Every finding on record at Evercare of Swansea

Based on observation, interview and record review, the facility failed to ensure residents were free of abuse for 2 (R6 and R7) of 4 residents reviewed for abuse in a sample of 9. Findings include: 1. R6's Undated Face Sheet, documents R6 was initially admitted to the facility on [DATE] with diagnosis including schizophrenia. R6's Quarterly Minimum Data Set (MDS) dated [DATE] documents R6 was cognitively intact. Behaviors: delusions: yes and other behavioral symptoms not directed towards others occurred 1 to 3 days. R6's Care Plan, dated 4/14/2026 documents he has hx (history) of aggravated assault. The resident is/has the potential to be physically aggressive. Goal: the resident will not harm self or others through the review date. Interventions: administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits and assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc.R6's Behavior Note, dated 6/12/2026 at 3:52 PM V3, ADON (Assistant Director of Nurses) documents resident placed on 1 on 1 monitoring for 72 hrs. r/t (related to) physical altercation with another resident. Resident up adlib ambulating throughout facility. No distress noted or aggressive behaviors. On 7/21/2026 at 4:15 PM R6 was observed yelling, screaming and cursing sitting on a chair in the hallway. R6 was very agitated and not interviewable at that time.On 7/23/2026 at 9:00 AM R6 stood at the nurse's station and when questioned what happened between him and (R7) he stated, You are an investigator and I am not telling you s****. 2. R7's Undated Face Sheet, documents R7 was initially admitted to the facility on [DATE] with diagnoses including depression, anxiety, seizures and psychosis. R7's Quarterly MDS dated [DATE] documents R6 was cognitively intact. No behaviors exhibited. R7's Care Plan, dated 8/28/2025 does not address abuse. R7's Behavior Note, dated 6/12/2026 at 3:16 PM V3, ADON documents made aware by staff that resident had altercation with another resident where this resident initiated confrontation with another resident causing both residents to fall on ground. Resident immediately assisted to chair and separated to different areas of the building. Resident has small abrasion above R (right) eye with no bleeding. Able to be redirected with no further issues noted. Currently seated in bedroom on bed with normal breathing pattern and no signs of distress. Guardian, psych NP (nurse practitioner) and MD (physician) made aware of situation. Resident placed on 1 on 1 observation x 72hrs (hours.)On 7/21/2026 at 10:48 AM, (R7) was walking down the hall with his wheeled walker. (R7) went to his room and sat on his bed. (R7) stated he didn't recall having an altercation with another resident in June 2026 but his memory isn't that great anymore and he has adopted a new philosophy don't cause no s*** there won't be no s***. On 7/22/2026 at 10:25 PM V17, Physical Therapy Assistant (PTA) stated she recalled the day (R6) and (R7) had an altercation because it was traumatic. V17 stated she was walking another resident to the therapy room and she overheard residents yelling and cursing outside in the smoke area. V17 stated she went outside and witnessed (R7) was laying on the ground and (R6) was hitting him with both hands in a closed first. V17 stated (V10) was on her knees attempting to shield (R7) from being hit by (R6.) V17 stated she immediately got (R6) to stop hitting (R6) and assisted (V10) off the ground and they both assisted (R7) off the ground. V17 stated she reported the altercation to (V2), Director of Nurses (DON) and (V3), ADON immediately and they took over from there. V17 stated she told both (V2) and (V3) what she witnessed and she spoke to (V1), Administrator the next morning about it. On 7/22/2026 at 8:30 AM V2, DON stated on 6/12/2026 she recalled (R6) and (R7) were outside smoking and staff (V10), CNA was out there supervising them. V2 stated (R6) and (R7) had a verbal altercation and (V10) intervened at that time. V2 stated (R7) swung at (R6) and he lost his balance grabbing onto (R6's) shirt and both residents fell on the ground. V2 stated when a resident-to-resident altercation occurs she expects staff to report it to her and/or to the Administrator and the charge nurse if they are not present in the building at that time. V2 stated staff are to separate the residents immediately to diffuse the situation and ensure each resident is going to a different location because they believe they need to let off steam and calm down. The nurse(s) assigned to the resident(s) expected to document a nurse's note as to what occurred and the residents are assessed at that time as well, including a skin assessment. V2 stated she expected all staff to follow the facility's abuse policy and resident should be free from abuse and mistreatment including from other residents. The Facility's Abuse Prevention and Prohibition Program, reviewed 12/2/2025 documents residents have the right to be free from mistreatment and abuse. The facility has zero tolerance for abuse and mistreatment. The facility is committed to protecting residents from abuse by including other residents. The Administrator is responsible for coordinating and implementing the facility abuse prevention policies, procedures and systems.

Based on interview and record review the facility failed to thoroughly investigate an allegation of physical resident to resident altercation for 4 (R4, R5, R6, R7) of 4 residents reviewed for abuse in a sample of 9.Findings include: R6's Undated Face Sheet, documents R6 was initially admitted to the facility on [DATE] with diagnosis including schizophrenia. R6's Quarterly Minimum Data Set (MDS) dated [DATE] documents R6 was cognitively intact. Behaviors: delusions: yes and other behavioral symptoms not directed towards others occurred 1 to 3 days. R6's Care Plan, dated 4/14/2026 documents he has hx (history) of aggravated assault. The resident is/has the potential to be physically aggressive. Goal: the resident will not harm self or others through the review date. Interventions: administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits and assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc.On 7/23/2026 at 9:00 AM R6 stood at the nurse's station and when questioned what happened between him and (R7) he stated, You are an investigator and I am not telling you s****. R7's Undated Face Sheet, documents R7 was initially admitted to the facility on [DATE] with diagnoses including depression, anxiety, seizures and psychosis. R7's Quarterly MDS dated [DATE] documents R7 was cognitively intact. No behaviors exhibited. R7's Care Plan, dated 8/28/2025 does not address abuse.On 7/21/2026 at 10:48 AM, (R7) was walking down the hall with his wheeled walker. (R7) went to his room and sat on his bed. (R7) stated he didn't recall having an altercation with another resident in June 2026 but his memory isn't that great anymore and he has adopted a new philosophy don't cause no s*** there won't be no s***. On 7/22/2026 at 10:25 PM V17, Physical Therapy Assistant (PTA) stated she recalled the day (R6) and (R7) had an altercation because it was traumatic. V17 stated she was walking another resident to the therapy room and she overheard residents yelling and cursing outside in the smoke area. V17 stated she went outside and witnessed (R7) was laying on the ground and (R6) was hitting him with both hands in a closed fist. V17 stated (V10) was on her knees attempting to shield (R7) from being hit by (R6.) V17 stated she immediately got (R6) to stop hitting (R6) and assisted (V10) off the ground and they both assisted (R7) off the ground. V17 stated she reported the altercation to (V2), Director of Nurses (DON) and (V3), Assistant Director of Nurses (ADON) immediately and they took over from there. V17 stated she told both (V2) and (V3) what she witnessed and she spoke to (V1), Administrator the next morning about it. V17 stated she didn't write a witness statement because she wasn't asked to do so. Review of the Facility's Serious Injury Incident and Communicable Disease Initial Report, documents staff reported an alleged resident-to-resident physical altercation between (R6) and (R7) on 6/12/2026. Detailed Incident Summary documents (R6) BIMS 15 - cognitively intact with diagnosis of schizophrenia and (R7) BIMS of 6 - cognitively impaired with diagnosis of epileptic seizure disorder, anxiety disorder and depression disorder. Immediate actions taken: residents immediately separated, both residents placed on 15 minute checks x 72 hours, both residents assessed with no injury noted. BIMS, skin, trauma assessment completed. Local PD (police department) notified, investigation initiated, resident/staff interviews initiated, final report will be in 5 working days. Final investigation: (R7) was interviewed and stated (R6) was mumbling. (R7) voices mocking (R6.) (R7) stated they did not make any physical contact and that (R6) kicked (R7's) foot. (R6) was interviewed and stated they were sitting outside and they never had physical contact. (V10), Certified Nurse Assistant (CNA) was interviewed and stated both residents were outside having a verbal disagreement. (V10) confirms redirecting both residents. (V10) voices (R6) walked up to (R7.) (V10) voices (R7) reached out for (R6) shirt causing both residents to lose their balance. (V17,) Therapy was interviewed and voices responding to assist (V10) with redirecting both residents and the above account to be true. Other staff that were there also did not witness any physical contact between (R6) and (R7) and stated they were not arguing prior in the day. V1, Administrator signed the bottom of the final report and documented N/A (not applicable) to the question: did the investigation confirm abuse. The facility's final physical resident to resident altercation investigation did not include staff written statements and did not document what actually occurred between (R6) and (R7) on 6/12/2026.R4's Undated Face Sheet, documents R4 was initially admitted to the facility on [DATE] with diagnoses including: dementia, hemiplegia and hemiparesis.R4's Quarterly MDS, dated [DATE] documents R4 is cognitively impaired and no behaviors exhibited. R4's Care Plan does not address abuse or at risk for abuse. R4's Physical Aggression Received Form, dated 7/8/2026 V3, Assistant Director of Nurses (ADON) documents incident description: nurse witnessed resident swatting hand at other resident with an open hand while seated at dining room table.R5's Undated Face Sheet, documents R5 was initially admitted to the facility on [DATE] with diagnoses including: bipolar disorder and paranoid schizophrenia. R5's Significant Change MDS, dated [DATE] documents R5 was cognitively intact and did not exhibit behaviors. R5's Care Plan did not address abuse or aggressive behaviors prior to 7/8/2026. Review of the Facility's Serious Injury Incident and Communicable Disease Initial Report, documents staff reported an alleged resident-to-resident physical altercation between (R6) and (R7) on 6/12/2026.On 7/22/2026 at 9:50 AM V11, LPN stated she was in the dining room on 7/8/2026 and recalled she saw R5 swat at R4 but he didn't hit him he just swatted at him. The Police Department Incident Report, dated 7/8/2026 documents (V11) was interviewed by the police and reported she witnessed (R5) grab (R4's) arm and that (R5) struck (R4) on his left forearm.Review of the Facility's Serious Injury Incident and Communicable Disease Initial Report, documents staff reported an alleged resident-to-resident physical altercation between (R4) and (R5) on 7/8/2026. Detailed Incident Summary documents (R4) cognitively impaired with diagnoses of cognitive communication deficit, hemiplegia and hemiparesis and (R5) cognitively intact with diagnoses of schizophrenia and bipolar disorder. Staff reported an alleged resident to resident altercation. The facility's final investigation documents staff interviewed voice they did not witness any physical interaction between (R4) and (R5.) There was no documented statement from the nurse (V11.)On 7/22/2026 at 11:16 AM V2, DON (Director of Nurses) confirmed the abuse folders the surveyor had completed investigations and had all the documentation the facility had for the resident to resident altercations between (R4) and (R5) that occurred on 7/8/2026 and the resident to resident altercation between (R6) and (R7) that occurred on 6/12/2026. On 7/23/2026 at 8:15 AM V2, DON stated she expects the resident to resident altercation abuse investigation documentation to correspond what actually occurred with the resident. V2 expects staff to tell the facility and IDPH staff what they reported to the police regarding what was witnessed during a resident to resident altercation so the facility abuse investigations are thorough and complete. V2 stated V3, ADON interviews staff and residents when there is an abuse allegation and she didn't know the facility final abuse documentation didn't correlate with what actually occurred during these resident to resident altercations. V2 was unable to explain why the final abuse investigations didn't document what occurred regarding the resident to resident altercations between (R4) and (R5) on 7/8/2026 and between (R6) and (R7) on 6/12/2026. On 7/23/2026 at 10:10 AM V5, [NAME] President of Operations stated there was no willful intent to harm regarding these resident to resident altercations so the facility didn't substantiate them. The State Operations Manual, with the issued date of 7-23-25, defines the following: Abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The Facility's Abuse Prevention and Prohibition Program, reviewed 12/2/2025 documents the facility promptly and thoroughly investigates reports of resident abuse and mistreatment and witness reports must be given in writing and signed and dated.

Based on interview and record review, the facility failed to provide supervision and monitoring for 1 of 1 (R38) resident reviewed for elopement. This failure allowed a resident with fluctuating cognition impairments to sign himself out of the facility on 11/27/2025 at 3:00 PM with unknown destination, unknown return, and with staff unaware of his whereabouts. At 9:40 PM police found R38 sitting on the ground, very confused, a mile away from the facility by a busy 4 lane highway intersection. R38 was transferred to the emergency room with multiple abrasions, bruises and lethargy where he required IV fluids, a head CT, X-Ray of chest and right knee. On 12/11/2025 at 1:40 PM V2 Director of Nurses, V3 Assistant Director of Nurses, V10, V25, V26 and V27 were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 12/12/2025 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include: R38's Former Facility Weekly Summary, dated 11/12/2025 at 5:23 PM documents resident is alert and orientated with episodes of forgetfulness and confusion. Vision impaired. Ambulates with w/w (wheeled walker) at times forgets walker. 11/13/2025 at 3:36 PM documents resident alert to self. Ambulates with walker with supervision within facility. Incontinent of bowel and bladder. Peri care when staff he allows it. R38's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with diagnoses including Parkinson's, diabetes, Bipolar and Schizophrenia. R38's Baseline Care Plan, dated 11/18/2025, V13, LPN documented R38's vision was adequate. Functional Status: independent with eating, oral hygiene, toileting, dressing, putting on/taking off footwear, setup assistance needed for personal hygiene. Mobility: independent, walk 10 feet: not assessed/no information documented. No mobility device. Level of consciousness: alert, cognitively intact, continent of bowel and bladder. Psychotropic medications included Seroquel, Abilify and Sertraline. Self-Administer medications: no. No pain. Resident is not a diabetic and no history of falls documented. Resident is not an elopement risk documented. R38's Health Status Note, dated 11/18/2025 at 11:09 AM documents resident arrived to the facility via private vehicle. Escorted to room and orientated to call light and remote. Resident is alert and oriented x 3. No c/o (complained of) pain voiced or noted. All medication orders entered into electronic medical record. Skin assessment completed upon admission to facility. No areas of concerns noted at this time. Resident currently in bed resting with eyes closed. Respirations even and unlabored. Call light in reach and functional. R38's Electronic Medical Record dated 11/18/2025 at 11:10 AM through 11/27/2025 at 4:11 PM, no progress notes documented including no assessment of R38's cognition or behavior. R38's Nurse Practitioner (NP) New Admit Progress Note, dated 11/19/2025, documents [AGE] year-old male presents to me today at NF (nursing facility) as new admit. He has dx (diagnosis) of anxiety, bipolar disorder, HTN (high blood pressure), depression, COPD (chronic obstructive pulmonary disease), vitamin d deficiency, insomnia and diabetes. He is resting in bed. He appears stable in no acute distress. He voices no acute concerns. Nursing has no acute concerns. He is ambulatory. He is current smoker, and he does not wish to quit smoking. He is A&O (alert and oriented) to person and place. Cognitive status documented: forgetful.R38's Elopement Evaluation, dated 11/18/2025, documents he was not an elopement risk. R38's Functional Abilities and Goals - admission assessment, dated 11/18/2025 V13, LPN documented functional cognition: independent, no impairment for functional limitations range of motion, no mobility devices checked, independent with toileting. Walk 10 feet: not assessed/no information documented. Walk 50 feet with two turns: not documented. Walk 150 feet not documented. Walking 10 feet on uneven surfaces: the ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel: not documented. 1 step (curb): documented not assessed/no information. 4 steps: the ability to go up and down four steps with or without a rail: not documented. 12 steps: the ability to go up or down 12 steps with or without a rail: not documented. R38's Nurse Practitioner (NP) Progress Note, dated 11/26/2025 documents chief complaint/reason for this visit: low hemoglobin. HPI (History of Present Illness) to this visit: [AGE] year-old male is ambulatory and is A&O (Alert & Orientated) to person. Cognitive status: forgetful. R38's Health Status Note, dated 11/27/2025 at 4:12 PM, documents resident signed out LOA (leave of absence.) No documentation of where R38 was going, who he was going with, when he was expected to be back or what he was wearing when he left the facility. R38's Orders - Administration Note, dated 11/27/2025 at 6:57 PM documents LOA. No additional information was documented regarding R38 being on LOA. R38's Community Survival Skills Assessment documents the assessment date 11/18/2025 and created dated 11/28/2025 V2 documented the resident appears to be capable of outside pass privileges at this time. On 12/9/2025 at 10:00 AM V13, LPN (Licensed Practical Nurse) stated she didn't know R38 well because he was a new resident, admitted a few weeks prior. V13 stated she admitted R38 when he was initially admitted to the facility, R38 arrived with 3 or 4 pages of paperwork from the previous facility which included his medication list and a face sheet. V13 stated she documented R38's admission paperwork from the information and how he presented upon initial observation of him. V13 stated R38 seemed to be alert and oriented to person, place and time at the time of admission. V13 stated when a resident is initially admitted to the facility the assigned nurse is responsible for documenting a clinical assessment, which is the resident's initial nurse assessment, but she couldn't find that assessment in R38's electronic medical record, V13 stated she must have forgot to do it because she is always very busy with all resident care. V13 clarified she didn't document R38's Community Survival Assessment although it's dated 11/18/2025 V13 showed it was created and documented on 11/28/2025 by V2 and she didn't understand that because R38 left the facility LOA on 11/27/2025 and he didn't return to the facility. V13 stated she works full time at the facility and recalled as the days went by after R38 was admitted , she reassessed R38 and noted he talked to himself and was very confused and was alert to person only. V13 stated she didn't document that R38 was confused in his electronic medical record, but she probably should have but she was so busy at the facility and gets overwhelmed with admissions, discharges, medications and all the things and she can't document everything. V13 stated she couldn't recall what was documented on R38's face sheet if he was his own responsible party or not upon admission but she recalled at the end of November 2025 administration was running around trying to find out if R38 had a power of attorney or not because he signed himself out of the facility and was later found by the police. V13 stated R38 ambulated without an assistive device and his gait was steady at the facility. He required assistance from staff for ADLs (Activities of Daily Living) but he often refused care and was incontinent of bladder and cursed at staff when they attempted to provide incontinence care. R38 stated V13 didn't have safety awareness and shouldn't be anywhere including out in the community by himself because he was alert to person only. V13 recalled R38 was aggressive and refused care and cursed at staff. V13 stated if R38 was his own responsible party he could sign himself out of the facility because this isn't jail, but she would want to know where he was going and when he planned to be back to the facility. V13 clarified that R38 was confused and forgetful and he shouldn't have signed himself out and left by himself because he could've got hurt. On 12/10/2025 at 10:28 AM V16, LPN stated she is an agency nurse and works at the facility a few times a month. V16 stated she arrived at the facility on 11/27/2025 at approximately 7:00 AM and was assigned to the 100 hall and was assigned to R38. V16 stated she never met R38 before and she didn't get report from night shift nurse (name unknown) because the night shift nurse had left the facility prior to her arrival. V16 stated she recalled R38 took his medications without issue that morning, but she didn't know him at all and didn't know if he was alert or what his diagnoses were. V16 recalled R38 ambulated without an assistive device but she couldn't recall if his gait was steady or not. V16 recalled at approximately 3:00 PM R38 stated he was leaving the facility, so she asked the 200-hall nurse (V9) how to sign R38 out and she told her to have R38 sign out in the resident sign out book and to document R38 was leaving in his electronic medical record. V16 stated she didn't know if R38 had a power of attorney or if he was his own responsible party the time he requested to leave the facility but this isn't a prison so she thought he could leave. V16 stated she didn't look to see if R38 had medications due and didn't send any medications when he signed out. V16 stated she didn't ask R38 where he was going or when he'd be back to the facility, but it was Thanksgiving and she assumed he was going to have Thanksgiving dinner with his family. V16 stated there was a lot of residents coming and going that day and she didn't have time to look at all the resident's medical records to check on their face sheet status. V16 stated she left the facility for lunch for 30 minutes at 3:00 PM so she didn't let R38 out of the facility and she didn't see R38 leave the facility. R16 stated when she got back to the facility after coming back from lunch R38 was on LOA. V16 stated she didn't observe R38 walking around outside and if she did, she would have addressed him and asked what he was doing because he definitely shouldn't be walking around outside by himself because it was really cold that day and she would want to ensure he was safe. V16 stated she didn't know what the big deal was that R38 signed himself out because this isn't prison and he has the right to leave.R38's POS, dated 11/27/2025 documents R38 had medications prescribed at 5:00 PM for treatment of Parkinson's disease: Carbidopa Levodopa 25/100 milligrams (mg), medication to treat heart disease: Entresto 49/51 mg, medication to treat diabetes: Metformin 500 mg and medication to treat blood pressure: Metoprolol 25 mg. R38's Medication Administration Record (MAR), dated 11/27/2025 staff documented 1 in the space for R38's 5:00 PM medications absent from home without medications.On 12/10/2025 at 9:52 AM V9, Registered Nurse (RN) stated she worked 11/27/2025 day shift from 6:00 AM to 6:00 PM and was assigned to the 200 hall. V9 stated she didn't know R38 and didn't meet him. V9 didn't know who the 100 hall nurse was that worked that day but she recalled it was an agency nurse. R9 recalled at some point that day the 100 hall nurse asked her how to document when a resident wants to leave the facility and she showed the 100 hall nurse to document the resident was leaving and to document he was on LOA in his electronic medical record as well. When a resident wants to leave the facility V9 stated she first checks the resident's face sheet to ensure the resident is their own responsible party and doesn't have a power of attorney because if the resident has a power of attorney she would call the resident's POA to ensure they are picking the resident up and ask what time the resident's approximate time of return so she knew where the resident was going and to ensure the resident was safe. On 12/10/2025 at 12:30 PM V9 stated she didn't let R38 out of the facility on 11/27/2025 and she didn't see R38 leave the facility. On 12/10/2025 at 8:15 AM V20, CNA stated she worked day shift from 6:00 AM to 2:00 PM on 11/27/2025 and was assigned the split assignment, which consists of residents on both 100 and 200 halls. V20 stated R38 was independent with ADLs and residents on the 200 halls were dependent so she spent 99% of the shift on the 200 hall. V20 stated she didn't know R38's cognitive status and didn't know R38 well at all because he was a new resident. On 12/10/2025 at 12:33 PM, V20 stated she didn't assist R38 with any ADLs that shift, and she left the facility at 2:00 PM so she didn't walk him out of the facility and she didn't see R38 leave the facility. On 12/9/2025 at 9:00 AM V8, CNA stated she worked on 11/27/2025 and was assigned to 200 hall. V8 stated she arrived to the facility at 6:00 AM and left the facility around 6:00 PM that day. V8 stated she recalled R38 and stated he ambulated without any devices at the facility and his gait was steady. V8 stated R38 knew his name and talked to himself often. V8 stated R38 didn't have safety awareness and he was exit seeking all day long and often set exit door alarms off. R38 threatened staff he was going to sign himself out and leave the facility but V8 didn't think he should do that because he could get lost outside if he leaves by himself. V8 stated she didn't have a lot of hands on care interactions with R38 because she wasn't assigned to him but she could tell he was confused because he talked to himself often and he didn't know his name at times. 12/11/2025 at 2:16 PM V8, CNA spoke with me regarding R38 going LOA a few days ago and stated she worked day shift on 11/27/2025 and was assigned to 200 hall so she wasn't assigned to R38. V8 stated she assisted residents to the dining room from the 100 hall and observed R38 pacing back and forth at the 100 hall nurse's station at approximately 11:45 AM and he was saying he wasn't going to eat this s*** food and he was leaving. V8 stated it was a really busy day at the facility that day and that residents were going in and out of the facility. V8 stated she didn't let R38 out of the facility and didn't see R38 leave the facility.On 12/12/2025 at 8:30 AM V28, CNA stated she was assigned to 200 hall on 11/27/2025 and worked from 2:00 PM to 10:00 PM. V28 stated when she got to the facility that day there were no CNAs on the 100 hall and the day shift CNAs had already left the facility. V28 stated she did her best to take care of residents on both 100 and 200 hall but the 200 hall residents are more dependent on staff care so she stayed on the 200 hall most of the shift. V28 stated no CNAs were on the 100 hall until V30 got to the facility and that was between 4:00 PM and 4:30 PM that shift. V28 stated she didn't know R38 at all, she hadn't met him. V28 stated she didn't let any residents out of the facility that day and she didn't observe any residents leaving the facility (including R38.) V28 stated it was a very crazy day at the facility because residents were going in and out of the facility all day long. On 12/9/2025 at 1:15 PM V19, LPN stated she worked night shift on 11/27/2025. V19 stated she got to the facility at 6:00 PM and worked until 11/28/2025 at 6:00 AM. V19 stated she was assigned to the 100 hall, and she didn't receive nurse report from the day shift nurse (V16) because she already left the facility before she got there. V19 stated there were a lot of residents on LOA because they were with their families for Thanksgiving. V19 stated R38 was a new resident, he was admitted a few weeks ago and she worked night shift so she administered his medications a few times but that was all interactions she had with him, and he seemed to be alert. V19 stated she didn't know if R38 had safety awareness because she only had interactions of administering him medications at night. V19 stated R38 ambulated without an assistive device and his gait was steady. V19 didn't know R38 was on LOA that day until the police came to the facility at approximately 10:00 PM and told her R38 was found outside sitting on the side of the road and was transported to the emergency room. V19 stated she knew R38 was his own responsible party because when the police came to the facility, she printed his face sheet and there was no POA, or family contacts documented on R38's face sheet at that time. V19 stated after the police left the facility, she immediately called V2, DON and reported to her that R38 was found by the police and was at the emergency room. R38's Sign Out/Acceptance of Responsibility for Leave of Absence Form, documents he signed out at 3:00 PM on 11/27/2025. The responsible person signature is illegible. No additional documentation on this form. R38's Electronic Medical Record, dated 11/27/2025 no documentation of resident being found by the police in the community. A Police Report dated 11/27/2025 documents on 11/27/2025 at 9:40 PM police officer was dispatched to the area of Illinois 161 and Boul Avenue in reference to a pedestrian in the roadway. Dispatch advised the caller was an elderly black male and appeared intoxicated. Arrived in the area and located the caller, who pointed out the subject sitting on the ground on the north side of Illinois 161 across from 1721 Boul Avenue. I advised dispatch of the location and activated my emergency lights, which activated body cameras. Approached the subject, later identified as (R38.) I asked R38 what was going on. R38 attempted to stand and appeared very unsteady on his feet. I noted R38 appeared very lethargic and had a hard time keeping his eyes open. R38 had very slurred and garbled speech, but no other indications of intoxication. R38 was difficult to understand. However, I was able to gather that he lived at a nursing home, went for a walk and had got lost. R38 stated he lost his wallet and did not have a cell phone. R38 stated he was from Peoria, Illinois and he just wanted assistance getting home. Due to his state, I requested EMS respond to the scene. While waiting for the ambulance R38 was assisted by 2 police officers to a patrol car so he could sit inside and warm up. While waiting on the ambulance, I tried to gather more information from R38. Originally, he told me a wrong name (resident very confused and didn't know his name at that time) and that his birthday was sometime in June. I asked dispatch to run that name, but no records were located. R38 continued to state that he was from Peoria, Illinois. R38 stated that he did have Thanksgiving dinner somewhere nearby, but that I was unable to determine where. R38 only stated that he took a nap, went for a walk, and then ended up in an unfamiliar neighborhood. I asked R38 some medical questions and he confirmed that he was diabetic, I provided this information to the dispatch as well. When EMS arrived, I explained my findings to them and agreed R38 should be transported for advised that they had contacted all the local nursing homes and none of them have a patient missing from their facility. I search Omnigo and in house records, there was no record in either database for the resident's name. Upon arriving at the ambulance bay, the EMT advised R3's hands were too cold to extract to sample for a blood sugar test. When I arrived to the emergency room, I provided staff with the information I had. I continued speaking with R38 while the doctor performed an assessment. R38 had several bleeding lacerations and abrasions to his knees and shins. R38 also had a wound on his left foot. R38 both hands appeared black, which the doctor indicated was a sign of frostbite. I continued to ask questions and R38 advised that last name could be (R38 gave a different name), which I believed may be his mother's name. I asked dispatch to run that name combination, with no success. EMS personnel advised R38 kept stating he lived in Peoria at a facility that was named Ever-something. With this I decided to go to the facility in person to verify no patients were missing from the facility. When I arrived at the facility, I spoke with V19, who advised R38 was a resident of the facility but that he had been checked out earlier in the day. V19 showed me the resident sign out sheet, which showed someone checked R38 out at 3:00 PM. The place where the responsible party was to sign, was illegible, and no other information was completed on the sheet. I obtained an information sheet from the nurse, which showed no emergency contact information. I advised V19 I would have a report on file and that R38 was currently unwell at the local hospital. I returned to the emergency room and provided the doctor with R38's information sheet and medication list. She advised that R38 had abnormal labs and would be admitted for the night. The doctor stated when R38 is cleared, they will ensure he returns to the facility safely. Per the police report R38 gave the police officers over 3 different names. ON 12/10/2025 at 6:10 PM, V21 Police Officer stated a passerby called 911 and reported there was a pedestrian was in the middle of the road and they were afraid they were going to get hit by a car. V21 stated R38 was very confused and gave her at least 3 different names he was so confused he didn't even know his name. She had dispatch call around to local nursing homes to see if they were missing residents and the local nursing homes denied missing any residents. V21 stated her and another police officer had to assist R38 to sit in her police car until the ambulance arrived so he could warm up. V21 stated R38's gait was terrible, and he was stumbling around, V21 stated her and the other police officer were holding him up to walk him to her vehicle. V21 noted R38 had multiple bruises and scrapes on him so she called an ambulance to transport him to the emergency room. V21 stated she was very concerned for him because he was so confused and didn't know what was going on and he could have really got hurt outside in the cold and being by himself. R38 finally told her he lived at Ever something and so she went to the facility and staff told her R38 wasn't missing because he had signed himself out. V21 stated she spoke to V19 at the facility and she showed her that R38 signed himself out of the facility and stated she wasn't working at that time because R38 signed himself out at 3:00 PM and she arrived to work at the facility at 6:00 PM that day. V19 told her she didn't know R38's cognitive status and didn't know if he had safety awareness and didn't know if R38 was cognitively able to be out in the community by himself. V21 stated she updated V19 that R38 is currently at the emergency room getting assessed and that he was unwell. R38's Hospital Paperwork, dated 11/18/2025 documents history and physical illness: [AGE] year-old male with history of significant high blood pressure, COPD, heart failure, bipolar and dementia brought in by EMS from side of the road. Per EMS report patient has been out in the cold for a while found by PD called EMS patient reportedly alert orientated x 1 at the time of contacts. Unable to give much history according to PD, patient found on the found at highway. They believe that he may be from nursing home. Emergency department (ED) physical assessment: Constitutional appearance: ill- appearing. Vital signs temperature 97.8 degrees, pulse 116, respirations 23, blood pressure 106/70 and oxygenation saturation 100%. Skin: abrasion right knee and on the palm of the right hand, great toe on the left looks like that has some trauma to the toenail with blood underneath and bruising present. Neurological: unable to give name, date or location, oriented times zero at this time and weakness present. R38 had IV fluids to treat dehydration, blood work drawn, CT head without contrast and X-Ray of chest and right knee. ED triage notes: EMS reports patient had been out in the cold for a while by police department called EMS patient A&Ox1, unable to give accurate answers telling different year for the birthday and places. EMS reports patient possibly fell and complaint of knee pain, small laceration on right hand. An ER RN documented on 11/28/2025 at 2:48 AM, attempted to contact facility via phone to give an update regarding patient's admission status, no answer at this time. R38's Communication with Family (Next of Kin)/POA (Power of Attorney) dated 11/28/2025 at 5:18 PM, documents spoke with V6, R38's family. She states he is doing better today but states he could've frozen to death, and he has had to have a blood transfusion. She states we allowed him to be outside long. She states he shouldn't have been outside by himself. I explained he signed out and he had a coat on and was dressed appropriately. He told staff he was going out for Thanksgiving dinner. She is asking the facility what kind of compensation the facility will be giving him, and she wants to know by Mon (Monday) or she will be forced to call the state. I contacted our Admin (Administrator) to follow-up with her.On 12/9/2025 at 11:22 AM V6, R38's Family stated R38 has limited sight due to having cataracts and glaucoma and only see blurry images. V6 stated R38 was initially admitted to the facility a few weeks ago and no one at the facility contacted her to get information regarding R38's health or safety status. V6 stated she called and attempted to give the facility information regarding R38's care and lack of safety awareness but she wasn't transferred to a nurse, and no one called her back. V6 stated R38 has dementia, Parkinson's and psychotic disorders including Schizophrenia and Bipolar. V6 stated R38 knows his name and that's it, he is very confused and doesn't have safety awareness, R38 needs staff to assist him to change his clothes and he is incontinent of bowel and bladder, and he won't change his diaper if staff don't assist him. V6 stated the facility didn't notify her that R38 signed himself out of the facility or that the police were at the facility regarding his whereabouts or that he was in the hospital on [DATE]. At approximately 10:00 PM on 11/27/2025 the hospital called her and requested consent to treat R38, but she didn't know why he was at the hospital and didn't know he left the facility by himself until 11/28/2025 and she was very upset because she is R38's family and he shouldn't have been able to sign himself out because he is very confused and forgetful and isn't cognitive enough to be out by himself. V6 stated R38 was admitted to the facility because she could no longer take care of him because he needs managed care 24/7 and they let him leave the facility by himself and he could have died on the street by himself. On 12/10/2025 at 8:35 AM V6 stated in 2024 R38 left a hospital in St. Louis, Missouri and he ended up taking a train and to Illinois and he fell off the train platform and had to have extensive tests done and had a huge goose egg on his back from the fall. V6 stated when R38 was transferred to the facility from a sister facility the nurses, social worker and the transport staff told her that R38's paperwork including the POA paperwork was sent with him and given to staff at the facility upon admission on [DATE]. V6 stated she visited R38 in the evening on 12/9/2025 and he was a lot more alert and knew who the president is now and told her he was outside by himself a few days ago and he was scared to death because he couldn't see all he could see was bright lights and he felt he was going to get hit by a truck. R38 also told her that he was crawling around trying to get shelter because he was freezing and afraid he was going to freeze to death. On 12/10/2025 at 4:40 V22 former facility Administration stated R38 was a resident at that facility 11/15/2025 through 11/17/2025 and then R38 was transferred to the facility. V22 stated R38 was alert to person and place and was really confused. V22 stated R38 walked with a wheeled walker, and he often forgot it in his room so staff would go get it for him. V22 stated R38 could walk approximately 25-40 feet without his wheeled walker. V22 stated R38 was a fall risk as he fatigued while ambulating easily, so he always needed his wheeled walker with him. V22 stated R38 didn't have safety awareness and although he was his own responsible party, he wouldn't allow R38 to leave without someone to drive him because he was confused and forgetful and his facility is rural, surrounded by cornfields so it wouldn't be appropriate for R38 to sign himself out and leave the facility. On 12/10/2025 at 11:42 AM V2, DON stated R38 was admitted to the facility with 3 or 4 pages of information including a face sheet, medication list and a few nurse's notes. V2 stated there was no POA paperwork, no emergency contact and no family member documented on R38's admission paperwork. V2 stated there is a corporate liaison and they sent her preadmission paperwork regarding R38 and she wasn't updated that R38 was out by himself in the past and he got lost and fell off a train platform, if she would have been given that information, she wouldn't have accepted him as a resident because he needs a locked memory unit, and the facility isn't locked. The liaison told her R38 needed a private room due to aggressive behaviors but not that he was an elopement risk. Upon admission a licensed nurse assesses the resident and documents the assessment in a resident's electronic medical record, part of the admission assessment the nurse assesses the resident's cognitive status and if the resident's cognitive status changes after admission, V2 expects the nurse to document a progress note. When a resident is a new admission, she expects the assigned nurse to document a progress note at least once a day and document how the resident is doing for the next 7 days to ensure the resident is doing well at the facility. When a resident wants to sign out and go on leave of absence, she expects the assigned nurse to look at the resident's face sheet to see if the resident is their own responsible party or if they have a POA or guardian. If the resident has a POA she expects staff to contact the POA and ask who is picking the resident up and ask where they are going and when they are expecting to returned to the facility and the assigned nurse should document that information on the 24 hour nurse report sheet to ensure the facility knows when the resident is expected to return to the facility so if they aren't back by that time staff can start calling the resident's family so the facility knows the resident is ok. No staff called her regarding R38 going out LOA, but she doesn't expect staff to call her unless something is wrong. V2 stated the night shift nurse called her the evening of 11/27/2025 approximately 7:00 PM and reported to her that the police were at the facility and reported to staff that R38 was found over a mile and a half down the street, and he was very confused, and he was at the hospital. V2 stated she spoke to the police officer and confirmed R38 was a resident at the facility, and she didn't know he was at the hospital, and he was found on the sidewalk with multiple scrapes and bruises about his body. V2 stated she had 3 or 4 interactions with R38, and she didn't know R38 good enough to say if he had safety awareness or not. V2 stated she expected staff to follow policies and procedures of the facility to ensure residents are taken care of. On 12/12/2025 at 8:30 AM V2, DON stated she didn't understand the severity of the citation regarding R38 because he signed himself out of the facility and he was his own responsible party. V2 stated the facility didn't contact IDPH to report the incident regarding R38 being found by the police and be transported to the emergency room because he signed himself out and it was her understanding when a resident sign themselves out of the facility then the facility is no longer responsible for the resident and that was the purpose of the resident signing themselves out.On 12/10/2025 at 1:31 PM V14, NP stated she initially assessed R38 on 11/19/2025 and he was alert to person and place and was forgetful and confused but he had just moved to the facility, so she didn't know if that's his baseline or not because she just met him. V14 stated she reassessed R38 on 11/26/2025 and he was alert to self only that day and he was confused and forgetful and after that assessment, V14 stated it was her professional medical assessment that R38

Based on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 3 residents (R26) reviewed for abuse in a sample of 32. This failure resulted in R26 obtaining a laceration to the forehead requiring medical treatment.Findings Include:R26's Undated Face Sheet documents R26 was originally admitted to the facility on [DATE] and has a Medical Diagnosis of Hypertension, Schizophrenia, Depression, Type 2 Diabetes, and Hemiplegia Affecting Left Non-Dominant Side.R26's Minimum Data Set (MDS) dated [DATE] documents R26 is cognitively intact and has had verbal behavioral symptoms directed towards others occurring 1-3 days.R26's Care Plan Date Revised 12/2/2025 documents R26 is/has potential to be physically aggressive toward peers related to anger, poor impulse control.R26's Behavior Note dated 12/2/2025 at 8:48 PM documents This nurse was notified by a Certified Nursing Assistant (CNA) that resident was bleeding from being struck in the head with an object by roommate. Resident has a laceration to left side of forehead. Resident refused vital signs (v/s) resident was in full rage resident breathing and responding well and is able to state what is going on in details. Sending resident to hospital for eval.R26's No Type Specified Note dated 12/3/2025 at 4:09 AM documents Resident returned to facility via Emergency Medical Service (EMS) two EMS workers transported resident from stretcher to bed. Resident denies pain at this moment. Residents' laceration was repaired with sutures Per hospital report the sutures should dissolve on their own.R11's Undated Face Sheet documents R11 was originally admitted to the facility on [DATE] and has a Medical Diagnosis of Hypertension, Major Depressive Disorder, Bipolar Disorder with Psychotic Features, Generalized Anxiety Disorder, and Schizophrenia. R11's MDS dated [DATE] documents R11 is cognitively intact.R11's Care Plan Last Revised 10/15/2025 documents R11 is/has potential to be physically aggressive related to anger, poor impulse control, and Bipolar. The Facility's Initial Serious Injury Incident and Communicable Disease Report dated 12/2/2025 at 8:05 PM documents Staff reported an alleged resident to resident physical altercation.The Facility's Final Serious Injury Incident and Communicable Disease Report dated 12/8/2025 documents A comprehensive investigation including resident/staff interviews and review of both residents' medical records was conducted. Medical record review reveals R11 and R26 were involved in a relationship per both of their requests. R11 was interviewed and voices that R26 pulled her hair. R11 voices she struck R26 in an attempt to have him release her hair. R26 was interviewed and voices that he grabbed R11's hair. R26 voices R11 struck him in the head. Multiple staff members were interviewed. No staff witnessed any physical contact between the two residents. Follow up Actions: R26 was transported to Local Hospital for evaluation and treatment due to minor alteration in skin integrity to scalp. R26 received 1 suture to left scalp. R11 was transferred to Local Hospital for psychiatric evaluation. Both residents returned to facility and the following actions were taken: Resident safety checks were initiated and ongoing monitoring. Both residents were separated and placed in different rooms on different halls. R11 was offered the option to transfer to another facility. R11 agreed and was transferred to another facility. Based on the results of the investigation, the facility noted staff did not observe the physical altercation. Both residents provided conflicting accounts but confirmed physical interaction and mutual aggression. Appropriate medical and psychiatric evaluations were completed, and safety interventions-including separation and eventual resident transfer-were implemented to mitigate further risk. Both residents care plans were reviewed and updated accordingly.R26's Local Hospital Medical Records Date of Service 12/2/2025 at 9:41 PM documents Chief complaint: patient presents with assault victim. Patient brought in via Emergency Medical Service (EMS) from Nursing Home Facility. Per EMS patient was involved in a dispute over peanut butter and was hit with a metal footrest of a wheelchair on the left forehead by the other individual.R26's Local Hospital Medical Records Dated 12/2/2025 at 10:22 PM documents procedure laceration repair, repair type: sutures.On 12/11/2025 at 11:04 AM V13, Licensed Practical Nurse (LPN), stated R11 and R26 both have a lot of behaviors and have had multiple altercations with each other. V13 stated the last altercation with R11 and R26 was a physical altercation and both R26 and R11 were sent to the hospital for evaluation.On 12/11/2025 at 11:10 AM V9, Registered Nurse (RN), stated R11 and R26 have been verbally aggressive with staff, each other, and other residents. V9 stated R11 and R26 were in a relationship and would argue all the time.On 12/11/2025 at 11:15 AM V8, Certified Nursing Assistant (CNA), stated R11 and R26 have behaviors and have had altercations with each other.On 12/11/2025 at 11:51 AM V23, LPN, stated she was working at the facility on 12/2/2025 and was passing medications when staff came to her and stated there was an altercation between two residents. V23 stated when she went down the hall, she seen R11 holding a metal foot pedal from a wheelchair in her hand and R26 bleeding from his head. V23 stated R11 told her R26 pulled her hair and she then hit him in the head. V23 stated staff separated the residents and both were sent to local hospitals for evaluation. V23 stated R11 and R26 have had multiple verbal altercations prior to this physical altercation.On 12/11/2025 at 12:03 PM V14, Nurse Practitioner (NP), stated R11 and R26 have had altercations in the past, mostly being verbal altercations. V14 stated she was informed R11 had hit R26 in the head with an object. V14 stated R11 and R26 were sent out to Local Hospitals for evaluation. V14 stated R26 received a suture to R26's head from the altercation. V14 stated the facility should have interventions in place to keep residents safe and free from abuse.On 12/12/2025 at 8:47 AM V2, Director of Nursing (DON), stated R11 and R26 were in a relationship and would have disagreements all the time. V2 stated the facility would call R11 and R26 the facility's toxic couple. V2 stated both R11 and R26 have behaviors and the altercation that happened on 12/2/2025 was a physical altercation. V2 stated R26 stated R11 was trying to tell him to do something and R26 grabbed R11 by the hair and pulled R11 to the ground. V2 stated R11 grabbed the pedal from her wheelchair and hit R26 on the side on the head. V2 stated both R11 and R26 were sent to local hospitals and R26 obtained a suture to the laceration on R26's head. V2 stated R11 did not obtain any injuries from the altercation, that she only had some hair pulled out on the side of her head.The Facility's Abuse Prevention and Prohibition Program Policy Last Reviewed 6/1/25 documents Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property.

