Every finding on record at Evergreen Nursing & Rehab Center

Based on interview and record review the facility failed to provide adequate supervision for 1 of 5 (R1) residents reviewed for elopements in a sample of 5. The Findings Include;R1's face sheet documents an admission date of 1/27/2026. This same document includes the following diagnosis: unspecified dementia, mild intellectual disabilities and anxiety disorder. R1's elopement assessment was completed on 5/7/26. This assessment documents that R1 is cognitively impaired/has poor decision making skills and has pertinent diagnosis, he displays behaviors indicate of an attempt to leave (body language, etc) that an elopement is forthcoming and that an elopement care plan is initiated. R1's care plan has a problem area with an initiation date of 1/27/26 as follows: resident exhibiting wandering behaviors and is at risk for injury related to impaired safety awareness. The goal for this problem is to be free from injury by next review date of 4/27/26. The interventions for this problem area are: anticipate needs of resident as much as possible, approach resident in a calm manner, calmly redirect and cue as needed, and encourage resident to participate in activities of interest as tolerated. (All with start dates of 1/27/26).R1's most recent quarterly MDS (Minimum Data Set) dated 2/20/26 documents in Section C a BIMS (Brief Interview of Mental Status) score of 14, indicating that he is cognitively intact. In Section E 0900 it is documented that the resident has not exhibited behaviors of wandering or behavioral symptoms.On 5/31/26 at 1:15 PM, V1 (Administrator) stated that on 5/20/26 during the morning meeting with managers they were alerted by the IV (Intravenous) Drip team that R1 was missing. This was determined due to him having a scheduled drip service appointment. V1 stated that she immediately called a 'code elopement' and everyone began searching the building and outside. The code was called at around 10:30 AM and he was found at 10:37 AM by herself and V11 (Activities/CNA). V1 stated that R1 is alert and oriented and loves to go outside, but is considered an elopement risk. V1 stated that she is unsure which staff member or possibly a visitor that let R1 out to the patio at the back of the building. V1 stated that she educated the entire staff on safety and not allowing dependent residents outside on their own without someone supervising them. V1 stated that when she found R1 she asked him what happened and he walked her through it. V1 stated that R1 rolled his wheelchair to the gate of the fence and stood up to open the gate and proceeded to wheel himself on the sidewalk around the entire building. V1 stated that the sidewalk behind the building leads to the public street which then meets back up to the parking lot of the front of the facility. R1 was found on the street headed towards the parking lot. V1 stated that R1 was unharmed and immediately assessed by V12 (Registered Nurse/RN), however there is not a note put in the medical record about it. V1 stated that she educated the nurse to make sure these types of events are recorded. V1 reviewed the camera footage during this investigation and due to glitch in the video it is unable to be determined who allowed R1 outside with a code. On 5/31/26 at 12:00 PM, R1 stated that he is let outside by the facility staff all the time. R1 stated that he knows what he is doing and just likes to spend time outside getting fresh air. R1 stated that he cannot remember who let him out on 5/20/26 to the back patio, but after he sat there awhile by himself he rolled his wheel chair to the fence gate and stood up and let himself out. R1 stated that all he did was roll around the facility and get all wet due to the water on the side walk. R1 said by the time he got around the front of the building by the parking lot they were outside yelling for him. R1 stated he knows the rules of the road and would not be in any danger or get hit by a car. R1 stated that he didn't mean to get himself or anyone in trouble, he just wanted to go for a walk in his wheelchair on that nice sunny day. On 6/1/26 at 11:00 AM, V17(Licensed Clinical Social Worker) stated that he works at the facility on Mondays and Fridays. V17 stated that he did work on 5/20/26 and frequently lets R1 out on the back patio. V17 stated that it is his understanding that no one can be left out front in the gazebo or parking lot alone, but the back smoking patio they are allowed to sit out there alone. On 5/31/26 at 12:30 PM, V7 (Dietary Manager) stated that on 5/20/26 she was in the dining room around 10:15 AM when the managers came out of morning meeting and stated that R1 had eloped. V7 stated that she went outside and by the time she made it through parking lot V1 and V11 were wheeling R1 back in the parking lot. V7 stated he was coming down the road in his wheelchair when they found him. The Elopement Prevention Policy states: It is the policy of (Name of Facility) to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. Procedure:1. A licensed nurse will complete the Elopement Risk Assessment upon admission to the facility. An interim plan of care for minimizing the risk for elopement will be initiated upon the risk determination 3. The Interdisciplinary Team will initiate a plan of care for any resident determined at risk for elopement. Facility specific measures as well as resident specific measures will be included in each at risk resident's plan of care to minimize risk factors. Individualized care plans that specify how staff should redirect each resident based on their reason for attempted elopements and the ways that are proven to help redirect them. Communication of these interventions will be made to direct care staff through exposure to the resident's plan of care and periodic review and disclosure of the contents of Elopement Binder .7. The plan of care for minimizing elopement risks will be reviewed each time the Risk Assessment is completed.

