Every finding on record at Evercare at Edwardsville

Based on interview and record review, the facility failed to use the required equipment (gait belt) during transfer and appropriately use the full mechanical lift to prevent falls in 2 of 3 residents (R3, R29) reviewed for accidents and hazards in the sample of 38. These failures resulted in R3 sustaining a left femur fracture and R29 sustaining a hematoma to her head and requiring emergency care. Findings include: 1. R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, and abnormalities of gait and mobility. R3's Minimum Data Set (MDS) dated [DATE] documented R3 was moderately cognitively impaired and was dependent with transfers from chair to bed or bed to chair. R3's Care Plan initiated 8/30/25 documents R3 requires extensive assistance for transfers related to weakness and impaired mobility. R3's Progress Note by V34, Licensed Practical Nurse (LPN), dated 1/12/25 at 10:01 PM documents at approximately 6:55 PM, an unnamed Certified Nursing Assistant (CNA) reported R3 was on the floor. The CNA stated R3 became weak during transfer and shifted weight to her left side where she had an amputated leg. The CNA stated she fell with R3, and R3 reported pain to left hip. R3's 1/12/26 Fall Report by V34 documents R3 became anxious during transfer from wheelchair to bed and placed all weight on left below the knee amputation, causing her to lose balance. The CNA lowered R3 to the floor, placing herself under R3 to break the fall. R3 was sent to the Emergency Room. R3's Hospital Record dated 1/13/26 documents R3 sustained a complete acute transverse fracture to left humeral neck after sustaining a fall at the nursing facility. On 3/20/26 at 10:40 AM, V33, CNA, stated she was putting R3 back into bed from her wheelchair on 1/12/26 when R3 fell. R3 stated she felt like her right side was weak, so she put some weight on the left side where she had an amputation. V33 tried to break R3's fall, but both V33 and R3 fell on the floor. V33 stated she was previously told by other CNA's that R3 liked staff to use a bear hug method when transferring her, so she was not using a gait belt on R3 at the time. On 3/20/26 at 12:45 PM, V1 stated she would expect staff to follow the Facility's transfer policy and use gait belts for transfers. 2. R29's Undated Face Sheet documents R29 was admitted to the facility on [DATE] and has a medical diagnosis of Type 2 Diabetes Mellitus, Abnormalities of Gait and Mobility, Muscle Weakness, Altered Mental Status, Chronic Pain Syndrome, Osteoarthritis, Alzheimer's Disease, and Hypertension. R29's Minimum Date Set (MDS) dated [DATE] documents R29 is moderately cognitively impaired, uses a wheelchair, and is dependent on staff for sitting to standing, toilet transfers, and chair/bed to chair transfers. R29's Care Plan Start Date 12/27/2025 documents Falls: R29 had a fall on 12/27/2025. Intervention Start Date 12/27/2025 documents staff educated on the proper use of (full mechanical lift) to ensure that all sling attachments are secure before all transfers. R29's Care Plan Start Date 8/30/2025 documents ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential: R29 requires extensive assist for ADLs related to immobility, range of motion (rom) and pain. Intervention Start Date 8/30/2025 documents R29 needs total assist with transfers with the use of the (full mechanical lift) and 2 staff. R29's Progress Note dated 12/27/2025 at 8:38 AM documents This nurse called to resident room resident found laying on floor beside (full mechanical lift) Certified Nursing Assistant (CNA) replies she was transferring resident and hook on (full mechanical lift) unhooked resident started to slide out CNA replies she assisted resident to floor. Staff educated to make sure (full mechanical lift) sling is properly secured before transfer. Resident has a small hematoma noted to back of head 1 centimeter (cm) skin intact no bleeding noted. Resident denies any discomfort besides she replies her head hurts a little. 911 placed to pick resident up and transport to Local hospital for evaluation. R29's Progress Note dated 12/27/2025 at 8:45 AM documents Date/time of incident: 12/27/25 0838. Details: res was being lifted with (full mechanical lift) pad to wheelchair by staff when (full mechanical lift) strap came off of (full mechanical lift). Staff member held strap up while resident was lowered to the floor. Assessed resident did sustain a small hematoma to back of head. Root cause: strap not securely in place. R29's Fall Investigation Worksheet dated 12/28/2025 documents date of fall: 12/27/2025, time of fall 8:38 AM. Fall witnessed, location of fall: resident room. Was resident using an assistive device: yes, (full mechanical lift). Was resident injured: hematoma and scratch. Root cause of fall: improper placement of hook. R29's Local Hospital Records Dated 12/27/2025 documents Emergency Department (ED) Adult Initial Assessment Triage Note Patient (Pt) to the ED via Emergency Medical Service (EMS) for evaluation after a fall. Pt was in the (full mechanical lift) when a strap broke, causing the pt to fall 4 feet. Pt striked her head, and is complaining of neck pain. R29's Local Hospital Records Dated 12/27/2025 documents ED Triage Note Arriving to ED from Nursing Home with complaint of being transferred from bed to wheelchair via (full mechanical lift) the hook of the (full mechanical lift)) came undone or broke. Nursing Home staff states they lowered her to the floor but she struck the back of her head. On 3/19/2026 at 10:59 AM V20, Licensed Practical Nurse (LPN), stated the CNA came to her and stated she was transferring R29 using the (full mechanical lift) when the hook of the lift pad came unhooked from the (full mechanical lift) and R29 was assisted to the ground. V20 stated she assessed R29 and R29 had a small hematoma to her head and was sent to the local hospital for evaluation. On 3/19/2026 V2, Director of Nursing (DON), stated during R29's transfer, the hook was not completely on the (full mechanical lift), and when R29 went up in the air the hook came off. V2 stated the staff member held R29 and R29 was lowered to the ground. V2 stated the staff member was transferring R29 by herself. On 3/19/2026 at 1:06 PM R29 stated she remembers being put into the (full mechanical lift) sling by staff and does not know how she slipped out of the sling. R29 stated she is unsure if she slipped out of the pad due to the fault of the CNA. R29 stated she slipped out of the (full mechanical lift) pad and hit the top of her head on the floor. R29 stated it was a bummer that she fell and hit her head because it hurt really bad. R29 stated she was sent to the hospital and had her head scanned and it did not show anything. On 3/19/2026 at 1:26 PM V24, Nurse Practitioner, V24 stated she was notified of R29's fall and is unsure of the particulars of the fall and transfer because she was not in the room at the time the incident occurred. V24 stated she assessed R29 on 12/30/2025 and R29 was alert and oriented and able to follow commands. V24 stated she does not recall if R29 had a hematoma to her head and was not told by staff if R29 had one. V24 stated she excepts the facility to be following their fall and transfer policy. V24 stated she would except staff to be trained on how to properly use the facility's mechanical lift. On 3/19/2026 at 1:38 PM V25, CNA, stated on 12/27/2025 the facility was extremely short staffed, and she asked multiple staff members to help her use the (full mechanical lift) on R29 and no one would help her. V25 stated she used the (full mechanical lift) by herself to get R29 up to her chair from the bed. V25 stated the (full mechanical lift) sling hook had broken when she was lifting R29 and V25 caught R29 using her leg and lowered R29 to the ground. V25 stated she screamed for staff to come help her when the (full mechanical lift) sling strap broke and no one came into the room. V25 stated the facility allows staff to use the (full mechanical lift) with one person. The Facility's Transfers-Manual Gait Belt and Mechanical Lifts Policy Date Reviewed 6/1/2025 documents Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer techniques. The transferring needs of resident will be assessed on an ongoing basis and designated into one of the following categories: 0=independent, 1=1 person transfer (25% or less assistance from the caregiver) with gait belt, 2= 2 person transfer with gait belt (ONLY when use of mechanical lift is not possible), SS=sit to stand lift with 1 caregivers, H=mechanical lift (Hoyer) with 2 caregivers. Use of gait belt for all physical assist transfers is mandatory. The Facility's Fall Evaluation and Prevention Policy Date Reviewed 6/1/2025 documents Purpose: to ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents.

Based on observation, interview, and record review, the Facility failed to ensure food was stored in a manner that prevents foodborne illness. This has the potential to affect all 91 residents living in the Facility.Findings include:On 3/17/26 at 6:55 AM, in the standing freezer there were two boxes of uncooked beef patties stored directly on top of a box of cookie dough.On 3/17/26 at 7:00 AM, in the deep freeze there were multiple bags of food in plastic gallon storage bags. There were three bags labeled bone in chicken that had red frozen liquid inside. These bags were stored directly on top of bags labeled pound cake and brown sugar pineapple. V5, Cook, stated this freezer is primarily used for leftovers and asked if the chicken should be moved. She verified the chicken was uncooked and the beef in the other freezer was also uncooked.On 3/18/26 at 10:18 AM, V1, Administrator, stated she expects the Facility to follow its food storage policies.The Facility's Food and Supply Storage Policy dated 8/1/25 documents food and supply storage areas shall be maintained in a clean, safe, and sanitary manner.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 3/17/26 documents there are 91 residents living in the Facility.

Based on interview and record review, the facility failed to ensure that medication administration protocols were followed in 4 of 4 residents (R11, R21, R32, and R74) when reviewed for pharmacy services in the sample of 38.Findings include: 1. R74's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnosis: wedge compression fracture of T11-T12 vertebra and low back pain. R74's Quarterly Minimal Data Set, dated 12/23/2025 documents R74 was cognitively intact, high-risk drugs: opioid, pain management: resident received scheduled and PRN (when needed) pain medication regimen, pain last 5 days: yes, pain frequency: occasionally, pain interference with day-to-day activities: occasionally, pain intensity: 3 out of 10. R74's Care Plan, dated 3/30/2025 documents resident has chronic pain r/t (related to) T-12 compression fracture, chronic back pain, depression, long history of pain medication use, GERD, and head injury as a child. Approaches documented include: report to nurse my complaint of pain or requests for pain treatment, report to nurse loss of appetite, refusal to eat and weight loss, report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx (signs/symptoms) or c/o (compliant of) pain or discomfort, record/report to Nurse any s/sx of non-verbal pain, observe/record pain characteristics (FREQ) and PRN as needed): quality (e.g. sharp, burning); Severity (1 to 10 scale); anatomical location; onset; duration (e.g., continuous, intermittent); aggravating factors; relieving factors, observe/document for side effects of pain medication, observe the effectiveness of pain interventions, observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care, notify physician if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain, administer analgesia (pain medication) as per orders. R74's Physician Order Sheet (POS), dated 10/27/2025 documents a new physician's order for Hydrocodone 7.5 milligrams (mg) four times a day at 5:00 AM, 11:00 AM, 5:00 PM and 11:00 PM for low back pain. R74's Electronic Medical Record no documentation of Hydrocodone incident. On 3/17/2026 at 7:55 AM R74 was lying in bed and stated he committed a felony last week. R74 stated he is prescribed a pain medication, Hydrocodone 7.5 mg four times a day. R74 stated the nurses leave his medications at bedside and sometimes he doesn't need the pain medication, so he places the tablet in a secret place in his room. Last week a CNA (certified nurse assistant) named V6 wore a boot because she had recently fractured her ankle, and she was in a lot of pain. R74 stated he told V6 that if she hurt he had pain medication that would help with that and she said OK. R74 stated a few minutes later V6 came back to his room and stated she would like the pain medications. R74 stated he gave V6 2 Hydrocodone 7.5 mg tablets and a few hours later the Administrator and the Director entered his room and started asking him 100 questions. R74 stated management insisted he give them all the medications he had, and he did. R74 stated he had about 10 tablets of Hydrocodone in his secret stash and staff took them. On 3/17/2026 at 1:05 PM V6, CNA stated she entered R74 room one day last week and he asked her if her foot hurt because she's wearing a medical boot. V6 stated she told R74 that she was ok and R74 told her he has something that would handle that pain if she needs it. V6 reported what R74 said to the nurse V10, Licensed Practical Nurse, (LPN) and V10 told her to go back in R74's room a few minutes later and tell him she was hurting to see what he gives her. V6 stated she reentered R74's room a few minutes later and asked for pain relief and R74 handed her 2 white pills in a medication cup. V6 stated she took the pills directly to V10 who was sitting at the nurse's station and reported these pills were given to her by R74. V10 went directly to the DON's (Director of Nurses) office and the Administrator, DON, ADON (Assistant Director of Nurses) and V10 went to R74's room to start an investigation. V6 stated V10 told her later that they found over 26 Hydrocodone in his room that he was hoarding. V6 stated she had not observed any pills in a medication cup in R74's room nor had she observed a nurse place the medication cup of pills in R74's room without him taking them in front of the nurse. On 3/18/2026 at 8:33 AM V10, LPN stated she works day shift, and she has observed pills in a medication cup at R74's bed side in the past when she arrives to the facility she does rounds and she has observed pills in a medication cup on R74's table in his room a few times. V10 stated when she saw the medications in R74's room she gave them back to the night shift nurse to dispose of. V10 stated she couldn't recall what night shift nurses left the medications in R74's room and she recalled it occurred over a couple of times. V10 stated she always ensures all residents take their medications in front of her because that's nursing standard of practice. On day last week V10 stated V6, CNA came to her and told her R74 offered her pain medication, and she told her to go back in R74's room to see what medication he had. V6 returned to the nurse's station a few minutes later and gave her 2 Hydrocodone 7.5 mg tablets and stated R74 gave them to her. V10 stated she immediately took the medication to V1, Administrator and V2, Director of Nurses (DON) and the Assistant Director of Nurses (ADON) and an investigation was initiated at that time. On 3/18/2026 at 10:42 AM V2, DON stated one day last week V10 came to her and stated they had a situation regarding R74's Hydrocodone. V10 reported that R74 gave V6 2 Hydrocodone tablets for her foot pain and V6 gave both tablets to V10 and her, V1 and V3 went to R74's room and asked him why he gave Hydrocodone to V6 and V74 stated because V6 had recently broke her ankle and she was hurting. V2 stated she asked R74 for the other pills he had in his room, and he reached under his bed and got a black case that had 12 Hydrocodone in it. V2 asked R74 to leave his room so they could search it and staff found 14 more Hydrocodone, 2 Ibuprofen tablets and 2 Depakote capsules. R74 told V2 that sometimes night shift nurses drop off his medications on his bedside table while he's sleeping and when he wakes up he stashes them for a rainy day pain. R74 didn't state any specific nurses that drop his medications off in his room. R74 stated he hadn't given any medication to any other staff other than V6 and he didn't give medications to other residents. V2 stated R74 doesn't ever leave his room and doesn't have any visitors either. V2 stated she expected staff to report to her when they observe medications left in a resident's room so she can address that because narcotics are to be stored under a double lock and no residents, including R74's POS have an order to have Hydrocodone at bedside. On 3/18/2026 at 12:50 PM V2, DON stated R74's physician's order was for one Hydrocodone tablet four times a day scheduled during this time and the nurses must have left the medication with the resident over a period of time for R74 to have 26 Hydrocodone in his room. V2 clarified the nurses must have left the medication in R74's room [ROOM NUMBER] different times over a period of time for him to have that many tablets stashed. The Facility's Medication Administration Policy, reviewed 6/1/2025 documents purpose: to provide practice standards for safe administration of medications for residents in the facility. Policy: medications will not be left at bedside, medications will be administered by licensed nursing staff and the licensed nurse will remain with the resident until the medicine is actually swallowed. 2. R11's Face Sheet, undated, documents R11 has the following diagnoses: Unspecified Dementia, Osteoarthritis, Developmental Disorder, Borderline Intellectual Disorder, Obsessive Compulsive Disorder, Major Depressive Disorder, Bipolar Disorder, Borderline Personality Disorder, Autistic Disorder, and Attention Deficit Hyperactivity Disorder. R11's POS (Physician Order Sheet), documents the following physician orders: Acetaminophen 325mg (milligrams) 2 tablets every 4 hours as needed, dated 12/18/24, and Trazadone 100mg at bedtime, dated 6/26/25. R11's MDS (Minimum Data Set), dated 2/20/26, documents R11 is cognitively intact. R11's Care Plan, dated 11/10/25, documents R11 is at risk for medication noncompliance due to resident hoarding, with an intervention that staff will observe resident taking medication to ensure they are swallowed and not pocketed. R11's Progress Note, dated 11/10/25 at 11:11 AM, documents the following: Going into room noted resident had 4 pills in her hand and A.M (Morning) medication had not been given. When questioned resident said it was pills from the last two day that she hadn't taken 2 oblong white pills resident said was pain pills and 2 round white pills were trazadone. Resident stated while she feels great body wise, she feels she is falling apart in her mind that she was in a very dark place. Resident said she was having suicidal thoughts of killing herself. Resident began crying, I was able to calm resident down with reassuring words that I would get her help. The N.P (Nurse Practitioner) was walking by, I called her over and informed her of conversation I was having with Resident. (R11) repeated the thoughts of self-harm her and I informed her that resident was hording pills. (V24, Nurse Practitioner, NP) said to send resident to hospital. for Psych Eval (Psychiatric Evaluation). (R11's Family) was called and informed of resident hording pills and expressing wanting to kill herself. Also informed (R11's Family) that we have and order to send resident to the hospital for a psychiatric evaluation, agreed and stated (R11) has been going back and forth with that idea for a couple of days. Resident placed on one-on-one monitoring. Psychiatry called, information given on resident Spoke with (R11's Doctor), informed him of resident hording pills and wanting to kill self. Order was given to send resident to the (local psychiatric hospital). Hospital notified and informed them of resident's plan to commit suicide 911called to transport resident to hospital.) R11's Nurse Practitioner Progress Note, dated 11/10/25 at 9:50 AM, documents, in part, the following: Suicidal ideations: HPI (History of Present Illness): Patient is a [AGE] year old female with a PMH (Past Medical History) of Dementia, Hypertension, Dyslipidemia, Insulin-Dependent Diabetes, Hypothyroidism, Chronic Kidney Disease, Anemia, Osteoporosis, Autism, Depression, Anxiety, Bipolar Disorder and Attention Deficit Disorder, being seen today for complaints of suicidal ideations and hoarding medications. Patient found to have 4 medications in a pouch at her bedside, identifying them as trazadone and acetaminophen. States that she feels that she does not need them and is sleeping alright. States that she is feeling better than I ever have while also feeling like my body is telling me to kill myself. Patient states that she is very sorry for hording medications and denies any additional meds being kept. Call placed to patient sister who indicates that she feels the patient has been making these statements for a few days and that her emotional stability has been vacillating between very high and very low. R11's Progress Note, dated 11/10/25 at 4:42 PM, documents the following: Called (Psychiatric Hospital) to check status of resident. Resident admitted to adult behavior unit with Major Depressive Disorder. On 3/20/26 at 9:40AM, R11, stated, she doesn't know why she was keeping those medications, she was depressed, had thoughts of suicide but would not have attempted suicide by taking those pills. R11 stated they were two sleeping pills and two pain pills. R11 stated she went to the psychiatric hospital and was better. R11 stated she sees a psychiatrist and counselor regularly and denied thought of suicide at this time. R11 stated if she did have suicidal thoughts, she would alert the staff. R11 stated the nurses stay with her until she takes it, they will not leave her with it to take on her own. 3. R21's Undated Face Sheet documents R21 was admitted to the facility on [DATE] and has a medical diagnosis of Major Depressive Disorder, Chronic Pain, Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus, Paroxysmal Atrial Fibrillation, Hypothyroidism, Chronic Obstructive Pulmonary Disease, and Hypertension. R21's Minimum Data Set (MDS) dated [DATE] documents R21 is cognitively intact. On 3/17/2026 at 9:08 AM R21 stated medications are late almost every evening and night. R21 stated the facility can give medications 1 hour before and after the medications are due and the facility is passing medications at least 2 hours late. R21 stated unless the nurse starts on your hall, your medications will be late. 4. R32's Undated Face Sheet documents R32 was admitted to the facility on [DATE] and has a medical diagnosis of Type 2 Diabetes Mellitus, Systolic Congestive Heart Failure, Dysphagia, Peripheral Vascular Disease, Hyperlipidemia, Chronic Kidney Disease Stage 3, and Hypertension. R32's MDS dated [DATE] documents R32 is cognitively intact. On 03/17/2026 at 8:44 AM R32 stated the facility runs late on passing medications. R32 stated medications are passed late often and will be a couple hours late. R32 stated night medications are always late and have been passed around 11:30 PM or later. On 3/18/2026 at 10:37 AM V9, Ombudsman, stated residents have complained to her that their medications are being administered late frequently. On 3/18/2026 at 12:54 PM V2, Director of Nursing, stated acceptable medication administration times include medications passed 1 hour before or 1 hour after medications are due. V2 stated it is not acceptable for medications to be passed more than 1 hour after a medication is due. The Facility's Resident Council minutes dated 12/8/2025 documents Nursing: meds are late. The Facility's Resident Council Memorandum dated 12/8/2025 documents Department: Nursing. Issue: Medicine being passed late at night and not at the right time. The Facility's Resident Council minutes dated 1/5/2026 documents Nursing: Meds not being passed on time. The Facility's Medication Administration Policy Reviewed 6/1/2025 documents Medications may be administered one hour before or after the scheduled medication administration time. Medications will not be left at bedside. Medications and treatments will be administered only by licensed medical or licensed nursing staff. The licensed nurse will remain with the resident until the medicine is actually swallowed.

Based on interview, observation, and record review, the Facility failed to provide palatable meals for 4 of 4 residents (R4, R24, R34, R50) reviewed for food and nutrition services in the sample of 38.Findings include:1.R4's Face Sheet documents R4 was admitted to the facility on [DATE].R4's Minimum Data Set (MDS) dated [DATE] documented R4 was cognitively intact.R4's Diet Order dated 2/25/25 documents R4 is on a regular diet.On 3/17/2026 9:50 AM, R4 stated, The food is nasty, just ultimately nasty. We have complained and complained and complained and nothing changes. I think people in prison get better food than (we do) in here. The steam table doesn't work and the food is usually cold.2.R24's Face Sheet documents R24 was admitted to the facility on [DATE].R24's MDS dated [DATE] documented R24 was moderately cognitively impaired.R24's Diet Order dated 9/30/25 documents R24 is on a regular diet with no added salt.On 3/17/26 at 7:28 AM, R24 stated the food is terrible, has no taste, and is cold much of the time.3.R34's Face Sheet documents R34 was admitted to the facility on [DATE].R34's MDS dated [DATE] documented R34 was cognitively intact.R34's Diet Order dated 2/16/25 documents R34 is on a regular diet with no added sweets.03/17/2026 7:11 AM, R34 stated the food is terrible.4.R50's Face Sheet documents R50 was admitted to the facility on [DATE].R50's MDS dated [DATE] documented R50 was cognitively intact.R50's Diet Order dated 10/27/25 documents R50 is on a regular diet with double portions.On 3/17/26 at 7:15 AM, R50 stated the food is not good. The menu is terrible, and the food is usually cold.The Facility's Resident Council Meeting Minutes dated 12/8/25 document cold food as an issue.The Facility's Resident Council Meeting Minutes dated 1/5/26 document cold food and gross food as issues.The Facility's Resident Council Meeting Minutes dated 2/9/26 document food is not palatable.On 3/17/25 at 8:30 AM, test tray temperatures were obtained with a metal calibrated thermometer on the B Hall after the last resident hall tray was passed. The scrambled eggs measured 117 Fahrenheit (F).On 3/18/26 at 10:18 AM, V1, Administrator, stated the Facility used to have more homestyle cooking and more options before the new company took over, and the residents were accustomed to that. V1 would expect the Facility to follow its policies regarding food service.The Facility's Undated Food Preparation: Taste- Testing documents food items will not be served unless palatable and pleasing to the eye.

Based on observation, interview, and record review, the facility failed to prevent abuse for 2 (R4, R10) of 6 residents reviewed for abuse in the sample of 38. This failure resulted in R4 being tearful and scared of staff. Findings include:R4's Face Sheet documents she was initially admitted on [DATE].R4's Quarterly Minimal Data Set (MDS) dated [DATE] documents R4 is alert and cognitively intact with diagnoses included: anxiety, depression, malnutrition, debility, cardiorespiratory conditions, chronic obstructive pulmonary disease (COPD) and anemia.R4's Care Plan did not address abuse.R10's Face Sheet documents she was initially admitted on [DATE].R10's Quarterly MDS dated [DATE] documents R10 is alert and cognitively intact with diagnoses included: anxiety, malnutrition, respiratory failure, debility, cardiorespiratory conditions, chronic obstructive pulmonary disease, cancer, anemia and renal insufficiency. Received scheduled and PRN pain medication regimen. Pain was present occasionally. Pain interference with day-to-day activities occasionally. Pain intensity 3 out of 10.R10's Nurse Progress Notes, dated 2/2026 no documentation of allegations of abuse staff to resident.R10's Care Plan did not address abuse.On 3/18/2026 at 1:15 PM during resident council meeting residents were asked how staff treat them and if they have experienced abuse at the facility and R4 stated there was an agency nurse (V23, Licensed Practical Nurse, LPN) that cursed her and her roommate (R10) out and got in her face and flipped her the middle finger several times one day and then V23 had the nerve to return to work at the facility again a few days later and R4 stated, Oh h*ll no she is not working here! R4 stated her and V23 got into it because she wouldn't give her roommate (R10) her pain medication. R4 didn't know what day or shift this occurred on.On 3/19/2026 at 11:35 AM R4 stated she needed to clarify what occurred between her and V23. R4 stated V23 was mean and abusive to her and her roommate, (R10). R4 opened her notebook and read her notes regarding what occurred between her, V23 and R10. R4 stated it was a Saturday day shift, and she was upset with V23 because she wouldn't give her roommate, R10 her pain medications and she was hurting badly. R4 clarified what she meant by mean and abusive she stated V23 yelled and cursed at her and R10 and then got in her face and flipped her off using her middle finger in her room and then V23 stepped into the hallway and flipped her and R10 off again. R4 stated she was in shock when it occurred because no one has ever treated her like that before. R4 stated she dropped the ball because it was a weekend, and she didn't report what occurred until she saw V23 was passing medications on her hall that Monday and that infuriated her. R4 stated when she saw V23 working again that Monday she was on her way to the nurse's station and V23 said to her, Hey you, you want your medications now? and R4 stated V23 snickered as she said it. R4 stated she didn't answer V23, and she went to the nurse's station and told V26, LPN that that nurse shouldn't be here and that she needed to leave because she abused her and R10 a few days ago. R4 stated V26 went to V23, and she walked her to the front of the building and then walked her out of the building shortly after that. R4 stated she was very upset that V23 treated her that way and she felt it was abuse, R4 stated she was scared of V23 because she was a nurse and she was in charge of her and other residents lives. R4 stated she is not a [NAME] but when she saw V23 was working at the facility again she was enraged and was very upset and she cried because she didn't want V23 to yell at, curse, or get in her and other residents faces or give other residents the middle finger. R4 stated it was her fault V23 came to work again to the facility because she didn't report what occurred to anyone that shift because it was a weekend and no management was here so they wouldn't have been able to help her.On 3/19/2026 at 2:40 PM R10 was observed laying in bed. R10 stated she recalled the agency nurse (V23) who snapped on her and her roommate at the time, R4 sometime last month (date unknown) and stated V23 refused to administer her pain medication to her and her roommate R4 was standing up to V23 and telling her to administer the pain medication to me because I was hurting badly and V23 snapped on her and R4 cursing saying f*** you and go f*** yourselves to her and R4. R10 stated V23 flipped her and R4 off with her middle finger multiple times. R10 stated she was upset about how V23 treated her and R4 and she felt it was abusive and after V23 left their room that day her and R4 barricaded their door with their shelfs and were fearful V23 would come back in their room and hurt them. R10 stated her and R4 talked about what to do and they didn't know what to do and they didn't want to leave their room because they didn't know what V23 would do. R10 stated V23 never gave her pain medication that night and she laid in the fetal position all night because she was scared of V23 and didn't want to deal with V23 anymore. R10 stated no staff spoke to her about what occurred with her, R4 and V23. R10 stated she was surprised no one spoke to her and she felt this was all brushed under the rug as if it didn't even happen. R10 stated she was very grateful she didn't see V23 working at the facility again like R4 did because she would have lost it because she was very fearful of V23.V23's Written Statement, dated 2-23-2026 documents it was about the med that she wanted me to give R10. She was mad that the lady wasn't getting her medicine, she was still hurting, I asked if she needed anything. R4 started yelling at me that I had to give her her medicine. The next time I worked she walked up to nurse station and made the allegation that I put my finger in her face and then a lady walked me out.On 3/19/2026 on 1:02 PM V23, LPN stated she worked night shift (date unknown) and R4 was upset with her because she wouldn't give her roommate, R10 her pain medication but it wasn't time for them to be administered and she let both residents know she would administer the pain medication to R10 as soon as she could per the POS (physician order set) and R4 yelled because was upset because R10 was in pain. V23 denied flipping R4 or R10 off with her middle finger and denied cursing at either resident. V23 stated she came to work the next day shift and was passing medications on R4's and R10's hall and she saw R4 on the hall and she asked her if she wanted her medications and R4 stated she didn't want anything from her and a few minutes later a nurse told her to write a statement and she did and staff walked her out. V23 stated she didn't know why she was told to leave the facility because she didn't do anything wrong.On 3/19/2026 at 11:20 AM V26, LPN stated she works day shift and gets to the facility to work at approximately 6:00 AM. V26 stated she recalled R4 came to the nurse's station really upset one morning (date unknown.) R4 was physically shaking, yelling and crying pointing to V23 and stated, You get that nurse out of here right now! She shouldn't be here! Why is she here? Why is she here? I am not going back to my room until she (V23) leaves! She (V23) flipped me off over medications the other day and she cursed me and my roommate (R10) out. V26 stated she immediately went to V23 who was passing medications on R4's hall at that time and instructed her to lock her medication cart and to come with her to the front of the facility. V26 stated she called V1, Administrator and V1 told V26 to have V23 write a statement and then escort her out of the building. V26 stated after V23 was escorted out of the facility R4 was still shaking, crying and very upset and she sat at the nurse's station for 20 minutes telling her that a few days ago V23 cursed at her and R10 and got in her face and flipped her off several times and she was trying to intimidate her and R10. V26 stated she didn't interview any other residents including R10 regarding what occurred.On 3/19/2026 at 10:55 AM V3, Assistant Director of Nurses (ADON) stated she didn't know the exact date of the incident but she recalled V26 called her one morning and stated R4 was very upset because an agency nurse, V23 was working on R4's hall and she shouldn't be working here because V23 had recently cursed at R4 and her roommate R10 and also flipped them off with her middle finger. V3 stated she instructed V26 to pull V23 off the hall and have her write a statement. V3 stated she arrived to the facility about 10 minutes after V26 called her and she observed V23 writing a statement in the employee breakroom. V23 denied flipping residents off and denied flipping them off with her middle finger. V3 stated her and V26 walked V23 out of the facility a few minutes later. V3 stated she spoke to R4 and R4 told her V23 was in her face yelling, cursing and flipping her and R10 off regarding R10 getting her pain medication. V3 stated she didn't document the interview with R4, she didn't interview R10 and she didn't interview other staff or residents regarding what was told to her.On 3/19/2026 at 10:44 AM V2, Director of Nurses (DON) stated she wasn't at the facility (date unknown) when whatever occurred between the agency nurse V23, R4 and R10. V2 arrived to work on day (day unknown) and all heck broke loose with R4 because a nurse that she had an incident with a few days prior was working at the facility again and R4 was very upset about it. V2 stated she didn't know anything occurred between V23, R4 and R10 prior to that day (day unknown.) V2 stated R4 and R10 came to her office and both of them stated the agency nurse, V23 cursed at them over pain medications and got in R4's face yelling and cursing at her and flipped her middle finger off to both residents. V2 stated she didn't know what shift R23 worked when the incident occurred, and she didn't interview other residents or staff about the incident. At one-point R4 went to V26 and told her V23 shouldn't be working here because of how V23 treated her and R10 and V26 walked V23 out. V2 stated V1, Administrator is the abuse coordinator at the facility. On 3/19/2026 at 12:45 PM V1, Administrator stated she didn't know exactly what occurred between V23, R4 and R10 but it was reported to her one morning (date unknown) that R4 reported to staff that an agency nurse, V23 shouldn't be working here anymore and R4 was very upset. V1 stated V26 called her and reported that R4 was upset V23 was still working at the facility and staff immediately escorted V23 out of the building and she was not to return working here. V1 stated the situation was squashed immediately.On 3/19/2026 at 1:26 PM V24, Nurse Practitioner stated she wasn't aware of abuse or mistreatment of residents. V24 stated she expects the facility to follow abuse policy to prevent abuse from occurring.The Abuse Prevention and Prohibition Policy, with a review date of 12/2/25, documents, in part, the following: Each resident has the right to be free from mistreatment and abuse. Staff must not permit anyone to engage in verbal abuse or mistreatment. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems.

Based on observation, interview and record review the facility failed to follow the facility's abuse policy regarding abuse for 2 (R4, R10) of 6 residents investigated for abuse in the sample of 38.Findings include: R4's Face Sheet documents she was initially admitted on [DATE].R4's Quarterly Minimal Data Set (MDS) dated [DATE] documents R4 is alert and diagnoses included: anxiety, depression, malnutrition, debility, cardiorespiratory conditions, chronic obstructive pulmonary disease (COPD) and anemia.R4's Nurse Progress Notes, dated 2/2026 no documentation of allegations of abuse or mistreatment staff to resident.R4's Care Plan did not address abuse.R10's Face Sheet documents she was initially admitted on [DATE].R10's Quarterly MDS dated [DATE] documents R10 is alert and diagnoses included: anxiety, malnutrition, respiratory failure, debility, cardiorespiratory conditions, chronic obstructive pulmonary disease, cancer, anemia and renal insufficiency. Received scheduled and PRN pain medication regimen. Pain was present occasionally. Pain interference with day-to-day activities occasionally. Pain intensity 3 out of 10. R10's Nurse Progress Notes, dated 2/2026 no documentation of allegations of abuse or mistreatment staff to resident.R10's Care Plan did not address abuse.On 3/18/2026 at 1:15 PM during resident council meeting residents were asked how staff treat them and if they have experienced abuse at the facility and R4 stated there was an agency nurse (V23, Licensed Practical Nurse, LPN) that cursed her and her roommate (R10) out and got in her face and flipped her the middle finger several times one day and then V23 had the nerve to return to work at the facility again a few days later and R4 stated, Oh h*ll no she is not working here! R4 stated her and V23 got into it because she wouldn't give her roommate (R10) her pain medication. R4 didn't know what day or shift this occurred on.On 3/19/2026 at 12:45 PM V1, Administrator stated she didn't know exactly what occurred between an agency nurse V23, R4 and R10. V26, LPN called her one morning and stated that R4 was very upset that agency nurse, V23 was passing medication on her hall and stated she shouldn't be working at the facility because she mistreated R4 and R10. V1 stated staff immediately escorted V23 out of the building and she was not to return working here. V1 stated the situation was squashed immediately and there was no full investigation completed. V1 stated there was no reason a full investigation was not completed, once staff were aware of the situation the nurse was pulled from the hall, she wrote a statement and she was escorted from the facility, not to return. V1 stated she didn't interview any other residents other than R4 and she didn't interview staff either. No statements other than V23's was documented.On 3/19/2026 at 1:26 PM V24, Nurse Practitioner stated she wasn't aware of abuse or mistreatment of resident. V24 stated she expects the facility to follow the facility's abuse policy.The Abuse Prevention and Prohibition Policy, with a review date of 12/2/25, documents, in part, the following: Each resident has the right to be free from mistreatment and abuse. Staff must not permit anyone to engage in verbal abuse or mistreatment. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. The facility promptly and thoroughly investigates reports of resident abuse and mistreatment. The Administrator will provide initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies.

Based on observation, interview and record review the facility failed to report an allegation of abuse for 2 (R4, R10) of 6 residents reviewed for abuse in the sample of 38.Findings include:R4's Face Sheet documents she was initially admitted on [DATE].R4's Quarterly Minimal Data Set (MDS) dated [DATE] documents R4 is alert and cognitively intact with diagnoses: anxiety, depression, malnutrition, debility, cardiorespiratory conditions, chronic obstructive pulmonary disease (COPD) and anemia.R4's Nurse Progress Notes, dated 2/2026 no documentation of allegations of abuse or mistreatment staff to resident.R4's Care Plan did not address abuse.R10's Face Sheet documents she was initially admitted on [DATE].R10's Quarterly MDS dated [DATE] documents R10 is alert and cognitively intact and diagnoses: anxiety, malnutrition, respiratory failure, debility, cardiorespiratory conditions, chronic obstructive pulmonary disease, cancer, anemia and renal insufficiency. Received scheduled and PRN pain medication regimen. Pain was present occasionally. Pain interference with day-to-day activities occasionally. Pain intensity 3 out of 10.R10's POS, dated 2/2026 a physician's order dated 12/6/2025 Hydrocodone 10-325 mg 1 tablet every 8 hours for pain three times a day (TID) at 6:00 PM, 2:00 AM and 10:00 AM.R10's Nurse Progress Notes, dated 2/2026 no documentation of allegations of abuse or mistreatment staff to resident.R10's Care Plan did not address abuse.On 3/18/2026 at 1:15 PM during resident council meeting residents were asked how staff treat them and if they have experienced abuse at the facility and R4 stated there was an agency nurse (V23, Licensed Practical Nurse, LPN) that cursed her and her roommate (R10) out and got in her face and flipped her the middle finger several times one day and then V23 had the nerve to return to work at the facility again a few days later and R4 stated, Oh h*ll no she is not working here! R4 stated her and V23 got into it because she wouldn't give her roommate (R10) her pain medication. R4 didn't know what day or shift this occurred on.On 3/19/2026 at 12:45 PM V1, Administrator stated she didn't know exactly what occurred between an agency nurse V23, R4 and R10. V26, LPN called her one morning and stated that R4 was very upset that agency nurse, V23 was passing medication on her hall and stated she shouldn't be working at the facility because she mistreated R4 and R10. V1 stated staff immediately escorted V23 out of the building and she was not to return working here. V1 stated the situation was squashed immediately and there was no full investigation completed. V1 stated there was no reason a full investigation was not completed, once staff were aware of the situation the nurse was pulled from the hall, she wrote a statement and she was escorted from the facility, not to return. V1 stated she didn't interview any other residents other than R4 and she didn't interview staff either. No statements other than V23's was documented.On 3/19/2026 at 1:26 PM V24, Nurse Practitioner stated she wasn't aware of abuse or mistreatment of resident. V24 stated she expects the facility to follow the facility's abuse policy and report the allegations of abuse to appropriate agencies.The Abuse Prevention and Prohibition Policy, with a review date of 12/2/25, documents, in part, the following: Each resident has the right to be free from mistreatment and abuse. Staff must not permit anyone to engage in verbal abuse or mistreatment. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. The Administrator will provide initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies.

