Every finding on record at Evercare at University

Based on interview, observation, and record review, the facility failed to ensure fall prevention interventions were implemented in 1 of 4 residents (R9) when reviewed for falls in the sample of 12. This failure resulted in R9 sustaining a fall that resulted in a laceration requiring hospital evaluation and staples.Findings Include:On 8/19/26, R9 was observed in his room in a low bed, against the right wall with a floor mat to the left of R9's bed. R9 was unable to provide any details of his falls.R9's Face Sheet, undated, documents, R9 has the following diagnoses: Osteoarthritis, Parkinson's Disease, and Right Shoulder Dislocation.R9's Fall Risk Assessment, dated 6/22/26, documents R9 is at risk for falls.R9's Minimum Data Set, dated [DATE], documents R9 has severe cognitive impairment, requires substantial/maximum assist with transfers, and has a history of two or more falls.R9's Care Plan, dated 5/14/26, documents R9 is at risk for falls related to anemia, vitamin deficiency, anxiety, chronic pain, obstructive sleep apnea and parkinsonism. R9 has the following interventions listed: 6/22/26 - education provided to staff that resident cannot be left alone in his room; 4/16/26 - resident is to be in high traffic visual areas while awake and in his wheelchair. R9's Progress Note, dated 6/22/26 at 2:35 PM, documents the following: At 12:45 resident had unwitnessed fall while this nurse was in his room passing medication. This nurse heard a loud sound coming from restroom upon entering restroom resident was seen sitting on the floor on the side of the toilet. When asked what happened resident stated he fell trying to transfer himself. Upon assessment resident has small skin tear to left forearm. Resident stated he did not hit his head. No c/o (complaints of) pain or discomfort. This nurse cleaned and applied dry dressing. Resident was helped back into wheelchair by this nurse and 2 CNAs (Certified Nursing Assistant) and educated on safety precautions related to transfers. VS (vital signs) WNL (within normal limits) neuros started. MD (Medical Doctor), ADON (Assistant Director of Nurses), Administrator notified. POA (power of attorney) left voicemail to return call to facility.R9's Progress Note, dated 6/27/26 at 10:28 AM, documents the following: This nurse was notified by CNA that resident was on the floor in his room. When this nurse walked into residents' room he was sitting on the floor. Resident stated he was attempting to go to the bathroom and stood up and fell. No injury's noted to resident. No complaints of pain. Neuro checks initiated. On Call nurse notified. MD notified. POA called. Voice mail left to POA due to no answer.R9's Progress Note, dated 6/27/26 at 12:38 PM, documents the following: This nurse was notified by CNA that resident was laying on the floor. When this nurse went into resident room, resident was observed lying supine on the floor. A large amount of blood was noted on the floor. When this nurse assessed resident two areas on the posterior head were bleeding. Pressure applied to back of head to stop bleeding. Neurological assessment initiated. 911 called. Resident responsive at baseline during assessment. Report called to Nurse. V18, Medical Director notified. POA called multiple times. Voicemail left due to no answer from POA. On call nurse notified. VS. 139/81 p (pulse)90 r (respirations)16 t (temp)98.9 96% (SP02 - oxygen saturation).R9's Progress Notes, dated 6/27/26 at 2:47 PM, documents the following: Resident return back to facility via ambulance at 2:40 pm on a stretcher with 2 medics. Resident then transferred to bed in lowest position. Resident has 1 staple located at the posterior side of the scalp due to laceration. Dressing applied to resident head. Dressing clean, dry, and intact. Staple to be removed after 10 days. No other Skin issue noted. Resident has no complaints of pain or discomfort at this time. Neuro checks continued. Call light and fluids within reach. VS 148/79 R14 P62 T98.1 02 97%.R9's Progress Note, dated 7/13/26 at 4:15 PM, documents the following: Staff member alerted this writer (R9) was on the floor, this writer approached resident room observed resident on the floor sitting next to bed, this writer asked resident what happen resident stated he was trying to get to bed, ROM (range of motion) performed within normal limits, Neurochecks initiated within normal limits, lights on, no clutter, floor not wet, call light within reach, shoes on, no bruises no injuries noted at this time, no complaints of pain no discomfort no distress at this time, resident was placed in wheelchair taken to dining room, educated resident to use call light when needing help.R9's Hospital Records, dated 6/27/26, document R9 had a fall at the nursing facility and sustained a closed head injury, parietal hematoma, and a 1-inch laceration to the right scalp. Staples were placed to close the laceration.On 8/20/26 at 9:09 AM, V31, LPN (Licensed Practical Nurse), stated when R9 fell on 6/27/26 and had to go to the hospital for staples and prior to the fall he was up in his wheelchair in his room without staff.On 8/20/26 at 9:10 AM, V18, Medical Director, stated he would expect staff to be following all interventions, including fall interventions on the care plan. On 8/20/26 at 10:45 AM, V1, Administrator, stated she would expect fall interventions to be in place.The Fall Evaluation and Prevention Policy, with a review date of 6/1/25, documents the following: The purpose of this policy is 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. The facility will evaluate residents for their fall risk and develop interventions for prevention.

Based on observation, interview, and record review, the Facility failed to provide timely incontinence care for 1 of 3 residents (R5) reviewed for quality of care in the sample of 12. Findings include:R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including chronic pain and disorder of muscle. R5's Minimum Data Set (MDS) dated [DATE] documented R5 was cognitively intact, required substantial assistance with bed mobility, was dependent with transfer and toileting, and was always incontinent of bowel and bladder. R5's Care Plan dated 8/14/26 documents R5 has a self-care performance deficit in activities of daily living and is totally dependent on staff for toilet use and transfer. The Care Plan also documents R5 has bladder incontinence. On 8/19/26 at 1:15 PM, R5 was sitting up in bed in her room talking to V15, Certified Nursing Assistant (CNA). R5 told V15 she needed to be changed. V15 stated she would get someone to assist with changing R5 and left the room. R5 stated last night staff changed her and laid her down in bed at 8:30 PM. They did not change her again until 6:00 AM, despite pressing her call light twice. R5 stated staff have been using two incontinence pads at night, so they do not have to change her as often, and her urine soaked through both of them last night. R5 stated that made her feel itchy and unclean. On 8/19/26 at 1:41 PM, R5's room had been under continuous observation, and V15 had not returned to R5's room. R5's call light was still lit up and activated. On 8/19/26 at 1:44 PM, V15 and V16, CNA, came down to change R5. V15 told V16 they would apologize to R5 and let her know they got caught up helping another resident. On 8/20/26 at 8:31 AM, V1, Administrator, stated she expects staff to follow the Facility's policy regarding timely incontinence care. The Facility's Incontinence Care Policy revised 12/28/25 documents the purpose of the policy is to prevent excoriation, skin breakdown, and discomfort and maintain dignity. The guideline is incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.

Based on observation, interview, and record review the facility failed to assess, monitor and provide interventions to prevent pressures ulcers for 3 of 3 (R1, R7, R9) residents reviewed for skin breakdown in a sample of 47. This failure resulted in R7 who was admitted to facility without a pressure acquiring an avoidable stage III pressure ulcer/injury, R1 acquiring a pressure a pressure ulcer and R9 experiencing pain from pressure ulcer. Findings include:1. R7's Undated Face Sheet documents R7's initial admission date to the facility was on 2/4/2025 with diagnoses including paraplegia. R7's Nurse admission Observation dated 2/4/2025 documents skin color: normal, warm, dry and skin turgor: normal. No alternations in skin. No documentation of skin ulcers and no skin comments documented. R7's admission Braden Scale (prediction of pressure sore risk), dated 2/4/2025 moderate risk. Interventions: turning/repositioning program and application of nonsurgical dressings. Referrals that may be appropriate: occupational and physical therapy. R7's Annual Minimum Data Set, 2/13/2025 BIMS 6. R7 not at risk of developing pressure ulcers. No pressure ulcers. R7's Physician's Order Sheet (POS) dated 2/26/2025 documents weekly skin assessment. R7's Nurse Progress Note, 3/10/2025 at 5:45 PM area noted to left buttock, measures 3.0 x 3.0 Orders received for collagen and dry drsg (dressing) daily and PRN (as needed). No documentation of wound bed or what stage the wound was. R7's POS dated 3/11/2025 documents left buttock pressure ulcer apply medihoney and ca + alginate. R7's Care Plan, dated 3/11/2025 documents pressure ulcer to left buttock. Goal: pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included: enhanced barrier precautions, follow facility protocols for the prevention/treatment of skin breakdown, assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (physician), administer treatments as ordered and monitor for effectiveness. No interventions documented in R7's medical record to prevent skin breakdown/pressure ulcers although is was assessed to be at moderate risk upon admission. R7's Nurse Progress Note, dated 3/19/2025 at 12:49 PM documents wound care preformed to left buttock with 100% granulation tissue, with measurements as follows: 2.8 cm x 2.5 cm x 0.2 cm with per-wound clean, dry intact with no s/s of infection noted and treatment remains the same. R7's Weekly Skin Checks dated, 3/21/2025 through 6/10/2025 no documentation of left buttock pressure ulcer measurements or wound bed assessment. The Facility's Wound Spreadsheet documented all residents with skin breakdown from 3/2025 through 7/2025 including R7's wound. The spreadsheet documents R7 had a wound on his left ischium, no documentation of what was the wound was classified as or what stage pressure ulcer it was. R7's Weekly Skin Check, dated 6/11/2025 documents 1 inch by 1 inch round wound on medial coccyx and migration to left buttock. Notes: this resident has pre-existing wound to medial coccyx area which is migrating to left buttocks. R7's Weekly Skin Checks dated, 6/21/2025 through 7/15/2025 no documentation of left buttock pressure ulcer measurements or wound bed assessment. R7's POS dated 7/8/2025 documents wound nurse practitioner to evaluate and treat. R7's Wound Nure Practitioner (NP) Progress Note, dated 7/9/2025 documents reason for not seeing patient today: patient scheduled to be seen today, but visit was unable to be completed due to pt (patient) up at breakfast and decline to lay down. R7's Electronic Medical Record, dated 3/2025 through 7/15/2025 staff documented weekly skin checks for the left buttock pressure ulcer no documentation of weekly pressure ulcer measurements or wound bed assessment was documented. R7's Initial Wound NP Progress Note, dated 7/16/2025 evaluation of left buttock pressure ulcer which was noted on 3/12/2025 currently treating with silver alginate. Healing complicated incontinence of urine and feces. No recent labs available for review. Wound assessment: Stage III measured 2.0 cm x 2.0 cm x 0.3 cm 100% granulation, subcutaneous tissue exposed, wound edges attached, moderate sanguineous exudate. Interventions: off loading cushion for (reclining geriatric chair) and consult dietician. R7's Electronic Medical Record dated after 7/16/2025 no documentation of dietician consult until 10/14/2025. R7's Registered Dietitian (RD) Progress Note, dated 10/14/2025 documents increased nutrient needs r/t (related to) impaired skin integrity and recent weight loss AEB (as evidenced by) current weight = 169# an 11# significant loss x 1 mo. (-6.1%), 18# significant weight loss x 3 mo. (-9.6%). BMI = 24.9 (w/i normal range). Stage III pressure wound to L (left) buttock. R7's Quarterly MDS, dated [DATE] BIMS 3. Resident at risk of developing pressure ulcers. One Stage II unhealed pressured ulcers. Skin and Ulcer treatments: pressure reducing device for chair, pressure ulcer care, application of nonsurgical dressings and applications of ointments/medications. R7's Wound NP Progress Note, dated 12/17/2025 documents NP ordered a low air loss mattress for pt (patient) – ordered by nursing was documented. On 2/9/2026 at 10:35 V22, Facility Wound Nurse and V33, CNA entered R7's room to provide pressure ulcer treatment. V33 uncovered R7 and revealed there was no dressing on the pressure ulcer on R7's left buttock at that time. V33 stated she had just provided incontinence care, and the dressing was soiled so she removed it approximately 25 minutes ago and knew that V22 was going to do the treatment. V22 completed the left buttock pressure ulcer dressing treatment with no concerns noted. V22 measured the pressure ulcer on R7's left buttock at that time it measured 2.0 centimeters x 2.0 centimeters x 0.5 centimeters. V22 stated the wound bed had 70% granulation tissue and 30% dark (slough) tissue. On 2/9/2026 at 9:30 AM R7 was observed sitting up in his reclining geriatric chair in his room. There was no low air loss mattress on his bed at that time and no cushion in his reclining geriatric chair. R7 stated he has a sore on his butt. On 2/9/2026 at 2:05 PM R7 lay in bed with his reclining geriatric chair next to his bed, there was no cushion in his reclining geriatric chair at that time. On 2/10/2026 at 8:05 AM R7 was observed laid back in his geriatric reclining chair in the dining room asleep there was no cushion in his geriatric reclining chair at that time. On 2/10/2026 at 8:20 AM V31, CNA stated R7 doesn't have a cushion in his geriatric reclining chair, and he never had one. V31 stated R7 requires activities of daily living (ADL) for all ADLs including incontinent of bowel and bladder, turning and repositioning and he doesn't communicate verbally. V31 stated there is an open area on R7's buttock that has been there for a while. On 2/9/2026 at 10:55 AM V22 stated this was her third day working at the facility as the wound nurse and she doesn't know all residents' interventions in place to promote wound healing, relief pressure and to offload the pressure ulcer. V22 stated she didn't know why R7 didn't have a low air loss mattress and didn't know if R7 had a cushion for his geriatric reclining chair. On 2/10/2026 at 8:55 AM, V22 stated she was the new wound nurse at the facility, and she doesn't know who was responsible for updating the resident's care plan when a new pressure ulcer is assessed and didn't know who reviews the wound nurse practitioner's documentation to order new ordered equipment like a geriatric reclining chair cushion and a low air loss mattress. On 2/10/2026 at 9:00 AM V15, MDS nurse stated the wound nurse is responsible for everything regarding wounds including pressure ulcers. The wound nurse is responsible for updating the resident's care plan when a new pressure ulcer is assessed, to review wound nurse practitioner weekly assessments, to order recommended supplies for residents that have a pressure ulcer and to assess and document pressure ulcers weekly when a resident isn't being assessed by the wound nurse practitioner weekly. The wound nurse is also responsible to provide pressure ulcer treatment daily Monday through Friday. On 2/9/2026 at 2:18 PM V7, LPN stated she is the day shift nurse and assigned to R7 often. V7 stated R7 doesn't have a cushion in his geriatric reclining chair and doesn't have a low air loss mattress but that he probably should because he has a stage III pressure ulcer on his buttock. On 2/10/2026 at 10:30 AM V25, Former Facility Wound Nurse stated he worked at the facility Monday through Friday as the wound nurse from late June 2025 to January 2026 and he quit because he couldn't get administration to order supplies that the wound nurse practitioner ordered to promote pressure ulcer healing, offload and relive pressure for pressure ulcers including for R7 to have a cushion in his geriatric reclining chair and a low air loss mattress on his bed. V25 stated he asked administration weekly for these items for R7 and his requests fell on deaf ears. V25 stated he doesn't know why the supplies were not ordered but he thinks it was due to the cost of the supplies. V25 stated he requested the wound nurse practitioner to assess R7's pressure ulcer shortly after he started working at the facility in late June 2025 because after reviewing his medical record and noted the pressure ulcer wasn't healing it needed to be assessed by the wound nurse practitioner. V25 stated he assessed and documented R7's pressure ulcer which was located on his left buttock not his ischium and he doesn't know the facility was documenting the pressure ulcer on R7's ischium because it was definitely on his left buttock. On 2/9/2026 at 12:25 PM V2, Director of Nurses (DON) stated when a resident has a new open area staff are expected to assess the area, document the measurements and assessment of the wound bed, classification of the wound, notify the provider of the wound and get a treatment order. The facility wound nurse is responsible for updating the residents care plan with interventions to prevent the pressure ulcer from getting worse. V2 stated the wound nurse practitioner comes to the facility weekly and assesses all wounds, including pressure ulcers. V2 stated all residents that have wounds including pressure ulcers are assessed by the wound nurse practitioner weekly. V2 stated she didn't know R7 had a new open area in March 2025 and wasn't assessed by the wound nurse practitioner until 7/16/2025. V2 stated she didn't know the specifics of R7's pressure ulcer and/or interventions that have been recommended by the wound nurse practitioner or what interventions were currently in place. V2 stated she wasn't at the facility at this time and she refused to answer questions regarding resident care in 2025. On 2/9/2026 at 2:40 PM V12, Regional [NAME] President of Clinical Operations stated the facility assessed and documented R7's pressure ulcer. All measurements and wound bed assessments are documents on a spreadsheet that have other residents names on it. V12 stated she doesn't know if R7's weekly pressure ulcer assessments were documented in his electronic medical record. V12 stated R7 had a pressure ulcer located on his ischium but it merged with his left buttock. On 2/10/2025 at 9:00 AM V1, Administrator stated R7's left buttock pressure ulcer was documented assessed and documented on the facility's wound spreadsheet but it was labeled as R7's left ischium, not his left buttock and that it was a transcription error. On 2/10/2026 at 10:00 AM V22, R7's Wound Nurse Practitioner stated she recalled R7 and his pressure ulcer on his left buttock. V22 stated when she initially assessed R7's left buttock and classified as a Stage III pressure ulcer. V22 stated the facility had several different wound nurses over the last year and it makes it difficult to provide continuity of care. V22 recalled she ordered 2 items to offload, provide pressure relief and promote healing which was a cushion for R7's geriatric reclining chair and a low air loss mattress for his bed. V22 stated she asked V25, the Former Facility Wound Nurse multiple times for the geriatric reclining chair cushion and Low Air Loss mattress for R7 and V25 told her he let administration know she ordered it but they haven't ordered it yet. V22 stated administration called her 2/9/2026 and they told her R7's pressure ulcer was documented on his ischium and she told that she assessed it and it was actually located on his left buttock and not his ischium. V22 stated the left buttock and ischium are not the same areas and she expected the facility to document the correct anatomical location of resident's with pressure ulcers, including R7's. V22 stated when a resident is admitted to the facility and is documented as moderate risk for pressure ulcers she expects staff to address pressure ulcer risk on their care plan including interventions to prevent pressure ulcers. V22 stated R7 is dependent on staff for turning and repositioning, is incontinent of bowel and bladder and has a diagnosis of paraplegia which makes him at risk for skin breakdown. V22 stated she assesses R7's left buttock Stage III pressure ulcer every Wednesday and he is often incontinent of urine at that time which hinders the healing of the pressure ulcer. V22 stated when a resident is admitted to the facility with no pressure ulcers she expects staff to ensure interventions are in place to prevent avoidable pressure ulcers and R7's left buttock pressure ulcer was avoidable due to staff not implementing interventions to prevent pressure ulcers. 2. R1's Care Plan, dated reviewed/revised 08/13/2025, documents that Problem: R1 was admitted with pressure ulcers to my sacrum, right ischium, left ischium, right distal leg, right middle toes, upper back, and right upper thigh. R1's co morbidities include: dementia, hx (history of) of CVA (stroke), Hx of bariatric surgery, anemia, cachexia, abnormality of albumin and functional quadriplegia. It also documents Approach: Follow facility protocols for the prevention/treatment of skin breakdown. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. This resident at risk of developing pressure ulcers/injuries. On 2/5/2026 at 11 AM observed V20, Wound Nurse, perform treatment to R1 multiple wounds. R1 lying in bed. Foam boots in place to bilateral feet. Observed a large amount of red and brown drainage to R1 left boot. V20 opened boot and observed an open linear red area with red and brown drainage to forth toe. Area was protruding from beneath nail. Observed the toenail over the tip of the toe and into the skin. Observed dried brown and red drainage to the left side of the 3rd toe. When toes separated observed a linear red open area with brown drainage. Area to 3rd toe was linear in shape with red wound bed. Observed R1 facial grimacing when toes were manipulated by V20, Wound Nurse. On 2/5/2026 at 11:00 AM V20 stated that she was not aware of an open area to R1's toes. V20 stated that the areas area new. V20 stated that the toenail had grown over into the skin of the toe creating pressure causing the wound. V20 stated that it then pressed into the side of the other toe causing the pressure area. V20 stated that she was not aware of the pressure ulcer and verified that there was not treatment for it. On 2/5/2026 at 12:40 PM V19, Physician, stated that he was not aware of R1's toenails growing over and into her skin causing a wound to her left foot 4th toe. V19 stated that he was not aware of this. V19 stated that with this R1 would be experiencing pain. V19 stated that the toenail pain was the worst type of pain. V19 stated that the facility has a podiatrist and would expect R1 to have been seen by the podiatrist for R1's nails prior to injury. 3. R9's Care Plan, dated 1/26/26, documents that R9 require assist for my ADLs (activities of daily living) r/t (related to) comorbidities, require 1 assist with bed mobility. R9's Minimum Data Set (MDS), dated [DATE], documents that R9 is cognitively intact. R9's Norton Scale, dated 1/26/2026, documents that R9 is at risk for skin breakdown. R9's Progress Notes, dated 01/30/2026 at 6:06 PM, documents that upon skin assessment, area noted to right heel, 3x2xUTD (unable to determine) poa (power of attorney) and dr (doctor) notified. new orders for betadine and ca alginate and cover with silicone foam dressing. monitor for s/s (signs/symptoms) of infection and notify md if present. On 2/5/2026 at 9:46 AM Observed R9's skin. Observed large opened circular wound to the heal of the right foot. The wound bed was black in color. No dressing in place. Dressing removed from inside sock was dated 2/3/2026. On 2/5/2026 at 9:46 AM R9 stated that the nurses don't do her treatments. R9 stated that she has wound to her left foot and her right. R9 stated that the nurses perform the treatment to the left foot but forget about the right. R9 stated that they don't listen to her when she tells them. R9 stated that her legs have spasms and it difficult if not impossible at times to straighten her legs. R9 stated that sometimes they press into the mattress, and she can't move them. R9 stated that they put these things on her feet, but they don't stay in place. R9 stated that they come off. R9 stated that the wounds are painful. On 2/5/2026 at 9:50 AM R108 stated that it depends on which nurse is on the hall if the treatments will be completed. R108's MDS, dated [DATE] documents that R108 is cognitively intact. On 2/5/2026 at 1:25 PM V20 stated that the wound to R9's right heal is a pressure ulcer. The Facility's Wound Management Policy reviewed 9/5/2025, documents purpose: to provide a system for the treatment and management of residents with wounds including pressure ulcers. Policy: a resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Procedure: a licensed nurse will perform a skin assessment weekly and as needed for each resident. Upon identification of a new wound the licensed nurse will: measure the wound (length, width, depth), initiate a wound monitoring record sheet, implement a wound treatment per physician's orders. An assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to: identifying risk factors, treatment, mechanical offloading and pressure reducing devices, reducing skin friction, sheet and moisture, nutritional status and evaluation and modifying interventions for a resident with an existing PU (pressure ulcer.) Wound management: the attending physician will be notified to advise on appropriate treatment promptly, dietary contact will be made for nutritional assessment and rehabilitation services will be contacted for appropriate devices or pressure redistributing devices, a licensed nurse will develop a care plan for the resident based on recommendation from dietary, rehabilitation and the attending physician, per attending physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management, the attending physician and interdisciplinary team (IDT) will be notified of new pressure ulcers, pressure ulcers that do not respond to treatment, pressure ulcers that worsen. Documentation: wound documentation will occur at a minimum of weekly until the wound is healed. Documentation will include: location of wound, length width and depth measurements recorded in centimeters, appearance of the wound base, drainage amount and characteristics including color, consistency and odor, appearance of wound edges, description of the peri-wound condition or evaluation of the skin adjacent to the wound, presence or absence of new epithelium at wound rim and presence of pain. IDT will document discussion and recommendations for pressure ulcers that do not respond to treatment and pressure ulcers that worsen. Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis; document notifications following a change in the resident's skin condition and update the resident's care plan as necessary.

Based on observation, interview and record review the facility failed to perform timely incontinent care for 1 of 3 (R9) residents reviewed for incontinent care in a sample of 47. This failure resulted in R9 feeling embarrassed, ashamed, and miserable. This failure also resulted in R9 obtaining opening areas to her right buttock and experiencing pain as a result. R9's Care Plan, dated 10/27/2025, documents that Resident experiences bladder incontinence. It continues Provide incontinence care after each incontinent episode. It also documents that Apply moisture barrier to skin. R9's Minimum Data Set, dated [DATE], documents that R9 is cognitively intact and dependent on staff for toileting. On 2/2/26 at 8:25 AM observed V5, Certified Nurse Assistance (CNA), provide incontinent care for R9. Upon entering room, a strong, foul urine odor in room. R9 was incontinent of bowel and bladder. V5 removed cover from top of R9 revealing heavily soiled and saturated incontinent brief. The incontinent pad that R9 was lying on top of was wet with dark brown rings. V5 opened the incontinent brief and pulled from between R9's legs and inside of incontinent brief was saturated and brown. V5 cleansed R9's peri area and then assisted R9 onto her right-side revealing stool on R9's buttocks. V5 then rolled the brief and incontinent pad beneath V5 revealing a urine soiled and dried brown rings on sheet. V5 removed heavily soiled linen from bed. On 2/2/26 at approximately 8:28 AM R9 stated that she had not been cleansed at all on the night shift. R9 stated that she does not get any care. R9 stated that she lays in filth all night. R9 stated that they don't take care of her because she is not quiet. R9 stated that she is truthful and can be rough but that doesn't mean she should have to lay in her own waste. R9 stated that she waits so long that she falls asleep in her own filth and when she wakes up she is still dirty. R9 stated that she has never lived like that and feels embarrassed and ashamed because she stinks and is miserable. R9 stated that How would you feel if you were left to rot in your own s**t. R9 stated that she gets changed on the day shift. V5 and V6, CNA, provide good care to her and get her cleaned up. V5 stated that she shouldn't have to wait until they come in to be cleaned. On 2/2/26 at approximately 8:30 AM R108 stated that the staff on the midnight shift is horrible. R108 stated that sometimes they get care and sometimes they don't. R108 stated that they don't come in the room until about 4 AM. R108 stated that the weekend was horrible and they suffered. On 2/2/26 at 8:32 AM V5 stated that this is the first time he is changing R9. V5 stated that R9 is incontinent of both urine and bowel and dependent on staff for care. On 2/5/2026 approximately 9:46 AM observed V5 perform incontinent care. R9 was incontinent of urine. V5 opened the heavily soiled incontinent brief. V5 then cleansed R9's peri area. V5 then turned R9 onto her right side and cleansed R9's left buttocks, V5 then turned R9 onto the left side. Observed multiple open areas in various shapes and sizes to R9 right buttocks. On 2/5/2026 at 9:46 AM R9 stated that the areas to her buttocks burn. R9 stated that she told the CNA she was wet on nights. R9 stated that she was incontinent of stool around midnight. R9 stated that she told the CNA and the CNA informed R9 that she would be back. R9 stated that she was changed around 3:30 AM. R9 stated that shortly after that she went again. R9 stated that she then informed the CNA that she went again, the CNA informed R9 that she would be back and never came back. On 2/5/2026 at 9:50 AM V5 stated that the area to R9's right hip is new. On 2/6/2026 at 12:50 PM V1, Administrator, stated that she would expect her staff to perform rounds at least every 2 hours. V1 stated that she was not aware of residents not receiving care from 10:00 PM to 4 AM. V1 stated that the night shift is a shift that she has found to have some care problems. V1 stated that she is currently coming in unannounced to assure care is being completed. The facility's Incontinence Care policy, revised date 12/28/25, Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.

Based on interview and record review, the Facility failed to provide the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 99 residents living in the facility.Findings include: The Facility's Daily Staffing Schedules were reviewed for 8/1/25 through 2/6/26. These schedules do not document a RN worked for at least eight hours consecutive on 8/30/25, 8/31/25, 9/13/25, 9/14/25, 9/20/25, 9/28/25, 10/4/25, 10/5/25, 12/25/25, 12/21/25, 1/3/26, 1/4/26, 1/17/26, 1/18/26, 1/31/26, 2/1/26.On 2/6/26 at 10:28 AM, V15, Minimum Data Set Coordinator, stated that she does the schedule for the nurses. V15 stated there are days without RN coverage in the building. V15 stated that because they have IV's the RNs are schedule for those and that is 2 to 4 hours.The facility's Staffing policy, dated 12/5/2025, documents that POLICY: 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 need; by shift will be calculated based on the resident census and needs. Licensed nurses are required to be licensed by the State in which they are practicing. Copies of current licenses shall be displayed in the facility. Nurse Aids are required to be certified by the State in which the facility is located in compliance with Federal and State regulations. In addition, employees providing hands on care to residents shall agree to a criminal records search to demonstrate he/she has no convictions of abuse, neglect, or misappropriation of resident property according to State regulations. No person may provide direct resident care without certification and records check. RN are required to be licensed by the state in which they are practicing. Copies of current licenses shall be displayed in the facility.The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 2/2/26 documents there are 99 residents living in the Facility.

Based on interview and record review, the Facility failed to offer and provide influenza and pneumococcal vaccines for 4 of 4 consenting residents (R31, R36, R64, R81) reviewed for infection control in the sample of 47. Findings include: On 2/10/25 at 3:00 PM, V3, Assistant Director of Nursing (ADON), provided influenza and pneumococal vaccine records for R31, R36, R64, and R81. 1-R31's Face Sheet documents R31 was admitted to the facility on [DATE]. R31's Pneumococcal Vaccine Consent dated 9/5/25 documents R31 consented to the pneumococcal vaccine. There was no documentation that R31 received the pneumococcal vaccine. 2-R36's Face Sheet documents R36 was admitted to the facility on [DATE]. R36's Annual Influenza Consent Form dated 9/25/25 documents R36 consented to the influenza vaccine. There was no documentation that R36 received the influenza vaccine. 3-R64's Face Sheet documents R64 was admitted to the facility on [DATE]. R64's Pneumococcal Vaccine Consent Form was dated 12/12/24 and documented R64 consented to the pneumococcal vaccine. There was no documentation that R64 received the pneumococcal vaccine. 4-R81's Face Sheet documents R81 was admitted to the facility on [DATE]. R81's Pneumococcal Vaccine Consent Form was dated 12/2/24 and documented R81 consented to the pneumococcal vaccine. There was no documentation that R81 received the pneumococcal vaccine. On 2/10/25 at 7:55 AM, V3 stated she just took over the Infection Preventionist (IP) role in January 2026 and does not think the previous IP gave the pneumonia vaccines. She stated R36 has not yet received the influenza vaccine. R81 does not have updated vaccine consents since 2024, to she will talk to her power of attorney about that. On 2/10/26 at 11:20 AM, V1 stated she expects vaccinations to be given per Facility policy. The Facility's Undated Influenza/Pneumococcal/RSV (Respiratory Syncytial Virus) Immunizations Policy documents, Purpose: To minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumococcal pneumonia. Once a consent is signed indicating that they wish to receive the influenza vaccine, this consent is valid for the duration of the resident's stay and the influenza vaccine will automatically be given annually. Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period. Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized. The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident either received or did not receive the pneumococcal immunization due to medical contraindications or refusal.

Based on observation, interview, and record review, the facility failed to properly store medication and discard expired medication for 5 of 5 (R4, R12, R79, R92, R109) residents in reviewed for medication storage in a sample of 47. Findings include: On [DATE] at 9:15 AM the B Hall medication cart was inspected. In the medication cart's insulin section for all resident on the hall cart contained the following: R92's open and partially used multidose Lispro vial with open date 12/25 handwritten on vial and expiration date on vial [DATE].R79's open and partially used multidose Lispro vial with handwritten open date [DATE].R4's open and partially used multidose Gargline vial with handwritten open date [DATE].R12's open and partially used multidose Lantus vial. No open date on vial. On [DATE] 9:15 AM V4, Licensed Practical Nurse (LPN), stated that R92's medication was expired and should have been destroyed. V4 stated that R79's and R4's medication was after the use by dated and should be destroyed. V4 stated that R12 is discharged from the facility and medication should not be in the cart. On [DATE] at 8:30 AM V4 stated that the section of the cart where the above medication was found is for active residents and not a holding area for expired medication. V4 stated that the locked refrigerator in the medication room is also for active residents and not a holding area for expired medication. On [DATE] at 10:00 AM the facility Medication room was inspected. Upon entrance to the medication room the refrigerator was unlocked. The unlocked refrigerator located in the medication contained: 5. R109'S bottle of liquid Lorazepam.6. Observed pad lock lying on top of refrigerator. On [DATE] at 10:00 AM V15, Minimum Data Set Coordinator (MDSC), stated that the liquid Lorazepam was a controlled substance and is to be under a double lock system. V15 stated that the double lock system is the locked medication room and locked refrigerator. V15 agreed if the refrigerator was locked then the controlled drug would be under the double lock system. V15 stated that the pad lock lying on top of the refrigerator was what is used to lock the refrigerator and create the double lock system. On [DATE] at 8:05 AM V2, Assistant Director of Nursing, stated that when the insulin multidose vials and pens are first used the nurses are to transcribe the open date on the pen, vial and or bag. V2 stated that the medication is good for 30 days after opening and then are to be discarded. V2 stated that if a medication is expired it is to be destroyed. V2 stated that if a resident expires or discharges the medication is either destroyed at facility or returned to the pharmacy. V2 stated that the insulins after 30 days opened, expired, and discharged medication should be removed from the cart and destroyed. V2 stated that controlled medication requiring refrigeration are to be under a double lock system. The locked medication room as 1 and the locked refrigerator as 2. V2 stated that the refrigerator has a locked pad lock. V2 stated that the refrigerator should be always locked. The facility's medication Storage policy, dated [DATE], documents that Guidelines 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed returned to the supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened dateOf expiration once opened. 12. Controlled Substances Storage: 1. Facility should ensure that Schedule II-V controlled substances are only accessible to licensed nursing, Pharmacy and medical personnel designated by Facility. 2.Afterreceiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law) and doublelocked (i.e. locked narcotic drawer inside locked medication cart or locked box in locked medication room). 3.Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. 15. Facility should ensure that medications and biologicals for expired or discharged residents are stored separately, away from use, until destroyed or returned to the provider. 16. Facility should destroy or return ll discontinued, outdated/expired, or deteriorated Medications or biologic Law. ls in accordance with Pharmacy return/destruction guidelines and other Applicable 17. Facility\personnel should inspect nursing station storage areas for proper storage compliance on a regular scheduled basis.

Based on interview and record review the facility failed to complete quarterly smoking risk assessments for 2 of 3 residents (R5 and R88) reviewed for assessments in a sample of 47. Findings Include:1. R5's Face Sheet, admit date : [DATE] (current), documented he has diagnoses of but not limited to Chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, cirrhosis of liver, and acute hepatitis C without hepatic coma. R5's Minimum Data Set (MDS), dated [DATE], documented R5 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and requires supervision or touching assistance, and partial/moderate assistance with his activities of daily living (ADLs). R5's Care Plan, not dated, documented R5's preferences are to smoke while at the facility. Goal R5 will smoke with appropriate safety precautions and experience no injury to others when I smoke through the next review. Approach complete smoking assessment quarterly and prn (as needed). R5's Electronic Medical Record (EMR) was reviewed and on 09/23/2025 R5 had a smoking risk assessment completed by V11, Social Service Director. There were no other smoking risk assessments found in R5's EMR. 2. R88's Face Sheet, admit date : [DATE] (current), documented R88 has diagnoses of but not limited to Emphysema, Acute bronchitis, COPD, and nicotine dependence. R88's MDS, dated [DATE], documented R88 was cognitively intact with a BIMS of 15 out of 15 and is independent with all his ADLs. R88's Care Plan, admit date of 12/01/2025, documented R88's preferences are to smoke while at the facility and currently do not want to participate in a smoking cessation program. Goal R88 will smoke with appropriate safety precautions and experience no injury to others when he smokes through the next review. Approach complete smoking assessment quarterly and prn. R88's EMR was reviewed and there was no smoking assessment completed upon his admission. On 02/10/2026 at 09:55 AM V1, Administrator stated she would expect smoking risk assessments to be completed quarterly and upon a change. On 2/10/26 at 7:31 PM, V1, Administrator, stated she expects Facility staff to follow their smoking policy. Findings Include: The facility's Smoking by Residents Policy, reviewed 09/04/25, documented Purpose To respect resident choice to smoke and to maintain a safe healthy environment of both smokers and non-smokers. It further documented Policy IV. Residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas. It also documented Procedure I. Smokers shall be identified at the time of the admission process if resident identifies as a smoker and upon request. II. A licensed nurse will completed a smoking assessment during the admission process and quarterly for residents who wish to smoke. A. All smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly as outlined by OBRA assessment timeframes.