Based on record review and interview, the facility failed to ensure that dialysis services were provided within the professional standards of practice for 1 of 3 residents (R1) reviewed for appointments in a sample of 7. This resulted in R1 experiencing fluid overload and being hospitalized .Findings include:R1's Face sheet documents an admission date of 2/18/26 with the following diagnoses included: acute respiratory failure with hypoxia, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, end stage renal disease and unspecified diastolic (congestive) heart failure.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 15, indicating that R1 is cognitively intact. Section O - Special Treatments, Procedures, and Programs documents that R1 uses oxygen continuously and receives dialysis treatment.R1's care plan documents a focus area of Resident at risk for complications due to end stage renal disease and hemodialysis.On 4/13/26 at 2:17pm, V6 (Dialysis Administrator) stated there was an issue a couple weeks back with R1 not making his dialysis appointments on time. V6 stated that she called the facility and spoke with V1 (Administrator) and the issue has since been resolved. V6 stated R1's chair time for dialysis is 5:30am, meaning he should be starting his treatment at 5:30am, his arrival time is 5:15am. V6 stated if R1 does not get here on time and start treatment at time, it jeopardizes his treatment. V6 stated R1's treatment is 3 1/2 hours for a reason, if he starts late, even by 15 minutes, his blood is not being cleansed. V6 stated shortened treatments prevent them from being able to remove all the toxins from R1's blood. V6 stated there were multiple instances in March where R1 did not start his treatment until 6-6:15am. V6 stated more than once someone from the facility would call and try to cancel R1's treatments, some of those may have been moved later in the day. V6 stated she had to explain to them multiple times, cancelling R1's treatments is not an option, skipping treatments is dangerous and detrimental to R1's health. V6 stated R1's issue is not typically fluid retention, he is a small man, it's more about removing the toxins from his blood. V6 stated she recalled the facility continued to say they were having issues with the transportation van, and they were unaware that 5:30am was his chair time, not arrival time. V6 stated R1 was late for his treatment on 3/4/26, 3/9/26, 3/13/26, 3/16/26, 3/23/26 and 3/27/27. V6 stated on 3/16/26 R1 did not start his treatment until 6:53am and was taken off at 9:11am, she stated that treatment was less than 3 hours. V6 stated dialysis patients who miss treatment or do not get their full treatments are at a very high risk of hospitalization. V6 stated some things that can happen are shortness of breath, hypoxemia and eventually respiratory failure and sometimes death. V6 stated that missing dialysis may not necessarily cause pneumonia, but often fluid overload is misdiagnosed as pneumonia. V6 stated fluid overload or blood not being properly cleansed can cause complications with pneumonia and congestive heart failure in dialysis patients.4/13/26 at 10:04am, R3 stated his brother was having some issues getting to appointments. R3 stated his brother is R1, he lives across the hall, but it has gotten better. R3 stated the van was having some problems and the staff just acted like it was no big deal.On 4/13/26 at 1:11pm, V1 (Administrator) stated they do not document when residents leave the facility with staff. They have a sign-out book when residents leave with family or visitors.On 4/13/26 at 1:24pm, R1 stated he has no issues with dialysis, but there was an issue with the facility getting him there on time for a while. R1 stated it has gotten better. R1 stated he wasn't sure why he wasn't getting there on time; he felt like the facility just didn't care. R1 stated he gets rides from different places, but it is usually the facility that takes him, and the community transit van brings him back. R1 stated he was hospitalized recently because he couldn't breathe. R1 stated the hospital told him he had too much fluid in his lungs. R1 stated he also has congestive heart failure, and he doesn't know what exactly happened when he was hospitalized , he was really sick.On 4/13/26 at 1:27pm, V2 (Registered Nurse) stated there is an order created when residents have an appointment that has to be checked off. V2 stated there is no policy as to when this should happen, but that she checks it off as the resident is leaving and to her knowledge that is the expectation of all staff.On 4/13/26 at 2:27pm, V1 stated they do not sign R1 out when he goes to dialysis, he leaves with a facility staff member and comes back on the local transit service. V1 stated when R1 first started dialysis she had a memo out that he was to be at dialysis at 5:30, not realizing that was what time he was supposed to start.On 4/14/26 at 10:01am, V1 stated they do not have a communication book for dialysis for R1 but they have communication sheets that they send to dialysis.On 4/14/26 at 1:27pm, V1 stated on the morning of 3/16/26 the lift for the van got stuck and they were unable to get R1 to dialysis timely. V1 stated staff attempted to get it working but were unsuccessful. V1 stated they called another facility, and they were able to get their van and get R1 to dialysis. V1 stated the van went into the shop the next day and was fixed.On 4/15/26 at 11:04am, V7 (family member) stated they were having issues with the facility getting R1 to dialysis in March, but it has gotten better. V7 stated they kept blaming it on issues with the van lift. V7 stated there was one-week R1 did not get his full dialysis, they tried to talk to someone at the facility about it and they were told he doesn't need full dialysis. V7 stated V8 (family member) had told staff on more than one occasion that R1 has to go to dialysis, and he has to get his whole treatment; this is a life-or-death situation. V7 stated R1 and R3 both heard staff laughing about it. V7 stated R1 and R3 are brothers, and they are across the hall from one another and R3 told them staff said to R1, Your brother is being dramatic, he is acting like you're going to die if you don't get dialysis. V7 stated she went to visit R1 a day or two before his hospitalization. V7 stated you cannot usually tell if R1 is retaining fluid by looking at him, but when she visited him, he was looking really puffy.On 4/15/26 at 11:22am, R1 stated staff did chuckle one morning he was late for dialysis and said, your brother is so dramatic, he is acting like we are going to kill you or something. R1 stated one time he was stuck in the van, he couldn't recall the date, but two girls lifted him out while still in his chair. R1 stated he was fine but one of the staff members fell and he was worried he was going to go down with them, but he was fine. R1 stated they got another transport van to take him, and he was really late for treatment.On 4/15/26 at 11:26am, R3 stated he heard staff laughing at V8 in the hallway one day. R3 stated staff was wheeling R1 out and said, well we have to get you to dialysis, your brother is being dramatic and saying you're going to die if you don't! R3 stated he could not recall who the staff was, he could not see them. R3 stated R1 was hospitalized a week or two