documents, Medical Doctor contacted regarding abnormal labs, no new orders given at this time. R444's Laboratory Report dated 2/27/25, documents Phenytoin (Dilantin) level as 3.8 L (Low) with a reference range of 10-20 ug/ml (microgram per milliliter). R444's Medication Administration Record for 3/2025 documents, Dilantin NA (Not Available) for R444 on 3/1/25 at 1800 (6:00 PM). R444's progress note dated 3/2/25 documents, R444 experienced two mild seizures. The first seizure occurred approximately at 6:42 AM and lasted for one minute. The second seizure occurred two minutes after the first and lasted for one minutes. Facility policy titled Medication Administration documents, medications are administered as prescribed in accordance with good nursing principles and practices; the facility has sufficient staff and medication distribution system to ensure safe administration of medications without unnecessary interruptions; if a medication with a current, active order cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/ emergency kit. 52136 Findings include: On 3/3/25 at 12:47 PM R15 was observed lying in bed resting, R 15's dresser next to bedside was observed to have a bottle of Liquid suspension Phenytoin sitting on dresser with R15's name on it. R15 stated she was unaware who placed the Phenytoin on her dresser, and she thought she was no longer receiving Phenytoin medication. R15's face sheet dated March 4, 2025, shows R15 was admitted to the facility on [DATE] with multiple diagnoses including Convulsions, schizophrenia, hypertension, dementia, insomnia, glaucoma (left eye), rheumatoid arthritis, major depressive disorder, cognitive communication deficit . R15's MDS (Minimum Data Set) dated December 6, 2024, shows R15 has a score of 13 which means R15 is cognitively intact. R15's care plan dated July 30,2024 shows R15 has potential for injury from seizure activity. Intervention/Tasks: staff will administer [R15's] anti-seizure medication as ordered. R15's Physician Order Sheet with order dated for June 3,2024 that states Dilantin Oral Suspension 125 MG/ML (Phenytoin) give 5 ml by mouth two times a day for seizures. On 03/03/25 at 12:52 PM V 21 Licensed Practical Nurse (LPN ) stated that she is the nurse for R15 and that R15 is not allowed to self-administer her own medication because she does not have an order to self-administer medication. V21 stated there are a lot of resident's who wander on this unit and there is a high risk for a resident to wander into anymore and take the Phenytoin medication that was sitting on the dresser.V21 stated that R15 has an active order to receive Phenytoin suspension twice a day and that she did not administer Phenytoin suspension per physicians orders today because she was unable to locate the medication in the cart and was going to contact pharmacy. V21 was given the Phenytoin suspension bottle that was on top of R15's dresser by the surveyor and V21 confirmed the Phenytoin suspension medication was prescribed for R15. R15's Medication Administration Record dated for March 4,2025 displays that Phenytoin 5ml medication dose was not administered by V21 on March 3, 2025, documentation charted by V21 at 10:00 am states NA (Not Available). R15's Phenytoin (Dilantin) level results dated for (2/18/25 is 3.7L, 2/25/25 is 4.4L, 3/4/25 is less than 1.8L). Laboratory report dated 3/4/25 states Phenytoin( Dilantin) level therapeutic reference range is (10-20). V21 documented in Progress note dated for 3/3/25 at 14:55 pm Dilantin medication made available at facility.NP aware next dose to be giving at schedule time. V43 Nurse Practitioner (NP) documented a progress note dated 3/4/25 at 18:59pm that states Results viewed for 3/4/25 by V43.See PCC (Point Click Care) for new orders for extra Dilantin. Okay for nurse to clear results and confirm orders. R15's prescription sheet for Phenytoin(Dilantin) dated for 3/5/25 with V43 as prescriber states Dilantin (Phenytoin) give 5ml by mouth one time only for low phenytoin level less than 1.7 until 3/4/25 23:59 pm, give extra 5mg tonight and **DAW** give 2.5ml by mouth two times a day for low phenytoin level less than 1.7 until 3/6/25 23;59pm, give an extra 2.5 ml with the already scheduled 5 ml at 10am and 5pm.

Based on interviews and record review, the facility failed to provide restorative services for four physically impaired residents: R445, R59, R88 and R85. This failure has affected four of four residents reviewed for restorative services and has resulted in R445 becoming visibly emotional while expressing her fear of deteriorating in bed. Findings include: R445 is a [AGE] year old with diagnosis including but not limited to: multiple sclerosis, secondary malignant neoplasm of brain, neuromuscular dysfunction of bladder and adult failure to thrive. R445's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. R59 is [AGE] year old with diagnosis including but not limited to: rheumatoid arthritis, functional quadriplegia, presence of unspecified artificial hip, contracture of muscle to right upper arm and left upper arm, contracture to muscle of right lower leg and left lower leg. R59's Care Plan documents, R59 has no cognitive impairment and/ or impaired thought process and functions at an independent level in decision making. R88 is [AGE] year old with diagnosis including but not limited to: Parkinsonism, depression, long term use of anticoagulants and essential hypertension. During investigation on 3/3/25 at 11:40 AM, R445 said that she sometimes get uncomfortable lying on her tailbone and that she is not repositioned correctly. Surveyor inquired about rehabilitation services such as therapy or restorative services. On 3/3/25 at 11:40 AM, R445 said I have not received any therapy or restorative services since being admitted to this facility about two weeks ago. I am capable of moving a little bit, but I feel like the more I lay here in bed, he more disabled I am becoming. I hate that I have to lay here and wait for help when I need to move. It becomes depressing. At that time, Surveyor noted R445 becoming tearful and emotional. Surveyor inquired about the facility's restorative program. On 3/3/25 at 11:59 AM, V13 (Restorative Director) said that upon admission to the facility, every resident is assessed by restorative and receives restorative services if they do not receive physical therapy, in order to maintain their current level of function and ROM (range of motion). V13 said, After a resident is assessed and it is determined that the resident would benefit from restorative services, the resident is then added to the restorative list (caseload). Their services should start no later than three to four days after their admission to the facility. It should not take two weeks for a resident to begin their restorative programs. Surveyor requested the restorative program schedule. On 3/3/25 at 11:59 AM, V13 (Restorative Director) said that there is no restorative schedule that the restorative team follows. On 3/3/25 at 11:59 AM, V13 said that she (V13) was not sure why R445 was not added to the restorative list and that the list is usually updated twice per month. On 3/4/25 at 9:45 AM, V22 (Restorative Nurse) said, We are supposed to see everyone on the restorative list daily for 15 minutes per day. If the restorative techs aren't working the floors as CNAs (Certified Nurse Assistants) due to call offs, they work the restorative program. There is no restorative schedule of days and times that residents receive services. On 3/4/25 at 12:00 PM, V25 said The restorative caseload list includes residents on restorative programs and what programs they are on. A resident can be on Active ROM (A) or Passive ROM (P) exercises that are done with a restorative aide. The restorative list is a way to make sure no resident is overlooked. On 3/5/25 at 10:35 AM, V3 (DON/ Director of Nursing) said that the purpose of the restorative staff is to exercise with patients at risk for contractures and deterioration. The goal is to maintain range of motion (ROM), functioning and to prevent further contraction. On 3/5/25 at 10:43 AM, V28 (Restorative Aide) said that she (V28) is the only restorative aide for the first floor and that when there is downtime from doing resident's weights or working the floor as a CNA, then she (V28) will do restorative exercises with some of the residents on her list. Surveyor inquired about R445 and R88 restorative services. On 03/05/25 at 10:20 AM, V28 (Restorative Aide) said that she (V28) had not worked with R445 as of yet and does restorative exercises with R88 when she (V28) is able to. On 03/05/25 at 10:20 AM, V28 said that there was no restorative schedule that she (V28) is aware of and that she (V28) does whatever she can in the time that she has. On 03/05/25 at 11:25 AM, R59 said that her last time exercising with staff was about one week ago. On 03/05/25 at 11:25 AM, V29 (Restorative Aide) said that she (V29) had not performed PROM (Passive Range of Motion) exercises on R59 in about a week because R59 seemed to be in pain when she exercises. On 03/05/25 at 11:26 AM, R59 that she has pain in her limbs sometimes because she never moves them, but has never said that she didn't want to exercise due to pain. Surveyor inquired about the purpose of bedbound and immobile residents receiving restorative services when there is no therapy in place. On 3/6/25 at 11:05 AM, V45 (MD/Medical Doctor) said that restorative services is important to restore the resident's condition and prevent further contractures. R455's Section GG- Functional Abilities assessment dated [DATE] documents, R445 needs partial assistance from another person to complete upper and lower extremity (arms and legs) range of motion. R445's Care Plan dated 2/21/25 documents, R445 would benefit from a PROM (Passive Range of Motion) program due to risk for developing contracture related to Multiple Sclerosis and general weakness; R445 will retain current ROM ability to the affected areas; Provide PROM exercises to the affected extremities as indicated. Facility's document titled Restorative Caseload excludes R445 as a resident receiving restorative services. R59's Section GG- Functional Abilities assessment dated [DATE] documents, R59 needs partial assistance from another person to complete upper and lower extremity (arms and legs) range of motion. R59's Care Plan documents, R59 presents with a functional deficit in bed mobility related to contractures and rheumatoid arthritis; R59 would benefit from a PROM program due to contractures; provide PROM exercises to the affected extremities as indicated. Facility's document titled Restorative Caseload includes R59 as a resident to receive passive ROM (range of motion) exercises. R88's Section GG- Functional Abilities assessment dated [DATE] documents, R88 needs partial assistance from another person to complete upper and lower extremity (arms and legs) range of motion. R88's Care Plan documents, R59 presents with a functional deficit in bed mobility related to contractures and rheumatoid arthritis; R88 would benefit from a PROM program due to the risk of developing contractures/ actual contractures provide PROM exercises to the affected extremities as indicated. Facility's document titled Restorative Caseload includes R88 as a resident to receive passive ROM (range of motion) exercises. Facility policy titled Restorative Nursing Program documents, Purpose: to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. 32338 On 3/4/25 at 10:15 AM, R85 complained that he stays in bed all day, and no staff has helped him with exercising his right leg and left arm for a while. R85 added that he(R85) understands that Restorative staff might not want to do exercise for his right arm because of the dressing on the right shoulder area, but that he(R85) wants the other leg and arm to be exercised so he will not get weaker and weaker by staying in bed. R85 explained that once when they (Restorative staff) came, he(R85) was getting ready to go for dialysis, and they (Restorative staff) never came back. R85 wants the restorative staff to come at a time different from his scheduled Dialysis time. R85 explained that he goes for Dialysis on Mondays, Wednesdays, and Fridays. On 3/4/25 at 2:20pm, V13(Restorative Director) stated that R85 was discharged from Therapy to Restorative Care about 2 weeks ago. V13 explained that she(V13) went to do restorative for R85 up to 3 times in the past 2 weeks. Inquired from V13 about the records of the restorative care she(V13) provided to R85 so far, V13 stated that she did not document it, but she follows the care plan and no records available. On 3/04/25 at 10:15 AM, R85 complained that he stays in bed all day, and no staff has helped him with exercising his right leg and left arm for a while. R85 added that he(R85) understands that Restorative staff might not want to do exercise for his right arm because of the dressing on the right shoulder area, but that he(R85) wants the other leg and arm to be exercised so he will not get weaker and weaker by staying in bed. R85 explained that once when they (Restorative staff) came, he(R85) was getting ready to go for dialysis, and they (Restorative staff) never came back. R85 wants the restorative staff to come at a time different from his scheduled Dialysis time. R85 explained that he goes for Dialysis on Mondays, Wednesdays, and Fridays. On 3/4/25 at 2:20pm, V13(Restorative Director) stated that R85 was discharged from Therapy to Restorative Care about 2 weeks ago. V13 explained that she(V13) went to do restorative for R85 up to 3 times in the past 2 weeks. Inquired from V13 about the records of the restorative care she(V13) provided to R85 so far, V13 stated that she did not document it, but she follows the care plan and no records available. R85's Physical Therapy Discharge Summary shows that R85 was discharged from therapy on 2/14/2025(almost 3 weeks ago). Care plan dated 7/16/24 states R85 would benefit from a PROM/AROM (Passive/Active Range of Motion) program due to the risk for developing contractures and would benefit from AROM (Active Range of Motion) program due to Weakness and Impaired Mobility. Facility's policy on Restorative Nursing Program dated 1/4/19 states in part: Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Documentation of the interventions and the resident's response will be completed with each implementation. Care plan dated 7/16/24 states R85 would benefit from a PROM/AROM (Passive/Active Range of Motion) program due to the risk for developing contractures and would benefit from AROM (Active Range of Motion) program due to Weakness and Impaired Mobility. Facility's policy on Restorative Nursing Program dated 1/4/19 states in part: Each resident involved in a restorative program will have an individualized program with individualized goals and measurable objectives documented on the plan of care. Documentation of the interventions and the resident's response will be completed with each implementation.