Based on observation, interview, and record review, the facility failed to wear appropriate PPE (Personal Protective Equipment) and perform hand hygiene to prevent the spread of infections. This failure has the potential to affect all 58 residents residing in the facility.Findings Include: 1.On 12/9/2025 9:54 AM R59 stated he tested positive for COVID last week and the facility staff have not worn gowns when coming into his room to provide care. There was no container or red biohazard bag observed in R59's room or bathroom to dispose of dirty Personal Protective Equipment (PPE) in. R59 stated there have been no containers with red biohazard bags to dispose dirty gown and gloves in and staff are putting their dirty gloves in his trash can. Sign of R59's door states Warning COVID-19 high risk of infection beyond this point. Please wear a face covering. No sign indicating resident is on contact/droplet isolation for COVID. R59's Undated Face Sheet documents R59 was originally admitted to the facility on [DATE] and has a Medical Diagnosis of Heart Failure, Hypertension, and Major Depressive Disorder. R59's MDS (Minimum Data Set) dated 12/5/2025 documents R59 is moderately cognitively impaired and is on isolation or quarantine for active infectious disease. R59's Care Plan Date Initiated 12/11/2025 documents R59 has infection of the Respiratory Systems. Intervention Date Initiated 12/3/2025 documents maintain universal precautions when providing resident care. R59's Physician Order dated 12/5/2025 at 8:27 PM documents strict isolation- all care to be given in room. R59's No Type Specified Note dated 12/3/2025 at 8:54 PM documents R59 returned from Local Hospital with Diagnosis (DX): of COVID. No new orders received. R59's Health Status Note dated 12/4/2025 at 1:59 PM documents Tested positive for covid 01 12-3. No distress noted. Complaints of (C/O) headache and effective treatment with Tylenol. Continues on isolation. R59's Health Status Note dated 12/10/2025 at 1:43 AM documents Resident on isolation related to (r/t) COVID 19. 2.On 12/9/2025 at 10:11 AM V7, Housekeeping, observed cleaning room [ROOM NUMBER] with a surgical mask and gloves on. Signs on room [ROOM NUMBER]'s door states Enhanced Barrier Precautions, Warning COVID-19 high risk of infection beyond this point. Please wear a face covering. V7 stated room [ROOM NUMBER] has residents that are positive for COVID-19 and she knows what Personal Protective Equipment (PPE) to wear from the sign on the room door. 3.On 12/09/25 at 12:15 PM, R1 had a sign on the outside of the door indicating COVID-19 high risk of infection beyond this point, please wear a face covering beyond this point. There is nothing indicating R1 is on contact/droplet precautions for COVID or what PPE is required to enter the room. R1 stated she tested positive for COVID after she was admitted to the facility, she has to stay in her room and sometimes the staff wear a mask when they come in her room but nothing else. The Line Listing for COVID-19 Outbreaks, document R1 tested positive for COVID on 12/4/25. 4.On 12/09/25 at 2:34 PM, R9 had a sign on the outside of the door indicating COVID-19 high risk of infection beyond this point, please wear a face covering beyond this point. There is nothing indicating R9 is on contact/droplet precautions for COVID or what PPE is required to enter the room. Face covering required beyond this point. There wasn't any trash receptacle in or immediately outside of the room to dispose of PPE or trash. The Line Listing for COVID-19 Outbreaks, document R9 tested positive for COVID on 12/6/25. 5.On 12/9/2025 at 10:31 AM V9, Registered Nurse (RN), arrived to R23's to change R23's colostomy bag. V9 put on clean gloves without washing her hands. V9 asked V5 (Certified Nursing Assistant, (CNA), if V5 could go get some hand sanitizer for her. V5 brought in bottle of hand sanitizer and place bottle on R23's bed side table. V9 removed R23's current colostomy bag and cleansed around R23's stoma. V9 disposed of gloves and put on another pair of clean gloves without performing hand hygiene and continued to cleanse R23's stoma. V9 removed gloves and donned a new pair of gloves with no hand hygiene and began cutting new colostomy bag for R23. V9 placed new colostomy bag around R23's stoma site. V9 removed gloves and began to cut adhesive tape and placed tape around R23's colostomy bag without performing hand hygiene. R23's Undated Face Sheet documents R23 was originally admitted to the facility on [DATE] and has a Medical Diagnosis of Chronic Kidney Disease Stage 3, Colostomy Status, Hypertension, Chronic Diastolic (Congestive) Heart Failure, and Need for Assistance with Personal Care. R23's MDS dated [DATE] documents R23 is cognitively intact, is dependent on staff for toileting hygiene, physical hygiene, and has a colostomy. R23's Care Plan Date Revised 11/20/2025 documents R23 will remain on Enhanced Barrier Precautions related to colostomy status. On 12/9/2025 at 10:05 AM V10, Regional Nurse Consultant, stated each resident who is on isolation for COVID-19 should have a container and a red biohazard bag in their room to dispose PPE in. On 12/12/2025 at 12:49 PM V2, Director of Nursing (DON) stated if a resident tests positive for COVID-19, the resident is to wear a mask in their room and all staff that enter the resident's room is to wear a mask. V2 stated if the resident comes out of their room, the resident is strongly encouraged to wear a mask. V2 stated staff and visitors should wear a mask and gloves when entering a resident's room who is positive for COVID-19. V2 stated staff should wear a mask, gown, and gloves if they will come into contact with a resident's bodily fluids who is COVID-19 positive. V2 stated staff and visitors are made aware of which type of personal protective equipment (PPE) to wear when entering a resident that is COVID-19 positive by the signage posted on the resident's door. V2 stated the sign posted on a resident's door will say Warning, you are required to wear a mask. On 12/12/2025 at 12:49 PM V2, Director of Nursing (DON) stated all staff are required to wash their hands every time they make contact with a resident, before assisting with food, and after touching any high contact areas. V2 stated she expects staff to wash their hands or perform hand hygiene before putting on gloves, when changing gloves, and after taking off gloves. On 12/12/2025 at 12:53 PM V26, Administrator Sister Facility B, stated a resident that is positive for COVID-19 should be on Contact Isolation. The CDC (Centers for Disease Control) Infection Control Guidance for SARS-CoV-2, dated 6/24/24, documents, in part, the following: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control is recommended for individuals in healthcare settings who have suspected or confirmed SARS-CoV-2 infection. HCP (Healthcare Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The Infection Precaution Policy, dated 10/1/25, documents all PPE should be used once and discarded in either the trash or used linen receptacle before you leave the room. The Centers for Medicare & Medicaid Services, Form 671, dated 12/9/25, documents there are 58 residents residing in the facility.

Based on observation, interview and record review, the Facility failed to provide residents with flavorful and properly cooked food for proper food temperatures and ensure food is held at temperatures to prevent food borne illness. This has the potential to affect all 58 residents living in the facility. Findings include: On 12/10/2025 at 7:40 AM, The Food Log for 12/10/2025 for the breakfast services was blank and did not document any food temperatures. On 12/10/2025 at 8:08 AM, during the breakfast service V24, Dietary Manger took out an industrial size pan of hash browns out of the oven. (V24) did not take the temperature of the hashbrowns and placed it in the steam table and served the residents without taking any temperatures. On 12/10/2025 at 8:59 AM, a food tray was taken after the last resident had been served and the eggs hashbrowns were not palatable and were cold with a rubbery texture and were not pleasant to eat. The hashbrowns were cold and mushy in texture. The temperatures taken with a calibrated metal thermometer were 90.4 F for the eggs and the hashbrowns were 101.0 F.On 12/10/2025 at 9:13 AM, V24, Dietary Manager stated he did not record any temperatures in the Food Logbook this morning for the breakfast menu. 1-R43's Minimum Data Set (MDS) dated [DATE] document he was cognitively intact for decision making of activities of daily living. On 12/10/2025 at 2:22 PM, R43 stated the food is not hot when it is supposed to be hot and yesterday the breakfast was cold. 2-R13's MDS dated [DATE] document she was cognitively intact for decision making of activities of daily living. On 12/10/2025 at 2:24 PM, R13 stated because of COVID they are serving everyone out of Styrofoam containers and her breakfast was cold today. The meals are cold a lot here. 3-R18's MDS dated [DATE] document she was cognitively intact for decision making of activities of daily living. On 12/10/2025 at 2:25 PM, R18 stated the food is not always hot and her breakfast this morning with state in the building was cold.4-R15's MDS dated [DATE] document she was cognitively intact for decision making of activities of daily living. On 12/10/2025 at 2:27 PM, R15 stated her food is cold and this morning her eggs were cold, and she could not eat them. The food is usually cold here.4-R59's MDS dated [DATE] documents he was cognitively intact for decision making of activities of daily living.On 12/10/2025 at 2:29 PM, R59 stated the food is usually cold when it comes out to the residents. Resident/Family Council Minutes dated 9/24/2025, Dietary Cold Food, Cold coffee. Resident Council Meeting Minutes dated 11/2025 document, Food has gotten better in dietary. (hotter). Dietary: No complaints food better. Resident Council Meeting dated 1/20/2025 Dietary: Running out of substitutes. Food served cold, especially the soups.On 12/12/2025 at 10:15 AM, V34, Dietician stated, I expect all food on the steam table to be held at minimum 135 degrees Fahrenheit. Anytime food temperatures drop less than 135 degrees it puts the resident at risk for food borne illness. All food should always be over 135 F while sitting on the steam table of higher.

Based on observation, interview and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 58 residents living in the Facility. Findings include: During the breakfast service on 12/10/2025 at 8:16 AM, V24 was serving eggs, oatmeal, and toast, and was not wearing gloves and he was touching the toast for each resident's breakfast meal without gloves. He was touching the oven, oven mitts and other things without washing his hands or disinfecting his hands. V24 handled every piece of toast without gloves. On 12/10/2025 at 8:16 AM, V32, [NAME] was on her personal cell phone, and was wearing gloves, and after the phone call had ended, she put the phone in her pocket did not change gloves or wash hands. V32 was handling butter packets and putting them in a large container. On 12/10/2025 at 8:17 AM, V32 stated she had just started working this week and has not completed any food safety training and did not know she was supposed to wash her hands after touching her phone before handling food. On 12/10/2025 at 8:19 AM, V24, Dietary Manager stated he would expect all staff to wash their hands after touching their phones and handling any food items. On 12/12/2025 at 10:20 AM, V34, Dietician stated, I would expect staff to leave all of their personal items behind including phones and drinks. If any staff would touch something like a phone, I would expect them to go to the sink in the kitchen and wash their heads because this creates cross contamination to food. I would not expect any kitchen staff to directly touch food and I would expect them to use tongs when touching toast. The Facility Dietary Staff Hand Hygiene Policy reviewed 10/1/2025 Hand washing Policy Purpose: To establish standards for employee dress, personal hygiene and hand hygiene practices. Guidelines: 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 . Dietary employees will adhere to the facility hand hygiene policy and will perform hand hygiene as follows: Before preparing food or putting on gloves.The CMS 671 Form dated 12/9/2025 documents there were 58 residents living in the facility.

Based on interview and record review the Facility failed to ensure Care Plans were resident centered and up to date for 1 of 5 residents (R13) reviewed for Care Plans in the sample of 32. Findings include: R13's Physician Order Sheet for December 2025 documents a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, adjustment disorder with anxiety, polyneuropathy, unspecified, acute posthemorrhagic anemia, unspecified sequelae of cerebral infarction, depression, mood disorder, hypertension, tachycardia, heart failure, and epilepsy. R13's POS also documents she has an order for Lidocaine External Patch 4 % (Lidocaine), Apply to left leg topically in the morning for leg pain. Lidocaine External Cream 3 % (Lidocaine). Apply to bilateral leg topically two times a day for leg pain, Date initiated 5/23/2025. R13's Hospital Physician Notes dated 10/22/2025 at 11:30 AM, 1) Knee: Bilaterally primary osteoarthritis of knee. I will provide bilateral knee braces today. Meloxicam 15 mg (milligrams), take 1 tablet every day by oral route. 2) Lumbar stenosis with neurogenic claudication. Neurological Surgeon Referral. Schedule within providers discretions. Note to Provider: Evaluate and treat. R13's Care Plan with a review date of 8/19/2025 does not address any pain in R13's knees. On 12/10/2025 at 10:02 AM, V2, Director of Nursing stated, We currently do not have a Care Plan Coordinator. We all (management) try and step in and make sure all of the Care Plans are up to date. All Care Plans should be resident centered. On 12/10/2025 at 10:24 PM, V2, Director of Nursing stated, Apparently (R13) has a lot of arthritis and she did see the specialist and they recommended therapy, but her insurance would not pay for it. She was complaining about pain, and she was supposed to get an appointment with the orthopedic specialist. I do not know anything about her having a brace. We lost our Social Service Person so I will try and make sure she gets an appointment. I did not realize (R12's) Care Plan did not address the pain in her legs. (R12's) Care Plan should have addresses her knee pain. The Care Plan Policy with a reviewed date of 9/2/2025 documents, to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.

Based on observation, interview and record review the Facility failed to address pain in 1 of 4 residents (R13) reviewed for pain in the sample of 32. Findings include: R13's Physician Order Sheet for December 2025 documents a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, adjustment disorder with anxiety, polyneuropathy, unspecified, acute posthemorrhagic anemia, unspecified sequelae of cerebral infarction, depression, mood disorder, hypertension, tachycardia, heart failure, and epilepsy. R13's POS also documents she has an order for Lidocaine External Patch 4 % (Lidocaine), Apply to left leg topically in the morning for leg pain. Lidocaine External Cream 3 % (Lidocaine). Apply to bilateral leg topically two times a day for leg pain, Date initiated 5/23/2025. R13's Care Plan with a review date of 8/19/2025 does not address any pain for R13's knee. R13's Minimum Data Set (MDS) dated [DATE] BIMS 13/15, resident is independent on most task. Does use a walker. No impairments on upper or lower extremities. On 12/10/2025 at 9:34 AM, R13 was rubbing her knees and was grimacing when she bent her legs. On 12/10/2025 at 9:39 AM, R13 stated, I am having a lot of issues, my knees, and have been in a lot of pain. My knees are killing me, and I thought they were supposed to get an appointment with the knee/bone specialist but if they have, I do not know when that appointment is, and I feel like things should be more organized. Resident was not wearing any knee braces. R13 stated her pain is a 10 out of 10 this morning. On 12/10/2025 at 10:00 AM, R13 stated she was never given a knee brace. R13 also stated they did give her pain medicine this morning, but she just took it. On 12/10/2025 at 10:03 AM, No knee braces were being stored in R13's room, under the bed and/or in the closet. On 12/10/2025 at 10:03 AM, V14, Social Service Director stated he has been here for two weeks now and was not sure about any orthopedic appointments for (R13). I will look into it. On 12/10/2025 at 10:23 AM, V14 stated, (R13) does not have any appointment scheduled for (R13) with any orthopedic specialist. R13's Hospital Physician Notes dated 10/22/2025 at 11:30 AM, 1) Knee: Bilaterally primary osteoarthritis of knee. I will provide bilateral knee braces today. Meloxicam 15 mg, take 1 tablet every day by oral route. 2) Lumbar stenosis with neurogenic claudication. Neurological Surgeon Referral. Schedule within providers' discretions. Note to Provider: Evaluate and treat. On 12/10/2025 at 10:24 PM, V2, Director of Nursing stated, Apparently (R13) has a lot of arthritis and she did see the specialist and they recommended therapy, but her insurance would not pay for it. She was complaining about pain, and she was supposed to get an appointment with the orthopedic specialist. I do not know anything about her having a brace. We lost our Social Service Person so I will try and make sure she gets an appointment. On 12/10/2025 at 12:56 AM, V2 stated I just talked with (R13) and she said she did have some braces but they were too big and so she did not wear them. I did not know this until today. The Facility Pain Policy with a reviewed date of 6/1/2025 documents, To ensure accurate assessment and management of the resident's pain.

Based on observation, interview, and record review, the facility failed to administer medications as prescribed by the physician in 2 of 3 residents (R7, R22) reviewed for medication errors in the sample of 32. Findings Include:1.On 12/10/25 at 8:05 AM, V12, Agency LPN (Licensed Practical Nurse), was observed administering medications to R7. V12 did not administer R7's Timolol eye drops, Anastrozole, or Omeprazole. R7's Face Sheet, undated, documents R7 has, in part, the following diagnoses: Malignant Neoplasm of the Right and Left Breast and Glaucoma. R7's MAR (Medication Administration Record), documents the following physician orders: 11/15/25 Timolol Maleate Ophthalmic Solution 0.5% instill one drop in the right eye twice daily for eye pressure; 11/15/25 Anastrozole 1mg (milligram) daily for breast cancer; 11/15/25 Omeprazole 20mg twice daily for acid indigestion. R7's MAR goes on to document that on 12/10/25, the above medications were not administered as ordered. R7's Progress Notes, dated 12/10/25, fail to document that R7's Physician was notified that those medications were not administered. 2.On 12/10/25 at 8:15 AM, V12, Agency LPN, was observed administering medications to R22. V12 did not administer R22's Omeprazole, Endurant, or OsCal. R22's Face Sheet, undated, documents R22 has, in part, a diagnosis of HIV (Human Immunodeficiency Virus). R22's MAR, documents the following physician orders: 1/14/25 Omeprazole 20mg twice daily for GERD (Gastroesophageal Reflux Disorder); 1/14/25 Edurant 25mg daily for HIV; 1/14/25 Oyster Shell 500mg twice daily. R22's Progress Notes, dated 12/10/25, fail to document that R7's Physician was notified that those medications were not administered. On 12/10/25 at 8:15 AM V12, Agency LPN, stated R7's Timolol, Anastrozole, and Omeprazole are not in the medication cart. V12 stated R22's Omeprazole, Endurant, and OsCal are not in the medication cart. V12 stated she will make a note and try to find them later. If she finds it, she will give it, but she is not going to stop because she doesn't know where the medication room is. On 12/12/25 at 1:15 PM, V2, DON (Director of Nurses), stated when a medication is not available in the medication cart, the nurse is to check the medication supply room, if it is not found, they are to contact pharmacy to see what the status is on the medication. Then the resident's physician is to be notified that the medication was not administered with a request to hold the medication until it arrives. The Medication Administration Policy, with a review date of 6/1/25, documents, in part, if a medication is not given, licensed personnel should document the medication was not given, notify the physician, and place a note in the resident's chart.

Based on observation, interview and record review, the facility failed to perform hand hygiene before and after glove changes and wear personal protective equipment during wound care for 3 of 3 (R1, R2 and R4) residents, reviewed for infection control in a sample of 8. Findings include:1.V5, Licensed Practical Nurse (LPN), performed hand hygiene and donned gloves but did not don an isolation gown for enhanced barrier precautions to perform wound care to R2. There was not any signage on R2's door or supplies for enhanced barrier precautions. V5 removed an old dressing from R2's left calf that was dated 11/17/2025. She then, without benefit of hand hygiene or glove change, cleansed R2's open area on his left calf with wound cleanser, covered with polymem max silver dressing, super absorbent dressing was placed, and area was wrapped with kerlix. She then removed her gloves and performed hand hygiene. She prepared the dressing supplies for R2's right leg. V5 applied gloves without benefit of hand hygiene, removed the dressing, which was dated 11/17/25 from R2's right calf and without benefit of hand hygiene or glove change, she cleansed the open area with wound cleanser. She then took triad cream and applied it to the polymem max silver dressing. With the same gloved hands applied the polymem max silver dressing that had triad cream on it, applied the super absorbent dressing and wrapped R2's right leg with kerlix. 2. V5, LPN, entered R4's room, donned gloves without benefit of hand hygiene and did not don a gown for enhanced barrier precaution. There was no signage on R4's door to notify staff that he was on enhanced barrier precautions nor was there supplies for enhanced barrier precautions. She opened the 4x4 gauze pads and sprayed wound cleanser on them, with the same gloved hands and she cleansed the area to the back of R4's left calf. She then, with the same gloved hands, opened a package of skin prep and applied it to the back of R4's left calf wound.3. V8, Registered Nurse, performed hand hygiene and donned a pair of gloves. She then opened a package of 4x4 sponges, took the Dakin's solution bottle and moistened the sponges and cleansed R1's wound on his outer ankle. V8, RN then removed her gloves and donned another pair of gloves without benefit of hand hygiene and opened the mupirocin ointment container and applied it to another 4x4 gauze sponge. She then doffed her gloves and without benefit of hand hygiene and donned another pair of gloves and she opened the calcium alginate package and cut a piece from it for R1's wound, then opened the bordered gauze dressing package, and removed it. With the same gloved hands, V8, RN applied the mupirocin ointment, and the calcium alginate to R1's wound bed and then covered the area with the bordered gauze dressing.On 11/19/2025 at 11:00 AM, R7 stated that the nurses do not wear an isolation gown when they come in to take care of her wounds. R7's Face sheet, documented that she was her own responsible party. R7's Physician's order sheet, dated 11/18/2025, documented, Enhanced Barrier Precaution initiated r/t wounds.On 11/18/2025 at 11:00 AM, R4 stated that the nurses don't wear the gowns when they come and fix his leg. R4's Minimum Data Set (MDS) dated [DATE] documented that his cognition was moderately impaired. R4 Physician's order sheet, dated 11/18/2025, documented, Enhanced Barrier Precaution initiated r/t wounds.On 11/17/2025 at 10:00 AM, R2 stated that the nurses don't where the isolation gowns when they change my dressing. R2's MDS, dated [DATE], documented that his cognition was intact. R2's R2's Physician's order sheet, dated 11/18/2025, documented, Enhanced Barrier Precaution initiated r/t wounds.On 11/18/2025 at 10:20 pm, V5, LPN, stated that she should have worn a gown but some of the residents don't like it if they are wearing a gown because they think they are contagious with a STD and that R2 and R4 should be on Enhanced barrier precautions. She also stated that she should have washed her hands in between glove changes.On 11/19/2025 at 11:02 AM, V11, LPN stated that she wears the isolation gowns when she does residents treatments. She also stated that hands should be washed in between glove changes.On 11/19/2025 at 11:05 AM, V3, LPN stated that she wears the isolation gowns when she does the residents wound care and now, they have the supplies outside of the resident's doors and signage. V3, LPN stated that hands should be washed in between glove changes.11/20/2025 at 3:00 PM, V2, Director of Nurses, stated that she would expect the staff to wear isolation gown and wash hands between glove changes.The facility's policy, EBP, (Enhanced Barrier Precautions), undated, documented, EBP may be considered and implemented for: Wounds and/or indwelling medical devices (central line, feeding tube, tracheostomy, drains, ect.) It continues, Personal Protective Equipment: Standard Precaution must be followed with all cares. Additionally, gown and gloves must be worn when providing the following cares. It continues, Wound care.The facility's policy, Hand Hygiene, undated, documented, When to Wash hands with soap and water only (May use Alcohol Based Hand Sanitizer for All Other): It continues, After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. After contact with inanimate object (including medical equipment) in the immediate vicinity of the patient. If hands will be moving from a contaminated-body site to a clean-body site during patient care. Before glove placement. After glove removal.

Based on interview and record review, the facility failed to initiate, implement, and add progressive care plan intervention for 2 of 3 residents (R5 and R8) reviewed for falls in a sample of 23. This failure resulted in R5 falling and sustaining a laceration to his head and R8 falling and sustaining a fracture to her left wrist. Finding Include:1. R8's admission Record, print date of 08/05/25, documented R8 has diagnoses of but not limited to Multiple Sclerosis and other abnormalities of gait and mobility. R8's Minimum Data Set (MDS), 05/27/25, documented R8 is cognitively intact with a brief interview of mental status (BIMS) of 14 out of 15 and she requires substantial/maximum assistance from staff for toileting hygiene and she requires partial/moderate assistance with transfers from bed to chair and toilet transfers.R8's Baseline Care Plan, dated 05/16/25, documented under section Functional Abilities and Goals- Mobility for toilet transfer: The ability to get on and off a toilet or commode not assessed/no information. Under safety risks does resident have a history of falls? There was no documentation noted. R8's Care Plan, admission date of 05/16/25, documented R8 has had an actual fall with injury to left wrist Poor Balance, Poor communication/comprehension, Unsteady gait (Date initiated 07/03/25). Goal: resident's left wrist will resolve without complication by review date. Interventions include but not limited to Resident will ask for assistance with transfers.R8's Un-witnessed Fall, dated 07/02/25 at 10:50 AM, documented the nurse heard someone yelling for help, sound coming from 200 hall shower room. Resident observed sitting on the floor near toilet in shower room. No emergency light flashing for assistance at time of incident. Resident stated I fell trying to go to the bathroom. I think I broke my hands and wrists when I fell. A full body assessment was completed and there was bruising noted to the back of bilateral hands. STAT x-ray was ordered. Predisposing Physical Factors were gait imbalance, predisposing situation factors ambulating without assist and during transfer.R8's Progress Notes, dated 7/2/2025 at 11:08 AM, documented Incident Note Nurse heard someone yelling for help, sound coming from 200 hall shower room. Resident observed sitting on the floor near toilet in shower room. No emergency light flashing for assistance at time of incident. Resident stated I fell trying to go to the bathroom. I think I broke my hands & wrists when I fell. Full body assessment completed. Bruising noted to BILAT (bilateral) wrists. ROM (range of motion) WNL (within normal limits) to BILAT Upper extremities. ROM WNL to BILAT Lower extremities. Resident stated she did not hit her head. C/O (complained of) pain to wrists/hands BILAT. No other c/o pain noted. Resident assisted to toilet and into w/c (wheelchair) after. Ice applied to BILAT wrists/hands. STAT X-rays orders of BILAT upper extremities. MD (medical doctor), DON (director of nursing), Administrator made aware immediately. POA (Power of Attorney) to be made aware.R8's Progress Notes, dated 7/2/2025 at 11:37 AM, documented Note Text: Biotech Xray Tech here to obtain x-rays of BILAT wrists/hands. Awaiting results.R8's Progress Notes, dated 7/2/2025 at 2:55 PM, documented POA contacted and given update on results (negative/no Fx's (fractures) noted) and assured that if any new orders are received, she would be notified.R8's Progress Notes, dated 7/3/2025 at 10:53 AM, documented Biotech called back with update stating that the Medical Director will be reviewing the reading we received from yesterday's x-ray since there had been a discrepancy in reading with new results stating the L (left) wrist has a transverse fracture of the distal radius.R8's X-ray report, dated 07/02/25, documented Findings: There is no significant soft tissue swelling appreciated. There is a traverse fracture of the distal radius. Impression: transverse fracture of the distal radius.R8's Progress Notes, dated 7/3/2025 at 12:56 PM, documented Ambulance arrived to transport resident to local hospital related to (r/t) left wrist swelling r/t fall. Bruising and visible swelling to Left wrist. Able to make needs know and voice discomfort upon discharge (d/c). Refused noon medication upon leaving. R8's Physician's Orders, dated 07/07/25, Occupational Therapy (OT) clarification order: OT to treat 3-5x/wk (times/week) x 41 days for ADL retraining, neuro re-ed, therapeutic activities, therapeutic exercise and group therapy as per Plan of Care (POC). R8's Physician's Orders, dated 07/08/25, documented Physical Therapy (PT) clarification order: Skilled PT 3-5x/week for 41 days with treatment to include therapy exercises (ex), therapy activities (act), neuro re-ed, gait training, group and manual therapy for treatment of diagnoses M62.81 and R26.81 per PT initial POC. R8's Illinois Department of Public Health Long- Term Care Facility & IID- Serious Injury Incident and Communicable Disease Report, Incident Date of 07/03/25, documented Final Report R8 had a fall with physical harm or injury. She uses a wheelchair and is a transfer with two assists. R8 is interviewable, can make informed decisions, and is alert and oriented times three. The conclusion: R8 suffered a transverse fracture of the distal radius to the left wrist during a fall where she was transferring without asking for assistance. R8 does have several diagnoses that would make her more susceptible to fractures. Root cause of that fall was due to R8 lack of safety awareness which is shown by not asking for assistance or use of a call light, nor did she turn on the lights while trying to self-transfer. R8 was educated (BIMS 14) and reminded to use call light system if needing assistance. R8 stated understanding. On 08/19/25 at 9:05 AM, R8 had an orange plaster cast on her left hand and wrist. She (R8) said she fell while trying to go to the bathroom. She said she was using the bathroom in the shower room when she fell. She said there was no handrail to help her, and she feels that is part of the reason she fell.On 08/25/25 at 11:06 AM, V10, Regional Maintenance Man said not all of the bathrooms have handrails in them. He said they would do a safety assessment on the resident first and if they had no issues with them, they would install the handrails. He said as far as he knows there is no regulation about having handrails in the bathrooms.On 8/26/25 at 1:02 PM, Follow up interview with R8. R8 was propelling self-down hall in wheelchair. Stated she goes to the bathroom by herself and went to the bathroom by herself before she broke her wrist. Denies getting any assist from staff for toileting.On 8/26/25 at 1:05 PM, V32, CNA, stated R8 is standby assist for toileting. R8 is pretty independent and likes to do things on her own but she does let us know when she needs to use the bathroom because she likes someone to be there with her. She can do just about everything, but we help her pull her pants up. R8 did not require any assist with toileting prior to breaking her wrist and was independent with toileting.On 08/26/25 at 1:41 PM, V33, Nurse Practitioner (NP) said if someone has a diagnosis of Multiple Sclerosis (MS) they are a higher risk for falls, and she would assume the facility would have something in place for falls.2. R5's admission Record, print date of 08/10/25, documented R5 has diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alzheimer's disease, muscle weakness, and seizures.R5's MDS, 06/25/25, documented R5 is moderately cognitively impaired with a BIMS of 09 out of 15 and he is dependent on staff or requires substantial/maximal assistance with his activities of daily living (ADLs). He is always incontinent of bowel and bladder.R5's Care Plan, admission date of 01/17/25, documented R5 has had an actual fall related to (r/t) mobility, weakness. 05/08/25 actual fall, 06/15/25 actual fall, 08/09/25, actual fall. Goal: R5 will remain free from falls and injury. Interventions include but not limited to 5/8/25: Keep bed in lowest position (date initiated: 05/15/25). 6/15/25: Do not leave in room up in wheelchair if resident is restless (date initiated: 08/05/25). 8/9/25 Educate resident on allowing staff to assist with getting out of his wheelchair (date initiated 08/20/25).R5's Progress Notes, dated 05/08/2025 at 05:18 AM, documented Incident Note This Nurse was on 100 hall passing meds (medications) when notified by staff that the resident was on the floor. When this Nurse entered the room, the resident was found lying flat on his back side, head against his nightstand with left leg bent up dressed in his sleepwear. This Nurse did a full head to toe assessment and found a slight lump/bump on the top of his head. No skin tears noted. Resident was unable to give description of the incident. Resident voices pain to back and neck. On the pain scale 0-10 resident stated pain was an 8. Resident is A&Ox2 (alert and oriented times two). V/S (vital signs) WNL (within normal limits). DON (Director of Nursing) notified and made aware. R5's son was contacted, no answer, message left. Local ambulance was contacted; they arrived at 23:02pm (11:02 PM). 2 EMT (emergency medical technicians) transferred resident out to local hospital for further evaluation. Report was called and given to hospital RN (Registered Nurse), ER (emergency room) charge Nurse.R5's Progress Notes, dated 6/15/2025 at 1:42 PM, documented Staff assisted resident back to own room after lunch. Resident was fidgeting in w/c (wheelchair). Resident lowered self out of w/c onto floor softly and laid down on back. Resident alert entire time and did not hit head during change of plain. Full body assessment completed. Resident assisted back into w/c and positioned. No s/s (signs or symptoms) of injury noted. No c/o (complaints of) pain noted. ROM (range of motion) WNL. 5's vital signs were stable. Administrator & Family made aware.R5's Fall Risk Evaluation, dated 06/15/25, documented R5 has had 1-2 falls in the past three months, he is chairbound/incontinent, predisposing diseases: respond based on the following predisposing conditions: hypotension, vertigo, cardiovascular accident (CVA), Parkinson's Disease, loss of limb(s), Seizures, Arthritis, osteoporosis, fractures, and delirium. It documented he had none of the predisposing conditions present. Under Gait/Balance it documented R5 has decreased muscular coordination. Under risk for falls there is no documentation noted. R5's Fall Investigation Worksheet, dated 08/09/25 at 9:50 PM, documented R5 takes antianxiety, antihypertensive, and cardiovascular medications. He was agitated, restless, and combative. It also documented R5 had an unwitnessed fall in his room, and he requires supervision. Contributing clinical factors: Hemiplegia/Hemiparesis and Cognitive impairment. Root cause of fall was he was attempting to get up without assistance. It documented he did not have a call light within reach because he was sitting in front of the television (TV). Handwritten statement by V25, CNA documented she tried to lay R5 down around 7:40 PM. R5 didn't want to go to bed at that time. Later another CNA went in to try to get him to lie down and he became combative, so she let his CNA (V25) know. V25 then went in at around 8:30 PM to see if she could get him to lie down before it was time for her to leave for the evening. It documented she went to gather her things and her, and another CNA were going to go and put R5 to bed. When they walked into R5's room at 9:46 PM R5 was on the floor face down.R5's Progress Notes, dated 8/10/2025 at 01:28 AM documented Incident Note 2150p (9:50 PM) This nurse was notified by assigned CNA (Certified Nursing Assistant) staff resident was found face down on the floor by door of assigned living area. Resident was laying prone on the floor with face (left face down) looking over right shoulder. Resident was bleeding from left side of head (unknown origin) with large hematoma on left upper forehead. Resident was conscious A/O x3 and able to respond to verbal commands. Resident was not moved from original position. Patient stated that he did not have any pain/discomfort from extremities; however, expressed discomfort when his head was touched. Resident's vitals were assessed with BP (blood pressure) 108/53 / PR (pulse rate) 68 / O2 (oxygen) 95%. Resident informed of transport and agreed to be taken to local hospital via ambulance upon arrival of local Ambulance at 10:10p. DON notified of incident at 10:15p once resident stable and assessed by EMS (emergency medical services) with neck brace applied and soft stretcher used to log roll resident to supine position. Resident further assessed and taken by ambulance. Local PD (police department) responded to call.Note: Resident has verbal challenges that made it difficult to assess situation.R5's Progress Notes, dated 8/10/2025 at 01:34 AM, documented Resident transported to local hospital via ambulance after 911 call made due to fall. Resident refused to be placed in bed with staff reporting multiple attempts to transfer resident to bed with resident being combative. Resident was redirected several times per assigned staff resulting in resident refusing to leave position in chair. Nurse observed resident in prone position with injury to left side of head. All details of incident reported by CNA. DON notified of findingsR5's Progress Notes, dated 8/10/2025 02:38 AM, documented Resident being monitored for injury with report from hospital RN noting that resident is in the ER pending stiches/staples to laceration on left forehead. All scans returned with no fx (fracture) found. Resident is resting well awaiting discharge from ER. DON notified of all findings. R5's Progress Notes, dated 8/10/2025 at 04:29 AM, documented Per local hospital ER Resident has been treated with three steri strips to the wound on left forehead. Resident is waiting for transport by ambulance back to facility. DON updated on progress of resident.R5's emergency room Report, dated 08/09/25, documented the reason for his visit was due to a fall and his diagnoses were fall and head contusion. On 08/25/25 at 10:45 AM, V24, [NAME] President (VP) of Clinical Services said it would depend on the situation. If the resident was restless and up in their chair, she would expect them to bring the resident out to the common area unless it would upset them more. If it would cause them to become more agitated, then they should increase monitoring due to increased behaviors. She said they are wanting to change R3's wheelchair so it is more comfortable and safer for him.On 08/26/25 at 1:41 PM, V33, NP said she would expect the nursing staff to keep a close eye on him (R5) if he was restless and became combative due to not wanting to go to bed. You can't force them to go to bed so she would expect the nursing staff to keep a close eye on him.The facility's fall evaluation and prevention policy, not dated, documented 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. It further documented RESIDENTS SHOULD BE EVALUATED FOR THEIR FALL RISK *On admission/re-admission to the home, *Following any change of status that may affect balance, mobility, or safety, *Following a fall, and *Quarterly. RISK FACTORS ASSOCIATED WITH A FALL Intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications. The following are examples of common intrinsic risk factors: *Gait and balance disorders, *Muscular weakness (particularly of the lower extremities), *Stroke, *Seizure disorder, and *Previous falls. It also documented Extrinsic risk factors for falls are part of the resident's environment and are most likely to be seen in areas such as the bedroom, bathroom, dining room, and hallways. The following are typical examples of extrinsic risk factors: *Lack of or loose handrails. It also documented Fall Evaluation and Prevention Provide an elevated toilet seat and grab bars in the bathroom if indicated. Refer resident to PT or OT. It further documented Evaluate the environment where the fall occurred, noting any factors that may have contributed to the fall (i.e., wet floor, socks without skid resistant pads, assistive device out of reach). Ask the resident what happened prior to the fall or what may have caused the fall. Root Cause.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/15/25 documents there are 56 residents living in the Facility.