Based on observation, interview, and record review, the Facility failed to ensure food was provided in a form to meet individual needs for 2 of 2 residents (R64, R95) reviewed for food and nutrition services in the sample of 47.Findings include: 1-R64's Face Sheet documents R64 was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities and gastro-esophageal reflux disease. R64's Minimum Data Set (MDS) dated [DATE] documented R64 was severely cognitively impaired, ambulated via wheelchair, had coughing or choking during meals or when swallowing medications, and was on a mechanically altered diet. R64's Diet Order dated 11/3/25 documents pureed diet with thin liquids. R64's Care Plan starting 8/12/25 documents, Serve diet as ordered. R64's Meal Card for lunch on 2/2/26 documents pureed diet with thin liquids. On 2/2/26 at 11:58 AM, R64 was feeding herself lunch in the dining room. On 2/2/26 at 12:06 PM, observed R64's pureed tray. The broccoli contained chunks that were larger than grains of rice. On 2/2/26 at 12:08 PM, V28, Cook, stated she tries to get the pureed items free of all chunks. On 2/2/26 at 12:10 PM, V17, Dietary Manager, stated she thinks V28 is still new at her job and did not leave the broccoli in the blender long enough. 2-R95's Face Sheet documents R95 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), disturbances of salivary secretion, and dysphagia (difficulty swallowing). R95's MDS dated [DATE] documented R95 was moderately cognitively impaired, ambulated via wheelchair, had coughing or choking during meals or when swallowing medications, and was on a mechanically altered diet. R95's Diet Order dated 11/5/24 documents pureed solids with honey thickened liquids. R95's Care Plan starting 8/3/19 documents, Serve diet as ordered. R95's Meal Card for lunch on 2/2/26 documents pureed diet with moderately thick liquids. On 2/2/26 at 12:25 PM, R95 was sitting at a table in the dining room coughing loudly with green chunks coming out of his mouth. V3, Assistant Director of Nursing (ADON) came over and patted R95 on the back which expelled a green chunk approximately one inch in diameter. On 2/6/26 at 9:43 AM, V16, Speech Language Pathologist (SLP), stated pureed foods should be blended and should not contain any chunks. R64 and R95 should be on pureed diets. R95 has severe dysphagia and really needs a pureed diet. On 2/10/26 at 7:31 PM, V1, Administrator, stated she would expect dietary staff to follow their policy regarding pureed diet preparation and consistency. The Facility's Pureed Policy from (Contracted) Dietary Service Menu Guide documents food should be processed until there is a smooth, pudding-like or smooth, mashed potato consistency.

Based on observation, interview, and record review the facility failed to assess, monitor, supervise and implement interventions for 2 of 6 (R9, R31) residents reviewed for accidents and supervision in a sample of 47. Findings include:1. R9's Care Plan, revised dated 1/19/2026, I have experienced an actual fall on 11/2/25, 1/17/26 1/19/26. It also documents Date: 11/03/2025 Continue interventions on my at risk fall care plan. 01/17/2026 Low bed. 01/19/2026 Fall mats at bedside. R9's Progress Notes, dated 11/02/2025 at 4:30 PM, documents that This nurse was outside of resident's room when a resident roommate called for me, i went in and seen resident on the floor and wheelchair is tipped over forward when she was reaching forward to put something on bed and her legs still behind the foot pedals. resident stated she put her hands out and did not hit her head, full assessment completed, no deformity noted, full ROM (range of motion); baseline for resident, perrla (pupils equal, round, reactive to light and accommodation), neuros in place. skin tear noted to left shin, new orders for TAO (triple antibiotic ointment) and cover with drsg. (dressing) dr notified. R9's Progress notes, dated 01/17/2026 at 8:30 AM, documents that at 0815 resident was calling for help asking to get help off the floor, nurse entered the room and resident was sitting up leaning against the bed and the dresser, this nurse asked what she was doing prior to fall and she stated she was laying in bed but her leg spasms caused her to fall out of bed, this nurse asked if she had any pain from the fall and resident denied, resident stated she hit her head on the dresser drawer, neuros initiated and WNL (within [NAME] limits) VS (vital sign) 98.7, 83, 16, 137/86, 97%, no new skin issues noted at this time, 2 CNAs (Certified Nurse's Assistant) transferred resident back in bed using mechanical lift, wheeled to the dining room to eat breakfast, on call nurse and MD made aware. R9's Event Report, dated 1/17/2026, documents R9 observed on floor next to bed. R9's Fall Investigation Worksheet, dated 1/18/2026, documents R9 fall to floor with root cause leg spasm R9's progress notes, dated 01/17/2026 at 2:55 PM As resident was being wheeled to the dining room she stated y'all better call me an ambulance or I will. This nurse went over to where resident was sitting in the dining room and asked what was going on and why she needed an ambulance, resident stated I am in so much pain and no one cares This nurse asked the location of pain and assured it is priority to keep residents as pain free as possible, resident stated the location was her neck and left shoulder, this nurse educated we can get a doctors order to do an in-house x-ray and resident was unsatisfied, let resident know X ray could be done today, at 1505 (local) Police Department called and stated resident called 911 for herself to go to the hospital. MD and on call nurse made aware. R9's Local Hospital Patient Visit Summary, dated 1/17/2026, documents that R9 was seen for a Fall and Contusion of left shoulder. R9's Progress Notes, dated 01/19/2026 at 02:29 AM Resident heard yelling for help. Upon entering room resident was observed sitting on floor next to her bed. Resident denies pain or discomfort. VS as follows 114/70, 97.2, 18, 88, 93% on room air. Resident stated she fell out of bed d/t (due to) her muscle spasms. ROM (range of motion) x 4 WNL (within normal limits) for this resident. No injuries noted. Resident assisted back to bed via 3 staff members. Resident resting in bed with call light in reach. Resident also stated she did not want her emergency contact call d/t it being too early in the morning. On 2/2/2026 at 8:25 AM R9 lying in bed. Bed in high position. No floor mat in place. No floor mat observed in room. On 2/5/2026 at 9:46 AM R9 lying in bed. Bed in high position. No floor mat in place. No floor mat observed in room. On 2/6/2026 at 8:15 AM R9 lying in bed. Bed in high position. No floor mat in place. No floor mat observed in room. On 2/5/2026 at 9:46 AM R9 stated that she has fallen out of bed several times due to the spasms in her legs. R9 stated that when she falls, she lays on the floor for a long time. R9 stated that she is not sure of the time, but it feels like it's a long time. On 2/9/2026 at 10:27 AM V1, Administrator, stated that she expects the fall interventions to be put in place. On 2/9/2026 at 12:42 PM V2, Director of Nursing, stated that R9 has had multiple falls from the bed. V2 stated that R9 says it because of spams in her leg. V2 stated that R9 has attention seeking behaviors and has noticed that R9 hangs her feet across the bed and believes this is what is causing the fall. V2 stated that after each fall an intervention was created and that she expects the staff to put them in place. On 2/10/2026 at 1:00 PM V3, Assistant Director of Nursing, stated that after a fall the IDT review the fall and an intervention is created. V3 stated at that time the nurse is notified of what the intervention is and is responsible for putting the intervention in place. V3 stated that she does not perform in-services and that the nurse notifies the staff when they work the hall of the interventions. V3 stated that there is no reason that R9's interventions shouldn't be in place. V3 stated that she expects the interventions to be in place. The facility's Fall Evaluation and Prevention policy, dated 6/1/25 documents that Following the resident's evaluation, transfer the resident to the appropriate surface and evaluate further if indicated. Monitor closely for indications of pain or discomfort in any area, reddened or discolored areas, or other signs of an injury. Evaluate the environment where the fall occurred, noting any factors that may have contributed to the fall. Ask the resident what happened prior to the fall or what may have caused the fall. Root cause. The IDT team will review the plan of care and update the interventions as appropriate. 2-R31's Face Sheet documents R31 was admitted to the facility on [DATE] with diagnoses including smoking. R31's Minimum Data Set (MDS) dated [DATE] documented R31 was cognitively intact and ambulated by wheelchair. R31's Care Plan dated 8/28/25 documents R31's preferences are to smoke while at the facility and, require actual assistance with smoking, and is not allowed to keep smoking material in her room. R31's Progress Note by V18, Licensed Practical Nurse (LPN), dated 1/24/26 at 9:03 AM documents Certified Nursing Assistants (CNAs) noticed a strong cigarette odor by the nurse's station. After investigating, the CNA found R31 in her room with visible smoke in the room. V18 asked R31if she was smoking, and R31 said, Not anymore. V18 and CNAs searched the room for cigarettes and discarded them. On 2/6/26 at 10:34 AM, V18 was unavailable by phone. On 2/02/2026 9:10 AM, R31 stated she found a cigarette butt in the front lobby, and another resident let her borrow their lighter She brought the lighter and the cigarette into her room, went in the bathroom, lit the cigarette, took a puff, and then flushed it. She stated staff must have smelled smoke because they came in her room, but she had already flushed the cigarette down the toilet. She gave the lighter back to the resident who gave it to her but would not give the name of that resident. On 2/6/26 at 9:30 AM, V11, Social Services Director (SSD), stated R31 had recently lost smoking privileges when the incident occurred. R31 told V11 she had a couple cigarettes hidden and only took a puff. V11 stated R31 has ordered lighters in the past that look like lipstick and other things you would not expect to be lighters. On 2/6/26 at 11:40 PM, R31 stated she never knew she was not allowed to keep cigarettes in her room. She said always kept them right out in the open with her door open so that anyone walking by could see them. On 2/10/26 at 7:31 PM, V1, Administrator, stated she expects Facility staff to follow their smoking policy. The Facility's Smoking by Residents Policy reviewed 9/4/25 documents, Smoking is not allowed anywhere inside the facility. Residents who are not able to smoke independently and safely will be accompanied by facility staff while smoking. The smoking policy shall be thoroughly explained to the resident/family and/or resident representative at the time of admission. Residents will be allowed to smoke in designated smoking area(s) only. All smoking materials will be stored in a secure area to ensure they are kept safe. Cigarette butts are disposed of only in provided receptacles. Residents are prohibited from soliciting smoking materials from staff, visitors, and other residents.

Based on observation, record review, and interview, the facility failed to assess for use of and review the risk versus benefits for 1 of 2 (R55) resident reviewed for restraints in a sample of 47.Findings include: R55's Care Plan, Last Reviewed/Revised date 01/26/2026, does not address R55's restraint. Falls I have experienced an actual fall on 3/25/21, 3/26, 4/4/21, 7/5/2021, 8/27/21, 10/23/2021, 6/18/25. seat belt applied to wheelchair.R55's Minimum Data Set, dated [DATE], documents that R55 is moderately cognitively impaired and does not use restraints.R55's Physician Orders, dated February 2026, fails to document orders for the seatbelt or a restraint.R55's Electronic Health Record was reviewed on 2/2/2026 and documents no assessment for restraints or usage of seatbelt. It also documents no consent for usage of seatbelt or restraint.On 2/2/2026 at 9:58 AM observed R55 sitting in her wheelchair and observed to have a seat belt in place, resting slightly above her waistline. When asked if she could remove it, resident touched the seat belt buckle, but did not open the seat belt buckle.On 2/9/2026 at 12:35 PM observed R55 sitting in wheelchair and observed to have a seat belt in place, resting slightly above her waistline. On 2/2/2026 at 9:58 AM R55 stated that she was not able to remove the seatbelt. R55 stated that she was informed to click it or ticket. R55 stated that if she doesn't click it, they (facility) will get a ticket. R55 stated that the seat belt is so she won't stand up out of her chair. R55 stated that the seatbelt prevents her from getting out of the chair.On 2/6/2026 at 8:00 AM V3, Assistant Director of Nursing, stated that the facility does not have any restraints.On 2/9/2026 at 12:55 PM V21, Certified Nurses Assistant, stated that she got R55 up in her chair. V21 stated that she applied the seatbelt because it was on the wheelchair.On 2/9/2026 at 1:00 PM V4, Licensed Practical Nurse (LPN), stated that she is not aware of R55 having a seatbelt. V4 stated that they do not have any restraints in the facility.On 2/9/2026 at 1:04 PM V7, LPN, stated that the there is only 1 person in the facility with a seatbelt. V7 stated that R55 does not have a seatbelt.On 2/9/2026 at approximately 1:10 PM V1, Administrator, stated that the facility was not aware of R55 having a seatbelt. V1 stated that R55 received a new upgraded wheelchair, and the seatbelt came with the wheelchair.The facility's Restraint policy, reviewed date 9/5/25, documents, Purpose Residents shall be provided in an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. The policies definitions include, Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, beds against walls, restrictive clothing, etc. The policy documents the following care planning: A. Documentation for residents with restraints shall include the following: i. A comprehensive assessment. ii. The least restrictive alternatives attempted. iii. A specific medical symptom{s). iv. The Rationale for physical restraint use v. Restraint information {type and period of time). vi. A signed consent form vii. A written physician's order for restraint use. viii. A plan for gradually reducing or eliminating restraint. ix. The resident's response to restraint application, reduction, or elimination. x. Observation, range of motion and repositioning.

Based on observation and interview, the Facility failed to post nurse staffing information in a prominent place that was readily accessible to residents and visitors. This has the potential to affect all 99 residents living in the Facility. Findings include: On 2/02/2026 at 9:00 AM, there was no nurse staffing visibly posted in the Facility's lobby or at the nurse's station. On 2/10/26 at 7:55 AM, V3, Assistant Director of Nursing (ADON), stated nurse staffing is not posted in a location that is visible for residents, visitors and staff, and visitors normally just have to check with the nurses on the units to find out about staffing assignments. On 2/10/26 at 12:10 PM, V1, Administrator, stated the Facility does not have a policy regarding nurse staffing postings but will be posting it in the future. The Facility's Long-Term Care Resident Application for Medicare and Medicaid (CMS 671) dated 2/2/26 documents there are 99 residents living in the Facility.

Based on interview, observation, and record review, the Facility failed to ensure residents were free from sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 being sexually abused by R3 on 10/5/25 and again on 10/6/25.This Immediate Jeopardy began on 10/5/25 at 5:30 PM when V7, Certified Nursing Assistant (CNA), witnessed R3 sexually abusing R2. The Facility did not report or investigate this, and no interventions were put in place to protect R2 from R3. The following day, on 10/6/25 at approximately 9:00 AM, R3 entered R2's room and sexually abused R3 again. V1, Administrator, was notified of the Immediate Jeopardy on 10/17/25 at 12:02 PM. The surveyors confirmed through observation, interview and record review that the Immediate Jeopardy was removed on 10/17/25, but noncompliance remains at Level Two because additional time is needed to evaluate implementation and effectiveness of the removal plan.Findings include:On 10/16/25 at 1:30 PM, R2 was sleeping in bed in her room on a specialty mattress with a fall mat to the right side of her bed. R2 did not respond when spoken to. On 10/15/25 at 11:41 AM, V6, Certified Nursing Assistant (CNA), stated she was doing rounds on the hall and noticed R3 was in R2's room and was trying to get in bed with R2. R2 is non-verbal and cannot consent to sexual relations.On 10/15/25 at 2:10 PM, V7, CNA, stated on 10/5/25 around 5:30 or 6:00 PM, R2 was sitting in her reclining wheelchair in the dining room with her legs in the air. R3 was in his wheelchair sitting next to and facing toward R2 moving his arm back and forth repeatedly. V7 walked closer and saw R2's lower buttocks exposed with R3's hand in her diaper. R3 stated he was checking her diaper. V7 told R3 to stop and moved him away from R2, then asked V18, Licensed Practical Nurse (LPN), and V19, LPN, for help. V19 told R3 to go to his room, and V7 took R2 to her room. R2's incontinent brief fell off when staff were transferring her to her bed because the fasteners on the briefs were torn apart. R2 was agitated and resistive when staff were trying to clean her. V18 never came down to the room to check on R2, and when V7 was finished providing care, she was told V18 left the Facility. V7 then told V20, LPN, who notified V1, Administrator. V7 stated R2 is non-verbal and not able to communicate or consent, and this was a sexual assault. If someone had done something about this, the incident the following day would never have happened.On 10/16/25 at 9:43 AM, V18 stated on 10/5/25 V7 reported R3's hand came out from under R2's blanket. V18 watched the Facility cameras with V19, LPN, and did not see anything happen.On 10/16/25 at 9:51 AM, V19, LPN, stated V7 told her R3 had his hand under R2's blanket in the dining room. V19 reviewed the camera with V18 and did not see anything happen. V19 stated they contacted V1 about this.On 10/16/25 at 11:09 AM, V1 stated she was notified about V7's allegation on 10/5/25. She watched the video surveillance and did not see anything, but V7 was determined it happened. V1 had no idea why V7 would say that, but unfortunately, something happened the next day. V1 stated the original videos have been deleted, but did have one saved video from her phone for surveyors to review. On 10/17/25 at 11:09 AM, the Facility video footage was reviewed with the following noted: The video was dated 10/5/25 and was time stamped with footage from 5:59 PM to 6:03 PM. The video showed R2 sitting in her chair on the far lower left corner of the screen. R2's legs were not in full view the entire time. R2 was moving around and moving her legs up and down. R2 was wearing dark colored pants and a blanket. The blanket was covering R2's left leg, and the lower right leg of R2's pants was pushed up due to movement. R2 had wiggled her way around in the chair, and some of her incontinent brief was exposed on the right side. The video did not fully capture R3 in the frame, and the times did not encompass the entire time frame reported by V7.On 10/16/25 at 11:42 AM, V25, Wound Nurse/LPN, stated he was asked to fill out involuntary hospital paperwork R3 on 10/6/25 for inappropriate behavior. V25 stated he was told R3 was putting shaving cream on R2's buttock and needed to be sent out to the hospital.On 10/16/25 at 2:07 PM, V26, Psychiatrist, stated staff told him R3 was being sexually inappropriate, getting into another residents bed and smearing feces in the Facility, so he ordered to have him sent to the hospital. V26 reviewed R3's Progress Note and stated R3 entered in another resident's room, removed her incontinent brief, put shaving cream on her, and said he wanted to have sex.On 10/16/25 at 2:45 PM, V2, Director of Nursing (DON), stated R3 was trying to get into R2's bed. V2 called V26 who wanted R3 to be sent to the hospital for a medical evaluation. Apparently R3 put his hands on R2 on 10/5/25. That is all V2 knew because V1 handles the abuse allegations. V7 was very upset and calling everyone. We told staff to report all allegations to V1 and not discuss with anyone else. R3 was discharged to a men's unit. We felt more comfortable that way.On 10/16/25 at 2:54 PM, V20 stated when she got to work she was informed by V7 that R3 was observed with his hands in R2's incontinent brief. V20 was told V1 had not been notified, so she notified V1 who stated she would take care of it. V20 stated R3 was not placed on any enhanced supervision and was able to move about the facility independently. V20 stated the staff often place R2 in her reclining wheelchair at the nurse's station. V20 stated R3 would propel himself in the hallway, and when he got near R2 he would slow down and look at her. On 10/16/25 at 2:57 PM, V24 stated staff reported R3 went into R2's room, pulled down her (incontinent brief), took his pants down and put shaving cream on her. We had him sent out to the hospital. V24 would expect the facility to keep residents free from abuse. Residents need to be in a safe environment. R3 admitted to V24 that he wanted to have sex. V24 stated that is not ok for him, and she let him know that. R2 is non-verbal and not very engaged or conversational, and V24 does not think she has the ability to consent. There is always potential for psychosocial harm with sexual abuse because that is a violation of personal space and overall safety.On 10/16/25 at 3:14 PM, V1, Administrator, stated on 10/6/25 V6 was rounding and saw R3 in R2's room. Someone said R3 had shaving cream in there. When V1 went to R2's room, R2 was lying in bed on her left side curled up in a ball. She was not wearing a brief because she was in bed and sometimes staff just put the incontinent pad underneath them. Due to fact R3 attempted, we contacted V26 who ordered him to go to the hospital. We wanted to find a (different) Facility for R3, because usually if they do it once they are going to do it again. Allegations of abuse should be reported immediately and residents should be separated to make sure they are safe. She did not report the allegation on 10/5/25 to law enforcement or the Department. She stated it just did not cross her mind because nothing happened.On 10/17/25 at 8:30 AM, V6 stated when she found R3 in R2's room, he was not in the bed with her but looked like he was going to get in the bed his with her. R3's pants were pulled down and he had shaving cream on his hands. R2 was wearing a brief and gown, but her blanket was pulled back. V6 notified V2. On 10/17/25 at 9:17 AM, V27, R2's Family, stated R2 is not able to make her own decisions and does not communicate. On 10/17/25 at 9:26 AM, V28, R2's Family, stated R2 is not alert, oriented, or able to make her own decisions. R2 does not communicate.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and generalized anxiety disorder.R3's MDS dated [DATE] documented R3 was cognitively intact and ambulated via wheelchair.R3's Care Plan initiated 9/29/25 documents R3 has a history of inappropriate contact with peers and staff.R3's Progress Note by V2 dated 10/6/25 at 9:00 AM documents, Resident was found in another resident's room. Resident was removed from female resident's room and moved to another hallway.R3's Psychiatry Note by V24, Nurse Practitioner (NP) note dated 10/9/25 documents, Per staff patient entered into female peer room, got into her bed remove(d) her (incontinent brief) and put shaving cream on her. Admits to going into peer room states he wanted to have sex.Local Police Report printed 10/16/25 documents on 10/6/25 at 10:56 AM, dispatch forwarded an anonymous caller regarding an alleged rape occurring today at (Facility). The caller stated multiple incidents were happening at the facility, but the administrators were not reporting them to the police. The caller stated a resident staying at the facility was sexually assaulting another individual by the name of (R2) but did not know the suspect's name. The caller stated the facility administrators were not doing anything about the incidents. V1 had been made aware of the alleged occurrence and stated than an incident had occurred. V1 showed surveillance video which showed R3 moving his wheelchair down the hallway and entering R2's room at 8:59 AM on 10/6/25. V7 was seen entering R2's room and calling for V18. At 9:04 AM on 10/6/25, R3 was seen wheeling himself out of the room. V18 stated V7 entered the room to find R3 out of his chair and lying in bed with R2. V18 said R3 had shaving cream on R2's right butt check and heard him say, You stopped me before I started. V18 said R2 was found lying on her left side, facing the facility wall, and had shaving cream on her right butt cheek. The Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents 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. 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. The Administrator is responsible for coordinating and implementing the facility abuse prevention policies, procedures, training programs, and systems. The Facility promptly and thoroughly investigates reports or resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.The Immediate Jeopardy and deficiency practice that began on 10/5/25 was corrected/removed on 10/17/25 after the Facility took the following actions to correct the noncompliance: V1 and V2 were in-serviced on abuse and neglect by V41, department heads were in-serviced on abuse and neglect policy and procedure by V1, 24 hour reports for the last seven days were reviewed, 24 hour report audits were initiated, interviews with 5 staff members 5x/week x 4 weeks were initiated to ensure staff know who to report abuse and neglect to, and root cause analysis was completed for abuse and neglect. The abatement was validated by review of abuse policy, review of root cause analysis and interviews from V3, V22, V25, V29, V32, V33, V35, V36, V37, V38, V39, V40.

Based on interview and record review, the Facility failed to provide adequate supervision following an allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R3 entering R2's room without staff supervision and sexually abusing R2.Findings include:1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.On 10/16/25 at 1:30 PM, R2 was sleeping in bed in her room on a specialty mattress with a fall mat to the right side of her bed. R2 did not respond to verbal stimuli. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and generalized anxiety disorder.R3's MDS dated [DATE] documented R3 was cognitively intact and ambulated via wheelchair.R3's Care Plan initiated 9/29/25 documents R3 has a history of inappropriate contact with peers and staff. The Care Plan does not address any interventions for these behaviors until 10/6/25.On 10/15/25 at 2:10 PM, V7, Certified Nursing Assistant (CNA), stated on 10/5/25 around 5:30 or 6:00 PM, R2 was sitting in her reclining wheelchair in the dining room with her legs in the air. R3 was in his wheelchair sitting next to and facing toward R2 moving his arm back and forth repeatedly. V7 walked closer and saw R2's lower buttocks exposed with R3's hand in her diaper. R3 stated he was checking her diaper. V7 told V20, Licensed Practical Nurse (LPN), who notified V1, Administrator. V7 stated R2 is non-verbal and not able to communicate or consent, and this was a sexual assault. If someone had done something about this, the incident the following day would never have happened.On 10/16/25 at 2:54 PM, V20 stated when she arrived at work she was informed by V7 that R3 was observed with his hands in R2's incontinent brief. V20 notified V1, Administrator. R3 was not placed on any enhanced supervision and was able to move about the facility independently. On 10/16/25 at 11:09 AM, V1 stated she was notified about V7's allegation on 10/5/25. She did not report the incident and unfortunately, something happened the following day. R3's Progress Note by V2 dated 10/6/25 at 9:00 AM documents, Resident was found in another resident's room. Resident was removed from female resident's room and moved to another hallway.On 10/15/25 at 11:41 AM, V6, CNA, stated she was doing rounds on the hall and noticed R3 was in R2's room and was trying to get in bed with R2. R2 is non-verbal and cannot consent to sexual relations.On 10/16/25 at 11:42 AM, V25, Wound Nurse/LPN, stated he was told very R3 was putting shaving cream on R2's buttock and needed to be sent out to the hospital.On 10/16/25 at 2:07 PM, V26, Psychiatrist, stated staff told him R3 was being sexually inappropriate, getting into another residents bed and smearing feces in the Facility.On 10/16/25 at 2:45 PM, V2, Director of Nursing (DON), stated apparently R3 put his hands on R2 on 10/5/25, but she has limited knowledge, as V1 handles all abuse allegations. On 10/6/25, R3 was trying to get into R2's bed. V2 called V26 who wanted R3 to be sent to the hospital for a medical evaluation. R3's Psychiatry Note by V24, Nurse Practitioner (NP) note dated 10/9/25 documents, Per staff patient entered into female peer room, got into her bed remove her depends and put shaving cream on her. Admits to going into peer room states he wanted to have sex.On 10/16/25 at 2:57 PM, V24 stated staff reported R3 went into R2's room, pulled down her (incontinent brief), took his pants down and put shaving cream on her. We had him sent out to the hospital. I would expect the facility to keep residents free from abuse. They need to be in a safe environment. R3 admitted to V24 that he wanted to have sex. That is not ok for him, and I let him know that. R2 is non-verbal and not very engaged or conversational, and I really don't think she has the ability to consent. There is always potential for psychosocial harm with sexual abuse because that is a violation of personal space and overall safety.On 10/17/25 at 8:30 AM, V6 stated when she found R3 in R2's room, he was not in the bed with her but looked like he was going to get in the bed his with her. R3's pants were pulled down and he had shaving cream on his hands. R2 was wearing a brief and gown, but her blanket was pulled back. V6 notified V2. On 10/16/25 at 3:14 PM, V1 stated on 10/6/25 V6 was rounding and saw R3 in R2's room. Someone said R3 had shaving cream in there. When V1 went to R2's room, R2 was lying in bed on her left side curled up in a ball. She was not wearing a brief because she was in bed and sometimes they just put the incontinent pad underneath them. Due to fact R3 attempted, we contacted V26 who ordered him to go to the hospital. We wanted to find a (different) Facility for R3, because usually if they do it once they are going to do it again. Allegations of abuse should be reported immediately and residents should be separated to make sure they are safe. Local Police Report printed 10/16/25 documents on 10/6/25 at 10:56 AM, dispatch forwarded an anonymous caller regarding an alleged rape occurring today at (Facility). The caller stated multiple incidents were happening at the facility, but the administrators were not reporting them to the police. The caller stated a resident staying at the facility was sexually assaulting another individual by the name of (R2) but did not know the suspect's name. The caller stated the facility administrators were not doing anything about the incidents. V1 had been made aware of the alleged occurrence and stated than an incident had occurred. V1 showed surveillance video which showed R3 moving his wheelchair down the hallway and entering R2's room at 8:59 AM on 10/6/25. V7 was seen entering R2's and calling for V18. At 9:04 AM on 10/6/25, R3 was seen wheeling himself out of the room. V18 stated V7 entered the room to find R3 out of his chair and lying in bed with R2. V18 said R3 had shaving cream on R2's right butt check and heard him say, You stopped me before I started. V18 said R2 was found lying on her left side, facing the facility wall, and had shaving cream on her right butt cheek. The Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents 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. 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.

Based on interview, observation, and record review, the Facility failed to follow its abuse policy in preventing, reporting and investigating allegations of abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 being sexually abused on 10/6/25 after previous allegation was not reported or investigated and no interventions were put in place to prevent further abuse.Findings include:On 10/16/25 at 1:30 PM, R2 was sleeping in bed in her room on a specialty mattress with a fall mat to the right side of her bed. R2 did not respond when spoken to. On 10/15/25 at 11:41 AM, V6, Certified Nursing Assistant (CNA), stated she was doing rounds on the hall and noticed R3 was in R2's room and was trying to get in bed with R2. R2 is non-verbal and cannot consent to sexual relations.On 10/15/25 at 2:10 PM, V7, CNA, stated on 10/5/25 around 5:30 or 6:00 PM, R2 was sitting in her reclining wheelchair in the dining room with her legs in the air. R3 was in his wheelchair sitting next to and facing toward R2 moving his arm back and forth repeatedly. V7 walked closer and saw R2's lower buttocks exposed with R3's hand in her diaper. R3 stated he was checking her diaper. V7 told R3 to stop and moved him away from R2, then asked V18, Licensed Practical Nurse (LPN), and V19, LPN, for help. V19 told R3 to go to his room, and V7 took R2 to her room. R2's incontinent brief fell off when staff were transferring her to her bed because the fasteners on the briefs were torn apart. R2 was agitated and resistive when staff were trying to clean her. V18 never came down to the room to check on R2, and when V7 was finished providing care, she was told V18 left the Facility. V7 then told V20, LPN, who notified V1, Administrator. V7 stated R2 is non-verbal and not able to communicate or consent, and this was a sexual assault. If someone had done something about this, the incident the following day would never have happened.On 10/16/25 at 9:43 AM, V18 stated on 10/5/25 V7 reported R3's hand came out from under R2's blanket. V18 watched the Facility cameras with V19, LPN, and did not see anything happen.On 10/16/25 at 9:51 AM, V19, LPN, stated V7 told her R3 had his hand under R2's blanket in the dining room. V19 reviewed the camera with V18 and did not see anything happen. V19 stated they contacted V1 about this.On 10/16/25 at 11:09 AM, V1 stated she was notified about V7's allegation on 10/5/25. She watched the video surveillance and did not see anything, but V7 was determined it happened. V1 had no idea why V7 would say that, but unfortunately, something happened the next day. V1 stated the original videos have been deleted, but did have one saved video from her phone for surveyors to review. On 10/17/25 at 11:09 AM, the Facility video footage was reviewed with the following noted: The video was dated 10/5/25 and was time stamped with footage from 5:59 PM to 6:03 PM. The video showed R2 sitting in her chair on the far lower left corner of the screen. R2's legs were not in full view the entire time. R2 was moving around and moving her legs up and down. R2 was wearing dark colored pants and a blanket. The blanket was covering R2's left leg, and the lower right leg of R2's pants was pushed up due to movement. R2 had wiggled her way around in the chair, and some of her incontinent brief was exposed on the right side. The video did not fully capture R3 in the frame, and the times did not encompass the entire time frame reported by V7.On 10/16/25 at 11:42 AM, V25, Wound Nurse/LPN, stated he was asked to fill out involuntary hospital paperwork R3 on 10/6/25 for inappropriate behavior. V25 stated he was told R3 was putting shaving cream on R2's buttock and needed to be sent out to the hospital.On 10/16/25 at 2:07 PM, V26, Psychiatrist, stated staff told him R3 was being sexually inappropriate, getting into another residents bed and smearing feces in the Facility, so he ordered to have him sent to the hospital. V26 reviewed R3's Progress Note and stated R3 entered in another resident's room, removed her incontinent brief, put shaving cream on her, and said he wanted to have sex.On 10/16/25 at 2:45 PM, V2, Director of Nursing (DON), stated R3 was trying to get into R2's bed. V2 called V26 who wanted R3 to be sent to the hospital for a medical evaluation. Apparently R3 put his hands on R2 on 10/5/25. That is all V2 knew because V1 handles the abuse allegations. V7 was very upset and calling everyone. We told staff to report all allegations to V1 and not discuss with anyone else. R3 was discharged to a men's unit. We felt more comfortable that way.On 10/16/25 at 2:54 PM, V20 stated when she arrived at work she was informed by V7 that R3 was observed with his hands in R2's incontinent brief. V20 was told V1 had not been notified, so she notified V1 who stated she would take care of it. V20 stated R3 was not placed on any enhanced supervision and was able to move about the facility independently. V20 stated the staff often place R2 in her reclining wheelchair at the nurse's station. V20 stated R3 would propel himself in the hallway, and when he got near R2 he would slow down and look at her. On 10/16/25 at 2:57 PM, V24 stated staff reported R3 went into R2's room, pulled down her (incontinent brief), took his pants down and put shaving cream on her. We had him sent out to the hospital. V24 would expect the facility to keep residents free from abuse. Residents need to be in a safe environment. R3 admitted to V24 that he wanted to have sex. V24 stated that is not ok for him, and she let him know that. R2 is non-verbal and not very engaged or conversational, and V24 does not think she has the ability to consent. There is always potential for psychosocial harm with sexual abuse because that is a violation of personal space and overall safety.On 10/16/25 at 3:14 PM, V1, Administrator, stated on 10/6/25 V6 was rounding and saw R3 in R2's room. Someone said R3 had shaving cream in there. When V1 went to R2's room, R2 was lying in bed on her left side curled up in a ball. She was not wearing a brief because she was in bed and sometimes staff just put the incontinent pad underneath them. Due to fact R3 attempted, we contacted V26 who ordered him to go to the hospital. We wanted to find a (different) Facility for R3, because usually if they do it once they are going to do it again. Allegations of abuse should be reported immediately and residents should be separated to make sure they are safe. She did not report the allegation on 10/5/25 to law enforcement or the Department. She stated it just did not cross her mind because nothing happened.On 10/17/25 at 8:30 AM, V6 stated when she found R3 in R2's room, he was not in the bed with her but looked like he was going to get in the bed his with her. R3's pants were pulled down and he had shaving cream on his hands. R2 was wearing a brief and gown, but her blanket was pulled back. V6 notified V2. On 10/17/25 at 9:17 AM, V27, R2's Family, stated R2 is not able to make her own decisions and does not communicate. On 10/17/25 at 9:26 AM, V28, R2's Family, stated R2 is not alert, oriented, or able to make her own decisions. R2 does not communicate.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and generalized anxiety disorder.R3's MDS dated [DATE] documented R3 was cognitively intact and ambulated via wheelchair.R3's Care Plan initiated 9/29/25 documents R3 has a history of inappropriate contact with peers and staff.R3's Progress Note by V2 dated 10/6/25 at 9:00 AM documents, Resident was found in another resident's room. Resident was removed from female resident's room and moved to another hallway.R3's Psychiatry Note by V24, Nurse Practitioner (NP) note dated 10/9/25 documents, Per staff patient entered into female peer room, got into her bed remove(d) her (incontinent brief) and put shaving cream on her. Admits to going into peer room states he wanted to have sex.Local Police Report printed 10/16/25 documents on 10/6/25 at 10:56 AM, dispatch forwarded an anonymous caller regarding an alleged rape occurring today at (Facility). The caller stated multiple incidents were happening at the facility, but the administrators were not reporting them to the police. The caller stated a resident staying at the facility was sexually assaulting another individual by the name of (R2) but did not know the suspect's name. The caller stated the facility administrators were not doing anything about the incidents. V1 had been made aware of the alleged occurrence and stated than an incident had occurred. V1 showed surveillance video which showed R3 moving his wheelchair down the hallway and entering R2's room at 8:59 AM on 10/6/25. V7 was seen entering R2's room and calling for V18. At 9:04 AM on 10/6/25, R3 was seen wheeling himself out of the room. V18 stated V7 entered the room to find R3 out of his chair and lying in bed with R2. V18 said R3 had shaving cream on R2's right butt check and heard him say, You stopped me before I started. V18 said R2 was found lying on her left side, facing the facility wall, and had shaving cream on her right butt cheek. The Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents 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. 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. The Administrator is responsible for coordinating and implementing the facility abuse prevention policies, procedures, training programs, and systems. The Facility promptly and thoroughly investigates reports or resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.