Based on observation, interviews and record review, the facility failed to provide continuous supplementary oxygen to one resident (R19); failed to provide the correct concentration of oxygen for R73; and failed to ensure that oxygen tubing for one resident (R544) was dated. This failure has resulted in R19 having an oxygen saturation of 89% and has the potential to affect 30 Residents using oxygen in the facility. Findings include: R19 is [AGE] year old with diagnosis including but not limited to: Chronic obstructive pulmonary disease, malignant neoplasm of unspecified bronchus or lung, secondary malignant neoplasm of brain and chronic kidney disease. During investigation on 3/3/25 at 11:15 AM, R19 yelled out, I can't breathe. At that time, Surveyor entered R19's room and noted a nasal cannula hanging from R19's ear but not placed into his nostril. On 3/3/25 at 11:15 AM, Surveyor went to inform V11 (LPN/ Licensed Practical Nurse) that R19 needed help ASAP (as soon as possible). On 3/3/25 at 11:16 AM V11 (LPN) measured R19's oxygen saturation with an oxygen monitoring device and the device documented 89 % oxygen on room air (without supplementary oxygen). At that time, V11 reapplied R19's nasal cannula to his (R19's) nose and observed his oxygen level increase on the oxygen monitoring device. Surveyor asked how long R19's nasal cannula was misplaced. On 3/3/25 at 11:20 AM V11 (LPN) said that she (V11) was not sure how long R19's oxygen tubing was misplaced Surveyor asked what the purpose of a continuous oxygen order, V11 (LPN) said that continuous oxygen orders are ordered for people who are not able to get enough oxygen alone (without supplementary oxygen). On 3/3/25 at 11:25 AM, R19 said, My oxygen been off of my face for a while now. I tried to call for help cause it was hard for me to breathe. Surveyor inquired about possible adverse reactions to a resident having low oxygen levels below 90%. On 3/6/25 at 11:03 AM, V45 (MD/Medical Doctor) said that a resident with low oxygen and no supplementary oxygen could continue to desaturate (oxygen levels decline) and can possibly result in respiratory failure. R19's Order listing report documents the following active oxygen order: Oxygen at 3 LPM (Liters per minute) per nasal cannula/ mask continuously, monitor every shift. R19's Care Plan report documents, R19 has altered respiratory status/ difficulty breathing related to COPD (Chronic obstructive pulmonary disease); monitor for signs and symptoms of respiratory distress. Facility Oxygen list documents thirty residents with active oxygen orders in the facility. Facility policy titled Oxygen Delivery System documents, it is the policy of this facility that oxygen will be delivered to the resident based upon physician's orders. Facility policy titled Oxygen Therapy documents, to deliver oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Indications for oxygen use via nasal cannula include: reverse the effects and symptoms of hypoxia; it is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care; keep resident as comfortable as possible. 45346 Findings include: R544's diagnosis includes, but are not limited to, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure with hypoxia, parkinsonism, unspecified, and essential (primary) hypertension. R544 has a Brief Interview for Mental Status (BIMS) dated 01/20/2025 which documents that R544 has a BIMS score of 15, indicating R544's cognition is intact. R544's Physician Order Summary Report dated 03/04/2025 documents, in part, Oxygen at 4 LPM (liters per minute) per nasal cannula continuously-monitor every shift. On 03/03/2025 at 11:39am observed R544 with oxygen concentrator machine, nasal cannula in nostrils, oxygen tubing was not dated with a date indicating when the tubing was changed. R544 stated staff change my oxygen tubing once a week and I haven't seen the staff place a label on the tubing. On 03/05/2025 at 11:05am V30(LPN/Licensed Practical Nurse) stated the oxygen tubing for those resident's requiring oxygen is changed weekly and as needed. V30 stated the nurse is responsible for changing the oxygen tubing. V30 stated the oxygen tubing and water canister should be dated with the date the change occurred. V30 stated the reason for changing the oxygen tubing and canister and dating the items is so that the resident does not have the canister and tubing for a longer than usual time and to prevent infection from occurring. On 03/05/2025 at 2:00pm V3(DON/Director of Nursing) stated the oxygen tubing is to be changed every Wednesday by the night shift nurse. V3 stated the oxygen tubing is not dated because the tubing does not have a place for the nurses to write the date. V3 stated a date is placed on the water canister when changed. V3 stated the oxygen tubing and water canister are changed to prevent bacteria and mold from growing. The facility's policy dated 12/1/2021 and titled Care and Cleaning of Respiratory Equipment documents in part, underneath Procedure: VII. Labeling A. All disposable respiratory equipment is labeled with date when placed in use. 51772 Findings include: R73's Face Sheet dated March 4, 2025 documents a diagnosis of including but not limited to Chronic Obstructive Pulmonary Disease, Long Term Use of Inhaled Steroids, Anemia, Unspecified Severe Protein-Calorie malnutrition, Bilateral Primary Osteoarthritis of Knee, Chronic Respiratory Failure with Hypoxia, Personal History of COVID-19, Repeated Falls. R73's Physician Order Sheet documents an order for Oxygen at 2 Liters per minute dated 7/20/2023. On 03/03/25 at 11:24 AM, R73 had 2 oxygen concentrator machines one on both sides R73's of bed. One of the Oxygen concentrators had a mask attached without a date. R73's oxygen concentrator was set to deliver 4 Liters per minute. R73 had an oxygen tank sitting on the floor at the head of his bed without a holder. On 03/04/25 at 01:34pm, V2, Director of Nursing (DON) stated that the resident's oxygen concentrator is set between 3 and 4 liters. V2, DON stated that he is not sure what R 73's oxygen concentrator should be set on 2, 3, or 4 liters. V2, DON asked R73 if he adjusts his oxygen and R73 stated NO. Facility's Policy document named Oxygen Delivery System documents It is the policy of the facility that oxygen will be delivered to the resident based upon physician's orders. Facility's Policy document named Oxygen Therapy documents the following: PURPOSE: To deliver oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Indications for oxygen use via nasal cannula include: -Reverse the effects and symptoms of hypoxia. Policy: It is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulation and the standard of care. Procedure: Keep resident as comfortable as possible.

Based on observation, interview and record review, the failed to ensure residents are free from unnecessary psychotropic medication use; failed to ensure that gradual dose reductions were completed. This failure caused harm to R58, causing R58 to exhibit symptoms of sedation. On 3/3/2025 at 10:37 AM, R58 was observed in semi-Fowlers position resting in bed. Resident was difficult to arouse by voice and appeared lethargic. When being interviewed, R58's voice was unclear when speaking and was falling asleep mid conversation. Record review of R58's minimum data set (dated 12/19/2024) documents in part that R58 has clear speech, is able to make self understood, able to express ideas and wants; has a brief interview of mental status summary score of 10, indicating R58 has cognitive impairment; has no hallucinations, delusions, physical/verbal or other behaviors towards others, has not rejected care; does not have any serious mental illness (SMI). Record review of R58's admission record documents in part a diagnosis of unspecified dementia without behavioral disturbance. Record review of R58's care plan identifies that R58 displays socially inappropriate behaviors, attention seeking behaviors and maladaptive behaviors related to R58's diagnosis of dementia with symptom manifestation including agitation, combative behaviors, verbally aggressive behaviors, crawling on the floor, and falsely accusing others of wrong doing; identifies R58 utilizes psychotropic medications with a goal of .free of drug related complications including .cognitive/behavioral impairment with interventions including, monitoring for fatigue, pacing/wandering, disrobing, inappropriate response to verbal communication, aggression towards others, Et Cetera and document per facility protocol. The plan of care does not identify other non-pharmacological interventions that were ineffective prior to administration of the psychotropic medications. Non-pharmacological interventions initiated prior to psychotropic medication use were requested on 3/5/2025 from V3 (Director of Nursing) and not received by the end of the survey. No symptoms of psychosis or other serious mental illness were noted within the care plan. Record review of R58's physician orders documents in part that R58 has an active order (dated 9/17/2023) for QUEtiapine Fumarate (Seroquel) (Antipsychotic Medication) 25 mg tablet, give 0.5 tablet (total dose=12.5 mg) by mouth at bedtime for dementia with behavioral disturbance. Additionally, R58 has an active order for Sertraline 25 (Antidepressant Medication) mg tablet, give 1 tablet by mouth one time per day for hypersexuality. Record review of Black Box Warning attached to R58's physician order documents in part, .Warning: Increased mortality in elderly patients with dementia-related psychosis (,) Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis . Record review of R58's behavioral charting documents does not document any abnormal or targeted behaviors (as identified within the plan of care or related to psychiatric diagnosis) from 10/2025-3/2025. On 3/4/2025 at 1:42 PM, V20 affirmed that V20 oversees the psychotropic medication use within the facility. V20 reviewed R58's physician orders and diagnosis and affirmed that R58 is receiving QUEtiapine for dementia and Sertraline for hypersexuality. V20 denied ever witnessing any psychotic behavior by R58 or any behaviors. V20 reviewed the black box warning attached to R58's order and affirmed that R58 is at increased risk of death. V20 was unaware why the medications what target behaviors were being addressed by the medication. V20 affirmed that R58 has clear speech and is usually pretty alert. V20 affirmed that antipsychotic medication use can cause sedation. On 3/5/2025 at 10:50 AM, V34 (Nurse Practitioner) affirmed that V34 is the psychiatric provider for R58 and is the prescriber for the R58's psychotropic medications. V34 explained that R58 is taking QUEtiapine for dementia with behaviors and Sertraline for hypersexuality. V34 stated that QUEtiapine is the standard of care for dementia with behavioral disturbances. V34 described R58's behaviors related to dementia as aggressive and resistive to staff. They (the facility) have to give the medication so R58 allows them to care for (R58) so she doesn't refuse. (R58) is also very sexual in the past and has a history of sticking objects in her privates. Surveyor read the black box warning to V34 and V34 affirmed that it can place residents at risk for cardiac events. Surveyor asked what V34's rationale is for treating R58 with QUEtiapine when it is not approved for dementia, and V34 responded, We don't really have much to treat dementia. There is one medication Rexulti that has been approved for dementia related aggression. V34 stated that V34 did not prescribe Rexulti (approved medication) because it's too new. V34 affirmed that R58 does not have any hallucinations, delusions or other signs of psychosis and is R58 is utilizing these medications to treat aggressive and hypersexual behaviors. V34 was unaware of the last time R58 had any behaviors. V34 stated that the psychotropic medication can have sedative effects and that is why it is typically given at night. On 3/5/2025 at 11:43 AM, R58 was observed resting in bed with respirations even and unlabored in bed. Surveyor attempted to arouse resident via voice and was unsuccessful. R49 (R58's Roommate) observed surveyor trying to wake R58 and R49 stated, Good luck! (R58) is always like that, knocked out. They (the staff) always have a hard time waking her up. R58's Minimum Data Set (dated 12/23/2024) documents in part that R58 has a Brief Interview of Mental Status Score (BIMS) of 15, indicating that R58 is cognitively intact. On 3/5/2025 at 12:27 PM, V31 (Pharmacy Consultant) affirmed that V31 is a pharmacist and is the consultant pharmacist for the facility. V31 explained that dementia with behaviors is absolutely not an appropriate diagnosis that warrants Seroquel (QUEtiapine) use. Using Seroquel (QUEtiapine) for aggression caused by dementia or hypersexual behavior is not appropriate. V31 stated that V31 recommended the QUEtiapine and Sertraline to be discontinued 9/17/2024 but was denied by the provider. V31 affirmed that R58 is due for GDR requests this month. V31 stated QUEtiapine is known for being very sedative and can have other side effects like abnormal involuntary movements. Facility policy titled, Psychotropic Medication- Gradual Dose Reduction (dated 2/1/18) documents in part, .Purpose: To ensure that residents are not given psychotropic drugs unless drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions .

Based on interview and record review, the facility failed to implement their fall prevention policy to ensure the safety of a resident by failing to assess for the risk for falls and implement appropriate fall prevention interventions. The facility also failed to provide supervision and assistive devices to utilize as necessary for one of three residents (R1) reviewed for falls. These failures resulted in R1 falling, requiring transport to the local emergency department where R1 was diagnosed with a closed fracture of the neck of the left femur, requiring surgical repair. Findings include: R1's clinical record indicates R1's medical diagnoses including epilepsy, history of falling, essential hypertension, dementia, psychotic disorder with delusions, elevated prostate, disorder of the kidney and ureter, and schizophrenia. R1's Minimum Date Set [MDS] section [C] dated 11/25/24 indicates R1 is severely cognitively impaired. R1's fall assessment indicates R1 is a high fall risk. R1's Lab: 11/25/24 phenytoin level = 23.2 [high level] the range is [10-20] valproic acid level = 35.4 [low] the range is [50-100] R1 hospital document dated 11/25 indicates in part: R1 admitting diagnosis of mechanical fall, closed fracture of neck of left femur. R1's concise hospital course: R1 arrived to the emergency department from the facility due to a mechanical fall on 11/25/2024. Per nursing home staff R1 was in dining room when he got up to stand and walk. He then fell landing on his left side. R1 begin endorsing severe pain with movement of the left foot leg after the fall on 11/25/24. X-rays were obtained of R1's bilateral hips, legs and knees and showed an acute left femoral neck fracture. Additional work up revealed supratherapeutic phenytoin level likely cause gait instability resulting in mechanical fall and urinary tract infection. Workup was negative for metabolic sources of encephalopathy, cardiogenic and neurogenic causes of syncope. Hip fracture treated with hemiarthroplasty on 11/27/24. R1's urinary tract infection was treated with intravenous antibiotics. R1's supratherapeutic phenytoin treated with the discontinue of medication and was replaced with Keppra (anti-convulsant). R1's hospital course complicated by post op hematoma of prostate posterior left hip. Orthopedic surgery recommended no reoperation in setting of risk of additional bleeding. R1's care plan documents the following: 9/2/24- R1 is to be up and in close proximity of staff attending to him d/t (due to) his impulsiveness to get up and wander around aimlessly. R1 is ambulatory but at times his gait can get unsteady. Labs were also ordered to rule out any abnormalities. 