Every finding on record at Evercare of Jerseyville

Based on observation, interview and record review the Facility failed to ensure meals were being served at regular times and without long waits. This has the potential to affect all 58 residents living in the facility. Findings include: On 6/24/2026 at 9:30 AM, in the main dining room area there is a bulletin board that documents scheduled mealtimes for breakfast at 7:30 AM, lunch at 11:30 AM, and dinner at 5:00 PM. On 6/24/2026 at 9:39 AM, V1, Administrator stated lunch was served at 11:30 AM, daily. On 6/24/2026 at 12:05 PM, V34 was the only staff in the kitchen. The dining room is full of residents sitting at tables waiting for their lunch. On 6/24/2026 at 12:10 PM, all food was placed on the steam table and V34, Dietary Manager took the temperatures. Residents were waiting in the dining room to be served lunch. On 6/24/2026 during the lunch service the last resident was served at 1:18 PM, for a total of one hour and 48 minutes lunch service for 59 residents. R31's Minimum Data Set (MDS) dated [DATE] document R31 was cogntively intact for decision making for activities of daily living. On 6/24/2026 at 3:00 PM, R31 stated they have had issues related to the food being cold and they have discussed this at the Resident Council Meetings with the food being cold and having to wait so long. If you were in a restaurant you would get up and leave after an hour. Lunch is supposed to be at 11:30 AM. Breakfast is at 7:30 AM, lunch at 11:30 AM, and dinner at 5:00 PM. R30's MDS dated [DATE] document R30 was cogntively intact for decision making for activities of daily living. On 6/24/2026 at 3:04 PM, R30 stated the food is cold at times and we have complained about having to wait so long for food in the dining room. Lunch is supposed to be at 11:30 AM. April's Resident Council Meeting Notes dated 4/7/2026 documents, Residents express their concern about meals being late. On 6/30/2026 at 10:20 AM, V36, Corporate Dietician stated she expects meals to be served at reasonable time without waiting and waiting over an hour for service was too long for 59 residents. The CMS 802 Form provided by the facility on 6/23/2026 documents a total of 58 residents living in the facility. The Resident Right Policy with a revision date of 11/2018 documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation, interview and record review, the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination for 4 of 25 residents (R11, R30-R32) reviewed for food temperatures in the sample of 32. Findings inclue:On 6/25/2026 at 11:30 AM, V34, Dietary Manager was placing items from the oven into the steam table. V34, took the temperatures and recorded them in her Food logbook with no issues. No additional food temperatures were taken during the entire meal service, which lasted one hour and 48 minutes for the food service for 59 residents. During the lunch service after the last person had been served on 6/25/2026 from 1:01 PM-1:19 PM, R11, R30, R31 and R32 were all served the corn. On 6/25/2026 at 1:19 PM, the temperatures were taken with a calibrated metal thermometer, and the following items were not above 135 degrees Fahrenheit. The corn was 103.0 F, the mechanical stew registered at 104.0F. R31's Minimum Data Set (MDS) dated [DATE] document R31 was cogntively intact for decision making for activities of daily living. On 6/24/2026 at 3:00 PM, R31 stated they have had issues related to the food being cold and they have discussed this at the Resident Council Meetings. R31 stated his corn was cold today. R30's MDS dated [DATE] document R30 was cogntively intact for decision making for activities of daily living. On 6/24/2026 at 3:04 PM, R30 stated the food is cold at times and we have complained. My corn was cold today too. On 6/25/2026 at 1;20 PM, V34, Dietary Manager stated all food being held on the steam table should always be at least 135 degrees or higher before serving. I did not realize it took that long to serve everyone out today. On 6/30/2026 at 10:20 AM, V36, Corporate Dietician stated she would expect all food on the steam table to be held at least 135 degrees or higher to prevent bacterial growth and protect residents, who are often older or have weakened immune systems. The Food Hold Temperature Policy dated 10/1/2025 documents, Foods will be cooked to the appropriate internal temperatures to prevent food borne. The major cause of food borne illness are improper cooking, cooling, reheating, and holding temperatures, illness. [NAME] food to the proper temperatures and take the temperature with a clean and sanitized probe thermometer. Reheat food in the oven and check temperatures before placing on a steam table or hot holding unit. Never use the steam table to reheat food. Hold all hot foods at 135 degrees F and check temperatures frequently.

Based on interview and record review the facility failed to report a change in condition to a resident's family/responsible party for one (R5) of 3 residents sampled for notification in a sample of 33. Findings include: R5's Undated Face Sheet, documents he was initially admitted to the facility on [DATE].R5's Quarterly Minimum Data Set (MDS), dated [DATE] R5 was cognitively intact. R5's Physician's Order Sheet (POS) dated 3/28/2026 documents a new physician's order for Ertapenem Sodium injection intravenous (IV) use 1 gram one time for UTI/proteus in urine until 4/4/2026. No documentation R5's family or responsible party was notified. R5's Medication Administration Record (MAR) dated 3/29/2026 staff documents 9 in the box for the Ertapenem IV medication. R5's Nursing Note, dated 3/29/2026 at 10:58 AM documents this writer attempted to place an IV in resident's right wrist, was unsuccessful. Resident stated he would only allow this writer to attempt one time. DON (Director of Nurses) notified and will attempt to place IV. No notification of R5's family or responsible party was notified.On 6/24/2026 at 12:52 PM V2, Director of Nurses (DON) stated when a resident has a change in condition staff are instructed to notify the resident's family and to document that in the progress notes and if it's not documented she can't prove staff called R5's family when he was transferred to the hospital and diagnosed with UTI and prescribed antibiotics.The Facility's Undated Change of Condition Policy, documents to ensure that medical care problems are communicated to the attending physician and family/responsible party in a timely, efficient and effective manner. The facility will notify the resident's physician and family when there is a significant change in the resident's physical status such as a clinical communicates such as recurrent UTI.

Based on interview and record review the facility failed to provide discharge planning and a letter stating when Medicare days would be exhausted for one (R4) of 3 residents at the facility sampled for resident's discharge rights in a sample of 33. Findings include: R4's Undated Face Sheet documents she was initially admitted to the facility on [DATE]. Review of R4's Electronic Medical Record including Progress Notes dated 2/2026 through 3/2026 there was no documentation of discharge planning. On 6/23/2026 at 1:00 PM V4, Social Services Director stated she started as the facility social worker in March 2026 so she wasn't working her when R4 was initially admitted to the facility on [DATE]. V4 stated after a resident is admitted to the facility, they have an initial care plan meeting where discharge planning is discussed which is 72 hours after admission and then they have Medicare meetings every Monday but she just got access to the web link for those Monday Medicare meetings so she has attending 1 or 2 of them. V4 stated it was her understanding that R4 was discharging home with family and that was the discharge plan the entire time. V4 stated she had an understanding that R4 was Medicare and she voiced she couldn't stay after she used all her Medicare days because she would be self-pay and she voiced she couldn't afford that. V4 stated she didn't know what occurred with R4's Medicare stay days because that was a billing issue. On 6/25/2026 at 2:50 PM V7, Business Office Manager stated R4's 100th Medicare day was on 3/18/2026 and staff gave R4 discharge paperwork on 3/24/2026. During the stay at one-point R4's Medicare days were updated and 10 days were used at another facility and when she realized that she updated the Medicare days left and R4 didn't have any so she issued the invoice to R4 on 3/24/2026 and R4 discharged with family on 3/25/2026. V7 confirmed that R4 was billed for her stay at the self-pay rate of $225.00 day from 3/19/2026 through 3/25/2026 and R4 was not aware her Medicare days were exhausted during that time. On 6/25/2026 at 3:50 PM V2, Director of Nurses (DON) stated she started working at the facility as the DON on 2/2/2026 and R4 was admitted to the facility on [DATE]. V2 stated she was so new as the DON she wasn't doing 72 hour admission care plan meeting or anything like that and stated she stays out of billing for the most part because there is so much nursing responsibilities but she understands discharge starts on admission and her understanding was that R4 was admitted to the facility for skilled therapy/ rehabilitation and the discharge plan was to return home with her family. V2 stated she didn't know anything about Medicare/Skilled but her understanding was that 10 Medicare days were used prior to R4's admission and they Medicare billing report wasn't updated in a timely manner from the other facility so when the facility billing staff were aware of the update to R4's Medicare days R4 was given an invoice and she was discharged home with family the next day. V2 stated she understood R4 didn't get discharge notice but it was because the facility thought she had 10 additional Medicare stay days and she didn't. On 6/25/2026 at 4:13 PM V1, Administrator stated the facility does not give any documentation or letter to residents when they exhaust their Medicare days. On 6/25/2026 at 4:33 PM V1 stated the facility does not have a discharge policy.

Based on interview and record review the Facility failed to ensure Residents' allergies were being followed/honored for 1 of 3 residents (R3) reviewed for allergies in the sample of 31. This failure resulted in (R3) being exposed to bleach which was listed as an allergy for her, and being sent to the hospital. Findings include:A. R3's Physician Order Sheet for June 2024 documents a diagnosis of burns involving 20-29% of body surface with 20-29% third degree burns; essential (primary) hypertension; type 2 diabetes mellitus with unspecified complications; personality disorder, anemia; unspecified post-traumatic stress disorders, hypothyroidism. R3's Minimum Data Set (MDS) dated [DATE] documents she is cognitively intact for decision making of activities of daily living. She has no impairment on her upper or lower extremities. She uses a wheelchair and needs assistance with most ADL's. (activities of daily living). R3's Medical Records under allergies document R3 was allergic to bleach. R3's Care Plan does not document anything related to a bleach allergy. R3's Initial Incident Report dated 4/17/2026 at 8:30 AM, (R3) is a [AGE] year-old female resident that resides at (Facility) with a BIMS (Brief Interview for Mental Status) of 15 (cognitively intact). (R3) has a diagnosis of burns involving 20-29% of body, HTN (hypertension); type 2 diabetes, Personality disorders, Anemia, PTST (post traumatic stress disorder); Solitary Pulmonary Nodule, Protein Calorie Malnutrition, GERD, Hypothyroidism, and pain. Social Service Director informed Administrator of an allegation of abuse. Staff member suspended immediately, MD (Medical Doctor), police, RP (Responsible Party) and Ombudsman notified. Investigation initiated, final to follow. R3's Final Incident Report dated 4/17/2026 at 8:30 AM, (R3) is a [AGE] year-old female resident that resides at (Facility). (R3) has a diagnosis of, but not limited, to personality disorders, PTSD (post-traumatic stress disorder), pulmonary nodule, and hypothyroidism, BIMS (Brief Interview of Mental Status). (R3) reported feelings of neglect to the SSD (Social Service Department). Initial interventions; (R3) sent to the ER (emergency room) per her request. Staff member suspended pending investigation. Initiated staff education. Initiated staff and resident interviews. Reported allegation to (State), MD (Medical Doctor), Ombudsman, RP (Responsible Party), police were notified. Investigation: (R3) made a statement of neglect to SSD (Social Service Director) who reported to the administrator. (R3) stated her response for making the allegation is that she requested to go to the hospital because she was in anaphylactic shock. When asked why she felt that she was in anaphylactic shock, (R3) stated that they used bleach in my room to clean up a red (powdered drink mix) stain. When asked why she felt it was neglect, she stated they know I'm allergic to bleach and they used it in my room. Prior to this allegation, (R3) was noted to be going home that afternoon. She also was noted to be outside cursing and having a behavioral episode toward staff before the allegation. Staff members were interviewed, statements show that (R3) asked the housekeeping staff to clean her room due to her spilling (powdered drink mix). Housekeeping staff entered the room, there were two small spots on the floor, which they did spray with cleaner and wipe up, they proceeded to mop the entire room, not with a bleach substance. (R3) was asked to remain out of her room until the floor dried. She did not follow instructions, entered the room, exited the room within seconds of entering, stating they used bleach, and she is in anaphylactic shock. (R3) was assessed immediately; no finding of anaphylactic shock or any allergic reaction were noted. (R3) proceeded to go to the dining room, outside to smoke, and back into the dining room to speak with residents and staff. After that (R3) went to the SSD (Social service Director) to report her allegation. Upon her allegation and request that she was still in anaphylactic shock she was transported to the hospital. En route to the hospital (R3) made the allegation to the police department and they arrived at the facility. Police assisted with the investigation due to (R3) allegation that staff knowingly harmed her with bleach. Upon return a few hours later from the ER (Emergency Room), there were no findings of anaphylactic shock noted. (R3) discharged to home on 4/17/26 per original plan of care. A follow up call was made and she said she is doing well. R3's Medical Records does not document any vitals were taken on 4/17/2026. On 6/24/2026 at 3:53 PM, V26, Housekeeping stated, I remember (R3) came to me and asked me if I was cleaning her hall and I told her yes. She asked me if I could come clean her room because she had spilt some red (powdered drink solution) on her floor and she did not want it to stain. I was never told (R3) had any allergies to bleach. When we went into (R3's) room we sprayed bleach on area with a cleaner that had bleach in it and is used in nursing homes and then we mopped the floor. We always use bleach in anything that is white including towels, sheets and to my knowledge (R3) has never had a reaction. I was never told not to use bleach on (R3's) stuff or that (R3) had a bleach allergy. Statement from V26, Housekeeper undated documents, (R3) told me this morning she spilt (powdered drink solution) on her floor and needed her room to be cleaned first. When we go to her room there were only two dots of (powdered drink solution) on the floor so it got sprayed with two dots of bleach because it was red (powdered drink solution) and it stains and immediately got wiped up, the room did not smell like bleach at all, She came walking down the hall and politely got asked not to go into her room because the floor had just been mopped. She then started to walk faster and immediately went into her room. On 6/24/2026 at 4:14 PM, V23, Housekeeping Supervisor stated, (R3) was mad at me prior to the incident with the bleach. I had to do a room move with her and she was not happy with me after that. (R3) approached (V26, Housekeeper) because she said she has spilt some red punch on her floor. (R3) was not in the room at the time we cleaned it. I sprayed bleach on the area, it was not very big, and then we mopped the entire floor. Nobody ever communicated to me that (R3) was allergic to bleach. I had no idea. The floor was still wet and we told (R3) to wait until the floor dried. (R3) had been outside smoking a cigarette and she walked over the wet floor and into her room and then came out and said we had used bleach, and we were putting her in anaphylactic shock, and she left and walked up the hallways. I do not remember her breathing different or acting differently. V23, Housekeeper statement undated statement documents, Went to (R3's) room to assist housekeeper with cleaning. Resident has two small spills of red (powdered drink solution). I sprayed it with bleach and instantly wiped up the spots. Met (R3) in hallway and informed her that the floor was wet, to please wait a minute; she instantly started walking faster and entered her room. There was no smell of bleach. She came out of her room saying I put her in shock. I went straight to the nurse. On 6/25/2026 at 8:42 AM, V25, Medical Records stated, (R3) came into my office and said (V23) had sprayed bleach in her room and she was allergic to bleach, and she was in shock and needed to go to the hospital. (V5, Transportation) went and got her nurse (V24) and she checked (R3) out, and she was talking normal and breathing normal and appeared okay. (R3) has a history of making things up. (V23) said she (R3) had two small spots on her floor that she cleaned up with bleach and then she mopped the floor. (R3) was told not to go into her room until the floor was dry but she went into the room anyway. (V24) sent her out to the hospital. V25, Medical Records statement dated 4/17/2026 documents, (R3) came into the office saying that she was in anaphylaxis due to 'bleach allergy.' Resident did not appear to be in any distress. Resident stated that she would go to the hospital; (V5, Transportation) went to get her nurse. The nurse came to check on her, then went to call for ambulance. R3'S Police Report dated 4/17/2026 documents, she is a resident at (Facility). (R3) stated she is deathly allergic to bleach. (R3) stated the staff at (Facility), and the house keeping supervisor, (V23), knew of her allergy. (R3) stated she and (V23) used to be friends, but recently, (V23) and her had a falling out. (R3) stated she had spilled some red (powdered drink solution) the night before. (R3) stated she told (V23), and she had asked if she could clean it up. (R3) stated, she was later talking with some people, when (V23) walked by. (R3) stated (V23) told her they had mopped her room and the floor was wet. (R3) stated (V23) never told her she used bleach. (R3) stated she had a recording of the conversation. In the recording, (V23) states, Your room's done. It's wet. (R3) stated she walked into her room, and she began to have an allergic reaction. (R3) stated she went to the front office. (R3) stated she told the social worker, (V4, Social Service Director), what had happened and that she needed an ambulance. (R3) stated (V23) did not call an ambulance, but asked to see her phone to review the recording. (R3) stated she had to ask again for an ambulance, before one was contacted. (V24) stated (R3) said it feels like the staff does not listen to her, and that she had recorded (V23) telling her the room was wet, but she left out that she had used bleach. When (R3) asked to go to the hospital (V23) had (V25) get (V24), and they had (V24) call. (V1) stated there is a note in her chart that (R3) is allergic to bleach. (V1) stated (R3) has never brought bleach allergy up as a problem. (V1) stated (R3's) bathroom and the community towels are cleaned with bleach. (V26) stated she was unaware of (R3's) bleach allergy. After speaking with (V23), it was determined no charges would be filed. (V23) did not mean to cause (R3) any harm. If (R3) was injured from the bleach, it was due to an accident, not on purpose. On 6/25/2026 at 8:49 AM, V24, Licensed Practical Nurse (LPN) stated, I was passing out meds on my hall when (R3) came out of her room and she was yelling and hollering and saying (V23) had used bleach in her room and she was allergic to bleach. She went up front to the business office, and they called me, and I went and assessed her, and she seemed okay, but she was demanding to be sent to the hospital, so I sent her out. I am not sure if I took any vitals on her, but she was talking and acting like normal. I have no idea if she is allergic to bleach. V24, Licensed Practical Nurse (LPN) dated 4/17/2026 documents, I was walking down C hall to give meds to another resident when (R3) approached me stating that housekeeping used bleach in her room and that she was going into 'anaphylactic shock.' Housekeeping Supervisor stated at that time that she informed resident not to enter the room due to it just being mopped. (R3) was yelling about bleach use and housekeeping informed her that she used a small amount to remove a (powdered drink solution) stain on the floor. There was no bleach odor in room. Resident proceeded to services office and informed resident would like to go to the ER (emergency room). This nurse called 911. R3's Hospital Records dated 4/17/2026 documents, [AGE] year-old female to the emergency department from work by ambulance after allergic reaction being exposed to bleach. Reports it makes her throat swell shut. In the past reports she needed steroids, Benadryl, epinephrine, and famotidine. Her workplace gave her Tylenol PM because it did not have regular Benadryl. EMS gave her IV Benadryl and Solumedrol. Will add famotidine 40 mg IV in the emergency department. Did not warrant epinephrine at this point. No lip or tongue swelling. She reports she feels like it is harder to breathe. No other acute issues. Does have skin graft multiple areas from portable heater blowing up on her within the last year. On 6/24/2026 at 2:04 PM, V4, Social Service stated, (R3) came to me, related to an incident where bleach was sprayed in her room, and she wanted to be sent out to the hospital. The nurse came and checked her out and sent her to the hospital. When she came back, she packed up her stuff and went home. She was supposed to go home on Friday originally. We did an investigation, and it was unfounded. (R3) was told not go into her room because the floor was wet, and she went in the room anyway. R3's Progress Notes dated 4/17/2026 at 1:15 PM, Note Text: resident returned from hospital. She walked straight to her room, started to pack her belongings. A CNA helped her bring her belongings to son's car. As she was walking past the nurses' station, I asked if she wanted her meds to take home and how she was feeling. She denied any distress at the time. Then went to the kitchen, as we were packing her meds, to get some food. We handed her meds, and she left the facility. On 6/24/2026 at 10:01 AM, V1, Administrator stated (R3) made an allegation of abuse because of some bleach, and I did an investigation, and had no findings. On 6/24/2026 at 10:30 AM, V2, Director of Nursing stated. If a resident has an allergy, I would not expect any staff to have that item near the resident or any potential for exposure that could cause a reaction. If a resident has an allergy to bleach, I would not expect bleach to be used. R3's Investigation Report dated 4/16/2026 documents, 8:26 am received a call from SSD that (R3) claims the housekeeping supervisor was rude to her and was on her way to the hospital because she has a bleach allergy and was in 'anaphylactic shock' 8:30 am resident was leaving in ambulance. 8:30 am spoke with Housekeeping Supervisor and told her she was suspended. Collected statements from staff members. 9:13 am emailed reportable to corporate for review. 9:30 am police entered to question staff- allegation that resident requested 911 several times before staff would do it and that staff used bleach in her room. 9:30 am to 11 :00, police interviewed staff in administrator's office. Housekeeping Supervisor- stated she was explaining the cleaning plan to her staff this morning and said they would clean (R3's) room last because she is discharging today and would be a deep clean. (R3) walked by and heard it and asked to have her room cleaned because she spilt (powdered drink liquid) all over the floor. (V26) Housekeeper and (V23), Housekeeping Supervisor went to C7 and saw two tiny dots of red (powered drink liquid) on the floor. (V23) sprayed a dot of bleach on each mark and wiped it up. (V26) swept the floor and then (V23) mopped the whole room. When they came out, (V23) told (R3) her room was just cleaned and mopped, so her floor is wet, and to wait a few minutes before going in; (R3) walked really fast to get to the room and immediately came out and said 'you used bleach and put me in anaphylactic shock' then walked up the hallway. On 6/25/2026 at 11:01 AM, V1, Administrator stated, (R3) doesn't like (V23). She was upset with (V23) after we had to have a room change for her. I interviewed staff and they told me (R3) was outside smoking and when she went to go back to her room the housekeeping had cleaned some areas with bleach on her floor, and she stated she was allergic to bleach. (V23) told her the floor was wet and to wait before going into her room, which she ignored. All staff interviewed stated (R3)was talking normally and going around telling everyone she was allergic to bleach and (V23) used bleach in her room. (V4) said that (R3) was going around talking to staff and residents but her voice did become softer and they sent her out to the hospital. The nurses confirmed she did have an allergy to bleach. But, only a small amount of bleach was used on the floor to get off the red (powered drink solution) that was on her floor. On 6/30/2026 at 9:20 AM, V22, Medical Director stated, he did not believe (R3) had a true allergy to bleach and he did not believe cleaning her room with bleach caused her any harm. He would be more worried with direct contact with her skin. If she was truly allergic to bleach it could harm her but he did not believe she was truly allergic to the bleach. On 6/30/2026 at 9:25 AM, V1 stated there was no policy Allergic reactions. B. Based on interview and record review the facility delayed treatment for a urinary tract infection (UTI) for 1 (R5) of 4 residents sampled for following physician's order in a sample of 33. Findings include: R5's Undated Face Sheet, documents he was initially admitted to the facility on [DATE]. R5's Nurse Progress Notes, dated 2/2026 or 3/2026 documents no signs or symptoms of UTI or that a urinalysis (UA) or C&S (culture and sensitivity) were ordered. R5's Physician's Order Sheet (POS) dated 3/28/2026 documents a new physician's order for Ertapenem Sodium injection intravenous (IV) use 1 gram one time for UTI/proteus in urine until 4/4/2026. R5's Medication Administration Record (MAR) dated 3/29/2026 staff documents 9 in the box for the Ertapenem IV medication. R5's Nursing Note, dated 3/29/2026 at 10:58 AM documents this writer attempted to place an IV in resident's right wrist, was unsuccessful. Resident stated he would only allow this writer to attempt one time. DON (Director of Nurses) notified and will attempt to place IV. R5's Progress Notes dated 3/28/2026 through 3/30/2026 no documentation R5's physician was notified that staff were not able to get an IV started on R5. R5's POS, dated 3/30/2026 a new physician's order for Ertapenem intramuscular (IM) 1 gram for UTI/proteus in urine for 7 days. R5's MAR dated 3/31/2026 staff documented Ertapenem 1 gram IM was administered on 3/31/2026. R5's Nursing Note, dated 3/31/2026 at 2:25 PM documents resident started IM injection/ABT for UTI today. Resident will be doing IM injection x7 days. On 6/24/2026 at 12:52 PM V2, Director of Nurses (DON) stated she expects staff to document when a resident has a change in condition in the nurse's notes and also document when the physician is notified of the change in condition and gives new medication orders, she expects staff to document the orders in the nurse's notes. V2 stated she recalled R5 had a change in behaviors and on 3/26/2026 staff notified his physician, and a UA/C&S was ordered. On 3/28/2026 the physician ordered IV Ertapenem because R5 had proteus in his urine. V2 stated on 3/29/2026 staff reported to her that that they were unable to get an IV started on R5. V2 stated she attempted to start an IV on R5 as well, but she was also unsuccessful. V2 stated she expected staff to notify R5's physician when they weren't able to get the IV line started on R5 so they could get new orders. V2 stated R5 refused to go to the hospital and his family didn't want him to go to the hospital either but staff should have documented that as well. V2 stated staff notified R5's physician on 3/30/2026 that the IV was not able to be started and R5's physician ordered the same medication in an IM dose and that was administered per physician's orders starting on 3/31/2026. V2 stated she understands the delay in medical treatment. The Facility undated change of condition policy documents, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/ responsible party in a timely, efficient, and effective manner.