Based on observation, interview and record review the facility failed to investigate abuse for 2 (R4, R10) of 6 residents investigated for abuse in the sample of 38.Findings include:R4's Face Sheet documents she was initially admitted on [DATE].R4's Quarterly Minimal Data Set (MDS) dated [DATE] documents R4 is alert and diagnoses included: anxiety, depression, malnutrition, debility, cardiorespiratory conditions, chronic obstructive pulmonary disease (COPD) and anemia.R4's Care Plan did not address abuse.R10's Face Sheet documents she was initially admitted on [DATE].R10's Quarterly MDS dated [DATE] documents R10 is alert and diagnoses included: anxiety, malnutrition, respiratory failure, debility, cardiorespiratory conditions, chronic obstructive pulmonary disease, cancer, anemia and renal insufficiency. Received scheduled and PRN pain medication regimen. Pain was present occasionally. Pain interference with day-to-day activities occasionally. Pain intensity 3 out of 10.R10's POS, dated 2/2026 a physician's order dated 12/6/2025 Hydrocodone 10-325 mg 1 tablet every 8 hours for pain three times a day (TID) at 6:00 PM, 2:00 AM and 10:00 AM.R10's Nurse Progress Notes, dated 2/2026 no documentation of allegations of abuse staff to resident.R10's Care Plan did not address abuse.On 3/18/2026 at 1:15 PM during resident council meeting residents were asked how staff treat them and if they have experienced abuse at the facility and R4 stated there was an agency nurse (V23) that cursed her and her roommate (R10) at her and got in her face and flipped her the middle finger several times one day and then V23 had the nerve to return to work at the facility again a few days later and R4 stated, Oh h*ll no she is not working here! R4 stated her and V23 got into it because she wouldn't give her roommate (R10) her pain medication. R4 didn't know what day or shift this occurred on.On 3/19/2026 at 11:35 AM R4 stated she needed to clarify what occurred between her and V23. R4 stated V23 was mean and abusive to her and her roommate, (R10.) R4 opened her notebook and read her notes regarding what occurred between her, V23 and R10. R4 stated it was a Saturday day shift, and she was upset with V23 because she wouldn't give her roommate, R10 her pain medications and she was hurting badly. R4 clarified what she meant by mean and abusive she stated V23 yelled and cursed at her and R10 and then got in her face and flipped her off using her middle finger in her room and then the V23 stepped into the hallway and flipped her and R10 off again. R4 stated she was in shock when it occurred because no one has ever treated her like that before. R4 stated she dropped the ball because it was a weekend, and she didn't report what occurred until she saw V23 was passing medications on her hall that Monday and that infuriated her. R4 stated when she saw V23 working again that Monday she was on her way to the nurse's station and V23 said to her, Hey you, you want your medications now? and R4 stated V23 snickered as she said it. R4 stated she didn't answer V23, and she went to the nurse's station and told V26, LPN (Licensed Practical Nurse) that that nurse shouldn't be here and that she needed to leave because she abused her and R10 a few days ago. R4 stated V26 went to V23, and she walked her to the front of the building and then walked her out of the building shortly after that. R4 stated she was very upset that V23 treated her that way and she felt it was abuse, R4 stated she was scared of V23 because she was a nurse and she was in charge of her and other residents' lives. R4 stated she is not a [NAME], but when she saw V23 was working at the facility again she was enraged and was very upset and she cried because she didn't want V23 to yell at, curse or get in her and other residents faces or give other residents the middle finger. R4 stated it was her fault V23 came to work again to the facility because she didn't report what occurred to anyone that shift because it was a weekend and no management was here so they wouldn't have been able to help her.On 3/19/2026 at 2:40 PM R10 was observed lying in bed. R10 stated she recalled the agency nurse (V23) who snapped on her and her roommate at the time, R4 stated sometime last month (date unknown) V23 refused to administer her pain medication to her and her roommate R4 was standing up to V23 and telling her to administer the pain medication to me because I was hurting badly and V23 snapped on her and R4 cursing saying f*** you and go f*** yourselves to her and R4. R10 stated V23 flipped her and R4 off with her middle finger multiple times. R10 stated she was upset about how V23 treated her and R4 and she felt it was abusive and after V23 left their room that day her and R4 barricaded their door with their shelves and were fearful V23 would come back in their room and hurt them. R10 stated her and R4 talked about what to do and they didn't know what to do and they didn't want to leave their room because they didn't know what V23 would do. R10 stated V23 never gave her pain medication that night and she lay in the fetal position all night because she was scared of V23 and didn't want to deal with V23 anymore. R10 stated no staff spoke to her about what occurred with her, R4 and V23. R10 stated she was surprised no one spoke to her and she felt this was all brushed under the rug as if it didn't even happen. R10 stated she was very grateful she didn't see V23 working at the facility again like R4 did because she would have lost it because she was very fearful of V23.V23's Written Statement, dated 2-23-2026 documents it was about the med that she wanted me to give R10. She was mad that the lady wasn't getting her medicine, she was still hurting I asked if she needed anything. R4 started yelling at me that I had to give her (R10) her medicine. The next time I worked she walked up to nurse station and made the allegation that I put my finger in her face and then a lady walked me out.On 3/19/2026 on 1:02 PM V23, LPN stated she worked night shift (date unknown) and R4 was upset with her because she wouldn't give her roommate, R10 her pain medication but it wasn't time for them to be administered and she let both residents know she would administer the pain medication to R10 as soon as she could per the POS (Physician Order Set) and R4 yelled because R4 was upset because R10 was in pain. V23 denied flipping R4 or R10 off with her middle finger and denied cursing at either resident. V23 stated she came to work the next day shift and was passing medications on R4's and R10's hall and she saw R4 on the hall and she asked her if she wanted her medications and R4 stated she didn't want anything from her and a few minutes later a nurse told her to write a statement and she did and staff walked her out. V23 stated she didn't know why she was told to leave the facility because she didn't do anything wrong.On 3/19/2026 at 11:20 AM V26, LPN stated she didn't interview any other residents other than R4 including R10 or staff regarding what occurred and she didn't write a statement regarding what occurred and she only spoke to R4 regarding what occurred, V26 didn't interview R10 or any other residents or staff regarding the incident.On 3/19/2026 at 10:55 AM V3, Assistant Director of Nurses (ADON) stated she didn't know the exact date of the incident, but she recalled V26 called her and reported that R4 was very upset that an agency nurse, V23 was still working at the facility and passing medications on her hall. V3 stated she interviewed R4 regarding what occurred, but she didn't interview R10 and she didn't interview any other residents or staff regarding the incident.On 3/19/2026 at 10:44 AM V2, Director of Nurses (DON) stated she didn't know anything occurred between V23, R4 and R10 prior to that day (day unknown.) V2 stated R4 and R10 came to her office and both of them stated the agency nurse, V23 cursed at them over pain medications and got in R4's face yelling and cursing at her and flipped her middle finger off to both residents. V2 stated she didn't document the interviews with R4 and R10 and she didn't interview other residents or staff about the incident. V2 stated V1, Administrator is the abuse coordinator at the facility, and she would be the one to conduct abuse investigations. On 3/19/2026 at 12:45 PM V1, Administrator stated she didn't know exactly what occurred between an agency nurse V23, R4 and R10. V26, LPN called her one morning and stated that R4 was very upset that agency nurse, V23 was passing medication on her hall and stated she shouldn't be working at the facility because she mistreated R4 and R10. V1 stated staff immediately escorted V23 out of the building and she was not to return working here. V1 stated the situation was squashed immediately and there was no full investigation completed. V1 stated there was no reason a full investigation was not completed, once staff were aware of the situation the nurse was pulled from the hall, she wrote a statement and she was escorted from the facility, not to return. V1 stated she didn't interview any other residents other than R4 regarding the incident, and she didn't interview staff either. No statements other than V23's was documented.On 3/19/2026 at 1:26 PM V24, Nurse Practitioner stated she wasn't aware of abuse or mistreatment of residents. V24 stated she expects the facility to follow the abuse policy and to investigate allegations of abuse. The Abuse Prevention and Prohibition Policy, with a review date of 12/2/25, documents, in part, the following: Each resident has the right to be free from mistreatment and abuse, the Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. The facility promptly and thoroughly investigates reports of resident abuse and mistreatment.

Based on interview and record review, the Facility failed to follow their abuse policy by reporting and investigating allegations of misappropriation for 1 of 3 residents (R3) reviewed for abuse in the sample of 8. Findings include:R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy and Alzheimer's disease.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was severely cognitively impaired and dependent with transfer. R3's Physician Order dated 5/28/25 documents 5 mg (milligrams) oxycodone, given every four hours.On 12/11/25 at 2:59 PM, V1, Administrator, stated V6, R3's Family, reported R3 did not receive any of her medications on 11/21/25. V6 reported she watched the video footage from the video camera in R3's room, and R3's nurse never entered R3's room to give medications. On 12/11/25 at 3:20 PM, V1 stated the Facility did notify her of V6's allegation of missing medications on 11/21/25, and the nurse in question was V20, Licensed Practical Nurse (LPN). V1 stated she came in and watched the Facility's video footage that night and checked R3's Medication Administration Records (MARs) which documented the medications had been given. V1 felt the issue had been resolved and did not report or investigate the allegation.On 12/12/25 at 9:02 AM, V6 stated R3's nurse, whose identity was unknown, never entered R3's room during her shift, and R3 never received her medications. The nurse told V6 the oncoming nurse would give R3 her medications. The oncoming nurse, whose identity was also unknown, told V6 the medications were missing and had been documented as given. One of the Certified Nursing Assistants (CNAs), whose name was unknown, notified V1 of the situation. V1 stated she would be in the next day to talk to V6, but she never showed up or called.On 12/12/25 at 1:58 PM, V1 stated there is a camera at the nurse's station that is aimed down the hall and another camera a couple feet into the hall. The video footage showed V20 going from room to room and entering R3's room, but you cannot see which medications were administered. V1 stated she did not report or investigate this because she watched the video and found it was not substantiated. On 12/12/25 at 2:12 PM, V2, Director of Nursing (DON), stated if diversion is alleged, the Facility would notify her or V7, [NAME] President (VP) of Clinical Operations, and we would investigate it. We would check the counts, check the cards on the cart, and then we would check the signage on the MAR and on the narcotic book. If we found a discrepancy, we would investigate further. V2 stated she was not aware of this allegation and asked V1 if she had notified V7. V1 stated she did not notify V7.The Facility's Abuse Prevention and Prohibition Program Policy reviewed 12/2/25 documents, Each resident has the right to be free from misappropriation of property. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. The Administrator will provide initial and follow-up written report of the results of all abuse investigations and consequent actions to the appropriate agencies.

Based on interview and record review, the Facility failed to report an allegation of misappropriation for 1 of 3 residents (R3) reviewed for abuse in the sample of 8. Findings include:R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy and Alzheimer's disease.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was severely cognitively impaired and dependent with transfer.R3's Physician Order dated 5/28/25 documents 5 mg (milligrams) oxycodone, give 1 tab every four hours.On 12/11/25 at 3:20 PM, V1 stated the Facility notified her that V6 alleged R3 had medications missing on 11/21/25.On 12/12/25 at 9:02 AM, V6 stated R3's nurse, whose identity was unknown, never entered R3's room during her shift and told V6 the oncoming nurse would give R3 her medications. The oncoming nurse, whose identity was unknown, told V6 the medications were missing and had been documented as given. One of the Certified Nursing Assistants (CNAs), whose name was unknown, notified V1 of the situation. V1 stated she would be in the next day to talk to V6, but she never showed up or called.On 12/12/25 at 1:58 PM, V1 stated she did not report this to IDPH or law enforcement.The Facility's Abuse Prevention and Prohibition Program Policy reviewed 12/2/25 documents, Each resident has the right to be free from misappropriation of property. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. The Administrator will provide initial and follow-up written report of the results of all abuse investigations and consequent actions to the appropriate agencies.

Based on interview and record review, the Facility failed to investigate an allegation of misappropriation for 1 of 3 residents (R3) reviewed for abuse in the sample of 8. Findings include:R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy and Alzheimer's disease.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was severely cognitively impaired and dependent with transfer.R3's Physician Order dated 5/28/25 documents 5 mg (milligrams) oxycodone, give every four hours.On 12/11/25 at 2:59 PM, V1, Administrator, stated V6, R3's Family, reported R3 did not receive her medications on 11/21/25. On 12/11/25 at 3:20 PM, V1 stated the Facility did notify her of V6's allegation of missing medications on 11/21/25, and her nurse was V20, Licensed Practical Nurse (LPN). V1 came in and watched the Facility's video footage that night and checked R2's Medication Administration Records (MARs) which documented the medications had been given. V1 felt the issue had been resolved and did not investigate the allegation.On 12/12/25 at 9:02 AM, V6 stated R3's nurse, whose identify was unknown, never entered R3's room during her shift. The nurse told V6 the oncoming nurse would give R3 her medications. The oncoming nurse, whose identity was unknown, told V6 the medications were missing and had been documented as given. One of the Certified Nursing Assistants (CNAs), whose name was unknown, notified V1 of the situation.On 12/12/25 at 1:58 PM, V1 stated there is a camera at the nurse's station that is aimed down the hall and another camera a couple feet into the hall. The video footage showed V20 going from room to room and entering R3's room, but one could not see what medications were being administered. V1 stated she did not investigate this because she watched the video and it was unfounded.On 12/12/25 at 2:12 PM, V2, Director of Nursing (DON), stated if diversion is expected, the Facility would notify her or V7, [NAME] President (VP) of Clinical Operations, and they would investigate it. They would check the counts, check the medication cards on the cart, and then check the signage on the MAR and on the narcotic book. If they found a discrepancy they would investigate further. V2 stated she was not aware of this allegation and asked V1 if she had notified V7. V1 stated she did not notify V7 of this.The Facility's Abuse Prevention and Prohibition Program Policy reviewed 12/2/25 documents, Each resident has the right to be free from misappropriation of property. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. The Administrator will provide initial and follow-up written report of the results of all abuse investigations and consequent actions to the appropriate agencies.

Based on interview and record review, the Facility failed to allow resident to remain at the Facility and failed follow proper procedures for discharge for 1 of 3 residents (R2) reviewed for discharge in the sample of 8.Findings include:R2's Face Sheet documents R2 was initially admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon and chronic pain.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively impaired and required substantial assistance with transfer.R2's Care Plan dated 9/2/25 documents, My goal is to remain in the facility for long-term care.R2's Progress Note by V21, Licensed Practical Nurse (LPN), on 10/23/25 at 10:42 PM documents R2 returned to the Facility after being sent out for aggressive behaviors.R2's Progress Note by V25, Registered Nurse (RN), on 10/24/25 at 11:50 AM documents R2 was transferred to (Facility) with medications. On 12/10/25 at 8:53 AM, V9, Ombudsman, stated she received an email stating R2 got into an altercation with another resident. R2 was sent to the hospital for a psychological evaluation, then was transferred to (Facility). V9 went to (Facility) to check on R2, and R2 was very upset because she did not want the transfer. V9 appealed the transfer, and V5, Administrative Law Judge ( ALJ) ordered the Facility to take R2 back.On 12/10/25 at 9:38 AM, V4, R2's Family, stated the Facility called her, stating R2 got in an altercation with another resident and would have to be placed in another facility. V4 stated she was not happy about this, but the Facility presented it as their only option. She stated the Facility did not let them know their rights as a family and did not follow the proper steps for discharge.On 12/10/25 at 10:10 AM, V1, Administrator, stated R2 had behavioral problems and it had been discussed previously that if they continued R2 may need to go to a different facility. On 12/11/25 at 1:20 PM, V5 stated the Facility allowed R2 to return, but they never filed the Involuntary Discharge (IVD) paperwork and still need to resolve the hearing regarding the IVD that is scheduled for later this month.On 12/12/25 at 8:55 AM, V18, Social Services Director (SSD), stated something happened with R2 after she had already gone home one day, then the next day she came in and R2 had already transferred to (Facility).On 12/12/25 at 12:26 PM, V19, Restorative Aid, stated he transported R2 to (Facility). R2 did not want to go and said they were putting her out because she did something to another resident. V19 later got a phone call from V1 stating he would have to go get her at (Facility) and bring her back because V4 had not approved of the transfer.On 12/12/25 at 3:35 PM, V25 stated she was not aware R2 was discharging until she was leaving the building with V19. She was R2's nurse and did not even have R2's discharge paperwork ready.On 12/12/25 at 1:58 PM, V1 stated she does not remember the Facility choices that were given to R2 prior to transfer.The Illinois Department of Public Health (IDPH) Involuntary Transfer or Discharge Request for Hearing for R2 dated 10/24/25 documents, No IVD paperwork was given to resident.The IDPH Administrative Law Judge Conference Report and Order dated 12/4/25 documents the Administrative Law Judge ( ALJ) and Parties including R2 and the Facility held a Prehearing. The case was ordered to be continued for Emergent Evidentiary Hearing on December 5, 2025. On 12/11/25 at 12:30 PM, V1, Administrator, stated there was no Involuntary Discharge (IVD) paperwork provided to R2.The Facility's Notice of Transfer and Discharge Policy revised 6/1/25 documents prior to discharge, the Facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The notice will be provided 30 days in advance or as soon as practicable.

Based on interview and record review, the Facility failed to communicate required resident information to the receiving provider for 1 of 3 residents (R2) reviewed for discharge in the sample of 8. Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon and chronic pain.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively impaired and required substantial assistance with transfer.R2's Progress Note by V25, Registered Nurse (RN), on 10/24/25 at 11:50 AM documents R2 was transferred to (Facility) with medications. V25 was unable to give report to the receiving (Facility), and there was no documentation that paperwork was sent with R2.On 12/12/25 at 3:35 PM, V25 stated she discharged R2, If you want to call it that (discharge). She was not aware that R2 was being discharged until V19, Restorative Aid, came to tell her as they were getting ready to leave the Facility. V25 stated she did not even have R2's paperwork ready.On 12/10/25 at 9:38 AM, V4, R2's Family, stated the Facility did follow the proper steps when discharging R2.On 12/11/25 at 2:50 PM, V1, Administrator, stated when discharging residents, the Facility will send a medication list, two weeks of progress notes, and the resident's care plan and face sheet. The resident's chart should document that it was sent with them. The Facility's Notice of Transfer and Discharge Policy revised 6/1/25 documents when the facility discharges a resident for any reason, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Deficiencies at this level require two deficient practice statements.A. Based on interview and record review the Facility failed to ensure residents were free of neglect for 1 of 3 residents (R2) reviewed for neglect in the sample of 16. This failure occurred when (R2) was transferred from another nursing home to the facility on [DATE], with no dialysis services set up and/or scheduled prior to her acceptance to the facility. No alternate dialysis treatment was put into place while the facility was waiting for the new provider to perform treatment. R2, who was receiving dialysis 5 days per week prior to her facility admission, subsequently did not receive dialysis services for 12 days, experienced shortness of breath, sweating, weakness, jaundice eyes, and critical lab levels (potassium levels (6.2 mEq/L - milliequivalents/Liter) (normal 3.4-5.0) ; BUN (blood urea nitrogen (74) (normal 7-25 <=23.0) , and elevated serum creatinine levels 9.17 (normal 0.55-1.02 mg/dl - milligrams/deciliters) requiring hospitalization.B. Based on interview and record review the facility failed to prevent resident-to-resident altercations for 1 of 3 (R7) residents investigated for abuse in a sample of 16.Findings include: The Immediate Jeopardy was presented and called on 10/29/2025 at 1:12 PM, with V1, Administrator, V22, [NAME] President of Clinical Operations and V23 Regional Director of Operations. The Immediate Jeopardy began on 10/8/2025 at 1:20 PM when R2 arrived at the facility. The first abatement plan dated 10/29/2025 was not accepted. The fourth abatement plan on 10/30/2025 at 9:03 AM was accepted. The surveyor confirmed by observation, interview, and record that the Immediate Jeopardy was removed on 10/30/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the facility's policies and procedures and in-service training. R2's Physician Order Sheet (POS) for October 2025 documents a diagnosis of Hypoglycemia, unspecified; Hyperlipidemia, unspecified; End stage renal disease; Dependence on renal dialysis; Disorder of kidney and ureter, unspecified; Essential (primary) hypertension; Acquired absence of right leg below knee, type 1 diabetes mellitus without complications. R2's POS does not have an order for dialysis. R2's POS does document, Monitor dialysis catheter, Twice A Day 6:00 AM- 6:00 PM, 6:00 PM - 6:00 AM. R2's POS from the former facility documents R2 was receiving dialysis five days a week but no dialysis order was on the admission physician orders. R2's Facesheet documents R2 was admitted to the facility on [DATE]. R2's Care Plan with a start date of 10/8/2025 documents, Problem: I am at risk for alteration in nutrition due to d/x (diagnosis of) hypertension, Chronic systolic (congestive) heart failure, Disorder of kidney and ureter, End stage renal disease. R2's Care Plan does not document R2 was receiving dialysis. R2's Care Plan does not document anything related to waiting on dialysis treatment and or alternate treatment while the facility is waiting for the dialysis provider to accept her. R2's Transfer Sheet documents R2 was admitted from another nursing home on [DATE]. R2's Transfer Care Plan with a date initiated of 1/30/2025 from the previous facility documents Dialysis: Resident has potential for impaired renal function secondary to dialysis ESRD (end stage renal disease). R2's Medical Records document (R2) was transferred from another nursing home to the facility on [DATE], with no dialysis services set up and/or scheduled prior to her acceptance to the facility. No alternate dialysis treatment was scheduled and or put into place while the facility was waiting for the new provider to perform hemodialysis treatment for R2. R2 did not receive any dialysis services while in the facility for 12 days. R2's Progress Notes dated 10/8/2025 at 1: 20 PM, arrived at facility via facility van with staff x2. Resident a/o (alert and orientated) x3. Wheelchair independent use, and stated she is able to transfer self. Wheelchair is her personal WC (wheelchair). Speech clear and understood. smoking status, vape used. Denied tobacco use. MD (Medical doctor) in house for rounds upon arrival. Medications reconciled. BIMS (Brief interview for mental status) at a 14 (out of 15) with denying depression (cognitively intact for decision making). R2's Progress Notes do not document R2 was seen by the MD, and R2's Progress Notes do not have any documentation by the Physician. R2's Progress Notes from V20, Nursing Home B, document on 10/8/2025 at 11:40 PM, R2 was transferred from their facility to (Facility). On 10/28/2025 at 10:12 AM, V6, Licensed Practical Nurse (LPN) stated, I know (R2) needed an x-ray and some labs when she first got here and she was supposed to have dialysis, but we were waiting on the new dialysis center. I took an x-ray on her chest right before I went on vacation and when I came back (R2) still had not had dialysis but then she was sent out to the hospital. I was not given any additional instructions related to her dialysis and or what to do while she was waiting for dialysis. R2's Progress Notes 10/12/2025 at 10:58 AM, Resident has c/o (complained of) being SOB (short of breath), hot, weak, and is excessively sweating. Resident states she missed dialysis on Friday. MD (Medical Doctor) made aware of the missed dialysis day. Resident's glucose was low at 49. VS (vital signs) are as follows: 97.8, 140/85, 84, 93% on RA (Room air). MD made aware of VS (vital signs) and patient complaints, MD states just to monitor her glucose level in an hour, and send her to dialysis tomorrow, which is her normal dialysis day. Resident currently at lunch table eating a snack to bring glucose level up. R2's Progress Notes do not document V4, Medical Doctor, was notified the following day when R2 did not receive dialysis treatment. R2's Progress Notes do not document any follow up and/or anything is being put into place to address dialysis. R2's Progress Notes does not document any alternate treatment and or recommendations for addressing R2's dialysis care. R2 was not sent to dialysis and no follow up occurred. R2's Progress Notes for the month of October 2025 do not document V4 was aware R2 was not receiving any dialysis treatment while she was in the facility. No plan was documented with regards to what to do while R2 was waiting for dialysis treatment and for a bed to open it. None of R2's Progress Notes document any follow up and/or anything was being put into place to address dialysis treatment for R2. R2's October 2025 Progress Notes do not document V4, Medical Doctor was aware R2 went 12 days without receiving dialysis. R2's Progress Notes dated 10/20/2025 at 2:02 PM, spoke with resident, sister and ADON (Assistant Director of Nursing) regarding resident need of dialysis. Resident waiting on approval from dialysis clinic this week. Rec'd (received) order to send to ER (Emergency Room) for eval (evaluation) and need of dialysis. Family and resident aware of this and agree as she has not had treatment this week. NP (Nurse Practitioner) in for rounds this day and assessed resident and agreed to send to ER for eval (evaluation) and tx (treatment) if needed. EMS (Emergency Medical Services) here to transport to (nearby hospital). Per wound nurse her skin is intact with no concerns, resident verbalized that she was not in pain. R2's Hospital records dated 10/20/2025 document R2 had not had dialysis in about two weeks since coming to the new facility and had elevated potassium levels (6.2 mEq/L) (normal 3.4-5.0); BUN ((blood urea nitrogen (74) (normal 7-25 <=23.0) , and elevated serum creatinine levels 9.17 (normal 0.55-1.02 mg/dl). Patient states she had not underwent hemodialysis and the nursing facility was spoken with this nurse who informed them that they were not able to set up outpatient hemodialysis sessions prior to patient's transfer to their facility unfortunately, patient is asymptomatic but needs dialysis. (R2) states she has not received dialysis since being there. She is unsure why. R2 received dialysis services at the hospital. R2's Hospital Records dated 10/25/2025 at 1:17 PM, Medical Problems: Hyperkalemia, End-stage renal disease needing dialysis, Hypertension, Insulin dependent diabetes mellitus and document R2 was discharged back to the facility on [DATE]. R2 was admitted to the hospital for five days. On 10/23/2025 at 1:46 PM, V3, Assistant Director of Nursing (ADON) stated, When we get a new admit normally the DON would review the admitting nurse's notes and ensure there are no errors. The communication papers are put in a mailbox and then the DON reviews them. Since the DON is no longer working here, me and V14, Registered Nurse (RN) review everything to make sure there are no errors. As far as (R2), I did call the dialysis provider. (R2) was getting dialysis five times a week at the other facility in house. We do not do dialysis in house and use several contractors. I did call the (V15, Contractor A). (V15) wanted a chest x-ray and blood work on (R2) before they would admit her. Then they need a chair and space for her. (R2) was not getting dialysis from the provider because we were waiting for approval from them before we could send her. I am not aware of any other plans in place for dialysis until we heard back from the dialysis contractor (V15). On 10/23/2025 at 4:30 PM, V4, Medical Doctor stated, If a resident does not receive dialysis and/or misses a dialysis appointment I would expect to be notified. I am not sure which resident you are referring to and I am not aware of a resident coming from another facility with dialysis and not receiving dialysis while at the facility. I would expect to be notified if a resident missed an appointment. On 10/29/2025 at 9:22 AM, V21, Nephrologist (Kidney Specialist) stated, It is critical that if a resident who is receiving dialysis and goes to another facility that dialysis is set up ahead of time and no treatments are missed. No treatments should be missed. ESRD (End stage renal disease) depends in dialysis. A resident may not even be having symptoms because a lot of these things are silent killers and can affect the heart and cause death. If a resident does not have dialysis set up, I would expect them to be sent the ER to get treatments until they are able to get treatments from the new facility. Any resident missing 10 treatments I would absolutely consider that neglect. This could cause serious harm and death the body is depending on the dialysis treatment. The Facility Abuse Prevention and Prohibition Program Policy undated documents, To ensure that facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial well-being. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. The Immediate Jeopardy that began on 10/8/2025 when R2 was admitted without any hemodialysis treatment scheduled and or given for 12 days while she was in the facility was removed on 10/30/2025 after the facility took the following actions to remove the Immediacy: 1. The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on neglect r/t (related to) coordination of care by not setting up dialysis treatments. 2. All department heads on abuse and neglect policy and procedure and no staff was allowed to work until they were in-serviced on abuse and neglect. 3. 24-hour report sheet was made up starting 11/1/2025. It was made to ensure that there were no dialysis residents that missed/ needed set up for treatment. 4. A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed daily x 4 weeks to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect r/t coordination of care for all new residents and dialysis treatment. B. R7's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE]. R7's EMR dated 5/20/24 documents Complete traumatic amputation of right great toe, subsequent encounter and Type 2 diabetes mellitus with foot ulcer. R7's EMR dated 1/20/25 documents anxiety disorder, unspecified. R7's Care Plan dated 2/7/25 documents Problem: (R7) has a behavior problem r/t descriptive accounts of occurrence involving her and/or others. R7's Care Plan dated 10/21/25 documents Problem: I have conflicts with other residents as evidenced by altercations verbally and being aggressive towards them verbally. R7's MDS (Minimum Data Set) dated 8/18/25 documents a BIMS (Brief Interview for Mental Status) score of 13 out of 15. The MDS documents That the resident requires substantial/maximal assistance for roll left and right, sit to lying, and lying to sitting on side of bed. The MDS documents that the resident is dependent for sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS documents that the resident has not exhibited any behaviors. The facility's Serious Injury Incident and Communicable Disease Report dated 9/16/25 documents (R8) is a [AGE] year-old female who resides at (Facility) with a BIMS that is unable to be scored. Diagnosis included but are not limited to: Generalized Anxiety Disorder, Essential Primary Hypertension, Bipolar Disorder Unspecified. (R7) is a [AGE] year-old female who also resides at (Facility) with a BIMS of 13. Diagnosis include but are not limited to: Anxiety Disorder, Unspecified, Type II Diabetes, Essential (primary) Hypertension. On 9/16/2025 around 5:00 pm staff witnessed an alleged resident to resident interaction between (R7) and (R8). Both residents separated immediately and placed on enhanced supervision. MD (Medical Director), POA's (Power of Attorney), Administration and Ombudsman made aware. Both residents placed on 15-minute checks. Investigation initiated. Initial Interventions: 1) Residents were separated immediately and placed on 15-minute checks for 48 hours. 2) (R7) assessed for injuries, skin and pain assessment completed, no new findings. 3) Staff and resident interviews initiated. 4) In-service on abuse policy initiated. Investigation: (R8) denies making any contact with (R7). (R7) stated that (R8) hit her on the arm, but also states she did not care, it did not hurt Staff members were interviewed and stated that they heard the residents verbally arguing and that they were seated within proximity of each other. Other residents were interviewed that were present at the alleged incident, report no knowledge of any alleged abuse and feel safe and wish to remain at (Facility). Conclusion: This allegation is unsubstantiated due to no physical evidence on residents skin assessments indicating that physical contact was made, no certain eyewitnesses saw contact made, and both residents deny wrongdoing. A verbal altercation occurred, both residents feel safe and did not feel threatened, it was more of a disagreement. Final Interventions: 1) 15-minute checks completed. No further incidents. 2) SSD (Social Services Designee) to follow up and ensure that residents remain feeling safe. 3) Behavior tracking updated. 4) Investigation completed. 5) In-service on behaviors/ abuse & neglect completed. 6) Final sent to IDPH (Illinois Department of Public Health). Facility's Serious Injury Incident and communicable Disease Report dated 10/23/25 documents (R8) is a [AGE] year-old female who resides at (Facility) with a BIMS that is unable to be scored. Diagnosis included but are not limited to: Generalized Anxiety Disorder, Essential Primary Hypertension, Bipolar Disorder Unspecified. (R7) is a [AGE] year-old female who also resides at (Facility) with a BIMS of 13. Diagnosis include but are not limited to: Anxiety Disorder, Unspecified, Type II Diabetes, Essential (primary) Hypertension. On 10/17/2025 around 5:00 pm staff witnessed an alleged resident to resident interaction between (R7) and (R8). Both residents separated immediately and placed on enhanced supervision. MD, POA's, Administration and Ombudsman made aware. Investigation initiated. Initial Interventions: 1) Residents separated immediately. 2) Both residents placed on enhanced monitoring. 3) Skin and pain assessment completed on (R7). 4) Investigation initiated. (R7) was allegedly speaking with another resident in the dining room when (R8) rolled up behind her to grab her hair and made contact with her back side. (R7) acknowledges feeling safe in the facility and wishes to remain at (Facility). (R8) states that she reacted after being called a derogatory name by (R7). (R8) suggested that (R7) was also blocking her from getting past. (R11) interviewed and states that she did witness (R7) rolling back to block (R8) but she did not hear any name calling. (R11) acknowledges feeling safe in the facility and wishes to remain at (Facility). Other residents that were present at the time of this alleged incident report seeing (R7) and (R8) interacting but feel safe in the facility and wish to remain at (Facility). (R7) had a small bruise noted on her back, noted on a skin check from 10/17. On 10/22 another skin check was completed and noted no bruising on (R7's) back. This investigation is unsubstantiated due to this being repeated behaviors that both resident's display. Neither resident was harmed in this alleged interaction, and both wish to remain at (Facility). Final Interventions: 1) Care plans reviewed and updated for both residents. 2) Staff in-serviced on facility abuse prevention and policy. 3) Psychosocial follow ups completed, no changes. Both residents wish to remain at (Facility). 4) Both residents' care plans reviewed and updated accordingly. 5) Final sent to IDPH. R7's Weekly Skin assessment dated [DATE] documents quarter size bruise noted to residents left upper back area bluish in color. On 10/28/25 at 12:22 PM, R7 stated that she does not recall exactly what happened during the altercation in September, she just remembers that (R8) hit her. She stated that the week ago altercation, (R8) hit her twice and pulled her hair. On 10/28/25 at 12:45 PM, R13 stated he witnessed (R8) hit (R7) in the stomach in September. He stated that (R7) did not hit her back and told him to get a CNA (Certified Nursing Aid). On 10/28/25 at 12:59 PM, R12 stated that she witnessed (R8) hit (R7) in the dining room last week. On 10/28/25 at 1:00pm, R10 stated she witnessed (R8) hit (R7) but she does not remember when and where. Facility policy Abuse Prevention and Prohibition Program undated documents To ensure that facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.