11/25/24- Staff were re-educated on the importance of being within close proximity of R1 due to his impulsiveness to get up and wander around aimlessly. R1 is ambulatory with supervision, touching assist but at times gait can be unsteady due to multiple contributing factors. Labs were previously ordered on this day. Findings were abnormal valproic acid level as well as abnormal phenytoin level which could have possibly contributed to the R1's unsteady gait. R1 was also sent out to hospital for x-ray of left hip due to complaints of pain. Staff will follow post-discharge medication regimen upon return to facility. R1 was also referred to therapy for gait/balance re-training. Fall mat on right side of bed also implemented to decrease chance of further injury. R1 also with 1:1 supervision as precautionary measure due to R1's impulsiveness to get up and walk unassisted. R1's progress note documented in part: 11/25/2024 17:12 V8 [Nurse Practitioner] Progress Notes Note Text: labs viewed for 11/25/24. Okay for nurse to clear labs. New orders to hold Phenytoin/Dilantin and increase in dosage for Divalproex BID. Plus, one-time extra dose of divalproex for low level. Nurse to confirm orders in PCC. 11/25/2024 21:36 Nurses Notes V7 [Licensed Practical Nurse] Note Text: R1 in the dining room with staff, patient attempted to stand and lost balance, falling on the left side. Assessed the patient, during assessment the patient expressed verbal pain to the left side. Staff stated R1 did not lose consciousness or hit his head. V8 [Nurse Practitioner] notified and received stat orders for pain management and to send the patient to the hospital. V3 [R1's Family Member] notified, voiced concerns, requesting a call from management. R1 left facility via ambulance. Interviews: On 12/7/24 at 10:20 AM, V3 [R1's Family Member] stated, On 11/25/24, the nursing staff called me and told me he was in the dining room, tried to stand up but lost his balance and fell on his left side. The first question I asked was how R1's phenytoin was and valproic acid levels. The nurse told me the phenytoin was 23.2 which is high and valproic acid level was 35.4 which was low. R1 was sent to the hospital because he complained of pain in his left hip. During R1's visit in the emergency department, the physician told me that R1's phenytoin level was like 32 which is high and valproic acid was low would make R1 weak, unbalance, unstable and disorientated that contributed to R1's fall, which led to a fracture left hip. Normally R1 was able to go from sit to stand and ambulate without any assistance or assistive devices. The nurse knew his level was high and she continued to give him the medication anyways, because his level in the hospital was much higher. The nursing staff know when his levels are not right, he will fall. The same situation happened in September; R1 fell but did not hurt himself. The director of nursing told me the nursing staff is aware that when R1's levels are not therapeutic, R1 is at a very high risk to fall and to monitor him closely. On 12/7/24 at 10:50 AM, R1 was resting in bed low to the floor, with a mat on the floor, call light in reach with a staff member at bedside. V9 [Certified Nurse Assistant] stated, I been sitting with R1, providing one to one assistance and monitoring. R1 has been resting and receiving pain medication as needed. On 12/7/24 at 1:40 PM V6 [Certified Nurse Assistant] stated, I was R1's certified nurse assistant on 11/25/24. I witnessed R1's fall. After dinner around 8:45 PM, R1 was in the dining room sitting in a chair, when he tried to stand up, lost his balance and fell . R1 was not in a wheelchair. I got the nurse [V7 Licensed Practical Nurse] to assess him. R1 did not complain of pain until we tried to put him in the bed. I was not made aware R1's seizure medication was abnormal, and he gait would be unsteady. After dinner other nursing certified aides was walking in and out the dining room toileting residents and assisting them to bed. I was not monitoring R1 continuous. When I entered back in the dining room, I saw the fall. On 12/8/24 at 9:05 AM V7 [Licensed Practical Nurse] stated, I been working here for thirteen years. I been taking care of R1 since his admission several years ago. I am familiar with R1. I was R1's nurse on 11/25/24. The start of my shift I noticed R1 was more confused and was not acting like himself. I know he usually act like this when his antiseizure medication levels are out of range. I notified V8 [Nurse Practitioner], and received an order for a phenytoin, and valproic acid level. I placed in the lab order and notified the lab. I continued with my morning medication pass. The lab came and took R1's blood, later R1 received all his medications. I worked a double shift on 11/25, later around 5 PM, I received his lab results. R1's phenytoin level was 23.2 [high level] the range is [10-20], valproic acid level was 35.4 [low] the range is [50-100]. I notified V8 and received an order to hold R1's evening dose of phenytoin and to increase R1's Depakote. After dinner around 9PM, R1 was sitting in the dining room when V6 observed him try to stand up from the chair, lost his balance and fell before she could reach him. I was in another resident's room when I heard R1 fall, I ran right in to assist. There was other residents and nursing staff going in and out the dining room taking residents to their room to change them and helping them to bed. I know when R1's phenytoin and Depakote levels are not in the correct range it makes R1 wobbly and more confused, which I noticed at the start of my shift. When R1 fell , I assessed him, and the nursing staff and I assisted R1, and he did not complain of pain. When we tried to help him in bed, R1 complained of pain in his left leg. I phoned V8 and received an order to send R1 to the hospital. I'm not sure if I told V6 to monitor R1 closely because his blood levels were abnormal. It was around dinner time, and everyone was busy. On 12/7/24 at 11:10 AM V10 [Licensed Practical Nurse] stated, I am R1's nurse today and familiar with R1. Since his fall he been in bed resting with a one-to-one sitter. V8 monitors R1 blood levels for his seizure medications. I know that when R1's seizure medication is high or low it makes R1 gait unsteady and needs close monitoring. On 12/7/24 at 2:10 PM, V5 [Director of Restorative/Registered Nurse] stated, I assist with fall investigations and develop an individualized care plan related to each fall, to prevent another fall from occurring. Prior to R1's fall he was able to go from sitting position to standing up alone without any assistance. R1 ambulated with a steady gait without any assistance from staff nor any assistive devices. On 9/2/24 R1 had a fall, when labs findings were abnormally low valproic acid level, which could have contributed to R1's fall. When valproic acid levels are low, that causes the resident to become weak and to have an unsteady gait. The interventions for 9/2/24 fall was for R1 to be up and in close proximity of staff attending to him due his impulsiveness to get up and wander around aimlessly. On 11/25/24, R1 was in the dining room after dinner around 8:30 PM, R1 went to stand up, lost his balance and fell . Interventions: staff was re-educated on importance of being within close proximity of R1 due to his impulsiveness. R1 is ambulatory but needs supervision, and at times his gait can be unstable due to his valproic acid levels and phenytoin levels were abnormal which could contribute to R1's fall. Now R1 is one -to one monitoring with low bed with mats. The nursing staff was made aware of R1's fall interventions for 9/2/24. R1 has been a resident here for some years. It's known that when his antiseizure medication levels are abnormal, R1 is at high risk to fall. R1's nurse should have monitored R1 closely and had him near her at the nursing station and provided R1 with a wheelchair due to his unsteady gait. On 12/7/24 at 3:38 PM V4 [Assistant Director of Nursing] stated, I reviewed R1's fall care plan. I seen R1 fell on [DATE] due to his seizure medication not being in therapeutic range. Whenever anyone's Depakote or phenytoin levels are not in therapeutic range it causes weakness, and unsteadiness. R1's plan of care indicates when R1's levels are not normal to monitor R1 closely. After dining the certified nurse assistances are taking residents out of the dining room, providing incontinent care can assisting residents to bed. R1's fall was avoidable, once V7 was made aware of R1's abnormal labs, V7 should have told R1's certified nurse assistant [V6], to monitor R1 very close. While the certified nurse assistants were busy providing care, V7 should've had R1 at the nursing station with her for close monitoring. Since R1's return, he has a sitter in his room to provide one to one monitoring. On 12/9/24 at 12:22 PM, V8 [Nurse Practitioner] stated, R1 is normally able to ambulate without assistance or the use of any assistive devices. The nurse [V7] made me aware that R1 was unsteady, and he was more confused than usual. I ordered Depakote and phenytoin levels. I reviewed R1's labs and ordered to hold R1's phenytoin for the next three days until 11/27/27 at 3PM. Re-start phenytoin on 11/27 at 5PM dose. I increase R1's Depakote dose I received a phone call that R1 had tried to stand up, lost his balance and fell on his left side. R1 became guarded on his left leg. I ordered state x-rays for R1, but the x-ray company could not come out. So, then I gave the order to sent R1 to the hospital for further evaluation. Policy documents in part: Fall prevention program dated 11/28/12 to assure the safety of all residents in the facility when possible. The program would include measures which determine the individual needs of each resident by assessing the risk of falls and implementing of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The fall prevention program uses and implements of professional standards of practice, and communication with direct care staff members, save the interventions will be implemented for each residence identified at risk, direct care staff will be orientated and trained in the fall prevention program. Licensed Practical Nurse job description: Direct the day-to-day functions of the nursing assistants. Provide leadership to nursing personnel assigned to your unit and ship. Monitor your assigned personnel to ensure they are following established safety regulations.

Based on interviews and record reviews the facility failed to follow their discharge policy to ensure R1 was safely discharged home with the necessary durable medical equipment [DME] in a sample of 6 residents. This failure resulted in R1 with an increase in pain to the surgical right hip, and emotional distress leaving R1 feeling upset, afraid, sometimes crying scared that R1 was going to fall and hurt herself. Findings included: R1's clinical record document in part: R1 is an [AGE] year-old admitted on [DATE] and discharged on [DATE], with the medical diagnosis of displaced fracture of base of neck of right femur encounter for closed fracture with routine healing, history of falling, Alzheimer disease, dementia, syncope and collapse, kidney failure, long term use of anticoagulant, abnormalities of gait and mobility, weakness, and lack of coordination. R1's minimum data set [MDS] Brief Interview Mental Status Score Indicates R10 is mildly cognitively impaired. R1's discharge summary documents in part dated 9/14/23: - Sitting to lying need moderate assistance -Chair to bed to chair transfer, need moderate assistance -Can not walk 10 feet independently, need moderate assistance -Weight bearing status -weight bearing as tolerated -No prior equipment used before hip fracture R1's progress notes document in part: -9/12/2023 14:35 Physiatry Progress Note Text: SERVICE DATE: 9/11/2023. PHYSICAL MEDICINE AND REHABILITATION PROGRESS NOTE CHIEF COMPLAINT: [R1] Impairment of ADLs and mobility 2/2 R hip fracture with muscle weakness and difficulty with functional mobility. R1 is an [AGE] year-old female with history of Alzheimer s disease with dementia, hypertension, who was admitted to the nursing home after a fall at home. The history was obtained by chart review. Reports from her family, as she has dementia, and she is a poor historian. The patient [R1] was recently transferred to a Memory Care facility from her assisted. living facility due to behavioral disturbances from her Alzheimer s dementia. After the fall x-ray of hip showed R femoral neck fracture. The patient [R1] was surgically treated and stabilized. The patient was transferred to this facility for subacute rehab to optimize functional status. I was asked to see the patient [R1]to optimize rehab. Assessment: ADL and mobility dysfunction, gait abnormality, pain management, right hip fracture, Alzheimer, dementia, fall risk. plan: pain: Norco 5 mg 1 tablet q.4h PRN. Tylenol for breakthrough. Wean opioids as tolerated. Continue to monitor for Fall risk: Continue fall precautions, Right hip fracture: continue to monitor for signs of increased pain, Alzheimer s dementia: Continue Aricept, and Behavioral medications, redirection. rehabilitation nursing, acute Interventions as warranted. Monitor closely for medication side effects and safety. R1's progress note documents: 9/15/2023 15:00 Social Service [V7-Social Service Assistant] Note Text: R1 will discharge back to the community on tomorrow 09/16/23 to live with V3 [R1's family member] in the community. Nursing staff has obtained an order of discharge to the community with medications and DME has been obtained from the physician and referrals faxed for Home Health and Home Health (another home health agency) and DME (medical equipment) to company on the resident's behalf. The resident's transportation will be arranged by V3 for the transition home and Nursing staff will assist in packing all of her belongings. All medications will go with the resident and V3 will be educated on all medications and upcoming appointments. All appropriate IDT [Interdisciplinary team] members have been informed of the discharge. R1's note documents: 9/15/2023 17:09 Nurses Notes [V9-Unit manager/Registered Nurse] text: V3 in facility met with Social Services staff [V7] and this writer. Discussed discharge plans again he wants home-health care and DME equipment now. V3 wanted a guarantee that resident DME and Home-health will be in place prior to discharge. Social Services staff [V7] informed V3 the referral was faxed out on the resident behalf. Other option discussed that resident can be discharged pending DME and home-health to begin. V3 agreed' s for resident to stay until 9/16/2023. On 10/5/23 at 9:47 AM, V3 [R1's Family Member] stated, R1 lived at home on her own, until R1's memory and cognition started to decrease. R1 then was moved to live in assisted living facility, but three days later the facility said R1 was not appropriate for assistant living due to R1's dementia, R1 was moved to their memory care facility. R1 fell and broke her hip at that facility. After her hospital stay R1 was transferred to the current facility for therapy. Around 9/12/23, someone notified my sibling that R1 was cut from the insurance. My sibling told me that she told the person, R1 could not return back to assisted living facility, because R1 did not meet the criteria, R1 could not walk nor transfer on her own, and there was a decrease in R1's memory. Also, because R1 fell and broke her hip on the memory care unit, R1 will not be going back to that facility, R1 will be going home. I was notified by V7 [Social Service Assistant] on 9/14/23 that R1's insurance company notified the facility on 9/12/23, that R1 will be cut from the insurance company and the last day covered day was on 9/14/23. On 9/15/23 I met with V7 and V9 [Unit Manager/Registered Nurse]. I explained to V7, V9 and therapy staff that R1 was in the memory care unit at her previous facility, but fell and fractured her hip, and R1 would not be returning to any facility, R1 would be going home. Also, R1 does not have any durable medical equipment [DME] at home because during that time R1 was walking. Therapy staff told me that R1 would need a wheelchair, and bed side commode at home for R1's safety. I requested to V7 and V9 that R1's DME (wheelchair and bed side commode) would need to be delivered prior to R1's discharge home. V7 ensured me that R1 will have the needed equipment before R1 is discharged . V7 told me she faxed over the information to the home health agency and medical equipment company. V7 gave me another option to pay $333.00 per day until Monday or Tuesday to wait for medical equipment to be delivered to the facility. I explained the family did not have over a thousand dollars to pay all those days. V7 then said that the equipment should be delivered to the house on 9/16/23, and I can pick R1 up on 9/16/23. I explained to V7 and V9 that I was not comfortable taking R1 home without the equipment delivered before R1 came home, and I felt, that the facility was made aware R1 was being cut on 9/12/23 and the DME should have been ordered earlier to ensure delivery before R1 was