Based on interview and record review, the facility failed to implement its abuse and resident background check policies by failing to screen for potentially abusive residents during the admission process, failing to report and track residents qualifying criminal offenses, failing to ensure a risk assessment was completed, and failing to implement protective measures to prevent abuse for 1 of 3 (R54) residents reviewed for abuse in the sample of 35. This failure resulted an Immediate Jeopardy when R62 was admitted to the facility on [DATE] without appropriate screening, referrals and interventions for criminal convictions and proceeded to sexually abuse R54. This has the potential to affect all 55 residents who reside in the facility. The Immediate Jeopardy began on 9/26/25 when R62 was admitted to the facility. R62's Criminal History record, dated 9/29/25, documented R62 has a history of criminal convictions including retail theft, obstructing justice, deceptive practice, battery, and aggravated battery with great bodily harm. R62's care plan, undated, documented I/my representative deny any history of abuse, neglect, or mistreatment, and there is no indication that I have been a recipient or a perpetrator of mistreatment. R62's care plan documented R62 is an identified offender, his CHIRP (Criminal History Information Response Process) indicates that R62 has a criminal felony background. R62 has been screened through the admission process and is expected to acclimate safely in this setting. R62's criminal history includes retail theft, battery, and aggravated battery. Notify the resident that a representative from the ISP (Illinois State Police) will conduct an interview either in person or via a video call to ascertain the resident's risk level. On 12/9/25 at 12:35 PM V1 Administrator stated the facility did not notify the IOP (Identified Offender Program) of R62's criminal convictions nor was a criminal risk assessment completed. This failure resulted in R54 being abused by R62 on 11/8/25 when R62 flashed his genitals at R54 and then R62 grabbed R54's breast. On 12/10/25 V1 Administrator stated she does not know how many identified offenders are residing in the facility. On 12/11/25 at 10:57 AM Surveyor requested R62's fingerprint criminal records and V1 Administrator stated the facility does not have a copy of those results. Surveyor asked V1 if it is facility policy to attain and keep those records on file and V1 replied, I don't know. On 12/10/25 Surveyor requested R62's criminal background and it documented multiple criminal convictions including burglary, retail theft, criminal trespass to buildings, and violations of order of protections. V1 stated she did not notify the IOP of R62's criminal history therefore no criminal risk analysis was conducted nor does R62's care plan address his potential risks to other residents. V1 Administrator and V3 ADON (Assistant Director of Nursing) were notified of the Immediate Jeopardy on 12/11/25 at 1:05 PM. The immediacy was removed on 12/12/25 but the facility remains out of compliance at a Level II due to additional time needed to evaluate implementation and effectiveness of training. Findings Include:R54's Medical Diagnosis sheet, print date of 12/9/25, documented R54 has diagnoses including Parkinsonism, dementia, osteoporosis, atherosclerotic heart disease, polyneuropathy, and cognitive communication deficit. R54's MDS (Minimum Data Set), dated 9/17/25, documented R54 is severely cognitively impaired and dependent on staff for ADLS (activities of daily living) and mobility. R54's care plan, undated, documented R54 has little, or no activity involvement related to immobility, physical limitations, due to Parkinson's and dementia. R54's progress note, dated 11/8/25 at 5:45 AM, documented resident was up at the end of C hall in (reclining) chair sleeping when witnesses observed another resident flash his genitals to her. Staff informed aggressor that was inappropriate, and aggressor laughed. Aggressor proceeded to grab resident breast. Staff removed aggressor from resident and took aggressor to another room. Skin check of resident done, and no injuries noted. Resident went right back to sleep after incident. Resident POA (Power of Attorney) made aware, DON (Director of Nursing), Administrator and MD made aware. R62's face sheet, print date of 12/9/25, documented R62 has diagnoses including major depressive disorder, morbid obesity, hypertension, restlessness and agitation, panic disorder, psychophysiologic insomnia, and anxiety disorder. R62's MDS, dated [DATE], documented R62 is cognitively intact. R62's MDS, dated [DATE], documented R62 is supervision or touching assistance with ambulation. R62's care plan, undated, documented R62 has a criminal felony background, has been screened through the admission process and is expected to acclimate safely in this setting. It continues, my criminal history includes retail theft, battery, and aggravated battery. R62's care plan interventions include notify the resident that a representative from the ISP (Illinois State Police) will conduct an interview either in person or via a video call to ascertain the resident's risk level. R62's care plan does not document R62's risk level. R62's progress note, dated 11/8/25 at 5:15 AM, documented resident in wc (wheelchair) wheeling self-up and down hallway, grabbing onto railing and propelling self, grabbing on to locked med carts and trying to open drawers, grabbing gloves and papers sitting on med cart and throwing them, going to the phone on the wall on c hall and attempting to make calls from it, wrapping cord of phone around hand and trying to hang phone up. Once staff was able to get phone back in place resident followed nurse down the hall blocking her between med cart and wouldn't let go, unable to redirect. Refuses to leave oxygen on, refuses to cover self, and is wheeling the hallway in a gown with legs spread wide open. Will not stay in room. R62's progress note, dated 11/8/25 at 5:40 AM, documented resident getting into things and throwing things in hall. Resident exposing self to other resident and refusing to cover genitals. Staff asked resident to stop and explained that was inappropriate. Resident laughed and continued to lift up gown and wheel up and down hall and by nurse's station. The facility's Serious Injury Incident and Communicable Disease Report, dated 11/8/25, documented final report, R62 perpetrator, and R54 victim. Detailed Incident Summary - Initial: It was reported at approximately 5:50 AM, that R62 and R54 were involved in an alleged altercation with inappropriate contact. Investigation initiated, POA (Power of Attorney) and MD notified. Investigation: On 11/8/25 at approximately 5:50 AM it was report by DON that V16 CNA witnessed R62 expose himself and inappropriately touched R54. V16 was interviewed by the administrator. V16 stated that she was up by the nurse's station, when R62 started lifting his gown exposing himself to R54, CNA asked R62 to stop, he did with a laugh. R62 started to go towards his room when he reached out to grab R54's right breast. V16 stated that she got R62 to let go of R54's chair, R62 proceeded to grab V16 and bite her. V17 CNA was interviewed by the administrator. V17 stated she saw R62 expose himself towards R54 and told him that it was inappropriate. V17 stated when R62 was headed towards his room, he reached out and grabbed R54's chair. V17 saw V16 remove R62 from the situation and tried to bite V16. Conclusion: Both residents at the time of the allegation showed no serious injury or harm. No redness, discoloration, or pain was noted immediately after the alleged incident. This is an isolated incident with both residents, neither resident has had an altercation with each other prior. Neither resident targeted each other. This incident is unsubstantiated as a resident-to-resident abuse allegation. The contact was not made in a threatening manner or intent to harm or hurt the other resident. This document does not note police notification. V16's written witness statement dated 11/8/25 documented R62 was sitting up by the nurse's station when he started lifting his gown up exposing his self to R54. When asked by 2 CNAS, V16 and V17, to please stop, he did with a laugh. R62 then started wheeling his self-back down his hall when he stopped by R54 and reached over grabbing her right breast. When asked by CNA V16 to please let go he laughed then grabbed her chair to mover her with him. When asked to let go, he just laughed and wound not let go of chair. Two CNAS (V16 and V17) finally got him to let go as he kept trying to then grab CNA V16 and bite her. R62 was finally taken to his room. R62 then came back out of his room and went into 2 female's room, laughing not wanting to let go and was finally taken to his room again. V17's written statement dated 11/8/25 documented R62 was sitting up by the nurse's desk and exposed himself towards R54. I told him that was inappropriate and that he couldn't do that he then turned around and exposed himself again. I then saw him pulling on top part of wheelchair and when the CNA V16 tried to remove his hand he was trying to bite her. On 12/9/25 at 12:35 PM V1 Administrator stated the facility did not notify the IOP (Identified Offender Program) of R62's criminal convictions nor was a criminal risk assessment completed. On 12/9/25 at 1:04 PM V15 Regional Nurse Consultant stated she would expect the Administrator V1 to notify the IOP so a risk assessment could be completed. V15 stated no risk assessment was completed on R62. On 12/10/2025 9:09 AM Surveyor asked V1 Administrator why she did not substantiate the abuse allegation between R62 and R54. V1 replied because there was no indication of it happening, no physical indicators of abuse, no redness nor anything. Surveyor asked V1 if staff witnessed R62 grab R54's breast and V1 replied, that is what they thought they saw. On 12/11/25 at 8:12 AM V1 Administrator stated she did not call the police when R62 grabbed R54's breast. V1 stated she does not know if it is policy to call the police or not when there is a resident-to-resident abuse incident. V1 stated the facility did not complete any type of risk assessment of R62. On 12/11/25 at 10:57 AM Surveyor requested R62's fingerprint criminal records and V1 Administrator stated the facility does not have a copy of those results. Surveyor asked V1 if it is facility policy to attain and keep those records on file and V1 replied, I don't know. On 12/11/25 at 11:42 AM V13 LPN (Licensed Practical Nurse) stated R62 exhibited multiple behaviors while he resided at the facility. V13 stated R62 was verbally abusive and uncooperative with staff. V13 stated R62 was able to propel himself around in the wheelchair and he would stop in resident doorways and try to speak with them. V13 stated R62 was alert and oriented throughout his stay at the facility. Surveyor asked V13 if facility administration notified her of R62's criminal history and V13 replied, no. On 12/11/25 at 11:57 AM R62's physician V35 stated R62's behaviors were extreme while he was at the facility, he was driving the girls there crazy, he was drug seeking, requesting narcotics, requesting antianxiety meds, calling 911 all the time, and he went to the ER 4 or 5 times while he was at the facility and just wasting resources. V35 stated R62 abused the system by always requesting to go to the ER. Surveyor asked V35 if he was aware of R62's criminal convictions and he replied no, then asked what the convictions were for. Surveyor asked V35 if R62 had the potential to harm other residents and if he expected the facility to follow their policy and regulations to ensure other vulnerable residents were protected. V35 replied R62 was a big guy, he could have potentially harmed another resident, and he would expect the facility to follow policies and regulations with resident background checks/criminal convictions. The facility's Abuse Prevention and Prohibition Program, dated 12/2/25, documented Purpose: 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. II. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial well-being. III. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. Procedure: I. The Administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the Facility. 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. B. The facility screens for potentially abusive residents during the pre admission process. The facility's Background Checks: Employee (s) and Resident (s), dated 9/15/25, documented Purpose: To maintain a safe and secure environment for our residents and staff to comply with IDPH (Illinois Department of Public Health) regulations. Procedure: Resident checks: LTC (Long Term Care) facilities must conduct a name-based criminal history check on all new residents within 24 hours of admission. Identified Offenders: If a resident's name-based check indicates potential risks, further investigation including a fingerprint check may be required. Facilities must report any residents identified as potential risks. The Immediate Jeopardy that began on 9/26/25 was removed on 12/12/25, when the facility took the following actions to remove the immediacy. A. R62 no longer resides in the facility. B. R54 remains in the facility. Will remain free from sexual abuse. No incident has occurred since allegation. C. Administrator and DON will be in-serviced on the abuse policy, the admission process, how to track and report qualifying criminal offenses, ensure that risk assessments are completed, and failing to implement protective measures to prevent abuse. (Completed by RNC on 12/11/25). D. Administrator will in-service IDT team on abuse and neglect, the admissions process, and implement protective measures to prevent abuse. (Completed by the Administrator on 12/11/25). E. IDT team will in-service staff on abuse and neglect policy, the admission process, and implementing protective measures. F. The DON will in-service nursing staff on the abuse policy, the admission process, ensure that risk assessments are completed, and to implement protective measures to prevent abuse. (Completed by DON/Designee on all current working staff completed on 12/11/25). G. Staff will not work until in-serviced on the abuse policy, the admission process, ensure that risk assessments are completed, and implement protective measures to prevent abuse. (Completed by DON/Designee this will be on-going.)H. 24-hour report reviewed for the 14 days to ensure that there were not allegations of abuse or neglect. (Completed by VP of Clinical Services on 12/11/25). I. Facility will interview residents to ensure that no abuse allegation have not gone unreported. (Started by Administrator on 12/11/25, completed by 12/12/25.)J. Administrator will review all residents to ensure that their background checks are completed, and the process of reporting and tracking is initiated. K. A quality assurance tool was implemented: 1. On-going audit: The Administrator/Designee will review the 24-hour report 5x/week x 4 weeks to ensure that there are no reports of abuse or neglect. If abuse was reported was interventions put in place. (Start date 12/11/25 by the Administrator/designee will be ongoing.) 2. On-going Audit: The Administrator/designee will audit 5x/week x 4 weeks all new admissions to ensure that their background check was completed and report if needed. (Start date 12/11/25 by the Administrator/designee will be ongoing). 3. On-going Audit: The DON/designee will audit all new/re-admissions 5x/week x 4 weeks to ensure that their risk assessment has been completed. (Start date 12/11/25 by the DON/designee will be on-going).L. Root cause analysis completed for abuse and neglect. (Completed by VP of Clinical on 12/11/25.)

Based on observation, interview and record review the facility failed to provide timely and complete incontinent care for 4 of 4 (R7, R8, R22, R24,) residents in a sample of 35. This failure resulted in R24 feeling angry, embarrassed, unwanted, depressed and a burden. Findings include:1. R24's Care Plan, dated 3/25/2025, documents that the resident has bladder incontinence r/t (related to) Confusion, Dementia, Impaired Mobility, Poor toileting habits total assist with transfers per Hoyer lift. It also documents interventions: Brief Use: The resident uses disposable briefs. Change every 2 hours and prn (as needed). Clean peri-area with each incontinence episode. Incontinent: Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. R24's Minimum Data Set (MDS), dated [DATE], documents that resident is rarely/never understood, always incontinent of bowel and bladder and dependent on staff for activities of daily living. R24's Neurologic Focused Evaluation, dated 11/28/2025, documented that Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. On 12/8/2025 from 9:36 AM to 1:28 PM R24's sat in urine without the benefit of toileting and or incontinent care. At 9:36 AM R24 was transported from the dining room to her room and placed at the foot of the bed. R24, slumped and leaning forward and to the right side, stated that she had used the bathroom on herself and needed to be cleaned. At 9:48 AM R24 was heard calling for call light. At 9:53 observed reaching for call light. From 10:00 AM to 11:00 AM no staff entered room. 11:36 AM R24 was repositioned not toileted. 11:36 AM transported to dining room. 12:40 PM waiting to smoke. 1:00 PM Outside smoking. 1:16 PM sitting at nurses' station I need to go to the bathroom. 1:28 PM V11, Certified Nursing Assistant (CNA), and V12, CNA, performed incontinent care. R7 was incontinent of urine and stool. V11 and V20, CNA, transferred R24 into the bed. V11 and V20 then removed R24's urine soiled pants and heavily soiled incontinent brief. V11 and V20 then turned R24 onto her right side and placed bedpan beneath. V11 and V20 applied R24's blanket and left room. At 1:56 PM V11 and V19 CNA, turned R24 onto her right side and removed the bedpan from beneath R24. The bedpan was empty, but the large amount of formed stool was on buttocks. V11 then using a wet washcloth wiped R24's left buttock. An incontinent brief was placed beneath R24. R24 was then rolled on her back. V11 then with a wet washcloth cleansed R24's right and left groin and inner labia. V11 did not cleanse R24's left buttock, inner thighs, supra pubic area. On 12/8/2025 from 9:36 Am to 1:56 PM R24 was observed as being alert and oriented x3, appropriately answering questions and corresponding. On 12/10/2025 at 10:10 AM R24 stated that yesterday she sat wet for hours. R24 stated it happens all the time. R24 stated t makes her angry and embarrassed. R24 stated she feels like a burden and that no one wants to help her. R24 stated she can smell herself and the odor is bad. How horrible is that? R24 stated she feels pain when she sits for so long wet. R24 stated she feels depressed. On 12/10/2025 at 10:13 AM V11 stated R24 is alert and able to answer questions appropriately. On 12/10/2025 at 12:52 PM V25, Registered Nurse (RN), stated R24 can use her call light if it is in her reach and attached to wheelchair. R24 stated R24 can use her phone with her fingers, and she has no issues with using her call light. On 12/11/2025 at 12:00 PM V35, Physician, stated R24 is alert and able to make her needs known and answer questions appropriately. V35 stated R24 can verbalize and express her feelings appropriately. V35 stated R24's call light is to be always in reach when R24 is in the room. V35 stated R24 can use call light when in reach. 2. R7's Care Plan, dated 4/9/2025, documents the resident has bladder incontinence r/t Confusion, Dementia, Impaired Mobility, Inability to communicate needs, Physical limitations, Poor toileting habits. Interventions: The resident uses disposable briefs. Change every 2 hours and prn. Clean peri-area with each incontinence episode. Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. R7's MDS, dated [DATE], documents R7 is cognitively impaired, frequently incontinent of stool and always incontinent of urine and dependent on staff for toileting. On 12/8/2025 at 10:40 AM V11, CNA, and V12, CNA, assisted R7 with incontinent care. R7 was incontinent of urine and stool. R7's incontinent brief and using a wet washcloth V11 wiped R7's right and left groin area and inner labia. V11 and V12 then turned R7 onto her right side and cleansed R7's left buttock. V11 and V12 then turned R7 onto her left side and partially cleansed R7's right buttock. V11 did not cleanse R7's inner thighs, supra pubic, outer labia, and entire right buttock. 3. On 12/20/2025 at 12:41 PM during incontinent care. V21, CNA used wet washcloths then sprayed no rinse cleanser on washcloth. V21, CNA cleansed R8's right groin, then left groin, scrotum and then penis. V21, CNA did not pull foreskin back to cleanse. V21, CNA then turned R8 to his right side facing the wall. R8 incontinent of stool. V21 cleansed rectal area. V21 did not cleanse inner thighs or buttocks. V21 did not dry R8 prior to putting on clean adult diaper. R8's care plan dated 7/31/2025 documents R8 has an Activity of Daily Living (ADL) self-care performance deficit related to hemiplegia, impaired balance, limited mobility, limited Range of Motion (ROM), stroke. R8's care plan documents R8 requires assistance by one staff for toileting. R8's care plan documents R8 has bowel incontinence related to immobility. R8 care plan documents intervention to provide peri care after each incontinent episode. R8's MDS dated [DATE] documents R8 is always incontinent of bowel and bladder. 4. R22's Medical Diagnosis sheet, print date of 12/9/25, documented R22 has diagnoses including bilateral primary osteoarthritis of knee, COPD (chronic obstructive pulmonary disease), depression, hypertension, hyperlipidemia, obesity, chronic pain syndrome, and muscle weakness. R22's MDS, dated [DATE], documented R22 is cognitively intact, is always incontinent, and is dependent on staff for toileting hygiene. R22's care plan, undated, does not address R22's incontinence needs. On 12/8/25 at 1:50 PM V10 CNA placed damp wash cloths on R22's footboard of bed. V10 then removed R22's urine saturated adult diaper and cleansed on each side of R22's labia without the benefit of cleansing R22's inner labia. V10 then rolled R22 on her left side and cleansed R22's buttock without the benefit of changing gloves. V10 also did not cleanse R22's outer hip region. V10 stated he used body wash to cleanse R22. V10 did not rinse the body wash after cleansing R22 nor did V10 dry R22 after cleansing her with the wet washcloths. On 12/10/2025 1:47 PM V3 ADON (Assistant Director of Nursing) stated she would expect the CNAs to cleanse inner labia and buttocks during peri-care. V3 stated the facility body wash is not a no-rinse wash so the CNA should have rinsed and dried R22. The facility's Incontinence Care policy, dated 6/17/25, documented 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. Procedure: 1. Explain procedure to resident and bring equipment to bedside. Provide privacy. 2. Perform hand hygiene and put on non-sterile gloves. 3. Assist the resident to lie on back and expose the perineal area. 4. Soap one cloth at a time to was genitalia using clean part of the cloth for each swipe. In the female, separate labia with strokes from top downward, each side separately with a clean cloth or clean area of the cloth. Keep labia separated with one hand. In the male resident, wash the penis first, turn the resident to the side, then wash perineal area. A. Wash the labia first then groin area. B. Rinse with remaining cloth using clean surfaces for all 3 surface areas (female). Do not place soiled soapy cloths back in clean basin water until procedure completed. May drape soiled cloths over the side of the wash basin, or place directly in soiled linen plastic bag. C. Clean/rinse inner/upper thigh areas to remove urine moistures. 5. Observed for redness, irritation, and discharge. 6. Gently pat area dry with towel from anterior to posterior. 7. Assist resident to turn to side away from you. Remove/wipe any fecal material first with toilet tissue as necessary. 8. Using the final rinse cloth, from front washing, wash and rinse the peri-anal area. Pat dry. 9. Change gloves and perform hand hygiene. 10. Apply clean incontinence brief or incontinence pad. 11. Empty basin, clean, and dry. Place soiled cloths in linen plastic bag. Put soiled toilet tissue or incontinence wipes and soiled incontinence brief in plastic trash bag. 12. Assist resident to a comfortable position and place call light in reach. Do not touch any clean surfaces while wearing soiled gloves. 13. Assist resident to a comfortable position and place call light in reach.

Based on observation, record review, and interview, the facility failed to ensure 1 of 3 (R24) resident's call light in reach in a sample of 35. This failure resulted in R24 unable to call for help for over 2 hours. This also resulted in R24 sitting in urine, feeling angry, embarrassed, unwanted, depressed and a burden.Findings include:R24's Care Plan, dated 3/25/2025, documents R24 has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, Impaired balance, Limited Mobility, Limited ROM (range of motion), Stroke with left sided weakness. Interventions Encourage the resident to use bell to call for assistance. R24 is at risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs. Interventions The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach to right side of resident.R24's Minimum Data Set (MDS), dated [DATE], documents R24 is cognitively impaired, always incontinent of bowel and bladder and dependent on staff for activities of daily living.On 12/8/2025 at 9:36 AM R24 was transported from the dining room to her room and placed at the foot of the bed. R24 faced the bed with right side at foot of bed. R24, slumped and leaned forward and to the right side. R24 stated she had used the bathroom on herself and needed to be cleaned. R24's call light was located at the top of bed. At 9:48 AM R24 was heard calling for call light. At 9:53 AM observed reaching for call light. From 10:00AM to 11:00 AM resident observed sitting in wheelchair. Call light remained out of reach and no call light on. At 1:28 PM R24 was assisted to bed and placed on bedpan by V11, Certified Nurse's Assistant (CNA), and V20, CNA. V20 gave R24 the call light and informed R24 to use when ready. At 1:56 PM Call Light on. V19, CNA, responded to call light. V11 and V19 assisted R24 with incontinent care at time.On 12/10/2025 at 10:10 AM R24 stated yesterday she sat wet for hours. R24 stated it happens all the time. R24 stated she could not reach her call light. R24 stated she would have used it if she could reach it. R24 stated it makes her angry and embarrassed. R24 stated she feels like a burden, and no one wants to help her. R24 stated she can smell herself and the odor is bad. How horrible is? R24 stated she feels pain when she sits for so long wet. R24 stated she feels depressed.On 12/10/2025 at 10:13 AM V11 stated R24 is alert and able to answer questions appropriately. V11 stated R24 can use her call light.On 12/10/2025 at 12:52 PM V25, Registered Nurse (RN), stated R24 can use her call light if it is in her reach and attached to wheelchair. R24 stated R24 can use her phone with her fingers, and she has no issues with using her call light.On 12/11/2025 at 12:00 PM V35, Physician, stated R24 is alert and able to make her needs known and answer questions appropriately. V35 stated R24 can verbalize and express her feelings appropriately. V35 stated R24's call light is to be always in reach when R24 is in the room. V35 stated R24 can use call light when in reach.The Residents' Rights Long Term Care Ombudsman Program Booklet, dated 11/18, document Your facility must treat you with dignity and respect and must care for you in a manner promotes your quality of life.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. 1. All residents have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.

Based on interview and record review, the facility failed to prevent physical abuse of a resident from another resident with a known criminal history for 1 of 4 residents (R54) reviewed for abuse in the sample of 35. This failure resulted in R62 exposing his genitals to R54 and R62 then grabbed R54's breast. A reasonable person would expect to be safe in their home and would experience fear/anxiety, humiliation, and anger if physically and sexually abused. Findings Include:R54's Medical Diagnosis sheet, print date of 12/9/25, documented R54 has diagnoses including Parkinsonism, dementia, osteoporosis, atherosclerotic heart disease, polyneuropathy, and cognitive communication deficit. R54's MDS (Minimum Data Set), dated 9/17/25, documented R54 is severely cognitively impaired and dependent on staff for ADLS (activities of daily living) and mobility. R54's care plan, undated, documented R54 has little, or no activity involvement related to immobility, physical limitations, due to Parkinson's and dementia. R54's progress note, dated 11/8/25 at 5:45 AM, documented resident was up at the end of C hall in (reclining) chair sleeping when witnesses observed another resident flash his genitals to her. Staff informed aggressor that was inappropriate, and aggressor laughed. Then aggressor proceeded to grab resident breast. Staff removed aggressor from resident and took aggressor to another room. Skin check of resident done, and no injuries noted. Resident went right back to sleep after incident. Resident POA (Power of Attorney) made aware, DON (Director of Nursing), Administrator and MD made aware. R62's face sheet, print date of 12/9/25, documented R62 has diagnoses including major depressive disorder, morbid obesity, hypertension, restlessness and agitation, panic disorder, psychophysiologic insomnia, and anxiety disorder. R62's MDS, dated [DATE], documented R62 is cognitively intact. R62's MDS, dated [DATE], documented R62 is supervision or touching assistance with ambulation. R62's care plan, undated, documented R62 has a criminal felony background, has been screened through the admission process and is expected to acclimate safely in this setting. It continues, my criminal history includes retail theft, battery, and aggravated battery. R62's care plan interventions include notify the resident that a representative from the ISP (Illinois State Police) will conduct an interview either in person or via a video call to ascertain the resident's risk level. R62's care plan does not document R62's risk level. R62's progress note, dated 11/8/25 at 5:40 AM, documented resident getting into things and throwing things in hall. Resident exposing self to other resident and refusing to cover genitals. Staff asked resident to stop and explained that was inappropriate. Resident laughed and continued to lift up gown and wheel up and down hall and by nurse's station. The facility's Serious Injury Incident and Communicable Disease Report, dated 11/8/25, documented final report, R62 perpetrator, and R54 victim. Detailed Incident Summary - Initial: It was reported at approximately 5:50 AM, that R62 and R54 were involved in an alleged altercation with inappropriate contact. Investigation initiated, POA (Power of Attorney) and MD notified. It continues, Investigation: On 11/8/25 at approximately 5:50 AM it was report by DON that V16 CNA (Certified Nurse Assistant) witnessed R62 expose himself and inappropriately touched R54. It continues, V16 was interviewed by the administrator. V16 stated that she was up by the nurse's station, when R62 started lifting his gown exposing himself to R54, CNA asked R62 to stop, he did with a laugh. R62 started to go towards his room when he reached out to grab R54's right breast. V16 stated that she got R62 to let go of R54's chair, R62 proceeded to grab V16 and bite her. V17 CNA was interviewed by the administrator. V17 stated that she saw R62 expose himself towards R54 and told him that it was inappropriate. V17 stated that when R62 was headed towards his room, he reached out and grabbed R54's chair. V17 saw V16 remove R62 from the situation and tried to bite V16. Conclusion: Both residents at the time of the allegation showed no serious injury or harm. No redness, discoloration, or pain was noted immediately after the alleged incident. This is an isolated incident with both residents, neither resident has had an altercation with each other prior. Neither resident targeted each other. This incident is unsubstantiated as a resident-to-resident abuse allegation. The contact was not made in a threatening manner or intent to harm or hurt the other resident. V16's written witness statement dated 11/8/25 documented R62 was sitting up by the nurse's station when he started lifting his gown up exposing his self to R54. When asked by 2 CNAS, V16 and V17, to please stop, he did with a laugh. R62 then started wheeling his self-back down his hall when he stopped by R54 and reached over grabbing her right breast. When asked by CNA V16 to please let go he laughed then grabbed her chair to mover her with him. When asked to let go, he just laughed and wound not let go of chair. Two CNAS (V16 and V17) finally got him to let go as he kept trying to then grab CNA V16 and bite her. R62 was finally taken to his room. R62 then came back out of his room and went into 2 female's room, laughing not wanting to let go and was finally taken to his room again. V17's written statement dated 11/8/25 documented R62 was sitting up by the nurse's desk and exposed himself towards R54. I told him that was inappropriate and that he couldn't do that he then turned around and exposed himself again. I then saw him pulling on top part of wheelchair and when the CNA V16 tried to remove his hand he was trying to bite her. On 12/9/25 at 12:35 PM V1 Administrator stated the facility did not notify the IOP (Identified Offender Program) of R62's criminal convictions nor was a criminal risk assessment completed. On 12/9/25 at 1:04 PM V15 Regional Nurse Consultant stated she would expect the Administrator V1 to notify the IOP so a risk assessment could be completed. V15 stated no risk assessment was completed on R62. On 12/10/2025 9:09 AM Surveyor asked V1 Administrator why she did not substantiate the abuse allegation between R62 and R54. V1 replied because there was no indication of it happening, no physical indicators of abuse, no redness nor anything. Surveyor asked V1 if staff witnessed R62 grab R54's breast and V1 replied, that is what they thought they saw. On 12/11/25 at 8:12 AM V1 Administrator stated she did not call the police when R62 grabbed R54's breast. V1 stated she does not know if it is policy to call the police or not when there is a resident-to-resident abuse incident. V1 stated the facility did not complete any type of risk assessment of R62. The facility's Abuse Prevention and Prohibition Program, dated 12/2/25, documented Purpose: 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. II. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial well-being. III. The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. Procedure: I. The Administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the Facility. 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. B. The facility screens for potentially abusive residents during the pre admission process.

Based on interview and observation, the facility failed to post the facility staffing data daily, reviewed for staffing in the sample of 35. This failure has the potential to affect all 55 residents residing in the facility. The findings include: On 12/8/25 at 8:00 AM and upon entrance to the facility, there was no posting of daily staffing seen on the boards or walls in the front lobby or in the halls. On 12/9/25 at 4:30 PM, there was still no posting of the facility daily staffing seen.On 12/10/25 at 8:00 AM, there was still no posting of the facility daily staffing seen.On 12/10/25 at 8:30 AM, V3, Assistant Director of Nursing (ADON), stated, I am the one who posts the daily staffing, and I have not done it this week. I usually post it either by the front door or by the Director of Nursing's (DON's) office.On 12/10/25 at 3:45 PM, V1, Administrator, stated, I don't think we have a policy on posting of staffing. I would expect the staff to be posting the staffing daily.On 12/10/25 at 3:47 PM, V28, Regional Director of Operations, stated, We would follow the State and Federal guidelines for the posting of daily staffing. The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 10/8/25, documents there are 55 residents residing in the facility.