after.On 4/15/26 at 11:30am, V4 (Registered Nurse) stated they do not have a dialysis communication book for R1, they use a communication form that is sent back and forth with him. V4 stated they are not good at sending them back, she will have to call them for report when she is his nurse. V4 stated she recalled last month there were some days R1 was late for treatment because they were having issues with the van, but it is fixed now. V4 stated she sent R1 to the hospital on 3/29/26 because he was having breathing issues. V4 stated he had previously been treated for pneumonia, but that is really all she knew about it.On 4/15/26 at 11:39am, V1 provided R1's nephrologists number, number was called and office stated R1 was not a patient there.On 4/15/26 at 12:08pm, V8 (family member) stated he had several conversations with the facility about how important R1's dialysis treatments were. V8 stated staff brushed him off about it every time. V8 stated they told him they were having transportation issues. V8 stated R1 has been on dialysis for 13 years and has managed it really well with minimal hospitalizations. V8 stated R1 was being treated for pneumonia at the facility before he was hospitalized . V8 stated when R1 was sent to the emergency room, hospital staff were not aware R1 had not been getting his full dialysis treatment. V8 stated the hospital told him they weren't sure if he actually had pneumonia or if it was caused by all the fluid in his lungs. V8 stated R1 has congestive heart failure, and the hospital staff were initially saying they thought the fluid on his lungs was from it, not pneumonia, but when they found out he wasn't getting his full treatment, they stated it was all just a bad combination and a recipe for disaster. V8 stated he doesn't know if he has ever seen R1 so sick, he stated he thought he might lose him at that point. V8 provided name of R1's nephrologist.On 4/15/26 at 12:27pm, V3 (Registered Nurse) stated she provided care for R1 on midnights. V3 stated R1 did get late to some treatments due to the van malfunctioning. V3 stated she thinks there was also a mix up about arrival times also. V3 stated she was not sure who took R1 to dialysis on specific dates, she stated she knew V13 (Certified Nursing Assistant/CAN) and V14 (CNA) did, but she couldn't remember specific dates.On 4/15/26 at 1:07pm, V13 (CNA) stated she had transported R1 to dialysis on occasion. V13 stated there was a little confusion on arrival time and where they were going. V13 stated they thought R1 had to be at dialysis by 5:30am, but he actually needed to be there by 5:15am and start his treatment at 5:30am. V13 stated they were having issues with the van lift and that caused some difficulty, but it is fixed now. V13 stated they send a communication form with R1 to dialysis, but they do not always get it back. On 4/15/26 at 1:20pm, V11 (Nephrologist) stated the facility did not notify him of R1 not receiving his full dialysis treatment, but he was made aware by the dialysis clinic documentation and staff. V11 stated most of the time R1 was only missing 10-15 minutes of treatment, but it is crucial that he receive the full treatment. V11 stated R1 has been receiving dialysis for years and every time he does not receive full treatment; the toxins are not removed from his blood. V11 stated a dialysis patients' chances of complications and hospitalization increase significantly when treatments are repeatedly shortened, death in the most serious cases. V11 stated hyperkalemia and hypoxemia are common. V11 stated hyperkalemia can cause cardiac complications and R1 has cardiac issues also. V11 stated he cannot specifically speak on R1's most recent hospitalization, but missed dialysis treatments can lead to fluid overload, shortness of breath and respiratory failure. V11 stated missed or shortened dialysis treatments complicate conditions such as congestive heart failure and pneumonia. V11 stated that incomplete dialysis treatments can certainly lead to shortness of breath and hypoxic respiratory failure.On 4/15/26 at 2:45pm, V1 stated that dialysis does not always send the communication form back and she does not know what she is supposed to do when dialysis does not do what they are supposed to.During the course of this investigation, the facility was unable to provide reproducible evidence of the staff members responsible taking R1 to his dialysis appointments.R1's Continuity of Care Document under vital signs, with a date range of 2/20/26-4/14/26, does not document a pretreatment weight for R1 on 3/16/26.On 4/14 /26 at 10:01am V1 provided a document signed by her that she said she posted for staff regarding R1's dialysis appointments. Document included: (R1) Dialysis is Mondays, Wednesday, Fridays. He must arrive at (dialysis center) by 5:30 AM. Dated 2/20/26. Weight & vitals must be obtained prior to leaving, report to nurse. Nurse's --> Dialysis communication form must be completed and sent with driver. Make sure transport gives you this form back after they pick the resident up to review-document-then to be scanned into chart.Facility document titled, DIALYSIS CONTINUITY OF CARE COMMUNICATION FORM dated 2/23/26 documents under Dialysis Center Report that R1's treatment time was 5:43am.Facility document titled, DIALYSIS CONTINUITY OF CARE COMMUNICATION FORM dated 2/25/26 documents under Dialysis Center Report that R1's treatment time was 5:45am.Facility document titled, DIALYSIS CONTINUITY OF CARE COMMUNICATION FORM dated 3/18/26 documents under Dialysis Center Report that R1's treatment time was 5:45am.R1's progress notes document on 03/16/2026 at 7:24am, Resident arrived to Dialysis at approx (approximately) 0645 due to transportation issues. Dialysis stated he would receive partial treatment today. (transportation company) to pick up resident around 0930 to transport back to facility.R1's progress notes document on 03/19/2026 at 5:34PM . Mild edema noted to BLE (bilateral lower extremities) with very dry skin with large flakes .R1's emergency room notes on 3/29/26 at 7:35pm documents, Concern for fluid overload and possible pneumonia on my interpretation of chest x-ray so broad-spectrum antibiotic given . Has underlying renal failure on his labs. BNP (B-type natriuretic peptide) significantly elevated. In this same document under Problems Addressed: ESRD (end stage renal failure) on dialysis: acute illness or injury. Hypoxic respiratory failure: acute illness or injury.R1's emergency room notes on 3/29/26 at 10:05pm documents, (R1) Has been treated outpatient for pneumonia, his workup so far shows that he has a worsening appearance of his chest possibly due to CHF (congestive heart failure) versus pneumonia.R1's progress notes document on 04/02/2026 at 04:52 PM, Resident returned to facility via (name of transport company). New order to discontinue (antibiotic). Dx (diagnosis) of acute hypoxic respiratory failure.Undated document titled, Care of ESRD (end stage renal disease) patients documents under policy; Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.Facility document titled, NURSING HOME DlALYSIS TRANSFER AGREEMENT dated May 15, 2012, documents under the section titled Transportation of Designated Resident. Facility will be responsible for arranging suitable transportation of the designated resident to and from the center.