discharged home. V7 explained to me she was not a social worker and the social worker for the facility is on vacation and that she [V7] was doing the best she could do. Then I spoke to V2 [Director of Nursing] and I explained everything to her, she told me it was the family's responsibility to follow up with the discharge planner with the needs of R1. I picked up R1 on Saturday (9/16/23) the nurse told me no equipment was delivered to the facility and I informed the nurse that no equipment was delivered to R1's home. On the discharge paperwork the DME company was listed. On that following Monday (9/18/23), I called the DME company and spoke with the manager [V4]. She told me that they did not receive any fax from the facility regarding R1 and could not release any DME to me without the physician order. On 9/18/23 I received a phone call from V7, and she asked me if the DME was delivered. I told V7, no it was not delivered. V7 told me I have the phone number and for me to follow up with the DME company because the order was faxed. I have not received any more follow up calls from the facility. I have been R1's main caretaker, and by her not having the recommended DME (wheelchair and bed side commode), from 9/16/23 to 9/20/23, she was crying in pain, and scared to move with my assistance, afraid she was going to fall. I tried to give the facility a couple of days to correct the situation, since V7 was made aware that the DME was not delivered. However, on 9/21/23, I went and purchased a wheelchair and a bed side commode out of my own money. On 10/5/23 at 10:15 AM, R1 stated, I did not have my wheelchair, I was upset, afraid, sometimes cried, scared that I was going to fall and hurt myself. Trying to get around without a wheelchair, made my hip hurt really bad. On 10/4/23 at 10:56 AM, V4 [Operational Manager] stated, I'm in charge of this company, and this company supplies durable medical equipment to people in the community. The process is for me to receive the required physician order and insurance information from the facility. Then the medical equipment would be delivered to the person's home, or the facility requested. I work with the facility in question; however, I have no information on record for R1. No one from the facility requested any equipment for R1. On 10/4/243 at 2:40 PM, V10 [Therapy Director] stated, R1 is alert and oriented X2-3 and confused sometimes. I explained to V3 that R1 needed a wheelchair and a bed side commode for safe mobility and transfers along with 24-hour care. V3 told me that R1 would be going home upon discharge, and R1 did not have any equipment at home. Social service is responsible to order needed equipment at home. R1's last day of therapy was on 9/14/23. On 10/4/23 at 1:37 PM, V7 [Social Service Assistant] stated, I've been working here for [AGE] years as a social service assistant. I am not a social worker. I assess cognition, talk with the residents, follow up on behaviors, write care plans, and code the minimum data sets [MDS]. I have nothing to do with discharge planning. My director of social services [V8] completes the discharge planning. I wrote the social service discharge note for R1 dated 9/15/23 at 15:00, only because V8 was off work on vacation. R1 was a pleasant lady, alert, and oriented x1-2 with periods of confusion and needed extensive assistance. V8 had set up arrangements already for R1 and gave me the DME [Durable Medical Equipment] phone number to fax the order to, and I faxed the information on 9/15/23. On 9/18/23, I phoned V3 [R1's family member] to follow up. V3 told me the equipment was not there and he has spoken to the company to see if they will provide the equipment for R1. I did not call the DME company, because V3 said he had the number and already faxed the company. I did not follow back up with V3 to see if the equipment was delivered. On 10/4/23 at 2:10 PM, V8 [Social Service Director] stated, I was off work on vacation from 9/13/23 thru 9/24/23 and returned back on 9/25/23. While I was gone, V7 [Social Service Assistant] was covering the facility. I provided V7 with a discharge calendar and instructions. R1 was here for therapy with her personal insurance. R1's insurance company only gave the facility a 48- hours-notice, when the insurance will stop paying for services. R1's insurance company gave me a 48-hour notice on 9/12/23 via email. I called the first contact on R1's face sheet to notify the family. R1's daughter told me R1 was going back to assisted living facility, so that's why I did not order any DME equipment. I did not document in R1 electronic chart I just wrote it in on the Notice of Medicare Non-Coverage form. The next day on 9/13/23, I was off work on vacation. However, I left the referral and physician order with V7, all she had to do was fax the orders to the home health agency and DME company. I prepared the documents just in case R1 was going home. V7 could've sent the wheelchair here at the facility home with R1. That is what I do, if the DME is not going to be delivered on time. On 10/5/23 at 10:15 AM, V2 [Director of Nursing] stated, R1 is alert x2-3 with periods of confusion. R1 needs extensive assist for transfers. I was informed from V8 that R1 was going back to assisted living facility and R1 had a house but could not live there. V9 spoke with V3 [R1's family member] on 9/15/23 and told V3 there was no guarantee the DME (wheelchair and bed side commode) would be delivered on Saturday (9/16/23). Due to R1 being an insurance cut, that if R1 was not discharged by 9/16/23, then V3 would be responsible to pay $333.00 per day. V3 made the decision to take R1 home on 9/16/23. V7 told me she faxed over the order to the home health agency and DME company. V7 and V9 took over the discharge process with V3, because V8 was on vacation. The insurance cut occurred on 9/12/23, and V8 started her vacation on 9/13/23. V7, V9 nor I called the assistant living facility for a transfer in care. V9 intervened and assisted V3 from that point. When V8 received the insurance cut on 9/12/23, V8 should've had a clear understanding where R1 was going, to have the DME delivered timely. If a resident is discharged without the needed DME, the discharge could potentially be unsafe for the resident. On 10/5/23 at 10:45 AM, V9 [Unit Manager/Registered Nurse] stated, I started working here around 9/12/23. V7 came to me for a care plan for a discharge meeting with V3. V8 was out of town so I spoke with the family. During the care plan discharge meeting, V3 was made aware that R1 was cut by her insurance and need to be discharged by 9/16/23 or the family would need to pay $333.00 per day. V3 wanted R1 to be discharged home because the family did not have the $333.00 per day to pay. I told V3 that DME would not be there by 9/16/23, however V3 insisted for R1 to be discharged . The physician was made aware and gave the discharge order for R1 to go home on 9/16/23. V7 faxed over the information for home health and DME. I not sure what happened after that. On 10/5/23 at 11:20 AM, V1 [Administrator] stated, I've been an administrator since 1999. I have been working here since this April 2023. This facility has 240 beds. I have one social worker [V8] and one social worker assistant [V7]. V8 was on vacation from 9/13/23 thru 9/24/23 and returned on 9/25/23. V7 is not a social worker, but she was covering V8, we do not have any other social worker to cover. V8 was issued Notice of Medicare Non-Coverage was ending for R1 on 9/12/23. R1 was to leave on 9/14/23. V3 told the V8 that R1 was going back to assisted living facility. The last minute, on 9/15/23 V3 told the V7 that he wanted to take R1 home and needed DME delivered to the house by 9/16/23. V3 understood that the equipment will probably not deliver by 9/16/23 and he could have paid $333.00 per day for R1 to stay until the following Tuesday to ensure the equipment would be at the home. V3 did not want to cover the cost, so he took R1 home on 9/16/23. I was not aware that R1 never received her DME equipment/supplies. V8 doesn't work on the weekend anyways. All this happened on a weekend, not sure why a social worker needed to be involved on a Saturday. If V8 was not on vacation, she still would not have been in the facility on that Saturday anyways. If a resident is discharged without the necessary DME, potentially it can cause nothing, or a fall, increase in pain or an injury. Policy document in part: Notice of Transfer and discharge date d 5/8/23. -Discharge from the facility will include review of all necessary items to maintain the individuals highest practical well- being. This includes necessary DME or equipment.

Based on observations, interviews and review of records the facility failed to follow treatment per physician orders of a sacral pressure ulcers for 2 residents (R31 and R35) out of 35 residents reviewed for pressure ulcer treatment and prevention. These failures resulted in worsening of sacral pressure ulcer for R31 and R35 and opening of new wound for R31. Findings include: 1. R31 is [AGE] years old, initially admitted on [DATE]. R31's brief interview for mental status dated 12/21/2022 is 12 that means R31 cognition borders from being intact and moderately impaired. R31 medical diagnosis includes pressure ulcer stage 4, sepsis and Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. Review of R31's sacral treatment orders dated 9/15/2022 to present are as follows: Cleanse sacrum with normal saline or wound cleanser. Protect peri wound with skin prep, then apply calcium alginate and cover with dry dressing. On 01/11/2023 at 11:17 AM. With V29 (Wound Care Coordinator) said, Yes, R31 and R35 wounds worsened a little bit. However, V29 was unable to answer questions about resident pressure ulcers. V29 then said that she will print R31 and R35 orders. V29 then left the conference room and did not come back after multiple requests (V29 and surveyor spoke in the confrerence room). After review of R31's and R35's TAR for December 2022 and January 2023, multiple dates of treatment were initialed by V29 (Wound Coordinator) that was not present during review on 1/10/2023. R31's Treatment Administration Record for December 2022 reads that 17 days was not signed as treatment was performed. On 1/11/2023 at 11:46 AM, V29 came back and said that she signed treatment administration record (TAR) that was not previously signed for both residents (R31 and R35) for December 2022 and January 2023. V29 modified R31 and R35's TAR's after the surveyor asked for them to be printed and already saw the missing treatments. At 3:50 PM. V2 (Director of Nursing) was informed about modification of V29 putting her initial to treatment administration record today for dates that are in the past that extend up to December 2022 for both R31 and R35. V2 said, Yes, I was informed about that, and we will do something about it. But as to not documenting treatment or signing treatment, in nursing what is not documented is not done. Pressure ulcers has been identified as a problem and that we need to improve in that area. R31's sacral pressure injury wound assessments worsen and increased in size as to facility and physician assessment by V41 (Wound Doctor). Facility Wound Assessment of R31's sacral pressure injury are as follows: Pressure injury assessment dated [DATE] has a measurement of 4.3 by 4.4 centimeters (length by width) depth was documented as unapplicable. Total area of the pressure injury was 14.6 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 5.1 by 5.5 by 0.5 centimeters (length by width by width). Total area of the pressure injury was 23.2 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 6.1 by 5.6 by 0.7 centimeters (length by width by width). Total area of the pressure injury was 23.2 cm2 (square centimeter). V41 (Wound Doctor) assessment for R31 sacral wound are as follows: Pressure injury assessment dated [DATE] has a measurement of 4.3 by 4.4 by 0.5 centimeter (length by width by width). Total area of the pressure injury was 14.86 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 5.1 by 5.5 by 0.5 centimeter (length by width by width). Total area of the pressure injury was 22.03 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 6.2 by 6.9 by 1 centimeter (length by width by width). Total area of the pressure injury was 26.829 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 6.2 by 6.9 by 1 centimeter (length by width by width). Total area of the pressure injury was 33.599 cm2 (square centimeter). R31's sacral pressure injury wound assessments worsen and increased in size as to facility and physician assessment by V41 (Wound Doctor). Facility assessment dated [DATE] to 12/27/2022 increased in size, from 14.6 cm2 (square centimeter) to 23.2 cm2 (square centimeter). And V41 (Wound Doctor) assessment dated [DATE] to 1/5/2023 increased in size, from 14.86 cm2 (square centimeter) to 33.599 cm2 (square centimeter) more than doubled. R31's wound worsened and increased in size on the December 2022 TAR, where treatment on the TAR (Treatment Administration Record) was not signed as being performed as ordered by physician. On 1/11/2023 at 02:22 PM. R31 was seen with V29 inside the room. R31 was alert and verbally able to express his thoughts. V29 with the use of cotton tip and paper measuring tape measured R31's pressure injury. V29 said, These are the measurement of R31's pressure ulcer, 8 centimeter in length, 10 centimeter in width and 1.5 centimeter in depth (after placing the cotton tip at the bed of the pressure injury). Then V29 pushed the cotton tip inside R29's pressure ulcer at the upper right area. V29 then said, Yes, there is an undermining from 12 o'clock to 2 o'clock. Sacral pressure injury appears to be red, swollen, with drainage, also showing white color bone-like appearance around 2 by 2 centimeters length and width. Surveyor noticed a new wound in the left buttock with serosanguinous fluid in moderate amount. V29 then said, Yes, this is a new wound. I will measure it. Then V29 said, This is the measurements of R31's new pressure ulcer, 0.8 by 1.5 centimeters that length by width. 2. R35 is [AGE] years old, with medical diagnosis of Cerebral Infarction initially admitted on [DATE]. R35's brief interview for mental status dated 12/13/2022 was 12 that means R35 cognition borders from being intact and moderately impaired. R35 was seen on 1/10/2023 at 11:21 AM inside dining room alert and able to verbalize thoughts during conversation. R35 said that she has wound in her buttocks area. When asked if treatment was being done to her wound. R35 said, No, I don't remember if anyone did something on my wound. On 1/10/2023 review of R35's treatment on her sacral wound are as follows: R35 has physician order dated 12/13/2022 until 1/5/2023 for hydrocolloid dressing after cleansing with normal saline. This order was changed on 1/5/2023 for bordered foam dressing after cleansing with normal saline that still active currently. R35's treatment administration record (TAR) which document every time treatment is perform per physician was not signed as being performed from 1/5/2023 to 1/10/2023. R35's sacral pressure injury wound assessments worsen and increased in size as to facility and physician assessment by V41 (Wound Doctor). Facility Wound Assessment of R35's sacral pressure injury are as follows: Pressure injury assessment dated [DATE] has a measurement of 2.2 by 3.4 centimeters (length by width) depth was documented as unapplicable. Total area of the pressure injury was 4.5 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 2.5 by 3.1 by 0.2 centimeters (length by width by width). Total area of the pressure injury was 4.8 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 3.0 by 6.3 by 0.2 centimeters (length by width by width). Total area of the pressure injury was 7.1 cm2 (square centimeter). V41 (Wound Doctor) assessment for R35 sacral wound are as follows: Pressure injury assessment dated [DATE] has a measurement of 2.2 by 3.5 by 1 centimeter (length by width by width). Total area of the pressure injury was 6.048 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 2.6 by 3.1 by 0.2 centimeter (length by width by width). Total area of the pressure injury was 6.33 cm2 (square centimeter). Pressure injury assessment dated [DATE] has a measurement of 5.0 by 8.0 by 0.2 centimeter (length by width by width). Total area of the pressure injury was 31.416 cm2 (square centimeter). R35's sacral pressure injury wound assessments worsened and increased in size as to facility and physician assessment by V41 (Wound Doctor). Facility assessment dated [DATE] to 1/10/2023 increased in size, from 4.5 cm2 (square centimeter) to 7.1 cm2 (square centimeter). And V41 (Wound Doctor) assessment dated [DATE] to 1/12/2023 increased in size, from 6.048 cm2 (square centimeter) to 31.416 cm2 (square centimeter) more than 5 times increased in size. Per treatment administration record (TAR) physician order for treatment of sacral pressure injury dated 01/05/2023 to clean sacral pressure injury and cover with bordered foam dressing was not signed as treatment was being performed from 01/05/2023 to 01/10/2023 the same time pressure ulcer worsened. On 1/11/2023 at 02:38 PM. R35 was seen with V29 inside the room. R35 was alert and verbally able to express his thoughts. V29 with the use of cotton tip and paper measuring tape measured R35's pressure injury. V29 said, R35's wound has 5 centimeters length and 8.2 centimeters width. I put wound depth at 0.2 centimeter. R35 pressure injury appears to be red, swollen, with serosanguinous drainage. On 01/12/23 at 10:25 AM. V29 (Wound Coordinator) stated that both R31 and R35 sacral pressure sores increased in size. V29 further stated that part of the reason was incontinence, and it should be care planned. V29 denies doing the care plan, stated that R31's care plan does not include that she (R31) has pressure ulcer. V29 again admitted on signing treatments that was not signed. V29 stated that she modified orders, and signed treatment administration records because she was behind on her work. admitted on signing treatments that was not signed for both R31 and R35. Skin Protection Guideline Policy dated 7/7/2021 in part, reads: The purpose is to provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at the facility are evaluated and provided individualized interventions to prevent, reduced and treat skin breakdown. Policy does not include pressure ulcer documentation. After multiple requests for Wound pressure ulcer policy including procedure documentation or how to properly document treatments. On 01/12/2023 at 6:02 PM. V16 (Nurse Consultant / Registered Nurse) said that facility does not have policy specific to proper documentation of wound treatment. V16 further said that issues regarding wound documentation including treatment documentation was identified as a problem and would help if they have the policy.