Based on interview, and record review, the facility failed to ensure the continuing competence of Certified Nursing Assistants (CNAs), by providing 12 hours of education and/or training per year, including dementia management training and resident abuse prevention training, reviewed for required training for CNAs in the sample of 35. This failure has the potential to affect all 55 residents residing in the facility.The findings include:On 12/10/25 at 8:35 AM, V3, Assistant Director of Nursing (ADON), stated, When we hire a new CNA, they always have a license already. They will go through orientation with V18, Medical Records/CNA. Then they will have at least 3 days of floor training with a peer. If that person needs more training, we will give them more days. We do monthly in-services that are scheduled, and each employee must do that in-service before their next day of work. We also do competencies yearly for each staff member and then PRN (as needed) if someone is lacking in a certain task. When asked to see any CNAs 12-hour training, V3 stated, (V1, Administrator) has that binder.On 12/10/25 at 8:45 AM, When V1 was asked to see the training binder, V1 opened the binder, and a list of staff was seen with no training hours listed. V1 stated to V3, This is how they were keeping track of the training?On 12/10/25 at 8:50 AM, When asked to show each CNA's 12-hours of annual training, V1 stated, I will have to look and go through each in-service and add up their hours.On 12/11/25 at 10:45 AM, V27, CNA, stated she has been working at facility since July 2025 and her initial training consisted of 3 days on the floor and no other computer or paper training done. V27 stated they have monthly in-services and talk about different things. V27 stated she does not remember having any training for abuse or dementia.On 12/11/25 at 10:55 AM, V2, Director of Nursing (DON), stated, Staff training is done by either me, or (V3, ADON), including the CNA annual training for abuse and dementia. I have not heard of any staffing problems since I've been here and if we have call-ins, we try to get it filled or someone from the offices will go out and help.On 12/11/25 at 11:03 AM, V21, CNA, stated, I have been here since September 2024 and my training was three days of orientation on the floor and no other training. We do have monthly in-services, and I did the abuse and dementia training.On 12/11/25 at 11:10 AM, V34, CNA, stated, I've been here since November 2024, and I had on the floor training only. We do have in-services monthly and I remember doing the abuse and dementia training.A random pick of CNAs with a review of their annual education, shows that none of the CNAs have had a total of 12-hours of annual training with only three of the nine having abuse training, and four of the nine having dementia training. V9, CNA's, CNA In-Service Record, dated from 6/25/24 through 10/14/25, documents V9 was hired on 5/13/24 and has only 10.5 hours of training and is missing the required dementia training.V10, CNA's, CNA In-Service Record, dated from 1/14/25 through 9/9/25, documents V10 was transferred to this facility on 11/1/24 and has only 3.0 hours of training and is missing both the required abuse prevention training and the dementia training. V16, CNA's, CNA In-Service Record, dated from 6/25/24 through 8/12/25, documents V16 was hired on 5/24/24 and has only 8.5 hours of training and is missing both the required abuse prevention training and the dementia training. V17, CNA's, CNA In-Service Record, dated from 7/25/24 through 5/14/25, documents V17 was hired on 6/27/24 and has only 5.0 hours of training.V21, CNA's, CNA In-Service Record, dated from 5/14/25 through 11/13/25, documents V21 was hired on 9/4/24 and has only 3.0 hours of training and is missing the required abuse prevention training.V30, CNA's, CNA In-Service Record, dated from 9/9/25 through 11/13/25, documents V30 was hired on 9/2/25 and has only 3.0 hours of training and is missing the required abuse prevention training.V31, CNA's, CNA In-Service Record, dated from 8/12/25 through 9/9/25, documents V31 was hired on 7/6/25 and has only 3.5 hours of training and is missing both the required abuse prevention training and the dementia training.V32, CNA's, CNA In-Service Record, dated from 8/19/25, documents V32 was hired on 7/17/25 and has only 0.5 hours of training and is missing both the required abuse prevention training and the dementia training.V33's CNA In-Service Record, undated, documents V33 was hired on 7/25/25 and has only 0.0 hours of training and is missing both the required abuse prevention training and the dementia training.The facility's CNA Training Policy, dated 11/1/25, documents in part Education: CNAs are responsible for obtaining and maintaining current certification. CNAs are required to obtain 12-hours of continuing education provided by the facility during in services and 1:1 interaction to ensure they are up to date with CMS compliance.The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 10/8/2025, documents 55 total residents in facility.

Based on interview, observation, and record review, the facility failed to perform hand hygiene and to don appropriate Personal Protective Equipment (PPE) for 4 of 24 residents (R7, R8, R27, R54), and the laundry staff failed to don PPE while laundering isolation linen, all was reviewed for infection control in the sample of 35. These failures have the potential to affect all 55 residents residing in the facility.The findings include: 1. On 12/9/25 at 8:09 AM, V14, Certified Nursing Assistant (CNA), was seen feeding two residents while sitting between them, no hand hygiene seen as she would turn and feed R54 on her right side, then with no hand hygiene, would turn and feed R27 on her left side. V14 was seen assisting other residents across the table with their drinks while feeding R54 and R27 with no hand hygiene seen done before, during, or after assistance given. On 12/11/25 at 10:55 AM, V2, Director of Nursing (DON), stated, I would expect the staff to do hand hygiene when assisting the residents in feeding and should not be feeding one resident after another without doing hand hygiene between. 2. On 12/10/25 at 12:55 PM, V23, Housekeeping/Laundry Supervisor, stated, If there is a resident on isolation, the staff will put all linen and trash into red bags, the laundry is then placed into a yellow barrel with a lid, transported to the laundry room where it is placed inside a washer. After completed, that washer is decontaminated by using the Isolation/#6 button on the washer. Then the yellow barrel is decontaminated by a spray and wipes. The staff doing this in the laundry room should be wearing appropriate PPE, including gown and gloves. On 12/10/25 at 1:00 PM, when asked what she wears when doing isolation laundry and transferring the contaminated items from yellow barrel to the washer, V24, Laundry Aide, stated, I wear what I have on. We do not have any gowns or anything else to wear in the laundry room. On 12/10/25 at 1:10 PM, V23 stated, I have only been here a couple of weeks, and I was not aware the staff in the laundry room did not have PPE available. I will make sure they have it immediately and will discuss with them in tomorrow's meeting. This can potentially contaminate all resident linen being done by V24 as she was not wearing appropriate PPE while washing contaminated linen, then would continue to wash and fold the normal linen afterwards. On 12/11/25 at 12:55 PM, V1, Administrator, stated, I would expect them to perform hand hygiene and all infection control practices while serving food to the residents. I would expect all staff to perform hand hygiene when caring for a resident, when providing feeding assistance to a resident, and to don PPE for a resident on isolation. 3. On 12/10/2025 at 12:41 PM, V21, CNA, pushed R8 in wheelchair in his room to provide care. V21 did not don gown or gloves prior to entering R8's room. V21, CNA then transferred R8 from wheelchair to bed. V21 then pulled R8's pants down to provide care. Sign posted on the wall outside R8's room documents the facility Enhanced barrier precautions, undated posted outside R8's room documents, Stop, everyone must cleanse their hands, including before entering and leaving room. Providers and staff must also: wear gloves and gowns for the following high contact R8's electronic medical record documents R8 has a pressure sore to Right hip. On 12/10/2025 at 12:48PM V21, CNA stated to V25, Registered Nurse (RN), I did not do that, I thought it was for (R8's) roommate, while observing V25 donning gloves and gown prior to entering R8's room to change R8's dressing. 4. On 12/8/2025 at 8:45 AM observed R7 lying in bed. Overbed table was soiled with food, liquid and brown sticky substance over the top of the table. V9, CNA, and V10, CNA, performed incontinent care. R7 was incontinent of bowel and bladder. V10 placed wash cloths in the sink and wet them with water. V10 then placed wet towels on the soiled over bed table. V10 then removed the wipes sprayed with peri wash and placed them back on the dirty table. V10 then used the towels from the soiled overbed table to cleanse R7's peri area. The Facility's Hand Hygiene policy, undated, documents in part Examples of When to Perform Hand Hygiene (Either Alcohol Based Hand Sanitizer or Handwashing): Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed), After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, before glove placement, and after glove removal. The Facility's Linen Handling-Laundry Department Policy, dated 10/25/25, documents in part Purpose: To ensure the proper handling, storage, processing, and transport of all linens and laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible. 1.The Laundry Department shall be designed so that there is a flow of functions that prevents contamination of clean linen. 2.Chemical barrels and other supplies are stored on skids to aid floor care. Work surfaces shall be cleaned daily, including sinks, lint traps and washer and dryer surfaces by laundry personnel. 3. Every effort will be made to ensure that soiled articles do not come into contact with the floor, uniforms, furniture, or other areas deemed clean. 6.Laundry personnel shall wear aprons and utility or non-sterile gloves when handling linens soiled with blood or body fluids. 9.Aprons and gloves shall be removed, and hand hygiene performed prior to handling clean linens and personal laundry. 16. Hands shall be washed immediately in the event of accidental contamination of blood and body fluids and handling soiled linens and laundry. The Facility's EBP Policy, undated, documents in part Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug- resistant organism status. EBP may be considered and implemented for: Wounds and/or indwelling medical devices (central line, feeding tube, tracheostomy, drains, etc), infection or colonization with a novel or targeted MDRO when contact isolation does not apply (see CDC listed MDRO list), at discretion of the Infection preventionist. Standard Precautions must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares: Dressing, Bathing/Showering, Providing Hygiene, Changing Linens, Incontinence Care, Medical Device Care, Wound care. Points to Remember: Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment. Alcohol-based hand rub may be used if hands are not visibly soiled. Sign will be posted to door to notify that on EBP to notify family and visitors. The Facility's Infection Prevention Policy, undated, 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. The 2007 Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions will be utilized in this facility with some modifications. Transmission-Based Precautions will be employed for known or suspected infections for which the route of transmission/prevention is known. The transmission-based categories are the following: Airborne, Droplet, and Contact. Handwashing (hand hygiene) is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belongings and equipment. Alcohol-based hand rub may be used if hands are not visibly soiled. Gather all equipment and supplies needed before going into the room. Only take needed supplies into the room. When possible, dedicate the use of noncritical resident-care equipment to a single resident or cohort of residents infected or colonized with the pathogen requiring precautions. When use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident. The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 10/8/25, documents there are 55 residents residing in the facility.

Based on interview, observation, and record review, the facility failed to dispose of expired food items, to wear proper hair nets when required, and to practice proper infection control including using clean utensils and performing hand hygiene, reviewed for the storage, preparation, and sanitary serving of food in the sample of 35. These failures have the potential to affect all 55 residents in the facility.The findings include: On 12/08/25 at 8:40 AM, Initial Kitchen Observation completed with V4, Dietary Manager, who has a valid food service certificate. Upon entrance to the kitchen, V4 was seen in the kitchen without a hair net on with short hair, a mustache and a beard.On 12/8/25 at 8:42 AM, V6, Dietary Aide, was seen working in kitchen with a hair net on and large amounts of hair coming out from the front, sides, and back of her hair net. On 12/8/25 at 8:44 AM, V7, Cook, seen in kitchen working with the food, serving the food to residents at the warming station, with a hair net on and large amounts of hair coming out of front, sides, and back of the hair net.The Refrigerator located in the main kitchen: There was a gallon jug of Aloe Gel with approximately 1/4 left, the writing on top of the lid documents Do Not Eat, and on the product label, it documents Not for Internal Use.On 12/8/25 at 8:55 AM, there was a bag of dried Au gratin potatoes slices with a date of 10/28/24 on the package. When asked about these, V4 stated We don't even use those, they must be left over from the previous company.On 12/8/25 at 11:20 AM, during lunch observation, V4 was seen walking around kitchen without a hair net or beard net on. V6 and V7 seen serving food with gloves on and no hand hygiene prior to donning gloves.On 12/8/25 at 11:22 AM, V6, Dietary Aide, was seen working in kitchen and assisting with food and making sandwiches with a hair net on and large amounts of hair coming out from the front, sides, and back of her hair net.On 12/8/25 at 11:34 AM, While checking the food temperatures, V7 used no gloves, handled each utensil to mix the food item in the food pans. The scoop utensil used in the pureed stew fell into the food, V7 used her bare hands and pulled it out, wiped it off, and left inside the pan of food, then used it to serve the residents. Once temperature checks were completed, V7 donned gloves with no hand hygiene and began serving the food onto plates. V7 kept the same pair of gloves on the entire time serving, including reaching for lids, utensils, dishes, and getting a tray of deserts from a cart. V7 was serving the cornbread with her hands and same pair of gloves on and no tongs.On 12/8/25 at 11:35 AM, V7 was seen in kitchen plating the food with a hair net on and large amounts of hair coming out of front, sides, and back of the hair net. There were multiple staff were seen lined up outside the kitchen serving line, taking a lunch tray to residents in the dining room with no hand hygiene seen done. On 12/8/25 at 11:47 AM, V6, Dietary Aide, was asked to make a ham and cheese sandwich. V6 donned gloves, went into the walk-in fridge and got packages of cheese, ham slices, and then a loaf of bread. With the same gloves on, V6 opened each package and put together a sandwich, then delivered it to the window for staff to deliver to a resident. V6 doffed her gloves and without any hand hygiene, donned new gloves and assisted again with assembling lunch trays.On 12/8/25 at 11:55 AM, V8, Dietary Aide, was seen assisting in the kitchen with hair net on and large amounts of hair coming out from the front, sides, and back of her hair net.On 12/8/25, V7 was asked about several food items that are in the storage room in a plastic container sitting on a shelf. V7 stated, Those items are resident food items from when a family brings it in, we store it for them and will give to the resident when asked. When asked who checks the expiration dates, V7 stated, I'll be honest, I don't check the expirations on any food that resident family brings in. Found in the container was a packet of soup mix that had an expiration date of 9/19/25, an opened 6-ounce bag of French Dried Onions that had an expiration date of 12/2/25. There were 16 pouches of ranch dressing mix, that had an old appearance, one being opened and undated, with an unknown date of expiration or Best if Used By on the packet. The only numbers seen on the packet was 0430930 20A 14:25. There was no date written on the packets, either expiration or best used by. On 12/9/25 at 10:50 AM, V4 was seen in the kitchen with no hair net covering his head, beard, or mustache. After interviewing V4, he was noted to get a hair net and put it on his head only.On 12/11/25 at 10:50 AM, V8, Dietary Aide, stated, I do hand hygiene anytime I come out of the kitchen to help in the dining room and any time I am messing with the food. I wear a hair net all day long. When asked if her hair is supposed to be tucked inside her hair net, which is currently sticking out on front, sides, and back, V8 stated, Yes, my hair is supposed to be tucked under the hair net at all times, I thought it was.On 12/11/25 at 12:55 PM, V1, Administrator, stated, I would expect the dietary staff to always have their hair up inside the hairnet while in the kitchen. I would expect them to perform hand hygiene and all infection control practices while serving food to the residents.The Facility's Dietary Staff Hygiene/Hair Nets Policy, undated, documents, 1. Employees shall adhere to the standards in the facility-wide Employee Hygiene and Hand Washing Policies/Procedures, except when a more restrictive standard is included in this policy and in the Dietary Operations Manual. 2. d) Hairnets or coverings shall be worn at all times in the Dietary Department and applied appropriately to keep hair from contacting exposed food, clean utensils and single service/use items, if unwrapped. e) Beards are to be trimmed and covered with face mask or snood (beard net). 4. Dietary employee will adhere to the facility hand hygiene policy and will perform hand hygiene as follows: a) Before preparing food or putting on gloves. g) After engaging in any activities that might contaminate the hands, such as taking out garbage, handling soiled utensils or equipment, or handling cleaning chemicals. h) Directly before touching ready-to-eat food or food-contact surfaces.The Facility's Hand Hygiene Policy, undated, documents Examples of when to perform hand hygiene (either alcohol-based hand sanitizer or handwashing): Before glove placement, After glove removal.The Facility's Food and Supply Storage Policy, dated 8/1/25, documents in part 6. All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product. The Facility's Food from Family, Visitors, Community Policy, undated, documents in part Residents may choose to accept food from family, friends, or other guests and may choose to participate in meals provided by community groups. In order to prevent foodborne illness outbreaks, the facility staff will ensure proper handling, serving, and storage of any food item brought into the facility. 5. Food stored for residents should be labeled and dated appropriately and discarded per safe food storage guidelines. A facility may choose to utilize a specific refrigerator or area of cooler for resident food.The Facility's Staff Hygiene/Hair Nets Policy, undated, documents in part 1. Employees shall adhere to the standards in the facility-wide Employee Hygiene and Hand Washing Policies/Procedures, except when a more restrictive standard is included in this policy an in the Dietary Operations Manual. d. Hairnets or coverings shall be worn at all times in the Dietary Department and applied appropriately to keep hair from contacting exposed food, clean utensils and single service/use items, if unwrapped. e. Beards are to be trimmed and covered with face mask or snood {beard net). 4. Dietary employee will adhere to the facility hand hygiene policy and will perform hand hygiene as follows: g. After engaging in any activities that might contaminate the hands, such as taking out garbage, handling soiled utensils or equipment or handling cleaning chemicals.The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 10/8/25, documents there are 55 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to properly store medication, label and discard expired medication. This has the potential to affect all 55 residents residing in the facility.Findings include:On 12/8/2025 at 8:59 AM the facility medication room was inspected. In the refrigerator located in inside the medication room observed: 1. 3 boxes of Influenza with expiration date 6/2025. 2. 1 box of open and partially used multidose vial of Aplisol with handwritten date of 11/1/25. 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 12/9/2025 at 3:24 PM V29, Licensed Practical Nurse, stated the facility did administer influenza. V29 stated the influenza vaccine is stored in the refrigerator in the medication room. V29 verified the influenza vaccine was expired. V29 stated the medication should not be in the refrigerator and should have been destroyed. V29 verified the Aplisol multidose vial 11/1/25 date was the open date, and the vial should be destroyed. V29 stated the influenza vaccine and Aplisol are stock meds and used for everyone as long as they have an order and no allergy. 3. On 12/9/25 at 9:40 AM, Med Cart on the C-Hall was observed with V13, Licensed Practical Nurse (LPN), with the following noted:Aspirin 325 MG (milligram) - expiration date 10/2025, had an open date of 8/12/24.CoQ10 100 MG - expiration date 10/2025, did not have an open date. 4. The following medications were in the cart and did not have an open date written on the open bottle:Tylenol 500 MG (almost empty), Vitamin C 500 MG, Tylenol 325 MG (almost empty), Vitamin B12 (1 pill left), Arthritis Pain/Tylenol 650 MG, Vitamin B ComplexMagnesium Oxide 400 MG X2, MVI with Iron, Ibuprofen 200 MG, Tums, Mucous Relief 600 MG, Calcium 500 MGIron Tabs, Geri-Kot 8.6 MG, Iron 27 MG, Melatonin 3 MG, Loratadine 10 MG, and Docusate 100 MG. On 12/11/25 at 8:45 AM, V2, Director of Nursing (DON), stated, The nurses are supposed to date when they open a bottle of medication. I would expect the nurses to be dating all medications they open and to discard of expired medications. On 12/11/25 at 8:47 AM, V3, Assistant Director of Nursing (ADON), stated, I would expect the nurses to be dating all medications they open as well as discarding any expired medications. On 12/11/25 at 10:40 AM, V25, Registered Nurse (RN), stated, The nurses should be discarding any medication that is expired. Anytime we open a medication bottle, we should be dating the bottle. On 12/11/25 at 12:55 PM, V1, Administrator, stated,I would expect expired medications to be discarded, and all open medications should be dated when opened. The Facility's Medication Storage policy, dated 8/1/25, documents in part 3. General Storage Procedures: 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. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medication. 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. 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 10/8/2025, documents 55 total residents in facility.

Based on interview and record review the facility failed to answer call lights timely for 4 of 24 residents (R2, R6, R12 and R30) reviewed for call lights in the sample of 35. Findings include:1. On 12/9/2025 at 10:30AM during resident group meeting. R2, R6, R12 and R30 all stated call lights are not answered timely.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. R6's MDS dated [DATE] documents R6 is cognitively intact.R12's MDS dated [DATE] documents R12 is cognitively intact.R30's MDS dated [DATE] documents R30 is cognitively intact.Resident council minutes dated 12/2/2025 documents residents feel that call lights are not being answered in a timely manner.Resident council minutes dated 10/6/2025 documents call lights are not being answered in a timely manner.Resident council minutes dated 8/4/2025 documents call lights are taking too long to be answered.Resident council minutes dated 6/2/2025 documents call lights are takin too long to be answered.On 12/10/2025 at 9:25AM V21 Certified Nursing Assistant (CNA) stated some days there is not enough staff. V21 stated call lights are to be answered when can get to it. V21 stated if there is a delay in answering call light it is because providing care to someone else. The facility policy Call light, undated, documents the purpose is to respond to resident requests and needs in a timely and courteous manner. The policy documents resident call lights will be answered in a timely manner. The policy documents all staff should assist in answering call light. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered.

Based on observation, interview and record review the facility failed to implement fall interventions as identified in resident care plans for 4 of 9 residents (R1, R9, R33 and R53) reviewed for accidents in the sample of 35. Findings include: 1. On 2/8/2025 at 8:50 AM recliner in R53's room does not have mat in the seat. On 2/10/2025 3:15PM R53's recliner in room does not have mat in the seat as identified as intervention in care plan. R53's care plan dated 10/29/2025, documents R53 is at risk for fall, refuses wheelchair handles on wheelchair, related to stroke with right sided weakness, confusion, gait/balance problems and incontinence poor communication/comprehension, Unaware of safety needs. R53's care plan documents the following intervention for fall: 9/25/2025 place Dycem in recliner chair, follow facility fall protocol. R53's care plan documents that R53 has had 5 falls since 7/24/2025. R53's Minimum Data Set (MDS) dated [DATE] document R53 has severe cognitive impairment. R53's MDS documents R53 requires substantial/maximal assistance for transfer from chair to bed 2. R9's face sheet dated 12/10/2025 documents in part a diagnosis of flaccid hemiplegia affecting right dominant side. On 12/9/2025 during the noon meal and on 12/10/2025 at 12:13PM R9 eating lunch in dining room. R9 in his wheelchair. R9's Minimum Data Set (MDS) dated [DATE] documents R9 has severe cognitive impairment. R9's MDS documents R9 is dependent on staff for eating. R9's MDS documents R9 requires substantial/ maximal assistance for chair to bed transfer. R9's progress notes 11/24/25 at 10:06AM documents clinical meeting for fall 11/22/2025 root cause resident wheeled self to room after he finished eating and attempted to transfer self to bed. Intervention resident will be placed in regular chair at meal, until staff is able to put him to bed. R9's care plan dated 9/2/2025, documents R9 is at risk for falls related to gait/balance problems, poor communication/comprehension, psychoactive drug use, unaware of safety needs, CVA (cerebrovascular Accident) and hemiplegia. R9's care plan documents the following intervention: Intervention for fall 11/22/2025 resident to be placed in a regular chair at meals. On 12/10/25 at 1:04PM V25, Registered Nurse (RN) stated the facility puts interventions in place after falls. V25 stated R9 is to be placed in a regular chair at meals. V25, RN stated R9 should have been in a regular chair at lunch, and not his wheelchair. The facility Fall evaluation and prevention policy, dated reviewed 6/1/2025 documents the purpose is to ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. The policy documents the facility will evaluate residents for their fall risk and develop interventions for prevention. 3. R33's Medical Diagnosis sheet, print date of 12/9/25, documented R33 has diagnoses including pulmonary fibrosis, anxiety disorder, dementia, aphasia, dysphagia, osteoarthritis, bipolar disorder, major depressive disorder, and unspecified protein-calorie malnutrition. R33's Minimum Data Set (MDS), dated [DATE], documented R33 is severely cognitively impaired and requires partial/moderate assistance with transfers. R33's fall risk assessment, dated 11/17/25, documented R33 is at high risk for falls. R33's progress notes and incident reports documented R33 sustained falls on 7/19/25, and 11/5/25. R33's care plan, print date of 12/9/25, documented a fall intervention of a bolster mattress was implemented on 2/17/25. On 12/9/25 at 8:50 AM surveyor asked V13 LPN (Licensed Practical Nurse) if R33 has a bolster mattress on her bed as documented on her care plan. Surveyor observed V13 pull back R33's sheets on her mattress, V13 stated there are no bolsters on R33's mattress. On 12/9/25 at 9:04 AM Surveyor asked V3 ADON (Assistant Director of Nursing) if R33's current care plan documents R33 is supposed to have bolsters on her mattress to reduce her risk of falls. V3 agreed R33's current care plan documents a bolster mattress and V3 agreed R33's bed does not have bolsters on the mattress. On 12/11/25 at 9:36 AM V3 ADON stated R33 is considered high risk for falls based on her fall risk assessments. 4. R1's Medical Diagnosis sheet, print date of 12/12/25, documented R1 has diagnoses including Epilepsy, Dementia, Moderate Intellectual Disabilities, Glaucoma, and Anxiety. R1's MDS, dated [DATE], documented that R1's is severely cognitively impaired and requires partial/moderate assistance with transfers. R1's Fall Risk Assessments, dated 6/19/25, 7/5/25, 8/22/25, 8/31/25, 9/12/25, 9/16/25, 11/6/25, documented R1 is at high risk for falls. R1's progress notes and incident reports documented R1 sustained falls on 7/5/25, 8/22/25, 8/31/25, 9/12/25, 9/22/25, 11/6/25, R1's Care Plan, dated 2/14/2025, documents the resident is at risk for falls r/t (related to) Confusion, Gait/balance problems, Unaware of safety needs. Interventions: Intervention for fall 11/6/2025-green sign next to bathroom door to ask for assistance to toilet. Intervention for fall 5/14/2025 lower cloths rod in closet. Intervention for fall 5/9/2025 place wheelchair in hall when resident in bed. Intervention for fall 6/18/2025 Bolster mattress. Intervention for fall 6/18/2025 ensure resident is placed in center of bed. Intervention for fall 7/5/2025 green sign to ask for help. Intervention for fall 8/22/2025 drop wheelchair seat, anti-tippers. Intervention for fall 8/31/2025 resident not to be left unattended in room. Intervention for fall 9/12/2025 floor bed. Intervention for fall 9/22/2025, sign in room to alert CNAS that if resident is in room to lay resident down. On 12/8/2025 at 8:37 AM no floor bed or bolster mattress in place to bed. No sign in room to lay resident down when in room. On 12/9/2025 at approximately 1:00 PM R1 observed in room in wheelchair. No staff present. 1:30 PM R1 lying in bed on the edge. R1's bed not on floor. On 12/12/2025 at 1:46 PM Observed R1 lying in bed. No bolster mattress in place and bed not in low position. V3 verified that R1 did not have a bolster mattress in place and the bed was not in the lowest position. V3 then proceeded to lower the bed to the floor. On 12/12/2025 at 1:47 PM V3, Assistant Director of Nursing, stated that R1 is high risk for falls. V3 stated that R1 is alert and confused. V3 stated that R1 has memory problems. V3 stated that R1 is not aware of safety problems. V3 stated that R1 has fallen because she tries to take herself to the bathroom and bed. V3 stated that R1 would not read the sign, remember it or follow due to her confusion and impaired cognition. V3 stated that the interventions on the care plan are to be in place. V3 stated that at this time she is not sure why they are not but would find out. The facility's Fall Prevention policy, dated 6/1/2025, documents that 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.