Based on interview and record review, the Facility failed to investigate an allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in witnessed sexual abuse on R2 by R3 the day after a sexual abuse allegation for the same two individuals was not thoroughly investigated.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and generalized anxiety disorder.R3's MDS dated [DATE] documented R3 was cognitively intact and ambulated via wheelchair.R3's Care Plan initiated 9/29/25 documents R3 has a history of inappropriate contact with peers and staff. R3's Care Plan was not updated with interventions until 10/6/25.On 10/15/25 at 2:10 PM, V7, Certified Nursing Assistant (CNA), stated on 10/5/25 around 5:30 or 6:00 PM, R2 was sitting in her reclining wheelchair in the dining room with her legs in the air. R3 was in his wheelchair sitting next to and facing toward R2 moving his arm back and forth repeatedly. V7 walked closer and saw R2's lower buttocks exposed with R3's hand in her diaper. R3 stated he was checking her diaper. V7 told V20, Licensed Practical Nurse (LPN), who notified V1, Administrator. V7 stated R2 is non-verbal and not able to communicate or consent, and this was a sexual assault. If someone had done something about this, the incident the following day would never have happened.On 10/16/25 at 2:54 PM, V20 stated when she arrived at work on 10/5/25 she was informed by V7 that R3 was observed with his hands in R2's incontinent brief. V20 notified V1 who stated she would take care of it. On 10/16/25 at 11:09 AM, V1 stated she was notified about V7's allegation on 10/5/25. She watched the video surveillance and did not see anything happen, so she did not investigate it further. Unfortunately, something happened the following day. R3's Progress Note by V2 dated 10/6/25 at 9:00 AM documents, Resident was found in another resident's room. Resident was removed from female resident's room and moved to another hallway.On 10/15/25 at 11:41 AM, V6, CNA, stated she was doing rounds on the hall and noticed R3 was in R2's room and was trying to get in bed with R2. R3's Psychiatry Note by V24, Nurse Practitioner (NP) note dated 10/9/25 documents, Per staff patient entered into female peer room, got into her bed remove(d) her (incontinent brief) and put shaving cream on her. Admits to going into peer room states he wanted to have sex.On 10/16/25 at 3:14 PM, V1, Administrator, stated on 10/6/25 V6 was rounding and saw R3 in R2's room. We wanted to find a (different) Facility for R3, because usually if they do it once they are going to do it again. Allegations of abuse should be reported immediately, and the residents should be separated to make sure they are safe. Local Police Report printed 10/16/25 documents on 10/6/25 at 10:56 AM, dispatch forwarded an anonymous caller regarding an alleged rape occurring today at (Facility). The caller stated multiple incidents were happening at the facility, but the administrators were not reporting them to the police. The caller stated a resident staying at the facility was sexually assaulting another individual by the name of (R2) but did not know the suspect's name. The caller stated the facility administrators were not doing anything about the incidents.The Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents 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. 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. The Facility promptly and thoroughly investigates reports or resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.

Based on interview and record review, the Facility failed to report allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and generalized anxiety disorder.R3's MDS dated [DATE] documented R3 was cognitively intact and ambulated via wheelchair.R3's Care Plan initiated 9/29/25 documents R3 has a history of inappropriate contact with peers and staff.On 10/15/25 at 2:10 PM, V7, Certified Nursing Assistant (CNA), stated on 10/5/25 around 5:30 or 6:00 PM, R2 was sitting in her reclining wheelchair in the dining room with her legs in the air. R3 was in his wheelchair sitting next to and facing toward R2 moving his arm back and forth repeatedly. V7 walked closer and saw R2's lower buttocks exposed with R3's hand in her diaper. R3 stated he was checking her diaper. V7 told V20, Licensed Practical Nurse (LPN), who notified V1, Administrator. On 10/16/25 at 2:54 PM, V20 stated when she arrived at work on 10/5/25 she was informed by V7 that R3 was observed with his hands in R2's incontinent brief. V20 notified V1 who stated she would take care of it. On 10/16/25 at 11:09 AM, V1 stated she was notified about V7's allegation on 10/5/25, but did not report the allegation because nothing had happened. Local Police Report printed 10/16/25 documents on 10/6/25 at 10:56 AM, dispatch forwarded an anonymous caller regarding an alleged rape occurring today at (Facility). The caller stated multiple incidents were happening at the facility, but the administrators were not reporting them to the police.The Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents 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. 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. The Administrator is responsible for coordinating and implementing the facility abuse prevention policies, procedures, training programs, and systems. The Facility promptly and thoroughly investigates reports or resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.

Based on interview and record review, the Facility failed to completed physician's ordered wound care for 1 of 3 residents (R2) reviewed for wound care in the sample of 4. Findings include: 1. R2's Face Sheet documents R2 resides in the Facility with diagnoses including paraplegia, pressure ulcer, and acquired absence of both left and right leg below the knee. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, dependent for mobility, and had two pressure ulcers that were present on admission. R2's Care Plan dated 6/8/21 documents R2 is at risk for impaired skin integrity. R2's Care Plan dated 5/29/24 documents R2 has wounds to left thigh/buttock region and right thigh. R2's Wound Consultant Company Report dated 5/27/25 documents R2 had a wound to left posterior thigh measuring 17 cm (centimeters) x 8.9 cm x 0.3 cm. The previous treatment prescribed by V8, Wound Nurse Practitioner, was continued which consisted of cleansing with normal saline or wound cleanser, applying collagen and silver alginate, covering with silicone superabsorbent foam, and changing daily and as needed. R2's Physician Order with start date of 4/10/25 documents cleanse left posterior upper thigh with normal saline or wound cleanser, apply collagen sheet and silver alginate with silicone bordered foam, and change daily and as needed, if soiled. R2's Treatment Administration Record (TAR) does not document R2 received the treatment to the left posterior upper thigh on 5/16/25, 5/20/25, 5/26/25, 6/1/25, 6/3/25, or 6/4/25. R2's Physician Order starting 4/3/23 documents skin prep to bilateral stumps daily. R2's TAR does not document skin prep to bilateral stumps was completed on 4/5/25, 4/6/25, 4/11/25, 4/19/25, 4/20/25, 4/28/25, 5/16/25, 5/19/25, 5/20/25, 5/26/25, 6/1/25, 6/3/25, or 6/4/25. On 6/11/25 at 8:10 AM, V2, Director of Nursing (DON), stated complete treatments should be documented in the TAR. R2's Wound Consultant Company Note, dated 5/14/25 documented new surgical wounds to abdomen measuring 2 cm x 2 cm x 0.2 cm and 1 cm x 1 cm x 0.2 cm. The treatment V8 prescribed for both areas were cleanse with normal saline or wound cleanser, apply silver alginate, and cover with dry dressing daily and as needed. R2's Physician Orders dated 6/10/25 do not document any treatments for abdominal wounds. R2's TAR reviewed since 5/14/25 and does not document any treatments for abdominal wounds. On 6/11/25 at 9:30 AM, V8, Wound Nurse Practitioner, stated R2 does not have any orders for wound treatments to his abdomen, but should. She ordered silver alginate on her last visit, but the order was never entered by nursing. On 6/11/25 at 12:30 PM, V2 stated V9, Former Wound Nurse, would have been responsible for entering V8's wound care orders. She would expect nurses to enter orders in a timely fashion, provide treatments as ordered, and document treatments as given, when completed. The Facility's Undated Documentation - Nursing Policy documents the purpose is to provide documentation of resident status and care given by nursing staff. Documentation will be concise, clear, pertinent and accurate. Treatment administration records are completed with each treatment completed and are completed and documented per physician order.

Based on interview and record review, the Facility failed to treat resident's pressure ulcers per physician's orders for 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 4. Findings include: 1.R2's Face Sheet documents R2 resides in the Facility with diagnoses including paraplegia, pressure ulcer, and acquired absence of both left and right leg below the knee. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, dependent for mobility, and had two pressure ulcers that were present on admission. R2's Care Plan dated 6/8/21 documents R2 is at risk for impaired skin integrity. R2's Care Plan dated 5/29/24 documents R2 has wounds to left thigh/buttock region and right thigh. R2's Wound Consultant Report dated 5/27/25 documents R2 had a Stage 3 pressure ulcer to left proximal thigh measuring 2.9 centimeters (cm) x 1.9 cm x 0.2 cm. The previous treatment prescribed by V8, Wound Nurse Practitioner, was continued which consisted of cleansing with normal saline or wound cleanser, applying collagen and silver alginate, covering with silicone superabsorbent foam, and changing daily and as needed. R2's Physician Order, PO, starting 2/12/25 documents cleanse proximal thigh with normal saline, apply gentamycin and silver alginate, and cover with silicone bordered foam dressing daily and as needed. R2's Treatment Administration Record (TAR) does not document R2 received treatment to the left proximal thigh on 3/10/25, 3/28/25, 3/29/25, 5/16/25, 5/20/25, 5/26/25, 6/1/25, 6/3/25, or 6/4/25. On 6/11/25 at 8:10 AM, V2, Director of Nursing (DON), stated complete treatments should be documented in the TAR. On 6/11/25 at 12:30 PM, V2 stated V9, Former Wound Nurse, would have been responsible for entering V8's wound care orders. She would expect nurses to enter orders in a timely fashion, provide treatments as ordered, and document treatments as given, when completed. The Facility's Undated Documentation - Nursing Policy documents the purpose is to provide documentation of resident status and care given by nursing staff. Documentation will be concise, clear, pertinent and accurate. Treatment administration records are completed with each treatment completed and are completed and documented per physician order. The Facility's Undated Medication Administration Policy documents the time and type of treatment administered to the resident will be recorded.

Based on interview and record review, the facility failed to notify resident's representatives of a fall in 1 of 4 residents (R3) reviewed for accidents in the sample of 4. Findings include: 1.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including osteoporosis, pain and dementia. V4, R3's Family, is listed as R3's Emergency Contact and Durable Power of Attorney. R3's Minimum Data Set (MDS) dated [DATE] documented R3 was severely cognitively impaired and required partial assistance with bed mobility and transfer. R3's Fall Report dated 5/27/25 documents R3 had an unwitnessed fall. R3's Progress Note dated 5/27/25 at 10:31 AM by V5, Licensed Practical Nurse (LPN), documents R3 was found on the floor with a hematoma (bruise) on the right side of (her head). R3's Progress Note dated 5/28/25 at 4:07 PM by V6, Social Services Director, documents V4, R3's family, was not notified of R3's fall, and it was determined that the contact number for V4 was incorrect. On 6/10/25 at 11:20 AM, V1, Administrator, stated V5 tried to call V4 when R3 fell, but the voicemail box was not set up. V4 came to the Facility later and noticed R3's face was bruised and was upset that nobody had contacted her. V1 followed up with V5, and they discovered the phone number V5 used was not correct. On 6/10/25 at 1:18 PM, V5 stated she tried to contact R3's family after her fall, but the number she dialed was not the correct number. On 6/10/25 at 1:24 PM, V6, Social Services Director, stated V4's contact number was not listed correctly, so V4 was not aware of R3's fall until she came to the Facility to visit. On 6/10/25 at 2:35 PM, V4 stated when she came to visit R3, the entire side of her face and eye were black and blue. She was shocked and upset that the Facility did not contact her regarding R3's fall. On 6/11/25 at 12:30 PM, V2, Director of Nursing (DON), stated she expects staff to notify resident representatives of falls and would expect them to ensure the contact information is accurate. The Facility's Undated Change of Condition Policy documents medical care problems will be communicated to the resident's family or responsible party in a timely, efficient and effective manner, and the Facility will inform the resident's legal representative when there has been an accident involving the resident.

Based on interview and record review the Facility failed to assess and treat a change of condition for 1 of 3 residents (R2) reviewed for change of condition. This failure resulted in R2 having a significant change in condition for several hours without interventions that ultimately required an emergency transfer in which her family called 911 and R2 experienced respiratory distress, was intubated en route to the hospital and placed on a mechanical ventilator. The Immediate Jeopardy began on 5/2/2025 when R2 began to experience respiratory/breathing issues and was not sent to the hospital in a timely manner. On 5/8/2025 at 12:43 PM, V1, Administrator, V2, Director of Nursing (DON), V3, Assistant Director of Nursing (ADON), V17, Regional Nurse Consultant/ VP Clinical Services and V18, RDO/CEO (Regional Director of Operations) and CEO were notified of the Immediate Jeopardy. The surveyor confirmed by observations, record review and interview, that the Immediate Jeopardy was removed on 5/9/2025 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: R2's Physician Order Sheets (POS) for May 2025 document, a diagnosis of Urinary tract infection, site not specified; Type 2 diabetes mellitus with diabetic neuropathy, unspecified; End stage renal disease; Dependence on renal dialysis; Heart failure, unspecified; Presence of cardiac pacemaker; and Essential (primary) hypertension. R2's POS also documents an order with a start date of 4/23/2025 for Oxygen up to 4 L (liters) Continuous. R2's Minimum Data Set (MDS) dated [DATE] document R2 was cognitively intact for decision making of activities of daily living. R2's Care Plan does not address any oxygen use and/or respiratory issues or her dialysis. R2's Progress Notes dated 4/4/2025 at 10:15 AM, 95 yo (year old) female readmitted to (Facility) on 4/3/25 from (Hospital) for pulm (pulmonary) edema. Res (Resident) returned with on O2 (oxygen) 2L/NC (2 liters nasal cannula). Per facility nurses' notes, resident vitals were stable with O2 sats (saturations) at 91%, no cough, pain or discomfort, A&O X2-3 (alert and orientated x 3) with intermittent confusion. On 5/7/2025 at 11:00 AM, V5, Family of R2 stated, I got a call from the facility around 7:00 PM, I was in my pajamas. They told me my mom was having a panic attack. When I got there at the facility my mom was not having a panic attack, she was gasping for air, and she was in distress. It was unimaginable seeing her like that. I got to the facility about 8:00 PM and seeing my mom gasping for air I tried to find a nurse, and could not find anyone, so I called 911 because something was not right. My mom is still at the hospital, but she is on a ventilator now and we have to decide if we want to keep her on it. I don't know why (Facility) did not send my mom out when she started having problems, I am at loss. R2's Progress Notes dated 5/2/2025 at 8:45 PM, This writer was doing med (medication) pass and CNA's (certified nursing assistants) on the hall attempted numerous times to reposition resident to get resident comfortable, and with no success. CNA took O2 (oxygen) and was stating at 76% on 2L (liters). This nurse tried 4L of Oxygen with no success of bringing O2 stats above 76%. Call was placed to daughter to see if she could come out and help. Daughter could not calm resident down and finally called 911 for her mother. At approximately 8:50 PM EMS (Emergency Medical Services) arrived to transport resident to (Hospital). R2's Progress Notes does not document the Physician was notified. On 5/6/2025 at 8;44 AM, V4, Emergency Medical Service Staff stated, (V5, Family of R2) called EMS yesterday on 5/2/25 around 9 PM. She reported (R2) had been complaining of shortness of breath since the afternoon and the nurse (V6) did nothing for her and just told her to 'calm down'. No information was provided him upon arrival, and we did not get a handoff report. When EMS arrived, (R2) was in respiratory distress, not arrest, and did not go into arrest because they gave her a lot of ketamine. We did attempted intubation x 2 unsuccessful, and then had to use an I-gel for airway. R2 was transferred to (Hospital). R2's EMS (Emergency Medical Services) report dated 5/2/2025 at 9:07 PM, documents, Dispatch reason: breathing problems, primary symptoms: Shortness of breath, Providers primary impression: Respiratory failure, unspecified. Narrative documents was dispatched to (Facility) for a [AGE] year old F (female) with shortness of breath. EMS responded emergent and arrived on scene without incident. EMS went inside the building and was directed to the PT (Patient's) room by the PT's daughter. PT's daughter reports that she called 911 after she found her mother lying in bed struggling to breathe. Pt's daughter reports the PT received dialysis earlier in the day. EMS found the PT sitting semi-Fowlers (lying in bed with the head and upper body elevated to an angle of 30 to 45 degrees) in her bed. PT was a & o (alert and orientated) x 2 with a weak radial pulse, shallow and rapid respirations, and an open airway. PT's skin was flush and blue in extremities. PT was wearing a nasal cannula set at 6 lpm O2 (oxygen). EMS obtained a pulse Ox reading of 50. (Normal 92 or higher). EMT went to find the PT's nurse to obtain a report for the PT. Nurse came by to tell EMS that she is printing the PT's demographics and states that PT has been struggling to breathe for several hours. Nurse reports she came into the PT's room several times to tell her to calm down and slow her breathing for several hours. Nurse left the room, and EMS placed the PT on the stretcher and NRB at 15 lpm. EMS never received a throughout PT care report from the nurse nor was given the PT demographics. PT demographics were obtained from the hospital. EMS brought the PT to the ambulance and obtained vitals, attempted IV (intravenous) access 3x with 1 success, obtained 4-lead DKG, and placed the PT on CPAP with albuterol in line, EMS left the scene en route to (Hospital) emergent. PT began to become more lethargic and slowed her respirations while on CPAP. EMS determined the PT would inevitably go into respiratory arrest and began prepping for intubation. EMS estimated the PT weighed roughly 80 kg (kilograms). EMS began ventilating the PT via BVM and administrated 150 mg (milligrams) Ketamine. EMS attempted intubation 2x without success and placed a size 4 I-gel with success. EMS contacted (hospital) with their inbound report and received no questions or orders. EMS shortly arrived after without incident. (all times are approximate). On 5/7/2025 at 2:12 PM, V7, Certified nursing assistant (CNA) stated she works full time in the facility. She only takes vitals if a nurse would ask her, as usually they like to do it themselves. Vitals would be blood pressure, temperature, pulse, and oxygen. Anything like that. If she would chart vitals then they would be in the electronic medical records under vitals. On 5/8/2025 at 2:17 PM, V9, CNA stated she has been working here in the facility for two years. CNA's can take vitals, but don't normally take vitals. She will take vitals if a nurse asks her to, but the nurses usually do not ask her. Vitals would include temperature, blood pressure, pulse and oxygen. All vitals are documented in the resident's electronic records under the vitals tabs. On 5/8/2025 at 2:19 PM, V10, CNA stated, she had been working in the facility for over a year now. If a nurse asks me I will take vitals, but the nurses usually take their own vitals. If I would ever take a vital, I would put it in the computer under vitals. I am not aware of (R2) ever having panic attacks. On 5/7/2025 at 10:33 AM, V11, Licensed Practical Nurse (LPN) stated she likes to take her own vitals, blood pressure, temperature, pulse oxygen. If a resident is experiencing a change of condition, she will always take their vitals. Vital are then charted in the computer under the vital section. (R2) would yell at a lot and scream if she wanted something. She was cognitively intact and was redirectable. I am not aware of her refusing care or needing her family to get her in order for her to do something. She was on dialysis on Mondays, Wednesdays, and Fridays, and she was on oxygen. I am not aware of her ever having panic attacks. On 5/7/2025 at 4:04 PM, V12, CNA stated, (R2) was able to tell you what she wanted. She would yell and scream if she wanted something. She likes to try and stay up until 7:30 PM most nights and then she would fall asleep in her wheelchair and not want to lay down. She was on oxygen and dialysis. I never saw her have any panic attacks. I don't usually take vitals. On 5/7/2025 at 4:14 PM, V13, CNA stated, I will take a vital if the nurse asks me to. Otherwise, I normally do not take vitals. If I take vitals I record it in the computer under the vital spot. (R2) was on dialysis and normally did not get back until later. (R2) is in the hospital right now. Her old roommate passed away. I am not aware of (R2) having any behaviors and/or panic attacks. R2's Oxygen Vitals for May 2025 do not document any vitals were taken for R2 and/or documented as being performed. R2's emergency room Visit Hospital Records dated 5/2/2025 document, On EMS arrival patient the patient was cyanotic with a SPO2 of 50% with labored breathing. She was placed on a non-re-breather mask and then CPAP with an increase of her SPO2 to the 70's. Eventually an LMA (laryngeal mask airway) was placed, and she was bagged on arrival. Due to high probability of clinically significant, life-threatening deterioration, the patient required my highest level of preparedness to intervene emergently, and I personally spent this critical care time directly and personally managing the patient. The patient was evaluated by myself in the emergency department. History obtained from EMS report along with patient's daughter who arrived shortly after EMS and physical exam was performed/ external medical records were reviewed at this time. IV (intravascular) was established and pertinent tests were ordered. EMS did attempt to intubate the patient prior to arrival to the emergency department and they were unsuccessful, an I-gel was placed at this time and patent is currently bagged. Shortly after arrival to the emergency department, patient was intubated due to hypoxic respiratory failure and severe respiratory distress. Shortly after intubation, patient's blood pressure dropped, and patient is currently mapping less than 65. Patient was administrated 1 L (liter) IV fluid bolus with normal saline without any improvement of her blood pressure and at this time she was started on pressors with norepinephrine due to concern for shock. Review of Systems was unable to be obtained as R2 was on mechanical ventilation. On 5/7/2025 at 9:25 PM, V14, Wound Nurse Licensed Practical Nurse (LPN) stated, I remember that night because I got called in because another nurse did not show up. When I walked in the door, they handed me the keys to the med cart and then the phone rang, and I was on the phone for over 30 minutes. (R2) was hollering and yelling all night. 'I can't breathe, I can't breathe' we were telling her to calm herself down and I am in the middle of a medication pass. Her oxygen level was 76% but I think she was in a panic attack, and we were trying to get her to calm down. I did not take her oxygen, but I watched (V15, CNA) take it and it was at 76 %. I am not sure if I contacted the doctor. We normally send residents out to the hospital when the oxygen is 84% or less. I did not send (R2) out because it was a crazy night, and I thought (R2) was having a panic attack and just wanted someone to sit with her. We contacted her daughter and she came and she was the one that called 911. On 5/7/2025 at 9:55 PM, V15, Certified Nursing Assistant (CNA) stated, (R2) started yelling out for help, she was yelling I can't breathe, I can't breathe. I went into her room to check on her. It seemed like (R2) was having a panic attack. I had to answer a few more call lights, and (R2) continued to yell out. I called her daughter, and she came out because I thought she was having a panic attack. We got two admits back-to-back that night, so we were busy. Then, I think her daughter called 911. We did not call 911. I did take vitals on (R2) but I can't remember what they were. I wrote them down a piece of paper and gave them to (V14). I did not put them in the computer. On 5/8/2025 at 7:46 AM, V16, Medical Director stated, I would expect all oxygen levels to be at 92% or higher. If a resident was stating they could not breathe and their oxygen levels were 76 % I would expect staff to ensure the resident was not in distress, maybe change the tank, make sure everything was working, if the levels did not improve then I would have them send them out immediately. If they were in distress, I would want them sent out immediately. I was not aware of (R2) I get so many calls I cannot say if I was or was not contacted. Nothing is coming to my mind, but if she was distressed and the levels were not improving, I would of wanted her sent out immediately. On 5/8/2025 at 12:24 PM, V2, Director of Nursing stated, I expect all vitals to be charted and, in the resident's, medical records. I was not aware (R2) was in distress with her oxygen levels. The Facility undated Change of Condition Policy 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. A significant change in the residents' physical, mental, or psychosocial status (i.e.) deterioration in health, mental, or psychosocial status in either life- threatening conditions or clinical complications); A decision to transfer or discharge the resident from the facility. IJ Abatement: 1. R2 is no longer in facility. 5-8-25 2. Admin/DON were inserviced by VP of Clinical 3. Admin inserviced IDT team 4. Current staff inserviced on change of condition and notifying nurse. Change of condition, notifying MD, document vitals, SBAR, head to toe assessment, full set of vitals, and continued vitals. Completed by 5-8-25 2.Completed by VP of Clinical Services. 3.Completed by Administrator. 4. Completed by IDT team, DON, & administrator. 5. Last 30 days of change of conditions in residents have been reviewed to ensure that no other issues have been identified. 6. All residents with change of condition reviewing medical records. 7. Review of policy and procedures have been completed with MD. Reviewed & updated. 8. Initial change of conditions in residents nurse will notify MD and follow MD orders at the time of change of condition. 9. Noted change of condition where oxygen levels are below 92%, titrate it up 1L, recheck q 30 mins until O2 can reach 92%, if distress is noted notify MD. If no, change in condition MD is to be notified again. Standing order provided by MD. Being completed by VP of clinical, Director of Nursing, MD, and administrator by 5/9/25. 10. All working staff have been in -serviced on change of condition policy and procedure. Currently all staff on shift have been in-serviced. Total facility staff in-serviced at 75%. 100% completion will be done by 5/9/25. Being Completed by IDT team, DON, administrator, and/or designee by start of next worked shift. 11. No staff will work before being in serviced on change of condition. Ongoing - Beding completed by IDT team, DON, administrator, and/or designee by start of next working shift. 12. A Quality assurance tool was implemented; daily audit of the 24 hour report and dc notices for change of conditions, vitals, dc notes, and MD notification if there is a noted change of condition. Audits to continue daily x4 weeks to ensure that change of condition is documented. 5/9/25 Audits complete by: DON/Designee 13. Root Cause Analysis completed for Change of Condition Deficiency: Failed to assess change of condition. Root Cause: Attached Initiated: 5/8/2025

Based on the interview and record review, the facility failed to monitor and assess blood sugar levels for residents with diabetes, for 1 of 3 residents (R2) were reviewed for quality of care in the sample of 14. This failure resulted in R2 requiring emergency intervention for blood glucose level 24 and hospitalization . Findings include: R2's Face Sheet, undated, documents she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition. R2's Minimum Data Set (MDS) dated [DATE] documented that she was cognitively alert and oriented. R2 has an active diagnosis for diabetes. R2's Care Plan, dated 8/12/24, documents, Problem: I have a diagnosis of diabetes mellitus, which places me at risk for medical complications. The goal for this care plan documents, I will experience no medical complications related to their diabetes through the next review. Interventions for this care plan include HgbA1c (Hemoglobin A1c is a blood test that measures the average blood sugar level over the past 2-3 months) as ordered by a physician, follow protocol per facility for low blood sugars, administer my medications as ordered MD (medical doctor), and accu checks as ordered by a physician. R2's Physician's Order, dated 8/12/2024, documented that R2 is to receive Humalog (lispro) insulin 20 units subcutaneously before meals three times per day. R2's Medication Administration Record (MAR), dated 12/1/24-12/27/24 documented R2 did not receive the scheduled insulin ordered by the physician 13 times in a six-day span including 12/1/24 (morning), 12/1/24 (afternoon), 12/1/24 (evening), 12/2/24 (morning), 12/2/24 (afternoon), 12/2/24 (evening), 12/3/24 (morning), 12/5/24 (morning), 12/5/24 (afternoon), 12/5/24 (evening), 12/6/24 (morning), 12/6/24 (afternoon) and 12/6/24 (evening). The reason documented that these insulins were not given is documented as Not Administered: Other or Not Administered: another comment with the blood glucose level documented. R2 also did not receive her scheduled insulin on 12/7/24 (morning), and the reason was that R2 was sleeping. R2's Progress Notes did not document that R2's Physician, V22, was not notified when R2's insulin was not given as ordered on the above dates. R2's Progress Note, dated 12/8/24 at 4:33 PM, documents, Resident was sent out to the (local) hospital at 4:33 PM for Change of condition. The resident was not responding to verbal cues. Vitals 98% (oxygen saturation level), 86 (pulse), 86/56 (blood pressure), 20 (respirations). POA (Power of Attorney) notified, Left message with (V22's, medical doctor) on-call nurse. R2's progress notes and December 2024 Medication Administration Record (MAR) did not document that R2's blood glucose level was checked at the time of condition change. R2's Emergency Medical Services (EMS) report printed on 2/18/25 documents that EMS arrived at the facility on 12/8/24 at 4:41 PM to find R2 unresponsive with an altered level of consciousness (LOC). Per this report, EMS obtained R2's vital signs and noted her blood glucose level was 24. The report also documented that EMS administered Glucagon to treat R2's critically low blood glucose level and transported her to the local hospital. R2's Hospital Record, dated 12/8/24 - 12/12/24, document under Assessment and Plan, Type 2 Diabetes Mellitus with hypoglycemia- long term (current) use of insulin: Status: acute; Assessment and Plan: HgbA1c 5.6%, blood sugar in 20's in nursing home, 60 on arrival to the ER (emergency room ), currently trending 70-100. Hold insulin for now; she may not need insulin with her A1C. On 2/18/25 at 10:30 AM, V2, Director of Nursing (DON), provided a document that she stated was V22's standing order for his residents in the facility. This document stated that for residents with the following diagnoses/conditions: Endocrine: Diabetes Mellitus. The standing orders documented that glycated hemoglobin (HgbA1C) is to be drawn every three months, hold insulins if blood sugar levels are below 80 (Recheck in one hour), call provider for any blood sugar above 350, and hypoglycemic protocol: May use fingerstick glucose checks as needed (PRN) for signs and symptoms of hypoglycemia. Give a glass of orange juice (OJ) with sugar or glucose gel, 1 ounce, squeezed into mouth PRN hypoglycemia. If unable to give OJ, give one glucagon injection subcutaneously (SQ) or intramuscularly (IM). On 2/13/25 at 11:15 AM, V10, Registered Nurse (RN), stated that the physician was made aware of a resident's blood sugar by the staff calling him. V10 noted that if a resident is to receive insulin, there should be a range of blood sugars for when the insulin should be given and when it should be held. If there is not a range of blood sugars listed, V10 stated that the physician should be called. On 2/13/25 at 11:20 AM, V11, a Licensed Practical Nurse (LPN), stated that she remembers R2's blood sugars being fine. V11 stated that R2 typically did not receive her scheduled insulin because her blood sugars weren't high enough. V11 stated that she would document this, but the physician was not always notified. On 2/13/25 at 2:50 PM, V13, LPN, stated that she had only worked at the facility for two weeks. V13 does not remember taking R2's blood sugar prior to sending her out with emergency services. She stated that she kind of remembers that R2 was seated in a high-back reclining chair. V13 stated that she did remember the EMS checking R2's blood sugar. On 2/13/25 at 3:09 PM, V14, LPN, stated that she was vaguely familiar with R2. V14 stated that she usually worked on the B hall, and R2 resided on the C hall. V14 remembered working with the nurse who sent her out. V14 thought she may have been an agency nurse, and she remembers printing the face sheet for her. V14 doesn't remember R2 being unresponsive or any blood sugars that may have been taken. On 2/18/25 at 8:50 AM, V2 stated that if a resident's blood glucose is out of range or if the Resident's insulin is not given as ordered, the nurse should call or text the physician. V2 would expect this to be documented in the progress notes. V2 stated that staff are not good at documenting this in the progress notes, but she said they are getting better. On 2/18/2025 at 2:00 PM, V11 was shown a copy of R2's December 2024 MAR documentation regarding R2's insulin administration. V11 reviewed R2's original insulin order in the presence of surveyors and stated that there were not any parameters included in the insulin order of when the insulin should be held. V11 stated that she uses nursing judgment when deciding to hold a resident's insulin. V11 stated that she was not comfortable giving that amount of insulin with a blood sugar that was 90-100. V11 stated that each time she holds the insulin is very situational and dependent on the individual Resident and the amount of insulin they are supposed to receive. V11 stated anytime a resident's insulin is held, the physician should be notified. V11 stated she did not notify the physician when she held R2's insulin, but she should have. V11 stated that she has not had any conversation with any physician or nurse practitioner regarding the frequency with which she held R2's insulin on the days prior to R2 being sent to the hospital with low blood sugars. V11 stated that she had never seen any real change in R2's condition, which she had recalled. V11 stated that the physician should be notified when the insulin is held, especially when it is being held as often as R2's was being held. On 2/18/25 at 2:30 PM, V2 was shown the hard copy of the standing orders that she had provided. V2 stated that these orders are entered into the computer when the nurses need to use them. She stated that the nurses all have access to these at the desk. V2 stated that standing orders are not entered until the physician says to use them. V2 stated that these orders can be used as soon as the Resident is admitted . On 2/18/25 at 3:00 PM, V11 was shown V22's standing orders and asked if she was familiar with these. V11 stated that she was and that they were available in the nursing binder at the desk. V11 stated that if a resident's blood sugar is low, she would pull out the standing orders and follow them. She stated she would hold the insulin based on the standing order. Still, she would not necessarily enter that standing order into the resident's orders into their Electronic Medical Record (EMR) because she has the standing order hard copy to follow. On 2/19/25 at 8:23 AM, V21, Nurse Practitioner (NP), stated that she was not aware that R2's insulin was held 13 times in a six-day span from 12/1/24 to 12/6/24 due to the nurse determining R2's blood sugar was too low to receive that much insulin. V21 stated she remembered receiving a couple of texts from the nurse caring for R2 informing her that she had held the dose of insulin, and V21 stated she told the staff that it was okay. V21 added that she is aware that sometimes a resident may not eat and will have random low blood sugar. V21 stated that the nurses should notify her every time a dose of insulin is held. V21 stated that she had seen R2 in October, and no changes were made to her insulin. V21 stated that if she is notified that the insulin is being held frequently and is aware of this, she can make the necessary changes to the ordered insulin dose. V21 stated that R2 should have had a HgbA1C in November, three months after she was admitted , but there was no HgbA1C result found in the R2's EMR for November 2024. V21 stated she would have adjusted the current insulin dose based on a recent A1C result. She also stated that if she was made aware of multiple insulin doses being held, she would have ordered an HgbA1C. V21 stated that if an HgbA1C had been done as ordered in November 2024, the results may have resulted in a decreased insulin dose if appropriate. V21 stated that if the HgbA1C result had been lower, there was no way she would have continued the current insulin dose. V21 added that she cannot adjust the Resident's insulin based on a couple of texts or calls that a nurse had held the insulin. Still, if she had been aware that they had held the insulin 13 times in six days, she would have ordered an HgbA1C and adjusted R2's insulin according to the results. V21 stated that the standing orders provided to the facility are based on current evidence-based practice and diabetic, heart health, and specific diagnoses recommendations. The standing orders are reviewed annually according to these guidelines. The labs in the standing orders are essential because they are based on these guidelines. V21 expects that on admission, the pertinent standing orders should be entered for each Resident. V21 stated she couldn't guestimate (guess/estimate) what is happening when they have only received a couple of notifications that insulin has been held on the Resident. V21 stated that when they are in the facility, she and V22 review the physician order sets for the last couple of months, along with any lab results available. V21 stated that they depend on the staff to notify them if the blood glucose results are abnormal. V21 also stated it should be documented in the progress notes every time a nurse contacts the physician/ nurse practitioner. V21 was asked if she was aware that R2 had a significant weight loss from 170 pounds to 136 pounds in a four-month period. V21 stated she was not aware of the weight loss, and if V22 was aware of it, he would have addressed it in his progress notes. V21 stated she last saw R2 in October 2024. V21 stated this weight loss would have most definitely influenced the hypoglycemia as the weight loss has a direct effect on the metabolic system. There was no documentation in R2's EMR that R2 was seen by V21 or V22 after October 2024. The facility's undated policy, Medication Administration, documents, Purpose: To provide practice standards for safe administration of medications for residents in the facility. Whenever a medication is held for any reason, the licensed nurse will initial the appropriate area on the MAR and circle their initials. The licensed nurse will document the reason the medication was held on the back of the Mar. If medication is not given, licensed personnel should document the medication was not given, notify the MD (medical doctor), and make a note in the resident's chart.

