Every finding on record at Evercare of Collinsville

Based on interview and record review the facility failed to ensure staff witnessed the destruction of narcotics and staff watched the evidence custodian destroy the items and signed off confirming the destruction took place to ensure the diversion of drug disposal for 4 of 10 residents (R7, R8, R9 and R10) reviewed for the destruction of narcotic drugs in the sample of 10.The surveyor confirmed by observation, interview and record review that the deficiency practice occurred on 1/2/2026 and was corrected on 1/5/2026, prior to the start of this survey, and was therefore Past Noncompliance.Findings include: On 8/6/2026 at 2:33 PM, V1 Administrator stated We did have to terminate our former Director of Nursing (DON) because she had a resident's narcotic card in her possession in her vehicle. We also did an audit, and some staff members signed off for the destruction of the narcotics, but the narcotics were never destroyed. I expect all staff to watch the destruction and then sign off as a witness with the date. When we interviewed staff, we found three staff members that had signed off on the destruction of narcotics without witnessing the narcotics being destroyed, which goes against our policy. V10's statement dated 1/9/2026 documents, (V10) was asked to confirm the signature on R7's Lorazepam count sheet and if it was hers. (V10) confirmed the signature was hers. (V10) was asked to explain why she would sign as a witness when she didn't actually witness. (V1) voices she would take narcotic sheet to DON. (V10) voices DON would ask her to sign her and (V10) would go back to work. On 8/7/2026 at 1:33 PM, V3, Licensed Practical Nurse (LPN) stated she knew she was supposed to watch the narcotic drug be destroyed before she signed off on it, but she did not do it. She signed the sheet for (R7) without actually watching the DON destroy the medication. She was busy that day and the DON told her she would destroy it and she trusted her and thought she would do the right thing. V3's statement dated 1/8/2026 documents, (V3) was asked based on her experience here if she had any concerns related to narcotic destruction, misuse, etc. (V3) voiced no. When a medication is DC'd (discontinued) she tries to get it off the cart. (V3) voiced it needs destroyed with 2 nurses and 2 nurses watching. (V3) asked if that was her signature on the narcotic sign out sheet and she said yes. (V3) was asked to explain why the medication had not been destroyed at that time. (V3) voices she probably just signed and walked away. On 8/7/2026 at 2:04 PM, V11, LPN stated, She knows there is always supposed to be two nurses destroying narcotic medication. She knows she is supposed to watch the other nurse the entire time destroy the medication but honestly, she was so busy that day and signed off without watching the DON destroy (R9's) medication. The DON told her she would destroy the medication, and she trusted her. V11's statement dated 1/12/2026 documents, (V11) was asked to confirm her signature on (R8's) oxycodone, (R9's) lorazepam, and (R10's) oxycodone. (V11) confirmed her signature. (V11) was asked why she would sign without actually witnessing the destruction. (V11) voices she trusted her supervisor. (V11) was asked to explain the proper process to destroy narcotics, (V11) was able to verbalize the process. (V11) voices she understands the importance of destroying narcotics properly. On 8/7/2026 at 3:03 PM, V2, Director of Nursing stated no nurse should ever sign off for a medication being destroyed if they did not actually see/witness the medication being destroyed. This allows the medication to not be accounted for, and opens the door for possible theft, which is what happened. She expects all staff to follow policy and when they sign their name as a witness then they witnessed the medication being destroyed. The Facility Medication Administration Policy dated 6/15/2026 documents, To provide practice standards for safe administration of medications for residents in the Facility. The Facility Controlled Substance Disposal Policy effective date 10/25/2014 documents, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses or pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason.The Facility Controlled Substance Policy dated 10/25/2014 documents, When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses or pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason. Never sign as a witness to the destruction of medications if you did not visibly witness the destruction. Never take someone's word for it or trust that another individual carried out the destruction in your absence. If you do so and medications are later missing, it is your word against theirs.This tag was corrected on 1/2/2026 Prior to the survey date, the facility took the following actions to correct the noncompliance. All nursing staff were in-serviced with the responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses or pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses or pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason. Never sign as a witness to the destruction of medications if you did not visibly witness the destruction. Never take someone's word for it or trust that another individual carried out the destruction in your absence. If you do so and medications are later missing, it is your word against theirs. The results of the audits will be presented to the Quality Assurance Performance Improvement Committee by the Director of Nursing or designee or review and further recommendations as deemed necessary and we will continued to be monitor with audits.

Based on interview and record review the Facility failed to ensure misappropriations of property did not occur for 1 of 10 residents (R6) reviewed for misappropriations of property in the sample of 10.The surveyor confirmed by observation, interview and record review that the deficient practice occurred on 1/2/2026 and was corrected on 1/5/2026, prior to the start of this survey, and was therefore Past Noncompliance.Findings include: R6's Physician Orders Sheet (POS) dated January 2026 documents a diagnosis of Anxiety disorder, Polyneuropathy, Depression, and Spinal stenosis. R6's Minimum Data Set (MDS) dated [DATE] documents R6 was cognitively intact for decision making for activities of daily living. No impairments on upper or lower extremity. He uses a wheelchair. On 8/6/2026 at 1:11 PM, R6 stated back in January we had a different Administrator and Director of Nursing (DON) (V9). I got called into the office because apparently the police stopped the former DON (V9), and they found a medication card, with my name on it, for one of my medications, was in her car. It was Xanax. I guess (V9) was stealing my Xanax. I think I got all of my medications, but it makes you wonder. R6's Incident Report dated 1/6/2026 at 6:15 PM, (R6) [AGE] year-old male. Staff report of misappropriation: Immediate Actions taken: Notified police, Resident assessment completed (skin, Pain, BIMS (Brief Interview of Mental Status); Physician Notified, Administrator Notified Investigation initiated. A Follow up report will be completed and submitted within five working days. An investigation was initiated when (V9) did not report for her scheduled shift, resulting in the notification from (V9) that she had been arrested due to having an outstanding warrant for not having car insurance. (V9) was suspended pending an investigation into her arrest. The facility required the police report to corroborate with the information provided by (V9). The police report revealed that (V9) was in possession of a card of medication that did not belong to her, but belonged to (R6), a resident within the facility. (R6) a resident within the facility. The medication that was noted in the police report had been discontinued in August, and the number of tablets noted was the same as the number that were noted as being destroyed. Indicating that no tables were missing. (R6) had no knowledge of missing medication, nor any complaints that he was not getting his medication. He noted to feel safe in the facility and would like to remain in the facility. Facility wide narcotic count was completed, and all narcotics were accounted for. Alert/orientated residents were interviewed and none voiced missing any medications or any concerns with medications being administrated. Conclusion: Based on the information obtained, it was confirmed that the medication in question or any concerns with medication destruction procedure. Facility wide narcotic count was completed, and all narcotics were accounted for. Alert/orientated residents were interviewed and none voiced missing any medications or any concerns with medications being administrated. All residents feeling safe in the facility and would like to remain. Conclusion: Based on the information obtained it was confirmed that the medication in question was prescribed to (R6), and that (V9) did not have authorization to possess or remove his medication. The medication that was removed was not an active order for (R6) and at current facility narcotic counts were accounted for with no residents having concerns of missing narcotics. (V9) was reported to the IDFPR. (V9's) employment was terminated due to not following proper policy and procedures, Licensed staff were in-serviced on narcotic destruction policy. The facility will assist local law enforcement with any further information that they may need. V9's Police Report dated 1/6/2026 documents, During our initial interaction, I immediately detected a strong odor consistent with an alcoholic beverage emanating from (V9's) breath, which became more pronounced as she spoke. In addition, I observed that her eyes were glassy and unfocused, and her speech was noticeably slurred and thick-tongued. While searching (V9's) vehicle, I observed several open alcohol containers on the passenger side floorboard and behind the passenger seat. These containers were photographed as evidence. Additionally, I located a cardboard sleeve inside the vehicle's center console containing 15 capsules of Alprazolam (FHPD Exhibit 1). The sleeve had the patient's name obscured with black marker. However, through the marker, I could partially make out the name (R6), indicating that the medication belonged to someone other than (V9). Given (V9s) earlier statement that she was a licensed nurse, I suspected that the medication was stolen, and it was seized as evidence. Further examination of the vehicle revealed a small black satchel positioned directly behind the driver's seat. Inside the satchel, I found a plastic bag containing four small blue pills, which were later identified as thyroid medication. There was also an unidentified white pill marked with G552. These pills could not be identified using conventional identification methods (FHPD Exhibit 2). The pills were also photographed and secured for evidence. On 8/6/2026 at 2:33 PM, V1 Administrator stated, We did have to terminate our former DON (V9) because she had a resident's narcotic card on her possession in her vehicle and no medication cards should ever leave the facility. On 8/7/2026 at 3:03 PM, V2, Director of Nursing (DON) stated no nurse should ever take any resident medication out of the facility. This allows the medication to not be accounted for, and opens the door for possible theft, which is what happened with our former DON (V9) who was terminated. She expects all staff to follow policy and when they sign their name as a witness then they witnessed the medication being destroyed. The Facility Abuse Policy dated 12/2/2025 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. This tag was corrected on 1/2/2026 Prior to the survey date, the facility took the following actions to correct the noncompliance. All nursing staff were in-serviced with the responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses or pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses or pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason. Never sign as a witness to the destruction of medications if you did not visibly witness the destruction. Never take someone's word for it or trust that another individual carried out the destruction in your absence. If you do so and medications are later missing, it is your word against theirs. The results of the auditions will be presented to the Quality Assurance Performance Improvement Committee by the Director of Nursing or designee or review and further recommendations as deemed necessary and we will continued to be monitor with audits.

Based on observation, interview and record review, the facility failed to document pressure ulcer treatments were administered per physician's orders twice a day and to reposition timely to promote healing of a pressure ulcer for 1 (R4) of 3 residents reviewed for pressure ulcers in the sample of 13. Findings include: R4's Undated Face Sheet, documents he was initially admitted to the facility on [DATE].R4's admission Minimum Data Set (MDS) dated [DATE] documents R4 was cognitively intact, three pressure ulcers.R4's Physician's Order Sheet (POS) dated 5/2026 cleanse sacrum wound with NS (normal saline), apply zinc barrier cream to periwound PRN (when needed), loosely pack wound bed with Dakin's moistened gauze and cover with dry clean dressing BID (two times a day) and PRN soiled every day and evening shift for wound healing. R4's Treatment Administration Record (TAR) dated 5/2026 no documentation sacrum pressure ulcer treatment was administered on evening shift on 5/2/2026, 5/17/2026 and on day shift on 5/3/2026, 5/15/2026 and 5/18/2026. R4's POS dated 5/2026 right heel cleanse wound with NS, apply Dakin's moistened gauze to wound bed and cover with ABD pad and gauze wrap BID every day and PRN every day and evening shift for wound healing. R4's TAR dated 5/2026 no documentation right heel pressure ulcer treatment was administered on evening shift on 5/17/2026 and day shift on 5/18/2026. On 5/21/2026 at 11:58 AM V11, Certified Nurse Assistant (CNA) and V12 CNA transferred R4 to his wheelchair using a Hoyer lift. On 5/21/2026 at 2:33 PM R4 was sitting up in his wheelchair in his room. R4 was alert and stated his pressure ulcer was hurting from sitting up but that staff told him he has to stay up in his wheelchair until at least 3:00 PM due to his family telling them he has to sit up that long. At that time R4 used his right arm to push against the right arm of his wheelchair and he attempted to reposition himself and he was grimacing at that time and said he was hurting badly. R4 pushed his call light and V13 CNA entered R4's room at 2:38 PM, promptly turned his call light off and asked him what he needs, R4 told V13 that he was hurting from sitting up since 12:00 PM and he wanted to lay down. V13 said OK and left R4's room. R4 sat up in his wheelchair and continued to attempt to reposition with facial grimacing and stated he feels like a kid because they make him stay up in his wheelchair which is demeaning to him. R4 stated he feels staff doesn't care that he is hurting and they won't assist him to bed until after 3:00 PM. On 5/21/2026 at 3:10 PM V14, CNA Supervisor and V13, CNA entered R4's room and transferred him to bed. V14 stated she was not aware that R4 wanted to lay down sooner than that and V13 stated she was told by staff that R4 has to stay up until 3:00 PM and so she didn't tell any staff that R4 wanted to lay down. On 5/26/10:20 AM V2, Director of Nurses (DON) stated R4 has chronic pressures on his sacrum and right heel, and he was admitted to the facility with them. V2 stated R4 recently had a family loss and his family wanted him to stay up 3-4 hours a day because he was getting depressed. When staff answer a resident's call light, she expects staff to respond to the resident's needs as soon as they enter the resident's room and definitely not enter the resident's room, turn the call light off and not assist the resident. V2 stated when R4 complained of buttocks/pressure ulcer is hurting due to the pressure from sitting up, she expected staff to immediately lay him down and even if his family wants him to stay up for 3 to 4 hours due to his depressed mood she expected staff to report R4 was complaining of increased pressure ulcer pain from sitting up and lay him down and she would let R4's family know why staff laid R4 down earlier than initially requested. R2 stated after nurses administer pressure ulcer treatments she expects the nurse to document the treatment was administered on resident's TAR and if staff don't document the treatment was administered then she can's say the treatment was administered she can't say staff are following physician's orders and she expects all staff to be following physician's orders and the facility's pressure ulcer policy as well. On 5/26/2026 at 11:45 AM V1, Administrator stated she is a nurse and stated if a resident has a pressure ulcer on their sacrum and the resident is left up for long periods of time the sacrum pressure ulcer could get worse due to the extended pressure from sitting up. The Facility's Wound Management Policy, reviewed 9/5/2025 documents per attending physician order, the nursing staff will initiate treatment and utilize intervention for pressure redistribution and wound management. A wound monitoring record will be completed for each wound.

Based on interview and record review the facility failed to ensure R8's batteries in alarm working, as identified as an intervention for falls for R8, for 1 of 5 residents (R8) reviewed for accidents in the sample of 67. This failure resulted in R8 falling and fracturing humerus. Prior to the survey date of 12/15/2025, the facility had taken the following action to correct the noncompliance:1 On December 2, 2025, the facility [NAME] President of Clinical Services reviewed the Fall evaluation and Prevention policy.2. On December 2, 2025, the Regional Nurse Consultant in-serviced the Facility Administrator, DON, ADON, MDS Coordinator were in-serviced on Fall Prevention Policy.3. On December 2, 2025, the Administrator/DON/ Designee Initiated In-service with front-line staff on Fall Prevention Policy and where to verify Care Plan Interventions. In-servicing ongoing. 4. On December 3, 2025, the DON/ADON/ CNA staffing coordinator initiated In-serviced Nursing staff on how to find care plan/fall interventions in EHR. Staff will not work next shift until Fall Prevention In-service is completed. In-servicing on going.5. On December 2, 2025, the RNC/RDO completed an initial audit of all falls from 4/8/25 to present to ensure current interventions are initiated and effective. Care plans will reflect interventions that are effective and/or within the last 90 days. Audits are ongoing.6. On December 2, 2025, the RNC/RDO/DON/ADON completed an initial audit of fall risk assessments to ensure that appropriate prevention interventions are in place & care plans are reflecting those interventions. Audits are ongoing.7. On December 2, 2025, the RDO implemented quality assurance tool. An audit will be completed 5x/week x 4 weeks during clinical meeting to ensure that any fall, has a root cause analysis, progressive intervention, and care plan is updated by the DON/ADON and on-going audit.8. On December 2, 2025, the Interdisciplinary Team initiated a root cause analysis for Fall Prevention and interventions being placed on care plan and physically in place will be reviewed weekly during Facility Risk Meeting x 4 weeks.Findings include:1. The facility long-term care facility serious injury incident and communicable disease report dated 7/9/2025 at 10:05AM documents nurse observed resident sitting on buttocks in front to the bathroom floor door with her walker flipped over in front of her. Report documents resident was assessed and complained of pain to her right arm, in house x-ray was obtained per dr order x-ray results on 7/9/2025 revealed acute humeral fracture documents investigation initiated per protocol, follow up will be sent. The facility long term care facility serious injury incident and communicable disease report dated 7/11/2025 documents Nurse Practitioner gave order to send resident to the emergency room for further evaluation. During emergency room evaluation R8 was diagnosed with Urinary Tract Infection (UTI) and Bradycardia. The report documents resident was interviewed prior to leaving for the ER. she stated she was on her way to the bathroom, could not recall why she was on the floor. The report documents in conclusion the Quality Assurance (QA) committee met and determined that the fall and fracture was a result of her R8's altered mental status. Intervention when R8 returned was to include educating her to ask for assistance to and from the bathroom and resuming Occupational Therapy (OT) and Physical Therapy (PT) for strengthening and safety awareness. R8's x-ray of Right humerus 2 plus views dated 7/8/2025 at 16:00pm documents acute humeral fracture. R8's facility unwitnessed fall report dated 7/8/2025 at 10:05 documents nurse observed resident sitting on buttocks in front of the bathroom door with walker in front of her tipped over, resident is alert and orientated, resident has hematoma to right wrist, resident bed alarm was plugged up but not sounding appropriately. nurse assessed resident with ROM to right arm and resident wasn't able to do ROM to R arm. Resident was assisted from floor to bed with a mechanical lift with assist of two. Report documents R8 stated that she was going to the bathroom, came out of bathroom and loss balance and stated that her arm was twisted and behind her. Report documents hematoma to back of Right hand. Report documents mental status oriented to person, place and time. The report documents predisposing environmental factor; fall alarm. The fall report documents predisposing physiological factor as gait imbalance. The report documents no statements found. R8's progress notes dated 7/9/2025 at 11:33AM documents incident note. Interdisciplinary Team (IDT) met to review resident's unwitnessed fall. Care plan reviewed and updated. Resident is at risk for fall related to uses a walker, weakness, paranoid schizophrenia, diabetes, depression, cardiac arrythmia, bipolar disorder, cardiac medications, antihypertensives, and psychotropic medication use. Current fall interventions include staff assisted resident in organizing her room and ensured the floor was free from clutter, informed to utilize call light for assistance for help for both her and roommate, removed ill-fitting shoes and replaced with non-slip socks, and resident to sit in shower chair for every shower. root cause for fall, alarm was not sounding. Intervention: staff to ensure that fall alarm has working batteries. R8's hospital H and P documents R8 was admitted to the hospital on [DATE] with bradycardia, right humeral fracture with non-op management, pain control and to continue immobilizer.R8's Minimum Data Set (MDS) dated [DATE] documents R8 is cognitively intact with a BIMS of 15. R8's MDS documents R8 requires partial to moderate assistance for personal hygiene, lower body dressing and sit to standing. On12/18/2025 at 1:24PM V19 Certified Nursing Assistant (CNA)stated she is not aware of any interventions in place for falls for R8.On 12/18/2025 at 2:31PM V2, Director of Nursing (DON) stated fall interventions should be in place for residents. V2 stated if a resident has an alarm in place staff should check to make sure batteries are working.On 12/19/2025 per telephone interview at 12:12PM V32, physician stated R8's fall resulting in a fractured humerus could have been prevented if R8's alarm had been sounding. V32 stated staff need to check batteries to ensure they are working. The facility Fall evaluation and prevention policy dated, reviewed 6/1/25 documents the purpose is to ensure 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 policy documents the goal is to prevent falls if possible and avoid any injury related to falls. The policy will evaluate residents for their fall risk and develop interventions for prevention. The policy documents the goal is to prevent fall if possible and avoid injury related to falls. The policy documents risk factor associated with aa fall are intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications. The following are examples of common intrinsic risk factors: gait and balance disorders, confusion, incontinence, Parkinson's disease, vision and hearing impairments, depression, seizure disorder, previous falls, certain medication classes such as: antipsychotics, sedatives and hypnotic, tricyclic antidepressants. The policy document the Interdisciplinary team (IDT) will review the plan of care and update the interventions as appropriate. The policy documents education of staff related to fall prevention documents providing a safe environment for residents, cause and risk factor for falls as well as the interventions to manage risk, safe transferring techniques, use of assistive devices, exercise programs to improve balance, gait and strength.

Based on interview and record review the facility failed to provide pain medication according to physician's order and effectively treat pain for 1 of 4 residents reviewed for pain management is a sample of 67. This failure resulted in R2 experiencing days of increase excruciating pain and feeling like no one cares.Findings include:1 R2's Electronic Health Record, not dated, documents admission date of 3/24/2025 and lists the following diagnosis: Peripheral Vascular Disease, Occlusion and Stenosis of bilateral Carotid arteries, Anxiety, Polyneuropathy, Dorsalgia, Weakness, Disease of the Spinal Cord, Chronic Pain, Spinal Stenosis, Cervical region, and Spondylolysis Lumbar Region.R2's Care Plan, dated 9/23/2025, documents that R1 has Acute Pain / Chronic Pain. It also documents interventions: Apply hot or cold packs for comfort. Determine Resident's satisfactory pain level. Establish a pain management treatment plan. Evaluate for non-verbal indicators of pain. Evaluate pain. Monitor for factors / activities that precipitate or aggravate pain. Utilize adaptive equipment as needed.R2's Minimum Data Set, dated [DATE], documents that R2 is cognitively intact. It also documents that R2 frequently experiences pain, and the pain interferes with day-to-day activities.R2's Administration Note, dated 11/27/2025 at 7:21 PM, documents that Orders-Note Text: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth four times a day for pain oos (Out of stock).R2's Administration Note, dated 11/28/2025 at 8:33 PM, documents that Orders - Note Text: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth four times a day for pain Medication unavailable.R2's Administration Note, dated 11/28/2025 at 11:30 PM, documents that Orders - Note Text: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth four times a day for pain Medication unavailable.R2's Health Status Note, dated 12/11/2025 at 1:55 PM, documents that Note Text: V32, Physician, in for rounds this day. rec'd order to increase his Norco from 5 mg to 7.5 mg. sent order to pharmacy for fill, requested pharmacy to send proper script to md office for fill out. will have previous order continue until new script is filled and delivered.R2's Administration Note, dated 12/13/2025 at 12:15 PM, documents that Orders - Note Text: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth four times a day for pain for 3 Days pain drug unavailable, MD notified of new script needed pharm aware.R2's Administration Note, dated 12/13/2025 8:18 PM Orders - Administration Note, Note Text: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth four times a day for pain for 3 Days pain This medication is unavailable at this time. Medication requires a new Rx per pharmacy. This nurse called on call provider and left a voice message informing the MD that medication requires a new Rx. Pending a reply.R2's Administration Note, dated 12/13/2025 8:24 PM, documents that Orders - Note Text: Tizanidine HCl Oral Tablet 2 MG Give 1 tablet by mouth in the evening for Pain Medication is currently unavailable at this time. Medication is not present in Pyxis to administer. Medication is on order at this time Pending delivery from pharmacy.R2's Administration Note, dated 12/14/2025 02:10 AM, documents that Orders - Note Text: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth four times a day for pain for 3 Days pain Still waiting for response in regards to pharmacy receiving new script for new dosage.R2's Administration Note, dated 12/14/2025 11:41 Orders - Administration Note, Note Text: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG Give 1 tablet by mouth four times a day for pain for 3 Days pain drug unavailable, talk to pharmacist states some will be delivered tonight.On 12/16/25 at 8:21 AM, V15, LPN, was observed giving R2 his morning medications when R2 told V15 that they changed his pain medication and now he seems to be in pain again. V15 stated she was off for five days and when she looked in R2's orders, she stated Yes, they did reduce his pain medicine. Why would they do that when he is still in pain. I will have to call and check on that.On 12/16/2025 at 11:20 AM R2 stated that he has severe pain. R2 stated that when he receives his pain medication the pain is manageable. R2 stated that the pain never goes away. R2 stated that they have been running out of his medication. R2 stated that just last week he had to sit in pain for days because they didn't have his medication. R2 stated that the pain is unbearable. R2 stated that he has migraines that feel like someone is tearing open his skull from the inside. R2 stated that the amount of pressure is unbearable. R2 stated that he injured his back years ago and the pain is overwhelming. R2 stated that when he is in that much pain he doesn't want to be bothered, easily irritated, and agitated with everyone even the people he likes. R2 stated that once the medication comes in it takes a long time to get the pain under control. R2 stated that he received an increase in his pain medication last week and have not received it yet. How am I supposed to live in that much pain. R2 stated that he has not had or been offered any ice packs. R2 stated that the nurses don't even ask him if he is in any pain. They don't ask. They don't care.On 12/22/2025 at 12:39 PM When asked why R2 hadn't received his Norco 7.5mg pain medication as prescribed on 12/11/2025. V2, Director of Nursing, stated that R2's Norco 7.5mg tablet was not available and R2 hadn't received his Norco 7.5mg because the pharmacy hadn't received a script. V2 then verified that R2 had not received his medication as prescribed. When asked why R2 had not received his Norco 5mg as prescribed on 11/27/2025, 11/28/2025, 11/29/2025, 12/13/2025 and 12/14/2025 V2 stated that there is no excuse for that because the nurses have access to the medication in the Nexus medication machine that's located in the medication room. V2 stated that the Norco is available in the medication machine. V2 stated that when a new or reorder for a narcotic is given the pharmacy is notified and a script is sent. V2 stated that the nurse is to follow up and verify the script was received by the pharmacy and the medication is then sent out. If the medication is not delivered the nurse is to follow up with the pharmacy. V2 stated that this process takes 24 to 48 hours. V2 stated that if a resident missed his dose of pain medication he would be in pain.On 12/23/2025 at 8:48 AM V33, Pharmacist stated that they received an order for R2's Norco 7.5mg. V33 stated that they had not received a script for this medication and was unable to send this medication out. V33 stated that they have requested the script from the provider by fax, phone and email without success. V33 stated that they have also contacted the facility and sent appropriate forms in attempt to get script. V33 stated that at this time R2's Norco has not been filled. V33 stated that they did receive a refill request on 12/14/2025 for Norco 5mg and due to having a script this medication was sent out. V33 stated from 12/11/2025 to 12/14/2025 the nexus system had not been accessed for R2. V33 stated that because of the class of medication the medication requires a code that is given by the pharmacy. The facility's Pain Management policy, dated 6/1/25, documents that Purpose: To ensure accurate assessment and management of the resident's pain. Policy 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. Procedure: II. Pain Management: A. The Licensed Nurse will administer pain medication as ordered, and document medication administered on the Medication Administration Record (MAR).

Based on interview, observation, and record review, the facility failed to administer medications according to the professional standards, including having a Licensed Nurse administer the medications, and ensuring the residents are taking their medications, for 2 of 4 residents (R2, R6) reviewed for medication errors in the sample of 67.The findings include: 1. R6's admission Record, dated 12/17/25, documents R6 was originally admitted to the facility on [DATE] with diagnosis of Malnutrition, Catatonic Schizophrenia, Anxiety Disorder, Hypertension (HTN), Dyskinesia, Falls, Type 2 Diabetes Mellitus (DM), Major Depressive Disorder, and Pneumonitis.R6's Care Plan, dated 3/3/25, documents R6 has Impaired Coping, has a Self-Care Deficit, Risk for Decreased Cardiac Output, Risk for Impaired Communication, Decreased Cardiac Output, Arrhythmia, Hypertension, Disturbed Sensory Perception: Audible/Visual, Malnutrition. It continues 12/1/25: R6 has a behavior problem related to catatonic schizophrenia, anxiety and depression. examples walking fast for hours without sitting down, attempts at grabbing items not belonging to him and walking up onto others quickly. Interventions: Administer medications as ordered. R6 has Diabetes Mellitus. R6 is on anticoagulant therapy related to atrial fibrillation. Interventions: Administer Anticoagulant medications as ordered by physician. R6 is on diuretic therapy. Interventions: Administer Diuretic medications as ordered by physician. R6 is on pain medication therapy. Interventions: Administer Analgesic medications as ordered by physician. R6 uses antidepressant medication related to Depression Diagnosis. Intervention: Administer Antidepressant medications as ordered by physician. R6 uses anti-anxiety medications. Intervention: Administer Anti-Anxiety medications as ordered by physician. R6 uses psychotropic medications. Intervention: Administer Psychotropic medications as ordered by physician. R6 has fluctuations in mood related to Catatonic Schizophrenia. Interventions: Administer medications as ordered.R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs).R6's Physician Order (PO), dated 12/16/25, documents May crush medication.R6's PO, dated 11/10/25, documents Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (milligram) Give 2 capsule by mouth one time a day for Anticonvulsants.R6's PO, dated 10/1/25, documents Austedo Oral Tablet (Deutetrabenazine) Give 6 MG by mouth every 12 hours for Psychosis.R6's PO, dated 9/30/25, documents Haloperidol Tab 5 MG Give 1 tablet by mouth two times a day for Schizophrenia.R6's PO, dated 2/10/25, documents Carvedilol Oral Tablet 3.125 MG Give 1 tablet by mouth two times a day for HTN Take with meals.R6's PO, dated 8/29/25, documents Furosemide Oral Tablet 20 MG Give 1 tablet by mouth two times a day for diuretic.R6's PO, dated 4/17/25, documents Hyoscyamine Sulfate Oral Tablet Disintegrating 0.125 MG Give 1 tablet by mouth every 4 hours as needed for secretions.R6's PO, dated 3/18/25, documents Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth four times a day.On 12/16/25 at 8:00 AM, V15, Licensed Practical Nurse (LPN), was observed administering medications to R6. V15 obtained all R6's medications from the medication cart. V15 crushed up all medications except for the Depakote capsules which were opened and put in with all the other crushed meds. V15 mixed the crushed medications with a spoonful of oatmeal. After mixing the medications in the oatmeal, V15 put the spoonful of oatmeal mixed with medications in the bowl of oatmeal and delivered it to R6's room where V16, Certified Nursing Assistant (CNA) was sitting assisting R6 with breakfast. V15 placed the bowl of oatmeal with the spoon of medications onto R6's breakfast tray and left the room. V16 attempted multiple times to feed R6 his oatmeal, not knowing that there were medications in the bowl, and each time R6 refused to eat the oatmeal. On 12/16/25 at 8:50 AM, V16, CNA, stated (R6) did not eat any of his oatmeal this morning. Someone came in and took his breakfast tray out of the room. R6 did not get any of his morning medications.R6's Incident Note, dated 12/16/25 at 9:21 AM, and documented on 12/17/25 at 8:22 AM by V2, Director of Nursing (DON), documents During medication administration it was identified that prescribed oral medications were crushed and mixed into oatmeal for consumption. Resident did not consume the medication mixed with the food as resident refused breakfast this AM. Nurse Practitioner (NP), DON notified, left message for Power of Attorney (POA) to notify. No return call back will continue to attempt.R6's Health Status Note, dated 12/16/25 at 1:44 PM, documents Resident continues on hospice services with care focused on comfort and safety. Resident remains on 1:1 supervision with 15-minute safety checks in place. During this shift, resident was noted to exhibit wandering behaviors, requiring continued close monitoring. Resident refused breakfast despite staff encouragement, verbally stating no. Later in the shift, resident accepted and consumed pudding cups and consumed approximately 50% of lunch. At the time of this note, resident is sitting in the small dining/TV room with staff in close proximity. No acute distress noted.On 12/17/25 at 8:45 AM, R6 seen in bed with V16, CNA, at bedside. R6 appears clean and dry and without odors. When asked if she ever gives a resident their medications, V16 stated No, I'm not licensed to give medications to a resident and would not do so. On 12/16/25 at 2:25 PM, V4, Assistant Director of Nursing (ADON), was advised of R6 not receiving his morning medications from V15, LPN. V4 stated Well, that would contribute to some of his behaviors lately.On 12/16/25 at 3:40 PM, V28, Nurse Practitioner (NP), stated I was not aware of (R6) not getting any of his medications today, only that he was having behaviors this morning and that was probably because he didn't sleep last night. I did stop (R6's) Eliquis, but I did not stop his Plavix or Aspirin. The Depakote DR Sprinkles I believe is approved to sprinkle over food and such, so it is ok for them to open the capsules. I'm not sure what to say about the CNA, but I would not expect the CNA to be given him his medications. (R6) has all his medications ordered and he should be getting them as ordered. If (R6) has missed multiple doses, that could contribute to behaviors.2. R2's admission Record, dated 12/17/25, documents R2 was admitted on [DATE] with diagnosis of Peripheral Vascular Disease (PVD), Stenosis of carotid arteries, HTN, Anxiety Disorder, Post-Traumatic Stress Disorder (PTSD), Polyneuropathy, Dorsalgia, Disease of spinal cord, Alcohol abuse, Depression, Generalized Anxiety Disorder, Major Depressive Disorder, Spondylolysis, and Spinal stenosis.R2's Care Plan, dated 9/23/25, documents R2 is at risk for Harm: Self Directed or Other-Directed, 11/13/25: R2 is/has potential to be verbally aggressive, 9/12/25: R2 has a behavior problem, resident has been verbally aggressive, Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness.R2's MDS, dated [DATE], documents R2 is cognitively intact and requires supervision/touching assistance for ADLs and transfers.R2's PO, dated 3/24/25, documents Calcium Carbonate Oral Tablet Chewable, Give 2 tablet by mouth in the morning.On 12/16/25 at 8:21 AM, V15, LPN, gave R24 his medications in one medicine cup with his Calcium Carbonate tablets in another cup. V15 left the Calcium Carbonate sitting on his bedside table and stated, He will take that when he wants to. and left the room.On 12/23/25 at 8:20 AM, V23, LPN, stated When passing meds, I make sure the resident takes them before I leave the room and would never leave them for a CNA to give them to the resident.On 12/23/25 at 8:25 AM, V17, LPN, stated I stand by the resident to make sure they take the medication and don't choke on them. I would not leave them with a CNA for them to give to the resident.On 12/23/25 at 8:35 AM, V15, LPN, stated I always watch the resident take their meds and would never leave the meds with a CNA for them to give to the resident.On 12/23/25 at 9:20 AM, V2, Director of Nursing (DON), stated I would expect the nurses to stand by the resident and ensure the resident takes all their medications. They should never leave the medications with a CNA or at the resident's bedside.The Facility's Medication Administration Policy, dated 6/1/25, documents in part Medications will be administered by a Licensed Nurse per the order of Attending Physician or licensed independent practitioner or as consistent with state law. III. Medications must be given to the resident by the Licensed Nurse to prepare the medication, to as consistent with state law. V. Medications may be administered one hour before or after the scheduled medication administration time. VIII. Medications will not be left at bedside. IX. If the attending physician increases or changes a medication order, this is an automatic stop or discontinue order for the original order. Procedure: VIII. Compare the licensed practitioner's prescription/order with MAR (Medication Administration Record) (first check). XV. Administer the medication to the resident. XVI. The licensed nurse will remain with the resident until the medicine is actually swallowed.

Based on observation and interview, the facility failed to have the State Inspection report readily available for residents to read without asking. This had the potential to affect the 78 residents who resided in the facility.Finding includes:On 12/17/2025 at 1:30 PM a resident council meeting occurred. During the meeting R66, R57, R12, and R15 stated that they did not know where the inspection book was located or that they could look at it. When informed that the survey book is in the front lobby, R66, R57, R12, and R15 stated that they can't go to the lobby without permission.On 12/17/2025 at 1:40 PM R66 stated that the staff do not let you go to the lobby. R66 stated that the staff must put the code in. R66 stated that if you go through it and the alarm goes off, they chase you down like a criminal.R66's Fall Risk Evaluation, dated 12/2/2025, documents that R66 is alert and oriented x3.On 12/17/2025 at 1:41 PM R57 stated that the staff do not allow them in the lobby unless they are leaving the facility. R57 stated that if anything is in the lobby they wouldn't know about it and would not have access to it. R57 stated that there is an alarm on the door.R57's Minimum Data Set (MDS), dated [DATE], documents that R57 is cognitively intact.On 12/16/2025 at 2:03 PM V16, CNA, stated that residents do not go out in the lobby without staff. V16 stated that the staff must let them out to the lobby. On 12/17/2025 at 1:43 PM R12 stated that he does not know where the inspection book is and doesn't know how to find it. R12 stated that they guard the lobby with their life.R12's MDS, dated [DATE], documents that R12 is cognitively intact.On 12/17/2025 at 1:45 PM R15 stated that she is the president of resident council. R15 stated that they don't have access to the lobby without staff permission and help due to the door alarm.On 12/17/2025 at 11:27 AM V1, Administrator, stated that the facility does not have a policy for the survey book. V1 stated that they follow the Guidelines.The facility's Resident Rights policy, dated 6/1/25, documents that the resident has the right to Examine survey results.The Department of Health and Human Services Centers for Medicare and Medicaid Services Long-Term Facility Application for Medicare and Medicaid Form, dated 12/15/2025, documents 78 residents residing in the facility.

Based on interview, observation, and record review, the facility failed to staff a Registered Nurse (RN) for eight hours per day, seven days a week for October, November, and December of 2025. This failure has the potential to affect all 78 residents residing in the facility.The findings include:On 12/15/25 at 8:30 AM, upon entering the facility and each day of the survey, there were three Licensed Practical Nurse (LPNs) working and no RNs.On 12/22/25 at 9:13 AM, V4, Assistant Director of Nursing (ADON), stated No, we don't have any RNs on our schedule, and I am an LPN. When asked about the one RN listed on the December schedule, V4 stated I don't even know who that is. On 12/22/25 at 9:15 AM, When asked about no RNs working in the facility, V1, Regional Administrator/Director of Operations, stated I believe that is correct, there are no RNs working here.On 12/22/255 at 9:17 AM, V2, Director of Nursing (DON), stated We don't have any RNs on our schedule except for one PRN (as needed) Nurse, and she hasn't worked in a while. I did hire one, but she has not started yet.A review of the nurse schedule for the past three months, documents in October 2025, there were two RNs on the schedule with a total of three days worked. The November nurse schedule documents no RNs on the schedule the entire month. The December nurse schedule, documents one RN on the schedule and she has not worked any shifts.On 12/22/25, V1 stated This is the only policy we have on staffing. We do not have one that covers RN's or the daily posting of staff. The Facility's Staffing Policy, undated, documents It is the policy of (Facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. The division of nursing needs by shift will be calculated based on the resident census and needs. 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. RNs are required to be licensed by the State in which they are practicing. Copies of current licenses shall be displayed in the facility.The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 12/15/25, documents 78 residents reside in the facility.

Based on interview, observation, and record review, the facility failed to post the nurse staffing data daily at the beginning of each shift. This failure has the potential to affect all 78 residents residing in the facility.The findings include:On 12/15/25 at 8:30 AM, upon entering the facility and each day of the survey, there was no posting of the facility staffing found anywhere in the facility.On 12/22/25 at 9:15 AM, When asked about posting of staffing daily, V1, Regional Administrator/Director of Operations, stated They have not been doing that here.On 12/22/255 at 9:17 AM, When asked about posting of staffing for public to see, V2, Director of Nursing (DON), stated We haven't been doing that.On 12/22/25, V1 stated This is the only policy we have on staffing. We do not have one that covers RN's or the daily posting of staff. The Facility's Staffing Policy, undated, documents It is the policy of (Facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. The division of nursing needs by shift will be calculated based on the resident census and needs. 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. RNs are required to be licensed by the State in which they are practicing. Copies of current licenses shall be displayed in the facility. The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 12/15/25, documents 78 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to properly store, label, and discard expired medication. This has the potential to affect all 78 residents residing in the facility.Findings include:On 12/16/2025 at 8:12 AM the 200 Hall Medication room was inspected. In the refrigerator located in the medication room contained: 1. 1 clear plastic with R41's Bisacodyl 10mg suppository with expiration date 7/31/2025. The clear bag contained 20 suppositories. 2. 1 open and partially used multidose vial of Tuberculin. No open date. The Tuberculin box documents house stock. The Tuberculin (Aplisol) Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. On 12/16/2025 at 8:19 AM V14, Licensed Practical Nurse (LPN), verified that R41's suppositories were expired and should have been removed from use, destroyed, and reordered. V14 stated that R41 does have a current order for the bisacodyl 10mg. V14 stated that the tuberculin multidose vial was open and in use. V14 stated that the multidose vial should have an open date on the box or the vial. V14 stated that this is done at the time that the vial is accessed for the first time. V14 stated that Tuberculin has a shorter expiration and use by date once open. V14 stated that placing the open date on the vial or box is how they make sure the medication is not used passed the use by or new expiration date. V14 verified that there was not an open date, or any date written on the box or vial. On 12/16/2025 at 9:00 AM the 100/300 Hall Medication Room was inspected. The refrigerator located inside the medication room contained: 3. Bisacodyl 10mg suppositories. 6 Bisacodyl 10mg suppositories with expiration date 7/2023 and 10 Bisacodyl 10mg suppositories with expiration date 8/2024. 4. Acetaminophen 650 mg suppositories. 4 Acetaminophen 650 mg suppositories with expiration date 7/2024, 11 Acetaminophen 650 mg suppositories with expiration date 9/2025, and 3 Acetaminophen 650 mg suppositories with expiration date 8/2025. 5. 1 open and partially used multidose vial of Tuberculin. No open date. On 12/16/2025 9:07 AM V17, Licensed Practical Nurse (LPN), stated that the Bisacodyl suppositories and the Tuberculin are stock medications. V17 stated that these medications are for stock medications and are used for every resident as long as they have an order. 6. R85's package of 8 Acetaminophen 650 mg suppositories with discard date 10/18/2025, and expiration date November 2025 on label. R85's EHR documents that R85 was discharged from the facility on 3/26/2025. 7. On 12/16/25 at 8:28 AM, V15, LPN, prepared to administer Lispro Insulin 2units to R55. V15 drew up the Insulin in a syringe and set it on the cart. When asked about the date of 10/2/25 that was written on the box of Insulin, V15 stated that is when it was opened. V15 then checked the actual label, and the insulin was dispensed to the facility on [DATE] and V15 then stated, I don't know why anyone would write that date on there because it was before we even got it. When asked how long the Insulin was good for once opened, V15 stated It's good for 30-days. I guess I should throw this one away. V15 threw that bottle of Insulin and the syringe out and obtained a new bottle from the med room. If not questioned, V15 was prepared to administer the expired Insulin to R55. On 12/23/25 at 8:20 AM, V23, LPN, stated If I find any medications that are expired, I will remove it from the cart and obtain a new bottle and would not give the expired med to the resident. On 12/23/25 at 8:25 AM, V17, LPN, stated If I find an expired medication, I will dispose of the med and get another one and would not give it to the resident. On 12/23/25 at 8:35 AM, V15, LPN, stated Anytime I find expired medications, I dispose of it and will get another bottle. I check the resident cards weekly for anything expired and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) checks the carts for expired bottles. On 12/23/25 at 9:20 AM, V2, DON, stated I would expect staff to properly dispose of contaminated linen and not throw them on the floor. Me and the ADON do check the med carts monthly and if a nurse finds something expired, they should bring it to us, and we will dispose of it and make sure they have a replacement. The Facility's Medication Storage policy, dated 8/1/25, documents that Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles. 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 or returned to the supplier. 5.Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 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 all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law. 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.

Based on observation, interview and record review the facility failed to properly store, label and date opened food. This failure has the potential to affect all 78 residents at the facility.Findings include:On 12/15/2025 at 8:50AM during the initial tour of the kitchen; dry storage room floor has case of [NAME] choice diced pears in box on the floor. The walk-in refrigerator inside door on the shelf on right has opened carton of traditional scrambled egg mix. There is no date on the carton identifying when the scrambled egg mix was opened. On another shelf 2 separate clear containers with green lids contained noodle in broth. The 2 containers were not labeled or dated, a metal container with metal lid contained cooked cereal, no label or date on container, metal container of sliced tomatoes covered with clear wrap, unlabeled, and not dated, metal container of sliced onions covered with clear wrap unlabeled and undated, opened bottle of thick and easy thickened orange juice with half of orange juice out of container is not dated. In the walk-in freezer Box with plastic bag of mixed vegetables on shelf in freezer, plastic bag open .box labeled white fully cooked diced chicken 3/8 inch has plastic bag containing chicken has been opened, not sealed or dated. The Central Management Services (CMS) 671 Long Term Care Facility Application for Medicare and Medicaid dated 12/15/2025 documents a census of 78. On 12/17/2025 at 11:15AM V9 dietary manager stated all opened food in the freezer and refrigerator should be labeled and food should not be stored on the floor. The facility policy Storing, food storage, undated documents food should be stored and prepared in a clean safe sanitary manner that complies with state and federal guidelines. The policy documents food is stored at least 6 inches from the floor. The policy documents all food not in original containers should be labeled and dated. The policy documents food should be labeled and dated to monitor food safety.

Based on interview and record review the facility failed to answer call lights timely for 4 of 24 (R12, R15, R57, R66) residents reviewed for call lights in a sample of 67.Findings include:1. The facility Resident Council Minutes, dated October 15, 2025, July 16, 2025, and May 21, 2025, document concerns about call lights not being answered in a timely manner and staff turning off call lights.2. On 12/17/2025 at 1:40 PM R66 stated that the staff do not answer the call lights. R66 stated that the staff are no where to be found. R66 stated that it's horrible. R66's Fall Risk Evaluation, dated 12/2/2025, documents that R66 is alert and oriented x3. 3. On 12/17/2025 at 1:41 PM R57 stated that the staff do not answer the call lights timely if they answer them at all. R57 stated that you must go and find someone to help you and they may come or not. R57's Minimum Data Set (MDS), dated [DATE], documents that R57 is cognitively intact. 4. On 12/17/2025 at 1:43 PM R12 stated that the staff do not answer the call lights timely if they answer them at all. R12 stated that they are either wrapped in blankets sleep or they are sitting in the TV room. R12 stated that they do not answer the lights. How do you get help.R12's MDS, dated [DATE], documents that R12 is cognitively intact. 5. On 12/17/2025 at 1:45 PM R15 stated that she is the president of resident council. R15 stated that the staff do not answer the call lights timely if they answer them at all. R15 stated that the staff will also come in the room turn the light off and never return. R15's MDS, dated [DATE], documents that R15 is cognitively intact.On 12/18/2025 at 9:16 AM V25, Certified Nurse's Assistant (CNA), stated that it is everyone's responsibility to answer a call light. V25 stated that the call lights should be answered timely and this is about 3 minutes of the light coming on.On 12/18/2025 at 9:18 AM V15, Licensed Practical Nurse (LPN), stated that it is everyone's responsibility to answer call lights. V15 stated that it shouldn't take longer than 5 minutes to answer the call light. V15 stated that the older staff do turn the call lights off. V15 stated that she would expect the staff to return within 10 minutes to perform the care. V15 stated that newer CNAs leave the call light on as a reminder to return.The facility's Call Light policy, not dated, documents Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. 4.Requests shall be responded to in a courteous and professional manner.The Residents' Rights for People in Long-term Care Facilities Booklet, dated 10/20, documents that Your -facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on record review and interview the facility failed to provide activities for 5 of 5 (R2, R12, R15, R57, R66) residents reviewed for activities in the facility in a sample of 67. Findings include:1 On 12/16/2025 at 11:25 AM R2 stated that there are no activities. Nothing. Just bingo. But what about the people that don't like bingo. I'm bored out of my mind. R2 stated that there is no activity person. So no activities.On 12/17/2025 at 1:30 PM a resident council meeting occurred. During the meeting R66, R57, R12, and R15 stated that they don't have any activities at the facility. R66, R57, R12, and R15 stated that they are bored there is nothing to do.2. On 12/17/2025 at 1:40 PM R66 stated that there are no activities. R66 stated that there is nothing to do. R66 stated that when you get bored you start doing your own thing and that isn't always good.R66's Fall Risk Evaluation, dated 12/2/2025, documents that R66 is alert and oriented x3.3. On 12/17/2025 at 1:41 PM R57 stated that there isn't anything to do around here. R57 stated that since the activity person got sick and quit there hasn't been any the activities. R57 stated that they had another and she didn't stay long. R57 stated that she didn't do any activities. R57 stated that she walks around sometimes but there is nothing to do.R57's Minimum Data Set (MDS), dated [DATE], documents that R57 is cognitively intact.4. On 12/17/2025 at 1:43 PM R12 stated that he is bored at the facility. R12 stated that there are no activities at all.R12's MDS, dated [DATE], documents that R12 is cognitively intact.5. On 12/17/2025 at 1:45 PM R15 stated that they cut out the bingo. R15 stated that since the activity person left, they have not had any consistent activities. R15 stated that they don't have a calendar with the activities on them or nothing.During investigation from 12/15/2025 to12/18/2025 from 8AM to 3PM no activities were observed.On 12/18/2025 at 1:19 PM observed December Activity Calendar on the hall wall.On 12/18/2025 at 1:20 PM When asked where are the activities, listed on the Activity Calendar, occurring V1 stated that the activities are usually done in the dining room. V1 stated that they are not occurring because they do not currently have an activity person. V1 stated that they are actively recruiting and hiring at this time.The facility's Activities Program, dated 12/1/25, documents Purpose: To provide an ongoing program of activities designed to appeal to the residents' interests and to enhance his or her highest practicable level of physical, mental, and psychosocial well-being. Guidelines: The Activity Director, trained staff, or volunteer will: 1. identify and involve each resident in an ongoing program of activities that is designed to appeal to his or her interests and needs. 2.Enhance the resident's highest practicable level of physical, mental, and psychosocial well-being by offering a program of activities that provides the following: a. A heightened sense of well-being b. Promotion of feelings of self-esteem, pleasure, comfort, education, creativity, success, and independence c. That promotes educational or intellectual thought and requires thinking d. Age and gender-specific e. Produce something useful and provide purpose f. Relate to previous work g. Allow for socializing with visitors and participating in community events h. Allow for opportunities for creativity and creative expression i. Physically active programming j. Produce or teach something k. Religious activities l. Opportunities for activities that contribute to the facility 3. A minimum of 4-7 organized activities will be scheduled daily. 4. Provide programs for residents who will not, or cannot, effectively plan their own activity pursuits. 5. Provide for residents needing specialized or extended programs to enhance their overall daily routine and activity pursuit needs. 6. The program of activities will include a combination of large and small groups, one to one's, and self-directed activities. 7. The program of activities will include a system that allows the activity staff to develop, implement, and evaluate the resident's interests and involvement in the activities provided and adjust the daily programming as needed in order to meet the needs of the residents.