Based on interview and record review, the facility failed to identify and monitor the use of a lap tray for 2 of 2 (R27, R54) residents reviewed for restraints in a sample of 35.Findings include: 1. R27's admission Record, print date 12/9/2025, document R27 has diagnosis including Vascular Dementia, Anxiety, and Depression. R27's Care Plan does not address R27's lap tray and restraint. R27's Minimum Data Set, dated [DATE], documents that R27 is cognitively impaired, dependent on staff for care and does not use restraints. R27's Physician Orders do not document an order for a lap tray or a restraint. On 12/8/2025 at 9:41 AM observed R27 sitting in room facing television. R27 sitting in reclining wheelchair with lap tray attached and secured across R27's lap. R27 was not able to remove lap tray upon request. 12/9/2025 at 10:00 AM observed R27 sitting in reclining wheelchair with lap tray attached and secured across R27's lap. On 12/10/2025 at 8:24 AM observed R27 sitting in reclining wheelchair with lap tray attached and secured across R27's lap. On 12/10/2025 at 8:25 AM V27, Certified Nurse's Assistant (CNA), stated that R27 is not able to remove the lap tray. 2.R54's Medical Diagnosis sheet, print date of 12/9/25, documented R54 has diagnoses including Parkinsonism, dementia, osteoporosis, atherosclerotic heart disease, polyneuropathy, and cognitive communication deficit. R54's MDS (Minimum Data Set), dated 9/17/25, documented R54 is severely cognitively impaired and dependent on staff for ADLS (activities of daily living) and mobility. R54's MDS documented no restraint in use and does not document R54's lap tray restraint. R54's care plan, undated, documented R54 has little, or no activity involvement related to immobility, physical limitations, due to Parkinson's and dementia. This care plan also documented R54 has impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions. R54's care plan documented R54 is at risk for falls related to her confusion. R54's care plan does not address her lap tray restraint. R54's physician orders, dated 12/10/25, do not document an order for a lap tray restraint. On 12/8/25 at 1:0 PM R54 was observed sitting in her reclining wheelchair in her room with a lap tray attached to her chair. R54 was lethargic and confused. On 12/8/25 at 1:43 PM V10 CNA stated R54 has a lap tray on when up except while she is eating. V10 stated R54's daughter insists R54 has it on because she slides out of the chair. V10 stated the lap tray is provided by hospice. On 12/9/25 at 8:53 AM R54 was observed sitting in a reclining wheelchair in her room with a lap tray on. Surveyor asked R54's nurse V13 LPN if R54 can remove the lap tray on command. V13 stated somedays she can remove it and other days she is not able to. R54 was lethargic and did not respond to questions during this observation. R54 was not able to release the lap tray when requested by the nurse. On 12/9/25 at 11:52 AM V3 ADON (Assistant Director of Nursing) stated the facility did not complete a restraint assessment on R54's lap tray, did not care plan the lap tray, nor has the facility been documenting on the use of the lap tray. On 12/10/2025 2:39 PM V15 Regional Nurse Consultant stated she expects the facility staff to follow the facility Restraint Policy when residents utilize lap trays. The facility's Restraints Policy, dated 8/29/25, documented Purpose: Residents shall be provided an environment that is restraint- free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. Policy: 1. Definitions: Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed tails, beds against walls, restrictive clothing, etc. Medical Symptom is defined as an indication or characteristic of a physical or psychological condition. Chemical Restraint is defined as any drug that is used for discipline or convenience and not required to treat medical symptoms. Treatment Restraint is a restraint used for the protection of the resident during treatment and diagnostic procedures. Postural Support means any method other than orthopedic braces used to assist patients to achieve proper body position and balance. Postural support may include devices such as soft ties, seat belts, lap trays, lap buddies. Lateral supports or cloth vests. 2. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than treatment of the resident's medical symptoms. The facility will ensure that restraints will not be imposed for purposes of discipline or convenience. 3. Medical symptoms will be evaluated to determine if underlying causes may be eliminated. 4. If underlying causes of medical symptoms cannot be eliminated, alternative measures must be tried before a restraint is used. 5. If alternative measures are unsuccessful, the least restrictive form of a restraint will be used. 6. Unless otherwise specified by the Attending Physician's order, alternative methods of behavioral control must be attempted and documented in the resident's medical record before a physical restraint is used. 7. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. Treat the medical symptom; b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well-being. 8. The facility will not use restraints on a PRN of as necessary basis. 9. Every attempt will be made to avoid a decline in the resident's physical functioning. 10. Except in emergency situations, a physical restraint shall be used only after the Interdisciplinary Team (IDT) has performed an assessment, attempted to determine, and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device. a. Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less- restrictive interventions are feasible. b. The attending physician must be notified of such use and the reason for the order. c. Orders for emergency restraints may be received by telephone. d. The emergency use of restraints must not extend beyond the immediate episode. 11. Treatment restraints: a. Informed consent will be obtained from the resident or responsible party if a restraint will be used during treatment or diagnostic procedures. b. Treatment restraints shall be applied for no longer than the time required to complete the treatment. It continues, 13. Postural Support: a. Postural support will only be used to improve a resident's mobility and independent functioning, or for positioning, rather than to restrict movement. The use of postural support and the method of application will be specified I the resident's Care Plan. b. Postural supports will be applied: i. Pursuant to an Attending Physician's order. ii. Under the supervision of a Licensed Nurse; and iii. In accordance with principles of good body alignment and with concern for circulation and allow for change of position. c. Use of postural support for these purposes is not considered a physical restraint. Procedure: I. An assessment will be completed by a licensed nurse prior to the application of any device that restricts movement or access to one's body. The assessment will be repeated quarterly thereafter. If a resident is admitted with a restraint, the assessment will be completed upon admission. It continues, V1. Physician Order – There must be a physician's order for the use of the restraint which includes A. Medical symptoms for use. B. Frequency of use. C. Type of restraint. D. Release protocols; and E. Plan for reduction, when applicable. VII. Informed Consent: A. Before any type of restraint is used, the Licensed Nurse will verify that informed consent has been obtained from the resident/ responsible party and that the resident/ responsible party was educated regarding the risks and benefits of restraint use. B. If the resident or their representative refuses to consent, the IDT will meet with the Administrator, Ombudsman, Attending Physician, and the resident and/or surrogate decision-maker to determine if the resident's physical or behavioral issues jeopardize the facility's ability to provide for the safety of the resident and/or others. C. If immediate action is necessary to prevent serious bodily harm or to protect others, the Licensed Nurse is not required to document that the resident and/or his or her representative has consented to the restraints. In this emergency situation when it is impractical to obtain the required consent, the restraint use must be the customary proactive of Attending Physicians and Licensed Nurses in good standing. VIII. Application of Physical Restraints: A. Nursing staff will remove any potentially harmful objects (e.g. neckties, shoestrings, belts, necklaces, sharp rings) before applying restraints. B. Nursing staff will apply the restraint so that the circulation is not impaired in any way. It continues, IX. Safety Guidelines: A. Restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident. B. Acceptable forms of physical restraints are cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices. C. Physical restraints shall be applied in such a manner that they can be easily removed in case of fire or other emergency. D. A resident placed in a restraint will be observed at least every 30 minutes by Nursing staff. E. The opportunity for motion and exercise will be provided for a period of not less than ten (10) minutes during each 2 hours in which restraints are employed. F. Nursing staff will ensure that the resident is restrained only in an area that is under supervision of staff and is afforded protection from other residents who may be in the area. G. Seclusion, which is defined as the placement of a resident alone in a room, shall not be employed. H. If the unsafe behaviors continue to escalate while the resident is receiving a physical or chemical restraint, the facility will implement a plan to keep the resident and others safe until the unsafe behaviors cease. It continues, II. Care Planning - Care plans for residents with restraints will reflect: A. The type of restraint to be used. B. The medical symptoms requiring the use of restraints. C. The treatment team's goals in using the restraint. D. Interventions that address the immediate medical symptom(s) and the underlying problems that may be causing the symptom(s). E. Systematic and gradual approaches for minimizing or eliminating the concerning behavior and restraint use. F. Frequent observation and release every 2 hours for toileting and /or repositioning and checking the condition of skin and impaired circulation if indicated. G. The use of postural support and the method of application will be specified in the resident's care plan. II. Medical Record Documentation: A. Documentation for residents with restraints shall include the following: i. A comprehensive assessment. ii. The least restrictive alternatives attempted. iii. A specific medical symptom. iv. The rational for physical restraint use. v. Restraint information (type and period of time). vi. A signed consent form. vii. A written physician's order for restraint use. viii. A plan for gradually reducing or eliminating restraint. Ix. The resident's response to restraint application, reduction, or elimination. x. Observation, range of motion and repositioning. B. The licensed nurse may use the restraint log to document residents with restraints. i. Postural support devices do not need to be documented on the restraint log. IV. Ongoing Review: A. Restrained residents will be reviewed regularly (at a minimum of quarterly) by the IDT to determine the continued need for restraints. The IDT will consider the elimination of restraints, less frequent use of restraints, or a less restrictive device whenever possible. It continues, C. The IDT will monitor the resident for any adverse effects of the use of restraints including but not limited to i. Declines in the resident's physical functioning and muscle condition. ii. Contractures. iii. Increased incidence of infections and pneumonia. iv. Impaired skin integrity, bruising, or abrasions. v. Withdrawal from social activities. vi. Mood changes such as agitation, depression, or delirium. vii. Sensory deprivation. viii. Decreased appetite. ix. Sleeping pattern disturbances. x. Incontinence or constipation. D. The IDT will document the effectiveness of the use of restraints in the resident's medical record.

Based on observation, interview and record review the facility failed to provide eating assistance for 1 of 24 residents (R9) reviewed for assistance with eating in the sample of 35. On 12/09/2025 at 8:00AM R9 observed sitting in wheelchair in dining room eating cooked cereal out of bowl. Glass of orange juice, and glass of water sitting in front of R9. Plate with scrambled eggs and biscuit with jelly also in table. At 8:47AM R9 observed eating scrambled eggs with his hands. R9 ate 100% of cooked cereal and drank glass of water. At 8:55AM R9 drank 100% of orange juice. At 8:58AM R9 turned plate clockwise with biscuit and jelly and scrambled eggs., touched eggs with hands. At 9:03AM V34, Certified Nursing Assistant (CNA) approached table and ask R9 if would like more to drink, and requests coffee. V34 did not provide R9 touch assistance or encouragement to eat his scrambled eggs or biscuit. R9 had 50% of his scrambled eggs and 1/2 of biscuit remaining on his plate. R9's dietary note dated 11/11/2025 at 13:45 documents Registered Dietitian (RD) for weight variance. Note documents R9 receives a regular diet as ordered with intake noted to be 51-100% of meals. R9's dietary note documents R9's weight on 11/6/2025 151 pounds. R9's note documents review of weights shows loss over 30days of 5% (8#). Note document's goal is for intake of meals to remain greater than 50% with no significant weight change.R9's Physician Order (PO) dated 8/29/2025 documents regular diet, regular texture, regular thin consistency.R9's care plan dated 9/2/2025 documents R9 has unplanned/unexpected weight loss related to poor food intake.R9's Minimum Data Set (MDS) dated [DATE] documents eating, supervision or touch assistance.R9's weight summary documents weight of 169.6 pounds on 8/29/2025, and most current weight of 152 pounds on 12/5/2025. On 12/20/2025 at 12:30PM V1, Administrator stated R9's weight was 169 pounds on admission to facility from the hospital.On 12/11/2025 at 2:50PM V3, Assistant Director of Nursing (ADON) stated she would expect staff to provide assistance and cueing if needed during meals. The facility policy Activities of Daily Living (ADL), Supportive dated, revised 7/15/2025 documents residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy 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 and oral hygiene. The policy documents appropriate care and service will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks) The policy documents interventions to improve or minimize a resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on observation, interview and record review the facility failed to provide feeding assistance for a resident with weight loss for 1 of 24 residents (R9) reviewed for nutritional status in the sample of 35.On 12/09/2025 at 8:00AM R9 observed sitting in wheelchair in dining room eating cooked cereal out of bowl. Glass of orange juice, and glass of water sitting in front of R9. Plate with scrambled eggs and biscuit with jelly also in table. 8:47AM R9 observed eating scrambled eggs with his hands. R9 ate 100% of cooked cereal and drank glass of water. At 8:55AM R9 drank 100% of orange juice. At 8:58AM R9 turned plate clockwise with biscuit and jelly and scrambled eggs., touched eggs with hands. At 9:03AM V34, Certified Nursing Assistant (CNA) approached table and ask R9 if would like more to drink, and requests coffee. V34 did not provide R9 touch assistance or encouragement to eat his scrambled eggs or biscuit. R9 had 50% of his scrambled eggs and 1/2 of biscuit remaining on his plate. R9's dietary note dated 11/11/2025 at 13:45 documents Registered Dietitian (RD) for weight variance. Note documents R9 receives a regular diet as ordered with intake noted to be 51-100% of meals. R9's dietary note documents R9's weight on 11/6/2025 151 pounds. R9's note documents review of weights shows loss over 30days of 5% (8#). Note document's goal is for intake of meals to remain greater than 50% with no significant weight change.R9's Physician Order (PO) dated 8/29/2025 documents regular diet, regular texture, regular thin consistency.R9's care plan dated 9/2/2025 documents R9 has unplanned/unexpected weight loss related to poor food intake.R9's Minimum Data Set (MDS) dated [DATE] documents eating, supervision or touch assistance.R9's weight summary documents weight of 169.6 pounds on 8/29/2025, and most current weight of 152 pounds on 12/5/2025. On 12/20/2025 at 12:30PM V1, Administrator stated R9's weight was 169 pounds on admission to facility from the hospital.On 12/11/2025 at 2:50PM V3, Assistant Director of Nursing (ADON) stated she would expect staff to provide assistance and cueing if needed during meals. The facility policy Activities of Daily Living (ADL), Supportive dated, revised 7/15/2025 documents residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy 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 and oral hygiene. The policy documents appropriate care and service will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks) The policy documents interventions to improve or minimize a resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on observation, interview and record review, the facility failed to develop/implement interventions for 1 of 3 residents reviewed for pressure ulcers in the sample of 4. Findings include: R2's face sheet documents an admission date of 4/27/2025. Diagnosis include Hypertensive Heart Disease with Heart Failure, Human Immunodeficiency Virus, Chronic Obstructive Pulmonary Disease, Acute Myocardial Infarction, Cerebral Infarction. On 6/5/2025 at 8:15AM V3, Assistant Director of Nursing, ADON, stated R2 does not have any skin issues. On 6/5/2025 at 8:30AM V3 stated, We just did a skin check on R2 and she does have a new area to her left buttock. We just found it this morning. She recently came back from the hospital. I talked to the nurse who did R2's admission assessment and he denied any skin issues. She was in the hospital quite a while. On 6/5/2025 at 9:30AM V3, Assistant Director of Nursing, ADON, and V4, Licensed Practical Nurse, LPN, performed skin check to R2. Dime size open reddened area noted to left buttock. R2's Minimum Data Set, MDS, dated [DATE] documents R2 has no cognitive deficits. R2's MDS dated [DATE] documents R2 has no unhealed pressure ulcers. R2's Care Plan dated 5/25/2025 documents R2 has potential for pressure ulcer development related to decline in medical, physical, mental status. incontinence. assist with transfers and turning and repositioning. Interventions include: R2 requires the bed as flat as possible to reduce shear. R2 prefers to be repositioned with 2 people, lifter. R2 requires pressure relieving device on bed/chair. R2's Braden scale for pressure ulcer development dated 5/12/2025 documents R2 is at moderate risk for pressure ulcer development. R2's progress notes dated 6/5/2025 at 8:53AM document Skin Issue: #001: New skin Issue. Location: Buttocks - generalized. Laterality / Orientation: Left. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Wound is new. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 0.7 Width (cm): 0.7 Depth (cm): 0.1 Undermining: No. Tunneling: No. Skin Issues Note: order for triad paste put in place. R2's Clinical admission dated 5/27/2025 documents no skin issues. R2's Skin Issues assessment dated [DATE] documents new issue, buttocks, pressure ulcer/injury, left. Stage 2, in house acquired. Stage by in house nursing, .7cm x .7cm x .1cm. On 6/5/2025 at 8:30AM R2 stated, I got a pressure ulcer, and they haven't done anything. I have had a pressure ulcer before. I did have a cushion for my chair, but I don't know what happened to it. I like to be up in my chair all day. I like to smoke. On 6/5/2025 at 1:30PM R2 up in wheelchair in smoking area. R2 did not have a cushion or pressure relieving device in chair or on bed. On 6/5/2025 at 1:40PM V2 stated R2 was much more independent when she first came in. She wants to be up most of the day. We encourage her to lay back down in the afternoon or use a pressure relieving cushion. On 6/5/2025 at 1:40PM V3 stated, We encourage R2 to try one of the recliners to sit up in to relieve the pressure and reposition. She may have a cushion. Facility's pressure ulcer policy updated 6/2/2025 states: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by licensed nurse and documented in the resident's clinical record.

Based on interview, observation, and record review, the facility failed to provide and implement interventions to prevent resident falls for 4 of 4 residents (R11, R19, R29, R32) reviewed for resident safety in the sample of 27. This failure resulted in R32 transported to the hospital for a facial laceration with sutures and a fractured humerus on one incident, and a fractured hip with surgery on another incident. The Findings Include: 1. R32's Face Sheet, undated, documents R32 was admitted to the facility on [DATE]. R32's medical diagnosis include Major depressive disorder, Dementia with behavioral disturbances, Anxiety Psychotic disorder, Hypertension, (HTN), Gastroesophageal reflux disease, (GERD), and Insomnia. The facility's Fall Analysis Log, undated, documents, R32 had a fall on 7/26/23, 7/27/23, and 8/28/23. R32's Fall Risk was entered into the Care Plan on 9/5/23 after R32 had several falls. There were no interventions added after each fall. R32's Care Plan, dated 9/5/23, documents, Falls: R32 admitted Hospice due to medical and physical decline. Diagnosis: Dementia, resident is non-mobile, assist with transfers, sits in geriatric reclining wheelchair, has risk factors that require monitoring and intervention to reduce potential for self-injury. Interventions: Attempt to anticipate needs - toileting, hydration, hunger and provide cares before resident attempts to fulfill on own, bring to nurses station when out of bed for observation, assist resident to clean and place prescribed eyewear when awake, fall risk assessment quarterly and as needed with change in condition or fall status, keep call light within reach at all times, answer promptly and notify resident that help is coming, check every two hours when in bed for safety, side rails in up position while in bed to facilitate safe and more independent bed mobility. R32's Minimum Data Set, (MDS), dated [DATE], documents, R32 is cognitively intact and requires extensive assistance from two staff members for bed mobility, transfers, locomotion, toilet use, and bathing. R32 is occasionally incontinent of urine and always continent of bowel. R32's Nurses Note, dated 7/27/23 at 6:25 AM, documents, Called to room to assess resident. Upon entering room, resident observed on floor sitting with back against bedside table. Incontinent of urine and shoes next to bed instead of on feet, lighting adequate, no apparent injuries noted at this time other than redness to left upper extremity (bicep) and to left side/back. VS, (Vital Signs): T, (temperature), 99.7, P, (pulse), 60, R, (respirations), 16, BP, (blood pressure), 115/77, SpO2, (oxygen saturation), 96% RA, (room air). Resident transferred to bed with gait belt X two assist. CNAs, (Certified Nursing Assistants), report she is weaker than normal. Neuro checks initiated at this time. R32's Nurses Note, dated, 7/28/23 at 3:45 PM, documents, Returned from (local ER), tetanus shot given, Suture (6) to left eyelid, F/U, (follow-up), with provider in five days for removal and wound check. CT, (Cat Scan), of spine and head, Chest and Pelvic X-Rays which showed closed nondisplaced fracture of surgical neck of right humerus (likely old); No medication order except OTC, (over the counter), Tylenol for Motrin take as according; Resident brought back to facility by Ambulance and two EMTs, (Emergency Medical Technicians), resident resting VS 98.2, 82, 18, 122/52, no signs of discomfort or pain, continue to monitor. R32's Nurses Note, dated 8/28/23 at 1:00 AM, documents, Called to assess resident in room. Observed her sitting on floor next to bed facing lights on wall. C/O, (complained of), severe right hip pain. RLE, (right lower extremity), noted to be externally rotated and shortened. Unable to do ROM, (Range of Motion), or move it at all. R32's Nurses Note, dated 8/28/23 at 1:05 AM, documents, EMS, (Emergency Medical Service), called to transport resident to ER, (emergency room ), for evaluation. R32's Nurses Note, dated 8/28/23 at 1:15 AM, documents, VS T-98.1, P-106, R-22, BP-140/102, SpO2-96%. R32's Nurses Note, dated 8/28/23 at 1:30 AM, documents, EMS here and resident lifted from floor to stretcher via draw sheet and X two EMS with X three NH, (Nursing Home), staff. R32's Nurses Note, dated 8/28/23 at 1:35 AM, documents, Report called to hospital. POA, (Power of Attorney), called and updated. R32's Nurses Note, dated 8/28/23 at 2:20 AM, documents, (Local Hospital), called and admitting resident with Dx, (diagnosis): Right hip fracture. Message sent to MD, (Medical Doctor), DON, (Director of Nursing), POA said to call in AM, (morning), with updates. On 9/27/23 at 11:30 AM, V2, DON, stated, We only do a Quality Assurance Fall Analysis for residents fall. We don't do any other investigation on the falls. R32's Quality Assurance Fall Analysis, documents, R32's had falls 7/26/23, 7/27/23, and 8/28/23. This document provides the Root Cause Analysis Identified from the Investigation and the Prevention Plan for each date of a fall. There is no fall investigation done on resident falls. R32's Quality Assurance Fall Analysis, for fall on 7/26/23, documents, Root Cause Analysis Identified from the Investigation, as Resident had previously returned from (regional hospital) where they said she fell on Psych unit. Had been given IM, (intramuscular), Haldol at hospital and has been unsteady since. Prevention Plan: Med check and labs done by (Physician). R32's Quality Assurance Fall Analysis, for fall on 7/27/23, documents, Root Cause Analysis Identified from the Investigation, as Resident on high dose of Depakote, unsteady. Was found to have gotten self out of bed, Prevention Plan: (Physician) D/C's, (discontinued), Depakote with continued behavior monitoring. R32's Quality Assurance Fall Analysis, for fall on 8/28/23, documents, Root Cause Analysis Identified from the Investigation, as Got self out of bed without assistance. Bed alarm going off, Prevention Plan: Low bed initiated. R32's Physician Order, dated 9/5/23, documents, D/C Pressure Alarm while in bed and up in chair. On 9/27/23 at 10:30 AM, V10, MDS Nurse, stated, I am the one who puts in the fall risk assessments on residents. I do them quarterly. I don't do one after a resident fall, I only do them quarterly. R32's Fall Risk Assessment, dated 9/5/23, documents, R32 is a High Fall Risk with a score of 19. A score of 10 points or more = High Risk Score. R32's Fall Risk Assessment, dated 8/11/23, documents, R32 is a High Fall Risk with a score of 21. A score of 10 points or more = High Risk Score. R32's Fall Risk Assessment, dated 5/4/23, documents, R32 is a High Fall Risk with a score of 16. A score of 10 points or more = High Risk Score. On 9/25/23 at 9:48 AM, R32 is sitting in geriatric reclining wheelchair in her room by herself. R32 was not interviewable. On 9/26/23 at 3:40 PM, R32 is sitting at the Nurses desk in her Geriatric reclining wheelchair. 2. R29's Face Sheet, undated, documents, R29 was originally admitted to the facility on [DATE]. R29's Medical Record, documents, R29's diagnosis include Dementia, Schizophrenia, Bipolar disorder, HTN, GERD, Myelodysplasia, COVID 19. R29's Care Plan, dated 8/4/23, documents, Falls: Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Interventions: Insure that adaptive devices-walker/cane/wheelchair within reach and in good repair, encourage and assist placement of proper non-skid footwear, observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended, attempt to anticipate needs-toileting, hydration, hunger and provide cares before resident attempts to fulfill on own, observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed, monitor resident for signs or fatigue during ambulation, fall risk assessment quarterly and as needed with change in condition or fall status, provide activity supplies in reach of resident to keep busy and distracted from getting up unassisted, keep environment well-lit and clutter free, keep call light within reach at all times, answer promptly and notify resident that help is coming, check every two hours while in bed for safety, keep bathroom light on at night to provide adequate safe lighting levels, encourage resident to wear brief during daytime hours to minimize risk of slipping on wet floor during toileting. There were no fall risk interventions in place prior to 8/4/23, with R29 having falls on 5/11/23 and 6/4/23. R29's MDS, dated [DATE], documents, R29 has a moderate cognitive impairment and requires supervision for personal hygiene and bathing and is independent for all other Activities of Daily Living, (ADLs). R29 is always continent of both bowel and bladder. The facility's Fall Analysis Log, undated, documents, R29 had falls on 5/11/23 and 6/4/23. R29's Fall Risk Assessment, dated 1/20/23, documents, R29 was not a High Fall Risk with a score of 7. A score of 10 points or more = High Risk Score. R29's Fall Risk Assessment, dated 4/30/23, documents, R29 was not a High Fall Risk with a score of 7. A score of 10 points or more = High Risk Score. R29's Fall Risk Assessment, dated 8/4/23, documents, R29 was not a High Fall Risk with a score of 7. A score of 10 points or more = High Risk Score. R29's Physician Order, dated 8/8/23, documents, D/C half rails. R29's 3-Day Incident Charting, dated 5/11/23, documents, Using walker, wheel got caught upon something on floor and she fell on butt. Did not hit head. Denies pain. Able to help herself up with CNA assist. No signs of injury. R29's 3-Day Incident Charting, dated 6/4/23, documents, Res, (resident), stood from dining room chair, stumbled backward and fell on buttocks. Res later said, also hit left elbow. Small superficial abrasion, just below left elbow. R29's Quality Assurance Fall Analysis for fall on 5/11/23, documents, Root Cause Analysis Identified from the Investigation, as Resident was looking behind her while walking forward. Prevention Plan as Educate resident on looking forward while walking. R29's Quality Assurance Fall Analysis for fall on 6/4/23, documents, Root Cause Analysis Identified from the Investigation, as Stumbled backwards when getting up from dining room table. Prevention Plan as Educate resident on getting up slowly and asking for assistance for walker. On 9/26/23 at 8:48 AM, R29 lying in bed, walker at bedside, tennis shoes on floor by walker. R29 got out of bed herself, no walker used, regular socks on, walked to restroom and back. On 9/27/23 at 12:35 PM, R29 was seen in dining room without a walker, cane, or wheelchair, then stood up and walked down the hall towards her room. 3. R19's Face Sheet, undated, documents, R19 was originally admitted to the facility on [DATE]. R19's Medical Record, documents, R19's medical diagnosis include Dementia, Depressive disorder, Schizophrenia, Anxiety, Repeat Falls, Dysphagia, Intertrochanteric fracture, HTN, Peripheral Vascular Disease, (PVD). R19's Care Plan, dated 3/10/23, documents, Falls: R19 does not understand mobility limits due to cognitive limitations. Resident has been known to attempt to get out of bed unattended. Risk factors include: unsteady gait, unable to regain balance by self, current cognitive level is: BIMS 00. Current transfer/mobility limitations are: Dependent assist X two with dressing, personal hygiene, and shower. Limited assist X three with bed mobility, and toilet use, and transfer. Interventions: Fall risk assessment quarterly and as needed with change in condition and fall status, attempt to anticipate needs-toileting, hydration, hunger and provide cares before resident attempts to fulfill on own., observe for unsteady/unsafe transfer, remind of safety precautions and limitations as necessary, assess cognitive deficits and accommodate forgetfulness regarding safety devices and environmental risks, toilet per schedule and as needed when restless or agitated, encourage resident to wear Depends during daytime hours to minimize risk of slipping on wet floor when toileting. R19's MDS, dated [DATE], documents, R19 has a severe cognitive impairment and requires extensive assistance from two staff members for bed mobility, transfers, and dressing. R19 is total dependence of two staff members for toileting and bathing. R19 is always incontinent of both bowel and bladder. The facility's Fall Analysis Log, undated, documents R19 had a fall on 5/22/23. R19's Physician Order, dated 5/27/21, documents, Safety Device: Low bed due to frequent falls. R19's Physician Order, dated 5/31/21, documents, D/C, (discontinue), low bed. Resident in Bolster mattress for safety. R19's Fall Risk Assessment, dated 12/8/22, documents, R19 was a High Fall Risk with a score of 19. A Score of 10 points or more = High Risk Score. This was the last Fall Risk completed on R19. R19's 3-Day Incident Charting, dated 5/22/23, documents, Res, (resident), observed lying on right side next to low bed with blanket. Res was incontinent. No s/s, (signs/symptoms), of discomfort, no visible injuries noted, ROM, (Range of Motion), is WNL, (within normal limit). There were no updated interventions placed in R19's care plan after the fall on 5/22/23. R19's Quality Assurance Fall Analysis, for fall on 5/22/23, documents, Root Cause Analysis Identified from the Investigation, as CNA found resident laying on floor next to her bed from rolling out on floor on right side. Prevention Plan: Placed bed against the wall to prevent resident from rolling out of bed (favors right side). On 9/25/23 at 9:32 AM, R19, lying in bed, not interviewable/non-verbal, call light hanging over headboard. There is a sign on R19's restroom door Remember to sit down when changing. On 9/28/23 at 10:40 AM, R19 seen sitting in living area in her wheelchair by herself, regular socks on, no shoes. 4. R11's Face Sheet, undated, was originally admitted to the facility on [DATE]. R11's Medical Record, documents, R11's medical diagnosis include: Depression, Anxiety, Dementia, Bipolar, and HTN. R11's Care Plan, start date of 5/4/23, however was entered by V10, MDS Nurse, on 7/3/23, documents, Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Interventions: Review quarterly and PRN, resident's ADL, mobility, cognitive, behavior, and overall medical status, encourage and assist placement of proper non-skid footwear, assist resident to clean and place prescribed eyewear when awake, monitor resident for signs of fatigue during ambulation, Fall risk assessment quarterly and as needed with change in condition or fall status., keep environment well-lit and clutter free, add additional lighting at night, keep call light within reach at all times, answer promptly and notify resident that help is coming, check every two hours when in bed for safety, keep bathroom light on at night to provide adequate safe lighting levels, encourage resident to wear brief during daytime hours to minimize risk of slipping on wet floor during toileting, encourage resident to use call light and ask for help when feeling weak or lightheaded, 2/26/23: monitor BP for one week, ensure resident is wearing tennis shoes, not slippers, resident provided walker with green sign, removed high riser from toilet, low height bed. R11's MDS, dated , 8/3/23, documents, R11 has a severe cognitive impairment and requires limited assistance of one staff member for dressing, toilet use, personal hygiene, and bathing. R11 requires supervision for all other ADLs. R11 is occasionally incontinent of both bowel and bladder. The facility's Fall Log, documents, R11 had a Fall on 3/4/23, 3/31/23, 4/20/23, 5/11/23, 6/13/23, and 8/27/23. R11's Fall Risk Assessment, dated 10/7/22, documents, R11 is not a high fall risk with a score of 9. A Score of 10 or more = High Risk Score. There is no other fall risk completed and in R11's Medical Record. R11's 3-Day Incident Charting, dated 3/31/23, documents, Resident was getting cup of coffee at kitchen window, as she was turning, feet got twisted and went down. No injuries at this time. R11's 3-Day Incident Charting, dated 6/13/23, documents, Fall in room. C/O right shoulder and knee pain and cut on right eyebrow, sent to (local hospital) ER For eval. No fractures. R11's 3-Day Incident Charting, dated 7/25/23, documents, Resident fell in room attempting to get up without walker. Res heard yelling help. Staff observed res on floor. Neuro VS started, no injuries noted, ROM, WNL, awake and alert. R11's 3-Day Incident Charting, dated 8/27/23, documents, Laundry aid hollered, stated res fell . Res sitting on hallway floor with head against wall. Neuro checks initiated. Res alert and able to move all extremities without difficulty. On 9/25/23 at 9:36 AM, R11, was asleep in bed, walker on side of bed, R11 stated, that she fell down so now has to use her walker to get around. R11 stated, that she has fallen around three times now. There is a sign posted on the wall Use call light for help. On 9/26/23 at 9:05 AM, R11 was sitting in a chair in her room, walker next to her, sign on the walker read, (R11), pick up your feet when you walk. Take your walker with you at all times. On 9/27/23 at 10:00 AM, R11 lying in bed, legs hanging off the bed, walker in the room close to restroom and not next to bed. R11's Quality Assurance Fall Analysis for fall on 3/4/23, documents, Root Cause Analysis Identified from the Investigation, as Not picking up her feet with house shoes on, Prevention Plan: House shoes taken and replaced with tennis shoes during the day and grippy socks at night. R11's Quality Assurance Fall Analysis for fall on 3/31/23, documents, Root Cause Analysis Identified from the Investigation, as Walking around dining table and tripped over own feet, Prevention Plan: OT, (Occupational Therapy), pick up for gait and balance training. R11's Quality Assurance Fall Analysis for fall on 4/20/23, documents, Root Cause Analysis Identified from the Investigation, as Walking up hallway, yelled out, she was unsteady, grabbed handrail and lowered self to floor yelling she fell , Prevention Plan as Given walker for unsteady gait. R11's Quality Assurance Fall Analysis for fall on 5/11/23, documents, Root Cause Analysis Identified from the Investigation, as While sitting on toilet seat riser, slid off and resident slid to floor., Prevention Plan as Seat riser removed from bathroom. R11's Quality Assurance Fall Analysis for fall on 6/13/23, documents, Root Cause Analysis Identified from the Investigation, as Resident couldn't say, found wrapped in blankets on floor next to bed., Prevention Plan as Given a low bed. R11's Quality Assurance Fall Analysis for fall on 8/27/23, documents, Root Cause Analysis Identified from the Investigation, as Shuffling feet while walking up hall with walker., Prevention Plan as Sign attached to walker to remind resident to pick up her feet while walking. On 9/28/23 at 12:46 PM, V2, DON, stated, I would expect the staff to perform Fall Risk Assessments during admission, quarterly, and after a resident fall. There should be fall interventions placed in the resident's care plan after each fall, and the staff should be following these interventions. The 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. 1. Conduct Fall Assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. All staff must observe residents for safety. If residents with a high-risk code are observed up or getting up, help must be summoned, or assistance must be provided to the resident. 3. 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. 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. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new interventions deemed to be appropriate at the time. The unit nurse will also place any new interventions on the CNA assignment worksheet. 7. 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 follow their policy by ensuring all staff are vaccinated for COVID-19 or have a medical or religious exemption. The facility failed to develop a contingency plan for staff who are unvaccinated without exemptions in the sample of 29. This failure resulted in four residents (R28, R29, R30, R31) testing positive for COVID-19 infection on 9/19/2022. Findings include: The Facility's Healthcare Personnel COVID-19 Vaccination report provided on 10/17/22 documents there are six employees (V14, V16, V17, V18, V19, and V20) who have not completed their initial Covid-19 vaccine series consisting of either one dose of a single dose vaccine or both doses of a two-dose vaccine. The F888 Staff Vaccination Formula documents 87.8% of staff have had their initial vaccine series. On 10/18/22 at 9:12 AM, V2, Director of Nursing (DON), stated there are several staff members that are not fully vaccinated without medical or religious exemptions. She stated, (V14) is brand new and was going to get vaccinated. I may have an exemption for (V16). We are trying to get ahold of some of these staff members to see which vaccines they have had. The National Healthcare Safety Network (NHSN) documents 74% of Facility staff had completed their initial vaccine series as of the week ending on 10/2/22. On 10/18/22 at 1:46 PM, V1, Administrator, stated, I report data to the NHSN (National Healthcare Safety Network). There is a discrepancy between NHSN (74%) and the numbers I provided (87.8%) because I only report the numbers to NHSN of who is working during that time frame. If the employees do not work, I do not report them on the website. I misplaced (V20)'s card so I am getting with her. I am also trying to get with (V16) and (V18) regarding their vaccination status. On 10/19/22 at 8:45 AM, V1 stated, Our new employees who are not vaccinated have been working the floor. On 10/18/22 at 3:57 PM, V20, Licensed Practical Nurse (LPN), was sitting at the nurse's station charting. She stated, I just started working here. I am a nurse on evenings. The Facility's COVID positive residents in the last 4 weeks list signed and dated by DON on 10/17/2022 documents R28, R29, R30, and R31 all tested positive for COVID on 9/19/2022. On 10/20/22 at 2:35 PM, V1 stated she would expect the Facility to follow its policies regarding 100% staff Covid-19 vaccination unless exempt. The Facility's Covid-19 Vaccine Policy and Procedure revised 11/29/21 documents, The purpose of this policy and procedure is to outline the facility approaches to encourage both staff and residents to receive a Covid-19 vaccine to reduce the risk of residents and staff of contracting and spreading Covid-19 and to establish a process to comply with the Federal Mandate that all staff are vaccinated against Covid-19, unless they have an approved medical or religious exemption. All facility staff are required to have received at least one dose of an FDA-authorized COVID-19 vaccine by December 6, 2021 and the second dose by January 4, 2022. New hires will be subject to the same requirements as current staff and must have received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine by the regulatory deadline or prior to providing any care, treatment or other services for the facility and/or its residents.