Based on interview and record review the facility failed to assess and develop behavioral interventions for a resident with diagnoses of schizophrenia and bipolar disorder and notify the physician of resident having active hallucinations for 1 of 1 resident (R3) reviewed for behavioral services in a sample of 23. This failure resulted in R3 being sent out to the emergency room (ER) for evaluation and found to have a fractured nose and two fractured ribs. Findings Include:R3's admission Record, print date of 08/20/25, documented R3 has diagnoses of but not limited to Schizophrenia and bipolar disorder.R3's Minimum Data Set (MDS), dated [DATE], documented R3 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 04 out of 15, he requires supervision/touching assistance with most of his activities of daily living (ADLs), and he doesn't have any behavioral symptoms.R3's Care Plan, admission date of 08/04/25, documented Behavior Management New Delusional/hallucinations behavior related to his schizophrenia 8/16/25 resident was seeing snakes and bugs and trying to stomp on them. Resident also jumping around off and on furniture, swinging arms around swatting at birds, diving onto the floor. Goal: Cause of new onset behaviors will be evaluated/determined and undesirable behavior(s) will be monitored/managed. Interventions include but not limited to ensure the safety of resident and others and evaluate medication schedule and possible pharmacologic causes of hallucinations. The date created for this problem was 08/18/25. R3's Progress Note, dated 8/17/2025 at 01:12 AM, documented Behavior Note: Resident running up and down the hallway screaming rat's, snakes and birds were in his room. resident jumping up and down stomping on the floor saying he is stomping the rats. Resident re-directed back to his room.R3's Progress Notes, dated 8/17/2025 at 02:33 AM, documented Note Text: Resident came out of his room with blood on his face and nose. Resident nose twisted to the right. Local ambulance called to transport resident to local hospital. Call placed to Power of Attorney (POA) with no answer. Message left to call the facility.R3's Physician's Orders, dated 08/06/25, documented R3 has an order for Ziprasidone Mesylate (Geodon) Intramuscular Solution Reconstituted 20 milligrams (MG) (Ziprasidone Mesylate) Inject 0.5 milliliters (ml) intramuscularly as needed (PRN) for extreme agitation. R3's Medication Administration Record (MAR), for the month of August 2025 had documentation he was given his PRN Geodon on 08/11/25 and on 0813/25. There was no documentation he received his any PRN medication on any other days.R3's Progress Notes were reviewed and had no documentation the physician was notified of R3 having active hallucination. R3's emergency room History and Physical Report, dated 08/17/25, documented R3 is a [AGE] year-old male patient with a medical history significant for but not limited to bipolar disorder, schizophrenia, dementia, hypertension, anemia presents to the ED via EMS from local nursing home with a chief complaint of facial injury. R3's Computed Tomography scan (CT-scan) of Facial Bones, dated 08/17/25, documented R3' findings as a minimally impacted anterior nasal bone fracture. R3's CT-scan of the Cervical Spine, dated 08/17/25, documented R3 had findings of Other osseous structures: Mildly impacted fractures of the right 2nd and 3rd ribs.On 8/21/25 at 1:10 PM, V8, Certified Nursing Assistant (CNA) stated V2, Director of Nursing (DON) asked her about R3, but she wasn't here that day. She said he had been running around, chasing snakes, hallucinating, jumping around, wandering into other resident rooms. V8 doesn't know what happened to R3. He could have run into a wall or something, the way he was acting. He had been like that since he got to the facility but hadn't been there too long. She said maybe this facility was not a good fit for him.On 8/21/25 at 1:13 PM, V25, CNA, stated R3 was always running everywhere. He was a safety risk to himself and may have been better in a lockdown unit. V8, CNA was standing in the area and stated We do have a lot of guys that can get angry and territorial around here.On 8/21/25 at 3:52 PM, V30, CNA stated she did not see it happen, he had gone to his room, came out, stood at nurse's station, and she asked what happened to his nose because it had blood at the bridge of it. R3's nose looked crooked, so the Nurse assessed him and made some calls. One was to the sister, there was no answer, so a message was left. Then they called 911. V30 said she hadn't worked with R3 before. She said he was up and down the halls, around nurse's station, sitting on floor, in hallway, stating he saw bugs or a snake, saw a bird. She said R3 was bad, and he had been acting like that all shift. She saw him go towards a few doors but never actually went in that she saw. V30 said she had never seen him that bad, never seen him act like that. He would walk up and down the halls and around the nurse's station. DON interviewed me about this.On 8/21/25 at 4:00 PM, V29, CNA said R3 was acting different, running around nurse's station, skipping, wasn't saying anything to nobody. When you told him to slow down or to sit down, he would for about two minutes and then he would get back up. He was really fidgety that night. She gave R3 a snack and some water and when he was done, he said he was going to bed. He would go to his room and then he would come right back out. V29 said around 3:00 AM she went to the bathroom and she heard a bump in his room due to it is right next to the bathroom wall. She said she came out and he was coming out of his room and another CNA asked what was wrong with his nose. The nurse said it was crooked and it had some drops of blood on it. V29 said they just thought he may have hit it on the headboard or maybe he fell and hit his nose. She said they had never seen him act like that before. On 8/22/25 at 8:14 AM, V28, Licensed Practical Nurse (LPN) stated R3's fall and bloody nose were two separate incidents. R3 fell earlier in the night around 7:30 PM. He had been running up the hall toward the 100 hall and ran into her. He fell on his bottom. No injuries. Around 3AM he came out of his room after being in there about 45 min and he had blood on his face. She said she was cleaning him up and noticed his nose was crooked, so she sent him out because she assumed it was broken. V28 called an ambulance and tried to call the family several times with no answer and left a message to call the facility back. R3 told V28 a man picked him up and threw him and when asked who he said he didn't know, it was dark. V28 said she went in his room and bathroom and the only person in there was his roommate who is not steady enough to stand up and do that. She said there were a couple drops of blood on the floor, so she knows whatever happened, happened in his room. She said he was hallucinating all night, beating on the floor to kill snakes and he was seeing birds. She said he always runs but he was different that night and she had never seen him act that way. V28 said R3 doesn't bother anybody, he just walks around and sometimes looks in rooms but doesn't go in and he is easily redirected. V28 said R3 is always confused and doesn't sleep good at all and is usually up all night. He has PRN Geodon, but it only works for about 10 minutes. doesn't work. V28 said she did not contact the Nurse Practitioner (NP) or the Medical Doctor (MD) regarding R3's unusual behaviors.On 08/26/25 at 1:41 PM, V33, Nurse Practitioner said if someone has hallucinations, they are a harm to themselves. She said she would expect the nursing staff to notify her or the physician if the resident was getting worse. She said if the resident had PRN medication that was ordered she would expect it to be given.The facility's Behavior Management Policy, review date of 08/01/25, documented Purpose To implement the most desirable and effective interventions to change, modify decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. PolicyThe concept of behavior management is an interdisciplinary process. The key components of this process are: Identifying residents whose behaviors may pose a risk to self or others; Developing individual and practical care strategies based on assessed needs; Implementing the behavior management program; and Ongoing assessment, monitoring and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs.The goal of any behavior management process is to maintain function and improve quality of life. The goal of the Intradisciplinary Team (IDT) team is to promptly identify behavior management issues and develop an effective management program. It further documented When a resident displays adverse behavioral symptoms (e.g. Crying, yelling, hitting, biting etc.), Licensed nursing staff will assess the behavioral symptoms to determine possible causal factors, contact the attending physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s).The facility must provide necessary behavioral health care and services which include: Ensuring that the necessary care and services are person-centered and reflect that resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well- being; Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident's customary routines, interests, preferences, etc. and enhance the resident's well-being. Providing an environment and atmosphere that is conducive to mental and psychosocial well-being; and Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated. ProcedureI. Assess Causal Factorsa. When a resident exhibits adverse behavioral symptom (e.g., crying, yelling, hitting, biting, etc.) licensed nursing staff will document those behaviors in the medical record, noting the time the behavior(s) occur, antecedent events, possible causal factors and interventions attempted.b. Upon observing the adverse behavioral symptom, staff will do the following as indicted:i. Ensure the safety of the resident as well as all other residents.ii. Document notification of attending physicianiii. Document notification of resident's family and/or responsible party about the change in behaviors and the attending physician response.iv. Document the incident. c. The charge nurse will assign a staff member(s) to monitor/shadow the resident as needed.i. Such monitoring is for the protection of the resident as well as all others and is not meant to restrict their movement or mobility.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/15/25 documents there are 56 residents living in the Facility.

Based on observation, interview, and record review, the Facility failed to store food in a manner that prevents foodborne illness. This has the potential to affect all 56 residents living in the Facility.On 8/20/25 at 8:53 AM, in the refrigerator/freezer unit on the wall of the kitchen entryway, there was a large package of uncooked beef patties in the freezer stored directly above a box of popsicles. On 8/20/25 at 8:55 AM, in the standing refrigerator on the adjacent wall, there was a plastic tub of sour cream with manufacturer's Best By date of 7/2/25. There was a clear container with hamburger patties that was not labeled or dated. There was a container labeled banana pudding with a prepared date of 8/12 and no discard date. There was a container labeled chocolate pudding with prepared date of 8/11 with no discard date. There was a container labeled tuna with a prepared date of 8/13 and no discard date. V19, Dietary Manager, stated someone did not write the discard date on the label. On 8/20/25 at 9:00 AM, in the dry storage room refrigerator, there was a package labeled turkey with a Use By date of 1/2/26.On 8/20/25 at 9:38 AM, R12's personal refrigerator in her room was inspected. There was a carton of 2% milk with Use By date of 7/8/25. There were two protein shakes with Use By dates of 3/5/24 and 7/4/24. There was a Styrofoam container with a facility provided meal ticket inside dated 6/30/25. R12 stated staff do not have the time to clean out her refrigerator.R12's Minimum Data Set (MDS) dated [DATE] documented R12 was cognitively intact.On 8/22/25 at 3:16 PM, V1, Administrator, stated she expects dietary staff to follow food service policies.The Facility's Food and Supply Storage Policy dated 8/1/25 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. 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 Long-Term Care Application for Medicare and Medicaid (CMS 671) dated 8/15/25 documents there are 56 residents living in the Facility.

Based on observation, interview, and record review the facility failed to provide a clean and safe, sanitary environment for 4 of 5 residents (R1, R7, R10, and R11), reviewed for environment in a sample of 23. This has the potential to affect all 56 residents who reside at the facility.Findings Include:Survey Team Observations:On 08/15/25 at 11:00 AM, While touring the 100 hallways there was a room that had a large brown smear (appeared to be feces) on the floor in front of the first bed. There was trash scattered on the floor.On 08/15/25 at 11:11 AM, The main hallway of the facility had a large pink stain on the floor in front of the dining room and there were black scuff marks up and down the hallway.On 08/15/25 at 11:13 AM, V6, Housekeeping was using the wet vac to clean up water in two of the rooms on the 200 hallways. On 08/15/25 at 11:30 AM, A room on the 200 hallways had a dirty urinal lying on the floor and a box of incontinent briefs sitting on the floor in the room. There was a bag of trash tied to the handrail outside of the room door.On 08/18/25 at 9:20 AM, The floor in the dining room had salt/pepper packets and sugar packets lying on the floor. There was a large red Kool- aide spot by one of the front dining room tables. There was an orange peeling lying on the floor. There was an old Styrofoam container in a bucket that was sitting on a chair at the front of the dining room, and it had old, mashed potatoes and stewed tomatoes in it. There were multiple black skid marks all over the floor.On 08/18/25 at 10:10 AM, The shower room located on the 200 hallways was inspected at this time. There were no towels or washcloths seen in the shower room. There was dried feces in the toilet bowl, the toilet-paper dispenser was broke (no cover on it), there was no handrail to assist with getting up seen on the wall by the toilet, and behind the door to the shower room the baseboard had fallen off and was lying on the floor.On 08/19/25 at 9:15 AM, V17 said there was some mold behind the desk (same room as flooding). On the far east wall, behind an old desk. There was also stuff piled on top of the desk and this surveyor was able to see but could not reach what appeared to be black mold. This surveyor was unable to see how far it went across the wall. In the area where the dirty laundry is washed there was a hallway off to the left. In the hallway there was an area measuring approximately 8.5 feet long and 3 feet high where the wall was missing plaster. Up against the wall was a piece of some kind of paneling/board measuring approximately 2.5/3 feet x 2.5/3 feet. This surveyor pulled the board away from the wall and there was black mold covering the back of the board from halfway up the board to the bottom of the board. There was also black mold on the wall behind the board.On 08/19/25 at 2:12 PM, The employee bathroom on the 200 hallways was inspected and the following was discovered:1. Two ceiling tiles were missing from the ceiling and were broke and up against the wall.2. One ceiling tile was bulging. 3. Two ceiling tiles had water stains.4. There was a large plastic trash can with about 3 inches of water in the bottom of it.5. There was exposed duct work, exposed pipes, and exposed wiring.On 8/21/2025 at 9:46 AM R11, was not in his room, R11's floor was sticky and visibly dirty with wheelchair wheel marks. The 100-hall flooring is sticky and visibly dirty.On 08/18/25 at 9:50 AM, R7 said the week before last she had a big puddle in the middle of her floor. She said they had to put blankets down on the floor to soak up the water. She said they told her it was a pipe. R7 said it was good for about a week then it happened again.On 8/20/2025 at 3:22 PM, R1 When asked about the cleanliness of facility, R1 states Do you see these floors?. R1's eyes got big, and she stared at the floors. The floors are observed to be sticky and visibly dirty (dark brown spots.) and she said her trash doesn't get taken out very often in her room.On 8/21/2025 at 11:43 AM, When R10 was asked about cleanliness of facility, R10 states just look around. R10 states the facility is dusty. R10 states the facility was deep cleaning the floors, but the facility has cut the housekeeping staff due to budget. R10 states she has been told by staff and during resident council that housekeeping staffing has been cut due to budget. On 08/15/25 at 11:13 AM, V6, Housekeeping said the toilets have backed up and overflowed since she started working here back in February. V6 said it happens pretty much with all the toilets on the 200 hallways. She said maintenance works on it, but she hasn't seen anyone come in and look at it. V6 said there is a sewer problem in the building.On 08/15/25 at 11:20 AM, V7, Registered Nurse (RN) said the toilets overflowing happens often. She said they had someone out to look at it a couple of weeks ago but other than that the maintenance man takes care of it. She said this has been going on for years. V7 said when someone uses the bathroom and then they flush it they will have BM and urine all on the floor.On 08/15/25 at 11:25 AM, V8, Certified Nursing Assistant (CNA) said the bathroom toilets on the 200 hallways have been backing up and overflowing for a long while. She said sometimes after the residents use the bathroom (bowel movement (BM)/Urinate) and they flush the toilet it will overflow onto the floor.On 08/18/25 at 11:30 AM, V13, Housekeeping said they have had water backup here at the facility. She said it does it in most of the bathrooms here at the facility. She said they have also had it flood in the kitchen and the laundry. V13 said they have had to have someone come out and look and it a while back and then they had to come back again about two weeks ago. V13 stated she has a difficult time getting her regular cleaning done because before she can start on that she has to clean up any flooding that has happened. She said they will have to soak up the water with blankets or they will use a wet vac to get it cleaned up and it puts her behind with her regular duties. On 08/19/25 at 9:15 AM, V17, Laundry said they do have some flooding in the laundry room when it rains. She said water comes in from the bottom of a pipe that is in the other room. V17 then took this surveyor to the room where they wash the dirty cloths and said when it rains it will flood by the door that is over by the washing machines and down a hallway off to the left. She said there is also mold down that hallway.On 08/19/25 at 2:05 PM, V7, RN said the shower use to have mold in it but she believes they have taken care of that and there was a room that had mold in it but they have taken care of that and gutted out the room. She said the resident's rooms that had the ceiling caving in have been fixed already and the only ceiling left that is caved in is the employee bathroom. She said it happened about a week ago.Resident Council Minutes, dated 07/28/25, documented trash is being sat in the hallway and taken out at the end of the shift. It clutters up the hallway. It also documented the 200 hallway needs more attention and toilets need cleaned regularly.The facility's Physical Plant & Environmental Policy & Guidelines not dated documented Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well-maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA codes. It further documented Maintenance/Approved Contractors Routine care and repairs to interior finishings- repairing ceiling/wall damage, painting, floor. It also documented Housekeeping Routine daily room cleaning and sanitizing, routine daily cleaning of all common areas and dining areas, routine daily cleaning of all shower rooms and restrooms. It further documented Scheduled stripping and waxing of floors (if required floor type).The facility's Housekeeper Job Summary, not dated documented Housekeepers are responsible for maintaining the facility in a clean, orderly and sanitary manner. It further documented Responsibilities: 1. Duties a) Clean, organize and sanitize each resident room, all hallways, congregate areas, nursing station and offices at least once each day. b) Deep clean assigned bath/shower rooms, each resident room and all other rooms or areas at least once each month or per the cleaning schedule or as directed. It also documented d) Bath/Shower rooms are monitored for cleanliness and sanitation and the need for soap and paper products at least 4 times each shift. e) All floor surfaces are continually monitored for wet, dirty spots debris and other safety hazards. Unsafe and unsanitary conditions are corrected immediately. It also documented i) Dining Rooms and other areas used for eating will be cleaned after each meal including wiping tables and chairs with a sanitizing solution. After breakfast floors in eating areas will be wet mopped completely; after other meals floors may be dry mopped completely and wet mopped where necessary. The policy further documented k) Sweeps and wet mops every room in the facility every day (including weekends and holidays) using a cleaning/sanitizing solution. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/15/25 documents there are 56 residents living in the Facility.

Based on observation, interview, and record review, the Facility failed to provide adequate clean linen supplies for 4 of 4 residents (R7, R10, R20, R21) reviewed for clean, comfortable, homelike environment in the sample of 23.R7's Minimum Data Set (MDS) dated [DATE] documented R7 was cognitively intact.On 8/18/25 at 9:50 AM, R7 stated there are not enough towels and wash cloths in the Facility. She likes to wash her face daily, so her family has to bring in wash cloths and towels in order for her to do that.R10's MDS dated [DATE] documented R10 was cognitively intact.On 8/22/2025 at 11:00 AM, R10 stated the Facility is always out of towels and wash cloths. She has had to wait up to two weeks for a shower because staff tell her they do not have enough towels and wash cloths.R20's MDS dated [DATE] documented R20 was cognitively intact.On 8/21/25 at 11:35 AM, R20 stated there are never enough towels for bathing.R21's MDS dated [DATE] documented R21 was cognitively intact.On 8/22/2025 at 11:05 AM, R21 stated the Facility frequently runs out of towels and wash cloths and has been unable to take showers for weeks at a time for this reason.On 8/21/25 at 11:30 AM, V21, Certified Nursing Assistant (CNA) went to the Clean Utility closet where she would obtain linens. There were no towels in the closet. On 8/21/25 At 11:40 AM, V8, CNA, went to the closet where she would obtain linens. It was the same closet shown by V21. V8 stated the towels are probably down in laundry.On 8/22/25 at 1:15 PM, V27, CNA, stated there has been a shortage of towels and wash cloths in the facility which she believes is due to some CNAs throwing them in the trash instead of rinsing them and putting them in the laundry.On 8/22/25 at 8:50 AM, V2, Director of Nursing (DON), stated towels are just disappearing in the Facility. She is unsure if they are being thrown away, but suspects some residents are stashing them in their rooms.The Facility's Linen Handling-Nursing Policy reviewed 6/1/25 documents, Clean linen shall be stored in such a manner to prevent contamination. Linens shall be maintained in the linen room or in enclosed or covered carts. Laundry personnel shall be responsible for assuring adequate amounts of clean linen and personal clothing are available on each nursing unit.

Based on interview and record review, the Facility failed to provide reasonable access to a telephone in an area where calls can be made without being overheard for 1 of 3 residents (R2) reviewed for communication with privacy in the sample of 23.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including depression, hypertension, and heart failure.R2's Minimum Data Set, dated [DATE] documented R2 was moderately cognitively impaired.R2's 7/25/25 Progress Note documents R2 became upset because he wanted to use the phone, but the nurse was already using it.On 8/20/2025 at 9:10 AM R2 stated V14, Licensed Practical Nurse (LPN), would not allow him to use the phone at the nurse's station. He stated, I have the right to use the phone.On 8/22/25 at 10:27 AM, V14 stated R2 wanted to use the phone, but she asked him to finish up his call because there were three other residents waiting in line for the phone, and V14 needed to make important nursing callsOn 8/22/25 at 10:15 AM, V2, Director of Nursing (DON), stated phones for resident use are currently located at the nurse's stations. The nurses do need to make calls on these phones, but we should have phones available for these residents to use. The Facility was wrong for that.The Facility's Resident Rights Policy revised 6/1/25 documents residents have the right to use a phone in privacy.

Based on interview and record review, the facility failed to follow advanced directives for 1 of 3 (R5) residents reviewed for advanced directives in a sample of 16. This failure resulted in an Immediate Jeopardy on [DATE] when staff performed unnecessary chest compressions, respiratory ventilation for 20 plus minutes, and intubation on R5 against his advanced directive status. On [DATE] at 9:22 AM V1, Administrator was notified of the Immediate Jeopardy. The Surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on [DATE], after abatement reviews dated [DATE] at 7:35 AM and [DATE] at 3:07 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training and policies and procedures.Findings include:R5's Physician Order Sheet (POS), dated 7/2025, documented diagnoses of Chronic Obstructive Pulmonary Disorder, Chronic Diastolic Congestive Heart Failure, and Morbid (severe) Obesity with Alveolar Hypoventilation. It also documented an order dated on [DATE] DNR (Do Not Resuscitate).R5's Post Acute Care Transfer Report from the local hospital, dated [DATE], documented, Code Status Information: Limited: No CPR (cardiopulmonary resuscitation) Modified Resuscitation Specifics: Provide aggressive: No intubation.R5's Care Plan did not document R5's code status.On [DATE] at 9:56 AM, V7, Licensed Practical Nurse, (LPN), stated that at around 5:20 AM on [DATE], she was passing medications, and she stopped at R5's room, and took his medications in to him. She stated that she set them down on the table, called his name and he didn't respond, so she shook him, and he felt cold, and his color was pale. He did not respond, so she rubbed his chest and checked his neck for a pulse and did not feel anything. She stated she yelled for help, she checked her computer, that was right outside of R5's room, and there was not a code status in the computer. V7 was asked where she would find a code status on a resident in the computer, V7 stated that on the MAR (Medication Administration Record) by the resident's picture is their code status. V7 stated that the other nurse called 911, and she started Cardiopulmonary Resuscitation (CPR), had the bed flat. V7 stated that Emergency Management Services (EMS) arrived 15-20 minutes later and took over CPR. V7 stated that since she could not find the code status, she treated it as a Full Code. She also stated that while EMS was performing CPR, she went to the nurse's station and checked the BIG computer and there still wasn't a code status that could be found. She continued to state that she entered R5's room and EMS had stopped CPR at around 5:47- 5:50 AM and the MD (medical doctor) from the hospital called it (time of death). V7 stated that when the day shift nurse came in, she showed her where R5's code status was in miscellaneous in R5's electronic medical records. V7 stated that prior to her going into R5's room to give him medication at 5:20 AM, the last time she checked on R5 was around 12:30-12:45 AM. V7 stated that code status for all residents is on the home page and the Medication Administration Record (MAR), both located in the electronic medical record (EMR). On [DATE] at 2:00 PM, V8, Certified Nurse Assistant, (CNA) stated that she was not R5's CNA the night he passed away, but she was working so she went down to his room while CPR was in progress and before EMS came, and V7 had her perform CPR, because the nurse was getting tired. V8 stated that she couldn't answer where she would find a resident's code status.On [DATE] at 9:30 PM, V14, LPN, who was the day shift nurse on [DATE] that came in at 6:00 AM for her shift and assisted V7 with finding the code status, stated that when she came in, R5 was being coded by EMS, and that he was intubated. V14 stated that the DNR was in the miscellaneous section of his chart and that it was not on the computer screen where V7 could find it. V14 stated that she knew he was a DNR because she admitted him from the hospital on [DATE]. V14 also stated that there is a list of residents who are DNR at the nurse's station by the computer, but his name wasn't on it. V14 stated that EMS did intubate R5 and used the Ambu bag and that the doctor at the hospital told EMS to stop CPR. V14 was asked when a resident returns from the hospital, like R5 did, who gets the order from the doctor for the new code status? V14 stated that it is usually the admitting nurse, but she continued to state that she didn't think she got the order for R5's DNR nor did she put it in the computer and that was why it did not show up when V7 was looking for it. V14 stated that when she was helping V7 look for it, it was not on R5's home page in the electronic medical record and that was why V7 couldn't find it. On [DATE] at 11:55 AM, V17, Social Services Director, stated that she was not aware of R5's code status change when he returned from the hospital on [DATE]. V17 stated that no one notified her of the change of code status from full code to DNR, so a new POLST (Physician Orders for Life-Sustaining Treatment) was not made in June. V17 stated that when R5 returned from the hospital she went down to see him, and he gave her his will and the healthcare power of attorney, and she continued to state that in that paperwork there was no DNR, nor did it document a code status change. V17 then stated that you can't be a DNR and be comfort care and that she did not think this was a DNR, but she also did not approach R5 with a new POLST since she was not aware of his decision.On [DATE] at 12:25 PM, V2, Director of Nurses, stated that R5's code status was changed when he came back from the hospital on [DATE] and she did not know why an order was never written on that date. She continued to state that the social worker was given his living will, but she doesn't remember who the nurse was or what had happened to the hospital paperwork, but the DNR never was put into their computer system on [DATE]. V2 stated that the nurse started CPR on [DATE] on R5 because she couldn't find in the system where R5 was a DNR, so their protocol was to start CPR. V2, stated that 2 things happened during that code, 1. the paper was found that he was a DNR and 2. the daughter told them to stop CPR. V2 stated that the issue was that the nurse working did not see where the code status was. V2 stated that someone, could not recall which nurse, communicated with her that R5 was a DNR on [DATE], it's possible that that nurse is no longer employed at the facility, it is the responsibility of that nurse to write the order for the DNR and to make sure social services knows and then we follow up on it to make sure it was done. No one followed up on his DNR and that was why the order was written on [DATE] and back dated for [DATE]. V2 stated that R5 should not have been Coded on [DATE] but the agency nurse did not see he DNR and our protocol is to start CPR. V2 stated that agency nurses have access to the medical records system where it has code status and there was a list at the desk of who are do not resuscitate (DNR).On [DATE] at 2:00 PM, V1, Administrator, stated that what she is learning at this time was that at the hospital he decided to make that change and that paperwork, with the DNR and it was not given to social services. V1 stated that the nurse who admitted him on [DATE], should have put the DNR orders in when he was re admitted and then let social services know so a new POLST could have been done. V1 stated that she would expect the staff to know where to find a resident's DNR on the dashboard and in point click care (electronic medical records). V1 stated that R5 should have been reassessed upon readmission and the breakdown in communication was that social service was not being made aware by nursing of the change in code status and that the physicians order should have been written by the nurse. On [DATE] at 3:03 PM. V12, R5's daughter and Healthcare Power of Attorney (HCPOA), stated that her father did not want to be intubated but when they called her that morning and was told they were doing CPR, she stated that she told them to stop CPR because he was a DNR. V12 continued to state that the last time her father was in the ICU, which was the end of May and early June, they, her, her sister (V13) and the doctor had a serious talk about code status and that her dad wanted CPR but did not want to be intubated and that the doctor told him one could not be done without the other. V12 stated that they all had a concern that if her father was to be intubated, then he may never get off a ventilator and he did not want that, so he decided that he would be a DNR. V12 stated that early June is when the paperwork was done, and it went back to the nursing home with him that he would be a DNR.On [DATE] at 10:35 AM, V18, R5's Nurse Practitioner, stated that code statuses are updated in the files and when she looked this morning, in his file, he was a DNR. She continued to state that they, do not have a specific procedure with DNR, if it was signed at the hospital and that it was signed by a physician there. V18, stated that she would expect the facility to honor the residents wishes with their code status.R5's Progress Note, dated [DATE], at 6:35 AM, written by V7 documented, This nurse started CPR until (Local) police arrived with paramedics and this nurse was instructed to stop CPR. This nurse left out of the room and continued to find polst form for code status. Another nurse came in and went into computer and located DNR paperwork and this nurse went and took paperwork to medical staff assisting with the code. This nurse called POA, and she stated that the resident just signed DNR forms and to stop CPR. The physician that called time of death is (Hospital Doctor) with (local) hospital. Time of death called at 6:07 am. Daughter is in route to facility. DON called and informed of resident expiring awaiting daughter to arrive. This nurse spoke with coroner (County Coroner). Oncoming nurse aware that she will need to call coroner with name of funeral home once next of kin arrives.The Facility's policy, Advance Directives, undated, documented, 1. At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. 2. The Social Service and/or Admissions Director will be responsible for providing copies of state statutes, regulations, and information regarding Advanced Directive(s), to resident, legal representatives upon admission, and also to families who wish to receive such information and assistance regarding Advanced Directive(s) and decisions regarding life sustaining measures and in no event shall give legal advice on the need for medical care directives. 3. The resident, the legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advanced Directive, as recognized under the state law, has been executed. Documentation concerning this inquiry, and the individual response shall include the date the entry was made and the individual making this inquiry. This information shall then be included in the resident's medical record. It continues, 6. Copies of the resident's Advanced Directive shall be made and maintained in the resident's clinical record and financial folder.The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy:1) A) Admin/SSD were in-serviced by the VP of clinical services on POLST forms, updating in medical records, timeliness of updating medical records. Completed [DATE].B) Admin will in-service IDT on POLST forms, expectations, where to locate code status of residents, and who can perform CPR, what to do when resident is found to be in distress. Completed [DATE].C) Current staff in-serviced on code status, where to find in residents' chart. Completed [DATE].D) Current licensed staff in-serviced on code status, where to find in residents' chart, who can perform CPR, and who to inform if a new code status when resident is admitted /readmitted . Completed [DATE].2) A) All residents that reside in the facility will have their POLST forms audited within the last 30 days. Completed on [DATE] by RNC & Administration. From [DATE]-[DATE]. Completed on [DATE]. B.) All residents will have a code status order and care plan updated within the last 30 days related to their POLST forms. Completed by RNC and Administrator on [DATE].C) Review of policy and procedure of advanced directives and system that is in place for updating code status. Residents that do not have a POLST form will remain a full code until POLST form can be obtained. Completed by VP of Clinical Services on [DATE]. 3) All working staff have been in-serviced on where to locate code status, who to give POLST forms to when a new admission or re-admission changes code status. Currently all staff on shift are in-serviced. Total facility will be 100% by 7.22.25. If staff are not in-serviced, they will be in-serviced prior to working their next shift.4) No staff will work before being in-serviced on code status. Ongoing being completed by IDT (Interdisciplinary team) or designed by start of next working shift. 5) A quality assurance tool was implemented; Daily audit will be completed of the 24-hour report to see if there are any new admissions &/or readmissions, POLST status will be reviewed, and if it a part of the medical record. Audit will continue daily x 4 weeks to ensure that code status is updated timely and located within the medical chart. Ongoing. Audits to be completed by Administrator/Designee.6) Root Cause Analysis Completed for POLST Forms.Deficiency: failed to follow POLST form that reflected residents wishes.Root Cause: Attached. Initiated on [DATE] and completed 100%.

Based on interview and record review the facility failed to implement its written policy by not ensuring that required background checks were completed prior to allowing direct care staff to work with residents. This failure had the potential to place all 52 residents living in the facility. Findings include:V37's, Certified Nursing Assistant, CNA, personnel file documented R37 was employed by facility beginning on 3/3/2025 through 5/15/2025. There was no Criminal Background Check completed by the facility; however, the facility did have a background check from previous employer dated 11/27/2024. V1, Administrator, stated Ideally this facility should've done a background check. V1 stated (V37) came from a sister facility and just kind of showed up one day. V2, Director of Nursing, DON, stated Typically when a staff member requests a transfer from a sister facility, we would call that facility and let them know the staff is requesting a transfer. There are new procedures put in place now that onboarding and background checks are to be done. Facility's undated abuse policy states 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.Facility's resident roster dated 7/14/2025 documents 52 residents residing in the facility.

Based on interview and record review, the Facility failed to ensure residents were free from misappropriation of property for 1 of 6 residents (R10) reviewed for abuse in the sample of 17.1.R10's Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced dementia and need for assistance with personal care.R10's Minimum Data Set (MDS) dated [DATE] documented R10 was moderately cognitively impaired with inattention and disorganized thinking and ambulated with walker.R10's Care Plan does not address risk of abuse and neglect.The Facility's Initial Report sent to the Illinois Department of Public Health (IDPH) on 2/18/25 documents R10 notified V17, Social Services Director, of allegation of misappropriation of money, and an investigation was initiated.The Facility's Abuse Investigation Report by V46, Former Administrator, documents, On 2/18/25 (V17) made a phone call when (R10) was in her office to (V36, R10's Family) regarding (R10)'s debit card due to it not working. (V36) has (R10)'s bank statement and informed (V17) and (R10) that the debit card had been used in (four various cities). (V36) named multiple places it was used, including (Real Estate Company). (V36) included the phone number for the real estate group. He stated (R10) had no money because of this. The Facility's Summary of Investigators Findings documents, (V17) discovered (R10)'s debit card was used on multiple dates in January (2025). Per real estate group, debit card was used on 1/17/25 to pay rent in the amount of ($)209.99 for (V25, Certified Nursing Assistant, CNA). On 7/18/25, V25 and V46 were no longer working in the Facility.The Facility's 2/20/25 interview with V47, CNA, documents R10 asks people all the time to go to the store for him.The Facility's 2/20/25 interview by V48, CNA, documents R10 is always giving out his (debit) card.The Facility's 2/21/25 interview by V40, Housekeeper, documents R10 asks anyone and everyone to go to the store for him.On 7/22/25 at 12:50 PM, V33, CNA/Transportation, stated R10 has asked her to buy him things with his debit card.V17's Written Statement documents V36 reported all R10's money was gone and stated it looked like it was spent in four different towns, beginning on 1/16/25. V36 stated there was a $209.00 payment made to a phone number on 1/17/25 for which a reverse search listed a (Real Estate Group). R10 stated he did not remember who he gave his card to, when he gave it to them, or what they looked like.On 7/18/25 at 1:50 PM, V17 stated it was reported several months ago that V25 took money from R10. The allegation was reported and investigated, and V25 was terminated. V17 stated (R10) has alcoholic dementia, and he always wants to give his debit card to people. We try to remind him to only give his card to me to purchase items for him, but he forgets. The Facility's 2/21/25 Abuse Allegation Interview with V25 documents R10 is always asking people to go to the store for him. V25 was asked whether she had ever purchased anything for herself with resident money, and she stated, No, my hands have not been on his debit card. V25 was informed that a transaction was made on the debit card in her name for rent. She stated, I didn't touch his debit card, but I can give it back. I can bring it to you.On 7/18/25 at 2:07 PM, V25 was not available for interview by phone.On 7/22/25 at 2:45 PM, V33, CNA/Activities, stated V25 used R10's debit card, then ended up getting fired. The Facility's Final Report sent to IDPH on 2/24/25 documents during the investigation, it was noted that R10's debit card was compromised and had been used in the (Local) area. R10 is known to give money or debit card to anyone, including other residents and visitors if he feels they will purchase items for him at the store. There was one possible purchase that could be linked to a facility member in January 2025. On 7/23/25 at 11:55 AM, V1, Administrator, stated she was not the administrator at the time of R10's investigation, but stated it looked like it happened, and the detective said who came out to the Facility to follow up on the case stated V25 used R10's debit card to pay rent. She stated she would expect the Facility to follow its abuse policy.The Facility's Undated Abuse Prevention and Prohibition Program Policy documents each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.