Based on interview and record review, the facility failed to promptly notify a residents Physician and resident representative of a medication error for 1 of 3 residents (R1) reviewed for notification of changes in the sample of 9.Findings include:R1's Face Sheet documented an admission Date of 6/6/25 and listed diagnoses including Diabetes Type 2 and Hypertension. The Face Sheet also identified V11 as R1's Power of Attorney.R1's Minimum Data Set, dated [DATE] documented that R1 has no deficits in cognition.R1's Care Plan dated 8/25/25 documented a problem area, Resident is at risk for complications due to Diabetes diagnosis, with corresponding intervention, administer meds (medications) as ordered and/or sliding scale.R1's September 2025 Physicians Order Sheet documented orders for Tresiba Flextouch U-100 (insulin degludec) (long acting) insulin pen 100/u (units) per ml (milliliter) administer 30u subcutaneously at bedtime, 7pm to 10pm, and Insulin Aspart (rapid acting) u100 pen give 10 u with meals.R1's Medication Administration Record (MAR) for September 2025 documented that on 9/30/25, R1 received Tresiba Flextouch 30u at bedtime from 7pm to 10pm, with V5, Licensed Practical Nurse, signing off on the administration. The MAR documented that the insulin aspart 3pm to 6pm dose was not administered as R1 refused it. There was no further documentation of the insulin aspart on 9/30/25.R1's Nursing Progress Notes documented the following:10/1/25, 1:04am. Blood sugar alarm at 70. Cranberry sauce given per patient request. Will recheck. A/O (Alert and oriented) x 4 (to person, place, time, and purpose).10/1/25, 1:22am: BS (Blood Sugar) 108. Resident states she is tired. Laying in bed call light in reach. PWD (Pink, Warm, Dry Skin), A/O x4. Resident stated, maybe she gave me too much insulin. Insulin charted as ordered on previous shift. Will continue to monitor.10/1/25, 2:09am: BS 179. Pt (patient) resting comfortably in bed. Arouses easily. PWD. Call (light)in reach.10/1/25, 3:03am: BS 144 currently. Resident resting comfortably in bed with call light in reach. PWD. Arouses easily. will continue to monitor.10/1/25, 4:42am: BS 156 resting comfortably, rouses easily. PWD. Call light in reach.10/1/25, 5:55am: BS 114. Resident resting in bed, arouses easily. PWD. Call light in reach.10/1/25, 9:08am: (V4, Physician) office called a short while ago and updated of resident condition and the thought of resident probably receiving wrong insulin last night at bedtime. Spoke to nurse at office that will pass to (V4). Nurse updated of resident BS and checked every hour and resident remained stable.10/1/25, 1:29pm: Medical Director also made aware and updated earlier as well this morning. Also, (V11, Power of Attorney) was here this morning and updated as well. Resident remains stable at this time and no issues noted. No new orders received from (V4) either at this time. Will continue to monitor.There were no Nursing Progress Notes in R1's chart for 9/30/25.An Incident Report dated 10/1/25 documented, Detailed incident summary: Resident notified staff of not feeling well around 1am. Once checking blood sugar, blood sugar level was 70. Resident was given cranberry juice and checked several times throughout the night. Resident stated to the nurse that came on at midnight that maybe she got the wrong dose of insulin. Staff nurse who is (V5) is unable to recall which insulin she gave. Resident was closely monitored and did not appear to be in any distress. Resident is alert and oriented during this entire situation. (V4) was notified, Medical Director was notified, (V2, Director of Nurses) and (V1, Administrator) notified and (V11) notified and texted to notify. Nurse was wrote up and educated. A written statement from V5 in this investigation documented, Approximately 10pm on 9/30/25 I was at the medication cart getting meds (medications) together for (R1) she was to also get insulin, Tresiba 30u which is a long-acting insulin. During the time of getting medications together, I was interrupted by CNA (Certified Nursing Assistant) multiple times. I got (R1) medications ready along with the insulin. Went into room to get CBG (Capillary Blood Glucose), according to her (trade name continuous monitoring glucose system) her blood sugar was 296, resulting in resident receiving scheduled Tresiba 30u, I then gave her medications. I proceeded to gather the other residents' medications and administer, when I got to (R3), he also received Tresiba at bedtime at this time it triggered a memory that I believed I gave (R1) the wrong insulin. At approximately 11:30pm I asked to see her blood sugar again and it had dropped to 135, I became concerned. At 12am, (V10, Registered Nurse) came in to relieve me and I informed her of what I believed I had done. (V10) then went into (R1) room and checked blood sugar and it had fallen to 70. I had checked it at approximately 11:40pm and it was 75. Her sugar was dropping significantly, as a nursing measure because resident refused to eat, I gave her a glucagon pen to bring sugar up. At 1am her sugar had risen to 125, when I left facility at 1:30am her sugar was 141. I spoke with (V10) to contact me at home if resident became worse and I would return to the facility. I spoke with the resident, she informed me that I told her I gave the wrong insulin, I had not told her that. I then explained that I thought I might have when I was giving (R3) his Tresiba but was not sure. I realized I did when her sugar continues to drop significantly. (R1) was very upset with me at this point. I went home and (V10) called and explained the resident was very upset with me. She also let me know (R1) sugar was good. I texted (V2 and V3, Assistant Director of Nurses), regarding the event and explained all that had transpired. I then went into the facility in the morning to explain. This note is a result of that meeting with (V2 and V3).On 10/15/25 at 10am, R1 was alert and oriented to person and place but not time. R1 stated on 9/30/25, around 8pm, V5 gave her 30 units of fast acting insulin instead of 30 units of the long-acting insulin that was prescribed. R1 stated she is not sure if V5 told her this or not, but she knows it's true because her blood glucose bottomed out shortly after receiving the insulin. R1 stated her blood sugar stabilized during the morning hours of 10/1/25. R1 stated she has not seen V5 since then and she thinks V5 was fired.On 10/15/25 at 11:55am, V11(Power of Attorney for R1) stated he did not find out about the medication error until R1 called him after 11:30am on the morning of 10/1/25. V11 stated he came to the facility before noon on 10/1/25 and confronted V2 about the facility not contacting him when the error was discovered, and V2 did not have a reason as to why he had not been contacted immediately upon discovering the error.On 10/16/25 at 10:20am, V2 (Director of Nurses) stated V11 presented to the facility the morning of 10/1/25 as R1 had informed him of what happened, so staff explained the situation to him in full. V2 stated staff should have notified V4 and V11 at the time the error was discovered. V2 stated on 10/1/25 in the morning hours, R1's blood sugar had stabilized, and no further action was needed and there were no adverse consequences.On 10/16/25 at 11:45am, V4 (Physician) stated his understanding of the medication error is that R1 received 30 units of fast acting insulin instead of 30 units of long-acting insulin as ordered. V4 stated staff gave R1 food and got her glucose level stabilized during the night, and R1's status was then baseline. V4 stated he was notified about the error the next morning during office hours. V4 stated he is not sure why the facility did not contact him at the time the error was discovered. V4 stated normally the facility does a good job keeping him updated about his residents.An undated Preventing and Detecting Adverse Consequences and Medication Errors Policy dated stated, G. The attending Physician is notified promptly of any significant error or adverse consequence. Facility staff monitor the resident for possible medication related adverse consequences, including mental status and level of consciousness, when the following conditions occur: 6. Medication error example given, wrong or expired medication.A Change in Condition Policy dated February 2012 documented, It is the policy of (the facility) that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner. Definition: Change in condition is defined as an improvement or decline in the resident's physical, mental, or psychosocial status that affects two or more activities of daily living. Procedure: 4. The residents primary Physician or designated alternative will be notified of any change in resident's physical or medical condition, this includes, A. Accident involving the resident; B. Deterioration on health mental, or psychosocial status; C. Need to alter treatment (in example, need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment; 5. The resident's designated medical contact or guardian will also be notified.