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for 2 (R3, R151) residents out of a total sample of 35 residents. This failure resulted in R3 sustaining a left forearm fracture. Findings include: 1. On 01/11/2023 at 09:38 AM, surveyor entered R3's room for an interview. R3 was alert and oriented to person, place, time, and situation. R3 stated [R3] fell sometime in the evening during late summer. R3 reported sustaining a left arm fracture from the fall. R3 stated V32 (CNA, Certified Nurse Aide) was providing incontinence care. R3 stated V32 positioned [R3] on left side facing the window. V32 left R3 and went to the bathroom to run the water in the sink and wait for it to get warm. R3 stated V32 told [R3] not to move but [R3] was having a hard time staying in place due to having a large, loose bowel movement and being too close to the edge of the bed. R3 stated while V32 was coming back from the bathroom, R3 slipped out of the bed and fell on the floor. R3 stated [R3] could not hold onto anything because [R3] doesn't have bedrails and was too close to the edge of the bed. R3 stated [R3] can lift left arm but right arm is weaker. Observed R3 lift left arm to shoulder height vs right arm which [R3] cannot lift as high. At 12:15 PM, surveyor reviewed facility's IDPH (Illinois Department of Public Health Incident Report Form for 08/26/2022 incident. It documents in part that R3 experienced a fall while in bed. R3 complained of left forearm pain. Left forearm and wrist x-ray resulted in possible acute fracture. R3 sent to the hospital for further evaluation. Facility's radiology report documents in part an x-ray of left forearm with examination date of 08/27/2022. Findings document in part: There is acute fracture in the middle third of the radius with moderate displacement and angulation. R3's hospital paperwork from 08/27/2022 hospital admission documents in part an x-ray of left forearm. Findings: There is an oblique minimally comminuted mildly displaced fracture of the mid shaft of the radius. Chronic deformity of the distal radius and ulna are seen with a suspected superimposed acute fracture involving the distal ulnar metaphysis. Soft tissue swelling is seen. At 12:26 PM, surveyor reviewed R3's progress notes. V30's (Nurse) progress note dated 08/26/2022 8:49 PM documents in part: When asked how did [R3] fall from bed resident stated that [R3] tried to grab on to side of bed to hold [R3] to side while waiting for CNA and rolled to floor, resident denied hitting head or face. At 12:30 PM, surveyor reviewed R3's Quarterly MDS (Minimum Data Set) assessment dated [DATE]. It documents in part that R3 requires extensive assistance with two plus persons physical assist for bed mobility and toilet use. At 01:30 PM, surveyor conducted a follow-up interview with R3. R3 stated it was only one CNA, V32, assisting [R3] with incontinence care. R3 was laying on left side. R3 had right arm across chest and was laying on left arm. R3 was not holding onto anything. R3 stated [R3] was having a hard time staying in place on [R3's] side. R3 stated [R3] was positioned too close to the edge of the bed. R3 stated V32 already placed [R3] on [R3's] left side but R3 continued to have a bowel movement so V32 went to the bathroom to get the water going. R3 stated V32 told [R3] not to move and to stay in place but [R3] could not. R3 stated [R3] called V32 to let [V32] know R3 was falling. V32 was on the way back to R3 but V32 was too late because R3 fell . On 01/12/2023 at 09:55 AM, surveyor interviewed V31 (Restorative Nurse). V31 stated R3 requires extensive assistance with bed mobility. V31 stated R3 has about 65% functional strength in arms. Turning from side to side would require 75% effort from staff for positioning. V31 stated with bed mobility, R3 does about 15-30% of the work. V31 stated a CNA is not supposed to walk away from R3 while performing incontinence care and while R3 is laying on one side. Facility's Fall Evaluation Safety Guideline policy effective 11/28/2017 documents in part: The intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: i. Identification of hazards and risks ii. Evaluation iii. Implementation iv. Monitoring v. Analysis 2. R151 has diagnosis not limited to History of Falls, Cerebral Infarction, Type 2 Diabetes Mellitus, Encephalopathy, Heart Failure, Chronic Kidney Disease, Abnormalities of gait and Mobility, Dysphasia, Weakness, Lack of Coordination, Cognitive Communication Deficit, Conversion Disorder with Seizures or Convulsions, Dementia, Hyperlipidemia, Essential (Primary) Hypertension and Atherosclerotic Heart. MDS (Minimum Data Set) Section C Cognitive Patterns document in part: Cognitive Skills for Daily Decision Making 3. Severely impaired - never/rarely made decisions. Care Plan The resident has a communication problem and has unclear speech/is primarily non-verbal however, is sometimes understood and sometimes understands AEB (As Evidenced By) making appropriate sounds/gestures and nodding his (R151) head appropriately. Date Initiated: 09/27/22. Anticipate and meet the resident's needs. Ask yes/no questions in order to determine the resident's needs. Date Initiated: 09/27/2022. The resident displays cognitive impairment with impaired thought processes as r/t (related to) DX: (Diagnosis) Dementia. Date Initiated: 09/27/22. BED MOBILITY: Bed Mobility - Resident has a self-care deficit in bed mobility related to (decrease ability to position or re-position self in bed, turn from side to side, push self-up in bed, moves from lying to sitting position. R151 requires (specify) assist for bed mobility Date Initiated: 10/07/22. The resident displays behavior of resistance to care, symptoms are manifested by agitation, refusing medication, refusing care, combative and physically aggressive towards staff i.e. (Example) (yelling, swinging and hitting staff during care provision, smearing feces). Date Initiated: 09/27/22. Use the buddy system when providing care and give clear explanation of all care activities prior to and as they occur during each contact to promote comfort during care. Date Initiated: 09/27/22. R151 is at risk for falls r/t confusion and non-compliance with staff. Actual Fall: 01.10.23 Date Initiated: 09/27/22. On 01/10/23 at 12:05 PM, during the facility tour R151 room door was observed closed. Surveyor knocked on R151 door and heard R151 moan. Surveyor opened the door and observed R151 on the floor lying on the left side next to the mattress on the floor. Surveyor informed staff that R151 was on the floor. On 01/10/23 at 12:15 PM, V14 (Restorative Tech) exited R151 room and stated R151 has behaviors and do not listen. The aide was trying to get R151 up earlier. R151 was slightly aggressive, and I encourage the staff to walk away and come back later. R151 is up in the wheelchair now. On 01/10/23 at 12:19 PM, R151 was observed up in the wheelchair On 01/10/23 at 12:40 PM, V16 (Registered Nurse) stated I think we are going to send R151 out. The Nurse Practitioner was observed in hall with stethoscope to R151 chest. V15 (Registered Nurse) stated we are sending R151 out for an unwitnessed fall and change in condition. R151 is not swallowing and pocketing food. R151 will be evaluated for that as well. On 01/11/22 at 11:06 AM, V19 (Certified Nurse Assistant) stated I have worked here for 5 months. V19 stated I have not work with R151 that much. R151 like to grab and can get combative. R151 is a fall risk, and we constantly try to monitor R151, sometime the entire eight-hour shift. R151 will get out of the bed at times and onto the floor. R151 is alert and can communicate his (R151) needs. When I did my first rounds R151 trunk was on the mattress but the lower body from the hips was on the floor, and I assisted R151 back onto the mattress. Thirty minutes later R151 whole body was completely on the floor beside the mattress. I put R151 back on the mattress and notified the nurse. The third time about 20 - 30 minutes later R151 upper tarsal was on the mattress and R151 lower body from the hips was on the floor. I assisted R151 back onto the mattress. R151 has behaviors of getting off of the mattress and onto the floor himself. I had already been in R151 room to put R151 back on the mattress. Periodically I was going back to check on R151. I was going to get R151 up, but it would be after lunch. R151 was partially dressed because when I was doing patient care R151 could not stand up because R151 was weak. If I would have put R151 up in the wheelchair R151 would not have been able to sit up. R151 mattress has been on the floor since I have been working on this floor. R151 is normally talkative, busy and is normally up in the wheelchair. It's been a change in R151 mental status. On 01/11/23 at 11:28 AM, V15 (Registered Nurse) stated I was not made aware that R151 was on the floor prior to being notified that R151 was observed on the floor. R151 was a little weaker but the pocketing of the food was new for me. R151 was not up in the wheelchair because V19 (Certified Nurse Assistant) said that R151 was sleeping. We usually get R151 up. V19 (Certified Nurse Assistant) let me know that she V19 (Certified Nurse Assistant) had checked on R151 three times. When I observed R151 on the floor, R151 head was facing what would be considered the foot of the bed. R151 had no injuries. R151 require assistance. It is considered a fall when a resident body touches the floor, a change in plane. If there is an unwitnessed fall the resident is assessed, ask them what happen, notify the doctor/family, and carry out the doctor orders. R151 said that he (R151) rolled out of the bed. R151 is alert and oriented x 1-2. On 01/12/23 at 10:17 AM, V31 (Restorative Director) stated I was made aware of R151 fall when R151 was getting ready to be sent out to the hospital. R151 was being sent out because R151 was found on the floor. To my knowledge this was R151 first fall. I am not aware of a fall on 11/13/22. I should have been informed of the fall so that I could have figured out interventions like moving R151 close to the nurse station, getting R151 up in the dining room, activities, and close monitoring. R151 room is still down the hallway. I would be the one to update the care plan. R151 should have had the interventions on the care plan updated. R151 has behaviors and may have gotten down and crawled. I am not certain if it was a fall. A fall is a change in plane, maybe from a higher level to a lower level. I was not aware that R151 mattress was on the floor. On 01/12/23 at 10:31 AM, R151 was observed lying in a low bed with a matt on the floor next to the bed. 01/12/23 at 09:06 AM, V2 (Director of Nursing) stated The incident with R151, we have R151 in the lowest position and the mat is on the floor. R151 is a high fall risk and R151 is able to move his (R151) extremities. The aide will go in and reposition R151. A fall is a change in plane. R151 has known documented behaviors. The Certified Nurse Assistant finding F151 off the matt one time adjust but the second time R151 should have been gotten up. R151 would have been brought to the common area or by the nurse station. That was a lack of understanding for the aide. My expectation, if a resident is a fall risk, I would get R151 up and speak to restorative or the nurse. After finding R151 off of the matt the second time I would have gotten R151 up. Progress note dated 01/10/23 12:30, document in part: *Fall Note Text: Writer called to room due to patient noted on the floor on the side of the bed. Patient asked by writer what happened, patient stated I rolled on the floor. Writer asked patient did he fall, resident replied no I rolled. Patient assisted in chair and placed in the dining room for lunch. During mealtime patient noted pocketing food and spitting up fluids. NP (Nurse Practitioner) made aware, and patient assessed by NP, new orders received to send resident out to Hospital for change in condition and also for further evaluation due to patient noted on the floor. Progress note dated 01/11/23 14:32 document in part: *Health Status Note (nurses note) Note Text: Patient A/O X's 1. Patient returned from hospital via ambulance 01/10/23 @ 4pm. Record review document R151 prior hospitalization for a fall occurred on 11/13/22 due to a fall. Policy: Titled Fall Evaluation Guideline effective date 11/28/17 document in part: Purpose: to consistently identify and evaluate residents at risk for falls. To prevent and reduce injuries related to falls. Falling is an unintentional change in position coming to rest on the ground floor or onto the next lower surface. Falls include any fall regardless which setting it may have occurred. The intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: I. Identification of hazards and risks, II. Evaluation, III. Implementation, IV. Monitoring, V. Analysis. A fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Fall prevention is achieved through an IDT (Interdisciplinary Team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Involve Interdisciplinary team on: Need for supervision, Development, and implementation of interventions to reduce accidents. Fall Management: Develop and implement interventions, Ongoing evaluation of effectiveness of interventions. Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Purpose: 3. To prevent or reduce injuries related to falls. 6. Individualize interventions for each resident. Guidelines for Evaluation May include Procedure: 2. If the evaluation finds the resident at risk, implement resident specific interventions/precautions. 3. Initiate, review and revise the fall care pan as appropriate, with new or discontinued interventions. 4. The Interdisciplinary team (IDT) will evaluate the resident's fall risk in conjunction with the care plan to develop, review and revise at a minimum quarterly with increased frequency as needed to reduce resident falls. 8. All residents identified as at risk for falls will be reviewed for individualized interventions. 40061