Based on observation, interview, and record review the facility failed to ensure residents were supervised to prevent elopement. This failure resulted in R2 eloping from the facility on 6/15/2025, unknown as being gone and spotted 0.2 miles from the facility, alone in a parking lot by V5 (Certified Nurse Assistant) who was returning from lunch. R2 was brought back to the facility but her return condition at the time of her return remains unknown, as she received no assessment for injuries and no longer resides in the facility. This failure also resulted in R22 eloping from the facility on 7/8/25 when R22's nurse (V30) noticed him missing between 9:30 AM to 10 AM. V30 stated R22 was returned to the facility at approximately 12:40 PM. The Immediate Jeopardy began on 6/15/25 when due to the facility's failure to provide adequate supervision for R2 who has a diagnosis of schizophrenia, periods of confusion with a physician order for memory diagnostic clinic for concerns for underlying neurocognitive disorder of which the facility failed to schedule following R2's recent hospitalization after she was found at an airport with confusion and claiming she had been kidnapped. R2's care plan did not document R2's risk of elopement nor was it updated following R2's elopement from the facility on 6/15/25. The facility failed to follow its policy and did not implement interventions after R2's facility elopement risk assessment deemed R2 at risk for elopement and R2's facility community survival skills assessment conclusion documented R2 does not appear to be capable of unsupervised outside pass privileges at this time. On 6/15/25 at approximately 11:20 AM a facility CNA (Certified Nurse Assistant) was returning to the facility from her lunch break and spotted R2 in an apartment parking lot approximately 0.2 miles from the facility without the facility's knowledge of R2 being gone from the facility. R2 was not assessed for injuries upon return to the facility after she eloped on 6/15/25. R2 remained at the facility until her family discharged her on 6/17/25. The facility did not update R2's care plan nor implement any risk reduction measures prior to nor following her 6/15/25 elopement. V1, Administrator, and V11, [NAME] President of Clinical Services, were notified of the Immediate Jeopardy on 6/25/25 at 12:30 PM. The facility then failed to implement elopement precautions for R22 after he was assessed as at risk for elopement. R22 has a diagnosis of paranoid schizophrenia and a history of elopement from his prior facility. R22's nurse V30 had previously cared for R22 at his prior facility and was aware of R22's history of elopement. V30 noticed R22 was not in the facility between 9:30 AM and 10 AM on 7/8/25 and was not returned to the facility until approximately 12:40 PM when the facility transportation CNA observed R22 approximately 0.2 miles from the facility. R22 stated he walked down to the city fountain which is located approximately 1 mile away from the facility. The Immediacy was removed on 7/8/25 but the facility remains out of compliance at a Level II. Findings Include: 1.R2's census sheet, print date of 6/18/25, documented R2 was admitted to the facility on [DATE]. R2's medical diagnosis sheet, print date of 6/18/25, documented R2 has diagnoses including schizophrenia, depression, heart failure, cardiomyopathy, coronary atherosclerosis, hypertension, pneumonia, type 2 diabetes mellitus, and depression. R2's elopement evaluation, dated 5/21/25, documented a score value of 1 or higher indicates risk of elopement. R2's elopement evaluation score was 6. R2's community survival skills assessment, dated 6/8/25, documented R2 is not sufficiently alert, oriented, coherent nor knowledgeable to be considered for independent outside pass privileges. This form documented R2 does not know the facility address nor how to ask for/seek help in an emergent or problematic situation. This form also documented R2 does not have the ability to adhere to pass privilege policies, e.g., getting permission to leave, signing out, respecting time parameters and curfews, and informing staff upon return. This assessment conclusion documented the resident does not appear to be capable of unsupervised outside pass privileges at this time. R2's MDS (Minimum Data Set), dated 5/29/25, documented R2 is cognitively intact although on 6/18/25 at 11:51 AM V10 (Social Service Director) stated she completed R2's cognitive assessment and that R2 was able to answer the questions on the assessment but R2 was absolutely not safe to go outside on her own and that R2 would not have known to sign herself out of the building. R2's care plan, print date of 6/18/25, does not document or address R2's elopement risk. R2's hospital H&P (history and physical), dated 5/6/25, documented Pt (patient) with psychosis that appears to be new, but it appears has not been evaluated by a medical professional. She is also having an acute on chronic systolic heart failure exacerbation. Diagnosis for cause of psychosis is unclear but there is suspicion for a dementia related diagnosis given the age of onset. R2's regional hospital inpatient Discharge summary, dated [DATE], documented principal problem pneumonia of right lower lobe due to infectious organism. Active problems: delirium. Resolved problems: no resolved hospital problems. Details of hospital stay per H&P on 5/6/25 R2 is a [AGE] year old F (female) w/ (with) PMH (past medical history) of dilated cardiomyopathy, CAD (coronary artery disease), HTN (hypertension), DM (diabetes mellitus), insulinoma s/p (status post) Whipple (surgical procedure of pancreas), depression who was brought to the hospital by ambulance for paranoia, found to have exacerbation of known heart failure. Per chart review, patient was BIBEMS (brought in by emergency medical services) as she came to the airport and told people there, she had been kidnapped. On arrival to the ED (emergency department) patient was combative, attempting to leave the emergency department. She was treated with Ativan, Zyprexa, and eventually IM (intramuscular) Haldol multiple times during ED stay. It continues, patient was evaluated by psych team in ED who noted unspecified schizophrenia and other psychotic disorder but given elevated BNP (B-type natriuretic peptide) concerning for HF (heart failure) exacerbation, not appropriate for psych admission at this time. Patient arrived to the floor agitated, kicking at staff, but on room air and with stable vitals. Unable to obtain medical or social history from patient. It continues, hospital course: delirium and agitation: patient brought to the ED by EMS for bizarre behavior. Initially combative and aggressive requiring multiple doses of IM Haldol and patient was placed on elopement precautions. Intermittently requiring physical restraints during the initial presentation, patient became more appropriate, with better insight as her admission progressed. This was in the context of a psychiatric consult and the initiation of scheduled PO (by mouth) Haldol for symptom management. Given acute presentation, infectious workup was completed which was negative, at which point antibiotics were discontinued. Treatment of acute heart failure exacerbation as below. Improvement in heart failure exacerbation coincided with improvement in mental status, but this is in conjunction with scheduled antipsychotic medication. Initial attempts to wean off Haldol coincided with increased confusion and irritability, so psychiatry was reengaged and recommended a taper off of Haldol and onto Seroquel. This taper was initiated inpatient, and instructions for further tapering were provided to skilled nursing facility at time of discharge (see below). Per psych the underlying diagnosis for this is agitation in the setting of delirium and Seroquel is scheduled to stop after 2 weeks on just Seroquel, with encouragement to follow up outpatient with memory diagnostic center and geriatric clinic. It continues, Haldol to Seroquel taper (instructions below), f/u w/ memory diagnostic clinic for concerns for underlying neurocognitive disorder. On 6/26/25 at 10:26 AM V25 Transportation CNA stated she took care of R2 a few times during her stay and R2 was confused and wandered around the facility. V25 stated she started doing transports about a month ago and she did not take R2 to any appointments nor know anything about her order for a memory diagnostic center. Surveyor asked V25 how she is notified of resident appointments and V25 replied the nurses are supposed to write it down for her although they have not been doing this, so she is being trained on how to check the EMR (electronic medical record) for appointments.On 6/26/26 at 10:42 AM V25 stated she started doing resident transports on 6/2/25 and stated the facility has agency nurses and they usually do not know the process therefore she is often not notified of appointments that are needed for residents. On 6/26/26 at 10:47 PM surveyor called the Memory Diagnostic Center where R2 was referred to and V26 office employee stated there was never an appointment made for R2.On 6/26/25 at 11:16 AM V1 Administrator stated the facility never made the appointment for R2's discharge to be evaluated at the Memory Diagnostic Center. V1 stated she does not know why it was not made because the prior transport aide quit with no notice.On 6/26/25 at 12:27 PM V1 Administrator stated all resident discharge orders from hospitals including orders for follow up appointments should be added the resident's physician orders upon admission.R2's hospital progress notes/referral documents, dated 5/15/25, documented CT (computed tomography scan) head without contrast. History: [AGE] year-old female presenting with altered mental status. Findings: encephalomalacia in the right occipital lobe. According to the National Institutes of Health (NIH.gov) encephalomalacia is the softening or loss of brain tissue after cerebral infarction, cerebral ischemia, infection, craniocerebral trauma, or other injury. According to NIH.gov symptoms of encephalomalacia include memory loss, difficulty concentrating, difficulty with reasoning and judgment, and impaired problem solving. NIH.gov noted brain tissue damaged by encephalomalacia cannot regenerate and results in permanent brain damage. It continues, assessment/plan: AMS (altered mental status) - patient is poor historian and unwilling to participate in interview but based on collateral from friend patient with 3-5 years of worsening delusions and paranoia, has filed multiple police reports against neighbors. It continues, unclear if this is patient baseline, or gradual worsening of chronic condition vs (versus) acute presentation at this time. It continues, delirium precautions, elopement precautions. R2's hospital internal medicine daily progress notes, dated 5/12/25, documented interval history: afebrile, hemodynamically stable. Remains intermittently confused, although cooperative with staff and exam. R2's facility admission notes, dated 5/21/25 at 3:43 PM, documented resident transferred to facility via ambulance. This nurse received report from (nurse) at (regional hospital). Resident is a [AGE] year-old female. Alert, confusion at times, early onset dementia. Resident was found at an airport. Resident didn't remember how she got to the airport; told hospital staff she was kidnapped. Resident noted to have delusions at times. R2's facility progress note, dated 5/22/25 at 12:38 AM, documented alert with intermittent confusion. High elopement risk. Staff has to monitor very closely. Resident approached side doors several times during the shift but easily redirected. R2's progress note, dated 5/27/25 at 5:34 AM, documented resident walked around all night with no recollection of previous encounters with staff seen within 30-minute time frame. Resident seemed angry and distressed. Resident stated that she was looking for something and stood in the dining area for one hour under supervision until moved back to room. Resident became very angry if touched all efforts redirected by letting resident move when ready. Sign has been placed on door to help resident identify living area. R2's Nurse Practitioner progress note authored by V22, dated 5/28/25, documented [AGE] year-old female presents to me today at NF (nursing facility) as new patient. She admitted from hospital after paranoia, AMS (altered mental status), and HF (heart failure) exacerbation. It continues, she is A&O (alert and oriented) to self. Cognitive status: confused. R2's progress note, dated 6/11/25 and authored by V22 Nurse Practitioner, documented R2 presents to me today at NF for nursing reports that R2 has been refusing medications and her sister is here and concerned about her edema. Her sister wants her to go to ER d/t (due to) the refusal of meds and her edema. She is adamant she does not wish to go. She is very agitated and paranoid this am. She will not answer ROS (review of systems) questions and only allows for limited exam. Sister wants me to give her something to be more compliant, explained that is not possible. She is also requesting (regional) hospital. Explained EMS makes that call. Also explained if she refuses when EMS arrives there is strong chance, they will not take her. She is up in chair. She is A&O (alert and oriented) to self. R2's behavior progress note, dated 6/9/25 at 3:20 AM, documented resident attempted several times to leave facility and had to be redirected multiple times. Resident states that she cannot stay here because her house is waiting for her. It continues, resident is starting to wander in the room of other residents. R2's progress note, dated 6/11/25 at 10:08 AM, documented resident out in dining room during breakfast with x2 family members present. Resident having increased behaviors, yelling, cursing, refusing medications and meal. DON (Director of Nursing), Administrator, ADON (Assistant Director of Nursing), and NP (Nurse Practitioner) present and aware. Orders received per NP to send resident to ER (emergency room) for evaluation. Resident refusing all care. Family requesting resident may need to be sent to psych (psychiatric) eval (evaluation) for AMS (altered mental status) and increased behaviors, plus refusal of medications and care. It continues, resident currently ambulating self around facility, staff supervision/monitoring continues. R2's next progress note following the 6/11/25 progress note was on 6/14/25 at 12:57 PM and it documented resident has refused all medications, including blood glucose monitoring/insulins for this nurse today. Several attempts to offer medications during scheduled times refused and resident stated, I don't take medicine.R2's initial psychiatric evaluation, date of service 6/13/25 and authored by V28, documented per staff patient wanders a lot and voice thoughts indicative of delusions and paranoia. Per staff patient voiced she was kidnapped and feels that she is not safe because someone wants to kill her. Patient also believes that her credit card was used to fund breakfast. Per staff patient believes she has been to jail and works at the airport. Patient appears to be exit seeking at times as she believes she needs to get to work at the airport. Per staff patient can be irritable and has been refusing to take her medication. She appears suspicious of staff and paranoid. Upon assessment today patient was not cooperative. She states, I already have a doctor I don't need to talk to you. Denied feelings of anxiety and depression. Denies concerns with sleep or appetite. When asked about hallucinations patient states I am done with you go on Per documentation/chart review patient was recently discharged from the hospital for bizarre behaviors, delusions, and agitation and was started on medication management. Per staff family would like for patient to get [NAME] (long acting injectable). Mental status examination documented Thought Process: disorganized, Associations: loosening associations, Thought Content: paranoia and delusions elicited, Mood: irritable, Attention: impaired, Insight: poor, Judgement: poor, Orientation: person. R2's progress note, dated 6/15/25 at 10:32 AM, with a created date of 6/16/25 at 10:34 AM, and authored by V1 Administrator, documented R2 exited the facility without signing out. This writer remined R2 of the importance of signing out with the nurses and showed her where the sign out book was located. R2 has a BIMS of 13 and voiced understanding. R2's incident progress note, dated 6/15/25 at 1:16 PM, documented resident exited building and went outside. Staff with resident and assisted resident back in facility. Resident educated and reminded to sign out when going outside of building and tell staff before exiting. Resident verbally agreed. Enhanced supervision provided. R2's behavior progress note, dated 6/16/25 at 5:39 AM, documented resident A/O X 2 did not sleep well in assigned area with consistent ambulating to dining hall and sleeping on couch. Pt (patient) was redirected several times to assigned living area. Pt is pleasant but confused on why she is living here. Pt is exit seeking and sleeps no more than three to four hours late nights. It continues, resident has been placed with safety protocols. Will continue with plan of care. R2's behavior progress note, dated 6/16/25 at 6 AM, documented resident attempted exit and redirected to unit 200. Returned to hallway seeking exit 5 per staff. R2's progress note, dated 6/17/25 at 1:35 PM, documented upon return from LOA (leave of absence), residents sisters voiced that resident will be leaving facility and not returning. Family refused to wait until MD (medical doctor) notified. Family also refuses to make facility staff aware of where resident is discharging to. On 6/18/25 at 8:25 AM V7 LPN (Licensed Practical Nurse) stated R2 discharged from the facility yesterday and R2's family did not say where she was going. V7 stated she was not working when R2 left the building, but she heard R2 eloped and was by the highway. V7 stated a CNA noticed R2 on her way back from lunch and picked her up. V7 stated the times she cared for R2 in the last 2 weeks R2 was paranoid and combative. On 6/18/25 at 8:30 AM V5 CNA approached surveyor and stated, I was working last weekend, I was returning from lunch around 11:20, and I saw (R2) down the street. V5 stated she did a u turn, stopped, and said to (R2) I will take you home. V5 said (R2) replied I know you from somewhere. and then got into the car with her and she brought her back to the facility. V5 stated she does not know how long (R2) was gone but she did see her at breakfast that day. V5 stated she called and reported the incident to the DON (Director of Nursing).On 6/18/25 at 8:45 AM V9, Activity Director, stated she was not at work when R2 eloped last weekend and stated R2 was confused at times during her stay at the facility.On 6/18/25 at 8:52 AM V10, Social Service Director, stated R2 was at the facility for 2 or 3 weeks, she was very confused, combative, and non-compliant. V10 stated she completed her community assessment, and she was not safe to be out of the facility by herself. V10 stated R2 could not have signed herself out because she came to the facility after she was found at the airport claiming she was kidnapped.On 6/18/25 at 8:57 AM V1, Administrator, stated she did not report R2's elopement because she looked at her (cognitive assessment) and she was a 13. Surveyor asked V1 if she looked at R2's community/elopement assessment and V1 stated no.On 6/18/25 at 9:03 AM V11, [NAME] President of Clinical Services, stated based on R2's (cognitive assessment) and cognition at that time they don't think it was an elopement.On 6/18/25 at 11:43 AM V12 CNA stated she was not at work last weekend when R2 eloped. V12 stated R2 was very much confused all the time when she saw her or took care of her during her stay at the facility. On 6/18/25 at 11:51 AM V10 Social Service Director stated she completed R2's cognitive test, and R2 could answer those questions but she was absolutely not safe to go outside on her own. V10 stated she does not know what door R2 exited the facility from, but she was in room [ROOM NUMBER] which is located 2 doors down from that hall exit door. V10 stated R2 never left the faciity on her own and she would not have known to sign herself out to leave the building.On 6/18/25 at 12:17 PM V1, Administrator, stated she believes R2 exited the front door when she left the facility. Surveyor asked how she reached that conclusion and V1 replied a nurse saw her by the front door around 11 AM on 6/15/25. V1 stated she did a timeline, and she thinks R2 was only out of the facility for approximately 5 minutes. Surveyor requested a copy of the timeline and V11, Regional Director, stated we are working on it. Surveyor asked if someone deactivated the door alarm without checking to see why it went off and V1 replied she assumes so.On 6/18/25 at 12:23 PM V11, [NAME] President of Clinical Services, stated she knows the facility did have elopement risk binders for the residents at risk for elopement because she is the one who put them together. V11 stated she does not know if R2 had an elopement risk binder or not. V11 stated R2 was cognitively intact based on her cognition score and with resident rights she had the right to leave if she wanted to. Surveyor questioned V11 regarding the reason R2 was admitted to long term care after she was found at the airport with confusion and claiming she was kidnapped. V11 replied R2 had a hospitalization following that. Surveyor then questioned if V1 and V11 had reviewed R2's chart as it documented R2 had confusion throughout her stay at the facility and her community assessment documented she is unsafe to be out on her own. V11 replied I am confused at times and residents still have rights.On 6/18/25 at 12:43 PM V1, Administrator, provided R2's elopement evaluation dated 5/21/25 with a score of 6. Surveyor asked V1 if a score of 6 indicates R2 was at risk for elopement. V1 replied let me look and left the room. This form documented score value of 1 or higher indicates risk of elopement. On 6/18/25 at 12:46 PM V1 returned and stated it doesn't say she is high risk for elopement. Surveyor asked V1 if a score value of 1 or higher as documented on the elopement evaluation indicates R2 was at risk of elopement and V1 replied yesOn 6/18/25 at 2:34 PM V13 LPN stated she did not write a written statement regarding R2's elopement from the facility but she did document it in her progress notes. V13 stated she was R2's nurse on 6/15/25 and she last saw her before she started her medication pass before 11 AM on 6/15/25. V13 stated she did not see R2 again until she was returned to the facility by a CNA around 11:20 AM. V13 stated she did not document an assessment of R2 upon her return to the facility. V13 stated R2 was confused on the morning of 6/15/25, was carrying some of her belongings around in bags, and stated she was leaving. V13 stated she had previously cared for R2 on 2 other shifts at the facility and R2 was also confused during those shifts.On 6/18/25 at 2:53 PM V1 Administrator stated R2 did not have a photo taken during her admission to the facility nor did she have an elopement risk binder per the facility missing resident/elopement policy.On 6/18/25 at 3:13 PM surveyor asked V1 what enhanced precautions were put into place for R2 as documented in R2's progress notes upon her return to the facility after being found walking up the street and V1 replied we just checked on her frequently, I don't know if it was documented or if her care plan was updated. I will checkOn 6/24/25 at 10:37 AM V11 Regional Clinical Director stated if residents are at risk for elopement, then they do not have an elopement binder but if they are high risk then they do have an elopement binder. V11 stated the facility did have binders for the high-risk residents but they were misplaced when surveyor requested them, so she redid them. V11 stated she does not know why R2 did not have an elopement binder and was unaware of her history of wandering.V11s tated she would expect all staff to immediately respond to door alarms except the dining room door because there is usually a staff member outside with the residents and it is fenced in. Surveyor asked if the gate is locked as it is a fire egress and V11 stated she does not know if it is locked or not. On 6/24/25 at 10:40 AM surveyor asked V2 DON if she considered R2 high risk for elopement and V2 replied R2 wanted to go home, she went to the doors and looked out. Surveyor then asked V2 if R2's memory diagnostic appointment was completed as documented in R2's facility admission orders from the regional hospital and V2 replied she does not know if the appointment was made or not. Surveyor asked if a physical assessment of R2 was completed following R2's elopement from the facility and V2 stated she would look and see if there is one in R2's medical record. On 6/24/25 at 11:01 AM V13 LPN stated she was R2's nurse when R2 left the building on 6/15/25 without the knowledge of staff and she does not know how long she was gone from the facility although she recalls seeing her 15 to 20 minutes prior to the CNA bringing her back in. V13 stated she did not complete nor document a skin nor any type of assessment on R2 after R2 eloped. V13 stated R2 was absolutely unsafe to go out of the facility on her own due to her psychiatric issues, periods of confusion, and poor safety awareness and stated when she cared for R2 she was fixated on wanting to leave the facility. V13 stated she does not know what door R2 left from, but she would guess door 10 as her room was just 2 doors down from that exit. V13 stated R2 didn't recall leaving and stated she didn't leave when she got back. On 6/24/25 at 2:24 PM V1, Administrator, stated R2 does not have an incident report, nursing assessment, nor skin assessment for the day she exited the building alone.On 6/25/25 at 8:59 AM V22 Nurse Practitioner stated she assessed R2 on two separate dates during her stay at the facility. V22 stated R2 was very paranoid and when she saw her on 6/11/25 she wanted to send R2 to the hospital but R2 refused. V22 stated R2 was tearing up V22's papers while she was assessing her and that R2 had been refusing medications. V22 stated R2 was confused both times she assessed her and R2 was not safe to leave the facility on her own.On 6/25/25 at 11:06 AM V5 CNA stated R2 was standing on the corner of the parking lot of the apartment building on Pawnee drive and north Illinois street when she spotted R2 as she was returning from her lunch break. V5 stated R2 seemed confused when she gave her a ride back to the facility.On 6/26/25 at 10:23 AM V24 RN (Registered Nurse) stated R2 was very confused and exit seeking every time she was R2's nurse. V24 stated she was R2's nurse multiple times. V24 stated she did not know anything about R2's order to be seen at a memory diagnostic center.On 6/26/25 at 12:31 PM V28 PMNHP (Psychiatric Mental Health Nurse Practitioner) stated she evaluated R2 on 6/13/25 and based on that evaluation and information provided by facility staff R2 was not safe to leave the facility on her own. V28 stated R2 was oriented to self only on 6/13/25, R2 did not want to speak to her, and R2 was very paranoid. V28 stated the facility staff reported R2 had been delusional, confused, exit seeking, and non-compliant with PO (by mouth) medications.On 6/26/25 at 12:48 PM V11, [NAME] President of Clinical Services, stated she did not review R2's hospital records prior to R2's admission to the facility. V11 stated based on what she knows about R2 now, R2 should have had elopement risk interventions, R2's care plan should have been updated, the hospital discharge orders for R2 to follow up with specialists should have been put onto R2's physician orders, and those appointments should have been made. Surveyor asked V11 why R2 was placed in a room [ROOM NUMBER] doors down from an exit as the facility elopement policy documents room placement close to common area and away from exits. V11 replied based on what she knows now R2 should have been placed in a room closer to the nurse's station.Facility plans to remove immediacy: Description of Occurrence:Facility failed to ensure residents were supervised to prevent elopement.Action Taken Completion Date1) R2 is no longer in the facility 6.25.252) a) Admin/ DON were in-serviced by the VP of clinical services. a) Completed 6.25.25b) Admin in-serviced the IDT team. b) Completed 6.25.25c) Current staff in-serviced on elopement policy and procedure. c) Completed 6.25.25 EOD by IDT team.3) a) All residents that resided in the facility will have an elopement risk assessment completed within the last 30 days. a) Completed by VP of clinical services, DON, & administrator by 6.25.25b) Elopement Binder will be updated based on those risk assessments. b) Completed by VP of clinical services, DON, & administrator by 6.25.25c) Review of policy and procedure completed to reflect current practice. c) Completed by VP of clinical services by 6.25.25. 4) All working staff have been in-serviced on elopement, monitoring, and procedures on what to do if a resident is at risk. Currently all staff on shifts are in-serviced. Total facility staff will be 100% by 6.25.25.On-going- being completed by IDT team or designee by start of next working shift.5) No staff will work before being in-serviced on elopement procedures.6) A quality assurance tool was implemented; daily audit of the 24 hour report for wandering/elopement risks. Daily audit for elopement risk assessments completed within 72 hours of admission. Audits to continue daily x 4 weeks to ensure that elopement risk is documented. On-going. Audits completed by: Admin/ Designee 7) Root Cause Analysis completed for elopement.Deficiency: Failed to prevent elopement. Root Cause: Attached. Initiated- 6.25.25 Completed 100% Completed by:[NAME] [NAME]- VP of Clinical ServicesYehuda [NAME]- CEOMonica [NAME]- AdministratorTracey Berry- DON2.)R22's clinical census sheet, print date of 7/8/25, documented R22 was admitted to this facility on 7/1/25. R22's medical diagnosis sheet, print date of 7/8/25, documented R22 has diagnoses of paranoid schizophrenia, muscle weakness, gastro-esophageal reflux disease, primary generalized osteoarthritis, and drug induced subacute dyskinesia. R22's MDS, dated [DATE] at 12:53 PM, documented R22 is moderately cognitively impaired. This assessment was completed by V10 Social Service Director. R22's progress note, dated 7/8/25 at 1:02 PM and authored by V9 Activity Director, documented a second cognitive assessment with a higher score indicating R22 is cognitively intact. R22's clinical resident profile/face sheet, print date of 7/8/25, does not have R22's photo. R22's care plan, print date of 7/8/25, documented R22 is at risk for wandering/elopement with goals of the resident will not leave facility unattended and the resident's safety will be maintained. Interventions are schedule time for regular walks/appropriate activity. R22's care plan, undated, documented 7/8/25 actual elopement: placed on 1:1, will be supervised when outside, elopement risk assessment reassessed. Placed in elopement binder. Date initiated: 7/8/25. Elopement risk assessment will be completed within 72 hours of admission, readmission, and quarterly. Engage resident in purposeful activity, identify if there are triggers for wandering/eloping, provide reorientation to surroundings, and schedule time for regular walks/appropriate activity. R22's fall risk evaluation, dated 7/8/25 at 8:39 PM, documented R22 has intermittent confusion.On 7/8/25 at 10:32 AM two surveyors observed facility staff walking at a fast pace up and down the halls looking for a resident. At 10:38 AM V1 Administrator was in the conference room with the surveyors and unaware other facility staff were looking for a resident. Surveyor then alerted V1 that staff were looking for a resident. The facility does not have an overhead paging system, so surveyors did not hear any facility employees including the leadership team announce code pink per the facility policy when a resident is missing. At 10:43 AM V2 DON was observed walking at a fast pace down the 200-unit corridor, surveyor asked what resident is missing, and V2 replied (R22). At 11:00 AM surveyor checked the facility elopement binders and R22 did not have an elopement binder nor a photo in his EMR (electronic medical record). Multiple employees wer

Based on interview, and record review, the facility failed to physically assess a resident (R2) after a fall. This failure resulted in R2 sustaining a tibial plateau fracture on 11/22/2024 and not being sent to hospital for evaluation until 11/26/2024. Findings include: R2's Facesheet documents an admitted [DATE]. Diagnosis include Dementia, Cerebrovascular Accident, Seizures, Hypothyroidism, Hypertension. R2's Minimum Data Set, MDS, dated [DATE] documents R2 has no cognitive deficits. R2 requires substantial/maximum assist with chair to bed transfers. R2's Care Plan dated 11/26/2024 documents R2 is at risk for falls. R2 does not understand mobility limits due to cognitive limitations related to dementia and Alzheimer's disease. Actual fall 11/26/2024. R2's Fall investigation dated 11/27/2024 at 3:00PM documents fall with physical harm/injury. Detailed incident summary documents R2 is a [AGE] year-old female resident with cognitive impairments. R2's Fall investigation/Findings: R2 when interviewed stated that she fell but could not provide details of when or how she fell . When asked if it was recent, she stated Yes. R2 stated she feels safe at facility. Staff members who were interviewed stated that R2 runs her wheelchair into doors and doorways. Staff try to redirect her, but she continues to have behaviors. A Certified Nursing Assistant, CNA, stated that 11/22/2024 R2 needed to be lowered to the floor via gait belt but that she was lowered to her bottom without incident. When asked about the incident the CNA stated R2 was holding onto the arms of the chair and not letting go during the transfer, so the CNA was going to sit her back into her wheelchair when R2 locked her arms and legs and had to be lowered to the floor. R2's Nurse's notes dated 11/25/24 at 8:00PM documents left leg swollen, bruised, warm to touch. Reported via secure communication. New order received. Negative Holman's sign bilaterally. No signs/symptoms of pain when active range of motion performed. Call light within reach. R2's Nurse's notes dated 11/25/24 at 10:00PM documents radiology company notified of X-ray and Doppler order. R2's Nurse's notes dated 11/26/24 at 1:49AM documents result of X-rays of left femur, left knee and left tibia and fibula sent to secure communication. R2's Nurse's notes dated 11/26/24 at 6:30PM documents R2 left facility via ambulance with 2 emergency medical technicians, EMTs, to local hospital. R2's X-ray report dated 11/26/2024 documents frontal and lateral views of the left femur submitted. Tibial lucency can be evaluated with tibial imaging. Impression no acute fracture visualized femur. Impression Age indeterminate tibial plateau fracture. On 12/12/2024 at 3:20PM V3, Certified Nursing Assistant, CNA, stated, on 11/22/2024 in the evening, I went into R2's room to put here to bed. I had not been here very long, so I didn't know R2 well. I was told R2 was a one person assist, but she needed to be a 2 person assist. When I began to transfer her after I put the gait belt on her, she locked her arms on the wheelchair and would not let go. I set her down in the wheelchair and talked to her and told her she has to let go of the wheelchair to be able to get in bed. I tried to transfer her again and again she locked her arms on the wheelchair and would not let go. This time she was out further from the wheelchair, and I was unable to get her back in the wheelchair. R2 then slid to the floor. Her legs were bent against her dresser in what looked to be an uncomfortable angle. I left the room to get another CNA to help me. We got her up off the floor and into bed. R2 denied being in pain. I told the nurse I was working with what had happened. I don't know the nurse's name. On 12/13/2024 at 2:00PM V13, Licensed Practical Nurse, LPN, stated she was working the evening of 11/22/2024 and was R2's nurse. V13 denies being told R2 was lowered to the floor or R2 having any incident at all. On 12/13/2024 at 2:25PM V15, Certified Nursing Assistant, CNA, stated I helped V3 with R2 when R2 was lowered to the floor. When I went in the room R2 was sitting with her bottom on the floor and her hands were still holding the arms of the wheelchair. Her legs were straight. We got her off the floor and onto the bed. She did not complain of pain. On 12/17/2024 at 9:45AM V16, Nurse Practitioner, stated I would've expected R2 to have been assessed at the time of her fall on 11/22/2024. When I was notified about R2's leg appearing red and swollen was on 11/25/2024. I then ordered a Doppler and x rays. There is no documentation of R2's fall or any assessments on file for 11/22/2024. Facility's undated fall policy states 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 notify the Physician and/or Nurse Practitioner in a change in condition for 1 of 1 resident (R95) reviewed for change in condition in the sample of 24. Due to this failure R95's condition worsened with increased blood noted in his stools the next day, requiring him to be admitted to the hospital for treatment. Findings include: R95's Face Sheet documents he was admitted to the facility on [DATE]. R95's Cumulative Diagnosis Log, undated, documents his diagnoses as: Ortho Aftercare, (right hip fracture post-surgery); Gastrointestinal Bleed, (GI Bleed); Reduced Mobility-Activities of Daily Living Deficit; Gout; Wound Surgical Site Care; and Gastroesophageal Reflux Disease, (GERD). R95's Nurse's Notes dated 9/17/23 at 5:00 PM documents, Resident quiet today, no complaint of discomfort. Had some blood in his stool this morning, but no more today. Need to let (V18, Nurse Practitioner (NP),) know, when possible, on Wednesday. Resident is resting in bed, call light nearby. Yet waiting on meds to come into the facility. R95's Nurse's Notes dated 9/18/23 at 6:00 PM documents, CNA, (Certified Nursing Assistant), notified this writer that resident had blood in his stool. Upon assessing resident, this writer observed large amounts of bright red blood mixed in loose stool. On call NP notified. Gave verbal orders to send resident to nearest ER, (emergency room ). 911 called. EMS, (Emergency Medical Services), enroute to transport resident at this time. Emergency contact called and voicemail left to return call at earliest convenience. R95's Hospital Records dated 9/18/23 to 9/20/23 documents he was admitted to the hospital for diagnosis of Gastrointestinal Hemorrhage, Chronic Kidney Disease, Chronic Anemia, and Moderate Malnutrition. Per the hospital records, R95 was in the hospital from 9/18/23 to 9/20/23. A handwritten, undated, unsigned document included in the Nurse's Note section of R95's chart documents R95's first name, GI Bleed, none there, blood transf, (transfusion), on admission, refused care and colonoscopy, hemoglobin stable, wounds-Santyl and will come with creams, vitals-128/90, P (pulse) 82, 100 % room air RA (room air), 18, 98.2; refused to eat= no trust, LBM (last bowel movement)-18th, and no Amlodipine (B/P) (blood pressure) EMS pick up at 6:30 PM. These handwritten notes were written on the back of a facility census report that was dated 9/20/23. On 9/27/23 at 3:45 PM V2, Director of Nursing, (DON), stated, she would expect staff to call the Doctor or Nurse Practitioner immediately if they observed blood in a resident's stool. V2 stated, she would consider blood in a resident's stool to be an abnormal finding and the Nurse should check to see if the resident had a bleeding hemorrhoid or something that may cause the blood in the stool, but it should still be reported right away. V2 stated, the Nurse Practitioner comes to the facility every week, but not always on the same day. She stated, by notifying the Doctor or Nurse Practitioner, that would allow for them to order additional tests to determine what is causing the blood in the stool. On 9/27/23 at 3:50 PM V6, Licensed Practical Nurse, (LPN), stated, she is the nurse who wrote the Nurse's Note on 9/17/23 regarding blood in R95's stool. V6 stated, she saw it in the morning after they toileted R95 and it was not a lot of blood. V6 stated, she was unable to notify the Nurse Practitioner, because R95 had not been entered into the facility's Electronic System and therefore she could not send the Nurse Practitioner a message about him. V6 stated, she did not feel the amount of blood she saw in his stool was blood transfusion amount. V6 stated, she had checked him for hemorrhoids, but he did not have any. V6 stated, she did write that V18, Nurse Practitioner, should be notified on Wednesday when she would be in the facility. V6 stated, she was not sure who is responsible for entering residents into the system when they are first admitted , but R95 was not admitted until the previous Friday evening, so there was no one here to enter him into the system. V6 stated, it was a Sunday when she first noted R95 had blood in his stool. On 9/27/23 at 4:30 PM V1, Administrator, stated, the Nurse would have been able to notify the Nurse Practitioner of the blood in R95's stool even if he had not been entered into the facility's system. V1 stated, the Nurse Practitioner should have been notified when V6 first saw blood in R95's stool. On 9/28/23 at 8:15 AM V18, NP, stated, V6, LPN should have notified the Nurse Practitioner on call as soon as she noted R95 had blood in his stools, because of his Medical History of a GI bleed. V18 stated, any staff can add a resident's name to the Electronic Medical System the facility uses to notify Doctors and Nurse Practitioners when a resident has a change in condition. V18 stated, the actual treatment probably would have been the same, but there should not have been a delay in reporting abnormal signs and symptoms, including R95 having blood in his stools. V18 stated, she does not know why they would have waited until Wednesday to notify her when the blood was observed in R95's stool on Sunday. The facility's policy, Notification for Change in Resident Condition or Status, revised 12/7/17 documents, Policy: The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, Physician, Guardian, HCPOA (Health Care Power of Attorney), etc.) of changes in the resident's medical/mental condition and/or status. Procedure: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a. Any symptom, sign or apparent discomfort that is 1. Sudden in onset 2. A marked change (i.e., more severe) in relation to usual signs or symptoms 3. Unrelieved by measures already prescribed, e. A significant change in the resident's physical/emotional/mental condition h. A need to transfer the resident to a hospital/treatment center. 2. The nurse supervisor/charge nurse will notify the DON, Physician, and unless otherwise instructed by the resident the resident's next of kin or representative when the resident has any of the afore mentioned situations or: b. There is a significant change in the resident's physical, mental or psychological status, e. It is necessary to transfer the resident to a hospital/treatment center. 3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical /mental condition or status.

Based on interview and record review, the facility failed to provide supervision to prevent falling for 1 of 2 residents (R34) reviewed for supervision in the sample of 31. This failure resulted in R34 falling and being sent to the emergency room (ER). R34 sustained a right acute femoral neck fracture. Findings include: R34's Quarterly Minimum Data Set (MDS), dated [DATE] documents R34 is cognitively impaired, uses no mobility devices, not steady, only able to stabilize with staff assistance for walking, moving on and off the toilet, surface to surface transfers and moving from seated to standing position. R34's MDS document R34 requires limited assistance of staff with one-person physical assist for transfers and walking. The MDS documents R34 is totally dependent with one-staff person physical assistance for toileting and personal hygiene. The MDS documents R34 has had no falls. R34's Fall Risk Assessment, dated 1/4/2022, documents R34 is at risk for falls. R34's Care Plan, documents R34 is a high fall risk without device, unsteady gait & needs staff assist to maintain balance. R34's Care Plan Goal documents R34 approaches uses 1 assist and gait belt for all ambulation. Use additional assist as needed when resident is not feeling well, feeling weak or dizzy. Observe for and educate on proper technique and use of device. Monitor resident for signs of fatigue during ambulation. Fall risk assessment quarterly and as needed with change in condition or fall status. Inform MD (physician) of any falls, including report of injuries. Request MD review of medications and conditions during nursing home visit especially after falls. Encourage resident to sit in areas well supervised by staff that also afford opportunity for increased socialization and distraction. Toilet per schedule and as needed when restless or agitated. Encourage resident to wear a brief during daytime hours to minimize risk of slipping on wet floor during toileting. 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. R34's Nurse's Note dated 2/5/2022 at 4:30 PM documents This nurse was called to patient room, stated pt was walking from bathroom lost balance fell to floor. This nurse observed pt in sitting position on floor. Pt able to perform ROM (range of motion) without difficulty. Pt was able to stand without discomfort. Assisted to bed. Placed call to on call MD (physician) awaiting return call. 5:00 PM on call MD call back new order x-ray to right hip (2 views.) Call to x-ray company made aware of new x-ray orders. Will send next available technician. R34's Physician's Order Sheet (POS) dated 2/5/2022 documents STAT (immediately) x-ray of right hip (2 views) T.O. (telephone order) from physician. No scheduled or when necessary (PRN) pain medication ordered. R34's Nurse's Notes dated 2/5/2022 at 6:15 PM X-ray company here to complete x-rays. R34's X-Ray Patient Report, dated 2/5/2022 documents reason for x-ray: pain, s/p (status post) fall, limited ROM (range of motion), difficulty with ambulation. Clinical indication: pain. Findings: acute femoral neck fracture noted. R34's Nurse's Notes dated 2/5/2022 at 10:30 PM documents result of x-ray of right hip shows sacute hip fx (fracture.) Resident complaint of pain, Tylenol given. Doctor gave orders to send resident to hospital for tx (treatment) and eval (evaluation.) Family called with message left on machine after no answer. Ambulance called for transport. Vital signs documented. R34's POS, dated 2/5/2022, documents send to ER (emergency room ) R/T (related to) hip fracture. R34's Incident Report Form - IDPH Notification, dated 2/6/2022 documents alleged fall with injury. X-ray obtained and revealed right acute femoral neck fracture. Investigation initiated. Final report will be sent. Res was hospitalized on [DATE] at 10:40 PM. Physician notified 2/5/2022 at 5:00 PM and family notified on 2/6/2022 at 6:30 AM. On 8/16/2022 at 9:45 AM, V16, Certified Nurse's Aide (CNA) stated R34's ambulates with a gait belt because her gait is unsteady. On 8/16/2022 at 9:50 AM, V35, CNA, stated R34 has good and bad walking days. Some days she (R34) is steady and other days she is unsteady on her feet. V35 stated, on R34's unsteady walking days she needs more staff assistance when up walking, usually one staff with a gait belt. On 8/16/2022 at 2:15 PM, V27, CNA, stated she was assigned to R34 on 2/5/2022. She went to get R34 up for supper and assisted R34 to ambulate to the bathroom. V27 stated she always ambulated with R34 because R34 had an unsteady gait. V27 stated, while R34 was in the bathroom V27 left the room to get a washcloth and returned within 30 seconds. V27 stated R34 was on the floor. V27 reported incident to the nurse (name unknown.) V27 stated she knew not to leave R34 on the toilet by herself, but she was going to be right back. V27 stated she told the nurse she (V27) was in the room when the resident (R34) fell because she didn't want to get in trouble. On 8/16/2022 at 12:02 PM, V2 (Regional Nurse), stated she expected staff to ambulate with residents that need assistance. V2 stated, when a resident is weak, she expects staff to ambulate the resident with a gait belt and 1-2 staff. V2 stated she didn't have additional information specific to the fall or injury R34 sustained. V2 stated she expected the resident's care plan to be updated with how they transfer. The Facility's Fall Prevention Policy, revised 11/10/2018 documents To provide for resident safety and to minimize injuries related to falls, decrease fall and still honor each resident's wishes/desires for maximum independence and mobility. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the 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. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting any new interventions will be written on the care plan.

Based on record review and interview, the facility failed to assess and monitor a resident per physician's orders who tested positive for COVID-19 for 1 of 3 residents (R46) reviewed for a change in condition in the sample of 31. This failure resulted in a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R46's Quarterly Minimum Data Set (MDS) dated [DATE] documents he was moderately cognitively impaired. R46's MDS also documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's COVID test specimen was collected on [DATE] and reported on [DATE]. The COVID test results documents R46 was positive. R46's Nurse's Notes, dated [DATE] at 10:00 PM documents resident (R46) was moved to room (number) O2 (oxygen) intact 2 L (liters)/NC (Nasal Cannula) VS (vital signs) 98.6, 80, 18, ,d+[DATE] and 95% oxygen saturation with O2. CXR (chest x-ray) results rec'd (received): negative for acute cardiopulmonary disease. Res (resident) voiced no C/O (complaint of). R46's Nurse Practitioner Progress Note, dated [DATE] documents reason for visit: nausea and fever. Resident is resting in bed; he appears weak and tired. He reports loss of appetite, nausea and fever. He states he has no desire to eat. Vital signs at 9:21 AM ,d+[DATE], 63, 18, 99.8. Notify provider of any acute changes or if oxygen at 2L falls below 90%. R46's Nurse's Notes, dated [DATE] at 3:00 AM documents VS 98.2, 84, 18, ,d+[DATE] and oxygen saturation 94% with oxygen on 2L/NC. R46's Nurse's Notes, dated [DATE] at 11:00 AM documents patient seen by doctor. NO (new order) received faxed to pharmacy labs ordered. R46's Nurse Practitioner Progress Note, dated [DATE] documents reason for visit: nausea and fever. Resident is resting in bed; he appears weak and tired. He reports loss of appetite, nausea and fever. He states he has no desire to eat. Vital signs at 9:52 PM ,d+[DATE], 62, 16, 97.8. Notify provider if symptoms persist or worsen. R46's Nurse's Notes, dated [DATE] at 6:10 AM documents resident noted to be pale. Observed resident to not have pulse, respirations or blood pressure, verified with another nurse at this time. R46's Medication Administration Record (MAR), dated ,d+[DATE] documents vital signs every 4 hours with oxygen saturation. Staff initialed the resident's vital signs were assessed 6:00 AM - 6:00 PM one time on [DATE] through [DATE] and one time 6:00 PM - 6:00 AM on [DATE], but no vital signs were documented. R46's Certificate of Death Worksheet documents R46 died on [DATE] with cause of death being COVID-19. On [DATE] at 2:55 PM, V2 (Regional Nurse) stated when a resident was assessed to have a change in respiratory condition, she expected full vital signs to be assessed which includes blood pressure, heart rate, respirations and oxygen saturation per the facility policy. She also expected staff to document if the resident was on oxygen and if they were assessed to have labored breathing, shortness of breath and pain. V2 expected staff to follow physician's orders and to document vital signs in the resident's medical record. V2 reviewed R46's [DATE] POS and [DATE] MAR and stated staff should have assessed and documented his vital signs including oxygen saturation in his medical record every 4 hours instead initialing the MAR. V2 stated, a nurse should assess what his respiratory status was and what his oxygen saturation so the nurse would know if they should have notified the physician if the resident's oxygen saturation was below 90%. On [DATE] at 8:50 AM, V47 (Nurse Practitioner) stated physician's orders for vital signs including oxygen saturation % every four hours are standard protocol for COVID positive patients. V47 said she would expect staff to assess and document the resident's vital signs including oxygen saturation % somewhere in his medical record. Staff documenting vital signs every 4 hours on the resident's ,d+[DATE] MAR and initialing the box was not acceptable. V47 expected staff to document the resident's vital signs and oxygen saturation % so other staff can monitor how he is doing. A magic cup (high protein, high calorie supplement) was ordered because R46 was not eating well. V47 said she expected staff to document the resident's intake and output in his medical record. V47 expected staff to check on COVID positive residents every 1 - 2 hours to ensure the resident hasn't had a change in condition. V47 stated she expected staff to notify the resident's physician or nurse practitioner if the resident had a change in medical condition. V47 stated, if necessary, she would have ordered the resident (R46) to be transferred to the hospital for further evaluation and treatment. If staff would have notified the resident's physician or nurse practitioner of a change in medical condition it could have affected the outcome of the resident health status. V47 stated, the lack of assessment and documentation of R46 does not show evidence that physician ordered monitoring of the COVID positive resident occurred. The facility's Notification for Change in Resident Condition or Status policy, revised [DATE], documents the facility staff shall promptly notify appropriate individuals of changes in resident's medical condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been any symptom, sign or apparent discomfort that is: sudden in onset, a marked change (i.e., more severe) in relation to usual signs or symptoms, unrelieved by measures already prescribed. A significant change in the resident's physical condition. A need to transfer the resident to a hospital/treatment center. Onset of temperature of a temperature two degrees higher than baseline.

Based on observation, interview and record review the Facility failed to implement interventions to address off loading and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R3 developing a stage 4 pressure ulcer on his left lateral heel. Findings include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 was cognitively intact, is not steady for moving on and off surface to surface transfers (between bed and or wheelchair), R3 does not walk, and is at risk for developing pressure ulcers, but had no pressure ulcers at that time. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Care Plan with a start date of [DATE] document R3 is a full mechanical lift with staff members for transferring. R3's Care Plan dated [DATE] documents reposition per positioning schedule- See plan of care. (No plan of care was attached). R3's Care Plan does not document any refusal of being turned and/or repositioned. On [DATE] at 1:09 PM, V4, MDS Coordinator, stated, I am not sure what 'plan of care' means for (R3), I will have to call someone to find out. I am new to this position and will try and find out. On [DATE] at 1:16 PM, V4 stated, (R3's) plan of care is to be turned and repositioned at least every 2 hours. On [DATE] at 1:42 PM, V1, Administrator, provided a list of residents in the facility with pressure ulcers and R3 was identified as having a facility acquired pressure ulcer to the left lateral heel measuring 1.4 x 1.5 x 0.3 centimeters (cm). R3's Braden Scale for Predicting Pressure Ulcer Risk dated [DATE] documents R3 as High Risk for pressure ulcer. R3's Specialty Physician Wound Evaluation and Management Summary, dated [DATE], documents no pressure ulcers. Specialty Wound Physician seeing R3 weekly. R3's Specialty Physician Wound Evaluation and Management Summary, dated [DATE], documents, At the request of the referring provider, (V3, Physician), a thorough wound care assessment and evaluation was performed today. (V3 no longer works at the facility and expired on [DATE] and has not been at the facility for a year.) It also documents an initial evaluation of an Unstageable (due to necrosis) of the left, lateral heel measuring 3.5 x 2.5 x 0.3 cm, 30 % slough, etiology pressure, with duration of greater than 5 days. Recommendations: Reposition per facility protocol, Place padding on or remove metal resting bar on wheelchair, Antibiotic choice: [MEDICATION(S)] 875 mg po (by mouth) bid (2 times a day) for 7 days, Xray: foot xray to evaluate for [CONDITION(S)]. Surgical excisional debridement was performed. R3's Specialty Physician Wound Evaluation and Management Summary, dated [DATE], documents, He has an unstageable DTI (deep tissue injury) of the right, first toe for at least 3 days duration. It also documents a Stage 4 Pressure Wound of the Left, lateral heel, etiology pressure, wound size 3.0 x 2.5 x 0.3 cm, duration greater than 20 days with 20 % slough. Surgical excisional debridement was performed. Initial evaluation of an Unstageable DTI of the right, first toe, etiology pressure, duration greater than 3 days, measuring 1 x 2 x not measureable cm. R3's Specialty Physician Wound Evaluation and Management Summary, dated [DATE], documents a Stage 4 Pressure Wound of the Left, lateral heel, etiology pressure, wound size 1.5 x 2.0 x 0.3 cm, 20 % slough with duration greater than 28 days. Surgical excisional debridement was performed. Unstageable DTI of the right, first toe, etiology pressure, duration greater than 11 days, measuring 1 x 2 x not measureable cm. R3's Specialty Physician Wound Evaluation and Management Summary, dated [DATE], documents, It documents a Stage 4 Pressure Wound of the Left, lateral heel, wound size 1.4 x 1.5 x 0.3 cm, 20 % slough with duration greater than 49 days. Surgical excisional debridement was performed. Recommendations: X-ray foot to evaluate for [CONDITION(S)], Antibiotic choice: [MEDICATION(S)] 875 milligrams by mouth two times a day for 7 days. Place padding on or remove metal resting bar on wheelchair. Reposition per facility protocol. Unstageable DTI of the right, first toe, etiology pressure, duration greater than 32 days, measuring 1 x 2 x not measureable cm. R3's Specialty Physician Wound Evaluation and Management Summary dated [DATE], documents a Stage 4 Pressure Wound of the Left, lateral heel, etiology pressure, wound size 1.4 x 1.5 x 0.3 cm, 20 % slough with duration greater than 55 days. Surgical excisional debridement was performed. R3's Medical records, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:45 PM, R3 stated, I lost my leg back in January. I was having some stomach pain they sent me out to the hospital. The hospital did a MRI on me and told me that they had to cut off my leg because it was so infected. I am having some of the same issues on my good leg now. They do not have any regular staff now and they use all agency. The staff on the weekends do not change my dressing and that scares me because I do not want to lose both legs. I told (V5, Licensed Practical Nurse) that they were not changing my bandages and putting medicine on it. (V5) is really good about changing my bandages. Sometimes when she comes in she can tell they did not change my bandages. On [DATE] at 11:03 AM, V5, Licensed Practical Nurse (LPN) stated, When I work I am always changing( R3's) dressings and when I come in after the week-ends (R3) tells me that his dressing did not get changed. When I change the gauze the dates are off and the dressing have not been changed and sometimes they do not even date the bandages. But (R3) he knows they haven't been changed and it makes me sad and he tells me they did not get changed. On [DATE] at 3:23 PM, R3 was lying in bed with his pressure relieving boots on and his heels were not being floated. The boots were directly making contact with the bed. On [DATE] from 8:15 AM- 11:02 AM based on 15 minute or less observation intervals, R3 remained in his wheelchair without benefit of repositioning or off loading. R3 was sitting in his room in his wheelchair with his back to the door. His chin was to his chest, his head was down and his eyes were closed. He had a bib wrapped around his neck from breakfast still on him. His right leg was extended and was in a pressure reduction boot which was resting directly on a metal rest pedal for the wheelchair. On [DATE] at 10:15 AM, V6, Certified Nursing Assistant (CNA), stated, (R3) is alert and orientated, we do not turn and reposition him he just tells us when he wants to lay down. If a resident refuses any care we let the charge nurse know. On [DATE] at 10:18 AM, V10, CNA, stated, I am agency. I personally have not had any issues with (R3) refusing care or anything. If I have a resident that refuses care I let the charge nurse know. On [DATE] at 10:20 AM, V11, CNA, stated, I work for agency, too, and I have not had any issues with (R3). He can tell you want he wants, is soft spoken. He has never refused care for me. On [DATE] at 10:22 AM, V12, CNA, stated, I am agency. I go and look at the book at the nurses station to find out what everyone's activities of daily living are and what kind of help they need. I have not had any issues with (R3) refusing care. On [DATE] at 2:31 PM, V7, CNA, stated I am agency. I can tell you who on the 200 hall needs to be repositioned every 2 hours. I have not had any issues with (R3) refusing any care. On [DATE] at 2:33 PM, V8, CNA, stated, I am agency. I go and look in the books at the nurse's station to see what residents need. (R3) is total care and needs assistance with almost everything. I have not had any issues with him refusing care. On [DATE] at 2:35 PM, V9, CNA, stated she was agency and she goes around and checks on resident's needs. V9 stated she does not have any problems with (R3) and he was alert and able to tell you his needs. On [DATE] at 2:43 PM, V13, LPN, stated, I have not had any reports of (R3) refusing care. On [DATE] at 2:49 PM, V5 stated, I have not had any issues with (R3) refusing care and or not wanting anything done because of his foot. He lost the one leg and does not want to lose both legs. R3's Nursing Notes dated [DATE] at 1:30 PM, Went into resident's room to change dressing 2 CNA's were in there with me. Resident is telling CNA that if this nurse does not come and change his dressing he is reporting me to the Administrator. During this survey, no Director of Nursing or Assistant Director of Nursing was available to interview. All nursing staff working the floor did not know when R3 first developed his pressure ulcer and or how long they pressure ulcers had been there and or what stages it was found and or discovered. R3's Medical records were reviewed and there was no documentation of when R3's pressure ulcer was first discovered. On [DATE] at 4:01 PM, V15, Wound Doctor, stated, I was originally taking care of (R3) about 2 years ago and then another provider came into the Facility and I was not treating (R3) anymore until recently. He was not my patient when he went out to the hospital and had to have his leg amputated. I can't tell you when his wounds first appeared. I started seeing him after he came back from the hospital. (R3) has a lot of health issues and when [CONDITION(S)] takes over it becomes a challenge. I would expect (R3) to wear his boot at all times but it should be off loaded at least every 2 hours and not sitting directly on the wheelchair and/or bed. There should be something in place so there is not direct contact with the wound. The Facility's Pressure Ulcer Policy with a revision date of ,d+[DATE] documents, It is the policy of the facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Upon notification of skin breakdown the Quality Assurance form for Newly Acquired Skin Conditions will be completed and forwarded to the Director of Nursing. The Facility's Pressure Sore Prevention Guidelines with a revision date of ,d+[DATE] document, It is the Facility's policy to provide adequater interventions for the prevention of pressure ulcers for residents who identified as High or MODERATE risk for skin breakdown as determined by the Braden Scare. For those residents identified as high risk, the facility's documented the intervention as Turn and reposition every two hours. Comments, Turning and positioning may be more often than every 2 hours for high risk, if indicated.