Based on interview and record review the Facility failed to ensure coordination of care for a resident to receive medically necessary hemodialysis for 1 of 3 residents (R2) reviewed for dialysis services in the sample of 16. This failure occurred when (R2) was admitted to the facility on [DATE] and did not receive dialysis services for 12 days. R2 was sent to the hospital per family request where she was found with critical lab values, shortness of breath and had a 5 day hospital stay.Findings include:The IJ (Immediate Jeopardy) was presented and called on 10/29/2025 at 1:12 PM, with V1, Administrator, V22, [NAME] President of Clinical Operations and V23 Regional Director of Operations. The Immediate Jeopardy began on 10/8/2025 at 1:20 PM when R2 arrived at the facility. (R2) was transferred from another nursing home to the facility on [DATE], with no dialysis services set up and/or scheduled prior to her acceptance to the facility. No alternate dialysis treatment was put into place while the facility was waiting for the new provider to perform treatment. R2, who was receiving dialysis 5 days per week prior to her facility admission, subsequently did not receive dialysis services for 12 days, experienced shortness of breath, sweating, weakness, jaundiced eyes, and critical lab levels (potassium levels (6.2 mEq/L - milliequivalent/Liter) (normal 3.4-5.0) ; BUN (blood urea nitrogen (74) (normal 7-25 <=23.0) , and elevated serum creatinine levels 9.17 (normal 0.55-1.02 mg/dl - milligrams/deciliters) requiring hospitalization. The first abatement plan dated 10/29/2025 was not accepted. The fourth abatement plan on 10/30/2025 at 9:03 AM was accepted. The surveyor confirmed by observation, interview, and record that the Immediate Jeopardy was removed on 10/30/2025, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the facility's policies and procedures and in-service training.R2's Physician Order Sheet (POS) for October 2025 documents a diagnosis of Hypoglycemia, unspecified; Hyperlipidemia, unspecified; End stage renal disease; Dependence on renal dialysis; Disorder of kidney and ureter, unspecified; Essential (primary) hypertension; Acquired absence of right leg below knee, type 1 diabetes mellitus without complications. R2's POS does not have an order for dialysis. R2's POS does document, Monitor dialysis catheter. Twice a day 6:00 AM-6:00 PM- 6:00 PM- 6:00 AM.R2's Facesheet documents R2 was admitted to the facility on [DATE].R2's Care Plan with a start date of 10/8/2025 Problem: I am at risk for alteration in nutrition due to d/x (diagnosis of) hypertension, Chronic systolic (congestive) heart failure, Disorder of kidney and ureter, End stage renal disease. R2's Care Plan does not document R2 was receiving dialysis and or waiting to set up hemodialysis treatments.R2's Transfer Sheet documents R2 was admitted from another nursing home on [DATE] at 11:40 AM. R2's Transfer Physician Orders Sheets (POS) document dialysis five times a week. R2's Transfer Care Plan with a date initiated of 1/30/2025 documents, Dialysis: Resident has potential for impaired renal function secondary to dialysis ESRD (End State Renal Disease).R2's Progress Notes document (R2) was transferred from another nursing home to the facility on [DATE], with no dialysis services set up and/or scheduled prior to her acceptance to the facility. No alternate dialysis treatment was scheduled and or put into place while the facility was waiting for the new provider to perform hemodialysis treatment for R2. R2's Progress Notes do not document R2 received any dialysis services while in the facility for her first 12 days. (10/8/2025-10/20/2025).R2's Progress Note dated 10/8/2025 at 1: 20 PM, arrived to facility via facility van with staff x2. Resident a/o (alert and orientated) x3. Wheelchair independent use, and stated she is able to transfer self. Wheelchair is her personal wc (wheelchair). Speech clear and understood. Smoking status, vape used. Denied tobacco use. MD (Medical doctor) in house for rounds upon arrival. medications reconciled. BIMS (Brief interview for mental status) at a 14 (out of 15) with denying depression (cognitively intact for decision making). R2's Progress Notes do not document any dialysis appointments and/or address any alternate treatments if R2 was not able to get into dialysis right away. R2's Progress Notes 10/12/2025 at 10:58 AM, Resident has c/o (complained of) being SOB (short of breath), hot, weak, and is excessively sweating. Resident states she missed dialysis on Friday. MD (Medical Doctor) made aware of the missed dialysis day. Resident's glucose was low at 49. VS (vital signs) are as follows: 97.8, 140/85, 84, 93% on RA (Room air). MD made aware of VS and patient complaints MD states just to monitor her glucose level in an hour, and send her to dialysis tomorrow, which is her normal dialysis day. Resident currently at lunch table eating a snack to bring glucose level up.R2's Progress Notes does not document R2 received dialysis on 10/13/2025 (next day). R2's Progress Notes do not address anything related to where or what company she is to receive dialysis treatment, and/or any alternate plan to receive dialysis. R2 was not sent to dialysis and no follow up occurred regarding to her having shortness of breath and or not receiving dialysis. R2's Progress Notes do not document any dialysis plan and or future dialysis appointments.R2's Progress Notes dated 10/20/2025 at 2:02 PM, spoke with resident, sister and ADON (Assistant Director of Nursing) regarding resident need of dialysis. Resident waiting on approval from dialysis clinic this week. Rec'd (received) order to send to ER (Emergency Room) for eval (evaluation) and need of dialysis. Family and resident aware of this and agree as she has not had treatment this week. NP (Nurse Practitioner) in for rounds this day and assessed resident and agreed to send to ER for eval (evaluation) and tx (treatment) if needed. EMS (Emergency Medical Services) here to transport to (nearby hospital). Per wound nurse her skin is intact with no concerns, resident verbalized that she was not in pain.On 10/23/2025 at 2:59 PM, V12, Family of R2 stated, My sister is mentally delayed. She does not read, write and is unable to count money. About three weeks ago I went to her former nursing home, and they told me (R2) was no longer there. I was really confused because nobody asked me. I do not know how or why she got to (Facility). When I finally went to the (Facility) (R2) was not doing well at all. Her face was swollen, she was having shortness of breath, and her eyes were yellow like jaundice. I went to find the nurse and ask her when the last time (R2) had dialysis, and the nurse did not even know my sister was supposed to be getting dialysis. I asked them to send her to the hospital which they did, and she was admitted , and she is still there. (R2) did not get one treatment of dialysis while she was there, and she was getting five treatments a week at the other facility. I was so confused and don't know how this could have happened. I know they told me (R2) was to never go more than 2-3 days without dialysis because her fluids would build up and toxics would build up and it could harm her. How did this happen? (R2) has two children, a 7 and a 9-year child. I don't know what we are going to do if something bad happened to her. I feel like she was supposed to get dialysis, how could they wait so long, and not make sure she got dialysis.On 10/23/2025 at 1:23 PM, V5, Former Director of Nursing (DON) stated when staff are receiving a new patient, we review the orders and have them put in the paperwork and leave everything in a black metal mailbox to review for later to make sure nothing was missed and/or overlooked. Typically, this is something the DON would do. I cannot say who is reviewing the paperwork now. I would look at the medication to make sure no medications are forgotten, and for example if they were on dialysis, I would make sure they have that set up already and notify transportation, so they do not miss any appointments. If a resident is coming from another facility and is already on dialysis, then we already know they are going to need dialysis and that should have already been set up before they even got into the facility. Then we make sure our driver knows when the appointments are so they can ensure they do not miss any of their appointments.On 10/23/2025 at 1:37 PM, V13, Social Service Director (SSD) stated, Normally if a resident is on dialysis that is something we would look at before admitting them and make sure all of that is set up before they arrive, so they do not miss any appointments. I am not sure what happened with (R2).On 10/23/2025 at 1:42 PM, V13 provided R2's transfer paperwork which included her POS and Care Plan from the previous facility.On 10/23/2025 at 1:46 PM, V3, Assistant Director of Nursing (ADON) stated, When we get a new admit, normally the DON would review the admitting nurse's notes and ensure there are no errors. The communication papers are put in a mailbox, and then the DON reviews then. Since the DON is no longer working here, me and V14, Registered Nurse (RN) review everything to make sure there are no errors. As far as (R2), I did call the dialysis provider. (R2) was getting dialysis five times a week at the other facility in house. We do not do dialysis in house and use several contractors. I did call the (V15, Dialysis Center). (V15) wanted a chest x-ray and blood work on (R2) before they would admit her. Then they needed a chair and space for her. (R2) was not getting dialysis from the provider because we were waiting for approval from them before we could send her. I am not aware of any other plans in place for dialysis until we heard back from the dialysis contractor (V15).On 10/23/2025 at 4:30 PM, V4, Medical Doctor stated, If a resident is coming from another nursing home facility and they are receiving dialysis, he would expect for coordination of care for the new nursing home to put things in place to assure dialysis services would be provided, with the least interruption possible, and for policy to be followed and coordinated. Any interruption from this schedule could have the potential for harm, and if the resident was having symptoms he would expect to be notified and would send them out to the hospital for missed appointments of over two days depending on labs. A resident missing dialysis and exhibiting symptoms would more than likely experience fluid overload, they usually will have SOB (shortness of breath), chest pain, other things and a lot of things. Usually fluid overload. Skipping dialysis can lead to fluid overload where the fluid builds up in the body leading to symptoms such as shortness of breath (SOB), swelling. This can result in emergency situations requiring hospitalization. It can lead to elevated potassium levels in the blood which can affect the heart and toxic buildups as the body is not able to remove waste products from the blood. If left untreated it can cause harm and possible death.R2's Hospital records dated 10/20/2025 document R2 had not had dialysis in about two weeks since coming to the new facility and had elevated potassium levels (6.2 mEq/L) (normal 3.4-5.0); BUN ((blood urea nitrogen (74) (normal 7-25 <=23.0) , and elevated serum creatinine levels 9.17 (normal 0.55-1.02 mg/dl). Patient states she had not underwent hemodialysis and the nursing facility was spoken with this nurse who informed them that they were not able to set up outpatient hemodialysis sessions prior to patient's transfer to their facility unfortunately, patient is asymptomatic but needs dialysis. (R2) states she has not received dialysis since being there. She is unsure why. R2 received dialysis services at the hospital.R2's Hospital Records dated 10/25/2025 at 1:17 PM, Medical Problems: Hyperkalemia, End-stage renal disease needing dialysis, Hypertension, Insulin dependent diabetes mellitus and document R2 was discharged back to the facility on [DATE]. R2 was admitted to the hospital for five days.On 10/28/2025 at 3:59 PM, V19, Transportation stated, I had a referral out to (V15, Dialysis Center) regarding (R2) receiving dialysis. I had faxed them twice and had a referral out to them, but I guess they did not get it, so it did not go through. I guess my fax was not going through and I followed up with them on Friday and today was (R2's) first day of getting dialysis treatment. I tried to set something up when she was first admitted . (R2) is set up now and today was her first dialysis treatment since admission.On 10/28/2025 at 4:11 PM, LPN V18, LPN stated, I remember when (R2) was a new resident and she came from (Nursing Home B). I do not know anything about her needing dialysis when she first arrived. I know (R2) was sent out to the hospital. I was not told what to look for and or send her out if she had any of those symptoms from not having dialysis. I know when she just came back from the hospital, she is on dialysis now and it is all set up.On 10/29/2025 at 9:22 AM, V21, Nephrologist (Kidney Specialist) stated, It is critical that if a resident who is receiving dialysis and goes to another facility that dialysis is set up ahead of time and no treatments are missed. No treatments should be missed. ESRD (End stage renal disease) depends in dialysis. A resident may not even be having symptoms because a lot of these things are silent killers can affect the heart and cause death. If a resident does not have dialysis set up, I would expect them to be sent the ER to get treatments until they are able to get treatments from the new facility. Any resident missing 10 treatments I would absolutely consider that neglect. This could cause serious harm and death the body is depending on the dialysis treatment.The Facility Change of Condition Policy undated documents, To ensure that medical care problems are communicated to the attending physician or authorized designee and family/ responsible party in a timely, efficient, and effective manner. The facility will inform the resident, consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: An accident involving the resident which results in injury and has the potential for requiring physician intervention. A significant change in the residents' physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life- threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a stage 2 pressure sore, onset or recurrent periods of delirium, recurrent urinary tract infection, or onset of depression. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before).A decision to transfer or discharge the resident from the facility. The Immediate Jeopardy and deficiency practice that began on 10/8/2025 when R2 was admitted without any hemodialysis treatment scheduled and or given for 12 days while she was in the facility was removed on 10/30/2025 after the facility took the following actions to remove the Immediacy:1. The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on dialysis care r/t (related to) coordination of care by not setting up dialysis treatments.2. All department heads on dialysis and procedure and no staff was allowed to work until they were in-serviced on dialysis.3. 24-hour report sheet was made up starting 11/1/2025. It was made to ensure that there were no dialysis residents that missed/ needed set up for treatment. 4. A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed daily x 4 weeks to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect r/t coordination of care for all new residents and dialysis needs are addressed.

Based on interview and record review the Facility failed to notify the physician for 1 of 3 residents (R2) reviewed for notification in the sample of 16. This failure resulted in R2's Physician not being notified when R2 did not receive dialysis for 12 days resulting in R2 being hospitalized . Findings include: R2's Physician Order Sheet (POS) for October 2025 documents a diagnosis of Hypoglycemia, unspecified; Hyperlipidemia, unspecified; End stage renal disease; Dependence on renal dialysis; Disorder of kidney and ureter, unspecified; Essential (primary) hypertension; Acquired absence of right leg below knee, type 1 diabetes mellitus without complications. R2's POS does not have an order for dialysis. R2's POS does document, Monitor dialysis catheter, twice a day 6:00 MA-6:00 PM-6:00 PM - 6:00 AM.R2's Facesheet document R2 was admitted to the facility on [DATE]. R2's Care Plan with a start date of 10/8/2025 Problem: I am at risk for alterations in nutrition due to d/x (diagnosis of) hypertension, Chronic systolic (congestive) heart failure, Disorder of kidney and ureter, End stage renal disease. R2's Care Plan does not document R2 was receiving dialysis and or was waiting for approval for potential dialysis treatments. R2's Progress Notes dated 10/8/2025 at 1:20 PM, arrived to facility via facility van with staff x2. Resident a/o (alert and orientated) x3. Wheelchair independent use, and stated she is able to transfer self. Wheelchair is her personal WC (wheelchair). Speech clear and understood. smoking status, vape used. Denied tobacco use. MD (Medical doctor) in house for rounds upon arrival. medications reconciled. BIMS (Brief interview for mental status) at a 14 (out of 15) with denying depression (cognitively intact for decision making). (Author V3). R2's Progress Notes do not document R2 was seen by the MD.R2's Progress Notes 10/12/2025 at 10:58 AM, Resident has c/o (complained of) being SOB (short of breath), hot, weak, and is excessively sweating. Resident states she missed dialysis on Friday. MD (Medical Doctor) made aware of the missed dialysis day. Resident's glucose was low at 49. VS (vital signs) are as follows 97.8, 140/85, 84, 93% on RA (Room air). MD made aware of VS and patient complaints, MD states just to monitor her glucose level in an hour and send her to dialysis tomorrow, which is her normal dialysis day. Resident currently at lunch table eating a snack to bring glucose level up. R2's Progress Notes does not document V4, Medial Doctor was notified the following day when R2 did not receive dialysis treatment. R2's Progress Notes do not document V4 was aware R2 was not receiving any dialysis treatment while she was in the facility. R2's Progress Notes do not document V4 was aware R2 went 12 days without receiving dialysis.On 10/28/2025 at 1:32 PM, V4, Medical Director stated, On the day (R2) arrived he saw her, but he has not yet uploaded his physician notes (date of service 10/8/2025). He knows (R2) missed some dialysis, but he was under the impression that (R2) was coming from home not from another facility. The following week when (R2) was having issues he was notified but he was not notified that she did not receive dialysis the next day as recommended, and they (Facility) should have notified him, and he does not know what the issue was they were having. He reviewed her labs on her first day and her labs were good considering she was on dialysis. He can say he was not informed of her situation. If he would have known (R2) did not get her dialysis treatment he would have sent her to the hospital for treatment.R2's Hospital records dated 10/20/2025 document R2 had not had dialysis in about two weeks since coming to the new facility, and had elevated potassium levels (6.2 mEq/L - milliequivalents/Liter) (normal 3.4-5.0); BUN (blood urea nitrogen (74) (normal 7-25 <=23.0) , and elevated serum creatinine levels 9.17 (normal 0.55-1.02 mg/dl - milligrams/deciliter). Patient states she had not underwent hemodialysis and the nursing facility was spoken with this nurse who informed them that they were not able to set up outpatient hemodialysis sessions prior to patient's transfer to their facility unfortunately, patient is asymptomatic but needs dialysis. (R2) states she has not received dialysis since being there. She is unsure why. R2 received dialysis services at the hospital. R2's Hospital Records dated 10/25/2025 at 1:17 PM, Medical Problems: Hyperkalemia, End-stage renal disease needing dialysis, Hypertension, Insulin dependent diabetes mellitus and document R2 was discharged back to the facility on [DATE]. R2 was admitted to the hospital for five days. The Facility Change of Condition Policy undated documents, To ensure that medical care problems are communicated to the attending physician or authorized designee and family/ responsible party in a timely, efficient, and effective manner. The facility will inform the resident, consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: An accident involving the resident which results in injury and has the potential for requiring physician intervention. A significant change in the residents' physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life- threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a stage 2 pressure sore, onset or recurrent periods of delirium, recurrent urinary tract infection, or onset of depression. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before).A decision to transfer or discharge the resident from the facility.

Based on interview and record review the facility failed to provide enough licensed nursing staff to adequately meet the needs for 4 of 4 (R3, R10, R12, and R13) residents reviewed for staffing in the sample of 13. These failures have the potential to affect all residents residing at the facility. Findings include:1.R3's face sheet, print date of 9/15/25, documented R3 has diagnoses including pneumonia, anemia, hyperlipidemia, generalized anxiety disorder, insomnia, chronic pain, hypertension, paroxysmal atrial fibrillation, heart failure, hemiplegia and hemiparesis following cerebral infarction, unspecified convulsions, and COPD (chronic obstructive pulmonary disease). R3's MDS (Minimum Data Set), dated 7/7/25, documented R3 is cognitively intact.On 9/16/25 at 8:18 AM R3 stated her evening shift medications are often administered late and the nurses must wake her up so she can take them. Surveyor asked R3 if she has experienced increase pain due to her scheduled Tylenol not being administered as ordered every 4 hours and R3 replied sometimes I have had pain from not getting it on time. Surveyor asked R3 if she feels the facility has enough nurses and R3 replied no, they don't.2. R10's face sheet, print date of 9/16/25, documented R10 has diagnoses including wedge compression of first lumbar vertebra, insomnia, hypertensive heart disease, primary pulmonary hypertension, paroxysmal atrial fibrillation, altered mental status, hyperlipidemia, major depressive disorder, generalized anxiety disorder, and hypertension.R10's MDS, dated [DATE], documented R10 is cognitively impaired although at time of interview R10 was alert and oriented. On 9/16/25 at 6:03 AM R10 stated last night she did not receive her 8 PM meds until after 10 PM and the night before it was after midnight. Surveyor asked R10 if she knows why and she replied, they don't have enough nurses.3. R12's face sheet, print date of 9/16/25, documented R12 has diagnoses including fracture of right humerus, pain, insomnia, anxiety disorder, COPD, anemia, hypertension, major depressive disorder, and hyponatremia. R12's MDS, dated [DATE], documented R12 is cognitively intact. On 9/16/25 at 6:50 AM R12 stated she is the [NAME] President of the Resident Council and at the last meeting it was all about evening medications being administered late. R12 stated a whole lot of residents were upset because 3 nurses are not enough to pass medications so many residents are receiving their 8 PM medications late. R12 stated she and other residents have had their 8 PM medications administered at midnight or after.4. R13's face sheet, print date of 9/16/25, documented R13 has diagnoses including hypertension, diabetes mellitus, hyponatremia, infection, and inflammatory reaction due to internal right hip prosthesis, Marfan syndrome, pain, depression, bipolar disorder, and glaucoma. R13's MDS, dated [DATE], documented R13 is cognitively intact. On 9/16/25 at 6:58 AM R13 stated she has been getting her 8 PM medications late due to the facility being short staffed. R13 stated there have been a few times when she did not receive her 8 PM medications until after midnight. R13 stated she gets pain medications in the evening, and she has experienced increased pain due to the medications being administered late. On 9/16/25 at 5:17 AM V15 LPN (Licensed Practical Nurse) stated the 8 PM medication pass is rough with just 3 nurses, meds are sometimes late, 3 nurses must share the D hall med cart because the residents are split between the 3 nurses. V15 stated this company cut the 4th nurse from 6 PM to 10 PM to save money.On 9/16/25 at 5:25 AM V16 LPN stated nurse staffing is not sufficient from 6 PM to 10 PM, used to have 4 nurses then the owner cut the 4th nurse from 6 PM to 10 PM. V16 stated (R12) has complained about her meds being late. On 9/16/25 at 5:30 AM V17 LPN stated they really need 4 nurses for the 6pm to 10pm med pass to ensure quality of care. On 9/16/25 at 6:10 AM V18 Wound Care Nurse stated 3 nurses from 6 PM to 10 PM is not enough nurses. On 9/16/25 at 7:37 AM V1 Administrator stated some residents were upset in the last Resident Council meeting about receiving their medications late on the evening shift. Surveyor asked V1 if she expects the facility nurses to sign their medications off as they administer them and V1 replied yes. Surveyor asked if she believes the medications were administered late when the evening shift nurses sign the medications off as charted late and V1 replied yes.On 9/16/25 at 9:27 AM V2 DON stated it is difficult for the nurses to complete all tasks with 3 nurses from 6 PM to 10 PM.The facility's Resident Council Memorandum, dated 8/4/25, documented issue: waiting till after 11 PM for meds. Residents getting very upset about it. DON (Director of Nursing) is aware of this issue. Response by V2 DON: will review staffing with (V1 Administrator) and (owner) to see if we can increase nursing staff at night to include 4 nurses until 10 PM to ensure residents are getting their meds in a timely manner. The facility's Resident Council Memorandum, dated 9/8/25, documented issue: nursing, meds are not getting to residents at right times, said nurses are getting angry at night. Call lights not being answered in a timely manner. The facility's staffing policy, undated, documented it is the policy of Evercare Skilled Nursing LLC to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and director of Nursing as specified by the Illinois Department of Public Health. The division of nursing needs by shift will be calculated based on the resident census and needs. The facility's Daily Census Report, dated 9/16/25, documented there are 100 residents residing at the facility.

Based on record review and interview the facility failed to administer medications at the scheduled times for 4 of 4 (R3, R10, R12, and R13) residents reviewed for medication administration in the sample of 13. These failures have the potential to affect all residents residing at the facility. Findings include:1.R3's face sheet, print date of 9/15/25, documented R3 has diagnoses including pneumonia, anemia, hyperlipidemia, generalized anxiety disorder, insomnia, chronic pain, hypertension, paroxysmal atrial fibrillation, heart failure, hemiplegia and hemiparesis following cerebral infarction, unspecified convulsions, and COPD (chronic obstructive pulmonary disease). R3's MDS (Minimum Data Set), dated 7/7/25, documented R3 is cognitively intact.R3's care plan, undated, documented R3 has chronic pain with interventions including administer analgesia as per orders. R3's 9/1/25 - 9/16/25 MAR (medication administration record) documented R3 has an order for acetaminophen 325 mg (milligrams), 2 tabs, every 4 hours. This MAR documented R3's scheduled 8 PM acetaminophen was signed off as late administration: charted late on 9/1/25 at 11:41 PM, on 9/3/25 at 1:58 AM on 9/4/25, on 9/4/25 at 9:56 PM, on 9/8/25 at 10:14 PM, on 9/11/25 at 1:56 AM on 9/12/25, on 9/13/25 at 4:39 AM on 9/14/25, on 9/14/25 at 11:20 PM, and on 9/15/25 at 10:06 PM.On 9/16/25 at 8:18 AM R3 stated her evening shift medications are often administered late and the nurses must wake her up so she can take them. Surveyor asked R3 if she has experienced increase pain due to her scheduled Tylenol not being administered as ordered every 4 hours and R3 replied sometimes I have had pain from not getting it on time. Surveyor asked R3 if she feels the facility has enough nurses and R3 replied no, they don't.2. R10's face sheet, print date of 9/16/25, documented R10 has diagnoses including wedge compression of first lumbar vertebra, insomnia, hypertensive heart disease, primary pulmonary hypertension, paroxysmal atrial fibrillation, altered mental status, hyperlipidemia, major depressive disorder, generalized anxiety disorder, and hypertension.R10's MDS, dated [DATE], documented R10 is cognitively impaired although at time of interview R10 was alert and oriented. R10's care plan, undated, documented R10 has diagnoses of hypertension, cardiomegaly, atrial fibrillation, hypertension, and hyperlipidemia with interventions including administer medications as ordered. R10's MAR, dated 9/1/25 - 9/15/24, documented R10 has an order for a beta-blocker medication carvedilol 12.5 mg twice a day between 6 AM and 9 AM and between 7 PM and 10 PM. This MAR documented R10's evening carvedilol was signed off as late administration: charted late on 9/3/25 at 12:56 AM on 9/4/25, 9/6/25 at 11:16 PM, 9/11/25 at 12:50 AM on 9/12/25, 9/13/25 at 4:37 AM on 9/14/25 and 9/14/25 at 11:17 PM. On 9/16/25 at 6:03 AM R10 stated last night she did not receive her 8 pm meds until after 10 pm and the night before it was after midnight. Surveyor asked R10 if she knows why and she replied, they don't have enough nurses.3. R12's face sheet, print date of 9/16/25, documented R12 has diagnoses including fracture of right humerus, pain, insomnia, anxiety disorder, COPD, anemia, hypertension, major depressive disorder, and hyponatremia. R12's MDS, dated [DATE], documented R12 is cognitively intact. R12's care plan, undated, documented R12 has acute pain related to a fracture of her arm prior to admission with interventions including administer analgesia as per orders. R12's MAR, dated 9/1/25 - 9/15/25, documented an order for oxycodone 5 mg 3 times a day at 6 AM, 12 PM, and 6 PM. This MAR documented R12's 6 PM oxycodone as late administration: charted late on 9/7/25 at 8:40 PM, and on 9/12/25 at 8:08 PM. R12's MAR, dated 9/1/25 - 9/15/25, documented an order for trazadone 50 mg at 8 PM. This MAR documented R12's trazadone as late administration: charted late on 9/3/25 at 10 PM, on 9/4/25 at 9:52 PM, on 9/10/25 at 9:14 PM, and on 9/13/25 at 9:30 PM. On 9/16/25 at 6:50 AM R12 stated she is the [NAME] President of the Resident Council and at the last meeting it was all about evening medications being administered late. R12 stated a whole lot of residents were upset because 3 nurses are not enough to pass medications so many residents are receiving their 8 PM medications late. R12 stated she and other residents have had their 8 PM medications administered at midnight or after.On 9/16/25 at 10:57 AM R12 stated she has chronic pain from a shoulder fracture that was not operable, and she has had to wait for a long time for a pain pill on the evening shift due to the facility not having enough nurses. R12 stated her pain reached a level of 8 to 10 during the times her pain medication was late. R12 stated this just became an issue about 2 to 3 months ago. V12 stated she also takes trazadone to help her sleep and there have been times when she did not receive her trazadone until midnight. 4. R13's face sheet, print date of 9/16/25, documented R13 has diagnoses including hypertension, diabetes mellitus, hyponatremia, infection, and inflammatory reaction due to internal right hip prosthesis, Marfan syndrome, pain, depression, bipolar disorder, and glaucoma. R13's MDS, dated [DATE], documented R13 is cognitively intact. R13's care plan, undated, documented R13 has chronic pain with interventions including administer analgesia as per orders. R13's MAR, dated 9/1/25 - 9/15/25, documented an order for hydromorphone 6 mg four times a day for pain. This MAR documented R13's 7 PM to 9 PM hydromorphone was charted as late administration: charted late on 9/1/25 at 4:54 AM on 9/2/25, on 9/4/25 at 10:34 PM, on 9/5/25 at 10:58 PM, on 9/7/25 at 12:38 AM on 9/8/25, on 9/10/25 at 3:58 AM o 9/11/25, on 9/11/25 at 1:03 AM on 9/12/25, on 9/13/25 at 4:40 AM on 9/14/25, on 9/14/25 at 10:59 PM, and on 9/15/25 at 10:08 PM. On 9/16/25 at 6:58 AM R13 stated she has been getting her 8 PM medications late due to the facility being short staffed. R13 stated there have been a few times when she did not receive her 8 PM medications until after midnight. R13 stated she gets pain medications in the evening, and she has experienced increased pain due to the medications being administered late. On 9/16/25 at 5:17 AM V15 LPN (Licensed Practical Nurse) stated the 8 PM medication pass is rough with just 3 nurses, meds are sometimes late, 3 nurses must share the D hall med cart because the residents are split between the 3 nurses. V15 stated this company cut the 4th nurse from 6 PM to 10 PM to save money.On 9/16/25 at 5:25 AM V16 LPN stated nurse staffing is not sufficient from 6 PM to 10 PM, used to have 4 nurses then the owner cut the 4th nurse from 6 PM to 10 PM. V16 stated (R12) has complained about her meds being late. On 9/16/25 at 5:30 AM V17 LPN stated they really need 4 nurses for the 6pm to 10pm med pass to ensure quality of care. On 9/16/25 at 6:10 AM V18 Wound Care Nurse stated 3 nurses from 6 PM to 10 PM is not enough nurses. On 9/16/25 at 7:37 AM V1 Administrator stated some residents were upset in the last Resident Council meeting about receiving their medications late on the evening shift. Surveyor asked V1 if she expects the facility nurses to sign their medications off as they administer them and V1 replied yes. Surveyor asked if she believes the medications were administered late when the evening shift nurses sign the medications off as charted late and V1 replied yes.On 9/16/25 at 9:27 AM V2 DON stated it is difficult for the nurses to complete all tasks with 3 nurses from 6 PM to 10 PM.The facility's Resident Council Memorandum, dated 8/4/25, documented issue: waiting till after 11 PM for meds. Residents getting very upset about it. DON (Director of Nursing) is aware of this issue. Response by V2 DON: will review staffing with (V1 Administrator) and (owner) to see if we can increase nursing staff at night to include 4 nurses until 10 PM to ensure residents are getting their meds in a timely manner. The facility's Resident Council Memorandum, dated 9/8/25, documented issue: nursing, meds are not getting to residents at right times, said nurses are getting angry at night. Call lights not being answered in a timely manner. The facility's Medication Administration policy, dated 6/1/25, documented Purpose: To provide practice standards for safe administration of medications for residents in the facility. Policy: 1. Medication will be administered by a Licensed Nurse per the order of an attending physician or licensed independent practitioner or as consistent with state law. 2. No medication will be used for any resident other than the resident for whom it was prescribed. It continues, 5. Medications may be administered one hour before or after the scheduled medication administration time. It continues, Procedure: 1. Assemble the necessary equipment. 2. Wash hands before and after medication administration. 3. Gloves will be worn to administer medication when contact with blood or potentially infectious body fluid is anticipated. 4. Nursing staff will keep in mind the 7 rights of medication when administering medications: A. The right medication. B. The right amount. C. The right resident. D. The right time. E. the right route. F. Right indication. G. Right outcome. It continues, 15. Administer the medication to the resident. 17. The licensed nurse will chart the drug. Time administered and initial his/her name with each medication administration. The facility's Daily Census Report, dated 9/16/25, documented there are 100 residents residing at the facility.

Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (R2), reviewed for abuse in the sample of 5. This failure resulted in R2 being hit in the face by R1, which resulted in redness and R2 feeling fearful of R1.Findings Include:On 8/6/25 at 3:35 PM, R1 was observed, when surveyor knocked on his door, R1 cracked the door, the surveyor asked if she could come into his room, he stated no, when asked if she could talk with him, he stated no and shut the door. R1 appeared paranoid.On 8/6/25 at 3:37 PM, R2 was observed in his room, in a wheelchair, calm, and pleasant. R2 stated he had an incident with R1 a while ago, he had opened R1's room door for him, to be nice, and R1 was cussing at him and hit him upside the head in the face and scratched his arms. R2 stated his head bled where R1 had hit him. Stated he feels fairly safe in the facility but doesn't feel safe around R1. R2 stated he is around R1 sometimes and staff are around so he can get them if needed. R1's Face Sheet, undated, documents R1 has the following diagnoses: Obsessive Compulsive Disorder, Alzheimer's Disease, Psychosis, Obsessive Compulsive Personality Disorder, Unspecified Mental Disorder, and Dementia with Behavioral Disturbance.R1's MDS (Minimum Data Set), dated 6/14/25, documents R1 has a BIMS (Brief Interview of Mental Status) score of 13, indicating R1 is cognitively intact and rejects care.R1's Care Plan, dated 6/14/25, documents R1 has a history of inappropriate contact with his peers and staff. R1 had an encounter with another resident. R1 was placed on 15-minute checks with no further occurrence. Social Service Director to follow up and make sure both residents remain feeling safe at the facility. Behavior tracking updated, in-service on behavior, abuse and neglect completed. R1's Care Plan, dated 12/27/24, documents R1 has the potential to be physically aggressive related to anger, depression and poor impulse control.R1's Care Plan, dated 1/15/21, documents R1 becomes easily annoyed by fellow residents and will attempt physical aggression to get his point across, such as raising his fist at them.R1's Care Plan, dated 7/17/19, documents R1 doesn't like his personal space invaded or staff looking at him related to Paranoia.R1's Progress Note, dated 6/16/2025 at 9:03 AM, documents the following: IDT (Interdisciplinary Team) met regarding resident-to-resident allegation. Interviews and investigation initiated. Care plan reviewed and updated. New intervention: Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert Attention.R2's Face Sheet, undated, documents R2 has the following diagnoses: Cerebral Infarction, Major Depressive Disorder, Dementia without Behavioral Disturbance, and Alzheimer's Disease.R2's MDS, dated [DATE], documents R2 has a BIMS score of 15, indicating R2 is cognitively intact and doesn't exhibit any behaviors.R2's Care Plan, dated 11/13/24, has no documentation of R2 having any behaviors.R2's Progress Note, dated 6/16/25 at 9:51 AM, documents the following: IDT met to review resident to resident allegation. Skin and pain assessments complete. Interviews and investigation initiated. Care plan reviewed and updated. New intervention: Educate resident to ask for staff assistance when he notices that other residents are needing help.R1 and R2's Abuse Investigation Final Report, dated 6/18/25, documents the following: Incident date of 6/14/25 at 6:30PM, R2 was attempting to open the door for R1, unaware of any behavioral symptoms, which resulted in R1 reacting to reach out of the door and R1 made contact with R2. R1 was confused by R2's actions resulting in R1 reacting to the movement of the door. Redness was noted to R2's left cheek and left arm. R1 and R2 were placed on 15-minute checks with no further incidents. Conclusion: this allegation is unsubstantiated due to the unintentional interaction between the two residents. On 8/6/25 at 4:34 PM, V15, MD, denied concerns regarding abuse, he was in the facility today, 8/6/25, rounding and did not see anything concerning. V15 stated if an allegation of abuse occurred, he would expect the facility to notify him, investigate the allegation, and protect the resident. The Abuse Prevention Policy, dated 3/2025, documents the following: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Resident - to - Resident abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm.

Based on interview and record review the facility failed to perform timely incontinent care for 1 of 3 residents (R3) reviewed for incontinent care in the sample of 3. This failure resulted in R3 feeling embarrassed, ashamed, demeaned, disrespected, unwanted, and less than a man. Findings include:R3's Care Plan, dated 02/11/2025, documents Problem: I require assist for my ADLs (Activities of Daily Living) r/t (related to) weakness and decreased mobility. Approach: I require extensive assist of 2 staff with toileting tasks for bm (bowel movement) and 1 for urinal use.R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and bowel, and requires Partial/moderate assistance with toileting. R3's Progress Note, dated 07/20/2025 at 09:18 PM, documents Resident called 911 while CNA (Certified Nurse's Assistant) was in there attending to his roommate. Resident was aware that cna will assist him next. 911 stated that resident called them 5 times within a short span of time. In between resident calling 911, resident was also calling and ordering food for himself. Once food arrived, cna stated resident threw food and wasted drink on his bed after he was cleaned up.The facility Grievance/Complaint Log, dated June 2025, documents on 6/27/2025 R3 filed a grievance regarding call light response. The facility Grievance/Complaint Form, dated 6/27/2025, documents that R3 feels that nursing staff has poor response time to call light. It documents that the complaint was partially substantiated and corrective actions taken call light response audit.The Police Report, dated 7/2025, documents on 7-20-25 at 7:38 PM V9, Police officer, responded to facility in reference to patient R3 calling the police to get the nursing staff to help him. Upon arrival met with V10, Charge Nurse. V10 stated that R3 is a problem patient and falsely calls for help and uses up resources even though he doesn't need help. V9 explained to V10 why he was called. V10 stated that her staff will get to R3 when they can, because of shift change and other nursing duties. V9 then found R3 in his room. Overwhelming smell of feces, R3 had feces leaking out of R3's diaper all over his waist area. R3 stated that he turns on the patient signal light for help, but staff comes and turns it off but do not help him. V7 (CNA) was present in room helping another patient. V7 seemed overwhelmed and stated that she cannot change R3 by herself. When V7 started her shift, she was supposed to have help, but no one was coming to help her. Advising that the facility was understaffed. After approximately 15 minutes of V9 presence in the room, the staff arrived to help R3. On 7/28/2025 at 11:52 AM R3 stated that he received horrible care at the facility. R3 stated that he laid in urine for 45 minutes. R3 stated that a friend came to visit, and he smelled of strong urine. R3 stated that he was embarrassed and ashamed. R3 stated that he couldn't look his friend in the eyes. R3 stated that he was sitting in his own crap for so long that he called the police for help. R3 stated he had a bowel movement. R3 stated that he put the light on and nothing. R3 stated that there have been multiple times that the staff come in and turn the light out and never come back. R3 stated that he was covered with bowel. R3 stated that I am a man. Who wants to live like that. R3 stated that he felt it was demeaning and disrespectful too. R3 stated that he doesn't deserve that. R3 stated that he felt like he doesn't matter and less than a man. R3 stated that he was treated like a caged animal. R3 stated that he was treated less than a dog. On 7/28/2025 at 11:55 AM V5, R3's friend, stated that she has been at the facility on multiple occasions when R3 had to wait 45 minutes. V5 stated that she was told by the staff that there is only 1 staff on the hall at that time. V5 stated that R3 shouldn't have sit in filth that long that is ridiculous. V5 stated that R3 was embarrassed that he was wet and that she had to say something for the staff to respond. On 7/28/2025 at 1:17 PM, V6, Licensed Practical Nurse, LPN, stated that she entered R3's room around 8:00 PM and gave R3 his medication. V6 stated at that time R3 said he had an accident and needed to be cleaned. V6 stated that she notified the CNA and was told that she was the only one down on the hall and would have to wait to get someone to help with cleaning up R3. V6 stated that she notified another staff and was informed that they could not go in the room with R3. V6 stated that R3 did call the police. V6 stated that she is not sure of what time approximately 8:15 PM but not for sure. V6 stated that the police did come. V6 stated that she was not sure when the police got to the facility, V6 stated that the police spoke with the resident and the CNA. V6 stated that then the Officer told her that R3 had a bowel movement and needed to be changed. V6 stated that R3 was changed at that time. On 7/28/2025 at 1:54 PM V7, CNA, stated that she was the aide assigned to R3. V7 stated that she is an agency with this being her first time at the facility. Upon entering the facility, she was informed what hall she was on and that she would get help at 6pm from oncoming staff. V7 stated that she was informed to not provide care to R3 alone or you will get in trouble. V7 stated that she did clean R3 prior to supper before 5pm. V7 stated that R3 was incontinent of bowel. V7 stated that she was then informed to feed in the dining room, and she did and stayed in there until about 7:10 PM. V7 stated that she checked her hall, and no lights were on, and she went to lunch returning around 7:40 PM. V7 stated that when she returned the light to R3's room was on. V7 stated that R3 was incontinent of bowel with stool up his side. V7 stated that she left the room to find the other aide that was supposed to have arrived at 6 PM. V7 stated that she was informed that no one came in and no one was scheduled. V7 stated that she could not change R3 at that time because she didn't have help, so she went and helped another resident. V7 stated that by the time someone came to help the police were there. V7 stated that she was interviewed by the police and informed him that she was the only one on the hall. V7 stated that she informed the police that she was informed that she would have help on the hall, but this was not case. V7 stated that she cannot care for R3 alone and had to wait for someone to help her. V7 stated that she was informed that R3 is continent and can ask for help. V7 stated that it is possible that he pushed his button, and it was turned off. V7 stated that she was the only one on the hall and stated that someone could have turned it off and not returned. V7 stated that she was not on the hall from 5:00 PM to 7:40 PM. V7 stated that R3 is alert and oriented and can speak for himself. V7 stated that she would have helped R3 before, but she didn't have any help. On 7/29/2025 at 12:20 PM V2, Director of Nursing, stated that it is the expectation of the staff to round at least every 2 hours and more frequent if needed. V2 stated that if the staff identifies a resident is incontinent, they are to address it immediately. V2 stated that R3 requires 2 CNAs to be in room when providing care. V2 stated that this is to give the staff a witness for allegations. V2 stated that the CNA is to respond to the call light, go ask for help then start gathering supplies and start the process while the other staff is coming. V1 stated that this should take no more than 5 minutes. The facility's Incontinence Policy, dated 6/17/25, documents that the purpose is to prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: 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 interview and record review, the facility failed to provide sufficient nursing staff to assist residents with incontinent needs to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident for 1 of 3 (R3) reviewed for staffing in a sample of 3. This failure resulted in a delay in incontinent care for R3 causing him to feel embarrassment, ashamed, demeaned, disrespected, and unwanted. Findings include:R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and bowel, and requires Partial/moderate assistance with toileting. The Police Report, dated 7/2025, documents on 7-20-25 at 7:38 PM V9, Police officer, responded to facility in reference to patient R3 calling the police to get the nursing staff to help him. Upon arrival met with V10, Charge Nurse. V10 stated that R3 is a problem patient and falsely calls for help and uses up resources even though he doesn't need help. V9 explained to V10 why he was called. V10 stated that her staff will get to R3 when they can, because of shift change and other nursing duties. V9 then found R3 in his room. Overwhelming smell of feces, R3 had feces leaking out of R3's diaper all over his waist area. R3 stated that he turns on the patient signal light for help, but staff comes and turns it off but do not help him. V7, CNA, was present in room helping another patient. V7 seemed overwhelmed and stated that she cannot change R3 by herself. When V7 started her shift, she was supposed to have help, but no one was coming to help her. Advising that the facility was understaffed. After approximately 15 minutes of V9 presence in the room, the staff arrived to help R3. On 7/28/2025 at 11:52 AM R3 stated that he received horrible care at the facility. R3 stated that he laid in urine for 45 minutes. R3 stated that a friend came to visit, and he smelled of strong urine. R3 stated that he was embarrassed and ashamed. R3 stated that he couldn't look his friend in the eyes. R3 stated that that he was sitting in his own crap for so long that he called the police for help. R3 stated he had a bowel movement. R3 stated that he put the light on and nothing. R3 stated that there have been multiple times that the staff come in and turn the light out and never come back. R3 stated that he was covered with bowel. R3 stated that I am a man. Who wants to live like that. R3 stated that he felt it was demeaning and disrespectful too. R3 stated that he doesn't deserve that. R3 stated that he felt like he doesn't matter and less than a man. R3 stated that he was treated like a caged animal. R3 stated that he was treated less than a dog. On 7/28/2025 at 11:55 AM V5, R3's friend, stated that she has been at the facility on multiple occasions when R3 had to wait 45 minutes. V5 stated that she was told by the staff that there is only 1 staff on the hall at that time. V5 stated that R3 shouldn't have sit in filth that long that is ridiculous. V5 stated that R3 was embarrassed that he was wet and that she had to say something for the staff to respond. On 7/28/2025 at 1:17 PM, V6 LPN, stated that she entered R3's room around 8:00 PM and gave R3 his medication. V6 stated at that time R3 said he had an accident and needed to be cleaned. V6 stated that she notified the CNA and was told that she was the only one down on the hall and would have to wait to get someone to help with cleaning up R3. V6 stated that she notified another staff and was informed that they could not go in the room with R3. V6 stated that R3 did call the police. V6 stated that she is not sure of what time approximately 8:15 PM but not for sure. V6 stated that the police did come. V6 stated that she was not sure when the police got to the facility, V6 stated that the police spoke with the resident and the CNA. V6 stated that then the Officer told her that R3 had a bowel movement and needed to be changed. V6 stated that R3 was changed at that time. On 7/28/2025 at 1:54 PM V7, CNA, stated that she was the aide assigned to R3. V7 stated that she is an agency with this being her first time at the facility. Upon entering the facility, she was informed what hall she was on and that she would get help at 6pm from oncoming staff. V7 stated that she was informed to not provide care to R3 alone or you will get in trouble. V7 stated that she did clean R3 prior to supper before 5pm. V7 stated that R3 was incontinent of bowel. V7 stated that she was then informed to feed in the dining room, and she did and stayed in there until about 7:10 PM. V7 stated that she checked her hall, and no lights were on, and she went to lunch returning around 7:40 PM. V7 stated that when she returned the light to R3's room was on. V7 stated that R3 was incontinent of bowel with stool up his side. V7 stated that she left the room to find the other aide that was supposed to have arrived at 6 PM. V7 stated that she was informed that no one came in and no one was scheduled. V7 stated that she could not change R3 at that time because she didn't have help, so she went and helped another resident. V7 stated that by the time someone came to help the police were there. V7 stated that she was interviewed by the police and informed him that she was the only one on the hall. V7 stated that she informed the police that she was informed that she would have help on the hall, but this was not case. V7 stated that she cannot care for R3 alone and had to wait for someone to help her. V7 stated that she was informed that R3 is continent and can ask for help. V7 stated that it is possible that he pushed his button, and it was turned off. V7 stated that she was the only one on the hall and stated that someone could have turned it off and not returned. V7 stated that she was not on the hall from 5:00 PM to 7:40 PM. V7 stated that R3 is alert and oriented and can speak for himself. V7 stated that she would have helped R3 before, but she didn't have any help. On 7/29/2025 at 12:20 PM V2, Director of Nursing, stated that if the staff identifies a resident is incontinent, they are to address it immediately. V2 stated that R3 requires 2 CNAs to be in room when providing care. V2 stated that this is to give the staff a witness for allegations. V2 stated that the CNA is to respond to the call light, go ask for help then start gathering supplies and start the process while the other staff is coming. V1 stated that this should take no more than 5 minutes. The facility's Staffing Policy, not dated, documents that It is the policy of the (facility) to provide sufficient nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident.