Based on interview, observation, and record review, the facility failed to change and date humidified Oxygen (O2) water bottles for 4 of 4 residents (R1, R3, R36, R48) reviewed for respiratory care in the sample of 67.The findings include:1. R36's admission Record, dated 12/16/25, documents R36 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Atherosclerotic Heart Disease (ASHD), Major Depressive Disorder, Schizophrenia, Hypertension (HTN), and Mutism.R36's Care Plan, dated 11/19/25, documents R36 has oxygen therapy related to COPD and SOB (shortness of breath), has Emphysema/COPD. 11/24/25: R36 has asthma, and shortness of breath. Interventions: Give medications as ordered, monitor/document side effects and effectiveness, give nebulizer treatments and oxygen therapy as ordered. Oxygen Settings: O2 via nasal cannula (NC) at 2 L (liters).R36's Minimum Data Set (MDS), dated [DATE], documents R36 has a moderate cognitive impairment and requires supervision/touching assistance for Activities of Daily Living (ADLs) and transfers. Section I: Active Diagnosis Debility, Cardiorespiratory Condition. Section O: Special Treatments - Respiratory Treatments: Oxygen Therapy.On 12/15/25 at 10:00 AM, R36 had an oxygen concentrator in his room with the humidified water bottle dated 11/24/25.On 12/17/25 at 9:50 AM, R36 in his room sitting in wheelchair, water bottle still dated 11/24/25. R36 stated he only uses that when he needs it.R36's Physician Order (PO), dated 8/8/25, documents Oxygen 2L/NC Continuous/PRN (as needed), may titrate to keep SPO2 (oxygen saturation) above 90% as needed.R36's PO, dated 8/8/25, documents Humidification with oxygen, one time a day every Sunday and as needed. R36's PO, dated 8/8/25, documents Change oxygen tubing, one time a day every Sunday. R36's MAR (Medication Administration Record) - TAR (Treatment Administration Record), dated December 2025, documents Change oxygen tubing one time a day every Sunday. This was documented as completed on 12/7/25 and 12/14/25. R36's MAR-TAR, dated December 2025, documents Humidification with oxygen one time a day every Sunday. This was documented as completed on 12/7/25 and 12/14/25. 2. R48's admission Record, dated 12/16/25, documents R48 was admitted to the facility on [DATE] with diagnosis of COPD, Type 2 Diabetes Mellitus (DM) chronic kidney disease (CKD), Atrial Fibrillation, HTN, and Neuropathy.R48's Care Plan, dated 7/2/25, documents R48 has COPD with interventions: Oxygen Settings: O2 via nasal prongs at 2 L continuously. R48 has shortness of breath (SOB) related to COPD and Congestive Heart Failure (CHF).R48's MDS, dated [DATE], documents R48 is cognitively intact and requires supervision/touching assistance for ADLs and transfers. Section I: Active Diagnosis Debility, Cardiorespiratory Condition. O: Special Treatments - Respiratory Treatments: Oxygen Therapy.On 12/15/25 at 10:09 AM, R48 was observed on O2 at 2 L/NC with the humidified water bottle undated.On 12/17/25 at 9:54 AM, R48 was observed on O2 at 2 L/NC with bottle still undated. R48's PO, dated 2/3/25, documents O2 at 2l/NC to maintain SpO2 90% or above, every shift for monitoring.R48's PO, dated 1/22/25, documents Change O2 Humidity every 3 days and PRN, one time a day every 3 days related to COPD.R48's PO, dated 1/22/25, documents Change O2 tubing every 6 days, one time a day every 6 days related to COPD.R48's MAR-TAR, dated December 2025, documents Change O2 Humidity every 3 days and PRN, one time a day every 3 days. This was documented as completed on 12/1/25, !2/4/25, 12/7/25, 12/10/25, 12/13/25, and 12/16/25.R48's MAR-TAR, dated December 2025, documents Change O2 tubing every 6 days, one time a day every 6 days. This was documented as completed on 12/1/25, 12/7/25, and 12/13/25. 3. R3's admission Record, dated 12/16/25, documents R3 was admitted to the facility on [DATE] with diagnosis of COPD, Chronic Kidney Disease, Hepatitis C, Pulmonary Nodule, Abdominal Aortic Aneurysm (AAA), Transient Cerebral Ischemic Attack (TIA), Depression, HTN, CHR, Pneumonia, Anemia, and Atrial Fibrillation.R3's Care Plan, dated 1/20/25, documents R3 has Ineffective Airway Clearance. Intervention: Provide oxygen as indicated by Resident condition and / or provider order. It continues R3 is at risk for COPD Complication.R3's MDS, dated [DATE], documents R3 is cognitively intact and requires supervision/touching assistance for ADL. Section I: Active Diagnosis: Debility, Cardiorespiratory Condition. Section O: Special Treatments - Respiratory Treatments: Oxygen Therapy.On 12/15/25 at 11:00 AM, R3 sitting on side of his bed on oxygen at 3L NC with the humidified water bottle undated. Nebulizer on table with mask sitting on it and not in bag.On 12/17/25 at 9:45 AM, R3 sitting in wheelchair in his room, on oxygen at 2 L/NC with humidified water bottle undated with approximately half full.R3's PO, dated 2/3/25, documents Oxygen at 2L/NC maintain SpO2 at 92 or above every shift for monitoring.R3's PO, dated 2/3/25, documents Change oxygen humidity bottle Q (every) 3 days and as needed, every night shift, every 3 days related to COPD.R3's MAR-TAR, dated December 2025, documents Change Nasal Cannula Q (every) week and as needed, every night shift, every Tuesday. This was documented as completed on 12/2/25, 12/9/25, and 12/16/25. R3's MAR-TAR, dated December 2025, documents Change Oxygen Humidity Bottle Q 3 days and as needed, every night shift, every 3 days. This was documented as completed on 12/3/25, 12/6/25, 12/9/25, 12/12/25, and 12/15/25. 4. R1's admission Record, dated 12/16/25, documents R1 was admitted to the facility on [DATE] with diagnosis of Dyspnea, Dependence on Oxygen, Type 2 DM, Dementia, Anemia, HTN, Hallucinations, and Psychotic Disorder.R1's Care Plan, dated 1/20/25, documents R1 has an Impaired Gas Exchange. Intervention: Administer oxygen as prescribed or per standing order. R1 is at risk for Ineffective Airway Clearance. Intervention: Utilize humidity (humidified oxygen or humidifier). It continues R1 has SOB related to dyspnea. R1's MDS, dated [DATE], documents R1 has a severe cognitive impairment and is dependent on staff for ADLs. Section O: Special Treatments - Respiratory Treatments: Oxygen Therapy.On 12/15/25 at 11:10 AM, R1 lying in bed on O2 at 3L/NC with the humidified water bottle dated 11/29/25.On 12/17/25 at 9:40 AM, R1 lying in bed on oxygen running at 2 L/NC with humidified water bottle dated 11/29/25.R1's PO, dated 1/31/25, documents Oxygen at 2L/NC, every shift.R1's PO, dated 2/3/25, documents Maintain SpO2 90% or above, every shift, related to Dyspnea.R1's PO, dated 1/15/25, documents Change Oxygen Humidified Bottle every 3 days and PRN, every 72 hours related to Dependence on Supplemental Oxygen.R1's PO, dated 1/15/25, documents Change O2 Tubing every 6 days and PRN, every night shift, every 6 days, related to Dependence on Supplemental Oxygen.R1's MAR-TAR, dated December 2025, documents Change O2 Tubing every 6 days and PRN, every night shift, every 6 days. This is documented as completed on 12/5/25, and 12/11/25.R1's MAR-TAR, dated December 2025, documents Change Oxygen Humidified Bottle every 3 days and PRN, every 72 hours. This is documented as completed on 12/2/25, 12/5/25, 12/11/25, and 12/14/25. On 12/23/25 at 8:20 AM, V23, Licensed Practical Nurse (LPN), stated The nurses are responsible for changing the O2 cannulas and water bottle. It will pop up on the MAR-TAR when it is due to be changed.On 12/23/25 at 8:25 AM, V17, LPN, stated Nurses change the oxygen water bottles and cannulas, it will pop up on the MAR-TAR for us to do. I always check it off and will walk up and down the hall changing them.On 12/23/25 at 8:35 AM, V15, LPN, stated Oxygen water bottles and cannulas are changed by the nurses every Sunday and PRN. I usually don't work the 3rd shift so don't change them, they're supposed to be doing that.On 12/23/25 at 9:20 AM, V2, Director of Nursing (DON), stated I would expect the nurses to be changing the oxygen water bottles weekly as indicated on the MAR-TAR and not just sign them off as completed.The Facility's Oxygen Administration Policy, dated 8/1/25, documents in part Infection Control: A. All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: i) are for single resident use only. ii) will be changed weekly and when visibly soiled, or as indicated by state regulation. B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.

Based on record review and interview the facility failed to provide activities for 4 of 4 (R1, R16, R25, R34) residents reviewed for treatment and services for dementia residents in the facility in a sample of 67. Findings include:1. R16's admission Record, print date 12/17/2025, documents admission date of 1/17/2025 and lists dementia with anxiety as diagnosis.R16's Care Plan, dated 11/26/25, documents that R16 is an elopement risk/wanderer r/t (related to) disoriented to place, resident wanders aimlessly. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers:On 12/15/2025 at 11:25 R16 observed sitting in room with head down. R16 stated that he is not invited to any activities but would go if there were any. 2. R1's admission Record, print date 12/16/2025, documents admission date of 12/1/2024 and lists unspecified dementia, severe with psychotic disturbances as diagnosis.R1's Care Plan, dated 1/20/25, documents that R1 has Impaired Social Interaction. Interventions: Consult facility activities coordinator. Provide positive enforcement when Resident participates in activities.3. R25's admission Record, print date 12/17/2025, documents admission date of 12/1/2024 and lists dementia as diagnosis.R25's Care Plan, dated 2/25/2025 documents that R25 has Impaired Social Interaction. Intervention: Consult facility activities coordinator. Encourage Resident to participate in recreational activities.4. R34's admission Record, print date 12/17/2025, documents admission date of 8/18/25 and lists dementia with psychotic disturbances as diagnosis.R34's Care Plan, dated 9/12/25, documents that R34 has Impaired Social Interaction. Interventions: Consult facility activities coordinator. Encourage Resident to participate in social situations. Provide positive enforcement when Resident participates in activities.On 12/17/2025 at 1:30 PM a resident council meeting occurred. During the meeting R66, R57, R12, and R15 stated that they don't have any activities at the facility. R66, R57, R12, and R15 stated that they are bored there is nothing to do.On 12/17/2025 at 1:41 PM R57 stated that there isn't anything to do around here. R57 stated that since the activity person got sick and quit there hasn't been any the activities. R57 stated that they had another and she didn't stay long. R57 stated that she didn't do any activities. R57 stated that she walks around sometimes but there is nothing to do.R57's Minimum Data Set (MDS), dated [DATE], documents that R57 is cognitively intact.On 12/17/2025 at 1:43 PM R12 stated that he is bored at the facility. R12 stated that no activities at all.R12's MDS, dated [DATE], documents that R12 is cognitively intact.On 12/17/2025 at 1:45 PM R15 stated that she is the president of resident council. R15 stated that they cut out the bingo. R15 stated that since the activity person left, they have not had any consistent activities. R15 stated that they don't have a calendar with the activities on them nothing.During investigation from 12/15/2025 to 12/18/2025 from 8AM to 3PM no activities were observed.On 12/18/2025 at 1:19 PM observed December Activity Calendar on the hall wall.On 12/18/2025 at 1:20 PM When asked where the activities are, listed on the Activity Calendar, occurring V1 stated that the activities are usually done in the dining room. V1 stated that they are not occurring because they do not currently have an activity person. V1 stated that they are actively recruiting and hiring at this time.The facility's Activities Program policy, dated 12/1/2025, documents that Purpose: To provide an ongoing program of activities designed to appeal to the residents' interests and to enhance his or her highest practicable level of physical, mental, and psychosocial well-being. Guidelines: The Activity Director, trained staff, or volunteer will: 1. ldentify and involve each resident in an ongoing program of activities that is designed to appeal to his or her interests and needs. 2.Enhancethe resident's highest practicable level of physical, mental, and psychosocial well-being by offering a program of activities that provides the following: 3. A minimum of 4-7 organized activities will be scheduled daily. 4. Provide programs for residents who will not, or cannot, effectively plan their own activity pursuits. 5. Provide for residents needing specialized or extended programs to enhance their overall daily routine and activity pursuit needs. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs.

Based on interview and record review, the facility failed to complete a medication review for 1 of 1 resident (R8) reviewed for medications in the sample of 67.R8's Note to attending physician/prescriber dated, printed 7/26/2025 documents consider a gradual dose reduction for the following medication Buspirone 10mg daily. R8's Note to attending physician/prescriber fails to document physician review or signature. R8's Note to attending physician/prescriber dated, printed 8/27/25 documents consider a gradual dose reduction for the following medication: Sertraline 100mg daily the sheet fails to document physician review or signature as sheet is blank. R8's physician order dated 12/18/2025 documents Sertraline 100mg daily, Buspirone 10mg daily. R8's face sheet dated 12/17/2025 documents R8 has a diagnosis of paranoid schizophrenia, major depressive disorder and bipolar disorder, current episode manic without psychotic features. On 12/17/2025 at 11:44AM, V2 Director of Nursing (DON) stated by looking at the blank note to attending physician for consideration of medication reduction, they were not done. The facility policy Medication Regiment Review, undated documents in performing medication regimen reviews, the consultant pharmacist incorporates federally mandated standards of care, in addition, to other applicable standards, such as the American Society of Consultant Pharmacists Practice standard and clinical standards. The policy documents recommendations are acted upon and documented by the facility staff and or the prescriber. The policy documents the physician accepts and acts upon suggestion or rejects and provides explanation for disagreeing

Based on interview, observation, and record review, the facility failed to perform appropriate hand hygiene when assisting resident with feedings, when performing wound care, and then proper disposal of contaminated linen for 4 of 12 residents (R6, R11, R63, R77) reviewed for infection control practices in the sample of 67.Findings include:1. On 12/15/25 at 12:15 PM, during lunch observation, R6 was seen sitting in the dining room getting feeding assistance from V11, Certified Nursing Assistant (CNA). V11 was seen getting up, assisting other residents, walking to the kitchen and leaving R6 at the table by himself, picking up lunch trays and putting on cart, then sitting back with R6 to assist in feeding him again, all with no hand hygiene seen done before, during, or after assistance given. 2. On 12/15/25 at 10:50 AM, R63 had a contact isolation sign on the wall outside her door. V10, CNA, was performing peri-care on R63 with a gown, mask, and gloves on. V10 had thrown all the soiled linen and wet brief soaked in urine onto the floor. Upon entrance to the room, V10 then picked up the linen and put it in isolation container in room. There was a bottle of peri-cleaner and a roll of trash bags on the floor where the soiled linen was thrown. V10 picked up the bottle and trash bags and placed on the side table. V10 used the same soiled gloves while handling clean linen and other items in the room. R63 stated she is on isolation and not able to leave her room due to a bad infection. R63 has diagnosis of UTI/ESBL (Urinary Tract Infection/Extended-Spectrum Beta-Lactamases). R63's Care Plan, dated 11/24/25, documents R63 is on antibiotic therapy for ESBL, Macrobid 100 MG (milligram) PO (oral) BID (twice daily) x 10 days until 12/03/25, isolation precautions set up outside of room. R63's Order Note, dated 12/16/25 at 7:37 AM, documents Results rec'd (received) for UA (urinalysis) C/S (culture/sensitivity) notified NP (Nurse Practitioner) with orders for the following: Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for ESBL for 10 days. R63's Health Status Report, dated 12/17/25 at 9:29 PM, documents Resident on Macrobid r/t (related to) ESBL in the urine isolation precautions in effect, skin w/d (warm/dry) resp e/n (even/nonlabored), denies pain or distress, no urinary distress noted, fluids encouraged, 97.9 will continue with plan of care. 3. On 12/18/25 at 9:10 AM, V23, Licensed Practical Nurse (LPN), was observed doing wound care on R11. V23 walked into the room with supplies and then donned gloves with no hand hygiene done. V23 cleaned each area with wound cleaner and 4X4's, with glove changes between each area. V23 put Zinc Oxide ointment followed by anti-fungal cream onto the reddened areas with glove changes between each area. V23 did not do any hand hygiene before, during glove changes, or after care was done. On 12/23/25 at 8:20 AM, V23, LPN, stated I do hand hygiene before and after resident care. I change my gloves when going from dirty to clean areas, then do hand hygiene between glove changes. On 12/23/25 at 8:25 AM, V17, LPN, stated I do hand hygiene before walking into a room and when leaving the room. I change my gloves when they are soiled and will use hand sanitizer between glove changes. On 12/23/25 at 8:30 AM, V11, CNA, stated I do hand hygiene anytime I am doing resident care, before and after the care. I change gloves and will use hand sanitizer between glove changes. When feeding a resident, I use gloves and hand sanitizer. On 12/23/25 at 8:35 AM, V15, LPN, stated I do hand hygiene when passing meds and pretty much everything you do around here. When changing gloves, I use hand sanitizer between glove change. On 12/23/25 at 8:45 AM, V21, CNA, stated I do hand hygiene before and after resident care and between glove changes. If I am assisting a resident with feeding, I don't wear gloves but use hand sanitizer before. On 12/23/25 at 9:20 AM, V2, Director of Nursing (DON), stated I would expect all staff to perform hand hygiene before and after resident care, between glove changes, and while assisting residents with feeding. I would expect all staff to change their gloves when going from dirty to clean areas and in between residents. I would expect staff to properly dispose of contaminated linen and not throw them on the floor. 4. On 12/15/2025 at 12:20PM V12, CNA standing up beside R77. V12, CNA then pulls chair up beside R77. V12, CNA then picks up fork and starts feeding R77. V12 did not sanitize her hands prior to feeding R77. On 12.15//2025 at 12:36PM V12, CNA put her hands on her lap then gets spoon and starts feeding R77. V12 did not sanitize her hands. R77's Minimum Data Set (MDS) dated [DATE] documents Severe cognitive impairment with a Brief interview of Mental status (BIMS) if 6. R- MDS documents R77 is dependent on staff for eating. The Facility's Hand Hygiene Policy, undated, documents in part Examples of when to perform Hand Hygiene: Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed). After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. If hands will be moving from a contaminated-body site to a clean-body site during patient care. Before gloves placement. After glove removal. The Facility's Infection Prevention Policy, dated 10/1/25, documents in part It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of isolation precautions. Standard precautions will be employed by all personnel for all residents at all times. Points to remember: Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Linens soiled with blood, body fluids, secretions, and excretions will not be placed on the floor or other resident equipment.

Based on record review, and interview, the facility failed to ensure food was served at palatable temperatures for foods for 4 of 4 (R2, R15, R28, R57) people review for meal services in a sample of 67. Findings include:1. The facility's Resident Council Minutes dated October 15, 2025, documents concern with the food being cold and bland.The facility's Resident Council Minutes dated September 17, 2025; documents concern about food overall.The facility's Resident Council Minutes dated August 20, 2025; documents concern about being cold all the time.The facility's Resident Council Minutes dated June 18, 2025, documents concern with food being bland and cold.2. R2's Minimum Data Set, dated [DATE], documents that R2 is cognitively intact.On 12/16/2025 at 11:20 AM R2 stated that the food is horrible. It's cold. R2 stated that sometimes the food is done and sometimes it's not. R2 stated that If you don't have your own food you will starve. R2 stated that the food comes at different times. R2 stated that sometimes it's late and sometimes it doesn't come at all. 3. R28's MDS, dated [DATE], documents that R28 is cognitively intact.On 12/16/2025 at 11:49 AM R28 stated that the food is cold and delivered late. R28 stated that You don't know when the food is coming just have to wait until it gets there.4. R15's MDS, dated [DATE], documents that R15 is cognitively intact. On 12/17/2025 at 1:45 PM R15 stated that the food is horrible and tasteless. R15 stated that that the food is cold. R15 stated that they don't know when the food will be delivered. R15 stated that breakfast starts at 7 AM. R15 stated that they have had delays up to 2 hours. R15 stated that the food will get to you around 9:30 AM and then it's cold. R15 stated that if you don't eat it then you have nothing.5. R57's Minimum Data Set (MDS), dated [DATE], documents that R57 is cognitively intact. On 12/17/2025 at 1:41 PM R57 stated that the food is cold and late more often than not. R57 stated that it looks horrible and tastes horrible as well.The facility's Food Preparation: Teste-Tasting policy, not dated, documents that Procedure: 4. Food items will not be served unless palatable and pleasing to the eye.The facility's Food & Beverage Temperature Control policy, not dated, documents that Policy: Food temperature are maintained during serving times. Purpose to ensure residents receive safe food served at acceptable temperatures.

Based on observation, interview and record review the facility failed to provide assistance with eating for 2 of 8 residents (R50 and R70) reviewed for assistance with eating in the sample of 67. Findings include: 1. On 12/15/2025 at 12:08PM trays being passed in 2nd floor dining room. The meal consists of pasta with peas and chicken, cooked carrots, white cake with frosting. On 12/15/2025 at 12:13PM R50 sitting sideways in a regular chair at table with tray in front of R50 with plate with pasta, and cooked carrots, separate plate with cake, glass of water covered with plastic, orange drink covered with plastic, mighty shake (unopened)12:25PM R50 has not taken a bite, just looking at food drinks remain covered with plastic, and mighty shake unopened. On 12/15/2025 at 12:35PM R70 1/2 cake eaten, Casserole and carrots not touched. R70 drank 1/2 glass of drink. R70 is not being provided any cueing or encouragement to eat. At 12:37PM R70 dozing at table, knocks spoon off table to floor, then picks up spoon and places on tray. cake is on saucer on table. R70 is trying to get cake on fork and saucer keeps moving. R70 finally managed to spear cake with fork, then partially falls off onto tray then R70 manages to get some of cake off tray with fork. On 12/15/2025 at 12:40PM, V12 CNA sitting at table with R77 asks R70 if R70 needs anything, and states you too to R50 but did not encourage either one to eat. On 12/25/2025 at 12:45PM R50 continues to sit sideways at table, V12, CNA tells R50 she can drink, glasses remain covered with plastic and mighty shake unopened. At 12:47PM R50 removing plastic from orange drink and sipping drink. On 12/15/2025 at12:48PM V14, Licensed Practical Nurse (LPN) entered dining room and encouraging R70 to eat. V14 also encouraged R50 to eat casserole. On 12/15/2025 at 12:55PM R50 taking bite of casserole with fork. V12, CNA after taking R77 tray to cart asked R50 if wanted mighty shake opened, did not offer to open it for R50. On 12/15 2025 at12:54PM V12 CNA asked R50 if wanted to go to room. R50's glass of water still had plastic covering, mighty shake unopened. few bites of casserole, 100% cake eaten, carrots untouched. On 12/25/2025 at 1:04PM V12, CNA assisted R50 out of dining room. R50's Minimum Data Set (MDS) dated [DATE] documents R50 is cognitively intact with a Behavioral Interview for Mental Status (BIMS) if 15. R50's MDS documents R50 requires supervision or touch assistance for eating (helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R50's undated care plan documents R50 is at risk for self-care deficit: Bathing, dressing, and feeding. R50's care plan documents intervention provide assistance with ADLs as needed. R50's face sheet, dated 12/17/2025 documents a diagnosis in part, catatonic schizophrenia 2. R70's MDS dated [DATE] documents R70 has severe cognitive impairment with a BIMS of 6. R70's MDS documents R70 requires supervision or touching assistance for eating. (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity. Assistance may be provided throughout the activity or intermittently. R70's undated care plan documents R70 is at risk for self-care deficit: Bathing, dressing, and feeding. R70's care plan documents intervention provide assistance with ADLs as needed. On 12/18/2025 at 2:31PM V2, Director of Nursing (DON) stated residents who require assistance with eating should be provided assistance as needed.The facility policy Activities of Daily Living (ADL), supporting, dated reviewed 7/15/2025 documents residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. The policy documents if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a time or having another staff member speak with the resident may be appropriate.

Based on interview, observation, and record review, the facility failed to ensure a medication error rate of less than 5% for 2 of 4 residents (R2, R6) observed during medication pass. Fourteen errors were observed during 38 opportunities for errors during medication administration. This resulted in a medication error rate of 36.84 percent. The findings include:1. R6's admission Record, dated 12/17/25, documents R6 was originally admitted to the facility on [DATE] with diagnosis of Malnutrition, Catatonic Schizophrenia, Anxiety Disorder, Hypertension (HTN), Dyskinesia, Falls, Type 2 Diabetes Mellitus (DM), Major Depressive Disorder, and Pneumonitis.R6's Care Plan, dated 3/3/25, documents R6 has Impaired Coping, has a Self-Care Deficit, Risk for Decreased Cardiac Output, Risk for Impaired Communication, Decreased Cardiac Output, Arrhythmia, Hypertension, Disturbed Sensory Perception: Audible/Visual, Malnutrition. It continues 12/1/25: R6 has a behavior problem related to catatonic schizophrenia, anxiety and depression. examples walking fast for hours without sitting down, attempts at grabbing items not belonging to him and walking up onto others quickly. Interventions: Administer medications as ordered. R6 has Diabetes Mellitus. R6 is on anticoagulant therapy related to atrial fibrillation. Interventions: Administer Anticoagulant medications as ordered by physician. R6 is on diuretic therapy. Interventions: Administer Diuretic medications as ordered by physician. R6 is on pain medication therapy. Interventions: Administer Analgesic medications as ordered by physician. R6 uses antidepressant medication related to Depression Diagnosis. Intervention: Administer Antidepressant medications as ordered by physician. R6 uses anti-anxiety medications. Intervention: Administer Anti-Anxiety medications as ordered by physician. R6 uses psychotropic medications. Intervention: Administer Psychotropic medications as ordered by physician. R6 has fluctuations in mood related to Catatonic Schizophrenia. Interventions: Administer medications as ordered.R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs).R6's Physician Order (PO), dated 12/16/25, documents May crush medication.R6's PO, dated 11/10/25, documents Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (milligram) Give 2 capsule by mouth one time a day for Anticonvulsants.R6's PO, dated 10/1/25, documents Austedo Oral Tablet (Deutetrabenazine) Give 6 MG by mouth every 12 hours for Psychosis.R6's PO, dated 9/30/25, documents Haloperidol Tab 5 MG Give 1 tablet by mouth two times a day for Schizophrenia.R6's PO, dated 2/10/25, documents Carvedilol Oral Tablet 3.125 MG Give 1 tablet by mouth two times a day for HTN Take with meals.R6's PO, dated 8/29/25, documents Furosemide Oral Tablet 20 MG Give 1 tablet by mouth two times a day for diuretic.R6's PO, dated 4/17/25, documents Hyoscyamine Sulfate Oral Tablet Disintegrating 0.125 MG Give 1 tablet by mouth every 4 hours as needed for secretions.R6's PO, dated 3/18/25, documents Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth four times a day.On 12/16/25 at 8:00 AM, V15, Licensed Practical Nurse (LPN), was observed administering medications to R6. V15 obtained all R6's medications from the medication cart. V15 crushed up all medications except for the Depakote capsules which were opened and put in with all the other crushed meds. V15 mixed the crushed medications with a spoonful of oatmeal. After mixing the medications in the oatmeal, V15 put the spoonful of oatmeal mixed with medications in the bowl of oatmeal and delivered it to R6's room where V16, Certified Nursing Assistant (CNA) was sitting assisting R6 with breakfast. V15 placed the bowl of oatmeal with the spoon of medications onto R6's breakfast tray and left the room. V16 attempted multiple times to feed R6 his oatmeal, not knowing that there were medications in the bowl, and each time, R6 refused to eat the oatmeal. On 12/16/25 at 8:50 AM, V16, CNA, stated (R6) did not eat any of his oatmeal this morning. Someone came in and took his breakfast tray out of the room. R6 did not get any of his morning medications.On 12/16/25 at 2:25 PM, V4, Assistant Director of Nursing (ADON), was advised of R6 not receiving his morning medications from V15, LPN. V4 stated Well, that would contribute to some of his behaviors lately.On 12/16/25 at 3:40 PM, V28, Nurse Practitioner (NP), stated I was not aware of (R6) not getting any of his medications today, only that he was having behaviors this morning and that was probably because he didn't sleep last night. I did stop (R6's) Eliquis, but I did not stop his Plavix or Aspirin. The Depakote DR Sprinkles I believe is approved to sprinkle over food and such, so it is ok for them to open the capsules. I'm not sure what to say about the CNA, but I would not expect the CNA to be given him his medications. (R6) has all his medications ordered and he should be getting them as ordered. If (R6) has missed multiple doses, that could contribute to behaviors.2. R2's admission record, dated 12/17/25, documents R2 was admitted on [DATE] with diagnosis of Peripheral Vascular Disease (PVD), Stenosis of carotid arteries, HTN, Anxiety Disorder, Post-Traumatic Stress Disorder (PTSD), Polyneuropathy, Dorsalgia, Disease of spinal cord, Alcohol abuse, Depression, Generalized Anxiety Disorder, Major Depressive Disorder, Spondylolysis, and Spinal stenosis.R2's Care Plan, dated 9/25/25, documents R2 is cognitively intact and requires supervision/touching assistance for ADLs and transfers.R2's MDS, dated [DATE], documents R2 is cognitively intact and requires supervision or touching assistance for ADLs. R2's PO, dated 3/24/25, documents Calcium Carbonate Oral Tablet Chewable, Give 2 tablets by mouth in the morning.On 12/16/25 at 8:21 AM, V15, LPN, gave R24 his medications in one medicine cup with his Calcium Carbonate tablets in another cup. V15 left the Calcium Carbonate sitting on his bedside table and stated, He will take that when he wants to. and left the room.On 12/23/25 at 8:20 AM, V23, LPN, stated When passing meds, I make sure the resident takes them before I leave the room and would never leave them for a CNA to give them to the resident.On 12/23/25 at 8:25 AM, V17, LPN, stated I stand by the resident to make sure they take the medication and don't choke on them. I would not leave them with a CNA for them to give to the resident.On 12/23/25 at 8:35 AM, V15, LPN, stated I always watch the resident take their meds and would never leave the meds with a CNA for them to give to the resident.On 12/23/25 at 9:20 AM, V2, Director of Nursing (DON), stated . I would expect the nurses to stand by the resident and ensure the resident takes all their medications. They should never leave the medications with a CNA or at the resident's bedside.The Facility's Medication Administration Policy, dated 6/1/25, documents in part . Medications will be administered by a Licensed Nurse per the order of Attending Physician or licensed independent practitioner or as consistent with state law. III. Medications must be given to the resident by the Licensed Nurse to prepare the medication, to as consistent with state law. V. Medications may be administered one hour before or after the scheduled medication administration time. VIII. Medications will not be left at bedside. IX. If the attending physician increases or changes a medication order, this is an automatic stop or discontinue order for the original order. Procedure: VIII. Compare the licensed practitioner's prescription/order with MAR (Medication Administration Record) (first check). XV. Administer the medication to the resident. XVI. The licensed nurse will remain with the resident until the medicine is actually swallowed.

Based on interview, observation, and record review, the facility failed to provide effective fall prevention and supervision for 1 of 3 residents (R2) reviewed for falls in the sample of 9. R2 is documented as experiencing 50 falls in the facility from 4/8/25 through 12/1/25. This failure resulted in R2 experiencing an injury on 4/11/25, 5/29/25, 6/15/25, 6/23/25, 7/4/25, 8/7/25, 8/13/25, 9/13/25, 10/14/25, 10/29/25, 11/7/25, 11/13/25, and 12/1/25 with R2 being sent to the emergency room on 8/7/25 with fall/contusion, 8/13/25 with fall/head injury with laceration, 10/14/25 with questionable fall/laceration of finger, 10/29/25 with fall/abrasion to face, and 11/7/25 with fall/closed head injury.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 4/8/25 when the facility failed to put fall interventions in place after R2 experience a fall. R2 also experienced falls on 4/8/25, 4/11/25, 4/19/25, 4/23/25, 5/9/25, 5/26/25, 8/26/25, 9/11/25, 9/19/25x2, 9/21/25x2, and 9/22/25 with no new fall interventions entered.V4, Regional Nurse Consultant, was notified of the Immediate Jeopardy on 12/2/25 at 12:18 PM. The surveyor confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 12/4/25, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training.The Findings Include:1. R2's admission Record, dated 11/18/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Malnutrition, Schizophrenia, Anxiety disorder, Hypertension (HTN), Deep Vein Thrombosis (DVT), Dyskinesia, Falls, Type 2 Diabetes Mellitus (DM), and Major depressive disorder. R2's Care Plan, dated 1/28/25, documents R2 is at Risk for Falls. Interventions: If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol.R2's Care Plan, dated 11/10/25, documents R2 has had an actual fall:4/8/25 witnessed fall with no injury - Intervention: No new interventions.4/11/25 witnessed fall with small re-open area to left chin and lump on back of head - no new interventions.4/19/25 unwitnessed fall with no injury - Staff educated to place roommate wheelchair on the outside of room when not in use.4/23/2025 unwitnessed fall - Educated staff to walk to and from meals.5/9/25 unwitnessed fall with no injury - Staff to assist 1:1 during residents increased agitation episodes/periods.5/26/25 unwitnessed fall with no injury - Staff to ensure resident has on non-skid socks.5/29/2025 unwitnessed fall with hematoma - Intervention: Sent to ER (emergency room) for eval.5/31/2025 unwitnessed fall with no injury - Intervention: Educate staff to be within arm's reach of resident during 1:1.6/10/25 fall with no injury - Intervention: Resident made 1:1 for remainder of shift.6/11/25 witnessed fall w/ no injury - Intervention: Pharmacy contacted for medication review. 6/15/2025 unwitnessed fall w/no injury - Intervention: Keep in visual when out of bed. 6/15/2025 unwitnessed fall w L hematoma to elbow - Intervention: Reeducate staff on 1:1. 6/17/25 witnessed fall no injury - Intervention: Staff to assist with seating to a chair with arms. 6/21/25 witnessed fall - Intervention: Staff to ensure that entryways are clear of clutter/residents. 6/23/25 witnessed fall no injury - Intervention: Staff to ensure chair is up against wall before resident sits down. 6/23/25 witnessed, skin tear to left knee - Intervention: Staff to increase toileting rounding with resident. 7/4/25 unwitnessed, with minor injury - Intervention: Staff to remove nightstand from room. 7/14/25 witnessed fall, no injury - Intervention: Staff educated not to put their hands on his back.7/26/25 witnessed fall - Intervention: Staff to assist resident to bed after evening snack.7/27/25 unwitnessed fall, no injury - Intervention: Staff to ensure that resident remote is kept within reach.8/5/25 witnessed fall, no injury - Intervention: Staff will keep pitchers of liquid out of reach. 8/7/25 witnessed fall - Intervention: Sent to hospital for eval/treatment.8/12/25 unwitnessed fall no injury - Intervention: Resident is to be placed in bed at lowest position.8/13/25 unwitnessed fall with injury - Intervention: Encourage resident to utilize wheelchair for mobility.8/16/25 unwitnessed fall, no injury - Intervention: Staff reeducated to frequently toilet resident.8/18/25 witnessed fall - Intervention: Staff to add (non-slip pad) to wheelchair.8/26/25 witnessed fall - Intervention: No new interventions.9/2/25 unwitnessed fall with no injury - Intervention: Staff to keep door to room open for frequent visual checks.9/4/25 unwitnessed fall with no injury - Intervention: Overnight staff to assist resident to chair in Tv room for AM activities.9/7/25 witnessed fall - Intervention: Staff reeducated not to place hands on resident back.9/11/25 witnessed fall - Intervention: No new interventions.9/13/25 unwitnessed fall - Intervention: Scheduled Care Plan meeting with (Local Hospice) to discuss frequent falls.9/13/25 unwitnessed fall - Intervention: Reeducate overnight staff to assist resident to chair in TV room for AM activities.9/13/25 unwitnessed fall - Intervention: Provide an early morning snack.9/15/25 unwitnessed fall - Intervention: Contacted (Local Hospice) to get prn medications scheduled.9/19/25 witnessed fall - Intervention: No new intervention9/19/25 witnessed fall - Intervention: No new intervention9/21/25 unwitnessed fall - Intervention: No new intervention9/21/25 unwitnessed fall - Intervention: No new intervention9/22/25 unwitnessed fall w/o injury - Intervention: Staff to allow resident to sit on floor as he desires.10/29/25 unwitnessed fall no injury - Intervention: Staff to check on resident more frequently during wake hours.11/7/25 unwitnessed fall with hematoma to head - Intervention: Continue with plan of care.Other Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Follow facility fall protocol. Anticipate and meet the resident's needs.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs). R2 is always incontinent of both bowel and bladder.The facility's fall log, dated September, October, and November 2025, documents R2 has had more falls that were not addressed in the Care Plan. These falls occurred on 9/24/25 x 2, 9/25/25, 11/1/25, 11/7/25, 11/13/25, and 12/1/25. There are missing Fall Risk Assessments that were not completed after each fall. R2's Hospital Record, dated 8/7/25, documents in part patient is a [AGE] year-old male who presents ER due to fall at his facility. Patient has catatonic schizophrenia and is a very poor historian. He denies any pain but will not answer orientation questions. He has old bruising to the face. Facility is concerned he may have internal bleeding due to his blood thinning agent. A Head CT (cat scan) was performed with impression: No acute intracranial hemorrhage or suspicious mass effect. Clinical Impression: Bruise to face.R2's Hospital Record, dated 8/13/25, documents in part this is a [AGE] year-old male presenting for ground level fall. Patient is nonverbal due to catatonic schizophrenia and cannot answer questions. Per EMS (emergency medical service) he fell from his chair and struck his head. Patient is on Eliquis. Patient can move 4 extremities to command although function is severely limited. CT was performed with impression: No acute intracranial hemorrhage or suspicious mass effect. Patient re-evaluated with any acute concerns, and his laceration was repaired. Bleeding controlled. discharge: Clinical Impression: CHI (closed head injury), Catatonic Schizophrenia, Forehead Laceration.R2's Hospital Record, dated 10/14/25, documents in part Patient is a [AGE] year-old male with past medical history of catatonia, diabetes, hypertension who presents with a fall and laceration. Patient was found after having a fall. Patient has catatonia and intermittently does not answer any questions. For me patient says that he has no pain. He can shake his head no to say that he does not feel sick today. Physical Exam: Head: External signs of trauma to head. Patient has well-healed laceration including left forehead with sutures still in place that were removed by myself. Musculoskeletal: On patient's left fifth digit there is a 1 CM (centimeter) laceration on palmar aspect overlying proximal phalanx. X-Ray of finger shows no acute fracture of dislocation. Laceration was repaired with 3 sutures. R2's Hospital Record, dated 10/15/25, documents in part R2 is a [AGE] year-old male presents to the ED by EMS from (Facility) for evaluation. Patient was evaluated at this facility yesterday for laceration to his left pinky. He received sutures at this time. Per EMS, staff found patient bleeding from his left pinky this morning and sent to the ED (emergency department). No other complaints. Clinical Impression: Visit for wound check.R2's Hospital Record, dated 10/29/25, documents in part R2 is a [AGE] year-old male presenting to the emergency department following a ground level fall. Patient is nonverbal with limited mobility at baseline. He was apparently walking behind a nurse and fell to the ground injuring his left knee. Shortly thereafter, the patient tripped over something on the ground and fell striking his head. Patient shakes his head when asked if he has any pain though does nod yes when palpating his back. A laceration to the corner of the right eyebrow. A CT of his head, cervical spine, thoracic, and lumbar spine was completed with negative results. Medical Management: The patient is a nursing home resident where ongoing medical care and assistance with activity of daily living will be provided. The fall was purely mechanical in nature by the patient's description, and the patient had no preceding dizziness, chest pain, or shortness of breath and has none of those symptoms now. The patient did not have any suggestion of a change in mental status during or following the event. This description of the events makes syncope or seizure exceedingly unlikely. A syncope work-up (labs, EKG) considered is deemed unnecessary due to the mechanical nature of the fall. Clinical Impression: Ground-level fall, knee abrasion, eyebrow laceration. R2's Hospital Record, dated 11/7/25, documents in part patient is a [AGE] year-old male arriving via EMS from SNF (skilled nursing facility) presenting after a witnessed ground level fall. Patient is A&O (alert and oriented) x3 but demonstrates variable cognitive function. Patient states that he tripped and sustained a head injury. Med list indicates he is on Eliquis. CT of head and neck demonstrated no acute abnormalities. CXR (chest x-ray) demonstrated no acute cardiopulmonary disease. CT pelvis showed moderate arthritis of left hip. Lab work WNL. Vitals remained stable throughout visit. Traumatic injury ruled out. discharged back to nursing home. Discharge instructions: Fall Prevention.R2's Fall Risk Assessment, dated 3/29/25, documents R2 is a High Fall Risk.R2's Incident Note, dated 8/8/25 at 9:43 AM, documents IDT (interdisciplinary team) met to review residents witnessed fall. Care plan updated. Resident at risk for falls related to schizophrenia, anxiety, hypertension, subacute dyskinesia, frequent falls, malnutrition, and antihypertensive and psychotropic medications. Previous interventions include: Recent medication adjustment related to increased anxiety, staff instructed to check on resident more frequently during wake hours, treated for an acute illness, staff educated walk resident to and from the dining room for meals, and staff instructed to ensure resident is wearing appropriate footwear at all times, and pharmacy consulted for medication review, staff re-educated on 1:1 procedure, staff to assist with seating by ensuring chair has arms for support, staff educated on keeping entry ways clear of clutter/residents, increased staff rounding to offer toileting, staff educated not to place their hand on his back while ambulating, staff will keep pitchers of liquid out of reach, staff will ensure resident's remote is within reach when he is in bed, facility removed side table from room, and staff to ensure chairs are pushed up against the wall for support before resident sits. Root cause: Resident became weak and fell. Intervention: Sent to the ER for evaluation and treatment.R2's Social Determinants of Health Note, dated 10/14/25 at 12:11 PM, documents This writer went to assist resident out of the doorway when this writer noted blood on the floor. This writer observed this resident's hand to see where the blood was coming from. This writer noted a skin tear about 2.5 CM long at the base of this resident's 5th digit right above the metatarsal. Resident noted to be on Eliquis and ASA (Aspirin) bleeding is not stopping. No one witnessed this resident fall as he has been in the floor most of the time he has been awake this shift. Resident unable to tell this writer what happened. Pressure applied to site. Resident sent to (local hospital) for further evaluation. Resident left this facility via stretcher accompanied by 3 paramedics. Hospice Aware. This writer attempted to notify this residents brother. This writer called this residents brother from line 1 per brothers request no answer at this time.R2's Social Determinants of Health Note, dated 10/29/25 at 9:58 PM, documents This writer was at the nurse's station on the phone with the DON (Director of Nursing) to report this resident's fall when this resident approached and fell at the nurses station. Resident noted to fall on his knee hitting his head on the bookshelf. Resident left this facility via ambulance on a stretcher accompanied by 2 paramedics in route to (local hospital). This writer attempted to call hospice back to inform them of second fall no answer at this time. This writer left a message for this resident's brother.R2's Incident Note, dated 11/7/25 at 9:02 PM, documents This nurse was sitting at the nursing station resident had just walked by and went into dining area and then I there was a loud sound. Immediately I walk into dining area resident was observed lying on his left side on the floor, head against the wall with the chair next to him. Resident was assessed then assisted from floor to chair. Resident alert, BP (blood pressure) 104/71, T (temperature) 97.8, P (pulse) 93, R (respirations) 20, O2 (oxygen saturation) 97% RA (room air), and all ext. (extremities) WNL (within normal limits). Resident denies pain. Hematoma to left back side of head and redness to the left front side of head. Hospice and DON notified. Hospice orders to send resident out to hospital for evaluation and treatment.R2's Fall Risk Assessment, dated 11/13/25, documents R2 is a High Fall Risk. R2's Fall Risk Evaluation Note, dated 11/13/25 at 11:31 AM, documents Fall Risk: History of falls (past 3 months): 3 or more falls in past 3 months. Resident is ambulatory / incontinent. Systolic blood pressure: No noted drop between lying and standing. Predisposing disease: 1-2 present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait / balance: Balance problem while walking. Gait / balance: Decreased muscular coordination. Gait / balance: Change in gait pattern when walking through doorway. Gait / balance: Jerking or unstable when making turns. Gait / balance: Balance problem while standing. Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 19.0. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.The following fall interventions were put in place after R2 experienced falls, however, they are not being followed: Staff to increase toileting rounding with resident, Staff reeducated to frequently toilet resident, Staff to remove nightstand from room, Staff to ensure that resident remote is kept within reach, Staff to keep door to room open for frequent visual checks, Staff to check on resident more frequently during wake hours, and Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 11/13/25 at 2:30 PM, R2 was seen lying on the floor in small dining room across from nurse's desk, rolling side to side, sitting up, then lying back down. Other residents were in dining room during this time with both staff and residents seen walking past and around R2 while he was on the floor.On 11/13/25 at 2:35 PM, V9, Licensed Practical Nurse (LPN), stated that R2 is care planned to be on the floor. V9 stated they tried everything to keep him from doing that but if staff tries to get him up, he becomes upset and has behaviors. V9 stated staff keep an eye on him and if he scoots too far, they will intervene to assist him to a chair. V9 stated she has worked with R2 for five years now and R2 can talk and tell you about his needs at times. On 11/17/25 at 8:17 AM, R2 was seen lying in bed with his call light on a nightstand in the middle of the room and not within reach of R2. The door to his room is closed with staff unable to watch R2. No other visible fall precautions noticed. On 11/17/25 at 10:25 AM, R2 still seen lying in bed, unchanged from earlier with his call light still on the nightstand and not in reach, and his door to the room remains closed with R2 not visible to staff.On 11/17/25 at 12:10 PM, R2 still lying in bed and in same position as earlier. When asked if he has gotten up today R2 nodded his head no. When asked if he has been cleaned up yet, R2 nodded his head no. The sheets under R2 appeared saturated in urine with a brownish stain around the wet area. R2's call light remains on the nightstand and not in reach of R2. R2's door remains closed with R2 not visible from hallway. On 11/17/25 at 12:24 PM, V12, Certified Nursing Assistant (CNA), and V14, Licensed Practical Nurse (LPN), both walked up to R2's door, opened it and looked inside, then closed the door and walked on down the hall without actually checking on R2.On 11/17/25 at 1:35 PM, V16, CNA, stated (R2) was up when I came on this morning and I helped to put him in his bed after breakfast, maybe around 9:00 AM. The other CNA on this hall left and I was the only one on the hall. I have been everywhere, and I did open (R2's) door to see if he was still breathing, but I didn't have the time to check for anything else. They called in (V15) to help me today.On 11/17/25 at 1:40 PM, V15, CNA, stated I hate to see him (R2) like this. It's too bad that I didn't know he was sitting like this earlier.On 11/17/25 at 1:42 PM, V15 and V16 assisted R2 to stand by the side of his bed with each CNA holding onto one of R2's arms. V16 held onto R2 by under his arm while he stood by side of his bed during peri-care with his pants saturated and down around his ankles. V15 put a clean incontinence brief between R2's legs and fastened it, walked to his recliner and pushed the recliner over to R2 and while still unlocked, had R2 pivot and sit into the unlocked recliner with no gait belt used. On 11/17/25 at 1:55 PM, V15 stated (R2) is a very high fall risk but if he knows you, he will cooperate with you and stand there during care.On 11/18/25 at 8:20 AM, R2 resting in bed with his call light on a nightstand and not within reach. On 11/19/25 at 12:45 PM, V2, DON, stated (R2) has a lot of interventions in place for his falls. We have been working with his hospice team and our Psych physician to see what things may work for him and what things don't. We have had a care plan meeting with his family to discuss these things as well.2. R3's admission Record, dated 11/18/25, documents R3 was originally admitted to the facility on [DATE] with diagnosis of Type 2 DM, Anemia, Atherosclerotic Heart Disease (ASHD), Bipolar disorder, Left below knee amputation (BKA), Morbid obesity, Hernia, Peripheral Vascular Disease (PVD), Major depressive disorder, Anxiety disorder, Falls, HTN, Myalgia of muscles, non-pressure chronic ulcer of skin, Chronic Obstructive Pulmonary Disease (COPD), and Schizophrenia.R3's Care Plan, dated 6/24/25, documents R3 is high risk for falls related to left leg amputee. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, follow facility fall protocol, review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. R3's MDS, dated [DATE], documents R3 is cognitively intact and is dependent on staff for ADLs. R3 is always incontinent of both bowel and bladder.On 11/17/25 at 11:35 AM, V11, CNA, and V12, CNA, rolled R3 over and placed a full body mechanical lift sling under him. V11 brought in R3's wheelchair and stood behind it at the foot of his bed while V12 attached R3's sling to lift device and lifted R3 off the bed, then pulled R3 from his bed over to his wheelchair in the middle of the room (approximately 4 feet) with no one holding onto R3 and R3 was freely swinging in the air. V11 then changed position and controlled the lift device while V12 went behind R3's wheelchair and held him while lowering him to the wheelchair.3. R1's admission Record, dated 11/18/25, documents R1 was originally admitted to the facility on [DATE] with diagnosis of Dementia, Alzheimer's Disease, Anemia, Glaucoma, Pulmonary Embolism, Malnutrition, HTN, DVT, Arthritis, and Asthma.R1's Care Plan, dated 6/2/25, documents R1 is at risk for falls related to confusion, gait/balance problems, unaware of safety needs. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, follow facility fall protocol. R1's MDS, dated [DATE], documents R1 has a severe cognitive impairment, is dependent on staff for all ADLs, and is always incontinent of both bowel and bladder.R1's Fall Risk Assessment, dated 6/3/25, documents R1 is a High Fall Risk.On 11/13/25 at 2:55 PM, R1 was seen lying in bed with the bed raised up, bilateral side rails up, and her call light on a recliner approximately 3 feet away from the bed and is not reachable.On 11/18/25 at 9:00 AM, R1 lying in bed raised about mid height with her call light on the recliner and not in reach.On 11/19/25 at 11:10 AM, V21, Regional Director of Operations, stated I would expect all staff to monitor fall risk residents and provide the interventions that are listed in the care plans to ensure resident safety. I would expect any staff transferring a resident using a (full body mechanical lift) to have continuous hold onto the resident during the transfer. I would expect all staff who are assisting a resident in transferring to use a gait belt during the transfer for resident safety.On 11/19/25 at 12:20 PM, V22, CNA, stated When we are transferring a resident using (full body mechanical lift), there needs to be two people with one person controlling the device while the other is standing by the resident. I did not know we are supposed to be holding onto the resident the entire time, I thought we just stood by them in case something happened.On 11/19/25 at 12:30 PM, V18, CNA, stated For resident falls, I would look in the care plan or on the clipboard for interventions. The nurses will usually let us know what to do or how to work with a particular resident. For transfers, I always use a gait belt on the resident (has one around her waist) and if using a (full body mechanical lift) we must have two people and always hold onto the resident. On 11/19/25 at 12:50 PM, V3, Assistant Director of Nursing (ADON), stated I would expect staff to keep the resident's call light in reach at all times, even if they are not cognitive enough to use it, they should have it available. I went through each of (R2's) fall interventions and realized that he did still have his nightstand in his room. I have removed that this morning. I also noticed that his call light was not in reach and does not have a clip on it to attach to his bed, so we will have to order some. I did make sure he has his call light now. I am not comfortable with (R2) lying on the floor in the dining room and have asked staff to help him with that. To me that is almost a dignity thing.On 11/19/25 at 12:35 PM, V2, DON, stated I would expect staff to use a gait belt when transferring a resident and to hold onto the resident at all times while transferring using a (full body mechanical lift). I would expect all staff to follow a resident's fall interventions to maintain resident safety. I would expect staff to keep the resident's call light in reach at all times.On 12/2/25 at 8:50 AM, V27, MDS Coordinator, stated I was told by corporate to get rid of anything old in the resident's Care Plan. I was told to do this quarterly, so anything older than 3 months was deleted. When asked about the interventions that were put in place for falls older than 3 months ago, V27 stated I would say those are discontinued because they are no longer in the Care Plan. On 12/2/25 at 9:00 AM, V28, Nurse Practitioner (NP), stated I have been working with (R2) for years now and he is a complicated resident. We have had meetings where we sat down with Hospice, Psych, and the facility staff to discuss him. I think it is a combination of things going on with him and he is declining and gets manic episodes at times and will take off with a fast walk and loses his balance. We have tried altering his medications to see what would work but he absolutely needs his psychotropic meds, or he will have behaviors. We stopped his Eliquis because it was of no benefit for him at this point. I know he has had numerous falls, but some of them might not have been falls, he has a tendency to sit himself down on the floor. I would always expect the staff to keep him safe and to follow the interventions put into place in order to keep him safe.On 12/2/25 at 10:03 AM, V28, NP, stated Anytime anyone falls and hits their head, there is a chance that they could have a head bleed and could even die from it. (R2) has fallen numerous times and hit his head and he hasn't had a brain bleed, however, it could happen, you just don't know. It is always a possibility. It is very tough to keep him down. We can't stop him and hold him down. The only thing we can do is to keep him safe and avoid an injury if possible.On 12/2/25 at 1:21 PM, V29, Facility Medical Director, stated I have been called numerous times for (R2). Your observations are serious, but we must be objective here. I would have to look at both sides. We have discussed (R2) at the QA meetings, and we had interventions put in place. If the facility did not follow the interventions, then that is one thing, because by regulation, all interventions should be put in place and followed. With all (R2's) falls, a lot of things could have happened. They must investigate what was observed and if they cannot justify why things were not done, and the resident is at risk, then that would be a neglectful act. Any resident who is incontinent and I see them like that, I would ask the staff why, what was their reason for not taking care of that resident and tell them they are doing a bad job and need to improve. If I was looking from your angle, then I would say it was neglectful period. To be fair, I have to see the other side first.On 12/2/25 at 1:35 PM, V30, Hospice Medical Director, was advised of this investigation and its findings and stated We had a team meeting about a month ago with everyone involved to discuss (R2) and interventions to protect him from further falls or minimize his falls. I know (R2) has had a huge number of falls and it is very concerning to everyone. Luckily, he has not had any bleed from his falls, but we removed his Eliquis due to the risk of a bleed with his falls. When asked about staff not following the fall interventions put in place, V30 stated I would expect the staff to be following his fall interventions and to put further fall interventions in place to minimize the number of falls. If all those observations are happening, then that is definitely a neglectful act. I assumed that things were going to be taken care of with (R2) after our meetings. I am not in the facility much and not involved with (R2's) day to day care. When advised of R2 sitting in his urine/feces for five hours, V30 stated I 100% agree that he should have been cleaned up. No one should be sitting in their urine or feces at all. That should not be happening at all and is not acceptable.The Facility's Fall Evaluation and Prevention Policy, dated 6/1/25, documents in part Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. Policy: The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. Residents should be evaluated for their fall risk on admission/re-admission to the home, following any change of status that may affect balance, mobility, or safety, following a fall, and quarterly.The Facility's Transfers-Manual Gait Belt and Mechanical Lifts Policy, undated, documents in part In order to protect the safety and wellbeing of the staff and residents, and to promote quality of care, this facility will use mechanical lifting devices for the lifting and movement of residents. Guidelines: 2. Refer to Manufacturer's Guide for proper instructions for use of equipment for transfer and weighing. 9. Use of a gait belt for all physical assistant transfers is mandatory. The Immediate Jeopardy that began on 12/2/25 was removed on 12/4/25, when the facility took the following actions to remove the immediacy.1. R2 is currently resides in the facility. A fall risk assessment was completed. Placed on 1:1 supervision.2. 1:1 sitter(s) in-serviced on 1:1 expectation related to coordination of care for R2.3. IDT team reviewed R2 Falls, starting on 4/8/25 to present to ensure that appropriate current interventions are in place.4. Facility Administrator, DON, ADON, MDS Coordinator were in-serviced on Fall Prevention Policy.5. In-service front-line staff on Fall Prevention Policy and where to verify Care Plan Interventions.6. In-serviced Nursing staff on how to find care plan/fall interventions in EHR. Staff will not work next shift until Fall Prevention In-service is completed. 7. An initial audit will be completed of all falls from 4/8/25 to present to ensure current interventions are initiated and effective. Care plans will reflect interventions that are effective and/or within the last 90 days.8. Initial audit completed of fall risk assessments to ensure that appropriate prevention interventions are in place & care plans are reflecting those interventions.9. A quality assurance tool was implemented: An audit will be completed 5x/week x 4 weeks during clinical meeting to ensure that any fall, has a root cause analysis, progressive intervention, and care plan is updated.10. A root cause analysis for Fall Prevention and interventions being placed on care plan and physically in place will be reviewed weekly during Facility Risk Meeting x 4 weeks.11. Review of the Fall Prevention Policy