Based on observation, interview, and record review the facility failed to implement interventions to address off-loading and treat pressure ulcers as recommended by physician for two of three residents (R4 and R5) reviewed for pressure ulcers in the sample of 7. This failure resulted in R4 being admitted to the hospital with diagnosed of infected sacral pressure ulcer requiring removal of R4's coccyx (tailbone). Findings include: 1. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. R4's MDS documents he has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's medical record documented R4 had a pressure ulcer develop on his left buttock on 12/15/20. R4's medical record documented his pressure ulcer showed improvement until 2/2/21 at which time, R4's left buttock pressure ulcer deteriorated, and he acquired a new pressure ulcer to his right buttock. R4's Wound Evaluation and Management Summary Form, dated 2/2/21, documents R4's left buttock pressure ulcer deteriorated to 6.5 centimeters (cm) x 4 cm and he had acquired a new shear wound to his right buttock measuring 6 cm x 3 cm. The Wound Consultant physician, V15, continued to recommended calcium alginate with gauze island for the left buttock and calcium alginate with [MEDICATION(S)] ointment applied once daily for 30 days for the right buttock shear wound. R4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented order for the [MEDICATION(S)] ointment to applied to R4's right buttock shear wound as V15 recommended. R4's PO, dated 2/2/21, was written on R4's Treatment Administration Record (TAR) as cleanse right and left buttock with wound cleanse, apply calcium alginate and cover with border gauze. The recommendation to apply the [MEDICATION(S)] ointment was not transcribed to the TAR. R4's Wound Evaluation and Management Summary Form, dated 2/9/21, documented R4's left buttock shear wound measured 6 cm x 4 cm and had improved. The Report documented R4's right shear wound improved measuring 5.5 cm by 3 cm. The form documented V15 recommended no change in treatment. R4's Wound Evaluation and Management Summary Form, dated 2/18/21, documented R4's left buttock decreased in size to 6 cm x 3.9 cm and right pressure ulcer measurement had not changed. The Form documented V15 recommended no changes in treatment at that time. R4's February 2021 Treatment Administration Record (TAR) documented that R4's pressure ulcer treatment was completed only 8 times in the entire month for both the right and left buttocks. There were no pressure ulcer measurements documented on R4's TAR for the last two weeks of February 2021. There was no documentation in R4's medical record documenting the status of R4's pressure ulcers from 2/18/21 through 3/9/21. R4's Physician Order, dated 3/9/21 documented Resume (Wound Consultant) for Left Above the knee amputation and right below knee amputation and coccyx. The Wound Evaluation and Management Summary form, dated 3/9/21, documents R4's shear wound to left buttock had improved and measured 3 cm x 0.5 cm. The Report documented R4's right buttock shear wound had improved measured 3 cm x 3 cm. The Wound Report documents R4 had acquired a new shear wound to the right proximal buttock measuring 2.0 cm x 2.5 cm. The Report documents R4 acquired a new shear wound to his sacrum with measurements of 1 x 0.5 cm with 20 % slough. The form documents V15 recommended the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's PO, dated 3/9/21, documented the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V15's recommendation for the calcium alginate with silver for the new right proximal buttock and sacrum pressure ulcers did not get transcribed to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Consultants Wound Evaluation and Management summary note, dated 3/16/21, documents R4's shear wound of left buttock measures 3 cm x 0.5 cm with no changes in wound progress. The dressing treatment plan was for alginate calcium apply once daily and gauze island daily. The Note documented R4's shear wound to the right buttock measures 3cm x 3 cm with no changes in wound progress. The dressing treatment plan was for alginate calcium and apply [MEDICATION(S)] ointment daily. The Note documented R4's shear wound of the right proximal buttock measured 2.0 x 2.5 cm with no change in wound progress The note documented R4's shear wound to sacrum was the same measurement from the previous week and showed no changes in wound progress. The dressing treatment plan for the right proximal buttock shear wound and R4's sacrum shear wound was for alginate calcium with silver apply once daily and gauze island. R4's POS dated 3/16/21 documents left buttock and sacrum: cleanse wounds cover with Calmoseptin and calcium alginate to Left buttock and sacrum cover with dry dressing change twice daily and as needed. Again, V15's recommendation for calcium alginate with silver for R4's right proximal buttock shear wound, and sacrum shear wound did not get transcribed to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Consultants Wound Evaluation Management report from 3/23/21 documents R4's shear wound of the left buttock deteriorated and measured 4.6 cm x 4.0 cm. The Dressing Treatment plan documented R4 should receive alginate calcium with gauze island applied twice daily and [MEDICATION(S)] ointment applied twice daily. The summary note documented there was no change in progress to R4's shear wound of the right buttock. The wound consultant noted the proximal and right buttock wound were now one continuous wound measuring 6 cm by 2 cm. The Note documented R4's shear wound to the sacrum deteriorated and measured 6 cm x 3 cm with 20 % slough. The Note documented a new shear wound to R4's left, proximal buttock measuring 1.5cm x 0.5 cm. The Note documented the dressing treatment plan was alginate calcium and gauze island applied twice daily with [MEDICATION(S)] ointment applied twice daily. The Wound Evaluation and Management summary form dated 3/31/21 documented R4's shear wound to the left buttock improved measuring measures 4.5 x 3 cm and no changes in treatment were made. The Note documented R4's shear wound to the right buttock deteriorated and measured 7.5 cm x 2 cm with no changes made to treatment. The Note documented R4's shear wound to the sacrum deteriorated and measured cm 6 cm x 3 cm x 0.4 cm with 70% slough. The Report documented Patient does not like or want to be turned. As a result, there is deterioration of sacral wound due to pressure of being in one position for prolonged periods of time. The Note documented V15's treatment plan was alginate calcium with silver applied twice daily with gauze island. The Note documented R4 had improvement to the shear wound of his left proximal buttock with decreased measurement of 1.3 cm x 0.5 cm. R4's PO dated 3/31/21 documents pressure preventing cushion for R4's chair and a low air loss mattress. The PO documents Santyl and Calcium Alginate to sacrum, and calcium alginate to right and left buttock. This PO does not document the V15's for calcium alginate with silver to be applied to R4's sacrum twice daily and V15 did not recommend Santyl. When surveyor requested R4's March 2021 Treatment Administration Records, the facility could not provide these. There was no documentation in R4's medical record to determine if R4 received any pressure ulcer treatments in March 2021. R4's Wound Evaluations and Management Summary, dated 4/6/21, documents R4's shear wound of left buttock deteriorated to 10 cm x 4 cm with 40% slough. The Summary documented the treatment plan as Alginate calcium applied twice daily with gauze island and [MEDICATION(S)] ointment applied twice daily. The summary documented the R4's shear wound of the right buttock had deteriorated and measured 9.5 cm x 8.0 cm. The form documented V15's treatment plan as alginate calcium apply twice daily with [MEDICATION(S)] ointment applied twice daily. The Summary documented R4's shear wound sacrum deteriorated and measured 7.5 cm x 5.0 cm x 2 cm with 40% slough. The recommendation made was again low air loss mattress; off-load wound and reposition per facility protocol. The summary documented a new shear wound to R4's left hip measuring 1 cm x 3 cm. The dressing treatment plan was for hydrogel and gauze island. The wound consultant did not want any labs at that time. R4's POS dated 4/6/21 documents low air loss mattress related to wounds. There was no PO written for the hydrogel to address R4's new left hip pressure ulcer. R4's April 2021 TARs documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no wound consultant notes from 4/6 through 4/20/21. There were no wound measurements during this time documented in R4's medical record. V17's Nurse Practitioner Note dated 4/20/21 documents the V21, R4's family, wants R4 to see an outside wound provider and R4 refused to go to an outside provider. He confirmed what the nurse said that his bottom causes him pain. R4 POS dated 4/20/21 documents R4 does not want outside wound services reconsult the facility contracted wound service. The Wound Evaluations and Management Summary dated 4/20/21, documented R4's shear wound to his left buttock improved and measured 9.5 cm x 4 cm by not measurable. The shear wound to left buttock 9.5 x 4 cm. The Summary documented R4's shear wound of the right buttock had improved and measured 8.5 cm x 5.5 cm by 2 cm. The Consultant treatment was alginate calcium apply twice daily and [MEDICATION(S)] ointment apply twice daily. The summary documented the sacrum shear had deteriorated and measured 7.5 cm by 5.0 cm x 2 cm. The recommendation for treatment was Dakin's solution applied twice daily for 30 days. Irrigate wound with Dakin's and then pack wet to dry twice per day with darkens solution. The shear wound to the left hip measures 1 x 3 cm and wound progress had no change. No changes to treatment were made. R4's PO, dated 4/20/21, documented to discontinue previous order for sacrum. The PO documented to cleanse and irrigate wound with normal saline, pack with 0/25% or Dakin's soaked gauze and cover with dry border gauze twice daily. R4's Nurse's note dated 4/21/21 documents [CONDITION(S)] called to state they are sending the resident to emergency room due to altered mental status and the inability to maintain posture. R4's Care Plan problem from 8/22/2018, documented R4 was at risk for pressure ulcers. R4's last documented revision on this care plan, dated 7/24/20, documented he was at high risk for pressure ulcers. R4 had multiple pressure ulcers from 2/2020 through 4/20/21. These were not documented on his care plan. No further assessments to address frequency of turning and repositioning and specific pressure relieving devices were documented in R4's Care Plan. R4 ' s Local Hospital emergency room report dated 4/21/21 documents Emergency Medical Services (EMS) picked R4 up from [CONDITION(S)] due to an episode of unresponsiveness. R4's Discharge Summary also documents R4 had a stage IV infected decubital ulcer with extensive soft tissue necrosis with foul smelling drainage. The report documented R4 underwent debridement of the sacral ulcer. His bone biopsy was positive for multiple organisms. The report documented R4 was placed on hospice. R4 s Operative Report dated 4/21/21 documents approximately 10 cm x 6-centimeter (cm) wedge of necrotic skin and fat was excised from the left superlateral aspect of a large sacral wound. There was a large amount of necrotic tissue in the subcutaneous tissue and muscle. R4's Intensivist Progress Note documents Excisional debridement of dead infected skin, fat, muscle, and bone of the sacrum 10 cm x 10 cm. Excisional debridement of dead infected skin, fat and bone of the right leg 3 x 3 cm and removal of the Coccyx ( tailbone). R4's Cat Scan documents underlying Coccyx [CONDITION(S)] soft tissue foci of gas concerning for gas forming bacterial infection. R4's Discharge Summary documents R4's cause of death was [CONDITION(S)], Metabolic [CONDITION(S)], Acute on Chronic Diastolic Heart Failure, Sacral Decubitus ulcer stage IV, Bilateral Stump Ulcers, Severe Protein Calorie Malnutrition, End Stage Renal Disease, Bilateral Lower Extremity Amputations, and Altered Mental Status. R4's Death Certificate, dated 4/28/21, documented his immediate cause of death was [CONDITION(S)] with approximate interval between onset and death of 2 weeks. On 04/30/21 at 8:30 AM V15, Wound Consultant Physician, stated the lack of treatments to R4's pressure ulcers could have contributed to R4's pressure ulcers declining. V15 stated At one point the family wanted him sent out to wound care and then changed their mind. They wanted me to see him again. I sent him to get his left leg amputated but he would not let them go above the knee, so he had to go back for a revision. He had moisture related issues on his back. He did not like to turn, and he refused some treatments. He went to [CONDITION(S)] two times per week and he would be in the same position for hours. His situation was multifactional. 2. R5's MDS dated [DATE] documents R5 is cognitively intact. R5's Care Plan dated 11/23/20 documents R5's treatment will be done as ordered cleansing and application of the medication packing and or dressing change with wound status and progress see POS for current treatment. On 04/29/21 at 1:20 PM R5 stated the facility now and again misses his treatment. R5's POS dated 2/24/21 documents cleanse coccyx wound with wound cleanser and apply calcium alginate silver and cover with a border gauze once daily. R5's POS dated 3/1/21 through 3/31/21 documents cleanse coccyx with wound cleanser and apply calcium alginate silver and cover with a border dressing gauze once daily. R5's Wound Evaluation and Management Summary dated 3/2/21 documents R5 had a Stage IV pressure ulcer to his coccyx which deteriorated measuring 1.2 cm x 0.5 cm x 0.4 cm. The Treatment recommendation was for Calcium Alginate with silver, apply twice daily with gauze island dressing. The Summary documented R5 had a shear wound of the right buttock measuring 4.0 cm x 0.6 cm which had deteriorated. The Treatment plan was skin prep apply once daily, alginate calcium with silver apply once daily with gauze island. R5's Wound Evaluation and Management Summary documented on 3/9/21, 3/16/21, and 3/23/21, R5's Stage IV had improved and the wound to his right buttock had resolved. R5's Wound Evaluation and Management Summary documented on 3/31/21, R5's Stage IV coccyx pressure ulcer had deteriorated. The Summary documented the pressure ulcer measured 1.0 cm x 0.3 cm x 0.3 cm with 10% slough. V15 recommended Santyl twice daily, Alginate Calcium with silver twice daily with gauze island dressing. The recommendation was to off-load wound and reposition per facility protocol. R5 had a new shear wound of the left buttock which measured 2.0 cm x 0.5 cm with treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's April 2021 TAR documents R5 treatment to his coccyx wound was only completed 13 times for the month of April. The Treatment to his left buttock wound was only completed 5 times for the month of April. On 4/30/21 at 8:25 AM V11, License Practical Nurse/LPN stated the facility could use a treatment nurse. On 4/30/21 at 8:29 AM V14 LPN stated, I don't usually have a problem getting to my treatments, but they don't have enough nurses. We could use a treatment nurse. The facility policy entitled Decubitus Care/Pressure Areas dated 1/2018 documents It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Re evaluate the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order.

Based on interview and record review the facility failed to provide care according to accepted standards of practice by failure to closely monitor change in condition for 1 of 3 residents (R3) reviewed for change in condition in the sample of 12. This failure resulted in R3 experiencing increased pain leading to hospitalization with [DIAGNOSES REDACTED]. Findings include: 1. R3's Nurse's Notes, dated 8/15/18 documents, 8/15/18. 2:10 PM. Resident complained of lower abdomen pain denies any nausea, vomiting. Stomach soft to touch no distention. (V11, Physician) notified of new symptoms, he states to monitor her closely and if she don't feel any better notify him. Vital signs: Blood pressure 111/51 mm (millimeter)/Hg (, Pulse 71, respirations 16, O2 stat. Will continue to monitor. R3's clinical record does not document R3 was closely monitored for her abdominal pain from 8/15/18 through 9/3/18 when she was eventually sent to the ER (emergency room ). R3's Situation Background Appearance Review and Notify (SBAR) Communication Form and Progress Note dated 9/3/18 at 12:00 PM, documents, Appearance. Summarize your observations and evaluation: (No entry). Nursing Notes: Resident been having complaint of abdominal pain last few days, gave treatment of [REDACTED]. Pain Evaluation: Worsening of chronic pain. Description/location: Abdominal Pain. Intensity: (No entry), Nonverbal Signs of Pain: Grimacing, Wincing. R3's Physician order [REDACTED]. R3's Medication Administration Record [REDACTED]. R3's MAR for 9/2018 documents R3 was given one dose of [MEDICATION NAME] on 9/3/18. There was no documentation in R3's record she was given any enema between 8/15/18 through 9/3/18. R3's record does not document assessment of her indwelling urinary catheter for patency related to the amount of urine output per shift from 8/15/18 through 9/3/18. R3's Nursing Home to Hospital Transfer Form dated 9/3/18 at 12:10 PM documents, Reason for Transfer: Complained of Pain, every intervention not working, family wants to go to ER. Most recent Pain Level: 10/10. R3's emergency room Visit Report dated 9/3/18 documents, Chief Complaint: Constipation. Associated Symptoms: Abdominal Pain. Denies: Fever, Vomiting. Duration: Days. Relieved By: None. Similar Symptoms: Yes. History of Present Illness: Patient sent over from the nursing home for constipation x 4 days. Her daughter states that she has been complaining that she is not feeling well with pain to her abdomen. Then her daughter stated she has began not to want to eat anything. Patient does have mild dementia. No fever or vomiting. Daughter stated she used to get constipation a lot when she lived at home and she would use (laxative) and prune juice and the nursing home did not have it. They did give [MEDICATION NAME] and 1 enema. R3's ER Computed Tomography (CT) Scan dated 9/3/18 documents, Abdomen/Pelvis: Impression: 1. Bilateral Hydro[DIAGNOSES REDACTED] and Hydroureter has shown increase from prior exam (5/6/18). Distended Urinary Bladder, Possible Bladder Outlet Obstruction. 2. Large Amount of Rectal Stool. 3. Small Pericardial Effusion 4. Small [MEDICAL CONDITION] Hiatal Hernia. R3's Hospital CT Scan Abdomen/Pelvis without Contrast dated 9/5/18 documents, Impression: 1. Mild stercoral [MEDICAL CONDITION] has developed since 9/3/18. Fecal Retention unchanged with rectal diameter 8.5 centimeters (cm) by 7.4 cm. 2. Hydrouretero[DIAGNOSES REDACTED] has mostly resolved since (catheter) placement. R3's Hospital Discharge Summary dated 9/10/18 documents, Hospital Course: 87 y/o female from a nursing home with past medical history of [REDACTED]. The patient's indwelling catheter was draining only very little amount of urine. She was found to have Urinary Tract Infection with ESBL (Extended-spectrum beta-lactamase) Infection and her blood cultures also grew ESBL. Her chronic indwelling catheter was not draining and another new catheter was placed. This new catheter drained almost 2 liters of urine once it was placed. She was started on intravenous ertapenem and completed her 7 days' course. The Summary further documents, Her mental status greatly improved with treatment of [REDACTED]. On 9/13/18 at 12:31 PM, V15, R3's Power of Attorney for HealthCare/Daughter, stated she visited R3 four times a week in the facility and during one visit on 8/28/18 around lunch time V15 noticed R3 was in a lot of pain, verbalizing pain on lower abdomen and not having had a bowel movement for a few days, was moaning and grimacing and ate only 2-3 spoonfuls of food. V15 stated she asked staff to check on R3's condition and she was told R3 was given a laxative and it should help. V15 stated she visited on 8/31/18 and R3 was still in pain and it seemed to her R3's pain was worse. V15 stated R3 has a high tolerance for pain and if she says it hurts so bad that meant she wanted to go to the hospital. V15 told V1, Administrator, about R3's pain and V15 asked V1 to send her to the hospital. V15 stated V1 replied nursing will be taking care of R3. V15 stated V1 asked the nurse to check on R3 who came back and reported to V1 and V15 that R3's bowels were moving per stethoscope check and told V15 that R3 will be given [MEDICATION NAME]. V15 stated she did not get the name of the nurse working for R3. V15 stated the nurses she talked to every visit did not seem to know what was wrong with R3. V15 stated she came again to visit R3 on 9/3/18 at lunch time, and saw R3 was looking terrible, in extreme pain, moaning and grimacing, guarding her lower abdomen and refusing to eat. V15 stated she touched R3's lower abdomen and it was so distended she told V6, Licensed Practical Nurse (LPN) that R3 has to go to the hospital now. V15 stated when R3 arrived at the ER R3's catheter was replaced with a new one and immediately was able to drain 2 urinals full of urine. V15 stated the urine was dark yellow, cloudy and had mucus in it. V15 stated R3 went off to sleep readily right away, so much relief showed on her face. V15 stated the ER staff told her R3 was impacted as well. V15 stated the facility never notified her of R3's lower abdominal pain and she learned of it first hand when she visited on 8/28/18. V15 stated she felt if she was not there and insisted for R3 to go to the ER, the facility would not have sent her on 9/3/18. On 9/19/18 at 3:15 PM, V14, Certified Nursing Aide (CNA), stated she took care of R3 a few days before R3 was transferred to the hospital. V6 stated R3 had very little bowel movement and urine output which she documented at the end of the shift on the ADL (Activities of Daily Living) book so the nurses are aware of what is going on. On 9/19/18 at 3:18 PM, V17, CNA, stated R3 had no bowel movement for 2 days that V17 was assigned to R3 days prior to being transferred to the hospital. V17 stated R3 always have very little urine output because she did not like to drink when offered. I notified the nurse when R3 would have no bowel movement during the shift and the nurse would tell me to let her sit in the toilet. On 9/13/18 at 1:33 PM, V6, LPN, stated she does not recall being aware R3 had abdominal pain prior to the day when she transferred R3 to the ER. V6 stated R3 would complain of upset stomach from time to time but not abdominal pain. V6 added vital signs are taken by the aides and the nurse would write them in the MAR. V6 stated the nurses fill out the residents' Monthly Intake/Output Flow Sheet from data collected by the aides. On 9/19/18 at 8:41 AM, V11, R3's Physician, stated it is hard to say if the facility should have sent R3 to the hospital prior to 9/3/18. V11 stated when the facility called him the first time on 8/15/18 it was early in the process so he would have expected the nurses to monitor the resident closely to observe for changes, like checking vital signs, asking the resident how she feels, palpating the resident, monitoring for output and bowel movement. V11 stated it is a straightforward process and part of basic nursing care to document that they have been closely monitoring the resident to determine if her symptoms progress/she was not feeling any better. V11 stated he expects the nurses to document that they were closely monitoring the resident, there is actually no excuse for failure to document. V11 stated even if you did it if it was not documented then you did not do it, and any excuse does not cut it.

Based on observation, interview and record review, the facility failed to provide close monitoring and assessment and failed to provide adequate care for lower abdominal pain, provide complete incontinent care, failed to document catheter care in the Treatment Administration Record for 3 of 3 residents (R1, R2, R3) reviewed for bladder and bowel function in the sample of 12. This failure resulted in R3 experiencing increased pain leading to hospitalization with [DIAGNOSES REDACTED]. Findings include: 1. R3's Minimum Data Set ((MDS) dated [DATE] documents R3 requires extensive assist with transfers, toilet use, and personal hygiene, occasionally incontinent of bowel and has a urinary indwelling catheter. R3's Physician order [REDACTED]. R3's Care Plan dated 7/28/18 documents, Resident will not have complications related to indwelling urinary catheter. Diagnosis: [REDACTED]. Check placement thru output, see POS to determine order for irrigation if applicable. catheter care every shift. Change catheter per order and as needed if plugged. Monitor for signs and symptoms of infection: dark, foul-smelling urine, blood or mucus in urine, burning/pain at catheter insertion or pelvic/groin/down legs, fever, increased confusion. Notify Physician of s/s/of infection for recommendation and treatment. The Treatment Administration Record (TAR) dated 7/2018 documents R3's catheter was not changed in (MONTH) (YEAR). R3's TAR for 8/2018 showed catheter care has not been consistently provided to R3 every shift. R3's Nurse's Notes dated 8/15/18 documents, 8/15/18. 2:10 PM. Resident complained of lower abdomen pain denies any nausea, vomiting. Stomach soft to touch no distention. (V11, Physician) notified of new symptoms, he states to monitor her closely and if she don't feel any better notify him. Vital signs: Blood pressure 111/51 mm (millimeter)/Hg (, Pulse 71, respirations 16, O2 stat. Will continue to monitor. R3's clinical record does not show R3 was closely monitored for her abdominal pain from 8/15/18 through 9/3/18 when she was eventually sent to the ER. R3's Situation Background Appearance Review and Notify (SBAR) Communication Form and Progress Note dated 9/3/18 at 12:00 PM, documents, Appearance. Summarize your observations and evaluation: (No entry). Nursing Notes: Resident been having complaint of abdominal pain last few days, gave treatment of [REDACTED]. Pain Evaluation: Worsening of chronic pain. Description/location: Abdominal Pain. Intensity: (No entry), Nonverbal Signs of Pain: Grimacing, Wincing. R3's Medication Administration Record [REDACTED]. R3's MAR for 9/2018 documents R3 was given one dose of [MEDICATION NAME] on 9/3/18. R3's record does not document assessment of her indwelling urinary catheter for patency related to the amount of urine output per shift from 8/15/18 through 9/3/18. R3's Nursing Home to Hospital Transfer Form dated 9/3/18 at 12:10 PM documents, Reason for Transfer: Complained of Pain, every intervention not working, family wants to go to ER. Most recent Pain Level: 10/10. R3's emergency room Visit Report dated 9/3/18 documents, Chief Complaint: Constipation. Associated Symptoms: Abdominal Pain. Denies: Fever, Vomiting. Duration: Days. Relieved By: None. Similar Symptoms: Yes. History of Present Illness: Patient sent over from the nursing home for constipation x 4 days. Her daughter states that she has been complaining that she is not feeling well with pain to her abdomen. R3's ER Computed Tomography (CT) Scan dated 9/3/18 documents, Abdomen/Pelvis: Impression: 1. Bilateral Hydro[DIAGNOSES REDACTED] and Hydroureter has shown increase from prior exam (5/6/18). Distended Urinary Bladder, Possible Bladder Outlet Obstruction. 2. Large Amount of Rectal Stool. 3. Small Pericardial Effusion 4. Small [MEDICAL CONDITION] Hiatal Hernia. R3's Hospital CT Scan Abdomen/Pelvis without Contrast dated 9/5/18 documents, Impression: 1. Mild stercoral [MEDICAL CONDITION] has developed since last scan on 9/3/18. Fecal Retention unchanged with rectal diameter 8.5 centimeters (cm) by 7.4 cm. 2. Hydrouretero[DIAGNOSES REDACTED] has mostly resolved since (catheter) placement. R3's Hospital Discharge Summary dated 9/10/18 documents, Hospital Course: 87 y/o (year old) female from a nursing home with past medical history of [REDACTED]. The patient's indwelling catheter was draining only very little amount of urine. She was found to have Urinary Tract Infection with ESBL (Extended-spectrum beta-lactamase) Infection and her blood cultures also grew ESBL. Her chronic indwelling catheter was not draining and another new catheter was placed. This new catheter drained almost 2 liters of urine once it was placed. She was started on intravenous ertapenem and completed her 7 days' course. The Summary further documents, Her mental status greatly improved with treatment of [REDACTED]. On 9/13/18 at 12:31 PM, V15, R3's Power of Attorney for HealthCare/Daughter, stated she visited R3 four times a week in the facility and during one visit on 8/28/18 around lunch time V15 noticed R3 was in a lot of pain, verbalizing pain on lower abdomen and not having had a bowel movement for a few days, was moaning and grimacing and ate only 2-3 spoonfuls of food. V15 stated she asked staff to check on R3's condition and she was told R3 was given a laxative and it should help. V15 stated she visited on 8/31/18 and R3 was still in pain and it seemed to her R3's pain was worse. V15 stated R3 has a high tolerance for pain and if she says it hurts so bad that meant she wanted to go to the hospital. V15 told V1, Administrator, about R3's pain and V15 asked V1 to send her to the hospital. V15 stated V1 replied nursing will be taking care of R3. V15 stated V1 asked the nurse to check on R3 who came back and reported to V1 and V15 that R3's bowels were moving per stethoscope check and told V15 that R3 will be given [MEDICATION NAME]. V15 stated she did not get the name of the nurse working for R3. V15 stated the nurses she talked to every visit did not seem to know what was wrong with R3. V15 stated she came again to visit R3 on 9/3/18 at lunch time, and saw R3 was looking terrible, in extreme pain, moaning and grimacing, guarding her lower abdomen and refusing to eat. V15 stated she touched R3's lower abdomen and it was so distended she told V6, Licensed Practical Nurse (LPN) that R3 has to go to the hospital now. V15 stated when R3 arrived at the ER R3's catheter was replaced with a new one and immediately was able to drain 2 urinals full of urine. V15 stated the urine was dark yellow, cloudy and had mucus in it. V15 stated R3 went off to sleep readily right away, so much relief showed on her face. V15 stated the ER staff told her R3 was impacted as well. V15 stated the facility never notified her of R3's lower abdominal pain and she learned of it first hand when she visited on 8/28/18. V15 stated she felt if she was not there and insisted for R3 to go to the ER, the facility would not have sent her on 9/3/18. On 9/19/18 at 3:15 PM, V14, Certified Nursing Aide (CNA), stated she took care of R3 a few days before R3 was transferred to the hospital. V6 stated R3 had very little bowel movement and urine output which she documented at the end of the shift on the ADL (Activities of Daily Living) book so the nurses are aware of what is going on. On 9/19/18 at 3:18 PM, V17, CNA, stated R3 had no bowel movement for 2 days when she took care of R3 a few days prior to being transferred to the hospital. V17 stated R3 always have very little urine output because she did not like to drink when offered. V17 stated she notified the nurse when R3 would have no bowel movement during the shift and the nurse would tell V17 to let R3 sit on the toilet. On 9/13/18 at 1:33 PM, V6, LPN, stated she does not recall being aware R3 had abdominal pain prior to the day when she transferred R3 to the ER. V6 stated R3 would complain of upset stomach from time to time but not abdominal pain, so there was nothing new to document until the day of transfer. V6 added urine output and bowel movement are taken by the aides and given to the nurse every end of the shift. V6 stated the nurses fill out the residents' Monthly Intake/Output Flow Sheet from data collected by the aides. On 9/19/18 at 3:21 PM, V24, Registered Nurse (RN), stated she took care of R3 on 8/28/18, 9/1/18 and 9/2/18 and she remembered each time R3 passed a little amount of stool and lots of gas. V24 stated R3 always complained of not having a bowel movement but never of stomach pain. V24 stated she can't remember the aides reporting to her any concern of R3's urine output and did not write any nurses notes. On 9/19/18 at 8:41 AM, V11, R3's Physician, stated it is hard to say if the facility should have sent R3 to the hospital prior to 9/3/18. V11 stated when the facility called him the first time on 8/15/18 it was early in the process so he would have expected the nurses to monitor the resident closely to observe for changes, like checking vital signs, asking the resident how she feels, palpating the resident, monitoring for urine output and bowel movement. V11 stated it is a straightforward process and part of basic nursing care to document that they have been closely monitoring the resident to determine if her symptoms progress/she was not feeling any better. V11 stated he expects the nurses to document that they were closely monitoring the resident, there is actually no excuse for failure to document. V11 stated even if you did it if it was not documented then you did not do it, and any excuse does not cut it. 2. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 has no cognitive impairment, totally dependent on staff for transfers, requires extensive assist with dressing, personal hygiene, and toilet use and has a urinary indwelling catheter. R1's Care Plan dated 8/22/18 documents, Will be free of symptoms of infection. Catheter care twice a day with cares with soap and water. R1's Nurses' Notes dated 9/17/18 documents R1 pulled his indwelling catheter out. On 9/18/18 at 9:46 AM, V12 and V13, both Certified Nursing Aides (CNAs), provided incontinent care to R1 in bed. R1 had an incontinent of urine episode and his briefs and hospital gown were wet. V12 used no rinse periwash and water solution and washcloths to cleanse R1. V12 cleansed the groin area and pubic area. V12 retracted the foreskin and cleansed the head of the penis. V12 failed to cleanse the shaft, the scrotal area, both upper inner thighs, buttocks and failed to dry the areas that were washed. V12 put a clean incontinent brief on R1 without pulling the foreskin to its normal position. On 9/20/18 at 1:39 PM, V2, Interim Director of Nursing (DON) stated she expects staff to follow the facility policy on incontinent care. The Facility Policy on Perineal Cleansing dated 12/17 documents, 5. Wash pubic area including upper inner aspect of both thighs as well as the penis and scrotum. Retract foreskin and wash carefully to remove secretions. Wash area under scrotum. Dry carefully, remembering to draw foreskin of the uncircumcised male back over the head of the penis. 3. R2's Face Sheet dated 9/5/18 documents R2 was admitted to the facility on [DATE]. R2's Admission Physician order [REDACTED]. R2's Nursing Admission assessment dated [DATE] documents R2 has an indwelling urinary catheter 16 French/10cc (cubic centimeter). R2's Treatment Administration Record (TAR) for 9/2018 does not document R2 has an indwelling catheter and needs catheter care. The TAR did not document any catheter care had been completed for R2. R2's Baseline Care Plan dated 9/6/18 does not address the presence of an indwelling urinary catheter and the need for catheter care. On 9/17/18 at 1:10 PM, R2 lay in bed and had catheter tubing connected to a urine bag with 250 cc yellow colored output. At this time R2 stated she was admitted to the facility on [DATE] with an indwelling urinary catheter. R2 stated she refused to have anyone other than staff present in her room during catheter care.

Based on interview and record review, the facility failed to provide an adequate individualized discharge care plan, failed to provide adequate effort to assist residents with sending referrals to other appropriate post-acute care options for 1 of 3 residents (R4) reviewed for discharge planning in the sample of 22. This resulted in R4 having difficulty sleeping, depressed mood, bouts of tearfulness and wanting to get out of the facility Findings include: R4's Face Sheet, undated, documents R4 was admitted on [DATE]. R4's clinical record does not have any evidence a comprehensive care plan was established and documented to address R4's care needs including R4's desire to be discharged to another facility as soon as possible. R4's Physician order [REDACTED]. On 8/22/18 at 8:50 AM, R4 was crying during interview. R4 stated, I've got to get out of here. R4 stated that V6, Social Services Director told her she had been denied the referrals that V6, Social Services Director (SSD), sent to 3 facilities, but won't tell her the reason for the denial. On 8/28/18 at 10:00 AM, R4 stated, she and V6 talked Friday (8/24/18) and R4 stated she reiterated she wants to leave the facility. R4 stated, I can't do this. I gotta get out of here. R4 stated the evening and night shift is awful she was left on the bed pan for 39-40 minutes the previous night and she phoned her grandmother who called V1, Administrator, about it. R4 stated she was using a regular bedpan for weeks and it was painful to be on it. R4 stated she finally got the fracture bed pan Friday. R4 stated she has a [MEDICATION NAME] she blows to when staff doesn't answer the call light. On 8/30/18 at 3:09 PM, V6 stated he faxed 3 referrals to other facilities and followed up with the facilities by phone. V6 stated there is no exchange of emails or faxed communication. V6 stated the facilities just tell him by phone that R4 was denied acceptance. On 9/5/18 at 9:10 AM, R4 stated she has not talked to V6 this last week. R4 stated V6 gave him a list of nursing homes in the area. R4 stated she felt so miserable she gave up and threw away the list that V6 gave her. R4 stated V6 told her he has faxed 3 referrals and all 3 declined to accept her. R4 stated V6 never told her the reason for the decline. R4 started sobbing and stated she feels the facility is trying to keep her here. R4 stated V6 told her he only sends one referral at a time and wait for a response before sending the next one. R4 stated she has not slept well, she felt bitter and depressed, she cries every time she feels she will never get out of this place. R4 denied receiving information about the other facilities V6 sent referrals to. R4 stated V6 just gave her a list containing names and addresses of nursing homes in the neighboring area and nothing else, no information to provide her an informed choice of nursing homes. R4 stated she was aware that as many as 6 referrals can be sent out by the facility at a time. On 8/30/18 at 2:46 PM, V6 presented faxed copies of R4's referrals he sent to 3 facilities in the neighboring towns. The dates of the referrals were 8/3/18 (marked NO), 8/17/18 (marked NO) and 8/27/18. V6 stated the ones marked No were denied and the one dated 8/27/18 V6 is waiting for response from the facility. On 9/6/18 at 10:15 AM, V1, Administrator, stated when a resident wants to be transferred to another facility, he gets in touch with SSD, they are given a list of the nursing homes, ask them where they would like to go, always seek their input, initiate calls, send other information on the resident, notify resident if they are accepted or not. V1 stated the facility initially started at the next town market and expanded to other towns. V1 stated he does not know what else the facility could have done; V6 tells V1 he updates R4 as soon as he knows something. V1 stated he does not really see any issues with how the facility is handling R4's discharge planning. On 9/12/18 at 9:01 AM, R4 stated that V6 has not updated her with any new referrals. R4 stated she has not seen V6 came to his room to give her updates of her discharge plans. The facility Policy on Discharge Planning dated 11/1/17 documents, It is the policy of this facility to assist each individual resident to make decisions in advance of discharge about the rehabilitative, psychosocial and health care goals of the resident. Whether resident or facility initiated, it is the intent of the facility to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution, provider, home caregiver or resident themselves to ensure continuity of care and services is maintained by developing and implementing a discharge plan in advance of the actual resident discharge. 1. The Social Service Director shall serve as Discharge Chairperson or Discharge Coordinator and will be responsible for providing multi-disciplinary participation in discharge. The policy further documents, 4. As soon as practical, and within 96 hours of noting/reporting by resident , resident responsible party, or facility staff that a resident has a discharge goal or has a discharge pending, the Discharge Chairperson/Coordinator will set a discharge conference date convenient to all with resident/interested parties and IDT (Interdisciplinary Team) to develop the Post Discharge Plan of Care. 5. A Post Discharge Plan of Care and a Discharge Plan of Care shall be developed for each resident anticipating discharge which should reflect input from the resident/resident responsible party and all disciplines as practical. This Plan should be initiated no later than 14 days upon resident reporting discharge goals and are to be reviewed at a minimum quarterly unless there is a change in the resident's condition or treatment is revised. Documentation of the plan shall be recorded on the Post Discharge Plan of Care. 6. A Discharge Care Plan shall be developed for each resident which should reflect input from the resident or resident representative and all disciplines as practical. This plan should be initiated no later than 14 days of admission and are to be reviewed at minimum quarterly unless there is a change in the resident's condition or treatment is revised. Documentation of the resident's discharge potential as determined by the Discharge Evaluation should be addressed in the discharge care plan.