Based on interview and record review, the facility failed to develop and implement a plan of care and supervision to prevent falls for a resident that was assessed as a high risk for falls. This failure resulted in 1 of 3 residents (R1) reviewed for falls, falling while left unattended and sustaining a fractured hip requiring an ORIF (Open Reduction Internal Fixation) for right hip fracture. Findings Include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Osteoarthritis, Abnormalities of Gait and Mobility, Weakness, Heart Failure, Essential (Primary) Hypertension, Major Depressive Disorder, Transient Alteration of Awareness, Displaced Fracture of Base of Neck of Right Femur, Subsequent Encounter For Closed Fracture with Routine Healing, Seizures, Pain in Right Hip, End Stage Renal Disease, Cognitive Communication Deficit and Lack of Coordination. R1 MDS (Minimum Data Set) Section C Cognition BIMS (Brief Interview for Mental Status) score of 11 indicating moderately impaired. On 12/20/22 at 01:18 PM, V7 (Nurse Practitioner) stated R1 used a wheelchair, was very weak prior to the fall and was not eating. R1 has Dialysis on Monday - Wednesday - Friday. R1 need to be seated and taken to places. R1 was ambulating by herself, that was on a Monday. R1 did not normally ambulate by herself and cannot ambulate by herself because R1 is too weak. The facility made me aware R1 was in the hallway. R1 is never in the hallway by herself, R1 is always in the room. R1 needs supervisor. We cannot control the residents; they are told to wait for the help, but people do what they do. If R1 had waited for help to go wherever she (R1) wanted to go the fall could have been avoided. On 12/20/22 at 2:21 PM, V23 (Certified Nurse Assistant) stated R1 requires cueing. On 12/20/22 at 2:33 PM, R1 was observed lying in bed with a dressing to right hip. R1 stated I fell trying to sit in my wheelchair. I was pushing the wheelchair walking down the hallway when I started feeling dizzy and felt myself falling. I tried to sit in the wheelchair, but I fell and broke my leg. I had to have surgery. I was supposed to have someone with me. The person that was with me was doing so many other things. I was trying to go to my dialysis. On 12/21/22 at 10:20 AM, V9 (Certified Nurse Assistant/Dialysis Transporter) stated R1 go to Dialysis on Monday - Wednesday - Friday. I let the residents know that I will be back to get them. I have to escort the residents to dialysis. The staff would get R1 up in the wheelchair. R1 uses the big brown recliner but before the fall R1 was in a wheelchair. I went to R1 room and told R1 that I will be right back. The next thing I know they said R1 would be going to the hospital. When R1 fell R1 was in the hallway kind of the middle of the hall. I pushed R1 there because I was going to get another resident at that time. R1 could self-propel the wheelchair. R1 got up and start walking, pushing her (R1) wheelchair. Therapy said R1 was not supposed to ambulate on her (R1) own. I have no knowledge of R1 having any other falls. When I went back to R1 she said she fell . I can take ambulatory residents and residents in the wheelchair to dialysis at the same time. Now we use a mechanical lift to transfer R1 and the dialysis chair. On 12/21/22 at 11:14 AM, V13 (Restorative Nurse) stated Prior to R1 fall R1 was supervision with ADL (Activities of Daily Living) care and transfers. The aides would give R1 the wash basin and clothes. I am not sure if R1 was walking long distances or able to transfer self. Based on the MDS (Minimum Data Set) for Locomotion dated 11/11/22, R1 was able to walk with supervision, it only occurred once or twice with one-person physical assist. Outside of the room basically R1 had someone to walk with and assist with walking and that occurred only once or twice that someone assisted R1 in the corridor. R1 was transported in a wheelchair. On 11/05/22 the Fall Risk assessment is a 6, anything 5 or above is considered a high fall risk. The Interventions are basically monitoring unless a resident has a fall, and we would not put anything in place besides monitoring. On 11/28/22 I am not sure if R1 medications changed and there is a diagnosis of depression that raised R1 fall score 11. All residents are considered a fall risk and should have at least one or two interventions to ensure the call light in reach and if they walk with an assistive device make sure it is within reach. Other interventions are the bed in lowest position and bed brakes are locked. All of the interventions are dated after R1's fall. R1 should have had more fall interventions on the care plan prior to the fall. She should have at least had those interventions on the care plan. The only intervention on R1 care plan prior to the fall was to anticipate the resident's needs. On 12/21/22 at 11:58 AM, V14 (Certified Nurse Assistant) stated R1 was able to ambulate prior to fall. The day R1 fell R1 was sitting outside her (R1) door waiting for V9 (Certified Nurse Assistant/Dialysis Transporter) to come pick her (R1) up for dialysis. R1 was in the hallway by her (R1) door by herself. The residents said that R1 is on the floor, and we ran to see what was going on. On 12/22/22 at 8:25 AM, V18 (Certified Nurse Assistant) stated I was one of the care givers on the floor the day R1 fell . R1 was trying to walk herself to dialysis when V9 (Certified Nurse Assistant/Dialysis Transporter) usually take R1 down to dialysis. I saw R1 on the floor and went to assist R1 up in the wheelchair. On 12/22/22 at 9:24 AM, V20 (Occupational Therapist) stated R1 decision making is poor and has a memory deficit. Therapy never approved R1 to walk and never issued a walker. R1 walk with staff only and use a wheelchair. R1 endurance is poor, cardiopulmonary endurance, shortness of breath and is unable to walk. Because of R1 endurance R1 was given a wheelchair. We do not tell residents to use a wheelchair to ambulate. R1 had Right knee pain and poor safety awareness. On 12/22/22 at 9:31 AM, V21 (Physical Therapy Assistant) stated We never instructed R1 to use a wheelchair to ambulate. R1 has a history of falling prior to admission and should always be supervised when up. On 12/22/22 at 9:58 AM, V5 (Support to the Director of Nursing) stated I do not know why R1 care plan is like that, to anticipate resident needs. For the Fall risk anything above a 5 is a high fall risk. A care plan is needed in order to know how to care for the resident. If it is not documented, it is not done. On 12/22/22 at 10:35 AM (Director of Nursing) stated I was informed R1 fell and started a fall investigation. R1 told to me she (R1) was ambulating behind the wheelchair and fell . R1 complained of pain and was sent out that is when we found about the fracture. I believe R1 transporting was with assistance and R1 was told she (R1) was not supposed to be ambulating. R1 was transported in a wheelchair. When a resident is admitted they have to be evaluated. When I saw R1, she (R1) was always in a wheelchair or dialysis chair. `R1 fall care plan was initiated on 11/06/22. The only one intervention I see on the care plan dated 11/06/22 is anticipate and meet the resident needs. The Fall assessment dated ,d+[DATE] has a score of 6. Total score of 5 or above is a high fall risk. If we have an evaluation and they are a high fall risk anticipate and meet the resident needs is not considered resident centered for R1 personal needs. Initial Reportable dated 12/02/22 document in part: upon rounding was noted on floor in hallway. Resident complained of right leg pain. Resident sent to the emergency room for further evaluation. Resident admitted to hospital with diagnosis of right lower leg fracture with post ORIF (Open Reduction Internal Fixation). Final Reportable dated 12/09/22 document in part: Resident experienced fall after ambulating with wheelchair up in hallway against therapy recommendations. Fall Statement dated 11/28/22 document in part: I V9 (Certified Nurse Assistant/Dialysis Transporter) spoke with resident to let her (R1) know I will be back to transport her (R1) dialysis. Notes dated 11/28/22 document in part: Resident stated she was walking behind her wheelchair on her way to dialysis and fell . Resident was informed the dialysis aide was coming to transfer her to dialysis but felt she was strong enough to walk herself using the wheelchair as support. Focus: Care Plan document in part: R1 is at risk for falls d/t (Due/to) unsteady gait as evidenced by requiring extensive assist x's 1 staff for transfers. Actual Fall: 11.28.22 Date Initiated: 11/06/22. Goal: The resident will be free of minor injury through the review date. Date Initiated: 11/06/22. Intervention: W/C (Wheelchair) brakes locked when sitting in w/c Date Initiated: 12/15/22 All staff o -Bed in low position when in bed Date Initiated: 12/15/22 All staff o -Ensure bed brakes are locked Date Initiated: 12/15/22 All staff o Anticipate and meet the resident's needs. Date Initiated: 11/06/22 All staff o Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 12/15/22 o Resident is currently receiving therapy and was informed to allow staff to assist in transferring. Resident was informed the dialysis aide was coming to transfer her to dialysis but felt she was strong enough to walk her self-using w/c as support. Resident was sent out to the hospital for further evaluation of rt. leg. Upon return resident will be educated to allow staff to transfer her and assist when needed. Resident to continue to work with Therapy and follow plan of care. 11.28.22 Date Initiated: 11/28/22. Care Plan document in part: The resident has an alteration in musculoskeletal status r/t (Related /to) fracture Date Initiated: 12/02/22. MDS (Minimum Data Set) Section G Functional Status dated 11/11/22 document in part: Mobility Devices Z. None of the above were used. B Transfer- Limited assistance, one-person physical assist. D. Walk in corridor- Activity occurred only once or twice, one-person physical assist. Progress note dated 11/28/22 12:40 PM document in part: *Fall Note Text: Resident noted laying on floor in hallway on right side of body alert and oriented times 4. Resident stated she (R1) was pushing her (R1) wheelchair heading to dialysis and she (R1) fell . Resident complains of pain and decreased movement to right leg. Resident noted with edema to right lower extremity. New orders given to send resident to hospital for evaluation. Progress note dated 11/28/22 12:49 PM, document in part: Transfer Note: R1 Most Recent Admission: 11/05/2022 23:07 Manual Wheelchair. Ambulates with assistive device, Falls Progress note dated 11/28/22 1:00 PM (13:00) document in part: *Fall Risk Evaluation: This evaluation is being completed related to: post fall evaluation. Fall Risk Score is: 11 Fall risk scored above 5, resident is at a HIGH risk for falls. Progress note dated 11/28/22 4:18 PM (16:18) document in part: Fall in her room, injured R (Right) leg. HPI History/Physical): Pt (Patient) seen today for a fall follow up, pt. reports she (R1) injured her R leg, has significant amt (amount) of pain. Pt sent to ER (emergency room ). Progress note dated 12/01/22 3:20 PM (15:20) document in part: *Health Status Note: Writer spoke with nurse on unit regarding follow up with resident. Nurse state resident is post ORIF (Open Reduction Internal Fixation) for right lower leg fracture. Progress note dated 12/02/22 9:31 PM (21:31), document in part: *Admission Summary: Resident has dressing noted to right hip with staples in place. Progress note dated 12/05/22 10:19 document in part: CHIEF COMPLAINT: Impairment of ADLs (Activities of Daily Living) and mobility 2/2 seizure disorder with muscle weakness and difficulty with functional mobility. The patient returned back to the facility. R1 had a dressing on her right hip with staples. She underwent ORIF for RLE (Right Lower Extremity) fracture. PHYSICAL EXAMINATION: 2. Neuromuscular weakness. 3. Gait Abnormality. 6. Fall risks. Progress note dated 12/06/22 12:43 PM, document in part: Readmission after hospitalization for unwitnessed fall. Pt reported severe pain all over upon arrival to ER, diagnosed with R (Right) femoral fracture. Pt had Ortho surgery to repair completed on 11/30., stabilized and transferred. Progress note dated 12/08/22 11:42 AM, document in part: R1 had a dressing on her right hip with staples. R1 underwent ORIF for RLE fracture. Interval History: The patient was seen and examined today. Sitting up in wheelchair, non-ambulatory. Following her (R1) right hip precautions per nursing staff. Fall Risk Evaluation dated 11/05/22 document in part: 2. Resident have generalized weakness and limited/poor mobility. 8. Resident is receiving Anti-Epileptic. 10. Resident receiving 9 or more meds. Fall risk score: 6. Fall Risk Evaluation dated 11/28/22 document in part: 2. Resident have generalized weakness and limited/poor mobility. 7. Resident have symptomatic depression. 8. Resident is receiving Anti-Epileptic. 9. Resident receiving Benzodiazepines. 10. Resident receiving 9 or more meds. Fall risk score: 11. Hospital Records dated 11/28/22 document in part: Principal/Secondary Diagnosis: Fall, Femoral Head Fracture. Procedure(s) Performed 11/30/22 - right cephalomedullary nail. Chief Complaint: unwitnessed fall, Right femoral head fracture. History of present illness: Presents with acute right femoral following unwitnessed fall. R1 attempted to walk unassisted with her (R1) wheelchair. R1 reported chest pain and dyspnea that began that day. X-ray femur 2 Views. Findings: Pelvis: There is a fracture at the base of the femoral head. The fracture is associated with apex lateral angulation between the proximal femur and femoral shaft. Impression: Acute right femoral basicervical fracture. Policy: Titled Notification of Changes Guideline effective date 11/28/17 document in part: Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. Objective The intent of the guidelines is to provide appropriate and timely information about changes relevant to a resident's condition or change in room or roommate to the parties who will make decisions about care, treatment, and preferences to address the changes. 6. Update the resident's care plan, transcribe, and implement provider's orders. 7. Communicate the changes to the rest of the care team and inform the supervisor. Titled Fall Evaluation Guideline effective date 11/28/17 document in part: Purpose: to consistently identify and evaluate residents at risk for falls. To prevent and reduce injuries related to falls. Falling is an unintentional change in position coming to rest on the ground floor or onto the next lower surface. Falls include any fall regardless which setting it may have occurred. The intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: I. Identification of hazards and risks, II. Evaluation, III. Implementation, IV. Monitoring, V. Analysis. A fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Fall prevention is achieved through an IDT (Interdisciplinary Team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Involve Interdisciplinary team on: Need for supervision, Development, and implementation of interventions to reduce accidents. Fall Management: Develop and implement interventions, Ongoing evaluation of effectiveness of interventions. Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Purpose: 3. To prevent or reduce injuries related to falls. 6. Individualize interventions for each resident. Guidelines for Evaluation May include Procedure: 2. If the evaluation finds the resident at risk, implement resident specific interventions/precautions. 3. Initiate, review and revise the fall care pan as appropriate, with new or discontinued interventions. 4. The Interdisciplinary team (IDT) will evaluate the resident's fall risk in conjunction with the care plan to develop, review and revise at a minimum quarterly with increased frequency as needed to reduce resident falls. 8. All residents identified as at risk for falls will be reviewed for individualized interventions. Titled Care plan Standard Guideline dated 11/28/17 document in part: the resident care plan will incorporate risk factors identified in preadmission assessment, hospital records and admission evaluations, with changes in condition, reviewed and updated quarterly. 2. The interdisciplinary team will continue develop a resident/client centered care plan that includes problem, need, or strength statements, measurable goal statements and resident/client specific interventions. 4. Interventions should be specific to reflect specific goal. The intervention should be individualized to the resident. 6. The care plan is to be revised to reflect the current status of the resident. 7. The care plan will be reviewed throughout the resident's stay upon admission, quarterly and with change in condition. The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes.