Based on observation, record review and interview, the facility failed to notify and consult with a dietician for unplanned severe weight loss and failed to monitor and implement new interventions for 1 of 1 resident (R7) reviewed for weight loss in the sample of 29. This failure resulted in R7's severe weight loss of 16.3 % in 6 months' time. Findings includes: On 10/19/2022 at 12:10 PM, R7 was sitting up to her wheelchair in the dining area, she had eaten approximately 20% of her ground meat and approximately 25% of her gelatin dessert. Her vegetables and potatoes were not eaten. Staff around the table were assisting other residents and occasionally giving R7 verbal cues. The facility's Monthly Weight Grid, dated November 2022 through October 2022 documented R7's weight 11/2021 of 162 lbs., 12/2021 of 154 lbs., 1/2022 of 148 lbs., 2/2022 of 144 lbs., 3/2022 of 140 lbs., 4/2022 of 135 lbs., 5/2022 of 133 lbs., 6/2022 of 132, 7/2022 of 125 lbs., 8/2022 of 119 lbs., 9/2022 of 120 lbs., 10/2022 of 113 lbs. Weight loss percentages in 3 months 11/2021 to 2/2022 was 11.11% and in 6 months,11/2021 to 5/2022, it was 17.9%. Weight loss percentage in 1 month (9/2022-10/2022) 5.83%, 3 months (7/2022-10/2022) 9.5%, in 6 months 4/2022-10/2022) 16.3% with current BMI (body mass index) of 19.2. R7's medical record has no documentation of any Dietician notes or recommendations from 11/2021 until 6/16/2022. R7's Dietary Services Communication, dated 6/16/2022, documents dietary recommendations to change house shake lunch & supper to super cereal at breakfast and magic cup lunch & supper. R7's medical record has no documentation of any Dietician notes or recommendations from the 6/16/2022 communication until the Dietary Notes of 9/27/2022. R7's Dietician notes, dated 9/27/2022 documented, Diet NAS (regular no added salt) mech (mechanical) soft, SC (Super Cereal) at breakfast, Magic cup L+S (lunch and Supper), pudding thick liquids, 2 Cal med pass 90 cc (cubic centimeters) tid (3 times a day). It also documents, Noted wt (weight) stable x 1 mo (month). Wt (decreased) prior months. It further documents, Wt (decrease) poss (possibly) D/T (due to) dx (diagnoses) [CONDITION(S)], schizo ([CONDITION(S)]), [CONDITION(S)], dysphagia, (decreased) appetite. It continues, Recommend (continued) diet therapy, (continue) (supplements), (encourage) (by mouth) intake, no (weight loss) desired. R7's Physicians Order Sheet, dated 10/01/2022, documented, Diet of Regular, mechanical soft with pudding thick liquids. R7's Physicians Order, dated 10/13/2022, documented (Discontinue) magic cup (with) meals. R7's Diet Order Form, dated 10/13/2022, documented, (Discontinue) Magic cup (with) meals. Nursing Judgment due to swallowing difficulties. There is no documentation that the Dietician was notified of this change or consulted for a replacement for this supplement. R7's Minimum Data Set, dated dated [DATE], documented that her cognition was severely impaired and that she requires limited assist of 1 staff member to assist with eating. R7's MDS also documents R7's weight as 119 pounds and weight loss of 5% or more in the last month or loss of 10% or more in last 6 months was no or unknown. R7's Nutrition Care Plan, started 11/19/21 and updated 01/12/2022, documented, Problem: Potential risk for altered nutritional status and/or weight loss. Resident has poor dental health receives mech soft diet. Approaches include: Encourage self feeding. Feed Resident to complete as much of meal as possible. Assist/feed at meal times as needed to complete meal. Report significant changes in weight to MD (Physician) & RD (Registered Dietician)/LDN (Licensed Dietitian/Nutritionist). Follow recommendations of RD/LDN. There were no new approaches added since Care Plan started on 11/19/21. On 10/19/2022 at 1:30 PM V9, Licensed Practical Nurse, stated that she did not know why R7's order for magic cup supplement was discontinued. On 10/19/2022 at 2:15 PM V2, Director of Nurses stated that R7's magic cup supplement was discontinued because she was choking on it. On 10/20/2022 at 09:10 AM V26, Dietician, stated that the nurses usually don't call her but with R7's weight loss they could have called her to seek an alternative to the magic cup. The facility's policy, Resident Weight Monitoring, dated 03/2019, documented, 9. The Dietitian shall review and document all significant weight changes along with any recommended nutritional interventions in the dietary progress notes in the medical record monthly.

Based on interview and record review, the facility failed to notify the physician and obtain treatment orders in a timely manner regarding continued pain and decreased mobility after a fall for one of four residents (R3) reviewed for notification in the sample of 4. This failure resulted in R3 remaining in the facility for multiple days after the fall, before being sent to the hospital with right leg pain and diagnosed with a fractured right hip requiring surgical intervention. Findings include: R3's Face Sheet, undated, documents R3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS), dated [DATE]documents R3 has moderately impaired cognition. R3's Nurse's Notes document on 10/21/2021 at 9:20 AM, R3 fell when attempting to stand up from R3's wheelchair and documented R3 was lying on R3's right side with arm tucked behind R3's back. The Note documented R3 sustained a reddened area to the right elbow and a small skin tear on the fourth finger. The Note documented the Director of Nurse's and the Physician were notified. R3's Nurse's Notes document on 10/22/2021 at 11:20 AM, R3 complained of pain to right leg and arm. The Note documented notification was sent to the Physician and an Xray was ordered. R3's X-ray report for his right hip, dated 10/22/21 documents Right Hip, Chronic and [CONDITION(S)] changes. Short interval follow-up are [sic] recommended, if symptoms persist, as a nondisplaced fracture cannot be excluded. R3's Nurse's Notes document on 10/23/2021 at 6:30 AM, R3 continues to complain of pain to right hip. The Note documented R3 refused pain medication. There was no documentation that R3's physician was notified. R3's Nurse's Notes dated 10/24/2021 7AM-3PM shift, document Res (resident) had pain in feet Tylenol 500 mg (milligrams) given. Aide reported more pain in R (right) foot. Pt (patient) assessed. R ft (foot) inward call to (V6, R3's Physician) at 1:50 PM awaiting call back. Will monitor. R3's Nurse's Notes, dated 10/25/21 at 10:25 AM, document call placed to (V6's) office. The Note documented a message left about R3 complaining of pain to right leg. R3's Nurse's Note, dated 10/25/21 at 2:30 PM, documented that V6's office returned call and would like R3 to go to emergency room for evaluation of right leg. R3's Nurse's Note dated 10/25/21 at 5:00 PM documents R3 was admitted to the local hospital with a hip fracture and would require surgery. R3's Hospital Report Radiology Report Exam, dated 10/25/21, documents R3 had a comminuted fracture of the right proximal femur through the trochanteric region. On 10/28/21 at 10:00 AM, V2, Director of Nursing, said R3 had witnessed fall on 10/22/2021. V2 stated The notes say (R3) fell on [DATE] but it was actually 10/22/2021. I saw (R3) fall. (R3) fell on (R3's) right side and (R3's) right arm was bent back behind (R3). We called the Doctor and (R3's) family. Xray was ordered. The Nurse would have faxed the results to the Doctor. I was not here all weekend to know (R3) was in pain. My expectation would be for the staff to use nursing judgement and send a resident to the emergency room if pain continued. On 10/29/21 at 11:10 AM, V3, Licensed Practical Nurse (LPN) stated she worked the weekend R3 fell . V3 stated that after R3 fell , R3 was not propelling himself around in R3's wheelchair as R3 usually did. V3 stated R3 complained of pain during this time. On 10/29/21 at 1:15 PM, V4, Certified Nurse's Aide (CNA), stated that after R3 fell , R3 complained of pain when R3 was up in his wheelchair. V4 stated that R3 had complained a whole lot when they would get R3 up. On 10/29/21 at 2:52 PM, V5, CNA, stated I could tell (R3) was in pain and I told the Nurse. (R3) stayed in bed for supper and (R3) is usually up in wheelchair. (R3) complained of pain all weekend. I told the Nurse. (R3) stayed in (R3's) bed all weekend.

Based on interview and record review, the facility failed to implement progressive interventions to prevent falls for one of four residents (R3) reviewed for accidents/supervision in the sample of 4. This failure resulted in R3 falling and sustaining a right [CONDITION(S)] requiring hospitalization and surgical repair. Findings include: R3's Face Sheet, undated, documents R3 has diagnoses of Dementia, [CONDITION(S)] and Repeated Falls. R3's Care Plan Problem, undated, documents R3 has impaired physical mobility related to his [CONDITION(S)] and Dementia. Care Plan Approach dated 3/4/21 documents one staff will assist R3 with ambulation, uses a walker and gait belt. R3's Care Plan Problem, undated, documents R3 has Self care deficit and needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADL's (Activities of Daily Living). Care Plan Approach, dated 3/4/21, documents Assist to transfer resident using one staff assist. Use gait belt for all hands on transfers from one surface to another. Explain all procedures prior to starting. Advise Resident what is expected of him/her during the transfer. Reassure Resident of safety as needed. R3's Care Plan Problem, undated, documents Resident does not understand mobility limits due to cognitive limitations. Resident has been known to attempt to get up from chair unattended. Resident has been noted to attempt to get out of bed unattended. The Care Plan Approaches, all dated 3/4/21, document the following: Assist resident to clean and place prescribed eyewear when awake; Encourage Resident to sit in areas well supervised by staff that also afford opportunity for increased socialization and distraction; Transfer to straight back dining chair for meals as Resident allows; Encourage and assist placement of proper non-skin footwear while out of bed; and Resident prefers to be provided privacy during toileting but has potential to attempt to get up while unattended- Remain with resident. R3's Minimum Data Set, dated dated [DATE], documents R3 has moderate cognitive impairment. The MDS documents that R3 requires limited assistance of one person for transfers and bed mobility. The MDS documents R3 is not steady and only able to stabilize with staff assistance with moving from the seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfers. The Facility Fall log documents R3 fell on [DATE], 8/15/21 and 10/22/21. R3's Nurse's Notes, dated 6/4/21 documents R3 had a witnessed fall resulting in a skin tear to the left hand. The Nurse's Notes did not document any interventions implemented after this fall. There is no documentation in R3's Care Plan that the facility implemented and documented progressive interventions to address this fall and prevent R3 from future falls. R3's Nurse's Notes dated 8/15/21, documents R3 fell while walking from room to hallway, resulting in skin tear to R3's elbow. The Nurse's Notes did not document any interventions implemented after this fall to prevent R3 from falling in the future. There is no documentation in R3's Care Plan that the facility implemented and documented progressive interventions to address this fall and prevent R3 from future falls. R3's Nurse's Notes, dated 10/21/21 documents R3 fell while attempting to stand from wheelchair. The Nurse's Note documented that R3 was observed to land on right side with arm tucked behind his back. The Nurse's Notes did not document any interventions implemented after this fall to prevent R3 from falling in the future. R3's Nurse's Note, dated 10/25/2021 documents a call was placed to Physician's office. R3's Nurse's Note, dated 10/25/21 at 2:00 PM, documents Physician's office returned call and orders received for R3 to be sent to emergency room . R3's Nurse's Note dated 10/25/21 at 5:00 PM documents R3 was admitted to the local hospital with a [CONDITION(S)] and would require surgery the next day. On 10/28/21, at 1:50 PM, V2, Director of Nurse's was asked to see the facility's investigation of R3's falls and documentation of how the facility determined the root cause of R3's falls and progressive interventions. V2 responded that she was unable to give the surveyors that information as it is Quality Assurance containing the investigation, root cause analysis and interventions implemented. V2 stated that is prohibited by her corporate office. The Facility's Fall Policy, 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. The Policy documents5. 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. 6. The unit nurse will place documentation of the circumstances of the fall in the nurses 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 assignment worksheet. 7. 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 interview and record review the facility failed to administer medications for one of three residents (R2) reviewed for significant medication error in the sample of 4. This failure resulted in R2 having multiple [MEDICAL CONDITION] and being sent to the emergency room for [DEVICE] placement when no RN available to give meds per IV (intravenous) access. Finding includes: 1. R2's December 2020 Medication Administration Record [REDACTED]. R2's MAR indicated [REDACTED]. R2's MAR indicated [REDACTED]. R2's Medication Administration Record [REDACTED]. R2's MAR indicated [REDACTED]. R2's Nurse's Notes dated 12/27/20 at 7:00 AM document that R2 had 5 [MEDICAL CONDITION] since 5:00 AM. R2's notes document that every time you barely bump R2's bed or change R2, R2 has a [MEDICAL CONDITION]. Nurse's notes document call place to Director of Nursing (DON) about IV push medications needed to be administered by a Registered Nurse (RN). Notes document no answer and that R2's mother notified and requested R2 be transported to hospital. R2's Nursing notes do not document any [MEDICAL CONDITION] activity from 11/29/20- 12/25/20 when R2 was receiving her medication as ordered. R2's hospital triage notes dated 12/27/20 at 8:45 AM document that R2 was transported to the hospital by Emergency Medical Services (EMS). R2's notes document that EMS services stated the facility notified them that R2 needed to be transported to the hospital because they could not use IV access for medication as there is no RN available to administer the medications. R2's hospital labs dated 12/27/20 at 9:50 AM at the hospital emergency room document sub therapeutic blood levels of R2's prescribed [MEDICAL CONDITION] medications: [REDACTED]<3.0 (normal 50.0-100.0). On 1/11/21 at 9:14 AM, V10, physician, stated omission of [MEDICAL CONDITION] medication could cause R2 to have [MEDICAL CONDITION]. The Facility Policy undated policy Medication Administration documents to document any medication not administered for any reason by circling initial and documenting on the back of the MAR indicated [REDACTED]. The policy documents to notify the physician as soon as practical when a scheduled does of a medication has not been administered for any reason. .

Based on interview and record review the facility failed to assess, monitor and implement progressive interventions to prevent falls for two of three residents (R1, R3) reviewed for falls in the sample of 6. This failure resulted in R3 having multiple falls sustaining skin tears, a laceration requiring sutures and a fractured cheek bone. Findings include: 1. R3's Face Sheet documents he was admitted on [DATE] with [DIAGNOSES REDACTED]. R3's Care Plan, undated, documented Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. Risk factors include: Decreased cognitive awareness, [MEDICAL CONDITIONS], dementia, delusions/ hallucinations. As evidence by noted resident unsteady gait, balance deficits, and previous history of falls resulting in fracture. The Care Plan noted the following interventions, dated 6/6/19, to address this problem: Encourage and assist placement of proper non-skin footwear; observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended; Attempt to anticipate needs-toileting, hydration, hunger and provide cares before resident attempts to fulfill on own; bring to nurse's station when out of bed for observation; Keep environment well-lit and clutter free; Remind of safety precautions and limitations as necessary; Low bed with mat on floor; Personal alarm on while in bed; Check position with cares and function each shift; Personal alarm while up in chair. Check position with cares and function each shift. R3's Minimum Data Set, dated dated [DATE], documents R3 required extensive assistance (resident involved in activity, staff provide weight-bearing support) of two plus person physical assistance for bed mobility and transfers. The MDS documents he had moderate impaired cognition. R3's Fall Risk assessment dated [DATE] documents R3 as high risk for falls. R3's Nurse's Notes dated 12/11/2019 at 10:30 PM documents R3 was found on floor lying on his right side in his bedroom. R3's Nurse's Note document R3 sustained a skin tear to his right elbow measuring 2.0 centimeter (cm) by 1.5 cm with steri-strips applied. This Nurse's Note does not document a root cause analysis of R3's falls. There was no documentation in R3's medical record if R3's personal alarm was sounding at the time of this fall or if fall interventions in the care plan were in place. There was no documentation R3's Care Plan was revised after R3's fall on 12/11/19 with progressive interventions to prevent R3 from future falls and injury. R3's Nurse's Notes dated 1/1/2020 at 1:50 PM documents R3 was noted in doorway on floor. R3's Nurse's Note documented he sustained a 2.5 cm laceration to his right brow and a bruise to his right cheek. R3's medical record has no documentation the facility identified a root cause analysis of R3's falls or if fall interventions on the care plan were in place at the time of the fall. R3's Care Plan was not revised until 1/9/20. Intervention dated 1/9/20, documented R3 was to have occupational therapy for therapeutic exercises, therapeutic activities, self-care, neuro re-education and group therapy. R3's Minimum Data Set ((MDS) dated [DATE] documents R3 has severe cognitive impairment and was frequently incontinent of bowel and bladder. R3's MDS documents R3 needs extensive assistance to transfer and total dependence with ambulation. R3's Nurse's Notes, dated 2/9/20, documents R3 attempted to stand up from wheelchair by nurse's desk. The Nurse's Note documented R3 stood up, lost balance and fell to floor to left side. The Note documented R3 sustained a skin tear by 2 inches at left elbow. This Nurse's Note does not document a root cause analysis of R3's falls. There was no documentation in R3's medical record determining if interventions on the care plan were implement and/or effective at the time of the fall. There was no documentation R3's Care Plan was revised after R3 fell on [DATE] with progressive interventions to prevent him from future falls and injuries. R3's Nurse's Notes dated 2/14/2020 at 4:00 AM documents R3 was observed in the bedroom on floor. The Nurse's Note documented R3 sustained a 1 cm cut above right eyebrow and the area was cleansed and three strips were applied to his right cheek. This Nurse's Note does not document a root cause analysis of R3's falls. There was no documentation in R3's medical record to determine if the care plan interventions were implemented and/or effective at the time of the fall. On 3/6/2020 at 1:20 PM V2, Director of Nurse's stated R3 has had several falls and is the only resident with a personal alarm. V2 stated when R3 fell on [DATE] at 4:00 AM, R3's personal alarm was not working. V2 stated there was no documented schedule to check function of personal alarms. R3's Nurse's Notes dated 2/14/2020 at 8:00 PM documents R3 fell out of bed and sustained a laceration to his upper right eye. The Note documented R3 was sent to the emergency room . There was no documentation in R3's medical record documenting a root cause analysis of R3's fall. There was no documentation in R3's medical record determining if the care plan interventions were implemented and/or effective at the time of this fall. R3's Nurses Notes documents on 2/14/2020 at 9:00 PM R3 went to the ER (emergency room ). The Nurse's Note documented a CAT (computerized axial tomography) Scan was completed and R3 required sutures to his laceration R3's emergency room report dated 2/14/2020 document R3 required 6 stiches to his right eye area. There was no documentation R3's Care Plan was revised after R3 fell on [DATE] at 4:00 AM and again at 8:00 PM. The Care Plan did not document progressive interventions to prevent him from future falls and potential injury. R3's Nurse's Notes dated 2/15/2020 at 11:30 AM documents R3 was in dining room and stood up from chair and fell to the right. The Nurse's Note documented R3 sustained a 2.5 cm skin tear to right hand and 0.5 cm skin tear to right upper extremity. There was no documentation in R3's medical record the facility conducted a root cause analysis of this fall. There was no documentation the care plan interventions were in place/effective at the time of this fall. R3's Care Plan documents 2/15/2020 intervention as Tylenol 500 milligrams tablets every 4 to 6 hours as needed, apply ice to right eye laceration and remove sutures in 7 days. There was no intervention to address R3's need for increased supervision to prevent R3 from future falls and/or injuries. R3's Nurse's Noted dated 3/1/2020 at 1:30 PM that R3 was observed on floor. The Nurse's Note documented R3 sustained a left eyebrow laceration. The Nurse's Note documented R3 was transferred to ER. R3's ER report, dated 3/1/20, documents a CAT scan was completed and R3 had a left zygomatic (cheek bone) fracture. On 3/10/2020 at 2:40 PM V5 Certified Nurse Assistant (CNA) stated monitoring means they give verbal cues to R3 to sit down when R3 attempts to get up. On 3/10/2020 at 2:50 PM V6, CNA stated monitoring means R3 was to reposition every 2 hours and check for incontinence. On 3/6/2020, the surveyor requested information regarding the investigation of R3's falls on 12/11/19, 1/1, 2/9, 2/14 and 3/1/2020. On 3/6/20, at 1:15 PM V2 Acting Director of Nursing (DON) stated the facility would not give a copy of the residents Fall Report or Investigation to the surveyor due to the forms were part of their Quality Assurance Program (QA) and not to be given to surveyors. On 3/10/2020 at 10:20 AM V2 stated the Facility's corporation stated the QA forms such as Incident/Accident Reports or Fall Log we don't give to surveyors due to it is part of QA. 2. R1's Physician order [REDACTED]. R1's Fall assessment dated [DATE] documents R1 at high risk. R1's MDS, dated [DATE], documented he required no assistance with transfers. The MDS documented he was not steady but was able to stabilize without staff assistance for moving from seated to standing position, walking, turning around and acing the opposite direction while walking and surface to surface transfers. Nurse's Notes dated 12/22/2019 at 4:10 AM documents nurse called to R1's room. The Nurse's Note documented R1 was laying on floor in room and had an approximate a 1.5 cm by 1.0 cm laceration to forehead and complained of pain in left thigh. The Nurse's Note documented he was sent to the ER and was admitted with a left fractured femur (thigh bone). R1 was sent to the emergency room . There was no documentation in R1's medical record the facility conducted a root cause analysis of R1's fall. There was no documentation in R1's medical record that R1's care plan interventions were in place and/or effective at the time of R1's fall on 12/22/19. R1's Care Plan, undated, documented R1 was at high risk for falls, had fallen in his room, will not allow staff to assist him, has unsteady gait with impaired ambulation skills. The Care plan documented he will sit himself on the floor also. The Care plan Interventions, all initiated on 12/26/19, documents the following: encourage and assist placement of proper non-skin footwear; remind to lock wheel chair brakes; observed for non-verbal signs of restlessness; observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed; IDT review of ADL status and fall potential with changes in condition fall status. Report significant findings to MD for follow up; Provide activity supplies to keep busy, Resident enjoys smoking, in room activities of making signs and notes and decorating his room, music and TV; Keep room and Pathways clear and free of clutter; Keep call light within reach and educate to use and request any assist; remind of safety precaution and limitations as necessary; and bed against wall and bolster mattress to bed. R1's Nurse's Note documented he was readmitted to the facility on [DATE]. The Note documented he returned with 42 staples to his left leg incision. R1's Nurse's Note, dated 12/27/19 at 6:30 PM documented that R1 fell while trying to go from his bed to his wheelchair. There was no documentation in R1's medical record that R1's care plan interventions were in place and or/effective at the time of R1's falls. There was no documentation that the facility revised R1's Care Plan with progressive interventions to address R1's fall on 12/27/19 or prevent him from future falls. R1's Nurse's Notes dated 12/29/2019 at 2:15 PM, documented R1 attempted to stand to reach his toothbrush and slid to the floor on his buttocks in from of his chair. There was no documentation that the facility revised R1's Care Plan with progressive interventions to address R1's fall on 12/29/19 or to prevent him from future falls. R1's MDS dated [DATE] documents cognition intact and transfers with extensive assistance. R1's Nurse's Notes dated 1/5/2020 documents R1 attempted to stand, lost his balance and fell . siting on buttocks. There was no documentation that the facility revised R1's Care Plan with progressive interventions to address R1's fall on 1/5/20 or to prevent him from future falls. R1's Nurse's Notes, dated 2/18/20 at 9:30 AM, documented R1 attempted to get up on his own and fell to the floor. There was no documentation in R1's medical record the facility attempted to determine the root cause analysis of this fall to prevent R1 from future falls. The Care Plan was revised on 2/18/19, documented that staff should encourage R1 to be up for breakfast at 7:30 AM when staff assisting to get resident up and due to swallowing issues to be in dining hall for more supervision. On 3/10/2020 at 12:25 PM V4 Licensed Practical Nurse (LPN) stated prior R1 was independent with ambulation in room with holding on to something in room to walk until he fractured his hip. R1 now can't stand and refuses physical therapy. On 3/10/2020 at 2:40 PM V5 CNA stated they started toileting R1 every hour today (3/10/20) and that is how they will monitor him. The Fall Prevention Policy, revision date of 11/10/2018, documents To provide resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desire for maximum independence and mobility. The Policy documents Procedures: #2. Documents All staff must observe resident for safety. If resident with a high-risk code are observed up or getting up, help must be summoned, or assistance must be provided to the resident.