Based on interview, observation, and record review, the facility failed to ensure a resident was free from neglect when they failed to monitor, assess, and put forth interventions for resident safety with a disregard for resident care, comfort or safety for 1 of 6 residents (R2) reviewed for Resident Neglect in the sample of 9. This failure resulted in physical harm of R2, being sent to the emergency room multiple times for his injuries from falls, and R2 being left saturated in urine and feces with no staff checking on him. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 4/8/25 when the facility failed to put fall interventions in place after R2 experienced a fall. R2 also experienced falls on 4/8/25, 4/11/25, 4/19/25, 4/23/25, 5/9/25, 5/26/25, 8/26/25, 9/11/25, 9/19/25x2, 9/21/25x2, and 9/22/25 with no new fall interventions entered, and with R2 observed to be left soiled in his room with the door closed for five hours with no staff checking or cleaning him. V21, Regional Director of Operations, V2, Director of Nursing (DON), and V3, (Assistant Director of Nursing (ADON), were notified of the Immediate Jeopardy on 12/2/25 at 3:18 PM. The surveyor confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 12/4/25, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training.The findings include: 1. R2's admission Record, dated 11/18/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Malnutrition, Schizophrenia, Anxiety disorder, Hypertension (HTN), Deep Vein Thrombosis (DVT), Dyskinesia, Falls, Type 2 Diabetes Mellitus (DM), and Major depressive disorder. R2's Care Plan, dated 1/28/25, documents R2 is at Risk for Falls. Interventions: If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol.R2's Care Plan, dated 11/10/25, documents R2 has had an actual fall:4/8/25 witnessed fall with no injury - Intervention: No new interventions.4/11/25 witnessed fall with small re-open area to left chin and lump on back of head - no new interventions.4/19/25 unwitnessed fall with no injury - Staff educated to place roommate wheelchair on the outside of room when not in use.4/23/2025 unwitnessed fall - Educated staff to walk to and from meals.5/9/25 unwitnessed fall with no injury - Staff to assist 1:1 during residents increased agitation episodes/periods.5/26/25 unwitnessed fall with no injury - Staff to ensure resident has on non-skid socks.5/29/2025 unwitnessed fall with hematoma - Intervention: Sent to ER (emergency room) for eval.5/31/2025 unwitnessed fall with no injury - Intervention: Educate staff to be within arm's reach of resident during 1:1.6/10/25 fall with no injury - Intervention: Resident made 1:1 for remainder of shift.6/11/25 witnessed fall w/ no injury - Intervention: Pharmacy contacted for medication review. 6/15/2025 unwitnessed fall w/no injury - Intervention: Keep in visual when out of bed. 6/15/2025 unwitnessed fall with L (left) hematoma to elbow - Intervention: Reeducate staff on 1:1. 6/17/25 witnessed fall no injury - Intervention: Staff to assist with seating to a chair with arms. 6/21/25 witnessed fall - Intervention: Staff to ensure that entryways are clear of clutter/residents. 6/23/25 witnessed fall no injury - Intervention: Staff to ensure chair is up against wall before resident sits down. 6/23/25 witnessed, skin tear to left knee - Intervention: Staff to increase toileting rounding with resident. 7/4/25 unwitnessed, with minor injury - Intervention: Staff to remove nightstand from room. 7/14/25 witnessed fall, no injury - Intervention: Staff educated not to put their hands on his back.7/26/25 witnessed fall - Intervention: Staff to assist resident to bed after evening snack.7/27/25 unwitnessed fall, no injury - Intervention: Staff to ensure that resident remote is kept within reach.8/5/25 witnessed fall, no injury - Intervention: Staff will keep pitchers of liquid out of reach. 8/7/25 witnessed fall - Intervention: Sent to hospital for eval/treatment.8/12/25 unwitnessed fall no injury - Intervention: Resident is to be placed in bed at lowest position.8/13/25 unwitnessed fall with injury - Intervention: Encourage resident to utilize wheelchair for mobility.8/16/25 unwitnessed fall, no injury - Intervention: Staff reeducated to frequently toilet resident.8/18/25 witnessed fall - Intervention: Staff to add (non-slip pad) to wheelchair.8/26/25 witnessed fall - Intervention: No new interventions.9/2/25 unwitnessed fall with no injury - Intervention: Staff to keep door to room open for frequent visual checks.9/4/25 unwitnessed fall with no injury - Intervention: Overnight staff to assist resident to chair in Tv room for AM activities.9/7/25 witnessed fall - Intervention: Staff reeducated not to place hands on resident back.9/11/25 witnessed fall - Intervention: No new interventions.9/13/25 unwitnessed fall - Intervention: Scheduled Care Plan meeting with (Local Hospice) to discuss frequent falls.9/13/25 unwitnessed fall - Intervention: Reeducate overnight staff to assist resident to chair in TV room for AM activities.9/13/25 unwitnessed fall - Intervention: Provide an early morning snack.9/15/25 unwitnessed fall - Intervention: Contacted (Local Hospice) to get prn medications scheduled.9/19/25 witnessed fall - Intervention: No new intervention9/19/25 witnessed fall - Intervention: No new intervention9/21/25 unwitnessed fall - Intervention: No new intervention9/21/25 unwitnessed fall - Intervention: No new intervention9/22/25 unwitnessed fall w/o (without) injury - Intervention: Staff to allow resident to sit on floor as he desires.10/29/25 unwitnessed fall no injury - Intervention: Staff to check on resident more frequently during wake hours.11/7/25 unwitnessed fall with hematoma to head - Intervention: Continue with plan of care.Other Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Follow facility fall protocol. Anticipate and meet the resident's needs.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs). R2 is always incontinent of both bowel and bladder.R2's Fall Risk Assessment, dated 3/29/25, documents R2 is a High Fall Risk.The facility's fall log, dated September, October, and November 2025, documents R2 has had more falls that were not addressed in the Care Plan. These falls occurred on 9/24/25 x 2, 9/25/25, 11/1/25, 11/7/25, 11/13/25, and 12/1/25. There are missing Fall Risk Assessments that were not completed after each fall. R2's Hospital Record, dated 8/7/25, documents in part patient is a [AGE] year-old male who presents ER due to fall at his facility. Patient has catatonic schizophrenia and is a very poor historian. He has old bruising to the face. Facility is concerned he may have internal bleeding due to his blood thinning agent. A Head CT (cat scan) was performed with impression: No acute intracranial hemorrhage or suspicious mass effect. Clinical Impression: Bruise to face.R2's Hospital Record, dated 8/13/25, documents in part this is a [AGE] year-old male presenting for ground level fall. Patient is nonverbal due to catatonic schizophrenia and cannot answer questions. Per EMS (emergency medical service) he fell from his chair and struck his head. Patient is on Eliquis. CT was performed with impression: No acute intracranial hemorrhage or suspicious mass effect. Patient re-evaluated with any acute concerns, and his laceration was repaired. Bleeding controlled. discharge: Clinical Impression: CHI (closed head injury), Forehead Laceration.R2's Hospital Record, dated 10/14/25, documents in part Patient is a [AGE] year-old male with past medical history of catatonia, diabetes, hypertension who presents with a fall and laceration. Patient was found after having a fall. Patient has catatonia and intermittently does not answer any questions. For me patient says that he has no pain. He can shake his head no to said that he does not feel sick today. Physical Exam: Head: External signs of trauma to head. Patient has well-healed laceration including left forehead with sutures still in place that were removed by myself. Musculoskeletal: On patient's left fifth digit there is a 1 CM (centimeter) laceration on palmar aspect overlying proximal phalanx. X-Ray of finger shows no acute fracture of dislocation. Laceration was repaired with 3 sutures. R2's Hospital Record, dated 10/15/25, documents in part R2 is a [AGE] year-old male presents to the ED (emergency department) by EMS from (Facility) for evaluation. Patient was evaluated at this facility yesterday for laceration to his left pinky. He received sutures at this time. Per EMS, staff found patient bleeding from his left pinky this morning and sent to the ED. No other complaints. Clinical Impression: Visit for wound check.R2's Hospital Record, dated 10/29/25, documents in part R2 is a [AGE] year-old male presenting to the emergency department following a ground level fall. Patient is nonverbal with limited mobility at baseline. He was apparently walking behind a nurse and fell to the ground injuring his left knee. Shortly thereafter, the patient tripped over something on the ground and fell striking his head. Patient shakes his head when asked if he has any pain though does nod yes when palpating his back. A laceration to the corner of the right eyebrow. A CT of his head, cervical spine, thoracic, and lumbar spine was completed with negative results. Medical Management: The patient is a nursing home resident where ongoing medical care and assistance with activity of daily living will be provided. The fall was purely mechanical in nature by the patient's description, and the patient had no preceding dizziness, chest pain, or shortness of breath and has none of those symptoms now. This description of the events makes syncope or seizure exceedingly unlikely. A syncope work-up (labs, EKG) considered is deemed unnecessary due to the mechanical nature of the fall. Clinical Impression: Ground-level fall, knee abrasion, eyebrow laceration. R2's Hospital Record, dated 11/7/25, documents in part patient is a [AGE] year-old male arriving via EMS from SNF (skilled nursing facility) presenting after a witnessed ground level fall. Patient is A&O (alert and oriented) x3 but demonstrates variable cognitive function. Patient states that he tripped and sustained a head injury. Med list indicates he is on Eliquis. CT of head and neck demonstrated no acute abnormalities. CXR (chest x-ray) demonstrated no acute cardiopulmonary disease. CT pelvis showed moderate arthritis of left hip. Traumatic injury ruled out. discharged back to nursing home. Discharge instructions: Fall Prevention.R2's Incident Note, dated 8/8/25 at 9:43 AM, documents IDT (interdisciplinary team) met to review residents witnessed fall. Care plan updated. Resident at risk for falls related to schizophrenia, anxiety, hypertension, subacute dyskinesia, frequent falls, malnutrition, and antihypertensive and psychotropic medications. Previous interventions include: Recent medication adjustment related to increased anxiety, staff instructed to check on resident more frequently during wake hours, treated for an acute illness, staff educated walk resident to and from the dining room for meals, and staff instructed to ensure resident is wearing appropriate footwear at all times, and pharmacy consulted for medication review, staff re-educated on 1:1 procedure, staff to assist with seating by ensuring chair has arms for support, staff educated on keeping entry ways clear of clutter/residents, increased staff rounding to offer toileting, staff educated not to place their hand on his back while ambulating, staff will keep pitchers of liquid out of reach, staff will ensure resident's remote is within reach when he is in bed, facility removed side table from room, and staff to ensure chairs are pushed up against the wall for support before resident sits. Root cause: Resident became weak and fell. Intervention: Sent to the ER (Emergency Room) for evaluation and treatment.R2's Fall Risk Evaluation Note, dated 11/13/25 at 11:31 AM, documents Fall Risk: History of falls (past 3 months): 3 or more falls in past 3 months. Resident is ambulatory / incontinent. Systolic blood pressure: No noted drop between lying and standing. Predisposing disease: 1-2 present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Gait / balance: Balance problem while walking. Gait / balance: Decreased muscular coordination. Gait / balance: Change in gait pattern when walking through doorway. Gait / balance: Jerking or unstable when making turns. Gait / balance: Balance problem while standing. Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 19.0. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.The following fall interventions were put in place after R2 experienced a fall, however, they are not being followed: Staff to increase toileting rounding with resident, Staff reeducated to frequently toilet resident, Staff to remove nightstand from room, Staff to ensure that resident remote is kept within reach, Staff to keep door to room open for frequent visual checks, Staff to check on resident more frequently during wake hours, and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 11/13/25 at 2:30 PM, R2 was seen lying on the floor in small dining room across from nurse's desk, rolling side to side, sitting up, then lying back down. Other residents were in dining room during this time with both staff and residents seen walking past and around R2 while he was on the floor.On 11/13/25 at 2:35 PM, V9, Licensed Practical Nurse (LPN), stated that R2 is care planned to be on the floor. V9 stated they tried everything to keep him from doing that but if staff tries to get him up, he becomes upset and has behaviors. V9 stated staff keep an eye on him and if he scoots too far, they will intervene to assist him to a chair. V9 stated she has worked with R2 for five years now and R2 can talk and tell you about his needs at times. On 11/17/25 at 8:17 AM, R2 was seen lying in bed with his call light on a nightstand in the middle of the room and not within reach. R2 was seen with his blanket off him and to the side of the bed. There is a noticeable wet spot on R2's sheet underneath his buttocks. The door to the room is closed.On 11/17/25 at 10:25 AM, R2 still seen lying in bed, unchanged from earlier with his call light still on the nightstand and not in reach, and his door to the room remains closed with R2 not visible to staff. R2 still seen lying in bed in the same position, unchanged from earlier, still has visible wet spot on his sheet.On 11/17/25 at 12:10 PM, R2 still lying in bed and in same position as earlier. When asked if he has gotten up today R2 nodded his head no. When asked if he has been cleaned up yet, R2 nodded his head no. The sheets under R2 appeared saturated in urine with a brownish stain around the wet area. R2's call light remains on the nightstand and not in reach of R2. R2's door remains closed with R2 not visible from hallway. On 11/17/25 at 12:24 PM, V12, Certified Nursing Assistant (CNA), and V14, Licensed Practical Nurse (LPN), both walked up to R2's door, opened it and looked inside, then closed the door and walked on down the hall without checking on R2.On 11/17/25 at 12:43 PM, V14, LPN, took a lunch tray into R2's room to assist in feeding him.On 11/17/25 at 12:50 PM, V14 walked out of R2's room with R2's lunch tray and placed it in cart in the hall.On 11/17/25 at 1:00 PM, R2 was still lying in bed now with his blanket pulled up and over him. When asked if he was cleaned up yet, R2 nodded no, when asked if he was still wet, R2 nodded yes. R2 pulled back his blanket showing that his sheet was still saturated and now with the brownish stain and his pants and shirt were also saturated. On 11/17/25 at 1:05 PM, V14 returned and was sitting at R2's bedside assisting R2 with his drinks. On 11/17/25 at 1:15 PM, V14 left after assisting R2 to eat and drink while R2 was saturated with urine/feces in bed. V14 failed to clean him or have CNAs clean him and instead covered R2 up with his blanket and left the room while closing the door behind him.On 11/17/25 at 1:35 PM, V16, CNA, stated (R2) was up when I came on this morning and I helped to put him in his bed after breakfast, maybe around 9:00 AM. The other CNA on this hall left and I was the only one on the hall. I have been everywhere, and I did open (R2's) door to see if he was still breathing, but I didn't have the time to check for anything else.On 11/17/25 at 1:40 PM, V15, CNA, stated I hate to see him (R2) like this. It's too bad that I didn't know he was sitting like this earlier.On 11/17/25 at 1:42 PM, V15 and V16 assisted R2 to stand by the side of his bed with each CNA holding onto one of R2's arms. V16 held onto R2 by under his arm while he stood by side of his bed during peri-care with his pants saturated and down around his ankles. V15 put a clean incontinence brief between R2's legs and fastened it, walked to his recliner and pushed the recliner over to R2 and while still unlocked, had R2 pivot and sit into the unlocked recliner with no gait belt used.On 11/17/25 at 1:55 PM, V15 stated (R2) is a very high fall risk but if he knows you, he will cooperate with you and stand there during care.On 11/18/25 at 8:20 AM, R2 resting in bed with his call light on a nightstand and not within reach. On 11/19/25 at 12:45 PM, V2, Director of Nursing (DON), stated (R2) has a lot of interventions in place for his falls. We have been working with his hospice team and our Psych physician to see what things may work for him and what things don't. We have had a care plan meeting with his family to discuss these things as well.On 12/1/25 at 8:35 AM, Upon investigation, R2 was seen lying on the floor by the side of his bed with his call light coiled up on the floor and not within reach, no staff was seen stopping to assist. V3, Assistant Director of Nursing (ADON), was notified and had V14, LPN, assist R2 to get up and then assisted R2 to the restroom. V26, CNA, assisted R2 from restroom to the dining room while walking besides R2 with no gait belt around R2. On 12/2/25 at 9:00 AM, V28, Nurse Practitioner (NP), stated I have been working with (R2) for years now and he is a complicated resident. We have had meetings where we sat down with Hospice, Psych, and the facility staff to discuss him. I think it is a combination of things going on with him and he is declining and gets manic episodes at times and will take off with a fast walk and loses his balance. We have tried altering his medications to see what would work but he absolutely needs his psychotropic meds, or he will have behaviors. We stopped his Eliquis because it was of no benefit for him at this point. I know he has had numerous falls, but some of them might not have been falls, he has a tendency to sit himself down on the floor. I would always expect the staff to keep him safe and to follow the interventions put into place in order to keep him safe.On 12/2/25 at 10:03 AM, V28, NP, stated Anytime anyone falls and hits their head, there is a chance that they could have a head bleed and could even die from it. (R2) has fallen numerous times and hit his head and he hasn't had a brain bleed, however, it could happen, you just don't know. It is always a possibility. It is very tough to keep him down. We can't stop him and hold him down. The only thing we can do is to keep him safe and avoid an injury if possible.On 12/2/25 at 12:58 PM, V28, NP, stated I would expect the staff to check on the residents every two hours and change them when needed. That is the standard of care. It is not standard of care to leave them sitting in incontinence without cleaning them up.On 12/2/25 at 1:21 PM, V29, Facility Medical Director, stated If the facility did not follow the interventions, and if they cannot justify why things were not done, with the resident at risk, then that would be a neglectful act. Any resident who is left sitting in their incontinence and I was looking from your angle, then I would say it was neglectful period.On 12/2/25 at 1:35 PM, V30, Hospice Medical Director, stated I would expect the staff to be following (R2's) fall interventions and to put further fall interventions in place to minimize the number of falls. If all those observations are happening, then that is a neglectful act. When advised of R2 sitting in his urine and feces for five hours, V30 stated I 100% agree that he should have been cleaned up. No one should be sitting in their urine or feces at all. That should not be happening at all and is not acceptable.The Facility's Abuse Prevention and Prohibition Program Policy, dated 6/1/25, documents in part 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. Identification: Physical Neglect: a. Malnutrition and dehydration. b. Poor hygiene. f. Inadequate provision of care. g. Caregiver indifference to resident's personal care and needs. i. Leaving someone unattended who needs supervision. The Immediate Jeopardy that began on 12/2/25 was removed on 12/4/25, when the facility took the following actions to remove the immediacy.R2 currently resides in the facility. R2 was provided with 1:1 sitter. DON/ADON completed skin assessment on R2 with no negative outcomes noted.Administrator, DON & ADON were in-serviced by the RNC the Abuse Prevention and prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.Administrator in-serviced all department heads on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.Department managers in-serviced department staff members on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.Staff will not work until in-serviced on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.DON/ADON/Department Manager will in-service any future agency employees on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.The DON/ADON/Licensed staff completed skin assessment on residents requiring incontinent care.A quality assurance tool was implemented: DON/ADON/CNA Supervisor will conduct 5 audits weekly X 4 weeks on residents requiring incontinent care and completed in timely manner.A quality assurance tool was implemented for SSD (Social Service Director) or designee to conduct 5 resident interviews weekly X 4 weeks to ensure there are no concerns related to Abuse/Neglect.The DON/ADON will complete audit review during daily (Monday-Friday) morning clinical meeting X 4 weeks to ensure compliance. Audit tool will also include review of new/re-admit fall risk assessments for resident high risk to ensure prevention measure are in place.Root cause analysis completed for neglect r/t (related to) coordination of care provided to residents.

Based on interview, observation, and record review, the facility failed to provide timely and complete incontinent care for 2 of 3 residents (R2, R3) reviewed for incontinent care in the sample of 9. This failure resulted in R2 lying in urine and feces for hours and any reasonable person would not like to sit in their urine or feces with staff not checking on them or cleaning them up timely. The findings include: 1. R2's admission Record, dated 11/18/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Malnutrition, Schizophrenia, Anxiety disorder, Hypertension (HTN), Deep Vein Thrombosis (DVT), Dyskinesia, Falls, Type 2 Diabetes Mellitus (DM), and Major depressive disorder. R2's Care Plan, dated 3/3/25, documents R2 has FUNCTIONAL bladder incontinence r/t catatonic schizophrenia. Interventions: Clean peri-area with each incontinence episode, ensure the resident has unobstructed path to the bathroom, limit fluids 2-3 hours prior to bedtime, monitor and document intake and output as per facility policy, monitor/document for signs/symptoms UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a severe cognitive impairment and is dependent on staff for all Activities of Daily Living (ADLs). R2 is always incontinent of both bowel and bladder.On 11/17/25 at 8:25 AM, R2 was seen lying in bed, awake, with blanket off him and to the side of the bed. There is a noticeable wet spot on R2's sheet underneath his buttocks. The door to the room is closed.On 11/17/25 at 10:25 AM, R2 still seen lying in bed in the same position, unchanged from earlier, still has visible wet spot on his sheet, and the door to room remains closed. On 11/17/25 at 12:10 PM, R2 was seen lying in bed, appears to be same as earlier. When asked if he has gotten up today R2 nodded his head no. When asked if he has been cleaned up yet, R2 nodded his head no. The sheets under R2 appeared to be even more saturated in urine with a brownish stain around the wet area with a foul odor. R2's door remains closed.On 11/17/25 at 12:24 PM, V12, Certified Nursing Assistant (CNA), and V14, Licensed Practical Nurse (LPN), both walked to R2's door, opened it and looked inside, then closed the door and walked on down the hall without checking on R2.On 11/17/25 at 12:43 PM, V14, LPN, took a lunch tray into R2's room to assist in feeding him.On 11/17/25 at 12:50 PM, V14 walked out of R2's room with R2's lunch tray and placed it in cart in the hall.On 11/17/25 at 1:00 PM, R2 was still lying in bed now with his blanket pulled up and over him. When asked if he was cleaned up yet, R2 nodded no, when asked if he was still wet, R2 nodded yes. R2 pulled back his blanket showing that his sheet was still saturated with the brownish stain, his clothes were also saturated, and still with a foul odor. On 11/17/25 at 1:05 PM, V14 returned and was sitting at R2's bedside assisting R2 with his drinks. On 11/17/25 at 1:15 PM, V14 left after assisting R2 to eat and drink while R2 was saturated with urine/feces in bed. V14 failed to clean him or have CNAs clean him and instead covered R2 up with his blanket and left the room while closing the door behind him.On 11/17/25 at 1:35 PM, V16 stated (R2) was up when I came on this morning and I helped to put him in his bed after breakfast, maybe around 9:00 AM. The other CNA on this hall left and I was the only one. I have been everywhere, and I did open (R2's) door earlier to see if he was still breathing, but I didn't have the time to check for incontinence.On 11/17/25 at 1:40 PM, V15 stated I hate to see him like this. It's too bad that I didn't know he was sitting like this earlier.On 11/17/25 at 1:42 PM, V15 and V16 entered to provide incontinent care on R2, both donned gloves with no hand hygiene seen done. Both CNAs pulled R2's shirt off, which was also saturated in urine. Both assisted R2 to stand by the side of his bed with each CNA holding onto R2's arm and no gait belt used. R2's pants were dropped to the floor and his saturated incontinence brief removed with both urine and feces inside. V16 held onto R2 while he stood by side of his bed during peri-care with R2's pants remaining wet and around his ankles. V15 had same soiled gloves on and reached in to get a wet washcloth, from a few washcloths inside a plastic measuring container with water, grabbed a washcloth, then put it back in the water, changed her gloves, then got a wet cloth again, sprayed peri-cleaner on the cloth, and began wiping R2's buttocks, and anal area. V15 changed gloves with no hand hygiene done, then repeated wiping R2 with wet cloths including down his legs, groins, and peri-area. There was no wiping or cleaning of R2's penis or testicles. V15 put a clean incontinence brief between R2's legs and fastened it, walked to his recliner and pushed the recliner over to R2 and while still unlocked, had R2 pivot and sit into the recliner. V16 then removed R2's wet pants and socks, then using same gloves, searched for pants in R2's closet. On 11/19/25 at 10:25 AM, When asked if R2 remembers lying in his wet bed yesterday, saturated in urine/feces, R2 nodded yes. When asked if he would rather be checked on and cleaned up quickly, R2 nodded his head yes. When asked if he likes lying in a wet bed, R2 nodded no, then stated They cleaned me up already. 2. R3's admission Record, dated 11/18/25, documents R3 was originally admitted to the facility on [DATE] with diagnosis of Type 2 DM, Anemia, Atherosclerotic Heart Disease (ASHD), Bipolar disorder, Left below knee amputation (BKA), Morbid obesity, Hernia, Peripheral Vascular Disease (PVD), Major depressive disorder, Anxiety disorder, Falls, HTN, Myalgia of muscles, non-pressure chronic ulcer of skin, Chronic Obstructive Pulmonary Disease (COPD), and Schizophrenia.R3's Care Plan, dated 6/24/25, documents R3 has functional bladder incontinence related to physical limitations, poor toileting habits. Interventions: Clean peri-area with each incontinence episode, encourage fluids during the day to promote prompted voiding responses, monitor and document intake and output as per facility policy, monitor/document for signs/symptoms UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. It continues R3 has bowel incontinence related to immobility, poor diet. Interventions: Check resident every two hours and assist with toileting as needed, provide bedpan/bedside commode, provide loose fitting, easy to remove clothing, provide peri-care after each incontinent episode.R3's MDS, dated [DATE], documents R3 is cognitively intact and is dependent on staff for ADLs, including toileting. R3 is always incontinent of both bowel and bladder.On 11/17/25 at 11:20 AM, V11, CNA, and V12, CNA, entered to do incontinent care on R3. Supplies were already on a bedside table with both CNAs having gloves on. R3's incontinence brief unfastened and open, V12 sprayed R3's peri-area with peri-care, obtained a wet washcloth and wiped the top of R3's peri-area, wiped down each groin, then testicles while folding washcloth between areas. V12 wiped the tip of R3's penis but failed to pull back the foreskin to wash his entire penis. V11 rolled R3 to his right side and held him while V12 obtained wet cloth and wiped R3's buttocks and anal area (feces noted). R3 was rolled to his left side and V12 cleaned R3's right buttock. There was no drying of R3 during incontinence care. On 11/17/25 at 11:00 AM, V10, Ombudsman, stated the residents are complaining to her about improper incontinent care.On 11/19/25 at 11:10 PM, V21, Regional Director of Operations, stated I would expect the staff to check on the residents at least every two hours for incontinence and to provide timely and complete incontinence care when needed.On 11/19/25 at 12:20 PM, V22, CNA, stated I check on my residents every two hours and some I will check every hour that way I don't have to do complete incontinent care. For males, I pull back the foreskin and will clean the penis.On 11/19/25 at 12:30 PM, V18, CNA, stated I check my residents at least every two hours and do complete incontinent care to all areas. For the uncircumcised male, I would pull back the foreskin, wipe the penis in circular motion, then replace the foreskin.On 11/19/25 at 12:35 PM, V2, Director of Nursing (DON), stated I would expect the staff to check on the residents for incontinence care at least every two hours and to provide timely and complete incontinent care, including pulling back the foreskin on uncircumcised males.The facility's Incontinence Care Policy, dated 6/17/25, documents in part 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. 2. Perform hand hygiene and put on non-sterile gloves. 4b. Do not place soiled soapy cloths back in clean basin water until procedure completed. In the male resident, wash the penis first, turn the resident to the side, then wash perineal area. 6. Gently pat area dry with towel from anterior to posterior. 9. Change gloves and perform hand hygiene.The facility's Hand Hygiene Policy, undated, documents in part When to wash hands with soap and water only: after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. If hands will be moving from a contaminated body site to a clean body site during patient care. Before glove placement. After glove removal.

Based on interview and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse by failing to perform background check screenings on current employees, having direct contact with residents. This failure has the potential to affect all 79 residents residing in the facility. This failure resulted in R4 who has a diagnosis of Bipolar Disorder, Depression and Anxiety, experience verbal abuse from a staff member and feeling fear, anger, ashamed and not wanting to come out of room until 8/21/2025. The Immediate Jeopardy began on 9/30/2024. The survey team validated the abatement on 9/15/2025 at 10:46 AM. The facility remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of policies and procedures and the in-service training.Findings include: R4's Care Plan, not dated, does not address abuse in R4's active care plan. R4's Minimum Data Set (MDS), dated [DATE] and 7/29/2025, documents that R4 is cognitively intact.R4's Serious Injury Incident and Communicable Disease Report, dated 6/20/2025, documents that R4 reported that a few weeks ago, kitchen staff member used inappropriate language towards him. R4's Serious Injury Incident and Communicable Disease Report, dated 6/24/2025, documents that on 6/20/25 V1, Administrator, R4 stated that a few weeks ago, kitchen staff member used inappropriate language towards R4. V10, Cook, immediately suspended per protocol. It continues to document that (R4) was initially interviewed and stated that he was in the dining room rear the kitchen doors when (V10), who was in the kitchen, used inappropriate language towards him. (R4) could not recall the date but stated it was a few weeks ago. (R4) could not recall if anyone was else heard the language. On 6/24/25(R4) was interviewed again. (R4) still could not recall if anyone else heard the language or when the incident happened. When asked if anything else was said during the conversation with (V10), (R4) could not recall anything. When asked if he could have misunderstood what (V10) said because of the noise that is in the kitchen, he agreed that it was possible. In conclusion, the facility was unable to substantiate the allegation of verbal abuse. Due to the noisy environment of the kitchen, this was a misunderstanding of words spoken. On 9/9/2025 at 1:10 PM R4 stated that this occurred sometime ago around April, May or June. R4 stated that R4 was in the dining room. R4 stated that that he complained about his food being cold and (V10) said that (V10) was going to whoop R4's ass. R4 stated that he had so many feelings from anger to fear. R4 stated that he was startled, embarrassed and ashamed being talk to that way. R4 stated that he feared he would have to fight V10. R4 stated that he would if he had to but why should he have to. R4 stated that it's hard to be on pins and needles every day. R4 stated that he didn't want to come out of his room while V10 worked at the facility. R4 stated that when he learned that V10 had gotten fired he felt relieved and safe. R4 stated that the facility did ask question about the incident, but they don't believe him. R4 stated that he knows what he heard and how he felt. On 9/9/2025 at 11:25 AM asked V1 for V10's background checks. On 9/10/2025 at 11:42 AM V1 stated that she could not find V10's background checks and could not verify if or when they were completed or if there were any offenses.On 9/10/2025 at 11:43 AM asked V1 for V12, Dietary Aide, V17, Housekeeper, V18, Maintenance, V19, Cook, and V20, Cook, healthcare worker registry and background checks. As of 9/11/2025 at 4:00 PM the facility had not provided V10's registry and background checks.On 9/11/2025 at approximately 1:30 PM V1 stated that under the previous ownership the background check facility stopped servicing the facility due to nonpayment and no one followed up. V1 stated that V17's, and V19's Healthcare worker registry checks and background checks were not completed timely. V1 stated that V12's, V18's, and V19's Healthcare Worker Registry and Background checks had not been completed at all. V1 stated that she is responsible for the background checks. V1 stated that she does not have a business office person at this time, and she is ultimately responsible. V1 stated that after finding that V10's background checks were not completed V1 then checked other hires. V1 stated that on 9/9/2025 and 9/10/2025 she ran background checks for employees hired in June and July as they were not done. V1 stated that V6's, CNA, and V16's, CNA, Healthcare worker registry checks and background checks were not completed. V1 stated that V6, V12, V16, V17, V18, V19 and V20 all have direct access to the resident and checks should have been done. V1 stated that prior to performing the Healthcare Worker Registry and Background checks herself on 9/9/2025 and 9/10/2025 she was not aware of any offenses that each employee had or if they were eligible to work in the facility. V1 stated that the background checks are to be completed upon hire and should have been completed.On 9/11/2025 at 2:44 PM V21, Medical Director, stated that he would expect the staff to follow the policy and guidelines set forth by the state regarding Healthcare Worker Registry and Background checks. V21 stated that the residents in the facility are vulnerable and need protection. V21 stated that it is imperative that the background checks are done and timely because you never know who is or will harm someone. V21 stated that the background checks should have been done. The facility's Prevention and Prohibition Program, dated 6/1/2025, documents that to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. Procedure II. Screening A. The Facility does not knowingly employ anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people.On 9/9/2025 the facility provided a facility matrix and room roster identifying 79 people residing in the facility. The Immediate Jeopardy that began on 9/30/2024 was removed 9/15/2025, when the facility took the following actions to remove the immediacy:A) Administrator was in-serviced by the VP (Vice President) of clinical services on background checks & the need to run prior to staff member working on 9/15/2025.B) Administrator will in-service department heads on ensuring that staff will not work without background check being completed on 9/15/2025.2. A) All staff members that are currently on the working schedule have had a background check completed & are eligible to work in a skilled facility. Completed 9/15/2025.B) Initial audit completed for all current employees, that a background check has been completed. Completed 9/15/2025.C) Review of current policy and procedure to reflect current practices. Completed 9/15/2025.1. No staff will work before having a background check. On-going2. A quality assurance tool was implemented: Audit will be completed for new hires to ensure that background check was completed prior to 1st working day. Administrator and department manager. On going. 3. Root Cause Analysis Completed for background checks. Deficiency: Failed to run background checks on new employees prior to them working their 1st shift.

Based on interview and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse by failing to perform background check screenings on current employees, having direct contact with residents. This failure has the potential to affect all 79 residents residing in the facility. This failure resulted in R4 who has a diagnosis of Bipolar Disorder, Depression and Anxiety, experience verbal abuse from a staff member and feeling fear, anger, ashamed and not wanting to come out of room until 8/21/2025. Findings include: R4's Care Plan, not dated, does not address abuse in R4's active care plan.R4's Minimum Data Set (MDS), dated [DATE] and 7/29/2025, documents that R4 is cognitively intact.R4's Serious Injury Incident and Communicable Disease Report, dated 6/20/2025, documents that R4 reported that a few weeks ago, kitchen staff member used inappropriate language towards him.R4's Serious Injury Incident and Communicable Disease Report, dated 6/20/2025, documents that on 6/20/25 V1, Administrator, R4 stated that a few weeks ago, kitchen staff member used inappropriate language towards R4. V10, Cook, immediately suspended per protocol. It continues to document that (R4) was initially interviewed and stated that he was in the dining room rear the kitchen doors when (V10), who was in the kitchen, used inappropriate language towards him. (R4) could not recall the date but stated it was a few weeks ago. (R4) could not recall if anyone else heard the language. On 6/24/25 (R4) was interviewed again. (R4) still could not recall if anyone else heard the language or when the incident happened. When asked if anything else was said during the conversation with (V10), (R4) could not recall anything. When asked if he could have misunderstood what (V10) said because of the noise that is in the kitchen, he agreed that it was possible. In conclusion, the facility was unable to substantiate the allegation of verbal abuse. Due to the noisy environment of the kitchen, this was a misunderstanding of words spoken.On 9/9/2025 at 1:10 PM R4 stated that this occurred sometime ago around April, May or June. R4 stated that R4 was in the dining room. R4 stated that he complained about his food being cold and (V10) said that (V10) was going to whoop R4's ass. R4 stated that he had so many feelings from anger to fear. R4 stated that he was startled, embarrassed and ashamed being talked to that way. R4 stated that he feared he would have to fight V10. R4 stated that he would if he had to but why should he have to. R4 stated that it's hard to be on pins and needles every day. R4 stated that he didn't want to come out of his room while V10 worked at the facility. R4 stated that when he learned that V10 had gotten fired he felt relieved and safe. R4 stated that the facility did ask questions about the incident, but they don't believe him. R4 stated that he knows what he heard and how he felt.On 9/9/2025 at 11:22AM V1 stated that she was made aware of the allegation. V1 stated that V10 was suspended immediately. V1 stated that an investigation was started. V1 stated that the conclusion of the investigation was that the allegation could not be substantiated due to no witnesses and R4 could not verify for sure that this was said. V1 stated that the allegation was unsubstantiated. V1 stated that V10 was let go from the facility on 8/21/2025 for safety reasons.On 9/9/2025 at 11:25 AM V10's background checks were requestedOn 9/10/2025 at 11:42 AM V1 stated that she could not find V10's background checks and could not verify if or when they were completed.On 9/11/2025 at approximately 1:30 PM V1 stated that she is responsible for the background checks. V1 stated that she does not have a business office person at this time, and she is ultimately responsible. V1 stated that the background checks are to be completed upon hire and should have been completed.The facility's Prevention and Prohibition Program, dated 6/1/2025, documents that to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. Procedure II. Screening A. The Facility does not knowingly employ anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people.

Based on interview, observation and record review the facility failed to ensure timely assesment for continuity of care for 1 of 3 residents (R1) reviewed for continuity of care in the sample of 3. This failure resulted in R1 with known epilepsy with seiziures, not receiving anti seizure medications for 4 days and being sent out for emergency treatment and had a seizure. Findings include: R1's Facesheet undated documents an admitted [DATE] and pertinent medical diagnoses of Epilepsy, unspecified., not intractable without status Epilepticus, Localization-related (Focal) (Partial) Symptomatic Epilepsy and Epileptic Syndromes with Complex Partial Seizures, Not Intractable Without Status Epilepticus, Major Depressive Disorder, Single Episode, Unspecified and Unspecified. Unspecified Atrial Fibrillation. R1's Physician Order Summary (POS) dated March 2025 documents R1's pertinent medications as Lacosamide 100 milligrams (mg) twice a day (Epilepsy), Fluoxetine 10 milligrams (mg) daily (Major Depressive Disorder), Metoprolol 1 tablet every 12 hours (Primary Hypertension) Amlodipine 10 milligrams (mg) (Unspecified Atrial Fibrillation), Levetiracetam 1000 milligrams (mg) twice a day all with a Start Date of 1/22/25 and Hold date from 3/14/25 to 3/17/25, Tradjenta 5 milligrams (mg) (Type 2 Diabetes Mellitus) 1 tablet daily Start Date of 2/5/25 and Hold date from 3/14/25 to 3/17/25. R1's Electronic Medication Administration Record (eMAR) dated March 2025 documents R1's 8:00 PM medications were held on 3/14/25, 3/15/25 and 3/16/25 for both 8:00 AM & 8:00 PM doses. The 8:00 AM dose on 3/17/25 was held. On 3/12/25 at 9:51 PM Nurse's Progress notes documents R1 was requesting her new pill. V17 Licensed Practical Nurse documents that R1 was overheard talking to her daughter (V5) about the new pill that she takes 3 times /day and then question as to if the daughter will bring it to her. V17 Licensed Practical Nurse documents that without an order for medication the medication could not be administered. On 3/14/25 at 1:51 PM Nurse's Progress notes documents (V4) Social Service Director addressed the daughter in regards to her giving resident medication while she is on a Leave of Absence (LOA) with her. (V5) daughter was stated that she hasn't given resident any medications , but she did display a bottle of Antibiotics that was suppose to be given from a local pharmacy. The directions for administration were 1 tablet twice a day and there was a total of 10 pills given, but she (R1) only had 4 pills left. (V5) repeatedly stated that she had not given resident (R1) any medications. On 3/14/2025 an email from V7 Nurse Practitioner to V2, Diretor of Nursing, documented an order to hold the medication of R1 due to a report from facility nursing staff that it was a possibility that R1 was being double or tripled dose by V5, her daughter. On 3/20/25 at 9:37 AM V16 Licensed Practical Nurse ( LPN) stated she was the one that was passing medications to R1 when she requested her new pill. As she (V16) was explaining to her that she did not have a new pill. R1 kept repeating that she had a new pill. R1 called her daughter (V5) and the conversation between the two of them was (R1) telling (V5) her daughter that she was not being given the new pill. (V5) R1's daughter came to the facility with a bottle of medicine and wanted it to be given to her mother. (V5) was advised that we could not give the medicine and we would need to obtain an order for the medication. On 3/20/25 at 11:31 AM V17 Nurse Practitioner stated she was on vacation for 2 weeks and V7 Psychiatric Nurse Practitioner (NP) was covering for her. V17 stated she was aware that (R1) was being followed by specialists but do not have any interactions with the specialists. V17 stated she was unaware of the labs ordered by the nephrologist. When she returned from vacation she did have an email from V7 advising that there was a possibility that R1 was receiving double dosages of a medicine thought to be an antibiotic. The move to hold the medication was based on not having any information as to why R1 was on any medication besides what was prescribed. V17 stated the expectation was for the specialist to contact us if they have any concerns. If she had any concerns she would contact them. On 3/20/25 at 11:43 AM V7 Psychiatric Nurse Practitioner stated she was not the regular provider for (R1). The nurse practitioner (V17) was on vacation and she (V7) was just covering for (V17). V7 stated she went with the information that was provided from the staff. The staff assumed (R1) was receiving double or triple doses of some type of medication. She (V7) did not know what the medication was and the staff did not specify the medication because they did not know. What was reported was (V5) the daughter was providing the medication to her mother (R1). On 3/20/25 at 12:25 V4 Social Service Director stated when (V5) daughter of R1 returned her mother (R1) to the facility she (V5) did not bring the medication or share that her mother was on a prescribed medication. We became aware of some medication only after the mother (R1) began asking about her new pill. On 3/20/25 at 4:20 PM V2 Director of Nursing stated we did what we were supposed to do. The staff continued to give prescribed medication until able to contact a provider. The order was via email dated 3/14/25 to Hold medications and to monitor (R1). Staff continued to monitor R1 until she was sent to the emergency room [DATE]. R1's medical records from a local hospital dated 3/17/25 documents residents seizure medications were stopped few days ago per the order of nursing home staff after they had negative interactions with (V5) patient's daughter . While in Triage patient had a tonic seizure lasting less than 1 minute. Patient was postictal and had a nasal trumpet inserted. On 3/21/25 at 10:26 AM V22 Medical Director stated the Nurse Practitioner's should be having contact with the specialist. On 3/21/25 at 2:30 PM V26 pharmacist stated the nurse practitioner dropped the ball, the nurse practitioner should have reviewed the medication before 3 days. It is definitely concerning because Lacosamide has a half-life of 13 hrs and Keppra has a half life of 6-8 hrs. Those meds are significant, while overdosing might be a concern, review of the medication and further assessment was warranted. Do not feel the facility was at fault, the problem lies with the nurse practitioner as a provider not reviewing or assessing the resident sooner. The facility did not have a policy on Continuity of Care.