Based on interview and record review, the Facility failed to ensure pain medications were readily available for administration in order to prevent increasing pain/discomfort for 1 (R1) of 3 residents reviewed for opioid medications, in the sample of 6. Findings include: On 11/26/2024 at 9:20 AM, a staff member who wishes to remain anonymous, stated, Sometimes (R1) runs out of pain meds (medication). I am not sure if it's the pharmacy or the doctors fault. It tells you on the card when to re-order so we should all be observant of that. I don't know where the disconnect it. The Nurse Practitioner (NP) can't write those scripts (Controlled substance prescriptions). (R1) was out the other day (pain medication not available). It was 11/22 (2024) and she was out a day or two. She claims her pain is 5-10 on the pain scale. On 11/26/2024 at 10:03 AM, R1 stated she takes Oxycodone because her hip deteriorated. R1 stated, Every month, it's no surprise- I need another script (prescription). They make phone calls. The doctor is either on vacation or whatever else and the nurse practitioner can't write the script, but they put her in charge. I have a history of rehab (rehabilitation) and withdraw. I dry heave, get hot then cold. It's no fun to deal with. I can't even make it from here (the bed) to the bathroom. I don't leave my room. I shut down completely. They don't give me a 'heads up' that I'm going to run out, but every month I'm dealing with it. They go through a whole sheet (medication card) and no one thinks to re-order it- I mean come on! Last week I was out. I just got it back Monday. I went 7 days without it. I told (V2, Director of Nursing, DON) and (V12, Licensed Practical Nurse (LPN). They call and leave messages but still here I sit in agony. I was almost to the point of causing myself 'an accident' just so I could go to the hospital to get my medicine. Not suicide or anything, just a fall or something. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. It further documents R1 had not received scheduled or PRN (as needed) pain medications nor received non-medication interventions for pain. It further documents a Pain Assessment Interview should be conducted. R1's Physician's Orders dated 7/30/2024 documents, Oxycodone 5 mg (milligrams)- take one tablet by mouth twice daily. R1's Care Plan dated 11/13/2024 documents R1 has potential for pain/discomfort and Approach: Observe the effectiveness of pain interventions q (every) shift. Review for compliance alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. R1's Care Plan dated 11/27/2024 documents, (R1) has complaints of chronic pain r/t (related to) right hip and rt (right) knee. Administer analgesic medications as ordered by pcp (primary care physician). R1's Medication Administration History dated 10/27/2024-11/26/2024 documents R1 did not receive Oxycodone 5 mg on 11/18/2024, 11/19/2024, 11/20/2024, and 11/21/2024 due to Drug/item unavailable. It further documents R1 received Oxycodone 5 mg on 11/17/2024 and rated her pain at 8 on a 1-10 pain scale. It continues to document R1 received her Oxycodone 5 mg on 11/22/2024 and rated her pain at 10 on the 1-10 pain scale. R1's Medication Administration History dated 10/1/2024-10/31/2024 documents, 10/11/2024- not administered: need script for both 7 AM and 7 PM doses. It further documents, 10/12/2024-Drug/Item Unavailable. Awaiting script from M.D (Medical Doctor). It continues to document, 10/18/2024-Drug/Item Unavailable. Awaiting script from M.D. On 11/26/2024 at 2:36 PM, V3, Assistant Director of Nursing (ADON) stated, All I'm going to say is I can't make someone do something. I notified the doctor we needed a script. That's all I can tell you. She (R1) told me she had been without her medicine. I reached out again and finally got her meds (medication) in. On 11/26/2024 at 2:41 PM, V2, stated he was aware R1 was out of her medicine. V2 stated, (V3) reached out to the doctor. I am not sure how many doses she missed. (V13) is our Nurse Practitioner (NP) but she does not have her DEA (Drug Enforcement Agency) number (required to write controlled substance medications). On 11/27/2024 at 8:49 AM, V12, LPN, stated, I know (R1) missed one dose for me, but they told me when I was off for a couple days she had missed some too. I got the script from (V14, NP). We kept calling pharmacy. If the doctor doesn't send the script to pharmacy-they won't send it. They have to have the script re-newed or else we could get it from the Ekit (Emergency medicine kit). It's a script thing. (R1) gets very upset about it. (V3) checks but sometimes it happens. She runs out. It's not right if she didn't get her medicine. R1's Quarterly Pain assessment dated [DATE] is incomplete. On 11/27/2024 at 1:55 PM, V2 stated, (R1) doesn't really have a diagnosis for the pain. We've done multiple X-rays of her knee and hip but they don't show much. She had her last quarterly pain assessment in June. It is not complete and she should have had one done again in September. We should probably refer her to pain management. On 11/27/2024 at 2:26 PM, V14, NP, stated R1 has been on oxycodone long term for neuropathy and chronic pain syndrome. V14 stated. As long as she is not going through withdraw, Tylenol can cover the pain. The relief won't be like receiving an Opioid pain killer, but can provide short term relief. On 12/2/2024 at 10:18 AM, V1, Administrator, stated, I'm sure if (R1) was complaining about pain, staff would have offered her Tylenol. R1's Current (12/2/2024) Physician's Orders does not include an order for Tylenol as needed. On 12/2/2024 at 12:09 PM, V2 Director of Nursing stated, I know she went without her oxy (oxycodone) but she didn't go without completely. She also has a lidocaine patch. She doesn't have PRN Tylenol though. The Facility's Pain Management Policy undated, documents, Purpose: To ensure accurate assessment and management of the resident's pain. Policy: A licensed nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. It further documents, The IDT (Interdisciplinary Team) committee review the pain assessment for each newly admitted resident identified by the licensed nurse to have pain and at least quarterly thereafter. A licensed nurse will reassess the resident for pain quarterly and eventfully. Pain Management: The licensed nurse will administer pain medication as ordered, and document medication administered on the Medication Administration Record (MAR). It further documents, Nursing staff will implement timely interventions to reduce the increase in severity of pain. The licensed nurse will update the care plan for pain management with any change in treatment and/or medication.

Based on interview and record review, the Facility failed to ensure the availability of scheduled opioid medication for 1 of 3 residents (R1) reviewed for pharmacy services, in the sample of 6. This failure caused R1 to miss several doses of pain medication, resulting in discomfort and experiencing symptoms of withdraw. Findings include: On 11/26/2024 at 9:20 AM, an anonymous staff member stated, Sometimes (R1) runs out of pain meds (medication). I am not sure if it's the pharmacy or the doctors fault. It tells you on the card when to re-order so we should all be observant of that. I don't know where the disconnect it. The Nurse Practitioner (NP) can't write those scripts (Controlled substance prescriptions). (R1) was out the other day (pain medication not available). It was 11/22 (2024) and she was out a day or two. She claims her pain is 5-10 on the pain scale. On 11/26/2024 at 10:03 AM, R1 stated she takes Oxycodone because her hip deteriorated . R1 stated, Every month, it's no surprise- I need another script (prescription). They make phone calls. The doctor is either on vacation or whatever else and the nurse practitioner can't write the script, but they put her in charge. I have a history of rehab (rehabilitation) and withdraw. I dry heave, get hot then cold. It's no fun to deal with. I can't even make it from here (the bed) to the bathroom. I don't leave my room. I shut down completely. They don't give me a 'heads up' that I'm going to run out, but every month I'm dealing with it. They go through a whole sheet (medication card) and no one thinks to re-order it- I mean come on! Last week I was out. I just got it back Monday. I went 7 days without it. I told (V2, Director of Nursing, DON) and (V12, Licensed Practical Nurse (LPN). They call and leave messages but still here I sit in agony. I was almost to the point of causing myself 'an accident' just so I could go to the hospital to get my medicine. Not suicide or anything, just a fall or something. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. R1's Physician's Orders dated 7/30/2024 documents, Oxycodone 5 mg (milligrams)- take one tablet by mouth twice daily. R1's Care Plan dated 11/13/2024 documents R1 has potential for pain/discomfort and Approach: Observe the effectiveness of pain interventions q (every) shift. Review for compliance alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. R1's Care Plan dated 11/27/2024 documents, (R1) has complaints of chronic pain r/t (related to) right hip and rt (right) knee. Administer analgesic medications as ordered by pcp (primary care physician). R1's Medication Administration History dated 10/27/2024-11/26/2024 documents R1 did not receive Oxycodone 5 mg on 11/18/2024, 11/19/2024, 11/20/2024, and 11/21/2024 due to Drug/item unavailable. It further documents R1 received Oxycodone 5 mg on 11/17/2024 and rated her pain at 8 on a 1-10 pain scale. It continues to document R1 received her Oxycodone 5 mg on 11/22/2024 and rated her pain at 10 on the 1-10 pain scale. R1's Medication Administration History dated 10/1/2024-10/31/2024 documents, 10/11/2024- not administered: need script for both 7 AM and 7 PM doses. It further documents, 10/12/2024-Drug/Item Unavailable. Awaiting script from M.D (Medical Doctor). It continues to document, 10/18/2024-Drug/Item Unavailable. Awaiting script from M.D. R1's Progress Notes dated 10/17/2024 document the medical doctor was made aware of the need for R1's oxycodone prescription. R1's Progress Notes dated 10/18/2024 documents V3 Assistant Director of Nursing (ADON) spoke with the pharmacy regarding the need for R1's oxycodone prescription. On 11/26/2024 at 2:36 PM, V3, (ADON) stated, All I'm going to say is I can't make someone do something. I notified the doctor we needed a script. That's all I can tell you. She (R1) told me she had been without her medicine. I reached out again and finally got her meds (medication) in. On 11/26/2024 at 2:41 PM, V2, stated he was aware R1 was out of her medicine. V2 stated, (V3) reached out to the doctor. I am not sure how many doses she missed. (V13) is our Nurse Practitioner (NP) but she does not have her DEA (Drug Enforcement Agency) number (requires to write controlled substance medications). On 11/27/2024 at 8:49 AM, V12, LPN, stated, I know (R1) missed one dose for me, but they told me when I was off for a couple days she had missed some too. I got the script from (V14, NP). We kept calling pharmacy. If the doctor doesn't send the script to pharmacy-they won't send it. They have to have the script re-newed or else we could get it from the Ekit (Emergency medicine kit). It's a script thing. (R1) gets very upset about it. (V3) checks but sometimes it happens. She runs out. It's not right if she didn't get her medicine. On 11/27/2024 at 2:26 PM, V14 stated she was aware of issues with getting opioid medications refilled. V14 stated there is a special process/protocol and sometimes the pharmacy doesn't get the order. V14 stated the Facility staff will call for refills and she will tell them to contact the pharmacy. V14 stated the pharmacy tells them to contact the doctor. V14 stated sometimes a day or two will go by and the patients still has not received their medication. V14 stated she will start the re-ordering process when the resident is down to a week or two left of the medication, but there is not guarantee the pharmacy will fill it early because they have to follow regulations. The Facility's Controlled Substance Prescription Policy dated 10/25/2024 documents, Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription. The written prescription may be faxed to the pharmacy for long-term care facility residents. It continues, The prescriber and/or nurse are contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available. It continues, If only one refill remains (C111-Vs?) or only a partial fill quantity remains (C11) the pharmacy will simultaneously dispense the remaining refill, contact the facility to verify the continuation of the medication is necessary and if necessary proactively seek out a new, complete prescription from the prescriber for future use. If a prescription is not obtained by the pharmacy before the medication would be 'due again', the facility is notified. In this situation, the facility may be asked to contact the prescriber for a new prescription prior to the medication running out.

Based on interview and record review the Facility failed to ensure safe transfers were being performed for 2 of 7 residents (R31, R53) reviewed for accidents and hazards, in the sample of 38. This failure resulted in R31 and R53 both being sent out to the hospital after sustaining injuries. Findings include: 1. On 3/14/2024 at 9:54 AM, R31 was sitting in her wheelchair, oxygen on and looking out the window. On 3/14/2024 at 9:56 AM, R31 stated, I remember the fall, I was going to the bathroom and tripped and fell and had to go to the hospital. I am not sure why I tripped. There was no staff with me when I fell . R31's Physician Order Sheet (POS) for March 2024 documented diagnoses of Heart failure, Chronic Kidney Disease, Gastrointestinal hemorrhage, unspecified (History of); Hyperlipidemia, unspecified; Age-related Osteoporosis without current pathological fracture; Dependence on renal dialysis; Type 2 diabetes mellitus without complications; Vitamin D deficiency, unspecified; Chronic Obstructive Pulmonary Disease, unspecified; Iron deficiency Anemia, unspecified; Anxiety disorder, unspecified; Chronic systolic (congestive) heart failure; Gastro-Esophageal Reflux Disease without Esophagitis; Essential (primary) Hypertension; Anemia in chronic kidney disease. R31's Minimum Data Set (MDS), dated [DATE], documented that she was moderately impaired for cognition of activities of daily living, requires partial/moderate assistance, helper does more than half the effort, helper lifts, holds, trunk or limbs, but provides less than half the effort. The MDS also documented that R31 used a wheelchair. The ability to move from sitting on side of bed to lying flat on the bed requires substantial/maximal assistance. R31's Care Plan with a target date of 6/9/2024 documented, Resident will be free from falls. R31's Care Plan also documented, Problem: Resident is at risk for falls due to Age-related Osteoporosis without current pathological fracture. I am at risk for decline in my ability to transfer due to weakness, with start date of 9/15/2022. R31's Progress Notes, dated 1/4/2024 documented, Resident was transferring to toilet with CNA while wearing slippers, slipped on the ground and fell face first into ground. Actively bleeding from forehead, pressure dressing applied, skin tear to right hand, bruising to nose. 911 notified of transport. R31's Progress Notes [Recorded as Late Entry on 01/08/2024 12:34 PM],IDT (intradisciplinary team): FALL: on 1/4/24 resident was walking to the bathroom with a walker and assist of one CNA (certified nursing assistant). Resident was wearing slippers and her foot slipped on the ground and resident fell face first into the ground. Active bleeding noted to forehead, pressure dressing applied, bruising to nose. 911 notified of transfer to hospital. Upon further review and discussion with IDT (intradisciplinary team, resident will be wearing non-skid socks. MD (medical doctor) and POA (power of attorney) updated. R31's Progress Notes, dated 1/4/2024 at 6:15 PM, documented, Resident came back from ER (emergency room ) this evening. C/o (complain of) head and neck pain. PRN (As needed) Tylenol given as ordered with little relief. MD (Medical Doctor) notified. Bruising noted underneath both eyes and bridge of nose. Abrasion noted to left knee. Skin tear to right wrist. CT (computerized tomography) scan negative per (Hospital) ER (emergency room ). Appetite poor. PO fluids (by mouth) encouraged. Respirations even and unlabored. No s/s (signs and symptoms) of distress. Call light within reach. Will continue to monitor. R31's Progress Notes dated 1/8/2024 at 1:14 PM, [Recorded as Late Entry on 01/09/2024 11:21 AM] documented, Resident is noted to have a laceration to the forehead that she received in a fall in an attempt to transfer herself to the toilet. Resident received 4 stitches to her forehead. Site is clear from redness and infection. No bleeding noted. Resident has no s/s (signs and symptoms) of discomfort. Will continue to monitor. Stitches will be removed on 01/11/24. MD, POA, Resident notified. R31's Incident Report dated 1/4/2024 at 1:03 PM, documented, What resident was doing just prior to fall, transferring to toilet, with severe pain to the head and neck, bleeding from forehead, skin tear to right hand, bruising to nose. Interventions: non-skid footwear. On 3/15/2024 at 10:04 AM, V3, Assistant Director of Nursing, stated, (R31) was using a walker and was walking to the bathroom when (R31) slipped and fell requiring her to have stitches. (V36) was the certified nursing assistant that was with her. I did not witness it. On 3/15/2024 at 10:14 AM, V36, Certified Nursing Assistant (CNA), stated, I was taking (R31) to the bathroom, she fell in the bathroom. (R31) had a gait belt on her and she had on some slipper shoes and one shoe fell off. We were getting ready to go on the toilet. I was holding on to the gait belt, (R31) was holding on to the walker, I was trying to help her turn and then she fell and hit her head. I never lowered her to the floor, she just fell . I did not fall with her. It just happened so fast. On 3/15/2024 at 10:32 PM, V37, Physical Therapist stated, If a resident is being transferred with a walker and a gait belt and the resident was starting to fall, the resident would fall forward usually on their knees and staff should be holding on to them and lowering them to the ground. 42834 2. R53's Face sheet documented an admitted [DATE]. Diagnoses included Dysphasia, Chronic Atrial Fibrillation, Lymphedema, Type 2 Diabetes. R53's Minimum Data Set, MDS, dated [DATE], documented that R53 is significantly cognitively impaired. R53 is dependent on staff for rolling left to right, sitting to lying and sitting up on bedside. R53's Care Plan, dated 3/13/2024, documented, I have experienced an actual fall on 8/19/23, 1/2/24, 1/25/24, 3/12/24. Interventions include geri care to be ordered by hospice, dycem added to wheelchair, interdisciplinary to review fall and provide interventions as indicated, increased supervision, laid down after meals. R53's fall risk assessments, dated 3/12/2024, documented, (R53) is at high risk for falls. R53's fall risk assessments, dated 1/2/2024, documented that R53 was at high risk for falls. R53's progress notes, dated 3/12/2024 at 1:50PM, Called to room by Certified Nursing Assistant, CNA. (R53) laying on the floor beside bed on her right side. The over bed table legs under (R53) had a large amount of blood noted from (R53's) head. (R53) alert and oriented to person. Complains of difficulty breathing through nose. Oxygen saturation 99% on room air. (R53) denies pain. Complains being cold and wanted off floor. 911 called. (R53) repositioned to remove table legs from under her. (R53) slowly rolled on her back supporting head and neck. Area to middle of forehead cleaned. Bleeding stopped and cool ice pace on forehead and bridge of nose. Nose purple in color and crooked. Power of Attorney called hospital. Called report to emergency room nurse. Emergency Medical Services, EMS, came and transported (R53) to hospital. (R53) was previously in bed resting with call light within reach. (R53) recently returned from lunch. (R53) is on hospice. Call placed to hospice nurse. R53's progress notes, dated 3/12/2024 at 6:54PM documented, (R53) returned to facility via EMS. Dressing intact to middle of forehead. Swelling and discoloration noted to bridge of nose and under both eyes. Denies pain currently. Awaiting delivery of new mattress. Will continue to monitor. R53's hospital discharge paperwork, dated 3/12/2024, documented, There is frontal scalp soft tissue swelling. There are likely changes of ocular lens replacement surgeries. There are fractures of the nasal bones and nasal process of maxilla, new from 1/25/2023. There is mild mucosal thickening in the paranasal sinuses. The mastoid air cells are normal. On 3/14/2024 at 1:45PM, V2, Director of Nursing, (DON) entered R53's room. R53 in room in geri chair with door closed. R53's room is several doors down from nurse's station. V2 stated, When (R53) fell the other day, she rolled out of bed and her face hit the bedside table leg. We assessed her immediately and called 911. I would expect (R53's) door to always be open. On 3/14/2024 at 11:00AM, V26, CNA, stated, I don't know of anything new we have to watch for on (R53) since she fell . On 3/14/2024 at 3:30PM, V27, CNA, stated, I wasn't here the day (R53) fell . I don't know of any new precautions we are taking with (R53). R53 did not have dycem in Geri chair. When asked about dycem not being in R53's Geri chair, V27, stated, We lose dycems a lot and we have to get new ones from therapy. On 3/14/2024 at 3:45PM, V16, CNA Coordinator, stated, I wasn't here when (R53) fell . I was told she rolled out of bed. I would expect her door to always be open. On 3/14/2024 at 2:15PM, V28, Advanced Practice Nurse, (APN), stated that she would expect R53, a resident with a high risk of falling, to be monitored more closely and not in room alone. She continued to state that monitoring is very important in a resident that is not alert and oriented. The facility's Fall policy, with a revision date of 7/2022, documented, The facility is committed to maximizing each resident's physical, mental, and psychosocial wellbeing. While preventing all falls is not possible, the facility will identity and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All residents' falls shall be reviewed, and the and the residents existing plan of care shall be evaluated and modified as needed.

Based on interview and record review the facility failed to provide consistent pain relief and timely management of pain pump for 1 of 2 residents (R138) reviewed for pain management in the sample of 38. This failure resulted in R138's pain not being managed properly. Findings Include: R138's Face sheet documented that he was admitted on [DATE]. R138's Minimum Data Set (MDS), dated [DATE], documented that R138 was moderately cognitively impaired. R138's Pain Care Plan, dated 3/9/24, documented, Problem: I have potential for pain/discomfort R/T (Related to) Acute and chronic respiratory failure with hypoxia and weakness. Approach: Record/report to Nurse any s/sx (signs and symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Approach: Observe the effectiveness of pain interventions q shift. Review for compliance alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Approach: Notify MD if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain. R138's Pain Care Plan did not document anything about R138's Morphine Pain Pump nor did the Pain Care Plan document anything about side effects of Morphine. It also did not document the use of Narcan. 03/12/24 09:30 AM R138 complained of pain in his right arm and butt pain. He stated, I haven't got anything for pain yet. R138's Medication Administration Record for the month of March, documented an order for, Acetaminophen 325 mg 2 tabs q 6 hours PRN (whenever necessary). The Acetaminophen was only given on the March 9, 10, and the 12. R138's Medication Administration Record for the month of March also documented an order for, Ibuprofen 400mg every 8 hours PRN for three days and it was not given at all. R138's Physician Order Sheet (POS), dated 3/13/24, documented, Nurse to go down to residents' room to help him deliver bolus pain medication 4 times a day. R138's Progress Note, dated 3/13/24, documented, Med (Medicare) A charting for muscle weakness, unsteadiness on feet, gait and mobility, dysphagia, cognitive and OT (Occupational Therapy) still evaluating. Glucose monitored and controlled. O2 as ordered. No signs/symptoms of respiratory distress. Helped resident to administer pain pump dose. Says he feels his pain is in much better control when he uses pain pump around the clock. Treatment completed to buttocks. Resting in bed with call light in reach. Will monitor. On 3/13/24 at 1:30 PM V38, Pain Doctor, stated, (R138) was on the morphine pump for lower back pain and ridicular. His (R138) was a continuous morphine pump totaling 450mcg per 24 hours including bolus. He should only get the bolus unless he complains of pain, after the fourth dose the machine locks out after 4 bolus. The dosage is Morphine 18.8 mcg continuous. The facility was unaware of the continuous dosing and the dosages of morphine. On 3/14/24 at 3:00 PM, V2, Director of Nursing stated, We are going down and helping him to use his Morphine pump every 6 hours at 12:00, 6:00, 12:00, 6:00PM. He is supposed to be able to administer it himself, but he cannot. No, I was not aware of the dosage for that (the morphine) or that it (the morphine) was continuous. We called (the local respiratory hospital) and they only had the information that it was for pain, and it was loaded 2 days before his discharge. My Nurse did call the pain clinic, but they did not say it was continuous. 03/13/24 02:44 PM, V15 LPN, stated, It's a pain control pump. It's given at 12AM, 6AM, 12PM 6PM. We have to open the app on his telephone so he can administer pump for self. On 3/13/24 at 3:00 PM, V35, RN, stated, It's implanted pump with morphine you go on his cell phone. You go on the cell phone you lay it on the pump and then it is administered. We don't change it (the pain pump). On 3/14/24 at 2:20 PM, V28, Nurse Practitioner, stated, He is on Morphine. (R138) was ordered Tylenol and Ibuprofen (which he did not receive). So I ordered him Tramadol 50mg every six hours, because his POA (power of attorney) said it worked well for him at home. He receives the Morphine every six hour per pump. No, I did not know it is also continuous. That was not clarified to me. No, I didn't know the dosage was 18.8 micrograms. I have not been in contact with the pain clinic. The facility's policy entitled Pain-Clinical Protocol dated March 2018 documents the physician and staff will identify individual who have pain or whom are risk for having pain. The nursing staff will assess each individual for pain upon admission to the facility. The physician will help identify causes of pain.

Based on interview and record review the facility failed to monitor, assess, and notify the physician of an acute change in condition to ensure timely medical treatment for 1 of 3 residents (R3) reviewed for quality of care in the sample of 5. This failure resulted in an Immediate Jeopardy when R3 began having ongoing respiratory distress with no medical monitoring resulting in death from pneumonia and acute respiratory failure. The Immediate Jeopardy began on [DATE] at 9:51 AM, when staff identified that R3 was having respiratory distress, failed to provide ongoing assessment/monitoring to address respiratory distressed caused by pneumonia. At 7:10 PM, R3 was found unresponsive, and the facility called 911. R3 expired at the hospital. V1, Administrator, and V2, Director of Nursing, were notified of the Immediate Jeopardy on [DATE] at 2:05 PM. Confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3's Face Sheet, undated, documented R3's was admitted on [DATE] with primary diagnosis as acute respiratory failure with hypoxia. R3's Care Plan, dated [DATE], documents PROBLEM: (R2) is at risk for SOB (shortness of breath) r/t (related to) DX (Diagnosis) of COPD (Chronic obstructive pulmonary disease). R3's Care Plan goal documents I will have no c/o (complaint of) SOB thru next review. R3's Care Plan approaches documented Document any difficulty breathing (Dyspnea) on exertion, Document S&S (signs & symptoms) of Acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis, Somnolence; Document S&S of Respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing; Head of bed to be elevated r/t SOB when lying flat; Inhaler as ordered-see MAR (Medication Administration Record) and; O2 (oxygen) at 2 liters (L) and O2 SAT's (saturation levels) as ordered. R3's Progress Note, dated [DATE], documented CXR (Chest Xray) results received, showing linear opacities in the right mid and lower lung field likely reflecting scar atelectasis on [sic] likely pneumonia. Call placed to (V9, R3's physician) results reported, N.O. (new order) for Augmentin (antibiotic) ,d+[DATE] mg (milligrams) po (by mouth) bid (twice daily) x 7 days plus probiotic entered as ordered. R3's Progress Note, dated [DATE] at 9:51 AM, written by V3, Licensed Practical Nurse/LPN, [Recorded as Late Entry on [DATE] 09:51 AM], documents Charge Nurse came to Nursing station, informed this writer was having difficulty administering meds to resident and asked this writer to assist. Entered room, resident noted in bed with HOB (head of bed) elevated to facilitate breathing, O2 continuous @ (at) 2L via nasal cannula. Resident not easily aroused by verbal stimuli, sternal rub administered, resident aroused, with meds given without difficulty. Resident stated she was hot, ac (air conditioner) turned on for comfort. Upon further assessment resident noted diaphoretic. VS (vital signs) 98 (temperature)-106 (pulse) -22 (respirations) ,d+[DATE] (blood pressure) O2 sats 89% on 2L oxygen increased to ,d+[DATE]L sats remained at 89% BS 189. Occasional audible wheezing with lung assessment completed with wheezing heard bilaterally. On ABT (antibiotic) for Pneumonia, no rash or anaphylaxis noted. Appetite poor, assist x 1 for consumption. Standing order entered for DuoNeb q (every) 6 hours prn (as needed), administered x1 with assist of Charge Nurse. O2 sats rechecked after completion stats 83% on 4L. DON made aware with further assessment completed, O2 sats increased to 92%. On [DATE] at 1:30 PM V3, stated that on [DATE] she was working when R3 had her change in condition. V3 stated that she was assigned to the hall. V3 stated that V6, LPN, came to her and told her that she was having a difficult time giving R3 her medications approximately 8:15 AM. V3 stated that when she went down to the room R3 was lying in bed. V3 stated that R3's oxygen was on, and her head of bed was up. V3 stated that when she called R3's name or tried to arouse R3 she would not respond. V3 stated that she then performed the sternal rub and R3 was able to arouse. V3 stated that this was not normal for R3. V3 stated that R3 was diaphoretic. V3 stated that she performed an assessment and found that R3's vitals were abnormal, and her oxygen level was low. V3 stated that they increased her oxygen to 4 liters and there was no change. V3 stated that R3 had wheezing bilateral in her lungs. V3 stated that all of this was new for R3. V3 stated that R3 was newly diagnosed with pneumonia. V3 stated that R3 did wear oxygen but that her oxygen levels had remained in the high 90s until this event. V3 stated that at approximately 8:30 AM they got an order for a breathing treatment and gave it to her. V3 stated that her oxygen levels did not improve in fact they got worse. V3 stated that V2, Director of Nursing/DON, was notified. V3 stated that unsure of time but per V2, R3's oxygen level did increase. V3 stated that this was the only time she cared for R3. V3 stated that she was not assigned to that hall. V3 stated that V9, Medical Director, was in the facility doing rounds and was not notified of R3's condition. V3 stated that a resident with an acute change in condition can be sent out to the hospital regardless of their code status. V3 stated that they send residents with DNRs to the hospital. V3 stated that just because you have a DNR does not mean you can't go to the hospital. On [DATE] at 5:52 PM V6, LPN, stated that she is new to the facility and on [DATE] she worked from 6AM to 6PM. V6 stated that she worked with R3 before. V6 stated that on [DATE], she went into R3's room to give her meds at approximately 8 AM. V6 stated that she couldn't wake R3. V6 stated that R3 was in a deep sleep with snoring respirations. V6 stated that she had never had this much trouble waking R3. V6 stated that she went and got V3. V6 stated that V3 had been there for years. V6 stated that V3 was able to get R3 awake enough to take her pills. V6 stated that R3 was awake but not really. V6 stated that V3 checked R3's O2 sats and it was 83. V6 stated that she knew something was not right. V6 stated that V2 was at the facility. V6 stated that she told V2 that R3 had a change in condition and that her O2 sats was 83 and not coming up. V6 stated that she was told by V2 that if there is something that can be done in the building then the resident stays in the building. V6 stated that V2 told her to get the fan out of the breakroom and put it on R3. V6 stated that V3 gave R3 a breathing treatment and after the treatment V6 rechecked R3's O2 sat, and it had dropped to 80. V6 stated that she again told V2 that R3 needed to go to the hospital because R3's O2 sats kept dropping. V6 stated that she was told no that V2 would go down to R3's room. V6 stated that shortly after V2 notified her that R3's O2 sat was up to 92%. V6 stated that R3's O2 continued to drop. V6 stated that she continued to talk with V2 and was told that R3 would stay at the facility. V6 stated that she knew that R3's change of condition was serious and that R3 needed to go to the emergency room . V6 stated that she notified the V2 and was told to keep R3 in the building. V6 stated that she did not notify the physician. V6 stated that she notified her DON and followed the instructions given. V6 stated that she notified the oncoming nurse in report of R3's change of condition, oxygen levels in the low 80's, and being given the direction of keeping R3 in the facility. V5 works day shift 6AM to 2 PM. On [DATE] at 1:44 PM V5, Certified Nursing Aide (CNA), stated that she worked with R3 when she got sick. V5 stated that R3 was responding and that she needed total care. V5 stated that R3 needed help with care but she would help some like hold the rail when turning over. V5 stated that R3 would yell out and liked being in her wheelchair and wanted you to push her around. V5 stated that on this day R3 was lethargic and did not help at all. V5 stated that they kept R3 in the bed. V5 stated that R3 did not eat and remain lethargic. V5 stated that her shift ends at 2:00 PM. V5 stated that R3 was lethargic when she left. On [DATE] at 3:48 PM V7, CNA Coordinator, stated that she worked the day that R3 had the change in condition. V7 stated that she came in at 2:00 PM. V7 stated that she went down and did a walkthrough of her hall. V7 stated that during that time she noticed that R3 did not look like herself. V7 stated that R3 was different than she was yesterday. V7 stated that the day before R3 was up and moving around in her wheelchair. V7 stated that when she went in the room R3 was lying in bed with a fan and a mask on. V7 stated that R3 was cold and R3's breathing wasn't right. V7 stated that she notified V6 and told V6 that R3 was not right. V7 stated that she told V6 that R3 needed to go to the hospital. V7 stated that V2 was in the facility as well. V7 stated that she was concerned about R3. V7 stated that at around 6:00 PM V10, LPN, came in. V7 stated that she told V10 about R3 and shortly after V10 sent R3 out. R3's Electronic Health Record (EHR) documents an abnormal O2 sat on [DATE] at 9:51 AM. There was no documentation in R3's Progress Notes or medical record regarding if the facility was assessing R3's respiration from 9:51 AM through 7:10 PM. As of [DATE], at 3:00 PM the facility failed to provide any additional documentation of vitals and or oxygen levels obtained on [DATE]. R3's [DATE] Medication Administration Record (MAR), documented O2 sat. q shift R/T COPD to be completed every shift. On [DATE], R3's O2 sat was documented as 87% on the day shift. There were no other documented O2 saturation levels in R3's medical record. R3's Progress Note, dated [DATE] 07:10 PM, written by V10, LPN, documents Resident found unresponsive. Not responding to verbal or painful stimuli. No response to sternal rub. Resident cold to touch. Nailbeds cyanotic, mottling noted to BLE (Bilateral lower extremities) Gurgling noted. Right pupil dilated. RESP (Respirations) 8 AND PULSE ,d+[DATE]. Unable to obtain SAO2 or B/P (blood pressure) at this time. 911 called. 1925 Ambulance here to transport resident to ED (Emergency Department) and request POA (Power of Attorney) be notified to meet or call (local ED) resident probably is not going to make it. (V4), (R3's) POA notified, report called to (Local ED) and (V2) DON notified.: R3's Progress Note, dated [DATE] 10:16 PM, documents Call placed to (Local) ed for update on resident. ED nurse states she is 'still holding on' condition remains guarded. Resident being admitted with DX (diagnosis) of PNE (pneumonia) and Acute UTI (urinary tract infection). R3's Progress Notes, dated [DATE] at 12:30 AM, documents Call received from (local hospital). They Report that resident has expired. R3's History and Physical from (Local Hospital), dated [DATE] at 11:09 PM, documents This a [AGE] year-old female who is presenting from local nursing home with worsening altered mental status. She is a DNR (Do Not Resuscitate), DNI (Do not Intubate), no Bipap (bilevel positive airway pressure). She was bagged for hypoxia in the ambulance en route. She was found minimally responsive by the nursing home staff. Her DNR comfort measures state that she does not want any intervention beyond basic comfort measures, per ER. The pt.'s (patient's) recent history includes recent pneumonia, found to be hypoxic, treated with assisted ventilation with bag valve mask until she arrived in the ER. In the ER the patient was noted to have a WBC (white blood cell count) 25.5 with 10 bands. Her CO2 (Carbon Dioxide) is high to > (greater than) 40, her cl (chloride) is low, and her bun (blood urea nitrogen)/cr (creatinine) are elevated ,d+[DATE].40. BNP (Brain Natriuretic Peptide) 1830, [NAME] pending, UA (urinalysis) + UTI (urinary tract infection). She looks very poor in the ER. Her SPO2 is < 50% on nonrebreather at 15L/min. Her RR (respiration rate) is <10. Just now her B/P dropped to 90's/50's. She looks to be in the process of passing away soon, possibly tonight. She is unresponsive to voice, light touch, and barely responds to noxious stimulus. R3's Death Certificated, dated [DATE], documents date of death [DATE]. It also documents the cause of death Acute Respiratory Failure with Hypoxia and Pneumonia. On [DATE] at 8:30 AM V2, Director of Nursing, stated that she became aware of R3's change in condition around 4:00 PM. V2 stated that she was told that R3 was having problems breathing and oxygen levels were low. V2 stated that the nurse wanted to send the resident to the hospital. V2 stated that she wanted to make sure that they did everything they could at the facility first. V2 stated that when she went into the room, she noted that R3 was mouth breathing. V2 stated that she put a mask on R3 and monitored R3. V2 stated that R3's oxygen level improved to 92% with the mask and 4 liters of oxygen. V2 stated that R3 was lethargic. V2 stated that R3 was diagnosed with pneumonia a day or so before and thought this was causing the lethargy. V2 stated that she felt that R3 was stable and did not need to go to the hospital or notify the physician up until she left at about 4:30 PM. V2 stated that R3 was sent to the emergency room by the night nurse. V2 stated that she is a firm believer of doing things in the building instead of sending R3 out. R3's EHR does not document any assessment performed by V2. R3's EHR does not document the application of a nonrebreather mask or physician notification of assessment and treatment performed by V2. On [DATE] at 10:56 AM V9, Medical Director, stated that the facility is usually pretty good about notifying him of change in conditions. V9 stated that his notification would be documented in the resident's chart. V9 stated that he was not aware of R3's ongoing respiratory distress. V9 stated that if he was made aware of R3's condition he would have sent R3 out. V9 stated that he may not have sent R3 out initially but if her condition continued to change or not improve, he would have sent her to the hospital. V9 stated that he expects the facility to monitor changes of condition and notify him of the patient's condition. V9 stated that he did not exam and was not notified of R3's ongoing condition on [DATE]. The facility's Change in Condition policy, dated ,d+[DATE], documents 1. Nursing will notify the resident's physician or nurse practitioner when b. there is a significant change in the resident's physical, mental or emotional status. c. It is deemed necessary or appropriate in the best interest of the resident. The Policy documents 3. The communication with the resident and their responsible part as well as the physician will be documented in the resident's medical record or other appropriate documents. The facility's Change in a Resident's Condition or Status, dated [DATE], documents 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or implementing standard disease-related clinical interventions. b. impacts more than one area of the resident's health status. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following action to remove the immediacy: Immediate Corrective Action: -Review of Change of Condition Policy as well as implementation of MD communications will be completed by [DATE] by V21, Director of Clinical Operations. -DON and Nursing staff have been educated on [DATE] for the change of condition policy as well as new MD communication by V21. -DON and licensed nursing staff have been educated on performance improvement tool on [DATE] by V21. Identifying other resident with potential for being affected and interventions to prevent this from occurring in the future: Whole house audit completed to determine all residents with potential for change of condition are care planned with appropriate interventions completed by V21 on [DATE]. Measures put in place to prevent reoccurrence. System revision: -DON and all licensed nursing staff have been educated on change of condition policy and procedures as well as MD Communication on [DATE] by V21. -All new licensed staff will be in-serviced on new hire orientation for MD form of communication, change of condition policy and procedure, and change of condition improvement tool by V22, Human Resource (HR) director. How Facility will Monitor System and corrective Action: -All change of condition in resident will be reviewed to ensure appropriate measures are taken. These reviews will take place by the V21 when auditing the performance tool and 24-hour nursing report 2 times weekly for 4 weeks, 1 time a week for 4 weeks, 1 time a month for 3 months starting on [DATE]. QAPI (Quality Assurance Performance Improvement): -All audit on change of condition will be reviewed by the facility's Quality Assurance Performance Improvement Committed to determine if any further staff education or facility policy changes are needed. Any deficiency will be corrected immediately and reviewed again by the Quality Assurance Performance Improvement Committee monthly. All above measures will be subject to review, assessment, and modification 2 times weekly for 4 weeks, 1 time a week for 4 weeks and time a month for 3 months. On [DATE], abatement plan reviewed, and the education provided the abatement had not been completed. The facility failed to educate all nursing staff by [DATE] on the change of condition policy as well as new MD communication, and the performance improvement tool. V1 was notified and V21 educated the nursing staff, modified the abatement plan, and changed the completion date to [DATE]. The surveyors reviewed all in-services. The last day in-services were provided to staff were on [DATE] and were completed by V21. The surveyors reviewed the facility's policies. R2's, R4's and R5's charts were reviewed for change in conditions. R2's, R4's and R5's EHR documents the change in condition, assessment, follow up documentation and physician notification. Surveyors observed V3 performing assessment on R2 and documenting this assessment. The MD communication and performance improvement tool was reviewed for all residents with a change in condition and included observations and assessments. Surveyors reviewed care plans of those residents who have been identified at risk for change in condition and verified they had been updated. Employees were interviewed to ensure that they were aware of current policies and procedures and had been in-serviced.