Based on observation, interview and record review the facility failed to monitor, treat and prevent pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 18. This failure resulted in a development of an unstageable pressure ulcer to R1's left heel. Findings include: R1's MDS (Minimum Data Set), dated 6/19/19, documents total dependence and two plus person assistance for bed mobility. R1's Care Plan, dated 6/26/19, documents R1 is at high risk for pressure ulcers. Interventions include Skin Check Daily with ADL's (Activities of Daily Living), Weekly Skin Checks per Nursing Staff, Provide Treatments per order to skin tears/pressure ulcer, and Assist resident to turn and reposition q (every) 2 hours and prn (as needed). On 7/15/19, R1 was lying in bed on her back from 8:05 AM until 11:30 AM without any intervention for repositioning, based on 15 minutes or less observation intervals. On 7/15/19 at 9:55 AM, R1 was lying on her back with her feet elevated off of the mattress resting on a pillow. V3, Certified Nurse Assistant (CNA), removed R1's sock from her left foot. R1 had a black ulcer approximately 2.5 x 1 centimeter, an Unstageable pressure ulcer-to R1's left heel. No dressing noted. V3 stated she was unaware of V1's pressure sore to the heel. On 7/16/19 at 9:50 AM, R1 was lying on her left side with her feet elevated off the mattress resting on a pillow. V6, Registered Nurse (RN), removed R1's sock from her left foot. V6 stated there was an unstageable pressure ulcer to R1's left heel. V6 stated she was unaware of the pressure ulcer to R1's left heel. V6 reviewed R1's nurse note's dated 6/25/19 with this writer which documents an unstageable area to R1's left heel measuring 1 cm (centimeter) x 1.5 cm. V6 stated that R1's physician (V15) was notified on 6/25/19 and there was an order received for skin prep to left heel until healed, but the order was not transcribed onto the MAR (Medication Administration Record). V6 stated that R1 has not received any treatment to R1's left heel ulcer since the order was received by V15 on 6/25/19. R1's Nurse Note, dated 6/25/19 at 10:40 AM, documents Resident was in therapy and was noted to have a dk (dark) area to L (left) heel unstageable 1 cm x 1.5 cm x? (V15) called with orders received. This note was authored by V17, RN. R1's Physician Order's, dated 6/25/19, documents, Skin Prep to L heel Q (every) shift T/H (till healed). R1's Treatment Record, dated 6/1/19 thru 6/30/19, does not document the physician order [REDACTED]. R1's Treatment Record, dated 7/1/19 thru 7/13/19, documents Skin Prep to Left heel until healed transcribed onto the MAR by V6 on 7/15/19. R1's Shower/Abnormal Skin Report's, dated 5/29/19, 6/5/19, and 6/12/19 document, skin clear no abnormalities found; reports dated 6/19/19 and 7/3/19 document no new findings; report dated 7/13/19 documents a light bruise to left lateral upper arm and bruise to right lateral upper arm. None of the reports document the pressure ulcer to the left heel. On 7/17/19 at 12:15 PM, V15, R1's Physician, stated you would think that the staff would have noticed R1's pressure ulcer to the left foot before it became unstageable. On 7/18/19 at 9:45 AM, V1, Administrator, stated, Absolutely, turning the residents every 2 hours has been a problem, but I don't know why. On 7/18/19 at 10:30 AM, V2 stated that R1's pressure ulcer to her left foot should have been found before it was unstageable. V2 stated that R1 is given a shower 2 times per week and would expect the staff to notice a change in skin condition during bathing and during turning and positioning every 2 hours. The Facility's Pressure Sore Prevention Guidelines Policy and Procedure, revised 4/2006, documents, Procedure: The following guidelines will be implemented for any resident assessed a Moderate or High skin risk. It follows with an Intervention table which includes for High Risk: Turn and reposition every two hours and Daily Skin Checks. The Facility's Newly Acquired Skin Conditions Policy and Procedure, undated, documents, 4. Physician notified with appropriated treatment obtained and initiated within a timely manner. The NPUAP (National Pressure Ulcer Advisory Panel) at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf documents the definition, 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 eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.

Based on record review and interview the facility failed to follow a physician's order for 1 out of 3 residents (R38) reviewed for medications in the sample of 25 causing R38 to become anxious and lose sleep due to worrying about her medications. Reasonable person concept would expect in a similar situation to suffer as a result of the noncompliance. Findings include: 1. R38 was admitted to facility on 12/2/2015. admitting [DIAGNOSES REDACTED]. On 9/19/18 at 10:00 during the resident council meeting R38 stated that a couple of weeks ago I didn't get my medications because they ran out. I didn't get it for 3 days and I really need it. It took them 3 days to get my medications. My daughter called the Administrator and the Administrator didn't know that I was out of medication for 2-3 days, I am still recovering. Twice I didn't get my medication at bedtime. I told the nurse and she acted like she didn't believe me. Then they said we will look and see if it's marked off. She could mark it off and not actually give it. I am still recovering from not having my medication. I have been on that medication for a long time and I really need it. It is very unpleasant not to have my medication. R38's Medication Administration Record [REDACTED]. On 9/10/18 at 12:00 pm and 8:00pm, on 9/11/2018 at 08:00 am, 12:00pm and 8:00pm, on 9/12/18 at 08:00am, 12:00pm and 8:00 pm. On 9/20/2018 at 1:30 PM V10 Registered Nurse (RN) stated that she doesn't know what happened because she was on vacation but confirmed that resident missed her medication for approximately 3 days 3 x daily. V10 also stated on these dates and times a circle around the initials indicate that there was no medication given. On 9/21/2018 at 10:30 AM R38 stated that she went without her medication for 3 days and she became very anxious and began to worry and asking staff where her medications were at. R38 also then stated that she couldn't sleep because she was getting worried maybe she wouldn't receive it any more. R38 stated that staff would blame pharmacy. R38 said she is still recovering but each day that she receives her medication she gets a little better. Physician's Orders Medications and Treatments dated 9/1/2018-9/30/2018 documents in part; [MEDICATION NAME] 0.5mg by mouth 3 times daily. Facility's policy and procedure Medication Administration dated 7/3/2013 documents in part; Document any medications not administered for any reason by circling initials and documenting on back of the MAR indicated [REDACTED]. If medication is not available for a resident, call the pharmacy and notify the and notify the physician when the drug is expected to be available. Notify the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason.

Based on observation, interview and record review, the Facility fails to implement measures to ensure that 1 of 2 residents (R4) reviewed for tube feeding (restore eating skills) in the sample of 25, obtains their highest practicable level of physical well-being causing resident to be nothing by mouth (NPO) for approximately 2 years. Reasonable person concept would expect in a similar situation to suffer as a result of the noncompliance. Findings include: R4 was admitted to facility on 9/15/2016. Nursing Admission assessment dated [DATE] documents; admitting [DIAGNOSES REDACTED]. Fluid restriction NPO (nothing by mouth). The [DIAGNOSES REDACTED]. On 9/18/18 at 12:15 PM R4 was observed sitting outside the dining room watching the other resident's eating lunch. stated that he was hungry and that he was hoping that he gets fed soon. R4's Minimum Data Set (MDS) of 6/8/18 documents R4 cognitively intact with a Brief Interview of Mental status of 14 with 15 being the highest. Facility failed again to recognize that R4 was hungry and wanted to eat and drink. A reasonable person concept, one would consider going 2 years with NPO would be harmful and suffering to one's mental and psychosocial well-being. R4's Care Plan dated 5/11/2017 documents in part; Restorative Nursing Program- Eating Problem/Need Non-compliant with NPO status. High risk for aspiration, has signed a waiver aware of risk. Takes foods and fluids when staff not looking regardless of signing a waiver in regards to noncompliance with NPO status. The Care Plan has several added dates, last being 10-19-2018. This would be considered a revision date to care plan that facility's write on care plans so that they know when it needs looked at again, if not comfortable with that revision date this just remove it from deficiency. With R4 having a history [DIAGNOSES REDACTED]. The facility has failed to implement measures in the progress for this resident to progress him back into the community. Approach/intervention; Staff will provide ongoing education of harm to self and risk for PO food or fluid intake. Do not leave fluids and foods to where R4 has assessed to them. Do not leave cans of feeding in room. Start date 5/11/2017. Report any S/SX- (signs and symptoms of) coughing, discomfort during swallowing. Care plan has several added dates the last being 10-19-2018. R4's Nurses note dated 6/10/2018, 6/13/18, 6/17/18, 6/18/18, 6/19/18, 6/20/18, 6/22/18, 6/23/18, 6/27/18, 6/28/18, 7/2/18, 7/3/18, 7/11/18, 7/13/18, 7/15/18, 7/17/18, 7/19/18, 7/20/18, 7/23/18, 7/28/18, 7/29/18, 7/30/18, 8/1/18, 8/2/18, 8/3/18, 8/4/18, 8/5/18, 8/8/18, 8/9/18, 8/15/18, 8/17/18, 8/20/18, 8/22/18, 8/24/18, 8/25/18, 8/26/18, 8/27/18, 9/8/18, 9/9/18, 9/11/18, 9/12/18, 9/15/18 and 9/17/18 documents in part; non-compliant with NPO (nothing by mouth) status/orders. R4's Nurses note dated 6/15/18 documents in part; New Order discontinued skilled Speech Therapy due to decreased patient participation. Nurses note dated 6/16/18 documents in part cont. to drink lemonade. Staff has been educated on aspiration risk. States doesn't care. R4's nurse's note dated 8/23/18 documents in part; (R4) has been drinking lemonade this am. Resident has been educated on aspiration risk. On 9/18/18 at 12:15 PM R4 was observed sitting outside the dining room watching the other resident's eating lunch. R4 stated that he was hungry and that he was hoping that he gets fed soon. On 9/20/2018 at 09:15 AM V7 Licensed Practical Nurse MDS/Care Plan Coordinator stated, He's been NPO since I have been here a little over 3 months. R4 drinks mountain dew and everything, he does fine when he drinks. I only ordered that one test 2 weeks ago and it came back promising. Speech Therapy Plan of Care dated 6/15/2018 (end of care) documents in part; Patient has [DIAGNOSES REDACTED]which places him at high risk of aspiration. SLP recommends a FEES (Fiber Optic endoscopic evaluation of swallowing) vs MBSS (Modified [MEDICATION NAME] swallow study) to assess swallow function and determine safety with various consistencies. On 9/21/18 V7 at 1:00 PM stated that a FEES test was not conducted because the facility had no contract with agency. On 9/21/2018 at 1:00 PM V7 stated, It took a care plan meeting with (R4's) family and the family requested to have the test done. I then called the doctor and asked for the test ([MEDICATION NAME] swallow). R4's Radiology Report dated 9/13/2018 documents in part; Modified [MEDICATION NAME] Swallow resulting in: Impression 1. Mild to moderate pooling of thin and thickened [MEDICATION NAME] preparations with subtle trace penetration of thin and thickened [MEDICATION NAME] from pooling. 2. There was minimal aspiration of [MEDICATION NAME] with uncontrolled bolus from a cup seen once. 3. Overall swallowing improves with chin tuck maneuver. Doctor visit dated 9/14/2018 documents in part Reason for visit; Visit for f/u (follow-up) recent swallow study noted. If will be able to get off TF (tube feeding). Pleasant and cooperative, voices no concerns. On 9/24/2018 at 1:20 PM V13 Medical Doctor (MD) advised that the facility did order a [MEDICATION NAME] swallow recently, and that the last time that he saw resident he recommended that the resident be seen by speech therapy. V13 stated that he was aware of resident being noncompliance with NPO order. V13 stated that resident was doing well and that he never have known resident to have developed aspiration pneumonia.

Based on observation, record review and interview, the facility failed to identify, assess, evaluate, monitor and treat pressure sores for 3 of 7 residents (R27, R43, R150) reviewed for pressure ulcers in the sample of 25 causing R150 and R43 pressure ulcers to worsen. Findings include: 1. R150 was admitted to facility on 9/4/2018. No admission assessment was located. Baseline Care plan dated 9/4/2018 documents; Identified Skin Risks: Skin Plan of Care documents the following; High Risk Braden Assess,W/C (wheelchair cushion), Wkly (Weekly) Skin chk (check), Current wound and Assisted Toileting. Cognition; Alert to: Time, Self, Others, Place and Make decisions. Ambulation assist of 1, Transfer assist of 2 plus On 9/19/2018 at 10:35 AM V7 Licensed Practical Nurse (LPN) looked through R150's chart and was unable to locate a Nursing Admission Assessment. On 9/21/2018 at 09:30 AM V7 LPN provided a Nursing Admission assessment dated [DATE] for R150 that documents wound measurements to Left heel 2.9 cm length x 2.1 cm width and Right heel 5.1 cm length x 3.9 cm width. R150's Nurse's note dated 9/4/2018 documents in part, Resident arrived per ambulance escorted by EMS. Alert and Oriented x 4. BLE (bilateral lower extremities) red with plus 2 [MEDICAL CONDITION] et blistered type areas. Areas to Left et Right heels covered at this time. Heels floated in bed. R150's Nurse's note dated 9/5/2018 documents in part; No [MEDICAL CONDITION] noted. Areas to bilateral heels covered. R150's Treatment Administration Record for month of (MONTH) documents order to cleanse areas to R & L heel with wound cleanser. Apply [MEDICATION NAME] and Santyl cover with Hydrocel dressing and wrap daily and as needed. There are no initials for (MONTH) 4, 5, and 6th indicating that treatment was conducted. R150's Nurse's note dated 9/9/18 documents in part; Tx's (treatment) as ordered. Noted odor. Will have culture done. Nurse's note dated 9/11/2018 documents in part; Tx's to both heels as ordered. Facility provided R150's initial measurements of wound evaluation & management summary from previous nursing home dated 9/4/2018 documents in part; Left heel unstageable (d/t necrosis) wound measurements 3cm length x 2cm width x depth not measurable. Right heel unstageable (d/t necrosis) wound measurements 5cm length x 4cm width x depth not measureable. R150's wound evaluation & management summary dated 9/17/2018 documents in part; Left heel unstageable (d/t necrosis) wound size 4cm length x 2cm width x depth not measurable. Right heel unstageable (d/t necrosis) wound size 10 cm length x 5 cm width x 0.2 cm depth. Wound progress: Deteriorated. On 9/18/2018 at 12:55 PM R150 stated, I haven't been here long, I have blood clots in both legs, wound on left heel and cellulite. On 9/19/2018 at 08:45 AM R150 was observed lying in bed, R 150 stated that, They didn't change my dressings yesterday, I think they got too busy. The last time that they straight catch me was around 7:30 PM last night. I'm not having any pain but I know when I have water though. During observation of R150's wound care on 9/19/2018 at 08:52 AM V11 Licensed Practical Nurse (LPN) removed ace wrap from R150's right foot and removed undated, no initials ensanguine gauze, then cleansed wound with normal saline and applied saintly to wound bed and then applied calcium alginate dressing over entire wound lapping over the margins onto the healthy skin. V11 stated that it was okay for the calcium alginate to be touching healthy skin. V11 then wrapped heel and foot in gauze. R150's pressure ulcer to right heel area was untraceable with slough and necrosis observed. V11 after completing the dressing V11 did not timely change her gloves and/or wash her hands during R150's right heel dressing change. V11 then removed the ace wrap from R150's left foot and removed saturated bloody gauze that had no initials or date. Bloody drainage was observed on bed sheet below wound. V11 stated I don't see any date or initials but it was marked on the Treatment Administration Record (TAR) that dressing was changed on the 8th. After V11 removed gauze from left heel a foul odor was noted. V11 stated, 'Yes, I do smell a odor.' V11 treated wound and then covered entire wound and surrounding margins with calcium alginate dressing and then wrapped entire heel and partial foot with gauze. R150's left heel had a foul odor untraceable pressure ulcer with slough and necrosis observed. V 11 stated that R150 was not currently taking any antibiotics. Manufacture Guidelines for Calcium Alginate Dressings documents in part; 1. Cut (using sterile scissors) or fold the dressing to fit the wound. 2. Apply to wound bed directly. Loosely fill deep wounds, ensuring the dressing does not overlap the wound margins. On 9/20/2018 at 2:45 PM V12 Wound doctor stated, I've been doing this for 8 years and it makes no difference if the calcium alginate dressing is covering the wound margins. On 9/19/2018 at 09:45 AM V7 LPN MDS/Care plan Coordinator stated, 'That when we received report (R150) only had two small areas on heels. We did treatments in house until wound doctor could see him on 9/17/2018. 'No nursing admission assessment for R150.' 'There were no measurements of wounds on TAR's.' 2. R43 was admitted to facility on 7/18/2018. R43's Nursing Admission assessment dated [DATE] documents in part; Left heel open 2cm x 1.5cm white dry scaly area scabby. R43's Braden scale dated 7/19/2018 scored an 18, moderate risk for pressure ulcers. R43's treatment administration record for (MONTH) (YEAR) has no initials for (MONTH) 1, 7, 10, 13, 14, and 15th for the skin check daily on evening shift with 'CROP' coding skin condition C-clear, R-red, O-open pressures S-skin tear. There are no initials for (MONTH) 10 and 13th for Left heel- cleanse affected area with NS, apply santyl to wound bed nickel thick cover with wet gauze, wrap foot with gauze daily and prn. R43's TAR dated 8/1/2018 - 8/31/2018 for treatment of [REDACTED]. On 8/14/2018- 8/17/2018 initials document O (open). On 8/18/2018-8/19/2018 again there are no initials on treatment record. On 9/21/2018 at 09:50 AM V7 LPN, stated I don't know what happened those days where there's no initials. R43's Nursing Care Observation Reports dated 9/3/2018-9/17/2018 documents under Functional status, Skin documents no wound descriptions or measurements for R43's left heel. R43's initial wound evaluation & management summary dated 9/17/2018 documents in part; Stage 3 pressure wound of the left heel wound size 5cm length x 4cm width and 0.2 cm Facility's policy and procedure dated 1/18 documents in part the following guidelines will be implemented, daily skin checks and will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse. 3. On 9/20/2018 at 1:20 PM V10, Registered Nurse (RN) completed wound care by washing her hands and donning gloves. On R27's upper right back under the lower part of the shoulder blade V10 removed bandage saturated with green serous drainage. V10 then applied wound cleanser and gently dabbed with sterile gauze, then applied santyl cream with cotton tipped applicator to area with green serous drainage and black eschar. V10 measured the unstageable open area at 4 centimeters (cm) by 3 cm with a reddened , swollen area of 3 cm beyond black escar. R10 then folded calcium alginate and place over the wound with gauze taped on outside dated and initialed tape. On 9/20/2018 1:20 PM V10 stated We just identified this area on 9/13/2018. It doesn't seem to be getting any better. On 9/20/2018 at 2:50 PM V7, Minimum Data Set (MDS)/Care Plan/ Infection Control Coordinator stated I called the( local lab company) and they said they never did receive the culture on the wound for (R27). On 9/25/2018 at 9:30 AM V7 stated I told you last week that the lab didn't get the culture for (R27's) wound. We have not repeated the culture for (R27's) wound. On 9/25/2018 V3, RN stated I identified on (R27's) upper right back the 3 cm open area draining green drainage with 3cm reddening around it on 9/13/18. I would have thought it would have at least been reddened prior to opening. I know she is hard to roll so maybe that is why it was not identified it earlier. We are supposed to do a skin check daily. (R27) is really hard to turn in bed. I was off for the three days before 9/13/18 so I can't say if her skin was actually checked. We are supposed to do daily skin checks. R27 has no Nurses Notes regarding skin assessment until 9/13/2018. R27's Physician order [REDACTED]. R27's Nurses Note dated 9/13/2018 at 10:30 AM documents Noted 3 cm open area on back with 3 cm surrounding are inflammed. Draining green. Appears to be a boil. Cultured. Send to lab in AM (morning). Notified MD (medical doctor) and guardian. R27's Nurses Note dated 9/17/2018 at 1:00 PM Resident continues on ABT (antibiotic) therapy as ordered and no adverse reactions noted. T (temperature) 97.4 Dressing changed to back done with wet to dry. Area in center is dark with 1 cm redness surrounding. Drainage green foul smelling. Will observe.

Based on observations, interviews and record review the facility failed to follow recommendations of speech therapy for FEES (Fiberoptic endoscopic evaluation of swallowing) diagnostic test, reevaluate to restore eating skills, implement interventions for weight loss for 2 of 5 residents (R4, R15) reviewed for tube feedings and weight loss in sample of 25. Reasonable person concept would expect in a similar situation to suffer as a result of the noncompliance. Findings include: R4 was admitted to facility on 9/15/2016. Nursing Admission assessment dated [DATE] documents; admitting [DIAGNOSES REDACTED]. Fluid restriction NPO (nothing by mouth). R4's Minimum Data Set (MDS) of 6/8/18 documents R4 cognitively intact with a Brief Interview of Mental status of 14 with 15 being the highest. R4's Care Plan dated 5/11/2017 documents in part; Restorative Nursing Program- Eating Problem/Need Non-compliant with NPO status. High risk for aspiration. Has signed a waiver aware of risk. Takes foods and fluids when staff not looking regardless of signing a waiver in regards to noncompliance with NPO status. Approach/intervention; Staff to provide ongoing education of harm to self and risk for PO (by mouth) food or fluid intake. Do not leave fluids and foods to where R4 has assess to them. Do not leave cans of feeding in room. Start date 5/11/2017. Report any S/SX (signs and symptoms of) coughing, discomfort during swallowing. Care plan has several added dates the last being 10-19-2018. R4's Nurses note dated 6/10/2018, 6/13/18, 6/17/18, 6/18/18, 6/19/18, 6/20/18, 6/22/18, 6/23/18, 6/27/18, 6/28/18, 7/2/18, 7/3/18, 7/11/18, 7/13/18, 7/15/18, 7/17/18, 7/19/18, 7/20/18, 7/23/18, 7/28/18, 7/29/18, 7/30/18, 8/1/18, 8/2/18, 8/3/18, 8/4/18, 8/5/18, 8/8/18, 8/9/18, 8/15/18, 8/17/18, 8/20/18, 8/22/18, 8/24/18, 8/25/18, 8/26/18, 8/27/18, 9/8/18, 9/9/18, 9/11/18, 9/12/18, 9/15/18 and 9/17/18 documents in part; non-compliant with NPO (nothing by mouth) status/orders. R4's Nurses note dated 6/15/18 documents in part; New Order discontinued skilled Speech Therapy due to decreased patient participation. Nurses note dated 6/16/18 documents in part cont to drink lemonade. Has been educated on aspiration risk. States doesn't care. R4's nurse's note dated 8/23/18 documents in part; (R4) has been drinking lemonade this am. Resident has been educated on aspiration risk. On 9/18/18 at 12:15 PM R4 was observed sitting outside the dining room watching the other resident's eating lunch. R4 stated that he was hungry and that he was hoping that he gets fed soon. On 9/20/2018 at 09:15 AM V7 Licensed Practical Nurse MDS/Care Plan Coordinator stated, He's been NPO since I have been here a little over 3 months. R4 drinks mountain dew and everything, he does fine when he drinks. I only ordered that one test 2 weeks ago and it came back promising. Speech Therapy Plan of Care dated 6/15/2018 (end of care) documents in part; Patient has [DIAGNOSES REDACTED]which places him at high risk of aspiration. SLP recommends a FEES (Fiberoptic endoscopic evaluation of swallowing) vs MBSS (Modified Baruim swallow study) to assess swallow function and determine safety with various consistencies. On 9/21/18 at 1:00 PM V7 stated, That the FEES test was not conducted due to facility did not have contract with agency. On 9/21/2018 at 1:00 PM V7 stated, It took a care plan meeting with (R4's) family and the family requested to have the test done. I then called the doctor and asked for the test ([MEDICATION NAME] swallow). R4's Radiology Report dated 9/13/2018 documents in part; Modified [MEDICATION NAME] Swallow resulting in: Impression 1. Mild to moderate pooling of thin and thickened [MEDICATION NAME] preparations with subtle trace penetration of thin and thickened [MEDICATION NAME] from pooling. 2. There was minimal aspiration of [MEDICATION NAME] with uncontrolled bolus from a cup seen once. 3. Overall swallowing improves with chin tuck maneuver. Doctor visit dated 9/14/2018 documents in part Reason for visit; Visit for f/u (follow-up) recent swallow study noted. If will be able to get off TF (tube feeding). Pleasant and cooperative, voices no concerns. On 9/24/2018 at 1:20 PM V13 Medical Doctor (MD) advised that the facility did order a [MEDICATION NAME] swallow recently, and that the last time that he saw resident he recommended that the resident be seen by speech therapy. V13 stated that he was aware of resident being noncompliance with NPO order. V13 stated that resident was doing well and that he never have known resident to have developed aspiration pneumonia. 2. On 9/18/2018 at 12:15 PM R15 was fed by staff at lunch consumed 50 percent of meal. On 9/19/2018 12:13 PM R15 fed self at lunch today consumed 80 percent of meal. On 9/21/2018 at 10:20 AM V25, Regional Nurse stated We do monitor weight and have interventions but we will not provide to the (state agency) our weight log and information. R15's Dietary Notes dated 4/20/2018 documents in part Resident has experienced a significant weight loss of 6.48% in 1 month. (MONTH) weight is 101 pounds. Reweigh with 108.2 pounds (consistent with (MONTH) weight). Resident is on a mechanical soft diet, Magic cup Bid (twice daily). PO (by mouth) intake of meals variable at 25-100 percent, fluids 120-240 cubic centimeters (CC) per meal. R15's Dietary Note dated 5/24/2018 documents in part Resident readmitted to facility 5/12/18 dx (diagnosis) knee abcess. (MONTH) weight is 98 pounds which is 82 percent IBW (ideal body weight) is a significant weight loss of 10.91% in 3 months. Resident is on a mechanical soft diet with po intake mostly R (refusal) - 50%. Recommend 2 cal supplement 90 ml (milliliters) bid (two times a day) and mvi (multivitamin). R15's Dietary Note dated 6/28/18 documents in part Resident readmitted to facility 6/19/18 dx right knee [MEDICAL CONDITION]. Hospice admitted [DATE]. (MONTH) weight is 96 pounds which is 80% IBW with significant loss of 11.11% in 3 months. Will request 2.0 cal supplement 120 ml tid (three times a day). R15's Dietary Note dated 8/29/2018 documents in part Resident has experienced a significant weight loss of 14.29% in 3 months, 23.64% in 6 months. (MONTH) weight is 84% which is 70% IBW. Resident is on a pureed diet, magic cup bid. Refuses 2 cal cupplement. Consuming magic cup continue it will also request supercereal. The facility's Resident Weight Monitoring Policy dated 10/14 documents in part 11. Significant weight changes are reviewed in the weekly Weight Committee Meeting. The Weight Committee will also identify any trends of gradual weight loss or gain. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed. 12. Resdients who have been determined by the Weight Committee to be at increased risk for weight loss will be put on weekly weights for at least 4 weeks. 14. When weekly weights are obtained, they must be reviewed weekly and action must be taken for any significant change.