Based on interview and record review, the facility failed to administer insulin according to physicians' orders for 1 of 9 residents (R1) reviewed for medication errors in the sample of nine.The findings include:R1's Face Sheet documented an admission Date of 6/6/25 and listed Diagnoses including Diabetes Type 2 and Hypertension. The Face Sheet also identified V11 as R1's Power of Attorney.R1's Minimum Data Set, dated [DATE] documented that R1 has no deficits in cognition.R1's Care Plan dated 8/25/25 documented a problem area, Resident is at risk for complications due to Diabetes Diagnosis, with corresponding intervention, Administer meds(medications) as ordered and/or sliding scale.R1's September 2025 Physicians Order Sheet documented orders for Tresiba Flextouch U-100 (insulin degludec) (long acting) insulin pen 100/u (units) per ml (milliliter) administer 30u subcutaneously at bedtime, 7pm to 10pm, and Insulin Aspart (rapid acting) u100 pen give 10 u with meals.R1's Medication Administration Record (MAR) for September 2025 documented that on 9/30/25, R1 received Tresiba Flextouch 30u at bedtime from 7pm to 10pm, with V5, Licensed Practical Nurse, signing off on the administration. The MAR documented that the insulin aspart 3pm to 6pm dose was not administered as R1 refused it. There was no further documentation of the insulin aspart on 9/30/25.R1's Nursing Progress Notes documented the following:10/1/25, 1:04am. Blood sugar alarm at 70. Cranberry sauce given per patient request. Will recheck. A/O (Alert and oriented) x 4 (to person, place, time, and purpose).10/1/25, 1:22am: BS (Blood Sugar) 108. Resident states she is tired. Laying in bed call light in reach. PWD (Pink, Warm, Dry Skin), A/O x4. Resident stated, maybe she gave me too much insulin. Insulin charted as ordered on previous shift. Will continue to monitor.10/1/25, 2:09am: BS 179. Pt (patient) resting comfortably in bed. Arouses easily. PWD. Call (light)in reach.10/1/25, 3:03am: BS 144 currently. Resident resting comfortably in bed with call light in reach. PWD. Arouses easily. will continue to monitor.10/1/25, 4:42am: BS 156 resting comfortably, rouses easily. PWD. Call light in reach.10/1/25, 5:55am: BS 114. Resident resting in bed, arouses easily. PWD. Call light in reach.10/1/25, 9:08am: (V4, Physician) office called a short while ago and updated of resident condition and the thought of resident probably receiving wrong insulin last night at bedtime. Spoke to nurse at office that will pass to (V4). Nurse updated of resident BS and checked every hour and resident remained stable.10/1/25, 1:29pm: Medical Director also made aware and updated earlier as well this morning. Also, (V11, Power of Attorney) was here this morning and updated as well. Resident remains stable at this time and no issues noted. No new orders received from (V4) either at this time. Will continue to monitor.There were no Nursing Progress Notes in R1's chart for 9/30/25.An Incident Report dated 10/1/25 documented, Detailed incident summary: Resident notified staff of not feeling well around 1am. Once checking blood sugar, blood sugar level was 70. Resident was given cranberry juice and checked several times throughout the night. Resident stated to the nurse that came on at midnight that maybe she got the wrong dose of insulin. Staff nurse who is (V5) is unable to recall which insulin she gave. Resident was closely monitored and did not appear to be in any distress. Resident is alert and oriented during this entire situation. (V4) was notified, Medical Director was notified, (V2, Director of Nurses) and (V1, Administrator) notified and (V11) notified and texted to notify. Nurse was wrote up and educated. A written statement from V5 in this investigation documented, Approximately 10pm on 9/30/25 I was at the medication cart getting meds together for (R1) she was to also get insulin, Tresiba 30u which is a long-acting insulin. During the time of getting medications together, I was interrupted by CNA (Certified Nursing Assistant) multiple times. I got (R1) medications ready along with the insulin. Went into room to get CBG (Capillary Blood Glucose) according to her (trade name continuous monitoring glucose system) her blood sugar was 296, resulting in resident receiving scheduled Tresiba 30u I then gave her medications. I proceeded to gather the other residents' medications and administer, when I got to (R3), he also received Tresiba at bedtime at this time it triggered a memory that I believed I gave (R1) the wrong insulin. At approximately 11:30pm I asked to see her blood sugar again and it had dropped to 135, I became concerned. At 12am, (V10, Registered Nurse)) came in to relieve me and I informed her of what I believed I had done. (V10) then went into (R1) room and checked blood sugar and it had fallen to 70. I had checked it at approximately 11:40pm and it was 75. Her sugar was dropping significantly, as a nursing measure because resident refused to eat, I gave her a glucagon pen to bring sugar up. At 1am her sugar had risen to 125, when I left facility at 1:30am her sugar was 141. I spoke with (V10) to contact me at home if resident became worse and I would return to the facility. I spoke with the resident, she informed me that I told her I gave the wrong insulin, I had not told her that. I then explained that I thought I might have when I was giving (R3) his Tresiba but was not sure. I realized I did when her sugar continues to drop significantly. (R1) was very upset with me at this point. I went home and (V10) called and explained the resident