Based on the interview and record review, the facility failed to implement interventions to address a significant weight loss for 1 of 3 residents (R2) who were reviewed for weight loss in a sample of 14. This failure resulted in R2 experiencing a significant weight loss of 20% over a four-month period. Findings include: R2's Face Sheet, undated, documents she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition. The R2 medical record did not document how the facility obtained R2's initial weight upon admission on 8/12/24. R2's Care Plan, dated 8/12/2024, documents the problem: Adult failure to thrive related to anorexia. The goal for this care plan documents (R2) will not exhibit signs of malnutrition or dehydration. The interventions for this care plan include assess for dehydration (dizziness on sitting/standing change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation fever, infection, electrolyte imbalance), encourage and record intake of food and fluids, monitor and record output, monitor for signs of malnutrition (pale skin; dull eyes; swollen lips; swollen and/or dry tongue with [NAME] or magenta hue; poor skin turgor; cachexia; bilateral edema; muscle wasting. R2's care plan was not updated to address her significant weight loss. R2's Physician's Order (PO), dated 8/13/2024, documented an order for pureed diet with thin liquids. R2's Nutrition Assessment, dated 9/12/2024, documented R2 being observed turning her head as staff attempted to feed her oral intake of less than 50% at most meals. R2 is taking fluids well. Her weight and body mass index (BMI) indicate obesity. Recent glycated hemoglobin (HgbA1C) is at a good level for diabetes. R2 is at high risk for weight loss. Continue the Pureed diet. Recommend Health Shake with all meals. R2's weight record, dated 9/12/24, documented her weighing 170 pounds. On 10/12/24, she weighed 168 pounds. On 10/28/24, she weighed 162 pounds. On 11/6/24, she weighed 152 pounds, and on 12/5/24, she weighed 136 pounds. These weights calculate a 20 % weight loss in three months from 9/12/24 to 12/5/24 and a 10.5 % weight loss over the last month from 11/6/24 to 12/5/24. R2's PO, dated 10/18/24, documented that R2 should receive health shakes with all meals. This was 36 days after V23; the Dietician recommended that R2 receive health shakes. R2's PO, dated 11/21/24, documented monthly weights to be performed on the fifth of the month to monitor weight loss. R2's meal intake record from 8/20/24 to 12/1/24 documented that of the 52 meals where the intake was recorded, 30 meals had an intake of none to 25%. There was no documentation in R2's medical record that the Dietician assessed R2 after the initial assessment of 9/12/25 or that the facility implemented any interventions to address R2's insidious weight loss after 10/18/24. On 2/13/25 at 11:25 AM, V2, Director of Nursing, DON, stated once the weights are obtained and these fluctuate from the normal for the resident, either herself or the nurse caring for the resident will notify the physician. V2 stated that they have until the tenth month to obtain the weights. V2 stated she would pull a weight report and review back to when the resident was admitted , and if there were any variations, she would notify the physician. V2 stated that the dietitian can obtain the report and view the weights. On 2/18/25 at 12:12 PM, V19, a Certified Nursing Assistant (CNA), stated that R2 was fed her meals, and she would usually eat about 25% of the meal. V19 stated that R2 liked her health shakes and would drink all of them. On 2/18/25 at 1:10 PM, V20, the CNA, stated she remembered assisting R2 with eating her meals and that she ate horrible. V20 stated that R2 always ate less than 25%, but she would always drink her health shakes or any beverage offered. On 2/19/25 at 8:23 AM, V21, Nurse Practitioner (NP), was asked if she was aware R2 had a significant weight loss from 170 pounds to 136 pounds in a four-month period. V21 stated she was not aware of R2's weight loss, but she only saw her in October and did not see her again. She stated that V22, R2's medical doctor, was aware of R2's weight loss; he would have addressed it in his progress notes. A review of R2's electronic medical record (EMR) did not include documentation that R2 was seen by V21 or V22 after V21 saw her on October 23, 2024. There was no documentation or plan in V21's progress notes regarding R2's weight loss, and there was no documentation in R2's progress notes that V21 or V22 had been notified of R2's significant weight loss. V21 stated this weight loss would have most definitely influenced the hypoglycemia as the weight loss has a direct effect on the metabolic system. On 2/20/25 at 11:19 AM, V23, the Registered Dietitian, stated she is rarely notified by the facility when a resident needs to be seen. She stated that she would run her own reports- like tube feedings and weight records, which tell her a lot. V23 stated that a resident should be weighed 24-48 hours after admission. She stated that she has not been contacted regarding new admissions or significant weight changes but figured it out herself. V23 stated that if a resident has a substantial weight change, they should notify her. V23 reviewed the initial nutritional assessment performed on 9/12/24 for R2. V23 stated she didn't know why R2 did not receive orders for the recommended health shake until over a month later. V23 stated that the process followed her recommendation to V1, Administrator; V2, Director of Nursing; and V5, Dietary Manager. From there, the recommendation should be sent to the physician for an order, placed in the resident's physician's orders, and implemented by the dietary staff. V23 stated this process should not take over a month. V23 stated she doesn't know why R2 was not seen and reviewed regarding her weight loss at the facility. V23 added she could not explain it. She doesn't understand why she missed it. V23 added that in comparison to her other facilities, this facility does not reach out to her with concerns. The facility's undated policy, Significant Weight Gain or Loss, documents, Purpose: To ensure that insidious/significant weight gain or loss will be identified so that nutritional needs can be evaluated, and appropriate intervention provided. Standards: All admissions will have a baseline weight obtained. If weight loss is noted, the family and resident will be notified in addition to the physician. Interdisciplinary Team (IDT) team will review monthly to assure appropriate plan of care and interventions for those with significant weight gain or loss.

Based on observation, record review, and interview, the facility failed to assess and provide medication for pain management for 2 of 3 residents (R4 and R7) reviewed for pain in the sample of 9. This failure resulted in R4 being in pain and R7 being unable to participate in therapy. Findings include: 1. On 11/13/2024 at 1:17 PM, R4 stated he did not receive pain medication for several days after admission. R4 stated, That was not good for me, as my pain was at an 8. R4 stated they were administered Tylenol, but that was not effective. R4's Medication Administration Record(MAR) History dated 11/1/2024-11-13-2024 documents Hydrocodone -acetaminophen -Schedule 2 table 5-325 Milligram (mg) administer 1 tablet every 8 hours as needed (prn). R4's MAR history documents start date 11/1/2024. R4's MAR history does not document R4 receiving pain medication until 11/8/2024. R4's Face sheet dated 10/29/2024 documents a diagnosis in part of low back pain, and pressure ulcer of sacral region stage 4. R4's progress notes dated 10/29/2024 at 10:51 AM document R4 arrived at the facility per ambulance. R4's progress notes dated 10/30/2024 at 1:53 PM documents a call placed to the hospital regarding the hard script required for the Norco order that was sent with R4 upon discharge. R4's progress notes document the hospitalist that discharged R4 on 10/29/2024 is not available. R4's progress notes document order will be entered once a hard script is provided or hospital escribes. R4's progress notes dated 11/1/2024 at 1:10 PM document a call placed to the hospital about the Norco script. 2. On 11/13/2024 at 2:21 PM, R7 was sitting in the dining room in a wheelchair, moaning. R4 stated being in pain. R4 described pain at a 7 on a scale of 1-10. R7 indicated his pain was in his belly. R7 said he gets pain medication once in a while. On 11/13/2024 at 2:50 PM, R7 was being pushed into the therapy room in a wheelchair, moaning. 2:54 PM, V9, COTA (Certified Occupational Therapy Aid) has a heat pack on his abdomen in the therapy room. Stated trying to relieve cramping stated they gave him pain medication before I brought him down. R7 continues to moan in pain. On 11/13/2024 at 2:55 PM, V9 pushed out of the therapy room to his room R7, continually moaning in pain. On 11/13/2024 at 2:58 PM, V9 reported to the nurse R7 reported pain 7 out of 10. the nurse enters the room and asks if in pain R7 says belly. And asks if R7 needs to go to the Bathroom or wants a drink. No type of abdominal assessment was performed when the surveyor asked if the nurse had done any assessment and stated that I had been in there a couple of times. I gave him Tylenol 30 minutes ago. 3:03 PM remains up in wheelchair in room moaning in pain. The nurse then goes to the nurses' station where (V16), the Medical Director, is across from the station. nurse is V11, LPN. 3:12 PM placed in bed by mechanical lift by V12, Certified Nursing Assistant (CNA), V13 CNA, V12, and V14 CNA. V13, CNA stated, He is yelling for no apparent reason. R7's care plan dated 1/26/2023, documents R7 has the potential for pain related to diagnosis of polyneuropathy, interstitial pulmonary disease, venous insufficiency, Gastroesophageal Reflux Disease (GERD), Pulmonary Vascular Disease (PVD), old meniscus bucket tear, derangement of unspecified lateral meniscus due to an old tear or injury, and chronic. R7's Care plan documents the following interventions 10/27/2024 administer pain medications as per orders 10/27/2024 Assess for pain every shift and document results, observe and report to the nurse changes in the usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care, record/report to nurse any signs/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, aggressiveness, squirmy, constant motion, refer to physician for adjustment in pain management as needed. R7's undated medication list documents hydrocodone0acetaminiophen 5-325mg i tab twice daily, starting on 11/8/2024. However, the list fails to document the last dose administered. R7's prescription order Norco 5/325 one by mouth twice a day script documents faxed 11/13/2024 with note at top of script please fil. On 11/13/2024 at 2:15 PM, V2, DON stated (R7's) pain medication was not available as the script had not been received from a physician. On 11/13/2024 at 1:20 PM, V2, the Director of Nursing (DON), stated she expected residents to have pain medication as ordered. The facility policy for pain management undated policy documents the purpose of ensuring accurate assessment and management of the resident's pain. The policy documents that 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. The policy documents the licensed nurse will administer pain medication as ordered, and documents medication administered on the Medication Administration Record (MAR). The policy documents that if there is a new onset of pain or if the pain has changed, the licensed nurse will notify the physician to review the medication. The policy documents that nursing staff will implement timely interventions to reduce the increase in the severity of pain.

Based on observation, record review, and interview, the facility failed to ensure wound treatments were completed, physician orders followed and residents repositioned timely for 1 of 3 (R2) residents reviewed for pressure ulcers. Findings include: R2's Care Plan, dated 6/15/2024, documents Last Reviewed/Revised: 07/25/2024 02:44 PM. PROBLEM: I have acquired an unstageable pressure ulcer to right posterior thigh My comorbidities include malnutrition and bed mobility. Approach: Administer treatments as ordered and monitor for effectiveness. APPROACH: Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (physician). APPROACH: Follow facility protocols for the prevention/treatment of skin breakdown. APPROACH: Monitor/document/report to MD PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), and stage. R2's Physician Order Sheet, dated 5/23/24, documents Resident must lie after EVERY meal to reduce pressure on buttocks and then back up to eat next meal. R2's Minimum Data Set, dated dated [DATE], documents that R2 is severely cognitively impaired, totally dependent on staff for all activities of daily living and mobility, and has an unstageable pressure ulcer. R2's weekly Skin Assessment, dated 6/15/2024, documents New Conditions: area to coccyx 0.5x0.5x0.1 and area to posterior right thigh (below buttock) 0.5x0.5xUDT R2's Progress Notes, dated 06/15/2024 at 10:16 AM, documents skin check performed, open area to coccyx noted 0.5x0.5x0.1 scant serous drainage noted, area noted to posterior right thigh (below buttock) 1.3x1.3xudt, resident denies pain, area cleansed with wound cleanser and covered. hospice notified, nurse coming in to evaluate. hospice stated they will call (V15) once they look at it. pt up in (reclining wheelchair), denies pain. awaiting hospice nurse The facility's Wound Report for Quality Assurance/Risk Management Committee, dated 7/14-7/20/2024, documents R2 wound location: Right posterior thigh, current treatment: Santyl, calcium alginate cove with silicon foam. Measurements 1.8x1.8x0.0. Pressure Redux Interventions: reposition every 2 hours, pericare every 2 hours and as needed. No documentation of 3 open areas to R2's coccyx 7/22-7/28/24 documents R2 wound location: Right posterior thigh, current treatment: Santyl, silver alginate, cover with a foam dressing. Measurements 2.3x3.3x unstageable. Pressure Redux Interventions: reposition every 2 hours, peri care every 2 hours and as needed. No documentation of R2's open areas to coccyx. A sign, not dated, above R2's Head of Bed documents turn and reposition every 2 hours, apply barrier cream if reddened, change briefs q 2 hours even if resident has a foley., utilize pillows for offloading buttocks area, resident should be up for every meal. On 7/24/2024 at 9:20 AM R2 sitting, in high back wheelchair, in living area portion of dining room being fed by son. At 10:48 AM R2 in hallway in wheelchair son leaving. At 11:00AM R2 in same position in wheelchair in hallway. At 11:14 AM R2 remains wheelchair in the hallway. At 11:22 AM R2 remains in hallway in same position. At 11:25AM R2 pushed down hall to her room by V4, Wound Nurse, and then left the room. V5, Certified Nurses Assistant (CNA) and V6, CNA, then assisted R2 into the bed. R2's heels were checked and no areas of redness or pressure. R2 adult diaper undid and R2 was not wet as verified by both CNAs. R2 was turned to right side and R2's open area with necrotic center to Right posterior thigh wound was observed and not covered by a dressing and no dressing present in adult diaper as verified by CNAs. Wound approximate size of quarter and deep circular wound with area of black necrotic tissue. V4 never does return. V8, LPN, was asked if the treatment nurse was returning. V8 stated that she would do the treatment and looked up order on the MAR. On 7/24/2024 at 11:57 AM V3, Assistant Director of Nursing, appeared with treatment cart and treatment nurse . V3 stated she was going to do the treatment. V3 put Santyl collagenase ointment in medicine cup, calcium alginate dressing and dressing then entered R2 room cleansed wound with wound cleanser and performed treatment. On 7/24/2024 at 11:57 AM V3 stated that the wound was unstageable. V3 stated that the pressure sores should have dressings on as ordered. On 7/29/2024 at approximately 10:00 AM V2 stated since being notified by surveyor of area and not having a dressing in place the facility completed a Performance Improvement Plan on 7/24/2024. V2 stated that this plan included education provided to the wound nurse, and floor nurses of importance of dcumentation and CNAs of assuring that they notify the nurse when a dressing is removed and not in place. V2 stated that audits were performed as well to assure that the system remained in place. On 8/1/2024 at 7:55 AM V8, stated that when she noted the area it was already necrotic. V8 Stated that she is not sure how the area occurred. V8 Stated that when performing her weekly skin check she noted the area. V8 Stated that the treatment is scheduled for nights but that she has had to perform the treatment on the day shift because the dressing was off. V8 Stated that R2 does scratch and pick. V8 Stated that R2 has not refused the treatment per say but that when trying to remove her pants or perform care sometimes she can swing at you or become combative. V8 Stated that it's not the treatment it's the overall care. On 8/1/2024 at approximately 1:50 PM V4 stated that she started at the facility the week after the fourth. V4 stated that she has been completing and measuring the wounds since starting. V4 stated that she does not have any and have not been able to locate any other other logs or measurements prior to her starting. On 8/5/2024 at approximately 2:15 PM V1, Administrator, stated that she expects the staff follow physician orders and to perform treatments as directed. The facility's Wound Management policy, dated 6/2020, documents Purpose: To provide a system for the treatment and management of residents with and non-pressure injury. Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. Pressure injury- any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injury, friction and shear are important contributing factors to the development of pressure injuries. Pressure injuries usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed. Ill. Documentation A. New pressure injuries or wounds will be documented on the 24 hour log. B. Wound documentation will occur at a minimum of weekly until the wound healed. Documentation will include: i. Location of wound ii. Length , width, and depth measurements recorded in centimeters iii. Direction and length of tunneling and undermining (if applicable) iv. Appearance of the wound base v. Drainage amount and characteristics including color, consistency, and odor vi. Appearance of wound edges vii. Description of the peri-wound condition or evaluation of the skin adjacent to the wound viii. Presence or absence of new epithelium at wound rim ix. Presence of pain C. IDT will document discussion and recommendations for: i. Pressure injury and wounds that do not respond to treatment. ii. Pressure injuries and wounds that worsen or increase in size. iii. Complaints of increased pain, di comfort or decrease in mobility by a resident. iv. Signs of ulcer sepsis, presence o exudates, odor or necrosis. v. Residents refusing treatment. D. Licensed Nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis. E. Document notifications following a change in the resident's skin condition. F. Update the res dent's care plan as necessary.

Based on interview and record review the facility failed to administer medications as ordered for residents (R1, R2, R3, R12) of 4 residents reviewed in a sample of 12. This failure resulted in R1 and R3 experiencing severe pain. Findings include: R1's face sheet, dated 5/23/24, documented that R1 was admitted on [DATE] with diagnoses of quadriplegia, hypertension, COPD (Chronic Obstructive Pulmonary Disease), spinal stenosis, intervertebral disk degeneration, osteoarthritis, and cirrhosis of the liver. R1's MDS (Minimum Data Set) dated 5/27/24 documented R1 is cognitively intact. On 5/23/24 at 6:40 AM, R1 stated that at the beginning of the week B hall did not have a nurse and that he did not receive any of his morning or noon medications. R1 stated that he went to the facility Administrator around 2 PM on this day and informed her that he had not received any medications all day. R1 stated that (V1) informed him she was aware of that hall not having a nurse and that the other nurses would administer his medication, or they will get fired. R1 stated he never did receive his morning or noon medications on this day. R1 stated he normally takes pain pills every 6 hours and that he had to go from 3:00 AM until 4:00 PM without pain medication. R1 stated that his pain rating was at a level of 10 by the time he finally received the pain medication at 4 PM. R1's MAR (Medication Administration Record) dated 5/23/24 documented that R1 has physician orders to receive the following medications between 7 AM and 10 AM: budesonide-formoterol aerosol inhaler 8-4.5 mcg (micrograms) 2 puffs inhalation, vitamin b-12 250 mcg , fibercon 625 mg (milligrams), finasteride 5mg, baclofen 5mg, arginine-glutamine-calcium 1.5 grams, lidocaine patch 5%, omeprazole 20mg, oxycodone 10 mg every 6 hours as needed, polyethylene glycol 17 grams, senna 8.6 mg, toprol XL 25 mg, venlafaxine 37.5 mg, and vitamin D3 25 mcg. The MAR (Medication Administration Record) does not have a nurse's initials documented for these medications on 5/20/24 indicating they were not administered as ordered by R1's physician. R1's MAR, dated 5/23/24, documented that R1 is to receive gabapentin 600 mg between 11 AM and 1 PM. R1's MAR does not have a nurse's initials documented as administered for this medication on 5/20/24. R1's MAR documented an order for a pain assessment to be completed every shift and as needed. The MAR did not document a pain assessment was completed on the day shift on 5/20/24. R1's MAR did document a pain assessment was completed on the evening shift of 5/20/24 and R1 rated his pain at a level of 10. R2's face sheet, dated 5/28/24, documented R2 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, COPD, generalized anxiety disorder, depression, anemia, and tachycardia. R2's MDS, dated [DATE], documented that R2 is cognitively intact. On 5/23/24 at 7:40 AM, R2 stated that on Monday, 5/20/24 he did not receive any of his medications all day. R2 stated that he was concerned because he is on a lot of medications, and it is essential he receives them for his high blood pressure and chronic liver disease. R2 stated he asked a nurse on another hall for his medications and that she stated she was not allowed to help him. R2 stated he then went to the Administrator's office and informed (V1) Administrator that he needed someone to give him his morning medications and that she replied okay. R2 stated he never did receive any of his morning nor noon medications. R2's MAR dated 5/23/24 documented that R2 has physician orders to receive the following medications between 7 AM and 10 AM: lidocaine adhesive medicated patch 4% and a steroid inhaler. The MAR does not have a nurse's initials documented for these medications on 5/20/24 indicating they were not administered. R2's MAR dated 5/23/24 documented that R2 has physician orders to receive the following medications every day at 11 AM: aspirin 81 mg, folic acid 1 mg, Lasix 20 mg, spironolactone 50 mg, tamsulosin .4 mg, iron 325 mg, and lactulose 20 mg. R2's MAR does not have a nurse's initials documented for these medications on 5/20/24 indicating the medications were not administered as ordered. R3's face sheet, dated 5/23/24, documented R3 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, generalized anxiety disorder, neuromuscular dysfunction of bladder, low back pain, chronic kidney disease, major depressive disorder, cerebral infarction, dementia, hyperlipidemia, anemia, diabetes, and chronic pain. R3's MDS, dated [DATE], documented R3 is moderately cognitively impaired. On 5/23/24 at 8:15 AM, V11, daughter of R3, stated that she received a call from her mother, (V12) on 5/20/24 at noon and that (V12) stated (R3) has not had any medications all day and that no one had checked (R3's) blood sugar. V11 stated that her dad, (R3) was in pain because he had not received any pain medication all day on 5/20/24. On 5/23/24 at 8:25 AM, V12, wife of R3, stated that her husband (R3) did not receive any medications on Monday, 5/20/24. V12 stated that (R3) has chronic back pain and has had 3 failed back surgeries. V12 stated her husband needs pain pills every 6 hours to control his pain and that he didn't receive any pain medication all day on 5/20/24. V12 stated that she went to the Administrator's office after lunch and the Administrator, (V1) stated the nurses out there can pass meds. V12 stated she informed (V1) that the nurses said they can't pass the medications on the B hall. V12 stated (V1) just shrugged her shoulders in response. R3's MAR, dated 5/23/24, documented R3 has physician orders for the following medications to be administered every day between 7 AM and 10 AM: ascorbic acid 1000 mg, Dulcolax 5 mg, duloxetine 30 mg, Eliquis 5 mg, finasteride 5 mg, furosemide 40 mg, guaifenesin 600 mg, hydralazine 25 mg, novolog insulin pen 100 unit/ml amount to administer per sliding scale, tamulosin .4 mg, and protonix 20 mg. R3's MAR does not have a nurse's initials documented as administered on 5/20/24 nor is there a blood sugar documented as ordered for the insulin administration. R3's MAR, dated 5/23/24, documented R3 has physician orders for the following medications to be administered every day between 11 AM and 1 PM: Ativan .5 mg, hydralazine 25 mg, hydroxyzine 25 mg, novolog insulin pen 100 unit/ml administer per sliding scale, and oxycodone 5 mg. R3's MAR does not document that these medications were administered on 5/20/24 nor does it document that a blood sugar test was completed as ordered for the insulin administration. R3's nurses note dated 5/22/24 at 3:38 PM documented We encountered a staffing challenge 5/20/2024. In this case residents' medications ran later than normal. MD (Medical Director) and POA (Power of Attorney) are aware. Crisis management and Inservice education in place. Additional CNA added to B hall for monitoring, VS (Vital Signs) q4 hrs until 5/24/2024. Additional leadership rounding in place. Staff will continue to mx residents for any concerns. This note was signed by V2, Interim Director of Nursing. R12's face sheet, dated 5/28/24, documented R12 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, congestive heart failure, history of embolisms, hypertension, anemia and chronic kidney disease. R12's MDS, dated [DATE], documented R12 is cognitively intact. R12's MAR, dated 5/23/24, documented R12 has physician orders for the following medications to be administered everyday between 7 AM and 10 AM: amlodipine 10 mg, entrestro 24 mg, famotidine 40 mg ferrous sulfate 324mg, flonase allergy relief spray 50 mcg, folate 1 mg, Humalog insulin 13 units, insulin glargine 60 units, Jardiance 10 mg, Lasix 40 mg, magnesium oxide 400 mg, metformin 50 mg, toprol 100 mg, aspirin 81 mg, and spironolactone 25 mg. R12's MAR does not have these medications documented as administered on 5/20/24. R12's MAR documents an order for blood sugars to be tested every morning between 6 AM and 8 AM. R12's MAR does not document a blood sugar result for 5/20/24 between the times of 6 AM and 8 AM. R12's MAR, dated 5/23/24, documented R12 has an order to receive 13 units of Humalog insulin every day between 11 AM and 12 PM. R12's MAR does not document this insulin was administered on 5/20/24. R12's progress note, dated 5/22/24, documented we encountered a staffing challenge on 5/20/24. In this case residents' medications ran later than normal. MD notified. Resident is own POA and is aware. Crisis management and in-service education in place. Additional CNA added to B hall for monitoring, VS q4 hrs until 5/24/2024. Additional leadership rounding in place. Staff will continue to mx residents for any concerns. On 5/23/24 at 1:45 PM, Administrator, V1 stated she was not made aware of the B hall not having a nurse assigned to it until 10:30 AM on 5/20/24. V1 stated the Interim DON (Director of Nursing) was scheduled to work the floor on 5/20/24 but that she got called in on the evening shift on 5/19/24 so she did not come in on 5/20/24. V1 stated she attempted to call a nurse in but was unsuccessful and that the facility does not have a contract with a staffing agency because the current owner has not paid the bill with the staffing agency. V1 stated on 5/20/24 she called the two floor nurses to her office and told them that this isn't ideal, but she needed them to pass medications to the residents on B hall and that the nurses refused to do so. On 5/28/24 at 10:23 AM, V17, Regional Director stated that she would have expected a licensed nurse to pass the medications to the residents on B hall on 5/20/24. On 5/28/24 at 2:35 PM, V1, Administrator stated that if there are no initials on the MAR then the medications were not administered. The facility's Administering Medications Policy, dated April 2019, documented medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time from. It continues, 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.

Based on interview and record review the facility failed to protect residents from employee misappropriation of resident funds and exploitation for one of 7 residents (R51) reviewed for misappropriation of resident property in the sample of 42. This failure resulted in an Immediate Jeopardy when V22, Certified Nursing Assistant, (CNA), began using R51's debit card without his permission on March 2, 2023, accruing more than $11,000.00 in charges. When R51 became aware, he was upset and worried about taking care of future expenses and needs. The Immediate Jeopardy began on 3/02/23, when V22 began using R51's debit card without R51's permission. On 1/26/24, at 4:00 PM, V1, Administrator, V3, Assistant Director of Nursing (ADON), and V47, Registered Nurse, RN, were notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 1/29/24, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's Final Facility Reported Incident report, dated 6/26/23, documents On 6/23/23 at 3:00 pm, R51 and V32, R51's family friend, reported possible misappropriation of R51's funds. The Report documented R51 was unable to provide name, description or exact dates and times. R51 and V32 reported R51's checking account was missing $20, 000.00. The Report documented R51's bank was contacted, and bank statements were obtained, and R51's debit card cancelled. The Report documented upon review of the bank statements it was determined that several cash app accounts (financial services platform which allows individuals to quickly receive and send money to other people from their mobile devices) had been making charges using R51's debit card. The Report documented names that appeared on R51's bank statement for cash app were search identifying 3 staff members came up. The Report documented 2 staff members, 1 Certified Nursing Assistant (CNA) and 1 nurse were interviewed about the charge on R51's bank account and they produced proof of where a 3rd staff member had paid them for lunch they had ordered as a group on 2 separate occasions. The Report documented the third staff member was identified as V22, CNA. The Report documented V22 was immediately suspended pending investigation and resigned her position prior to completion of the investigation. The Report documented V22 denied in her written statement of taking any funds from any residents or using their debit cards. The Report documented the local police were called and report was filed with a report under case number (case # identified) by (V48) police officer and they began their investigation. The Report documented V32 friend of R51, took all of R51's credit cards home with him (V32). The Report documented upon interviewing R51 about the incident and if he had given permission to anyone to make these transactions. R51 stated that he only gives his card to the girls to get him a soda or snacks out of the vending machines and nothing else. The Report documented R51 had no knowledge of the funds missing from his account until 6/26/23 when V32 reported it to the Administrator. The Report documented R51 reported he (R51) has not had no other issues involving his bank accounts since being a resident of the facility. The Report documented even though V22 resigned her position with the facility, Administrator and HR Director did notify V22 of her terminated (sic) based on the 2 transactions that can be traced back to V22. The Report documented Police investigation remain on-going, and they will be working with the facility as they subpoenaed items from cash app to determine full extent of misappropriation and to proceed with criminal charges. The Report documented based on the investigation, the facility substantiated misappropriation of resident funds and the police investigation remain on-going. The Police Report dated 6/26/23 documents at approximately 3:57 PM V48, Police Officer was dispatched to nursing home in reference to a fraud report. The Police Report documented V48 met with R51 and V32 friend of R51 who helps manage R51's finances. The Police Report documented R51 and V32 friend of R51 reported they observed odd amounts of currency missing from R51's bank account. The Police Report documented R51 stated he has a debit card which he often handed to nursing staff to purchase snacks for R51 from a vending machine at the nursing home. The Police Report documents R51 reported that someone was using his debit card without permission. The Police Report documents R51 advised the debit card has been deactivated to prevent further fraudulent charges. The Police Report documents beginning on 3-2-23 charges on R51's account from cash app began to accumulate. The Police Report documents R51 provided bank statements from January 2023 to May 2023. The Police Report documents there were approximately 80 fraudulent charges on R51's through Cash App starting in March 2023 totaling at approximately $11,657.36. The Police Report documents R51 stated there were numerous other fraudulent charges in June but the statements were not available yet. The Police Report documents R51 stated he did not give anyone permission to use his debit card other than to purchase him snacks from the vending machine. The Police Report displayed a list the Cash App username/[NAME] of all the recipients who received money from R51's account from March to May. The list consisted of twenty-seven (27) names. V48 Police Officer interviewed V3, Assistant Director of Nursing, ADON who was assisting R51 with his care. The Police Report documents V3 stated she suspected one of her co-workers V22 was the one who used R51's debit card. According to the Police Report, V48 conducted an open-source criminal history on V22 through the county courthouse and discovered V22 has an open case: Case number (case # included)-in an area Municipality: Charges-Aggravated ID Theft; Financial Exploitation of the Elderly (2 counts) [NAME] Trial set for 9-11-23. The Police report documented a search of area County Court documents a case number (case # included) set for trial 2/13/24 regarding V22 Misappropriation of R51's funds. R51's Bank Statements from March 2023 through June 2023 were reviewed. The Cash APP withdrawals began on 3/2/23. On 1/23/24 at 8:00 AM V1, Administrator stated she was unaware of any employees taking money or anything from residents. She stated she was not the administrator during that time and was unaware of the situation. V1 stated in-service training is on-going on all issues regarding resident care with an emphasis on abuse and prevention. V1 stated no resident has reported any theft to her. On 1/23/24 at 9:00 AM, V32, Friend of R51, stated he was reviewing R51's bank statement and discovered there were frequent cash app withdrawals on R51's statement. V32 stated when he questioned R51 about the cash app withdrawals, R51 denied making any withdrawals from his account. V32 stated R51 also denied giving anyone his debit cards. V32 stated the facility staff overheard the encounter between R51 and V32 and informed the Administrator. V32 stated 1 of the girls basically stole money from R51. V32 stated R51 gave her (V22) his debit card to get snacks out of the facility vending machines. V32 stated they contacted the bank and was informed that it was someone making withdrawals using a cash app. V32 stated the police are investigating, and the staff person is being charged. V32 stated The bank is refusing to refund R51's money because they said (R51) gave (V22) the debit card. On 1/23/23 at 10:00 AM V3, stated the staff always get together as a group and orders lunch. V3 stated one person will pick-up the food and each person will reimburse that person. V3 stated V22 reimbursed her with a cash app for the sum of $27.00. V3 stated V22 was assigned to R51 and was always in his room. V3 stated R51 trusted her because she always responded to his call light. V3 stated I was unaware that (V22) was using his debit card to purchase snacks or sodas from the vending machines until (V32) reported money missing from (R51's) account. When (V32) mentioned cash app I immediately thought of (V22). It was confirmed when I was questioned by the police. On 1/25/24 at 12:33 PM V48, Police Officer, stated he was called to the facility on [DATE] for a complaint of misappropriation of resident funds by a facility employee. V48 stated R51 and V32 reported that they noticed a lot of unusual transactions on R51's bank statements starting in March 2023. V48 stated R51 stated he had given his debit card to an employee to purchase snacks or sodas from the nursing home. V48 stated R51 did not give permission for his (R51) debit card for any other purchases and was unaware of its continued usage until 6/26/23. V48 stated V32 and the Administrator presented R51's bank statements to verify the unauthorized transactions. V48 stated both R51 and V32 were interviewed and did not appear to be falsifying statements. V48 stated he interviewed V3 and V27, CNA, who gave statements implicating V22. V48 stated V22 had left the premises and was unavailable for interview, but the facility had obtained a written statement from V22, denying the allegations. V48 stated the case was turned over to a detective, V49 for further investigation. On 1/25/24 at 2:30 PM, V32 stated the bank statements were provided to the prior facility Administrator and thought they could be made available. V32 stated initially R51 was upset and worried about the money stolen from him. R51 was worried about not being able to take care of his future needs. On 1/26/24 at 8:00 AM V49, Detective, stated the investigation of the case is on-going. V49 stated V22 was arrested and released pending trial. V49 stated the investigation regarding the misappropriation of funds from R51 and others are on-going. V49 stated at this point because of the on-going investigation, they are unable to prove or disprove if other residents were victimized by V22. V49 stated the police investigation is also including 3 other nursing homes where V22 was employed and has alleged misappropriated resident funds. On 1/26/24 at 8:45 AM R51 stated he had not talked about the money stolen from his account because he tries not to think about it. R51 stated he did give V22 his debit card one or two times to purchase snacks or sodas out of the vending machines. R51 denies giving V22 his debit card for further purchases. On 1/26/24 at 11:00 AM V19, CNA Coordinator, stated, I was unaware of the problem until I was interviewed by the police. They told me that my name was on (R51's) bank statement as receiving a cash app payment of $20.00. I explained that was because a coworker, (V22), reimbursed me for buying her lunch. I had no idea (V22) had set up a cash app using (R51's) bank account. On 1/29/24 at 2:00 PM V53, former facility Administrator, stated when he became aware of the concern expressed by R51 and V32, the bank was contacted with R51's and V32's permission and the bank statements were obtained. V53 stated copies of the bank statements documenting that $20,000.00 was missing from R51's account was included with the investigation. V53 stated R51 was using a flip phone and has no knowledge of how to set up or use a Cash APP. V53 stated the police were called, and they began their investigation. V53 stated he did maintain contact with the police department and the prosecuting attorney for updates on the case until he longer was employed at that facility. V53 stated V22 was not at work that day and was contacted at home that she was being suspended pending the outcome of the investigation. V53 stated V22 denied stealing money from R51 and then resigned from this employment. R51's Face Sheet undated documents diagnosis of Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting non-dominant side, Generalized Anxiety Disorder and Major Depression Disorder. R51's Minimum Data Set (MDS) dated [DATE] documents R51 is cognitively intact and does not exhibit disorganized thinking. The facility Policy and procedures Investigating Incidents of Theft and/or Misappropriation of Resident Property revised April 2017 documents residents have the right to be free from theft and/or misappropriation of personal property. The Policy documents Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The Immediate Jeopardy that began on 3/02/23 was removed on 1/29/24, when the facility took the following actions: 1. Identification for Residents Affected or Likely to be Affected: -The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion date: January 29th, 2024. -All staff were in-serviced by V1, Administrator, and V50, Social Services Director. The in-service included that staff will not take money from a resident for any reason, including taking money from the resident to obtain snacks from the vending machine, reporting any suspicion of a fell ow employee accepting money or gifts from a resident. Completed 1/29/24. -All staff were given a competency evaluation concerning the in-service material. The evaluation was conducted by V50. Completed 1/29/24. -The facility has appointed a selected group of employees permitted to assist residents with vending machine snacks or drinks, or any other necessary needs of the resident concerning exchange of money between an employee and resident. All residents and employees were informed. V13, Activity Director, V68, Accounts Receivable, V5, Dietary Manager, and V50, SSD. Completion 1/29/24 -The in-service was completed by V1 and V50. Completed on 1/29/24. -All residents are considered at risk for misappropriation of funds. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Completion date 1/29/24. -A QAPI team reviewed the policies regarding misappropriation of funds. -All staff have been in serviced regarding misappropriation of funds. See above. -A competency evaluation was given to each staff member regarding misappropriation of funds. See above. A Resident Council Meeting was called to notify residents of the procedures set forth including the appropriate staff members permitted exchange money with residents. -Residents who did not attend Resident Council were educated on changes on 1/29/24 by V13. -A log has been created that requires V50, V68, V5 and V13 to record any exchange of money between themselves and the residents. -A QAPI has been written addressing each issue listed above. -A Performance Improvement Tool has been created on 1/29/24 that reviews staff knowledge of the above-mentioned policies. -The Administrator will identify concerns during daily meetings. Any concerns identified will be addressed immediately. -The performance improvement (QAPI) monitoring and auditing procedures were initiated, and all findings will be presented at the monthly QAPI meeting. -Monitoring/auditing and reporting will continue for a minimum of four (4) weeks. A weekly ad-Hoc QAPI meeting will be held to discuss results of the monitoring/auditing to determine if addition interventions are necessary to ensure residents safety and compliance. -QAPI team consist of V1, V2, Director of Nursing, V3, Assistant Director of Nursing, V5, V68, V13, V22, Certified Nursing Assistant, V58, Restorative Aide, V18, Registered Nurse/Wounds, V28, Infection Control, V25, Maintenance Supervisor, V50, V20, Human Resource Director, and V69, Marketing Coordinator. The team completed the following from 1/26 through1/31/24 to validate the facility's abatement plan: V2, V3, V36, V57, V58, V64, V65, V66, V67 were interviewed about the in-services they received related to abuse and the Misappropriation of residents' property and that only certain designated management personnel will be allowed to obtain items for residents from vending machines. Among residents R23, R45, R8's, R71, and R54's were interviewed and were aware of the change in obtaining items from the vending machines if they are unable to on their own. The facilities in-services and policies were reviewed.