Based on observation, interview and record review, the Facility fails to implement measures to ensure that 1 of 2 residents (R4) reviewed for tube feeding (restore eating skills) in the sample of 25, obtains their highest practicable level of physical well-being causing resident to be nothing by mouth (NPO) for approximately 2 years. Reasonable person concept would expect in a similar situation to suffer as a result of the noncompliance. Findings include: 1. R4 was admitted to facility on 9/15/2016. Nursing Admission assessment dated [DATE] documents; admitting [DIAGNOSES REDACTED]. R4's Minimum Data Set (MDS) of 6/8/18 documents R4 cognitively intact with a Brief Interview of Mental status of 14 with 15 being the highest. R4's Care Plan dated 5/11/2017 documents in part; Restorative Nursing Program- Eating Problem/Need Non-compliant with NPO status. High risk for aspiration, has signed a waiver aware of risk. Takes foods and fluids when staff not looking regardless of signing a waiver in regards to noncompliance with NPO status. Approach/intervention; Staff will provide ongoing education of harm to self and risk for PO food or fluid intake. Do not leave fluids and foods to where R4 has assessed to them. Do not leave cans of feeding in room. Start date 5/11/2017. Report any S/SX (signs and symptoms of) coughing, discomfort during swallowing. Care plan has several added dates the last being 10-19-2018. R4's Nurses note dated 6/10/2018, 6/13/18, 6/17/18, 6/18/18, 6/19/18, 6/20/18, 6/22/18, 6/23/18, 6/27/18, 6/28/18, 7/2/18, 7/3/18, 7/11/18, 7/13/18, 7/15/18, 7/17/18, 7/19/18, 7/20/18, 7/23/18, 7/28/18, 7/29/18, 7/30/18, 8/1/18, 8/2/18, 8/3/18, 8/4/18, 8/5/18, 8/8/18, 8/9/18, 8/15/18, 8/17/18, 8/20/18, 8/22/18, 8/24/18, 8/25/18, 8/26/18, 8/27/18, 9/8/18, 9/9/18, 9/11/18, 9/12/18, 9/15/18 and 9/17/18 documents in part; non-compliant with NPO (nothing by mouth) status/orders. R4's Nurses note dated 6/15/18 documents in part; New Order discontinued skilled Speech Therapy due to decreased patient participation. Nurses note dated 6/16/18 documents in part cont. to drink lemonade. Staff has been educated on aspiration risk. States doesn't care. R4's nurse's note dated 8/23/18 documents in part; (R4) has been drinking lemonade this am. Resident has been educated on aspiration risk. On 9/18/18 at 12:15 PM R4 was observed sitting outside the dining room watching the other resident's eating lunch. R4 stated that he was hungry and that he was hoping that he gets fed soon. On 9/20/2018 at 09:15 AM V7 Licensed Practical Nurse MDS/Care Plan Coordinator stated, He's been NPO since I have been here a little over 3 months. R4 drinks mountain dew and everything, he does fine when he drinks. I only ordered that one test 2 weeks ago and it came back promising. Speech Therapy Plan of Care dated 6/15/2018 (end of care) documents in part; Patient has [DIAGNOSES REDACTED]which places him at high risk of aspiration. SLP recommends a FEES (Fiber Optic endoscopic evaluation of swallowing) vs MBSS (Modified [MEDICATION NAME] swallow study) to assess swallow function and determine safety with various consistencies. On 9/21/18 V7 at 1:00 PM stated that a FEES test was not conducted because the facility had no contract with agency. On 9/21/2018 at 1:00 PM V7 stated, It took a care plan meeting with (R4's) family and the family requested to have the test done. I then called the doctor and asked for the test ([MEDICATION NAME] swallow). R4's Radiology Report dated 9/13/2018 documents in part; Modified [MEDICATION NAME] Swallow resulting in: Impression 1. Mild to moderate pooling of thin and thickened [MEDICATION NAME] preparations with subtle trace penetration of thin and thickened [MEDICATION NAME] from pooling. 2. There was minimal aspiration of [MEDICATION NAME] with uncontrolled bolus from a cup seen once. 3. Overall swallowing improves with chin tuck maneuver. Doctor visit dated 9/14/2018 documents in part Reason for visit; Visit for f/u (follow-up) recent swallow study noted. If will be able to get off TF (tube feeding). Pleasant and cooperative, voices no concerns. On 9/24/2018 at 1:20 PM V13 Medical Doctor (MD) advised that the facility did order a [MEDICATION NAME] swallow recently, and that the last time that he saw resident he recommended that the resident be seen by speech therapy. V13 stated that he was aware of resident being noncompliance with NPO order. V13 stated that resident was doing well and that he never have known resident to have developed aspiration pneumonia.

Based on record review and interview the facility failed to follow a physician's order and administer a [MEDICAL CONDITION] medication for 1 out of 3 residents (R38) reviewed for medications in the sample of 25 causing R38 to become anxious and lose sleep due to worrying about her medications. Reasonable person concept would expect in a similar situation to suffer as a result of the noncompliance. Findings include: R38 was admitted to facility on 12/2/2015. admitting [DIAGNOSES REDACTED]. On 9/19/18 at 10:00 during the resident council meeting R38 stated that a couple of weeks ago I didn't get my medications because they ran out. I didn't get it for 3 days and I really need it. It took them 3 days to get my medications. My daughter called the Administrator and the Administrator didn't know that I was out of medication for 2-3 days, I am still recovering. Twice I didn't get my medication at bedtime. I told the nurse and she acted like she didn't believe me. Then they said we will look and see if it's marked off. She could mark it off and not actually give it. I am still recovering from not having my medication. I have been on that medication for a long time and I really need it. It is very unpleasant not to have my medication. R38's Medication Administration Record [REDACTED]. On 9/10/18 at 12:00 pm and 8:00pm, 9/11/2018 at 08:00am, 12:00pm and 8:00pm, 9/12/18 at 08:00am, 12:00pm and 8:00 pm. V10 Registered Nurse (RN) stated on these dates and times a circle around the initials indicate that there was no medication given. V10 also stated that she doesn't know what happened because she was on vacation when this occurred. On 9/21/2018 at 10:30 AM R38 stated that she went without her medication for 3 days and she became very anxious and began to worry and asking staff where her medications were at. R38 also then stated that she couldn't sleep because she was getting worried maybe she wouldn't receive it any more. R38 stated that staff would blame pharmacy. R38 said she is still recovering but each day that she receives her medication she gets a little better. Physician's Orders Medications and Treatments dated 9/1/2018-9/30/2018 documents in part; [MEDICATION NAME] 0.5mg by mouth 3 times daily. Facility's policy and procedure Medication Administration dated 7/3/2013 documents in part; Document any medications not administered for any reason by circling initials and documenting on back of the MAR indicated [REDACTED]. If medication is not available for a resident, call the pharmacy and notify the physician when drug is expected to be available. Notify the physician as soon as practical when a schedule dose of a medication has not been administered for any reason.

A. Based on interview and record review the facility failed to ensure that all staff has knowledge of the conditions that require the initiation of Cardio [MEDICAL CONDITION] Resuscitation (CPR) for one of three residents (R2) reviewed for Advance directives/CPR in the sample of 25. This failure resulted in the facility staff failing to follow R2's Advance Directives by initiating CPR for R2 who subsequently expired. This failure also has the potential to affect 16 of 25 residents (R3, R5, and R8-R21) reviewed for Advanced Directives who have full code status in the sample of 25. This failure resulted in Immediate Jeopardy which was identified to have begun on [DATE] when the facility failed to perform CPR on R2 and R2 expired. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continues to inservice facility staff on CPR certification. Findings include: 1. Facility's CPR Policy, undated, revised on ,[DATE] documents in part, Cardiopulmonary Resuscitation. It is the policy that 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]. Assess for cardiac distress. 2. Assess resident status (vital signs, color, consciousness, responsiveness) treat as indicated. 3. Call emergency rescue services unless resident is of No Code status. If 'No Code' status, notify physician and proceed as ordered. 4. If respirations are nonexistent or cease, initiate artificial respirations. 5. If pulse is absent, initiate artificial circulation/chest compression. 6. Continue CPR until: a. Advanced life support systems are available, operable and resume care. b. The resident responds. c. A physician orders [REDACTED]. 7. Document all observations and occurrences in the medical record. The AHA publication titled Circulation, Nov. 2010, Ethical Aspects of CPR and ECC, Part 3, S665, Withholding and Withdrawing CPR documented While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR might be appropriate, as follows: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril. Obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transaction, or decomposition.) A valid, signed, and dated advanced directive indicating that resuscitation is not desired, or a valid, signed, and dated DNAR (do not attempt resuscitation) order. R2's Minimum Data Set (MDS), dated [DATE], documents R2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Cognitive assessment dated [DATE] also documents R2 as having a BIMS of 15. R2's History and Physical dated [DATE] documents in part, History of Present Illness. (R2) is a [AGE] year old male. He remains a FULL CODE status. R2's Do-Not-Resuscitate (DNR) Practitioner Orders for Life-Sustaining Treatment (POLST) Form, undated, Section A, documents Cardiopulmonary Resuscitation (CPR) is checked for Attempt Resuscitation/CPR. R2's Profile Face Sheet, undated, documents Advanced Directives Resuscitate Full. R2's physician's orders [REDACTED]. R2's Admission Nurse's Notes, dated [DATE] at 4:00 PM, documents R2 as having full code is status. R2's Care Plan dated [DATE] does not list R2's code status. R2's Nurse's Note dated [DATE] at 8:35 PM documents in part, (R2) had call light on & (and) requested a pain pill because his back was hurting. P.P. (pain pill) given & (R2) thanks this nurse for P.P. (R2) was watching T.V. On [DATE] the Medication Administration Record [REDACTED]. There is no entry listed in the Medication Notes for [DATE] at 8:30 PM showing reason and/or result of medication given. R2's Nurse's Note dated [DATE] at 8:40 PM documents, CNA (Certified Nursing Assistant) went down to answer (R2) call light again. CNA came running to N.S. (Nurses Station) & (and) said (CNA) thought res (resident) had expired. This nurse (E18, Licensed Practical Nurse, LPN) & other nurse (E25, LPN) went to asses res (resident). Eyes were open, (no) pulse, (no) respirations. (R2) pronounced dead @ (at) 8:43P.M. R2's Nurse's Note dated [DATE] at 8:50 PM documents, Coroner was called & gave o.k. to call F.H. (funeral home). There is no further documentation in R2's chart after the [DATE] 8:50 PM Nurse's Note. On [DATE] at 2:20 PM, E18, LPN, stated, she was working on the evening shift (2:00 PM through 10:00PM). E18 stated E8 (CNA), E20 (CNA), E26 (CNA) and E25 (LPN) were also working. E18 stated R2 requested a pain pill. E18 further stated E20 came to let myself and (E25) know (R2) was gone. Went down and checked (R2) and (R2) was already gone and myself and other nurse pronounced (R2) dead. I called the coroner and funeral home and faxed over note to explain resident had expired to MD (physician). E18 stated No CPR was performed because (R2) was already gone, as pupils were fixed, and was very obvious (R2) was gone. E18 further stated in part, Don't know policy on CPR as it relates to a full code. Don't know policy on full code after someone is obviously deceased and doing CPR. I did not do CPR or call 911 either. (R2) was a full code. All happened about within half of an hour, and time was around 8:15 PM. E18 further stated she knew R2 was a full code when E25 told her of R2's code status at the nurse's station. On [DATE], at 10:38 AM E18, LPN, confirmed during a telephone interview, CPR would be started for a resident having difficulty breathing, motionless, not responding. E18 stated she would get someone to get backboard and have someone call 911. E18 stated I would see if the CNAs were CPR certified and one of them would do compressions and 1 CNA would do ambubag. On [DATE] at 2:30 PM, E25, LPN, stated she and E18 were working on [DATE] on the evening shift. E25 states at about 8:15 PM, E20 came to get her to assess R2. During that time, E18 came into the room and took over care for R2. E25 further stated, (R2) was cyanotic in (R2's) face, fingers and feet, eyes opened, pupils fixed, mouth open, no pulse, no respiration, cool to touch. E25 stated no sternal rub was performed, no rigor mortis was noted, and no CPR was performed. E25 stated she then went to the nurse's station to call the funeral home. E25 stated she only looked at the Face Sheet and not R2's Advanced Directive because E18 was in charge. E25 stated she informed E18 of R2's full code status when E18 came from R2's room to the Nurse's Station. When ask when do you do CPR, E25 responded When a resident is a full code only. E25 also stated she knows when to code a resident by the resident's Advanced Directive. On [DATE] at 9:00 AM, E8, CNA, verified she was working on [DATE] on both the evening and midnight shift. E8 stated between 8:15 PM and 8:30 PM, E20 came into the resident's room in which she and E18 were and stated R2 was gone. E8 stated both she and E18 went down to R2's room. E8 stated E25 came into the room and E18 left the room to look for contact information. E8 stated, No CPR was initiated by anyone. E8 stated after R2 was assessed by E18, she and E20 prepared R2 for the arrival of the funeral home. On [DATE] at 11:00 AM, E20, CNA, stated on [DATE], R2 turned on his call light about 10 minutes after 8:00 PM and was requesting a pain pill. E20 stated while she was in another resident's room, R2's light came back on and she could not get to R2, and stated it was about 15 minutes later when she entered R2's room. E20 stated once she entered R2's room, R2's mouth and eyes were open, and R2 was lying on R2's back and R2's face was facing the door. E20 stated she tried to speak to R2, but received no response. E20 stated she went to the nurse's station to retrieve a nurse, but was unable to find one. E20 stated she saw a medication cart down B Hall and that's when E18 and E25 went and assessed R2. On [DATE] at 9:10 AM, E2 stated, Expectation for the nurse in the case of a resident's Advanced Directive is to follow the directive. Currently, Advanced Directives can be either on colored paper or be white. No distinguishing between full code or DNR (Do Not Resuscitate) or Special Interventions. The nurses have to read to determine code status. On [DATE] at 10:03 AM, E29 (Regional Director) stated with regard to the list of residents that are full codes, she directed the Social Services Director to do an all chart audit. E29 stated the 16 current residents identified as full code status were R3, R5, and R8 through R21. On [DATE] at 11:40 AM, Z2 (Physician) stated he expects nurses and CNAs to perform CPR based on the Advanced Directive of the residents and the expectation is for staff to be trained with current certification to perform CPR. Z2 further stated he was aware R2 was a full code. On [DATE], 52 current residents' charts were reviewed. Of those 52, 16 residents had full code status (R3, R5, and R,[DATE]). The Immediate Jeopardy began on [DATE] when E18 and E25 did not perform CPR on R2 and R2 expired. E1, Administrator, and E2, Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 3:00 PM. On [DATE] the surveyor determined through observation, interview, and record review, the facility took the following action to remove the Immediacy: On [DATE], the following was initiated/completed; 1. The Regional Director and Social Service Director completed an initial audit of resident medical record for current status of advance directives related to code status, POLST, living will, POA-health care, POA-finance, Health Care Surrogate and Guardianship. 2. The Social Service Director initiated clarification of resident code status discrepancies identified during the audit of advance directives. 3. The Regional Nurse audited facility nursing personnel related to CPR certification. 4. The Regional Director contacted CPR instructor to schedule classes for facility staff certification on [DATE] at 10:00 AM and 2:00 PM. On [DATE] the following was initiated/completed: 1. The Social Service Director continued clarification of resident code status discrepancies identified during the audit of advance directives. 2. The Regional Nurse conducted random chart reviews for physician & family notification. 3. The Regional Director updated the facility staff roster. On [DATE] the following was initiated/ completed: 1. The Regional Director and Regional Nurse completed 100% in-servicing for all departments including Administration, Nursing, Housekeeping/Laundry, Dietary, and Maintenance regarding facility policy related to Physician & Family Notification, Advance Directives, and CPR including staff certification requirements and when to initiate CPR. 2. The Regional Nurse clarified with all staff during 100% in-service the identification of resident code status is located in each resident's medical record under the Advance Directive tab on the POLST form. 3. The Regional Nurse conducted random chart reviews for physician & family notification. 4. The Regional Director, Regional Nurse, and Social Service Director re-audited each resident's medical record for current status of advance directives related to code status including proper completion of POLST, cross referencing Face Sheet, Physician order [REDACTED]. Facility Regional Director and Regional Nurse will ensure that all new employees will be trained and educated during initial orientation prior to working the floor on facility policy related to Physician & Family Notification, Advance Directives, where to find code status in the medical record and when to initiate CPR. The Q.A. (Quality Assurance) team, including Administrator, Director of Nursing and the Interdisciplinary Team will assure compliance through the daily Quality Assurance Process. The Regional Director and Regional Nurse will monitor effectiveness of staff training regarding facility policy related to Physician & Family Notification, Advance Directives, and CPR. The Administrator shall receive copies of all in-service materials and the Medical Director is reviewing the Removal Plan for F155. B. Based on interview and record review, the facility failed to incorporate and communicate the resident's choice for Advance Directives into resident's treatment, care and services. This failure has the potential to affect 19 of 23 residents (R2, R3, R5, and R8-R23) reviewed for Advance Directives in the sample of 23. Findings include: Facility's Advance Directive Policy, dated ,[DATE] and revised on [DATE], documents regarding Procedure 3. After confirming the accuracy of provided documents, the document will be sent for appropriate signatures. No order for 'No Code' or 'DNR' shall be effective until the Uniform-Do-Not-Resuscitate (DNR) Advanced Directive Form is signed by resident/responsible party and physician order [REDACTED]. Advance directives specifying full code/Attempt Resuscitation/CPR, or the absence of determination shall be recorded as a 'Full Code.' Code status shall also be recorded on the resident's Physician order [REDACTED]. Implementation of a code is as follows: i) Direct and non-direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. ii) The nurse shall be summoned to respond, and upon review of chart documents determine code status. iii) The nurse shall evaluate the code status and notify appropriate staff for task assignment. If CPR is indicated only certified personnel shall administer CPR. The Policy documents 11. Facility shall provide education to all employees regarding advanced directives and the implementation of such. On [DATE] at 3:15 PM, E1, Administrator, stated he wasn't aware of how to determine resident's code status and relies on the DON to know that. E1 stated R2's Advanced Directive was not signed by the physician. On [DATE] at 3:00 PM, E2, Director of Nursing/DON, stated she was not sure of the policy on CPR as it relates to a full code. On [DATE] at 9:10 AM, E2 stated, Expectation for the nurse in the case of a resident's Advanced Directive is to follow the directive. Currently, Advanced Directives can be either on colored paper or be white. No distinguishing between full code or DNR (Do Not Resuscitate) or Special Interventions. The nurses have to read to determine code status. On [DATE] at 9:30 AM, E1, Administrator, stated the process for informing staff of changes to a resident's Advanced Directive is done when the family either brings in the paperwork and/or during the Care Plan conference. E1 stated E3, MDS Coordinator, was responsible for updating the information for Advanced Directives and Face Sheets. E1 further stated if a resident has an Advanced Directive citing as a Full Code and Advanced Directive is requested by the resident and/or Power of Attorney (POA) to be a DNR, the resident is a Full Code until the Advanced Directive is signed by the physician. On [DATE] at 10:01AM, E3 stated she was not aware of a system on how to readily identify code status other than on the Face Sheet and/or Advanced Directive, and if the both did not match, was unsure, and would seek guidance from the DON. On [DATE] at 10:20 AM, E2 states in part, (R2) does not have a listed code status and should have been listed on Care Plan as a full code, as all Advanced Directives are to be listed on all residents Care Plans. E2 stated R2's Physician order [REDACTED]. On [DATE] at 11:00 AM, E2 stated, (R2) is a full code because there is no documentation that states otherwise. All Advanced Directives for DNR/Full Code must be signed by MD. If not signed, resident is a Full Code. (R2's) Advanced Directive is not signed. On [DATE], 52 current residents' charts were reviewed for Advance Directives. Of the 52 reviewed, two residents, R22, R23, had no identifying information on or in their chart to determine if they were full code status or DNR. 16 residents' charts (R3, R5 and R8-R21) did not contain an identifying mechanism for staff to readily determine their code status which was full code. 5 of these 16 residents, R3, R8, R12, R13, had incomplete/blank DNR forms in their records. 2 of these 16 residents (R13 and R15) had no identifying stickers (red or green) located on their charts signifying full code status. On [DATE] at 10:50 AM, E19, LPN, stated she received training on Advanced Directives and CPR by reading the paperwork, and staff are now to go by the red sticker, meaning DNR and green sticker, meaning full code as of [DATE] or [DATE]. E19 further stated if the Advanced Directive and Face Sheet doesn't match to refer to the Advanced Directive. On [DATE] at 11:00 AM, E20, CNA, stated she was unaware how the facility determines Advanced Directives on residents. On [DATE] at 12:20 PM, E15, CNA, stated staff would start CPR on everyone while someone verifies the code status in the resident's chart. E15 stated if the resident's chart documents DNR staff would stop CPR. On [DATE] at 12:32 PM, E21, CNA, stated DON told us to go down start CPR, and someone else goes and checks the chart. If that resident is a DNR, then if find out resident not CPR, then you stop CPR. On [DATE] at 1:25 PM, E23, Registered Nurse, stated she would go to the chart, under Advanced Directive or on the physician's orders [REDACTED]. E23 stated that on [DATE], the DON was putting an alert system on the outside of the charts and orange stickers for DNR on those residents that are not a full code but staff are still responsible to check code status. On [DATE] at 1:45 PM, E13, CNA, stated if find a resident unresponsive and no vital signs, she would 1. Start CPR, 2. Yell help, hit call light, 3. Someone lets me know code status. 4. If come back and say a DNR, I'd stop. On [DATE] at 2:06 PM, E24, CNA, stated the facility has initiated a star system on resident's charts. E24 further stated, Green means go, means do CPR. Red means no CPR. On [DATE] at 3:05 PM E26, CNA, stated in part, she attended CNA class 3 years ago. Nothing here yet. CPR certification is expired. (E2) just told me charts will have a star, red for no code, green for full code. E26 further stated, Go down and find someone not breathing, no vitals, unresponsive get the nurse and she needs help with CPR, absolutely help that nurse do CPR. Only stop CPR when nurse calls it. On [DATE] at 9:00 AM, E8, CNA, stated on [DATE] after finishing the night shift, E2 in-serviced her on CPR. E8 further stated she is not sure where to look in the chart for any resident's code status. On [DATE] at 11:30 AM, E23, RN, stated if there is a chart and don't know the Advanced Directive, she would initiate CPR, and if unaware of the code status, that resident will receive CPR. E23 stated she would go to the physician's orders [REDACTED]. E23 is not aware of the facility policy on CPR or Advanced Directives. On [DATE] at 12:18 PM, E28, CNA, stated she had no training upon hire on Advanced Directives, CPR, and code status of residents. E28 stated (E2) went over with me on [DATE] CPR and code status and where to look for things. I would look for code status in the care plan. Right now, this week, have stars on charts too, but go by the care plan. E28 was not aware of any policies on CPR or Advanced Directives and was not sure where the Advanced Directive was kept on residents. C. Based on interview and record review, the facility failed to ensure staff maintain current CPR certification for healthcare providers. This had the potential to affect the 52 residents living in the facility. Findings include: On [DATE] at 9:45 AM, E1, Administrator, stated the facility did not have a policy for CPR Certification for staff, but that E23, Registered Nurse (RN), taught the course for CPR Certification for a nominal fee, and staff can get the certification. On [DATE] at 1:50 PM, E2 stated not all staff was currently certified in CPR and E18's, Licensed Practical Nurse, CPR certification expired on ,[DATE] and facility did not have a copy of E25's, LPN, CPR Certification. E2 further stated E18 had been employed at the facility since ,[DATE] and E25 had been employed since ,[DATE]. On [DATE] at 10:03 AM, E29, Regional Director, stated some of the nurses were not CPR certified and not all CNAs were currently certified. E29 confirmed E18 and E25 were not CPR certified. Facility's Advance Directive Policy dated ,[DATE] and revised on [DATE], documents If CPR is indicated only certified personnel shall administer CPR. The facility had no policy or procedure regarding staff maintaining current CPR certification for Healthcare providers. The Facility Data Sheet, dated [DATE], documents the facility has 52 residents living in the facility.