was very upset with me. She also let me know (R1) sugar was good. I texted (V2, Director of Nurses, and V3, Assistant Director of Nurses), regarding the event and explained all that had transpired. I then went into the facility in the morning to explain. This note is a result of that meeting with (V2 and V3).On 10/15/25 at 10am, R1 was alert and oriented to person and place but not time. R1 stated on 9/30/25, around 8pm, V5 gave her 30 units of fast acting insulin instead of 30 units of the long-acting insulin that was prescribed. R1 stated she is not sure if V5 told her this or not, but she knows it's true because her blood glucose bottomed out shortly after receiving the insulin. R1 stated her blood sugar stabilized during the morning hours of 10/1/25. R1 stated she has not seen V5 since then and she thinks V5 was fired.On 10/16/25 at 10:20am, V2 stated R1's glucose has been historically difficult to control and at times it dips below the normal range. V2 stated given the glucose's rapid drop, it is likely R1 got the wrong insulin. V2 stated staff closely monitored R1 during the early morning hours, and if R1's glucose had gotten critically low, staff would have gotten an order to send R1 to the Emergency Room. V2 stated the next morning at 9am, staff notified V4 (Physician) of the error.On 10/16/25 at 11:45am, V4 stated his understanding of the medication error is that R1 received 30 units of fast acting insulin instead of 30 units of long-acting insulin as ordered. V4 stated staff gave R1 food and got her glucose level stabilized during the night, and R1's status was then baseline.A facility policy titled Preventing and Detecting Adverse Consequences and Medication Errors (undated) stated, G. The attending Physician is notified promptly of any significant error or adverse consequence. Facility staff monitor the resident for possible medication related adverse consequences, including mental status and level of consciousness, when the following conditions occur: 6. Medication error example given, wrong or expired medication.

Based on observation, interview, and record review the facility failed to ensure treatments were administered as ordered by the physician for 1 of 3 (R3) residents reviewed for wounds in the sample of 28. Findings include: R3's Resident Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses that include anoxic brain damage, spastic hemiplegia, psychosis, major depressive disorder, peripheral vascular disease, anemia, osteoporosis, hypertension, acute kidney failure, acute myocardial infarction, dementia, and cellulitis. R3's MDS (Minimum Data Set) dated 07/17/2025 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R3 is cognitively intact. R3's current Care Plan documents a Focus area of Problem: Resident is at risk for pressure ulcer due to activity limited. This Focus area includes interventions of Weekly skin assessment with notes Start Date 04/17/2023 .Teach or do frequent small shifts of body weight Start Date: 04/17/2023 Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair. Start Date 04/17/2023 Pad bony prominences with foam wedges, rolled blankets, or towels. Start Date 04/17/2023 PT/OT (physical therapy/occupational therapy) when needed for eval (evaluation) and treat with w/c (wheelchair) Start Date 04/17/2023 .On 8/26/25 at 2:56 PM, V9 (Registered Nurse/RN) and V10 (RN) were observed administering treatment to the wound on R3's left ankle. There were no other wounds observed on R3's left leg/foot. V9 cleaned the wound and applied betadine using current standards of practice. R3 stated they did the treatments every day and denied any concerns with wound care. R3's Progress Notes document the following:7/11/25: V8 (Wound Specialist) was notified of R3's left hip area red and warm and ordered an antifungal cream and Diflucan. 7/12/25: R3's leg was splotchy, red, and warm to touch and R3 was transferred to the local hospital for evaluation and treatment.7/12/25: R3 was admitted to the hospital for suspected DVT (deep vein thrombosis). 7/14/25: 3:54 PM, Re-Admit from (name of local hospital) arrived to facility via facility van at approx (approximately) 3:15pm, res (resident) was admitted to hospital 7/12/25 due to suspected DVT, per report from (name of staff) at (name of local hospital) res is alert but confused. Max (maximum) 2 assist Hoyer to transfer required wheel chair for mobility, set up assistance for meals, takes meds (medications) whole, continent Bowel has ostomy incont (incontinent) bladder at times, skin check revealed redness and rash to LLE (left lower extremity) from above knee to end of toes and warm to touch bright red, has open area under Left knee along with small yellow filled blister top of foot small toes, res c/o (complaints of) pain to LLE res is wearing boot due to (name of local hospital) stating res has darkened areas to heel, reg (regular) diet thin liquids, had BM (bowel movement) on 13th (7/13/25), stoma red healthy, res took glasses with to hospital returned with glasses, DON (Director of Nurses), ADON (Assistant Director of Nurses) DR (Doctor) (notified) .7/14/25: 4:06 PM, DON notified Pharm (pharmacy) of med list script for vanco (vancomycin) faxed as well by this nurse .spoke with ADON regarding wounds and N.O. (new order) for Silver Sulfadiazine collagen and calcium alginate for both wounds daily,7/16/25: 1:51 AM, Reason for Antibiotic Use: Cellulitis, Soft Tissue / Wound Infection Symptoms: N/A (not applicable), Skin/Wound Red/warm skin surrounding small open area to L (left) medial ankle .R3's Wound Specialist