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of epilepsy/seizures received their anti-convulsant medications as ordered by the physician for 1 of 3 (R14) residents reviewed for medications in the sample of 3. This failure resulted in R14 missing 10 doses of his anti-convulsant medication and requiring evaluation and treatment in the emergency room (ER) following seizure activity. Findings include: R14's facesheet dated 4/29/25 documents his diagnosis to include epilepsy, unspecified, intractable, without status epilepticus and localization-related (focal) (partial) symptomatic epilepsy, epileptic syndromes with complex partial seizures, intractable, without status epilepticus, and other seizures. R14's care plan dated 4/29/25 documents The resident has a seizure disorder. Interventions for this care plan include give seizure medications as ordered by doctor. Monitor/document side effects and effectiveness. R14's medication administration record (MAR) dated 3/1/25-3/31/25 documents R14 did not receive his oxcarbazepine (anti-seizure medication) oral tablet 600 mg (milligrams) two tablets at 6:00 PM on 3/29/25 and at 8:00 AM on 3/30/25. R14's progress note dated 3/29/25 at 5:05 PM documents: orders-administration note oxcarbazepine oral table 600 mg give 2 tablets by mouth two times a day for epilepsy-awaiting med. R14's progress note dated 3/30/25 at 8:47 AM documents his oxcarbazepine was not available and reorder awaiting pharmacy. R14's [DATE]/30/35 at 8:39 AM documents R14's lacosamide oral tablet (anti-seizure medication) 100 mg give one tablet by mouth two times a day for epilepsy was not available, reordered awaiting pharmacy. R14's MAR dated 4/1/25-4/30/25 documents he did not receive his lacosamide on 4/3/25 (PM dose) 4/6/25 (PM dose) 4/7/25 (PM dose) and 4/8/25 (AM and PM dose). R14's Controlled Drug Receipt/Record/Disposition Form dated 3/22/25 documents he ran out of his lacosamide 100 mg tablets on 4/5/25 after PM dose. R14's Drug Receipt/Record/Disposition Form dated 4/9/25 documents he did not receive his next dose of lacosamide until 4/9/25 at 8:30 AM. There is no documentation on these count sheets of R14 receiving AM doses of lacosamide on 4/6/25 or 4/7/25 AM doses. R14's progress note date 4/1/25 at 4:45 PM documents Seizure activity noted in bed. Clonic episode lasting 2.5 minutes. Emesis noted. Resident placed in recovery position until seizure completion. EMS called. Post ictal phase noted with pupils dilated to 6. Walking around room without purpose and combative with staff. Unable to answer questions or respond appropriately. VS: 98.2, 88, 22, 131/74, and 95% on room air. No signs of pain or injury. Sent to (local hospital) for evaluation and treatment. On 4/29/25 at 12:50 PM V6 Nurse Practitioner stated she was first notified by staff to refill R14's lacosamide on 4/8/25. V6 stated she was reviewing R14's information from 4/6/25 and 4/7/25 and was not notified, but she would not know if staff reached out to another provider. V6 stated yes, it would be significant for R14 to receive anti-seizure medication since R14 has had seizures since the age of 9 and R14 is a difficult case and he needs to take his anti-seizure medications as ordered. On 4/29/25 at 1:50 PM V7 Pharmacy [NAME] Lead stated pharmacy was notified by fax on 4/8/25 at 7:21 PM requesting refill on R14's lacosamide. On 4/29/25 at 1:55 PM V8 Pharmacist stated lacosmide has a half-life of 13 hours, and R14 would have been sub therapeutic after 24-30 hours. V8 stated lacosamide was filled by pharmacy on 4/8/25 and started on 4/9/25. V8 stated R14 was sub therapeutic on 4/8/25 and 4/9/25 and was therapeutic by 4/10/25. V8 stated R14 was not therapeutic for 1 day and would not recommend doing this again. V8 stated R14 dodged a bullet that R14 did not have a seizure during that time. V8 stated he would consider this a significant medication error. V8 stated it is never recommended that a resident with a history of seizures misses any of their medication. On 4/29/25 at 1:22 PM V9 Registered Nurse (RN) stated she does not recall R14 ever being out of lacosamide, and if she pulled from pharmacies emergency stock of medication it would have been documented on a sheet. V9 stated she does not remember ever pulling a lacosamide for R14. V9 stated she is unsure of where she got R14's lacosamide doses on 4/625 and 4/27/25. On 4/29/25 at 2:20 PM V2 Director of Nursing (DON) stated as part of the plan of corrections she was auditing residents who took seizure medications. V2 stated if she saw a missed medication she would educate the nurse, and then should have documented everything in the resident's electronic medical record (EMR). V2 stated she went back and had to put late entries in some of the resident's progress notes related to missed medications. V2 acknowledged R14's controlled drug receipt/record/disposition form that stated R14 ran out of lacosamide after 4/5/25 PM and did not resume until 4/9/25 AM. V2 stated she has no idea how V9 RN would have gotten and documented lacosamide since the medication was not in the facility. V2 stated V11 Medical Doctor (MD) was called on 4/8/25 letting him know R14 needed a signed script for lacosamide. V2 unable to provide documentation of why R14's lacosamide was not refilled and available on 4/6/25. On 4/30/25 at 10:48 AM V2 stated lacosamide is not included in the emergency kit. The facilities policy revised 7/18/18 Emergency Pharmacy and Emergency Kits documents, Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved Emergency Medication kit/box or by special order from MAC Rx. MAC Rx supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in compliance with applicable state and federal regulations to serve the immediate clinical needs of the resident. The facilities policy undated policy Receiving Controlled Substances documents Procedures: H. Controlled substances are reordered when a four (4) day supply remains to allow for transmitted of the required written prescription to the pharmacist.

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of epilepsy/seizures received their anti-convulsant medications as ordered by the physician for 1 of 3 (R14) residents reviewed for medications in the sample of 3. This failure resulted in R14 missing 10 doses of his anti-convulsant medication and requiring evaluation and treatment in the emergency room (ER) following seizure activity. Findings include: R14's facesheet dated 4/29/25 documents his diagnosis to include epilepsy, unspecified, intractable, without status epilepticus and localization-related (focal) (partial) symptomatic epilepsy, epileptic syndromes with complex partial seizures, intractable, without status epilepticus, and other seizures. R14's care plan dated 4/29/25 documents The resident has a seizure disorder. Interventions for this care plan include give seizure medications as ordered by doctor. Monitor/document side effects and effectiveness. R14's medication administration record (MAR) dated 3/1/25-3/31/25 documents R14 did not receive his oxcarbazepine (anti-seizure medication) oral tablet 600 mg (milligrams) two tablets at 6:00 PM on 3/29/25 and at 8:00 AM on 3/30/25. R14's progress note dated 3/29/25 at 5:05 PM documents: orders-administration note oxcarbazepine oral table 600 mg give 2 tablets by mouth two times a day for epilepsy-awaiting med. R14's progress note dated 3/30/25 at 8:47 AM documents his oxcarbazepine was not available and reorder awaiting pharmacy. R14's [DATE]/30/35 at 8:39 AM documents R14's lacosamide oral tablet (anti-seizure medication) 100 mg give one tablet by mouth two times a day for epilepsy was not available, reordered awaiting pharmacy. R14's MAR dated 4/1/25-4/30/25 documents he did not receive his lacosamide on 4/3/25 (PM dose) 4/6/25 (PM dose) 4/7/25 (PM dose) and 4/8/25 (AM and PM dose). R14's Controlled Drug Receipt/Record/Disposition Form dated 3/22/25 documents he ran out of his lacosamide 100 mg tablets on 4/5/25 after PM dose. R14's Drug Receipt/Record/Disposition Form dated 4/9/25 documents he did not receive his next dose of lacosamide until 4/9/25 at 8:30 AM. There is no documentation on these count sheets of R14 receiving AM doses of lacosamide on 4/6/25 or 4/7/25 AM doses. R14's progress note date 4/1/25 at 4:45 PM documents Seizure activity noted in bed. Clonic episode lasting 2.5 minutes. Emesis noted. Resident placed in recovery position until seizure completion. EMS called. Post ictal phase noted with pupils dilated to 6. Walking around room without purpose and combative with staff. Unable to answer questions or respond appropriately. VS: 98.2, 88, 22, 131/74, and 95% on room air. No signs of pain or injury. Sent to (local hospital) for evaluation and treatment. On 4/29/25 at 12:50 PM V6 Nurse Practitioner stated she was first notified by staff to refill R14's lacosamide on 4/8/25. V6 stated she was reviewing R14's information from 4/6/25 and 4/7/25 and was not notified, but she would not know if staff reached out to another provider. V6 stated yes, it would be significant for R14 to receive anti-seizure medication since R14 has had seizures since the age of 9 and R14 is a difficult case and he needs to take his anti-seizure medications as ordered. On 4/29/25 at 1:50 PM V7 Pharmacy [NAME] Lead stated pharmacy was notified by fax on 4/8/25 at 7:21 PM requesting refill on R14's lacosamide. On 4/29/25 at 1:55 PM V8 Pharmacist stated lacosmide has a half-life of 13 hours, and R14 would have been sub therapeutic after 24-30 hours. V8 stated lacosamide was filled by pharmacy on 4/8/25 and started on 4/9/25. V8 stated R14 was sub therapeutic on 4/8/25 and 4/9/25 and was therapeutic by 4/10/25. V8 stated R14 was not therapeutic for 1 day and would not recommend doing this again. V8 stated R14 dodged a bullet that R14 did not have a seizure during that time. V8 stated he would consider this a significant medication error. V8 stated it is never recommended that a resident with a history of seizures misses any of their medication. On 4/29/25 at 1:22 PM V9 Registered Nurse (RN) stated she does not recall R14 ever being out of lacosamide, and if she pulled from pharmacies emergency stock of medication it would have been documented on a sheet. V9 stated she does not remember ever pulling a lacosamide for R14. V9 stated she is unsure of where she got R14's lacosamide doses on 4/625 and 4/27/25. On 4/29/25 at 2:20 PM V2 Director of Nursing (DON) stated as part of the plan of corrections she was auditing residents who took seizure medications. V2 stated if she saw a missed medication she would educate the nurse, and then should have documented everything in the resident's electronic medical record (EMR). V2 stated she went back and had to put late entries in some of the resident's progress notes related to missed medications. V2 acknowledged R14's controlled drug receipt/record/disposition form that stated R14 ran out of lacosamide after 4/5/25 PM and did not resume until 4/9/25 AM. V2 stated she has no idea how V9 RN would have gotten and documented lacosamide since the medication was not in the facility. V2 stated V11 Medical Doctor (MD) was called on 4/8/25 letting him know R14 needed a signed script for lacosamide. V2 unable to provide documentation of why R14's lacosamide was not refilled and available on 4/6/25. On 4/30/25 at 10:48 AM V2 stated lacosamide is not included in the emergency kit. The facilities policy revised 7/18/18 Emergency Pharmacy and Emergency Kits documents, Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved Emergency Medication kit/box or by special order from MAC Rx. MAC Rx supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in compliance with applicable state and federal regulations to serve the immediate clinical needs of the resident. The facilities policy undated policy Receiving Controlled Substances documents Procedures: H. Controlled substances are reordered when a four (4) day supply remains to allow for transmitted of the required written prescription to the pharmacist.

Based on interview, observation and record review, the facility failed to provide adequate supervision and progressive devices to prevent falls for one of thirteen residents (R2) reviewed for falls in the sample of 50. This failure resulted in R2 falling from the toilet when left unsupervised and sustained multiple rib fractures and laceration to his head. Findings include: R2's Cumulative Diagnosis Log undated documents diagnoses Paranoid Schizophrenia, anemia, hypothyroidism, hyperlipidemia, gastroesophageal reflux disease, vitamin D deficiency, anxiety, repeated falls, and major depressive disorder. R2's Fall Risk assessment dated [DATE] documents, a score of 20. 10 or more points = High Risk Score. R2's MDS, (Minimum Data Set), dated 09/13/23 documents, a BIMS, (Brief Interview of Mental Status), score of 15 out of 15. The MDS documents, that R2 requires limited assistance of one person for bed mobility, transfer, locomotion on unit, locomotion off unit, and personal hygiene. The MDS documents, that R2 requires extensive assistance of one person for toilet use. The MDS documents, that R2 is not steady, only able to stabilize with staff assistance. R2's Care Plan dated 03/07/19 documents, Has risk factors for falls: balance, assistive devices, needs assist for transfer, vision problems, medical conditions, meds, poor safety awareness, and behaviors put resident at risk. R2's Interventions: 02/26/23 r/t, (related to), fall, staff to check on frequently when in bed. 03/06/23 r/t fall, staff to utilize pressure alarm for bed and wheelchair. 08/17/23 r/t fall, educated resident and staff to ensure that w/c, (wheelchair) is locked during all transfers. 09/06/23 r/t fall, instructed to use call light and wait for assistance. R2's Nurses Note dated 11/06/22 at 6:27 AM documents Resident has a fall this morning he stated that his pain was 5 he was found lying on his left side. Stated that his left hip hurts. Vitals were B/P, (blood pressure), 120/58, P (pulse) 88, R, (respiration), 21, T, (temperature), 97.1. He stated that he was trying to put his tablet in his drawer. R2's Quality Improvement Review Note dated 11/07/22 at 9:00 AM documents, QA, (quality assurance), committee met to review fall on 11/07/22, resident attempting to put item in drawer, encourage to ask for assistance. No note written for fall on 11/22/22. On 11/16/23 at 3:00 PM, V2, DON, (Director of Nursing), stated that she could find a nurses note about any fall on 11/22/22. R2's Quality Improvement Review Note dated 11/22/22 at 9:15 AM documents, QA committee met to review fall with no injury noted. Resident was attempting to sit in w/c and missed, resulting in him sitting on floor in front of wheelchair. Encouraged resident to use call light and wait on staff assistance. Medical workup obtained. R2's Nurses Note dated 02/26/23 at 8:40 AM documents, This nurse passing HS meds when resident reported to nurse having severe pain 8/10 to left rib area. This nurse asked what happen to area, he reports he had a fall at 3a (SIC) while attempting to go to restroom in bedroom. Resident was able to recall event and states prior to falling he felt dizzy. Resident states he fell on the toilet landing on his left side and hitting head on the wall. Resident states he did not report incident sooner because he was scared and thought Jesus would heal him sooner. This nurse does not see any visible injuries. VS, (vital signs), WNL, (within normal limits). ROM, (range of motion), WNL. Lying in bed currently. Schedule PP, (pain pill), given. Call light in reach. Will follow up with NP, (Nurse Practitioner), for orders to send to ER, (emergency room ). R2's Nurses Note dated 02/27/23 at 2:00 AM documents, Nurse from (local hospital) called states resident is being d/c, (discharge), with multiple rib fracture and sternum mass on liver, no transportation to get resident back to facility, phone call to (V1) administrator to make her aware of situation, states (psychosocial program) can pick him up from hospital @ 7a (SIC) when they arrive. R2's Quality Improvement Review Note dated 02/27/23 at 10:30 AM documents, QA committee met r/t fall reported on 02/26/23. Resident reported to staff nurse that he fell overnight trying to go to bathroom w/o, (without), assistance, stated he felt dizzy and fell over toilet, he was sent to ER for eval, resident sustained multiple rib fractures from unwitnessed fall, he returned back to facility, staff to check more frequently when in bed. R2's Nurses Note dated 03/06/23 at 8:45 AM documents Resident was ambulating to bathroom on his way back out of bathroom he lost his balance, fell to floor landing on his left side. States he hit his head. Assessment by nurse. Moves all extremities WNL for this resident neuro checks started. V/S 120/77 - 66 - 18 - 97.8 96% RA, (room air), O2 sats, (oxygen saturation). C/o, (complaint of), pain to left ribs area. R2's Quality Improvement Review Note dated 03/07/23 at 10:15 AM documents QA committee met r/t fall on 03/06/23, resident attempted to go to bathroom without assistance. Resident lost balance and fell , staff to utilize pressure alarm for bed. R2's Nurses Note dated 05/19/23 at 11:35 AM documents, resident chair alarm going off. CNA went to room and resident noted to be on knees on the floor. this nurse came to room and resident was getting up from floor by himself. Resident states he has no pain to knees. Resident states he also hit his left shoulder on his roommate's bed. denies pain to shoulder and ROM WNL. Redness/abrasions noted post-fall. Attempted to call emergency contact (POA) but the number is incorrect. Attempted to call NP x 2 but went voicemail and voicemail is full. Will try again. neuro checks WNL - ROM WNL. VS 126/74, 72, 18, 97.5, 96% RA. Resident denies hitting head. Will monitor. Spoke with NP - 0 new orders. monitor for bruising/pain. No Quality Improvement Review Noted for fall on 05/19/23. No intervention noted for fall on 05/19/23. R2's Nurses Note dated 08/17/23 2:10 AM documents, Resident had a fall in bedroom. Staff was in room with resident. No injury noted. NP was notified. Administrator was notified. Resident emergency contact notified. R2's Quality Improvement Review Note dated 08/12/23 9:30 AM documents QA committee met r/t fall with zero injury noted on 08/17/23. Resident attempted to sit back in w/c after incontinent care with CNA, (Certified Nurse Aide), and w/c moved causing him to land on buttocks. Educated resident and staff to ensure that w/c is locked during all transfers. R2's Nurses Note dated 09/06/23 at 6:25 AM documents, Resident had a fall in his room. Writer went to resident room. Found him on the floor sitting on his buttocks. Resident stated, that he was trying to go to his closet to shut the door and went in the opposite direction and slipped and fell ed (SIC). No injury noted. Vitals are B/P 130/80, P - 113, R 22, T 97.4. Notified emergency contact, notified NP, notified Administrator, notified DON. Will follow facility protocol related to falls. R2's Quality Improvement Review Note dated 09/07/23 at 9:15 AM documents QA committee met r/t fall on 09/06/23 with no injury noted. Resident stated he was closing his closet door and walking backwards and fell , instructed to utilize call light and wait for assistance. R2's Nurses Note dated 11/06/23 at 6:27 AM documents Resident has a fall this morning he stated that his pain was 5 he was found lying on his left side. Stated that his left hip hurts. Vitals were B/P 120/58, P 88, R 21, T 97.1. He stated that he was trying to put his tablet in his drawer. No Quality Improvement Review Noted for fall on 11/06/23. No intervention noted for fall on 11/06/23. On 11/17/23 at 10:59 AM, R2 observed sitting in dining area in wheelchair unsupervised. Chair alarm noted attached to resident. On 11/17/23 at 10:55 AM, V16, CNA stated that they use bed and alarms to prevent (R2) from falling. She stated that he started ambulating with a walker under supervision with a wheelchair following. On 11/17/23 at 11:30 AM, V12, LPN, (Licensed Practical Nurse), stated that to prevent (R2) from falling they use bed alarm and chair alarm. (R2) is a one assist from staff. She stated that they re-educate him on using the call light. On 11/17/23 at 12:45 PM, V2, DON stated that she would expect there to progressive interventions added to a resident's care plan following a fall. Facility's Fall Prevention policy dated 11/10/18 documents To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions.

Based on interview and record review the facility failed to initiate appropriate interventions to prevent the dislodgement of 1 of 3 residents (R3) reviewed for gastrostomy tube, (g-tube), placement. This failure resulted in R3 gastrostomy tube being dislodged, causing R3 pain, and being sent to local emergency room and he had to be hospitalized for the replacement of the g-tube. R3's Admission sheet documents, that R3 was admitted [DATE]. R3's Care Plan, dated 7/7/23, documents, that R3 receives enteral nutrition support. Related diagnosis: Hypoxic Ischemic Brain Injury, G-Tube 18 FR R3's Nurses Notes, dated 9/17/22, documents, that the nurse entered the room for feeding and flush and noticed R3's gown wet. G-tube displaced and deflated. R3's Nurses Notes, dated 10/14/22 at 10 AM, documents, Resident was getting out of bed with assist with CNA. G tube sliding in and out balloon was deflated. Order was received to send R3 to ER. R3's Nurses Notes, dated 2/20/23 at 9:45 AM, documents, resident was sent to the (local) hospital r/t, (related to), G-tube kept popping out. R3's (Local Hospital) Patient Visit Information, dated 2/20/23, documents, that R3 was seen today for gastrostomy tube dysfunction. R3's G-tube was replaced. R3's Discharge Summary, dated 5/9/2023, documents, that R3 is [AGE] year-old patient with a history of stroke, hypertension, sleep apnea, paraplegia, who present to the ED, (Emergency Department), complaints dislodged G-Tube. It documents, that R3 was taken to the GI lab, (Gastrointestinal Laboratory), and G-tube was successfully replaced. R3's Progress Note, dated May 11, 2023, documents, that the reason for visit: presents after hospital stay for GT (Gastrostomy Tube) replacement. On 8/9/2023 at 8:14 AM V10, R3's mother, stated, that R3 came to the facility because he needed 24-hour care. V10 stated, that R3's g-tube has come out multiple times since being at the facility. V10 stated, that it was a total of six times while at the facility. V10 stated, that shortly after being at the facility R3 had to go to the emergency room because, his g-tube came out. V10 stated, that it had to hurt each time when that g-tube with the ball on it was pulled out of the small hole in his stomach. V10 stated, it would hurt me. V10 stated, that R3 cannot express himself, due to his stroke, but that doesn't mean that the pain isn't there. V10 stated, that each time his g-tube comes out he must go to the emergency room to get it put back in. V10 stated, that it's ridiculous. V10 stated, that the being pulled and jerked from bed to stretcher to bed to stretcher has too uncomfortable and painful as well. V10 stated, that her son would not be ok with this. V10 stated, that her son would not be ok with being in pain and taken back and for to the hospital. V10 stated, that she feels bad for him. V10 stated, that she was informed that the g-tube came out during care. V10 stated, that they are supposed to be trained to care for R3. V10 stated, that she was told that in May his feeding came out during a transfer. V10 stated, that she knew R3 was in pain and that she felt helpless. On 8/9/2023 at 3:44 PM V11, LPN, stated, that she provided care for R3. V11 stated, that R3's g-tube was pulled out a couple time when the staff turned him and cleaned him. R3 stated, that the tubing was under the cover and got pulled in the process. V11 stated, that R3 could not move his arms and could not have pulled them out himself. On 8/10/2023 at 2:00 PM V4, LPN, stated, that R3 was a quadriplegic and could not move without staff assistance. V4 stated, that R3 could not move his hands. V4 stated, that R3's g- tube came out multiple times. V4 stated, that she was not sure how many times. V4 stated, R3 was not capable of pulling the tubing out. V4 stated, that she was the nurse when R3's g-tube was pulled out during a transfer. V4 stated, she was able to get R3 out to the emergency room for g-tube replacement. V4 stated, that it was a while ago and she was unable to say what exactly happened. V4 stated, that it was pulled out during a transfer. V4 stated, that R3 did not have an abdominal binder. V4 stated, that they asked for a longer tubing, but did not get one. V4 stated, that the binder would have probably worked and kept his tubing from being pulled out, but they did not get one. On 8/14/2023 3:56 PM V14, Doctor, stated, that with the number of times that the g-tube was dislodged, he would have expected some interventions have been put into place. V14 stated, that an abdominal binder may or may not be appropriate depending on the patient, because it compresses breathing. V14 stated, that other interventions could have been put in place to prevent dislodgement like if the resident is pulling out then positioning the tubing so that the patient could not reach. V14 stated, that if the g-tube is being dislodged during care then getting a longer tube. V14 stated, that if the tubing was leaking then getting the appropriate tubing. V14 stated, that a dressing could have been applied to help maintain placement. V14 stated, that he would expect interventions to be put in place. On 8/14/2023 at 4:05 PM V11, LPN, stated, that the initial pull through the opening would cause R3 pain.

Based on interview and record review the Facility failed to assess and conduct root cause analysis of falls and implement progressive interventions to prevent falls for 1 of 3 residents (R2) reviewed for falls in the sample of 6. This failure resulted in R2 falling and sustaining a [CONDITION(S)]. Findings include R2's Cumulative Diagnoses Log in R2's paper medical record undated documents diagnoses of essential hypertension, [CONDITION(S)] (stroke) and [CONDITION(S)]. R2's Cognitive assessment dated [DATE] document, R2 was severely impaired for cognition and activities of daily living. R2's Psychosocial assessment dated [DATE] and 9/22/2022 document R2 has severe impairment in judgement, and safety awareness. R2's Discharge Evaluation dated 2/16/2022 and 9/22/2022 document R2 was forgetful and had safety awareness. R2's Discharge Evaluation dated 6/27/2022 and 9/22/2022 document R2 has a history of falls in the last 30 days. R2's Medical Records does not have a Fall assessment completed for R2 before 9/7/2022. R2's emergency room visit dated 3/1/2022 documents, Chief complaint: Fall. Patient is a [AGE] year-old male presenting to our facility after he slipped out of a chair at a nursing home. I spoke with the nurse at the facility, and she states that the patient was found on the floor near to his wheelchair as if he had slipped out of the chair this morning. R2's Nurse's Note, dated 4/27/222 documented Resident was in the T.V. room when I heard resident fall. It was unwitnessed. Full assessment done. The Nurse's Note did not document R2 sustained injury from this fall. R2's Care Plan was not revised with any interventions to address R2's fall on 4/27/22 or progressive interventions to prevent future falls. R2's Minimum Data Set (MDS) dated [DATE] document R2 was severely impaired for cognition. R2's Nurse's Note, dated 5/20/2022 at 5:20 PM, documents Resident fell in hallway, trying to walk, unwitnessed fall. The Nurse's note documented neuro checks were started and family and physician were notified. The Nurse's Note did not document what the facility put into place after this fall to prevent R2 from future falls. R2's Nurse's Notes dated 5/20/2022 at 5:30 PM, Resident got out of bed and fell again. EMT (Emergency Medical Technician) called to transport to hospital. R2's Nurse's Note, dated 5/20/22 at 10:15 PM, documented R2 had no injuries and would be returning to the facility. R2's Care Plan does not document this fall and his medical records do not document any progressive interventions for either of his two falls on 5/20/2022. R2's Nurse's Note, dated 5/23/2022 at 5:35 AM, document Environmental manager reported resident was on the floor, this nurse assessed resident and found abrasion on right side lower back, MD, DON, Administrator and (family) notified. The Note documents EMT (Emergency Medical Technician) called and left facility at 3:50 PM to transfer to (Hospital). R2's Nurse's Notes dated 5/23/2022 at 10:21 PM, documents Placed a call to (Hospital) to check on resident status. Spoke to his nurse and was informed resident was admitted c (with) hip fx. (fracture), subacute [CONDITION(S)] et (and) fall. R2's Care Plan and Medical Records does not document any progressive interventions for R2's fall on 5/23/2022. R2's Hospital Procedure Note dated 5/24/2022 document a displaced right hip femoral neck fracture subacute. R2's Hospital Discharge Records dated 5/29/2022 at 1:42 PM, documents, Visit reason: Right [CONDITION(S)], [CONDITION(S)] subacute fall. Medical Problem: Closed displaced fracture of the neck of right femur, acute [CONDITION(S)], fall. R2's Nurse's Note, dated 8/29/22 at 4:10 PM, documents FOF (found on floor) on knees in dining room. No injuries to pt.'s (patient's) knees. See incident report for falls. The facility had no documentation of this incident report to review. R2's Care Plan was not revised after this incident to address progressive interventions to prevent R2 from potential future falls. R2's Nurse's Note, dated 9/1/22 at 3:40 PM documents Resident FOF (found on floor), assessed no apparent injuries. Assisted to w/c (wheelchair) per (full body mechanical) lift accompanied by multiple staff. R2's Care Plan, revised on 9/1/22, documents r/t (related to) fall, pressure alarm for chair. R2's Hospice Discharge Summary dated 9/2/2022 document under health history- history of falling. Summary of Care: Patient admitted to hospice after sustaining a fall and broken hip. During hospital admission patient found to have [CONDITION(S)] (cerebral vascular accident). R2's Fall Risk assessment dated [DATE] documents a score of 17 (Score of 10 points or more equal to high risk for falls). R2's Progress's Notes dated 9/7/2022 document, Resident was sitting in wheelchair in TV room and chair alarm sounded. This nurse went to assist resident to scoot back in his wheelchair, resident fell forward onto floor. Resident did not hit his head and no visible injuries were observed. R2's Care Plan, revised on 9/7/22, documented r/t fall, pressure alarm for chair (and) keep in visual when out of bed. R2's Quality Improvement Review Note dated 10/6/2022 at 9:00 AM, documents, IDT meeting held related to fall 10/5/2022 with small abrasion to right forehead. Resident dizzy, neuro checks were initiated. Resident sent to ER (emergency room ) for evaluation and returned. Continue with neuro checks. Reeducated resident of the importance of using a call light for assistance. There is no documentation in R2's Nurse's Note that R2 fell on [DATE]. There is no documentation of R2's fall on 10/5/2022 on the facility's fall log. R2's Medical Records do not have any other documentation including the incident reports documenting this fall. R2's Care Plan was not revised after this fall with progressive interventions to prevent future falls. On 11/10/2022 at 9:35 AM, the facility provided an incident report and R2 was documented for an incident on 9/1/2022 at 3:35 PM, fall in dining room, no injury and 9/17/2022 at 3:00 PM, falling at Recreation Room, No injury. No other incident reports were provided. There was no documentation in R2's medical record he fell on [DATE]. On 11/10/2022 at 2:41 PM, V8, Corporate assisting with Director of Nursing duties stated, For any fall I would expect staff to notify the physician and Power of Attorney of the fall and wait for orders from the doctor. All falls should be charged in the Nurse's Notes and all falls should be addressed at the Quality Assurance Meetings and the Care Plan updated to address the fall. On 11/10/2022 at 2:52 PM, V1, Administrator stated, Whenever a resident falls I expect all staff to assess the residents, get the resident comfortable, complete a nursing report, notify the physician and POA and incorporate any follow up with any physician orders. I expect this to all be documented in the Nurse's Notes and fall reporting. We do a quality assurance every morning and we do updates and would address any falls. The Minimum Data Set (MDS) Coordinator would then update the care plan to reflect the care and interventions that were put in place. I am not sure why those things are not in place for (R2). This is the only Care Plan we have for (R2). On 11/10/2022 at 3:03 PM, V10, Speech Therapist stated, Physical Therapy staff have already left for the day. I worked with (R2) a little but he was very confused and was not able to communicate with me except yes or no questions and his answers would always fluctuate. He had some severe communication deficits. I am not sure if he could tell you what was going on with him. Again, very confused. On 11/15/2022 at 11:29 AM, V11, Family of R2 stated, My father had a history of falls, and he could not verbally speak or tell you what was going on with him. Whenever he would fall, I would get a call telling me he had fallen but I never had any Care Plan meetings talking about his falls or anything the facility was doing to make sure he was safe and anything they were doing to prevent him for falling. Then he kept falling and fell and broke his hip. On 11/15/2022 at 11:48 AM, V3, Registered Nurse stated, I work, by choice. I am the Registered Nurse working here all but maybe 2 or 3 days a month. I usually worked weekends too. We currently do not have a full time Director of Nursing. (R2) was unsteady on his feet before his amputation. He could not talk to you really and he had some good days and bad days. Some days he could answered 'yes ma'am' to you other days he could not respond. I do not remember anything related to if he was at a fall risk or if he had any falls with injury honestly, I do not remember. On 11/15/2022 at 12:13 PM, V12, Nurse Practitioner stated, For any falls I would expect the facility to contact us, document the falls in the Nurse's Notes and address interventions and always document in the Care Plan. I am not sure what happened with (R2) and why his falls were not documented. The Facility Fall Policy with a revision date of 11/10/2018 documents, To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Assessments of Fall Risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The admitting nurse will assign the temporary risk category. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA (certified nursing assessment) assignment worksheet. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on observation, interview and record review, the facility failed to administer medication as ordered for 1 of 25 residents reviewed for medication (R8) in the sample of 42. This failure resulted in R8's significant med errors of missing two doses of insulin with subsequent need for transfer to the emergency room (ER) due to elevated blood sugar. Findings include: R8's Undated Face Sheet documents she was admitted on [DATE]. R8's Care Plan, dated 4/15/2022 and reviewed 7/13/2022 R8's care plan did not address R8's had diabetes or any goals or approaches. R8's Minimum Data Set (MDS) dated [DATE] documents R8 iscognitively impaired and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R8's Physician Order Sheet (POS) dated 9/26/2022 documents [MEDICATION(S)] 5 units subq (subcutaneous) TID (three times a day) with meals breakfast and lunch. [MEDICATION(S)] 20 units subq at bedtime (HS.) There was no sliding scale insulin order on the readmission POS dated 9/26/2022. R8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation [MEDICATION(S)] insulin was administered at 4:00 PM on 9/26/2022 and no documentation [MEDICATION(S)] insulin 20 units was administered at 8:00 PM. R8's Nurse's Note, dated 9/26/2022, has no documentation of why R8 didn't receive the two doses. R8's Nurse's Notes dated 9/27/2022 at 11:20 AM document notified MD (physician) via internal electronic system of elevated blood glucose reading high. N.O. (new order) given to give 10 units [MEDICATION(S)] subq now and to recheck reading in 1 hour. 12:30 PM rechecked resident blood glucose at this time. Blood glucose reading hi. Notified MD via internal electronic system. N.O. send to ER and give 5 units. 1:00 PM called EMS (Emergency Medical Services)/ambulance for transport. Called local hospital with report. Called 911 for transport. 1:32 PM Resident left facility via ambulance with emergency medical technicians (EMTs) x4. R8's ER Visit Note, dated 9/27/2022 documents HPI (history of present illness) patient is an [AGE] year-old female who presents ER with [CONDITION(S)] (high blood sugar.) Apparently today at the nursing home her blood sugars have been running in the 400s and they cannot get it controlled with her new sliding scale insulin. Nursing home contacted and they did not give the patient (R8) her [MEDICATION(S)] ([MEDICATION(S)] insulin) last night. Blood sugar coming down with 1 dose of insulin 10 units. We will have patient's home [MEDICATION(S)] tonight and inform the nursing home that they can readminister tomorrow. Additional instructions: your blood sugar was elevated because you did not receive your [MEDICATION(S)] last night. You were given your home [MEDICATION(S)] dose while in the ER today. R8's POS, dated 9/26/2022 documents no physician's order for sliding scale insulin. On 10/20/2022 at 12:45 PM, V13, Consultant RN (Registered Nurse), stated she expects staff to administer medications per physician's orders. V13 stated when a resident is readmitted to the facility, she expects staff to document a nurse's note to state the resident was readmitted , so all staff know the resident is back in the facility. V13 stated the facility holds resident's bed and medications for 14 days when they are discharged . V13 stated the 14th day the medications are returned to the pharmacy. V13 stated if R8 was discharged on [DATE] and readmitted on [DATE], that was 15 days so her medications would have to be reordered from the pharmacy and she expected the medications to be available at the facility within a few hours of the resident being back at the facility. V13 stated insulin is considered a significant medication because if the resident misses a dose of insulin the resident's blood sugar can quickly plummet. V13 stated she expected staff to either retrieve insulin from the facility's insulin emergency kit or call the pharmacy and get a STAT (immediately) run from the pharmacy to deliver the insulin so the resident doesn't miss a dose. When staff obtain insulin from the facility's emergency kit or contact pharmacy for a STAT delivery of insulin, she expects staff to document a nurse's note, so staff know what has been done to ensure the resident gets the physician prescribed medication. V13 stated if the box for the corresponding date is blank on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/20/2022 at 3:45 PM, V20, Nurse Practitioner (NP), stated when a resident is readmitted to the facility if the resident was on the medication in the past, she expected the medication to be immediately available to the resident and if the medication was not available, she expected staff to utilize the facility's insulin emergency kit to ensure the physician order medication in a timely manner. V20 stated she expected staff to document physician's orders correctly and to administer insulin as prescribed. V20 stated she wasn't aware R8 missed two doses of insulin on 4/26/2022, she stated the insulin should have been available and administered per physician's orders. V20 stated insulin is considered a significant medication because of what can occur if the resident doesn't receive a scheduled dose which includes diabetic coma. The Facility's Medication Administration Policy revised 11/18/2017, documents each facility shall establish a policy for the routine time of medication administration. Medications must be prepared and administered within one hour of the designated time or as ordered. Medications must be identified by using the 7 rights of administration which includes right resident, right drug, right dose, right consistency, right time right route and right documenation. After a medication is given, record the date, time and name of drug, dose and route on the resident's individual MAR. Document any medications not administered for any reason by circling initials and documenting on the back of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . If the medication is not available for the resident, call the pharmacy and notify the physician when the drug is expected to be available. Nofiy the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason.

Based on interview and record review, the facility failed to provide supervision for 1 of 4 residents (R111) reviewed for elopement in the sample of 42.This failure resulted in R111 leaving the facility on 12/11/2021 without any of the staff attempting to stop him or alerting any staff he was leaving. R111 left the facility unnoticed without staff intervention. Findings include: R111's Progress Notes dated 11/9/2022 at 6:36 PM, documents, Resident is a new admit from (Hospital). He was admitted on [DATE] for a fall. He was found in his garage. No injuries substantiated. Increased confusion noted from family. Diagnosis of: kidney disease, [CONDITION(S)] positive, [CONDITION(S)] (hypertension), nephrectomy. He is orientated to himself. He is ambulatory but has issues with balance. R111's Elopement Evaluation dated 11/9/2022 documents: Resident is able to exit the building; requires assistance once outside the building; poor decision making; inability to identify safety needs; severe mental illness. R11's Score 6, High Risk= 5-10. R111's Care Plan documents a diagnosis of dementia. R111's Cognitive Assessment for November 2022 documents R111 was moderately impaired for cognition. 111's Nutritional Assessment documents a diagnosis of altered mental status, dementia, malnutrition, nephrectomy and AIDS. R111's Psychosocial Social Service Progress Notes dated 12/3/2021, Resident entered Social Service Office to inquire about his car. Social Service Director (SSD) reminded resident that his car was at his house in the garage and SSD also reminded resident that resident was very thankful. R111's Care Plan with a start dated of 11/22/2021 documents (R111) discharge not feasible due to care needs. R111's care plan with a goal date of 3/12/2022 for Behavior documents, (R111) may seek to leave home. Related diagnosis include: Altered mental status due to metabolic [CONDITION(S)]. Desires discharge from facility. Brief Interview Mental Status of 9 (9 out of 15= moderately impaired cognition) on admission assessment. (R111) has a cell phone and is able to make and receive calls independently. Validate (R111's) desires to leave the facility. Allow him to verbalize feelings. Seek to resolve any concerns. Educate (R111) on the need to sign out of the facility if going out on leave. R111's Psychosocial Social Service Progress Notes dated 12/2/2021, Friend in facility visiting resident and he asked to speak with myself (V14) (SSD) friend came to SS (social service) office and introduced himself (V14) and he began providing information about resident's family and informed friend that family relationships was beyond my practice and that my jobs was to ensure that resident was taken care of while in our facility friend then stated that upon discharge that resident could move with him and his mother. SSD informed friend that she (SSD) would inform resident of his friend's offer and he was very thankful. Very thankful. R111's Nurse's Notes dated 12/11/2021 at 11:17 AM, I was informed that resident did not return from out on pass. I immediately drove to the facility at this time, already notified corporate, and called all department heads, resident's brother, and police while staff did an outdoor facility grounds and neighborhood search. Staff had thought resident went out on pass but not sure of the visitor he left with. On 10/21/2022 at 9:10 AM, V4, Registered Nurse (RN) stated, I remember I got a phone call in the middle of the night telling me (R111) was missing. Those are my notes in his chart documenting the elopement. We think (R111) left with a visitor. We have a locked door that needs a code in order to open the doors. We are not allowed to give the code out to anyone including visitors. We are supposed to assist them. We discussed it at the meeting and we do not know how (R111) got out of the facility. On 10/21/2022 at 12:34 PM, V28, Housekeeping/ Activities, stated, I remember working that night and I saw (R111) with his bags packed. He told me his boyfriend was coming to pick him up and take him home. I did not see him leave or help him with the code to get out. We are not to ever give out the door codes to visitors. I never questioned him about leaving or checking to see if he was okay to go home. I was pushing my laundry cart and just making conversation. R11's Incident Report dated 12/15/2021 document, On 12/11/2021 at 10:30 PM, staff reported that (R111) was out on a visit and had not returned to the facility. Investigations began immediately including notifications to police, physician and family. During this investigation, staff and alert residents were interviewed. Two housekeepers stated they saw (R111) leave out the door by Nurse's station rolling a Suit Case and was with another male whom was there visiting with (R111) around 2:30 PM. The oncoming Nurse received report from previous Nurse. The nurse that come on shift asked where the Resident was at because he was not in the room and the Nurse stated that the Resident was out on a visit and had not yet returned. When resident's brother was called to inquire when resident would be returning, he stated that (R111) was not with him and he was not sure who visited him earlier. The oncoming Nurse immediately contacted Administrator and Assistant Director of Nursing (ADON), to notify them that the resident was out of the facility and had not returned, head count completed and (R111) was not counted. Staff immediately looked outside, looked in all rooms, bathrooms, storage areas, closets, laundry area etc. Staff and alert residents were interviewed for possible sightings. Facility conducted a thorough search of the grounds including outdoor shed, staff members worked together to sweep each consecutive room to avoid possibility of resident moving to adjacent room undetected. ADON, Administrator was called immediately. Investigation began immediately including notification to police, physician and family. Staff searched parked cars, ditches, expanding search through the neighborhood by foot and car also. Police were given a description of resident and clothing worn and they immediately began assisting with search. Search was done of facility, grounds and expanding search through community by foot and car. Police notified the facility that they sent ping to the Residents cell phone to track his location. Administrator contacted every possible contact for the Resident. The following morning 12/12/2021 at 9:33 AM. (R111) made contact with facility Social Service (V10) and informed her that he was at his Residence and that he was safe. He informed Social Service that he left the facility with his friend on 12/11/2021 and that his friend will be staying with him and helping him at home. On 12/12/2021 at 9:33 AM, Social Service Director informed (R111) that she would meet him at his residence and the resident agreed to that. Resident informed SSD that he did not want to come back and that he wanted to stay at his residence with his friend. Resident signed Against Medical Advise (AMA) and gave the resident the rest of his belongings. Family, and Physician notified. R111's medical records does not document any outing visit he took on 12/11/2021. R111's Interdisciplinary Summary dated 12/11/2021, At facility calling resident family and friends. Family and friends did respond and stated that they hadn't heard from resident. Informed both parties to have resident call. Facility to confirm his safety. On 10/20/2022 at 11:34 AM, V10, Social Service Director, stated, When (R111) came into the facility, he had a lot of confusion. He was [CONDITION(S)] positive, he had hypertension. He was very confused and was always wanting to know where his car was. He liked to play the piano and he would have visitors come and visit him. His son would come and other male friends. One Saturday in December, I got a call from (the former Administrator) because (R111) was missing. I was not working that day so I cannot say how he got out of the facility. All I know is that he got out on the afternoon because some housekeepers saw him leave the building with another person. As soon as I got the call, I came in and started call his cell phone and family. The family did not know where he was at. The next day, (R111) called me and told me he was safe and I went to his house. I never went inside his house. There was another man there and he was yelling out at me and telling me (R111) was not going back to our facility and he was going to take care of (R111). He (the other man) said he was staying with him (R111) and he (R111) was not going back. I tried to talk to (R111) and he nodded to everything the other man was saying. I do not know the name of the man that was yelling at me. I think it was his partner but that is just a guess. I asked (R111) if he wanted to come back and he shook his head 'no' and then (I) asked him to sign the Against Medical Advice (AMA) papers and he did and I left. R111's elopement and medical records do not document who was at R111's house and who stated they would be assisting with his care. There was no name or person identified by the facility assisting R111 with his care. On 10/21/2022 at 9:01 AM, V25, Activities, stated, I was working in the business office the day (R111) eloped. I do not know how he got out of the building. That night, I got a call telling us he was missing, but I was not aware of anything while I was working that Saturday. On 10/21/2022 at 9:46 AM, V1, Administrator, stated, I was not here working at the time (R111) eloped from the facility. I would expect statements to be included from staff working that day of what they saw and interviews documenting it. I would expect the administrator to view the cameras to see what happened and how (R111) even got out of the building. Staff are to never give out codes to visitors. Our cameras are only good for seven days so I cannot even tell you what was on the camera. I would expect staff to never give out codes and for staff to never assist a resident with leaving without checking with others to make sure they are cleared to leave. The Facility Missing Resident Policy with a revision dated 8/13/2014, documents, It is the policy of (Facility) that reasonable precautions are taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to door alarms, personal door alarm activities devices, staff intervention, staff education regarding response to door alarms and individual resident intervention. It is the policy of (Facility) to demand immediate response to elopement attempts, door alarm activation and participating in search attempts in the event that a resident is deemed missing. The Door Alarm Policy with a revision date of 10/2006 documents, It is the policy of the (Facility) to ensure resident safety and security through the use of door alarms. Door alarms require immediate attention and response by facility staff to ensure the safety of all residents. Disengaging the alarms is not allowed until the reason for activation is determined. Steps to be taken: Go directly to the door where the alarm is sounding. Go completely outside the door to view the environment. Initiate a search of the immediate area if no resident or visitor is visualized. Instruct visitor or vendors how to properly disengage the alarm before leaving the facility. Conduct an immediate count of all residents. Initiate the Missing Resident Policy when unable to account for all residents. B. Based on interview and record review, the facility failed to perform a safe transfer for a dependent resident for 1 of 6 residents (R9) reviewed for falls in the sample of 42.This failue resulted in R9 falling out of a full mechanical body lift. Findings include: R9's Nurses Notes dated 8/4/22 at 2:00 PM document, Resident had a fall. She fell out of the (full body mechanical lift) sling. Staff stated that one of the straps was not connected while lifting her up. She has bilateral 4 inches of scratches to elbow. No other injury noted. NP (Nurse Practitioner) was notified . She was in the building. Administrator was notified. Resident is on 15 minute checks and neurochecks. Resident is laying in bed at this time. X-rays was ordered to sacrum, coccyx, lumbar spine, x-rays bilateral elbows. R9's Minimum Data Set (MDS) dated [DATE] documents she is severely cognitively impaired. It also documents she is dependent on staff for transfers. R9's Care Plan dated 7/13/22 documents, (P) Problem: Resident has risk factors that require monitoring and intervention to reduce potential for self injury. (Consider medical conditions, sensory alterations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medications, restrictions, restraints). A new approach added to this care plan dated 8/4/22 documents, Related to fall, staff to ensure that resident understands transfer process. On 10/19/22 at 1:35 PM, V7, Licensed Practical Nurse (LPN), stated she was the nurse on 8/4/22 and documented R9's fall. V7 stated (V11) and (V12) Certified Nursing Assistants (CNAs) were transferring R9 when she had a fall from the full body mechanical lift. V7 stated R9 fell to the floor and she thinks R9 was caught and lowered to the floor by the CNAs. On 10/19/22 at 2:00 PM, V1, Administrator, presented R9's document, Quality Improvement Review dated 8/5/22 at 9:30 AM which documents, QA (Quality Assurance) committee meet to review fall on 8/4/22, staff reported resident fell out of (full body mechanical lift) sling b/c (because) one of the straps was not connected. Resident sustained bilateral scratches to elbow, no other injury noted. Resident complained of no pain or discomfort, was placed on 15 minute checks with neuro checks. Staff educated on transfer process and proper sling placement. X-rays were ordered with no findings. R9's Fall Risk assessment dated [DATE] documents a score of 22 indicating she is high risk of falls. R9's x-ray reports dated 8/4/22 of coccyx/ sacrum/lumbar region and right and left elbows document R9 did not have any fractures from her fall. On 10/19/22 at 3:48 PM, V11, CNA, during phone interview, stated she and another CNA (V12) were transferring R9 from her chair to the bed when R9 fell on [DATE]. V11 stated V12 had attached the straps of the sling to the lift. V11 stated she was observing and controlling the remote to lift R9 out of her chair. V11 stated they had just lifted R9 and removed her chair from under her and one of the straps on the side of the sling just snapped out and R9 fell to the floor onto her butt. V11 stated R9 was not that high, but they were not able to slow her fall and she fell directly to the floor. V11 stated R9 had complained of pain to her elbows or ankles, she could not remember which, but any injury she sustained was minor. V11 stated she did not help transfer R9 from the floor to her bed but three staff lifted R9 from the floor without the mechanical lift and placed her in her bed. V11 stated she had not received any training on using the full body mechanical lift, but was just told briefly how to use it during her orientation. On 10/19/22 at 3:59 PM, V12 stated she and V11 were transferring R9 from her chair to her bed when R9 fell from the (full body mechanical lift). V12 stated R9 was already hooked up to the lift when she walked into R9's room. V12 stated that was her first day working in the facility and she did not know why they had V11 training her because V11 was a brand new CNA herself. V12 stated she thinks V11 had not hooked up the sling straps to the mechanical lift correctly and that is why R9 fell from the sling. V12 stated R9 was not very high in the air when she fell and she did not think R9 was injured. V12 stated she had experience using full body mechanical lifts during her time as a CNA but did not receive any instructions from the facility regarding their policy for using the lift. V12 stated after R9's fall, V7, LPN, did educate her and V11 on using the lift. V12 stated she, V7, LPN and V6, CNA, lifted R9 from the floor and put her into her bed after her fall. The facility's policy, Mechanical Lift revised 10/30/08 documents, Policy: The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel. Under Procedure it documents, 9. Attach the appropriate colored loops on the bars.