Based on interview and record review, the facility failed to notify the Primary Care Physician of ongoing respiratory distress for 1 of 3 residents (R3) reviewed for notification in the sample of 5. This failure resulted in R3 having a delay in treatment and subsequent death. Findings include: R3's Face Sheet, undated, documented R3's was admitted on [DATE] with primary diagnosis as acute respiratory failure with hypoxia. R3's Progress Note, dated [DATE] at 9:51 AM, [Recorded as Late Entry on [DATE] 09:51 AM], documents Charge Nurse came to Nursing station, informed this writer was having difficulty administering meds to resident and asked this writer to assist. Entered room, resident noted in bed with HOB (head of bed) elevated to facilitate breathing, O2 (oxygen) continuous @ (at) 2L (liters) via nasal cannula. Resident not easily aroused by verbal stimuli, sternal rub administered, resident aroused, with meds given without difficulty. Resident stated she was hot, ac (air conditioner) turned on for comfort. Upon further assessment resident noted diaphoretic. VS (vital signs) 98 (temperature)-106 (pulse) -22 (respirations) ,d+[DATE] (blood pressure) O2 sats (oxygen blood saturation levels) 89% on 2L oxygen increased to ,d+[DATE]L sats remained at 89% BS (blood sugar) 189. Occasional audible wheezing with lung assessment completed with wheezing heard bilaterally. On ABT (antibiotic) for Pneumonia, no rash or anaphylaxis noted. Appetite poor, assist x 1 for consumption. Standing order entered for duoneb q (every) 6 hours prn (as needed), administered x1 with assist of Charge Nurse. O2 sats rechecked after completion stats 83% on 4L. DON (Director of Nursing) made aware with further assessment completed, O2 sats increased to 92%. There was no documentation that V9, R3's physician was notified of R3's respiratory distress. On [DATE] at 1:30 PM V3, stated that on [DATE] she was working when R3 had her change in condition. V3 stated that she was assigned to the hall. V3 stated that V6, LPN, came to her and told her that she was having a difficult time giving R3 her medications at approximately 8:15 AM. V3 stated that R3's oxygen was on, and her head of bed was up. V3 stated that when she called R3's name or tried to arouse R3 she would not respond. V3 stated that she then performed the sternal rub and R3 was able to arouse. V3 stated that this was not normal for R3. V3 stated that R3 was diaphoretic. V3 stated that she performed an assessment and found that R3's vitals were abnormal, and her oxygen level was low. V3 stated that they increased her oxygen to 4 liters and there was no change. V3 stated that R3 had wheezing bilateral in her lungs. V3 stated that all of this was new for R3. V3 stated that R3 was newly diagnosed with pneumonia. V3 stated that R3 did wear oxygen but that her oxygen levels had remained in the high 90s until this event. V3 stated that at approximately 8:30 AM they got an order for a breathing treatment and gave it to her. V3 stated that her oxygen levels did not improve in fact they got worse. V3 stated that V2, Director of Nursing/DON, was notified. V3 stated that unsure of time but per V2, R3's oxygen level did increase. There was no documentation in R3's medical record that V3 contacted R3's physician regarding R3's respiratory distress. On [DATE] at 5:52 PM V6, LPN, stated that she is new to the facility and on [DATE] she worked 6AM to 6PM. V6 stated that she worked with R3 before. V6 stated that on [DATE], she went into R3's room to give her meds at approximately 8 AM. V6 stated that she couldn't wake R3. V6 stated that R3 was in a deep sleep with snoring respirations. V6 stated that she had never had this much trouble waking R3. V6 stated that she went and got V3. V6 stated that V3 had been there for years. V6 stated that V3 was able to get R3 awake enough to take her pills. V6 stated that R3 was awake but not really. V6 stated that V3 checked R3's O2 sats and it was 83. V6 stated that she knew something was not right. V6 stated that V2 was at the facility. V6 stated that she told V2 that R3 had a change in condition and that her O2 sats was 83 and not coming up. V6 stated that she was told by V2 that if there is something that can be done in the building then the resident stays in the building. V6 stated that V2 told her to get the fan out of the breakroom and put it on R3. V6 stated that V3 gave R3 a breathing treatment and after the treatment V6 rechecked R3's O2 sat, and it had dropped to 80. V6 stated that she again told V2 that R3 needed to go to the hospital because R3's O2 sats kept dropping. V6 stated that she was told no that V2 would go down to R3's room. V6 stated that shortly after V2 notified her that R3's O2 sat was up to 92%. V6 stated that R3's O2 continued to drop. V6 stated that she continued to talk with V2 and was told that R3 would stay at the facility. V6 stated that she knew that R3's change of condition was serious and that R3 needed to go to the emergency room . V6 stated that she notified the V2 and was told to keep R3 in the building. V6 stated that she did not notify the physician. V6 stated that she notified her DON and followed the instructions given. V6 stated that she notified the oncoming nurse in report of R3's change of condition, oxygen levels in the low 80's, and being given the direction of keeping R3 in the facility. There was no documentation in R3's medical record that V6 notified V9. On [DATE] at 3:48 PM V7, CNA Coordinator, stated that she worked the day that R3 had the change in condition. V7 stated that she came in at 2:00 PM. V7 stated that she went down and did a walkthrough of her hall. V7 stated that during that time she noticed that R3 did not look like herself. V7 stated that R3 was different than she was yesterday. V7 stated that the day before R3 was up and moving around in her wheelchair. V7 stated that when she went in the room R3 was lying in bed with a fan and a mask on. V7 stated that R3 was cold and R3's breathing wasn't right. V7 stated that she notified V6 and told V6 that R3 was not right. V7 stated that she told V6 that R3 needed to go to the hospital. V7 stated that V2 was in the facility as well. V7 stated that she was concerned about R3. V7 stated that at around 6:00 PM V10, LPN, came in. V7 stated that she told V10 about R3 and shortly after V10 sent R3 out. R3's Progress Note, dated [DATE] 07:10 PM, written by V10, documents Resident found unresponsive. Not responding to verbal or painful stimuli. No response to sternal rub. Resident cold to touch. Nailbeds cyanotic, mottling noted to BLE (Bilateral lower extremities) Gurgling noted. Right pupil dilated. RESP (Respirations) 8 AND PULSE ,d+[DATE]. Unable to obtain SAO2 or B/P (blood pressure) at this time. 911 called. 1925 Ambulance here to transport resident to ED (Emergency Department) and request POA (Power of Attorney) be notified to meet or call (local ED) resident probably is not going to make it. (V4), (R3's) POA notified, report called to (Local ED) and (V2) DON notified. R3's Progress Notes, dated [DATE] at 12:30 AM, documents Call received from (local hospital). They Report that resident has expired. R3's Death Certificated, dated [DATE], documents date of death [DATE]. It also documents the cause of death Acute Respiratory Failure with Hypoxia and Pneumonia. On [DATE] at 8:30 AM V2 stated that she became aware of R3's change in condition around 4:00 PM. V2 stated that she was told that R3 was having problems breathing and oxygen levels were low. V2 stated that the nurse wanted to send the resident to the hospital. V2 stated that she wanted to make sure that they did everything they could at the facility first. V2 stated that when she went into the room, she noted that R3 was mouth breathing. V2 stated that she put a mask on R3 and monitored R3. V2 stated that R3's oxygen level improved to 92% with the mask and 4 liters of oxygen. V2 stated that R3 was lethargic. V2 stated that R3 was diagnosed with pneumonia a day or so before and thought this was causing the lethargy. V2 stated that she felt that R3 was stable and did not need to go to the hospital or notify physician up until she left at about 4:30 PM. V2 stated that R3 was sent to the emergency room by the night nurse. V2 stated that she is a firm believer of doing things in the building instead of sending R3 out. On [DATE] at 10:56 AM V9, R3's Physician/Medical Director, stated that the facility is usually pretty good about notifying him of change in conditions. V9 stated that his notification would be documented in the resident's chart. V9 stated that he was not aware of R3's ongoing respiratory distress. V9 stated that if he was made aware of R3's condition he would have sent R3 out. V9 stated that he may not have sent R3 out initially but if her condition continued to change or not improve, he would have sent her to the hospital. V9 stated that he expects the facility to monitor changes of condition and notify him of the patient's condition. V9 stated that he did not exam and was not notified of R3's ongoing condition on [DATE]. The facility's Change in a Resident's Condition or Status policy, dated May/2017, documents that 1. Nursing will notify the resident's Attending physician or physician on call there has been d. a significant change in the resident's physical, mental or emotional status. e. need to alter the resident's medical treatment significantly. g. need to transfer the resident to a hospital/treatment center.

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 3 residents (R3) reviewed for neglect in the sample of 5. This failure resulted in R3 having ongoing respiratory distress from 8:00 AM until 7:10 PM without physician consultation and medical treatment. R3 expired from pneumonia and acute respiratory failure. Findings include: The facility's Abuse and Neglect-Clinical Protocol policy, dated [DATE], documents Neglect as 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. The Policy documents The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The Policy documents The medical director will advise facility management and staff about ways to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. R3's Face Sheet, undated, documented R3's was admitted on [DATE] with primary diagnosis of acute respiratory failure with hypoxia. R3's Progress Note, dated [DATE], documented CXR (Chest Xray) results received, showing linear opacities in the right mid and lower lung field likely reflecting scar atelectasis on [sic] likely pneumonia. Call placed to (V9, R3's physician) results reported, N.O. (new order) for Augmentin (antibiotic) ,d+[DATE] mg (milligrams) po (by mouth) bid (twice daily) x 7 days plus probiotic entered as ordered. R3's Progress Note, dated [DATE] at 9:51 AM, written by V3, Licensed Practical Nurse/LPN, [Recorded as Late Entry on [DATE] 09:51 AM], documents Charge Nurse came to Nursing station, informed this writer was having difficulty administering meds to resident and asked this writer to assist. Entered room, resident noted in bed with HOB (head of bed) elevated to facilitate breathing, O2 continuous @ (at) 2L (liters) via nasal cannula. Resident not easily aroused by verbal stimuli, sternal rub administered, resident aroused, with meds given without difficulty. Resident stated she was hot, ac (air conditioner) turned on for comfort. Upon further assessment resident noted diaphoretic. VS (vital signs) 98 (temperature)-106 (pulse) -22 (respirations) ,d+[DATE] (blood pressure) O2 sats (blood saturation levels) 89% on 2L (liters) oxygen increased to ,d+[DATE]L sats remained at 89% BS (blood sugar) 189. Occasional audible wheezing with lung assessment completed with wheezing heard bilaterally. On ABT (antibiotic) for Pneumonia, no rash or anaphylaxis noted. Appetite poor, assist x 1 for consumption. Standing order entered for DuoNeb q (every) 6 hours prn (as needed), administered x1 with assist of Charge Nurse. O2 sats rechecked after completion stats 83% on 4L. DON (Director of Nursing) made aware with further assessment completed, O2 sats increased to 92%. On [DATE] at 1:30 PM, V3 stated that she was working when R3 had her change in condition. V3 stated that she was assigned to the hall. V3 stated that V6, LPN, came to her and told her that she was having a difficult time giving R3 her medications at approximately 8:15 AM. V3 stated that when she went down to the room R3 was lying in bed. V3 stated that R3's oxygen was on, and her head of bed was up. V3 stated that when she called R3's name or tried to arouse R3 she would not respond. V3 stated that she then performed the sternal rub and R3 was able to arouse. V3 stated that this was not normal for R3. V3 stated that R3 was diaphoretic. V3 stated that she performed an assessment and found that R3's vitals were abnormal, and her oxygen level was low. V3 stated that they increased her oxygen to 4 L and there was no change. V3 stated that R3 had wheezing bilateral in her lungs. V3 stated that all of this was new for R3. V3 stated that R3 was newly diagnosed with pneumonia. V3 stated that R3 did wear oxygen but that her oxygen levels had remained in the high 90s until this event. V3 stated that they got an order for a breathing treatment at around 8:30 AM and gave it to her. V3 stated that her oxygen levels did not improve in fact they got worse. V3 stated that V2, Director of Nursing (DON), was notified. V3 stated that unsure of time but per V2 R3's oxygen level did increase. V3 stated that this was the only time she cared for R3. V3 stated that she was not assigned to that hall. V3 stated that V9, Medical Director, was in the facility doing rounds and was not notified of R3's condition. There was no documentation in R3's medical record that V3 contacted V9 regarding R3's respiratory distress during her shift. On [DATE] at 5:52 PM V6, LPN, stated that she is new to the facility and worked from 6AM to 6 PM on [DATE]. V6 stated that she worked with R3 before. V6 stated that she went into R3's room to give her meds at approximately 8:00 AM. V6 stated that she couldn't wake R3. V6 stated that R3 was in a deep sleep with snoring respirations. V6 stated that she had never had this much trouble waking R3. V6 stated that she went and got V3. V6 stated that V3 had been there for years. V6 stated that V3 was able to get R3 awake enough to take her pills. V6 stated that R3 was awake but not really. V6 stated that V3 checked R3's O2 sats and it was 83. V6 stated that she knew something was not right. V6 stated that V2 was at the facility. V6 stated that she told V2 that R3 had a change in condition and that her O2 sats was 83 and not coming up. V6 stated that she was told by V2 that if there is something that can be done in the building then the resident stays in the building. V6 stated that V2 told her to get the fan out of the breakroom and put it on R3. V6 stated that V3 gave R3 a breathing treatment and after the treatment V6 rechecked R3's O2 sat, and it had dropped to 80. V6 stated that she again told V2 that R3 needed to go to the hospital because R3's O2 sats kept dropping. V6 stated that she was told no that V2 would go down to R3's room. V6 stated that shortly after V2 notified her that R3's O2 sat was up to 92%. V6 stated that R3's O2 continued to drop. V6 stated that she continued to talk with V2 and was told that R3 would stay at the facility. V6 stated that she knew that R3's change of condition was serious and that R3 needed to go to the emergency room . V6 stated that she notified the V2 and was told to keep R3 in the building. V6 stated that she did not notify the physician. V6 stated that she notified her DON and followed the instructions given. V6 stated that she notified the oncoming nurse in report of R3's change of condition, oxygen levels in the low 80's, and being given the direction of keeping R3 in the facility. There was no documentation in R3's medical record that V6 notified V9 of R3's respiratory distress and low oxygen saturation levels during her shift. On [DATE] at 3:48 PM V7, CNA Coordinator, stated that she worked the day that R3 had the change in condition. V7 stated that she came in at 2:00 PM. V7 stated that she went down and did a walkthrough of her hall. V7 stated that during that time she noticed that R3 did not look like herself. V7 stated that R3 was different than she was yesterday. V7 stated that the day before R3 was up and moving around in her wheelchair. V7 stated that when she went in the room R3 was lying in bed with a fan and a mask on. V7 stated that R3 was cold and R3's breathing wasn't right. V7 stated that she notified V6 and told V6 that R3 was not right. V7 stated that she told V6 that R3 needed to go to the hospital. V7 stated that V2 was in the facility as well. V7 stated that she was concerned about R3. V7 stated that at around 6:00 PM V10, LPN, came in. V7 stated that she told V10 about R3 and shortly after V10 sent R3 out. R3's Electronic Health Record documents an abnormal O2 sat on [DATE] at 9:51 AM. There was no documentation in R3's Progress Notes or medical record regarding that the facility was assessing R3's respiration from 9:51 AM through 7:10 PM and no documentation that V9 was notified of R3's condition by V2, V3 and V6. R2's [DATE] Medication Administration Record (MAR), documented O2 sat. q shift R/T COPD to be completed every shift. On [DATE], R3's O2 sat was documented as 87% on the day shift. There were no other documented O2 saturation levels in R3's medical record. R3's Progress Note, dated [DATE] 07:10 PM, documents Resident found unresponsive. Not responding to verbal or painful stimuli. No response to sternal rub. Resident cold to touch. Nailbeds cyanotic, mottling noted to BLE (Bilateral lower extremities) Gurgling noted. Right pupil dilated. RESP 8 AND PULSE ,d+[DATE]. Unable to obtain SAO2 or B/P (blood pressure) at this time. 911 called. 1925 Ambulance here to transport resident to ED (Emergency Department) and request POA be notified to meet or call (local ED) resident probably is not going to make it. (V4), R3's POA notified, report called to (Local ED) and (V2) DON notified. R3's Progress Note, dated [DATE] 10:16 PM, documents Call placed to (Local) ed FOR UPDATE ON RESIDENT. ED nurse states SHE IS STILL HOLDING ON CONDITION REMAINS GUARDED. Resident being admitted with DX (diagnosis) of PNE (pneumonia) and Acute UTI (urinary tract infection). R3's Progress Notes, dated [DATE] at 12:30 AM, documents Call received from (local hospital). They Report that resident has expired. R3's Death Certificated, dated [DATE], documents date of death [DATE]. It also documents the cause of death Acute Respiratory Failure with Hypoxia and Pneumonia. On [DATE] at 8:30 AM V2 stated that she became aware of R3's change in condition around 4:00 PM. V2 stated that she was told that R3 was having problems breathing and oxygen levels were low. V2 stated that the nurse wanted to send the resident to the hospital. V2 stated that she wanted to make sure that they did everything they could at the facility first. V2 stated that when she went into the room, she noted that R3 was mouth breathing. V2 stated that she put a mask on R3 and monitored R3. V2 stated that R3's oxygen level improved to 92% with the mask and 4 liters of oxygen. V2 stated that R3 was lethargic. V2 stated that R3 was diagnosed with pneumonia a day or so before and thought this was causing the lethargy. V2 stated that she felt that R3 was stable and did not need to go to the hospital or notify the physician up until she left at about 4:30 PM. V2 stated that R3 was sent to the emergency room by the night nurse. V2 stated that she is a firm believer of doing things in the building instead of sending R3 out. R3's EHR does not document any assessment performed by V2. R3's EHR does not document the application of a nonrebreather mask or physician notification of assessment and treatment performed by V2. On [DATE] at 10:56 AM V9, Medical Director, stated that the facility is usually pretty good about notifying him of change in conditions. V9 stated that his notification would be documented in the resident's chart. V9 stated that he was not aware of R3's ongoing respiratory distress. V9 stated that if he was made aware of R3's condition he would have sent R3 out. V9 stated that he may not have sent R3 out initially but if her condition continued to change or not improve, he would have sent her to the hospital. V9 stated that he expects the facility to monitor changes of condition and notify him of the patient's condition. V9 stated that he did not exam and was not notified of R3's ongoing condition on [DATE].

Based on observation, interview, and record review, the facility failed monitor, encourage nutritional intake, and assist with eating as needed to maintain adequate nutritional status for 1 of 1 residents (R22) reviewed for nutrition/ weight loss in sample of 39. This failure resulted in R22's significant unplanned weight loss of 5.6% in one month and her severe unplanned weight loss of 15.89% in 2 months. Findings include: R22's face sheet, with admitted [DATE], documents that R22 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's Minimum Data Set (MDS), dated [DATE], documents that R22 is moderately cognitively impaired, and requires supervision and set up with eating. R22's Care plan, problem start date 12/29/2021, documents, Problem: I am at risk for alteration in nutrition due to poor food and fluid intakes at times. Approaches include: Allow me time to perform the task of eating a meal-assist as needed. Observe and report to MD (medical doctor) s/sx (signs/symptoms) of malnutrition: Emaciation, muscle wasting, significant weight loss which is 3 pounds in a week, over 5% in one month, over 10% in 3 months, over 10% in 6 months. Observe/document/report to MD if I have signs of dysphagia: (ie: pocketing, choking, coughing, drooling. Holding food in mouth, several attempts at swallowing, refusing to eat, appearing concerned). Substitute offered commonly. The Care Plan also documents Evaluation Notes, dated 2/10/2022, Resident is on a regular diet with mighty shakes TID (3 times a day) and magic cup at lunch and supper. Writer will add resident to weekly weights to monitor and refer to RD (Registered Dietician) for further evaluation. R22's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's Weights, dated from 01/04/22 to 03/07/22, document that on 01/04/22, R22's admission weight was 107 pounds (lbs). 2/9/22 weight 101 lbs, a loss of 6 lbs (5.6%) in one month. 03/07/22 weight 90 lbs, a loss of 17 lbs (15.89%) in 2 months. R22's Meal intake/fluid intake, dated 12/29/21-03/16/22, documents food consumption from dates, 12/29/21-01/27/22. On the following dates, 12/29/21, 01/07/22, 01/10/22, 01/12/22, 01/18/22, and 01/27/22, only one meal per day was documented. There was no documentation for food consumption from 01/28/22-03/16/22. No substitutions or alternates were documented. R22's Dietitian note, dated 01/18/22, documents, Recommend continued diet therapy, Mighty shakes, encourage oral intake, wt (weight) maintenance ok. R22's Dietitian note, dated 02/17/22, documents, February wt 101# (pounds), January 104#, 107#. Noted wt loss. Recommend continued diet therapy, continue supplements, 2 CAL (calorie) med pass 60cc (cubic centimeters) tid, encourage oral intake, no wt. decrease desired. R22's Dietitian note, dated 03/14/22, documents, March wt 90#, February 91#, 101#, January 107# continues with poor intake, will ask about a possible appetite stimulant. On 03/15/22 at 09:20 AM, R22 was sitting in her room at the over the bed table with her breakfast tray in front of her. R22 was frail, thin appearance, and R22 clothes were loose and baggy. R22 was making no attempt to eat her meal. No one was in room assisting her with meal, and no substitutions were offered. On 03/15/22 at 09:30 AM, V12, Certified Nursing Assistant (CNA), went into R22's room, and removed R22's breakfast tray that had very little eaten from it. No assistance with the meal was offered, nor was R22 asked if she would like something else to eat. On 03/16/22 at 12:50 PM, R22 was sitting in room with her lunch tray. No one was assisting R22 with her meal, nor were substitutions offered. On 03/16/22 at 1:06 PM, V13, CNA, went into R22's room and removed R22's lunch tray, which still had all the food on the tray. R22's tray still had the cover on the food cup and ice cream cup was also unopened. No assistance was offered, nor was R22 offered any substitutions. On 03/16/22 at 1:08 PM, V13, CNA, was questioned about what she would do if she noticed that R22 wasn't eating. V13 stated that they give R22 ensure, and she has that to drink. On 03/17/22 at 08:46 AM, V2, Director of Nursing (DON), stated that she would expect the CNA's to offer snacks, offer substitutions, let the nurse know that the resident wasn't eating, and to assist or offer to assist the resident with their meal. On 03/17/22 at 10:19 AM, V2, DON, stated that she would expect the CNA's to document all the resident's meal consumption. On 03/17/22 at 10:32 AM, V14, R22's Primary Care Physician, stated that he would expect the nurses and CNA's to monitor R22's food consumption, assist her with eating if needed, and to offer her substitutions if R22 doesn't eat. V14 stated that he was just made aware of R22's weight loss issues yesterday (03/16/22). When V14 was questioned, if he would have initiated something sooner if he had been made aware, V14, stated, Yes, Of course I would. Facilities Policy and procedure, with a revised date of March 2011, documents Weighing and Measuring the Resident. Purpose: The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. It further documents Reporting: 1. Report significant weight loss/weight gain to the nurse supervisor. 2. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria (where percentage of body weight loss= [usual weight-actual weight]/ x 100): a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months- 10% weight loss is significant; greater than 10% is severe. 3. Notify the Nurse Supervisor if the resident refuses the procedure. 4. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview and record review, the facility failed to ensure that resident's received proper wound care treatments and discontinued treatments without a Physicians order for 4 of 6 residents (R26, R28, R105 and R108) reviewed for non-pressure related wound care in the sample of 42. This failure resulted in not treating wounds and R108 returned to ER for wound care and treatment and R108 did not receive 2 [MEDICAL TREATMENT] treatments because of lack of facility arranging transportation. Findings include: 1. On 9/30/20, V40 (R108's spouse) stated the hospital discharged R108 to the facility (unsure of date) with a dressing in place to his abdomen. V40 stated she went to the facility to get him for [MEDICAL TREATMENT] on a Tuesday and could smell the wound. V40 stated the facility (unable to state who) told her R108's dressing hadn't been changed, because they didn't have wound care orders, but the Physician was coming on Wednesday to do a wound assessment. V40 stated she looked at the dressing and it was dated for 07/10/20, the day he was admitted to the facility. R108's Face Sheet documents R108 was admitted on [DATE] with a [DIAGNOSES REDACTED]. R108 was discharged on [DATE]. R108's Minimum Data Set/MDS, dated [DATE], documents R108 requires assistance with bed mobility, toileting and hygiene. R108's Admission Body Observation Report, dated 7/10/20, documents R108 was admitted to the facility with vascular wounds to both lower extremities, fungal infection to multiple skin folds, rashes to the neck and abdomen and open wounds to the left upper abdomen and left foot. R108's Care Plan, dated 7/10/20, fails to document R108's wounds or interventions related to the wounds. R108's Hospital Discharge Records, dated 7/10/20, document R108 underwent a sharp excisional debridement of necrotic skin and subcutaneous tissue of the abdomen on 7/3/20. R108's Hospital Discharge Orders, dated 7/10/20, document orders for dressing changes daily and as needed and to see wound care sheet for orders. In review of R108's hospital discharge records and orders there was no wound care sheet identified to address treatment orders for the wound to the abdomen. The Discharge Orders included orders for [MEDICATION NAME] 2% cream, apply to affected skin folds twice daily and [MEDICATION NAME] 2% cream, apply to affected skin folds twice daily. Both orders fail to clarify which skin folds the creams are to be applied to. R108's Hospital Discharge Records, dated 7/14/20, document R108 was admitted to the hospital with [REDACTED]. The records go on to document that R108 comes from the nursing home in which he was not receiving proper wound care. Underwent an I&D on abdomen last week but has not had appropriate dressing changes. Patient also notes his chronic lower extremity wounds have not been redressed in 4 days. There was no documentation identified in the hospital discharge records identifying if dressings were in place to R108's wounds upon arrival to the hospital. R108's Hospital Skin Exam, dated 7/14/20 at 6:59pm documents R108 has beefy red painful skin in the inguinal bilateral folds consistent with yeast infection, moist satellite [MEDICAL CONDITION]. R108's Progress Notes were reviewed and document the following: 7/13/20 at 3:28pm - Called hospital wound care clinic, resident stated he routinely goes there for wounds. Message left to call facility with wound orders for lower extremities; 7/13/20 at 4:34pm - Dressing to abdomen dry/intact; 7/13/20 at 9:37pm - Dressing to abdomen dry/intact; 7/14/20 at 4:32pm - Hospital wound center called and stated resident has never been seen by their facility. The nurse practitioner to see resident in the morning; 7/14/20, no date, Cardiology note - Facility is reporting non-compliance with [MEDICAL TREATMENT]. Patient missed last 2 appointments this week as wife has been unable to transport. According to facility, [MEDICAL TREATMENT] is requesting patient be sent to ER; 7/14/20 at 7:35pm - Wife at facility took all belongings and meds. The progress notes fail to document that R108's Physician was notified of the need for treatment orders and to clarify the current treatment orders for R108's wounds. R108's Treatment Administration Records for July 2020 were reviewed and fail to document the sites the [MEDICATION NAME] and [MEDICATION NAME] creams were applied to or any treatments completed to the leg wounds or abdominal wounds. On 10/20/20 at 10:14am, V2 she would expect staff to notify the Physician of a new wound/pressure ulcer, need for treatment orders or a change in condition. The facility policy and procedure titled Pressure Ulcers/Skin Breakdown, dated April 2018, document staff will examine newly admitted residents for evidence of existing pressure ulcers or other skin conditions and the physician will order pertinent wound treatments. The facility policy and procedure titled Resident Change in Condition Physician Notification dated 10/10/12, documents staff will notify the attending physician or physician on call of all condition or health status changes. 2. On 10/06/20 at 3:39 PM R26 was lying on her back in her bed and stated she has a lot of pain in her legs, especially her left hip and knee. She stated she had been in the hospital with a bad urinary tract infection [MEDICAL CONDITION] and was just readmitted to the facility a day ago. She had pressure relieving boots on both lower legs, and left lower leg and foot were turned outward and knee was contracted. R26 was not wearing a splint or brace on her left leg. On 10/7/20 at 9:55 AM V17 (Wound Nurse) stated R26 needs to be medicated before they turn her and do her dressing changes because she has a lot of pain in her legs. On 10/7/2020 at 10:25 AM V17 stated R26 did not want to be turned for a skin check until it was her scheduled time to be turned because it was too painful for her to turn and reposition. R26's Face Sheet documents her diagnoses to include [MEDICAL CONDITION], Muscle Weakness, Chronic Pain, and Unspecified Fracture of Lower End of Left Femur. R26's Minimum Data Set ((MDS) dated [DATE] documents she is alert and oriented and requires extensive assist for bed mobility. R26's Care Plan, dated 5/11/20 documents: Category: ADL (Activities of Daily Living) Functional/Rehabilitation - has recent fractured left knee; documents: Approach Start Date: 5/11/20 - DC (discontinue) on: 9/19/20 - Discontinued left knee immobilizer hip to ankle R26's Progress Notes dated 5/2/20 at 5:15 PM document R26 was found lying on the floor on her back in her room. The progress note documented she complained of pain to her left hip and left foot at the time of the fall, and the Medical Doctor ordered x-rays of both her left hip and left foot. The radiology reports dated 5/2/20 document there were no acute fractures or dislocations of R26's left hip or left foot. R26's Progress Notes dated 5/6/20 at 10:56 AM document R26 complained of pain in her left knee that was not relieved with the pain medication administered. The progress note documented R26 had a fall a few days ago, and she had knee surgery in the past. R26's physician was notified, and she ordered an x-ray of R26's left knee. The radiology report of R26's left knee, dated 5/6/20, documented R26 had a complete comminuted distal femoral fracture involving the femoral component of the total knee replacement. A handwritten note at the bottom of the report documented that the Medical Doctor was notified of the report and orders received to send R26 to the local emergency room . R26's Progress Note dated 5/9/20 at 4:45 PM document she returned from the hospital with an immobilizer to her left lower extremity from her hip to her ankle. The progress note documented that instructions from the hospital indicated the brace is only to be removed for skin checks and for adjustments. R26's Progress Note dated 6/12/20 at 11:10 AM documents the nurse from V23 (Orthopedic doctor) called and canceled her follow up appointment and left an order for [REDACTED]. R26's Progress Note dated 6/25/20 at 9:01 AM documents V22 (Assistant Manager of the orthopedic office) called the facility with new orders for R26 to continue to wear the knee immobilizer, making sure it is centered, perform daily skin checks to monitor for skin breakdown, and continue to be non-weight-bearing to left side for 6-8 weeks, and get x-rays in 6-8 weeks. Review of R26's Progress Notes from 6/26/20 through 10/12/20 do not document any communication between the facility and R26's orthopedic doctor. There is no documentation of any changes in the orders regarding R26 wearing the left knee immobilizer. R26's Electronic Medical Record does not document any follow up x-ray results after those done on 6/12/20. R26's Progress Notes dated 10/13/20 at 8:55 AM document the facility's Nurse Practitioner was notified of need for a follow-up x-ray of R26's left knee and new order received. There was no documentation of the facility notifying V23 that the x-rays ordered to be done 6-8 weeks after 6/25/20 were not done, or that the facility had discontinued the splint. On 10/13/20 at 10:31 AM V4 (MDS/Care Plan Nurse) stated the facility did not get the x-rays as ordered for R26 by her orthopedist in 6-8 weeks from 6/25/20 but would be getting them today because they had notified the facility's Registered Nurse Practitioner of need for the x-rays and she gave the order for them to be done. V4 stated the facility's contracted radiology company will be coming today to do them. V4 stated the appointment with the orthopedist was rescheduled for 10/27/20. V4 stated V8 (Licensed Practical Nurse/LPN) informed V4 that she had gotten the order to discontinue R26's left leg splint in September. On 10/13/20 at 10:31 AM V4 provided the following documentation: R26's Physician order [REDACTED]. V4 also provided R26's Care Plan dated 5/11/20 with Problem: ADL (Activities of Daily Living) Functional/Rehabilitation Potential: has recent fracture of left knee, with an intervention: Approach start date: 5/11/20 - DC on 9/19/20-discontinue left knee immobilizer hip to ankle: Discontinued (DC'd) 9/19/20; DC reason: doctor discontinued. V4 also provided an order, dated 10/13/20 for: x-ray left knee f/u (follow up) fracture May 2020 and ordered by the facility's nurse practitioner. On 10/13/20 at 4:00 PM per phone interview, V22 stated regarding R26's splint and x-ray orders from that office, the orthopedic office documentation on communication with the facility regarding R26 includes: On 6/12/20 V23's office called and requested X-rays be done .continued to recommend treatment to be non-operative tx (treatment). V22 stated the physician's office received the images (x-ray), and on 6/25/20 V23 (Orthopedist) continued to recommend non-operative treatment, continue the immobilizer, remain non-weight bearing for 6-8 weeks, and V23 gave a detailed instruction on how splint was to be worn and cared for and this was relayed to V39 (Registered Nurse/RN) at the facility, and new x-rays were to be done in 6 weeks, which should have been the beginning of August, according to V22. She stated the last communication from the facility regarding R26, with the physician's office, was on 6/25/20 until today, 10/13/20, when someone from the facility called and made an appointment for R26 on 10/27/20 for follow-up visit. V22 stated that will be the first time R26 will be seen in the physician office. She stated there was no documentation of the immobilizer splint ever being discontinued, and if the x-rays would have been done in 6 weeks after they were ordered on [DATE], the physician would have given appropriate orders at that time. On 10/14/20 at 6:36 AM V8 (LPN) stated she is the nurse who discontinued R26's splint on September 19,2020. V8 stated she came in to work that morning on day shift and R26 had pressure relieving boots on her feet but V8 could not find her knee splint, so she discontinued it. She stated she felt the boots on her lower legs offered just as much support as the splint had so she did not feel like R26 needed it. V8 stated she did not know if R26 was even being followed by an ortho doctor or if she had been seen by one after she got out of the hospital. V8 stated she discontinued the splint and meant to tell the facility's Nurse Practitioner that she did it and get the order, but she forgot. V8 stated she had her personal notes from the date that she discontinued the splint and was able to tell V4 (Care Plan Coordinator) that she discontinued it on 9/19/20. V8 stated, That was my mistake .I forgot to tell anyone that I had discontinued the splint. As of 10/15/20 at 4:00 PM R26 still did not have an order to resume wearing the knee brace/immobilizer that was ordered by the orthopedist. R26's Progress Note dated 10/20/20 at 4:00 PM documents: (V23's) office called the facility. Reports the resident (R26) needs to be seen on 10/27/20 to re-eval of femur fracture. Dr. office reports if previously used knee brace available - reapply. Use Ace wraps (elastic bandages) under brace. If unable to find knee brace, ace wraps to be applied. R26's Progress Note dated 10/20/20 at 8:11 PM documents, Unable to find knee brace. Ace wrap times 2 applied to left upper leg. Air boots on left used as temporary splint for knee. R26's Progress Note dated 10/21/20 documented that ortho office was ordering the proper brace for R26's left knee. R26's Progress Note dated 10/21/20 at 2:11 PM documents, New order received for leg brace on at all times per (facility's Nurse Practitioner) and applied. On 10/27/20 at 12:17 PM V2 stated V23 (Orthopedist) should have been notified and asked if the splint he ordered for R26 could be discontinued. V2 stated a nurse should never discontinue an order for [REDACTED]. On 10/28/20 V22 sent a copy of V23's Progress Note from visit on 10/27/20. V22 stated V23 will be doing surgeries for the rest of the week and probably will not be available to talk about the report. V23's Progress Note documents that he had reviewed R26's radiographs of her knee which demonstrates a further impacted apex anterior periprosthetic femur fracture without any evidence of healing. Under Plan, V23's Progress Note documents that he thinks the only treatment for [REDACTED]. The knee immobilizer has potential to give her soft tissue compromise due to her contractures. 3. On 10/8/20 at 9:15 AM V17 (Wound Nurse) removed a soiled dressing from R28's left lower leg, while V33 (Certified Nursing Assistant/CNA) lifted his leg to allow V17 access to R28's entire lower leg, including his posterior calf. The old dressing was moist due to R28's left lower extremity weeping serous fluid, and his exposed skin was red, with areas of flaking skin particles coming off. V17 used a wet washcloth and wound cleanser to wipe the skin on R28's left lower extremity, and applied Ammonium [MEDICATION NAME] Lotion 12% to top of R28's left lower leg but did not lift his left leg off the mattress and failed to apply the ordered lotion to the macerated skin on his posterior lower left leg. R28's Face Sheet documents his diagnoses which include [MEDICAL CONDITION] of left lower limb and Chronic Peripheral [MEDICAL CONDITION]. R28's Minimum Date Set ((MDS) dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating he is alert and oriented to person, place, time and situation. The same MDS documents R28 requires extensive assist of 2 staff for bed mobility and bathing, and he is dependent on staff for transfers. It documents that he is always continent of bowel and bladder, and he has 3 arterial/venous ulcers and Moisture Associated Skin Damage (MASD). Per the MDS, his treatment for [REDACTED]. R28's Care Plan dated 05/28/2020, last reviewed 10/6/20 documents, Category: Skin; PROBLEM: 9-16-20 right lower lateral leg mixed vascular 9-17-20 right inner calf mixed vascular 9-28-20 left lower extremity posterior venous; Diagnosis: [REDACTED]. APPROACH: treatment to left lower extremity APPROACH: treat to right inner calf as ordered R28's Physician order [REDACTED]. lotion; 12 %; amount: thin layer; topical Special Instructions: Cleanse bilateral lower extremities with soap and water, apply thin layer, wrap with Kling (gauze dressing) and then Ace wrap (elastic bandage) daily. R28's lab reports include a Wound Culture Final Report, dated 9/18/20 with results right and left lower legs: Heavy growth of Proteus Mirabilis. A handwritten documentation at the bottom of the report stated, Sent to NP (Nurse Practitioner) NO (New Order): [MEDICATION NAME] (antibiotic) 750 mg QD x 5 days. 4. On 10/14/20 at 12:32 PM per review of R105's electronic medical record, she was admitted to the facility with wounds on her right foot and toes that were infected with ESBL. Her wounds to her right foot were healed on 5/19/20 and then she developed a blister on her right foot which opened on 6/18/20. R105's Discharge Summary dated 7/28/20 documents she was discharged to another long-term care facility on that date. R105's Face Sheet documents her diagnoses to include: Non-pressure chronic ulcer of other part of right foot with unspecified severity, Non-pressure chronic ulcer of other part of left foot with unspecified severity, and [MEDICAL CONDITION]. R105's Progress Notes dated 06/15/2020 at 5:51 PM documents: Resident noted with 1.5 cm x 1.5 cm fluid filled blister to RLE. Resident states unsure how she obtained it. New order: cleanse with NS or wound cleanser and apply dry dressing daily. Resident aware. Will monitor area. R105's Progress Notes dated 06/18/2020 at 11:03 AM documents: Blister to RLE ruptured with moderate amount of serous drainage noted. New orders: D/C dry dressing. Start: cleanse with Dakin's solution and apply calcium alginate and bordered gauze dressing daily and PRN until healed. Resident aware of new orders. Will monitor area. R105's Progress Notes dated 06/24/2020 at 09:48 AM documents: Weekly wound assessment performed. Ruptured blister to RLE measures 1.5 x 1.5 cm. Light amount of sanguineous drainage noted. No s/s infection noted. Cont. with Dakin's cleanse and applying calcium alginate with dressing. Right second toe noted with scabbed area. Cont. cleansing area and covering with dry dressing. No c/o pain to either area. Will re-assess areas next week. R105's Progress Notes dated 07/01/2020 at 09:00 AM documents: Weekly wound assessment performed. Area to RLE measures 0.5cm x 0.3 cm with scant amount of serosanguinous drainage. No s/s infection noted. Denies pain to area. Area noted with 100% granulation. Cont. with calcium alginate + dry dressing. Scabbed areas cont. to right 2nd and 3rd toes. No drainage noted. Denies pain to area. Cont. with cleansing with Dakin's solution and applying dry dressing as preventative. Will re-assess next week. R105's Physician order [REDACTED]. Apply calcium alginate and apply bordered gauze dressing daily and PRN (as needed) until healed. R105's Care Plan with the start date: 10/17/19 documents history of skin impairment to lower extremities: 10/16/19 admitted with arterial ulcers right foot/toes; 11/19/19 arterial ulcer right anterior ankle - healed 5/20/20; 4/13/20 right lower leg arterial ulcer healed 5/19/20; 5/20/20 right lower extremity and left lower extremity continue with dry scabbed areas; 6/03/20 right lower extremity healed; 6/15/20 right lower extremity blister. Interventions to this care plan document: treatment as ordered R105's TAR dated 7/1/20 -7/31/20 documents an order to Cleanse right lower extremity with Dakin's solution, apply calcium alginate and apply bordered gauze dressing daily and prn until healed with no [DIAGNOSES REDACTED]. Documentation of administration of this order indicates it was not administered as ordered on [DATE], 7/5/20, 7/7/20, 7/12/20, 7/17/20, 7/20/20, 7/21/20, or 7/27/20. The TAR documents R105 refused treatments on 7/6/20 and 7/8/20. R105's Discharge Summary dated 7/28/20, when she was transferred to a sister facility, documents discharge instructions documents R105 has treatments but does not specify what type of treatment or the where the treatment is applied. 5. On 10/07/20 at 9:30 AM, R45 was observed sitting up in her wheelchair in her room. R45 was confused and only alert to herself. There was a dressing observed on left lower leg that was dated 10/03/20. When R45 was asked about the dressing, she did not recall which leg the dressing was on. When R45 was asked how often the staff change the dressing, she stated every day. On 10/08/20 at 10:00 AM, V17 (Wound Nurse) stated she already changed the dressing on R45's lower leg. She stated it was scabbed and almost healed and she would probably heal out next week. V17 confirmed that R45 was a daily dressing change and could not explain why the dressing had not been changed since 10/03/20. The Event Summary List report, dated 10/03/20 at 6:09 PM, documented skin tear to left lower leg. No other information given regarding type of dressing or treatment applied. The Physician order [REDACTED]. Cover with bordered dressing. Until healed. The Treatment Administration Record (TAR), dated 10/04/20, 10/05/20, 10/06/20 and 10/07/20 were blank for any treatments completed for R45. On 10/20/20 at 1:30 PM, V2 (DON) stated she was not aware that R45's dressing had not been changed from 10/03/20 to 10/08/20.