notes document the following:7/18/2025: .Arterial Wound of the Left, Medial Foot Full Thickness .Wound Size .4.2 x 2.3 x 0.2 cm (centimeters) no signs of infection .Dressing Treatment Plan .Alginate calcium apply once daily and as needed For 30 days; Collagen powder apply once daily and as needed .Silver Sulfadiazine apply once daily and as needed .For 30 days. Secondary Dressing(s): Gauze island w (with) br (border) apply once daily and as needed .Wound of the Left, Posterior Knee Full Thickness .Wound Size 5.3 x 3.1 x 0.2 cm .Dressing Treatment Plan .Alginate calcium apply once daily and as needed .Collagen powder apply once daily and as needed Silver sulfadiazine apply once daily and as needed Antifungal OTC (over the counter) apply once daily and as needed for 30 days: clotrimazole. Secondary Dressing (s) Gauze island w/bdr apply once daily and as needed for 30 days.7/25/2025: .Arterial Wound of the Left, Medial Foot Full Thickness .Wound Size .0.5 x 1.5 x 0.2 cm (centimeters) no signs of infection .Dressing Treatment Plan .Alginate calcium apply once daily and as needed . Collagen powder apply once daily and as needed .Silver Sulfadiazine apply once daily and as needed .Betadine apply once daily and as needed Secondary Dressing(s): Gauze island w (with) br (border) apply once daily and as needed .Wound of the Left, Posterior Knee Full Thickness .Resolved Arterial Wound of the Left Heel Undetermined Thickness Wound Size 2 x 2 x Not Measurable cm Dressing Treatment Plan: Alginate calcium apply once daily and as needed Collagen powder apply once daily and as needed Betadine apply once daily and as needed For 30 days .Gauze island w/bdr apply once daily and as needed Arterial Wound of the Right, Medial Ankle Full Thickness .Wound Size: 2.5 x 2 x Not Measurable cm Dressing Treatment Plan Alginate calcium apply once daily and as needed Collagen powder apply once daily and as needed .Betadine apply once daily and as needed Gauze island w/bdr apply once daily and as needed 8/1/25: .Arterial Wound of the Left, Medial Foot Full Thickness . Wound size 0.5 x 1.4 x Not Measurable cm Dressing Treatment Plan Betadine apply twice daily and as needed .Arterial Wound of the Left Heel Full Thickness .Wound Size 1.8 x 2 x Not Measurable cm Dressing Treatment Plan Betadine apply twice daily and as needed Arterial Wound of the Right, Medial Ankle Full Thickness .Wound Size .2.4 x 2 x Not Measurable cm .Dressing Treatment Plan Betadine apply twice daily and as needed 8/8/25 .Arterial Wound of the Left, Medial foot (Resolved on 8/8/2025) Arterial Wound of the Left Heel Full Thickness Wound Size 1 x 2 x Not Measurable cm .Dressing Treatment Plan .Betadine apply twice daily and as needed .Arterial Wound of the Right, Medial Ankle Full Thickness Wound Size 2.4 x 2 x 0.2 cm Dressing Treatment Plan Betadine apply twice daily and as needed 8/15/2025 .Arterial Wound of the Left Heel (Resolved on 8/15/2025) Arterial Wound of the Right, Medial Ankle Full Thickness Wound Size 1.5 x 1.8 x 0.2 cm Dressing Treatment Plan Betadine apply twice daily and as needed 8/22/2025 Arterial Wound of the Right, Medial Ankle Full Thickness .Wound Size 1.3 x 1.8 x 0.2 cm Dressing Treatment Plan Betadine apply twice daily and as needed R3's Physician Orders include the following Physician Orders: 1. Betadine solution; 10% ; amt (amount): thin layer; topical Special Instructions: Cleanse area to left medial foot with NS (normal saline) or wound cleanser and apply a thin layer of betadine daily .Start Date: 07/25/2025 . 2. Betadine solution; 10% ; amt (amount): thin layer; topical Special Instructions: Cleanse area to left heel with NS (normal saline) or wound cleanser and apply a thin layer of betadine daily .Start Date: 07/29/2025 3. Betadine solution; 10% ; amt (amount): thin layer; topical Special Instructions: Cleanse area to left medial ankle with NS (normal saline) or wound cleanser and apply a thin layer of betadine, calcium alginate and dry dressing daily and as needed .Start Date: 07/29/2025 .R3's Treatment Administration Record (TAR) dated 07/01/25 to 07/31/25 documents no treatments were administered to wounds on R3's left leg/foot from 7/14/25 to 7/25/25. On 08/27/2025 at 10:58 AM, V3 (ADON/Assistant Director of Nurses) stated she wasn't sure why the Wound Specialist note documents the wound on the left ankle as being on the right ankle. V3 stated R3 never had a wound on the right ankle, and she will contact the Wound Specialist to change that. This surveyor reviewed the progress notes, Wound Specialist notes, Physician Orders, and Treatment Administration Records with V3 and asked why there were no orders and/or treatments administered from 7/14 and 7/16 (when the wounds were identified) until 7/25/25. V3 stated she wasn't sure and would review R3's medical record and let this surveyor know. On 8/27/25 at 2:30 PM, V3 (ADON) stated the nurse took the telephone order for the areas on the heel, knee, and foot on 7/14/25 but did not implement the orders until 7/25/25. V3 stated the area on the left ankle was identified on 7/16/25 and there was not a treatment implemented until 7/29/25. V3 stated she didn't know why the nurse didn't put the orders in the system so they could be implemented. The facility policy Obtaining and Following Physician Orders dated July 2014 documents, Policy: It is the policy of (name of facility) that physician orders will be obtained by licensed personnel and followed. If the licensed professional does not in his/her best judgment think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified.