Based on interview and record review, the facility failed to provide effective pain management, and failed to ensure pain medication is available for 3 of 8 residents (R1, R2 and R4) reviewed for pain management in the sample of 22. This resulted in R4 having difficulty sleeping, depressed mood, bouts of tearfulness and wanting to get out of the facility Findings include: 1. R4's Minimum Data Set ((MDS) dated [DATE] documents R4 has a BIMS (Brief Interview for Mental Status) score of 15 (no cognitive impairment) and is receiving pain medication as needed, receives no scheduled pain medication, has reported frequent pain with the worst pain at 8 (0 to 10 scale, with zero being no pain and 10 as the worst pain you can imagine). R4's Base Line Care Plan dated 8/7/18 documents, Assess Pain. R4's Hospital Discharge Medication List dated 8/3/18, documents (in part), [MEDICATION NAME] Immediate Release 5 milligrams (mg) Take 1 tablet by mouth every 4 hours as needed. R4's Admission Physician order [REDACTED]. Take 1 tablet by mouth every 4 hours as needed. R4's Medication Administration Record [REDACTED]. The facility could not find the Controlled Substance Record for any [MEDICATION NAME] supply prior to 8/10/18. R4's Controlled Substance Record dated 8/10/18 documents, [MEDICATION NAME] IR (Immediate Release) 5 mg every 4 hours as needed, 30 tablets, last dose was given to R4 on 8/21/18 at 4:00 PM. The next [MEDICATION NAME] IR Controlled Substance Record dated 8/22/18 for 30 tablets documents the first dose from this delivery was given to R4 on 8/22/18 at 8:00 PM. R4 did not have supply available for 28 hours. On 8/24/18 at 5:15 AM, V7, Registered Nurse (RN), stated R4 ran out of [MEDICATION NAME] when V7 worked Tuesday (8/21/18). V7 stated she did not know how long R4 was out of it. On 9/4/18 at 8:59 AM, R4 stated she was asking for [MEDICATION NAME] when she was admitted but they did not have any supply for 3 days and the nurses were giving her Tylenol which did not help at all. R4 stated she could not sleep at night, couldn't move, it was painful. R4 stated she could ask for [MEDICATION NAME] every 4 hours as needed while in the hospital and she knew she had the same ordered medication for pain when she got to the facility. On 9/5/18 at 9:10 AM, R4 stated she pushed her call light that morning at 7 to ask for pain medication and waited 30 minutes for staff to come and she had to tell whoever answered the call light to ask the nurse when she had her last dose of [MEDICATION NAME]. R4 stated eventually she got a pain pill close to 8 AM. R4 stated it was horrible every night after 10 pm. The staff doesn't come down this way and she was at the end of the hall. R4 stated she had her call light on and drifted back to sleep for at least 2 1/2 hours and woke up and the call light was still on. R4 stated she used her teacher to turn it off. R4 stated she wanted a pain pill, some ice and a sleeping gown to put on because she was sleeping in her street clothes. R4 stated being diabetic she would be thirsty but had to limit her fluids to avoid having to use the bed pan at night and go through being left on it for so long or be wet for hours. R4 was crying with tears running down her face midway through the interview. R4 stated she is feeling bitter and depressed. R4 stated she only had as needed pain medication every 4 hours and since she had to wait for staff to answer her call lights, the waiting time for the [MEDICATION NAME] gets longer. R4 stated she tries to ask for pain medication when her pain level is below 5 but by the time the pain medication is brought to her pain has increased to an 8-8.5. R4 stated she wished she could tell the doctor to give her [MEDICATION NAME] routinely. On 9/6/18 at 1:00 PM, V1 stated medications can be E-run (Emergency-run) to order before running out. The nurse needs to notify the pharmacy and should notify V14 (Physician) if needing preauthorization, if payment issues to notify V1. The Facility Policy on Pain Prevention and Treatment revised 12/7/2017 documents, Policy: It is the facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems , maximize ADL (activities of daily living) functioning and enhance quality of life. Procedure: 1. Each resident will be assessed for pain using the Pain Assessment Form including an appropriate Pain Rating Scale upon admission. The MDS Coordinator will complete the Pain Assessment Form at least quarterly and with any significant change in condition. 2. Assessment of pain will be completed with changes in the resident's condition, self-reporting of pain or evidence of behavioral cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but is not limited to date, rating, treatment intervention and resident response. 3 The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, [DIAGNOSES REDACTED].). 4. Information collected on the Pain Assessment Form will be used to formulate and implement a resident specific Pain Treatment Plan documented in the resident's care plan. 2. R2's Physician order [REDACTED]. This POS also documents [REDACTED]. Take 1 tablet by mouth 3 times daily as needed. R2's Minimum Data Set (MDS), dated [DATE], documents R1 has a Brief Interview of Mental Status (BIMS) of 15 which indicates R1 is cognitively intact. R2's Care Plan, dated 8/16/2018, documents, in part, (P) (problem) Alteration in Comfort/Pain (G) (goal) Will verbalize comfort with current pain regime x 90 days. (A) (Approach) Administer pain medication as ordered. On 8/24/2018 at 4:32 AM, R2 told, V28 Certified Nurse Aide (CNA), that she would like her [MEDICATION NAME] for pain. R2 stated the pain was in her legs. On 8/24/2018 at 6:04 AM, V28, stated, I don't believe I did let V7, Registered Nurse (RN), know that (R2) wanted [MEDICATION NAME]. On 8/24/2018 at 6:40 AM, V7 stated, I was unaware of (R2) asking for [MEDICATION NAME]. On 8/24/2018 at 6:45 AM, V7 administered the [MEDICATION NAME] to R2. 3. R1's Admission Face Sheet dated 8/1/2018; documents R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS), dated [DATE], documents R1 has a Brief Interview of Mental Status (BIMS) of 15 which indicates R1 is cognitively intact. R1's POS dated 7/28/2018, documents, in part, [MEDICATION NAME]-acetamin 5-325 mg. Take 1 tablet by mouth every four hours as needed for pain. R1's Controlled Substances Proof of Use, Amount Rec. (received) 30, Date Rec 8/8/2018 documents, in part [MEDICATION NAME]-Acetamin 5-325 mg. Take 1 tablet by mouth every four hours as needed for pain. Date 8/21/ (2018), Time 8:00 AM, QTY (quantity) 1, rem (remaining) 0. R1's Controlled Substances Proof of Use Amount Rec. no documentation noted, Date Rec. no documentation noted, documents, in part, [MEDICATION NAME]-Acetamin 5-325 mg. Take 1 tablet by mouth every four hours as needed for pain. Date 8/22/(2018), Time 8:00 PM, QTY(quantity) 1, rem (remaining) 29. On 8/22/2018 at 9:11 AM, R1 stated that he is having a difficult day. R1 said he was [DIAGNOSES REDACTED]. R1 stated that the pain is around his head throbbing and is intense. On 8/23/2018 at 11:40 AM, R1 stated, On 8/22/2018 I was out of my pain medication ([MEDICATION NAME]-Acetamin) I was out for 36 hours. I have [DIAGNOSES REDACTED]s and [MEDICAL CONDITION]. My pain was an 8 it about did me in. I have headaches because of the [DIAGNOSES REDACTED]s. I asked for pain medication 8/22/2018 at night and the nurse told me we were out. On 8/22/2018 at 9:35 AM, V3, Licensed Practical Nurse (LPN), stated, He (R1) ran out of [MEDICATION NAME] last night. It should be here today sometime. Not sure what happened. On 8/22/2018 at 9:35 AM, V3 stated that (R1's) medications are not in yet. V3 stated that she has to send authorization over to (V14 Physician) to get approval prior to receipt from pharmacy. On 9/6/2018 at 1:00 PM, V1, Administrator, stated, Medications can be stat run from the pharmacy if the resident is out. The nurse needs to notify pharmacy of needing the medication. If the medication needs a preauthorization they should notify the doctor. If it is a payment issue pharmacy should notify me. On 9/6/2018 at 12:35 PM, V14, Physician, stated, The nurses should be ordering pain medications/ medications a day before they run out. It is inexcusable to let a patient be in pain because they have run out of medication. The facility should police when the residents are running out of drugs.

Based on record review and interview, the facility failed to adequately assess and notify the physician to provide appropriate treatment services for symptoms of an infected surgical site for one of three residents (R3) reviewed for treatment of [REDACTED]. This failure resulted in R3 being hospitalized for [REDACTED]. Findings include: The Nurses Note, dated 5/24/2017 at 4:30 PM documents R3 was admitted to the facility after a hospitalization [MEDICAL CONDITION] and right above the knee amputation (RAKA). R3's [DIAGNOSES REDACTED]. A Physician's Order (PO) from Z2, Nurse Practitioner (NP), obtained by telephone by E7, Licensed Practical Nurse (LPN) on 6/03/2017, documents, Remove sutures to right stump. Apply dry dressing after cleansing area until scabbed area falls off, then LOTA (leave open to air). R3's Nurses Note documented by E7, dated 6/03/2017 at 1:05 PM, documents, in part, Sutures removed from stump, dressing applied. Incision well approximated and closed. Scab noted to right lateral side of wound, no redness noted. Pus noted to be secreted from 1 suture site, TAO (triple antibiotic ointment) applied to wound after cleansing. No odor noted. There is no documentation a physician or NP was notified. There is no physician's order to apply the topical antibiotic ointment in R3's Physician's Order Sheets (POS) for 5/2017, 6/2017 or 7/2017. There is no skin assessment or measurements of R3's surgical incision site to the RAKA. There is no documentation of how many sutures or staples were removed on 6/03/2017. The SBAR (Situation Background Assessment Recommendation) Form for R3, dated 6/07/2017 at 12:15 AM, documents, in part, The change in condition, symptoms or signs observed and evaluated is/are confusion, hallucinations, combativeness, restlessness. Other relevant information RAKA. Primary Diagnosis-confusion,[MEDICAL CONDITION]. Skin evaluation, describe symptoms or signs-multiple areas to buttocks. Not clinically applicable to the change in condition being reported. The section of Skin evaluation has no check mark next to the evaluation of Wound (describe) on the SBAR Form. R3's Nurses Note, documented by E7 and dated 6/07/2017 at 11:05 AM, documents, in part, Resident (R3) sent to (local hospital) 10:00 AM. (R3) RAKA incision red, warm to touch, swollen. Drainage noted at site. (Family member) aware of transfer. (Ambulance) called and transported (R3). On 11/01/2017 at 10:00 AM, E7 reported she is the Resident Care Coordinator (RCC) at the facility. E7 reported she could not remember if she called a doctor or NP about the pus coming from R3's surgical site of the RAKA. E7 reported she called Z4, R3's vascular surgeon, to get an order to remove the sutures and was unsuccessful with contact. E7 reported she called Z1's (R3's Physician) office and received a telephone order from Z2, Z1's NP, to remove the sutures. E7 stated, I put TAO on it (R3's surgical site). I don't remember if I called or not. R3's emergency room Visit Report, dated 6/07/2017 at 10:58 AM, documents, in part, [AGE] year old male with past medical history of [REDACTED]. Patient is only alert X 1. Patient confused. Wound drainage, [DIAGNOSES REDACTED] of RLE (right lower extremity), wound infection, [MEDICAL CONDITION].[MEDICAL CONDITION] positive. R3's Infectious Disease Screening Report, dated 6/07/2017 at 4:18 PM, documents, in part, (R3) had to have a RAKA via (Z4, vascular surgeon) on 5/01/2017. Patient then transferred to a rehab facility where staff report that his RAKA site was draining yellow, non-malodorous drainage with brown necrotic area to the distal portion of the incision. He has been admitted for IV (intravenous) antibiotics and evaluation of his wound by vascular. On 11/01/2017 at 2:55 PM, E7 reported R3 did not have sutures, but had staples in the stump to the right leg, that she removed on 6/03/2017. E7 reported she is in charge of doing the weekly skin assessments usually, and the assessments for R3 would be documented on the back of R3's Treatment Administration Records (TAR). R3's 5/2017 TAR documents, in part, Weekly skin checks (ordered 5/24/2017). The date of 5/24/2017 was initialed as completed, but there is no documentation on the Weekly Summary on the back of R3's TAR of the surgical wound site, the location or size of the wound, or how many sutures or staples were in the RAKA wound. The 5/2017 TAR also documents, Stump: Cleanse site with (wound cleanser); Apply dressing daily and PRN (as needed). There is no documentation the treatment was done for R3's right stump on 5/26 or 5/31/2017. R3's admission Nurses Note, dated 5/24/2017 at 4:30 PM, has no assessment, measurements or documentation of the RAKA. R3's 6/2017 TAR has no documentation weekly skin assessments were completed at all for the month of June 2017 for R3's right surgical wound. There is no documentation the cleansing and dressing changes were done on 6/04 or 6/06/2017 for R3's right stump. R3's 7/2017 TAR only has one weekly skin assessment documented by E7 on 7/14/2017 for the right stump has scab on it, and small open area to the right buttock. Unable to measure at time related to resident hitting. There are no treatment orders on R3's 7/2017 TAR for the right stump. On 11/01/2017 at 8:18 AM, Z2 reported she would expect a nurse to call a physician or NP if pus was coming from a surgical site. Multiple attempts to contact Z1 and Z4 for interview were unsuccessful. R3's Care Plan, dated 5/24/2017, documents, in part, admitted to facility for continued monitoring and treatment of [REDACTED]. G (goal) Relief of symptoms of infection by completion of treatment regime. See POS for antibiotic use. Evaluate effectiveness of medication by reduction of symptoms. Notify MD (Medical Doctor) if no reduction in symptoms or if medication complications. Notify MD if symptoms or status worsen. R3's Care Plan, further documents, At risk for skin breakdown. Risk factors, Right stump old surgical incision. Will have no skin breakdown throughout admission review and care plan. A(approach) Skin check by nurse weekly if moderate or low risk, or daily if high risk. Skin check by CNA (Certified Nurses Aide) during daily cares and bath/shower. Report any new skin concerns to the doctor for treatment and follow up. Treatment per order/see TAR. The facility's Notification for Change in Resident Condition Status policy and procedure, revised 10/12/2005, documents, in part, The facility and/or facility staff shall promptly notify appropriate individuals, (i.e. (that is), Administrator, Director of Nursing (DON), Physician, HCPOA (Health Care Power of Attorney), etcetera) of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been: Symptoms of any infectious process. The facility's Dressing Change policy and procedure, revised 7/2007, documents, in part, POLICY: To avoid introducing organisms into a wound. RESPONSIBILITY: All Licensed Personnel. The facility's Aseptic Wound and Skin Treatment policy and procedure, revised 1/2002, documents, in part, POLICY: To prevent contamination of the wound and to protect wound from mechanical injury. To stimulate, restore and promote circulation and healing. To prevent further deterioration of skin tissue, to prevent necrosis of deeper body structures and to promote resident comfort. Document procedure on treatment sheet.

Based on interview and record review, the facility neglected to correctly administer and document the anti-coagulant medication, [MEDICATION NAME] as ordered by the physician, for one of two residents (R2) reviewed for the neglect in the sample of 4. This resulted in R2 receiving too much [MEDICATION NAME], which caused an elevated [MEDICATION NAME] Time (PT or [MEDICATION NAME]) and INR (international normalized ratio), spontaneous internal bleeding of the right lower extremity, [MEDICAL CONDITION] and an elevated heart rate. As a result, R2 was hospitalized and received an injection of Vitamin K and a transfusion of packed red blood cells. Findings include: 1. The facility's policy and procedure, dated 7/03/2013 and entitled, 'Medication Administration' documents, in part, The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders [REDACTED]. When preparing medication for administration, check the label of the drug container at minimum three times for safety and accuracy. Report errors in medication administration immediately per policy. Report suspected adverse reaction immediately per policy. 2. The facility's policy and procedure, dated 7/01/2012 and entitled, 'Notification for Change in Resident or Status' documents, in part, The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been: A discovery of injuries of an unknown source; a significant change in the resident's physical/emotional/mental condition; a need to transfer the resident to a hospital/treatment center; abnormal lab findings. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. 3. The Geriatric Dosage Handbook, 12th Edition, page 1646, documents, in part, [MEDICATION NAME] ([MEDICATION NAME]) High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error. Overdose/Toxicology-Symptoms include internal or external hemorrhage and hematuria. When an overdose occurs, the drug should be immediately discontinued and vitamin K ([MEDICATION NAME]) may be administered, up to 25 mg IV (intravenously). When hemorrhage occurs, fresh frozen plasma [MEDICAL CONDITION] can help control bleeding by replacing clotting factors. 4. The physician's orders [REDACTED]. The physician's orders [REDACTED]. A Laboratory Report, dated 6/17/2016, documents R2 had a PT of 18.9 seconds (normal=9.2-12.6 seconds) and an INR of 1.8 (normal=0.8-1.2). There was no PO for a change in [MEDICATION NAME] dosage at that time from Z5 or Z9, Physician's. The Nurse's Note from E10, Licensed Practical Nurse (LPN), dated 6/26/2016 at 7:00 PM, documents, CNA (Certified Nurses Aide) went to check on resident (R2) and found a large amount of bluish discoloration of right leg, measurements 20 cm (centimeter) X 5 cm. Patient states she's in pain. PRN (as needed) pain medication noted. (Z6), Nurse Practitioner paged and awaiting call back. DON (E2, Director of Nursing) called, Administrator (E1) word/message left to call facility as soon as possible. The Nurse's Note from E10, dated 6/26/2016 at 8:00 PM, documents, N.O. (new order) apply ice, get PT/INR in the AM. There is no written PO for this in R2's clinical record. The Nurse's Note from E8, LPN, dated 6/26/2016 at 11:30 PM, documents, Lab here to draw PT/INR. Specimen taken from left forearm. Awaiting results. The Nurse's Note from E8, dated 6/27/2016 at 2:00 AM, documents, in part, Lab called facility to notify this nurse of critical labs. PT results over 100 (normal=12.0-18.5 seconds on this report). The Nurse's Note from E8 documents a call was placed at 2:05 AM of 6/27/16 to Z5's, Physician/Medical Director, office with an urgent page requested. E8 then documents on 6/27 at 3:10 AM, Z5's office was called again related to the critical laboratory reports for R2 with no response. E8's Nurse's Note, dated 6/27/2016 at 3:26 AM, documents E2 was called and a message was left to return the call. E8 documents in the Nurses Note that at 3:36 AM, E2 called back with an order to send R2 to the local hospital. E8's Nurses Note documents Z4, Nurse Practitioner, returned the call at 3:50 AM on 6/27 and was informed of the critical PT, and agreed to send R2 to the hospital. At this time, 8 hours and 50 minutes had passed since E10 left the first urgent message at Z5's exchange about R2's new large bruise to the right leg, and 1 hour and 45 minutes since E8 called to report the critical PT results for R2. The Nurse's Note from E8 documents R2 left the facility by ambulance at 4:30 AM on 6/27/2016. The Resident Transfer Form completed by E8 on 6/27/2016 at 3:00 AM, documents R2's vital signs as BP (blood pressure) is 102/84, heart rate 86, respirations of 20, temperature of 97.3 Fahrenheit, and pulse oximeter of 97 percent. R2's emergency room (ER) Visit Report, dated 6/27/2016, documents R2 was seen by Z10, Physician, at 6:02 AM. The ER Report documents that R2's RBC (red blood cells) were low at 1.92 (normal is 3.9 to 5.3 million cells per microliter), a low hemoglobin of 6.5 (normal is 12.0 to 15.5 grams/deciliter), and hematocrit is 20.7 percent (normal is 34.9-44.5 percent), high platelet count of 471 (normal is 150 to 450), elevated PT of 50.9, and INR of 5.72 and an elevated PTT (partial [MEDICAL CONDITION] time) of 62 seconds, (normal is 25=30 seconds). The ER Report documents, in part, Lab results comment: Remarkable [MEDICAL CONDITION] and dehydration. new bruising noted on extremities, redness and tenderness of left lower leg. Clinical Impression: Abnormal laboratory test result, anticoagulated on [MEDICATION NAME] ([MEDICATION NAME]), dehydration, [MEDICAL CONDITION] of left leg, elevated INR. The Hospitalist Discharge Summary, dated 7/01/2016, documents R2 was admitted to the local hospital on [DATE] and, Was found to have an elevated INR, a rather large hematoma in the right lower extremity, [MEDICAL CONDITION] of the lower extremities and a urinary tract infection with Pseudomonas (a bacteria), [MEDICAL CONDITION] secondary to chronic disease and secondary to acute blood loss in the hematoma. The patient was transfused a total of 2 units of packed red blood cells. The facility's Medication Administration Record [REDACTED]. Eight doses of [MEDICATION NAME], 6 mg were given and 6 doses of [MEDICATION NAME], 5 mg were administered to R2, totaling 14 doses. The nurses that documented this medication was given on those dates are E5, E6, and E10, LPN's. According to Z5's (Physician) orders, R2 was to only receive a 6 mg dose of [MEDICATION NAME] on Sunday 6/19 and Wednesday 6/22/2016. On 7/08/2016 at 1:40 PM, Z7, General Manager for the facility's Pharmacy, reported 4 pills of 6 mg of [MEDICATION NAME] and 11 pills of 5 mg were delivered to the facility on [DATE], with specific orders for what dose on what day were to be given to R2. Z7 reported these should have lasted 2 weeks, not 9 days. Z7 reported the facility failed to send any medications or empty cards back to determine what was given by the facility nurses. Z7 reported there is standard procedure for returning unused medication and a form to complete for the return. Z7 reported E2 told her the medication was sent back in a return tote, but E2 was unable to identify which nurse gave them to the pharmacy driver. Z7 identified R2's prescribing physician as (Z5). The pharmacy's Shipment Details Invoice, dated 6/17/2016, documents the medication was received and signed for by E12, LPN, on 6/17 at 12:52 PM. The Invoice documents 4 tablets of 6 mg of [MEDICATION NAME] and 11, 5 mg tablets of [MEDICATION NAME] were signed for at that time. The prescribing physician is documents as (Z5). On 7/08/2016 at 10:39 AM, Z5 reported, I was not aware of this patient (R2). Z5 reported he had never examined R2 since admission to the facility on [DATE]. Z5 reported too much [MEDICATION NAME] could cause bleeding or possibly death. Z5 reported he was unaware R2 received too much [MEDICATION NAME] or that the PT was over 100, critically high. Z5 reported he was unaware R2 was hospitalized or which one of his Nurse Practitioners (NP)sent her. Z5 stated, There was a breakdown of communication for sure. The staff thought (R2) was a patient of (Z9's, Physician). Z5 reported that maybe his NP ordered the PT and INR. On 7/07/2016 at 12:15 PM, E10 reported that on 6/26/2016, E7, CNA, reported to him a huge bruise to R2's right leg. E10 stated, I know it had something to do with PT and INR. I called the DON (E2) and she told me not to send (R2) out, to talk to (E1, Administrator) first. I called and texted (E1). I called the exchange for (Z5). (E4, NP) called back with an order to do PT/INR in the AM. When third shift nurse (E8) came in, she said we can't wait until tomorrow morning. (E2) just threw it off on (E1). I texted (E1) about a bruise of unknown origin. I filled out a QA (quality assurance) paper about what I saw. The bruise looked really fresh. The lab came after I left. I asked (E2) if I should call (Z1, R2's Power of Attorney) and she told me to call (E1) first. (Z6) was on call, but (Z4) returned the call. Usually when you call the (Z5) exchange, they call back within 20 to 40 minutes. They are trying to cover themselves now. I did everything I was supposed to do. My last day to work was 7/06/2016. I got fired. I'm taking the fall for this. They didn't want you to talk to me. On 7/07/2016 at 3:45 PM, E7 reported she found the bruise on R2's right leg and reported it to E10. E7 stated, I want to say it was gray-blue in color. The right leg wasn't swollen. It was hot to the touch. (R2) complained of pain and said her legs hurt. (E10) put cream on her leg and gave her a pain pill. (E10) called the DON (E2) and I overheard the conversation. (E10) began to email and text department heads. (E2) told (E10) not to send (R2) out (to the hospital). He begged (E2) to send (R2) out. He completed an incident report and documented. I did not document anything. (E8) came in and (E10) gave report to her and told her to try to get ahold of (Z5), who didn't call back. (E10) scheduled a STAT (immediately) PT and INR before he left. E10 felt like it was because of [MEDICATION NAME] (Wafarin). On 7/07/2016 at 1:00 PM, E2 stated, (E10) did not call me. Only (E8) called me and said the bruises are getting worse. I didn't speak to (E10) at all. I thought the bruises were getting worse due to the high PT and INR. There is no investigation started because it was not a bruise of unknown origin. When asked if E10 started an investigation about R2's bruise, E2 stated, No, there is no investigation. On 7/07/2016 at 3:00 PM, E2 was asked about the [MEDICATION NAME] administration for R2. E2 replied, (Z2, Pharmacist) is counting pills returned to see if they gave both doses of 5 mg and 6 mg or if they (nurses) just signed it as given. I'm hoping they were careless in signing them as given. (E10) and (E5, LPN) are questioning about this. I don't understand why. On 7/07/2016 at 1:38 PM, E5 stated, (E10) came and got me the day (R2) was sent out. He showed me the bruises, and I told him to call (E2) and went to work to the other end. I told him to let me know what (E2) said so I can help him send (R2) out. I came back and asked (E10) if (R2) was being sent to the hospital. He replied (E2) said not to send her out. Then the night nurse came in, (E8) and she saved the day. (E8) called the doctor and got a PT/INR STAT and then sent her to the hospital when the results came in. (R2) was alert when she left the facility. She could talk on the phone. E5 reported she signed the MAR for R2 at 4:00 PM on 6/21, 6/22 and 6/23/2016 for the administration of [MEDICATION NAME] 5 mg and 6 mg. E5 reported she had been disciplined by E2 for not signing the MAR, so she signs it to fill in the blanks. On 7/07/2016 at 1:20 PM, Z2 reported if a resident receives too much [MEDICATION NAME] their INR will be high. Z2 stated, I just look at the INR. They would have to hold it. [MEDICATION NAME] can cause bleeding. The higher the INR, the more bleeding. If INR is over 4, probably hold [MEDICATION NAME]. Z2 reported if R2 received too much [MEDICATION NAME], this is a significant medication error. R2's Care Plan, dated 6/16/2016, documents, in part, Anticoagulant/ At risk for increased bleeding. (R2) will not have severe bruising. Notify MD (medical doctor) as needed related to excessive bleeding. Observe for tarry stool. Labs per MD orders.

Based on interview and record review, the facility failed to administer medications as ordered by the physician, for one of two residents (R2) reviewed for medication administration in the sample of 4. This resulted in a significant medication error with R2 receiving too much [MEDICATION NAME], which caused an elevated [MEDICATION NAME] Time (PT or [MEDICATION NAME]) and INR (international normalized ratio), spontaneous internal bleeding of the right lower extremity, [MEDICAL CONDITION] and an elevated heart rate. As a result, R2 was hospitalized and received an injection of Vitamin K and a transfusion of packed red blood cells. Findings include: 1. The physician's orders [REDACTED]. The physician's orders [REDACTED]. A Laboratory Report, dated 6/17/2016 documents R2 had a PT of 18.9 seconds (normal=9.2-12.6 seconds) and an INR of 1.8 (normal=0.8-1.2). There was no PO for a change in [MEDICATION NAME] dosage at that time from Z5 or Z9, Physicians. The Nurse's Note from E10, Licensed Practical Nurse (LPN) dated 6/26/2016 at 7:00 PM, documents, CNA (Certified Nurse'sAide) went to check on resident (R2) and found a large amount of bluish discoloration of right leg, measurements 20 cm (centimeter) X 5 cm. Patient states she's in pain. PRN (as needed) pain medication noted. (Z6), Nurse Practitioner paged and awaiting call back. DON (E2, Director of Nursing) called, Administrator (E1) word/message left to call facility as soon as possible. The Nurse's Note from E10, dated 6/26/2016 at 8:00 PM, documents, N.O. (new order) apply ice, get PT/INR in the AM. There is no written PO for this in R2's clinical record. The Nurses Note from E8, LPN, dated 6/26/2016 at 11:30 PM, documents, Lab here to draw PT/INR. Specimen taken from left forearm. Awaiting results. The Nurse's Note from E8, dated 6/27/2016 at 2:00 AM, documents, in part, Lab called facility to notify this nurse of critical labs. PT results over 100 (normal=12.0-18.5 seconds on this report). The Nurse's Note from E8 documents a call was placed at 2:05 AM of 6/27/16 to Z5's office with an urgent page requested. E8 then documents on 6/27 at 3:10 AM, Z5's office was called again related to the critical laboratory reports for R2 with no response. E8's Nurses Note, dated 6/27/2016 at 3:26 AM, documents E2 was called and a message was left to return the call. E8 documents in the Nurse's Note that at 3:36 AM, E2 called back with an order to send R2 to the local hospital. E8's Nurses Note documents Z4, Nurse Practitioner returned the call at 3:50 AM on 6/27 and was informed of the critical PT, and agreed to send R2 to the hospital. At this time, 8 hours and 50 minutes had passed since E10 left the first urgent message at Z5's exchange about R2's new large bruise to the right leg, and 1 hour and 45 minutes since E8 called to report the critical PT results for R2. The Nurse's Note from E8 documents R2 left the facility by ambulance at 4:30 AM on 6/27/2016. The Resident Transfer Form completed by E8 on 6/27/2016 at 3:00 AM, documents R2's vital signs as BP (blood pressure ) is 102/84, heart rate 86, respirations of 20, temperature of 97.3 Fahrenheit, and pulse oximeter of 97 percent. R2's emergency room (ER) Visit Report, dated 6/27/2016, documents R2 was seen by Z10, Physician at 6:02 AM. The ER Report documents that R2's RBC (red blood cells) were low at 1.92 (normal is 3.9 to 5.3 million cells per microliter), a low hemoglobin of 6.5 (normal is 12.0 to 15.5 grams/deciliter), and hematocrit is 20.7 percent (normal is 34.9-44.5 percent),high platelet count of 471 (normal is 150 to 450), elevated PT of 50.9, and INR of 5.72 and an elevated PTT (partial [MEDICAL CONDITION] time) of 62 seconds, (normal is 25=30 seconds). The ER Report documents, in part, Lab results comment: Remarkable [MEDICAL CONDITION] and dehydration. new bruising noted on extremities, redness and tenderness of left lower leg. Clinical Impression: Abnormal laboratory test result, anticoagulated on [MEDICATION NAME] ([MEDICATION NAME]), dehydration, [MEDICAL CONDITION] of left leg, elevated INR. The Hospitalist Discharge Summary, dated 7/01/2016, documents R2 was admitted to the local hospital on [DATE] and, Was found to have an elevated INR, a rather large hematoma in the right lower extremity, [MEDICAL CONDITION] of the lower extremities and a urinary tract infection with Pseudomonas (a bacteria), [MEDICAL CONDITION] secondary to chronic disease and secondary to acute blood loss in the hematoma. The patient was transfused a total of 2 units of packed red blood cells. The facility's Medication Administration Record [REDACTED]. Eight doses of [MEDICATION NAME], 6 mg were given and 6 doses of [MEDICATION NAME], 5 mg were administered to R2, totaling 14 doses. The nurses that documented this medication was given on those dates are E5, E6, and E10, LPN's. According to Z5's (Physician) orders, R2 was to only receive a 6 mg dose of [MEDICATION NAME] on Sunday 6/19 and Wednesday 6/22/2016. On 7/08/2016 at 1:40 PM, Z7, General Manager for the facility's Pharmacy, reported 4 pills of 6 mg of [MEDICATION NAME] and 11 pills of 5 mg were delivered to the facility on [DATE], with specific orders for what dose on what day were to be given to R2. Z7 reported these should have lasted 2 weeks, not 9 days. Z7 reported the facility failed to send any medications or empty cards back to determine what was given by the facility nurses. Z7 reported there is standard procedure for returning unused medication and a form to complete for the return. Z7 reported E2 told her the medication was sent back in a return tote, but E2 was unable to identify which nurse gave them to the pharmacy driver. Z7 identified R2's prescribing physician as (Z5). The pharmacy's Shipment Details Invoice, dated 6/17/2016, documents the medication was received and signed for by E12, LPN on 6/17 at 12:52 PM. The Invoice documents 4 tablets of 6 mg of [MEDICATION NAME] and 11, 5 mg tablets of [MEDICATION NAME] were signed for at that time. The prescribing physician is documented as (Z5). On 7/08/2016 at 10:39 AM, Z5 reported, I was not aware of this patient (R2). Z5 reported he had never examined R2 since admission to the facility on [DATE]. Z5 reported too much [MEDICATION NAME] could cause bleeding or possibly death. Z5 reported he was unaware R2 received too much [MEDICATION NAME] or that the PT was over 100, critically high. Z5 reported he was unaware R2 was hospitalized or which one of his Nurse Practitioners (NP)sent her. Z5 stated, There was a breakdown of communication for sure. The staff thought (R2) was a patient of (Z9's, Physician). Z5 reported that maybe his NP ordered the PT and INR. On 7/07/2016 at 12:15 PM, E10 reported that on 6/26/2016, E7, CNA reported to him a huge bruise to R2's right leg. E10 stated, I know it had something to do with PT and INR. I called the DON (E2) and she told me not to send (R2) out, to talk to (E1, Administrator) first. I called and texted (E1). I called the exchange for (Z5). (E4, NP) called back with an order to do PT/INR in the AM. When third shift nurse (E8) came in, she said we can't wait until tomorrow morning. (E2) just threw it off on (E1). I texted (E1) about a bruise of unknown origin. I filled out a QA (quality assurance) paper about what I saw. The bruise looked really fresh. The lab came after I left. I asked (E2) if I should call (Z1, R2's Power of Attorney) and she told me to call (E1) first. (Z6) was on call, but (Z4) returned the call. Usually when you call the (Z5) exchange, they call back within 20 to 40 minutes. They are trying to cover themselves now. I did everything I was supposed to do. My last day to work was 7/06/2016. I got fired. I'm taking the fall for this. They didn't want you to talk to me. On 7/07/2016 at 3:45 PM, E7 reported she found the bruise on R2's right leg and reported it to E10. E7 stated, I want to say it was gray-blue in color. The right leg wasn't swollen. It was hot to the touch. (R2) complained of pain and said her legs hurt. (E10) put cream on her leg and gave her a pain pill. (E10) called the DON (E2) and I overheard the conversation. (E10) began to email and text department heads. (E2) told (E10) not to send (R2) out (to the hospital). He begged (E2) to send (R2) out. He completed and incident report and documented. I did not document anything. (E8) came in and (E10) gave report to her and told her to try to get ahold of (Z5), who didn't call back. (E10) scheduled a STAT (immediately) PT and INR before he left. E10 felt like it was because of [MEDICATION NAME] (Wafarin). On 7/07/2016 at 1:00 PM, E2 stated, (E10) did not call me. Only (E8) called me and said the bruises are getting worse. I didn't speak to (E10) at all. I thought the bruises were getting worse due to the high PT and INR. There is no investigation started because it was not a bruise of unknown origin. When asked if E10 started an investigation about R2's bruise, E2 stated. No, there is no investigation. On 7/07/2016 at 3:00 PM, E2 was asked about the [MEDICATION NAME] administration for R2. E2 replied, (Z2, Pharmacist) is counting pills returned to see if they gave both doses of 5 mg and 6 mg or if they (nurses) just signed it as given. I'm hoping they were careless in signing them as given. (E10) and (E5, LPN) are questioning about this. I don't understand why. On 7/07/2016 at 1:38 PM, E5 stated, (E10) came and got me the day (R2) was sent out. He showed me the bruises, and I told him to call (E2) and went to work to the other end. I told him to let me know what (E2) said so I can help him send (R2) out. I came back and asked (E10) if (R2) was being sent to the hospital. He replied (E2) said not to send her out. Then the night nurse came in, (E8) and she saved the day. (E8) called the doctor and got a PT/INR STAT and then sent her to the hospital when the results came in. (R2) was alert when she left the facility. She could talk on the phone. E5 reported she signed the MAR for R2 at 4:00 PM on 6/21, 6/22 and 6/23/2016 for the administration of [MEDICATION NAME] 5 mg and 6 mg. E5 reported she had been disciplined by E2 for not signing the MAR, so she signs it to fill in the blanks. On 7/07/2016 at 1:20 PM, Z2 reported if a resident receives too much [MEDICATION NAME] their INR will be high. Z2 stated, I just look at the INR. They would have to hold it. [MEDICATION NAME] can cause bleeding. The higher the INR, the more bleeding. If INR is over 4, probably hold [MEDICATION NAME]. Z2 reported if R2 received too much [MEDICATION NAME], this is a significant medication error. R2's Care Plan, dated 6/16/2016, documents, in part, Anticoagulant/ At risk for increased bleeding. (R2) will not have severe bruising. Notify MD (medical doctor) as needed related to excessive bleeding. Observe for tarry stool. Labs per MD orders. The facility's policy and procedure, dated 7/03/2013 and entitled, Medication Administration documents, in part, The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders [REDACTED]. When preparing medication for administration, check the label of the drug container at minimum three times for safety and accuracy. Report errors in medication administration immediately per policy. Report suspected adverse reaction immediately per policy. The facility's policy and procedure, dated 7/01/2012 and entitled, Notification for Change in Resident or Status documents, in part, The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been: A discovery of injuries of an unknown source; a significant change in the resident's physical/emotional/mental condition; a need to transfer the resident to a hospital/treatment center; abnormal lab findings. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. The Geriatric Dosage Handbook, 12th Edition, page 1646, documents, in part, [MEDICATION NAME] ([MEDICATION NAME]) High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error. Overdose/Toxicology-Symptoms include internal or external hemorrhage and hematuria. When an overdose occurs, the drug should be immediately discontinued and vitamin K ([MEDICATION NAME]) may be administered, up to 25 mg IV (intravenously). When hemorrhage occurs, fresh frozen plasma [MEDICAL CONDITION] can help control bleeding by replacing clotting factors.