Based on observation, interview, and record review the facility failed to timely identify, assess, monitor and provide treatments for pressure ulcer treatment and prevention for 1 of 3 residents (R59) reviewed for pressure ulcers in the sample of 42. This failure resulted in R59 developing 3 facility acquired pressure ulcers requiring a right above the knee amputation. Findings Include: R59's Facesheet documents admission to facility on 2/3/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R59's Minimum Data Set (MDS) dated [DATE] documents R59 is at risk for pressure ulcers but had no pressure ulcers present. R59's MDS also documents he is totally dependent on staff for bed mobility and all ADLs (activities of daily living), and has impairment on lower extremity one side. R59's Nursing Assessment sheet dated 5/29/2022 has no documentation of pressure ulcers. R59's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R59's Nurse's notes dated 5/2/22-6/4/22 have no documentation of the presence of any issues with R59's heels. R59's Nurse's notes dated 6/5/2022 documents (R59) has 2 pressure ulcers to bilateral heels. Left heel 7X5 (w), 3X3 (L), Right 3X10 (w), 7X3 (L) with eschar. R59's Nurse's notes dated 6/5/2022 documents, Clean right and left heel ulcers with normal saline and apply [MEDICATION(S)] ointment and non adhesive dressing daily for 5 days. R59's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R59's PO dated 6/6/2022 documents, [MEDICATION(S)] iodine 10% solution apply to left and right heel daily. R59's 6/2022 Treatment Administration Records (TAR) Weekly Summary documents 6/5/2022 Right heel- pressure ulcer 3x10 (w), 7x3 (L) Eschar, Left heel- pressure ulcer 7x5 (w) 3x3 (L) red and inflamed. No other documentation of weekly summary of pressure ulcers on 6/2022 TAR. R59's Nurse's notes dated 6/6/2022 documents (R59) has black mark on left heel and red mark on right heel. (Wound doctor) viewed marks and ordered [MEDICATION(S)] to both heels daily. R59's Nurse's Notes, dated from 6/7/22-10/9/22, have nothing documented about R59's bilateral heel pressure ulcers. R59's 7/2022 TAR has no documentation of weekly summary of pressure ulcers. R59's TARs regarding weekly skin checks shows no skin checks completed on 6/12/2022, 6/19/2022, 6/26/2022, 7/3/22, 8/7/22, 8/14/2022, 9/10/2022, 9/17/2022, 9/24/2022. R59's TAR regarding [MEDICATION(S)] to bilateral heels shows no treatments on 6/17/2022, 6/20/2022, 6/26/2022, 6/30/2022, 9/10/2022, 9/11/2022, 9/12/2022, 9/13/2022, 9/14/2022, 9/15/2022, 9/16/2022, 9/17/2022, 9/18/2022, 9/19/2022, 9/21/2022, 9/22/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/26/2022. R59's Wound physician notes dated 8/2/2022 document Site 1 Unstageable DTI (Deep Tissue Injury) of the left heel partial thickness with intact skin of greater than 73 days duration. Wound size 2 x 3 x Not measurable cm (centimeters). Continue [MEDICATION(S)] twice daily. Site 2 Unstageable DTI of the Right heel partial thickness with intact skin of greater than 62 days duration. Wound size 4 x 5 x Not measurable cm. Continue [MEDICATION(S)] twice daily. Etiology of both: pressure. Factors complicating wound healing: Diabetes Mellitus. This was the first visit by wound physician. https://npiap.com/page/PressureInjuryStages documents the definitions, Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). R59's Wound physician notes dated 8/9/2022 document Site 1 Unstageable DTI of the left heel partial thickness with intact skin. Continue [MEDICATION(S)] twice daily. No change in wound size or wound progress. Site 2 Unstageable due to necrosis of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. Surgical excisional debridement procedure performed on right heel wound. R59's Wound physician notes dated 8/16/2022 document Site 1 Unstageable DTI of the left heel partial thickness with intact skin. Wound size 2 x 1 x not measurable cm. Continue [MEDICATION(S)] twice daily. Wound progress: improved. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound size 4 X 5 X not measurable cm. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. R59's Wound physician notes dated 8/23/2022 documents Site 1 Unstageable DTI of the left heel partial thickness with intact skin. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. R59's Wound physician notes dated 8/30/2022 documents Site 1 Unstageable DTI of the left heel partial thickness with intact skin. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound size 4 X 4 X not measurable cm. Wound has thick adherent black necrotic tissue 100%. Wound progress: improved. Continue [MEDICATION(S)] twice daily. R59's Wound physician notes dated 9/6/2022 documents Site 1 Unstageable DTI of the left heel partial thickness with intact skin. No change in wound size or wound progress. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. R59's Nurse Practitioner progress notes dated 9/8/2022 documents Skin normal temp and color. R59's Nurse Practitioner progress notes dated 9/12/2022 documents Skin normal temp and color. R59's Wound physician notes dated 9/14/2022 documents Site 1 Unstageable DTI of the left heel partial thickness with intact skin. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. R59's Wound physician notes dated 9/20/2022 documents Site 1 Unstageable DTI of the left lateral heel partial thickness with intact skin. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. Surgical excisional debridement procedure performed on right heel wound. Site 3 new Unstageable DTI of the left medial heel partial thickness with intact skin of greater than 2 days duration. Wound size 3 x 3 x not measurable cm. Etiology: pressure. [MEDICATION(S)] twice daily. R59's Care Plan, start date 9/20/2022 and reviewed 9/22/22, documents Pressure Ulcer Present. Braden score 21 (Total score of 12 or less represents HIGH RISK for pressure ulcer). Risk factors include incontinent of bowel and bladder and needing assistance for transfers. Interventions include, assess for cause of pressure of pressure ulcer. Observe for pressure cause friction and contributing factors. Complete avoidable/Unavoidable pressure ulcer assessments as needed to investigate contributing factors and preventions interventions used. Nurse to measure and monitor wound status progression or deterioration every week. Notify Medical Doctor (MD) and family of changes, Document physician response. Treatments as ordered. Pressure relieving device in wheelchair and pressure reducing mattress. Pressure reduction boot when in wheelchair. Float heels when in bed. Skin risk assessment. Braden scale weekly for 4 weeks upon admission or readmission and then quarterly and as needed. R59's medical record has no documentation of a Pressure Ulcer Care Plan prior to the one initiated on 9/20/22 although R59 was identified with pressure ulcers on 6/5/22. R59's Minimum Data Set (MDS) dated [DATE] documents R59 is at risk for pressure ulcers, has 3 unstageable pressure injuries presenting as deep tissue injuries, none of which were present on admission. R59's MDS also documents he is totally dependent on staff for bed mobility and all ADLs (activities of daily living), and has impairment on lower extremity one side. R59's Treatment Administration Records (TAR) regarding weekly skin checks shows no skin checks completed on 6/12/2022, 6/19/2022, 6/26/2022, 7/3/22, 8/7/22, 8/14/2022, 9/10/2022, 9/17/2022, 9/24/2022. R59's TAR regarding [MEDICATION(S)] to bilateral heels shows no treatments on 6/17/2022, 6/20/2022, 6/26/2022, 6/30/2022, 9/10/2022, 9/11/2022, 9/12/2022, 9/13/2022, 9/14/2022, 9/15/2022, 9/16/2022, 9/17/2022, 9/18/2022, 9/19/2022, 9/21/2022, 9/22/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/26/2022. R59's Wound physician notes dated 9/27/2022 document Site 1 Unstageable DTI of the left lateral heel partial thickness with intact skin. No change in wound size or wound progress. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. Wound size 3.8 X 4.1 X not measurable cm. Wound progress: improved. Add Alginate Calcium with Kerlix (gauze wrap) once daily, Change [MEDICATION(S)] to once daily. Surgical excisional debridement procedure performed on right heel wound. Site 3 Unstageable DTI of the left medial heel partial thickness with intact skin. Wound size 3 x 2.8 x not measurable cm. Wound progress: improved. Continue [MEDICATION(S)] twice daily. R59's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R59's Wound physician notes dated 10/4/2022 document Site 1 Unstageable DTI of the left lateral heel partial thickness with intact skin. Wound size 1.6 x 1 x not measureable. Wound progress no change. Continue [MEDICATION(S)] twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. Wound size 4 X 4 X not measurable cm. Wound progress: no change. Continue Alginate Calcium with Kerlix once daily and [MEDICATION(S)] once daily. Surgical excisional debridement procedure performed on right heel wound. Site 3 Unstageable DTI of the left medial heel partial thickness with intact skin. No change in wound size or wound progress. Continue [MEDICATION(S)] twice daily. R59's Nurse Practitioner progress notes dated 10/10/2022 documents presents for nursing report that Right heel wound has increased drainage and odor. Nursing reports he has been followed by (Wound Consultant) for wound care. Skin: right heel with large unstageable wound moderate amount of serosanguinous drainage, right foot is red and warm to touch, + odor. Left heel with blister and blister to left great toe. Assessment and plan: right and left heel wound: concern for [CONDITION(S)] vs [CONDITION(S)]. Transfer to ER (emergency room ) for further care of wounds to bilateral heels. R59's Nurse's notes dated 10/10/2022 (R59) sent to ER due to wound on right heel having a foul order. R59's Hospital H&P (history and physical): HPI History of Present Illness report dated 10/10/2022 at 4:15PM documents Chief Complaint right foot wound. It continues, R59 presents for evaluation of a malodorous, nonhealing right foot wound. Plan x rays of the foot showed multiple pockets of gas and recommends were to proceed with right above the knee amputation urgently. It further documents a right above the knee amputation was performed without complications. Assessment and plan 1. Severe [CONDITION(S)] 2. Necrotizing soft tissue infection 3. Diabetic infection of right foot: status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R59's hospital discharge Patient Signature Page, given to patient on 10/13/22, documents R59 was seen for: Severe [CONDITION(S)], [CONDITION(S)] of right foot, acute [CONDITION(S)]. R59's Nurse's notes dated 10/13/2022 documents (R59) readmitted with right above the knee amputation (AKA). Waffle boot to left foot with heel protector. Stump sock to right AKA. On 10/19/2022 at 1:15PM, R59's right above the knee amputation Wound site was clean and dry with sutures intact. No drainage observed. Left heel appeared soft, intact and red with minimal drainage. On 10/20/2022 at 3:50PM, V20, Nurse Practitioner, stated, Our practice wasn't following (R59)'s wounds because he was being followed by a wound company. I am the one who sent (R59) out to the hospital. I asked the nurse taking care of (R59) the day he went out, how long his wound had smelled and she said just that day. It is hard to say if missing a treatment would have contributed to the gangrene. I would expect treatments to be completed as ordered. I would also expect the care plan to be updated so everyone is aware of changes. On 10/21/2022 @ 9:15AM, V4, Infection Preventionist, stated I was the nurse the day (R59) went out. Staff noticed the smell and thought (R59) just needed a shower. I had the Nurse Practitioner look at it and she sent him out. On 10/20/2022 at 2:30PM, V17, Certified Nursing Assistant (CNA), stated I knew his foot looked bad because it was black. It smelled terrible the day he went out. I didn't smell it before that. The Facility's Decubitus Care/ Pressure Areas policy and procedure, revised 1/2002, documents, Policy: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. It continues, Procedure: 1. Upon notification of skin breakdown, an Newly Acquired Skin Condition report will be completed and forwarded to the Director of Nurses. 2. The pressure area will be assessed and documented on the Pressure Sore Record form. And, 3. Notify the physician for treatment orders. 4. Documentation of the pressure area must occur upon identification and at least once each week on the Pressure Sore Record. 5. Reevaluate the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order. 7. Initiate problem on care plan.

Based on interview and record review the Facility failed to notify the physician of abnormal laboratory results for 1 of 3 residents (R2) reviewed for physician notification of laboratory results in the sample of 8. This failure resulted in R2 not being sent out to the hospital, a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R2's Progress Notes dated 8/15/2022 at 4:48 AM, Resident complaining constipation, nausea and says he has had several bouts of emesis with last episode being yesterday evening. Abdomen soft and not distended. BS (Bowel Sounds) present x 4. Says he had a very small Bowel Movement (BM) on 8/12/2022 but he just feels like crap Vital signs 99.3 temperature (slightly elevated), 76 (pulse rate) 20 (respiratory/ rate of breathing), 128/76 (blood pressure), 91. Medical Director notified. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Fleets enema x 1 [MEDICATION(S)] 10 mg by mouth, once daily, [MEDICATION(S)] 5 mg by mouth once daily, [MEDICATION(S)] 18 grams by mouth in water daily. STAT (immediately) KUB (kidney, ureter and bladder), STAT CBC (complete blood count) with differential /Platelet, CMP (comprehensive metabolic panel) and vital signs every 4 hours for the next 24 hours. There was no signature or name of any a physician, physician assistant, or nurse practitioner of who had placed the order. R2's Laboratory results, dated 8/15/22, at 4:50 PM, documented R2's Chloride was 89 (low with normal 97-110), BUN 48 (high with normal 6-25), and Creatinine 4.29 (high with normal 0.8-1.30). These were the only laboratory results that were given to the surveyors. R2's POS dated 8/18/2022 (no time) documents Ok to send to ER (emergency room ) for treatment and evaluation. This documented V6, Nurse Practitioner. On 8/31/2022 at 10:20 AM, during a phone interview V8, Medical Director stated, (Facility) is all paper records so I cannot pull anything up to review. I have not seen that patient. V6, Nurse Practitioner (NP) would be more familiar with the case then me. Give her a call and see what she may or may now know about (R2). She sees patients more often than I do. I have not seen (R2). On 8/31/2022 at 10:48 AM, V6, Nurse Practitioner (NP) stated, I was not working 8/13/2022 to 8/21/2022 so I cannot tell you about anything that happened with (R2). My name should not be on the orders as I did not order anything in the time frame. Looking at the records from my end, I see that we were contacted on 8/15/2022 and some labs were ordered. I cannot tell you if anyone was contacted again. I do see the white count at 11 thousand, (R2's) creatinine was also abnormal. I can see the labs and they were off. Try and call (V7), the other NP maybe she knows something. I would expect someone to be addressing the abnormal labs. On 8/31/2022 at 11:02 PM, V7, Nurse Practitioner stated, I was filling in when (V6) was on vacation. I remember someone from the facility contacted us on 8/15/2022 regarding (R2) complaining of constipation, and nausea. I ordered an enema, [MEDICATION(S)] 10 mg and [MEDICATION(S)] 5mg and [MEDICATION(S)] and STAT (immediately) KUB (kidney, ureter and bladder), STAT CBC (complete blood count) with differential /Platelet, CMP (comprehensive metabolic panel and vitals for 24 hours. I never received the labs back and was not aware (R2's) labs were abnormal, his white blood count was 11 k, and his creatinine was 4.29. If I would have seen the lab results, I would have sent him out to the hospital immediately and not waited until 8/18/2022 and delayed any treatment. R2's Hospital Records dated 8/18/2022 at 3:58 PM, [AGE] year old male with [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] (Hypertension), and chronic back pain. Here for abdominal pain and found to have septic shock. Patient was complaining of constipation with nausea and vomiting for the past three days. On 8/15/2022 lab work drawn at that time shows a white count 11 k (thousand), otherwise normal. CBC comprehensive shows a BUN (blood urea nitrogen) 48 (normal 10:1 and 20:1), creatinine 4.3 (normal 0.6 to 1.2 milligrams (mg) per deciliter (dl) in adult males. KUB showed multiple nondilated gas filled loops of bowel on that day. Patient is alert and oriented times three most days but today he was only orientated x 1. The Laboratory Test Policy with a revision dated of 9/27/2017 documents, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. Obtain laboratory orders upon admission, readmission and PRN for medication and condition monitoring per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview, and record review the facility failed to timely notify physician of abnormal lab levels which delayed treatment for 1 of 3 residents (R2) reviewed for quality of care in the sample of 8. This failure resulted in R2 experiencing nausea and vomiting for multiple days and being admitted to the hospital on 8/18/2022 with septic shock and small bowel obstruction. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE]. R2's Cumulative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (The log does not document chronic constipation). R2's Minimum Data Set (MDS) dated [DATE] documents R2 was an extensive assist of one person for toilet use. The MDS documented R2 uses the toilet room, commode, bedpan, or urinal, transfer on/off toilet, cleanses self after elimination and adjust clothes. The MDS documented R2 was not on a bowel toileting program and no constipation was documented as being present. R2's medical records dated 3/30/2022 from his previous care giver document in his Assessment/Plan document R2 has chronic constipation, (R2) has had constipation for years. On OTV (on-treatment visit) doculax from time to time. Other constipation, [MEDICATION(S)] 10 grams/5 milliliters (ml) oral solution, take 15 milliliters (ml) every day by oral route as directed for 30 days. Refills three. R2's Medication documented [MEDICATION(S)] (muscle relaxer) 10 milligrams take 1 capsule three times a day by oral route as directed for 30 days. Metamucil 3.4 grams/5.4 gram oral power take 1 tablespoon twice a day by oral route. Note: stir in 8-10 ounces of water/drink. R2's Care Plan with a start date of 5/3/2022 documents, Resident has risk factors that require monitoring and intervention to resident potential for self-injury, consider medical conditions, sensory altercations, balance, gait, assistance devices, cognition, mood/behavior, safety awareness, compliance, medications. Attempt to anticipate needs-toileting, hydration, thing and provide care before Resident attempt to fulfill on own. R2's Care Plan does not address his constipation or any side effects of the drug [MEDICATION(S)]. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Take 1 tablet by mouth three times a daily. Side effects: constipation. R2's Physician Order, dated 5/31/22 documents Reguloid (medication to treat constipation) powder Sugar Free 284 Grams. Mix 1 tablespoon in liquid and take by mouth twice daily as needed (PRN). Side effects: [CONDITION(S)] obstruction, intestinal impaction, gastrointestinal obstruction. R2's Progress Notes dated 8/15/2022 at 4:48 AM, Resident complaining constipation, nausea and says he has had several bouts of emesis with last episode being yesterday evening. Abdomen soft and not distended. BS (Bowel Sounds) present x 4. Says he had a very small Bowel Movement (BM) on 8/12/2022 but he just feels like crap. Vital signs 99.3 temperature (slightly elevated), 76 (pulse rate) 20 (respiratory/ rate of breathing), 128/76 (blood pressure), 91. Medical Director notified. R2's Progress Notes dated 8/15/2022 STAT KUB (Kidney, Ureter, and bladder X-ray. R2's Progress Notes dated 8/15/2022 5:42 AM, STAT LABS called in confirmed. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Fleets enema x 1 [MEDICATION(S)] 10 mg by mouth, once daily, [MEDICATION(S)] 5 mg by mouth once daily, [MEDICATION(S)] 18 grams by mouth in water daily. STAT (immediately) KUB, STAT CBC (complete blood count) with differential /Platelet, CMP (comprehensive metabolic panel) and vital signs every 4 hours for the next 24 hours. There was no signature or name of any physician, physician assistant, or nurse practitioner who had placed the order. R2's Medical Records dated 8/15/2022 to 8/18/2022 does not document any assessment was performed on R2 after the enema was administered. R2's Activities of Daily Living Flow Record documents R2 had the following bowel movements (BM): On 8/16/2022 a large BM on second shift; on 8/17/2022 a large BM on 1st shift and a medium BM on second shift; and on 8/18/2022 none in the morning before he was sent out to the hospital. This record does not document the consistency of R2's BMs. R2's Laboratory results, dated 8/15/22, at 4:50 PM, documented R2's Chloride was 89 (low with normal 97-110), BUN 48 (high with normal 6-25), and Creatinine 4.29 (high with normal 0.8-1.30). These were the only laboratory results provided to the surveyors. R2's Progress Notes dated 8/18/2022 at 5:20 AM, Resident observed by writer grimacing and guarding abdomen. Complaint of severe abdominal pain and chills. Vitals 97, 78, 108/60, 20: 91:1 Resident denies Shortness of breath, Abdomen is distended and painful to touch. States he has been vomiting and not informing staff. Bowel sounds hypoactive to right upper and right lower and left lower guard. Medical Doctor (MD) notified. R2's Progress Notes dated 8/18/2022 at 5:59 AM, Voicemail left for son to call facility for update on father's status. R2's Progress Notes dated 8/18/2022 at 6:01 AM, Emergency Medical systems, (EMS) called to transport resident to (hospital) for treatment and evaluation. R2's Progress Notes dated 8/18/2022 at 12:20 PM, Resident is being admitted to (Hospital) Intensive care unit with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Power of Attorney update. R2's Hospital Records dated 8/18/2022 at 3:58 PM, [AGE] year old male with [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] (Hypertension), and chronic back pain. Here for abdominal pain and found to have septic shock. Patient was complaining of constipation with nausea and vomiting for the past three days. On 8/15/2022 lab work drawn at that time shows a white count 11k (thousand), otherwise normal. CBC comprehensive shows a BUN (blood urea nitrogen) 48 (normal 10:1 and 20:1), creatinine 4.3 (normal 0.6 to 1.2 milligrams (mg) per deciliter (dl) in adult males. KUB showed multiple nondilated gas filled loops of bowel on that day. Patient is alert and oriented times three most days but today he was only orientated x 1. R2's Death certificate dated 8/23/2022, documented R2's cause of death as [CONDITION(S)], Perforation of intestine (non-traumatic). On 8/31/2022 at 10:20 AM, during a phone interview V8, Medical Director stated, (Facility) is all paper records so I cannot pull anything up to review. I have not seen that patient. (V6, Nurse Practitioner/NP) would be more familiar with the case then me. Give her a call and see what she may or may not know about (R2). She sees patients more often than I do. I have not seen (R2) and I am based up in the northern area. On 8/31/2022 at 10:48 AM, V6, Nurse Practitioner (NP) stated, I was not working 8/13/2022 to 8/21/2022 so I cannot tell you about anything that happened with (R2). My name should not be on the orders as I did not order anything in the time frame. Looking at the records from my end, I see that we were contacted on 8/15/2022 and some labs were ordered. I cannot tell you if anyone was contacted again. I do see the white count at 11 thousand, (R2's) creatinine was also abnormal. I can see the labs and they were off. Try and call (V7), the other NP maybe she knows something. I would expect someone to be addressing the abnormal labs. On 8/31/2022 at 11:02 PM, V7, Nurse Practitioner stated, I was filling in when (V6, Nurse Practitioner) was on vacation. I remember someone form the facility contacted us on 8/15/2022 regarding (R2) complaining of constipation, and nausea. I ordered an enema, [MEDICATION(S)] 10 mg and [MEDICATION(S)] 5mg and [MEDICATION(S)] and STAT (immediately) KUB (kidney, ureter and bladder), STAT CBC (complete blood count) with differential /Platelet, CMP (comprehensive metabolic panel) and vitals for 24 hours. I never received the labs back and was not aware (R2's) labs were abnormal. His white blood count was 11k, and his creatinine was 4.29. If I would have seen the lab results, I would have sent him out to the hospital immediately and not waited until 8/18/2022 and delayed any treatment. On 8/31/2022 at 2:06 PM, V13, Licensed Practical Nurse stated, I worked that Monday (8/15/2022) when I came in that day (PM) the certified Nursing Assistant, can't remember her name told me (R2) was hurting. I went and asked him what was wrong, and he said his stomach hurt. I looked at the nurses notes and saw he had an order, and his pain was being addressed. He had some labs ordered. I never saw any of the results of the labs that day. I told (R2) to drink and keep drinking so he would not get dehydrated. He kept saying his stomach was hurting. 8/31/2022 at 5:30 PM, V17, Corporate stated, I know when (R2) first came into the facility he was having issues with his bowels. I am not sure if it is hereditary. Poor thing. On 9/2/2022 at 12:53 PM, V2, Corporate Director of Nursing (DON), stated, If a resident was complaining constipation, nausea and says he has had several bouts of emesis I would expect staff to monitor. If an enema was given, I would expect nursing to follow up with the size, description, if it was solid or runny. If the resident was still having pain. I would expect all of this to be documented in the Nurses Notes. We have been having some issues with the lab getting information back to us. We are currently looking for a new lab. I am not sure why lab results were not reported for (R2). The Facility's Notification of Change in Resident Condition or Status Policy dated 7/1/12 documents 1. The Nurse supervisor/charge nurse will n notify the resident's attending physician or on-call physician when there has been: m. abnormal lab findings. The Laboratory Test Policy with a revision dated of 9/27/2017 documents, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. Obtain laboratory orders upon admission, readmission and PRN for medication and condition monitoring per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review the facility failed to notify the Physician and the responsible party of two, new unstageable pressure ulcers, for 1 of 1 residents (R16) reviewed for change of condition in the sample of 23. This failure resulted in R16's having two unstageable pressure ulcers, being untreated by staff for 21 days. Findings include: On 12/26/19 at 5:22 AM V19, Certified Nursing Assistant (CNA) turned R16 onto his right side to perform incontinent care. R16 had two unstageable pressure ulcers to his right and left inner buttocks, with both wound beds covered with yellow slough. There was a moderate amount of drainage on his soiled adult diaper and a small amount of drainage on his bed sheet where the pressure ulcers were touching. There was no dressing covering either of the pressure ulcers. V19 confirmed that there was no old dressing contained in the soiled adult diaper. V19 stated staff were putting protective cream on R16's buttocks and coccyx. She applied [MEDICATION NAME] Antifungal Cream, over and around the pressure ulcers. The Pharmacy label on the bottle, documented the instructions to apply to buttocks and sacrum twice daily. The directions on the bottle document to use this medication for 2 weeks, if no improvement, notify the Doctor. R16 also had dressings on his left outer knee and left ankle dated 12/23/19, 3 days ago. On 12/26/19 at 10:00 AM V3, Licensed Practical Nurse (LPN) measured the unstageable pressure ulcer on right buttock as 2.5 centimeters (cm) by 1.5 cm, and the unstageable pressure ulcer on his left buttock as 3 cm by 1 cm. V3 stated, It's not healing; it's worse than when he came back from the hospital, because it was just a rash. I don't think the Aloe Cream is doing the trick. He needs to be seen by the Wound Doctor. V3 stated, she last looked at R16's skin on 12/13/19 when she last worked and stated the wound on the right buttock was not getting better. V3, LPN, stated the area to the right buttock had been two smaller wounds, but now was one big wound. V3, LPN, acknowledged R16's dressings on his left ankle and left heel dated, 12/23/19 (three days ago) and stated she did take care of R16 on 12/24/19, but did not get a chance to do his dressing changes. V3 stated, I don't even know what's under those dressings. R16's Discharge Hospital Report - Wounds, dated 12/04/19 documents that he had peeling, flaking open skin to buttock surrounded by maceration from incontinence, with measurements: 0.2 centimeters (cm) by 0.2 cm by 0.1 cm R16's Discharge Medication List dated 12/05/19 listed the following order: [MEDICATION NAME] dressings to all pressure areas- left upper foot (medial), left heel, left medial heel, left lateral ankle, right lateral ankle, and right hip. R16's Nursing Admission assessment dated [DATE] includes a body diagram for an admission skin assessment which has an arrow pointing to the left ankle and documents wounds. No other areas were identified on the body diagram. A Nurses Note dated 12/06/19 at 6:00 AM, documents that during incontinent care, R16 was found to have 2 small open areas to his coccyx, but there was no description of the wounds or measurements documented. No further documentation was found in R16's Medical Record regarding open areas to R16's coccyx, or of his Physician being notified for treatment orders. R16's Physician order [REDACTED]. which was written and signed by V21, Family Nurse Practitioner, (FNP). On 12/27/19 at 11:55 AM, V9 LPN stated she had notified V21 FNP, of R16's new unstageable pressure ulcers to his buttocks and requested a referral for the wound Physician to evaluate and treat him. V9 stated that V21 responded that she had already given that order on 12/09/19, but to go ahead and make the referral now. V9 stated she did not know why the referral for the Wound Physician was not done on 12/9/19, but that sometimes the nurses waited until the Wound Physician was in the facility before informing him of new referrals. V9 confirmed there was a 21-delay in the FNP being notified of the unstageable pressure ulcers on R16's buttocks from when they were discovered on 12/6/19. On 12/27/19 at 11:55 AM, V21, FNP stated she had not been informed that R16 had two new unstageable pressure ulcers on his buttocks. She stated she had given an order on 12/09/19 for R16 to be seen by a Wound Specialist, for wounds he had after a hospitalization to his lower extremities. V9, LPN, had requested another referral for a Wound Specialist and for a low air loss mattress on 12/27/19 for R16 due to new wounds on his buttocks. No wounds had yet been evaluated. V21 stated she would have expected the staff to notify her or the Physician of any changes in R16's condition for prompt, appropriate treatment. On 12/27/19 at 1:45 PM, V29, R16's mother and Responsible Party according to R16's undated Face Sheet, stated the facility would notify her any time R16 was sent to the hospital. The facility did not notify R16's mother that R16 had bed sores on his buttocks. V29 stated the hospital had notified her when he was admitted to the hospital and that R16 had bed sores and stated they had taken pictures of the sores on his ankle, heels and hip. V29 stated R16's sister visits him more often than V29, and stated he is often wet when she comes to visit. V29 stated this could cause his bed sores. The Facility's Policy, Notification for Changes in Resident Condition or Status dated 07/01/12 documents, Policy: The Facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, Physician, Guardian, HCPOA, etc.) of changes in the resident's medical/mental condition and/or status. Responsibility: Administrator, Director of Nursing, Charge Nurse. Procedure: 1. The nurse supervisor/charge nurse will notify the resident's attending Physician or on-call Physician when there has been: a. Any symptom, sign, or apparent discomfort that is: 2. A marked change (i.e. more severe) in relation to usual signs or symptoms, and 3. Unrelieved by measures already prescribed. and o. Onset of pressure ulcers or stasis ulcers. and 2. The nurse supervisor/charge nurse will notify the DON (Director of Nursing), Physician, and unless otherwise instructed by the resident, the resident's next of kin or representative when the resident has any of the afore mentioned situations.

Based on observation, interview, and record review the facility failed to follow Physician's Orders to treat and monitor pressure ulcers, repositioning and offload pressure for 3 of 3 residents (R1, R16 and R18) reviewed for pressure ulcers in the sample of 23. This failure resulted in R16 acquiring two unstageable pressure ulcers. Findings include: 1. On 12/26/19 at 5:22 AM V19, Certified Nursing Assistant, (CNA), turned R16 onto his right side while removing his soiled adult diaper during incontinent care, and he had unstageable pressure ulcers to his right and left inner buttocks with both wound beds completely covered with yellow slough. The skin surrounding the pressure ulcers had deep wrinkles that remained during care. There was no dressing covering the pressure ulcers on either buttock and V19 confirmed that there was no old dressing contained in the soiled adult diaper. V19 stated staff were putting protective cream on the R16's buttocks and V19 applied [MEDICATION NAME] Antifungal Cream over and around the pressure ulcers after cleansing the skin around them, but not the wound beds. The Pharmacy label on the bottle of [MEDICATION NAME] documented the instructions to apply to buttocks and sacrum twice daily. The directions on the bottle document to use this medication for 2 weeks and if no improvement, notify the doctor. R16 also had dressings on his left outer knee and left ankle which were dated 12/23/19, 3 days ago. R16's Cumulative [DIAGNOSES REDACTED]. R16's Braden Score for Preventing Pressure Ulcer Risk dated 11/18/19 documents a score of 11, indicating he is at high risk of developing pressure ulcers. No other updates to the skin risk assessment were documented. R16's Nursing Admission assessment dated [DATE] documents: Excoriation to coccyx. The body diagram does not document any areas of concern except his gastrostomy tube site. On 12/26/19 at 10:00 AM, V3, Licensed Practical Nurse (LPN), measured R16's unstageable pressure ulcer to his right buttock as 2.5 centimeters (cm) by 1.5 cm, and the unstageable pressure ulcer to his left buttock as 3 cm by 1 cm. She stated she would say they were Stage 2 pressure ulcers, but because there was yellow slough covering both wound beds, they were unstageable. She stated the pressure ulcer on the right buttock had been two separate wounds before, with a strip of skin separating the two wounds, but now it is larger and one wound. V3 stated she had no idea what was under the dressings on R16's left knee or left foot. V3 stated the nurses are responsible for doing the treatments as ordered by the Physician. R16's Nursing Admission assessment dated [DATE] does not document any pressure ulcers and the body diagram has an arrow pointing to his left ankle and foot labeled wounds. A Nurses Note dated 12/06/19 at 6:00 AM documented noted 2 small open areas to coccyx. Areas cleansed, and incontinence pad applied. Also noted [MEDICATION NAME] dressings on right hip and 3 to left foot. No description or classification of any of the wounds, documentation of Physician notification or new treatment orders were documented in R16's medical record. The next acknowledgement of R16's pressure ulcers on his buttocks was documented in a Nurse's Note dated 12/19/19, Breakdown noted to sacral area 2+ decub noted. Barrier cream applied. Will continue to monitor. No description of the pressure ulcers nor notification of MD for new treatment orders were documented on that date. R16's Hospital Comprehensive Wound Report dated 12/03/19 documents the following wounds: Left Medial Heel- Stage II Pressure Ulcer 2.5 cm by 3.5 cm; Left Hip Deep Tissue Pressure Ulcer 4 cm by 4 cm; Left Heel- Deep Tissue Pressure Ulcer 2 cm by 2 cm; and Coccyx- Friction, Description: unapproximated macerated: 0.2 cm by 0.2cm by 0.1 cm. V3's measurements done today (12-26-2019) are 2.5 cm by 1.5 cm unstageable pressure ulcer on the right buttock and 3.0 cm by 1.0 cm unstageable pressure ulcer on left buttock. No wound measurements or assessments for any of R16's pressure ulcers to his left knee, left hip, left ankle or left heel were found in his facility medical record. R16's Discharge Packet, dated 12/12/19 included the discharge instructions: Wound Instructions: -Apply Triple Care Antifungal cream to maceration on sacrum and buttock. Apply every 12 hours. -Apply 4X4 [MEDICATION NAME] borders to the ulcers on right hip, left heel, and right lateral ankle. Change daily. -Daily apply Silver gel to the ulcers on left lateral ankle and knee and cover with 4X4 [MEDICATION NAME] border. Review of R16's medical record on 12/27/19 indicate that V3 did not document finding the new pressure ulcers, a description of the pressure ulcers and notification of the Physician or FNP and there were no new or updated orders for treatment of [REDACTED]. There was no facility skin assessment done on 12/14/19 when R16 returned from the hospital where he had been admitted on [DATE] with a [DIAGNOSES REDACTED]. R16's Care Plan dated 10/01/19 documents he is at risk for skin breakdown per Braden Risk Assessment. Risk Score High. The goal documented, Will have no skin breakdown thru admission review and care plan. Interventions include: Skin check by nurse weekly on 2-10 PM shift; Incontinent care and barrier cream after incontinence care as needed.; Report any new skin concerns to the Doctor for treatment and follow up; Prevent skin areas from prolonged contact, use pillows for positioning, float heels, assist to turn at least every 2 hours and prn. R16's care plan was updated on 12/26/19 with: Resident noted to need wound treatments to both heels and skin treatment to hip areas. All these areas need to be assessed and MD to be notified and treatments to be put in place. The care plan does not identify that R16 has unstageable pressure ulcers on his buttocks, or pressure ulcers to his left knee and ankle. R16's Treatment Administration Records (TAR) dated 11/01/19 through 11/30/19 and 12/01/19 to 12/31/19 document an order for [REDACTED]. Another order on the TAR dated 12/14/19 documents: Apply 4X4 [MEDICATION NAME] dressing to ulcers on right hip, left heel, and right lateral ankle daily. Another order on the TAR was undated: Apply silver-sept to ulcers on left lateral ankle and left knee. Cover with [MEDICATION NAME]. Between the dates of 12/14/19 and 12/27/19, the [MEDICATION NAME] Cream treatment was applied only once a day on (MONTH) 14, 18, 20, 22, 23, 24, 25, 26 and 27. No treatment was applied to R16's coccyx/ buttocks on (MONTH) 16, 17, 19 and 21. According to R16's (MONTH) TAR, the treatments to R16's left ankle, left knee, right hip, left heel, and right lateral ankle were not done on (MONTH) 14, 16, 17, 18, 19, 21, 24, 25, 26 and 27. There was no order on the (MONTH) TAR for treatment of [REDACTED]. R16's Physician Order Sheet dated 12/09/19 documents, Refer to Wound Specialist. There is no documentation that Wound Specialist was notified of this order, nor that R16 has been evaluated by a Wound Specialist as of 12/27/19. On 12/26/19 at 1:40 PM V3 stated she was going to change the dressings on R16, but she did not know where his TAR was, so she was just going to put some dressings on. V3 removed a dressing from a wound on the back of R16's right hand, cleansed it with Theraworx, applied [MEDICATION NAME] and a dry dressing. V3 stated the wound on the back of his right hand was from a fluid filled blister that had popped. She then removed a dressing from his left lateral knee, cleansed a Stage II pressure ulcer that was covered with slough, with Theraworx, and applied skin protectant with vitamins A&D to the wound and covered it with [MEDICATION NAME]. V3 stated the wound on his left knee had some kind of ointment on it but she wasn't sure what it was, so she was just going to put protectant ointment on it. She then removed the gauze dressing that was wrapped around his left heel and saw another dressing to his left lateral ankle. Upon removing dressing that was dated 12/23/19 (three days ago) from left lateral ankle, she stated, Oh, this one is kind of bad. An unstageable pressure ulcer to the left lateral ankle was covered with yellow slough, and the old dressing was saturated with serosanguinous bloody drainage. V3 cleansed the wound with Theraworx then applied [MEDICATION NAME] and a dry dressing. She then cleansed the necrotic pressure ulcers on R16's medial and lateral left heel with Theraworx, applied protective ointment with vitamins A &D and a dry dressing, wrapped it with gauze and then wrapped it with an ace bandage. V3 stated she did not measure the wounds because the Wound Doctor would do that. R16's unstageable pressure ulcers were uncovered and V3 stated she had applied the [MEDICATION NAME] that was ordered for that area. On 12/26/19 at 11:26 AM, V1, Administrator, was asked for an accurate wound report that included all the residents with pressure ulcers in the facility. The list of residents with pressure ulcers provided on the first day of the survey, 12/24/19, included only one resident with a pressure ulcer. The accurate list, labeled Skin Care Treatments provided on 12/26/19 from V2, MDS Coordinator, included 6 residents, including 3 with pressure ulcers. V1 stated, To be honest, this is a problem that I'm hoping to address with my new Assistant Director of Nursing who is starting on 12/30/19. No one is following up with weekly wound assessments or measurements except the Wound Physician. On 12/27/19 at 11:55 AM V21, Nurse Practitioner, stated she was not aware of R16 having pressure ulcers on his buttocks, but would expect nurses to notify her of any changes in condition, including pressure ulcers. She stated she would expect nurses to follow Physician Orders for wound care, so the nurse should have applied silver gel to the wounds as ordered, not [MEDICATION NAME]. On 12/27/2019 at 12:10 PM V22 Physician Wound Doctor stated [MEDICATION NAME] and silver gel are not the same type of treatment and are not interchangeable. He stated he would expect nurses to follow Physician Orders and perform wound care as ordered and notify either him or the Medical Doctor of any changes in wound status. 2. On 12/26/19 at 5:50 AM V19, CNA, provided incontinent care for R1, who was lying flat on her back. R1 stated this was the first time V19 or any other staff had come in to check and change her on the night shift. When V19 rolled R1 onto her right side to cleanse fecal material from her rectum and buttocks, R1 had deep red wrinkles on both of her buttocks that remained while V19 cleansed her skin and put on a new adult diaper. When V19 was finished with R1's incontinent care, she left R1 on her back with no repositioning with pillows to relieve pressure from her buttocks. R1's MDS dated [DATE] documents she is alert and oriented to person, place, time and situation. The same MDS documents she requires extensive assist with bed mobility. On 12/27/19 at 9:20 AM R1 stated she is afraid she will get a sore on her bottom because she is not able to move herself around in bed, and staff do not come in to reposition her. She stated she wished staff would give her one hour of good care a day and that would make her feel much better. R1's Braden Scale for Predicting Pressure Ulcer Risk dated 9/17/19 documents her score of 14 indicating she is at high risk of developing pressure ulcers. R1's Care Plan dated 09/28/19 documents R1 is at risk for Pressure Ulcers related to her High Risk per Braden Scale. It documents interventions to include: Reposition per positioning schedule- see positioning schedule (Schedule not part of R1's Care Plan); Prevent skin area from prolonged contact. Use pillows, place padding between legs, etc. R1's TAR documents an order to perform skin checks weekly on Saturdays, but there is no documentation that skin checks have been performed in (MONTH) 2019. 3. R18 was admitted to the facility 4/07/2016 (current) and 5/30/2008 (original) with a [DIAGNOSES REDACTED]. R18's Minimum Data Set ((MDS) dated [DATE] document a Brief Interview of Mental Status (BIMS) score being blank indicating severe cognitive impairment and is totally dependent on staff assistance for most Activities of Daily Living (ADLS). On 12/26/2019 at 10:00-10:50 AM R18 was observed sitting in a small TV room across the nurse's station. At 10:50 AM R18 was then pushed into the dining room. At 10:50-12:45 PM R18 was observed in dining room. At 12:45 PM V20 Certified Nurse's Assistant (CNA) is observed pushing R18 from dining room to his room. V20 CNA and V12 CNA transferred R18 from wheelchair to bed operating a mechanical lift. A strong foul-smelling urine noted and R18's pants were visibly wet. V20 and V12 stated that another CNA got R18 out of bed for the 8:00 am breakfast and that they hadn't laid R18 down until now. V12 CNA left the room and returned with one partially wet white towel. V20 and V12 then removed R18's incontinent brief and deep red creases noted on R18's buttocks and back of legs. A deep open stage 4 pressure area noted on R18's right buttocks, with no dressing. V20 then took the wet towel and wiped R18 from the scrotum area back to his right buttocks wiping 2-3 times and then discarded towel. V20 then pulled R18 onto his right side and scar tissue noted on R18's left buttocks and dried feces noted on buttocks and rectum area. V20 and V12 then pulled up the incontinent brief and covered R18 up with covers. V20 and V12 then removed their gloves and left resident's room without washing their hands. On 12/26/2019 at 1:20 PM V3 Licensed Practical Nurse (LPN) stated, R18's wounds are being treated by the Wound Doctor. V3 also stated, The wound is open, so the Wound Doctor can pack it when they come. V3 stated, Apparently he (Wound Doctor) doesn't want a dressing on it. V3 stated, I will send the CNA's back in to clean R18. On 12/27/2019 at 09:20 AM V4 LPN stated, No, R18's wounds are not supposed to be open, they are supposed to be covered. I haven't had a chance to do my dressing changes yet. V4 LPN stated, It looks like there are 2 different orders, one for day shift and one for evenings. I have never had 2 different orders for one wound before, I think one of those orders should have been discontinued. V4 stated, V3 is Agency Nurse, so when she stated that R18's wound should be open to air, then she should of wrote the new order. V4 stated, (R18) wounds need dressings because R18 is incontinent of urine and stool. On 12/27/2019 at 08:00-11:45 AM R18 was observed sitting in wheelchair in TV room across from the Nurses station. No staff observed off loading or repositioning R18 during this time. On 12/27/2019 at 12:10 PM V22 Physician Wound Doctor (R18's MD) stated, I would expect the Nurses to follow my orders. V22 stated, (R18) is supposed to receive one treatment a day for his right and left buttocks. V22 stated, Most of the nurses have left and now they have Agency Nurses that don't know what's going on. V22 stated that the facility has had no Director of Nursing or Assistant Director of Nursing for months. V22 stated that Silva Gel and Medi-Honey are not the same treatment. V22 stated, There is no guidance at that facility, they need management. V22 stated, (R18) only has treatments to his right and left buttocks and wasn't familiar with left hip. R18's Treatment Administration Record dated 12/1/2019-12/31/2019 documents: Cleanse Right Buttock apply crushed [MEDICATION NAME], Collagen, Calcium Alginate & Dry Dressing every other day and as needed. On 12/6/19 and 12/20/2019 there are initials indicating treatment was completed. There are no initials on 12/02, 12/04, 12/08-12/16 to indicate treatment was completed. R18's TAR 12/01/2019-12/30/2019 documents: Cleanse Left Buttock, Pack with [MEDICATION NAME] coated [MEDICATION NAME], Cover with Dry dressing every other day and as needed. (Dated 07/30/19 on TAR), only on 12/6 and 12/20 were initials indicating treatment was completed. R18's TAR dated 12/01/2019-12/30/2019 documents: Cleanse wound to left hip apply Mupirocin, collagen, calcium alginate daily and as needed. (Order has no start date indicated on TAR) Weekly Skin Assessment with note on Saturday 2-10 PM. On 12/16/2019 there are initials indicating skin check completed. R18's Wound Evaluation & Management Summary dated 12/9/2019 documents: Stage 4 Pressure Wound of the Left Buttock, Wound size Length 1cm x Width 1cm depth 1.5 cm. Duration greater than 2130 days. Undermining 10 cm at 9 o'clock. Exudate: Moderate Serous. Dressing treatment plan: [REDACTED]. R18's Wound Evaluation & Management Summary dated 12/9/2019 documents: Stage 4 Pressure Wound of the Right Buttock. Wound size Length 0.5 cm x Width 0.5 cm x Depth 1 cm. Duration greater than 306 days. Dressing treatment plan: [REDACTED]. Recommendations: Limit sitting to 60 minutes; Off-load wound; Reposition per facility protocol. R18's Care Plan date 10-10-2019 documents; Mobility, Impaired physical. Interventions: Turn and reposition following the resident's reposition schedule at least every 2 hours and as needed. Alteration in Bladder Elimination as related to incontinence. Interventions: Continue to monitor on going for any signs and symptoms of urinary tract infection. All care and comfort measures extended to assure maximum comfort to keep resident clean dry and free from odor. Encourage fluids. Pressure Ulcer Present Right and Left Buttock. Interventions: Assist Resident to turn and reposition every 2 hours and as needed or more frequently per reposition schedule. Braden Scale High Risk daily skin check with documentation, apply house/stock Theraworx to peri area with personal care after every incontinent episode and as needed. Lotion skin with cares and as needed, avoid friction over boney prominences. Wound Doctor consultant every week. Dressing change daily as ordered. Facility's Policy and Procedure 'Decubitus Care/Pressure Areas' dated 05/07 documents: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. The pressure area will be assessed and documented on the Treatment Administration Record (TAR). Complete all areas of the TAR: Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician). Documentation of the pressure area must occur upon identification and at least once a week on the TAR. The assessment must include: Characteristic (size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.). Treatment and response to treatment.

Based on observation interview and record review the facility failed to follow Physician's Orders for treatment of [REDACTED]. This failure resulted in R18's stage 4 pressure ulcers. Findings include: R18 was admitted to the facility 4/07/2016 (current) and 5/30/2008 (original) with a [DIAGNOSES REDACTED]. R18's Minimum Data Set ((MDS) dated [DATE] document a Brief Interview of Mental Status (BIMS) score being blank indicating severe cognitive impairment and is totally dependent on staff assistance for most Activities of Daily Living (ADLS). On 12/26/2019 at 10:00-10:50 AM R18 was observed sitting in a small TV room across the nurse's station. At 10:50 AM R18 was then pushed into the dining room. At 10:50-12:45 PM R18 was observed in dining room. At 12:45 PM V20 Certified Nurse's Assistant (CNA) is observed pushing R18 from dining room to his room. V20 CNA and V12 CNA transferred R18 from wheelchair to bed operating a mechanical lift. A strong foul-smelling urine noted and R18's pants were visibly wet. V20 and V12 stated that another CNA got R18 out of bed for the 8:00 am breakfast and that they hadn't laid R18 down until now. V12 CNA left the room and returned with one partially wet white towel. V20 and V12 then removed R18's incontinent brief and deep red creases noted on R18's buttocks and back of legs. A deep open stage 4 pressure area noted on R18's right buttock, with no dressing. V20 then took the wet towel and wiped R18 from the scrotum area back to his right buttock wiping 2-3 times and then discarded towel. V20 then pulled R18 onto his right side and scar tissue noted on R18's left buttock and dried feces noted on buttocks and rectum area. V20 and V12 then pulled up the incontinent brief and covered R18 up with covers. V20 and V12 then removed their gloves and left resident's room without washing their hands. On 12/26/2019 at 1:20 PM V3 Licensed Practical Nurse (LPN) stated, R18's wounds are being treated by the Wound Doctor. V3 also stated, The wound is open, so the Wound Doctor can pack it when they come. V3 stated, Apparently he (Wound Doctor) doesn't want a dressing on it. V3 stated, I will send the CNA's back in to clean R18. On 12/27/2019 at 09:20 AM V4 LPN stated, No, R18's wounds are not supposed to be open, they are supposed to be covered. I haven't had a chance to do my dressing changes yet. V4 LPN stated, It looks like there are 2 different orders, one for day shift and one for evenings. I have never had 2 different orders for one wound before, I think one of those orders should have been discontinued. V4 stated, V3 is Agency Nurse, so when she stated that R18's wound should be open to air, then she should of wrote the new order. V4 stated, (R18) wounds need dressings because R18 is incontinent of urine and stool. On 12/27/2019 at 08:00-11:45 AM R18 was observed sitting in wheelchair in TV room across from the Nurses station. No staff observed off loading or repositioning R18 during this time. On 12/27/2019 at 12:10 PM V22 Physician Wound Doctor (R18's MD) stated, I would expect the Nurses to follow my orders. V22 stated, (R18) is supposed to receive one treatment a day for his right and left buttocks. V22 stated, Most of the nurses have left and now they have Agency Nurses that don't know what's going on. V22 stated that the facility has had no Director of Nursing or Assistant Director of Nursing for months. V22 stated that Silva Gel and Medi-Honey are not the same treatment. V22 stated, There is no guidance at that facility, they need management. V22 stated, (R18) only has treatments to his right and left buttocks and I wasn't familiar with left hip. R18's Treatment Administration Record dated 12/1/2019-12/31/2019 documents: Cleanse Right Buttock apply crushed [MEDICATION NAME], Collagen, Calcium Alginate & Dry Dressing every other day and as needed. On 12/6/19 and 12/20/2019 there are initials indicating treatment was completed. There are no initials on 12/02, 12/04, 12/08-12/16 to indicate treatment was completed. R18's TAR 12/01/2019-12/30/2019 documents: Cleanse Left Buttock, Pack with [MEDICATION NAME] coated [MEDICATION NAME], Cover with Dry dressing every other day and as needed. (Dated 07/30/19 on TAR), only on 12/6 and 12/20 were initials indicating treatment was completed. R18's TAR dated 12/01/2019-12/30/2019 documents: Cleanse wound to left hip apply Mupirocin, collagen, calcium alginate daily and as needed. Transcribed from Physician's Order dated 9/02/2019) (Order has no start date indicated on TAR). Staff initials are observed on 12/05, 12/08-12/12, 12/17, 12/20 and 12/22-12/23. Weekly Skin Assessment with note on Saturday 2-10 PM. On 12/16/2019 there are initials indicating skin check completed. R18's Wound Evaluation & Management Summary dated 11/04/19 documents: Stage 4 Pressure Wound Left Buttock Wound Size 1cm x 1cm x 1.5 cm. Undermining 10cm at 9 o'clock. Wound Progress: No change. Dressing treatment plan: [REDACTED]. R18's Wound Evaluation & Management Summary dated 11/4/2019 documents: Stage 4 Pressure Wound of Right Buttock Wound Size 1 cm x 0.5 cm x1 cm. Wound Progress: No change. Dressing treatment plan: [REDACTED]. These Physician orders were not transcribed to R18' s' November`s TAR or followed. R18's Wound Evaluation & Management Summary dated 11/11/19 documents: Stage 4 Pressure Wound Left Buttock Wound Size 1cm x 1cm x 1.5 cm. Undermining 10cm at 9 o'clock. Wound Progress: No change. Dressing treatment plan: [REDACTED]. Discontinue Silver [MEDICATION NAME]. R18's Wound Evaluation & Management Summary dated 11/11/19 documents: Stage 4 Pressure Wound of Right Buttock Wound Size 0.5 cm x 0.5 cm x1 cm. Dressing treatment plan: [REDACTED]. Discontinue Silver [MEDICATION NAME]. These Physician's orders were not transcribed to R18's (MONTH) TAR or followed. R18's Wound Evaluation & Management Summary dated 11/18/19 documents: Stage 4 Pressure Wound Left Buttock Wound Size 1cm x 1cm x 1.5 cm. Undermining 10 cm at 9 o'clock. Wound Progress: No change. Dressing treatment plan: [REDACTED]. R18's Wound Evaluation & Management Summary dated 11/18/19 documents: Stage 4 Pressure Wound of Right Buttock Wound Size 0.5 cm x 0.5 cm x1 cm. Dressing treatment plan: [REDACTED]. Discontinue Silver [MEDICATION NAME]. These Physician's orders were not transcribed to R18's (MONTH) TAR or followed. R18's Wound Evaluation & Management Summary dated 12/9/2019 documents: Stage 4 Pressure Wound of the Left Buttock, Wound size Length 1cm x Width 1cm depth 1.5 cm. Duration greater than 2130 days. Undermining 10 cm at 9 o'clock. Exudate: Moderate Serous. Dressing treatment plan: [REDACTED]. R18's Wound Evaluation & Management Summary dated 12/09/19 documents: Stage 4 Pressure Wound of the Right Buttock. Wound size Length 0.5 cm x Width 0.5 cm x Depth 1 cm. Duration greater than 306 days. Dressing treatment plan: [REDACTED]. Recommendations: Limit sitting to 60 minutes; Off-load wound; Reposition per facility protocol. R18's Care Plan date 10-10-2019 documents; Mobility, Impaired physical. Interventions: Turn and reposition following the resident's reposition schedule at least every 2 hours and as needed. Alteration in Bladder Elimination as related to incontinence. Interventions: Continue to monitor on going for any signs and symptoms of urinary tract infection. All care and comfort measures extended to assure maximum comfort to keep resident clean dry and free from odor. Encourage fluids. Pressure Ulcer Present Right and Left Buttock. Interventions: Assist Resident to turn and reposition every 2 hours and as needed or more frequently per reposition schedule. Braden Scale High Risk daily skin check with documentation, apply house/stock Theraworx to peri area with personal care after every incontinent episode and as needed. Lotion skin with cares and as needed, avoid friction over boney prominences. Wound Doctor consultant every week. Dressing change daily as ordered. On 12/27/2019 at 12:10 PM V22 Physician Wound Doctor (R18's MD) stated, I would expect the Nurses to follow my orders. (R18) has one treatment only once a day to his Right and Left Buttocks. V22 also stated, That facility has no Director of Nursing (DON) or Assistive Director of Nursing, there is no guidance there. V22 stated, Most of the nurses have quit and now they have Agency Nurses that don't know what's going on.