Based on record review, and interview, the facility failed to ensure that ostomy appliances were on to prevent skin breakdown, failed to follow the skin management guidelines, failed to assess pain level, failed to conduct a thorough skin assessment on admission, failed to conduct skin assessments as ordered, and failed to obtain treatment orders for one of six residents R3 in the sample. These failures resulted in R3's 8/25/21 pain rated 7/10 due to facility acquired severe abdominal cutaneous maceration. Findings include. R3 was admitted on [DATE] was sent to the urology clinic on 8/25/21 and did not return to the facility. R3's 8/13/21 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluate pain every shift. [MEDICATION(S)]/[CONDITION(S)] care every shift and as needed check appliance and empty. Change [CONDITION(S)] bag and appliance daily if needed every shift. On 9/8/21 at 10:11AM, surveyor inquired about R3 V10 (Unit Manager) stated She was ambulatory, alert, had two ostomy's. She would constantly get out the bed and it would come off, I would have to put it back on. On 9/8/21 at 10:32 AM, surveyor inquired about concerns with R3's ostomies. V13 (Certified Nursing Assistant) CNA stated She was real sweet, if she needed something she asked. She had like two [CONDITION(S)]'s it was a lot going on with her. The way those bags were on her were like close together so it would be like seeping stool and stuff because the ostomies was big. On 9/9/21 at 10:15 AM, surveyor inquired about potential harm to skin integrity if ostomy waste is not contained in collection bags. V18 (Medical Director) stated You're going to get skin breakdown, there's concern for infection, [CONDITION(S)] and pain. On 9/9/21 at 12:03 PM, surveyor inquired about facility protocol for skin assessments V16 (Wound Care Nurse) stated When the patient comes in, they should receive a skin assessment from the admitting nurse and someone from wounds. Surveyor inquired about R3's skin assessments. V16 responded Her admission assessment says she has a [MEDICATION(S)] and a [CONDITION(S)], that's it. No skin impairments however the 8/13/21 assessment which she was referring to includes skin impairments on the right and left thigh There was no description/measurements for either wound. Treatments were not prescribed for either site. Surveyor inquired if any additional skin assessments were documented in the PCC (as ordered) V16 reviewed PCC and stated, I cannot see anything for R3. V16 advised If they check off the positive sign (during skin assessment) it triggers for the evaluation to be done by wound care. I never assessed her for any wounds, nobody ever reported any issues. Even excoriation is something that they should report. R3's MAR (Medication Administration Record) affirms 8/25/21, dayshift pain evaluation is blank therefore not assessed (as ordered). R3's 8/25/21 urology history & physical states presents today in distress, severe abdominal pain, without appliances on either her [CONDITION(S)] or ileal conduit (covered with a diaper on exam) with substantial cutaneous maceration of her lower abdomen. Has been at Nursing Home for past several weeks per report and has not been provided ostomy supplies, has been complaining of severe pain. R3's 8/25/21 hospital history & physical states she was found to be lying on the exam table in a fetal position complaining of 7/10 pain on skin around the stoma. The skin management guideline states skin will be observed daily during cares by the nursing assistants. If any skin concerns are noted, they are to be reported to the licensed nurse. Weekly skin observation will be performed by a licensed nurse. If skin concern is noted, refer to the skin and wound care formulary. The (9/11/20) abuse/neglect prevention policy states neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Findings include: On 9/28/21 at 1:39 pm, V21 (Registered Nurse, RN) stated that she recalled R3 leaving the facility for a doctor's appointment on 8/25/21. V21 stated that R3 did complain of the peristomal skin being irritated, and when V21 assessed R3's ostomy sites, she would either change R3's ostomy wafer/bag or would reinforce the leaking wafer to R3's skin with tape. V21 stated that when R3 was admitted to the facility, R3's peristomal skin was not excoriated. V21 stated, When it (peristomal skin) became excoriated here, we used (ointment) to help. On 9/28/21 at 2:21 pm, V2 (Director of Nursing, DON) stated that she expects her nurses to assess a resident's ostomy site once a shift to ensure that it's intact and functioning. V2 stated that CNA's will also assess the ostomy site upon emptying the ostomy bag, and if there is any leaking from the ostomy site noted, the CNA is to notify the nurse. V2 stated that if an ostomy site is leaking and there is skin irritation present, the nurse should be notifying the doctor and wound care team for them to assess it. V2 stated that she reviewed R3's hospital records prior to R3's admission to the facility, and the hospital records indicated that leaking from R3's ostomy sites was resolved prior to (R3) coming here. V2 stated that her nurses should not try to reinforce a leaking ostomy wafer and bag due to the wafer not is not properly adhering to the skin. V2 stated that the peristomal skin should be cleansed and a new wafer and bag must be placed over the ostomy. On 9/29/21 at 10:53 am, V30 (CNA) stated, she cared for R3 on 8/25/21 to get R3 ready for the doctor's appointment. V30 stated, she remembered that R3's ostomy bags were hard to stick to her stomach. V30 stated, on 8/25/21, she assisted R3 in getting dressed. When this surveyor asked if R3's ostomy bags were intact and adhering on 8/25/21, V30 stated, I can't comment if the bags were intact, but I do remember that the area (by the ostomies) being juicy. I didn't want her clothes to get wet, so I put an extra diaper over her stomach. The skin was angry looking red in color around the ostomies. V30 stated, she informs the nurse of any changes in the skin.

Based upon record review, and interview, the facility failed to implement care plan interventions, failed to ensure that treatment orders are entered on the TAR (Treatment Administration Record), failed to apply ostomy bag to stomas, and failed to follow physician orders for one of six residents (R3) in the sample. These failures resulted in R3's severe cutaneous maceration of her abdominal wall and R3 at risk for infection due to ostomies being covered with diapers and not contained with ostomy bags. Findings include. R3 was admitted on [DATE] was sent to the urology clinic on 8/25/21 and did not return to the facility. R3's 8/13/21, care plan states, resident admitted to facility with [CONDITION(S)]/[MEDICATION(S)]. Monitor stoma site for stool leakage and skin irritation. Change [CONDITION(S)] bag and appliance as ordered/as needed. Monitor stoma site for signs of bleeding or inflammation and notify physician. Monitor for signs or symptoms of pain with [MEDICATION(S)] or stools and notify physician. Resident has potential for skin breakdown related to mobility and medical comorbidities. Follow facility policies/protocols for the prevention of skin breakdown. R3's 8/13/21, POS (Physician Order Sheets) include [MEDICATION(S)]/[CONDITION(S)] care every shift and as needed check appliance and empty. Change [CONDITION(S)] bag and appliance daily if needed every shift. On 9/2/21, at 11:20 AM, V2 (Director of Nursing) presented R3's (August 2021) TAR (Treatment Administration Record) which was blank (there were no physician orders). Surveyor inquired if ostomy care and bag/wafer changes are documented on the TAR V2 stated They should be. On 9/8/21 at 10:02 AM, surveyor inquired about obtaining resident ostomy supplies. V8 (Unit Manager) stated, Central supply orders any equipment we may need. On 9/8/21 at 10:27 AM, surveyor inquired about R3's ostomy needs. V12 (Central Supply) stated, She (referring to R3) had an [CONDITION(S)] and [CONDITION(S)] if I'm not mistaken. There's just ten in a bag and I have to order twenty just in case something happens. Surveyor inquired if R3 ran out of ostomy supplies while at the facility. V12 responded No therefore ostomy invoices were requested at this time. On 9/8/21 at 10:32 AM, surveyor inquired about concerns with R3's ostomy's. V13 (Certified Nursing Assistant) stated, She had like two [CONDITION(S)]'s it was a lot going on with her. The way those bags were on her were like close together so it would be like seeping stool and stuff because the ostomy's was big. On 9/8/21 at 11:40 AM, V12 presented (8/24/21) purchase order which includes [MEDICATION(S)] pouch with Convex BA (quantity: 1) V12 affirmed there were no additional ostomy orders placed during R3's stay at the facility.The order was placed eleven days after her admission. The facility provided no evidence during this survey that R3's required ostomy supplies were available. R3's 8/25/21, Urology history & physical states she is found to have no appliances on either her [CONDITION(S)] or ileal conduit, appears to have not been appropriately cared of for some time due to severe cutaneous maceration and sensitivity on much of her abdominal wall. LLQ (Left Lower Quadrant) and RLQ (Right Lower Quadrant) [MEDICATION(S)] without appliances are covered with a diaper on exam, substantial fecal and urinary contents covering lower abdomen. On 9/9/21 at 10:15 AM, surveyor inquired about potential harm to skin integrity if ostomy waste is not contained in collection bags V18 (Medical Director) stated You're going to get skin breakdown, there's concern for infection, [CONDITION(S)] and pain. On 9/9/21 at 11:56 AM, surveyor inquired about R3 V16 (Wound Care Nurse) stated I don't have any records for her (R3) and affirmed she (R3) was not referred to the wound care team. The 6/29/21 [CONDITION(S)], [MEDICATION(S)] care policy states it is essential that a pouch be placed over a stoma correctly so the output from the stoma is contained, the skin around the stoma is protected and a patient is free from odor or leakage. Change the ostomy pouches when they are 1/3-1/2 full to avoid leakage, which can lead to chemical or enzymatic injury to the skin. Findings include: On 9/29/21 at 10:53 am, V30 (CNA) stated, she cared for R3 on 8/25/21 to get R3 ready for the doctor's appointment. V30 stated, she remembered that R3's ostomy bags were hard to stick to her stomach. V30 stated, on 8/25/21, she assisted R3 in getting dressed. When this surveyor asked if R3's ostomy bags were intact and adhering on 8/25/21, V30 stated, I can't comment if the bags were intact, but I do remember that the area (by the ostomies) being juicy. I didn't want her clothes to get wet, so I put an extra diaper over her stomach. The skin was angry looking red. The skin around the ostomies. V30 stated that she informs the nurse of any changes in the skin. On 9/28/21 at 1:39 pm, V21 (Registered Nurse, RN) stated, she recalled R3 leaving the facility for a doctor's appointment on 8/25/21. V21 stated, R3 did complain of the peristomal skin being irritated, and when V21 assessed R3's ostomy sites, she would either change R3's ostomy wafer/bag or would reinforce the leaking wafer to R3's skin with tape. V21 stated, when R3 was admitted to the facility, R3's peristomal skin was not excoriated. V21 stated, When it (peristomal skin) became excoriated here, we used (ointment) to help. On 9/28/21 at 2:21 pm, V2 (Director of Nursing, DON) stated, she expects her nurses to assess a resident's ostomy site once a shift to ensure that it's intact and functioning. V2 stated, tCNA's will also assess the ostomy site upon emptying the ostomy bag, and if there is any leaking from the ostomy site noted, the CNA is to notify the nurse. V2 stated, if an ostomy site is leaking and there is skin irritation present, the nurse should be notifying the doctor and wound care team for them to assess it. V2 stated that she reviewed R3's hospital records prior to R3's admission to the facility, and the hospital records indicated that leaking from R3's ostomy sites was resolved prior to (R3) coming here. V2 stated that her nurses should not try to reinforce a leaking ostomy wafer and bag due to the wafer not is not properly adhering to the skin. V2 stated, the peristomal skin should be cleansed and a new wafer and bag must be placed over the ostomy.

Based on interview, and record review, the facility failed to provide necessary care and services to monitor and prevent injury for one resident (R1) reviewed for unknown injury in the sample. This failure affected R1 who was found with a swollen left leg. R1's X-Ray showed that R1 had acute oblique fracture to distal femur with dorsal displacement distal fragment, resulting in R1 being sent to the local hospital and had an Open Reduction and Internal Fixation left femur surgery on 4/06/21. Findings include: On 04/12/21, R1's admission record showed that R1 was admitted to the facility on [DATE] with last initial admitted [DATE] with diagnosis that includes but not limited to Unspecified Dementia with behavioral Disturbances, unspecified [CONDITION(S)], [CONDITION(S)], Weakness, History of falling, Altered Mental Status Unspecified Displaced fracture of second Cervical Vertebra subsequent encounter for fracture with Nonunion, [CONDITION(S)] unspecified, and other Lack of Coordination. R1 was sent out to the local hospital for unknown injury resulting in an oblique fracture distal to distal femur with dorsal placement distal fragment. R1's hospital record documented that R1 has an open reduction internal fixation left femur surgery on 04/06/21 then R1 returned to the facility on [DATE]. R1'S hospital medical record presented dated 04/07/2021 documented that R1 is s/p open reduction and internal fixation left femur on 4/06/21. R1's Fall Risk Evaluation Report with effective date 11/03/20 scored 16, on 11/24/19, scored 7, on 04/09/2021, scored 13. R1's category rated as high level of risk based on Acute Chronic illnesses or injuries which poses a threat to life or bodily function. On 04/12/21 at 1:05pm, interview conducted with V10 LPN (Licensed Practical Nurse) stated in part about a year ago R1 was prone to fall and tends to attempt to get up by-self without assistance of staff. V10 stated R1 needs total assistance with ADL's (Activity of Daily Living). V10 confirmed that she was the nurse on duty 4/5/21 who sent R1 to the hospital. V10 explained that the CNA (Certified Nurse's Aide) identified as V6 called her to R1's room to assess R1's left leg because it is swollen and R1 was in pain. V10 stated upon assessment the left leg was swollen from the hip area (pointing to her own left leg in description). V10 added that R1 was screaming to touch R1's left leg. V10 stated she called the unit supervisor and V12 NP (Nurse Practitioner) immediately. V12 ordered an X-Ray, and Doppler test. V10 stated after about 20 minutes, the X-Ray result showed that R1 had fracture and V12 stated send R1 to the hospital. The surveyor then asked V10 about the first time she saw R1 for the first time during her shift. V10 replied when she gave R1 her morning medication after breakfast. V10 stated she could not recollect the time. When asked to check the computer for the time that it was documented that R1's am (Morning) medication were administered, V3 RN (Registered Nurse) unit manager told the surveyor that the information cannot be given to the surveyor and the surveyor should go ask V1 (Administrator) or V2 DON (Director of Nurses). This was brought to V1 and V2's attention. As of 4/15/21 this information was not provided. On 4/15/21 at 10:35am, interview with V17 (CNA) who worked with R1 on 04/04/21 3pm to 11pm shift, V17 stated in part that he does not work with R1 all the time but have escorted R1 for appointment's when R1 had a neck brace. V17 explained that on 04/04/21 he laid R1 in bed using a lifting device with no complaint of pain, or any accident with R1. V17 stated although she worked on the same floor from 11pm to 7pm, she was not the CNA for R1. V17 stated through-out the night there was no complaint that R1 had any problem. On 04/15/21 at 10:57am, telephone interview conducted with V15 (CNA) who worked with R1 from 11pm to 7am shift on 04/04/21. V15 stated in part that she is familiar with R1. V15 stated through-out the night shift R1 had no pain or any accident or incident. V15 stated she made rounds every 2hrs. V5 explained that if the resident walks rounds are made every hour to make sure the resident did not fall. On 04/15/21 at 12:39PM telephone interview with V19 (LPN) regarding R1's health status on 04/04/21. V19 was unable to recall any accident or incident during the shift. V19 stated she did not work directly with R1. At 12:46PM, telephone interview conducted with V18 (LPN), V18 stated in part that he worked with R1 but there was no incident or accident and no abnormal occurrence with R1. V18 stated he made rounds every 1-2 hours. V18 stated R1 does not ambulate around stating (R1) cannot walk, needs to be transferred with a (lifting transfer device). V18 could not recollect the last time he physically saw R1. On 04/15/21 at 1:13pm, telephone interview with V12 (NP), V12 stated in part that the oblique fracture for R1 can be connected to [CONDITION(S)] because [CONDITION(S)] causes the bones to be soft. V12 stated any little thing (Referring to trauma) can cause someone to have fracture. On 04/15/21 at 1:55pm, telephone interview with V16 (Restorative Aide) for third floor stated on Sunday (4/4/21) she helped transfer R1 from bed to the wheel chair during the 7am to 3pm shift and she performed ROM (Range of Motion) with assistance of another staff with R1. V16 stated R1 did not complain of pain during the ROM. When the surveyor asked how the transfer was done V16 stated one staff was on one side (Referring to left side) and the other side (Referring to right side). The surveyor asked what type of transfer device was used in transferring R1? V16 replied that no device was used, because R1 can help in transferring. The surveyor then clarified with V16 about use of transfer devices. V16 replied, (R1) can stand no device was used. V16 could not precisely remember what time the transfer was done but she stated, it was before lunch. R1's plan of care for transfer focus initiated 11/24/2019 documented that (R1) has a self-care deficit in transfers related to generalize weakness. Interventions includes but not limited to use of gait belt with extensive assistance. On 04/15/21 at 2:09pm, interview conducted with V8 (Restorative Nurse Director) stated regarding devices needed in transferring R1 from bed to wheelchair. V8 stated in part that R1 needs to be transferred with a gait belt and a walker. The surveyor asked should the lift, gait belt, or walker have been used for transfer. V8 replied it is required because R1 is not in a transfer program. Review of facility investigation interview statement dated 4/5/2021 at 10:00am states V2 DON (Director of Nurses) explained that she conducted the interview and V8 did not say anything about the transfer device but V8 is expected to make use of transfer device when transferring any of the resident's. According to the Facility Investigation Interview/Statement Record dated 4/5/21 at 10:00am shows V2 DON (Director of Nurse's) conducted the interview with V8, and V8 did not say anything about the transfer device but V8 is expected to make use of a transfer device when transferring any of the residents. On 4/4/21 at 2:45pm, surveyor conducted telephone interview with V12 (NP). Surveyor asked V12 if a resident with a diagnosis of [CONDITION(S)] or [CONDITION(S)] is transferred from the bed to a wheelchair with no transfer device as stated in plan of care, can that cause an oblique fracture? V12 replied, It is possible. I cannot tell you it is not possible because of the nature of the bone itself, the bone is very, very fragile. R1's facility assessment tool dated December 3, 2020 section G coded R1 3/3 for transfer for ADL (Activity of Daily Living) assistance which showed that R1 needs extensive assistance with two person's assistance. BIMS (Brief Interview for Mental Status) of 06. The most resent assessment dated [DATE] section G scored R1 3/2 for transfer that showed R1 needs extensive assistance with one-person assistance. BIMS of 08. The facility policy on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with effective date 11/28/2017 defined Injury of Unknown Origin as injury of unknown source when both of the following conditions are not met: i. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. ii. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time.