Based on interview, observation and record review, the Facility failed to assess/evaluate, treat and prevent pressure ulcers for 3 of 5 (R2,R9, R10) reviewed for pressure ulcers in the sample of 10. This failure resulted in R9's pressure ulcers worsening to Stage 4 with osteo[DIAGNOSES REDACTED]. Findings include: 1. R9's [DIAGNOSES REDACTED]. R9's Admission Assessment, dated 7/16/15, documents 2 open areas 1) left buttocks centimeters (cm) x 2 cm x 2.3 cm. 2) Sacral 8 cm x 10.2 cm, depth .7 cm. R9's Wound Assessment Details, dated 8/6/15, document R9 was seeing Z4, Wound Nurse Practitioner, in-house until 11/9/15 when R9 was sent to Z2, Wound Management Physician, for treatment of [REDACTED]. R9's Admission Minimum Data Set (MDS), dated [DATE], documents R9 is cognitively intact, requires extensive assistance from one staff for Activity of Daily Living (ADL's), is at risk for developing pressure ulcers, and has 2 stage 3 pressure ulcers. R9's quarterly MDS, dated [DATE], documents R9 is cognitively intact, requires extensive assistance from staff for ADL's, and has 2 stage 4 pressure ulcers. R9's Care Plan, dated 7/16/15, with updates 10/20/15 and 12/26/15, has no documentation that R2 is non compliant with dressing changes. R2's Care Plan documents: sacral ulcer stage IV, ischial ulcer stage IV, left lateral Left ankle ulcer osteo[DIAGNOSES REDACTED]: Improvement in skin condition and no further breakdown thru admission review and care plan. Treatment per order- See Physician order [REDACTED]. Assess and measure wound weekly and PRN (as needed). Skin check daily. Notify Medical Doctor (MD) if condition worsens or if no improvement of wound over time with current treatment. Monitor site for infection-redness, drainage, foul smell, decline in function, pain. Report signs of infection to MD for recommendations. Abt (antibiotic) per orders see physician order [REDACTED]. R9's lab work, dated 11/17/15, documents a protein level of 7.5 with a normal range of 5.7-8.2 and an [MEDICATION NAME] level of 3.2 with normal range of 3.2-4.8. R9's Braden Pressure Ulcer Risk Assessment, dated 7/16/15 upon admission, and on 12/26/15, documents R9 is high risk for pressure ulcers. R9's November 2015 Treatment Administration Record (TAR) documents R9's refusal for dressing changes on 11/4, 11/5, 11/7, 11/14, 11/17, 11/19, 11/25, and 11/29/15. On 11/18/15, the back of the TAR documents a note skin w/d (warm and dry) Color good. Open areas to coccyx and right ischium continues. Heels intact. Area around [MEDICAL CONDITION] with some redness noted however no open areas noted. On 11/19/15, the back of the TAR documents a note (R9) refused for me to change it, says she wants it to change when she goes to bed. No other documentation that dressing change to R9's sacral wound were done on 11/19/16 at a later time as requested by R9. Wound measurements documented on the back of TAR for November as follows: 11/4/15 coccyx 7.7 cm x 8.2 cm x 1 un (undermining) 9-12 o'clock 1 cm with mild drainage and no odor. Ischium 3 cm x 2.3 cm x 1 with mild drainage and no odor. 11/11/15 measurement 1) coccyx 7.5 cm x 8.5 cm x 1 cm, undermining 9-12 at 1.2 cm with mild drainage and no odor. 2) ischium 2.8 cm x 2.5 cm x .1 cm with mild drainage and no odor. 11/18/15 coccyx 7.1 x 7.7 x .9 with mild draining and no odor. Ischium 3 cm x 7.1 x 3. mild drainage and no odor. 11/23/15 coccyx 7 cm x 7.5 cm x. 7 with mild drainage and no odor. Ischium 3 cm x 2 cm x 2 cm with mild drainage and no odor. No other documentation for R9's left lateral malleolus pressure area or any skin breakdown prior to 11/30/15 when R9's wound clinic identified the new area. R9's Physician order [REDACTED]. Clean wound with wound cleanser. May shower and or cleanse wound with mild soap and water. Primary wound dressing: Left lateral malleolus-santyl ointment-in wound center only. Secondary dressing-left lateral malleolus: foam and kerlix gauze. Frequency of dressing changes- change dressing every other day. R9's Physician order [REDACTED]. Clean wound with wound cleanser. May shower and/or cleanse wound with mild soap and water. Primary Wound Dressing: Alginate-[MEDICATION NAME] for right ischium and sacrum wounds, santyl ointment in wound center only for left later al malleolus. Secondary Dressing for sacrum and right ischium-foam. For left lateral malleolus-foal and kerlix gauze. Radiology: X-ray and MRI (Magnetic Resonance Imaging), left ankle- subacute osteo[DIAGNOSES REDACTED], left ankle and foot. R9's Telephone Order (TO) from Z1, R9's Medical Doctor, documents on 12/1/16: Cleanse (left outer ankle) with theraworks, apply [MEDICATION NAME]/calcium alginate. Cover with dressing. Changed daily and PRN. R9's Physician order [REDACTED]. May shower and/or cleanse wound with mild soap and water. Primary Wound Dressing: alginate-[MEDICATION NAME] for right ischium and sacrum wound, wound gel and alginate-[MEDICATION NAME] for left lateral malleolus. Secondary dressing for right ischium, sacrum and left lateral malleolus- foam. Consults: Podiatry-to nail trimming. Notes: Please obtain MRI pelvis and left ankle as directed. R9's Physician order [REDACTED]. May shower and/or cleanse wound with mild soap and water. Primary Wound Dressing: alginate-[MEDICATION NAME] for right ischium, sacrum wound, and right great toe, wound gel and alginate-[MEDICATION NAME] for left lateral malleolus. Secondary dressing for right ischium, sacrum, right great toe and left lateral malleolus- foam. Notes: Please obtain MRI pelvis and left ankle. Send reports when available, obtain foam booties and have patient wear at all times. R9's December 2015 TAR documents daily skin checks were not done 12/18-12/31/15. R9's TAR further documents no dressing changes to R9's sacral wound, ischial wound and left outer ankle from 12/19-12/25/15. R9's TAR documents on 12/1/15, left outer ankle 2.3 x 2 x .5, mild drainage and no odor. Ischium 3 x 2.1 x 2, sacral 7.1 x 7.7 x 0.9, both with moderate drainage and no odor. On 12/8/15, R9's left outer ankle measurements as 2 x 2 x .5, mild drainage and no odor. Coccyx 7 x 7.5 x. 9, mild drainage and no odor. Ischium 3 x 2 x 2 with mild drainage and no odor. On 12/14/15, measurements for left outer ankle 2.7 x 2 x 1.8 mild drainage , no odor. Coccyx 7.1 x 9 x 0.9 with mild drainage and no odor. Ischium 3 x 2.3 x 0.4 with mild drainage and no odor. On 12/29/15 measurement: 1) sacrum 7.4 x 8.3 x 0.9 cm with moderate drainage, no odor. 2) right ischium 2.7 x 2 x 1.8, tunnel time 7, 1.8 cm moderate drainage and no odor. left lateral malleolus 3.2 x 2.5 x 0.7 with mild drainage, no odor. There is no measurements for the week of 12/21/15 documented. R9's Physician order [REDACTED]. left ankle more necrotic MRI left ankle scheduled for 12/10/15 canceled. Will ask NH to reschedule. R9's January 2016 TAR documents no dressing changes to sacral pressure ulcer from 1/15/16 through 1/31/16. The TAR further documents the treatment of [REDACTED]. The TAR documents the treatment for [REDACTED]. R9's order, dated 12/28/15, for sacrum, right ischium wound is Alginate-[MEDICATION NAME] and the left lateral malleolus dressing is wound gel, alginate-[MEDICATION NAME]. Cover all with foam. R9's wound dressing order for 1/5/16, 1/14/16, 1/21/16 for sacrum, right ischium and left lateral malleolus is alginate-[MEDICATION NAME]. Cover all with foam dressing. R9's January TAR further documents measurements on 1/4/16 sacrum 7.4 cm x 8.3 x 0.9, right ischium 2.7 x 2 x 1.8 cm, left lateral hell 3.2 x 2.5 x 0.7. All wounds with moderate drainage. No odor. On 1/11/16, sacrum 7.3 x 8 x 0.7, right ischium 2.6 x 1.8. 1.8, left lateral mild drainage, no odor, l malleolus 3.4 x 2.3 x 0.5. Mild drainage. No odor. On 1/18/16 sacrum 7.3 x 7.8 x 0.7. Right ischium 2.5 x 2 x 1.7. Left lateral malleolus 3.3 x 2.1 x 0.4. All having mild drainage. No odor. 1/25/16 sacrum 7.7 x 8.5 x 1, undermining 3 cm. Moderate drainage. No odor. Right ischium is 1.7 x 0.6 x 1.6, tunneling 1 cm, mild drainage, no odor. Left malleolus 3.4 x 3.2 x 1, mild drainage. no odor. On 1/6/16, R9's dressings were not completed. A note on the back of R9's TAR documents: (R9) refused to get her Treatment done around 9:00 PM went in and she said she wants it (treatment) done later around 11-11:30 PM. (R9) said she don't want to be touched right now. There is no documentation that R9 was re-approached for dressing changed for 1/6/16. R9's Wound Care Communication Log from the Wound Clinic, dated 1/5/16, documents Z3, Registered Nurse (RN) called and spoke with E3 and documents the following: Called and spoke with (E3) regarding order for MRI and foam boots for pressure relief. (R9) had MRI of pelvis on 11/25/15 and was scheduled for transportation for 12/10/15 for MRI of ankle (no record in hospital system of ankle MRI being done). (E3) is going to call and find out what happened with that test. Wound care Communication from 1/21/16 documents Z3 spoke with E3 to follow up on MRI of left ankle. (E3) stated she sent over the MRI of the pelvis had set up MRI of the ankle to be done. That is scheduled for January 26 th at 8 AM. R9's Wound Assessment from Wound clinic, dated 2/25/16, documents sacrum wound measurements as follows: Length 10.2 x 7.6 x 2.1 cm with undermining starting at 7 o'clock and ending at 5 o'clock. Wound description: Classification: Category/Stage IV, Wound Margin: fibrotic scar, thickened scar, Exudate Amount, Type and Color: Large, Purulent, yellow, brown, green. Foul odor after cleansing: yes. Fascia Exposed: yes; Muscle exposed: yes; Bone exposed: Yes. Assessment Notes Bandage removed was not dated; heavy purulent drainage with strong odor upon removal. Purulent drainage noted leaking into and beginning to saturate her depends around the dressing. Positive odor after cleansing. New bone exposed in wound bed. R9's Wound Assessment, dated 2/25/16, documents right ischium wound measurements as follows: Length 0.4 x 1 x 1.5 cm. Wound description: Classification: Category/Stage III, Wound Margin: distinct; Exudate Amount, Type and Color: Medium, serosanguinous, red, brown. Foul odor after cleansing: no. Assessment Notes: There was no dressing on this wound upon arrival. R9's February 2016 Treatment Administration Record (TAR), documents R9 refused treatment to left ankle on 2/9/16, and 2/12/17 through 2/24/16. The treatment documented on the TAR is calcium alginate with bordered foam to left ankle and non bordered to left heel daily. R9's TAR where refusals were documented does not document any reasons for treatment refusals for R9's left ankle. A 2nd page of R9's February TAR documents treatments for R9's sacrum, Right ischium and Left lateral malleolus with no start date as follows: cleanse with wound cleanser-apply [MEDICATION NAME] alginate cover with ABD (absorbent dressing), change every other day. The treatment order from Z2, dated 2/4/16, documents for R9's sacral, right ischium, and left lateral malleolus pressure ulcers - [MEDICATION NAME] alginate, bordered foam. R9's treatment order changed on 2/18/16 to [MEDICATION NAME] with foam for R9's sacrum, right ischium and left lateral malleolus pressure ulcers. R9's February TAR does not document the [MEDICATION NAME] or the [MEDICATION NAME] dressing change orders. The February TAR does not document any measurements from 2/1/16 through 2/25/16 of R9's sacral, right ischium or left lateral malleolus pressure areas when R9 was admitted to the hospital for osteo[DIAGNOSES REDACTED] of decubitus. R9's POS, dated 2/9/16, documents a copy of a prescription from Z2 on 2/4/16, faxed 2/9/16, for Keflex 500 milligram (mg) three times a day (TID). R9's POS documents a copy of a prescription order from Z2, dated 2/11/16, faxed 2/12/16, for [MEDICATION NAME] 500 mg one twice daily (BID) and [MEDICATION NAME] 100 mg BID. The fax sheet further documents start these antibiotics, stop Keflex until appointment with (Z5, Infectious Disease Doctor). The sheet has a handwritten note, dated 2/23/16, 1 PM to start above as written. R9's February 2016 Medication Administration Record [REDACTED]. This should have stopped on 2/12/16 as ordered. The February 2016 MAR further documents [MEDICATION NAME] 500 mg one BID x 21 days and [MEDICATION NAME] 100 mg one BID x 21 days started on 2/24/16. These should have started on 2/12/16 as ordered. R9's Nursing Notes, dated 2/9/16 9 PM, document, in part: Started Keflex this evening. R9's Nursing Notes, dated 2/23/16, document: 1 PM: Wound clinic notified that orders faxed over on 2/12/16 were never initiated and order received to start antibiotics as ordered. R9's Wound Assessment from Wound Clinic, dated 2/4/16, documents left lateral malleolus measurements: Length 3.8 x 3.2 x 1 cm. Wound description: Classification: Category/Stage IV, Wound Margin: distinct, Exudate Amount, Type and Color: Medium, serosanguinous, red, brown. assessment Notes Bandage that was removed was dated 2/21/16; purulent drainage weeping from bandage. Strong odor upon removal; positive odor after cleansing. Wound bed is moist and soft. R9's Debridement Detail from Wound Clinic, dated 2/18/16 and 2/25/16 documents, R9's left lateral malleolus, sacrum, and right ischium was debrided. R9's Wound Assessment from Wound Clinic, dated 2/25/16, documents left lateral malleolus acquired date: 11/30/2015; measurements: Length 3.5 x 2.6 x 1 cm. Wound description: Classification: Category/Stage IV, Wound Margin: distinct, Exudate Amount, Type and Color: Large, Purulent, yellow, brown, green. Foul odor after cleansing: yes. Fascia Exposed: yes; Fat layer exposed: yes; Muscle exposed: yes. Assessment Notes Bandage that was removed was dated 2/21/16; purulent drainage weeping from bandage. Strong odor upon removal; positive odor after cleansing. Wound bed is moist and soft. R9's Wound Care Notes from the Wound Clinic, dated 2/25/16, documents: Notes; right medial malleolus has reddened area appears to be stage 1 pressure ulcer 2.2 length x 2.5 width; bilateral feet dry and scaly, bilateral toenails curled under toes. Dressing on left malleolus has purulent drainage seeping out; date on it 2/21/16. Strong odor. R9's Physician order [REDACTED]. Clean wound with normal saline. Clean wound with wound cleanser. May shower and/or cleanse wound with mild soap and water . Wound dressing: [MEDICATION NAME]. Secondary dressing: foam. Off loading: keep weight off area of wound at all times, felt/foam/ortho-wedge/surgical shoe-foam booties, do not sit for long periods of time. Notes: continue antibiotics. R9's Progress note from Wound Clinic, dated 2/18/16, documents in part: subq debride. appeared that ankle dressing had not been changed recently. On [MEDICATION NAME]/doxy for osteo. R9's Progress note from Wound Clinic, dated 2/25/16, documents: concerns remain regarding dressing changed. one wound has not dressing. one wound last changed 2/21 (dated) per wd care nurse. cont prism/foam. discussed with hospitalist. will admit for social service evaluation. R9's History of Present Illness (HPI) Progress Note Details from Z2 dated 11/9/15, 11/30/15, 12/7/15, 12/14/15, 12/28/15, 1/5/16, 1/14/16, 1/21/16, 2/4/16, 2/18/16, 2/25/16, and 3/4/16 documents: Patient has an ulcer to sacrum/r (right) gluteus, deep stage 4. Pt device used in NH (Nursing Home) not working properly needs KCL wound vac to date, no wound vac obtained in nursing home. Tissue cultures showed slight growth of e coli. R9's Problem list from Wound Clinic, dated 2/25/16, documents Pressure ulcer of right hip, unspecific state, pressure ulcer of contiguous site of back, buttock and hip, stage 4 and subacute osteo[DIAGNOSES REDACTED], left ankle and foot. R9's Physician order [REDACTED]. May shower and or cleanse wound with mild soap and water. Wound dressing: [MEDICATION NAME] Secondary Dressing: Foam; Off-loading: keep weight off area of wound at all times, felt/foam/ortho-wedge/surgical shoe-foam booties. Notes: continue antibiotics. Patient being admitted for stage 4 pressure ulcer. R9's Hospital records, dated 2/25/16, document, in part: chief complaint, decubitus ulcer, osteo[DIAGNOSES REDACTED]. History of Present Illness: [AGE] year old female with subtotal colectomy and [MEDICAL CONDITION], sacral decub ulcers with chronic osteo[DIAGNOSES REDACTED] was here at the wound care center and was sent in by (Z2) for poor care at the nursing home. According to him the patient did not have dressing changed since the last time she was seen at the wound care center about a week ago . R9's Encounter Discharge information, dated 2/25/16, documents: Discharge destination: admitted to hospital. R9's Hospital Nursing Notes, dated 2/25/16, document in part: 2:30 PM, (R9) admitted from wound clinic to hospital admitting [DIAGNOSES REDACTED]. On 3/2/16 at 10:30 AM, R9 stated she doesn't refuse dressing changes and that staff changes her dressings. R9 stated she thinks her dressings are changed daily. On 3/2/16 at 10:40 AM, E2, Director of Nursing (DON), and E14, RN, did a skin check on R9. R9's dressing to her sacrum was soiled with old brown drainage with a foul odor. E14 stated R9 gets dressing changes on evening shift. E14 took off R9's sacrum dressing and large area over sacrum/coccyx noted to have bone and adipose tissue exposed. The wound bed was cleansed with theraworks and dried with 4 x 4's. A foul odor continued to be noted after the wound bed was cleansed . The dressing was dated 2/29/16. There was no dressing to R9's right ischium. E14 stated You're (R9) missing other bandage on right ischium. There was no dressing on R9's left lateral malleolus. E2 retrieved a 4 x 4 from the inside of R9's sock. E14 stated R9 gets a Duoderm to her left ankle. At this time, E1 stated she has never seen any of R9's pressure areas prior to today. On 2/29/16 at 12:00 PM, E2 stated pressure ulcers measurements are documented on the back of TAR. E2 stated R9 goes to wound clinic offsite so no one at the facility measure her wounds. E2 stated the wound clinic measures them. E2 stated that E9 transcribes R9's measurements to the back of the TAR after R9 returns from wound clinic. E2 stated she doesn't know why February TARS do not have measurements for R9's pressure areas. E2 stated she was unsure why R9 had so many pressure ulcer treatments documented as not done or refusals with no reason why or documentation on re-approaching R9 at a later time. E3 stated she would expect staff to re-approach R9 at a later time if she was refusing, or try on different shift or re-educate R9. E3 stated R9 has [MEDICAL CONDITION] so sometimes R9 is non-compliant when she is out of cigarettes. E3 stated she has educated staff on re-approaching R9 when she refuses treatment changes. E3 stated she thought R9's dressing change refusals are on R9's Care Plan. E3 further stated she did not know why R9's [MEDICATION NAME] and [MEDICATION NAME] antibiotic that were ordered on [DATE] did not get started until 2/24/16 or why R9's Keflex that was to be discontinued when the [MEDICATION NAME]/[MEDICATION NAME] started continued until 2/23/16. E2 further stated E9 transfers the dressing orders to R9's TAR after each visit. E2 stated she wasn't aware that the treatments were not being transcribed or carried out as ordered by Z2. E3 confirmed that R9 has osteo[DIAGNOSES REDACTED] in her left lateral malleolus pressure ulcer and also the sacrum pressure ulcer. E3 stated she wasn't aware R9 had a new area on the right medial malleolus. On 3/2/16 at 9:25 AM, Z3, Wound Clinic RN, stated that she had concerns with R9 getting dressings changed timely and the decline in R9's wounds. Z3 stated when R9 had a visit to the wound clinic on 2/18/16, R9's dressing had drainage that was dried hard with blood in it. Z3 stated It takes a long time for drainage to set up in that condition. Z3 stated R9's hip/ischium pressure ulcer did not have a dressing on and the sacrum dressing looked terrible. Z3 stated when R9 came for visit on 2/25/16, R9's left lateral malleolus dressing was dated 2/21/16. Z3 stated R9's dressings are ordered to be changed every other day and when needed. Z3 stated R9 was admitted to the hospital on the visit on 2/25/16 for osteo[DIAGNOSES REDACTED] to left lateral malleolus and ischium. Z3 stated the clinic found a new stage 1 on the inside of R9's right ankle and the facility was supposed to be offloading and using foam booties. Z3 stated R9's heels are very dark and very spongy and R9 is at risk for breakdown. Z3 stated their clinic first observed R9's left lateral malleolus on 11/30/15. Z3 stated it was a stage 3 pressure area at that time and now it is a stage 4 with osteo[DIAGNOSES REDACTED]. Z3 stated the facility did not notify the clinic of this new pressure area on R9's left lateral malleolus, that the wound clinic discovered it during a skin check. Z3 further stated the wound clinic doesn't routinely do skin checks, but given R9's poor wound care and new areas the clinic identified, it has become routine for R9 to have skin checks done on each visit. Z3 stated the measurements on 11/30/15 for R9's left lateral malleolus were 2.4 x 1.6 x 0.3. Z3 stated R9 has never refused care at the wound clinic and is very cooperative. Z3 stated R9's pressure areas have gotten worse since treating R9. Z3 further stated that Z2 ordered X-ray and MRI of R9's sacrum and left lateral malleolus on 11/30/15, but the facility did not follow through with testing until 1/26/16 (a delay of almost 2 months) for the left lateral malleolus. Z3 stated the facility did not inform the wound clinic that R9's [MEDICATION NAME] and [MEDICATION NAME] antibiotic duo ordered 2/11/16, were not started until 2/24/16 and that Keflex continued to be given after being discontinued on 2/11/16. On 3/3/16 at 9:42 AM, Z3 stated Z2 ordered a wound vac for R9's sacrum/coccyx and still would like for R9 to have a wound vac. Z3 stated she does not have any communication from the facility why R9 has not received a wound vac to date. Z3 stated the wound clinic was not aware the facility was not following Z2's order for wound care and that [MEDICATION NAME] was not used as ordered. Z3 stated there would be a note in the wound clinic system if the facility called and Z2 changed R9's order to calcium alginate, but there is no record of Z2 changing R9's orders. On 3/2/15 at 9:40 AM, Z2 stated he and his office staff had concerns with R9's pressure dressings being changed. Z2 further stated R9 comes to wound appointments and there have been times when R9 pressure areas are not covered. Z2 stated he ordered an MRI of R9's left ankle and sacrum and it took the facility a long time to complete the order. Z2 further stated his wound clinic identified R9's left lateral malleolus pressure area. Z2 further stated the order for alginate-[MEDICATION NAME] is a combo dressing. Z2 stated there is [MEDICATION NAME] impregnated with the alginate. Z2 stated he expected the [MEDICATION NAME] to be used for R9's dressing when it was ordered. Z2 stated he was not aware pressure dressing orders were not done as prescribed. On 3/4/16 2:50 PM, via telephone, Z3 stated R9 had returned to the wound clinic 3/4/16 and had the same concerns that R9 did not have dressings on her left lateral malleolus or her right ischium and R9's sacrum dressing was soiled and needed to be changed. The dressing was dated 3/2/16. At this time, Z2 stated he would want R9 to have a wound vac to the sacrum pressure ulcer if patient would comply. Z2 stated the delay in proper antibiotic treatment delayed R9's treatment for [REDACTED]. On 3/2/16 at 2:04 PM, E2 stated she was unaware R9 needed a wound vac. E2 stated that E3 gets R9's Wound Physician Details with the orders and measurements from the wound clinic and that E3 transcribes the measurements and orders on the back of R9's TAR. E2 stated she did not know why there was a scheduling delay in getting R9's MRI to left lateral malleolus. On 3/3/16 at 10:28 PM, E3, Licensed Practical Nurse (LPN)/ Resident Care Coordinator, stated she was not the treatment or wound nurse. E3 stated she has been told this several times by different people but that she is E2's assistant. E3 stated the floor nurses do the treatments and the facility doesn't have a treatment nurse. E3 stated she oversees the treatments when she can. E3 stated I try to oversee it all. My job is to make sure (R9 and R10) go to the wound clinic and follow up. E3 stated E1 oversees 100 hall pressure ulcers and she (E3) oversees 200 hall. E3 stated they were to ensure new orders and treatments. E3 stated she saw R9's pressure ulcers on 2/29/16 when R9 readmitted back to the facility. E3 stated it had been 2-3 weeks since she had seen R9's wounds before then. E3 stated she gets an update from the Wound Clinic and the wound clinics measurements and documents the Wound Clinic's measurements on the back of R9's TAR. E3 stated the floor nurse does the treatments and will come and get her if they need help. E3 stated the facility gets new orders from the wound clinic via fax or it comes with residents. E3 stated once the facility gets the new orders then staff carries them out-put in Nurses' Notes, put order on TAR, and let R9's mom know of any changes. E3 stated she is unsure why R9's Keflex continued past the ordered stop date on 2/4/16. E3 stated she is unsure why R9's [MEDICATION NAME] and [MEDICATION NAME] antibiotic due didn't start until 2/24/16 when it was ordered on [DATE]-unless the facility couldn't get the antibiotics. E3 further stated she was unaware that Z2 wanted a wound vac put on R9's sacrum and to her (E3's) knowledge R9 never had a wound vac while at the facility. E3 stated there would be no reason why R9 couldn't have a wound vac unless it wasn't coordinated. E3 stated she did not know why there were no measurements on the back of R9's TAR for February 2016. On 3/3/16 at 11:00 AM, E1, Administrator, stated it is a joint venture between E2 and E3 for wound care and overseeing coordination of wound care. E1 stated E2 used to do wound care but when she took over as DON it transferred to E3. The Facility's Decubitus Care/Pressure Areas Policy, dated 5/2007, documents: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. Procedure: 2) The pressure area will be assessed and documented on the TAR. 3) Complete all areas of the TAR. i) Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician). ii) document the stages of the pressure ulcer as follows iii) document the color according to the following: .4)Notify the physician for treatment orders. The physicians orders should include: i) type of treatment. ii) frequency treatment is to be performed. iii)how to cleanse, if needed. iv) site of application v) no PRN order is acceptable for pressure ulcer. The order must have specific frequencies vi) Initiate physician order [REDACTED]. The assessment must include: i) Characteristic (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) treatment and response to treatment. 2. On 2/22/16 at 12:15 PM, E2 and Z4 performed a treatment to R2's sacral wound. At this time, there were pressure ulcers present on the left and right distal buttocks. On 2/22/16 at 1:29 PM and 2/23/16 at 8:50 AM, R2 was observed in bed with heels directly on a pillow, not floated. On 2/22/16 at 12:15 PM, E2, stated, I was unaware of these pressure areas, I usually don't do the treatments. On 2/22/16 at 12:15 PM, Z4, stated, These 2 buttock pressure ulcers are new since I saw (R2) last week and I was unaware of them. Z4 further stated, These pressure ulcers are avoidable, (R2) had a heavy bath blanket between her bottom and the low airloss mattress. The bath blanket was wrinkled and pushed into (R2's) buttock creases. There should only be a sheet between (R2's) buttocks and the low airloss mattress. On 2/22/16 at 1:29 PM, E13, Certified Nurses Aide (CNA), stated, I noticed her buttocks had areas where the skin was off. I did tell the nurses it was either (E7, LPN ) or (E12, LPN ). E13 further stated, This was probably on Tuesday of last week, they were smaller when I first saw them. On 2/22/16 at 1:40 PM, E7, stated, I was unaware of new buttock wounds. On 2/22/16 at 2:02 PM, E11, CNA, stated, I worked a double on Friday and she had 2 small blisters on her lower buttocks. I told (E12). On 2/22/16 at 2:05 PM, Z4, stated, If I had been made aware of the blisters, I would have ordered skin prep or [MEDICATION NAME] to be applied to the blisters daily in an attempt to keep them intact. Also (R2) should have been kept off her buttocks. Where these areas are if they were blisters it would be classified as a Stage 2 pressure ulcer because it is directly over bone. On 2/22/16 at 2:24 PM, E12, stated, I was told on Friday of (R2's) buttocks. The areas were little intact blisters. I informed (E2) and I sent the measurements to (E3) via text message. E12 further stated, (E2) did not say anything about the wounds. E12 stated, I determined that we were using a thick sheet under her buttocks and we changed it to a thinner sheet. (R2) has had skin issues in the past and a small change would fix it. I was hoping for the best. I did not document my measurements/ assessment of the areas, I did not inform the doctor, I did notify the family though. Not charting the wounds probably was a failure on my part. On 2/22/16 at 2:45 PM, E3 stated, I got texted over the weekend on (R2's) new wounds. (E12) was suppose to notify the doctor, family and chart on the wounds. On 2/25/16 at 3:00 PM, E2 stated, (E12) should have implemented our policy and procedure for pressure ulcers when he found the wounds. R2's MDS, dated [DATE], documents, in part, R2 was re-admitted [DATE] with [DIAGNOSES REDACTED]. The MDS also documents, R2 was admitted with 1 Stage 4 pressure ulcer, is totally dependant on 2 staff for bed mobility and transfers and is moderately impaired with a memory problem. R2's Braden Scale For Predicting Pressure Ulcer Risk, dated 11/17/16, documents R2 is at high risk for pressure ulcers. R2's Care Plan, dated 1/11/16, documents, in part, Pressure ulcer worsen upon readmission. (Pressure relieving) boots per orders see P.O.S. (Physician order [REDACTED]. R2's Multi Wound Chart Details, dated 2/22/16, documents, The right distal buttocks had a Stage II pressure ulcer measuring 1.0 cm X (by) 2.4 cm X 0.1 cm with a small sero-sanguineous exudate amount. The left distal buttocks had a Stage II pressure ulcer

Based on interview, observation and record review, the facility failed to accurately and consistently assess/evaluate and treat pressure ulcers for 3 of 3 residents (R1, R2 ,R3) reviewed for pressure ulcers in a sample of 3. This failure resulted in no treatment in R1's coccyx pressure ulcer which declined to unstagable and a decline in R3's coccyx pressure ulcer from from scratches to an unstageable ulcer. Findings include: 1. The Admission Record documents R1 was readmitted to the facility on [DATE] with Hospice services. R1's Care Plan, dated 12/24/15, documents R1 was admitted to the facility with skin breakdown. The Care Plan interventions document staff to treat as ordered, assess and measure wounds weekly and PRN (as needed), evaluate for additional calories, vitamins, minerals for healing, notify MD (Medical Doctor) if condition worsens or if no improvement of wound over time with current treatment, monitor site for infections, assess for pain and medicate as ordered. R1's December 2015 Treatment Administration Record (TAR) note, dated 12/24/15, documents several dried scabbed areas on buttocks c (with) a 1.5 x 1.5 cm (centimeter) stage I pressure ulcer on coccyx. R1's TAR documents on 12/29/15 coccyx open area .5 x .5 x .1 no odor or drng(drainage) indicating a decline from admission. R1's Hospice Notes dated 12/29/15 documents R1 had a stage I pressure ulcer on her coccyx. R1's December 2015 physician's orders [REDACTED]. R1's December TAR documents the Zinc was first applied on 12/30/15. There is no documentation on R1's TAR from 12/24 through 12/28/2015 that staff applied Skin Prep as ordered. R1's TAR documents staff applied Skin Prep only on the 6-2 shift on 12/29/2015. R1's Hospice Note, dated 1/5/16, documents R1's coccyx pressure ulcer as unstageable 2.8 x 1 with a note referral made to wound specialist added. Hospice Note dated 1/11/16 documents R1's coccyx pressure ulcer as unstagable with a newly developed in house acquired pressure ulcer on R1's hip on 1/11/16. No treatment change or notification to the physician or family is documented in the Hospice notes regarding the decline in the coccyx pressure ulcer and newly acquired pressure ulcers to R1's hip. R1's January 2016 TARs do not include any documentation regarding R1's hip ulcer which was identified by Hospice on 1/11/16. R1's TAR documents on 1/6/16 R1's coccyx wound as coccyx .5 x .5 x .1 stage 2 even though Hospice documented R1's pressure ucler as Unstageable on 1/5/16. On 1/13/16 at 12:00 pm, R1's coccyx pressure ulcer was uncovered, irregular shaped, bigger than a quarter in size and dark black/grey in the center with white/beefy red edges surrounding. The periwound of the coccyx pressure ulcer was deep purple. There was minimal drainage on the incontinent pad under R1. R1 also had a golf ball size unblanchable deep purple Stage I pressure ulcer on her left hip. R1's heel protectors were off both her feet and her feet were lying directly on the mattress. She had no pressure relieving device between her knees. E4, Facility Wound Nurse, stated she did not know about R1's hip pressure ulcer and that the Hospice Nurse had been there earlier in the day. E4 stated the Hospice nurse probably removed the dressing from the coccyx wound. E4 also stated Hospice had made a Wound Clinic recommendation last week and they were waiting for consent from the facility before seeing the Wound Specialist. E4 stated the order for Zinc ointment was from the Hospice, however, there was no evidence of zinc on the wound at that time. R1's medical record contained no documenation regarding a dressing to R1's coccyx pressure ulcer. At this time, E4 did not assess R1's pressure ulcers or document any description of the pressure ulcers. On 1/13/16, at 2:40pm , E4 stated she was planning on measuring R1's wounds later that evening. E4 stated the wound specialist hadn't seen R1 yet as the facility had yet to get a consent signed from the family member. On 1/14/16 at 10:40 am, wound documentation completed by E4 on 1/13/15 was reviewed. E4 assessed R1's coccyx pressure ulcer as 2 x 1.5 x .1 stage II c mild drainage + no odor. E4 documented R1's hip pressure ulcer as a fluid filled blister 1 x 2.5 surrounding skin slightly red, scab noted to edge of blister 0.4 x 0.3. There was no documentation in the nurse's notes that the family and/or physician were notified of decline in the coccyx pressure ulcer and the newly developed hip pressure ulcer. On 1/14/16, at t 10:55 am, E3 Registered Nurse (RN) caring for R1 looked at R1's coccyx pressure ulcer and said That is not a stage II. It's unstageable and also noted the hip ulcer which was now dry and deep red in color. No Zinc cream was evident at the coccyx area and R1. E3 stated she was going to call Z2, Physician, and get a treatment order. At 11:53 am, E3 stated she called Z2 and got an order for [REDACTED]. On 1/14/16, at 11:35 am , Z1, Hospice Nurse, stated she identified the coccyx ulcer as unstagable on 1/5/16 and the hip pressure ulcer on 1/11/16 which she discussed with E4, Wound Nurse and the other staff nurses at the time she noted it. Z1 stated the facility was aware of both and should have notified the physician and gotten orders at the time they were identified. Z1 also stated she questioned why the facility staff didn't see it before her since neither wound was new when she saw it and they should have been applying the Zinc Oxide ointment to it. Z1 also stated she is not real familiar with pressure ulcers and made the recommendation for the Wound Specialist on 1/5/16 when she first noticed the coccyx ulcer as unstageable. Z1 stated whether the resident is Hospice or not, it is the responsibility of the facility's nurses to follow thru with appropriate notification to the physician for treatment orders. On 1/15/16, 10 days after Z1 recommended the referral to the Wound Specialist, the wound specialist evaluated R1's coccyx wound and measured it to be 3 cm x 3 cm x 0.1 cm, necrotic/unstageable, with 51-75% adherent yellow slough and 1-25% granulation. The left hip measured .4 x .5 necrotic/unstageable and right hip 1.9 x 2cm, suspected deep tissue injury. On 1/15/16 at 10:10 am, Z2 stated he was not made aware that R1's pressure ulcer had decline to an unstageable ulcer until yesterday and that he would have expected the facility's nurses to contact him with that information promptly. Z2 stated had he been notified when the ulcer declined, he would have ordered a dressing to cover but not an aggressive treatment since she was overall deteriorating. Z2 stated he would expect the facility to be accurately assessing the wounds periodically and take actions accordingly. The facility policy entitled Decubitus Care/Pressure Areas, dated 5/07, documents it is the policy of the facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing on any pressure ulcer, once identified. Under procedure, the policy documents that Upon notification of skin breakdown, a 'Newly Acquired Skin Condition' report will be completed and forwarded to the Director of Nurses. The Pressure ulcer will be assessed and documented on the TAR with documentation to include size, stage, site, depth, drainage, color, odor, and treatment. The policy documents the physician will be notified for treatment orders and documentation will occur upon identification, at least once weekly on the TAR, and response to treatment. The policy documents nursing personnel are to notify dietary personnel to seek nutritional support and monthly reviews by the Registered Dietician (RD.) 2. R2's Admission Sheet documents R2 was admitted to the facility on [DATE] from the hospital. R2's Nursing Admission Assessment, dated 12/30/15, documents R2 had a Stage II pressure ulcer on her coccyx and nothing on her heels. R2's Nurse's notes document R2 went to the hospital for cardiac issues on 1/2/16 and returned to the facility on [DATE] on Hospice. The first assessment on R2's coccyx ulcer was documented on 1/4/16 on the back of the January 2016 TAR. It documents R2's coccyx ulcer was a Stage II pressure ucler measuring 0.5 cm x 1cm and blisters on bil (bilateral) heels. Right heel measured 4 cm x 5 cm and left heel 4 cm x 7.5 cm. R2's Treatment orders, dated 1/4/16, include Cleanse left buttocks with wound cleanser and Santyl to wound bed, apply [MEDICATION NAME] change daily and PRN. The orders also included to float R2's heels at all times and monitor bilat (bilateral) heel/apply [MEDICATION NAME] drsg every other day and as needed. R2's January 2016 TAR had an order for [REDACTED]. There is no documentation the nurses went back on any of those days in an effort to do the treatment. On 1/13/15 at 3:14 pm, E3 rolled R2 to her right side. R2's dressing at the coccyx area was bunched up in the middle and just attached on each side. The wound bed was visible. R2's heels were not floated and her heel protector boots were off and laying under the covers at the end of the bed. R2's right heel was black with an unattached outer edge between 4 and 7 o'clock which looked scabby with slight drainage. R2's left heel was an intact dusky purple blister. On 1/13/16, E3 obtained a new order for R2's coccyx ulcer to discontinue the Santyl and cleanse with wound cleanser, apply [MEDICATION NAME] dressing every three days and as needed til healed. No orders were obtained for the open heel pressure ulcer even though it was weepy with drainage. 3. R3's Admission Sheet documents R3 as being initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Admitting Orders, dated 10/24/2015, document R3 to have a gastrostomy tube and a urinary catheter. The Minimum Data Set ((MDS) dated [DATE] documents R3 to have cognitive impairment and require total assist of all activities of daily living. The Nursing Admission Assessment, dated 10/24/15, documents R3 had no opened areas identified on the skin except the [DEVICE] insertion site. The Progress notes dated 10/24/15 at 9:00 pm document R3 had a skin check completed with identified bilateral heels as dry crusted skin. There was no other documentation of R3's heels regarding the description of these areas. On 10/31/15, the progress notes document R3 was sent back to the hospital. R3's Progress notes documented she was readmitted on [DATE] with 2 small skin tears on her coccyx. On the back of the November TAR, a note dated 11/7/15 documented R3 as having small skin tears on middle of her buttocks identified with an order to cleanse and apply a gauze dressing. The TAR documented an order for [REDACTED]. On 11/19/15, R3's Progress Notes document R3 was transferred out and returned to the facility on [DATE]. A hospital transfer form, dated 11/23/15, documents R3 had an unstageable pressure ulcer on her coccyx with a physician's orders [REDACTED]. There was no documentation the facility assess R3's coccyx pressure ulcer at that time to determine size, color, depth, odor or drainage. The 11/2015 TAR documents an open area on coccyx with [MEDICATION NAME] and [MEDICATION NAME] ordered. R3's TAR documents the [MEDICATION NAME] was applied for the first time on 11/26/15, two days after readmission. On 11/29/15, R3's Progress Notes document she was discharged to the hospital and readmitted on [DATE]. No assessment of R3's coccyx wound is documented until 12/14/15 and reads coccyx measures: 5 x 5.4 x .1 c (with) no drainage + no odor. There was no staging with this assessment. R3's physician's orders [REDACTED]. On 12/14/15, wound specialist evaluated R3 and documented the wound as being necrotic (unstageable), small amount of exudate, sero-sanguneous, no odor or pain. The assessment further documented 51-75% moist black eschar with 1-25% [MEDICATION NAME] and granulation. On 12/20/15, the nurse documents R3's treatment not done as the floor nurse requested to change treatment. On 12/21/15, the dressing again is not documented as done. On 12/21/15, E4 documents R3's pressure ulcer as measuring 2.3 cm x 3.4 cm x 0.1 cm with slight drainage. There is no documentation she completed the treatment at that time on R3's pressure ulcer. On 12/28/15, E4 documents R3's pressure ulcer measures 5 cm x 4.5 cm x 1.5cm with mild drainage + slight odor. On 12/28/15, R3's wound was debrided and measured 6 cm x 4.5 cm x 1.5cm according to the Wound Specialist note. On 1/1/16, R3 Progress Notes document she was transferred to the hospital and returned to the facility on [DATE]. R3's Admissions Orders document she should have Santyl and Calcium Alginate daily to her coccyx pressure ulcer. The January 2016 TAR documents R3's coccyx wound as measuring 5.5 cm x 5 cm x 2.5 cm with undermining at 10-2 o'clock of 2.3cm, moderate drainage x no odor on 1/11/15. On 1/13/16 at 12:30 pm, no initials were present on the R3's TAR documenting R3's daily treatment of [REDACTED]. On 1/13/15 from 11:30am to 2:50pm, R3 was in the same position in bed. At 2:50 pm, R3's coccyx pressure ulcer dressing was intact only on the top and sides, the bottom of the dressing was loose with the wound bed exposed and bowel movement on the bottom edge of the dressing. Both heels were dark with dry calloused skin. No padding was between her legs and she had a 1/4 folded top sheet and heavy cloth incontinent pad under her. E4 stated at the time that her dressing is done by the 2-10pm shift and would be done next shift. E4 did not remove the soiled dressing from R3's pressure ulcer. Dietary Notes show R3 was last assessed by dietary on 12/7/15 and receives Glucerna 1.2 feeding at 65cc/hour for 23 hours a day. However, it does not show R3' gets any other nutritional or supplemental assist besides the Glucerna and a daily multiple vitamin/mineral. The dietary note dated 12/7/15 documents R3 as having a stage III pressure ulcer and no assessment has been done since it's been assessed as unstageable. [MEDICATION NAME] lab dated 1/10/16 documents it as low at 3.2 with normal 3.5-5.2. On a Hospital History and Physical dated 11/19/15, R3's [MEDICATION NAME] was 3.9. The January 2016 POS also fails to show any nutritional support ordered to aid R3's in the healing process of her coccyx wound. On 1/18/16, the wound specialist evaluated R3's coccyx wound and measured her coccyx wound to be 4.4 cm x 4 cm x 1.5 cm with undermining from 12-2 o'clock at 2.6cm deep.

Based on record review and interview, the Facility failed to obtain a urine sample as ordered by the Nurse Practitioner to rule out a urinary tract infection [MEDICAL CONDITION], and failed to provide timely treatment for [REDACTED]. This failure resulted in R2 being admitted to the hospital on [DATE] for treatment of [REDACTED]. Findings include: The Nursing Admission Assessment, dated 5/30/2014 documents R2 was admitted to the Facility with an old gastric bypass, status [REDACTED]. The POS for 6/2014 documents an oral diet order of "Regular with ground/chopped" and "Flush GT (gastrostomy tube) with 90 cc (cubic centimeter) water every shift to maintain patency", and an order for [REDACTED]. R2's Care Plan, dated 6/17/2014, documents, in part, "Needs monitored for side effects of diuretic medication for treatment related to cardiac issues [MEDICAL CONDITION](hypertension). Monitor for serious side effects and notify MD (medical doctor) as necessary: dehydration, weakness. (R2) has alteration in bladder elimination as related to episodes of incontinence at times. Will not have any infections. Monitor for infection such as burning urination urinary frequency, complaints of pain, foul odor. Encourage fluids and notify physician if symptoms occur related to UTI." The Nurses Note, dated 6/26/2014, at 1:00 AM, documents R2 had a "subdued affect." The Nurses Note, dated 6/26/2014, untimed, documents, "New Order for UA (urinalysis) and C&S (culture and sensitivity) related to confusion" from Z1, Nurse Practitioner (NP) for Z2, Physician. The Nurses Notes from 6/26/2014 through 6/29/2014 fail to document a urine sample was obtained for a urinalysis or C&S for R2. There is no Laboratory Report for R2 in the clinical record for a urinalysis with a C&S dated as collected 6/26/2014 or thereafter. The Nurses Note, dated 6/27/2014 at 10:00 AM documents, in part, R2 was "sleepy with confusion." The Nurses Note, dated 6/27/2014, at 2:00 PM, documents R2 was seen by Z2 and a new order was received for an appetite stimulator. The Nurses Note, dated 6/28/2014 at 9:30 AM, documents, in part that R2 began to complain of pain and discomfort to all over her body and pain medication was given and effective. The Nurses Note, dated 6/29/2014, at 10:00 AM, documents, in part, that R2 was alert with confusion with complaint of "pain all over", with pain medication given. There is no documentation Z1 or Z2 were notified. The Nurses Note, dated 6/29/2014, at 5:30 PM, documents Z1 and Z2's paging service was called and a message was left to call the facility due to R2's confusion and weakness. The Nurses Note, dated 6/29/2104, at 6:40 PM documents R2's Power of Attorney (POA) wanted R2 to be sent to the local emergency department for evaluation. The Nurses Note, dated 6/29/2014 at 7:00 PM documents R2 left the Facility by ambulance with her family. A Nurses Note from E2, Director of Nursing (DON), dated 6/30/2014, at 11:30 AM, documents, in part, " 6/29/2014, client (R2) was noted to be lethargic and no urine output for evening shift. Client's flushes were reviewed with POA (Power of Attorney). UA (urinalysis) was not obtained." On 7/08/2014, at 2:50 PM, Z1 was interviewed about R2. Z1 reported she was not aware of R2's poor fluid intake or the Facility's failure to obtain a urine sample for a urinalysis or C&S. Z1 reported she was unaware why the message from the facility on 6/29/2014 at 5:30 PM was not received by her until 7:15 PM, after R2 had left for the hospital. Z1 reported if the urinalysis had been obtained at the Facility, R2 could have been treated with an antibiotic, push fluids or increase the [DEVICE] flushes to promote hydration.. On 7/09/2014, at 10:15 AM, E5, LPN was interviewed about R2's condition the evening of 6/29/2014. E5 reported she had called Z2's answering service when she noticed R2 had increased confusion and needed a physician order [REDACTED]. On 7/08/2014, at 2:20 PM, E3, LPN was interviewed about R2. E3 reported she took care of R2 the day of 6/28/2014. E3 reported she did not obtain a urine sample from R2 for a UA or call the physician. On 7/09/2014, at 4:29 PM, E4, LPN was interviewed about R2 on the evening and night shift of 6/26/2014. E4 reported E5, LPN for the evening shift had reported to her R2 was having increased confusion and she (E5) had been waiting for Z1, NP to call back to the Facility about R2. E4 reported Z1 called the Facility between 10:30 PM or 11:00 PM of 6/26/2014,and gave her an order for [REDACTED]. The emergency room Visit Report, dated 6/29/2014, documents, in part, "(R2) here with altered mental status. Per (family) patient has had confusion beginning 1 week prior. (Family) came to see her at the care Facility and she was noted to be worse. Was not responding appropriately so patient sent in for further evaluation. Patient currently altered and unable to provide any history. Lab Results Comment: Remarkable. Patient confused. Clinical Impression: Acute Urinary Tract Infection,[MEDICAL CONDITIONS], Altered Mental Status." The Hospitalist History and Physical, dated 6/30/2014, documents, in part, "Sepsis with elevated WBC (white blood cell), SIRS (Systemic [MEDICAL CONDITION] Response Syndrome) criteria, and with suspected UTI. [MEDICAL CONDITION] related to poor intake. For now will hydrate the patient gently and monitor. Acute [MEDICAL CONDITION]-acute dehydration suspect related to poor intake. UTI-significant pyuria (pus in urine). On [MEDICATION NAME] (antibiotic used to treat UTI) to cover." The Hematology Report for R2, dated 6/29/2014, at 8:57 PM, documents, in part, an elevated WBC of 15.5, normal =4.6-10.2. The Urinalysis Report, dated 6/29/2014 at 8:28 PM, documents R2's urine was cloudy, normal=clear and contained Leuocytes of 500, normal=negative, with WBC's in R2's urine of 1702, normal =0-2. R2's Urine C&S, dated 6/29/2014, documents a colony count of over 100,000 CFu/mL (colony forming units per milliliter) of the bacteria, [DIAGNOSES REDACTED] pneumoniae, ESB (extended spectrum beta lactamase, a multi-drug resistant organism-MDRO) and 50,000 CFU/mL of a gram positive organism, and 50,000 CFU/mL of a gram negative Bacilli, resembling Proteus Mirabilis."