Based on observation, interview, and record review, the facility failed to ensure safe beverage serving temperatures to prevent thermal burns and adequate supervision to prevent falls for 3 of 9 residents (R60, R62, and R68) reviewed for accidents/hazards in the sample of 42. These failures resulted in R62 and R68 sustaining second degree abdominal burns and R60 falling and sustaining nasal fracture. Findings include: 1.R62's Face Sheet documents R62 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, essential primary hypertension, chronic obstructive pulmonary disease, type 2 diabetes mellitus with hyperglycemia, anxiety, encephalopathy, stage 3 chronic kidney disease, and obesity. R62's Minimum Data Set (MDS) dated [DATE] documented R62 was severely cognitively impaired and required substantial assistance rolling in bed and transferring. R62's 11/2/23 Care Plan documents R62 obtained a burn to her abdomen after spilling hot tea on her abdomen. The Facility's Incident Initial Report sent to IDPH (Illinois Department of Public Health) on 11/2/23 documents, On 11/2/2023 at 9a (9:00 AM) it was reported to (V1, Administrator) from Nurse that (V19, Certified Nurse's Aide/CNA/ Coordinator) went to give (R62) hot tea in the dining room. (R62) asked (V19) for a hug, as (V19) went to hug (R62) she accidentally tapped cup with her elbow as she was hugging resident which made the cup of hot tea spill on the resident's abdomen. Nurse immediately took (R62) to her room and assessed (R62) and noted a blister on (R62)'s abdomen. (R62) was not upset and told (V19) she knew it was an accident and was okay. Nurse contacted MD/POA (Medical Doctor/Power of Attorney). Investigation initiated. R62's Progress Note by V17, Registered Nurse (RN), on 11/2/23 at 9:22 AM documents, resident was sitting in dinning [sic] room when staff member and resident hugged knocking over hot tea onto resident abd (abdomen) and staff arm. Resident taken to room assessed and given first aide to abd are [sic]. skin noted to be red with slight blistering. md (Medical Doctor) and poa (Power of Attorney) notified. n.o. (New Order) for ssd (Silver Sulfadiazine) cream and to keep area covered. On 1/23/24 at 1:00 PM, V17, Registered Nurse/RN, stated she did not witness R62's accident in the dining room. She stated, I guess (R62) had a Styrofoam cup of hot tea, and she went to hug (V19), and their hands kind of got tangled up, and it ended up getting spilled on her. (V19) came and got me. It was red. It was a decent sized area to the lower abdomen. It hurt her. The tea was steaming out of the cup. I very rarely work on that hall, but I notified the daughter and the doctor. V17 stated It got pretty nasty after the first few days and (R62) was seen by (Wound Consultant Company) for quite a while. I can't say if the coffee was always that hot. The Facility had gone back and forth over the coffee; it was too hot for a while, then it was too cold. V19, Certified Nursing Assistant (CNA)'s Hand-Written Statement dated 11/2/23 documents, At breakfast (R62) ask me to get her some hot tea. I went to get (R62) some hot tea took it back to her and sat it in front of her and she reach out to give me a hug forgetting the hot tea for her, and I went to hug he (her) back and my right arm hit the cup of hot tea and it spilled on my arm and also (R62) stomach and I reported to the nurse. On 1/23/24 at 11:12 AM, V19 stated, (R62) asked for a cup of hot tea, so I went and got it for her and set it down on the table. She reached her arms out to hug me and it got her stomach and my right elbow. I got (V17) and we pulled (R62) out (of the dining room) to the shower room. Her stomach was red but didn't blister. I think (V17) got Silvadene for her stomach and also for my arm. I felt so bad, I cried. On 1/23/24 at 11:15 AM, R62 stated, It was an accident. One of the girls dumped hot tea on me and it was steaming hot. It was nasty for a while. It is all healed up now. She felt terrible, she did not mean to do it. The Facility's Incident Final Report submitted to IDPH on 11/2/23 documents, On 11/1/2023 at 9a (9:00 AM) it was reported to (V1) from (V17) that (V19) went to give (R62) hot tea in the dining room. (R62) asked (V19) for a hug, as (V19) went to hug (R62) she accidentally tapped cup with her elbow as she was hugging (R62) which made the cup of hot tea spill on (R62)'s abdomen. (V17) immediately took (R62) to her room and assessed (R62) with interventions in place. (R62) remains at baseline. (V17) contacted MD/POA. Upon investigation, (V17) had applied silver sulfadiazine cream to (R62)'s abdomen. In conclusion, the quality assurance team met, new interventions were discussed: silver sulfadiazine to be applied 2x day to abdomen covered with dry dressing. Kitchen informed to offer lids for hot drinks. R62's Physician Order Report documents 11/3/23 order, Cleanse burn to abdomen with NS (Normal Saline) or wound cleanser, apply SSD (Silver Sulfadiazine) cream and calcium alginate, cover with silicone bordered foam dressing. Change twice daily and PRN (as needed) if soiled. R62's (Wound Consultation Company) documentation dated 11/8/23 documents, Nursing requests that I examine her abdomen, which was noted on 11/2 to have a burn on her abdomen from a spill of hot tea, currently treating with silvadene. The burn to R62's abdomen measured 14 cm (centimeters) x 17cm x 0.3cm and required mechanical debridement. On 1/23/24 at 8:40 AM, V7, Dietary Aide, stated they were previously writing down the temperatures of hot beverages, but she was off work for a couple days and they might have stopped. She stated, It's supposed to be no more than 140 Fahrenheit (F). I didn't calculate it today. On 1/23/24 at 8:43 AM, V5, Dietary Manager, stated, I thought it was supposed to be 145-150 F. V5 stated You want it a little hotter going in to the hall trays, because if you put them on at 140-145 F here (the cart) it'll be down to 120 F when it gets to them, and they are going to complain that it's too cold. 145 F is the goal. On 1/23/24 at 9:52 AM, V7, Dietary Aide, said the department stopped tracking temperatures almost two months ago. On 1/23/24 at 9:56 AM, V1, Administrator, stated the Facility added hot beverage temperatures to QAPI (Quality Assurance Performance Improvement). On 1/23/24 at 10:02 AM, V5, Dietary Manager, provided QAPI notes from 11/8/23 and stated, Apparently they were only supposed to take the temperatures for four weeks. She was unsure if there is a policy on hot beverage temperatures but will check on it. On 1/23/24 at 1:43 PM, V2, Director of Nursing (DON), stated, (R62) had a decent size wound and was treated by (Wound Consultant Company). She was on prophylactic antibiotics. When it first happened, it was not open and had just started to blister at the time. I didn't realize it would be hot enough to cause burns like that. It should be under 140 F. I was not told dietary was no longer checking the temperatures. I thought that was a process they put in place here. On 1/25/24 at 2:39 PM, V1, Administrator, stated she was unaware that staff was no longer taking hot beverage temperatures and would expect staff to be aware of safe serving temperatures and provide beverages to residents at safe temperatures. She stated, The Facility Policy for serving temperatures states staff will follow the guidelines, so I provided the list of our guidelines. For hot beverages, they have to temp at 140 F or below. The Facility's undated Serving Temperatures for Hot and Cold Foods documents, Staff will follow the guidelines below when serving hot and cold beverages and food. It documents hot beverage temperatures are per Facility Guidelines. The Hand-Written document signed by V1, Administrator, on 1/25/24 documents, For hot beverages, they have to temp at 140 F or below. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities documents a water temperature 155 F can cause a third-degree burn in one second. It documents burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. 34964 2. R68's Event Report dated 11/7/23 at 8:15 PM documents, Resident states that hot tea was spilled on her abdomen at breakfast. States it may have happened a day or so ago. She states she can't remember how it got spilled. States she might have bumped her cup. Burn is on right mid quadrant of abdomen, approximately 1.5-inch x (by) 1 inch with popped blister mid region. The Event documents, Partial thickness burn (Second Degree) extend through the epidermis and into the dermis. These burns are typically very painful, red, blistered, moist, soft and blanch when touched. Examples include burns from hot surfaces, hot liquids or flame. On 1/23/24 at 9:33 AM R68 stated the burn on her abdomen is healed now. She stated it happened when the CNA was putting her tray down on the table at breakfast. She stated she could not remember if the CNA had handed her the cup of tea or if it was on the table, but it spilled on her. R68 stated the tea was very hot but it didn't hurt too bad and V15, CNA told her to have the nurse look at it. R68 stated after breakfast she went to the nurse's station and showed the burn to V17, Registered Nurse (RN) who was her nurse that day. R68 stated V17 told her, Yeah, that's a burn but didn't do anything at that time. R68 stated nobody did anything about her burn until V16, RN, came to work that night and looked at it and put a dressing on it and then the wound nurse started seeing her. R68 stated the wound nurse told her she had a third degree burn on her abdomen. R68 stated it seems like the tea is always too hot and she has to wait for it to cool down before she can drink it. She stated she doesn't want to act like she knows more than she does, but she has worked as a dietary aide in the past and she knows they have to check the temperatures of the food and drinks. R68 stated after she was burned the staff did start taking temperatures of the drinks for a while, but she doesn't know if they still do them. She stated the temperatures were cooler for a while, but they are hotter again lately. R68 stated when the incident happened, V15 asked her right away if she was alright, but it didn't hurt too bad, so she kept her same shirt on. R68 stated V17 was standing right there and didn't do anything. R68 stated V17 didn't look at it until she wheeled herself to the nurse's station after she was done with breakfast. On 1/25/24 at 9:00 AM R68 was lying in bed and pulled her blanket back and lifted her shirt to show writer a light pink quarter-sized faint scar that she stated was from her burn that happened when the hot tea spilled on her. R68's MDS dated [DATE] documents she is alert and oriented. R68's Physician Order dated 11/8/23 documents she may be seen by the specialized wound consultant. R68's Wound Consultant progress note dated 11/8/23 documents this was the initial consult for R68 who suffered a burn of her abdomen on 11/5/23. The note documented wound consultant ordered a treatment of: cleanse with normal saline or wound cleanser, apply Santyl and calcium alginate and cover with dry dressing; change daily and as needed. R68's Care Plan dated 11/5/23 documents, I obtained a burn to my abdomen related to spilled hot tea. Interventions for this care plan document, Assess my burn and document weekly on my condition including the size, color, drainage, odor until healed; Avoid giving me warm liquids in cups without a lid. Cool my liquids before providing them to me. May substitute chocolate milk for hot chocolate; Observe my burn for signs and symptoms (s/s) of healing or lack of healing and send report to providers COC (change of condition) if observed; Observed for s/s of pain related to my wound and treat my pain as indicated; Wound nurse to monitor, consult with NP, MD, and hospice (R68 not on hospice). Treat as ordered until healed. On 1/23/24 at 10:00 AM V15, CNA stated on the day R68 was burned with hot tea she was giving R68 her breakfast tray in the dining room. V15 stated she had set the cup of hot tea down on the table and the nurse, V17, spoke to her and she turned around to face the nurse, and when she turned back around, she thinks she may have bumped the table, or R68 bumped the table and the hot tea spilled onto R68's abdomen and thigh. V15 stated she grabbed the bib off the table and blotted the hot tea off R68's shirt and pants right away. She stated the hot tea was in a coffee cup. V15 stated the nurse was standing right there and said she would look at R68's skin after she was finished with breakfast. V15 stated she looked at R68's skin when it happened and her abdomen was very red where the hot tea had spilled on her, and her thigh was red, but not as bad. V15 stated she did not know if the nurse looked at it or not and she (V15) looked at it again before the end of her shift and it was still very red, but she was not sure if there was a blister or not on the area. V15 stated after the incident they (facility) had a meeting about it, and they started checking the temperatures of the hot drinks before they put them out for the CNAs to use. V15 stated they started using different containers to pour from but then residents were complaining the coffee and tea was not hot enough. She stated the kitchen checks the temperatures before they put the water for tea and the coffee out, but she has not seen them actually do it, but the dietary aides had told her they have to check the temperatures now before they put them out. V15 stated she has not known any other residents who have been burned by hot liquids, more often they complain the coffee and tea is not hot enough. On 1/23/24 at 1:03 PM V17, RN stated she was told about R68's burn on a day she was not working. V17 stated she did not know about R68's burn and was not told about it when it happened. V17 stated she wrote a statement that she was not aware of R68's burn and turned it into the Director of Nursing. V17 stated it was a few days later that she heard about the burn on a chat group that was between the nurses, including the DON and Assistant Director of Nursing (ADON). She stated she had never seen R68's burn, but then stated she may have done the treatment a couple of times. She stated the last time she saw it, there was no longer a treatment in place. On 1/23/24 at 1:40 PM V2, Director of Nursing (DON), stated she does not know exactly when R68's burn occurred but she thinks it happened on 11/5/23 but nothing was reported to her until 11/7/23 when the night shift nurse called her. V2 stated the Medical Doctor (MD) was also notified of R68's burn at that time. V2 stated R68's burn was small on her abdomen. She stated she was not even aware that the temperatures of the tea were hot enough to cause that type of burn. On 1/23/24 at 1:50 PM during phone interview, V16, RN stated she works night shift and documented finding R68's burn on 11/7/23. V16 stated she was giving R68 her nighttime insulin and when she pulled her shirt up to give her the injection, she saw the burn on R68's right abdomen. V16 stated R68's answers were vague and iffy about when it occurred. V16 stated she notified the physician of the burn right away but was not sure if he gave her the order that night or the next day for the treatment. V16 stated the burn was open and scabbed over. She stated it was just a little smaller than a half dollar. V16 stated the wound did not look infected but looked like a blister that had popped and was drying up. V16 stated besides the MD, she also reported the burn to the DON and ADON. 01/24/24 10:50 AM V24, Wound Nurse Practitioner returned call and stated she had assessed and treated both R68's and R62's burns and would have considered them both to be second degree burns because they were both blistered and then opened. She stated they both healed without problem. V24 stated she does not know off the top of her head what temperature of hot liquid would cause these second-degree burns, but she knows the facility reconciled the problem with the hot water temperatures because she was concerned other residents could be hurt. V24 stated she discussed concerns with V2, DON and V3, ADON while they were making rounds. On 1/25/24 at 9:06 AM V41, Medical Doctor stated he is familiar with R68 and remembers when she had the burn from the hot tea. He stated sometimes when a person has a burn, they don't have pain right away, but he would expect to be notified right away of the incident. V41 stated the area should be assessed to monitor for changes in the burn. 42834 3. R60's Face Sheet, undated, documented R60 was admitted on [DATE] with diagnosis of Congestive Heart Failure, Type 2 Diabetes Mellitus, Idiopathic Progressive Neuropathy, Chronic Kidney Disease, Malignant of Prostrate. R60's MDS, dated [DATE] documents R60 uses manual wheelchair. R60's MDS documents R60 requires substantial/maximum assist with toilet transfers and partial/moderate assist with toilet hygiene. R60's Care Plan with problem start date of 11/12/23, documents R60 is at risk for falls due to diagnosis of idiopathic progressive neuropathy. The Care Plan Interventions include provide individualized toileting interventions based on needs/patterns, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk, implement exercise program that targets strength, gait, and balance. All Intervention start dates are 11/12/23. R60's Care Plan updated 12/15/2023 documents I have experienced an actual fall on 2/21/2022, 6/26/23, 12/13/23. The Care Plan Interventions include provide me with follow up care as indicated related to my injury until healed, nonskid socks applied to feet, complete post fall assessments and monitoring per facility protocol, notify my provider if any change in condition is observed, Dycem applied to wheelchair, physical/Occupational therapy referral, interdisciplinary team to review fall and provide interventions. R60's Fall Risk assessment dated [DATE] documents R60 has visual impairment, has balance and gait problem while walking, has impaired mobility, and is at risk for falls. The facility's incident report form dated 12/13/2023 at 12:30PM, Nurse advised Administrator that resident was found to be on floor in resident bathroom face first. Nurse immediately assessed Resident. Resident was noted with laceration to nose. Resident stated he was trying to move up on toilet and lost his balance. Nurse immediately called 911 and sent to (local hospital ER) for evaluation. MD (medical doctor)/POA (Power of Attorney notified). Investigation initiated. R60's Progress Note, dated 12/13/2023 at 12:46PM documents Writer heard crash in resident's bathroom. Resident noted to be on floor, face first. Resident able to answer questions and respond appropriately. Laceration noted to nose. Blood coming from nose. Bump noted to forehead. Numerous skin tears noted to BUE (bilateral upper extremities). Resident laying on left arm. Pain noted to left arm. 911 called. R60 transported to (local hospital) ER (emergency room ). R60's Progress Note, dated 12/13/2023 at 6:30PM documents R60 returned at this time from local hospital. The Note documented R60 returned via ambulance stretcher with x2 emergency medical technicians, EMTs, present. The Note documented R60 had a hematoma noted to forehead, lacerations noted to bridge of nose, and left arm. The Note documented Computerized Tomography (CT) scans note frontal scalp hematoma, fractures to nasal bones, nasal septum, and frontal and ethmoid sinuses. Resident was started on amoxicillin-potclavulanate 875-125mg Q (every) 12 hours for 10 days. Discharge report from hospital ER nurse states resident does have sutures to nasal lacerations which will need to be removed in 7-10 days. R60's CT scan report dated 12/13/2023 at 2:11PM documents Findings: Maxillofacial CT: There is a frontal scalp hematoma. There is a laceration of the nose. There are fractures of the nasal bones, nasal septum, and frontal and ethmoid sinuses including the medial walls of the orbits and the anteroinferior aspect of anterior cranial fossa. There is a small focus of pneumocephalus There is mucosal thickening in the paranasal sinuses. The mastoid air cells are normal. There is extensive dental disease. On 1/24/2024 at 10:45AM V29, Certified Nursing Assistant, CNA, stated I put (R60) on the toilet. I did leave the bathroom. He was able to adjust himself and had the call light. I heard the nurse yell and (R60) was on the floor. He had landed on his face and there was a lot of blood. I'm not sure what he was trying to do. On 1/24/2024 at 11:20AM V30, Licensed Practical Nurse, LPN, stated The day (R60) fell I was out passing meds in the hallway, and I heard him yell out. He was left in the bathroom by himself and fell face first into the sink. (R60) was known to readjust himself when sitting. We called 911 and he went to the hospital. On 1/24/2024 at 3:10PM V3, Assistant Director of Nursing, ADON, stated I would expect a resident with a history of falls to be supervised while in bathroom and not left unattended. On 1/25/2024 at 9:09AM V41, Medical Director, stated If (R60) has history of falls and is at risk for falls I would expect (R60) to need supervision. Fall policy with a revision date of 2018 states University Care Center will provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. All resident falls that occur within the facility will be tracked, analyzed, and trended. This information will be used to assist facility management and direct care staff in maintaining a safe environment. It is the responsibility of the facility to assure that all residents are assessed to determine fall risk and history or falls. Individualized preventative approaches should be provided to assist with fall prevention.

Based on interview and record review, the facility failed to adequately assess and ensure a resident receiving continuous Gastrostomy tube (G-tube) feeding did not experience significant weight loss for 1 of 2 residents (R13) reviewed for nutrition in the sample of 42. This failure resulted in R13 having an insidious significant weight loss of 12 pounds in three months while receiving nutrition via G-tube. Findings include: R13's Face Sheet, undated, lists her diagnoses to include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Aphasia following unspecified cerebrovascular disease, Dysphasia following cerebral infarction, and Gastrostomy status. R13's Minimum Data Set (MDS) dated [DATE] documents her weight as 198 even though her weight documented under vital signs in her electronic medical record (EMR) documents her weight as 189# on 11/4/23, which was the last weight documented before the MDS was done. According to the MDS, R13 has a feeding tube, and incorrectly documents R13 had no significant weight loss/ gain. R13's Care Plan documents the problem dated 10/12/20: I am at risk for alteration in nutrition r/t (related to) other specified nutritional deficiencies, specified depressive episodes, pure hypercholesterolemia, gastrostomy status, unspecified dementia without behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting left, dysphagia following cerebral infarction, Type 2 diabetes mellitus with hyperglycemia, NPO (Nothing by mouth) status. The goal for this care plan with target date of 4/25/24 documents, I will maintain my weight +/- 5 pounds (lbs) through next review date. The interventions for this care plan include the following: Administer medications as ordered; allow me time to perform task of eating a meal-assist as needed, (R13 is unable to eat anything by mouth); Gastrointestinal tube feeding (Glucerna 1.2 80 ml/hr (milliliters per hour); R13's Physician Order dated 1/4/24 documents, Diet: NPO Glucerna 1.2 65 ml/hr continuous 22 hrs (hours) *hold 2 hrs per day*. Flush with 300 ml H2O every 4 hours. Special instructions: 50 ml before and after each medication administration; Observe and report to MD (medical doctor) s/s (signs and 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 (Medical Doctor) if I have signs of dysphagia: (i.e. (for example): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appearing concerned. (R13 is NPO); RD (registered dietician) to evaluate and make diet change recommendations prn. Weight to be completed monthly and prn. R13's Physician Order dated 1/4/24 document: Diet: NPO Glucerna 1.2 65 ml/hr continuous 22 hrs (hours) *hold 2 hrs. per day*. Flush with 300 ml H2O every 4 hours. Special instructions: 50 ml before and after each medication administration. R13's Registered Dietician (RD) progress note dated 10/31/2023 at 9:11 AM documents Readmit/TF status. readmitted to facility 10/27 from hospital dx (diagnoses) COVID/UTI (Urinary Tract Infection). Weight (10/12)-189 lbs, BMI-30.5. Noted weight has had trend down -2 lbs x 1 month, -4 lbs x 3 months, -7 lbs x 6 months. NPO with Glucerna 1.2 55 ml/hr continuous with 300 ml water flush Q4 and 50 ml flush before/after meds. Provides: 1518 kcals, 76 g pro, and 1018 ml fluid (2818 ml total with flushes). Prostat 30 ml daily ordered. No skin concerns noted at this time. [NAME] meds: mvi (multivitamin), levemir, levetiracetam, reglan, senna, folic acid. Weekly weights in place to monitor nutritional status closely. Current tube feeding fluids/water flushes exceeding estimated fluid needs. RECOMMEND: 1. d/c (discontinue) prostat 30 ml daily as no skin concerns at this time 2. Suggest increase tube feeding to Glucerna 1.2 65 ml/hr continuous (hold 2 hours/day for ADLs) to better meet estimated energy needs. Monitor weights, tube feeding tolerance, and labs as available. R13's last Registered Dietician (RD) progress note was dated 11/16/23 at 3:07 PM and documented: RD consulted due to weight loss. Current weight 182# (pounds), showing trend down. NPO with Glucerna 1.2 55 ml/hr continuous with 300 ml water flush every 4 hours and 50 ml flush before/after meds. Provides: 1518 kcals, 76 g (grams) protein, and 1018 ml fluid (2818 ml total with flushes). Prostat 30 ml daily ordered. No skin concerns noted at this time. Weekly weights in place to monitor nutritional status closely. Recommend: 1. Suggest increase tube feeding to Glucerna 1.2 65 ml/hr continuous (hold 2 hours/day for ADLs (Activities of Daily Living) to better meet estimated energy needs. Monitor weights, tube feeding tolerance, and labs as available. RD to follow up as needed. There were no further RD progress notes documented in R13's EMR after 11/16/23 as of 1/23/24. On 1/25/24 at 10:45 AM V2, Director of Nursing (DON) provided an email document dated 1/2/24 that documents she notified the facility's RD that R13 receives tube feedings for nutrition, her weight was 183# and now it's 177#, and that weight was verified with a re-weight. In the document V2 asks the RD, Is this an intentional decrease in her weight? and requested the RD review and advise with any recommendations she has. On 1/25/24 at 10:45 AM V2 provided a document titled, Weight dated 1/4/24 from the facility's RD that documented, I had noticed that her (R13's) weight was trending down. I also noticed that her TF (tube feeding) was decreased. Here are my recommendations to prevent further weight loss: Increase tube feeding to Glucerna 1.2 65 ml/hr continuous (hold 2 hours/day for ADLs) to better meet estimated energy needs. Monitor weights, tube feeding tolerance, and labs as available. The RD recommendations dated 10/31/23 and 11/16/23 to increase R13's tube feeding to 65 ml/hr was not followed until after another RD recommendation was received on 1/4/24 to increase the tube feedings to 65 ml/hr after R13's Medical Doctor V41 was notified of R13's continued weight loss. On 1/25/24 at 10:45 AM V2 provided a copy of a photocopied text message to V41, Medical Doctor (MD) dated 1/2/24 that documented, (R13) receives tube feeding for nutrition. Was 183 now 177, verified with second. Another message at 1:30 PM documented, The dietician to review. She shouldn't have weight loss with tube feeding. V2 stated this was V41's response to her notification of R13's weight loss and she notified the RD of the need to review R13 for weight loss. V2 stated she could not find any other notifications that V41 had been notified of R13's weight loss prior to this date. R13's Electronic Medical Record was reviewed for weights. R13's weights were documented as: 7/23 (195#); 8/8/23 (192#); 9/12/23 (191#); 10/3/23 (197#); 11/4/23 (189#), 12/23/23 (183#), and 1/4/23 (177#). These weights represent R13 having a 4% weight loss in one month, and 10% weight loss (significant) at both 3 and 6 months. On 1/23/24 at 4:10 PM V3, Assistant Director of Nursing (ADON) provided R13's reweight taken just now as 176.4#. On 1/24/24 at 9:00 AM V2 stated they just got a new dietician, so she does not know if she is aware of R13's additional weight loss. V2 stated she does not know why R13 was not weighed in December as she is just learning the electronic system. V2 stated when tube feeding is running using a generic bag for the formula, the bag should be labeled with the date and time it was hung and the name of the formula should be included since there is no label on a bottle with this information. On 1/25/24 at 9:06 AM V41, MD, stated he was looking back in his notes/emails from the facility and does not see where the facility notified him that R13 continued to lose weight. V41 stated he would expect the facility to notify him of changes and recommendations from the Registered Dietician and would not expect a resident who is consistently receiving tube feeding to have significant weight loss. On 1/25/24 at 11:10 AM V2 stated she does have documentation of some of R13's weekly weights and provided paperwork. She also provided a copy of emails to V41 dated 1/2/24 when facility reported R13's weight loss to him. V2 also provided documentation of assessment by RD dated 1/4/24 that recommends increasing tube feeding to Glucerna 1.2 to 65 ml/hr continuous (hold 2 hours/day for ADLs) to better meet estimated energy needs. Monitor weights, tube feeding tolerance, and labs as available. Writer asked V2 if she was aware that the dietician had recommended these changes on 10/31/23 and again on 11/16/23 and it was not done. V2 stated she was not aware of those recommendations. The facility's policy, Weight Assessment and Intervention, revised September 2008, documents, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual 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. 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: f. Increased need for calories and/or protein; h. Fluid and nutrient loss.

Based on interview and record review, the facility failed to refill medications timely for 1 of 3 (R2) residents reviewed for medication administration in a sample of 10. This failure resulted in R2 being admitted to the hospital for breakthrough seizure activity. Findings include: On 10/17/2023 at 11:30 AM, R2 stated that she was sent to the hospital because she was having seizures. She continued to state they didn't give her seizure medicine to her for at least a day or 2 and it sent her into full active seizures. She stated that they told her that they didn't have it and it was unacceptable to her. She continued to state that she was on top of her medication and it has happened before when they have run out of different medications for her. R2's Minimum Data Set, dated dated [DATE], documented that her cognition was intact. R2's Physicians order sheet, dated 10/2023, documented an order for Clonazepam 3 mg, oral, Twice A Day, by mouth twice a day. R2's Care Plan, dated 02/27/2023, documented, Approach: Medications as ordered by MD. R2's Medication Administration Record (MAR), dated, October 2023, documented, that on 10/3/2023 at 8:00 AM, R2 was given 3 milligrams (MG) of Clonazepam. R2's Controlled Substance record dated 10/3/2023 at 8:00 AM R2 received 2 mg of Clonazepam. R2's Medication Administration Record, dated October 2023, documented on 10/3/2023 at 7:28 PM Clonazepam 3mg was not administered/drug item unavailable. R2's Medication Administration Record, dated October 2023, documented on 10/4/2023 at 10:27 AM Clonazepam 3mg was not administered/drug item unavailable. R2's MAR, dated October 2023, documented, that on 10/4/2023 at 7:27 PM, Clonazepam 3mg was not administered/drug item unavailable. The facility's electronic notification application, dated 10/3/2023 at 1:24 PM, documented, (R2) (date of birth) 07/03/1983 need a script for clonazepam 1 mg tablets, give 3 tablets (twice a day.) It continues, She is completely out. The facility's electronic notification application, dated 10/3/2023 at 5:13 PM, documented, Clonazepam 1mg (by mouth) (twice a day) one hundred eighty #180. It was signed by V6, R2's Physician. R2's Nurses Note, dated 10/04/2023 at 09:15 PM, Called to resident room, resident is in active seizure. Resident laid to left side head is free from clutter. Resident lasted in seizure for 30 seconds. Is now awake and oriented x3. States she had a few seizures earlier in the day but came out of them quickly, doctor notified. (Vital Signs)-120/78, 112 (heart rate), 22 (respirations), 98.4 and 95% (room air). Resident states she feels okay now. Frequent checks initiated. Call light within reach. R2's Nurses notes, dated 10/04/2023 at 09:27 PM, documented, Called to resident room. Resident is having another seizure at this moment. Resident is noted to have emesis on bed, resident is laying on side provided by staff. This nurse calls 911 for transport and (transfer) to (local hospital). doctor and (Power of Attorney) notified. R2's Local Hospital History and Physical, dated 10/5/2023, documented, Plan: (R2) is a [AGE] year-old female with a history of intractable epilepsy presenting for increased seizure frequency. Likely provoked by medication non-compliance and underlying UTI, (Urinary Tract Infection). It continues, Patient takes several anti-seizure medications and resides in a nursing home. Recently they ran out of patient's Klonopin, so she had not been receiving it. She presented yesterday due to increase in baseline seizures. (Emergency Medical Staff) was called and patient received 2 milligrams (MG) Versed en route. On arrival to (local hospital emergency department) she continued to have seizures (described as (Right upper extremity) and right facial twitching.) R2's Regional Hospital History and Physical, dated 10/11/2023, documented, Hospital Course: (R2) is a 40 (year old) woman who presents with provoked seizures in setting of benzodiazepine withdrawal (did not receive Klonopin at her nursing home). Her past medical history is most significant for focal epilepsy and cerebral hemi atrophy . It continues, Provoked seizures (secondary to) benzodiazepine withdrawal (no longer occurring.) Resident Council Meeting minutes, dated 07/05/2023, documented, Resident complained that she has ran out of meds for a few days. On 10/17/2023 at 11:15 AM, V5, Licensed Practical Nurse, (LPN), stated, that there were no issues with getting medications refilled from the pharmacy and that R2 does not refuse her medications. On 10/17/2023 at 11:20 PM, V3, LPN stated, they have no issues with getting refills from the pharmacy. She continued to state that she will call the pharmacy for a refill, she will fax the order for the resident and if she doesn't have a medication, they do have an emergency medication kit and she would check to see if the medication would be in there but not all medications are in there. On 10/17/2023 at 1:15 PM, V3, Assistant Director of Nurses, LPN, stated, that the pharmacy sent a 1/2 card of R2's clonazepam because there was a shortage of that medication. She continued to state that R2 missed the PM dose on Tuesday (10/3/2023) and the AM dose on Wednesday (10/4/2023) she had 2 seizures, and she was sent out to the hospital that night. On 10/17/2023 at 1:39 PM, V2, Director of Nurses, (DON), stated, that R2's Doctor was notified for a new order through the texting application the facility uses. On 10/17/2023 at 4:00 PM, V9, Order Entry Supervisor from the Facility's Contracted Pharmacy, stated, that there was only a shortage of Clonazepam 0.25 mg tablets and that it did not affect R2 because she was dispensed 1 mg tablets. She continued to state that the last supply of 15 days' worth of medication was dispensed on 10/11/2023 but prior to those 60 tablets of 1mg Clonazepam was sent to the facility on [DATE] and that Clonazepam was not refilled until 10/11/2023. On 10/17/2023 at 4:25 PM, V2, DON, stated, that she would expect the nurses to reorder resident medications from the pharmacy in time before the medications run out. The facility's policy, Medication and Treatment Orders, dated 07/2016, documented, 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing Pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.

Based on observation, interview and record review, the facility failed to provide resident bariatric equipment/bedside commode needed to promote resident dignity for 1 of 1 resident (R185) reviewed for accommodation of needs in a sample of 35. This failure resulted in R185 having feelings of embarrassment regarding being made to urinate/defecate in an adult incontinent brief instead of toileting. Findings include: R185's Undated Face Sheet, documents he was admitted to the facility on [DATE]. R185's Electronic Medical Record, dated 3/6/2023 at 2:14 PM documents R185 weighed 540.2 pounds and is 5 foot 11 inches tall. R185's Admission Minimum Data Set (MDS) dated [DATE] documents R185 is alert, frequently incontinent of bladder and occasionally incontinent of bowel. R185's MDS documents R185 requires supervision with setup assistance for toileting. On 3/16/2023 at 10:00 AM R185 was sitting in his wheelchair. He stood up, leaned against his dresser and showed an incontinence brief under him. R185 stated, I have a wound on my buttocks and staff put cream on it several times a day. There isn't a place for me to poop because I can't fit on the toilet in the bathroom in this room, and the facility doesn't have a bedside commode (BSC) that's big enough for me. When I have to poop staff told me to go in my {adult incontinence brief} and they will clean me up. I push my call light after I am done pooping and staff assist to clean me up within 20 minutes. I know when I have to poop and to have to go in my {adult incontinence brief} and have staff clean me up is embarrassing. No staff have offered to take me to the shower room to poop. I wouldn't be able to walk or propel myself to the shower room. I've talked to the facility social worker and nursing about the need to get a bariatric bedside commode, no one is responding to me. I just want to poop like a regular person, on a toilet/BSC. On 3/16/2023 at 1:50 PM V6 *(Certified Nursing Aide/CNA) stated, I have asked (V28/Maintenance Director), (V27/Housekeeper) and (V12/Social Worker) and they told me to look in the storage room for a BSC for (R185), and I have looked for one in the storage room. There were some there, but not a bariatric one. (R185) has to lay in bed and poop in a {adult incontinence brief} and we clean him up afterwards. (R185) doesn't want to have to poop in a {adult incontinence brief} or even wear a {adult incontinence brief}, but he won't fit on the toilet in his room, and they don't toilet residents in the shower rooms on the halls. On 3/16/2023 at 3:00 PM V24 (CNA) stated, (R185) always gets upset when he has to have a bowel movement. He doesn't have a BSC that fits him and (R185) doesn't fit in his bathroom because he is obese, so he has to lay in bed with a brief on, have a bowel movement, then we get him cleaned up. V24 stated R185 told her time and time again that he wanted a BSC that was big enough for him and she told nurses about it (names unknown), but he had to go potty in his brief because there wasn't a toilet/BSC big enough for R185's use. On 3/16/2023 at 2:30 PM V2 (Director of Nursing/DON) stated at one point R185 had a bariatric BSC but it went missing. V2 stated they have ordered R185 one and put a toilet riser in his bathroom in his room today. V2 wasn't aware R185 was told by staff to have a bowel movement in his pants because the facility didn't have the proper equipment for him. On 3/16/2023 at 3:30 PM R185 was sitting up in his wheelchair playing a video game. (R185) stated staff put a rise over his toilet but he won't fit to sit on it because he is wider than the toilet riser, and he attempted to sit on it already. R18 stated it wasn't wide enough for him; it poked him on both sides, and he was afraid it would cause skin breakdown on both sides. On 3/17/2023 at 9:00 AM V12 (Social Worker) stated no one reported to her that (R185) didn't have a toilet so he could have a bowel movement. V12 stated she ordered a bariatric BSC for him when she became aware of the issue on 3/16/2023. R185's Equipment Invoice, dated 3/16/2023 at 4:39 PM, documents a bariatric commode was ordered. A Written Statement, undated, written by V2 (DON) documents, (V12) and I spoke with (R185) on 3/16/2023 to inform him we had ordered him a larger bedside commode that could accommodate him. Resident was very pleased. Stated he did have a bedside commode when he arrived in facility, but it was removed because it was not large enough. Stated he tried using that toilet, but it was too close in proximity to the wall. He was also given a toilet riser but said it would be too small and therapy felt a bedside commode would be better. Resident stated he uses bedpan and said he has bedside commode; he will still need help cleaning up because he can't reach his buttocks. At home he used a toilet but there was more room in bathroom, and he still needed help wiping. Resident stated he is actively trying to lose weight so he can do these things himself. He said he is pleased with the care and is very outspoken. He stated, 'If there is a problem with care that I will let you and (V12/Social Worker) know myself.' On 3/17/2023 at 12:00 PM V28 (Maintenance Director) stated, (R185) had a BSC when he was initially admitted to the facility. At one point (R185) asked for staff to remove the BSC from his room. V28 stated he didn't know why R185 didn't want the BSC anymore or what size the BSC was. On 3/17/2023 at 1:10 PM, V27 (Housekeeping Director) stated when R185 was initially admitted he had a bariatric bed and a BSC in his room; she didn't know what size it was but one day it was no longer in his room. V27 stated R185 didn't tell her he needed a bigger BSC commode, and no staff told her he needed one either. On 3/17/2023 at 1:48 PM V23 (Nurse Practitioner) stated, It is not dignified to tell a resident to have a bowel movement in his pants because the facility didn't have a bariatric BSC to fit the resident. The Facility's Accommodation of Needs policy, revised 1/2020, documents Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes. Staff will interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity. Staff will help to keep adaptive devices clean and in working order for the resident.