Based on interview and record review the facility failed to obtain timely treatment for [REDACTED]. This failure resulted in R52 not receiving medical treatment for [REDACTED]. This would cause a reasonable person great pain. Findings include: The Illinois Department of Public Health (IDPH) Notification Form, dated 12/4/18, documents on 12/3/18 at 4:30 AM, R52 was observed on the floor. An x-ray was obtained. The Notification Form documented on 12/4/18 the x-ray revealed a fracture of R52 left hip. The Form documented the physician was notified at 2:45 PM on 12/4/19. This was 24-hours after the facility received the X-ray report form. R52's X-ray results documented R52 had a left [MEDICAL CONDITION]. These results were received at the facility on 12/3/18 at 2:05 PM as indicated by the (X-ray service) Patient Report form. There is no documentation in R52's medical record that the facility was assessing R52's condition or monitoring R52 for pain. R52'S History and Physical from the local hospital dated 12/4/18 documents, (R52) states, he was walking yesterday when he tripped, fell into dresser, striking his left hip and then falling to the floor. (R52) was assisted to his bed and they called for an x-ray, which was apparently done yesterday; however, the facility did not get the result back until today (12/4/19) at which time it was noted that he does have a fracture. R52 received treatment for [REDACTED]. On 9/12/19 at 1:45 PM V11, Registered Nurse (RN) stated, When a resident has a change of condition like a fall, if it is a bad one I will call the doctor immediately. If I get x-ray results that indicates something is wrong I would call the doctor immediately. On 9/12/19 at 11:20 AM V29, Medical Director, stated, I believe the resident (R52) experienced significant amount of pain and harm from the delay in notification. I would have initiated a treatment earlier if I was notified of the x-ray results when the facility received them. The Notification for Change in Resident Condition or Status Policy, revised 12/2017, documents The facility and/or facility staff shall promptly notify appropriate individuals (Administrator, Director of Nursing, Physician, Guardian, HCPOA, etc.) of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there is an accident or incident involving the resident; a significant change in the resident's physical/emotional/mental condition; a need to alter the resident's medical treatment significantly; a need to transfer the resident to the hospital/treatment center.

Based on interview and record review the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) for 1 of 15 residents (R15) reviewed for Advanced Directives/CPR in the sample of 15. Facility staff failed to follow R15's Advanced Directives by not initiating CPR for R15, who subsequently expired. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility failed to perform CPR on R15 and R15 expired. This failure had the potential to affect 52 of 65 residents (R1-R8, R13, R18-R47, and R49-R61) whose Advance Directives indicate Full Code Status. The immediacy was removed on [DATE] when the facility completed the following: On [DATE], the Regional Nurse and Social Service Director completed an initial audit of resident medical records for current status of advance directives related to code status, POLST, living will, POA-health care, POA-finance, health Care Surrogate and Guardianship. On this day, the Social Service Director initiated clarification of resident code status discrepancies identified during the audit of advance directives related to completion of POLST. The Regional Nurse audited facility nursing personnel related to CPR certification. The Administrator contacted CPR instructor to schedule classes for facility staff certification. On [DATE], the Social Service Director continued clarification of resident code status discrepancies identified during the audit of advance directives related to completion of POLST. The Regional Nurse conducted random chart reviews for physician and family notification. On [DATE], the Regional Nurse completed 100% staff in-servicing for all departments including Administration, Nursing, Housekeeping/Laundry, Dietary, and Maintenance regarding facility policy related to Physician and Family Notification, Nursing Assessment, Advance Directives, POLST, and CPR including staff certification requirements and when to initiate CPR. On this day, The Regional Nurse clarified with all staff during 100% inservice that identification of resident code status is located in each resident's medical record under the Advance Directive tab on the POLST form. If there is no POLST form, resident remains a full code. The Regional Nurse conducted random chart reviews for physician and family notification. The Regional Director, Regional Nurse, and Social Service Director re-audited each resident medical record for current status of advance directives related to code status including proper completion of POLST, cross referencing Face Sheet, Physician order [REDACTED]. Findings Include: The Facility's Cardiopulmonary Resuscitation Policy, revised on [DATE], documented It is the policy of (Facility) that cardiopulmonary resuscitation (CPR) shall be initiated and maintained by qualified staff, in cases of recognized cardiac and/or [MEDICAL CONDITION] arrest to sustain or support a resident's cardiac and/or [MEDICAL CONDITION] function until advanced life support systems are available. Cardiopulmonary resuscitation shall be initiated on all residents except those who have designated through advanced directives and/or have a specific physician order [REDACTED]. The Policy documented the following procedure should be directed by a licensed nurse in the event of cardiac distress:1. Assess for cardiac distress; 2. Assess resident status (vital signs, color, consciousness, responsiveness) treat as indicated. Initiate oxygen at 6 liters per minute for any of the above symptoms; 3. Call emergency rescue services unless resident is of NO Code status. If 'No Code' status, notify physician and proceed as ordered; 4. Place on a hard surface; 5. Initiate Artificial circulation/chest compression if pulse is absent; 6. Initiated artificial respirations if respirations are non existent or cease; Continue CPR until: a. Advanced life support systems are available, operable and resume care b. The resident responds, c. A physician orders [REDACTED]. Document all observations and occurrences in the medical record. The Facility's Do Not Resuscitate Policy, dated [DATE], documents it is their policy that CPR and other emergency procedures will be initiated in all circumstances of a resident cardiac or [MEDICAL CONDITION] arrest unless a valid Do Not Attempt Resuscitate (DNR) order is written in the resident's record. R15's Physician order [REDACTED]. R15's POS, dated [DATE], documents R15 is a Full Code. R15's Nurse's Notes, dated [DATE], documents, resident (R15) time of death is 4:45 PM determined by writer (E25, Former Facility Licensed Practical Nurse, LPN), and (E7, LPN) other staff nurse verified by no pulse, no heart beat, and no respirations, 5:00 PM (Z2, Physician) and Coroner was notified. At 5:25 PM the local funeral home was notified to pick up the body. At 6:45 PM the local funeral home here to pick up the remains. (R15's) son in law was at her bedside. R15's State of Illinois Certificate of Death Worksheet, dated [DATE], documents R15's date of death as [DATE]. The form also documents her cause of death [MEDICAL CONDITION], Acute [MEDICAL CONDITION] Infarction, and Hypertension. The Facility's Untitled time line form, dated [DATE], documents (in part) at 2:35 PM, R15 was greeted by E12, Certified Nursing Assistant (CNA), at 3:30 PM, E16, CNA, toileted R15, at 3:45 PM, R15 in the television room, at 4:33 PM, R15 in her room watching television, at 4:40 PM, R15 was found slumped in her chair, and at 4:45 PM, per nursing notes resident's time of death. The Facility's Incident Report Form/Illinois Department Public Health Notification, dated [DATE], documents allegation of neglect. Nurse immediately suspended, investigation initiated per protocol, and the type of incident as inappropriate action by staff. A Facility Letter to Illinois Department of Public Health, dated [DATE], documents (in part) please accept this letter as the final report to the initial notification submitted on [DATE] regarding an allegation of neglect involving (R15) and (E25). During the investigation it was noted that approximately 4:40 PM on [DATE] (R15) was found unresponsive. The staff members notified (E25) LPN of the residents change of condition and report that (E25) failed to thoroughly assess (R15). (E25) was interviewed, and she made a visual assessment of her condition. (E25) reports that a second nurse (E7, LPN) assisted with assessment of the resident's condition. However the second nurse (E7) denied assessment of the resident. In conclusion the facility was able to substantiate the allegation and (E25) was terminated from her position. E26, former CNA, untitled employee statement, dated [DATE], documents E26 stated that she was working the 300 hall, helping residents to the dining room. At approximately 4:40 PM, she walked into R15's room, and saw R15's chair facing away from the television. E26 asked R15 if she needed assistance, but no reply from R15. E26 walked closer to R15, and noticed her lips and chin area were purplish in color. E26 called for another CNA, because R15 was not breathing. E26 tried to arouse R15 several times. Other CNA's went into the room. E26 heard a stat page to R15's room. E25 entered the doorway of R15's room, and stated Oh not (R15). E26 stated that E25 stated R15 is a full code. E25 left the room, and E26 didn't see E25 assess R15. E26 stated that after R15 had been transferred to the bed, E26 continued her regular duties of passing meal trays. E26 saw E25 sitting at the 300 hall nurses desk. E16, CNA, untitled employee statement, dated [DATE], from the facility investigation dated [DATE], documents E16 was assigned to R15. R15 was assisted to the bathroom by E16. R15 asked to be laid down, but E16 suggested that she go watch television until dinner. R15 was rolled to the dining area by E16. E16 continued her work assignment until 4:45 PM, when E26, CNA, told her R15 had died . E16 went to R15's room and saw E25 in the hallway, while E16 was in R15's room E16 did not see a nurse in the room. E12, CNA, untitled employee statement, dated [DATE], documents E12 didn't have any other interaction with R15 until approximately 4:42 PM when another CNA told her R15 had passed away. E12 went to R15's room, and she noticed that R15 was slumped in her chair and her lips were blue. E12 noticed E25 in the doorway, but she did not notice E25 enter the room. E12 stated she heard E25 state that R15 was a full code. E25 also told them to clean R15 up and put a gown on her. E13, CNA, untitled employee statement, dated [DATE], documents E13 and E15, CNA, were in the 200 hallway, when E13 heard the stat page to R15's room. E13 went into the room. Several CNA's were in the room. E25 was in the doorway. E13 heard E25 state put R15 to bed. E13 assisted with putting R15 to bed. E25 returned to her other duties, and E13 observed E25 sitting at the desk making a telephone call. E18, CNA, untitled employee statement, dated [DATE], documents E18 heard the over head page to room R15's room. E18 told the other CNA's to transfer R15 to bed. R15's face color was changing to a bluish color. E18 asked E25 if R15 was a full code. E25 did not respond, and E25 left the room. E18 overheard E25 ask for the number to the morgue. E7, LPN, untitled employee statement, dated [DATE], documents that E7 was on the 200 hall when a CNA notified E7 that she couldn't find the 300 hall nurse, and that R15 had passed away. E7 walked to the 300 hallway and saw E25 leaving the room, and closed the door behind her. E7 asked E25 if there was anything she could do, E25 asked her for paperwork. E7 went back to 200 hall. E25 called E7 wanting the telephone number to the coroner. E7 then went to 300 hall desk, and asked E25 if R15 was a full code. E7 looked at the list, and stated R15 is a full code. E7 then stated E25 stated, 'Oh my God, I don't know what to do.' E14, CNA, untitled employee statement, dated [DATE], documents E14 was in the dining room passing meal trays. A CNA ran into the dining room and stated R15 is dead. E15 and the other CNA went to R15's room, and R15 was slumped in her chair. E14 ran to the phone and paged E25. E14 went back to R15's room. E25 entered the room [ROOM NUMBER] to 5 minutes later. E14 said E25 stated R15 was a full code. E14 stated E25 left the room and didn't return. On [DATE] at 3:44 PM in a telephone interview, E25 stated, I decline to be interviewed. I would rather not speak on it. On [DATE] at 3:35 PM, E9, LPN, stated regarding what she expects the CNA's to do when they find an unresponsive resident, They (the CNA's) should get the nurse, and take their vitals, see if they are a full code, and start CPR. E14, CNA, on [DATE] at 3:25 PM, stated, I was in the dining room and one of the CNA's (E12) ran into the dining room looking for the nurse. We ran to the room, and (E15) was already in the room. We asked (E25) what to do, and she said put her into bed. I left the room to complete serving. We had an inservice on CPR therapy, but most of the CNA's were not CPR certified. We had a class on [DATE]. E15, CNA, on [DATE] at 3:10 PM, stated, I know it happened fast. I went to the room (R15's) mouth was blue black, and she was slumped over in her chair. I stayed in the room while everyone else went to get the nurse. I thought only the nurse could do CPR. The nurse just said laid her down. No one did CPR. E12, CNA, on [DATE] at 3:05 PM, stated, It was 4 PM, I was getting residents up for dinner. Me and (E14) were on break. We went to (R15's) room (E25) told us to lay (R15) down. (R15) made a gasping noise when we laid her down, and no one did CPR. We should start CPR, after the nurse is notified. E17, CNA, on [DATE] at 3:15 PM, stated I know (E14) made a call for everyone to get to (R15's room). (R15) was sitting in her chair. (E25) stood by the door, and asked (E14) to clean (R15) up. I wasn't CPR certified, and no one did CPR. I took a class myself outside of the facility. The nurse tells us what to do, check the book to see if they need CPR, and the other person puts the slide board under the patient. E19, CNA, on [DATE] at 3:20 PM, stated, I wasn't here the night it happened. I was inserviced on CPR. We get the nurse. I was CPR certified. I would go get the nurse crash cart, and then do CPR. E1, Administrator, on [DATE] at 8:11 AM, stated, The staff should look in the chart. Its color coded red or green. The red form is for stop, and the green one is for full code. The white form in the chart is the original. Yes, I expect the CNA's to do CPR under the direction of the nurse. E2, Director of Nursing, on [DATE] at 8:00 AM, stated, The staff should get the charge nurse. They should try not to leave the resident alone, but do emergency care. Start CPR after check positioning. I want the nurse to assess them. If deemed necessary, start oxygen, get the crash cart, and call 911. Z2, Physician, on [DATE] at 8:00 AM, stated, If the resident is a full code, the facility should do CPR. The Facility provided an undated resident roster with Full Code written at the top with residents highlighted in yellow that are a full code. This list included R1-R8, R13, R18-R47, and R49-R61. On [DATE], a Quality Assessment Meeting was held with Department Heads at facility, Medical Director and Pharmacist. On [DATE], the facility had a full code occurrence and through QAPI process and removal plans, staff were fully compliant as evidenced by adherence to established policies and procedures related to Advance Directives and CPR. The Meeting concluded that through QAPI and Removal Plan the facility was effective in attaining compliance with this issue. On [DATE], an Immediate Jeopardy was identified. E1, Administrator, and E2, Director of Nurse's, were notified of the Immediately Jeopardy Past Noncompliance on [DATE] at 10:21 AM. The Past Non Compliance began on [DATE] when the facility failed to initiate CPR for R15 who was a full code status. R15 subsequently expired. On [DATE], the surveyors determined through observation, interview and record review, the facility took the following actions to remove the immediacy: 1. On [DATE], the Regional Nurse and Social Service Director completed an initial audit of resident medical records for current status of advance directives related to code status, POLST, living will, POA-health care, POA-finance, health Care Surrogate and Guardianship. On this day, the Social Service Director initiated clarification of resident code status discrepancies identified during the audit of advance directives related to completion of POLST. The Regional Nurse audited facility nursing personnel related to CPR certification. The Administrator contacted CPR instructor to schedule classes for facility staff certification. 2. On [DATE], the Social Service Director continued clarification of resident code status discrepancies identified during the audit of advance directives related to completion of POLST. The Regional Nurse conducted random chart reviews for physician and family notification. 3. On [DATE], the Regional Nurse completed 100% staff in-servicing for all departments including Administration, Nursing, Housekeeping/Laundry, Dietary, and Maintenance regarding facility policy related to Physician and Family Notification, Nursing Assessment, Advance Directives, POLST, and CPR including staff certification requirement s and when to initiate CPR. On this day, The Regional Nurse clarified with all staff during 100% inservice that identification' of resident code status is located in each resident's medical record under the Advance Directive tab on the POLST form. If there is no POLST form, resident remains a full code. The Regional Nurse conducted random chart reviews for physician and family notification. The Regional Director, Regional Nurse, and Social Service Director re-audited each resident medical record for current status of advance directives related to code status including proper completion of POLST, cross referencing Face Sheet, Physician order [REDACTED].

A. Based on interview, observations and record review, the facility failed to provide necessary care and services and timely identify and assess/monitor a significant change in health condition for one of 3 residents (R14) reviewed for necessary care and services in a sample of 15. This resulted in hospitalization for R14 when she went unresponsive. R14 was admitted to the hospital with [REDACTED]. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents R14 to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The MDS documents R14 to be independent in transfers, and mobility about the room at the time of the assessment along with R14 to be occasionally incontinent. R14's Urinalysis with culture, dated 9/19/17, documented R14 had a urinary tract infection [MEDICAL CONDITION] which cultured >100,000 CFU (colony forming units) of Escherichia Coli and R14 was placed on [MEDICATION NAME]. (Cipro). R14's Telephone Orders, dated 9/22/17, [MEDICATION NAME] discontinued and [MEDICATION NAME] 875 milligrams twice daily for ten days was started. R14's Nurse's Note, dated 9/23/17, at 5:00 AM documented no (change) noted. ABT (antibiotic) therapy started, The Nurse's Note documented no discomfort or pain when asked and tolerating fluids well. Will cont (continue) to monitor. The next entry is at 10:30am and document denied pain/discomfort @ (at) this time. pt (patient) is afebrile 97 PO (by mouth) fluids encouraged Resp (respirations) even unlabored. Will cont to monitor. R14's Nurse's Note, dated 9/24/17 at 1330, written by E9, Licensed Practical Nurse (LPN), documented R14's temperature still afebrile with no adverse effects, fluids encouraged, c/o burning when urinates, excoriated skin. R14's Nurse's Note, dated 9/25/17, written by E7 (LPN) documented at 1400 (2pm) that R14 denies discomfort, is afebrile, PO fluids encouraged, is able to make needs known. R14's Nurse's Notes for 9/26/17 at 2:00 PM and 10:00 PM documented R14 had no complaints of pain and/or discomfort and fluids were encouraged. R14's Nurse's Note for 9/27/17 (no time), written by E9, documented R14's temperature was 98.1 degrees with no adverse reactions and fluids encouraged. At 10:15am, the NN document cont ABT for UTI s (without) adverse effects. R14's Nurse's Note, dated 9/28/17, at 10:40 PM documented remains on ABT for UTI. No adverse reactions noted. Voices no concern. R14's Nurse's Note, dated 9/29/17 at 11:10 AM, written by E7 Licensed Practical Nurse (LPN) documents Res (resident) to be seen in the ER (emergency room ) r/t (related to) AMS and possible dehydration. TO (Z2 - Medical Director.) The Resident Transfer Form dated 9/29/17 documents the reason for transfer is not eating or drinking, c/o (complains of) pain all over her body and refusing to eat or drink. The Emergency Medical Services (EMS) report dated 9/29/17 documented R14's Oxygen saturation was 72% on 3 Liters (L) of oxygen by nasal cannula. Hospital Emergency Department (ED) notes dated 9/29/17 documents R14 presented to the hospital unresponsive and was intubated for ventilator use. The ED Report dated 9/29/17 documents Pt (patient) is a 68 y/o (year old) female who presents to the ED, via EMS, c (with) c/o unresponsiveness and Per EMS report, they were called to the facility today due to the pt being unresponsive and having an SaO2 in the 70's. Upon EMS arrival, they placed a [MEDICAL CONDITION] machine on the pt, which brought her SaO2 up into the 80's. Pt began to respond to pain only en route to the ED. The Hospital History and Physical dated 9/29/17 documented The patient was admitted to the intensive care unit [MEDICAL CONDITION], hypercapnia, acute [MEDICAL CONDITION], lactic acidosis and [MEDICAL CONDITION]. The History and Physical Assessment and Plan documented Acute [MEDICAL CONDITION], Questionable for a UTI, Diabetic Ketoacidosis with metabolic acidosis, [MEDICAL CONDITION] secondary [MEDICAL CONDITION], and acute [MEDICAL CONDITION]. On 10/11/17 at 2:12 PM, E9 (LPN) stated R14 had been getting more confused and lethargic, something different about her in the week prior to her transfer. E9 stated R14 would usually get up early in the morning and then started to get up by noon. E9 stated she would also say off the wall things but couldn't recall anything specific except that R14 would look for things that were right in front of her, and turn her light on when she couldn't find it. E9 stated this began to occur on 9/27 and 9/28/17. E9 stated R14 wasn't eating as well either and it was taking her longer to do things than it normally did. E9 stated she thought it was just the UTI. E9 stated she had come in early on 9/29/17 and E7 LPN called her to R14's room. E9 stated when she went to R14's room that morning, R14 hadn't touched her breakfast yet and they couldn't get her to wake up for her medications. E9 stated R14 was not responding to voice commands but would moan when moved. E9 stated R14 also had trouble transferring herself the last few days and had therapy look at her. E9 stated R14 went from transferring herself to a full body mechanical lift in the last few days. E9 stated she didn't think it was a condition change just due to her having a UTI. On 10/11/17 at 12:40 PM, E3, Registered Nurse (RN), stated R14 was alert and oriented until the last few days adding that she used to come to the dining room for all three meals but did not do so the last couple of days she was here. On 10/8/17 at 9:55 AM, E7 (LPN) also stated R14 had been declining in the days prior to her hospitalization with no longer transferring herself, being a full body mechanical lift, no longer went to the dining room for breakfast, and was mostly incontinent. E7 stated on 9/26/17 she first noted that R14 didn't eat her breakfast when she went in to give her medications that morning. E7 stated she hadn't touched her coffee and refused to take her medications saying she was too tired. E7 stated when they first notified the EMS, they told them it wasn't an emergency, no lights, no sirens, but as they waited, R14 became unresponsive and they called EMS back to get them there sooner. E7 stated the first time she took R14's oxygen Saturations it was low 90's and the second time, dropped into the upper 80's. E7 didn't recall it being in the 70's as reported in the EMS report. E7 stated she started Oxygen at 3 L per a nasal cannula and waited for the EMS to arrive. On 10/11/17 at 12:50 PM, E2, Interim Director of Nurse (DON)/Registered Nurse (RN) stated R14 was alert and oriented times three but understood that she was a little confused the last few days needing more help. On 10/18/17 at 12:55 PM, Z2, Primary Physician stated he would have wanted to know if R14 had exhibited an overall decline in mobility and cognition in the days prior to her becoming unresponsive as he would have done something sooner. When told the nurses repeatedly documented no adverse effects in the NN but acknowledged in interview that R14 had an overall decline, Z2 stated They should write what they see and let him know. Z2 stated he didn't recall being told about the decline when he saw her on 9/25/17 for her monthly visit. A physician note dated 9/25/17 confirms R14 was seen by E2, Primary physician for a monthly visit with no abnormalities identified by the nurses to Z2 in terms of the changes/decline in R14's functional and cognitive abilities. The facility's policy/procedure entitled Notification for Change in Resident Condition or Status dated 8/1/12 documents it is the policy of the facility to promptly notify appropriate individuals (i.e., Administrator, DON , Physician, Guardian, HCPOA, etc) of changes in the resident's medical/mental condition and/or status. The Nurse Supervisor/charge nurse will notify the DON, physician, and unless otherwise instructed by the resident by the residents next of kin or representative when the resident has any of the afore mentioned situations. B. Based on observation, record review, and interview, the facility failed to provide necessary care, services and treat venous ulcers and skin conditions for two of two residents (R8 and R14) reviewed for wounds/skin conditions in the sample of 15. Findings include: 2. R14's Minimum Data Set, dated dated [DATE] documented R14 to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The MDS documented R14 to require extensive assist for bathing and occasionally incontinent. R14's Physician order [REDACTED]. R14's September 2017 Treatment Administration Record (TAR) documented the Antifungal cream as of 9/14/17. The TAR has blanks as the treatment not being done for the 6pm to 6am shift on 9/18, 9/19, 9/25 and 9/28/17. R14's September 2017 TAR Weekly Summary, dated 9/19/17 documented continue c (with) fungal rash to periarea/bottom O (no) open areas. Scabs to RFA (right forearm.) There were no measurements or any other information regarding the fungal rash being treated. The next entry into the TAR regarding R14's rash was dated 9/27/17 and documents cont (continue) c antifungal cream to buttocks. o (no) open areas. R14's Nurse's Notes, dated 9/29/17, at 11:10 AM document R14 being transferred to the hospital for an overall condition change. R14's Hospital History and Physical notes dated 9/29/17 document R14 to have possible [MEDICAL CONDITION] to her left buttock. The Note documented She has an abrasion to her right buttocks and she has an area around the peri-rectal area, and she also has an abrasion under left buttock, which is red and swollen. On 10/11/17 at 2:12 PM, E9, Licensed Practical Nurse (LPN) stated R14 had a rash on her bottom,big red splotchy rash which she had been getting [MEDICATION NAME] and a medicated cream for. E9 stated at first, it was the whole peri area and buttocks, but cleared up then came back with the Nurse Practioner giving the order on 9/14/17. On 10/18/17 at 9:55 AM, E7 (LPN) stated R14's rash started out just on her labias and was red and inflamed. E7 stated she didn't have any redness on her back side or rectal/buttocks area. On 10/17/17, the facility provided a Decubitus Care/Pressure Areas policy/procedure when asked for a wound and/or skin issue policy. The policy dated 5/07 documents the documentation of a new pressure area must occur upon identification and at least once a week on the TAR. The assessment must include: Characteristics (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) 2. On 10/11/17 at 10:40 AM R8's right heel venous ulcer dressing was wet. (substance unknown) R8's dressing was loose on the inner edges. E4, Certified Nurse's Aide (CNA) and E2, Interim Director of Nursing, were present. On 10/18/17 at 10:30 AM, E9, Licensed Practical Nurse (LPN) changed R8's right heel venous ulcer dressing. R8's right lower leg, ankle, and foot were covered in a thick white layer of dead dry flaky skin. Large pieces of dry skin fell on to the floor during R8's dressing change. E9 changed R8's dressing and replaced R8's sock onto R8's right foot without the benefit of applying lotion. On 10/18/17 at 1:00 PM R9 stated, They almost never lotion my legs except sometimes after my bath. On 10/18/17 at 2:30 PM, E2 stated dressings should be changed when wet or soiled and skin care should be done for all residents as needed. R8's Minimum Data Sets ((MDS) dated [DATE] documented R8 required assistance of one with bathing, dressing, and hygiene. R8's Care Plan dated 10/10/17 documented R8 has diabetic venous ulcers on right foot and has [MEDICAL CONDITION]. R8's Care Plan documented Lotion skin with care and as needed. Facility policy titled Preventive Skin Care (no date) documented,staff on every shift and as necessary will provide skin care after thoroughly cleansing of the skin, lotion is to be applied and observation of any reddened areas will be reported to the charge nurse. Any resident identified as being high risk for skin breakdown shall be turned and repositioned at a minimum every two hours. Provide good nutrition and adequate hydration, keep fluids within reach of each resident and/or offer frequently. Maintain wrinkle free, clean, dry bed linen.

Based on interview and record review, the facility failed to provide and administer insulin medication and failed to monitor blood glucose levels for 1 of 3 residents (R3) reviewed for change in condition in the sample of 6. This failure resulted in R3 being sent to the hospital and admitted to the Intensive Care Unit for Diabetic Ketoacidosis. Findings include: R3's Admission Physician order [REDACTED]. The POS further documents, Insulin [MEDICATION NAME] 100 units/ milliliter (ml) Sliding Scale before meals, and Insulin [MEDICATION NAME] 25 units subcutaneously q (at) hs (bedtime). R3's Medication Administration Record (MAR) dated 6/2017 documents R3's blood glucose reading on 6/10/17 at 6:00AM was 400 milligram/deciliter (mg/dl) and was administered 12 units of Insulin [MEDICATION NAME]. The MAR also documents R3's blood glucose levels at 6AM on 6/10/17, 6/11/17, and 6/12/17 but there were no blood glucose levels documented at 11 AM and 4PM on the same dates. The MAR documents, Insulin [MEDICATION NAME] inject 25 units subq (subcutaneously) at hs (bedtime), with initials circled on 6/9/17, 6/10/17 and 6/11/17. R3's Care Plan Master Listing dated 6/9/17, documents, Resident admitted with [DIAGNOSES REDACTED]. Approach: Close monitoring of blood sugar and give SSI (sliding scale insulin) as ordered and daily insulin as ordered. R3's Nurses Notes dated 6/12/17 at 8:30AM, documents, Resident was found in room during breakfast having increased respirations and difficulty being aroused. Due to patient being diabetic, she was sent to (city hospital) via paramedics, staff waited for paramedics. Vital signs: 105/85, 97.3, 22, 110. Blood sugar was checked 3 times before paramedics arrived and read 'high' all times. R3's emergency room Care Physician Documentation dated 6/12/17 at 9:30AM, documents, in part, Patient is a 69 y/o Caucasian female, with past medical history of [REDACTED]. Per EMS (Emergency Medical Services) report, the patient did not receive any insulin over the weekend, patient's blood sugar was >600 upon EMS arrival. R3's Hospital Discharge Summary dated 6/16/17 documents, in part, admitting [DIAGNOSES REDACTED]. Was sent to the ER with elevated blood sugar was found to have DKA was admitted to ICU (Intensive Care Unit) and treated with insulin infusion. On 6/20/17 at 9:42AM, E4, Licensed Practical Nurse (LPN), stated she admitted R3 around 2:30PM on 6/9/17, did the initial admission and filled out the MAR and faxed the POS to the pharmacy. E4 stated she reported to the oncoming nurse what she did. On 6/20/17 at 12:40PM, E7, LPN, stated she worked on 6/9/17 from 6PM-6AM and received report from E4 that E4 did as much as she could with R3's admission, but not specifically that the POS was faxed to the pharmacy. E7 stated she recalled R3 was on sliding scale insulin and she did Accuchecks and gave R3 insulin that night that she borrowed from stock. E7 stated there was no delivery of insulin for R3 that night. On 6/19/17 at 2:17PM, E6, LPN, stated she took care of R3 on the night shift of 6/10/17 and 6/11/17 and monitored R3's blood sugar levels in the MAR. E6 stated she does not recall giving any bedtime insulin to R3. E6 stated when she came in to work on 6/11/17, R3's supper tray was still on the table, and R3 was moving around in her room and to the bathroom with assist. E6 stated R3 did not have any insulin. E6 stated she was told R3's medications were ordered and were coming. E6 stated no medication was delivered for R3 on 6/10/17 and 6/11/17 and she reported it to the oncoming day shift nurse, E5, who was the oncoming nurse at both dates. On 6/19/17 at 2:02PM, E5, LPN, stated she took care of R3 during the 6AM-6PM shift on 6/11/17 and 6/12/17. E5 stated she did not give any insulin to R3 and did not receive R3's insulin from pharmacy. E5 stated she did not follow up with pharmacy and realized she should have followed up with pharmacy. E5 stated that on 6/12/17 she received report from E6 that R3's Accucheck was 155 mg/dl. E5 stated that on 6/12/17 at 8 AM during breakfast R3 was hard to arouse and having increased respirations. E5 stated she checked R3's blood sugar reading 3 times which read 'high' and called Z1, R3's Physician, and R3 was sent to the hospital. On 6/19/17 at 2:30PM, E2, Interim Director of Nursing (IDON), stated she expected the nurses to make sure any medications faxed to pharmacy came in and new admission medication orders are carried out. E2 stated she expected the nurses to have R3's insulin delivered on E-run for the time required. On 6/20/17 at 10:18AM, E1, Administrator, stated E5 told her on Monday morning on 6/12/17, that R3 did not get any insulin and that R3's insulin did not get in the facility and had orders to transfer to the hospital due to high blood sugar levels. On 6/20/17 at 9:43AM, E3, Regional Nurse, stated the facility does not have a policy that is specific on time frames for admitting medication orders. E3 stated she expected nurses to have communication with pharmacy with physician orders [REDACTED]. On 6/20/17 at 9:24AM, Z1, Medical Director and R3's Physician, stated it is obvious that R3's not receiving insulin over the weekend was a contributing factor to R3's diabetic Ketoacidosis but there are multiple components to it, like on the resident's part, what they eat or do not eat, family members bring them food. Z1 further stated, on the other hand, it is the responsibility of the facility for providing insulin and administering insulin and in this case, there was a breakdown in communication among nurses. Z1 stated if the admitting nurse did not get the ordered medication, they should call pharmacy to follow up or call physician on call for substitution. The Facility Policy on Medication Administration revised 7/3/13, documents, Procedure: 21. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Medications are not to be Borrowed from one resident for another. 22. Notify the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason.

Based on observation, record review and interview the facility failed to implement effective interventions, failed to identify new pressure ulcers, and failed to follow prescribed orders for 2 of 4 residents (R1, R3) reviewed for pressure ulcers in the sample of 4. This failure resulted in R3's hospitalization [MEDICAL CONDITION] from infected Stage 4 pressure ulcer. Findings include: 1. R3's Minimum Data Set (MDS), dated [DATE] for a significant change, documents R3 has severe cognitive impairment, requires extensive assist for Activities of Daily Living (ADL), and is always incontinent of bowel and bladder. R3's Treatment Administration Record (TAR), dated 1/21/16, documents an open area to coccyx noted 0.4 X 0.4 X 0.1. R3's Physician order [REDACTED]. R3's TAR, documented on 1/29/16, Skin is warm, dry and intact, no reddened areas noted. Treatment to buttock continues with healing noted. 0.3 X 0.3 X 0.1. R3's TAR documented on 2/4/16, Wounds noted to right inner heel 2 X 1.5 X 0.1 and left outer ankle 1 X 3. R3's wound management consultant records, dated 2/4/16, document Z1, wound management consultant Nurse Practitioner (NP), started seeing R3 to evaluate and treat for pressure ulcers to right medial heel and left ankle. R3's POS, dated 2/11/16, documented orders from Z2 to discontinue treatment to buttock, area healed. R3's TAR, documented on 2/29/16, wound to coccyx reopen, 0.5 X 0.5, stage 2 with new orders from Z2 to apply Duoderm to coccyx, change every 3 days and as needed. R3's TAR, documented on 3/3/16, wound measurements to coccyx as 2.8 X 1.2 X 0.1. There was no documentation in the Nurses Notes that the doctor had been notified of the worsening pressure ulcer. R3's March 2016 TAR documented the treatment cleanse buttock with wound cleanser, apply [MEDICATION NAME], change 3 times per weekly and as needed. This was documented by E5, Licensed Practical Nurse (LPN), as being done from 3/1/16 to 3/10/16. There was no order for this treatment in R3's POS. R3's POS and wound management documentation, dated 3/10/16, documents Z1 was informed of the pressure ulcer to R3's coccyx and orders were written to cleanse wound with cleanser, protect periwound with skin prep, apply [MEDICATION NAME] to wound bed, change every 72 hours and as needed for soiling and/or saturation. R3's Nurses Notes, dated 3/15/16 3:30 PM, documented worsening sacral area now measuring 12 centimeters (cm) X 4 cm X 2 cm deep. The Nurses Note also documents Z3, Z2's NP, was notified and ordered Santyl with dry dressing two times per day, have wound management consultant evaluate on Thursday, 3/17/15. R3's March 2016 TAR documented the treatment to cleanse sacral area with wound cleanser and apply Santyl with dressing two times a day (BID). R3's March 2016 TAR documented this dressing change was done only one time per day from 3/15/16 through 3/19/16. R3's POS, dated 3/17/16, documented orders from Z1 to send cultures of coccyx/sacral wound and (indwelling urinary) catheter to be placed. There was no documentation in R3's Nurses Notes that indwelling urinary catheter was placed. R3's SBAR (Situation, Background, Assessment, Recommendation), dated 3/20/16 by E6, Registered Nurse (RN) documented a change in condition for R3, low urine output, poor appetite, increased bleeding, decreased level of consciousness, hard nodule to left groin. E6 also documented on the SBAR that there was no output after 2 hours when (indwelling urinary) catheter was placed. R3's intake of fluid for March 2016 documented, 3/15/16- 240 cubic centimeters (cc), 3/16/16- 1200 cc, 3/17/16- 0 cc, 3/18/16- 840 cc, 3/19/16- 0 cc, 3/20/16 -240 cc. On 4/6/16 at 1:55 PM, E2, Director of Nurses (DON), stated that the facility usually only monitors resident's output if they have a (indwelling urinary) catheter. E2 stated she was not aware of the order for the (indwelling urinary) catheter for R3 on 3/17/16. E2 stated she would expect the nurse follow the orders for the (indwelling urinary) catheter on the day the order was given. E2 also stated she could not find the order to cleanse R3's buttocks with wound cleanser, apply [MEDICATION NAME], change 3 times weekly and as needed. On 4/7/16 at 10:05 AM, E6 stated that R3 had a really bad pressure ulcer and she had never seen a pressure ulcer that bad. E6 said the pressure ulcer was bleeding quite a bit and had a foul smell. E6 stated she found the order in the chart, dated 3/17/16, for the (indwelling urinary) catheter on 3/20/16 when she was notifying Z2 about R3's decline and bleeding. E6 stated she inserted the catheter and got no urine output, inserted another one, she still had no urine output. E6 stated Z2 told her to send R3 to the hospital for evaluation. Z5's emergency room Report, dated 3/20/16, documented R3's decubitus measurements to bone sacral region 10 cm X 12 cm with purulent drainage. R3's History and Physical from the hospital medical records by Z4, MD, dated 3/21/16, documented R3 was admitted with [DIAGNOSES REDACTED].[MEDICAL CONDITION], most likely related to the large [MEDICAL CONDITION] decubitus ulcer. 2. Large sacral decubitus ulcer, most likely infected given the drainage and the strong odor. 3. Left ankle ulcer. 4. Hypercalcemia, most likely related to dehydration. 5. [MEDICAL CONDITION]. 6. Acute kidney injury. 7. Dysphasia. 8. Dementia. 9. Urinary tract infection. 10. Recent [MEDICAL CONDITIONS]. On 4/6/15 at 2:30 PM, Z1 stated that she would expect staff to notify her of worsening pressure areas for the residents that she sees. 2. R1's Admission Face Sheet, dated 3/20/15, documents R1's [DIAGNOSES REDACTED]. R1's MDS, dated [DATE], documents that R1 is at risk for pressure ulcers, is totally dependant on staff for all activities of daily living, has contractures of his upper and lower extremities, and is also incontinent of stool. R1's Nursing Admission Note, dated 3/20/15, documents that R1 was admitted with two open areas of [MEDICAL CONDITION] on his lower extremities and a history of multiple wounds before admission. R1's wound management consultant records from January 2016 documents that since his admission to the facility, R1 has once again developed multiple open areas, and has seen multiple wound care providers. On 4/6/16 at 2:00 PM, Z1, wound management consultant, stated that she is currently following and treating R1 for 10 chronic open pressure areas/wounds. Z1 stated the current wounds were unavoidable, and related to a significant decline in R1's overall condition and extensive weight loss after several hospitalization s. On 4/4/16 at 1:00 PM, E5, Licensed Practical Nurse (LPN), the Facility wound care nurse, cleansed and re-dressed R1's wounds. The dressing covering the wound on R1's left great toe was removed by E5, who discussed one open area on the great toe. When asked if he was aware there were two open areas on the left great toe, E5 stated he was not aware of the second open area. During this same dressing change, R1's left foot and long great toenail was pressing into R1's right calf. A red intact area was noted on the right medial superior lower leg. The area was pointed out to E5. It did not blanch, and was still present at 3:00 PM. R1 had an alternating pressure/ low air loss mattress in place. The mattress felt very firm, with the pressure adjust knob set at 7.5. This setting remained for three days of the survey. R1 also had a bath blanket folded underneath being used as a draw sheet, for three days of the survey. R1 did not have any protective equipment, or sleeves covering his elbows and arms. During the dressing change on 4/4/16 at 1:00 PM, E5 stated, I was not aware of the second open area, which looks like it is necrotic. I measured it at 1 by 1.8 centimeters. During the same dressing change on 4/4/16 at 1:00 PM, when asked about the blanket being used as a lift sheet under R1, E8, Certified Nurse Aide (CNA), stated,We always use that. (R1) has continuous stool leaking all the time and it absorbs better than a regular sheet. R1's Nurses Note, dated 4/4/16 at 3:00 PM, documents the new area on the great toe, but not the reddened area on the right medial calf. On 4/5/16 at 11:00 AM, E3, LPN, completed the multiple dressing changes to R1's wounds. When asked if she saw the new open area on R1's right medial superior calf, which was open and draining a red/clear fluid, E3 stated she did not see the open area. This was the same area that was present, red and non-blanchable on 4/4/16. The area was cleansed, and treatment orders received by E3. E3 changed the dressing on R1's right medial back. When the bordered dressing was removed the area under the tape at the bottom of the dressing had a line of open weeping blisters. E3 cleansed the area and re-applied a new bordered dressing partially covering the open blistered area with tape. No skin protectant was applied to the blistered area before applying the new dressing. On 4/6/16 at 10:15 AM E4, LPN, stated she had just finished all of the dressing changes for R1. When asked to assist with a skin check, E4 was unaware of another new open area on R1's left elbow. The new area was then cleansed, documented as a stage 2 pressure ulcer and measured at 1.4 X 1.0 cm and a new dressing was applied. On 4/5/16 at 11:00 AM, E3 stated she was, Unaware of the open area on (R1's) calf. I did not see it. When asked about not applying any skin protectant to R1's blistered area on his back from the previous dressing, E3 replied, I didn't put any skin protectant on the blistered area. We do use that some time, I just turned the bandage a little bit. On 4/6/16 at 2:45 PM, E3 confirmed that R1's low air loss mattress was very firm to the touch and the pressure adjust knob was set at 7.5. On 4/6/16 at 10:15 AM, E4 stated, I didn't even look under his shirt at that other elbow, I just did the dressing on the right elbow. When asked about the wound on the right medial superior calf, E4 stated she did not change that area and was unaware that the dressing needed to be changed, because it wasn't on the treatment record. I checked the chart and saw the order, but it was never put on a treatment record. I just made one out now after we discussed the wound. On 4/6/16 at 11:20 AM, E2, Director of Nurses, stated Skin checks are to be done daily on (R1). Full wound documentation with measurements and descriptions is done weekly after rounds with (Z1) on the back of the Treatment Administration Record (TAR). Those are the facility notes on the wounds. On 4/6/16 at 2:00 PM, Z1 stated, By the time I was called in to see (R1), he already had multiple wounds and was placed on hospice. Our goal with hospice was to maintain his wounds, monitor him for new areas and prevent infection. He has since been taken off of hospice and if that continues we will need to get more aggressive, but I do not see his wounds healing completely. When there is a new open area, the staff call the Primary care Physician for orders. I don't know about it until I come in to do my weekly rounds. I sometimes have to change the orders when I come in, several days later. I encourage them to call me, they all have my phone number. (R1) has an alternating pressure/low air loss mattress on his bed I often find that staff turn it up for patient care and forget to turn it back down. Because (R1) has lost so much weight, he is 134 lbs I think, his mattress needs to be set between 4-6, otherwise it will be so firm it is worse for his skin than laying on a regular pressure reduction mattress. Under no circumstances should a blanket be used as a lift sheet, it defeats the purpose of the mattress. R1's Physicians Orders, dated 3/2016, document an order for [REDACTED].>R1's wound management consultant records, dated 3/31/16, document R1 has open areas at his sacrum, left lateral foot, left hip, right medial back, left medial superior back, right elbow, left medial great toe, and right hip. New Physicians orders written 4/7/16 by Z1 document new treatments for areas at the Distal left great toe, Left elbow and medial superior right lower leg. R1's Plan of Care, last updated on 1/20/16, documents that R1 is to have protective sleeves to both arms, and check Treatment administration record to address all wounds and treatments as ordered. The manufacturer's User Manual for R1's alternating pressure/ low air loss mattress documents on page 4, Generally a lighter patient will need a lower (softer) setting while a heavier patient will need a higher (firmer) setting, but pressure adjustment must ultimately be based on the patient's weight distribution. Please consult your Physician for an appropriate setting. The Facility's Decubitus Care/Pressure Areas Policy, dated 5/2007, documents, Policy: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing pressure ulcer, once identified. The policy also documents, 4) Notify the physician for treatment orders. The physicians orders should include: i) Type of treatment, ii) Frequency treatment is to be performed, iii) How to cleanse, if needed, iv) Site of application, v) No PRN order is acceptable for a pressure ulcer. The order must have specific frequencies. vi) Initiate physician order [REDACTED]. The assessment must include: i) Characteristic (i.e. size shape, depth, color, presence of granulation tissue, necrotic tissue etc.) ii) Treatment and response to treatment. R1's TAR for the months of January, February and March 2016 document inconsistent and incomplete documentation of greater than 5 weeks with no measurements which fails to follow the facility policy.

A. Based on record review and interview, the facility staff failed to report an allegation of abuse to the administrator immediately, allowed a Certified Nursing Assistant to have direct contact with residents after a potential abuse incident, and delayed the initial investigation of potential abuse for three residents reviewed for abuse investigations in the supplemental sample. This had the potential to affect all 50 residents in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 10/28/11, the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. The findings include: 1. On 10/25/11 at 11:40 AM, an interview was conducted with R7. She said she had trouble with a Certified Nursing Assistant (CNA) this past weekend. R7 stated she could not recall the CNA's name. R7 stated E7, Licensed Practical Nurse(LPN) was in the hallway so R7 explained to her how she felt the CNA had an attitude. R7 stated the CNA overheard their discussion and came back to her room asking how she had an attitude. R7 stated "She got upset, acting like she was going to whoop on me." R7 stated finally the CNA told her to "Go to hell." R7 stated "It shouldn't have gotten that far. Nurse should have taken care of it right away." R7 stated the CNA was still working in the facility but down a different hallway. The facility's Incident Report - IDPH (Illinois Department of Public Health) Notification form, dated 10/24/11, documented an allegation of verbal abuse. The form documented "Resident report that CNA was rude to her and cursed at her. The staff member was suspended pending an investigation. A five day report to follow." On 10/25/11, at 12:20 PM, an interview was conducted with E1, Administrator. E1 stated she had been notified of the incident which occurred between R7 and E15, CNA, on 10/24/11. E1 stated the Director of Nurses had been notified by E7 via the telephone early morning on 10/23/11. E1 confirmed she had not been notified until the next day. E1 stated E15 was pulled off the set so she would not have to take care of R7. E1 confirmed R15 worked her entire shift on 10/23/11. 2. The facility's Incident Report Form -IDPH Notification form regarding R9 , dated 9/7/11 was reviewed. The form documented "Two therapist overheard staff member speaking to the above listed resident in a louder than usual tone. They wrote statements and reported this alleged incident. The staff member was suspended pending an investigation. A five day report to follow." The form documented the date of the incident as 9/5/11. Z5, Physical Therapist Assistant/Program Director, wrote a statement regarding this incident on 9/5/11. The statement documented "I (Z5) and (Z6, Speech Therapist) overheard (E30, Transportation Worker) yelling @ (R9) telling him 'You know lunch is not till 11:30 and if you holler at me again I won't do something for you and we will call (Z7, R9's wife) and tell her and you know you will be in trouble." The statement documented the incident occurred around 10:15 AM. On 10/27/11at 8:30 AM an interview was conducted with Z6. Z6 stated that about one month ago she was sitting with Z5, the therapy program director., and they heard R9 yelling and screaming. Z6 stated this was not unusual behavior for R9. Z6 stated E30 began yelling back at R9 and threatened to call his wife. Z6 stated that Z5 wrote up a statement and placed it on E1's desk. On 10/26/11, at 2:25 PM, during an interview with E1 she stated that the incident regarding R9 occurred on 9/5/11 which was Labor Day weekend. E1 stated she was not notified until 9/6/11. E1 stated E30 was allowed to work her entire shift on 9/5/11 and until mid-afternoon on 9/6/11. E1 sated "I needed to see what was going on." E1 stated the report was not sent to IDPH until 9/7/11. E1 stated she failed to notify the IDPH timely. 3. The facility's Incident Report Form - IDPH Notification form, dated 4/20/11 regarding R16 was reviewed. The report documented "Alleged patient report of hand slapping by unknown CNA (unidentified). Patient report hand was 'pushed away by a CNA one morning not long ago when it was dark outside.' No injuries noted @ (at) this time." There was no further investigation documented regarding this incident. On 10/26/11, at 2:25 PM, E1 stated "I never have seen this allegation. This is the first time I saw it." E1 stated there was no investigation conducted regarding this incident with R16. 4. The facility's Abuse Policy dated 7/29/10 documented "Employees are required to immediately report any occurrences of potential/alleged mistreatment they observe, hear about, or suspect to a supervisor and the administrator." The policy continued to document "Supervisors shall immediately inform the administrator or designee of all reports of potential/alleged mistreatment. Upon learning of the report , the administrator or designee shall initiate an investigation." The policy did not document all employees shall report abuse immediately to the Administrator. The facility's Abuse Policy documented the following regarding "Protection of Residents": "Employees of this facility who have been accused of mistreatment will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment shall not complete their shift as a direct care provider to residents." The Immediate Jeopardy was identified to have begun on 10/26/11 when R7 identified potential verbal abuse by E15. The facility failed to notify E1 immediately of R7's allegations and the facility failed to remove E15 immediately from direct resident care. E1 and E31 were notified of the of Immediate Jeopardy on 10/26/11 at 5:00 PM. The Facility took the following actions to remove the Immediacy: 1. On 10/26/11, all 2 PM-10 PM and 10 AM - 6 AM employees were immediately in serviced prior to their scheduled shift by the administrator on the abuse prevention program and proper reporting. 2. On 10/26/11, Re-education was provided by the Regional Director. Education provided was reviewed of the "Abuse Policy", identification of suspected abuse allegation, need to immediately remove the employee, family member or visitor from the facility for suspected abuse. The Administrator and/or DON are to notify the Regional Director of any incident between an employee/family member/ resident/ visitor to ensure compliance with F225 and F226. 3. On 10/26/11, an abuse in service was initiated with emphasis placed on immediate reporting of suspected abuse to protect the resident from any future abuse, potential disciplinary action that will be taken for not reporting immediately to the administrator and the definition and identification of suspected abuse. Any employee that did not attend physically a personal phone call was made and each was in services over the telephone. 4. On 10/27/11, all 6 AM - 2 PM employees were in services prior to their shift by the administrator on the abuse prevention and reporting of abuse. 5. On 11/1/11, a complete reviewed of the Abuse Prevention Program, Policy & Procedure has been completed. Both the administrator and the DON have been counseled on reporting any and all alleged allegation to public health with a timely manner of 24 hours. 6. The facility's CMS-672, Resident Census and Conditions of Residents form dated 10/25/11 documented the facilty's census as 50.