Based on record review and interview, the Facility failed to assess and monitor daily fluid intake to maintain hydration for one of three residents, (R2) reviewed for fluid needs in the sample of 8. This failure resulted in R2 being admitted to the hospital on [DATE] for treatment of [REDACTED]. Findings include: The Nursing Admission Assessment, dated 5/30/2014 documents R2 was admitted to the Facility with status [REDACTED]. The POS for 6/2014 documents an oral diet order of "Regular with ground/chopped" and "Flush GT (gastrostomy tube) with 90 cc (cubic centimeter) water every shift to maintain patency", and an order for [REDACTED]. The Nutritional Assessment, dated 6/26/2014, documents R2's daily fluid requirements to maintain hydration is 1,827 cc's. The Food and Fluid Intake Sheet for June 2014 documents R2's daily oral fluid intake as less than 1,000 cc's daily, except for 6/14/2014 when R2 consumed 1,000 cc's of fluid. The Medication Administration Record [REDACTED]. Even with the addition of the [DEVICE] flushes, R2 still was under the required amount of fluid intake to keep her well hydrated. The Nurses Note, dated 6/27/2014 at 10:00 AM documents, in part, R2 was "sleepy with confusion." The Nurses Note, dated 6/27/2014, at 2:00 PM, documents R2 was seen by Z2, Physician and a new order was received for an appetite stimulator. There is no documentation that Z2 was notified at that time of R2's poor fluid intake. The Nurses Note, dated 6/28/2014 at 9:30 AM, documents, in part that R2 began to complain of pain and discomfort to all over her body and pain medication was given and effective. There is no documentation related to R2's poor fluid intake or if Z1, Nurse Practitioner or Z2 was notified of R2's poor fluid intake. The Nurses Note, dated 6/29/2014, at 10:00 AM, documents, in part, that R2 was alert with confusion with complaint of "pain all over", with pain medication given. There is no documentation Z1 or Z2 were notified. The Nurses Note, dated 6/29/2014, at 5:30 PM, documents Z1 and Z2's paging service was called and a message was left to call the facility due to R2's confusion and weakness. There is no documentation of R2's poor fluid intake. A Nurses Note from E2, Director of Nursing (DON), dated 6/30/2014, at 11:30 AM, documents, in part, "6/29/2014, client (R2) was noted to be lethargic and no urine output for evening shift. Client's flushes were reviewed with POA (Power of Attorney). UA (urinalysis) was not obtained." On 7/08/2014, at 2:50 PM, Z1 was interviewed about R2. Z1 reported she was not aware of R2's poor fluid intake or the Facility's failure to obtain a urine sample for a urinalysis or C&S. Z1 reported no one at the facility reported R2's daily fluid intake of less than 1,000 cc's to her for the month of June 2014. Z1 reported if the urinalysis had been obtained at the Facility, R2 could have been treated with an antibiotic, push fluids or increase the [DEVICE] flushes to promote hydration. On 7/03/2014, at 8:20 AM, E2 was interviewed about R2. E2 reported R2 received no enteral feeding solution through her [DEVICE], just water flushes each shift to maintain patency of the tube. E2 reported R2 was on daily Intake and Output (I&O) monitoring. On 7/03/2014, at 2:05 PM, E2 reported the night shift nurse is responsible for checking the accuracy and I&O records that are kept on a clip board at the nurse's station. E2 confirmed that R2's I&O records for June 2014 were incomplete, and do not include water or other fluid intake R2 may have consumed throughout the day, each day in June. On 7/09/2014, at 10:15 AM, E5, LPN was interviewed about R2's condition the evening of 6/29/2014. E5 reported she had called Z2's answering service when she noticed R2 had increased confusion and needed a physician order [REDACTED]. E5 reported R2 had a terrible water intake, did drink soda, but she did not document this fluid intake. E5 reported the Certified Nurse's Aides (CNA) record R2's fluid intake and food intake, put it on a CNA flow sheet and the nurse is responsible to transcribe the information on the Intake and Output Record and review. On 7/09/2014, at 4:29 PM, E4, LPN was interviewed about R2 on the evening and night shift of 6/26/2014. E4 reported E5, LPN for the evening shift, had reported to her R2 was having increased confusion and she (E5) had been waiting for Z1 to call back to the Facility about R2. E4 reported Z1 called the Facility between 10:30 PM or 11:00 PM of 6/26/2014, and gave her an order for [REDACTED]. On 7/08/2014, at 2:20 PM, E3, LPN was interviewed about R2. E3 reported she took care of R2 the day of 6/28/2014. E3 reported R2 had a poor fluid intake and refused water "quite a bit, even when giving medication, (R2) wouldn't drink all of the water. (R2) was a high risk for dehydration, ate lots of junk food with high salt concentration." The emergency room Visit Report, dated 6/29/2014, documents, in part, "(R2) here with altered mental status. Per (family) patient has had confusion beginning 1 week prior. (Family) came to see her at the care Facility, and she was noted to be worse. Was not responding appropriately so patient sent in for further evaluation. Patient currently altered and unable to provide any history. Lab Results Comment: Remarkable. Patient confused. Clinical Impression: Acute Urinary Tract Infection,[MEDICAL CONDITIONS], Altered Mental Status." The Hospitalist History and Physical, dated 6/30/2014, documents, in part, "Sepsis with elevated WBC (white blood cell), SIRS (Systemic [MEDICAL CONDITION] Response Syndrome) criteria, and with suspected UTI. [MEDICAL CONDITION] related to poor intake. For now will hydrate the patient gently and monitor. Acute [MEDICAL CONDITION]-acute dehydration suspect related to poor intake. UTI-significant pyuria (pus in urine). On [MEDICATION NAME] (antibiotic used to treat UTI) to cover." The hospital's Chemistry Profile for R2, dated 6/29/2014, at 8:57 PM, documents, in part an elevated potassium level of, "6.3 mmol/L (milimol per liter)-normal =3.3-5.1, BUN (blood, urea, nitrogen) of 83 mg/dL, normal=6-20, creatinine level 2.2 mg/dL, normal =0.5-1.1." The Hematology Report for R2, dated 6/29/2014, at 8:57 PM, documents, in part, an elevated WBC of 15.5, normal =4.6-10.2. The Urinalysis Report, dated 6/29/2014 at 8:28 PM, documents R2's urine was cloudy, normal=clear and contained Leukocytes of 500, normal=negative, with WBC's in R2's urine of 1702, normal =0-2. R2's Urine C&S, dated 6/29/2014, documents a colony count of over 100,000 CFU/mL (colony forming units per milliliter) of the bacteria, [DIAGNOSES REDACTED] pneumoniae, ESB (extended spectrum beta lactamase, a multi-drug resistant organism-MDRO) and 50,000 CFU/mL of a gram positive organism, and 50,000 CFU/mL of a gram negative Bacilli, resembling Proteus Mirabilis." R2's Hydration Assessment, dated 5/31/2014, documents, in part, that R2 is not on a diuretic medication, does not refuse fluids, does have dry skin turgor. The Hydration Assessment incorrectly documents R2's high risk for dehydration, therefore, a hydration program was not implemented. The ADL (activities of daily living) Flow Record, for 6/2014, documents R2's decrease in toileting from 6/25/2014 through 6/29/2014, with no documentation related to R2's hydration status or incontinence of urine. R2's Care Plan, dated 6/17/2014, documents, in part, "Needs monitored for side effects of diuretic medication for treatment related to cardiac issues [MEDICAL CONDITION](hypertension). Monitor for serious side effects and notify MD (medical doctor) as necessary: dehydration, weakness. (R2) has alteration in bladder elimination as related to episodes of incontinence at times. Will not have any infections. Monitor for infection such as burning urination urinary frequency, complaints of pain, foul odor. Encourage fluids and notify physician if symptoms occur related to UTI." The Facility's policy and procedure, entitled, 'Hydration Program', revised 2/2008, documents, in part, "It is the policy of (Facility) to assess individuals who are at risk for dehydration and to provide adequate fluids to all residents to maintain proper fluid balance, prevent skin breakdown, reduce infections and to maintain resident's current level of function. Complete Hydration Assessment for residents within 24 hours of admission, quarterly, and when there is significant change. Record the amount of fluids resident consumes at meals and any other specified times, on meal/fluid intake log. Develop an identifying mechanism that will be used at meals to alert the nursing staff to the residents who are at high risk for dehydration."

Based on observation, record review, and interview, the facility failed to investigate and implement progressive interventions to prevent falls for one of 4 residents (R10) reviewed for falls in the sample of 15; and failed to identify and assess for potential hazards and entrapments risk for two of four residents (R12, R15) reviewed for restraints in the sample of 15. This failure resulted in R10's fall on 7/27/12 resulting in a fractured right hip. Findings include: 1. R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's Fall Tracking and Skin Tear/Bruise Tracking Reports documented falls and/or skin tears on 7/2, 7/3, 7/12, 7/12, 7/17, 7/19, 7/27, and 8/3/12. The fall on 7/27/12 resulted in a fractured hip. R10's first fall was documented in Nursing Notes 7/2/12 at 7 AM, "Res noted on floor in room. Res. L. side laying with head in contact with floor.....Res. c/o (complaining of) generalized pain. M.D. notified.....". On 11/16/12, E2, Director of Nursing (DON), was asked to provide incident report and investigation of this incident. E2 stated she could not find the incident report. On 11/27/12, the facility faxed a report with a QA review dated 7/4/12 which stated (in part) "Labs done revealing increase in disease process....increase in muscle weakness.....increase in confusion. Labs done 8/8/12." There is no explanation how the 8/8 labs could have been done on 7/4/12. There are no new intervention to prevent falls in the future. On 7/12/12 at 9 AM, R10's Nursing Notes documented, "Res. noted ambulating in hallway. Observed walking into wall and going down to floor....". E2 stated she could not find the incident report for this incident on 11/16/12. On 11/27/12, the facility faxed an incident report with QA review dated 7/14/12 which documented (in part), "Increasing confusion et (and) muscle weakness for progressive disease process. Family considering hospice. admitted to Hospice.....8/22/12.". There is no explanation about the discrepancy in dates - 7/14/12 to 8/22/12. There are no new interventions to prevent future falls. On 7/27/12 at 13:15 (1:30 PM), Nursing Notes documented R10 was on the floor by the Nurses Station, lying on his left side. He had a small skin tear on his left elbow. No new interventions are documented to prevent future falls on the incident report or Nursing Notes. On 7/27/12 at 5:30 PM, Nursing Notes documented, "Resident noted in hallway on 200 hall floor. Laying on left side. Blood noted from left brow area and left elbow. Resident was walking with wife and fell . 911 called....Ambulance arrived....left on stretcher." R10 was sent to the hospital. Hospital History and Physical dated 7/27/12 documented a hip fracture. X-ray results of the right hip: Mildly displaced fracture of the right greater trochanter. R10's Minimum Data Set (MDS) is dated 7/9/12, and R10's ADL (Activities of Daily Living) assessments document he needs extensive assistance of two or more staff for bed mobility, transfers, ambulation in room and hall, and toilet use. His balance is assessed as NOT steady, only able to stabalize with staff assistance with impaired range of motion in both upper and lower extremities. R10's Nursing Notes document R10 ambulated without assistance of staff on numerous occassions, even after recommendations of need for increased assistance. On 6/29/12, E15, Physical Therapy Assistant, documented in Nursing Notes, "Nurse reports to this Therapist resident needs increased assist with ADLs. Recommend OT (Occupational Therapy) orders." On 6/30/12 at 13:30 PM, "....Ambulated independently"......On 7/1/12 at 13:45 PM. "........Res up, ambulated independently, gait steady....." . On 7/2/12 at 7:00 AM, "Res noted on floor in room....". On 7/5/12 at 10:20 AM, "...Res up ambulating independently...", on 7/7/12 at 3:00 AM, "Up this morning..... Roaming hallway....", On 7/12/12 9:00 AM, "Res noted ambulating in hallway. Observed walking into wall and going down to floor." On 7/13/12 at 3 AM, "Resident up ambulating in room.....". On 7/19/12 at 3 AM, "......Up ambulating in hallway......." The facility could not provide R10's comprehensive Care Plan for review to see if his Care Plan was reviewed and revised following each fall. On 11/16/12, at 10:30 AM, E2, DON, stated, "I don't know what happened to his Care Plan. I can't find it anywhere." 2. R12's POS dated 11/01 through 11/30/12, documented his [DIAGNOSES REDACTED]." On 11/14/12 at 2:12 PM, R12 was lying in his bed. R12's had four 1/2 side rails up on each side of his bed. He remained in his bed until at least 3:45 PM. This four rails would impede normal egress from the R12's bed. On 11/14/12 at 3:00 PM, R12 was lying in his bed. The head of his bed was elevated 15 degrees. Measurements of the gaps in the side rails were taken. The gap between the the split bed rails on the left side of the bed was 10.5 inches wide. The gap between the split bed rails on the right side of the bed was 11 inches wide. On 11/14/12 at 3:45 PM, an interview was conducted with E9, Certified Nurse's Aide (CNA). When questioned regarding R12 having four 1/2 side rails in the up position on his bed, she responded "Yes, we always put the 4 rails up. He has a tendency to throw his legs off the bed if they are not up." R12's Side Rail assessment dated [DATE] documented he was currently using side rails for positioning or support. The "RECOMMENDATIONS" section of the Side Rail Assessment documented he needed 1/2 bilateral side rails. The "INDICATIONS FOR SIDE RAIL" section documented "Serves to remind Resident to seek help-unaware of physical limits" and "Serves as Enable to promote independence in bed mobility." This Side Rail Assessment did not assess the risks versus benefits or entrapment hazards for the use of two 1/2 side rails on each side of his bed. The U.S. Food and Drug Administration's "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment - Guidance for Industry and FDA Staff" dated 3/9/2006 documented "To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. Country- specific anthropometric data show that a 1 st percentile female head breadth may be as small as 95 mm (3 3/4 inches). A dimension of 120 mm (4 3/4 inches) encompasses the 5 th percentile female head breadth in all data sources used to develop these recommendations, and includes 1st percentile female head breadth as reported in some data sources. FDA is therefore using a head breadth dimension of 120 mm (4 3/4 inches) as the basis for its dimensional limit recommendations." 3. R15's POS dated 11/1 thru 11/30/12 documented she had a [DIAGNOSES REDACTED]. [REDACTED]." On 11/15/12 at 2:00 PM, R15 was sitting at the nurse's desk in an enclosed ambulation device. R15's Minimum Data Set ((MDS) dated [DATE] documented he had a trunk restraint which was used daily. The MDS documented she had short and long-term memory loss and had severely impaired cognitive skills for daily decision making. The Care Area Assessment (CAA) Summary dated 10/17/12 documented "Uses (wheeled enclosed ambulation device) for mobility. May be considered restraint as resident is unable to release bar to open (wheeled enclosed ambulation device)." There was no documentation in R15's medical record regarding if the facility had assessed the risks versus benefits or medical reason for R15's enclosed ambulation device. R15's Nurse's Note dated 8/30/12 documented "5 AM - Another resident reported to this nurse that this resident was on the floor. Found resident in (wheeled enclosed ambulation device) on hands and knees the belt remained in place. Resident unable to say what happened." R15's Investigation Report for Falls dated 8/30/12 documented "What do you believe caused the fall? Resident leans forward until she is bending over while walking in (wheeled enclosed ambulation device)." There was no documentation in the section regarding what new interventions were implemented to prevent any further falls. The Quality Care Reporting Form dated 8/30/12 documented in the Root Cause with Recommendations section "Risk of injury still (lower) (with) (wheeled enclosed ambulation device). Monitor closely while in (wheeled enclosed ambulation device.)" R15's Nurse's Note dated 9/9/12 at 6:30 PM documented "Resident noted sitting on floor inside (wheeled enclosed ambulation device). Skin (check) completed. 0 injuries" There was no documented investigation of this fall. There were no new documented interventions implemented to address R15 falling while in the wheeled enclosed ambulation device. On 11/16/12 at 9:20 AM, E2 was interviewed regarding R15 falling in her wheeled enclosed ambulation device. E2 stated Hospice brought in an enclosed ambulation device which was too big and she was able to fall inside it.

Based on interview and record review, the facility failed to protect residents from sexual abuse for three of four residents (R13, R27 and R28) reviewed for sexual abuse allegations in the sample of 15. This failure resulted in R11 inappropriately touching R13's, R27's and R28's breasts. Findings include: R11's physician's orders [REDACTED]. R11's Nurse's Note dated 2/24/12 at 9:30 AM documented "Res having inappropriate behaviors. Res ambulated c (with) assist of w/c (wheelchair) up to this nurse c (with) back to res. Res then took his fingers and touched nurse's buttocks. When nurse turned around he grabbed the nurse's hand when she attempted to stop him. Nurse informed res that behavior is inappropriate . Res then looked @ nurse c (with) aggression et (and) said 'I know it is.' Nurse then informed SSD (Social Service Director) . (Z2, Psychiatrist) to see res this am et (and) will inform MD of increase in aggressive et (and) sexual behavior. [MEDICATION NAME] 2 mg give et seem to (not) be effective." On 2/24/12, Z2, Psychiatrist, saw R11 and documented the following progress note: "Reviewed note - Nurse did verbal warning but documentation not enough to support use of [MEDICATION NAME] - Discussed with (E12, SSD) - chart- flow of events, how it happened including verbal redirection and behavior modification. Will (decrease) dose of PRN (as needed) [MEDICATION NAME]. Will adjust meds to address sexually inappropriate behavior. If it fails will consider psychiatric hospitalization . Meds reviewed. Education." R11's Behavior Monitoring Record dated February 2012 documented his targeted behaviors as "Sexually Inappropriate Behavior - Attempts to grab/grope at staff. Disrobes in public." The Behavior Monitoring Record documented the following interventions to address this behavior: I) Use Name to Capture Attention J) Redirect to Activity of Interest or Social Service K) Explain that it is not appropriate behavior L) Approach at later time and give time of return. In addition, the Behavior Monitoring Record documented another targeted behavior as "Verbally Aggressive - Sexually Inappropriate Comments 'Play with me, I wanna f--k you, or suck my penis.' " The Behavior Monitoring Record documented the following interventions to address this targeted behavior: "I) Explain that he should not talk to others that way. K) Remove from point of anger/interest. L) Redirect to Activities of Social Services. M) Use name to capture attention." Both Behavior Monitoring Records documented he grabbed at another resident and made sexual comments towards a resident. This incident was not documented in his nurse's notes. The Behavior tracking documented throughout the month of February 2012 that R11 made many sexually inappropriate comments, pulled out his penis and showed his penis to staff and residents and groped and grabbed staff while doing care. R11's Nurse's Note dated 3/14/12 documented "5:30 PM Resident in the dining room, came behind another female resident placed his hands on her shoulders. Redirected resident. [MEDICATION NAME] 0.5 mg give po for aggression. Staff closely monitoring every 15 minutes." R11's Nurse's note at 6:30 PM (one hour after the initial incident) documented "Resident found in a resident's (R28) (female room) had his hands on her breast. Staff redirected him. Placed him by nurse's station." R11 was sent to the hospital and admitted for sexual aggression. On 3/26/12, upon return from the hospital, R11's Care Plan and Behavior Tracking Monitoring Records were not revised to implement new non-pharmaceutical interventions to address his sexually inappropriate behaviors. R28 could not be interviewed regarding this incident due to her cognitive impairment R11's Behavior Monitoring Record dated April 2012 documented he had five episodes of pulling out his penis in public and 12 episodes of sexually inappropriate comments towards staff such as asking staff if "they want to touch it?", and "want to s--k it?" Although R11 continued to have these sexually inappropriate behaviors, R11's Care Plan and Behavior Monitoring Record was not revised with new non-pharmaceutical interventions to address his sexually inappropriate behaviors. R11's Behavior Monitoring Record dated May 2012 documented he had an episode of sexually inappropriate behavior in another resident room on 5/21/12. There was no documentation in R11's nurse's note regarding this incident. There was no investigation regarding this incident. R11's Social Service Progress Review, dated 5/31/12 documented "(R11) wanders around the facility and sometimes into to other residents rooms but can be redirected easily. He can become easily distracted at times as well." The Progress Review documented "(R11) has shown some problems with inappropriate behavior and making sexually inappropriate comments. He sometimes attempts to grab or grope at staff during care. He can usually be easily directed. He does wander around the facility most times. Behavior tracking in place and (Z2) monitors his medications." This Review did not document R11's history of being sexually aggressive towards other residents. R11's Care Plan, revised on 6/1/12 documented "I am restless, I have socially inappropriate behaviors . I am on an antipsychotic. My goal is to have agitation and depression controlled on the lowest dose possible with ASE (any side effects). 1.) The Social Service Director will complete a social assessment upon admission, quarterly, and prn, implement appropriate interventions, and update care plan accordingly. 2) Advance directives: I am a DNR. 3) 1:1 as needed." Although multiple interventions regarding medications adjustments had been discontinued on the care plan, it did not address any non-pharmaceutical behavioral interventions to address R11's sexually inappropriate behaviors. R11's Minimum Data Set (MDS), dated [DATE] documented he wanders daily which significantly intrudes on the privacy or activities of others and has behavioral symptoms not directed towards others. R11's Care Plan was revised on 8/14/12 and documented "Resident has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against this Resident. Behavior exhibited-inappropriate sexual statements and inappropriate sexual touching." Interventions to address these behaviors were "Determine if behavior is stimulated by certain activities, noise levels, persons involved, time of day. Intervene as needed as soon as behavior is noted to ensure safety of residents and others. Gain attention of Resident by using name. Talk with resident in calm manner. Redirect to area where others will not be distracted. Staff to move between Resident and any dangers. Take to quiet location and divert from distracting stimuli. Discuss behavior with resident; watch for behavioral clues to understand. Help resident to understand why behavior is socially inappropriate/disruptive." The Behavior care plan documented "Resident has inappropriate behavior, such as resisting care and making sexual approaches and statements to staff and other residents.: Interventions to address these behaviors documented "Initiate Behavior Monitoring program to attempt to identify patterns, precursors, and causes of behavior and to attempt to understand the meaning of the behavior. Introduce self upon contact, make eye contact, approach from front, explain all procedures prior to beginning, seek resident input/reassurance with all cares. During periods of inappropriate behavior, use a consistent, calm, firm approach. use resident's name to help divert inappropriate behavior. Provide reality orientation as tolerated. Reviewed abnormal behaviors with IDT. Establish and maintain trust. Encourage family input as needed to assist win identifying issues of concerns." R11's Nurse's Note dated 9/27/12 documented "Res allegedly touched a resident (R27) in a sexually inappropriate manner around her breasts. Res approached et questioned r/t (related to) allegation. Res did not answer @ (at) first questioning. After repeating question, res states 'Hey baby. I want to f--k you.' 1:1 done speaking that behavior is inappropriate, resident smiled. Res placed in room et toileted. DON Made aware." This incident occurred in the dining room. R11 was sent to the hospital and admitted to hospital for aggressive behaviors. R27 could not be interviewed regarding this incident due to her cognitive impairment. R11's Hospital History and Physical dated 9/28/12 documented "[AGE] year-old male admitted to the Behavioral Health Unit yesterday in transfer from (facility). He is transferred for sexually inappropriate behaviors. This is his third or fourth hospitalization in this unit for the same problems. Most recent hospitalization was March 2012. He has been touching other female residents on the breasts and other sexually inappropriate statements to them and to the staff." R11 was readmitted to the facility on [DATE]. The facility did not revise R11's Care Plan or Behavior Monitoring Record with new interventions to address his sexual aggression. R11's Nurse's Note dated 11/6/12 at 4:30 "It was reported to this nurse that Res had been sexually aggressive toward a female res. (R13) Touching her breasts - genitals etc. Call out to (Z2, Psychiatrist)." R11 was transferred to the hospital. On 11/15/12, at 9:25 AM, an interview was conducted with R13. She did not recall this incident. On 11/16/12 at 1:25 PM an interview was conducted with E12, SSD. E12 stated R11 had a history of [REDACTED]." E12 stated R11 had dementia. He stated R11's sexual inappropriate behaviors were always directed towards females although there was no particular female he would target. E12 stated R11's wandered the hallways and sometimes into other residents rooms. E12 stated this wandering behavior was daily. E12 stated if R11 was sexually inappropriate staff would remove him form the situation, redirect, attempt to reorientate, and send him to the hospital if necessary. E12 stated R11 had medication changes which would improve his behaviors, but then R11 would get use to the medications, and his behaviors would return. On 11/16/12 at 2:50 PM, an interview was conducted with E2, Director of Nurse's (DON). E2 stated she was the facility's Abuse Coordinator. E2 stated that with regards to R11's behavior, staff would always separate the residents after an incident would occurred. E2 stated R11 was always sent to the Behavioral Health Unit for a psychiatric evaluation. E2 stated R11 was placed on 15 minutes checks and staff would keep a close eye on him. When questioned where the 15 minute checks were documented E2 stated "I don't know if they documented it anywhere." When questioned why no new non-pharmaceutical interventions were implemented after R11 became sexually aggressive towards residents, E12 stated "I don't know." The facility's Abuse Prevention Program, revised 11/11/11 documented "Resident Assessment. As part of the resident social history assessment,staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the changes of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis."

Based on observation, record review and interview the facility failed to provide a safe transfer for five of five residents (R1, R3, R6, R10, R13) reviewed for transfers, and failed to adequately investigate and provide preventative measures for two of nine residents (R4, R15), reviewed with a history of falls in a sample of 15. This failure resulted in one resident falling and being sent to the hospital with a Intertrochanteric Fracture (R15). Findings include: 1. A review of R15's physician's orders [REDACTED]. The most recent Minimal Data Set (MDS), dated [DATE], documented R15 was confused, and a one person assist for transfers. A review of Quality Care Reporting forms for R15 document the following; 9/14/11, 1800 / (6:00PM), "Attempting to get from W/C (wheel chair) to bed, on back with head towards dresser. Resident attempting to transfer self. No interventions implemented." 9/15/11, 1:30 AM, "Fall, Roommate said resident fell off stool in bathroom. Previously in low bed. Cause of fall - Resident was in bed covered up. Does not really know that she fell . Intervention - None / Blank box." 9/16/11, 1:30 AM, "Fall, Residents room, no injury sustained. Resident says she's fine. Resident monitored every 2 hours, with low bed. 9/16/11, Fall Risk Assessment - 10 / High Risk. 9/16/11, 7:40 AM, Fall, No injury, found between bed and wheel chair. Lying on floor. Fall risk assessment re-done shows score of 12 / High Risk. Unknown what resident was doing prior to fall, no fall prevention in place. Slippery shoes removed. 9/30/11, 3:20 AM, Resident was taking self to bathroom and slid to floor. Resident is independent, unable to communicate to ask for help, refuses lap buddy or seat belt. Resident remains in low bed. Resident observed throughout the night. 10/18/11, 5:30 PM, Found on floor in dining room, sitting in front of wheel chair. Resident is independent and refuses lap belt or lap top cushion. Wheels independently and wants to do this independently, has decreased physical strength. 10/31/11, 7:00 AM, Fall with skin tear to right hand. Resident restless and gets in and out of chair without assist, unable to keep resident from moving independently. Occurred while unattended, resident unsure what happened due to confusion. Follow up: Bed rearranged, Physical Therapy Referral - No, Prevent resident from being alone in room. 10/31/11 at 11:00 AM, Nursing notes document "New skin tear left elbow, unknown origin. Steri strips applied. 5:30 PM - Resident complaining of Left leg pain stating "my leg's broken, girls, get me to the hospital." Range of motion to bilateral lower extremities done with resident grabbing left leg when moved. MD paged. Order received for X-ray of left hip and leg. A review of R15's 10/31/11 X-ray report stated; A fracture involving the inter- trochanteric region is identified. The fracture does not involve the articular surface. Superior lateral displacement of the distal fracture fragment is noted. Diffuse osteopenia is noted. The femoral head is well seated within the acetabulum. Moderate degenerative changes are identified. Soft tissue swelling is noted. On 10/31/11 at 10:30 PM, the nursing notes document that R15's MD was notified of the X-ray results, and R15 was sent to the hospital. A review of R15's care plan was updated 8/3/11, prior to the onset of the above falls. The care plan documents, Falls - Resident has risk factors that require monitoring and intervention to reduce potential for self injury. Risk factors include: Dx of dementia, confusion. As evidenced by attempts to transfer self. Related [DIAGNOSES REDACTED]. Resident does not ask for assist with transfers. An update noted for R15's falls, was documented (but not dated) at some point between 8/3/11 and 10/31/11; R15's self release seat belt, low bed and personal alarms were discontinued. On 11/4/11 at 2:00 PM, in an interview with E3, Care Plan Nurse, and E2, Director of Nursing (DON). E2 stated; "On 8/31/11, R2's medications and restraints were discontinued by R15's family. R2 did not cooperate with taking the medications or leaving the seat belt on. She was confused and wanted to be independent. The family decided at her age they just wanted her to be happy. " Regarding the lack of documented interventions; E2 stated "E2 stated "I'm not sure what else we could do as R15 doesn't cooperate. E2 stated "that a physical therapy consult had not been sought." E3, Care Plan Nurse, E3, stated, "I did not update the care plan to include additional interventions for R15's falls, because I was not informed that R15 had been falling until this week. The fall reports are not shared with me." E2, Director on Nursing, confirmed E3 had not been informed of R15's falls prior to 11/1/11. 2. A review of R3's physician's orders [REDACTED]. The most recent MDS, documented R3 was confused, did ambulate, but needed staff assist of 1 for transfers and activities of daily living. The most recent care plan dated 9/14/11 documented; Resident has risk factors that require monitoring and intervention to reduce potential for self injury. Risk factors include requires supervision and stand by assist with ambulation. On 11/2/11, a facility Quality Care Reporting Form was reviewed and documented: 10/3/11, 8:00 AM, R3 was found in her room sitting on the floor in front of the toilet. R3 had attempted . R3 was last seen in the hallway propelling herself to her room. R3 reported "I slid on the floor." "Resident attempted to transfer self to toilet and fell to floor striking right posterior head on wall. Resident has decreased physical and cognitive ability. The incident report for falls dated 10/4/11, documented "Resident instructed to ask for assistance for transfers." The most recent care plan dated 9/14/11, failed to document the fall of 10/4, or any additional interventions to prevent falls. The physician's hospital report dated 10/6/11, documents R3 was hospitalized and treated for [REDACTED]. The Care plan did not document any updates regarding these new symptoms and fall potentials for R3. Review of the facility Quality Care Reporting Form dated 10/23/11, 1830 (6:30PM)documented R3 fell , and sustained a 3 centimeter bruise above her left eye. Pressure was applied X 5 minutes. "Resident physical and cognitive ability is declining. Refuses alarm or lap buddy or seat belt." There was no "Incident Report for Falls" form that accompanied this report. R3's care plan stated "fell out of w/c, bruising to face. Observe for changes, observe closer. Increased confusion and agitation. No further interventions or preventions were listed. On 10/30/11, 10:10 AM, R3 fell and sustained skin tears to two fingers of her left hand. The Investigation Report for Falls dated 10/30/11, documented R3 was sitting in her wheel chair in her room. Stated "I fell ." The report did not document a cause for fall as directed in the box. It stated a chair alarm was to be implemented. On 10/31/11, E2, Director of Nursing documented on the Quality Care Reporting form; "Resident declining cognatively and physically. Has been evaluated in ER for declining health. Leaning forward and falls out of chair. Refuses lap belt. The care plan showed an update on 10/30/11 "fell ", with no other interventions or preventions documented. Observation of R3 throughout the survey days of 11/1/11 through 11/4/11 indicated she had a large greenish / bluish bruise to her forehead above her left eye. The bruise extended down under her left eye and became dark blue. R2 was observed on 11/3, and 11/4 laying in her bed after breakfast /10:30AM, with the bed in the highest position, the wheel chair next to the bed / unlocked, and no fall mat on the floor or personal alarm on her person. On 11/4/11 at 11:00 AM, in an interview with E2, Director of Nursing, she stated that R3 had been declining in her health and abilities. E2 stated that the hospital had suspected R3 may be suffering from TIA's / Transient Ischemic Attacks as a reason for her falls. E2 stated that R3 did not use her call light, had refused the alarms, and lap buddy, and felt the facility was limited is what they could do to prevent R3 from falling. E2 stated that a physical therapy consult had not been sought which might offer some other suggestions for interventions. E2 was not aware that staff was leaving R3's unlocked wheel chair next to her bed, in light of the falls having all been from her wheelchair. Although the current care plan suggests R3 needs "monitoring due to risk factors", no additional or increased frequency monitoring of R3 was implemented, after her falls. 3. A review of R10's, Restorative Nursing Transfer Program dated 7/8/11, documented the following: Problem / Need; "Requires assist with task segmentation, cues, gait belt to bear wt to transfer. At risk for fall. CNA to place gait belt for all assisted transfers. On 11/1/11 at 1:10 PM, E8, Certified Nurses Aide, took R10 to the 200 hall bathroom. E8 grasped R10 under his arms, and transferred R10 from his wheel chair to the toilet without the use of a gait belt. R10 was wobbly as he attempted to step and pivot from the chair to the toilet. On 11/3/11 at 4:00 PM in an interview, E2, Director of Nursing stated R10 should be transferred with a gait belt for safety. 4. A review of R1's most recent care plan dated 8/19/11 documented the following; Safety - "I am at high risk for falls R/T requiring total assist with transfers, non-ambulatory, incontinent B & B, and poor safety awareness. My goal is to decrease risk of falls or injury. Fall risk assessment = 19 / high risk. On 11/2/11, at 1:20 PM, E16, CNA was observed as she walked from the bathroom back into her bedroom, and assisted R1 to sit in her wheel chair. E16 did not use a gait belt for this transfer. On 11/3/11 at 4:00 PM, in an interview, E2, stated a gait belt should have been used when transferring R1. 5. R4's Facility "Quality Care Reporting Form", dated 9/24/11, documents that on 9/24/11 at 9:30 PM, R4 was sent to the emergency room due to an "Alleged Fall" with resultant Left Hip Pain. There is no other information on the reporting form, such as causative factors with corrective action. R4's Facility nurses notes document "2130, Resident yelling for assistance. Resident lying on left side on floor propped up with left elbow. Complaining of severe pain to left upper thigh/hip area. Pain upon palpitation. Resident moaning and grimacing. Resident picked up by nurse, unable to bear weight at all, left leg and foot was externally rotated. Physician called. Orders received. Ambulance called to transport". The hospital "Consultation" report, dated 9/25/11, documents "The patient is a [AGE] year old female from the nursing home. Unfortunately, she went to the bathroom and fell , tripped up on her clothing trying to put her pants on. Diagnosis: [REDACTED]. On 11/1/11 at 2:15 PM, E2, DON, stated that the Facility does not have an investigation which includes potential causative factors and corrective action based on those factors for R4's fall on 9/24/11. 6. Review of the "Quality Care Reporting Form" dated 8/13/11, documents that R6 experienced a fall while being transferred with a mechanical lift. R6 complained of discomfort to the right side of her neck. The corresponding "Investigation Report for Falls" and the Facility's Nurses Notes dated 8/13/11 documents, "CNA stated mechanical lift started to tip, only one CNA in the room." The MDS dated [DATE], documents R6 requires the extensive assistance of two staff for transfers. In an interview with E3, MDS/ Care Plan Coordinator, on 11/2/11 at 10:50 AM, E3 stated the policy for mechanical lifts is "to use a minimum of two staff to transfer, if caught doing it alone, you are in trouble, counseled, your job is in jeopardy. If repeated, then termination." On 11/2/11 at 1:30 PM, E2, DON, stated the expectations for use of a mechanical lift are "two staff at all times, it is a huge safety risk. That is what happened with (R6), only one CNA was doing the transfer. That CNA is no longer here." 7. On 11/2/11 at 10:55AM, R13 was in her wheelchair with E16, CNA in the room. R13 was noted to be wet and E16 had E10 transfer R13 to her bed. E10 performed the transfer by herself, using a gait belt. A review of R13's MDS dated [DATE], for transfers, documented R13 requires assist of 2.

Based on record review, observation and interview, the facility failed to adequately investigate and provide progressive interventions and supervision for 2 of 7 residents (R4, R15) reviewed for falls in the sample of 9. Findings include: 1. The Facility "Quality Care Reporting Form" for R4, dated 12/5/11, documents that at 1:30 PM R4 had an "Alleged Fall" with "no apparent injuries". The "Root Cause with Recommendation by:" documents "unsteady gait with weakness. Needs personal alarm. Continues with physical therapy". The investigation does not state where R4's fall occurred or if anyone observed his fall. On 12/5/11 at 6:00 PM, "Quality Care Reporting Form" documents that R4 had an "alleged fall" with "no apparent injuries". The "Root Cause with Recommendation by:" documents "Resident slid out of chair reaching for something with his cane. Needs close monitoring and education. Physical therapy to evaluate and treat for weakness". The investigation documents that the fall was witnessed by another resident, does not state who the resident is, nor is there a statement from the resident witness. The investigation does not document if R4 had a personal alarm on at the time of the fall, or if the alarm was sounding. Throughout both days of the survey, 12/12 and 12/14/11, R4 did not have a personal alarm in place while sitting in his wheelchair or lying in his bed. R4 was asked during an interview on 12/14/11 at 2:50 PM, if he has ever had an alarm that sounded when he tries to stand up. R4 stated "No, I never had anything like that". E9, Certified Nurses Aide, CNA, who routinely works with R4, was asked on 12/14/11 at 3:00 PM if R4 has ever had a personal alarm. E9 said that to her knowledge, R4 has never had a personal alarm. On 12/14/11 at 3:10 PM, E2, Director of Nursing, DON, and E10, Care Plan Nurse, CPN, were asked if R4 is supposed to have a personal alarm on at all time. Both shook their heads up and down and stated "yes". R4 has diagnoses, in part, of Paget's Disease and Acute Kidney Failure. R4's most recent Minimum Data Set (MDS), dated [DATE], documents that he is independent for transfers and locomotion, and is "not steady but able to stabilize without human assistance" for walking and surface-to-surface transfer. R4 uses a cane and wheelchair for mobility. R4's Care Plan dated 11/9/11 does not document the use of a personal alarm. E10 was asked on 12/14/11 at 3:15 PM for documentation showing R4's assessment and plan of care for the use of a personal alarm. E10 stated that the documentation was incorrectly written on another resident's plan of care. E10 said that the other resident has the same first name as R4. 2. According to the History and Physical dated 12/2/11, R15 had a history of [REDACTED]. R15 was transferred back to the facility on [DATE] with "fall precaution" orders. E2, DON, stated in an interview on 12/14/11 at 2:00 PM that R15 had not been moving around much when she returned to the facility after her hip fracture. E2 stated there was no need for an alarm, and on 12/1/11 when R15 fell it was the first day R15 attempted to move or transfer herself. The only documentation for R15 for the 12/1/11 fall at 1:40 PM was a physician notification fax dated 12/1/11. The fax notification documented "Res (resident) noted on floor in room. (No) apparent injury noted. ROM (range of motion) WNL (within normal limits) (without) grimacing or c/o (complaint of) pain to all ext. (extremities). Res states "I'm okay". Res attempted self transfer from WC (wheelchair) to bed. Personal alarm to be placed. Res not to be in room alone. Res landed partially on floor mat. Some redness noted on side to floor. (No) malalignment of bones noted. (No) external head trauma noted. Res denies hitting head". The physician responded "Fall precaution", "ground to bed", and "inform family". The nurses note dated 12/1/11 at 1:30 PM described the fall as above. The note stated "Report given to oncoming nurse rt (related to) close supervision after fx (fracture) hx (history). Staff to cont (continue) to monitor." E2 stated in an interview on 12/14/11 at 2:00 PM that staff were to make sure R15 was at the nurses station to monitor her and to be with her when she transfers. E2 stated R15 "moved quickly" and staff were doing 50 minute checks. E2 stated R15 got to the bathroom without anyone seeing her because she was moving so fast. E2 confirmed R15 fell again on 12/1/11 while she was unsupervised. The nurses notes dated 12/1/11 at 6:20 PM documented "Resident found in room 215 at the edge of bed 1 (with) WC turned over on her. Her position of head was face down with (lower) extremities tangled in WC. Nurse did not move until the nurse from 100 hall helped her to get out from under her WC." When R15 complained of pain "all over" and "I want to go to the hospital" the physician was called with orders to send R15 to the emergency room . R15 was admitted to the hospital with [REDACTED]. No fracture was noted. According to the history and physical dated 12/2/11, R15 was treated for [REDACTED]. R15 was readmitted to the facility on [DATE]. The "Investigation Report For Falls" dated 12/1/11 noted R15 was trying to transfer herself to bed in another residents room and turned the wheelchair over. The fall report documented R15 had removed the personal alarm, however, the fall was not witnessed. The report documented as the "Root Cause Analysis" that "Resident doesn't understand she shouldn't get up unassisted. Resident was wandering around for her bed and found the room next door available and attempted to put herself to bed after unclipping her personal alarm. The report also stated "Resident is not to be in room alone. Nurse related this to the Hall 200 CNA's at beginning of shift". E2 stated on 12/14/11 at 2:00 PM they were "totally unprepared" for both falls on 12/1/11. E2 stated the incident happened on the weekend and she was not at the facility. E2 confirmed that she did not get statements from the staff. E2 stated when R15 came back on 12/2/11 to the facility they put a safety belt on R15. R15 was observed on 12/14/11 at 10:15 AM in a low bed with mats on the floor. At 11:25 AM she was observed in her wheelchair with a safety belt in place. The Care Plan dated 8/3/11 documented R15 had impaired cognition due to dementia. It also noted as a problem that R15 "wanders throughout nursing home in WC". The Care Plan also identified R15 was at risk for falls and attempts to transfer herself. The Care plan noted R15 should have a personal alarm when up in her chair. An alarm was placed on R15 after the first fall on 12/1/11. The "Fall Risk Assessment" dated 11/10/11 assessed R15 as 20 or at high risk for a fall.