Based on observation, interview and record review, the facility failed to assess, monitor, treat per standards of practice and implement interventions to prevent the formation and/or worsening of pressure ulcers for 2 of 9 residents (R68 and R282) reviewed for pressure ulcers in the sample of 35. This failure resulted in R282 developing two new unstageable pressure ulcers to bilateral heels. Findings include: 1. R282's Face Sheet, undated, documents diagnoses including Parkinson's disease, pressure ulcer of sacral region, unstageable, dysphagia, oropharyngeal phase, pressure ulcer of left hip, unstageable, mild protein calorie malnutrition, and dementia in other diseases classified elsewhere, severe, with agitation. R282's Minimum Data Set (MDS) dated [DATE] documented R282 was moderately cognitively impaired, required limited 1+ person assistance for bed mobility, required extensive 2+ person assistance with transfer, activity of walking activity did not occur over the previous 7-day period, and had one unstageable pressure ulcer that was present on admission. R282's Care Plan last revised 2/28/23 documents, I was admitted with a pressure ulcer to left hip. My co-morbidities include: malnutrition, repeated falls, atherosclerotic heart disease, dementia. The Care Plan interventions, dated 2/28/23, documented the following: Administer medications as ordered; Administer treatment as ordered and monitor for effectiveness; Assess/record/monitor wound healing, measure length, width, and depth where possible; Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD (Medical Doctor); Education resident /family/caregivers as causes of skin breakdown including transfer/positioning requirement, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility protocols for prevention/treatment of skin breakdown; if resident refuses treatment, confer with resident, IDT (Interdisciplinary Team) and family to determine why and try alternative methos to gain complaint; Monitor/document/report to MD PRN changes in skin status such as appearance, color, wound healing, signs and symptoms of infection, wound size and state, obtain and monitor lab/diagnostic work as ordered, and RD (Registered Dietitian) to review and make recommendations PRN. The Care Plan did not include any new interventions for wound care after 2/28/23. R282's Weekly Skin assessment dated [DATE] documented existing skin conditions/wounds to left hip, buttocks, and bilateral heels that were healing. There were no new skin conditions/wounds listed at that time. R282's Progress Note dated 3/5/23 at 3:18 PM documented, Resident is new to facility. Wound to coccyx. Low air loss mattress with bolsters to help with wound. Areas to skin changed daily. Will monitor. R282's Specialty Physician Wound Evaluation & Management Summary dated 3/7/23 documented, Chief Complaint: This patient has multiple wounds. This summary documented a total of five wounds to include the coccyx, upper left sacrum, right lower buttock, left hip, and left dorsal hand. V22 (Wound Specialist) documented treatment orders and recommended dietary consult, pre-albumin level, and culture of stage 4 pressure ulcer on coccyx. R282's Physician Order dated 3/9/23 documents, Dietitian to evaluate as needed for nutritional interventions. R282's Weekly Skin assessment dated [DATE] documented resident had existing skin conditions/wounds on left hip, buttocks and bilateral hands that were healing. There were no new skin conditions listed at that time. R282's Progress Note dated 03/14/23 at 10:49 AM documented, Coccyx pressure ulcer measuring 5cm (centimeters) x (by) 5 x 2cm. left hip pressure measuring 6 x 4 x 0.2. Left upper sacrum measuring 2 x 1 x UTD (unable to determine). R282's Specialty Physician Wound Evaluation & Management Summary dated 3/14/23 documented the resident had previous wounds to coccyx, upper left sacrum, right lower buttock, left hip, and left dorsal hand. In addition, there was a Focused Wound Exam (Site 6) - unstageable (due to necrosis) of the right heel, full thickness measuring 2.5 cm (centimeters) x 3.5 cm x not measurable cm and a Focused Wound Exam (Site 7) - unstageable DTI (deep tissue injury) of the left heel partial thickness measuring 1.5 cm x 1.5 cm x not measurable cm. R282's Weekly Skin assessment dated [DATE] documented resident had existing conditions/wounds on buttocks, left hip and bilateral hands. There was documentation of new pressure ulcers on R282's bilateral heels. On 3/16/23 at 1:58 AM, R282 was in his wheelchair in the therapy gym wearing tennis shoes with his shoes on the foot pedals of his wheelchair. On 3/16/23 at 1:25 PM, V3 (Assistant Director of Nursing/ADON) stated, (R282) stated he will only allow surveyors to observe wound care if they pay him. On 3/17/23 at 8:00 AM, R282 was sitting in his wheelchair in his room wearing tennis shoes with shoes on the foot pedals of his wheelchair. On 3/17/23 at 8:03 AM, V3 (ADON) stated, (R282)'s pre-albumin is pending. His wound culture is ordered for today. I thought it was done, but the lab said they didn't have it, so it is being done today. It doesn't really look infected, but it has that kind of chronic slough, so I think the doctor wanted to order the culture just to be sure. I could have sworn the heel wounds were here on admission, but it was not on the previous notes, and it was on Tuesday's notes, so I'm treating them as new. I put in orders for the Betadine which is now being treated. Our dietitian usually comes at the end of the month but does work remotely. I will see if she has any documentation for (R282). On 3/17/23 at 10:00 AM, V23 (Nurse Practitioner) stated, If a resident came in with wounds and is at high risk for developing wounds, I would expect preventative measures to be in place. This could include floating heels, heel boots, barrier cream, special mattresses, and things like that. I would expect those to be documented in the Progress Notes. Dietitian consults are important because they review the patient and estimate their nutritional needs. Sometimes they will recommend supplements, vitamin C, (arginine supplement), and extra protein to help rebuild healthy skin tissue. Poor nutrition can cause continued skin breakdown and abscesses. I would expect the dietitian to see the resident on their next visit to facility. If it is going to be a while, I would expect the facility to contact the dietitian, because these interventions need to be implemented right away. On 3/17/23 at 11:45 AM, V3 (Director of Operations/Infection Prevention Nurse Consultant) stated, I don't have any documentation that we did anything to prevent (R282's) wounds. On 3/17/23 at 12:25 PM, V1 (Administrator) stated she would expect facility to take preventative measures to prevent wounds and document all preventative measures. As of 3/17/23 at 2:00 PM, no Registered Dietitian (RD) documentation was received from Facility. The Facility's Nutritional Assessment Policy revised October 2017 documents, As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition. Increased need for calories and/or protein - onset or exacerbation of diseases or conditions that result in a hypermetabolic state and an increased demand for calories and protein (e.g., cancer, COPD, liver disease; hyperthyroidism, wounds). The Facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol Policy revised April 2018 documents, The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. The Facility's Wound Care Policy revised October 2010 documents, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Apply treatments as indicated. 45302 2. R68's Undated Face sheet documents she was admitted to the facility on [DATE]. R68's Hospital Discharge Paperwork, dated 1/27/2023 documents, VRE (Vancomycin -Resistant Enterococci) onset 1/6/2023 in resident's bone on buttocks. R68's Braden Scale for Predicting Pressure Sore Risk, dated 1/28/2023 at 1:58 AM documents, High risk. R68's Admission Minimum Data Set (MDS), dated [DATE] documents R68 was severely cognitively impaired, total dependence of two persons physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene. R68's MDS documents R68 is at risk for pressure ulcers and had a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) present upon admission. R68's MDS documents skin and Ulcer/injury treatments pressure reducing device for chair and bed, pressure ulcer care and application of ointments/ medications. R68's Care Plan, dated 1/31/2023 documents R68 was admitted with stage IV pressure area to coccyx. Goal: pressure ulcer will show signs of healing through the review date. Approaches: administer medications and treatments as ordered, assess/record/monitor wound healing, measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the MD (medical doctor), follow facility protocols for the prevention/treatment of skin breakdown, if the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance, document alternative methods, inform the resident/family of any new area of skin breakdown, observe the (s/s) signs and symptoms of pain or discomfort, pain management as per MD orders PRN (when necessary), observe for s/s of infection or pain, notify MD/NP (nurse practitioner) as needed, obtain lab/diagnostic testing as ordered and report results to MD/NP, pressure relieving mattress to bed, RD (registered dietitian) to review and make recommendations PRN, sees wound physician wound care specialist and turn and position when providing care as needed or requested. Problem: diagnosis of coccygeal osteomyelitis (VRE) and at risk for medical complications due to this diagnosis. Goal: will have no s/s of complications from my osteomyelitis through the next review. R68's Physician's Order Sheet (POS), dated 1/2023 documents diagnoses included pressure ulcer of sacral region, stage IV. R68's Nursing Progress Note, dated 1/27/2023 at 4:59 PM, documents, Resident arrived via EMS (emergency medical services) from a local hospital. Alert and oriented x1. Per EMS she knows her name and DOB (date of birth). Assisted from stretcher to bed by nursing staff and EMS. At this time, this nurse assisted CNA (Certified Nursing Aide) in skin check and rolled resident from side to side with little difficulty to remove hospital linens. Resident C/O (complained of) generalized pain. Large sacral wound with slough noted to sacrum. Dressing intact. MD (physician) aware of resident arrival. R68's Focused Observation (admission nursing assessment) dated 1/27/2023 at 6:26 PM written by V3, Assistant Director of Nurses (ADON) documented, alterations in skin? Yes. No assessment of the Stage IV pressure ulcer on R68's coccyx was documented including location, length, width, depth, and drainage and odor. R68's Electronic Medical Record, documents no skin assessment dated [DATE] through 2/2/2023. R68's Nursing Progress Note, dated 2/3/2023 at 3:49 PM, documents, Wound physician here this week to see resident for stage 4 pressure to sacrum measuring 11.5 centimeters (cm) x (by) 12.0 cm x 0.9 cm. moderate serous exudate. 30% necrotic tissue, 20% slough and 50% granulation tissue. post-surgical wound of left lower back measuring 1.0 cm x1.0 cm x 0.6 cm. moderate serous exudate with 100% slough. continue current treatment orders. POA (power of attorney) aware. R68's Nursing Progress Note dated 2/10/2023 at 12:31 PM, documents Wound physician here this week to see resident. stage 4 pressure ulcer to sacrum measuring 10.0 cm x 13.0 cm x 0.9 cm. moderate serous exudate with 30% necrotic tissue, 20% slough and 50% granulation tissue. all tx (treatment) orders are ssd (silver sulfadiazine) cream mix with collagen particles and apply to wound bed, cover with calcium alginate, and dry dressing. continues on LAL (low air loss) mattress. Hospice, MD and POA aware. wounds present on admission. R68's Nursing Progress Note, dated 3/3/2023 at 12:55 PM documents, Wound physician here to see resident this week. sacrum wound measures 7.0 cm x 13.0 cm x 0.9 cm with moderate serous exudate, 20% slough and 50% granulation tissue wound has improved. R68's March 2023 POS documents 3/9/2023 cleanse sacral wound daily with wound cleanser and 4 x 4 gauze. Pat dry. Mix compound (streptomycin, flucytosine, vancomycin) capsules with 15 pumps of [NAME]-gel into mixing container provided. Apply collagen particles to wound bed, cover with calcium alginate, apply silicone bordered dressing daily. May change as needed. On 3/16/2023 at 10:30 AM there was an isolation sign was on R68's door. V25 (Licensed Practical Nurse/LPN) entered R68's room wearing gown, gloves, booties, and gloves. When V25 entered (R68's) room, no handwashing or hand sanitize was observed. When V6 (CNA) turned R68 to her right hip, there was a large wound dressing on R68's sacrum/coccyx and left buttocks. All dressings were saturated with drainage and were not intact. V25 removed the old dressings and stated she's not good at describing the wound drainage, but it was bloody. V25 stated she's not good at describing wound bed, but that it had blood on it. V25 then removed multiple pieces of 4 x 4 gauze from R68's coccyx wound bed. V25 cleansed R68's coccyx wound bed with wound cleanser and patted dry with gauze. V25 dropped the coccyx foam border dressing on the floor. V25 removed her gloves and left the room. She reentered R68's room with gloves on, touching the door and R68's bedside table, then applied collagen wound filler (powder) to same gloved hands and applied the powder directly to the coccyx wound bed. V25 didn't wash her hands or use hand sanitizer when she reentered R68's room. V25 then applied calcium alginate to the coccyx pressure ulcer bed, then covered it with a large silicone foam dressing. V25 removed the non-intact dressing on R68's left lower buttock that had moderate amount of serous drainage and stated she needed to get the wound treatment clarified. V25 didn't cover the pressure ulcer at that time. This area was approximately the size of a quarter. V25 left the room at that time. R68's Nursing Progress Note, dated 3/16/2023 at 12:11 PM, documents Resident seen by (V22) Wound Physician for wound care. Sacral wound measures 8.0 cm x 12.0 cm x 0.9 cm with moderate amount of serous exudate. 30% necrotic 20% slough and 50% granulation. No change to wound. Per MD he believes it is a Kennedy Ulcer. Resident is terminally ill and continues on hospice. There was no assessment of left buttock wound/open area. On 3/16/2023 at 2:00 PM, V6 (CNA) and V25 (LPN) entered R68's room to complete wound treatment. V6 turned R68 to her right hip which showed R68's left lower buttocks pressure ulcer didn't have a wound dressing on it. Observation of the pad under R68 showed serous drainage on it from the left lower buttock open area. V25 cleansed the open area with wound cleanser and gauze. V25 applied SSD ointment, collagen particles mixed in a medication cup and applied it with a q tip applicator. V25 put calcium alginate over the wound bed then applied a silicone foam bordered dressing. The coccyx dressing was lifted on the edges in two sides, and the wound could be seen through the lifted edges at that time. On 3/16/2023 at 2:15 PM, V25 stated she had to get the lower left buttock wound treatment clarified and so she had to wait to get a physician's order for it. When she did the wound treatment on 3/16/2023 morning, the coccyx pressure ulcer and the lower left buttock dressings were not intact, no staff told her the wound dressings were not intact until V6 told her until at approximately 10:30 AM. V25 stated she thinks the dressing aren't intact because of the amount of drainage from the pressure ulcers. V25 stated she noted the wound on R68's left lower buttocks was open but the wound physician would be the one to assess it. V25 stated she always applies the collagen wound filler (powder) with gloved hands, she changes gloves and either uses hand sanitizer and washes her hands before and after pressure ulcer treatment. She didn't recall entering R68's room with gloved hands and applying the collagen wound filler to the wound bed with the gloved hand without washing her hands or using hand sanitizer first. R68's Electronic Medical Record, dated 3/17/2023, did not include documentation or assessment of the open area on R68's lower left buttocks. On 3/16/2023 at 2:30 PM, V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) were interviewed. V2 stated she expected staff to follow physician's orders for pressure ulcer treatments and to notify the resident's physician if the dressing isn't staying on and intact due to the amount of drainage. If staff found a pressure ulcer's dressing was not on or intact, they expected staff to notify the nurse and the dressing should be redone, so it is intact at all times. V3 stated this is to control the infection, control drainage and benefit wound healing. V3 stated staff are expected to sanitize their hands before entering the resident's room and then wash their hands prior to providing pressure ulcer treatment. V3 stated when staff need to get skin/wound care orders clarified, a dry dressing should be applied to the area and a physician's order should be on the POS within 1-2 hours. V2 and V3 stated they didn't know the initial pressure ulcer dressing was done at 10:30 AM and the resident didn't have a dressing on the lower right buttocks until 2:00 PM today. They also were not aware R68's coccyx wound dressing was not intact on all edges. V3 stated if the pressure ulcer dressing isn't intact, and the correct pressure ulcer treatment isn't administered per the POS it would ultimately cause the pressure ulcer to deteriorate. On 3/17/2023 at 10:00 AM, V23 (Nurse Practitioner/NP) stated upon admission a through skin assessment should be documented in the resident medical record including pressure ulcer size, tunneling/undermining, pain, drainage, appearance of the wound bed. This skin assessment should be documented in the resident's medical record within 24 hours so the facility has a baseline of what the pressure ulcer looked like on admission and if the pressure ulcer was facility acquired or if it was present upon admission. V23 stated she expected physician's orders to be followed and if a pressure ulcer dressing isn't intact, she expected staff to replace the dressing as soon as possible. V23 stated if the nurse needed to get pressure ulcer treatment clarification, she expected staff to apply a dry dressing over the area until the physician clarification is obtained because if the pressure ulcer was on the buttocks, that would keep feces out of it and help keep infection out. V23 stated she expected staff to wash their hands or use hand sanitizer prior to starting pressure ulcer treatment. V23 stated entering a resident's room with gloves on and touching items along the way, then providing pressure ulcer treatment (putting powder directly on the dirty gloves and applying it directly to the wound bed) is definitely improper infection control technique and can lead to infection to the wound bed because who knows what was on the items the nurse touched prior to applying the powder to the wound bed. The Facility's Wound Care Policy revised October 2010 documents, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound .Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Apply treatments as indicated.

Based on interview and record review the facility failed to provide a safe transfer to prevent injury for 1 of 3 residents (R2) reviewed for accidents/incidents in the sample of 6. This failure resulted in R2 sustaining a traumatic tearing injury to the left leg exposing muscle and fatty tissue requiring 17 sutures. Findings include: R2's Nursing Note dated 11/12/21 at 6:35 PM documents Called to room by CNA (Certified Nursing Aide) reporting a skin tear on resident's leg. Moderate amount of bright red blood coming from LLE (left lower extremity). Direct pressure applied and bleeding controlled. Res (resident) is A&O x3 (alert and oriented to person, place, and time) and responding appropriately. Res reports mild discomfort during assessment/treatment. Large skin tear noted to L (left) lateral lower extremity in shape of the letter C with skin flap currently attached. Measurements documented under event completed in chart. Res states, I must have caught my leg on the wheelchair (WC). CNA reports transferring res from WC to bed and then noticed blood on resident's leg. It documents NP (Nurse Practitioner), DON (Director of Nursing), etc notified. It continues, New order to send res to ER (emergency room ) for eval and treatment of LLE. POA (Power of Attorney) notified. 911 called for transport. Report called to (local hospital) ER. R2's Nursing Note dated 11/13/21 at 2:10 AM documents Res returned to facility via EMS (Emergency Medical services) and transferred to bed per EMT (Emergency Medical Technicians) x 2. Reoriented to call system and room. Res is Alert and responding per usual. 17 sutures noted to LLE with edges well approximated. PRN (as needed) Tylenol admin (administered) for c/o (complaint of) LLE pain 3/10 on pain scale. LLE elevated in bed. V/S (vital signs) WNL (within normal limits). New orders noted in TAR (treatment administration record). Sutures to be removed in 14 days on 11/26/21. FYI (for your information) sent to NP. POA aware of res return, current condition and orders. R2's Hospital report dated 11/12/21 documents Patient reports that she was being transferred from wheelchair to bed when her lateral left leg got caught on an object and she suffered a large laceration. R2's MDS dated [DATE] documents that R1 requires extensive assistance of one-person with transfers. On 11/16/21 at 9:53 AM, R2 stated, (V4) CNA is rude and mean to me. That night when she was helping into bed. I told her she needed more help. She told me she didn't need help and threw me into the bed. My leg was stuck and I told she was hurting me. I told to stop several times. I reach down to feel my leg because something didn't feel right. I felt a wad of skin and I had blood all over my hand. I got 17 stitches in my left leg. I guess I feel safe now, I didn't before. On 11/16/21 at 1:40 PM, V6, Paramedic stated, (R2) was thanking us as we were leaving for getting her out that place. She told us that this is not first time they have been rough with her. She stated that they kept pulling on her leg even though she said it hurt. One of the CNAs told us that her leg was stuck but she kept pulling. We had the ER staff take the bandage off so we could see it. It was called into 911 as a skin tear. That was more than a skin tear. It required 17 stitches. We heard her tell the ER nurse that she didn't feel safe there. On 11/16/21 at 3:43 PM, V8, Paramedic stated, We were called to (Facility) for an elderly female on blood thinners that had a skin tear. Staff said that her (R2) leg was stuck so they had to force it and she got a skin tear. Staff had pictures on her personal cell phone and showed them to me but it was hard to tell how bad it was. They already had it wrapped and it wasn't bleeding. We transported (R2) to the hospital she was visibly shaking and upset. She said she kept telling them it hurt and too stop but they kept forcing her leg. She held my hands and asked me to pray with her. She said that staff had been rough with her before. I witnessed her telling the ER nurse she doesn't feel safe at the facility. The ER nurse cut the bandage off and then I saw that this was not a skin tear. She had 4 inch C-shaped avulsion (a traumatic tearing injury) her left lower leg that had adipose (fatty) tissue and muscle tissue exposed. That's when I knew I had to call and report it. It takes a lot of force to cause that kind of wound. Facility unable to provide a accident/injury policy.

Based on observation, interview and record review, the facility failed to implement safe transfer techniques during mechanical lift transfers for 2 of 3 residents (R2, R3) reviewed for resident injury/accidents in the sample of 3. This resulted in R3 sustaining a fractured Left great toe and a 5 centimeter (cm) by (x) 1 cm x 1cm skin tear between the left great toe and left second toe. Findings include: 1. R3's face sheet, undated, documents a diagnosis of [CONDITION(S)], Convulsions and Functional [CONDITION(S)]. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has severe cognitive impairment and is dependent upon staff for transfers. R3's Care Plan, dated 10/15/21, documents R3 has a fracture of the left great toe with stitches between the left great toe and the left second toe. R3 requires an assistance of 1-2 staff with transfers and utilizes a mechanical lift. R3's Skin Integrity Event, dated 10/14/21 at 9:22 AM by V15, Licensed Practical Nurse (LPN), documents R3 sustained a laceration between the left great toe and left second toe, deep with a moderate amount of blood loss, occurred during a mechanical lift transfer and R3 was sent to the emergency room for evaluation. R3's Progress Note, dated 10/14/21 at 7:50 AM by V9, LPN/Wound Nurse, documents Upon entering R3's room, it was observed that R3 had a 5 centimeter (cm) x 1cm x 1cm laceration between the left great toe and first toe, laceration extended from the bottom portion of the toe to the top of the toe with bright red blood oozing from the wound, the fat layer was exposed. A pressure dressing was applied with approximately 60 milliliters (ml) of blood loss. Awaiting ambulance arrival. R3's Progress Note, dated 10/14/21 at 6:24 PM by V15, LPN, documents R3 returned from the emergency room with stitches between the left great toe and the second toe. R3's Progress Note, dated 10/21/21 at 11:04 AM by V2, Interim Director of Nurses (DON), document R3's foot was caught on the chair during a transfer causing the left great toe to bend and causing a laceration. Incident happened on 10/14/21. Therapy evaluated and resident to wear a foot protector on the left foot during transfers. R3's Investigative Final Report, undated, documents R3 was being transferred to her chair and the left great toe came into contact with her chair causing the left great toe to bend and the skin between the left great toe and second toe to open. R3 was sent to the emergency room for evaluation where she received stitches. An x-ray indicated the left great toe was fractured. R3's Hospital History & Physical, dated 10/14/21, documents Patient presents from nursing home with a laceration between the 1st and 2nd toes. The nursing home is not sure how the injury occurred. Patient is not alert, oriented and is non-verbal. There is approximately a 5cm laceration between the 1st and 2nd toes with bruising and swelling to the 1st toe. Patient's toe was a traumatic laceration injury. With the patient being bed bound she cannot have caused an injury of this nature on her own. R3's Hospital X-Ray Report of the left foot, dated 10/14/21, documents a fracture of the proximal phalanx of the left great toe. On 10/28/21 at 10:50 AM, V8, Certified Nurse's Assistant (CNA), stated she noticed blood on R3's sock, she removed the sock and blood was dripping from R3's left foot. V8 stated she was transferring R3 with the mechanical lift from the bed to the reclining wheelchair and I was the only one in the room doing the transfer. 2. R2's Face Sheet, undated, documents a diagnosis of Generalized [CONDITION(S)]. R2's MDS, dated [DATE], documents R2 is dependent with an assistance of two staff for transfers. R2's Care Plan, dated 3/13/20, documents R2 requires assistance with activities of daily living. On 10/21/21 at 3:00 PM, V3 and V4, CNAs, were transferring R2 using a full body mechanical lift. V3 lifted R2 up in the mechanical lift and transferred R2 from the bed to the wheelchair. During the transfer, R2 was dangling in the air and was not touched/guided by any staff person into the wheelchair. On 10/28/21 at 10:00 AM, R2 stated she uses the mechanical lift for transfers and sometimes there's 2 staff present and sometimes there's only 1 staff present. On 10/28/21, V10, DON, stated mechanical lift transfers require the assistance of two staff. The Manual/Electric Portable Patient Lift Owner's Operator and Maintenance Manual, undated, documents under section 1 - general guidelines, Manufacturer recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures. The Safe Lifting and Movement of Residents, with a revision date of 7/2017, documents In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on observation, interview and record review, the facility failed to ensure safe transfer techniques and ensure mechanical lift slings are in good repair during mechanical lift transfers for 4 of 4 residents (R1, R2, R3, and R4) reviewed for transfers in the sample of 4. This failure resulted in R2 falling from a mechanical lift and sustaining fractures to her left hip and left humerus. Findings include: 1. R2's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses of [CONDITION(S)], Chronic Pain, [CONDITION(S)], Congestive Heart Failure, Sleep Apnea, [CONDITION(S)], Hypertension, and Venous Stasis [CONDITION(S)]. R2's Minimum Data Set (MDS) dated [DATE] documents she is alert and oriented and is dependent on staff for transfers. R2's Care Plan dated 4/20/20 documents, I need 2 assist with transfers with mechanical lift. R2's Event Report dated 7/3/21 at 9:00 PM documents, Resident being transferred via (full body mechanical lift) from shower chair to bed after her shower, strap on (full body mechanical) lift broke mid-air and resident fell to floor feet first. First complained of feet, leg, and back pain. Within 5 minutes changed to severe left leg/hip pain. Called 911 to transfer to (local hospital), (local ambulance) would have taken 1 1/2 hours for transfer. EMTs (Emergency Medical Technicians) arrived at facility at 9:20 PM transferred resident to gurney and departed facility at 9:25 PM for (local hospital). Attached note documents, POA notified 2:02AM 7/4 per progress note. R2's Progress Note dated 7/3/21 at 9:08 PM, documents Resident fell -complained of severe pain foot, back, neck and left leg-called (Local Contracted Ambulance) -1 1/2 hour wait-called 911 to transport. R2's Progress Note dated 7/4/21 at 2:02 AM, documents Nursing staff called to follow up on resident. Per (emergency room Registered Nurse), resident will be transferred to (trauma hospital) due to L (left) hip and L shoulder fractures. POA (Power of Attorney) aware. R2's Progress Note dated 7/4/21 at 4:45 PM documents awakened with a call from work. Resident's daughter upset that she had not been informed of resident being sent to hospital. Apologized to POA-documentation indicates POA was notified at 2AM after receiving info from hospital on resident's condition. Advised POA that sling failed, and resident slid out of sling during transfer from shower chair to bed. CNAs (Certified Nursing Assistants) unable to prevent fall, but protected head from striking floor. R2's Progress Note dated 7/6/21 at 2:32 PM documents: IDT (Interdisciplinary Team): Fall- Resident had just been given a shower by CNA staff. CNA took resident back to her room in the shower chair. Two CNAs were transferring resident back to bed. CNAs began to raise resident out of shower chair when (full body mechanical lift) sling straps near resident's feet snapped. Resident slid to the floor feet first before staff could get her into the bed. Laying on floor facing ceiling. Staff caught her head before it could hit the floor. Nurse was immediately called to the room. Resident assessed on floor. Resident complained of feet, neck, and leg pain. VSS (vital signs stable). 911 was called for transfer to (local hospital). MD (Medical Doctor) and POA notified. Will assess for immediate intervention upon return to facility. R2's Progress note dated 7/7/21 at 10:13 AM documents, POA notified at 2:02 AM 7/4 per progress note. On 7/15/21 at 9:17 AM, the sling that was used when R2 fell on [DATE] was still in V1's, Administrator's, office and was observed with V1. The strap from the bottom right side of the sling was missing, the strap on the left bottom of the sling had the second loop torn, causing it to no longer have a loop, and the material around the bottom left strap, top right strap and top left strap all had tears in the material. V1 looked at faded writing on the label of the impaired sling and stated the date the sling was put into use in the facility was 1/20/19. She stated all the slings are dated the first time they are put out to be used. That dated indicated the sling was in use for 2 years and 5 months before the fall occurred. On 7/15/21 at 9:17 AM, V1 stated before the accident with R2, the facility did not have a process in place for inspecting the slings used with full body mechanical lifts. V4, Housekeeping/Laundry Supervisor, also present during interview with V1, stated there is a laundry aide who was good about inspecting the slings, but V4 did not know what happens when that laundry aide is not working. She stated the CNAs should also be checking the slings before they use them. V1 stated the facility has not had any other falls from the mechanical lift that she is aware of. On 7/15/21 at 10:20 AM, V1, presented the manual for the Manual/Electric Portable Lift and stated it was the manual for the lift that was used at the time of R2's fall. She stated she does not have a manual for the slings the facility uses with their lifts. On 7/15/21 at 10:30 AM, per phone interview, V12, Mechanical Lift Customer Service Representative with the manufacturer of the mechanical lift used during R2's fall, stated the warranty time of the slings they recommend for use with their mechanical lifts is one year. She stated that does not mean they can't or won't be used longer by a facility, that is just the manufacturer warranty. She stated the slings should be checked regularly for damage or signs of wear and tear and should be checked before every use with a resident. V12 stated, per the manual for their slings, the expected life of a sling is 13 months, but she cannot say what the expected life of the slings the facility bought from another manufacturer would be, but she would guess about the same. On 7/15/21 at 11:23 AM, V1, presented a copy of an email from the manufacturer of the sling used when R2 fell from the mechanical lift on 7/3/21 which documented, We do not have a claim stating that our slings work with (Lift) used at time of R2's fall. What we can say is that our slings attach to cradles that require a loop connection. The email was sent by the account service representative of the manufacturer of the slings used in the facility. On 7/16/21 at 9:25 AM, V1 stated the facility does not have a manual for their full body mechanical lift slings and presented a communication she received via email from the manufacturer of their slings which documents, Our slings carry a one year warranty. V1 stated they did not give her any documentation about how long slings could be used. The Owner's Operator and Maintenance Manual for the full body mechanical lift that V1 stated was used during the transfer for R2 when she fell on [DATE] documents, Using the sling: After each laundering (in accordance with instructions on the sling), inspect sling for wear, tears, and loose stitching. Be sure to check the sling attachments each time the sling is removed and replaced, to ensure it is properly attached before the patient is removed from a stationary object (bed, chair or commode). Lifting the Patient: When the sling is elevated a few inches off the surface of the bed or before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any of attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem-otherwise, injury or damage may occur. (Company Name) slings are made specifically for use with (Company Name) Patient Lifts. For the safety of the patient, DO Not intermix slings and patient lifts of different manufacturers. Warranty will be voided. The Owner's Operator and Maintenance Manual, Patient Slings, for the manufacturer of the full body mechanical lift used during R2's transfer when she fell on [DATE], documents, Service Life: The expected service life is thirteen (13) months for this product, provided the product is used in accordance with the intended use as set out in this document and all maintenance service requirements and laundering instructions are followed. While the expected service life may be exceeded if the product is carefully used and properly maintained, it can also be reduced by excessive or incorrect use. 2. R1's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses of Calculus of Kidney, Hypertension, Contracture of Right Knee, Chronic Pain, Muscle Weakness and Alzheimer's Disease. R1's MDS documents she is alert and oriented and dependent on staff for transfers. R1's Care Plan dated 3/26/20 documents, I need two assist with transfers. It does not document R1 is transferred using a full body mechanical lift. On 7/15/21 at 9:05 AM, V8, CNA and V9, CNA transferred R1 from her wheelchair (w/c) to her bed after she finished eating her breakfast. R1 already had the sling under her in the w/c and had a cloth incontinent pad between her and the sling. V8 and V9 put the loops on the sling over the hooks on the mechanical lift and checked that they both put same color loops in hooks. V8 used the electronic controls to raise R1 out of her w/c, suspended about 3 foot in the air, and swung her towards her bed without first double checking the straps and sling were intact and applied correctly to the lift, before proceeding to transfer R1 to her bed. V9 guided R1 in the sling as she was positioned over and lowered to the bed. On 7/15/21 at 9:10 AM, V9 stated she is not sure who is responsible for checking the slings to make sure they are ok. She stated she thinks it would be laundry or nursing management. V9 stated it would not be the CNAs responsibility to check the slings. 3. R3's Face Sheet documents her diagnoses as Cerebral Infarction, Dysarthria and Anarthria, and [CONDITION(S)] and [CONDITION(S)] Affecting Right Dominant Side. R3's MDS dated [DATE] documents she is alert and oriented and dependent of staff for transfers. R3's Care Plan dated 3/6/21 documents, I need 2 assist with transfers. On 7/15/21 at 11:35 AM, R3 was transferred from her bed to her w/c by V9, CNA and V13, CNA. The sling was already under R3 when transfer was observed. V9 and V13 attached straps of the sling to the hooks on the full body mechanical lift, and then V9 used electronic controls to raise R3 off her bed and they swung R3 around from her bed, with her suspended about 3 1/2 feet in the air , to her w/c and lowered her down into the chair. V9 and V13 did not double check the straps and sling for proper placement after raising R3 off the bed with the mechanical lift. 4. R4's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses of Urinary Tract Infection, Other Disorders of Bone Density and Structure, Multiple Sites, Chronic Kidney Disease and Type 2 Diabetes Mellitus. R4's MDS dated [DATE] documents she is alert and oriented and dependent on staff for transfers. R4's Care Plan documents, I need assist of 2 with transfers. On 7/15/21 at 1:05 PM, V13, CNA, V14, CNA, and V15, CNA transferred R4 from her w/c to her bed using the mechanical lift. V13 and V15 attached the straps of the sling (which was already under R4 at beginning of observation) to the hooks on the mechanical lift. V14 used the electronic control to raise R4 out of chair until she was suspended about 3 feet from the floor, then swung her around, until she was positioned over the center of her bed and lowered her onto her bed. V15 helped guide R4 to the center of her bed using handles on the sling. They did not pause lifting R4 while she was still over her w/c to double check the straps were appropriately attached to the mechanical lift, before proceeding to transfer her to her bed. On 7/15/21 at 1:15 PM, V15 stated she was recently educated on transferring with a full body mechanical lift and instructed to watch closely all four corners of the lift. She stated even though she did not physically check the straps on the sling after R3 was first lifted, she did keep her eye on all four straps. On 7/15/21 at 11:50 AM, during a second phone interview, V12, Mechanical Lift Customer Service Representative stated she cannot say the slings the facility are using from a different manufacturer are not able to be used on the mechanical lift, but stated they have not been tested for safety when using her company's full body mechanical lifts. The facility's policy, Lifting Machine, Using a Mechanical revised July 2017, documents, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. Steps in the procedure: 12. Attach sling straps to sling bar, according to manufacturer's instructions. c. Before resident is lifted, double check the security of the sling attachment. 13. Lift the resident two inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution.