Based on observation, interview, and record review, the facility failed to identify, assess and monitor pressure ulcers and provide timely turning and repositioning in 4 of 6 residents (R26, R39, R51, R205) reviewed for pressure ulcers in the sample of 42.This failure resulted in R51 getting multiple pressure ulcers to his left upper and lower heel and to his sacrum area. Findings include: 1. R51's Face Sheet documents R51 was admitted on [DATE] with a [DIAGNOSES REDACTED]. R51's Minimum Data Set (MDS), dated [DATE], documents that R51 requires extensive assistance of 2 staff with bed mobility, toileting and hygiene. It further documents that R51 has 2 stage 3 pressure ulcers. R51's Braden Assessment, dated 09/18/20, documents R51 is at moderate risk for the development of pressure ulcers. R51's Care Plan, dated 09/08/20, documents R51 has a stage 2 pressure ulcer to the sacrum. Interventions include to monitor, document, report to Physician changes in skin status including appearance, color, wound healing, signs/symptoms of infection, wound size and staging. R51's Wound History Report, dated 10/14/20, document R51 had stage 3 pressure ulcers to the left heel and upper left heel. The report documents that both areas were closed on 10/01/20 with no other documentation on measurements or assessment of the pressure ulcers identified after this date. R51's Shower Sheets document on 10/12/20 and 10/15/20, red areas to the left heel. On 10/14/20 at 10:41am, V17 (Registered Nurse/RN) stated R51's pressure ulcers to the left heel are healed. On 10/15/20 at 9:26am, R51's left heel was observed to have an area measuring approximately 6cm round with an area in the center measuring approximately 3.5cm x 2cm that is deep red in color and appeared to be a Deep Tissue Injury (DTI) pressure ulcer. R51's posterior left ankle was observed to have a deep red colored area measuring approximately 4cm x 2cm and appeared to be a DTI pressure ulcer. On 10/15/20 at 9:26am, V26 (Certified Nursing Assistant/CNA) stated R51's pressure ulcers to the left heel are most likely due to her boot that she wears. V26 stated she normally puts a long sock on R51 to keep the boot from rubbing R51's skin, but R51 did not have a long sock on that morning when she got R51 out of bed. R51's Progress notes were reviewed for October 2020 with no documentation identified of R51's pressure areas to the left heel prior to 10/15/20. R51's Physician order [REDACTED]. On 10/20/20 at 10:14am, V2 (Director of Nurses/DON) stated she would expect the nursing staff to assess the area and notify the resident's physician. The facility policy and procedure titled Prevention of Pressure Injuries, dated April 2020, documents to inspect the skin on a daily basis. Evaluate, report and document potential changes in the skin. The facility policy and procedure titled Pressure Ulcers/Skin Breakdown Clinical Protocol, dated April 2018, documents the nurse shall describe and document/report the following: full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue, pain assessment, resident's mobility status and current treatments. 2. On 10/07/2020 at 10:25 AM V17 (Wound Nurse) stated R26 did not want to be turned extra so her wound on her buttocks could be observed. V14 (CNA) stated she had last changed and turned R26 before she assisted her with breakfast at about 7:45 AM or 8:00 AM, 2 and 1/2 hours ago. V14 did not turn and reposition R26 at this time. On 10/07/20, per constant observation from 10:25 AM until 1:20 PM (3 hours) R26 was lying in the same position on her back in bed with indwelling urinary catheter tubing laying across her right leg. At 1:20 PM V14 and V17 turned R26 onto her right side, and she had a bordered foam dressing on her sacrum which was dated 10/02/20, indicating it had been applied 6 days ago. The dressing was not a DuoDerm dressing that was ordered by R26's physician. When V17 removed the dressing, it had dark material on it, that appeared to be feces. There were two small open areas on her inner right buttock. V17 stated she would be doing her weekly wound measurements on the next day, but both open areas appeared to be about 0.5 centimeters (cm) by 0.5 cm in size, with top layer of skin off. R26 had deep wrinkles on her buttocks and upper posterior thighs, and her skin on buttocks was red. Her pad was damp, and R26 stated she had spilled some water earlier. Her indwelling catheter was draining dark tea colored urine, so the moisture on her pad did not appear to be urine. R26's Progress Note dated 10/02/20 at 2:45 PM documented the facility had received report from the hospital that she would be returning to facility on that day and that R26 had maceration on her coccyx, and there was a bordered foam dressing in place. R26's Physician order [REDACTED]. R26's Admission Body assessment dated [DATE] at 7:34 PM documents R26 has a pressure ulcer on her coccyx but did not include any documentation of description of wound or measurements. R26's Braden Scale for predicting Pressure Ulcer Risk, dated 10/12/20, documents a score of 11, indicating she is at high risk for pressure ulcers. According to this assessment, R26's sensory perception (ability to respond meaningfully to pressure related discomfort) is very limited, R26 is chair bound, her skin is very moist, R26's ability to change and control body position is very limited, her nutrition is probably inadequate, and she requires moderate to maximum assist in moving. R26's Care Plan dated documents: 10/08/2020 03:14 PM Category: Skin: PROBLEM: stage 2 pressure ulcer sacrum has re-opened. Interventions for this problem include: Start Date: 10/08/2020: APPROACH: Educate caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. On 10/08/20 at 1:00 V17 stated she would expect anyone with a wound on their coccyx, or at risk for skin breakdown, to be turned and repositioned at least every two hours. 3. On 10/07/20 at 10:35 AM V14 unhooked R39's soiled adult brief and tucked it in under the resident, then turned R39 onto her left side and cleansed the fecal material from R39's rectum and buttocks. There was a small open area on R39's right buttock. V17 (Wound Nurse) at first stated she did not think it was open, then looked closer and stated, That would be a Stage 2. After V14 finished cleaning R39, V17 cleansed the open area on R39's right buttock with wound cleanser, measured it (0.5 cm X 0.5 cm) and then V14 applied zinc oxide protective cream over the area. R39 also had a round open sore behind her right knee. V14 asked her if she had picked at it and R39 said yes, but the wound was round, with thin layer of skin off of it, and its location was where R39's leg would have bent and rested against the edge of the seat when sitting in her chair. V17 cleansed and measured the wound and stated it was a skin tear measuring 0.6x0.6cm. R39's MDS dated [DATE] documents she is cognitively intact, requires extensive assist with bed mobility, transfers and toileting, and is always incontinent of bowel and bladder. R39's Care Plan dated 10/07/20 documents, I have developed an area on right buttock; stage 2. An approach for this care plan, dated 10/08/20 documents: Administer treatments as ordered and monitor effectiveness. R39's Braden Scale Score for Predicting Pressure Sore Risk dated 10/7/20 documents a score of 14, indicating she is at moderate risk for pressure ulcers. R39's Physician order [REDACTED]. 4. On 10/02/20 at 1:05 PM R205 stated she had a sore on her bottom and it is a little painful when she is sitting on it. On 10/06/20 at 2:50 PM V21 (CNA) assisted R205 to roll over and she had dressing on her bottom with curled up edges, making it a ball, causing an area of pressure to that area when she was sitting or lying on it. R205 stated her bottom hurt. V21 straightened the dressing on her coccyx and it was dated 09/30/20, indicating it had been in place for 6 days. The area around the dressing was red. R205's Physician order [REDACTED]. R205's Braden Scale for Predicting Pressure Sore Risk dated 09/26/20 documents a score of 16 indicating she is at risk for pressure ulcers. R205's MDS dated [DATE] documents she is cognitively intact, requires extensive staff assist for bed mobility, transfers, and toileting, is incontinent of bowel and bladder, and has no skin impairment. R205' Care Plan dated 10/08/20 documents: 10/08/2020 03:11 PM Category: Pressure Ulcer: PROBLEM: Resident is at risk for pressure ulcer due to moisture/impaired mobility history of reddened area coccyx. Interventions include: 10/06/2020 APPROACH: DuoDerm as ordered for prevention.

Based on observation, record review and interview, the facility failed to provide supervision to prevent falling for 3 of 9 residents (R45, R110, R115) reviewed for falls in the sample of 42. This failure resulted in R45 falling 32 times, hitting her head on 05/29/20 causing large bruise to left eye and on 08/09/20 causing bruising to right eye; R110 suffering lacerations to the head after falling backwards in a wheelchair in the facility van; and R115 falling on 12/23/19 suffering multiple rib fractures and internal bleeding. Findings include: 1. On 10/01/20 at 1:45 PM, R45 was observed sitting up in wheelchair in her room. R45 was alert to self only stating she gets help when she needs it. R45 stated she knows when to use her call light. When R45 was asked if she knew where her call light was, she stated No, not really. R45's call light was observed tied around the side rail on her left side. The physician's orders [REDACTED]. It documented on 03/19/20 an order for [REDACTED].>The Minimum Data Set (MDS), dated [DATE], documented R45 was moderately cognitively impaired and required extensive assist of one staff for bed mobility, transfers, locomotion, dressing, toileting, hygiene and bathing; and had balance deficits and was frequently incontinent of both bowel and bladder. The care plan, dated 08/28/20, documented R45 was identified as being high risk for falls with the following interventions: personal alarm to bed and chair and reminders to not take off. On 08/02/20, reminders/education to ask for assist to clean out drawers. On 07/08/20, non-skid socks/shoes when up in wheelchair. On 07/07/20, alarm checked & working. Post fall monitoring, notify provider if Change of Condition (COC), continue interventions on risk fall care plan, frequent visual checks, new body alarm at all times, medication review and therapy to screen. On 10/14/20 at 11:30 AM, V2 (Director of Nursing/DON) stated she was not aware of what the Risk fall care plan was used for or where that information was located in the medical record. On 03/13/20, R45's Fall risk assessment admission documented score of 3 or no risk. On 05/22/20, the Fall risk assessment quarterly documented a score of 18 which indicated high risk. On 06/09/20 and 09/04/20, it documented a score of 20 which indicated high risk. On 03/13/20, R45 was admitted to the facility. From 03/16/20 to 05/29/20, nurse's notes and fall reports documented R45 had 15 falls. On 05/29/20 at 10:25 AM, nurse's notes documented R45 was found on the floor in her room with a large bruise to the left eye. From 06/06/20 to 09/30/20, R45 had 16 additional falls. On 08/09/20 at 8:11 AM, nurse's notes documented R45 was found sitting on top of her bed covers with a large bruise to the right eye. There were no new interventions put into place, only repeated interventions. 2. On 12/23/2019 at 3:29 PM, a nurse's note documented, Resident is c/o pain to right side rib area. Called and rec'd orders to get x-ray of area. Writer called Biotech to give orders for x-ray they will be out today. Writer also called daughter and made her aware and will call with results to her. On 12/23/2019 at 3:47 PM, a nurse's note documented, Addendum from previous note: Writer assessed resident Right side where she was c/o pain. There are no bruising, open area, nor swelling noted to R. Rib area. Writer talked with DON about res c/o pain to this site writer was informed to get x-ray to make sure area was healing properly d/t resident having a previous fall that x-ray indicated that her 9/10 ribs were fx on right side. Resident denied any pain to touch upon assessment to area will con't to monitor for changes. On 12/24/2019 at 7:00 AM, a nurse's note documented, Resident c/o pain to R side, prn Tylenol administered did not complain of severe pain for rest of shift, as a professional this nurse did not believe necessary to further assess. On 12/25/2019 at 6:56 AM, a nurse's note documented, Resident c/o severe pain on the right side of her rib. vitals checked. BP-200/80, P- 58, O2- 96. Exchange called for physician, yet to hear from her. On 12/25/2019 at 2:22 PM, a nurse's note documented, Resident is hurting in upper and lower back area and rib cage area. resident POA here and wants resident sent to hospital, ok with physician to send resident to the hospital. On 12/26/2019 at 3:48 AM, a nurse's note documented, A hospital employee who is residents nurse called at 11:43 PM to inform us that resident has been admitted and will not be returning to the facility tonight. She also said resident has multiple broken ribs and internal bleeding. The Physician order [REDACTED]. The MDS, dated [DATE], documented R115 was identified as being severely cognitively impaired and required extensive assist of one staff for toileting; limited assist of one staff for transfers and walking; had a balance deficit and was occasionally incontinent of bladder. The care plan, dated 12/27/19, documented R115 was identified as being high risk for falls. The interventions dated 12/27/19 were to refer to therapy. On 10/08/19, it documented assist with reminders to use walker and wc; assist with proper fitting shoes and gripper socks. Remind to use call light. A Facility Event Summary Report, dated 10/08/19 at 2:40 PM, documented Daughter notified staff resident fell in room. Daughter stated she was making residents bed and thought resident was sitting in her recliner and heard her fall. Laceration to top of left eye, scratch with bruise to left arm. Neuro checks WNL. MD notified. Resident out with daughter. Educated daughter to ask for assist. Facility Event Summary Report, dated 10/28/19 at 2:51 PM, Resident observed in her bathroom on the floor. Resident was trying to go to the bathroom and said she got really weak and her legs gave out. Resident was incontinent of stool. Resident had no c/o's of pain at time of the fall. Resident is independent with mobility and wheeled walker. Resident c/o pain to left rib area on 10/30/19. X-ray obtained, and results revealed 9th and 10th rib fractures. MD and POA aware. Investigation sent to IDPH. On 10/20/20 at 11:30 AM, DON stated there was no investigation done for any falls in the month of December 2019. 3. On 10/01/20 at 2:07 PM R110 had her call light on stating she needed the bed pan. She stated she had just gotten back from the hospital where she had brain surgery. She could not remember how long she has been back at the facility. She stated she could not get up on her own and stated she had fallen in the past but could not remember when. R110's Face Sheet documents her [DIAGNOSES REDACTED]. R110's MDS dated [DATE] documents she is alert and oriented, requires extensive assist with transfers because she is not steady and only able to stabilize with staff assistance during transfers. R110's Care Plan for the problem labeled Falls documents R110 had a fall on 9/16/20 but does not include any new interventions regarding resident safety while being transported to or from the facility in the facility transport van. R110's Progress Note dated 9/16/20 at 11:30 AM documented: Nurse received notification from driver that resident had fallen backwards in her w/c (wheelchair) while he was driving her back to the facility. Resident was at a Doctor's appointment previously with Neurosurgeon regarding the [DIAGNOSES REDACTED] that was found at previous hospital stay and was returning back to the facility. Resident had a couple of small cuts and bleeding from the back of her head per driver, so he called EMS (Emergency Medical Services) to transport resident to the hospital. Driver also reported that he notified resident's daughter who is POA (Power of Attorney). R110's Event Report dated 09/16/20 documents, (R110) had an unwitnessed fall outside of the facility and injuries included laceration to the back of her head. The Event Report documents the Interdisciplinary Team (IDT) met to review the fall, and R110's Care Plan was reviewed and updated on 09/24/20, but R110 did not return from the hospital until 09/30/20. The Event Report did not include any assessment for the root cause of the fall or inspection of the seatbelts or fasteners that were not tight and allowed R110's wheelchair to fall backwards. R110's Care Plan was not updated with progressive interventions at the time of her fall or when she returned from the hospital. 10/13/20 02:22 PM V24 (Transportation Driver) stated on 09/16/20 he was bringing R110 back to the facility from an appointment and when he accelerated from a stop, R110 fell backwards in her w/c and hit her head. V24 stated when he first loaded R110 onto the van she was not at her usual baseline and was throwing herself back and forth in her w/c. He also stated he was not comfortable with the van he was driving, as it was a van from the sister facility, and the straps did not have a ratcheting mechanism he was used to that enabled him to tighten the straps. He stated he attached all four straps to the hooks on the floor to stabilize R110's w/c and he stated they were still attached after she fell backwards in her w/c. He stated he does not know why the straps did not stay tight and keep the w/c from tipping over backwards. He stated he had checked the straps when he first put R110 in the van to return her to the facility, and they were tight at that time. R110's Hospital Emergency Report dated 09/16/20 at 11:53 AM documents, She was seen at the Neurosurgery clinic earlier today and upon leaving by ambulance to transport her back to the nursing home her wheelchair was not secured and she fell while in the ambulance. V24 clarified she was being transferred back to the facility in a sister facility's transportation van. On 10/13/20 at 3:30 PM V1 (Administrator) provided a typed document signed by the administrator from the sister facility where the van had been borrowed from on 09/16/20 to transport R110. The document, undated, stated, On 09/16/20 an incident was reported that occurred in our van and a resident from (facility). At that time the seatbelts and fasteners were checked, and all were in proper working condition. V1 stated V24 had checked the seatbelts and fasteners at the time of R110's fall, and they were still attached so she does not know what happened. She stated the van did not have to be checked by the service department where it was purchased for faulty seatbelts because it was a brand-new van and there was nothing wrong with it. She was unable to state why the straps did not remain secure to prevent R110 from falling backwards when the van accelerated forward. On 10/20/20 at 11:30 AM, V2 (DON) stated there was no investigation done for any falls in the month of December 2019. She also stated that she was not employed by the facility during that time and was not aware of the incident that occurred on 12/23/19. She further stated that the staff that had documented in the nurse's notes were no longer employed by this facility. An attempt to get staff interviews regarding this incident was unable to be accomplished due to none of the current staff were employed at during this time period. This was verified by V1 and V2. The policy and procedure titled, Falls and Fall Risk, managing was reviewed. It documented under, Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls; 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Under, Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 5. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.

Based on interview and record review, the Facility failed to perform laboratory tests and administer high risk anticoagulant medication as ordered by the Physician for one of three residents (R113) reviewed for anticoagulant medications in the sample of 42. This failure resulted in R113 being hospitalized for [REDACTED]. Findings include: R113's Progress Notes dated [DATE] at 9:08 PM document she was transferred to the local hospital with a change of condition. R113's Death Certificate dated [DATE] documents R113 expired in the hospital on [DATE] with the [DIAGNOSES REDACTED]. R113's Face Sheet documents her [DIAGNOSES REDACTED]. R113's Minimum Data Set (MDS) schedule documents R113 was hospitalized from [DATE] to [DATE]. Her admission MDS, dated [DATE], which is her only MDS prior to discharge that included a cognitive assessment, documented she was alert and oriented. R113's Care Plan dated [DATE] documents: Problem: Altered cardio/vascular status related to [DIAGNOSES REDACTED]. The interventions include to do labs as ordered and administer medications as ordered. Per review of R113's electronic medical record, an Event Report dated [DATE] documents: Medication Error occurred on [DATE] at 3:44 PM. This report was initiated by V35 (Licensed Practical Nurse/LPN) who documented she completed a medication error report for (R113). The evaluation of the incident documents: Resident admitted to the hospital and placed on [MEDICATION NAME] drip. Nurse took verbal order for [MEDICATION NAME] and then did not place order on EMAR (Electronic Medication Administration Report). Education will be given to all nurses regarding the importance of PT ([MEDICATION NAME] Time)/INRs and proper [MEDICATION NAME] tracking. The Medication Error Report documents the description of the error as: Date error began: [DATE]; Correct order: [MEDICATION NAME] 4 mg daily; Orders were given to continue [MEDICATION NAME] and med was not given. R113's Progress Notes dated [DATE] at 10:10 AM documented her medical doctor (MD) was notified of critical lab results of INR, a test that along with PT, measures the time it takes blood to clot. Per this progress note, R113's MD gave an order for [REDACTED]. medication continued to be held on those days, and INR was to be repeated on [DATE]. Review of R113's progress notes document no new orders were documented related to R113's INR that was done on [DATE], and no additional INR was done on [DATE], [DATE] or [DATE]. There were no new orders to resume R113's anticoagulant medication. R113's progress note dated [DATE] at 10:55 AM documented, PT/INR results reported to MD office. R113's progress notes dated [DATE] at 11:13 AM document, Nurse from MD office called stating MD will have to be contacted due to INR being so low. R113's progress notes dated [DATE] at 2:12 PM document, MD office called back and requested (R113) be sent to hospital to be put on [MEDICATION NAME] drip to regulate blood viscosity. R113's Medication Administration Record [REDACTED]. R113's Hospital History and Physical Report dated [DATE] documents, Chief Complaint: Subtherapeutic INR (International Normalized Ratio). (R113) is a female with multiple medical problems to include [MEDICAL CONDITION] on [MEDICAL TREATMENT], [MEDICAL CONDITIONS], valvular [MEDICAL CONDITION] status [REDACTED]. (R113) apparently has not been receiving her [MEDICATION NAME] since sometime last week for reasons unclear to the patient. I asked if she inquired why her [MEDICATION NAME] was being held, and she tells me, 'I just trust that they know what they are doing.' She is now having to be admitted for [MEDICATION NAME] drip given the presence of mechanical valves. R113's Hospital Discharge Instructions dated [DATE] document: To continue daily PT/INR draws with results to (Cardiologist's) office in order to monitor her closely. This patient's INR drops quickly and it is important for orders for lab draws and medications to be followed appropriately in order to prevent adverse events such as a stroke or bleeding. On [DATE] at 11:15 AM per phone interview, V2 (Director of Nursing) stated she did review R113's medication error that occurred on [DATE], but could not understand exactly what happened, and none of the staff who were involved are employed by the facility anymore. V2 stated if a medication error occurs the facility follows the policy and procedure and notifies the resident's family and physician and follows out whatever orders are given. She stated the facility staff use a PT/INR machine now to perform labs and report the results to the MD for orders regarding [MEDICATION NAME] dose. V2 stated she does not know that there is a specific policy or procedure regarding high risk medications and double-checking orders, but she personally tracks residents who are on [MEDICATION NAME] to ensure the nurses are following through on the lab and MEDICATION ORDERS FOR [REDACTED] The facility's policy, Adverse Consequences and Medication Errors revised [DATE], documents: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. 12. In the event of a significant medication-related error or adverse consequences, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: b. Requiring hospitalization or extending a hospitalization .

Based on interview and record review, the facility failed to assess, monitor, and timely treat resident's pain and potential injury after a fall for 1 of 1 residents (R2) reviewed for pain in the in the sample of 5. This failure to assess R2's increased pain resulted in the delay of [DIAGNOSES REDACTED]. Findings include: R2's Physician order [REDACTED]. R2's physician's orders [REDACTED]. R2's Care Plan, dated 07/04/2019, documents, Meds as ordered and notify dr. (doctor) of unrelieved pain. R2's Care Plan, dated 07/14/2019, documents, doc (document) falls, bruises, skin tears and c/o (complaints of) pain new onset. R2's Minimum Data Set (MDS), dated [DATE], documents that R2's cognition was severely impaired and that she required supervision and set up help with walking in her room, the hallway and to and from the dining area and activities. On [DATE]20 at 9:15 AM, R5, R2's roommate, stated She (R2) was getting up, out of bed and she fell on to the floor. She got herself back up. She walks all the time with her walker. R5 stated that the incident with R2 happened a couple of days before Christmas. On [DATE]20 at 2:40 PM, V9, Certified Nurse Assistant (CNA), stated that on 12/23/2019 around 12:00 PM, he reported to V6, Licensed Practical Nurse (LPN), that R2 told him that she had fallen that morning, and was having pain to her right side. V9 stated that he observed a bruise area to R2's right upper back. On [DATE]20 at 12:00 PM, V6, LPN, stated, The CNA told me, that day, that she (R2) fell . The A hall nurse was not around, so I went to check on her to see if she didn't need to go to the (emergency room ) or was bleeding or anything, and she was ok as far as I could tell. I let the A hall nurse know (V11, LPN). V6 continued, I was busy with my hall, so I just looked at her and did not really assess her. On [DATE]20 at 3:55 PM, V11 stated that she and V7, LPN, were at the nurse's station when they were both told by V6, LPN, that R2 had fallen and was in pain and that she (V6) went and checked on her. V11 statedV6 told them R2 was fine. On [DATE]20 at 3:05 PM, V10, CNA, stated, She (R2) asked me, on 12/23/2019 around lunchtime, to help her walk to the bathroom because she fell earlier that morning and that's why she was in pain. I told (V7) about it. On 1/08/2020 at 10:45 AM, V5, CNA, stated I worked afternoons on December 23rd. When I checked on (R2) around 2:30 (PM), she was crying, saying she was in pain and short of breath. She was holding her right side like her upper abdomen. I told (V6) and (V7) and (V7) told me an x-ray was ordered. On [DATE]20 at 11:45 AM, V7 stated that neither CNAs or V11 told her during report, that R2 had fallen the morning of 12/23/2019. V7 stated that R2 did not tell her that she had fallen and all R2 told her was that she was hurting so bad. V7 stated that she talked to V2, Director of Nurses and V2 told her to get an x-ray for R2. R2's Resident Progress Notes, dated 12/23/2019 at 3:29 PM, written by V7 documented, Resident (R2) is (complaining of) pain to right side rib area. Called and (received) orders to get x-ray of area. Writer called (mobile x-ray company) to give orders for x-ray they will be out today. Writer also called daughter and made her aware and will call with results to her. There was no documentation V7 offered R2 pain medication or reassessed R2 for pain. R2's December 2019 Medication Administration Record [REDACTED]. On [DATE]20 at 2:10 PM, V8, LPN, stated, I took over for (V7) on A hall on 12/23/2019 around 3:15 (PM), but (V7) left before I got here. (V6) told me that they were waiting on x-ray for (R2) but did not tell me why or what happened to (R2). I left at 10:00 PM and the results of (R2's) x-ray was not back yet. When I came back to work, on December 24th at 6:00 AM, (R2) was complaining of right sided pain. I gave her Tylenol and she didn't complain the rest of the day about it, but I did not ask her after I gave it to her if she continued to have pain. R2's X-ray report, dated [DATE] at 11:24 PM documents she had no fractures. R2's Resident Progress Notes, dated 12/24/2019 at 7:00 AM, documented, Resident (complained of) pain to (right) side. (As needed) Tylenol administered did not complain of severe pain for rest of shift, as a professional this nurse did not believe necessary to further assess. R2's December 2019 MAR indicated [REDACTED]. R2's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There was no documentation in R2's Progress Note that facility reassess R2's pain or the efficacy of her pain medication after it was administered. R2's Resident Progress Notes, dated 12/25/2019 at 6:56 AM, documented, Resident (complains of) severe pain on the right side of her rib. Vitals checked. (blood pressure) 200/[AGE], (pulse) 58 and (Oxygen saturation) 96. Exchange called for (V12, Medical Doctor) yet to hear from her. R2's Resident Progress Notes, dated 12/25/2019 at 2:22 PM, documented, Resident is hurting in upper and lower back area and rib cage area. Residents (Power of Attorney) here (R2's daughter) wants resident sent to hospital. Ok with (V12, Medical Doctor) to send resident to (local hospital). There was no documentation from 6:56 AM through 2:22 PM the facility was assessing R2's pain or attempted to contact V12 of R2's increased pain. R2's History and Physical from (local hospital), dated 12/25/2019, documented, HPI (History of Present Illness) narrative: (R2) is 90 (year old) female who presents to the (Emergency department) via (Emergency Medical Services) from (Nursing home) secondary to fall that happened 2 days ago. (R2's) daughter states that (R2) had a fall 3-4 weeks ago and (R2) had an (x-ray) that showed 2 (left) rib (fractures). (R2's) daughter saw her Friday (5 days ago) and (R2) was able to walk with her walker in no pain. (R2's) daughter called the (nursing home) yesterday (12/24/2019) and the (patient) was complaining of pain but she (R2's daughter) could not see her until today (12/25/2019). When she (R2's daughter) saw her today the (R2) was doubled over on the side of the bed (complaining of) pain and she could not sit up straight. (R2) reports (right sided) (Abdominal) pain and back pain. (R2) states that she fell out of bed 2 days ago because her foot got stuck in her covers. (R2) states that she was able to get back up on her own. (R2) notes that she probably hit her head during the fall. (R2 reports intermittent neck pain, back pain, and a (Headache). R2's Computed tomography (CT) scan report from (local hospital), dated 12/25/2019, documented, Impression: 1. Multiple acute right rib fractures including the eighth to 11th ribs. There is a small right pleural effusion/Hemothorax. 2. Small pericardial effusion. On [DATE]20 at 4:20 PM, V2, DON, stated that she would expect her nurses to assess, monitor and start an investigation when a CNA reports that a resident has fallen or is in pain. V2 also continued state that she would expect the nurses to reassess a resident if they were given pain medication. On 0[DATE]20 at 9:05 AM, V12 Medical Doctor (MD), stated that she had not received a call about R2 on 12/23/2019 from the nursing home but she was called on 12/25/2019 by the nursing home about R2 and that she ordered an x-ray. V12 continued to state that she would expect the nurses to call her if a resident is having increased pain and shortness of breath. V12 also stated that this would be harm only if R2 was having breathing problems. The facility's policy, Acute Condition Changes -Clinical Protocol, dated March 2018, documents In addition, the nurse shall assess and documents/report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level. It continues, 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. The Policy documents 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. a. Phone call to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status.

Based on observation, interview, and record review, the facility failed to timely reposition 1 of 4 residents (R54), reviewed for pressure ulcers in a sample of 35. This failure resulted in R54 acquiring an open area to his scrotum. The facility also, failed to treat pressure ulcers per Physician order [REDACTED]. Findings Include: 1. On 04/17/19 at 10:30AM, R54 was lying on his back in bed, with 2 incontinent pads underneath him with a draw sheet lying under the incontinent pads. No positioning devices were noted on the bed nor under R54's body. V7, Registered Nurse (RN)/Wound Nurse, and V13, Certified Nursing Assistant (CNA), assisted R54 with rolling onto his right side. As R54 was positioned, onto his right side, there were red and white linear deep creases extending from his left mid back down extending down to his left mid-thigh area. There were copious amounts of dried stool noted to his buttocks, extending down to the middle of his bilateral thighs. On top of the dried stool was a large amount of soft stool noted to the rectal area. After V13, CNA, performed incontinent care, R54 was noted having 2 pressure ulcers to his left ischium and a open wound noted to his scrotum, that was bleeding. V7, RN, stated, she was not aware of the new area to R54's scrotum and would classify the area as open wound with drainage. V7, RN, measured the wound and found it to be 0.3 centimeters (cm) in length by 1 cm in width, and 0.2 cm in depth. V7 stated, it was a Stage 2 pressure ulcer. V7 further stated, the open area to R54's scrotum appeared to be shearing, at which time R54 asked V7, How can it be shearing, if there's a draw sheet under me? V7 did not respond to R54's question. After, V7 applied treatments to R54's left ischium, she stated, she was going to call the Physician to obtain an order for [REDACTED]. There was a pressure ulcer to his right ischium. V7, RN, measured the wounds and found them to be 10 cm by 14 cm and not blanchable. On 04/17/19, at 10:30AM, after receiving wound treatment to his pressure ulcers, R54 stated he hadn't been checked on or turned since yesterday (04/16/19) afternoon; they (the facility) don't answer my call light, that was on for over an hour and a half last night. R54 further stated, his dressing changes aren't done timely to his pressure ulcers. Face Sheet dated 04/22/19, document R54 was admitted to the facility on [DATE]. The face sheet also, documents R54 having Neuromuscular Dysfunction of the Bladder, Stage 4 pressure ulcers to his right and left buttocks, having [MEDICAL CONDITION], C5-C7 Complete, and a [MEDICAL CONDITION]. R54's Minimum Data Set (MDS), dated [DATE], documents R54 having a Brief Interview Mental Status (BIMS) score of 14, indicating cognition intact. The MDS further documents R54 being totally dependent on staff for all Activities of Daily Living (ADLs). R54's Care Plan dated 03/05/19, documents R54 being at high risk for abnormal muscle tone on his bilateral lower extremities. R54's Care Plan further documents for R54: Check every two hours and prn (as needed), for incont (incontinent) of bowel and need total assist with incont care. Pressure Ulcer Risk assessment dated [DATE], documents R54 scoring a 7, indicating a very high risk for skin breakdown. The facility's Wound Report fails, to list the measurements of R54's open area to his scrotum at the time of treatment on 04/17/19. Pressure Ulcer Wound Sheet report dated 04/09/19, documents R54 having Stage IV-Full Thickness loss with exposed bone, tendon or muscle. Sough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The wound sheet further documents R54 having the following measurements: 3 centimeters (cm) by 9 cm by 1 cm in depth, having undermining, with a large amount of serious exudate, with the surrounding skin having maceration. The current treatment, per the wound sheet, documents: Normal Saline/Wound Cleanser, Cleanse, pack with Santyl, and calcium alginate, cover with gauze and dry dressing, change daily and PRN (as needed). The report also, states that R54 has a low air loss mattress. On 04/22/19, at 2:28PM, V2, DON, stated the facility does not have wound measurements from when V7, RN, performed the treatment to R54's wounds with surveyor present on 4/17/19, and that she (V7) didn't write them down, and we (facility) was not aware of the new area to R54's scrotum until you (surveyor) pointed it out to her (V7). On 04/22/19 2:59PM, V18, R54's Nurse Practitioner, would expect R54 to have been turned and repositioned at least every 2 hours given R54 is a quadriplegic. On 04/24/19 at 9:21AM, V29, Medical Director and R54's Physician, stated she would have expected R54, to have been turned and repositioned per facility protocol, given the extent of his wounds and condition. V29 further stated, she would have expected to have R54's open area to his scrotum to have been documented in R54's Clinical Record. 04/23/19 at 2:45PM V2, DON, stated the expectation is for staff to turn and position anyone dependent on care, especially R54, given his condition and being a [MEDICAL CONDITION], and being admitted with Stage 4 pressure ulcers. V2 further stated, R54's Physician called the open area to R54's scrotum as maceration, and if the area is macerated, that means R54 is more susceptible to pressure ulcers. 2. On 04/16/19 at 10:50 AM, V7, RN, stated R234's pressure ulcer started out as moisture and shearing and the next day it was an open area with necrotic tissue. V7, RN, stated the facility sent him out to the hospital to have the area debrided and he came back last week and had a wound vac. V7 removed R234's left ischial pressure ulcer dressing and observed a Stage 4 pressure ulcer measuring 2.0 centimeters (cm) x 4.0 cm x 3.5 cm. On 04/17/19 at 1:08PM, R234 stated, I found out my (pressure relieving cushion) was not blown up, it was flat. My cushion not having air in it could have helped me get the pressure ulcer. I'm up a lot in my wheelchair and I don't want to lay down all the time. The head person in Therapy pumped up the cushion when we found out it was flat. I found out my (pressure relieving cushion) didn't have air in it right when I got this pressure ulcer. On 04/22/19 at 1:50PM, V32 Therapy Manager/Coordinator, stated, I have put air in (R234's) cushion a couple times before. If there wasn't enough air in the cushion, he would be sitting on a metal plate that's inside the cushion. The only way air could get out of the cushion is if there was a leak or if someone let it out with the pump. I don't know who's supposed to check for air in the cushion, I supposed it's to be the CNA's. Electronic Medical Record, (EMR), for R234, dated 04/18/19, documents, [DIAGNOSES REDACTED]. Weekly Nursing Skin Assessments, for R234, dated 03/22/19, documents in part a new area Right thigh (rear) Schering (sic) approx. (approximately) 3.0 x 2.0 x 0.1 cm, surrounding skin normal denies pain. Weekly Nursing Skin Assessments, for R234, dated 03/29/19, documents, new area UTD (unable to determine) ulcer necrotic eschar/slough covering wound bed, odor present, moderate yellow drainage, denies pain, peri wound white unbleachable, 6/2 x 4.4 x UTD cm resident sent to hospital for evaluation. Nurses Notes for R234, dated 03/29/19, documents as follows: 03/29/19 11:07AM received order to obtain wound culture(cx) of wound to buttocks. 3:44PM obtained order received to send to Hospital ER (emergency room ) for Eval. (Evaluation) and treatment. Hospital Report, for R234, dated 03/29/19, documents, Buttock, Debrided Tissue Left Decubitus Ulcer. Care Plan for R234, dated 04/19/19, documents, I am at risk for skin breakdown r/t (related to) impaired mobility, bowel incontinence, dx (diagnosis) [MEDICAL CONDITION] Interventions *pressure relief mattress on bed and pad in chair MDS for R234, dated 01/22/19, documents R234's BIMS score as 15, indicating cognition intact. R234's Functional Status for bed mobility and toileting documents R234 being totally dependent on staff and requires extensive assistance of two persons for transfers. The MDS further reports, R234 being incontinent of bowel and having an indwelling catheter. Manufactures guidelines documents, (pressure relieving cushion) (dated 2013) documents: Note: DO NOT sit on an improperly inflated cushion. under-inflated and over inflation of the cushion sections reduce or eliminate the cushion's benefits and could increase risk to the skin and other soft tissue. The cushion is most effective when there is 1/2 inch (1.5 cm (centimeters)) to 1 inch (2.5 cm) of air between the user's bottom and the seating surface. 3. R27's wound sheet dated, 04/12/19, documents, R27 has a Moisture Associated Skin Damage (MASD) to coccyx/sacral area, date of onset 11/21/18. Measurements on 04/12/19 are 1.5 cm X 0.3 cm X 0.1 cm. R27's Braden score dated 02/21/19, documents R27 scoring 14, indicating moderate risk for skin breakdown. R27's MDS dated [DATE], documents a BIMS score of 15, indicating cognition intact. R27's Physician order [REDACTED]. R27's care plan dated, 02/12/18 documents, Focus: I am at risk for skin breakdown, related to impaired mobility, bowel and bladder incontinence, [MEDICAL CONDITION]. Interventions include, administer my treatments as ordered. On 04/15/19, at 11:12AM, R27 stated, My dressing is not on, they are not putting dressings on it anymore. 4. On 04/16/19, at 2:40PM, V19, CNA, and V20, CNA, assisted R62 to the bathroom. V19 removed R62's soiled disposable brief and no dressing was on R62's pressure ulcer to the sacrum. R62's Pressure Ulcer Wound Sheet, dated 04/10/19, documents, Onset of pressure ulcer 04/10/19, site left sacrum, acquired in house, stage 2, measurements 2 cm X 0.5 cm X 0.1 cm. R62's Braden Score, dated 11/28/18, documents 15 (at risk). R62's MDS dated [DATE] documents, R62's BIMS is 8 (moderately impaired). R62's Physician order [REDACTED]. R62's Care Plan, dated 04/10/19, documents, Focus: Open area stage 2 noted on sacrum, Interventions: Treatment to sacrum as ordered. On 04/16/19, at 3:20PM, V7 Wound Nurse stated, The dressings should be on, I should be notified if it comes off, and I wasn't. Facility policy entitled Pressure Ulcer/Skin Breakdown-Clinical Protocol, revised on (MONTH) (YEAR), documents, Assessment and Recognition. 1. The nursing staff will assess and document significant risk factors for developing pressure ulcers. 2. The nurse will describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Facility policy entitled Turning a Resident on his/her side away from you, revised (MONTH) 2010, documents, Purpose. The purposes of this procedure are to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment.