Based on interview and record review the facility neglected to follow the facility's policies and procedures regarding Cardio-pulmonary Resuscitation (CPR) for 1 of 4 residents (R2) reviewed advanced directives/CPR in the sample of 25. This failure resulted in R2 having no opportunity for resuscitation after experiencing cardio and respiratory arrest. Findings include: Facility's Policy entitled Abuse Prevention Program, undated, revised on [DATE] documents in part, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Definitions. Neglect is the failure to provide, or willful withholding of, adequate medical care. The Policy documents Option 5: Possible Neglect. Definition: Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, and such failure results in the deterioration of a resident's physical or mental condition. Facility's Policy undated, revised on ,[DATE] documents in part, Cardiopulmonary Resuscitation. It is the policy that 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 designed through advanced directives and/or have a specific physician order [REDACTED]. Assess for cardiac distress. 2. Assess resident status (vital signs, color, consciousness, responsiveness) treat as indicated. 3. Call emergency rescue services unless resident is of No Code status. If 'No Code' status, notify physician and proceed as ordered. 4. If respirations are nonexistent or cease, initiate artificial respirations. 5. If pulse is absent, initiate artificial circulation/chest compression. 6. Continue CPR until: a. Advanced life support systems are available, operable and resume care. b. The resident responds. c. A physician orders [REDACTED]. 7. Document all observations and occurrences in the medical record. American Heart Associations Guidelines for CPR, reference site: https://eccguidelines.heart.org, entitled Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC (Emergency Cardiovascular Care) state in part, Summary of High-Quality CPR Components for BLS (Basic Life Support) Providers. Component: Recognition of [MEDICAL CONDITION]. Adults and Adolescents: Check for responsiveness. No breathing or only gasping (i.e. no normal breathing), No definite pulse felt within 10 seconds. Activation of Emergency Response System. If you are alone with no mobile phone, leave the victim to activate the emergency response system. Otherwise, send someone and begin CPR immediately. Compression-ventilation ratio without advanced airway: 1 or 2 rescuers 30:2(30 to 2). Compression-ventilation ratio with advanced airway: Continuous compressions at a rate of ,[DATE]/min (per minute). Give 1 breath every 6 seconds (10 breaths/min). Compression rate: ,[DATE]/min. Compression depth: At least 2 inches. Hand Placement: 2 hands on the lower half of the breastbone (sternum). Chest recoil: Allow full recoil of chest after each compression; do not lean on the chest after each compression. R2's History and Physical dated [DATE] documents in part, History of Present Illness. (R2) is a [AGE] year old male. He remains a FULL CODE status. R2's Do-Not-Resuscitate (DNR) Practitioner Orders for Life-Sustaining Treatment (POLST) Form, undated, Section A, documents Cardiopulmonary Resuscitation (CPR) is checked for Attempt Resuscitation/CPR. R2's Profile Face Sheet, undated, documents Advanced Directives Resuscitate Full. R2's physician's orders [REDACTED]. R2's Admission Nurse's Notes, dated [DATE] at 4:00 PM, documents R2 as having full code is status. Care Plan dated [DATE] does not list R2's code status. R2's Nurse's Note dated [DATE] at 8:35 PM documents in part, (R2) had call light on & (and) requested a pain pill because his back was hurting. P.P. (pain pill) given & (R2) thanks this nurse for P.P. (R2) was watching T.V. R2's Nurse's Note dated [DATE] at 8:40 PM documents, CNA (Certified Nursing Assistant) went down to answer (R2) call light again. CNA came running to N.S. (Nurses Station) & (and) said (CNA) thought res (resident) had expired. This nurse (E18, Licensed Practical Nurse, LPN) & other nurse (E25, LPN) went to asses res (resident). Eyes were open, (no) pulse, (no) respirations. (R2) pronounced dead @ (at) 8:43P.M. R2's Nurse's Note dated [DATE] at 8:50 PM documents, Coroner was called & gave o.k. to call F.H. (funeral home). There is no further documentation in R2's chart after the [DATE] 8:50 PM Nurse's Note. On [DATE] at 2:20 PM, E18, LPN stated, she was working on the evening shift (2:00 PM through 10:00PM). E18 stated E8, CNA, E20, CNA, E26, CNA and E25, LPN were also working. E18 further stated E20 Came to let myself and (E25) know (R2) was gone. Went down and checked (R2) and (R2) was already gone and myself and other nurse pronounced (R2) dead. I called the coroner and funeral home and faxed over note to explain resident had expired to MD (physician). E18 stated No CPR was performed because (R2) was already gone, as pupils were fixed, and was very obvious (R2) was gone. E18 further stated in part, Don't know policy on CPR as it relates to a full code. Don't know policy on full code after someone is obviously deceased and doing CPR. I did not do CPR or call 911 either. E18 stated she knew R2 was a full code when E25 told her of R2's code status at the nurse's station. On [DATE] at 2:30 PM, E25, LPN, stated she and E18 were working on [DATE] on the evening shift. E25 states at about 8:15 PM, E20 came to get her to assess R2. E25 stated during that time, E18 came into the room and took over care for R2. E25 further stated, (R2) was cyanotic in (R2's) face, fingers and feet, eyes opened, pupils fixed, mouth open, no pulse, no respiration, cool to touch. E25 stated no sternal rub was performed, no rigor mortis was noted, and no CPR was performed. E25 stated she then went to the nurse's station to call the funeral home. E25 stated she only looked at the Face Sheet and not R2's Advanced Directive because E18 was in charge. E25 stated she informed E18 of R2's full code status when E18 came from R2's room to the Nurse's Station. E25 stated when ask when do you do CPR, E25 responded when a resident is a full code only. E25 also stated she knows when to code a resident by the resident's Advanced Directive. On [DATE] at 9:00 AM, E8 verified she was working on [DATE] on both the evening and midnight shift. E8 stated between 8:15 PM and 8:30 PM, E20 came into the resident's room in which she and E18 were and stated R2 was gone. E8 stated both she and E18 went down to R2's room. E8 stated E25 came into the room and E18 left the room to look for contact information. E8 stated, No CPR was initiated by anyone. E8 stated after R2 was assessed by E18, she and E20 prepared R2 for the arrival of the funeral home. On [DATE] at 11:00 AM, E20 stated on [DATE], R2 turned on his call light about 10 minutes after 8:00 PM and was requesting a pain pill. E20 stated while she was in another resident's room, R2's light came back on and she could not get to R2, and stated it was about 15 minutes later when she entered R2's room. E20 stated once she entered R2's room, R2's mouth and eyes were open, and R2 was lying on R2's back and R2's face was facing the door. E20 stated she tried to speak to R2, but received no response. E20 stated she went to the nurse's station to retrieve a nurse, but was unable to find one. E20 stated she saw a medication cart down B Hall and that's when E18 and E25 went and assessed R2. On [DATE] at 11:40AM, Z2, Physician, stated he expects nurses and CNAs to perform CPR based on the Advanced Directive of the residents and the expectation is for staff to be trained with current certification to perform CPR. Z2 further stated he was aware R2 was a full code.

Based on interview, observation and record review, the facility failed to implement safety measures for mechanical lifts transfers for 2 (R11 and R2) of 6 residents reviewed for falls in a sample of 15. This failure resulted in R11 falling out of the mechanical lift sling sustaining a fractured femur. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R11 to be a [AGE] year old male admitted to the facility on [DATE] with no cognitive impairment. The MDS documents that R11 is totally dependent on staff for transfers. The care plan dated 9/2/11 identifies R11 to be at risk for falls due to paralysis. An incident report dated 9/28/11 indicates R11 had a fall during a mechanical lift transfer. Investigation Reports dated 9/28/11 identify the root analysis cause to be "lift sling may not have been strate." The report also indicates that only one certified nurses aide, E9, was present during the incident and that R11 started to slide out of the sling when she lift him. The summary of the investigation concluded that the CNA did not follow facility policy and procedure to have 2 staff present during all mechanical lift transfers and operation of the lift was not followed for sling application. On 11/17/11 at 3:15pm, both the Administrator and Director of Nurses confirmed that E9 was terminated due to not following policy to use two people with the lift. X-ray results dated 9/29/11 confirmed R11's injury as a "Acute moderate displaced fracture of distal shaft of femur as the result of the fall. On 11/17/11 at 2pm, R11 was observed to have contractures bilaterally lower extremeties with splints. R11 stated he recalled falling from the lift and that he slid out of the sling to the floor "breaking his leg." R11 stated one staff was present in the room when the fall occurred. 2. R2's MDS, dated [DATE], documented extensive assistance of two plus persons physical assistance with transfer. R2's Care Plan, current, documented R2 was at risk for falls related, in part, to right lower extremity amputation. It was also noted to use a "sit to stand" for transfer with two staff assistance. During observation of R2's transfer and toileting, on 11-16-11 at 10:00a.m., E8, CNA, did not properly secure R2's left leg prior to using the "sit to stand" lift. It was also noted two staff members did not assist with R2's transfer. E8 stated, "I made a mistake with that (transfer)."

Based on interviews, observations, and record review, the facility failed to have adequate monitoring for adverse side effects of [MEDICATION NAME], and failed to ensure that adequate monitoring occurred toward dose reductions for 1 (R1) of 3 residents on the sample receiving antipsychotic drugs in a sample of 4 residents. This failure resulted in R1 exhibiting a significant decline in overall conditions including communication skills, ambulation, eating skills with swallow deficits, drooling, lethargy and leaning without the facility identifying it as a possible side effect of [MEDICATION NAME], and providing further monitoring. Findings include: According to the Admission Sheet, R1 returned to the facility on [DATE] following a lengthy psychiatric stay at the hospital. The physician's orders [REDACTED]. According to the Behavioral Tracking sheet for November 2010, specific behaviors included [MEDICAL CONDITION], paranoia, cursing/name calling and crying. The Miminum Data Set, MDS, dated [DATE] identifies no cognitive impairment with extensive assist of one staff for most activities of daily living except eating which required only supervision. R1 has a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The care plan dated 11/10/10 indicates transfer orders will be followed per Dr.(Z4), and the goal is to"develop no severe side effects related to physhotropic med use for next 90 days" and "meds will be effective against [MEDICAL CONDITION] c [MEDICAL CONDITION]." Interventions include monitoring for side effects, and report changes to Dr., update Dr. as needed, tracking provided for noted behaviors, chart and report behaviors and mood problems/[MEDICAL CONDITION], determine caus for behaviors and provide distractions. The care plan does not include a plan for reduction or monitoring for the efficasy of the medications administered. R1's psychiatric disease was being treated and monitored by Z4, Psychiatrist. The Monitoring Flow Sheets for December 2010 indicate R1 had 2 episodes of [MEDICAL CONDITION], 5 of paranoia, 12 of cursing and name calling, and 13 of crying. In January 2011, the monitoring sheets document 2 episodes of [MEDICAL CONDITION] occurred, 3 of paranoia, 5 of cursing and name calling, and 12 incidents of crying. The sheets have no side effects identified as occurring for either month. The nurses notes from 11/11/10 through December 2010 include random entries about R1 yelling out and cursing at staff, having some crying episodes, but include no documentation toward R1 exhibiting any adverse effects from either the [MEDICATION NAME] or [MEDICATION NAME]. The nurses notes dated 12/5/10 at 1pm documents that R1's husband voiced concerns his wifes girth seems more distended, and that he had concerns about her occasional "drooling and tearfulness and occasional drowsiness et wanted Dr. informed." The notes document the physician (Z4) was notified with no new orders given. There is no documentation following this entry that suggests the nurses monitored R1 for drowsiness, drooling and/or tearfulness. The Restorative Notes dated December 2010 indicate that R1 was able to walk with a wheeled walker up to 120 feet on 12/7/10, but notes dated 12/1/10, 12/9/10, 12/10/10, and 12/15/10 indicate she refused. Of the 18 opportunities for her to walk, 10 refusals are documented. The next entry into the nurses notes is dated 12/23/10 when R1 was seen by Z4, Psychiatrist, and a new order was noted. The Psychiatry note dated 12/23/10 documents "Pt's (patient) husband reported that pt has been on a "daze" + speak in a "low" tone of voice + has been "drooling". I told him these are part of side effects of antipsychotic esp. [MEDICATION NAME]. He was wondering if it could be changed, at this point, I told him that she's NOT as delusional nor agitated so I'm hesitant to (decrease) or change her [MEDICATION NAME] for now. I suggested just giving PRN ( as needed) [MEDICATION NAME] for drooling/EPS/motor skills effects." an order for [REDACTED]. There is no documentation by nursing in R1's clinical record toward these identified side effects except the husbands voiced concerns. In addition, there are no changes to the care plan to include the noted side effects and interventions to address them. The Medication Administration Record, [REDACTED]. The next entry into the nurses notes is dated 12/28/10, and documents "CNA (Certified Nurses Aide) informed me about resident striking another resident and tellng her she couldn't sit there. Resdient was unharmed but R1 was still trying to hit her." The physician was called, and a new order for [MEDICATION NAME] 0.5mg every 6 hours as needed for agitation was obtained. The nurses notes fail to include any information as to what interventions were attempted at the time R1 struck another resident prior to calling the the psychiastrist, and included no further documentation as to whether the nurses further assessed R1 for physical or environmental factors that could have contributed to R1 aggression toward another resident at the time. According to the December 2010 MAR, no [MEDICATION NAME] and/or [MEDICATION NAME] was given. There are no nurses notes entries between 12/28/10 and 1/14/11 at 1:45pm when the nurse documents "noted res unable to feed self, starts to eat or drink but stops 1/2 way there. Will attempt to get U/A (urinalysis) due to urine strong." A urinalysis was done and found to show no urinary tract infection. No further documentation including an assessment concerning R1's decline in eating skills is evident in the nurses notes. On 1/14/11 R1 was seen by Z6, Primary Physician, and an order to continue to monitor food intake was given. January 2011 weight was down 17# over a 3 month period of time. The Physician order [REDACTED]. There is no documentation concerning the effectivenss of the reduction, and no changes to the care plan. On 1/19/11 a SEATING/POSITIONING EVALUATION was completed which indicated R1's functional status for transfers was maximum assist of 2 staff, sitting balance identifes a "lean to R (right) side" and cognition documents "Pt (patient) lethargic + oriented to person. Inconsistent with 1 step direction." A psychiatric note dated 1/22/11 documents "Back in December 28, 2010, R1 struck another resident and had to be redirected. [MEDICATION NAME] was ordered at that time. She has periods of being delusional. The patient seemed more flat in her affect and this may be secondary to the [MEDICATION NAME] given to her at the geriartric unit. I really did not want this patient to be on [MEDICATION NAME] because of its adverse consequences including motor side effects given that she already have parkinsonian tremors as baseline. She is not having significant mood swings. She has not been combative nor aggressive. She has not voiced any paranoia... energy level is down. Concentration is poor. Attention span is poor... Speech was soft with very slow and delay in her reponses. Affect was flat. Thought process was vague... has difficulty expressing needs. Insight and judgement are impaired." The January 2011 restorative ambulation notes document R1 is only ambulating up to 50 feet 5 of 20 opportunities with refusals documented the rest of the time. On 1/17/11 the restorative note states "leaning in chair." Physical therapy notes document "Pt (patient) may require sit-stand for transfers if cognition is decreased & level of arousal is decreased to prevent inury to self and staff." The nurses fail to monitor R1 toward these identified adverse effects of the [MEDICATION NAME] even though both R1's husband and the psychiatrist noted them. The nurses notes for February 2011 were reviewed, and also found void of any documentation toward R1's decline in functional ability (eating), drooling, and lethargy. Nurses notes dated 2/9/11 identify R1 to have lost an additional 9 pounds in the prior month. On 2/15/11 R1 had a cat scan of the abdomen and pelvis. On 2/28/11, R1 had a Gallbladder ultrasound ordered due to abdominal distention. The entry on 2/28/11 at 10:40am identifies abdominal distention, appetite poor and R1 being lethargic. However, there is no follow-up documentation in February 2011 concerning R1's possible adverse side effects of the [MEDICATION NAME] and these symptoms. Ambulation restorative notes now state "unable" for ambulating opportunities" with the note dated 2/4/11 documenting "res has been unable to walk to do exercises. Has been needing help feeding herself." In March 2011 the nurses notes continue to reflect R1's abdominal distention and gallbadder tests, but fail to include any documentation concerning R1's functional decline including diarhea. On 3/15/11 R1 had a speech evaluation completed. The notes document "does have a good liquid intake" and "skilled ST (speech therapy) should continue as the pt. exhibits sigsn/symptoms of dysphagia that could lead to aspiration pneumonia." A Psychiatry note dated 3/21/11 documents "Per husband, he's concerned that pt is "slumped over" + incoherent + hard to feed, concerned she may be overmedicated, however, staff reported that when he's gone res alert, coherent, able to actually respond + make conversation + she's eating when fed by others. He was made aware that [MEDICATION NAME] can cause motor side effects - leaning, disykinesia, etc." Z4 reduced the [MEDICATION NAME] monthly to 50mg and [MEDICATION NAME] daily to 2.5mg. The nurses notes reflect only that Z4 was here, and a new order was received. No monitoring of the drug reduction, and/or side effects/adverse reactions was documented. On 3/23/11 R1 was sitting in a recliner chair in front of the television in the lobby area of the facility. She dosed off and on all morning as she leaned heavily to her left side. At times she had her eyes open, but not focused on anything in the area. At 10:40am staff approached R1, rubbed her arm, received no response, and left her side. At 10:56am staff reapproached R1, applied a gait belt after sitting her up in the recliner, and transfered her to the wheelchair. She did not wake up during the transfer, and barely opened her eyes when she sat down in the wheelchair. Staff pushed her back to the hallway, turned around and brought her back to the dining room and left her at the table. She sat with her eyes closed. R1 had supports on both side of her wheelchair to keep her upright in the chair. At 11:35am R1 attempted to brush her cheek with a very slow deliberate movement. R1 had a flat affect when staff would address her, and did not respond when her food was served at 11:35am. R1 was fed by a CNA and did not open her eyes when food was brought to her mouth. R1 continued to lean to the right in her wheelchair. R1 was noted to gag, and was taken directly out of the dining room and returned to her room. At 12pm E8, CNA, attempted to get food out of her mouth. R1 sat with her mouth slightly open and her eyes shut. She mumbled slightly when E8 asked her questions. At 12:13pm the nurse came in and gave her a few swallows of water. E8 stated R1 was usually like this, said R1 has had no behaviors, and doesn't "say much." R1 was transfered to bed. No reponse was noted from R1 during the transfer. Once in bed E8 asked R1 questions, and R1 attempted to answer with gargled speech. R1's flat affect continued. According to E1, Administrator, on 3/25/11 during the daily meeting, R1 is "not the same person she was before she was hosptalized in October" saying that R1 used to sit up at the front door, and talk with people as they came in. E1 said R1 was delusional, but could converse and feed herself. E1 acknowledged that R1 had a major decline in condition, but added that she also had abdominal distention with possible gallbladder stones which they had been testing for, and thought the decline was attributed to these physical ailments. On 3/24/11 at 12:35pm E2, Director of Nursing, agreed that R1 has had an overall decline in health stating "she's just a different person. The change is "unreal" that included weight loss since her last hospitalization . E2 stated the [MEDICATION NAME] was for behaviors as R1 does not have a history of [MEDICAL CONDITION]. When asked what behaviors R1 had, E2 said auditory, usually hallucinations, cursing at staff, did converse but not much, and could feed herself. E2 also stated that R1 could toilet with staff assist, but has always been wheelchair bound. E2 also acknowledged that R1 did have drooling, but was sporadical and not all the time. On 3/24/11 at 12:35pm Z2, R1's husband, stated he noted her drooling, and informed the nurses. Z2 stated R1 has had a long history of mental illness, and has been on various other drugs including [MEDICATION NAME] but not [MEDICATION NAME], and he was concerned that she was overmedicated at the time and showing side effects. Z2 stated she also appears to be lethargic, unable to speak at times and barely moves her lips when trying to talk. Z2 also stated she doesn't eat well, has difficulty swallowing food, now is on a pureed diet, but drinks liquids without any difficulty. Z2 states he visits several times a week, and has noted an overall decline since her return from the hospital in November. Interviews with numerous staff confirm that R1 has had a major decline in overall condition including funcitonal ability. On 3/25/11 at 2:30pm E12, CNA, said R1 is "very different" since her last admission as R1 used to talk, could discuss things, used to feed herself, and no longer does adding that now she does nothing for herself. E13, CNA, agreed that R1 is very different since her return, and has declined a lot, adding that R1 "is not the same person." On 3/25/11 at 3:25pm E16, CNA, agreed that R1 has had a major decline over the past few months. On 3/31/11 at 2:10pm Z4, Psychiatrist, stated that she is not involved with behavioral program planning at all. Z4 said R1 returned from the hospital on [MEDICATION NAME] which was not her drug of choice. Z4 stated she did not receive any calls regarding any behaviors for R1 so thought that the [MEDICATION NAME] was effective in treating her [MEDICAL CONDITION] and paranoia. Z4 recalled her conversations with R1's husband regarding her drooling stating that the nurses had not mentioned it to her before the husband did. Z4 said she had not personally witnessed R1 drooling, but added the [MEDICATION NAME] for the drooling if they needed it. Z4 agreed that R1 is declining overall, and some could be attributed to possible physical conditions; however, she attributes some of it to the [MEDICATION NAME] use. Z4 stated she understands the need for monitoring, and identifying adverse effects and side effects of antipsychotic medications, and would expect the nurses to identify any if they occurred and inform her when needed. Z4 agreed the [MEDICATION NAME] could also be the causative factor for R4's swallowing deficits, that she was not aware of any weight loss, or that R1 had not been eating. Z4 states she does her own training and in-servicing, and she agrees that nurses should monitor the effectiveness of new medications and any increases/decreases when they occur. Z4 also stated she has totally discontinued both the [MEDICATION NAME] and [MEDICATION NAME] to see if they were the causative factors in R1's decline. On 4/15/11 the facility provided a written statement from Z4 which indicated the facility thought the "signs/symptoms thst she was manifesting were medically related to her physician condition and NOT necessarily due to her psych meds, that's why her primary care physician (Z6) was notified instead of me." The facility failed to follow R1's care plan in monitoring her for signs/symptoms of side effects, failed to monitor for efficacy of drug use, and response to reductions as appropriate.

Based on interviews, observations, and record review, the facility failed to assess a significant weight loss, monitor intake, provide assistance with feeding, and provide a theraputic diet for 1 (R1) of 3 residents on the sample with a significant weight loss in the sample of 4 residents. This failure resulted in a 28 pound weight loss in 4 months. Findings include: According to the Admission Sheet, R1 returned to the facility on [DATE] following a lengthy psychiatric stay at the hospital. On readmission R1 was receiving a low concentrated diet. The care plan dated 8/7/10 documents R1 was over weight, and the goal was to lose a pound a month for next 90 days. On readmission there were no changes made to the care plan. The problem was "does refuse, feeds self with foot items in reach. Few of won teeth, eats less than 100% of meals, no chewing no swallowing problems." The goal was to "maintain weight with no sig (Significant ) loss or gain of 5% in 30 days for the next 90 days." The interventions included recording percentages eaten, offer substitutes for food or fluids uneaten or refused or disliked, educate on the importance of following diet, monitor for mouth pain and report, monitor for teeth or gun pain also and report, monitor for chewing/swallowing problems and report, and monitor for [MEDICAL CONDITION] among others. January weight is recorded as 178 with a 17 pound weight loss over the prior 3 months. The nurses notes dated 1/14/11 at 1:45pm documents "noted res unable to feed self, starts to eat or drink but stops 1/2 way there." There is no follow-up to this observation in the nurses notes thru January 2011. The January 2011 meal intake record documents R1 eating 25% or less of her meals 51 mealtimes of 93. There is no indication the facility identified her poor intake as a problem, and implemented substitutes and/or alternate meals in response to her poor intake. According to the Registered Dietician's (RD) assessment dated [DATE], the RD identifies a signficant change with January 2011 weight of 179 pounds. The diet is low concentrated sweets, no labs to review, and R1 is still above ideal body weight. The assessment documents "res has stopped eating. being hand fed. Res been in and out of the geri-psych Hosp has had a wt loss at the hospital." No changes are made. The care plan has a goal to improve poor feeding skills dated 2/2/11, but fails to indicate she refuses to eat when fed, and has consistently poor intake. On 2/22/11 at 130pm the nurses notes document R1 "pocketing food + has needed more assistance lately. The primary physician was notified, and a speech/swallow eval was ordered. R1's weight as of 2/1/11 is 162.7 pounds. The intake records document of the 84 meal opportunitys, R1 ate 100% 8 times, 75-80% 14 times, 50% 21 meals, 20-25% -24 meals with 9 refused altogether, and 8 at 10% intake. There are no snacks and/or supplements ordered in an effort to increase her food intake and provide added calories. In March 2011 the nurses notes continue to document R1's abdominal distention and gallbadder tests but fail to include any documentation toward her functional decline including diarhea and weight loss/poor food intake. On 3/2/11 "handfeed" was written in as an interventions on her care plan, and losing a pound a month was deleted. No additional interventions were added to increase her intake. On 3/11/11 the physician was notified of R1's weight loss of 18% over the prior 6 months, and 9% over past 3 months with a recommendation to the physician to consider an appetite stimulant along with a CT scan due to distention which was approved 3/11/11 by the physician. The CT scan was completed 3/15/11 with impression indicating that R1 had markedly air distented colonic bowel loops noted, and numerous probably cholestrol stone of the gallbladder with no obvious obstruction of the ductal system noted. Calsified fibroids were also noted of the uterus. A review of the physician's orders [REDACTED]. According to E2, Director of Nursing, on 3/25/11 at 2:30p the appetite stimulant was not implemented as it was only a recommendation although the physician had approved it. E2 stated she was unable to find any documentation that the physician did not want the appetite stimulant ordered as approved. On 3/11/11 R1 also was taken for a swallow evaluation, but one could not be taken due to the patient being uncooperative according to the Evaluation. On 3/15/11 R1 had a speech evaluation completed. The notes document "does have a good liquid intake" and "skilled ST (speech therapy) should continue as the pt. exhibits sigsn/symptoms of dysphagia that could lead to aspiration pneumonia." This recommendation was never incooperated into the care plan, and implemented during mealtimes. There is also no indication the facility considered a liquid supplement to add needed calories when R1 refused and/or ate poorly. Intake records for March 2011 from 3/1/11 thru 3/25/11 document R1 refused full meals 24 of 74 meal opportunities, ate only 25% or less for 28 meals and 50% for 20 meals. On 3/24/11 the RD assessment indicates R1's current weight is down to 162 pounds, 4% in one month, and diet recommendation is pureed, thin liquids. The RD acknowledges that R1's albumen and total protein are both low, and recommends increasing calories due to weight loss and low protein and [MEDICATION NAME] levels. Recommendations include 1/2 cup supercereal at breakfast, whole milk three times daily with meal, 90CC 2.0 med Pass three times daily and a multiple vitamin daily to support diet. The written note indicates Total Protien 5.3 (normal 6.4-8.3) and [MEDICATION NAME] 2.9 (normal 3.4-4.8) "indicating depleted visceral protiem stores". The note does indicate a significant change was identified on 2/1/11. On 3/23/11 at 10:56am staff transfered R1 to her wheelchair. She did not wake up during the transfer, and barely opened her eyes when she sat down in the wheelchair. Staff pushed her back to the hallway, turned around and brought her back to the dining room and left her at the table. She sat with her eyes closed. At 11:35am R1 attempted to brush her cheek with a very slow deliberate movement. R1 had a flat affect when staff would address her, and did not respond when her food was served at 11:35am. R1 was fed by a Certified Nurses Aide (CNA), and did not open her eyes when food was brought to her mouth. R1 continued to lean to the right in her wheelchair. R1 was noted to gag, and was taken directly out of the dining room and returned to her room. At 12pm E8, CNA, attempted to get food out of R1's mouth. R1 sat with her mouth slightly open and her eyes shut. R1 mumbles slightly when E8 asked her questions. At 12:13pm the nurse came in and gave her a few swallows of water which she had no difficulty swallowing. R1 was transfered to bed with no offer of a supplement and/or shake since her intake was only a few bites for her noon meal. Speech therapy recommendations were also not followed to keep her up for 30 minutes following the mealtime. The weight record provided on 4/15/11 documents R1's weight on 3/29/11 was 150.6 pounds for a total weight loss of 28 pounds since readmission on 11/11/10. Interview with the Z3, Registered Dietician, RD, on 3/25/11 at 11:25am indicates weekly weights probably should have been done when the facility noted the first weight loss. Z3 did state the facility moved R1 to a feeding table in February 2011, but wasn't aware that she was refusing to eat so many meals. Z3 stated she would expect the nurses to monitor the intake, and act accordingly adding that most logs are filled out and filed, but need to be reviewed weekly. Interview with Z2, R1's husband, indicates R1 has had a major decline in eating with weight loss, but that she drinks just fine. Z2 states he visits often, and offered to bring in health shakes and/or supplements for her but the facility stated he could not as she didn't have any order from the physician. Z2 states R1 does have missing teeth, only a couple back teeth, and doens't like the pureed diet she is on. Interview with E3, Licensed Practical Nurse on 3/24/11 at 10:30am indicates that a swallow evaluation was attempted on 3/11/11, but not completed due to R1 being uncooperative. E10, LPN, stated on 3/25/11 at 10:50am that R1 swallows good, and confirmed that no supplements are offered when her intake is low. E10 states she doesn't like the food but will drink liquids well. E12 and E13 CNA's on 3/25/11 at 10:58am both stated R1 does pocket food with a regular diet, and they had been feeding her since February 2011. E12 and E13 indicated R1 drinks liquids without any difficulty. On 3/25/11 at 1:30pm E11, Dietary Manager, stated the facility has weekly meeting where they discuss residents with weight concerns and loss, but that R1 had not been added onto the list until the prior week. E11 was asked if anyone looked at the intake records, and she stated they are kept in the book until the end of the month and then filed, acknowledging that the intake records are not used as a tool to determine eating habits. E2, Director of Nursing, stated at this time that R1 had not been discussed at the weekly meetings as they were concerned with abdominal distention. E11, and E2 confirmed that weekly weights were not recorded. Interview with E2, E3, and E10 also confirmed that no one had assessed her mouth for abnormalities as indicated in the care plan. The current care plan of 3/25/11 had no additional interventions added to address R1's poor intake at mealtimes.