Based on interview and record review, the facility failed to allow a resident to have end-of-life [MEDICATION NAME] care visits from family for one of three residents (R2) reviewed for visitation in the sample of 4. This failure resulted in psychosocial harm in that R2 died in the facility without R2's daughter being allowed at R2's bedside. A reasonable person would have been upset without being able to see their child prior to death. Finding includes: R2's Care plan dated [DATE], documents the following as a problem area under category of psychosocial well-being: I am at risk for alteration in mood and psychosocial well-being due to the changes and restrictions on visitation imposed by the CDC guidelines because of the COVID 19 virus and risk for exposure. I am not able to see and interact with persons who are important to me. R2 Progress Note dated [DATE] at 10:57 AM documents (R2's family) called angry about visitation policy. Per IDPH one person is allowed into facility per day for 30 minutes to visit resident. It has to be the same person which was told to family. Daughter had come into visit yesterday and told the other daughter tried to come in to building to visit and she was not allowed. Since it was not the same daughter coming in such as policy states, we did not allow her in. Her husband called and upset about policy. R2's Progress Note documents on [DATE] at 05:21 AM CNA (Certified Nurse's Aide) summoned this nurse to resident's room. Upon entering resident's room this nurse noted resident to not be breathing. This nurse summoned second nurse to residents' room. Both nurses assessed for signs of life. None noted. No breath sounds, apical or radial pulses noted. Resident pronounced deceased at 5:19 AM by this nurse and DON. (Hospice) contacted. Awaiting their call back at this time. On [DATE] at 9:03 AM, V1, Administrator, stated Our policy for visitors is if a patient is actively dying one person can come in daily and that has to be the same person to visit daily. We tell the family they have to decide on the one person that will visit the patient. Since we are still in tier 3, CMS guidelines are very vague, but they say to be very restrictive. On [DATE] at 10:55 AM, V6, Licensed Practical Nurse, stated that R2 died this morning at approximately 5 A.M. V6 stated that R2 did not have COVID and death was due to medical condition. V6 stated R2 was on quarantine area due to recent re-admit back from the hospital. V6 stated that R2 did not have a good prognosis and came back on hospice. V6 stated there was no family with R2 when R2 died . V6 stated family is allowed with a resident if resident is actively dying. V6 stated the family member has to pass through screening to visit and wear the PPE gear. V6 stated There can only be one family member, but I think it can be different family each time, but I am not sure, I will have to ask, but I think they are allowed to swap, but again, I would ask to make sure first. On [DATE] at 11:16 AM, V3, R2's son-in-law, stated R2 was sent to hospital Friday for altered mental status, R2 had a history of [REDACTED]. V3 stated They decided (R2) would return to the nursing home on hospice. (V5, R2's daughter) called the facility and was told only one family member a day for 30 minutes and nothing more than that, no other specifics. (V5) let (V5's sister) go first on Saturday to see (R2). Then on Sunday, (V5) called to say (V5) was coming to visit, and the facility told (V5) they couldn't come inside. The facility told (V5) that only one family member could come a day and it had to be the same family member each day. V3 stated I called and tried to talk to them because we knew it wouldn't be long. (R2) had a swallow test and had no reflux and family had decided no feeding tube. When I called, they said they were going by the state mandated rules of only 1 visitor for hospice patients. V3 stated he went to IDPH's website and the rules were vague, but it did say to work with family to allow for in visit presentation. V3 stated I called back (V2, Director of Nurse/DON) and talked to both (V2) and (V1). I told them what I read online and asked why (V5) wasn't being allowed to visit. They told me that allowing more in would be putting other residents at risk because (V5) would be going up and down the hall around other residents. I then asked if we got (V5) COVID tested and proved negative would that work. They said that would take two weeks to get the results back. I asked them how they got to come in and aren't they getting tested weekly getting results faster than 2 weeks. I asked how they do it and get results back sooner to be able to be around residents. They then told me staff take precautions outside of work. I told them (V5) is a stay at home mom and took same precautions. They still wouldn't let (V5) go in to see (R2.) I asked for somebody higher up with the agency name and number and they gave me (V4's/ Corporate Nurse) name and number. I tried to call (V4), but (V4) was in a meeting and I had to go out on a flight. What really got my goat, when (R2) died , they said (V5) could now come into the facility to be with (R2). They wouldn't let (V5) come in because (V5) was putting others at risk when (R2) was alive, but when (R2) is dead, it is ok. That doesn't make sense. On [DATE] at 12:20 PM an interview was conducted with V1 and V2. V2 stated the following Unfortunately, yes, we only allow 1 person per family to do [MEDICATION NAME] care. The family has to pick the one person who gets to come in. It is usually the POA (Power of Attorney). They go through all the checks for COVID and then wear a gown, mask and gloves when visiting. V2 stated If we were to have an outbreak, we wouldn't be able to track everyone who was allowed into the building, if we let more in with a resident. We wouldn't be able to keep track of all visitors, there are days we don't have enough staff for that, depending on how staffing is at the time, and it is too hard to figure out who would need notified. V2 stated There was one time a couple months ago that the old administrator let a patient's wife and daughter both come in, but that is the only time we have done more than one. V1 stated I let both daughters come in this morning when (R2) passed away. V2 stated, (V1) did that because the family got a waiver. V1 stated Somebody above me made the decision to give the family a waiver on visitation. The POA's spouse, called (V4, Corporate Nurse), and (V4) called me and said (V4) gave the family a waiver to let both daughters come into the facility. V2 stated that V5 did not come to visit R2, even though they got a waiver. V1 stated (V4) was the one that told the family both daughters could do a bedside visit. On [DATE] at 12:26 PM V3 was called to verify that V4 had given the family a waiver to allow both daughters to visit R2 for [MEDICATION NAME] care visit prior to her death. V3 stated I didn't talk to (V4). (V4) wasn't in the office, I think they said (V4) was in a meeting, and then I had to go out on a flight. When I got back from the flight it was too late to call (V4) back. No, nobody called us to say they were giving us a waiver and (V5, R2's daughter) could go into the facility for a bedside visit. On [DATE], at 12:34 PM, an interview was conducted with V4 via telephone. V4 stated I didn't give the family a waiver, I didn't talk to (V3). I talked to (V1) about the patient. I do know with COVID we are trying to be very cautious. We try to do virtual visits or window visits. I didn't talk to the family. I told (V1) to go ahead and let both daughters come in and see (R2). When asked would was responsible for calling the daughters to let them know they could come for [MEDICATION NAME] care visit with R2, V4 stated (V1) or (V2) was supposed to call and let them know. At that time, while on the phone V4 asked if surveyor could put her on speaker to confer with V1 and V2. While V1, V2 and V4 were all on speaker phone, V1 stated We thought (V4) was telling (V3), because (V3) said (V3) was calling (V4). When we talked to (V4), we thought (V4) had (V3) on the phone and was going to tell (V3). We didn't call (V3). V1 confirmed that no one contacted V3 to ensure V5, R2's daughter, could make a bedside [MEDICATION NAME] care visit prior to his death. On [DATE] at 6:34 PM, V3 stated (R2) would have been upset that family wasn't allowed in. (R2) did better when family was around. What made it worse for (V5) is that (V5) was pregnant last of 2019 and didn't get to see (R2), then COVID hit 2020 and wasn't allowed inside visits anymore, so (V5) hadn't got to be with (R2) since end of 2019. (R2) had an extensive medical history with several [MEDICAL CONDITION] that left (R2) very impaired. Before (R2's) continued [MEDICAL CONDITION], (R2) was a very smart man, (R2) developed instruction manuals. (V5) was very protective of (R2), was (R2's) guardian and loved (R2). I think (R2) would be upset in knowing (V5) wasn't allowed to visit. (R2) loved family and loved seeing (V5). (R2) just did better when family was with him. Centers for Medicare & Medicaid Services (C.M.S.) issued QSO-,[DATE]-NH dated [DATE], for visitation guidance in nursing homes during the COVID-19 epidemic. The guidance provides reasonable ways a nursing home can safely facilitate in-person visitation to address the psychosocial needs of residents. The section titled [MEDICATION NAME] Care Visits, stated in part Through a person-centered approach, facilities should work with residents, families, caregivers, resident representatives, and the Ombudsman program to identify the need for [MEDICATION NAME] care visits.

Based on observation, interview and record review, the facility failed to provide feeding assistance to prevent weight loss in 2 of 5 residents (R42 and R51) reviewed for nutrition in the sample of 30. This failure resulted in R51's severe weight loss of 10.12% in 6 months and R42's severe weight loss of 5.63% in 90 days. Findings include: 1. On 01/19/21 at 12:45 PM, R51 was sitting in his wheelchair in his room with a plate containing a grilled cheese sandwich on the table in front of him. The sandwich had a few small bites taken out to the crust, but no full bites taken out of the sandwich. V8, Certified Nursing Assistant (CNA), was in R51's room sitting with his roommate who was done with his lunch as evidenced by paper napkin and utensils stacked on his plate. V8 stated R51 just needs verbal cues from staff and then he can feed himself. She stated to R51, Pick up your sandwich and take a bite. R51 did not respond and did not pick up his sandwich off his plate. V8 stated R51 has good and bad days with eating. She did not offer hands on assist to help R51 eat, instead, she left the room. On 1/20/21 at 9:02 AM, V7, CNA, was feeding R51 his breakfast. She stated R51 can do a little on his own when eating, but staff end up feeding him to ensure he finishes his meal. R51's weights for the past six months as documented in his Electronic Medical Record, (EMR), are as follows: July 18, 2020 (168#); August 13, 2020 (168#); no September weight was recorded; October 05, 2020 ((160#); November 24, 2020 (155#); December 23, 2020 (153#); and January 04, 2021 (151#) which indicated R51 had a 10.12% weight loss in 6 months and a 5.63% weight loss in 90 days. R51's Dietician Progress Note, dated 01/14/2021 at 10:56 AM documents, Nutrition follow up regarding weight, (wt): January wt: 155# - stable x1 month readmit, noted a -13% loss x 3 months. Diet continues as No Added Salt, (NAS), Low Concentrated Sweets, (LCS), mechanical soft. Supplemented with 30ml prostat TID (45g PRO, 200kcals) for wound healing along with Vit c, and 60ml SF, (sugar free) med pass BID (240kcals). Resident continues with a pressure to coccyx: 2.6x0.5cm and a stage III to coccyx: 3.0x0.8cm. Continue with current plan of care. Will continue to monitor and follow up as needed. R51's Dietician Progress Note dated 12/07/2020 at 9:45 AM documents, Nutrition assessment for readmission. Recent hospital stay for septic shock. Last wt: 155# - shows a -10% loss x 1 month, -8% loss x3 months. Diet restarted as LCS NAS, glucose well controlled. Diet is supplemented with 30ml prostat BID for wound healing, 60ml med pass daily now d/t recent wt loss. Resident continues with a stage III wound to coccyx. Recommend increasing med pass to BID. Please obtain a readmit wt. will monitor and follow up as needed. R51's Dietician Progress Note dated 11/19/2020 at 11:01 AM documents, Nutrition follow up regarding skin. Resident has a new stage III to coccyx: 2.0x0.4cm. On Vit C, Zn. Diet is LCS NAS. Recommend to start 30ml prosource BID x 30days. RD (Registered Dietician) to monitor. Nursing Progress Notes: 12/23/2020 04:03 PM IDT: NAR Resident had a positive weight gain this week. Working with speech therapy. Feed assists by staff. Resident recently returned from hospital stay. Dietician to monitor for interventions. MDS dated [DATE] documents he is severely cognitively impaired, requires extensive assist with bed mobility, transfers, personal hygiene and is dependent for dressing, toileting, and bathing, and supervision for eating. His pressure wounds to coccyx, and significant weight loss was not assessed on his MDS. R51's Care Plan documents: PROBLEM: I am at risk for alteration in nutrition r/t wearing dentures, prefers not to eat breakfast. Dx: diabetes, GERD, Gastroparesis, Erosive Esophagitis, Hx: GI bleed and small bowel obstruction. There was no intervention to assist R51 to eat. 01/26/21 at 9:10 AM V25, Speech Therapist, stated R51 had a bad UTI, (Urinary Tract Infection), a couple weeks ago and had a decline. She stated he refuses to wear his dentures but, tolerates a mechanical soft diet, but staff should sit with him during meals and give him constant cues to eat and help as needed. On 01/26/21 at 11:53 AM V2, Director of Nursing, stated she has been helping out on the floor, including feeding R51, and he requires physical assist to eat his meals. She stated the CNA should have sat down to help him eat his grilled cheese sandwich, not just given him verbal cues. She stated since he had COVID he has gone downhill physically and requires more help. She stated his care plan should be updated with his current status, including his need for assist with feeding and his indwelling urinary catheter should be care planned. 2. R42's Face Sheet documents a [DIAGNOSES REDACTED]. R42's Minimum Data Set (MDS), dated [DATE], documents R42 requires supervision with staff assistance for eating. R42's MDS, dated [DATE], documents R42 has had a weight loss and is not on a physician prescribed weight loss regimen. R42's Care Plan, dated 05/14/20, documents R42 is at risk for alteration in nutrition related to cognitive impairment with an intervention to assist as needed with meals. R42's Physician order [REDACTED]. R42's weights are as follows: 11/03/20 - 132 lbs; 11/24/20 - 123 lbs; 12/14/20 - 130 lbs; 12/15/20 - 127 lbs; 12/23/20 - 123 lbs; 12/28/20 - 125 lbs. R42's Interdisciplinary Note, dated 11/24/20 at 11:11am, documents R42's weight is 123 lbs. Resident has been eating fair but, has had weight loss. R42's Dietician Note, dated 12/03/20 at 1:33pm, documents the following: Current weight of 124 - shows a 6% loss for 1 month. Diet is regular, 60 milliliters of med pass daily just added as an intervention for weight loss. Encourage intake of meals and supplement. R42's Occupational Therapy note, dated 12/14/20, documents R42 requires supervision or touching assistance with a helper to provide verbal cues. R42's Speech Therapy Note, dated 12/15/20, documents R42 is at risk for weight loss due to a history of difficulty swallowing, resident is responsive to cues and staff should be available for assistance with cueing to maximize safe intake. On 01/20/21 at 8:31am, R42 was observed in the hallway, stating she is hungry. On 01/20/21 at 8:55am, R42 was observed in her room, feeding herself breakfast. R42 propelled herself away from the food several times during the observation and stated, she was hungry. No staff supervision or cueing was provided during observation. R42 consumed 25% of the sausage and 50% of the pancakes. On 01/20/21 at 9:37am, staff laid R42 down in bed and then took her breakfast tray without providing assistance with the meal. On 01/21/21 at 9:06am, R42 was in the hallway and stated, she was hungry and hasn't had breakfast. R42's breakfast tray was observed in her room on the bedside table. R42 consumed only a few bites. Staff did not provide supervision or cueing and took the tray without providing assistance. On 01/26/21 at 11:50am, V2, Director of Nurses (DON), states R42 requires constant cueing with meals due to her Dementia. The facility policy and procedure titled Weight Assessment and Intervention, dated 09/2008, documents The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; greater than 5% is severe. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: Cognitive or functional decline. Interventions for undesirable weight loss shall be based on careful consideration of the following: Functional factors that may inhibit independent eating.

Based on interview and record review the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) for 1 of 3 residents (R5) reviewed for Advanced Directives/CPR in the sample of 39. Facility staff failed to follow R5's Advanced Directives by not initiating CPR for R5, who subsequently expired. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility failed to perform CPR on R5 and R5 expired. This failure had the potential to affect 30 of 71 residents (R4, R6, R11, R12-R38) whose Advance Directives indicate Full Code Status. The Immediate Jeopardy was identified on [DATE]. On [DATE] at 11:51 AM, V1, Administrator, was notified of the Immediate Jeopardy. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1. R5's physician's orders [REDACTED]. R5's POS also documents [REDACTED]. R5's Care Plan, dated [DATE], documents, Advanced Directive: My wishes are that CPR be performed as indicated. Approaches include, CPR to be performed in the event of cardiac/respiratory arrest. R5's Practitioner Order for Life-Sustaining Treatment (POLST) form dated [DATE], documents, Attempt Resuscitation/CPR. R5's Nursing Progress Notes, dated [DATE] at 1:20 AM, documents that R5 was resting in bed with no signs and symptoms of distress. R5's Nursing Progress Note, dated [DATE] at 4:09 AM, documents, Resident with no vital signs, hanging over the side of his bed, cold to touch and lips cyanotic (lacking blood flow). POA called and notified. On [DATE] at 12:10 PM, V1, Administrator, was unaware if CPR was initiated on R5. V1 stated, Oh, I hope they did! An untitled statement from the facility, dated [DATE], documents, Administrator (V1) asked about (R5's) death and was CPR started. (V9, Licensed Practical Nurse, LPN) stated that she didn't remember (R5) passing away. (V9) then stated she did remember. I (V1) asked her (V9) if she or someone initiated CPR. (V9) stated someone did but she couldn't recall who. (V9) stated she did call (V19, R5's Physician) who gave her order not to continue CPR. (V9) stated resident was blue all over body and cold. An untitled statement from the facility, dated [DATE], documents, I (V1) interviewed (V10, LPN) concerning (R5's) death and asked her if she started CPR. (V10) started to cry and stated no CPR was started. I (V1) asked (V10) why she didn't report incident to the Director of Nursing (DON) or administrator. (V10) stated because she was scared. On [DATE] at 11:10 AM, V13, Certified Nursing Assistant (CNA), stated, I had (R5) on my hall. (R5) was pretty self-sufficient, but his roommate needed care. When I went in the room, I saw his arm hanging off the edge of the bed. I went and got the nurse. I don't recall which one was my nurse that night. Both nurses (V9 and V10) and another CNA came into the room. They said he was 'gone'. I don't know if CPR was started because I wasn't in there. On [DATE] at 11:16 AM, V14, CNA, stated, The other aide came looking for me. I went in there. We laid him down flat. The nurse on the hall (V10) was willing to do CPR. (V9) took over. (V9) said, 'I'm not doing CPR. What's the point? He is already gone.' She did not attempt or even try. The rest of us thought we should start CPR since he was a full code. I don't know how long he had been like that. He just looked like he was sleeping. He did not have a color change. He did not look different to me. He was not stiff. She (V9) should have at least tried. On [DATE] at 11:30 AM, V10, LPN, stated, (V13) came and got me and said, 'I think something is wrong with him (R5).' He was leaned over with his arm hanging off the bed when I walked in. He was blue in the face. I went and got the other nurse, (V9). We tried to pull him up on the bed so we could give CPR. She (V9) was like, 'Well, he's already blue. We probably can't bring him back.' I didn't know if he was a full code so we had to look it up in the computer. She (V9) took over everything. She wrote the note and called the family. I'm not sure if she called the doctor. No one did CPR. On [DATE] at 3:00 PM, V9, LPN, stated, I was summoned to (R5's) room. (R5) looked like he had passed. His lips and fingertips were blue. Rigor Mortis had set into his lower extremities where the blood was pooling. Rounds are done every 2 hours. I immediately called the doctor and he said not to start CPR. Someone should have started CPR while I called the doctor. The CNAs are trained in CPR too. The Code status is in their chart and on the computer. He (R5) was a full code. I thought I did chart calling the doctor, sometimes the computer times out while you are charting. I did not write a telephone order after speaking to the doctor. On [DATE] at 2:00 PM, V15, LPN, stated, First, I would check code status to see if they are full code or a Do Not Resuscitate (DNR). If they are a full code, I would call a code blue and start CPR immediately. Someone would bring the crash cart and someone else would call 911. I would continue CPR until the EMS (Emergency Medical Services) got here. CNAs can do CPR. I am current on my CPR certification. On [DATE] at 10:37, V11, CNA, stated, I am CPR certified. If I walked into room where someone was in distress, I would pull the light (call light) and yell for help. I would start CPR if there is not a nurse in the room. I would know if they were a full code by the green dot. I ask a lot of questions and I am pretty familiar with the residents. Our nurses give us report on them. I am also familiar with the procedure. The nurse would bring the crash cart. On [DATE] at 10:45 AM, V5, CNA, stated, I would scream for help, check the pulse, I would start CPR. There is a book at the nurses' station with their code status. Once you get help, it's a team. Someone is finding out the code status, someone is calling the ambulance and doctor. CPR continues until EMS gets there or the resident 'comes to' (responds). My CPR certificate just expired, but we are in the process of getting it renewed. On [DATE] at 10:55 AM, V17, CNA, stated, If they are a full code and you find them not breathing, you start CPR, and holler out for the crash cart and other assistance. The green dot or paper means they are full code. I am current on my CPR certification. The nurse will bring the crash cart. We would switch out doing compressions. If they are a full code, they are a full code, it doesn't matter, you start CPR. On [DATE] at 12:01 PM, when asked about the standard of practice regarding CPR, V18, Medical Director (MD), stated, It is supposed to be done according to their (the resident's) wishes. If the resident is a full code, CPR should started immediately if there is no response and no vital signs. I would expect them to at least attempt CPR even if the resident was cold and blue. I would expect them to notify me. On [DATE] at 12:33 PM, V1 stated, I would have expected notification to the DON and administrator after CPR was initiated, and EMS/MD and family notified. If I would have had knowledge of the situation, the nurses would have been instructed on proper protocol of following the Code Blue policy. Knowing if a person is full code is very easy. In matrix, it right by the resident's name, it says DNR (Do Not Resuscitate) or Full Code. I have implemented the green dot systems, POLST book at nurses' station. There is more than one way to find out their code status. We held off on CPR classes due to the COVID, but we feel that it is important to have CPR classes at this time. 2. The facility's Advanced Directives and Code Status Report, dated [DATE], documents the directive for R4, R6, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, and R38 as Full Code. The Facility's Code Blue Policy, revised [DATE], documents, The Code Blue policy is designed to outline the roles and responsibilities of the staff members responding to a Code Blue, the proper procedure for activation of a Code Blue. Code Blue is activated/called for any person experiencing respiratory distress or [MEDICAL CONDITION]. It continues, Purpose: To facilitate an efficient, effective and coordinated response to respiratory distress or [MEDICAL CONDITION]. Procedure: 1. Staff identifies a resident/patient/visitor and employee in distress 2. First responder relays message to a second staff member. One staff member stays with the victim and initiates CPR per BLS (Basic Life Support Training) It continues, 6. Delegate duties (To be done by victim's primary nurse): a. compressions. The policy further documents, 8. Victim's primary nurse documents the events 9. CPR does not stop until instructed by the responding Emergency Medical Personnel or MD (Medical Doctor). The Immediate Jeopardy that began on [DATE] when the facility failed to initiate CPR for R5 who was a full code status who subsequently expired was removed on [DATE] when the facility took following actions to remove the Immediacy: 1. All residents code status was reviewed, updated if needed and completed on [DATE] by the Social Service Director. All admissions, re admissions and change of POLST status review will be ongoing. 2. All staff will be inserviced by [DATE] on green dot system that identifies full code status of resident on resident name plate by the Administrator. This inservice will be on going with new staff. Staff will not be permitted to work until inservice is completed. 3. All nursing staff will be inserviced by [DATE] on identification of polst status located on MAR by Administrator. This inservice will be on going. 4. All staff will be inserviced on the Code Blue Policy by [DATE] by the Administrator. This inservice will be ongoing for any new staff or staff that were not able to attend. Staff will not be permitted to work until inservice is completed. 5. All staff will be inserviced by [DATE] on notifying the Director of Nursing and the Administrator if a resident ceases respirations to ensure 911, MD and family have been notified. This inservice is ongoing for any new staff or staff that were not able to attend. Staff will not be permitted to work until inservice is completed. 6. A Performance Improvement Tool has been created on [DATE] by the Administrator that reviews residents code status, staff knowledge of green dot system, staff knowledge where to locate residents code status, staffs knowledge of the code blue policy and notification of the Administrator, DON, MD, 911 and family in the event that a resident required CPR. 7. A QAPI has been written by the Administrator on [DATE] addressing each issue listed above. 8. A QA meeting will be held in [DATE] to review for any changes.

A. Based on interview and record review the facility failed provide supervision to [MEDICAL CONDITION] application of a heating pad for one of one resident (R29) reviewed [MEDICAL CONDITION] the sample of 38. This failure resulted in R29 sustaining a second degree burn to her mid back. Findings include: 1. R29's Face Sheet undated, documents R29 was admitted to the facility on [DATE] and having part the following Diagnoses: [REDACTED]. R29's Treatment Administration Record (TAR), dated 10/1/2018 - 10/31/2018, documents, Heat pack to lower back three times a day, with a start date of 11/30/2017. R29's Minimum Data Sets (MDS), dated [DATE] and 12/4/18, documents R29 has a Brief Interview for Mental Status score of 15, indicating cognition intact. The MDS further documents R29 requiring extensive assistance with care. On 1/28/19 at 1:05 PM, R29 stated she received a burn with blisters from having received a hot pack onto her back sometime last (MONTH) and It was too hot when she (V37, Certified Nursing Assistant/CNA) put it on me. Facility's Report of Incident, dated 10/25/2018, at 12:44 PM, documents Report to IDPH (Illinois Department of Public Health). Resident (R29), Date of Incident 10/22/2018 (notified staff of pain to area 10/24/18). The Report also documents R29 received a burn. The Report documents R29 complained of pain to her mid/lower back and upon assessment, R29 was noted with 2 areas of fluid filled blistering with red peri-wound. Assessment indicates residents has 2nd degree burn to mid/lower back. Upon interview resident reported to staff nurse that she believes the burn is from the application of a heat pack. The Report further documented that after review of video camera footage it was determined that on 10/22/2018 at (YEAR) (8:15 PM) V37 obtained the heat pack and applied it to the resident's back in a pillow case. The Report also stated the CNA as well as the nurse responsible for the resident's care at the time of the event received education and disciplinary actions per protocol. Disciplinary Action Notice, dated 10/22/18, documents V37 violated the facility policy for application of heat pack that was not in the scope of her practice. On 1/22/19 at 1:21 PM, V2, Director of Nursing (DON), stated in part, It is not the policy of the facility to have a CNA apply a heat pack of any kind, including a heating pad. Currently don't have any type of heat packs, and therapy doesn't use them. The CNA was counseled and re-educated on her scope of practice. The blisters are healed and resident did receive a second degree burn. On 1/23/19 at 11:23 AM V17, Certified Occupational Therapy Assistant (COTA), stated the therapy department does not use heat packs. On 1/22/19 at 1:21 PM, V2, DON, stated the facility does not have a policy on heat packs, as they are not used in the facility. B. Based on observation, interview, and record review the facility to provide supervision to prevent inappropriate language of cognitively impaired resident for two of two residents (R35 and R45) reviewed for supervision, in the sample of 38. Finding includes: 1. R45's Admission Face Sheet documents a facility admission date of [DATE]. The Face Sheet further documents in part, R45 having the [DIAGNOSES REDACTED]. R45's Minimum Data Set (MDS), dated [DATE] documents R45 having delusions, using a wheelchair as his primary mode of transportation. The MDS further documents R45 having a Brief Interview of Mental Status (BIMS) score score of 2, indicating severely impaired cognition. R45's Care Plan, undated, documents: BEHAVIOR: Identified Sexual Offender. Interventions Encourage resident to avoid unsupervised situations. If behavior occurs remove resident from the situation Notify IDP (Illinois Department of Public Health) per regulation. Observe for inappropriate behavior. Remind resident of appropriate behavior. Report any signs of inappropriate behavior with other residents/staff/visitors. The Care Plan also documents in part, that when R45 is anxious/upset he may make derogatory/accusatory statements about staff and care. Interventions documented are as follows: Allow time to calm down and re-approach later, encourage him to express his thoughts and needs, visit one on one as needed. R45's Care Plan further documents, Resident (R45) seeks out female residents and speaks to them inappropriate which makes females feel uncomfortable. Intervention listed is to encourage participation in activities of interest, and encourage resident to bring in personal items to make more home like. The Care Plan also documents for staff to Observe for changes in mood and/or behavior and notify MD as needed, and When (R45) I am agitated I may become verbally aggressive. Goal (R45) choose not to become verbally aggressive with others to the next review. Interventions Identify triggers and redirect resident away, remind resident that his behavior is inappropriate. Remove resident to a calm, quiet area. Talk one on one with resident as needed. The Illinois State Police Criminal History Record, undated, documents R45 was convicted on 3/2/1994 for 1 count of aggravated criminal sexual abuse for a victim under [AGE] years of age. Resident Grievance Form dated 3/6/18 documents 6 residents from the Resident Council have complained of R45 cursing at staff and other residents, and that (R45) talks dirty to his female friend in the dining room for all to hear. On 01/23/19 at 10:40 AM during a resident group meeting, multiple residents stated nothing was being done with R45 and his behavior towards them and R35. They stated the staff just offer him coffee to get him to calm down but that he is not always removed from the dining room when he using profanity and displaying inappropriate behavior towards R35. Residents expressed that V1 had stated to them in a previous Resident Council meeting that R45 has rights, and V1 has stated that V1 suggested that if they didn't like R45, they could move. All agree that nothing can be done, when referring to R45. On 1/24/19 during a morning activity being held in the dining room, R35 sat next to R45 at the dining room table. R35 proceeded to touch R45's left leg. At 11:04 AM, R35 and R45 sat by each other. At no time during the activity, did staff separate R45 and R35. R45 and R35 were not under direct staff supervision during the entire activity. On 1/23/19 at 12:50 PM V2, Director of Nurses (DON), stated the facility just sent information to the physician on 1/18/19 requesting medication review for R45's behaviors. V2 also stated the intervention now is to redirect him, and the Nurse Practitioner had just seen R45, but that I don't think anything was done yet, and the facility doesn't have any other interventions for R45. V2 further stated the facility is currently awaiting the psychiatrist response to a medication review request from the facility. On 1/23/19 at 11:27 AM, V18, CNA, stated she has been working at the facility for about 8 months and she is familiar with R35 and R45. V18 also stated the staff tries to keep them separated and that they keep a close eye on them. V18 further stated even if R35 and R45 were in close proximity, she would separate them. Psychiatric Progress Note dated 10/2/18, documents in part, He (R45) has a history of dementia with behavior disorder and anxiety. He has had sexually inappropriate behaviors toward staff and other residents. He will make innuendos toward females, will try to touch them. He is increasingly disruptive in the dining room area and is upsetting other clients (residents). He will yell, curse, threatened others. Has tried to strike people and has had his cane removed from his as a result. Psychiatric visit note dated 12/8/2018, documents R45 having Severe recurrent [MEDICAL CONDITION] with psychotic features, on 12/08/2018, and having [MEDICAL CONDITION] with behavior disturbance. The physician visit note further documents, Speech: *speech is articulate and coherent. Psychiatric: Thought Processes * goal-directed. Though Content: sexually motivated. (sic) The note further documents, act inappropriately in social situations. Judgment: Impaired (sic). Nurses Note dated 12/24/18 at 1:06PM, documents, nurse informed by staff member that resident (R45) was talking inappropriate to female resident. The staff member moved the female resident away from (R45). Nurse went to talk to (R45) but he was still upset about the staff member moving female resident away. (sic) Nurses Note dated 12/30/18 at 10:40AM, documents that R45 was in the dining room during church service and made several inappropriate remarks that caused other res (residents) to become very offended. This nurse (V14/RN) heard yelling and went to investigate to see several res yelling and point at (R45) saying 'get him out of here, he is being very hateful and rude to the ladies.' This nurse (V14) attempted to get res (resident) to leave the area but he continued to be vulgar and refused to stop. This nurse (V14) attempted to pull res (R45) from the dining room in his WC (wheelchair). Res suddenly turned in his chair and pinned this nurse against the wall and began to punch at her. Another nurse intervened and was able to get res to his room. Nurse's Note dated 1/20/19 at 5:45PM, documents in part, (R45) went over to another resident and started yelling and cussing her out for no reason. Staff removed resident from situation but resident got mad and started swinging at staff. (R45) continues to mumble to himself angrily. Will continue to monitor. Nurse's Note dated 1/20/19 at 4:17PM, documents in part, (R45) cussing at other residents and staff as he rolls by in his wheelchair. Staff reminded to keep resident away from other resident's. MD notified. Facility document dated 1/25/19 and authored by V30, Activity Assistant, documents in part that on 1/24/19 during the 10AM entertainment V30 was in the activity in which (R45) and (R35) were sitting together. I (V30) kept an eye on them and I did not see anything inappropriate. I did have to leave the room for less than five minutes. Once to take a resident to the nurses' station and once to get the check to pay the entertainer. On 1/23/19 at 11:27 AM, V18, CNA, stated she familiar with R45 and R35. V18 further stated in part, We try and keep them separated. Have not witnessed any inappropriate behavior from him in the dining room, and we keep a close eye on them. Even if they are close together, would separate them. On 1/23/19 at 1:05 PM, V14, Registered Nurse/RN, stated in part that she recalls back in (MONTH) a Sunday during church services in the dining room and that R45 just doesn't understand what is going on. She stated she wrote a nurses note for that date (12/30/18 at 10:40AM) and It was clearly noted that all the residents in there was upset with his behavior at the time. 1/23/19 at 1:00 PM V19, Licensed Practical Nurse/LPN, stated in part, that R45 uses inappropriate language and It happens quite often, mainly during evening hours. V19 also stated that out of her 3 days she works per week, she noted R45 using inappropriate language at least once and will have to redirect R45. V19 further stated R45's behaviors happen when he is leaving the dining room and he will stop at R35's table and if staff hear him inappropriately talking, it can become a shouting match. 1/23/19 at 1:28 PM, V7 Social Services Director (SSD) stated the interventions they have attempted are to try to redirect R35 because (R45) gets angry and curses and hollers at staff. V7, SSD, further stated that the other residents are hearing all of this because he is talking so loudly in the dining room, and that it is right by the doorway going into the dining room by the Nurse's Station or in the dining room is when this occurs. Have noted him talking sexual in nature and we attempt to redirect him. V7 stated R45 has been at the facility since 8/9/17. V7 also stated R45 is not getting any type of special programming but does see a psychiatrist here at the facility. V7 further stated, His (R45) behavior continues, because you can't reason with him. If you redirect him to his room, then 5 minutes later, he doesn't remember. V7 stated in the past that R45 and R35 were in a relationship, and both families were in agreement, but not to the best of her knowledge is there any type of sexual relationship occurring currently. V7 stated, This is a learning thing, because we haven't dealt with this type of behavior before. We have had a lot of changes in Administration. On 1/24/19 at 12:26 PM surveyor asked V7, SSD, if R45 and R35 are permitted to sit together during any activities or during meal times? V7, SSD, responded that neither R45 nor R35 should be sitting at the same table and that staff should be also aware of that as well. On 1/28/19 at 8:52 AM V1, Administrator, stated she reviewed the film of Wednesday night (1/23/19) in which R45 became verbally aggressive in the Dining Room. V1 further stated the staff redirected R45. V1 also stated R45 and R35 should not be sitting together in the dining room, even during an activity. On 2/5/19 at 8:30AM, V40, Regional Operations Director stated the facility did not have a specific policy for supervising cognitively impaired residents with behaviors.