Based on interview and record review, the facility failed to provide Range of Motion (ROM) exercises to 4 of 7 residents (R15, R59, R72, R78) reviewed for ROM, in a sample of 35. This failure resulted in R59 and R72 having a decline in Range of Motion. Findings Include: 1. R59's Face Sheet dated 4/23/19, document, R59 having a contracture of her right hand, right ankle, and left ankle. Minimum Data Set ((MDS) dated [DATE], documents R59 being totally dependent on staff for Activities of Daily Living (ADLs). The MDS further documents R2 having functional limitation in Range of Motion with impairment to her bilateral upper and lower extremities. R59's Care Plan dated 3/28/19, documents R59 being on a Restorative program for Active Range of Motion (AROM) due to having [DIAGNOSES REDACTED]. The Care Plan further, documents R59 having a goal and interventions as follows: Goal: Seated therapy exercises times 20 repetitions in all directions. Reaching for cones times 5, forwards, laterally, crossing midline and up. Interventions include: to document daily compliance, progress towards meeting goals, notify nurse if she experiences declines in her ability to complete AROM tasks and to record the minutes of task completed. The intervention also, includes, (R59) Seated there (therapy) ex (exercises) 1.5-2# AROM x (times) 15 reps (repetitions). Reach for cones 2 x fwd (forward), laterally, crossing midline and up. R59's Physical Therapy Plan of Care with a start of care date of 10/31/2018, documents, Functional Deficit Other. LLE (left lower extremity) ankle plantarflexion contracture -36 (negative) degrees from neutral reports R (right) foot hurts more than L (left) at times reports discomfort in back of (sic) calf when stretching with too much intensity. The Plan of Care further documents, Goal Patient (R59) will improve LLE ankle plantarflexion contracture to -26 degrees from neutral and RLE ankle plantarflexion contracture -9 degrees from neutral. R59's Rehabilitation Screen dated 4/17/19, completed by V33, Physical Therapist, documents that R59 has shown a decline in ROM. The Screen further documents, Comments/Recommendations: RLE (right lower extremity) plantar flexion -43 (degrees) and LLE Plantarflexion -55 (degrees). On 4/16/19 at 10:25 AM, R59's daughter stated, her mother Isn't getting any restorative ROM, she hasn't been getting that for a long time. 2. MDS dated [DATE], documents R72 having a Brief Mental Interview Status (BIMS) score of 15, indicating cognition intact. The MDS further documents R72 having impairment on both sides of his upper and lower extremities and requiring extensive assistance. Care Plan undated, documents R72 being on a Restorative Program as follows: Focus I have impaired mobility related to decreased strength and endurance. Goal. ROM to both hands times 10 repetitions 7 days a week. R72's Physical Therapy Plan of Care with a start of care date of 9/04/2018, documents that R72 has a contracture to his right hand and that the long term goal is for R72 to improve from -55% extension of his right 2nd Metatarsophalangeal (mp), -70 degrees to his right 3rd mp, -72 degrees his right 4th mp, and -65 degrees his right 5th mp to increase within normal limits (wnl) of the left. The goal date was for 9/24/18. R72's Rehabilitation Screen dated 4/17/19, documents R72 having a decline in the following digits: right 3rd mp -80 degrees, right 5th mp -90 degrees. On 4/15/19 02:40 PM, R72 stated he does get walked, but denies receiving ROM to his bilateral hands, and the facility doesn't have a restorative aide. 3. Face Sheet dated 4/23/19, documents R78 having a contracture of her right hand. Care Plan initiated on 1/18/2018 and revised on 3/6/19, documents, Restorative level 1: at risk for decreased strength, endurance, and ADLs, related to [MEDICAL CONDITIONS] and Dementia. The Care Plan lists R78 having the following interventions: Nurse to review program routinely and address residents progress toward meeting goals. PROM to r (right) hand 3-5 reps before applying splint in the am (morning). Record minutes of task completed in the P[NAME] (plan of care). Occupational Therapy Plan of Care for R78, dated 12/28/18 documents in part the reason for the referral being, history of right-hand contracture impacting the patient's (R78) ability to perform self-care. The Occupational Therapy Plan of Care further documents, (R78) will improve muscle strength to 4-5 good minus (full ROM against gravity and minimal resistance) in order to self-feed. MDS dated [DATE], documents R78 requiring extensive assistance with dressing and eating. The MDS also, documents R78 having Function Limitation in Range of Motion, with impairment to her upper extremity on one side and impairment to her bilateral lower extremities. The MDS further documents R78 having a BIMS score of 11, indicating moderately impaired cognition. Rehabilitation Screen for R78, dated 4/17/19, documents, R (right) 2nd mp (Metatarsophalangeal) -30 degrees, 3rd mp -65 degrees, 4th mp -75 degrees, 5th -25 degrees. The facility failed to provide a prior Rehabilitation Screen for R78. On 4/16/19 09:10 AM V2, Director of Nursing (DON) stated that the facility has had some concerns with getting a Restorative Aide and in the past the facility had 2 aides, including weekends, but that one aide went on leave of absence and the other aide quit. V2 further stated that V5, Restorative Nurse, has been doing restorative 5 days per week, but No, Restorative won't be done until we get the other person hired. On 4/17/19 at 12:30 PM, V5, Restorative Registered Nurse stated restorative ROM was done up until (MONTH) 18, 2019 when the restorative aide quit. V5 further stated, I had no help, everyone was being pulled to the floor. I can't do it all by myself. I didn't verify that ROM was being done. On 4/24/19 at 9:21AM, V29, Medical Director, stated she would expect the facility to follow their policy with regard to Range of Motion and Restorative programing to for the prevention of contractures or further decline in contractures. 4. R15's Care Plan dated 4/10/19 documents that R15 is at a Restorative level 2 and is at risk for decline in joint mobility. The care plan further documents R15's interventions to include passive range of motion to all joints for 5-10 repetitions as tolerated BID. The Facility Restorative Daily Attendance record fails to document R15 receiving any services. On 4/17/19 at 12:30 PM V5, Restorative Nurse, stated she has done Passive Range of Motion (PROM) on R15, but not daily, and states CNA's are supposed to do it also. R15's Rehabilitation Screen dated 4/17/19, documents R15 having ROM deficits as follows: right 2nd mp -30 degrees, right 3rd mp -65 degrees, right 4th mp -75 degrees, and right 5th mp -25 degrees. R15's Occupational Therapy Plan of Care dated 12/28/18 provided by the facility, does not list any ROM deficits for R15's Metaphalangeals. Facility Policy entitled Resident Mobility and Range of Motion, revised on (MONTH) (YEAR), documents in part, Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. The policy further documents in part, 8. Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. Facility Policy entitled Range of Motion Exercises, revised (MONTH) 2010, documents in part that the purpose of the ROM exercises is to exercise the resident's joints and muscles. The Policy further documents in part, Documentation. 1. The date and time that the exercises were performed. 2. The name and title of the individual(s) who performed the procedure. 3. The type of ROM exercise given. 4. Whether the exercise was active or passive. 5. How long the exercise was conducted. 6. If and how the resident participated in the procedure of any changes in the resident's ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the exercises. 2. Report other information in accordance with facility policy and professional standards of practice. Facility Policy entitled Resident Mobility and Range of Motion, revised (MONTH) (YEAR), documents in part, Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. 8. Documentation of the resident's progress toward the goals and objectives will include to address any changes or decline in the resident's condition or needs.

Based on interview and record review, the facility failed to immediately inform the resident's physician and family representative of repeated falls resulting in a significant change in condition for one of three residents (R101) reviewed for falls in a sample of 15. This resulted in a delay of treatment for [REDACTED]. Findings include: 1. On 6/29/18 at 8:34pm, a progress note in Electronic Health Record (EHR) entered by V8 Licensed Practical Nurse (LPN) documents Resident on the floor on top of the mat in an upright sitting position. ROM (range of Motion) to upper and lower extremities. Denies any pain or discomfort. Told writer he had to (have a bowel movement), informed Certified Nurse Aide (CNA). Will continue to monitor. There is no reference that V8 notified the physician or R101's family representative, V5, of this fall. On 7/5/18 at 2pm, V8 stated V8 did not report the fall to the oncoming nurse, V6, Registered Nurse (RN) nor did V8 notify R101's spouse or R101's physician, V4, of the fall. V8 stated V8 had been employed by the facility for approximately 3 months. On 6/30/18 0/18 at 12:30am, V6 (RN) documented in the Progress Notes upon rounds, observed resident lying on the floor on back. Resident very confused. (R101's) spouse had called requesting cell phone be put out of reach due to resident being confused and calling (R101's) spouse and not saying anything. Resident's neuro's (neurological checks) wnl (within normal limits) for resident. Resident c/o (complained of) left hip pain. No inward or outward rotation noted and no shorting of leg noted. Call placed to Dr V4 received order for portable left hip xray. (R101's) spouse also notified. Resident continues to confused. Placed on (full body mechanical lift) pad and assisted back to bed via (full body mechanical lift. On 7/6/18 at 9:38am, V6 stated V6 called V4 (Physician) and also left a message for V5, R101's spouse. V6 stated V5 returned V6's call around 5:45am that morning and V6 told V5 that R101 had fallen a couple times then. V6 stated it was the first night V6 worked by V6's self and V6 didn't know how to process the Xray order. V6 stated V6 called V16, LPN/Nurse Manager, who told V6, V16 would notify the Administrator (V1) and Director of Nurses (V2) in the morning but gave V6 no help in getting the portable xray ordered. V6 stated V6 did not call Hospice either. V6 stated R101 fell again just as V6 was finishing V6's shift between 6am -7am on 6/30/18. On 6/30/18 at 6am, V6 again documents in to the progress notes resident on floor a second time. Remains confused. Assisted to w/c (wheelchair) no noted abrasions to right elbow. Area cleansed and dressed. No c/o pain at this time. Neuro's wnl for resident. There is no documentation that Hospice, V4 Physician and/or R101's wife was notified of this fall. Hospice records signed by V12 RN dated 6/30/18 (no time) document R101 to have fall x (times) 3 < (less than) 12 hours unable to bear weight and under Summary, called due to pt falls. V12 documented pt c/o pain in R (right) hip post fall and that staff and POA instructed in pt safety and notify Hospice of xray results. The note documents the V4 was notified and an order received for [MEDICATION NAME] and to give the PRN [MEDICATION NAME] along with an order for [REDACTED].>At 12pm on 6/30/18, V11 LPN documented resident found on floor laying face up with head and body on beside mat. Continues to talk randomly about needing a hammer to get out of the closet. Hospice RN (V12) here at this time. MD aware. New orders obtained to increase [MEDICATION NAME] dosage due to increased pain and to give PRN [MEDICATION NAME] due to Hallucinations. POA (power of attorney)/Spouse aware. At 12:15pm on 6/30/18, the progress notes document the portable xray company was notified of the order for a left hip and pelvic xray and at 2:15pm, two hours later, xrays were documented as completed. A Patient Report dated 6/30/18 documents R101 to have a mildly displaced left femoral neck fracture with superior displacement of the distal component. At 1630 (4:30pm,) the V11 documents New orders to send resident out to (hospital) for L (left) [MEDICAL CONDITION]. POA aware, Administrator aware, Resident currently resting in bed at this time. No c/o pain at this time. On 7/3/18 at 2pm, V1 Administrator, stated V1 had identified issues/concerns with R101's falls and follow up and did V1's own investigation which V1 provided entitled Nurse Education. The Nurse Education report provided by V1, Administrator, on 7/3/18 documents under the subtitle Accidents/Incidents, documents physician, resident's responsible party, Administrator and Director of Nurses (DON) must be notified of all falls regardless of injuries in part. The Hospice Nurse V12 stated on 7/5/18 at 12:43pm that she was on call for the regular nurse who visited R101 and recieved a call around 9:30am on 12/30/18 from the facility reporting R101 having hallucinations and multiple falls. On 7/6/18 at 10:20am, V4 Physician stated V4 was called after the fall at 12:30am on 6/30/18 and then again by Hospice later in the day and gave an order for [REDACTED]. V4 stated V4 depends on the nurses to be V4's eyes and ears and asssess the residents then contacts V4 or Hospice for orders. The facility's policy/procedure entitled Change in a Resident's Condition or Status (undated) document the policy as Our facility shall promptly notify the reident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. change in level of care, billing/payments, resident rights, etc. Under Policy for Interpretation, it documents The nurse suprevisor/change nurse will notify the resident's attending physician or On-Call Physician when there has been: a. An accident or incident involving the resident, e. a significant change in the resident's physical/emotional/mental condition; f. a need to alter the resident's medical treatment significantly; h. a need to transfer the resident to a hospital/treatment center; in part. Under the policy, it documents unless otherwise instructed by the resident, the Nurse Supervisor/Charge nurse will notify the resident's family or representative (sponsor) when: a. The resident is involved in any accident or incident that results in an injury including injuries of unknown source; b. There is a signficant change in the resident's physical, mental or psychosocial status; in part.

Based on interview and record review, the facility failed to adequately identify, assess, monitor and treat a significant change in condition following repeated falls for one of three residents (R101) reviewed for falls with injury in a sample of 15. This failure resulted in increased pain and the adminsitration of antipsychotic medication. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R101 to be a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents R101 to have moderate cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 12 who requires extensive assist of one for bed mobility, extensive assist of two for transfers. The (MONTH) (YEAR) physician's orders [REDACTED]. The POS also documents [REDACTED]. On 6/29/18 at 8:34pm, a progress note in EHR entered by V8 Licensed Practical Nurse (LPN) documents Resident on the floor on top of the mat in an upright sitting position. ROM (range of Motion) to upper and lower extremities. Denies any pain or discomfort. Told writer he had to (have a bowel movement), informed Certified Nurse Aide (CNA). Will continue to monitor. On 6/30/18 at 12:30am, V6 Registered Nurse (RN) documented in the Progress Notes upon rounds, observed resident lying on the floor on back. Resident very confused. (R101's spouse) had called requesting cell phone be put out of reach due to resident being confused and calling (spouse) and not saying anything. Resident's neuro's (neurological checks) wnl (within normal limits) for resident. Resident c/o (complained of) left hip pain. No inward or outward rotation noted and no shorting of leg noted. Call placed to Dr V4 received order for portable left hip xray. (R101's spouse) also notified. Resident continues to confused. Placed on (full body mechanical lift) pad and assisted back to bed via (full body mechanical lift. There is no documentation that the xray was ordered or that R101's pain was assessed and treated. The next entry into the progress notes is 1 ½ hours later at 2am on 6/30/18 by V6 RN and documents only continues to be confused and restless. Neuro checks wnl for resident but fails to address R101's prior complaint of left hip pain and/or any additional physical assessment to determine if injury did occur. The progress notes dated 6/30/18 at 6am entered by V6 again documents resident on floor a second time. Remains confused. Assisted to w/c (wheelchair) no noted abrasions to right elbow. Area cleansed and dressed. No c/o pain at this time. Neuro's wnl for resident. Again, no physical assessment is documented nor is any documented toward his prior complaints of pain and no evidence that the order for the xray was processed. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Hospice records signed by V12 RN dated 6/30/18 (no time) document R101 to have fall x (times) 3 < (less than) 12 hours unable to bear weight and under Summary, called due to pt falls. V12 documented pt c/o pain in R(right) hip post fall and that staff and POA instructed in pt safety and notify Hospice of xray results. An EMAR (electronic Medication Administration Record) note dated 6/30/18 at 10:34am documents [MEDICATION NAME] (concentrate) Solution 20mg(milligram)/ml (milliliter) Give 0.25mg sublingually every 4 hours as needed for pain/SOB (shortness of breath) (5mg) was given and confirmed by documentation on the MAR. The progress notes fails to include an assessment of R101's overall condition and/or complaints of pain including the intensity and location of pain. The next entry is at 12pm on 6/30/18 when V11 LPN documented resident found on floor laying face up with head and body on beside mat. Continues to talk randomly about needing a hammer to get out of the closet. Hospice RN (V12) here at this time. MD aware. New orders obtained to increase [MEDICATION NAME] dosage due to increased pain and to give PRN [MEDICATION NAME] due to Hallucinations. POA (power of attorney)/Spouse aware. Assisted back to bed at this time. Call light within reach. Educated in regards to bed safety and voices understanding. Will continue to monitor Again, no evidence the nurses physically assessed R101 for injuries from his falls. At 12:15pm on 6/30/18, the progress notes document the portable xray company was notified of the order for a left hip and pelvic xray and at 2:15pm, two hours later, xrays were documented as completed. The progress notes dated 6/30/18 at 15:57 (3:57pm) document Hospice was notified of xray results, awaiting new orders from MD. At 1630 (4:30pm,) the V11 documents New orders to send resident out to (hospital) for L (left) [MEDICAL CONDITION]. POA aware, Administrator aware, Resident currently resting in bed at this time. No c/o pain at this time. The progress notes dated 6/30/18 document R101 was transported to the emergency room at 8pm. Hospital History and Physical dated 7/1/18 documents R101's assessment revealed Left Intertrochanteric fracture of femur. On 7/6/18 at 9:38am, V6 confirmed V6 called V4 (Physician) after (R101's) fall at 12:30am on 6/30/18 and an order for [REDACTED]. V6 stated V5, R101's (spouse) returned V6's call around 5:45am that morning and V6 told V5 that R101 had fallen a couple times then and would be getting an xray done. V6 stated R101 fell again just as V6 was finishing V6's shift between 6am -7am. V6 confirmed R101 had complained of left hip pain following the fall and didn't reassess V6 for injuries after that time. On 7/5/18 at 1:30pm, V11 LPN stated V11 came in at 6am on 6/30/18 and R101 was in R101's wheelchair at the nurse's station when V11 first saw R101. V11 stated V11 had been told by V4 that R101 had a couple of falls during the night but had no injuries. V11 was not aware an order for [REDACTED]. V11 knew R101 was on an antibiotic for a Urinary tract infection and that R101 usually hallucinated when R101 had a UTI so V11 didn't think of anything other than that to cause R101's confusion.V11 stated V11 called Hospice around 730am to 8am to inform them of the falls and discuss a medication, [MEDICATION NAME], for R101's hallucinations. V11 stated prior to Hospice V12 RN arriving, they had put R101 back to bed using a full body mechanical lift. V11 stated V11 had not assessed R101 physically or for pain before calling Hospice. V11 stated Hospice arrived later that morning and assessed R101, and at 12pm, she was notified that R101 had fallen out of bed again. V11 stated V12 notified the physician and received an order for [REDACTED]. On 7/6/18 at 12:30pm, V18 Certified Nurses Aide (CNA) stated V18 came on at 6am and R101 was on the floor. V18 stated R101 complained of pain in R101's left hip when they picked R101 up off the floor and put R101 to bed using the full body mechanical lift. V18 stated V6 RN was in the room at the time. On 7/6/18 at 12:19pm, V17 CNA stated V17 transferred R101 from R101's wheelchair to bed when Hospice came in and that R101 repeatedly said my leg, my leg reaching towards R101's left leg/hip. during the transfer. V17 thought it was about 9:30am to 10am when they transferred R101. Hospice Nurse V12 stated on 7/5/18 at 12:43pm that V12 was on call for the regular nurse who visited R101 and recieved a call around 9:30am from the facility reporting R101 having hallucinations and multiple falls. V12 stated V12 assessed R101 around 10:30am, R101 was in a lot of pain and was very restless adding that when V12 moved R101's right leg, (R101) screamed out in pain. V12 stated as V12 was writing V12's note at the nurses station, they informed V12 that R101 had fallen again. On 7/3/18 at 2pm, V1 Administrator, stated V1 had identified issues/concerns with R101's falls and follow up and did V1's own investigation which V1 provided entitled Nurse Education. The Nurse Education report provided V1, Administrator on 7/3/18 documents under the subtitle Accidents/Incidents documents You MUST assess the resident before they are moved. If you believe there is a fracture or serious injury, do NOT move the resident. Make them as comfortable as possible and dispatch EMS (Emergency Medical Services.) On 7/6/18 at 10:20am, V4 Physician stated V4 was called after the fall at 12:30am on 6/30/18 and gave an order for [REDACTED]. V4 stated V4 depends on the nurses to be V4's eyes and ears and asssess the residents then contact V4 or Hospice for orders. V4 stated that staffing is not consistent. The policy/procedure entitled Change in a Resident's Condition or Status undated documents Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changnes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The policy also documents The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. and If a signficant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments.

Based on interview, observation and record review, the facility failed to provide adequate supervision, failed to implement appropriate interventions following repeated falls and failed to use safe transfer technique as needed for 2 of 3 residents (R101, R104) reviewed for falls in a sample of 15. This resulted in a left Intertrochanteric Fracture of femur for R101 following 4 falls within a 16 hour period of time and aggravation/pain of an old fractured site to the 8th rib resulting from an unsafe transfer for R104. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R101 to be a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents R101 to have moderate cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 12 who requires extensive assist of one for bed mobility, extensive assist of two for transfers. The Fall Risk assessment dated [DATE] identifies R101 to be at high risk for falls. The care plan dated 4/11/18 fails to reflect a Falls Prevention Plan for R101 but does identify R101 to have a problem with trunk control, balance and positioning related to muscle weakness and arthritis. Interventions for this concerns include ½ side up times 2, assess quarterly and PRN (as needed,) eval (evaluate) risk or benefits, Identify signs/symptoms that warrant use of side rails, and pad side rails as needed. Progress Notes in the Electronic Health Record (EHR) dated 6/20/18 at 17:48 (5:48pm) documents Resident was very agitated this morning trying to climb out of bed and family member stated that yesterday R101 called her confused talking about finding a dog. Dr (V4) notified. New orders rec'd (received) to do UA (urinalysis) to check for UTI (urinary tract infection.) On 6/22/18 at 9:23am, the Progress notes document R101 to be on an antibiotic for a UTI. A Restorative Note in the EHR dated 6/29/18 at 12:45pm documents Res (resident) has been unable to do sit to stand at this time. On 6/29/18 at 8:34pm, a progress note in EHR entered by V8 Licensed Practical Nurse (LPN) documents Resident on the floor on top of the mat in an upright sitting position. ROM (range of Motion) to upper and lower extremities. Denies any pain or discomfort. Told writer (R101) had to (have a bowel movement), informed Certified Nurse Aide (CNA). Will continue to monitor. There is no documentation as to R101's level of cognition nor is there any evidence of further assessment and/or implementation of additional interventions including supervision implemented toward maintaining R101's safety and prevent further falls from occurring. The Incident/Accident Report dated 6/29/18 completed by V8 LPN documents assist c (with) bedpan for bowel evacuation. Monitor BM (bowel movement) assist PRN. The report documents the call light was not on, and under Falls Preventive Measures that were in place at the time of the fall, V8 has documented call light in reach, mat on floor. There is no causative factor documented for this fall and no indication additional interventions were put into place. On 7/5/18 at 2pm, V8 stated R101 had no confusion or hallucinations that V8 noted prior to or following the fall at 8:34pm on 6/29/18 but added that V8 normally works another hallway. V8 stated V8 did not report the fall to the oncoming nurse, V4, and couldn't recall any additional interventions put in place to prevent R101 from fallimg again. V8 stated V8's been employed by the facility for approximately 3 months. On 6/30/18 at 12:30am, V6 Registered Nurse (RN) documented in the Progress Notes upon rounds, observed resident lying on the floor on back. Resident very confused. (Spouse) had called requesting cell phone be put out of reach due to resident being confused and calling (spouse) and not saying anything. Resident's neuro's (neurological checks) wnl (within normal limits) for resident. Resident c/o (complained of) left hip pain. No inward or outward rotation noted and no shortening of leg noted. Call placed to Dr V4 received order for portable left hip xray. (Spouse) also notified. Resident continues to be confused. Placed on (full body mechanical lift) pad and assisted back to bed via (full body mechanical lift. There is no documentation that new interventions were put into place to prevent R101 from falling again. The Incident/Accident Report dated 6/30/18 signed by V6 documents R101 had just been changed a few minutes later I was doing rounds and PT (patient) was laying on floor. No causative factor was identified within this report. The next entry into the progress notes is 1 ½ hours later at 2am on 6/30/18 by V6 RN documenting continues to be confused and restless. Neuro checks wnl for resident. Again, there is no evidence V6 assessed R101's need for added safety measures given R101's to prior falls and R101's increased confusion and implemented additional interventions to prevent R101 from falling again following the fall at 12:30am or at this time. There is no evidence the facility assessed additional supervision. On 6/30/18 at 6am, V6 documents in the progress notes resident on floor a second time. Remains confused. Assisted to w/c (wheelchair) no noted abrasions to right elbow. Area cleansed and dressed. No c/o pain at this time. Neuro's wnl for resident. Again, no assessment is documented toward falls preventions and no added interventions were noted within the EHR. There is no Incident/Accident Form for this fall and no causative factor identified. The Progress noted dated 6/30/18 at 10:34am documents [MEDICATION NAME] (concentrate) Solution 20mg(milligram)/ml (milliliter) Give 0.25mg sublingually every 4 hours as needed for pain/SOB (shortness of breath) (5mg) Hospice records completed by V12 RN dated 6/30/18 (no time) document R101 to have fall x (times) 3 < (less than) 12 hours unable to bear weight and under Summary, called due to pt falls. V12 documented pt c/o pain in R (right) hip post fall and that staff and POA instructed in pt safety and notify Hospice of xray results. At 12pm on 6/30/18, V11 LPN documented resident found on floor laying face up with head and body on beside mat. Continues to talk randomly about needing a hammer to get out of the closet. Hospice RN (V12) here at this time. MD aware. New orders obtained to increase [MEDICATION NAME] dosage due to increased pain and to give PRN [MEDICATION NAME] due to Hallucinations. POA (power of attorney)/Spouse aware. Assisted back to bed at this time. Call light within reach. Educated in regards to bed safety and voices understanding. Will continue to monitor. There is no information as to what safety precautions R101 was educated on given R101's cognitive impairment and if any new intervention were put in place to address R101's continued falls. At 12:15pm on 6/30/18, the progress notes document the portable xray company was notified of the order for a left hip and pelvic xray and at 2:15pm, two hours later, xrays were documented as completed. At 1630 (4:30pm,) the V11 documents New orders to send resident out to (hospital) for L (left) [MEDICAL CONDITION]. POA aware, Administrator aware, Resident currently resting in bed at this time. No c/o pain at this time. The progress notes dated 6/30/18 document R101 was transported to the emergency room at 8pm. Hospital History and Physical dated 7/1/18 documents R101's assessment revealed Left Intertrochanteric fracture of femur. On 7/5/18 at 1:30pm, V11 LPN stated V11 came in at 6am on 6/30/18 and R101 was in R101's wheelchair at the nurse's station. V11 stated V11 had been told by V4 that R101 had a couple of falls during the night but had no injuries. On 7/3/18 at 2pm, V1 Administrator, stated V1 had identified issues/concerns with R101's falls and follow up and did V1's own investigation which V1 provided entitled Nurse Education. Hospice Nurse V12 stated on 7/5/18 at 12:43pm that V12 was on call for the regular nurse who visited R101 and recieved a call around 9:30am from the facility reporting R101 having hallucinations and multiple falls. V12 stated V12 assessed R101 around 10:30am, R101 was in a lot of pain and was very restless adding that when V12 moved R101's left leg, R101 screamed out in pain. V12 stated as V12 was writing V12's note at the nurses station, they informed V12, R101 had fallen again. The Nurse Education report provided V1, Administrator on 7/3/18 documents under the subtitle Accidents/Incidents, incident reports are to be completed any time a resident falls, is assisted to the floor, a skin tear or other skin abnormality, chokes, or there has been a medication error. The report continues You MUST assess the resident before they are moved. If you believe there is a fracture or serious injury, do NOT move the resident. Make them as comfortable as possible and dispatch EMS (Emergency Medical Services.) The report also documents the physician, resident's responsible party, Administrator and Director of Nurses (DON) much be notified of all falls regardless of injuries and You MUST put an intervention in place to prevent the resident from falling again. Ask yourself why the fall occurred and what you would do to stop it from happening again. This intervention should be documented on the incident report and communicated to all staff. If you are unsure of an intervention, you MUST call the nurse on call for assistance. On 7/6/18 at 10:20am, V4 Physician stated V4 was called after the fall at 12:30am on 6/30/18 and gave an order for [REDACTED]. V4 stated V4 depends on the nurses to be V4's eyes and ears and asssess the residents then contact V4 or Hospice for orders. V4 stated that staffing is not consistent. On 7/5/18 at 11am, R101 was in bed. R101's room is the last room on the C Hall. R101 had a mat beside each side of the bed, scoop mattress and 1/2 rails up on the bed. R101 stated R101 couldn't remember how R101 fell , R101 just remembers being on the floor. R101 stated R101 refused to get up so remains in bed all the time and uses R101's call light. The policy/procedure entitled Fall Prevention and Assessment undated documents staff will identify risk factors for subsequent falling, and the staff will evaluate/document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. The policy also documents For an individual who has fallen, staff will attempt to define possible causes. Resident who have had a fall will be reviewed during the clinical IDT (Interdisciplinary team). The policy documents If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The policy documents safety measures will be addressed immediately. Under Monitoring and Follow-up, the policy documents The staff will follow up on any fall with associated injury until the resident is stable and delayed complications have been ruled out or resolved and The staff will monitor and document the individuals response to interventions intended to reduce falling or the consequences of falling. The policy documents If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident's falling (beside those that have already been identified) and will re-evaluate the continued relevance of current interventions. 2. On 7/3/2018 at 1:30 PM R104 stated On (MONTH) 20, (YEAR) a Certified Nurse's Aide (CNA) was impatient and tried to transfer me from my bed to my wheel chair with no help. She didn't transfer me right and I was just sitting on the edge of my wheelchair. She shoved my ribs into the arm rest of my wheel chair. It hurt really badly and I yelled out. She then ran from the room and left me sitting like that with my weight resting on my ribs smashed up against the arm of my wheel chair. It hurt really badly for 4 to 5 days. My ribs hadn't been sore before that. They are always supposed to have 2 to transfer me but she was in a hurry and didn't want to wait for help. I don't remember if I have ever had my ribs broken before. I do not know the CNA's name. On 7/5/2018 at 2:47 PM, V13, CNA, stated I don't recall any incident in May. I don't recall any incident with (R104). I have not had any training in this facility, I don't work for this facility. I work for (local CNA Agency). I have not had any training in this facility. I have not had an in-service training at the (local CNA Agency) since May. R104's Minimum Data Set ((MDS) dated [DATE] documents Brief Interview for Mental Status (BIMS) cognitively intact with a score of 14. It also documents in part Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position requires extensive assistance with two persons physical assist. Balance during Transitions and Walking: Moving from seated to standing position - Not steady only able to stabilize with staff assistance. R104's Minimum Data Set ((MDS) dated [DATE] documents Brief Interview for Mental Status (BIMS) cognitively intact with a score of 13. R104's Nursing Quarterly assessment dated [DATE] documents in part, Balance: Balance with walking: Non ambulatory, Balance with transfers - Unsteady balance with transfers and requires staff to assist with balance. No Nursing Quarterly Assessment completed until 5/23/2018. R104's Nurses Note dated 5/20/2018 at 2:08 PM documents Resident reported to this nurse that at lunch time on prior shift that while being transferred by staff from bed to wheelchair that attempt was undershot and resident half sitting on wheelchair seat causing resident to lean onto arm of wheelchair in rib area. Now complain of rib pain and tenderness. Medical Doctor (MD) and Director of Nursing (DON) aware. New Order x-ray to rib area stat (immediately). Resident is own Power of Attorney (POA) and did not wish to call any relatives. Call light in reach. Medication given for pain relief. R104's Nurses Note dated 5/20/2018 at 5:13 PM documents X-ray results received. Resident and DON aware. Will continue to monitor. Still complains of pain to right rib area. The Final Report (R104) Fracture dated 5/25/2018 documents On 5/20/2018 resident complained of right sided pain. Medical Doctor (MD) notified. Stat (immediate) x-ray order. Results positive for eighth rib fracture possibly old per x-ray report. MD aware. Investigation initiated. Upon investigation resident states that (R104) had an agency CNA transfer (R104) to (R104's) wheelchair and she did not position R104 properly and (R104's) side was leaned against the side of arm rest on wheelchair. Resident denies any falls or abuse. On 5/21/2018 I spoke with the radiologist who stated that the fracture appeared to be an old fracture healing because of the calcifications that were noted. Resident states pain has improved. Pain management continues. Nursing staff was in-serviced by therapy on proper transfer techniques. Care plan updated. All parties notified of final conclusion. (R104's) care plan dated 3/13/2018 documents in part, Focus: I am at risk for falls related to unsteady balance/gait at times. Goal: I will have no falls. Interventions: assist with transfers and ambulation. The care plan had no further guidance or updates regarding proper transferring for R104. R104's Accident/Incident Report dated 5/20/2018 documents in part (R104) on 5/20/2018 at 4:00 PM, Type of Incident: Observed Fall. Level of Injury: None Apparent. Describe exactly what you observed or heard: Resident states that while being transferred from bed to wheelchair that attempt was under shot causing resident to lean on to arm of wheel chair at rib area. Recommend steps to prevent recurrence: Staff educated on proper transferring procedures. (V13, Agency CNA) 1:1 education. R104's Incident investigation had no further interview from the CNA involved, other staff, and/or other residents. No documentation provided staff proper transfer education. No documentation of any staff 1:1 proper transfer education. R104's X-ray report dated 5/20/2018 documents in part There is a lateral eighth rib fracture which may be old. On 7/3/2018 at 12:45 PM, V3, Physical Therapy Aid (PTA) stated I did do a group training for nursing staff on proper transfer but I don't have a sign in sheet for attendance and I don't remember when I did it. I did not do any individual staff training on proper transfer. (R104) requires 2 staff to assist her in transfer. (R104)'s incident was caused by a CNA transferring (R104) by herself. On 7/5/2018 at 8:05 AM, V1, Administrator, stated I was not here when (R104) incident of 5/23/2018 occurred. I could not find any documentation of in-service training on proper transfer. (V3,) said V3 did give a group meeting but has no documentation of it. I agree this investigation was not complete. I didn't find an interview from the CNA who did the transfer or any other residents or staff regarding this incident. The facility's Safe Lifting and Movement of Residents dated 2009 documents in part in order to protect the safety and well0being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preference for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation including restoring or maintaining functional abilities.