Based on record review and interview, the facility staff failed to operationalize the facility's abuse policy by failing to report an allegation of abuse to the administrator immediately, allowing a Certified Nursing Assistant to have direct contact with residents after a potential abuse incident, delaying the initial investigation of potential abuse for three residents reviewed for abuse investigations in the supplemental sample. This had the potential to affect all 50 residents in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 10/28/11, the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. The findings include: 1. The facility's Incident Report - IDPH (Illinois Department of Public Health) Notification form, dated 10/24/11, documented an allegation of verbal abuse. The form documented "Resident report that CNA was rude to her and cursed at her. The staff member was suspended pending an investigation. A five day report to follow." On 10/25/11, at 12:20 PM, an interview was conducted with E1, Administrator. E1 stated she had been notified of the incident which occurred between R7 and E15, CNA on 10/24/11. E1 stated the Director of Nurse's had been notified by E7 via the telephone early morning on 10/23/11. E1 confirmed she had not been notified until the next day. E1 stated E15 was pulled off the set so she would not have to take care of R7. E1 confirmed R15 worked her entire shift on 10/23/11. 2. The facility's Incident Report Form -IDPH Notification form regarding R9 , dated 9/7/11 was reviewed. The form documented "Two therapist overheard staff member speaking to the above listed resident in a louder than usual tone. They wrote statements and reported this alleged incident. The staff member was suspended pending an investigation. A five day report to follow." The form documented the date of the incident as 9/5/11. On 10/27/11 at 8:30 AM an interview was conducted with Z6. Z6 stated that Z5 wrote up a statement and placed it on E1's desk. On 10/26/11, at 2:25 PM, during an interview with E1 she stated that the incident regarding R9 occurred on 9/5/11 which was Labor Day weekend. E1 stated she was not notified until 9/6/11. E1 stated E30 was allowed to work her entire shift on 9/5 and until mid-afternoon on 9/6/11. E1 stated the report was not sent to IDPH until 9/7/11. E1 stated she failed to the notify IDPH timely. 3. The facility's Incident Report Form - IDPH Notification form, dated 4/20/11 regarding R16 was reviewed. The report documented "Alleged patient report of hand slapping by unknown CNA (unidentified). Patient report hand was 'pushed away by a CNA one morning not long ago when it was dark outside.' No injuries noted @ (at) this time." There was no further investigation documented regarding this incident. On 10/26/11, at 2:25 PM, E1 stated "I never have seen this allegation. This is the first time I saw it." E1 stated there was no investigation conducted regarding this incident with R16. 4. The facility's Abuse Policy dated 7/29/10 documented "Employees are required to immediately report any occurrences of potential/alleged mistreatment they observe, hear about, or suspect to a supervisor and the administrator." The policy continued to document "Supervisors shall immediately inform the administrator or designee of all reports of potential/alleged mistreatment. Upon learning of the report , the administrator or designee shall initiate an investigation." The policy did not document all employees shall report abuse immediately to the Administrator. The facility's Abuse Policy documented the following regarding "Protection of Residents": "Employees of this facility who have been accused of mistreatment will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment shall not complete their shift as a direct care provider to residents." On 10/27/11 during interviews with E10 (CNA), E17 (CNA), E22 (CNA), E23 (Restorative CNA), E24 (CNA), E33 (Activity Director) and Z6, Speech Therapist, they all stated they would report allegation of abuse to the nursing supervisor. None of these employees stated they would immediately report the allegation to the Administrator. The Immediate Jeopardy was identified to have begun on 10/26/11 when R7 identified potential verbal abuse by E15. The facility failed to notify E1 immediately of R7's allegations and the facility failed to remove E15 immediately from direct resident care. E1 and E31 were notified of the of Immediate Jeopardy on 10/26/11 at 5:00 PM. The Facility took the following actions to remove the Immediacy: 1. On 10/26/11, all 2 PM-10 PM and 10 AM - 6 AM employees were immediately in serviced prior to their scheduled shift by the administrator on the abuse prevention program and proper reporting. 2. On 10/26/11, Re-education was provided by the Regional Director. Education provided was reviewed of the "Abuse Policy", identification of suspected abuse allegation, need to immediately remove the employee, family member or visitor from the facility for suspected abuse. The Administrator and/or DON are to notify the Regional Director of any incident between an employee/family member/ resident/ visitor to ensure compliance with F225 and F226. 3. On 10/26/11, an abuse in service was initiated with emphasis placed on immediate reporting of suspected abuse to protect the resident from any future abuse, potential disciplinary action that will be taken for not reporting immediately to the administrator and the definition and identification of suspected abuse. Any employee that did not attend physically a personal phone call was made and each was in services over the telephone. 4. On 10/27/11, all 6 AM - 2 PM employees were in services prior to their shift by the administrator on the abuse prevention and reporting of abuse. 5. On 11/1/11, a complete reviewed of the Abuse Prevention Program, Policy & Procedure has been completed. Both the administrator and the DON have been counseled on reporting any and all alleged allegation to public health with a timely manner of 24 hours. 6. The facility's CMS-672, Resident Census and Conditions of Residents form dated 10/25/11 documented the facilty's census as 50. B. Based on interview and record review, the facility failed operationalize the facility's abuse policy by failing to conduct health care worker registry checks for potential abuse findings prior to hire for eight (E8,E15,E16,E17,E18,E19,E20, and E21) of 12 employee reviewed for pre-employment screening. This had the potential to affect all 50 residents in the facility. Findings include: 1. On 10/28/11, the facility's employee files were reviewed. The facility failed to check the Health Care Worker Registry prior to hire for E15, Certified Nursing Assistant (CNA), E16 ( CNA), E17( CNA), E18 (CNA)E19 (CNA), E20 (CNA), E8, Registered Nurse (RN), and E21, Licensed Practical Nurse (LPN). All of these employees had been hired since September 2010. On 11/1/11, at 10:00 AM, an interview was conducted with E26, Office Manager. She stated some of the Registry Checks were missing and she reprinted them off the Registry on 7/4 and 7/5/11. She stated she never check the Registry for the nurses. The facility's Abuse Policy dated 11/4/10 documented "Prior to a new employee starting a work schedule this facility will "Check the Illinois Health Care Worker Registry on any individual being hired for a position." 2. The facility's CMS-672, Resident Census and Conditions of Residents form dated 10/25/11 documented the facilty's census as 50.

A. Based on observation, interview and record review, the facility failed to follow isolation precautions and failed to clean and disinfect environmental surfaces for one of one resident (R50) reviewed for Clostridium difficile (C. diff) infection in the supplemental sample. This has the potential to affect all 50 residents in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 11/3/11, the Facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluate the effectiveness of the Infection Control policies and procedures. The findings include: 1. R50 was transferred from the hospital to the facility on [DATE]. The hospital's Patient Transfer Form dated 10/27/11 documented "Contact precautions ( +[DIAGNOSES REDACTED]) ." The EMS, Emergency Medical Service, Patient Care Report dated 10/27/11 documented "RN (Registered Nurse) also states pt. (patient) is on isolation for[DIAGNOSES REDACTED]." R50's nurse's note dated 10/27/11 documented "10 pm 47 y/o (year old) Caucasian female admitted to (Facility) from (Hospital) at 5:22 PM by (Ambulance)........Resident on contact isolation for[DIAGNOSES REDACTED] in stool per nursing report and MRSA per EMT report (nares)." R50's Care Plan, revised on 10/27/11, documented "Returned from hospital c (with) [DIAGNOSES REDACTED]. Resident now on contact isolation for[DIAGNOSES REDACTED]." On 10/28/11, at 8:49 AM, E2, Director of Nurse's was standing in front of R50's room. E2 stated "She is on isolation. I know I need to get her a sign." There was no isolation sign on R50's door. E7 and E34, Certified Nurse's Assistants (CNAs), were standing by R50's door. When asked why R50 was on isolation, E7 and E34 stated were not sure. On 11/1/11, at 9:10 AM, during an interview with E9 and E11, CNAs, both stated they were not sure why R50 was on isolation. E24, CNA, walked up and whispered "I know. She has Hepatitis C." E9 and E11 nodded their heads in agreement. E9, E11 and E24 were caring for R50 on the 6 AM - 2 PM shift. On 11/1/11, at 3:23 PM, E11, CNA, was interviewed regarding who was on isolation and for what reasons. E11 stated R50 was on isolation but she was not sure why. On 11/1/11, at 3:40 PM, E12, CNA, was interviewed regarding infection control. E12 stated she was not sure what residents were currently on isolation. She stated "I would know due to sign on door or biohazard red barrels in room." On 11/1/11, at 3:40 PM, E36, CNA, was interviewed regarding infection control. E36 stated he did not have anyone on his hallway who was in isolation. The facility's policy "Isolation Room Set Up" dated 3/02 documented "It is the policy of this facility to set up isolation for communicable diseases, which so require this procedure based on the guidelines per the Center for Disease Control." The policy documented the procedure "7. Place sign on door to resident's room for visitor's to inquire at nurse's desk prior to entering room." 2. On 11/1/11, at 9:20 AM, E13, Housekeeping Supervisor, was interviewed. When asked how the facility cleans and sanitizes rooms where residents with[DIAGNOSES REDACTED] reside, E13 responded "We use Clean Power Yellow on all surfaces in every room." E13 stated "It kills 99.1 % of germs." On 11/1/11, at 2:45 PM, the Manufactures label on Clean Power Yellow was reviewed. The manufacture's label did not document the product kills[DIAGNOSES REDACTED]. The Center for Disease Control, CDC, guidelines states under 11.1 Environmental measures "Certain pathogens (e.g.........C. difficile) may be resistant to some routinely used hospital disinfectants....Also, since [DIAGNOSES REDACTED]icile may display increased level of spore production when exposed to non-chlorine based cleaning agents, and the spores are more resistant than vegetative cells to commonly used surface disinfectants, some investigators have recommended the use of a 1:10 dilution of 5/25%.....hypochlorite (household bleach) and water for routine environmental disinfection of rooms and with patients with [DIAGNOSES REDACTED]icile when there is continued transmission... In one study the use of (bleach) was associated with a decrease in rates of [DIAGNOSES REDACTED]icile infections." On 11/8/11, the Material Safety Data Sheet for Clean Power Yellow documented the active ingredient for the solution was Ammonium Chloride. There was no hypochlorite or bleach ingredients in the solution. 3. E13, Housekeeping Supervisor, stated in an interview on 11/1/11 at 3:30 PM that she was not sure who was on isolation in the facility except for R50 and they had set up her room for isolation on Friday. E13 stated they use the same disinfectant, Power Yellow, in the mop water and spray bottles for cleaning all rooms. E13 stated she was not sure of the concentration and the disinfectant was dispensed already mixed. E13 stated the disinfectant "kills everything" and is "better than bleach". E13 stated they keep everything at "arms length" and have not had to use gowns when cleaning the rooms. Observation of the "Biohazard room" on 11/1/11 at 3:35 PM noted the biohazard barrel was overflowing and with red garbage bags and the lid was off. 4. The facility's CMS-672, Resident Census and Conditions of Residents form dated 10/25/11 documented the facilty's census as 50. The Immediate Jeopardy was identified to have begun on 10/27/11 when the facility failed to place R50 in contact isolation after her admission to the facility with[DIAGNOSES REDACTED]. The facility failed to notify the facility staff as to what type of infection R50 had to ensure proper infection control procedures were followed. The facility failed to sanitize environmental services with a product that kills[DIAGNOSES REDACTED]. E1 and E30 were notified of the Immediate Jeopardy on 11/1/11 at 4:00 PM. The Facility took the following actions to remove the Immediacy: 1. On 11/1/11, the facility in serviced all staff regarding immediately identifying any residents requiring isolation set up and the importance of the policy to complete the procedures. Any employee that did not attend physically a personal phone call was made and each was in serviced over the telephone or they were in serviced before they were allowed to be on the floor. 2. On 11/1/11, the facility staff were in serviced on the following policies: Leaving the isolation room infectious waste, removing gloves, contact precautions, laundry/linen handling, isolation room set up, cleaning of noncritical resident care items, cleaning and transporting of food trays for residents in isolation, hand washing, entering an isolation room,[DIAGNOSES REDACTED] policy and daily cleaning of[DIAGNOSES REDACTED] isolation rooms. 3. On 11/2/11, the facility's cleaning supply company provided in services to the nursing, laundry and housekeeping staff regarding the environmental disinfection of[DIAGNOSES REDACTED]. 4. On 11/2/11, R50 was moved to a private room with hand washing facilities and her room was cleaned with a 1:10 solution of bleach concentration. B. Based on observation, interview and record review, the facility failed to wash linens at temperatures above 160 degrees Fahrenheit (F) to remove potential microorganisms. This had the potential to affect all 50 residents in the facility. Findings include: 1. On 10/27/11 at 11:40 AM in the laundry room, the commercial washing machine had no temperature gauge to indicate at what temperature the machine was washing the linens. On 10/27/11 at 11:40 AM an interview was conducted with E37, Laundry Employee. She stated that all white linens were washed in bleach. E37 stated that the infectious linens and clothing are done the same as the regular laundry. E37 stated that resident personal clothing were washed without bleach. E37 stated she was not sure of the temperature of the washing machine because there was no temperature gauge on the machine. On 10/27/11 at 2:55 PM an interview was conducted with E38, Maintenance Supervisor. He stated the laundry had no heat booster for the commercial washing machines. E38 stated the laundry department received water from the main tank which was held at a temperature of 114 degrees F. On 10/27/11, at 3:55 PM, the thermometer of the side of the main hot water tank which serviced the laundry department read 110 degrees F. 2. The facility's CMS-672, Resident Census and Conditions of Residents form dated 10/25/11 documented the facilty's census as 50. C. Based on interview and record review, the facility failed to adequately develop an ongoing infection surveillance program that collected data to identify patterns, trends, and unusual occurrences. This failure has the potential to affect all 50 residents in the facility. Findings include: 1. The facility's Infection Control Logs for January 2011 through October 2011 were reviewed. The logs are not completed and do not contain sufficient data to calculate and analyze infection rates, identify patterns, trends, and unusual occurrences. There is insufficient data to plan infection control activities, staff education needs, and to detect outbreaks. The facility's Infection Control Logs do not identify the organism responsible for the infection. The Log does not list completion dates or follow up testing needed. The antibiotic ordered is identified but the Log does not list dose and directions. The Log incorrectly identifies the Nosocomial Infections versus community-acquired. There is no data from the laboratory or pharmacy included in the monthly infection control analysis. On 11/3/11 at 9:55 AM, E2, Director of Nursing (DON), stated she is Infection Control Nurse. E2 verified that the Infection Control Log did not consistently identify the organisms responsible for the infection, does not list the dosage or duration of antibiotic therapy, or need for follow-up testing such as culture and sensitivity. E2 stated she reviews the telephone order sheets for antibiotics ordered and places all residents receiving antibiotics on the infection control log. E2 stated, "I have instructed my nurses to inform the doctor when culture and sensitivity results return from the lab. They need to check that the antibiotic ordered was appropriate to treat the infection.". E2 stated she was unaware that nosocomial infections were infections that developed in the facility. She stated, "I googled the word 'nosocomial'. Maybe I misunderstood the meaning.". The facility's Infection Control - Surveillance and Monitoring Policy, Revised 5/07, documented (in part), "2. Monitoring of the day to day operation of the Infection Control Program will be conducted by the DON.....b. Determine and direct the correct procedures necessary for the prevention of infections....4. Responsibility of maintaining records of surveillance and monitoring will be the DON.....5. Surveillance and monitoring records shall be reviewed at least quarterly by the Quality Assurance Committee." 2. The facility's CMS-672, Resident Census and Conditions of Residents form dated 10/25/11 documented the facilty's census as 50. D. Based on observation and record review, the facility staff failed to wash their hands after incontinent care and after handling soiled resident equipment for three of 13 residents (R1, R3 and R5) observed for handwashing in the sample of 13. 1. On 10/25/11 at 9:00 AM, R5 was up in her wheelchair, with oxygen running via nasal cannula. R5 stated she was on Contact Isolation , "I think from a staph infection". R5 stated there was no bathroom in her room, that she had to use a bedpan. There was no equipment such as gowns, gloves, disposable plastic bags available outside R5's room. There was a sign posted on the door to see the nurse before entering the room. R5 was admitted to the facility on [DATE] at 3:30 PM. Nursing Notes dated 10/24/11 at 3:30 PM documented (in part), "Res arrived to (facility) on stretcher....Isolation VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) urine....." On 10/26/11 at 8:05 AM, E16, CNA, entered R5's room, carrying a bedpan that E16 had rinsed out in the soiled utility room. E16 was not wearing a gown or gloves as she carried the bedpan back to R5's room. E16 left the room and returned carrying a basin of water. E16 was joined by another CNA, E7, to clean R5 after she was incontinent. Both E16 and E7 were not wearing gowns. At 8:40 AM, E16 and E7 assisted R5 to stand and transfer to her wheelchair. After the transfer, E16, CNA, was asked if she know about R5's isolation. E16 stated R5 was on Contact Isolation. She stated the isolation precaution was to use gloves, that laundry goes into the red bin and trash goes into the other bin. E16 stated the information, "would be on her chart.". E16 was asked how she cleaned the bedpan for R5. E16 stated she took the bedpan into the soiled utility room, rinsed the bedpan with water in the hopper. E16 stated she did not disinfect the bedpan. At 8:45 AM, E19, CNA, entered R5's room without wearing gown or gloves. E19 picked up the water pitcher from the nightstand, carried the pitcher out to the hydration cart in the hallway, filled up the pitcher with ice and water, and returned the filled pitcher to the room. E19 left the room. She did not wash her hands. E19 continued walking down the hallway, stopping outside room [ROOM NUMBER]. E19 turned and went into the office across the hall from room [ROOM NUMBER] and took a piece of candy from the dietary manager. E19 returned to room [ROOM NUMBER] to assist with transfer of R10. E19 had not washed her hands after handling the pitcher for R6 or prior to assisting with the transfer of R10. The facility has several sinks normally used by staff either inaccesible or out of order. On 10/26/11 at 8:50 AM, the dirty utility room was filled with bins for laundry and trash. The sink was out of reach unless the bins would be moved out into the hallway. The Employee/Nurse Lounge on the 200 Hall sink was out of order in the restroom. The sink was covered entirely with a towel with an "Out of Order" sign propped up on the faucets. Most of the resident bedrooms on the 200 Hall do not have bathrooms in the room. If staff provide incontinent care to residents in the rooms with no toilet, there is no sink available to wash hands after providing care. There are common use bathrooms at the ends of the hallway. The facility's Contact Precautions Revised 12/09 stated (in part) to, "...use Contact Precaution or the equivalent for specified residents known .......to have microorganisms that can be transmitted by direct contact with the resident......wear a gown...when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or itmes in the resident's room, or if the resident is incontinent..." The Isolation Room Set Up Policy revised 3/02, stated (in part) , "Equipment outside the room: 1. Table or cabinet to hold clean supplies. 2. Long sleeved isolation gowns. 3. Masks (if applicable). 4. Gloves. 5. Cover for clean linen supplies if stored on the table. 6. Appropriate bags. There were no gowns available for use in or near R5's room. There were no isolation gowns in the clean utility rooms, nursing stations, supply closets. There was no sink in R5's room for staff to wash hands after providing care for R5. 2. On 10/25/11, at 11:24 AM, E9, CNA removed R1's incontinent brief, cleansed R1's right inner thigh and vaginal area and removed her gloves. After cleansing her hands and applying clean gloves, E9 cleansed R1's left inner thigh and left labia. E9 turned R1 to her right side and cleansed her left thigh and buttock. E9 used soiled gloves to apply a clean incontinent brief to R1 and attaching the front of the brief to the back with closure tabs. The facility's policy and procedure, entitled, 'Perineal Cleansing' documents after providing cleansing of the perineal area, "Dry area thoroughly. Remove gloves and wash hands with soap and water or cleansing gel. Apply new incontinent product, clothes or reposition comfortably. Wash hands with soap and water or cleansing gel. 3. The physician's orders [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documents R3 requires extensive assistance with personal hygiene and bathing. On 10/25/11, at 1:05 PM, R3 was transferred to bed by E6 and E7, Certified Nurses Aides, (CNA). After E6 removed R3's incontinent brief and covered him, R3 began to scratch at his perineal area. E6 or E7 failed to redirect R3 from scratching his crotch, or to assist him with hand washing. After removing their gloves, E6 and E7 left R3's room without cleansing or washing their hands. On 10/26/11, at 2:15 PM, R3 was siting in the activity area with peers. His fingernails remained jagged and broken, with brown debris under them. The facility's Handwashing policy documents, in part, "All staff will wash hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of there infection control and isolation precautions." 4. On 10/26/11, at 1:30 PM, E5, Licensed Practical Nurse (LPN) used scissors to remove the old dressing from R1's left foot. R1 has an unstageable pressure ulcer to the left heel and an open, Stage II pressure ulcer to the top of the left foot. After removing her gloves and cleansing her hands, E5 did not cleanse the scissors. E5 used the same scissors to cut the tape for the new dressing. The blades to the scissors were soiled with a dried debris. E5 cleansed the scissors with a hand sanitizer she also used to cleanse her hands. The hand cleanser product contained [MEDICATION NAME] 0.13% (per cent) and [MEDICATION NAME] 0.5% (a skin protectant). On 10/27/11, a review of the product information sheet for the sanitizer lists the bacteria and viruses affected, but fails to include the bacteria, Clostridium Difficile. The facility's policy and procedure, entitled, 'Cleaning of Non-critical Resident Care Items' documents, in part, "Non-critical items do not normally come in contact with the resident or touch only intact skin. Examples of non-critical items include, but are not limited to the following: crutches, walkers, canes, bedside tables, blood pressure cuffs, stethoscopes, bandage scissors, bedpans, urinals, linens, food utensils, furniture, floor. Transport all contaminated resident care items to the dirty utility room for cleaning. Rinse the item in cold water to remove any organic material. Use soap and water to wash the item. Rinse and dry the item. Disinfect the item, using the disinfectant provided by your facility."

Based on observation, interview and record review, the facility failed to follow an eating program to prevent aspiration for 2 of 2 residents (R6 and R17) reviewed for aspiration risks in a sample of 8. Findings include: 1. R6's Physician order [REDACTED]. The POS documents an order for [REDACTED]. The POS identifies R6 as having a diagnosis, in part, Dysphagia, Aspiration Pneumonia and Parkinson's, and documents an order on 12-7-11 indicating, "Slow rate of intake (may need to move plate out of reach). Drink after each bite. Chin tuck (R6 may need assistance with a hand at base of neck. Effortful swallow." R6 was observed at noon meal on 12-21-11 at 12:30PM to get a tray of pureed food and built up utensils provided. R6 received a pureed sandwich, pureed green beans, pureed fruit, pureed potato soup, a fortified ice cream cup, a pink milk shake supplement, thickened water, thickened orange juice and thickened milk. R6 was the only residents sitting at the table and there was a pitcher of unthickened ice water on the table. R6 helped himself to the regular water. R6 was observed to take large heaping spoonfuls of food, and to eat quickly. R6 ate all his food by 12:40 PM and removed himself from the dining room. There was no staff intervention to ensure the above eating program was implemented and followed. E2, Director of Nursing (DON), stated on 12-21-11 at 1:30PM, the Certified Nurse Aide (CNA) would be the staff who monitor R6's eating/swallowing program while eating. 2. R17's POS for December 2011 documents a [DIAGNOSES REDACTED]. R17 has an order of 12-7-11, "Swallowing strategies: 1. Drink after each bite. 2. Clear throat or cough after 3 bites, 3. Effectful swallow." R17 was observed to get a pureed diet with nectar thickened liquids at noon meal on 12-20-11. R17 was served her tray and proceeded to feed herself. There was no staff intervention or encouragement to follow the above swallowing strategies. R17 did not clear her throat or cough, and did not take drinks of fluids between bites of food. No one checked on R17 during the meal to monitor for effectful swallow. R17 was observed to get a pureed diet with nectar thickened liquids at noon meal on 12-21-11. R17 proceeded to feed herself. R17 was observed to take multiple bites of food without taking any liquid. At 12:20, E9, CNA, sat down by R17 and encouraged her to take a drink of fluids. E9 sat at the table while R17 took 3 bites of food and then offered her a drink of fluid. E9 then left the table. R17 was observed to take up to 13 bites of food without taking any fluid. E9 would walk by R17 or sit at the table for a very short time, and encourage R17 to take a drink sporadically. R17 was never encouraged to clear her throat or checked for effectful swallow.

A. Based on record review and interview it was determined that the facility failed to assess, implement interventions and identify causative factors contributing to falls for 5 of 6 residents (R13, R10, R9, R1, R3) reviewed for falls in the sample of 13. R13 fell and sustained a left hip fracture which required surgical intervention. R13 expired on [DATE]. The findings include: R13 was admitted to the facility on [DATE] with diagnoses, in part, of dementia, psychosis, congestive heart failure, and chronic obstructive pulmonary disease. The Minimum Data Set ((MDS) dated [DATE] assessed R13 with no wandering behaviors. The MDS assessed R13 as requiring extensive assistance of 1 person for transfer, dressing, toilet use and personal hygiene. R13 main mobility device was documented on the MDS as a wheelchair and once in the wheelchair required limited assistance with 1 person for locomotion. On [DATE] R13 was assessed as a high fall risk on the "Fall Risk Assessment". The fall assessment documented R13 needed assist to stand and walk with loss of balance with both activities. R13 mental status was documented as "Occasional confusion". The MDS documented R13 had "two or more" falls with no injury since the prior assessment. The care plan dated [DATE] documented under "Falls" that R13 had "risk factors that require monitoring and intervention to reduce potential for self injury". The goal for R13 was documented as "Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors thru next 90 days". On [DATE] R13 was found in her room on the floor according to the "Investigation Report for Falls" report. The fall was not witnessed. The report documented that R13 was transferring independently from the bed to the wheelchair to go to the toilet. There was no injuries noted. The "Root Cause Analysis" section was not filled in nor was the "What new interventions was implemented to prevent further falls" section. The Interdisciplinary Team (IDT) review dated [DATE] recommendation documented "Pt (patient) self-reliant, non-compliant (with) care (at) (times). Pt education re: (regarding) use of call light (with) all transfers given. Pt verbalized understanding". On [DATE] at 1:30 PM the "Investigation Report for Falls"documented R13 was at the nurses station and tried to get up unassisted and fell . R13 sustained a skin tear on the left third finger. The IDT recommended R13 to call staff for assistance when attempting to get up. The new intervention to prevent further falls was as "alarm in place". On [DATE] R13 fell and sustained a left intertochanteric hip fracture. There is no incident report or investigation for this fall. E1, Administrator, confirmed in an interview on [DATE] at 2:45 PM that there was no incident report for the [DATE] fall. The nurses notes dated [DATE] at 3:30 PM documented R13 was found in her room on the floor. R13 stated she was trying to put a soda on the night stand when she fell . The nurses notes do not identify if the alarm was sounding. Staff were unable to perform range of motion to the left leg and lifted R13 back into bed. R13 was unable to move her left leg due to the pain. The physician was notified and R13 was sent to the emergency room . R13 underwent surgical repair of the hip and returned to the facility on [DATE]. The nurses notes dated [DATE] documented a large bruise on her left hip and multiple bruises on her right and left arm. A skin tear was noted on her left elbow. On [DATE] R13 was admitted to hospice services. On [DATE] R13's medications were discontinued. On [DATE] at 9:00 Am the nurses notes documented R13 was deceased with no pulse noted. 2. On [DATE] at 12:15 PM, E7 and E22, Certified Nursing Assistants (CNA) transferred R10 from the bed to a reclining geriatric chair using a mechanical lift. R10 was wearing geri-sleeves on both arms. Both arms had multiple fading purplish bruises noted. His legs were pulled up into a fetal position. R10 was apprehensive during the transfer, speaking loudly and repetitively. R10's Care Area Assessment (CAA) dated [DATE] for falls stated (in part), "Will remain on high alert in regard to falls & incidents - resident is unable to recognize safety factors in general - so staff has to be on high alert @ all times in this regard." R10's Care Plan reviewed on [DATE] identifies the Problem: "Resident is at risk for falls due to his extensive dementia & inability to recognize safety factors & his limited physical abilities - sometimes he still thinks he is capable of doing things independently." Interventions include: "His bed is to be in the lowest position.....he has bilateral side rails to help with turning & repositioning....Remove any environmental barriers from his room that may cause problems." The facility's Fall Log and Investigations documented frequent falls and skin tears for R10. On [DATE] at 6:30 AM, R10 was found on the floor of his room. There are no new interventions listed on the incident investigation or Care Plan. On [DATE] at 9:50 AM, the Incident Report stated R10's "skin came off with shirt", while CNA was undressing him. No new interventions were listed on the investigation or Care Plan. On [DATE] at 5 PM, R10 sustained a skin tear due to "scratching himself". Geri-sleeves were placed on both arms and CNAs were directed to dress him in long sleeves. On [DATE] at 9:55 PM, R10 sustained another skin tear to left upper arm due to scratching himself. There were no new interventions listed on the investigation or Care Plan. On [DATE], R10 slid out of his chair onto the floor of the TV room. A personal alarm was added as a new intervention. On [DATE] at 9 AM, R10 received skin tears on both left and right elbows from the mechanical lift pad during a transfer. No new interventions were listed. On [DATE] at 4:30 PM, R10 received a skin tear to his right upper arm. No new interventions were listed. On [DATE] at 4:25 PM, R10 slid out of the geriatric recliner onto the floor. No new interventions were listed. On [DATE] at 5:50 AM, R10 was noted to have scratches to his right hip - no new interventions were listed. On [DATE] at 4:30 PM, R10 obtained a skin tear during transfer from bed to chair. No new interventions were listed. On [DATE] at 6:05 AM, R10, "was trying to get out of bed. Caught in between siderails." The investigation listed "Add padding to siderails" as a new intervention. On [DATE] (time unknown), R10 was found "arm through side rails, knees on mat". R10 obtained skin tears to his right elbow and right forearm. There were no new interventions on either the Care Plan or investigation. R10's Nursing Notes dated [DATE] at 2:10 AM documented (in part), "....res. was found on left side, caught in siderails. L.(left) arm caught under siderails." The facility's Investigative Report for Skin Tears/Bruises dated [DATE] stated, "Res. was trying to get out of bed, was caught in between siderails and bed. That's how s/t (skin tear) occurred." The Root Cause with Recommendation dated [DATE] stated, "add padding to S/R (siderail) to prevent future S/T." The was no reassessment of the safety of siderail use following this incident. The facility's Investigation Report for Falls dated [DATE] documented another incident involving R10's siderails. This report documented "arm through side rails, knees on mat". Witness Reports attached to the investigation by E27, CNA, documented he, "Found res sitting on floor mat holding on to bed rail in upright position." There was no recommendation following this incident. On [DATE] at 10:40 AM, R10 was asleep in his bed, on his left side. He had a mat on the floor and ,[DATE] siderails up on both sides of the bed. On [DATE] at 11:00 AM, E2, Director of Nursing, confirmed that R10 continues to use side rails. E2 stated she has been DON since [DATE]. She did not recall if there were re-assessments for safety of siderail use after the incidents on [DATE] and [DATE]. 3. The MDS, dated [DATE], documents R1 is moderately cognitively impaired, and requires extensive human assistance to stabilize her balance for transfers. The Fall Assessment, dated [DATE], scores R1 as a high risk for falls. The Quality Care Reporting Form, dated [DATE], documents R1 was ambulating independently, went outside the facility, sounded the exit door alarm and fell at 4:30 PM. R1 suffered a spiral fracture of the left distal fibula. The intervention documented to prevent further falls is, "Any and everyone react and respond to door alarms." A treatment intervention ordered by the physician on [DATE] is, "Fitted with fracture boot, must wear at all times, and continue non weight bearing status." On [DATE], at 9:40 AM, 10:57 AM, and 11:24 AM R1 was in bed with no personal safety alarm in place to the bed or to R1's clothing. At 11:37 AM, E9 and E19, CNA's applied to fracture boot to R1's left lower extremity and transferred R1 from the bed to the wheelchair with the use of a gait belt. E9 and E10 allowed R1 to use full weight bearing to both lower extremities during the transfer. On [DATE], at 11:50 AM, E2, Director of Nursing, (DON) reported R1 is supposed to have a personal safety alarm when in bed and in the wheelchair. At 11:52 AM, R1 was wheeled into the dining room with a safety alarm attached to the wheelchair and clipped to R1's blouse. On [DATE], at 1:05 PM, R1 was seated in her wheelchair in the hall. R1 was trying to rise from the wheelchair, and the clip to the safety alarm came unclipped. The alarm did not sound. At 1:20 PM, E9 and E10 transferred R1 to bed and the alarm was not attached and did not sound. E10 clipped the safety alarm to R1's blouse, and placed the base of the alarm on the mattress, next to the pillow. E10 did not secure the base of the alarm to anything, making it impossible to sound if R1 tried to get out of bed. On [DATE], at 2:21 PM and 2:50 PM, the personal safety alarm remained on the mattress, unattached. On [DATE], at 8:53 AM, 9:20 AM and 10:00 AM, R1 was in bed on her back. The base of the safety alarm laid on the bed unattached or secured to the bed. The clip of the alarm was attached to R1's left shoulder. R1's Care Plan, dated, [DATE], documents she is at risk for falls due to the [DIAGNOSES REDACTED]. The Care Plan documents R1 is monitored for trying to get up unassisted since she is used to walking independently, and does not have the cognitive ability to realize her limitations. The Care Plan documents a personal safety alarm is to be present on the wheelchair and when R1 is in bed. 4. The physician's orders [REDACTED]. The Fall Risk Assessment, dated [DATE], documents R3 is a high risk for falls. On [DATE], a review of the Nurses Notes document R3 was found on the floor after falling from his wheelchair on [DATE], [DATE], and [DATE]. The Quality Care Reporting Form, dated [DATE], documents R3 slid out of the wheelchair onto the floor of the activity room, with the (soft lap cushion) on his upper torso, not connected to the wheelchair. The Prevention Plan, dated [DATE] documents, "Monitor resident closely, within sight at all times. The Quality Care Reporting Form, dated [DATE], documents R3 slid from his wheelchair at 5:30 PM in the television room with the (soft lap cushion) next to him. The Investigation documents R3 was taken to the dining room where he tried to remove the (soft lap cushion) , then tried to slide under the lap cushion. The analysis of the fall documents R3 took off (soft lap cushion). The prevention plan, dated [DATE], documented is to "find better lap buddy", and "to make sure resident lap buddy is attached." On [DATE], at 3:00 PM, E2, DON reported the fall investigation of [DATE] could not be located at the facility. On [DATE], at 9:00 AM, 10:42 AM, 11:47 AM, 12:07 PM and 12:27 PM, R3 was up in his wheelchair with a (soft lap cushion) resting on his lap. The (soft lap cushion) was too small and did not attach effectively to the wheelchair. Only one side of the (soft lap cushion) was attached to the wheelchair. On [DATE], at 4:25 PM, 4:38 PM, and 4:40 PM, R3 was up in the wheelchair. R3 was observed pulling on the (soft lap cushion). On [DATE], at 8:30 AM, R3 was in the corner of the television room, with the soft lap cushion sitting on his lap. The lap cushion was completely unattached to the wheelchair. No staff were in the television room to monitor R3. On [DATE], the Physical Restraint/Enabler Consent, undated, documents the reason for the (soft lap cushion) is, "to promote upright position and to remind resident not to get up unassisted." On [DATE], at 2:15 PM, E18 and E35, CNA's reported R3 takes off the soft lap cushion, and sometimes puts himself in bed. Both E18 and E35 confirm R3 does not have a personal safety alarm on his bed or wheelchair. When E18 asked R3 to remove the lap cushion, R3 shook his head and refused. R3's Care Plan to address falls, dated [DATE], documents R3 does remove the soft lap cushion and scoots out of his wheelchair onto the floor. An intervention, dated [DATE], is listed as "new chair cushion given and continue to place in high visibility areas, attend more activities." No other progressive interventions to prevent falls are documented. The Care Plan documents the soft lap cushion has been in place to R3's wheelchair since [DATE], and may be removed at meal times. The facility's policy and procedure, entitled, 'Fall Prevention" does not address the use of a soft lap cushion as an intervention to prevent falls, but does document "Keep in visual when out of bed". On [DATE], at 4:00 PM, E2, DON confirmed R3's soft lap cushion is too small to fit his wheelchair appropriately. 5. R9's physician's orders [REDACTED].g., psychosis, depression)." The facility's Investigative Report for Skin Tears/Bruises dated [DATE] documented at 3:50 AM R9 was getting up out of bed trying to walk and fell . The Report documented " Nursing measures to prevent: needs low bed/ body alarm/ chair alarm is used already." The Quality Care Reporting Form dated [DATE] documented "Root Cause with Recommendation by pt (patient) up s (without) assistance. Recommend checking on patient more frequently. R9's care plan was not revised after this fall with any new interventions to prevent him from falling in the future. The facility's Quality Care Reporting Form dated [DATE] documented at 9:02 PM R9 fell in his room and sustained no injury. The Form documented "Root Cause with Recommendation by Resident up s (without) assistance remind of call light also monitor more frequently to have needs met." The facility's Quality Care Reporting Form dated [DATE] documented at 12:35 AM R9 fell in his room. The intervention listed on the Form documented "Res (Resident to be assist x 2 to help c (with) unsteady gait." R9's Care Plan was revised on [DATE] and documented "No injuries sustained in fall." No new progressive interventions were implemented to prevent R9 from falling in the future. The facility's Investigation Report for Falls form dated [DATE] documented at 3:00 PM R9 fell in his room trying to get into his wheelchair. There were no new interventions documented on the form to prevent R9 from future falls. The Report documented "What fall prevention techniques were in use prior to the fall? None. Were the fall prevention techniques in place? No." R9's Care Plan was not revised after this fall. The facility's Investigation Report for Falls form dated [DATE] documented at 8:00 AM R9 fell in his room trying to transfer without assistance. There were no new interventions documented on the form to prevent R9 from future falls. The Report noted the chair alarm was in use prior to the fall ; however, the Report documented "Were the fall prevention techniques in place? No." R9's Care Plan was not revised after this fall. The facility's Investigation Report for Falls form dated [DATE] documented at 12:35 AM R9 fell in his room trying to get into his wheelchair. The Report documented "May need low bed." The Report documented the body alarm was in place but did not document if the body alarm sounded. R9's Care Plan was revised on [DATE] and documented "Resident continued to have falls due to general further decline in motor skills and his inability to realize safety precautions any longer or to realize time factors of waiting for assistance. Staff tries to anticipate his needs. Keep in high visibility areas and 30 minute checks." The facility's Investigation Report for Falls form dated [DATE] documented R9 was found face first on floor in front of the nurses station at 4:40 PM. R9 sustained a reddened area to his forehead. The Quality Care Reporting Form documented "Root Cause with Recommendation by resident attempting to get his glasses. Continue current interventions and monitor him outside of his room." The Report documented R9's chair alarm was in place but did not document if the chair alarm functioned. R9's Care Plan was reviewed on [DATE] and documented "Staff continued c (with) 30 minute checks to be more aware of his whereabouts after meals, activities, etc. he continues to try to do things independently and due to his disease progress is not always aware of time frames, etc. Fortunately, his falls have not resulted in injuries thus far. As stated, he can't always (any longer) comprehend time frames. He may ask to go to bed, then shortly thereafter try to get up independently or vis versa." The Care Plan did not document any progressive interventions to prevent R9 from falling in the future. The facility's Investigation Report for Falls form dated [DATE] documented R9 fell in his room at 8:30 AM. The Report documented "Transfer self without assistance." The Report and the Quality Care Reporting Form documented no new interventions to prevent R9 from future falls. The Report did not document if R9 was up in his wheelchair or in bed. The Report did not document if alarms sounded to notify staff of his movement. The facility's 's Investigation Report for Falls form dated [DATE] regarding R9 documented "Getting up from w/c (wheelchair) to get into bed." The Report documented "Resident was in room/ found in sitting position." The Quality Care Reporting Form regarding this incident dated [DATE] documented "Root Cause with Recommendation by continuing 30 minute checks and monitor closely." The Report did not document if the alarms were sounding at the time of the falls. R9's Care Plan was not revised after this fall. On [DATE] at 1:30 PM R9 threw his legs over the side of his bed, placed his feet on the floor and stood. There was a low muffled alarm sounding that was barely audible. R9 was unsteady and bent forward at the waist. R9 attempted to grab his wheelchair. E7 was walking down the hallway and observed R9. She went into the room to assist R9. E7 and E9, Certified Nurse's Aides (CNA) assisted R9 into his wheelchair. E7 removed and reset the alarm box that sounded the alarm. The alarm box had been placed under R9's bed linens causing the alarm to be barely audible from the hallway. B. Based on observation, record review and interview, the facility failed to ensure hot water is maintained at safe temperatures in areas which are accessible for 4 of 13 residents (R1, R3, R6, and R9) who were confused and mobile in the sample of 13 and nine residents (R17, R18, R21, R31, R35, R38, R43, R55 and R56) in the supplemental sample; the facility failed to ensure electrical wiring is inaccessible and not exposed in resident rooms for three residents ( R36, R34, R49) in the supplemental sample. Findings include: 1. On [DATE] at 1:00 PM in the unlocked soiled utility room on the 300 hallway, the hot water temperature at the large utility sink was taken with a digital thermometer and was 123.4 degrees Fahrenheit (F). 2. On [DATE] at 8:20 AM in the unlocked male shower room on the 300 hallway, the hot water temperature was taken at the sink and was 120.3 degrees F. 3. On [DATE] at 8:25 AM in the unlocked female shower room on the 300 hallway, the hot water temperature was taken at the sink and was 115.7 degrees F. 4. On [DATE], at 8:34 AM, in R6's room, the hot water temperature at the sink fixture was 119 degrees F. 5. On [DATE], at 8:39 AM in R9's room, the hot water temperature at the sink fixture was 116.6 degrees F 6. On [DATE], the facility's policy Water Temperature Control, no dated was review. The policy documented "Two times each week a maintenance persona will take and record water temperatures from two taps supplied by each water heater (supply area)." The policy documented "4. Adjustments up or down shall be made at the temperature control valve and/or at the water heater to maintain water temperatures between 100 and 110 degrees." 7. On [DATE], the facility Maintenance Rounds log was reviewed. The logs documented the following temperatures on the North side of the building: [DATE]: 118 degrees F [DATE]: 112 degrees F [DATE]: No documented temperature [DATE]: 111 degrees F [DATE]: 114 degrees F [DATE]: 112 degrees F [DATE]: No documented temperature [DATE]: 111 degrees F [DATE]: 112 degrees F [DATE]: 111 degrees F [DATE]: 112 degrees F 8. The logs documented the following temperature on the South side of the building: [DATE]: 112 degrees F [DATE]:114 degrees F [DATE]: no documented temperature [DATE]: 115 degrees F [DATE]: 112 degrees F [DATE]: No documented temperature [DATE]: 115 degrees F [DATE]: 114 degrees F [DATE]: 116 degrees F [DATE]: 114 degrees F [DATE]: 116 degrees F 9. On [DATE] at 2:55 PM an interview was conducted with E38, Maintenance Supervisor. He stated the there were two water tanks which serviced the entire building. He stated the main tank in the furnace room was kept at 114 degrees F. At 3:55 PM, E38 stated if the hot water temperature got above 114 degrees F he would start adjusting the temperature. At 3:55 PM, the thermometer on the large 200 gallon water tank in the furnace room read 110 degrees. 10. On [DATE] at 12:37 PM in R49's room, there were exposed wires hanging from the call light junction box near her bed. 11. On [DATE], at 12:40 PM in R34's room, there were exposed wires hanging from the call light junction box near her bed. 12. On [DATE] 12:48 PM in the 300 hallway female shower, there were exposed wires hanging from the call light junction box near the toilet. 13. On [DATE] at 12:58 PM in R36's room, there were exposed wires hanging from th call light junction box near his bed. 14. On [DATE], the facility provided a Daily Roster which marked with residents who were confused and mobile. The following were marked with an "x" by their name: R1, R3, R6, R9, R17, R18, R21, R31, R35, R38, R43, R55, R56.

Based on observation, record review, and interview, the facility failed to timely obtain medication, failed to correctly transcribe and administer medications as ordered for end of life comfort measures for one of 1 residents (R14) reviewed for hospice services in the supplemental sample. This failure led to increased fear, anxiety, and shortness of breath for one terminally ill resident (R14). Findings include: 1. On 10/25/11 at 9:20 AM, R14 was observed in bed, with the head of the bed elevated. He was calling "help, help", appeared anxious, was experiencing shortness of breath. R14's oxygen was running but had been removed and the tubing was laying on the floor. E24 and E23, Certified Nursing Assistants (CNA), were notified by this surveyor that R14 needed help. On 10/25/11 at 1 PM, E25, Licensed Practical Nurse (LPN), documented (in part) in R14's Nursing Notes, "..C/O SOB (complaining of shortness of breath). Rhonchi noted on expiration. Respirations uneven & labored. MD called & notified of abnormal lung sounds not relieved with breathing TX (treatment). New orders received.....". Z2, Physician, ordered an extra nebulizer treatment of [REDACTED]. R14's condition continued to deteriorate, with increasing shortness of breath. On 10/25/11 at 3:00 PM, E25 contacted the Hospice Nurse, Z4, and obtained orders for stat [MEDICATION NAME] 0.25 mg. for anxiety, [MEDICATION NAME] ([MEDICATION NAME]) 10 mg every 6 hours for pain and shortness of breath, [MEDICATION NAME] Patches to dry up secretions. At 5 PM R14 remained in bed. R14 was experiencing continued, increasing agitation. He was very short of breath, with moist respirations audible from the doorway of his room. He sat upright in bed, gasping for breath. E23, CNA, was in R14's room, holding his hand, attempting to comfort him, urging him to breathe slowly, to try to relax. The medication had not arrived in the facility at this time. E23 stated in an interview on 11/1/11 at 9 AM, that she heard R14 calling out for help on the 10/25/11 day shift. E23 stated, "He told me he was having a lot of trouble breathing. He didn't want to be left alone. He held my hand and asked me how much longer he had.". E23 stated she left the building around 6 PM that night. R14 had not received medication before she left. E25, LPN, stated in an interview on 10/26/11 that the medications were not in the facility when she left around 4:30 PM. She ordered the medications and stated she had to change the [MEDICATION NAME]es to [MEDICATION NAME] drops because the [MEDICATION NAME] was not available. E28, Registered Nurse (RN), working the evening shift on 10/25/11, documented in Nursing Notes at 4:00 PM, "Res (R14) very restless, Hospice called.....pulse ox 79%..... Called pharmacy to have them send [MEDICATION NAME] stat e-run..." On 10/28/11, Z3, Pharmacist, faxed documentation that the [MEDICATION NAME] ([MEDICATION NAME]) arrived at the facility on 10/25/11 at 6:12 PM. E28 had signed for the [MEDICATION NAME] at that time; however, the [MEDICATION NAME] was not administered until 8 PM. R14's Medication Administration Records (MAR) and Controlled Substance Records documented that the first dose of [MEDICATION NAME] was administered by E28 at 8:00 PM, almost two hours after the pharmacy delivered the medication to the facility. R14's first dose of [MEDICATION NAME] drops was administered at 9 PM, which had been delivered to the facility at 7:39 PM. Pharmacy records documented the [MEDICATION NAME] ([MEDICATION NAME]) had been delivered at 6:12 PM. The [MEDICATION NAME] had been delivered at 7:39 PM. The MAR record for R14 transcribed by E28 listed the order for "[MEDICATION NAME] 10 mg. P.O. Q 6 hours"; however, the times to be administered were incorrectly listed at 0800 AM, 1600 (4 PM), 2000 (8 PM), and 0400 AM. Every 6 hours starting at 8 PM should be 8 PM, 2 AM, 8 AM, and 2 PM. The MAR documented that R14 did not receive a dose of [MEDICATION NAME] at 2 AM; he received his next dose at 4 AM. The MAR record transcribed by E28 for R14's [MEDICATION NAME] drops TID (three times daily) listed the times as 9 PM, 3 AM, and 1 PM. R14 received his first dose at 9 PM, but did not receive any doses after. He missed the 3 AM dose. On 10/27/11 at 3 PM, E28 reviewed the MAR and stated, "It looks like I wrote the wrong times on the MAR."