Based on observation, record review, and interview the facility failed to monitor and supervise a cognitively impaired resident (R1) by not implementing the facility's practice for monitoring residents every two hours and not having a functioning monitor alarm system in place to alert staff when a resident with a wandering behavior attempted to leave the building. As a result, a cognitively impaired resident (R1) with a known behavior of wandering exited out the facility without the staff alerted until R1's absence was noted. R1's whereabouts were unknown by the facility staff putting the resident at risk for possible harm. R1 was found 6 days after R1's elopement by family members. This was identified as an immediate jeopardy situation that began on [DATE] and was removed on [DATE]. V1 (administrator) was informed of the immediate jeopardy on [DATE] at 12:30pm. This deficient practice relates to 4 of 4 residents (R1, R2, R3, and R5) who were reviewed for elopement risk, in a sample of 11 residents. Findings include: Face sheet documents R1 is a [AGE] year old admitted to the facility on [DATE] with the diagnosis of the following: traumatic ischemia of muscle, [MEDICAL CONDITIONS], acute kidney failure, [MEDICAL CONDITIONS], generalized muscle weakness, stroke, [MEDICAL CONDITION], high blood pressure, and dementia. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 has moderate cognitive impairment. Care plan date [DATE], notes R1 displays movement behavior and may be an elopement risk/wanderer. Interventions identified include: secured unit, staff aware of R1's wander risk, and mechanical monitoring device. According to facility's room roster, R1 resided on the 3rd floor of the facility, which was identified as a locked or monitored unit. R1's Elopement Risk Review dated [DATE] documents R1 is at risk for elopement. The facility's incident report dated [DATE] documents on [DATE] staff observed R1 not in facility during shift. R1 was unable to be located. Investigation initiated, physician notified, police notified. On [DATE] 12:40pm, V21, (family member) stated V2 DON (director of nursing) informed V21 this facility does not lock any residents down. V21 stated R1 has a history of wandering when R1 resided at home. V21 stated the liaison for this facility was informed of R1's wandering history while R1 was still in hospital, prior to admission to facility. The liaison assured V21 that R1 would be placed on a secured unit for R1's safety. V21 stated V21 and V22 (family member) visited with R1 on the afternoon of [DATE] when they attended a care plan conference. V21 stated R1's history of wandering was discussed at this meeting. V21 stated when R1 wandered off at home, R1 could find way back home sometimes. Most of time, R1 would become confused and was not able to find way home. At the time of the interview, V21 stated R1 still remained at large. On [DATE] 11:25am V21 (family member) reported V21 was told by the local police R1 walked to the emergency room (ER) at a local hospital on [DATE]. R1 was not able to tell ER staff R1's address, so a community organization was notified, picked R1 up and brought him to a mission. R1 walked out of the mission the same day. R1 went to another local hospital at 3:00pm on [DATE] and was discharged from the emergency room at 7:00pm on his own. V21 stated family members found R1 on [DATE] at 8:00pm, standing in the middle a high traffic street. On [DATE] at 11:50am, V3 CNA (certified nurse aide) stated V3 worked 7am-3pm on [DATE]. V3 stated R1 walks the unit all day. V3 stated R1 is alert and oriented to person and place. V3 stated there is an alarm in the elevator that will sound if a resident with a mechanical monitoring device gets into the elevator. V3 stated this alarm is silent on the nursing unit, so the resident does not become scared of the alarm. V3 stated the alarm sounds at the first floor nursing unit to alert staff the resident is in the elevator. V3 stated that V3 rounds on assigned residents every two hours. V3 stated staff check for mechanical device placement on residents once a shift. On [DATE] at 12:15pm, V2 DON (director of nursing) stated the elevator alarm is supposed to alarm on each nursing unit. V2 denied this is a silent alarm. V2 stated the maintenance director is responsible for checking all door alarms and elevator alarms daily to ensure functioning properly. V2 stated social service staff are responsible for checking the mechanical monitoring devices to ensure the battery has not expired and to ensure these devices alarm when activated; this is done weekly. V2 stated staff are responsible for checking the placement of the mechanical monitoring device every shift. This surveyor observed during this same time,V2 with a mechanical monitoring device enter the elevator on the third floor nursing unit and exit elevator in basement; the device did not alarm at any time. V2 proceeded through a basement door leading to the stairwell. The exit door to the parking lot alarm sounded when the door was opened but did not alarm when mechanical monitoring device was near door. V2 and this surveyor proceeded onto the first floor nursing unit and the exit door alarm was not audible at the nurses' station. V2 stated the alarm in the elevator is supposed to sound when a resident with a mechanical monitoring device is near elevator door. The alarm is not supposed to stop sounding until the resident is away from the elevator. On [DATE] while with V2, the surveyor noted the facility's first floor has a main entrance/exit door on the northside of the building, one exit door on the east side of the building (leading to the parking lot), an exit door on the west side of the building, and one exit door on the south side of the building. On [DATE] at 4:10pm, V4 LPN (licensed practical nurse) stated V4 was working ,[DATE]:30pm shift on the first floor nursing unit on [DATE]. V4 stated V4 was in a resident's room near the stairwell providing care when V4 heard the stairwell alarm. V4 stated this alarm was faint; if V4 had not been near the exit V4 would not have heard the alarm. V4 stated V4 entered the code to de-activate the door alarm and checked the stairwell for any residents or staff. V4 stated V4 did not see anyone. V4 stated the exit door to the parking lot was also alarming. V4 stated the door would not open due to the alarm and V4 did not know the code to de-activate the alarm. V4 stated V4 went to the main entrance and got security staff to assist with de-activating the alarm. V4 stated this occurred about 10:00pm. V4 looked through a window (10 inches x 10 inches) on the exit door and did not see anybody outside. V4 stated V4 was not aware R1 was missing until the alert for a missing resident was paged overhead after 11:00pm. V4 stated V4 rounds on residents every two hours. On [DATE] at 4:20pm, V6 CNA stated V6 worked ,[DATE]pm shift on the third floor nursing unit on [DATE]. V6 stated V6 rounds on residents every two hours. V6 stated the last time V6 saw R1 was when V6 gave R1 dinner tray. V6 stated R1 is ambulatory and wanders on the unit. On [DATE] at 4:26pm, V8 CNA stated V8 worked ,[DATE]pm shift on the third floor nursing unit on [DATE]. V8 stated V8 rounds on residents every two hours. V8 stated the last time V8 saw R1 was in the dining room at dinnertime. V8 stated R1 is ambulatory and wanders on the unit. On [DATE] at 4:30pm, V9 CNA stated V9 worked ,[DATE]pm shift on the third floor nursing unit on [DATE]. V9 stated V9 rounds on residents (assigned from rooms [ROOM NUMBERS] west hallway) every two hours. V9 stated the last time V9 saw R1 was in dining room at dinner time. V9 stated R1 is ambulatory and wanders on the unit. On [DATE] at 4:35pm, V10 CNA stated V10 worked 7am to 10pm on the third floor nursing unit on [DATE]. V10 stated V10 rounds on residents every two hours. V10 stated the last time V10 saw R1 was in the dining room at dinnertime. V10 stated R1 is ambulatory and wanders on the unit. None of the CNAs (certified nurse aides) who were on duty [DATE] and could be interviewed were able to account for the R1's presence on the unit. The aide assigned to R1 that night was unavailable for an interview at the time of the survey. On [DATE] at 1:12pm, V20 LPN stated V20 worked ,[DATE]:30pm shift on [DATE] and was assigned to provide care for R1. V20 stated V20 brought R1 medications at 5:30pm while R1 was in dining room. V20 stated R1 approached V20 at medication cart 15 minutes later requesting medications. V20 stated V20 informed R1 that R1 just took medications. V20 stated R1 had an angry expression on R1's face. V20 stated R1 appeared to be upset but was not able to verbalize what was wrong. V20 stated that was the last time V20 saw resident that evening. V20 denied any increased monitoring was initiated or that V20 investigated R1's mood further. R1 went back to sit in dining room for dinner. V20 stated V20 administered R1's scheduled 9:00pm medications at 5:30pm because R1 can become aggressive if R1 is woken up from sleep for medications. V20 stated V20 does not round on residents, CNAs are responsible for rounding on residents. V20 stated at 10:00pm, V20 was informed R1 was not in R1's room. V20 stated staff searched all rooms and V20 notified V19 (supervisor). This facility's wandering and elopement guideline policy, dated [DATE] notes upon admission, residents will be evaluated for potential elopement risk. Information will be obtained from representatives, observation, and social history. At any time during a resident stay there may present indication of an elopement risk. It is the responsibility of staff to remain with the resident until a licensed nurse conducts an evaluation. The interdisciplinary team will meet with family and determine appropriate continued interventions and modify the care plan as needed. Residents identified at risk will have a mechanical monitoring device placed. Door security codes will be shared with staff members only. Security codes will not be shared with the resident representatives or residents. It is the responsibility of the staff to enter security codes to support visitors exiting the unit. Door alarm function will be checked daily by maintenance personnel. Maintenance is responsible for checking the resident transmitter to make sure door stays locked and alarm sounds when mechanical monitoring device is near elevator/door. On [DATE] at 12:00pm, this surveyor asked staff on the third floor nursing unit to enter the code for the elevator for this surveyor. Staff sitting at nurses' station, 20 feet away, verbalized the code to this surveyor so this surveyor could enter code. No staff member approached the elevator to enter elevator code. On [DATE] at 1:30pm, V1 administrator stated on [DATE] V1 interviewed V23 (maintenance director) regarding this facility's elevator and door alarms. V23 informed V1 that V23 had not checked the alarms for a long time but documented on the log sheets that checks had been done. V1 stated the alarms in the elevator were installed in (MONTH) and V1 believed alarms were functioning properly. This surveyor observed on [DATE] that a mechanical monitoring device was attached to the ankles of R2, R3, and R5. According to R2, R3, and R5 physicians' orders for (MONTH) 2019, R2, R3, and R5 do not have physicians' orders that allows them to leave the facility independently. R2's quarterly assessment [DATE] indicated R2 had moderate cognitive impairment and wandering behavior present. While present on the third floor unit [DATE] R2 exhibited wandering throughout the secured unit. R3's quarterly assessment [DATE] indicated R3 had cognitive impairment. According to the wanderer/elopement risk assessment dated [DATE], R3 was at risk for elopement. While present on the third floor unit [DATE], R3 exhibited wandering throughout the secured unit. R5 was newly admitted on [DATE] to this facility. R5 is alert and oriented x 1. While present on the third floor unit [DATE], R5 exhibited wandering throughout the secured unit The deficiency remains at a level 2 harm until the facility can complete in-servicing for any nursing staff members not on duty. However, the facility did the following to remove the immediacy: Immediate Action: On [DATE] MD ( medical doctor) notified of the event at approximately 12:05am. Family notified of event at approximately 12:10am. Police notified, and report filed at approximately 12:30am. 1st floor east exit door on [DATE] (no time given) was monitored every shift until vendor completed work on the electronic monitoring device system (work completed [DATE], time not given). Other residents have been identified as high risk for elopement as of [DATE]. As of [DATE], the nurse aide assigned to resident (R1) was suspended pending investigation. Nurse assigned to resident was suspended pending investigation. Maintenance personnel was terminated. New Maintenance Director promoted [DATE]. Education initiated on [DATE] at 3:00am, scheduled staff on duty have been in-serviced on the facility guidelines regarding Elopement/ Wandering guidelines. All remaining staff will be in serviced prior to the start of their next their next scheduled shift until all staff are in-serviced. Training will be repeated at the time of hire, annually, as needed, and will be monitored for compliance by the Administrator. Monitoring/Surveillance initiated on [DATE] at 10:30pm. Staff was stationed in the area to monitor daily and record until the installment of an alarm system for the facility's exit door. A mock code drill was completed on [DATE] ( no time given) and will be conducted weekly for 1 month, and quarterly thereafter by the Social Service Director. The interdisciplinary team reviewed all residents to determine risk for wandering/elopement and accuracy of evaluation and update as needed, ensuring residents at risk have an individualized care plan in place. Each resident, including residents identified by the state's surveyor, with an electronic monitoring device bracelet was checked and will be checked for placement and function every shift for 1 week by the assigned nurse. Compliance will be monitored by the social service director designee. Quality Assurance committee members held at meeting on [DATE] at approximately 11am with the Medical Director. All future audit results will be reviewed by the facility Quality Assurance Committee to determine if any further staff education of facility policy change is needed. Any non-compliance will be corrected immediately and reviewed again by the committee monthly. All the above measures will be subject to review, assessment, and modification. The surveyor confirmed by onsite observation, interview, and record review, on [DATE] and [DATE] the implementation of the above removal plan.