Based on interview, and record review the facility failed to provide ongoing assessment and monitoring to identify changes for notification to the Physician for 1 of 3 residents (R13) reviewed for wounds in the sample of 13. This failure resulted in the hospitalization of R13 and gangrene in R13's left 4th toe,[MEDICAL CONDITION] due to [MEDICAL CONDITION]-resistant Staphylococcus (MRSA) and amputation of R13's left 4th toe. Findings include: On 06/28/2018 at 3:04 PM, V20, family of R13, stated, I am not happy with the care (R13) received at all. The facility is the most unprofessional staff/facility that I ever ran into. My grandson came to visit (R13) and he called me and said I needed to get to the facility as soon as possible (ASAP) because (R13) was having some serious issues with (R13's) feet. He said the Hospice nurse was bathing (R13's) roommate and notified him by looking across the room and seeing (R13's) foot that something was wrong with (R13's) left foot. She wasn't even the nurse for (R13). When (R13) came to the facility (R13) had clean feet, no open areas on (R13's) toes. (R13) is diabetic and has had problems in the past so we were shocked when I got there and (R13's) foot was 3 times the size it should be. On (R13's) toe I could see brown bone with green mold. No one even told me (R13) was having problems with (R13's) feet. This should have never happened. (V8) the wound nurse was not checking (R13's) feet and (R13) was a diabetic. (V8) has not clue of what (V8) is doing. (V8) was in (V8's) office looking at index cards and when I took one look at (R13's) foot I knew (R13) needed more than antibiotics and (R13) needed to be sent out. (V8) started telling me that (V8) had contacted the doctor and they were going to start (R13) on antibiotics and were going to take an x-ray. I thought to myself 'No, (R13) needs to be sent to the hospital what is wrong with this wound nurse?' R13's Physician order [REDACTED]. R13's POS dated (MONTH) (YEAR), documents a [DIAGNOSES REDACTED]. R13's Quarterly Minimum Data Set ((MDS) dated [DATE] documents R13 is at risk for pressure ulcers. R13 is not documented as receiving Hospice. R13's Hospital Records dated 06/21/2018 documents Present at the Emergency Department (ED) with a chief complaint of left great toe infections. Per (ED) chart report nursing home staff found the patient's left great toe with necrosis, it is about to fall off, then it was wrapped and patient was transferred to the ED for further evaluation. Patient does have a history of recurrent [MEDICAL CONDITION] with chronic and acute osteo[DIAGNOSES REDACTED] and the rest of the toes had been amputated in the past. On further work up in the ED patient found to have slightly elevated white cell count and severe elevation in CRP blood cultures. Patient was referred for admission for further evaluation and treatment left great toe gangrene and left foot [MEDICAL CONDITION]. Skin, [DIAGNOSES REDACTED] and swelling of the left foot extending to the ankle, warm to palpation. The Hospital Records also document an amputation to the left 4th toe at the metatarsophalangeal joint (MPJ). R13's admitted d to the hospital was 06/21/2018 and R13's discharge date was 06/26/2018. The records also [MEDICAL CONDITION] due to [MEDICAL CONDITION]-resistant Staphylococcus (MRSA) likely source is left foot infection. On 06/28/2018 at 1:20 PM, V16, Certified Nursing Assistant (CNA) when asked about the incident involving R13 on 6/21/18 stated: a couple of days before there was nothing wrong with (R13's) feet. Hospice is giving (R13's) showers. When hospice came back (R13) was already dressed. No, (R13) does not dress (R13's) self, the certified nursing assistants (CNA's) dress (R13). When hospice gave (R13) a shower that day they informed me to tell the nurse about (R13's) foot. I was so busy that day and I forgot to tell the Nurse (V15). I was working the D Hall that day and I was all by myself and was really busy. This was the same day (R13) was sent out to the hospital. On 06/28/2018 at 3:04 PM, V14, Licensed Practical Nurse (LPN) when asked about the incident involving R13 on (MONTH) 21, (YEAR), stated: The hospice CNA was in the shower room with (R13's) roommate and she notified us (R13's) foot was really red. So we went down, (V15) Registered Nurse (RN) and looked at it and notified (V1), Administrator that (R13's) foot had a possible infection. To my knowledge no one was monitoring and/or taking care of R13's foot before then. Her family requested that (R13) be sent out to the hospital. On 06/29/2018 at 9:11 AM, V15, Registered Nurse (RN) when asked about the incident involving R13 on (MONTH) 21, (YEAR), stated (V18), Hospice Bath Aid was bathing R13's roommate and she noticed (R13's) foot was infected. The CNA's had given (R13) a bath and one of the CNA's had told (V19), CNA that there was an issue with (R13's) foot. (V19) forgot to notify a nurse. Anytime there are issues I would expect staff to tell a nurse. (V18) came and told me and (V14), Registered Nurse (RN) and we called (V10), Wound Nurse and we all went and looked at it. (R13's) foot was red on top, the foot was warm, there was an infection going on and it was like (R13's) toe was going to fall off. On 06/29/2018 at 9:35 AM, V18, Hospice Aid stated when asked about the incident involving R13 on (MONTH) 21, (YEAR) :Last Thursday I was giving (R13's) roommate a shower and I looked over at (R13) and I noticed (R13's) foot was really red. (R13) was already missing 3 toes and I thought it was really weird that (R13) did not have any treatment. It looked bad, there was a smell and drainage but no dressing. I mentioned this to (V19) CNA on duty and another CNA (V16) came in and (V19) told (V16) about (R13's) foot. When I finished showering my patient I stopped by the nurse's station and asked what had happened to (R13's) foot. (V14)LPN and (V15) RN both said they did not know any of this and they went down to (R13's) room to take a look at it. On 07/03/2018 at 12:08 PM, V11, Physician stated We were notified on 06/21/2018 of an infection. I would expect staff to take off socks every day and look at the feet with daily monitoring of the foot. We were not notified of a smell and/or necrosis of the foot. That is different than an infection and even a smell changes the treatment. (R13) should have been sent out immediately if (R13) had a smell and/or necrosis of the foot. That is why we ordered the antibiotic treatment and x-ray for the infection. R13's Progress Note dated 06/21/2018 at 12:13 PM, Communication with Family Power of Attorney (POA) document resident's left foot 4th toe was assessed and it was noted resident has open blister on toes measuring approximately 8.0 centimeters x 7.0 centimeters with pink granulation tissue intact 75% and red granulation tissue into 25 % on posterior toe, scant amount drainage noted, surrounding tissue has [MEDICAL CONDITION] warm to touch skin bright red, grandson here with resident (V11), Physician notified, new orders were received for [MEDICATION NAME] by mouth 300 milligrams (mg) three times a day for 14 days. Acidophilus wound culture, x-ray to left foot, and apply [MEDICATION NAME] solution daily. POA arrived at facility spoke with POA and POA requested resident to be sent out to evaluate and treatment. (V11) notified, back new orders were received to send to Local Hospital for evaluation and treatment POA is aware of wound status. R13's Progress Notes dated 06/21/2018 at 1:00 PM, Hospice aide called this nurse and (V14) Licensed Practical Nurse (LPN) down to resident's room. She was bathing resident's roommate and noticed (V13's) left foot. When staff went down to room resident was extremely pleasant and had no idea anything was wrong with (R13's) foot. Foot appeared red on top. Toe was white with a small amount of drainage. This nurse was not told about anything with the foot until hospice aid came. Bath Aide that day saw foot and passed onto (V16) CNA. V16 never reported to this nurse. V8, Wound Nurse in building so V8 was paged to resident's room. Antibiotics/ x-ray ordered. At this time family arrived and stated they wanted (R13) to be sent out to hospital. Resident sent to local hospital. Vitals were within normal limits at time of transfer. On 06/28/2018 at 10:44 AM, V1, Administrator stated On 06/21/2018 it was reported to me to come to (R13's) room. I went to (R13's) room and (V20) family member of R13 was there. (V20) told me that the hospice aid had reported to (V20) that there was a change in (R13's) foot. I told (V20) I would investigate and try and find out what happened. I left and spoke with (V15) Registered Nurse. (V15) stated (V16) CNA had told her about (R13's) foot and she got distracted and forgot to tell the nurse. I expect if there are any issues for CNA's to go directly to the nurses. I gave (V16) a final warning. R13's Treatment Administration Records (TARS) for (MONTH) (YEAR) documents, the following 1- [MEDICATION NAME] solution apply to left foot 4th toe topically every day shift for wound care. 2- Float both heels off pillows when in bed to offload pressure every shift for wound care/wound prevention. 3-Skin Prep Wipes Miscellaneous (Ostomy Supplies) Apply to both heels topically every day shift for wound prevention. On 06/28/2018 V8, Wound Nurse stated this is the only documentation I have on (R13). I do not have anything for (R13's) feet. The Change in Resident's Condition or Status with a revision date of 08/2014 documents in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (examples; changes in level of care, billing/payments, resident rights). 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: e. A significant change in in the resident's physical condition.

Based on interview and record review the facility failed to assess and monitor condition changes for 1 of 3 residents (R13) reviewed for change of condition in the sample of 13. This failure resulted in the hospitalization of R13 and gangrene in R13's left 4th toe,[MEDICAL CONDITION] due to [MEDICAL CONDITION]-resistant Staphylococcus (MRSA), and amputation of R13's left 4th toe. Findings include: R13's Physician order [REDACTED]. R13's POS dated (MONTH) (YEAR), documents a [DIAGNOSES REDACTED]. R13's Quarterly Minimum Data Set ((MDS) dated [DATE] documents R13 is at risk for pressure ulcers. On 06/28/2018 at 3:04 PM, V20, family of R13 stated, I am not happy with the care R13 received at all. The facility is the most unprofessional staff/facility that I ever ran into. My grandson came to visit (R13) and he called me and said I needed to get to the facility as soon as possible (ASAP) because (R13) was having some serious issues with (R13's) feet. He said the Hospice nurse was bathing (R13's) roommate and notified him by looking across the room and seeing (R13's) foot that something was wrong with (R13's) left foot. She wasn't even the nurse for (R13). When (R13) came to the facility (R13) had clean feet, no open areas on (R13's) toes. R13 is diabetic and has had problems in the past so we were shocked when I got there and (R13's) foot was 3 times the size it should be. On (R13's) toe I could see brown bone with green mold. No one even told me (R13) was having problems with (R13's) feet. On 06/05/2018 when I came into visit (R13) was wearing these tight fitting shoes and I asked the CNA why (R13) was wearing someone else's shoes and she laughed and said but (R13) loves those shoes. I asked to take the shoes off and when we pulled off the shoes (R13's) foot was red. Then 14-15 days later (R13) had to have surgery. This should have never happened. (V8) the wound nurse was not checking (R13's) feet and R13 was a diabetic. On 06/28/2018 at 1:20 PM, V16, Certified Nursing Assistant (CNA) when asked about the incident involving R13 on (MONTH) 21, (YEAR), stated: a couple of days before there was nothing wrong with (R13's) feet. Hospice is giving (R13) showers. When hospice came back (R13) was already dressed. No, R13 does not dress R13's self, the certified nursing assistants (CNA's) dress R13. When hospice gave R13 a shower that day they informed me to tell the nurse about (R13's) foot. I was so busy that day and I forgot to tell the Nurse (V15). I was working the D Hall that day and I was all by myself and was really busy. This was the same day (R13) was sent out to the hospital. I don't think there was anything wrong with (R13's) foot. On 06/28/2018 at 3:04 PM, V14, Licensed Practical Nurse (LPN) when asked about the incident involving R13 on (MONTH) 21, (YEAR), stated: The hospice CNA was in the shower room with (R13's) roommate and she notified us (R13's) foot was really red. So we went down, (V15) Registered Nurse (RN) and looked at it and notified (V1), Administrator that (R13's) foot had a possible infection. To my knowledge no one was monitoring and/or taking care of R13's foot before then. Her family requested that (R13) be sent out to the hospital. On 06/29/2018 at 9:11 AM, V15, Registered Nurse (RN) when asked about the incident involving R13 on (MONTH) 21, (YEAR), stated: (V18), Hospice Bath Aid was bathing R13's roommate and she noticed (R13's) foot was infected. The CNA's had given (R13) a bath and one of the CNA's had told (V19), CNA that there was an issue with (R13's) foot. (V19) forgot to notify a nurse. Anytime there are issues I would expect staff to tell a nurse. (V18) came and told me and (V14), Registered Nurse (RN) and we called (V10), Wound Nurse and we all went and looked at it. (R13's) foot was red on top, the foot was warm, there was an infection going on and it was like (R13's) toe was going to fall off. On 06/29/2018 at 9:35 AM, V18, Hospice Aid when asked about the incident involving R13 on (MONTH) 21, (YEAR), stated: Last Thursday I was giving (R13's) roommate a shower and I looked over at (R13) and I noticed (R13's) foot was really red. (R13) was already missing 3 toes and I thought it was really weird that (R13) did not have any treatment. It looked bad, there was a smell and drainage but no dressing. I mentioned this to (V19) CNA on duty and another CNA (V16) came in and (V19) told (V16) about (R13's) foot. When I finished showering my patient I stopped by the nurse's station and asked what had happened to (R13's) foot. (V14) and (V15) both said they did not know any of this and they went down to (R13's) room to take a look at it. On 07/03/2018 at 12:08 PM, V11, Physician stated We were notified on 06/21/2018 of an infection. I would expect staff to take off socks every day and look at the feet with daily monitoring of the foot. We were not notified of a smell and/or necrosis of the foot. That is different from an infection and the smell changes the treatment. (R13) should have been sent out immediately if she had a smell and or necrosis of the foot. R13's Progress Note dated 06/21/2018 at 12:13 PM, Communication with Family Power of Attorney (POA) document resident's left foot 4th toe was assessed and it was noted resident has open blister on toes measuring approximately 8.0 centimeters x 7.0 centimeters with pink granulation tissue intact 75% and red granulation tissue into 25 % on posterior toe, scant amount drainage noted, surrounding tissue has [MEDICAL CONDITION] warm to touch skin bright red, grandson here with resident (V11), Physician notified new orders were received for [MEDICATION NAME] by mouth 300 milligrams (mg) three times a day for 14 days. Acidophilus wound culture, x-ray to left foot, and apply [MEDICATION NAME] solution daily. POA arrived at facility spoke with POA and POA requested resident to be sent out to evaluate and treatment. (V11) notified, back new orders were received to send to Local Hospital for evaluation and treatment POA is aware of wound status. R13's Progress Notes dated 06/21/2018 at 1:00 PM, Hospice aide called this nurse and (V14) Licensed Practical Nurse (LPN) down to resident's room. She was bathing resident's roommate and noticed (V13's) left foot. When staff went down to room resident was extremely pleasant and had no idea anything was wrong with (R13's) foot. Foot appeared red on top. Toe was white with a small amount of drainage. This nurse was not told about anything with the foot until hospice aid came. Bath Aide that day saw foot and passed onto (V16) CNA. V16 never reported to this nurse. V8, Wound Nurse in building so she was paged to resident's room. Antibiotics/ x-ray ordered. At this time family arrived and stated they wanted her to be sent out to hospital. Resident sent to local hospital. Vitals were within normal limits at time of transfer. On 06/28/2018 at 10:44 AM, V1, Administrator stated On 06/21/2018 it was reported to me to come to (R13's) room. I went to (R13's) room and (V20) family member of R13 was there. (V20) told me that the hospice aid had reported to (V20) that there was a change in (R13's) foot. I told (V20) I would investigate and try and find out what happened. I left and spoke with (V15) Registered Nurse. (V15) stated (V16) CNA had told V15 about (R13's) foot and (V16) got distracted and forgot to tell the nurse. I expect if there are any issues for CNA's to go directly to the nurses. I gave (V16) a final warning. R13's Treatment Administration Records (TARS) for (MONTH) (YEAR) documents, the following 1- [MEDICATION NAME] solution apply to left foot 4th toe topically every day shift for wound care. 2- Float both heels off pillows when in bed to offload pressure every shift for wound care/wound prevention. 3-Skin Prep Wipes Miscellaneous (Ostomy Supplies) Apply to both heels topically every day shift for wound prevention. On 06/28/2018 V8, Wound Nurse stated this is the only documentation I have on (R13). I do not have anything for R13's feet. R13's Care Plan dated 05/15/2018 documents resident has pressure ulcer or potential pressure ulcer development related to unstageable right heel on admit, resident at risk for skin breakdown related to unstageable heel (healed 05/29/2018). R13's Care Plan dated 05/13/2018 documents float heel on pillows in bed. R13's Care Plan dated 05/15/2018 documents assess/record/monitor wound healing frequently. Measure length, width and depths where possible. Assess and document status of wound perimeter, wound bed and healing progress. Reports improvements and declines to Physician. R13's Care Plan under the Focus Area documents has impaired mobility, [DIAGNOSES REDACTED]. 06/21/2018 toe 4th toe open blister surrounding tissue red with [MEDICAL CONDITION]. Weekly Skin Assessment from 05/14/2018 - 06/19/2018 does not document any notes related to R13's feet. Resident's admission skin assessment dated [DATE] in part, left foot first three toes amputated left heel has open wound measures approximately 1.0 centimeter (cm) x 2.5 cm with necrosis intact 100 %. Scant amount of serosanguinous drainage noted right great toe has [MEDICAL CONDITION] cool to touch denies pain or discomfort right foot has old scar approximately 17.5 cm in length scar dry and clean old scab noted on right lower extremity measures approximately 0.5 cm x 0.2CM. R13's Hospital Records dated 06/21/2018 documents Present at the Emergency Department (ED) with a chief complaint of left great toe infections. Per (ED) chart report nursing home staff found the patient's left great toe with necrosis, it is about to fall off, then it was wrapped and patient was transferred to the ED for further evaluation. Patient does have a history of recurrent [MEDICAL CONDITION] with chronic and acute osteo[DIAGNOSES REDACTED] and the rest of the toes had been amputated in the past. On further work up in the ED patient found to have slightly elevated white cell count and severe elevation in CRP blood cultures. Patient was referred for admission for further evaluation and treatment left great toe gangrene and left foot [MEDICAL CONDITION]. Skin, [DIAGNOSES REDACTED] and swelling of the left foot extending to the ankle, warm to palpation. The Hospital Records also document an amputation to the left 4th toe at the metatarsophalangeal joint (MPJ). R13's admitted d to the hospital was 06/21/2018 and R13's discharge date was 06/26/2018. The records also [MEDICAL CONDITION] due to [MEDICAL CONDITION]-resistant Staphylococcus (MRSA) likely source is left foot infection. The Non Pressure Related Skin Management Policy with a revision date of 01/05/2015 document in part, This facility will provide necessary care to promote healing, prevent infection and prevent additional non-pressure areas from developing for each resident and his/her condition tolerates. C- [MEDICAL CONDITION]- ulcers caused by neuropathic and small blood vessel complications of diabetes. [MEDICAL CONDITION] typically occur over the plantar (bottom) surface of the foot on load bearing areas such as the ball of the foot. Ulcers are usually deep, with necrotic tissue, moderate amounts of exudate, and callused wound edge. The wounds are very regular in shape and the wound edges are even with a punched-out appearance. These wounds are typically not painful. 2. When a non-pressure area is identified the licensed nurse shall assess the alteration for: location, stage, size, depth and undermining, exudate, tissue and surrounding skin presentation and pain. The licensed nurse shall document findings on the Weekly Wound Evaluation Flow Records. 5. The licensed nurse shall notify the Resident, Responsible Party and the Physician and shall document the notifications.

Based on observation, interview and record review, the facility failed to provide supervision, reassess, monitor effectiveness of interventions and revise interventions as needed to prevent falls for 1 of 2 residents (R20) reviewed for falls in the sample of 28. This failure resulted in R20 falling multiple times and sustaining a left clavicle fracture, multiple hematoma's to the head and multiple bruises over the body and skin tears. Findings include: The physician's orders [REDACTED]. R20's Minimum Data Set (MDS), dated [DATE], documented R20 had a Brief Interview for Mental Status (BIMS) score of 2, indicating she was severely cognitively impaired. The MDS documented R20 required supervision while walking in the corridor and required extensive assist of at least one staff for eating, dressing, toilet use and personal hygiene. The Care Plan, dated 04/15/18, documented R20 was identified as being at risk for falls related to wandering, impaired safety awareness, incontinence, [MEDICAL CONDITION] medications, falls. It documented R20 has a shuffling, left side leaning gait especially when tired. There were multiple interventions, in part as, one on one for one hour, neuro checks, direct supervision and to assist to supervised area and give a busy box for activity. On 4/24/18 at 9:00 AM, R20 was observed in bed on her back fidgeting with the blankets. Upon entering the R20's room and greeting her, R20 did not respond or answer/respond to any questions. On 4/24/18 at 12:00 PM, R20 was observed sitting in regular chair at the assisted table in dining room waiting on lunch service. R20 was served the lunch meal at 12:30 PM. At 1:30 PM, R20 was observed wandering ambulatory up and down hallways unassisted by staff. There were no staff specifically supervising R20. R20 had a blank stare with shaking jaw and would drool at times. On 04/25/18 at 9:25 AM, R20 was ambulating up and down halls. R20 occasionally would go into other resident's rooms. R20 was observed with her bottom lip/jaw shaking and drooling. At times staff will wipe her chin. At 1:20 PM, R20 was observed ambulating up and down C hall unassisted. R20 was ambulating with head down looking at floor. At 1:30 PM, R20 was observed ambulating down D hall and wandered into Room D-10, stood with blank stare at the resident who was in bed asleep and then walked out. There was no staff in the hallway at this time supervising R20. On 4/25/18 at 2:14 PM, R20 was observed wandering up and down hallways without staff supervision and wandering in and out of other resident's rooms. There were no observed times during the survey that R20 was assisted to a supervised area and/or given an activity to do. Nurse's notes from 06/01/17 to 05/02/18 documented 26 falls with varying injuries, including skin tears, bruises, Wheaton's and fracture of left clavicle. R20's Nurse's Note, dated 6/9/17 documented resident found lying on floor in bedroom. The Note documented resident was put in site of nurse and staff would continue to monitor. On 08/14/17 at 12:00 PM, a Nurse's Note documented R20 had fallen and staff had heard her head hit the floor. It documented a hematoma to the left side of head. Also on 08/14/17 at 3:21 PM, a Nurse's Note documented R20 fell resulting in a two inch skin tear right arm. Both of these Nurse's Notes documented R20 would be placed on 30 minute visuals for the next three days. R20's Nurse's Note, dated 8/14/17 at 4:59 PM, documented she tripped over another residents wheelchair and slid down the door and hit her right arm. The Note documented she sustained a two inch skin tear to her right arm. The Note documented New order to monitor T/H. On 10/13/17, a Nurse's Note documented R20 fell hitting head and causing a left sided hematoma to the head. The Note documented after the incident she was placed on one to one with nurse. R20's Care Plan, with addition made on 10/13/17, documented Tripped over chair at nurse's station. Hematoma l (left) side of head (now resolved). The Care Plan Intervention, dated 10/16/17, documented Stationary easy chair. R20's Nurse's Note, dated 11/10/17 documented R20 fell while reaching for a blood pressure cuff. The Note documented she fell forward and hit her head on the wall. The Note documented she was placed on one to one with the nurse. R20's Care Plan Intervention, dated 11/10/17 documented Will offer busy box throughout the day. The facility had no documentation they completed investigation into the falls above to determine root cause analysis of falls and to determine if interventions were effective or needed to be revised. The only incident/accident report investigation provided by the facility as evidence of completed investigations for these falls was the incident which occurred on 02/06/18 that resulted in R20 sustaining a fracture. The Preliminary Report to Illinois Department of Public Health, dated 02/06/18 was faxed to the Department at 11:33 PM. It documented on 02/06/18 at 11:00 AM, R20 fell while ambulating down hallway. It documented the physician was not notified until 10:00 PM that evening at which time an X-ray was ordered of the left shoulder. The Bio Tech X-ray report, dated 02/06/18, documented a distal clavicular [MEDICAL CONDITION] shoulder. On 02/06/18 at 11:00 AM, a Nurse's Note documented R20 was ambulating quickly down the hallway, lost footing and fell into the wall hitting shoulder and head. It further documented noting a bump to left side of head and slight redness to left shoulder. Interventions were one on one with nurse for an hour, offer snack and drink and toilet. Nurse's Notes also documented R20 had fallen on 02/05/18 and 02/07/18 with no apparent injuries. Interventions for 02/05/18 were to toilet as needed and there were no documented interventions for 02/07/18. R20's Care Plan Intervention, with initiation date of 2/7/18, documented direct supervision when up/amb (ambulating). On 04/27/18 at 10:30 AM, V1, Administrator, stated that there were no other records/investigations the facility had on the other 25 falls. On 04/27/18 at 3:00 PM, V18, CNA stated R20 Falls all the time. She said sometimes (R20) was hard to keep track of because she wanders everywhere. On 05/02/18 at 12:40 PM, V16, Physician, stated the facility does not have enough staff to supervise 100% of the time due to staff cuts, call-offs and simply being busy with other residents. V16 stated she was told that restraining a resident with a lap cushion or other devices to prevent falls was illegal. After explaining to V16 that this was not true, V16 said that's probably the only way to keep R20 from falling. V16 stated R20 does not have safety awareness due to decreased cognition. The Falls Clinical Protocol, dated (MONTH) 2012, documented under Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on interviews and record review, the facility failed to provide a safe resident environment and protect residents from abuse for 1 of 9 residents (R2) reviewed for abuse in the sample of 9. This failure resulted in psychosocial harm in that, a reasonable person would react to such a situation with feelings of anxiety, distress, fearfulness and humiliation. Findings include: R2's Minimum Data Set ((MDS) dated [DATE] documented R2 is a [AGE] year old female who has a Brief Interview of Mental Status (BIMS) score of 5, indicating severely impaired cognition. The MDS also documents R2 requires extensive two staff assistance in mobility/toileting/dressing and requires one person physical assist with bathing. The Admission record, dated 10/2006, documents R2's [DIAGNOSES REDACTED]. R2's Nurse's Note dated 4/8/2018 at 8:40 AM documents, 0840 notified by housekeeper that she witnessed roughness with resident. Staff immediately removed CNA from facility and Administrator and DON (Director of Nurse's) notified. Attempted to notify IDPH (Illinois Department of Public Health) via fax however fax machine inoperable and emails currently not working. Administrator left two messages at IDPH office. Fax machine began working later and report sent at that time. Police notified, MD notified and POA notified and Ombudsman notified. Neuro checks initiated, and 30 min visual checks started. Upon interview with resident (R2) stated nobody has been physically or verbally abusive to (R2). The Facility's Final Investigation Report, undated, documents, On 4-8-2018 at 08:38am it was witnessed by staff members that (R2) was in (R2's) wheelchair at nurse's station with (R2's) head down, when (V5, Certified Nurse's Aide/CNA) came up to (R2) and pushed (R2's) head back and then placed hand on (R2's) back of neck and stated to resident, 'Get your a** back to your room.' Staff immediately notified nurse who intervened and separated resident from (V5). (V5) was escorted out of building and investigation immediately began. The Report documented Upon investigation, administrator interviewed all alert residents with no reports of abuse or mistreatment. Abuse allegation is substantiated and (V5) has been terminated. Facility's documentation of phone interview on 4/8/18 at 2:00 PM with V5 documents, Coming out of DR (dining room) no pants head down calling name lifted head up put hand on forehead shook (R2) around. I don't honestly recall cursing. On 4/18/2018 at 9:50 AM, V4, Licensed Practical Nurse (LPN), stated (V8, Housekeeper) reported to me on 4/8/2018 at 0830 am V8 had seen (V5, CNA) push (R2's) head up and pulled back of neck and stated, Get (R2's) a** down to (R2's) room. I immediately removed her, which (V5) became argumentative with me. I had to send her home due to report of situation. (V6 Certified Nursing Assistant Coordinator) notified and she called the Administrator. V4 also stated, I have had to educate (V5) at least twice in past for cursing. On 4/19/2018 at 8:45 AM V8 stated, On 4/8/2018, I let (V5) know that (R2) didn't have R2's diaper on and R2's pants was pulled down to knees. (R2) was wheeling R2's self to the dining room. R2 was in hallway near nurse's station. It's not unusual for R2 to take R2's own diaper off and not pull pants all the way up. When I told (V5), she came around nurse's station and (R2) had (R2's) head down. (V5) put the palm of her hand on (R2's) forehead forcing (R2's) head to jerk backwards as (V5) stated, 'Why the f*** don't you have a diaper on?' (R2) did not respond. (V5) then had one hand on the wheelchair and grabbed (R2) by the back of the neck and (V5) said, 'Get your a** back to your room.' (R2) did not respond. (V5) took (R2) back to (R2's) room. I went to get (V4) and told her what happened. V8's written statement, dated 4/8/2018 documents, On 4-8-2018, I informed (V5) that (R2) didn't have any bottoms on when (R2) was headed to the dining room for breakfast around 7:30 am.(V5) came from behind the nurse's station and approach (R2) who had (R2) head down that's when I observed (V5) push (R2's) head back and then grabbed (R2) by the back of the neck and wheeled (R2) to (R2's) room telling (R2) to get (R2's) (a**) to (R2's)room. I immediately reported to the nurse (V4) and she called the Administrator after she removed (R2) from the situation. On 4/17/2018 at 10:00 AM, V9, Housekeeper, stated, (V5) pushed (R2) head. I gave a statement, reported to the nurse and she called administrator. We have had in-services and had another meeting and they sent (V5) home. V9's written statement, dated 4/8/2018 documents, It was about 8:38 am I was at the nurse's station when (R2) came from the dining room and (V8) Housekeeper told (V5) that (R2) pants is right on (R2's) knees. She pushed (R2's) head back rough and told R2 to get her (a**) back to the room. On 4/17/2018 at 6:13 PM, V13, Local City Police Officer, was interviewed. V13 stated that during V13's investigation of the incident R2 said What she did to me wasn't right. On 4/18/2018 at 11:40 AM ,V1 stated, (V6) called me and I also spoke with (V4) who advised that (R2) came out room without pants on and (V5) pushed head back and turned (R2) around by (R2's) neck and guided back to room, stating Get you're a** back in room. On 4/18/2018 at 11:50 AM V2, Director of Nursing (DON) stated, (V1) called me on 4/8/2018 at 8ish. I did (R2's) full assessment skin check and took R2 to bathroom and (R2) didn't complain of any pain. V2 stated V5 has been disciplined in the past for Bad attitude. On 4/18/2018 at 12:05 PM V3, Registered Nurse/RN stated, I was told about it. (V4) called me, incident involving (V5) and (R2) involving abuse, pushed R2's head back. Oh yeah (V5) curses. On 4/19/2018 at 9:00AM V7, R2's Power of Attorney (POA) stated prior to R2's mental decline, (R2) would have been upset over this incident and would have been withdrawing. (R2) would have had behavioral changes. On 4/19/2018 at 9:00 AM R2 stated, I wouldn't like that, if someone cursed or pushed my head or grabbed my neck. On 4/19/2018 at 1:25 PM V15, R2's Physician, stated, I would expect staff to treat resident's like their own parents. When asked if this behavior was acceptable from staff, V15 responded Absolutely not. I would expect staff not to handle residents roughly or curse at them. On 4/19/2018 at 1:20 PM R4 and R5 stated if a staff member cursed at them or shook them it would make them feel angry, bad and/or frightened. A reasonable person would react to such abuse with such feelings as agitation, anxiety, frustration, fearfulness, humiliation and punishment. Facility's Policy and Procedure 'Abuse Prevention Program' dated (MONTH) (YEAR) documents, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The Policy documents The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident.

Based on interview, observation and record review, the facility failed to provide appropriate monitoring and assessment for potential [MEDICAL CONDITION] following the removal of the urinary catheter and failed to provide services in catheter care for 2 of 3 residents (R1 and R3) reviewed for catheters in a sample of 6. This failure resulted in R3 being hospitalized for [REDACTED]. Findings include: 1. R3's Admission Sheet, dated 6/8/16, identifies R3 as a [AGE] year old female admitted to the facility on [DATE] following hospitalization for a sacral and right pubis fracture sustained during a home fall. R3's Admitting orders document R3 to have a urinary catheter for retention and history of urinary tract infection (UTI.) R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact requiring extensive assist of two staff for bed mobility and transfers. The Interim Care Plan, dated 6/8/16, identifies R3 to have an indwelling catheter with interventions being clean/dry skin following each incontinence episode and catheter care. R3's Care Plan, dated 6/22/16, documents R3's Focus areas as incont (incontinent) of bladder and bowel at X's (times) and has DX (diagnosis) UTI, [MEDICAL CONDITION] and constipation had cath (catheter) on admit that has been dc'd. The Goal is to be continent during waking hours with interventions documented as documents signs/symptoms (s/s) of constipation, [MEDICAL CONDITION], UTI's, had KUB (Kidney/Ureters/Bladder), incontinent care after episodes, and take to bathroom before/after meals. R3's Care Plan documents the catheter being discontinued on 7/1/16 but a telephone order, dated 6/9/16, documents the catheter was discontinued on 6/10/16. R3's Progress notes from admission on 6/8/16 through 7/10/16 when R3 was discharged to the hospital has only 2 references to R3's catheter and no reference to voiding. The first entry is on 6/9/16 and documents R3's catheter is intact and draining and the second is on 6/10/16 and documents the catheter to be patent draining clear yellow urine. There is no documentation of the catheter being removed and no documentation of any monitoring the nurses did following removal to ensure R3 was voiding appropriately in sufficient amounts. The Medicare Skilled noted document only that the catheter was present on 6/9/16 and 6/10/16 and also fails to document any assessments and/or monitoring toward R3's urinary output to ensure it was sufficient and no retention was occurring. On 6/12/16, R3's POS documented an order for [REDACTED]. On 9/21/16, the facility provided R3's KUB report was provided that identified no problems except constipation. R3's Skilled Nursing note written by E12, Licensed Practical Nurse LPN on 7/10/16 at 1:38 AM documents nothing toward a condition change for R3 with vitals documented as blood pressure 122/82, Temperature 97.9, pulse 86 and respirations 22. There is no indication that E12 identified the low temperature and slightly elevated pulse and respirations as a concern. R3's Nursing-Situation Background Assessment Recommendation (N-SBAR), dated 7/10/16, (unsigned) documents at 14:20 (2:20 PM) that at 9:30 AM on 7/10/16, R3 had a condition change with blood pressure 86/52, pulse 76, respirations 16, pulse Oximetry 88% on 2 Liters of Oxygen. The N-SBAR documented Patient unable to stand to assist with transfer d/t (due to) weakness, lethargy, decreased urinary output, and unable to eat/drink d/t lethargy and under A Assessment or appearance as to what the nurse thought was going on documented Dehydration, Kidney failure as the resident appeared lethargic, sluggish. The N-SBAR documented Z2, Medical Doctor, ordered to send R3 to emergency room to evaluate and treat if necessary. R3's Nursing Progress notes did not document R3's condition change. However, on 7/10/16, E4, Licensed Practical Nurse (LPN) documented admitted to hospital with [MEDICAL CONDITION]. The Emergency Department (ED) documentation, dated 7/10/16, documents R3 presented to the ER at 14:40 PM with the chief complaint of abdominal distention, pedal [MEDICAL CONDITION] with the comment documenting presents to the ED from her skilled nursing facility with new abdominal distention and pedal [MEDICAL CONDITION]. Patient is nonverbal at this time . per nursing home, patient has been more lethargic and weak. The ED Notes physical exam documents abdomen tender, distended, (bowel sounds diminished, pain pump of Lt (left) side with swelling (pedal [MEDICAL CONDITION]). The ED Notes document R3's differential [DIAGNOSES REDACTED]. R3's Computerized Tomography (CT) scan documented abdomen and pelvis demonstrates severely distended bladder with retrograde and moderate hydro[DIAGNOSES REDACTED] bilaterally. Foley catheter did not appear to be functioning and under Assessment and Plan, the report documents [MEDICAL CONDITION] due to [MEDICAL CONDITION] resulting in acute [MEDICAL CONDITION] and metabolic acidosis. The report documented The patient's [MEDICAL CONDITION], I suspect there may be some chronic component to this, but is not helped by her chronic narcotic use and The patient had at least 3.5 L (liter) of urine out since the catheter was placed in ED. Her abdomen is now soft and nontender. I suspect that just the compression of the bladder will significantly improve the patient's renal function. The report also documents the physician suspect there may be some chronic component to this, but is not helped by her chronic narcotic use and Large amount of colonic stool likely due to relative obstruction from the severely distended bladder compressing the descending/sigmoid junction. R3's Hospital History/Physical, dated 7/10/16, documented The patient had a Foley Catheter placed at the nursing home with very little urine output and R3 was cathed with procurement of around 4 L of urine, with evidence of a UTI. Urinalysis dated 7/10/16 documents R3 to have a UTI culturing positive for Escherichia Coli. An Ultra Sound Kidney study, dated 7/13/16, documented R3 to have diffuse bladder wall thickening, likely secondary to [MEDICAL CONDITION] bladder or chronic outlet obstruction. R3's Facility's Progress Notes and Skilled Notes did not document a catheter insertion on 7/10/16 prior to R3 going to the hospital. The N-SBAR of 7/10/16 also fails to reflect the catheter insertion referred to in the hospital note. On 9/20/16 at 3:10 PM, E2, Director of Nursing stated R3 condition declined rapidly with increased pedal [MEDICAL CONDITION] and some distention along with lethargy. E2 stated E5, LPN, inserted a catheter and did get some return prior to sending her out to the ED. E2 was asked why the catheter was removed and stated they assess to remove all catheters when they are admitted with one from the hospital and put them back in if needed. E2 stated she was unaware of why R3 had the catheter on admission to begin with and was unable to provide any documentation of assessment towards removing the catheter. On 9/21/16 at 9:30 AM, E5 stated she was the nurse who cared for R3 and sent her to the ED on 7/10/16. E5 stated she received no information on concerns from the night shift nurse that morning in regards to R3 and first saw R3 around 8-8:30 AM. E5 stated R3 had slight [MEDICAL CONDITION] bilateral lower extremities 3+ which was a new onset. E5 stated a little after breakfast, R3 was lethargic so she had the Certified Nurses Aides (CNAs) put her to bed. E5 stated she assessed R3 again and found no bladder retention, distention and her abdomen was soft, chest sounds clear. E5 stated she inserted a catheter and got around 350 cubic centimeters (cc) of clear urine. E5 stated she decided to send R3 to the ED because she was going downhill fast with her blood pressure dropping. E5 was asked why she inserted a catheter when R3 had no retention or distention noted on assessment and E5 stated because of the [MEDICAL CONDITION], I wanted to try to pull some of that fluid out off her legs. E5 stated she documented the catheter insertion on the SBAR. E5 stated she was unsure why R3 had the catheter to begin with and was unaware that R3 had [MEDICAL CONDITION] history. The facility policy entitled Foley Catheter Removal dated 10/2010 documents the purpose of the policy is to provide guidelines for the approval method of removing a Foley catheter. The policy documents staff are to review the resident's care plan to assess for any special needs of the resident. The policy does not refer to any monitoring and/or assessment following discontinued use of the catheter to ensure retention does not occur as is standard nursing practice. 2. R1's MDS dated [DATE] documents R1 as having cognitive impairment and has a urinary catheter. R1's Care Plan dated 8/16/16 identifies R1 to have a catheter for urinary obstruction with interventions to keep tubing off floor, catheter care as ordered, cranberry pills, as ordered and monitor for s/s of pain, burning, blood tinged or cloudiness, and no output in part. On 9/16/16 at 11:10 until 1:32 PM, R1's urinary catheter was laying on the floor under her wheelchair. At 12:56 PM, E8, CNA propelled her from the dining room to bedside in her room with the tubing dragging on the floor as they went down the hall. E8 and E7, CNAs attached the full body lift sling to the machine to lift R1 from the wheelchair to the bed. E8 placed the catheter drainage bag onto R1's lap and E7 started to lift R1 from the chair. As they lifted R1 up, the front of the wheelchair started to come up with her. The catheter tubing was caught on the backside of the leg guard across the pedals. E7 and E8 were told the tubing was caught and they lowered her, unhooked the tubing and then proceeded with the transfer to bed. R1's urine was cloudy and some white sediment in it. On 9/21/16 at 10:30 AM, E2 acknowledged that the collection bag should not have been placed onto R1's lap during the transfer and more care should have been taken to ensure that the tubing was properly placed to ensure a safe transfer.