A) Based on observation, record review, and interview, the facility failed to timely obtain and administer medication for 2 of 13 residents (R6, R11) reviewed for medications in the sample of 13 and 1 of 2 residents (R14) reviewed for hospice services in the supplemental sample. This failure resulted in increased fear, anxiety, and difficulty breathing, due to delays in obtaining and administration of medication for one terminally ill resident (R14). Findings include: 1. On 10/25/11 at 9:20 AM, R14 was observed in bed, with the head of the bed elevated. He was calling "help, help", appeared anxious, was experiencing shortness of breath. R14's oxygen was running but had been removed and the tubing was laying on the floor. On 10/25/11 at 1 PM, E25, Licensed Practical Nurse, documented (in part) in R14's Nursing Notes, "..C/O SOB (complaining of shortness of breath). Rhonchi noted on expiration. Respirations uneven & labored. MD called & notified of abnormal lung sounds not relieved with breathing TX (treatment). New orders received.....". Z2, Physician, ordered an extra nebulizer treatment of [REDACTED]. R14's Nursing Notes documented that after the treatment was completed, E25 notified Z2 that R14's, "breathing had not improved...... Hospice ordered Ativan, Scopolamine Patch, & Morphine. Call POA & informed him of Hospice orders. POA was o.k. with new ordered per (Z1 - Hospice Physician)." On 10/25/11 at 4 PM, E28, Registered Nurse (RN), documented in Nursing Notes and was overheard as she talked on the telephone to Z4, Hospice Nurse. E28 informed Z4 that R14's condition continued to deteriorate, with pulse oximeter reading of 79% oxygen saturation. E28 notified Z4 the Scopolamine Patches were unavailable from the pharmacy. Z4 discontinued the Scopolamine Patches and ordered Atropine, 3 drops three times daily to decrease mucus secretions. E28 asked if Z4 would return and see R14. E28 called pharmacy and requested that all medications be sent stat (as soon as possible) and delivered in an e-run (emergency run). At 5 PM, R14 remained in bed. R14 was experiencing continued, increasing agitation. He was very short of breath, with moist respirations audible from the doorway of his room. He sat upright in bed, gasping for breath. E23, CNA, was in R14's room, holding his hand, attempting to comfort him, urging him to breathe slowly, to try to relax. The medication had not arrived in the facility at this time. E23 stated in an interview on 11/1/11 at 9 AM, that she heard R14 calling out for help on the 10/25/11 day shift. E23 stated, "He told me he was having a lot of trouble breathing. He didn't want to be left alone. He held my hand and asked me how much longer he had.". E23 stated she left the building around 6 PM that night. R14 had not received medication before she left. The following morning, on 10/26/11 at 6:20 AM, E29, LPN, night nurse, documented (in part) in Nursing Notes, "....Res. appears uncomfortable at this time. Wet coarse breathing heard upon exertion..... Res. remains on 02....After Roxanol given res appears a little bit @ ease." Nursing Notes dated 10/26/11 at 8 AM, documented a note by E2, Director of Nursing, "Spoke with (Z4) hospice nurse. RC'd (received) order to suction PRN & he is calling the MD to increase Roxanol and atropine....he will be here to see res. this morning...". Nursing Notes at 9:40 AM documented that Z4 Hospice Nurse arrived in the facility, and at 9:48 AM, R14 died . On 10/27/11, E28, RN, was interviewed regarding the delay in obtaining and administering the medications ordered to make R14 comfortable. E28 stated she had called the pharmacy to send medications stat at 4 PM. E28 stated the medications were sent in two different e-runs. The morphine (Roxanol) arrived around 8 PM. She stated she administered the first dose of Roxanol (morphine) around 8 PM. The Atropine arrived later. E28 stated she gave the first dose of Atropine drops at 9 PM. On 10/27/11 at 11 AM, Z1, Hospice Physician, stated in a telephone interview that the purpose of hospice care is to treat any pain or other discomfort such as nausea and vomiting, shortness of breath, spiritual issues. Z1 was asked how soon medications should be given to ease the discomfort. Z1 replied, "Ideally, we should have a turn around within the first hour after being ordered. Some facilities don't have the narcotics on hand..... DEA (Drug Enforcement Agency) regulations have made it more and more difficult to obtain medications for end of life." Z1 stated many facilities obtain the medication in advance and have them available on an emergency basis to eliminate long delays. On 10/27/11 at 1:35 PM, Z3, Pharmacist, was interviewed by telephone. He described the e-run delivery system to obtain emergency medication. Z3 stated the controlled substances such as Ativan, Vicodin, or Morphine must be accompanied by a signed prescription. If there are any questions regarding the order, the pharmacist must discuss questions with the physician personally. Telephone orders can not be filled. Z3 stated, "We have a couple of facilities with narcotics available in their Emergency Kits." Z3 stated the concern with having narcotics available in the facility is pilferage and diversion of medication. Z3 stated, "Sometimes you have to put up with some pilferage to meet the patient's needs. The new regulations from the DEA treat the long-term care residents the same as people who walk into the pharmacy with a prescription for morphine or ativan.". Z3 stated that morphine, atropine, and ativan were commonly prescribed for comfort measures at end-of-life. Z3 stated he has discussed the possibility of having emergency morphine, atropine, ativan in the emergency kit with E2, Director of Nursing. Z3 stated the facility has not implemented having narcotics available in the facility's Emergency Kit. On 10/28/11, Z3, Pharmacist, faxed documentation that the Roxanol (morphine) arrived at the facility on 10/25/11 at 6:12 PM. E28 had signed for the morphine at that time; however, the morphine was not administered until 8 PM. Z3 explained in a telephone interview at 2:37 PM, that 2 prescriptions were sent for Roxanol (morphine) and Scopolamine but the physician's signature had been covered with the other prescription. Z1, physician, refaced the prescription at 3:45 PM but did not notify the pharmacy that it had been sent. The pharmacy found the prescription at 4:45 PM, had it ready to go at 5 PM, was received in the facility at 6:12 PM. R14's Medication Administration Records (MAR) and Controlled Substance Records documented that the first dose of Morphine was administered by E28 at 8:00 PM, almost two hours after the pharmacy delivered the medication to the facility. R14's first dose of Atropine drops was administered at 9 PM, which had been delivered to the facility at 7:39 PM. Pharmacy records documented the Roxanol (morphine) had been delivered at 6:12 PM. The Atropine had been delivered at 7:39 PM. 2. R6 was admitted to the facility on [DATE]. R6 had a gastrostomy tube ([DEVICE]) on admission due to difficulty swallowing. On 9/28/11, R6 was prescribed Scopolamine Patch 1.5 mg every 72 hours, to help dry up saliva and oral secretions. The Care Plan is updated to show the order for Scopolamine Patch on 9/28/11. Nursing Notes dated 10/4/11 at 11:10 AM stated (in part), "VA pharmacy does not carry scopolamine 1.5 mg. patches.....". On 10/4/11, Nursing Notes and physician's orders [REDACTED]. There was no substitution suggested or ordered. On 10/28/11 at 8:25 AM, R6 was observed in his room. R6 had excessive saliva noted dripping out of his mouth and down the front of his jacket. At 10:45 AM, R6 continued to have excessive saliva. He was spitting frothy saliva into an emesis basin. R6 stated he had the problem with excessive saliva "once in a while." E25, LPN, stated there was no current order for medication to help dry up R6's excessive saliva. 3. The physician's orders [REDACTED]. A physician's orders [REDACTED]. On 10/27/11, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The documentation for the 8:00 AM dose from 10/03/11 through 10/26/11 was initialed and circled as not given. On 10/03, 10/07, 10/15, 10/16/, 10/17, 10/19, 10/21, and 10/22/11 the MAR indicated oos", (out of stock). The back of the MAR, under Medication Notes for 10/27/11 documents at 8:00 AM, "Omeprazole 20 mg, will call RX (pharmacy)." A review of the Nurses Notes for 10/11 were reviewed. It was documented that Z2, physician was called on 10/02, 10/12, 10/14, and 10/18 for various medical issues for R11, but no documentation is noted about the unavailability of Omeprazole. The Nurses Note, dated 10/24/11, at 10:00 PM, documents, "Also, MD (medical doctor) in this PM shift wrote new orders to change Omeprazole to what is covered ." The Nurses Note, dated 10/25/11 at 10:54 PM, documents, " Spoke with someone from pharmacy this PM shift related to need of equivalent to Prilosec (Omeprazole). Pharmacy stated they would send out Aciphex if covered by insurance." On 11/01/11, a new physician's orders [REDACTED]." During an interview at 8:42 AM, on 11/01/11, E2, Director of Nursing, (DON) stated, "We found out she (R11) is allergic to Omeprazole. That's why it wasn't given. A new order for Prilosec was obtained." On 11/01/11 R11's clinical record was reviewed. The only allergies [REDACTED]. The Geriatric Dose Handbook, page 1137, documents Omeprazole is the generic name for Prilosec, and is used to treat symptomatic GERD. The Consultant Pharmacist Summary, dated 5/27 to 6/29/11 and 6/30 to 7/18/11 documents, in part, "It is not recommended to keep circling a medication as out. The nurse needs to continue to follow up with the pharmacy and/or call the MD (medical doctor) to get the order changed or discontinued. The surveyors are concentrating on the type of activity." The medication for R11, Aciphex 20 mg, filled 10/24/11 was found in the top drawer of the medication cart. The physician's orders [REDACTED]. B) Based on interview, record review and observation the facility failed to return expired medications to the pharmacy for three residents (R41, R48, R45) in the supplemental sample. The facility failed to dispose of unused medications after residents had expired or left the facility for three supplemental residents (R14, R15, R51,R54) 1. On 11/1/11 at 10:20 AM, The 200 Hall Medication Room was inspected. There were medications remaining in the Medication Room for two residents that had died and one that had been discharged . R14 (expired) had 3 boxes of Ipratropium Bromide Solution, 3 boxes of Albuterol Solution, 4 ounce bottle of Megace Solution. R51 (expired) had a box full of Risperdal Consta Intramuscular Injections. The medication box stated "Store in Refrigerator" but was on the counter. R54 (discharged ) had 11 bottles of Geodon 20 mg/ml bottles 2. On 11/01/11, at 10:17 AM, the 300 hall medication room was examined with E8, Registered Nurse (RN), and the following expired medication was found; Aranesp 60 mg (milligram)/ 1 ml (milliliter) vial, expired 9/2011 for R41. At that time, E8 reported she was a new employee and was unaware of the expired medication. 3. On 11/02/11, at 10:25 AM, the 300 medication cart was examined with E5, Licensed Practical Nurse, (LPN). The following medications were found for R15, who is deceased : Actonel 35 mg, 4 tabs remaining, four transdermal patches of Clonidine 0.2 mg, a generic bottle labeled "Antacid Liquid", and a sealed bottle of Megestrol suspension 40 mg/ml. Eleven vials of Hydroxyzine 50 mg/ml, expiring 8/2011, were found in a plastic bag labeled for R48. E5 reported R48 is no longer on an intramuscular dose of that medication. On 11/02/11, at 11:10 AM, E5, LPN reported she was unaware of the facility's policy or procedure for the disposal of discontinued medications or the return of the medication of deceased or discharged residents.

Based on observation, record review, and interview, the facility failed to provide adequate comfort measures and coordination of hospice services for one of two residents (R14) reviewed for Hospice care on the supplemental sample; failed to provide coordination of [MEDICAL TREATMENT] services for one of one resident (R2) reviewed for [MEDICAL TREATMENT] in the sample of 13; failed to provide interim care plans addressing current needs for two of two residents (R7, R5) reviewed as new admissions, and failed to provide a treatment intervention for one of two residents (R1) reviewed for fractures in the sample of 13. This failure resulted in increased fear, anxiety, and difficulty breathing due to delays in administration of medication for one Hospice resident (R14). Findings include: 1. During initial tour of the facility on [DATE] at 9:20 AM, R14 was observed in bed, with the head of the bed elevated. He was calling "help, help", appeared anxious, was experiencing shortness of breath. R14's oxygen was running but had been removed and the tubing was laying on the floor. E24 and E23, Certified Nursing Assistants (CNA), were notified by this surveyor that R14 needed help. On [DATE] at 1 PM, E25, Licensed Practical Nurse, documented (in part) in R14's Nursing Notes, "..C/O SOB (complaining of shortness of breath). Rhonchi noted on expiration. Respirations uneven & labored. MD called & notified of abnormal lung sounds not relieved with breathing TX (treatment). New orders received.....". Z2, Physician, ordered an extra nebulizer treatment of [REDACTED]. R14's Nursing Notes documented that after the treatment was completed, E25 notified Z2 that R14's breathing had not improved. Z2 ordered R14 to be sent to the hospital. E25 notified R14's POA (power of attorney) that R14 was being sent to the hospital. E25 called the ambulance service to transport R14 to the hospital. E25 then called Z4, Hospice Nurse to notify him of R14's change of condition and orders to send him to the hospital. E25 documented in the Nursing Notes, "POA called & notified, Hospice called & notified of orders to send to ER for TX (treatment) and evaluation. Hospice disagree, ordered [MEDICATION NAME] Patch, & [MEDICATION NAME]. Call POA & informed him of Hospice orders. POA was o.k. with new ordered per (Z1 - Hospice Physician)." On [DATE] at 4 PM, E28, Registered Nurse (RN), documented in Nursing Notes and was overheard as she talked on the telephone to Z4, Hospice Nurse. E28 informed Z4 that R14's condition continued to deteriorate, with pulse oximeter reading of 79% oxygen saturation. E28 notified Z4 the [MEDICATION NAME] Patches were unavailable from the pharmacy. Z4 discontinued the [MEDICATION NAME] Patches and ordered [MEDICATION NAME], 3 drops three times daily to decrease mucus secretions. E28 asked if Z4 would return and see R14. E28 called pharmacy and requested that all medications be sent stat (as soon as possible) and delivered in an e-run (emergency run). At 5 PM R14 remained in bed. R14 was experiencing continued, increasing agitation. He was very short of breath, with moist respirations audible from the doorway of his room. He sat upright in bed, gasping for breath. E23, CNA, was in R14's room, holding his hand, attempting to comfort him, urging him to breathe slowly, to try to relax. The medication had not arrived in the facility at this time. E23 stated in an interview on [DATE] at 9 AM, that she heard R14 calling out for help on the [DATE] day shift. E23 stated, "He told me he was having a lot of trouble breathing. He didn't want to be left alone. He held my hand and asked me how much longer he had.". E23 stated she left the building around 6 PM that night. R14 had not received medication before she left. The following morning, on [DATE] at 6:20 AM, E29, LPN, night nurse, documented (in part) in Nursing Notes, "....Res. appears uncomfortable at this time. Wet coarse breathing heard upon exertion..... Res. remains on 02....After [MEDICATION NAME] given res appears a little bit @ ease." [DATE] Nursing Notes dated [DATE] at 8 AM, documented a note by E2, Director of Nursing, "Spoke with (Z4) hospice nurse. RC'd (received) order to suction PRN & he is calling the MD to increase [MEDICATION NAME] and [MEDICATION NAME].he will be here to see res. this morning...". Nursing Notes at 9:40 AM documented that Z4 Hospice Nurse arrived in the facility, and at 9:48 AM, R14 died . On [DATE], E28, RN, was interviewed regarding the delay in obtaining and administering the medications ordered to make R14 comfortable. E28 stated she had called the pharmacy to send medications stat at 4 PM. E28 stated the medications were sent in two different e-runs. The [MEDICATION NAME] ([MEDICATION NAME]) arrived around 8 PM. She stated she administered the first dose of [MEDICATION NAME] ([MEDICATION NAME]) around 8 PM. The [MEDICATION NAME] arrived later. E28 stated she gave the first dose of [MEDICATION NAME] drops at 9 PM. On [DATE] at 11 AM, Z1, Hospice Physician, stated in a telephone interview that the purpose of hospice care is to treat any pain or other discomfort such as nausea and vomiting, shortness of breath, spiritual issues. Z1 was asked how soon medications should be given to ease the discomfort. Z1 replied, "Ideally, we should have a turn around within the first hour after being ordered. Some facilities don't have the narcotics on hand..... DEA (Drug Enforcement Agency) regulations have made it more and more difficult to obtain medications for end of life." Z1 stated many facilities obtain the medication in advance and have them available on an emergency basis to eliminate long delays. On [DATE] at 1:35 PM, Z3, Pharmacist, was interviewed by telephone. He described the e-run delivery system to obtain emergency medication. Z3 stated the controlled substances such as [MEDICATION NAME], or [MEDICATION NAME] must be accompanied by a signed prescription. If there are any questions regarding the order, the pharmacist must discuss questions with the physician personally. Telephone orders can not be filled. Z3 stated, "We have a couple of facilities with narcotics available in their Emergency Kits." Z3 stated he has discussed the possibility with E2, Director of Nursing, but have not implemented having narcotics available in the facility's Emergency Kit. On [DATE], Z3, Pharmacist, faxed documentation that the [MEDICATION NAME] ([MEDICATION NAME]) arrived at the facility on [DATE] at 6:12 PM. E28 had signed for the [MEDICATION NAME] at that time; however, the [MEDICATION NAME] was not administered until 8 PM. Z3 explained in a telephone interview at 2:37 PM, that 2 prescriptions were sent for [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] but the physician's signature had been covered with the other prescription. Z1, physician, refaxed the prescription at 3:45 PM but did not notify the pharmacy that it had been sent. The pharmacy found the prescription at 4:45 PM, had it ready to go at 5 PM, was received in the facility at 6:12 PM. E25, LPN, was interviewed on [DATE] at 11:45 AM. E25 stated she had given R14 the extra breathing treatment on [DATE], but R14's condition did not improve. E25 stated she had notified Z2, physician, who ordered R14 to be sent to emergency room . E25 had initiated the transfer, called for an ambulance, notified POA and hospice. E25 stated that Hospice told her not to send R14 out. She stated Z4, Hospice nurse, stated Hospice would have to drop R14 if she sent him to the hospital. E25 stated Z4 is only to receive "Comfort Measures". E25 stated, "I said, 'but he's not comfortable, his anxiety is increasing, I can hear rhonchi in his respirations.' (Z4) put me on hold and another hospice nurse told me to cancel the ambulance". R14's record did not have a Hospice Care Plan. There were several Hospice Nursing Clinical Notes but no care plan. On [DATE], the facility received a faxed copy of R14's Hospice Care Plan. The Care Plan was dated [DATE]. The Need/Problem was end-stage [MEDICAL CONDITIONS]. Under the heading "Palliative care of symptoms, the symptoms are described as "SOB (shortness of breath), anxiety, pain." R14's current facility Care Plan updated on [DATE] stated, "All comfort and care measures provided per Hospice Protocol. Resident is a total care in all aspects of his ADLs (activities of daily living) and personal hygiene." There is no coordination of services from Hospice. There was no Hospice Care Plan available at the facility until [DATE], 2 days after he died . The Hospice Care Plan identified "Shortness of Breath" for symptom management. The goal listed is: 1. Patient Comfort, 2. Medication obtained if needed, 3. Medications/HME/Supplies obtained if needed. Interventions listed: 1. Evaluate medication needs 2. Obtain medications if applicable. R14's Hospice Care Plan for shortness of breath was not followed. Z4, Hospice Nurse, was interviewed by telephone on [DATE]. Z4 stated R14 was receiving hospice care for end-stage [MEDICAL CONDITIONS]. Z4 stated hospice goal is to provide comfort measure, pain management, anxiety management. Z4 stated, "We ordered [MEDICATION NAME] to relieve his shortness of breath." Z4 asked why the decision was made not to send R14 to the hospital when his condition deteriorated rapidly on [DATE]. Z4 stated, "Because he is hospice, we don't send him out to the hospital. The hospital's goal is curative - not comfort measures. We try to ease his transition." Z4 was asked why he did not return to the facility on [DATE] when R14's condition deteriorated. Z4 stated he had seen R14 earlier that day and there wasn't much more he could do. 2. On [DATE] at 9:00 AM, R5 was up in her wheelchair, with oxygen running via nasal cannula. R5 stated she was on Contact Isolation , "I think from a staph infection". R5 stated there was no bathroom in her room, that she had to use a bedpan. There was no equipment such as gowns, gloves, disposable plastic bags available outside R5's room. There was a sign posted on the door to see the nurse before entering the room. R5 was admitted to the facility on [DATE] at 3:30 PM. Nursing Notes dated [DATE] at 3:30 PM documented (in part), "Res arrived to (facility) on stretcher....Isolation VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) urine....." On [DATE] at 10:00 AM, E3, Care Plan Coordinator, was asked for R5's Interim Care Plan. E3 stated she didn't have an interim care plan ready for R5. She stated she hoped to have the care plan ready today. E3 was asked how do the CNAs and nurses know about R5's needs, level of assistance. E3 stated, "CNAs should be told by nursing staff.". 3. R7 was admitted to the facility on [DATE]. R7's Interim Care Plan was dated [DATE]. On [DATE] at 11:40 AM R7 was sitting up in her wheelchair in her room. R7 extremely obese and leaning forward in her chair. R7's feet were on the floor and her legs were wrapped compression bandages. R7 stated she had a pressure ulcer on her left thigh. R7 stated she preferred to stay up in the afternoon and not lay down. R7 remained in her wheelchair throughout the afternoon and did not lay down in her bed. On [DATE], at 4:34 PM, R7 was sitting in her wheelchair in her room. E38, Registered Nurse, handed R7 a medication cup with multiple medications in it. R7 removed the [MEDICATION NAME] (an anti-hypertensive medication) from the medication cup and stated she was not going to take the medication. R7 stated her blood pressure was too low to take the medication. On [DATE] at 8:25 AM R7 was sitting up in her wheelchair. R7 stated she had asked the nurse to come because she needed her pain medication. E25, Licensed Practical Nurse, entered the room and asked R7 if she needed pain medication. E25 stated "Is it just your legs that hurt? How long have you been in this chair?" E25 asked R7 if she would lay down for awhile and R7 refused. On [DATE] at 8:28 AM an interview was conducted with E25. E25 was questioned as to when she would complete the treatment to R7's pressure ulcers. E25 responded "She sometimes refuses because she wants to wait until daughter gives her a shower." R7's Treatment Administration Record dated [DATE] documented R7 had refused the compression bandages to her lower extremities eight times since her admission. R7's Treatment Record documented she was to receive [MEDICATION NAME] 2% powder to her abdominal folds and under her breast four times daily. The Treatment Record documented she had refused the [MEDICATION NAME] 18 times. R7's Interim Care Plan documented R7 had pressure ulcers on her coccyx. R7's care plan did not address R7's refusal of medications, treatments, and refusal for repositioning to prevent pressure ulcers. 4. The facility's Quality Care Reporting Form, dated [DATE], documents R1 was ambulating and fell , suffering a spiral [MEDICAL CONDITION] distal fibula, and was treated at the local hospital. The hospital's emergency room Discharge Instructions, dated [DATE], document, in part, "No weight bearing until followup, use the wheelchair, and ([MEDICATION NAME]) # 3 as needed." An orthopedic physician's orders [REDACTED]. Continue non-weight bearing, and re-evaluate in two weeks." The orthopedic's physician's orders [REDACTED]." On [DATE], at 9:40 AM, R1 was in bed laying on her back. The fracture boot was sitting in R1's wheelchair. A dressing was noted to R1's left foot. R1's feet were resting directly on the mattress. E8, Registered Nurse, (RN) stated at that time, "We take the boot off every two hours for ,[DATE] minutes." On [DATE], at 10:51 AM, R1 remained in bed without the fracture boot on her left foot. At 11:05 AM, E8 was in R1's room, and reported she had just completed the treatment to R1's left foot pressure ulcers. E8 left the room and failed to apply the fracture boot to her left foot. On [DATE], at 11:25 AM, R1's fracture boot remained in the wheelchair. On [DATE], at 11:37 AM, E9 and E10, Certified Nurses Aides, (CNA) transferred R1 to the wheelchair with a gait belt, after applying the fracture boot to her left foot. R1 used full weight bearing to both feet during the transfer to the wheelchair. On [DATE], at 1:20 PM, E9 and E10 transferred R1 to bed using gait belt. Again, R1 bore weight to both feet during the transfer. After R1 was placed in bed, E10 removed the left leg fracture boot and placed it in the wheelchair. On [DATE], at 2:21 PM and 2:50 PM, R1 remained in bed without wearing the fracture boot to her left foot. On [DATE], at 8:53 AM, 9:07 AM, 9:20 AM, and 10:00 AM, R1 was in bed without the fracture boot applied to her left foot. On [DATE], at 1:27 PM, E5, Licensed Practical Nurse (LPN) completed a treatment to R1's left foot. After completion of the treatment, E5 left R1's room without applying the fracture boot to her left foot. The fracture boot remained in the wheelchair. The facility's Treatment Administration Record, (TAR) for [DATE] documents, "FYI (for your information)-Must wear fracture boot at all times, and continue non-weight bearing status. Can take boot off for hygiene and put boot back on. Non weight bearing (NWB) left lower extremity (LLE)." No daily documentation of daily completion is on the TAR related to these treatment interventions for R1's fracture to the left foot. R1's Care Plan, dated [DATE], documents, "Resident was returned to facility with cast/(elastic support wrap) bandage. To have no weight bearing and assist of two people." The Care Plan fails to address which foot is non-weight bearing or the application of the fracture boot to the fractured left foot.. 5. R2 was admitted to the facility on [DATE] with diagnoses, in part, of end stage [MEDICAL CONDITION], [MEDICAL TREATMENT], [MEDICAL CONDITIONS], and barretts esophagitis. R2 attends [MEDICAL TREATMENT] three times per week. The October "Physician order [REDACTED]. milk per day, no oranges, bananas, baked potatoes or tomatoes. On [DATE] the physician increased his supplement of Nova Source Renal from 8 ounces twice a day to 8 ounces three times per day. According to the nutrition notes dated [DATE] and [DATE], R2's weight has remained stable at 150 pounds, however, his [MEDICATION NAME] levels which reflects visceral protein stores, have decreased. The "Nutrition Report" dated [DATE] from the [MEDICAL TREATMENT] center documented on [DATE] R2's [MEDICATION NAME] level was 3.5 grams per decaliter (normal 4.0 or higher). On [DATE] the level was 3.0 and on [DATE] the level was 2.9. The "Nutrition Report" documented R2's protein level was "very low" and recommended to eat more high protein foods and that a protein supplement may be recommended. On [DATE] at 9:35 AM, Z11, Registered Dietitian at the [MEDICAL TREATMENT] Center, stated in an interview that R2 was on a liberalized diet to a regular diet due to poor intake. Z11 stated R2's [MEDICATION NAME] level was low and he needed to increase his protein intake. Z11 stated they had increased the Nova Source Renal to three times a day to provide more protein. Z11 stated she had talked to the Director of Nursing about a month ago regarding his intake and increasing his protein intake but had not talked to the facility dietitian or food service director. Z11 was not aware R2 was not consuming the Nova Source as ordered. Z11 confirmed that R2 does not eat lunch at [MEDICAL TREATMENT] and did not think R2 brought a lunch with him on [MEDICAL TREATMENT] day. Z11 stated R2's treatment time was from noon to 4:00 PM on Monday, Wednesday and Friday. The tray card was observed on [DATE] for R2 and documented a diet order of regular, no concentrated sweets, no added salt with no oranges, orange juice, tomatoes, baked potatoes and limit milk to 8 ounces per day. The care plan dated [DATE] documents R2 receives a low concentrated sweets, no added salt diet with milk limited to ,[DATE] cup a day, no oranges, orange juice, bananas, potatoes of any kind, tomatoes, extra gravy and a protein snack in the evening. On [DATE] and [DATE] the care plan states no dietary changes. Review of Z8, Registered Dietitian, documentation dated [DATE] and [DATE] noted R2 is receiving a "renal diet" and low concentrated sweets, no added salt with limits of ,[DATE] cup of milk per day and no oranges, orange juice, banana, tomato juice. The notes document that R2 is receiving 4 ounces of Nova Source twice a day. Both notes documented low [MEDICATION NAME] levels. On [DATE] Z8 documented R2 had a [MEDICATION NAME] level of 2.7 which "may indicate depleted visceral pro (protein) stores". There is no documentation by Z8 regarding poor dentition which interferes with R2 eating meat, the order for the increase in Nova Source to 8 ounces three times per day, the [MEDICAL TREATMENT] center diet order of regular due to low protein stores, or R2 receiving lunch on the days of [MEDICAL TREATMENT]. E39 stated on [DATE] at 8:35 AM that R2 was on a renal diet at the facility and could not have any oranges, orange juice, bananas, baked potatoes. E39 provided a copy of the tray card which documented a low concentrated sweets, no added salt diet with the above restrictions. E39 confirmed that the order for the Nova Source 8 ounces three times per day had been given on [DATE] but they had not received the order til [DATE]. E39 stated she had never talked to the dietitian at the [MEDICAL TREATMENT] center or received any information from the [MEDICAL TREATMENT] center regarding R2's diet. E39 was not aware of the [MEDICAL TREATMENT] center order for a regular diet for R2. E39 had not talked to the dietitian at the [MEDICAL TREATMENT] center regarding R2 refusing to drink the Nova Source supplement. E39 stated R2 had refused a mechanical soft diet. E39 stated on [DATE] at 11:00 AM that they do not send a sack lunch with R2 to [MEDICAL TREATMENT]. R2 attends [MEDICAL TREATMENT] three times per week and received a new access shunt on [DATE]. R2's care plan dated [DATE] documented end stage [MEDICAL CONDITION] and [MEDICAL TREATMENT] as a problem. Approaches include to "Monitor resident closely upon return from [MEDICAL TREATMENT] for any untoward S/S (signs and symptoms) in regard to his RX (prescription). Check vital signs as order". The care plan does not identify what to monitor for such as bleeding, swelling or what to do if the condition should occur. The care plan does not identify emergency procedures related to [MEDICAL TREATMENT].

Based on record review and interview, the facility neglected to adequately assess and monitor 1 of 1 residents (R1) who smoked and used oxygen in a sample of 4. This neglect resulted in R1 smoking with his oxygen on which ignited the oxygen he was wearing. R1 sustained first and second [MEDICAL CONDITION] his face and abdomen. The findings include: R1 has diagnoses, in part, of [MEDICAL CONDITIONS] fibrosis, history of drug and alcohol use. The Minimum Data Set, MDS, identifies R1 as cognitively able to understand and be understood by others, and R1 is independent with activities of daily living. R1 has a physician order [REDACTED]. The incident report dated 7/2/11 documents that R1 went to the outside smoking area, unsupervised, with his oxygen tank on. The oxygen ignited, and R1 was found at the nurses station [MEDICAL CONDITION] the face and abdomen. R1 was sent to the emergency room . The hospital emergency room record dated 7/2/11 documents that R1 had first and second [MEDICAL CONDITION] the face. E4, Social Service Director, on 7/11/11 at 1:25 PM ; E5, Licensed Nurse, on 7/11/11 at 3:30 PM; and, E1, Administrator, on 7/11/11 at 12:00 PM confirmed by interview that R1 had a history of [REDACTED]. E5 stated R1 had been drinking alcohol at the time of the incident. All confirmed that even though R1 had a history of [REDACTED]. The social service note dated 3/30/11 noted R1 was smoking with his oxygen on. E2 stated in an interview on 7/11/11 at 1:45 PM that there was no behavior tracking for R1's use of oxygen when he smoked. E1 stated in an interview on 7/20/11 at 4:40 PM there was no smoking assessment completed for R1 prior to the incident on 7/2/11. The Care Plan dated 6/30/11 documented "Resident noted to be smoking in his room (with) O2 present. Counseled about extreme danger for him and other residents. Becomes rather defiant-insist there are "no real hazards" "He is educated in O2 safety". Once again re-educated to facility policy and extreme danger/hazard to facility". The facility policy and procedure titled "Oxygen Safety General Standards" documented that smoking is strictly prohibited around a source of oxygen due to the extreme danger.

Based on record review, interview and observation, the facility failed to assess, monitor, and implement pressure relieving methods, provide alternate treatment methods, and provide aggressive nutritional interventions to help heal pressure ulcers for 1 of 2 residents (R3) at risk for developing pressure ulcers in the sample of 4. This failure resulted in R3's pressure ulcers increasing in size. The findings include: R3 was admitted to the facility on [DATE] with diagnoses, in part, of depression, [MEDICAL CONDITION] arthritis, left lung nodule, [MEDICAL CONDITION], multiple abdominal fistulas and a pressure ulcer. The Minimum Data Set, (MDS), dated [DATE] assessed R3 as able to understand and be understood, with pain affecting his function (7 out of 10 pain rating), and a 5% weight loss in the last 30 days. The MDS documented that R3 had 1 stage two pressure ulcer present on admission and 3 stage three pressure ulcers that were not present on admission to the facility. The "Weekly Pressure Sore Tracking Sheet" documented the following information for R3's pressure ulcers: Week of 5/29/11 - 6/4/11: No tracking sheet could be located per E2, Director of Nursing, (DON) on 7/14/11 at 2:00 PM. Week of 6/5/11-6/11/11: Right buttocks 2.5 x 1.4 x 0.3 Left buttocks 3.2 x 2.7 x 0.4. The stage, treatment, where acquired, Dietitian Consult, average meal intake and diet supplement was not documented as required by the tracking sheet. Week of 6/12/11-6/18/11: Right buttocks 3.8 x 3.5 x 0.3 Left buttocks 2.5 x 3.0 x 0.3. The areas were both staged as a "III". The treatment was documented as "cleanse wound (with) santyl, 4 x 4, cover. There was no documentation for where the pressure ulcers were acquired, dietitian consult, meal intake or supplement. Week of 6/19/11-6/25/11: Right buttocks 2.8 x 1.6 x 0.4 Left buttocks 1.5 x 1.3 x 0.3. The same treatment as the previous week was the only documented information. Week of 6/26/11-7/2/11: Right buttocks 3.0 x 1.6 x 0.4 Left buttocks 1.5 x 1.4 x 0.3. The pressure areas were documented as stage II with the same treatment as the week before. Week of 7/3/11-7/9/11: Right buttocks 3.2 x 1.6 x 0.4 Left buttocks refused. The areas were both staged as "II" and "present on admission". The same treatment was noted as the previous week. The "Nursing Admission Assessment" dated 5/27/11 documented a 2.0 cm x 3.0 cm pressure ulcer on the right and left buttocks. The nurses notes dated 5/27/11 noted "2 wounds on coccyx 2 cm x 3 cm". On admission on 5/27/11, the physician order [REDACTED]. The admission orders but does not state what the area is. An order dated 6/9/11 documents "Santyl Ointment 30 gm (gram) Apply topically to upper buttocks wounds daily and as needed". The "Treatment Administration Record" dated 7/1/11 thru 7/31/11 noted R3 treatment order of Santyl remains the same as the 6/9/11 order. The "(Wound Management Company)" evaluation dated 6/9/11 noted R3 had "bilateral buttock stage III pressure ulcers" and recommended to discontinue the current treatment of [REDACTED]. The note also stated to "Continue to off load pressure. Notify NP (Nurse Practitioner)/PCP (Primary Care Physician) of changes. Continue with LAL (low air loss) mattress and (eggcrate) cushion in the wheelchair". Regarding the weight loss and nutritional insufficieny it was recommended to have "Dietitian monitoring, continue to monitor weight, and encourage patient at meals and to take supplements". On 6/16/11 the Wound Management Company noted no change in the pressure ulcers with no order changes. On 6/23/11 R3 was discharged from the Wound Management Company due to patient refusal. There were no recommendations made. R3 had the following orders/recommendations for nutrition, however, they were not done. On 5/30/11 the "Nutritional Assessment" recommended whole milk at breakfast. This was not done. On 6/7/11, "60 cc of med pass due to poor intake" was ordered. The "60 cc med pass" was documented on the June "Medication Administration Record"(MAR), however, there was no documentation that the supplement was given or refused. On 6/17/11, a "Dietary Consult" was ordered by the physician but not done until 6/21/11. On 6/21/11 a Dietary Consult was done and recommended to increase 2.0 Resource Med Pass to 90 cc's three times per day, 1 packet of [MEDICATION NAME] twice a day, and 120 cc's of juice to aide in healing the stage 3 pressure sore. This was not ordered until 6/30/1, however, the order was not carried out. R3's weight on admission to the facility was 98 pounds with a height of 5'10" according to the "Nutritional Assessment" dated 5/30/11. Ideal body weight was assessed as 166 pounds. R3's diet order was noted as "regular, small portions, 6 small meals/day, health shake TID" The [MEDICATION NAME] lab value was 2.7. E8, Registered Dietitian, noted the [MEDICATION NAME] was "low which may indicate depleted visceral protein stores". The Nutritional Assessment" noted R3 had a stage 2 pressure sore on the coccyx. The facility weight log documented R3's weight as 98 pounds for each weekly weight done for R3 since admission. The last weekly weight done on 7/9/11 documented the weight as 98 pounds. E6, Licensed Practical Nurse, stated in an interview on 7/13/11 at 11:10 AM that R3 had not been receiving any supplements with the medication pass nor the Arginade supplement with his meals. E2 confirmed on 7/13/11 at 11:50 AM that R3 was not receiving 90 cc (cubic centimeters) Resource 2.0 at med pass or the 1 packet Arginate twice a day as ordered by the Physician on 6/30/11. Review of the Medication Administration Record did not have either supplements documented on the MAR. R3 stated in an interview on 7/13/11 at 10:05 AM, the mattress on his bed was making his pressure ulcers worse and he would not lay on the bed. R3 stated he usually sleeps in his wheelchair as the mattress is not a pressure relief mattress and it hurts. R3 stated he would sit up and sleep in his wheelchair instead as it hurt less. R3 stated he had a lot of pain and took several pain medications. R3 was observed on 7/13/11 from 8:45 AM until 10:00 AM asleep in his wheelchair in his room. R3 stated the food was not very good and he was not served food he liked. R3 stated he wasn't that picky but would prefer the food hot. admission orders [REDACTED]. The wound management company noted on the 6/9/11 note to continue with an low air loss mattress. Observation of R3's mattress on 7/13/11 at 10:10 AM noted it was a regular mattress. E2, Director of Nursing, was present and stated in an interview, that the mattress was not a low air loss mattress. E2 stated R3 had a egg crate type mattress but didn't like it and the mattress was changed to the one presently on the bed. E7, Corporate Nurse, stated in an interview on 7/13/11 at 11:25 AM that R3 now had a low air loss mattress. A low air loss mattress was observed on the bed at 11:30 AM. The "Pain Assessment" dated 5/27/11, 6/14/11 and 6/25/11 documented R3 was experiencing pain almost constantly. The assessment noted the pain made it hard for R3 to sleep and R3 would limit his activities due to the pain. On admission R3 rated his pain as a 10 on a scale of 1 to 10 and "very severe, horrible" regarding the intensity. On 6/14/11 and 6/25/11 R3 rated the pain at a 7 with the intensity as "severe". The assessment noted the [DIAGNOSES REDACTED]. R3 had multiple orders for pain medications on admission to the facility.

Based on record review, interview and observation it was determined that the facility failed to assess and monitor 2 of 3 residents, (R1, R2), reviewed for smoking in a sample of 3. This failure resulted in R1 smoking while he was using an oxygen tank. There was a fire and R1 sustained first and second degree burns to his face and abdomen. The findings include: 1. R1 has diagnoses, in part, of chronic obstructive pulmonary disease, pulmonary fibrosis, history of drug and alcohol use. The Minimum Data Set identifies R1 as cognitively able to understand and be understood by others. R1 is independent with activities of daily living. R1 has a physician order [REDACTED]. According to the incident report dated 7/2/11, R1 went to the outside smoking area, unsupervised, with his oxygen tank on. The oxygen ignited and R1 was found at the nurses station with burns to the face and abdomen. E1, Administrator, stated in an interview on 7/11/11 at 12:00 PM, that R1 had gone out to smoke and forgot to turn the oxygen off on his tank. E1 stated R1 had burns to his face and chest and he was sent to the emergency room . E1 stated R1 had been able to keep his cigarettes and lighter with him but since this incident he would have to ask the nurse for them. E1 stated R1 was very upset and embarrassed about the incident. E4, Social Service Director, stated in an interview on 7/11/11 at 1:25 PM that R1 had been told before not to smoke with his oxygen on. E4 stated all staff know about him smoking with his oxygen on. E4 stated R1 was allowed to keep his cigarettes and lighter with him due to the fact that he was alert and oriented. The social service note dated 6/30/11 stated "Res (resident) aware of design. (designated) smoking area. Res is constantly reminded not to wear O2 when smoking but still wears it". The social service note dated 3/30/11 noted R1 was smoking with his oxygen on. E5, Licensed Practical Nurse, stated in an interview on 7/11/11 at 3:30 PM that R1 was standing at the nurses station after dinner and said he set himself on fire. R1 told her that he had taken the oxygen tank out with him to smoke. E5 stated he usually leaves the oxygen tank at the door before he goes out. E5 stated she could smell alcohol and R1 was stumbling when he got on the stretcher to go to the emergency room . E5 stated she asked R1 if he had had alcohol and he said yes and was slurring his words. E5 stated she reported that to the emergency room nurse. After he left E5 stated they searched R1's room and found alcohol and a lighter. There were no cigarettes. E5 stated she had seen R1 smoke with his oxygen on previously about 2 to 4 months ago. E5 stated she had educated R1 before about not smoking with the tank on and he would get irate about it. E5 stated R1 was fully aware to not smoke with the oxygen on. E5 stated R1 previously had no limits to when he could smoke but now would have to ask for the cigarettes and lighter. E5 stated the burns were second degree burns with half of his mustache and beard singed off, the burns looked like popped blisters and there was soot on his face. E5 stated there was a burn on his abdomen and his shirt was burned. E5 stated R1 complained of pain to the area. R1 returned to the facility with orders for triple antibiotic ointment to his face. The nurses notes dated 7/2/11 confirmed E5's interview. The hospital emergency room record dated 7/2/11 noted R1 had first and second degree burns to the face. The report states "Found outside NH smoking. Burns to face/Rt (right) nare and left abdomen. Singed rt nasal hairs and blisters noted to his upper lip. Small circular burn to abdomen left side. Tshirt burned through. (Physician) with pt. Pt. reports drinking 4-5 beers". R1 has a physician order [REDACTED]. of alcohol every 8 hours". E2, Director of Nursing, stated in an interview on 7/11/11 at 1 :45 PM that after the incident they took the cigarettes and lighter away from R1 and he would have to ask the nurse for it. E2 also stated they got the order for R1 to have alcohol from the physician after the incident. E2 stated there was no behavior tracking for R1's use of oxygen when he smoked. E1, Administrator, stated in an interview on 7/20/11 at 4:40 PM, that there was no smoking assessment completed for R1 prior to the incident on 7/2/11. E1 stated the smoking assessment was started after R1 was admitted and one was not completed for him. Observation on 7/11/11 at 12:40 PM of R1's burns on his face noted several burns on the face on both sides of his nose that were scabbing. The areas were red. R1 stated he was doing OK. R1 stated it was just an accident and he would now get his cigarettes from the nurse. The Care Plan dated 6/30/11 documented "Resident noted to be smoking in his room (with) O2 present. Counseled about extreme danger for him and other residents. Becomes rather defiant-insist there are "no real hazards" "He is educated in O2 safety". Once again re-educated to facility policy and extreme danger/hazard to facility". The facility policy and procedure titled "Oxygen Safety General Standards" states "since fires can ignite more readily in an oxygen enriched atmosphere, and there fires burn explosively, it is extremely important that fire prevention measures are taken to ensure safety". The policy states "No smoking: Smoking prohibited in all areas where oxygen is stored, transported, or used. This includes resident rooms where oxygen is being used, delivery truck, inside and outside storage bins, and bulk oxygen storage tank (both stationary and transportable)." It also states "Open flames will not be permitted in an oxygen administration area, this includes fires for cooking, gas heating appliances, candles, oil lamps, electric radiant heaters, etc". 2. On 7/11/11 at 1:40 PM R2 was observed at the nurses station holding a cigarette lighter. E3, Licensed Nurse, asked R2 where she got the lighter and she stated "I don't know someone gave it to me". Staff took R2 out to smoke. R2 has diagnoses, in part, of dementia, depression and anxiety. The Care Plan dated 4/24/11 states "resident has extensive cognitive deficits-which is reason for admission and inability to function independently in community any longer". It also states "Staff to take to smoke Resident to be monitored".

Based on record review and interview, the facility failed to provide scheduled and as needed (PRN) pain medication as ordered by the physician for 1 of 3 residents (R3) receiving pain medication in a sample of 4. This failure resulted in R3 experiencing severe pain, limitation of his activities and therapy, and problems sleeping. The findings include: R3 was admitted to the facility on [DATE] with diagnoses, in part, of depression, [MEDICAL CONDITION] arthritis, left lung nodule, [MEDICAL CONDITION], multiple abdominal fistulas and a pressure ulcer. The Minimum Data Set, (MDS), dated [DATE] assessed R3 as able to understand and be understood, with pain affecting his function (7 out of 10 pain rating), and a 5% weight loss in the last 30 days. The MDS documented that R3 had 1 stage two pressure ulcer present on admission and 3 stage three pressure ulcers that were not present on admission to the facility. R3 also has a fistula on his abdomen that required surgical intervention. R3 had the following physician orders [REDACTED]. [MEDICATION NAME] SA, 20 mg tablet, 1 tablet every 12 hours [MEDICATION NAME] IR, 5 mg tablet, take 2-3 tablets by mouth every 3 hours as needed. Oxandrolone, 2.5 mg tablet, take 2 tablets '5 mg' by mouth twice daily [MEDICATION NAME] Patch 100 mcg/hr, apply 1 patch topically and change every 72 hours [MEDICATION NAME] 600 mg tablet three times per day The "Controlled Substances Record" for [MEDICATION NAME] SA, 20 mg tab, take 1 tablet every 12 hours had documented R3 received 1 tablet on 6/8/11, none on 6/9/11 only 1 tablet on 6/10/11 and none on 6/11/11. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR indicated [REDACTED]. The "Medication Notes" had an entry dated 6/18/11 at 8:00 PM only that stated "[MEDICATION NAME] SA 20 mg-not given-not here-Reordered from Pharmacy". The "Controlled Substance Record" documented R3 received a dose on 6/18/11 at 8:00 AM and then not again until 8:00 PM on 6/19/11. The nurses notes dated 6/19/11 documented the pharmacy was called at 8:15 AM. The medication did not come in until 5:00 PM and R3 did not receive the medication until 8:00 PM according to the "Controlled Substance Record". There is no "Controlled Substances Record" for 6/3/11 8:00 PM dose through 6/8/11. E2, Director of Nursing (DON), confirmed in an interview on 7/13/11 at 9:55 AM that there were no "Controlled Substance Record" for those dates. The "Controlled Substances Record" for the PRN [MEDICATION NAME] IR 5 mg tabs, take 2-3 tablets by mouth notes that R3 ran out of the medication on 6/10/11 at 8:45 AM and did not receive another dose of the PRN until 6/11/11 at 6:30 PM. The nurses notes dated 6/10/11 documented at 1:50 PM that a call was out to the pharmacy for an emergency run and informed that a prescription was needed to refill the medication. The physician was notified at 2:15 PM for the need of the prescription. The next nurses note at 10:00 PM stated that R3 was "(up) in W/C (wheelchair) Was crying numerous times tonight Res (resident) aware his PRN script (prescription) didn't come in. Resp (respirations) even and non labored". Review of the "Fax Transmittal Form" dated 6/13/11 stated "(R3): Resident is completely out of PRN [MEDICATION NAME] IR 5 mg 2-3 tabs Q (every) 3 hrs. (hours). Resident takes this med (medication) on the hour of that 3 hour mark max We please have script for med fax to our pharmacy". There was no nurses notes regarding the fax. The "Controlled Substance Record" dated 6/13/11 documented R3 ran out of the medication at 3:00 PM and did not receive another dose of the medication until 6/18/11 at 2:55 AM. The nurses notes dated 6/13/11 only states "MD (medical doctor) aware pain med (medication) (not) working". There is no mention of R3 not receiving the medication until 6/14/11 when the nurses note states "No pain meds (PRN) received. Called to pharmacy for emergency. They will call (physician) to get more than 1 day supply". The note also states "Res very upset. Informed him he wouldn't get any stronger pain meds". E2, Director of Nursing (DON), stated in an interview on 7/13/11 at 9:40 AM R3 did not always receive his pain medications due to the fact that they were not ordered on a timely basis. E2 stated they found out that if there was no written "script" from the physician for the controlled drug then the pharmacy can't send the medication. E2 stated if it was a weekend or a holiday they couldn't get the physician to send the script. E2 confirmed that R3 did miss getting his medications on several occasions. E2 stated at 1:45 PM that they were trying to watch R3's medications on hand and make sure they were not running out. At 2:45 PM, E2 stated that R3 was taking his PRN medication every 3 hours as ordered and they would run out quickly. E2 stated it was hard to keep track of all the medications he was on at first and the order was not done timely. On 6/19/11 the "Controlled Substance Record" documented R3 received the last dose of PRN [MEDICATION NAME] at 6:00 PM of that prescription and did not receive another dose until 11:55 PM on 6/19/11. The nurses notes dated 6/19/11 at 8:15 AM documented the pharmacy was called regarding R3's [MEDICATION NAME] SA 20 MG scheduled medication and the [MEDICATION NAME] IR 5 mg, 2-3 tablets every 3 hours as needed dose as both prescriptions were out. R3 did not receive the PRN medication until 11:55 PM. On 7/3/11 R3 ran out of the PRN medication at 3:45 AM according to the "Controlled Substances Record" and did not receive another dose until 7/5/11 at 11:00 AM. The "Pharmacy documented on the "Controlled Substances Proof of Use" sheet that the PRN medication was received on 7/4/11. The MAR indicated [REDACTED]. E6, Licensed Practical Nurse, stated in an interview on 7/13/11 at 9:00 AM that a written "script" was needed from the physician when R3's medication had to be reordered. There were times R3 did not get his medication because there was no medication at the facility and they would have to contact the physician for the script. E6 stated that it was usually the PRN [MEDICATION NAME] that he didn't get every three hours. E6 stated R3 always takes the maximum dose of the PRN [MEDICATION NAME]. R3 stated in an interview on 7/13/11 at 10:05 AM, he had not been getting his "PRN medications" as ordered and had gone several days without getting them. R3 stated he had a lot of pain and took several pain medications. R3 stated he has been trying to hold off taking his [MEDICATION NAME] PRN's so they wouldn't run out and they wouldn't have to order so often but it was just making him miserable and it hurt. Usually the medication would run out on the weekends and the nurses would say they say can't do anything about it. R3 stated they are still running out of his medications and just ran out on Monday but they did get some in pretty quick. R3 stated he should take the PRN's regularly to help with the pain. R3 stated he usually sleeps in his wheelchair as the mattress is not a pressure relief mattress and it hurts. Review of the nurses notes dated Monday, July 11 documented at 1:30 PM that the pharmacy was contacted for an emergency run for pain medications. The nurses notes dated 7/11/11 at 9:00 PM stated "Pain meds here and PRN pain meds given". The "Controlled Substance Record" documented on 7/11/11 at 5:45 AM that three tablets were given. The next dose of the PRN medication was given at 9:00 PM on 7/11/11. The "Pain Assessment" dated 5/27/11, 6/14/11 and 6/25/11 documented R3 was experiencing pain almost constantly. The assessment noted the pain made it hard for R3 to sleep and R3 would limit his activities due to the pain. On admission R3 rated his pain as a 10 on a scale of 1 to 10 and "very severe, horrible" regarding the intensity. On 6/14/11 and 6/25/11 R3 rated the pain at a 7 with the intensity as "severe". The assessment noted the [DIAGNOSES REDACTED]. The Care Plan dated 6/16/11 noted R3 had not been cooperative with the therapy department and finds reasons to not cooperate. The care plan states "states he needs pain medication and when given-will still find reason to refuse". The physician "Interval Examination Form" dated 5/27/11 noted R3 continues to have multiple complaints "about everything, yet refused most care and focused on need for pain meds". The physician note also stated R3 was recently discharged from therapy due to patient refusal.