Based on observation, record review and interview, the facility failed to identify, assess, timely treat, and reposition residents for pressure ulcer prevention and healing for 4 of 7 residents (R3, R5, R7, R8) reviewed for pressure sores in the sample of 15. This failure resulted in R8 developing a pressure ulcer which deteriorated to a Stage IV. This failure resulted in R3 developing an unstageable pressure sore/deep tissue injury to the left heel and the right outer ankle and a stage II to the coccyx that were avoidable. Findings include: 1. The MDS, dated [DATE], documents R8 requires extensive assist of two staff for bed mobility, transfer, toileting and extensive assist of one for bathing and hygiene. R8's labs, dated 5/16/16, document a low [MEDICATION NAME] at 3.1 (normal 3.5-5.5). R8's January 2016 POS documents an order for [REDACTED]. R8's Care Plan, dated 12/24/16, documents under Skin, that R8's heel ulcer has deteriorated from when it was first identified as a stage II on 3/4/16 to a stage IV 10/6/16. The goal is for the ulcer to heal without signs/symptoms of infection by next review. Interventions include: assess/document wound size, depth, color and drainage weekly, float heels with pillows when in bed, wound care practitioner to see her, heel/elbow protectors on when in bed, monitor/record skin status weekly, monitor for lack of healing and report to physician, monitor for pain due to wound, obtain/monitor labs, position resident off affected area as much as possible, turn & reposition every 2 hours and PRN to maintain body alignment and try to maintain adequate circulation to all pressure points. Quarterly Dietary Notes written by E11, Dietary Manager, dated 1/12/17, document no pressure ulcers and under abnormal labs has n/a (not applicable) written. R8 has no supplemental support for low [MEDICATION NAME] ordered or prescribed even though the Annual Registered Dietician assessment, dated 5/16/16, documents a right heel wound with a Braden score of 14. On 1/17/17 at 11:10 AM, R8 was in her high back wheelchair at bedside. Her feet dangled off the floor and were extremely [MEDICAL CONDITION]. R8 told E8 and E9, Certified Nurse's Aides, CNAs, that she had stool all over her pants and requested to lie down. R8 was transferred to bed and had on a saturated disposable brief and was soiled with stool. R8 had deep red/white creases across her upper thighs, buttocks and hips. R8 repeatedly stated her bottom hurt as incontinent care was provided. At that time, E8 and E9 stated they had gotten R8 up between 7:30 AM and 8:00 AM earlier that morning. At 11:50 AM, R8's skin was still deeply creased. Her heel dressing was intact and dated 1/17/17 and her feet remained extremely swollen. On 1/18/17 at 1:07 PM, E10, Licensed Practical Nurse, LPN, undressed R8's heel. The wound was oblong and irregular shaped, deeper in the center. The surface of the wound was pale pink and the dressing had moderate serosanguinous drainage on it which was slightly pink in the center. No odor was noted. E10 stated the wound is chronic and while she acknowledged the extreme swelling of R8's feet, stated she really isn't up much. E10 confirmed the wound deteriorated then has gotten slightly better. Skin Reports, dated 3/4/16 when R8's heel ulcer was first identified, documents the wound to be 4 centimeters (cm) long by (x) 3.5 cm wide with 0.1 depth recorded and identified as a stage II. Exudate was documented as serosanguinous. There is no documentation present on the assessment that documents why R8's ulcer was not identified earlier considering the size of the wound on 3/4/16 and her need for staff assistance for all bathing and hygiene. The most recent skin report, dated 1/12/17 written by Z1, Nurse Practitioner/Wound Specialist, documents R8's right heel as being a chronic stage IV Pressure Injury which measurements of 0.4 cm x 0.9 cm x 0.1 cm with no undermining noted. The report documents a moderate amount of serosanguinous drainage with no odor. The report fails to document any information or identify the [MEDICAL CONDITION] of R8's feet. On 1/19/17 at 3:25 PM, Z1 stated R8's wound is chronic, but healing very slowly. Z1 stated they hesitate to order protein supplements without current labs and stated she was not sure about when R8's last had labs taken. Z1 stated R8's foot [MEDICAL CONDITION] could have an impact on the heel healing. 2. On 01/17/17, R3 remained in the dining room in her wheelchair with no foot pedals from 11:30 AM to 12:45 PM based on 10-15 minute observation intervals. On 01/18/17, R3 was in her wheelchair without foot pedals from 9:30 AM to 12:50 PM based on 10-15 minute observation intervals. R3's bilateral feet/ankles were [MEDICAL CONDITION] and reddish in color on both days. At no time during these observations were R3's feet offloaded or elevated. On 01/17/17 at 11:20 AM, during a skin check and toileting for R3, the adhesive dressing on R3's coccyx area was rolled up with the wound bed exposed. The dry dressing on R3's right calf was intact on the edges with scant amount of serosanguinous drainage in the middle of the dressing. The dressing on R3's left heel was intact with serosanguinous drainage in the middle of the dressing. R3's right heel dressing was intact with no drainage noted. E21, Certified Nurses Assistant (CNA), stated the wound nurse had already done dressings changes earlier in the day. On 01/19/17 at 2:05 PM, E10, LPN, performed dressing change and measurements of R3's pressure ulcers. When the dressing to R3's left heel was removed, there was bloody/brown drainage noted on the soiled dressing. The area had a large layer of dead skin at the 12 o'clock region that was removed by Z1, Nurse Practitioner/Wound Specialist, who stated the skin was from the blister that developed. The wound was measured at 2.1 centimeter (cm) x 3.2 cm x 0.1 cm with a large area of black/brown tissue on the upper region of the ulcer. The bottom portion was bloody and reddened with the center being brown/yellow. There was a smaller opened area at the 10 o'clock region that was bloody and measured 0.6 cm x 1.6 cm. The Physician Order, dated 01/17/17, for the treatment for [REDACTED]. On 01/19/17, Z1 stated the pressure area was unstageable and ordered a [MEDICATION NAME] wound debridement ointment (Santyl) with a dry dressing. Z1 also stated that the legs need to be offloaded to keep the [MEDICAL CONDITION] down and promote healing. The right outer ankle measured 0.5 cm x 0.2 cm and was observed as a deep purple area the surrounding tissue very swollen and hard. It was described as deep tissue injury by Z1 and to treat with skin prep and offload. The right heel and the left inner ankle were observed with closed skin, but were reddened and noted to have tissue loss from previous in-house acquired pressure ulcers that had recently been healed. The right calf had an unstageable vascular ulcer that was open measuring 2.9 cm x 3.0 cm with multiple black, red and yellow areas throughout the wound. The surrounding tissue was hard and reddish/purple. Z1 stated that the depth could not be determined due to the multiple areas of necrotic tissue. The treatment to the right calf was wound cleanser with 4 x 4 gauze, Santyl ointment and cover with dry dressing. Z1 further stated that offloading the leg wound promote healing and decrease the amount of [MEDICAL CONDITION]. The pressure ulcer on the coccyx was not observed. The Pressure Ulcer Wound Sheet, dated 01/06/17, documented R3's left heel ulcer developed in-house measuring 5.0 cm x 8.0 cm with [MEDICAL CONDITION] and painful during dressing change and staged at a level II. There was no causative factor listed. Z1 stated that the wound measurements significantly changed due to the blister had erupted and would change due to the areas of necrotic tissue. The Pressure Ulcer Wound Sheet, dated 12/07/16, documented R3 developed a stage II pressure ulcer to the right buttock/coccyx measuring 1.5 cm x 7.0 cm x 0.1 cm with scant serous drainage. The treatment ordered was for a [MEDICATION NAME] dressing to be changed every three days and prn. The Weekly Nursing Skin Assessment, dated 01/11/17, documented newly developed pressure areas to the right ankle measuring 0.5 cm x 0.5 cm and to the left ankle measuring 1.0 cm x 0.5 cm. The left ankle was resolved as of 01/19/17. The Minimum Data Set (MDS), dated [DATE], documented R3 requires extensive assist of at least one staff for bed mobility, locomotion, dressing, hygiene and bathing; and extensive assist of at least two staff for toilet use and transfers. The Care Plan, dated 01/06/17, documented R3 requires assistance with turning and repositioning. There was no documentation of encourage offloading in the Care Plan. The physician's orders [REDACTED]. The Braden Scale for Predicting Pressure Ulcer Development, dated 12/30/16, documented R3 was a moderate risk for developing pressure ulcers. On 01/19/17, E10, LPN, stated R3 had developed the bilateral heel ulcers and the right ankle ulcer from the foot pedals on the wheelchair. She stated that the coccyx ulcer developed from non-compliance and sitting in the wheelchair for extended periods of time. E10 stated that the ulcer on the right calf could have been caused by rubbing on the foot pedal as well, even though Z1 stated it appeared to be a vascular wound. E10 further stated that was the reason R3 did not have foot pedals on now. Z1 stated that the legs needed to be offloaded in order for the ulcers to heal. The Facility's Pressure Ulcer Treatment Policy, revised 10/20/05, documents, Purpose: To assure each resident that has a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing; and continues #7. Weekly weights will be obtained on all residents with stage III, stage IV or multiple stage II pressure ulcers. Weights and food consumption will be reviewed weekly to address need for supplementation or nutritional enhancement. 3. On 01/17/17 at 11:15 AM to 12:45 PM, R5 was in the dining room in a wheelchair with no foot pedals and no positioning cushion, leaning to the left side. R5's feet were [MEDICAL CONDITION] with no support socks on or shoes. On 01/18/17, R5 was asleep with her head slumped forward while sitting in a high back wheelchair with a positioning cushion that came up between her legs (pommel cushion) and bilateral foot pedals on the wheelchair from 9:20 AM to 12:20 PM without benefit of repositioning based on 10-20 minute observation intervals. Multiple staff walked by R5 during this period of time. The POS, dated 01/03/17, documented R5's diagnoses, in part as, Diabetes Mellitus, Obesity, Dementia with Behavioral Disturbances, [MEDICAL CONDITION], Restless Leg Syndrome and History of Falls. The MDS, dated [DATE], documented R5 was moderately cognitively impaired and required extensive assist of at least two staff for transfers, dressing and toilet use. The Care Plan, dated 01/18/17, documented R5 was identified as having potential for impaired skin integrity due to decrease mobility, incontinence and Diabetes Mellitus. It documented R5 required assistance with turning and repositioning every two hours and as needed to maintain body alignment. It also identified R5 as requiring a positioning device in wheelchair to maintain proper sitting position. 4. R7's undated admission sheet documents R7 diagnoses, in part of, Dementia, lack of coordination, abnormal posture, osteo[DIAGNOSES REDACTED], and major [MEDICAL CONDITION]. R7's Medical [DIAGNOSES REDACTED]. R7's MDS, dated [DATE], documents a Brief Interview Mental Status(BIMS) score of 12, indicating moderately impaired cognition. R7's Braden Pressure Ulcer Risk Assessment, dated 10/24/16, documents a score of 14, indicating moderate risk for developing pressure ulcers. R7's Care Plan, initiated 4/27/2012, and revised on 11/02/2016, documents in part, R7 needing assistance to reposition every 2 hours and as needed to maintain body alignment and to maintain adequate circulation to all pressure points. On 01/17/17, R7 remained seated in the wheelchair in her room without benefit of repositioning from 10:50 AM until 1:00 PM based on 10 to 15 minute observation intervals. At 1:00 PM, E4 and E6, CNAs, transferred R7 from the wheelchair to the toilet. E6 stated R7 had been up in the wheelchair since 7:45 AM. On 1/18/17, R7 remained seated in the recliner in her room without benefit of repositioning from 9:05 AM until 11:25 AM based on 10 to 15 minute observation intervals. At 11:25 AM, E5, CNA, wheeled R7 to the dining room. During the noon meal from 11:25 AM until 12:41 PM, R7 continued to sit in the wheelchair. At 12:43 PM, R7 was transferred from the wheelchair to the recliner. On 1/20/17 at 2:00 PM, E3, Assistant Director of Nursing (ADON), stated that it is the expectation of staff to reposition residents every 2 hours and as needed. The Facility's undated Positioning Policy documents, in part, The most effective means of pressure relief in positioning residents is the change of position. Pressure over extended periods of time results in tissue destruction.

Based on record review, observation and interview, the facility failed to provide effective fall interventions, measures and supervision for 4 of 10 residents (R6, R10, R16 and R15) reviewed for falls in the sample of 19. This failure resulted in R15 incurring a fractured wrist and R10 incurring a fractured nose after repetitive falls. Findings include: 1. R10's Minimum Data Set (MDS), dated [DATE], documented diagnoses, in part, of Alzheimer's Disease and Dementia, incontinent of urine, extensive assistance of one person physical assistance with mobility, transfer and toileting and no falls since admission. R10's Care Plan, created on 6-5-13, documented R10 was at a high fall risk due to, in part, weakness, impaired balance, impaired memory, decreased endurance, decreased safety awareness and incontinence. R10's Incident/Accident Reports, dated 9-27-13 to 12-22-13, documented R10 had 8 falls. On 9-27-13, R10 was found on the floor in her room and her body alarm was not attached; On 10-8-13, R10 was found on the floor in her room in front of her wheelchair. R10's alarm was attached and sounding; On 10-23-13, R10 was found on the floor in her room. R10's alarm was on attached and sounding; On 11-15-13, R10 was found on the floor beside her bed sitting in urine. R10's alarm was attached and sounding; On 12-11-13, R10 slid down the edge of her bed and was found sitting on the floor. R10's alarm was attached and sounding; On 12-15-13 at 3:30a.m., R10 was found on the floor bedside. R10's alarm was attached and sounding; On 12-15-13, R10 leaned forward in her wheelchair and fell incurred a 3 cm laceration to the bridge of her nose and bilateral nasal bone fractures; and, On 12-22-13, R10 was found lying on her right side from a fall from her wheelchair incurred a 7 cm x 5 cm hematoma to the right side of her forehead and a 3 cm x 2 cm hematoma to her left index finger. R10's alarm was attached and sounding. Interview of E1, (Administrator) and E2, (Director of Nursing, DON), on 1-28-14 at 2:00p.m., E1 and E2 stated that R10 was provided interventions after her falls. E1 and E2 provided a list of her falls and documentation of interventions after each fall. R10's interventions did not document reassessments of the effectiveness of R10's alarm in fall prevention, a change in the type of alarms until after R10's 12-22-13 fall or addressed additional supervision needs of R10. In addition, R10 was not placed on scheduled toileting until after her 12-11-13 fall. 2. R15's MDS, dated [DATE], documented R15 required extensive assistance for transfers and a Cognitive score of 9 with range 1 -15. The Care Plan, dated 11/26/13, documented R15 as high fall risk. Fall Risk Assessment, dated 9/25/13, is scored at 15 with score of 10 or above represents HIGH RISK. The Accident/incident report, dated 7/29/13, documented R15 was found laying on his back on the floor in his room. R15 sustained bilateral elbow skin tears. The Accident/incident reports documents R15 was last seen in bed approximately ten minutes prior to finding R15 on the floor. According to the Accident/incident form interventions were to prevent resident from falling again is staff is to bring R15 up to nurses station and remind him he is not able to walk. On 8/9/13 at 8:30AM, R15 had an unwitnessed fall. The Accident/incident report for R15 documents he was last observed in a high back wheelchair in tilt back position in hall just a few minutes prior finding R15 in his room on the floor laying, flat on back. R15 sustained a 3 corner 1cm (centimeter) by 1cm skin tear with bruised area approximately 3cm by 2cm to right elbow. Incident/accident form documents interventions for R15 is to not leave him up in high back wheelchair in his room or down the hall out of staff's eyesight. Personal alarm placed r/t (related to) second fall in less than 2 weeks. On 9/24/13 at 11:15pm, accident/incident report documents R15 was found on the floor with back to the bathroom door and alarms sounding Left hand/wrist swollen, discolored and pain noted. R15 had been in bed prior to the fall. R15's Accident/incident Form documents interventions of staff educated on promptly responding to alarms. R15 sustained a fracture of the left distal radius. In an interview on 1/28/14 at 2:05PM with E5 (LPN), (Licensed Practical Nurse) stated the bed alarm did go off but it took her and a CNA a few minutes to get there as they were using a mechanical lift on another resident. The Nurse was already in R15's room when E5 arrived. In an interview with E6 Registered Nurse (RN) on 1/28/14 at 2:10PM she stated the call light wasn't on. The bed alarm was going off. She was at the Nurses Station and didn't make it in time before R15 fell . E6 stated she was there seconds before the CNA. In an interview with R7, roommate to R15, on 1/28/14 at 1:00PM, he stated he was in bed and turned to look over to the door and saw R15 stand halfway from bed to bathroom and saw R15 falling backwards against the bathroom door. R7 stated he yelled for help and help took just couple of seconds to minutes to get there. R15 didn't remember if R15's bed alarm was sounding or not. 3. R16's MDS, dated [DATE], documented cognitive impairment, incontinent of bowel and bladder and extensive assistance of one person physical assistance with mobility, transfer and toileting. R16's Incident/Accident Reports, dated 8-30-13 to 1-9-14, documented the following falls: On 8-30-13, R16 slid down her door and incurred a right elbow skin tear. R16's alarm was sounding; On 10-16-13, R16 attempted to stand up from her wheel chair and slid and fell ; On 10-25-13, R16 slid from her wheel chair and sat on her buttocks; On 10-28-13, R 16, attempted to get up from her wheel chair, leaned forward, moved a treatment cart, fell forward and hit the left side of her head on the wall; On 11-23-13, R16 was found on the floor against her wheel chair in the hallway with her alarm sounding; On 12-5-13, R16 was found sitting on her bottom with her back against wall. R16 had been in her wheelchair; On 12-7-13, R16 was found in the dinning room on the floor with her alarm sounding after attempting to stand up from her wheel chair; and, on 1-9-14, R16 fell from bed even with her side rails up. R16's alarm was sounding. Interview of E1 (Administrator) and E2 (DON), on 1-28-14 at 2:00p.m., stated, that R16 was provided interventions after her fall. E1 and E2 provided a list of interventions after each fall; R16's 11-23-13 and 1-9-14 falls. It was also noted R16's alarm was not assessed for effectiveness to prevent falls or alternative interventions after assistance wheel chair devices were attempted and were discontinued to to R16's agitation. 4. On 01/22/14 at 9:40 AM, during tour of the facility R6 was observed sitting in a wheelchair in her room sleeping. R6 was observed to have a velcro shoulder strap harness and a chair alarm. The Physician order [REDACTED]. The MDS, dated [DATE], documented R6 as having moderate cognitive impairment requiring extensive assist of at least one staff for bed mobility, transfers, ambulation, dressing, hygiene, toileting and bathing. It also documented R6 is frequently incontinent of bladder and is unable to balance self without human assist. The Fall Risk Assessment, dated 01/08/14, documented R6 was a high risk for falls. The Care Plan, dated 12/27/13, identified R6, in part, as having cognitive loss and high risk for falls due to decreased safety awareness, impaired balance, impaired memory and incontinence. An Incident Report, dated 05/17/13, documented R6 fell from her wheelchair and was found on the floor and transferred to the Emergency Department for evaluation for lethargy. An Incident Report, dated 07/04/13, documented R6 fell from her wheelchair and was found on the floor near the bathroom door in her room. The report documented R6 complained of right knee and right hip pain, however X-rays obtained were negative for fracture. The intervention listed was for R6 to not be left alone in wheelchair, body alarm to wheelchair, pull alarm to bed and lay down when sleepy. On 09/23/13, an Incident Report documented R6 fell from wheelchair in the dining room. R6 sustained a 3 cm hematoma to right side of forehead. The report documented the body alarm was not sounding due to R6 removing it. Interventions were listed as monitor body alarm placement and lay resident down when sleepy. On 10/22/13, an Incident Report documented R6 fell from her wheelchair and was found on the floor in her room near the bathroom door. The report documented R6 sustained an 11 cm abrasion to her back, a 2 cm abrasion to her mid-back and skin tear to posterior lower left leg. The report also documented R6's alarm was not sounding due to the clipped string being too long and the call light was on. The intervention was to shorten the alarm string. On 12/27/13, an Incident Report documented R6 fell from her wheelchair and was found on the floor. The report documented R6's body alarm was not sounding due to staff not turning it on. The report documented R6 sustained two skin tears to the left hand. The interventions listed was to re-educate staff about proper use and function of the body alarm. On 12/30/13, a physician's orders [REDACTED]." On 01/07/14, an Incident Report documented R6 fell from her wheelchair in the dining room. The report documented the body alarm was sounding. The report documented two skin tears. The report also documented steps to prevent further incidents as shoulder strap harness to wheelchair secondary to resident leaning forward. There were no new interventions to prevent R6 from further falls. 5. The facility's Falls Management System policy and procedure, not dated, documented, in part, "It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if fall occurs. Each resident is assisted in attaining or maintain their highest practicable level of function through providing the resident adequate supervision, assistance devices and functional programs as appropriate to prevent accidents."

Based on interviews, observations and record review, the facility failed to implement safety measures including adequate supervision and assistance to prevent falls for 2 residents of 9 residents (R1 and R12) reviewed for falls in a sample of 21.. Findings include: 1. The Admission Sheet documents that R12 was admitted to the facility on [DATE] following hospitalization for a fractured femur from a fall 9/19/11 at another nursing home. According to the Incident/Accident Log, R12 has had repeated falls documented on 9/26/11, 10/1/11, 10/26/11, 12/10/11 and 12/13. The Minimum Data Set ((MDS) dated [DATE] identifies that R12 required extensive assist of one staff for bed mobility and transfer. According to the Incident/Accident Log, R12 fell on [DATE]. The Interdisciplinary Notes (IDT) dated 9/26/11 indicates she "leaped from bed, across room" as the nurse was outside of her room. Alarm was sounding. A low bed was implemented. There is no explanation as to why the facility would implement a low bed when she was doing a self transfer without assistance and fell across the room from the bed. The report documents that R12 fell again on 10/1/11 at 10:30am and was found on the floor. The fall was unwitnessed. The IDT notes indicate she was a low bed at the time and had a mat floor alarm but was "constantly on the move." On 10/26/11 at 4:05pm, R12 was sitting in a chair at the nurses station and stood at side with hand on the foot rest when she rolled herself toward the foot rest and slid to the floor. The alarm sounded but staff was unable to reach her before she fell to the floor. On 12/10/11 at 7:40am, the IDT notes indicate R12's alarm sounded and when staff responded found R12 had pulled herself up attempting to stand to ambulate causing herself to fall to the floor. She obtained as reddened area to her head. The IDT notes indicate R12 had a seat belt on which she removed herself prior to standing up. On 12/13/11 at 10:20pm, R12's alarm sounded again according to the IDT notes when she removed her belt prior to standing up and fell to the floor. Again, there is no indication as to why the staff were unable to respond more timely to the alarm and no indication further assessment was done toward a more appropriate device since she removed the belt and staff were unable to respond to the alarm to prevent falls. There are no assessments/documentation available to explain why R12's safety device were chosen. The MDS dated [DATE] indicated that R12 had cognitive impairment and still required extensive assist of one staff for bed mobility, transfers and locomotion outside of the room. The MDS also identified that R12 had balance deficits with on/off toilet being "unsteady" requiring human assistance. The care plan reflects R12's high risk for falls and includes interventions for alarms, bedside mat alarm, side rails among others but fails reflect her frequent prior falls and the need for constant supervision and quick response to the alarms sounding. R12 has also been placed on Hospice (November 2011). According to an Incident/Accident Report, on 1/25/12 at 5:30am, R12 was on the toilet and "leaned over et (and) fell to floor L (left) side" receiving a 3 cm (centimeter) skin tear to her left upper extremity and a 2 inch laceration to the left side of her head. R12 was sent to the emergency room for treatment of [REDACTED]. The Nurse Investigation of Accident/Incident dated 1/25/12 documents that R12 fell from the toilet, was seen 2 minutes prior to the fall and that her body alarm was not sounding. The investigation found that the Certified Nurses Aide (CNA) transferred R12 to the toilet and heard another residents alarm sounding across the hall. The CNA left R12 unattended on the toilet to go answer the other alarm. When she returned, R12 was laying on the floor. The investigation indicates the staff member was re- inserviced on leaving residents unsupervised. This information was confirmed by E2, Director of Nurses on 3/22/12 at 10:30am when she acknowledged that R12 should not have been left unattended by staff to respond to another residents alarm sounding stating she had no additional information to provide. E2 also stated R12 who had an chair alarm would not have had it on while on the toilet. 2. R1's MDS, dated [DATE], documented cognitive impairment, extensive assistance of two plus persons physical assistance with mobility, total dependence of two plus persons physical assistance with transfer and bathing. R1's Incident/Accident Report, dated 1-3-12,documented R1 incurred a laceration to his left upper eye brow, 1.5cm length, as a result of E18, Certified Nursing Assistant (CNA), placing R1 in the wrong shower chair during R1's shower. R1 was sent to a local hospital after falling from the shower chair.

Based on record review and interview, the facility failed to provide effective interventions to prevent falls for 2 of 3 residents (R2, R3) reviewed for falls in the sample of 3. This failure resulted in R3 falling several times; and after the last fall, he expired with a [DIAGNOSES REDACTED]. The findings include: 1. R3 has diagnoses, in part, of history of cerebral vascular accident, left cerebral vascular disease, and dementia with behaviors. R3 was assessed on the [DATE] Minimum Data Set, (MDS), as totally dependent on 2 staff for transfers, and extensive assistance of 2 staff for bed mobility and toilet use. R3 was assessed as usually understanding of others and in his ability to make self understood. R3 was assessed as moderately impaired with cognitive skills for daily decision making. R3 receives Plavix 75 mg (milligrams) daily and aspirin 81 mg daily due to history of cerebral vascular accident. The Care Plan dated [DATE] identifies R3 as "High Fall Risk" due to [DIAGNOSES REDACTED]."Attempt to keep in supervised area while up in wheelchair", "Ambulation monitor (personal alarm) to wheelchair (and)/or bed to alert staff resident is attempting independent transfer" and "[DATE] Res (resident) to remain in area close to nurse station/TV (television) area". The Care Plan also identified R3 was at risk for abnormal bleeding due to "antiplatelet medication". The following falls and interventions were documented for R3: [DATE]- R3 attempted to transfer himself to bed. No injury was noted. The intervention stated to place a alarmed floor mat at the bedside. [DATE]- R3 attempted to transfer himself to bed. No injury was noted. The intervention stated to lay R3 down after breakfast and remove his mattress from bed when up. [DATE]- R3 attempted to transfer himself to bed. R3 sustained a laceration to the right eyebrow. R3 was transferred to the emergency room and received 5 sutures to the laceration. The computed tomography (CT) scan of the brain did not note any intracranial bleeding . The intervention for this fall stated "Res (resident) will not be left in room alone", "Remain in area close to nurses station" and "body alarm". E8, Certified Nurses Aide, CNA, for R3 on [DATE], was provided an inservice on [DATE] with the topic as "Resident (with) alarms (not) to be left in room". [DATE]- R3 was sent to the hospital due to mental status changes. It was noted R3 had upper gastrointestinal bleeding with normal coagulation profile according to the "Gastroenterology Consultation" dated [DATE]. [DATE]- R3 leaned forward in his wheelchair and fell to the ground. No injury was noted. The incident report noted the alarm was not sounding and documented "? clip wasn't very secure?". The intervention was to use a "Prime snap to alarm (and) secure clothing". [DATE]- R3 was seated in his wheelchair and fell out of the wheelchair. R3 was non-responsive and transferred to the hospital and admitted with "mental status changes". On readmission to the facility on [DATE] multiple bruises were noted. The nurses notes dated [DATE] noted the following: - bruise, 12 cm by 4 cm, to the right temple and eye orbit, -5 cm (centimeter) by 3 cm blue bruise to the sternum, -dark purple bruising 20 cm by 21 cm to the left hand and forearm, -a green-purple bruise measuring 6 cm by 5 cm to the left AC -two bruises noted on the left shoulder measuring 3.5 cm diameter (black with green edges) -3.5 by 0.75 cm (purple with green edges), -left forearm green bruising 16.5 by 13 cm -Right wrist blue/brown bruise 6 cm by 3 cm. -blue brown bruise 3 cm by 2 cm to right shin [DATE]- R3 was found on the floor in his room after attempting to transfer himself to bed. No injuries were noted at the time. The alarm was sounding. The interventions stated to "keep at nurses station til staff assist to bed" and "Res. to be (at) nurses station (after) meals. Not to be in room by self". E2, Director of Nursing, (DON), stated in an interview on [DATE] at 2:05 PM that staff left R3 alone in his room unattended while staff went to get linens, and should not have left R3 alone. E2 stated R3 liked to be in bed and would self transfer himself to get into bed. E2 confirmed that there were no neuro checks done for R3 because he stated he had not hit his head when he fell . In an interview on [DATE] at 12:55 PM, with E4, Licensed Practical Nurse, (LPN), who worked the day shift (6:30 AM to 2:30 PM) on [DATE] and [DATE]. E4 stated she worked both days, and R3 did fall on the morning of [DATE]. E4 stated R3 was trying to put himself to bed, and denied hitting his head. E4 stated she did neuro checks on R3 at the time and they were normal. E4 stated that since R3 denied hitting his head she did not continue doing neuro checks. E4 stated she was not aware of any other falls on either days. E4 stated R3 always wanted to go to his room to go to bed so he had to stay at the nurses station for observation so he did not transfer himself. E4 stated in an interview on [DATE] that she felt R3 was reliable in his ability to tell her if he had hit his head and that is why she had not done neurochecks. The facility policy and procedure on "Neuro Checks" states "whenever a resident sustains an unwitnessed fall and cannot reasonably report whether head was struck or not, that resident will have neuro checks completed by the nurse...". The policy notes the neuro checks will be done for 72 hours. In an interview on [DATE] at 1:40 PM with E5, CNA, who worked day shift on [DATE] and [DATE], and she stated R3 always wanted to go to bed and would put himself in the bed if you did not watch him. E5 stated R3 did fall on one of the days she worked but could not recall the day. E5 stated there were no injuries and E4 checked R3 over. E5 stated R3 seemed the same after that but was agitated. In an interview on [DATE] at 1:50 PM, with E6, CNA, who worked day shift [DATE] and [DATE] morning shift, she stated on [DATE] that she was caring for R3 and took him to his room. E6 stated she told him she would be right back and went to get linens. E6 stated when she came back R3 was on the floor. The alarms were sounding. E6 stated R3 seemed fine and had no injuries. E6 stated she was not aware of any other falls that weekend. In an interview on [DATE] at 1:10 PM, with E7, LPN, who worked evening shift 2:00 PM to 10:30 PM on [DATE] and [DATE], she stated R3 was in bed on [DATE] for her shift as they could not find the mechanical lift pad to transfer him out of bed. E7 stated R3 had no problems on [DATE] and his vitals were fine. E7 stated R3 went to the evening meal on [DATE] and then stayed at the nurses station. At 6:00 PM R3 got his medications and then went to bed. E7 stated she woke R3 up at 9:00 PM for and R3 was alert. E7 did not see R3 after that and was not aware of any other falls. In an interview on [DATE] at 4:10 PM, with E8, CNA, who worked on the evening shift of [DATE], and she stated R3 was acting his normal self on Sunday, [DATE]. E8 stated she was not aware of any falls on her shift for R3. The Nurses Notes dated [DATE] and [DATE] did not document any problems such as lethargy, change in vital signs, for R3. The nurses notes on [DATE] at 4:00 PM documented no apparent injuries from the fall. The nurses notes, interviews and ambulance report have conflicting time frames. The nurses notes dated [DATE] by E9, LPN, at 12:20 AM noted R3 was having "loose, "gurgling" resp. (respirations) Res very lethargic. Attempted to give med. Res brought meds forward to lips wiped lips (with) tissue res mumbled something then became totally non responsive Due to (change) in condition from evening shift. Decision made to call (Z1)". The next nurses note was dated [DATE] at 1:10 AM and noted that Z1, Primary Care Physician, was called and orders were received to send R3 to the emergency room . E9 stated in an interview on [DATE] at 4:00 PM, that she worked the [DATE] midnight shift of 10:00 PM to 6:30 AM on [DATE]. E9 stated no problems had been reported to her from the previous shift. E9 stated the first time she saw R3 on ,[DATE] 11 he was lethargic and had gurgly respirations. E9 stated that she did not call the physician at that time. E9 stated the time was more like 12:45 to 12:50 AM when she first saw him and not 12:20 AM as charted. E9 stated she went and checked other residents and when she returned in about 5 minutes, R3 was unresponsive and she then called the physician. E9 stated she called 911. E9 confirmed she did not take R3's vital signs. E2 stated on [DATE] at 11:50 AM that she had discussed the incident with E10, CNA, who had worked the midnight shift starting [DATE] on [DATE] at the facility. E2 stated E10 did not note any problems with R3 until the nurse, E9, told her to clean R3 up at because he was being sent to the hospital around 12:20 AM on [DATE]. The report from the emergency medical department that responded to the 911 call documented the call was received at 1:15 AM. The ambulance arrived at 1:22 AM but could not get to R3 until 1:30 AM. The report states "Delay in arriving at the patient and exiting due to the nursing staff having the facility doors locked". R3 was taken to a local hospital emergency room . A Computed Tomography, (CT), scan noted a "large right subdural hematoma with midline shift and downward herniation". R3 was airlifted to a large metropolitan hospital. The CT scan dated [DATE] noted "Large right subdural hematoma" and as the findings noted "There is a massive mixed attenuation right subdural hematoma which causes profound right to left midline shift. There is uncal herniation". The "Consultation" report from neurosurgery dated [DATE] noted R3 "suffered a massive subdural hematoma with resulting severe and unrecoverable neurologic injury". R3 expired on [DATE]. Z1 stated in an interview on [DATE] at 11:15 AM, that R3 was diagnosed with [REDACTED]. Z1 confirmed that R3 hit his head and that caused the subdural hematoma. Z1 stated he was not aware how R3 hit his head or when. 2. R2 was admitted on [DATE] with diagnoses, in part, of cerebral aneurysm, Alzheimer's disease, hypertension, osteo arthritis. The care plan dated [DATE] noted that R2 was a high risk for falls due to cognitive loss. Interventions dated [DATE] documented R2 was to remain at the nurses station for observation. The interventions dated [DATE] documented the placement of a body alarm. The MDS dated [DATE] documented that R2 required moderate assist of 1 person to transfer. It also noted R2 had deficits in cognition. On [DATE] R2 was found in her room on the floor with no injuries noted. The intervention stated "laid res (resident) (down) after fall". On [DATE] R2 fell out of her wheelchair at the nurses station. R2 received a 1 cm laceration to the back of the head. The nurses notes dated [DATE] documented that R2 had "attempted to ambulate I (independently) (times 2) earlier in the shift but did not appear restless. Res (resident) was sleepy prior to fall. Res had been (checked) on by CNA (Certified Nurse Aide) (and) nurse approx. (approximately) 5 min. (minutes) prior to fall". E12, Registered Nurse, (RN), confirmed by interview on [DATE] that R2 was at the nurses station with no staff present. E12 confirmed that R2 had attempted to ambulate independently prior to the fall. E12 stated after R2 fell she kept R2 with her.

Based on record review, interview, and observation, the facility failed to properly transfer 1 of 1 residents (R1) reviewed for use of a mechanical lift for transfers in a sample of 3. The findings include: The nurses notes dated 7/19/11 documents that R1 had a bruise under her left eye and on her left thigh. The "Incident/Accident Report" dated 7/19/11 at 6:00 AM documents that R1 had two bruises on the left side of her body. The report documents a bruise 3.0 x 0.5 centimeters (cm) on her left eye with a swollen eye socket. It also described a bruise 4.0 x 1.0 cm on left thigh area. The bruises origin were unknown at that time. The report documents that a mechanical lift was used to transfer R1. Observation of R1 on 7/20/11 at 9:55 AM, and a quarter size bruise was observed under her left eye. R1 stated she did not know how the bruise occurred. E7, Licensed Practical Nurse, LPN, stated in an interview on 7/20/11 at 10:10 AM that she conducted the investigation for the bruises of unknown origin for R1. E7 stated the bruises were found on the morning of 7/19/11 about 6:00 AM, and she started the investigation about 8:00 AM. E7 stated she found that when she talked to E4, Certified Nurse Aide, CNA, at approximately 2:15 PM on 7/19/11, that E4 had been transferring R1 with the mechanical lift, and R1 had hit her head on the bar of the lift. E7 stated E4 was transferring R1 alone with the mechanical lift, and had left the side rails up also during the transfer. E7 stated E4 told her R1 hit her face, and then hit her leg on the side rail. E7 stated there should have been two staff to transfer R1, and E4 was given a written warning. E7 stated the report was not sent to the Department. The Care Plan dated 6/24/11 documents that R1 was at high risk for falls and to ensure residents safety during transfers E6, Corporate Nurse, stated in an interview on 7/20/11 at 10:20 AM that E4 had transferred R1 with only one staff, and should not have transferred R1 alone. E4 stated in an interview on 7/20/11 at 10:25 AM that she was transferring R1 alone with the mechanical lift right before the evening meal on 7/18/11. E4 stated she did not have the mechanical lift straps hooked up correctly, R1 shifted forward, and hit her face on the mechanical lift bar. E4 also stated she did not put the side rails down, and R1 hit her leg on the side rail. E4 stated she was alone when she transferred R1 with the mechanical lift. E4 stated she did not report the incident to E5, Charge Nurse, . The "Corrective Action Form" for a "Safety Violation" dated 7/19/11 for E4 documents a warning was given for transferring R1 alone and for not attaching straps correctly was given. The report documents this caused R1's face to hit on the lift bar and her thigh on the side rail. The report documents E4 did not report the incident. The "Corrective Action" documents "All (mechanical lift) transfers require assist of (2) for transfers et (and) placement of (mechanical Lift) pad properly positioned et applied." The facility policy and procedure for the mechanical lift documents (Company) recommends that two (2) assistants be used for ALL lifting preparation, transferring from and transferring to procedures. The use of one (1) assistance is totally based on the evaluation of the health care professional for each individual case". The "Addendum to Lifting using a portable Machine Policy" dated 11/22/10 documents "Two caregivers must be present at all times when using lift", and "One caregiver must secure the resident with a gait belt and maintain security during entire transfer".