Based on interview and record review the facility failed to position residents properly to prevent injury for 1 of 3 residents (R1) reviewed for accidents in a sample of 11. This injury resulted in R1 sustaining a closed displaced fracture of right femoral neck. This past non-compliance occurred between 01/19/25 and 01/23/25. Findings include: R1's face sheet documents an admitted [DATE] with diagnoses including: fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, Alzheimer's disease, osteoarthritis, iron deficiency, shortness of breath, nutritional deficiency, anxiety disorder, insomnia, muscle weakness, rheumatoid arthritis, pain, unsteadiness on feet, age related osteoporosis without current pathological fracture, mid cognitive impairment of uncertain or unknown etiology, vitamin D deficiency, displaced intertrochanteric fracture of left femur, presence of right artificial hip joint, nausea with vomiting, major depressive disorder. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 02, indicating R1 has severe cognitive impairment. R1 is documented as being dependent for being able to wheel 50 feet with two turns in a manual wheelchair and dependent for being able to wheel 150 feet in a manual wheelchair. R1's care plan documents a problem of pain with a start date of 07/30/24 with an approach of: handle gently and try to eliminate any environmental stimuli with a start date of 07/30/24. R1's care plan documents a problem category of: ADLs (Activities of Daily Living) functional status/rehabilitation potential with a problem start date of 06/06/24 with an approach listed as: overall I (R1) require extensive assistance with oral care, extensive with bathing, extensive with grooming, limited with eating, extensive with dressing, extensive with mobility with a start date of 06/11/24 and an approach listed as: safety: I (R1) will need to be monitored to prevent falling in my new environment. I will need assistance with bed/chair mobility, assistance with transfers, assistance with locomotion to prevent falling or injury with a start date of 06/11/24. R1's Serious Injury Incident Report to the Illinois Department of Public Health (IDPH) dated 01/27/25 and is documented as a final report. This report documents an incident date of 1/20/25 and documents under the section titled, detailed incident summary that facility ordered an x-ray on 01-20-25 due to resident grimacing in pain and having issues standing and rolling in bed. X-ray showed an acute subcapital right femoral neck fracture. DON (Director of Nursing) notified, family POA (Power of Attorney) of x-ray results and they wanted her sent to the hospital. Resident (R1) has an extensive history of Alzheimer's disease, osteoarthritis, nutritional deficiency, muscle weakness, rheumatoid arthritis, age related osteoporosis, mild cognitive impairment, vitamin D deficiency, past MVA (motor vehicle accident) where her right side was crushed and had screws in femoral plate. Resident was sent to the hospital and admitted . Resident's last fall was 01/07/25 with no complaints or pain noted. Following facility investigation while facility attempted to weigh resident her position in the wheelchair resulting in residents leg making contact with the bar on the scale resulting in impact to the right leg/foot area. Upon immediate assessment of resident she denied any pain or discomfort, following assessment noted grimacing from resident resulting in facility initiated x-ray. Due to resident's age, medical history, ortho notes of previous ORIF (Open Reduction Internal Fixation) of hip along with the accident all being contributing factors resulting in fracture. Facility has began reeducation and training on nurse on body alignment and positioning and have scheduled additional training. Facility will continue to monitor for any additional changes and needs and address any concerns. The facility investigation documents were requested from the facility and provided for review. These documents included Incident Investigation Reports documenting interviews with V5 (Licensed Practical Nurse/LPN) and V6 (Certified Nursing Assistant/CNA) and document the following: V5's statement dated 01/21/25 documents on Sunday 01/20/25 (per calendar Sunday's date was 1/19/25) I got reweight [sic] on the scale when pushing her on the scale she had her legs crossed and right foot hit the bar. Resident (R1) said 'ouch' wheelchair backed up and repositioned. Upon assessment ankle and foot evaluated and no abnormalities noted. V6's statement dated 01/21/25 documents over the weekend I noticed the resident (R1) was a lot weaker than normal. She was a 2 assist (hard). Resident had complained of hip on Sunday for sure and foot when you put on her shoe (right foot but kept left foot straight). I had layed [sic] resident down Sunday evening, but had to get her back up to get weighed. The nurse V5 (LPN) helped me get her back in bed and I had mentioned it to her again of her hip pain and she noticed that her right leg went inward. R1's Progress Notes document the following: 01/19/25 at 4:59 PM (recorded as late entry on 01/25/2025 at 4:59 PM) This LPN (V5) needed to reweight [sic] res (resident) (R1) as a result from a previous weight not being consistent with baseline. Staff was assisting res into bed as nurse came in and explained the need to reweight [sic]. Staff and nurse assisted res back into wheelchair and this nurse pushed res to weight scale. Once weight scale was turned on res was gently pushed up the incline when nurse heard res say ouch nurse observed res right foot resting against the bar on weight scale. This nurse observed res right foot resting against the bar on weight scale. This nurse immediately retracted the WC (wheelchair) from weight scale. Skin was observed to be free of marks or abnormalities. No outward rotation or shortening noted to right lower extremity. No pain noted as evidence by no facial grimace or verbal complaints of pain upon assessment once res in bed. 01/20/2025 at 6:32 AM documents (x-ray company) called and confirmed the order and will send to tech at this time. 01/20/2025 at 3:14 PM documents received notification via (x-ray company) that results show right hip is displaced. POA notified and stated would like resident sent to ER (emergency room ) for evaluation. (V11-family) also stated that she understood that resident is a 'stinker' at times and tries to transfer self and does not communicate needs at times. Doctor notified and stated resident's osteoporosis and advanced age plays a factor in risk for fracture. PRN (as needed) Tylenol order increased, and preparations started to send resident to ER. 01/20/2025 at 3:16 PM documents (R1) is displaying sign of pain such as grimacing and withdraw. This LPN adm (administered) tyn (Tylenol) and ineffective. NP (Nurse Practitioner) made aware and tramadol recommended for pain, tramadol administered. 01/20/2025 at 3:41 PM documents (R1) left facility via EMS (Emergency Medical Services) 01/21/2025 at 7:36 AM documents (R1) admitted to hospital on 01/20/25. 01/25/2025 at 2:16 PM documents in part (R1) arrived to facility via transportation from hospital. Report was being called in while resident was arriving. Report states that (R1) was admitted on the 20th for right hip fx (fracture) .Script for Norco was sent in packet. Also states that can re-start tramadol. New order for ASA (aspirin) 325mg (milligrams) BID (twice a day) x 14 days. Trouble taking fish oil and was not able to take and states that they have been crushing meds in ice cream and no issues noted since crushing. States that resident will need a f/u (follow up) appointment with (name of physician) in 10-14 days post-surgery and surgery. R1's X-Ray report with a date of service of 1/20/25 documents an 'Impression of Acute subcapital right femoral neck fracture. R1's local hospital History and Physical dated 1/20/25 document a Chief Complaint of hip pain. R1's Discharge Summary from the local hospital dated 1/25/25 documents a Principle Problem of Closed displaced fracture of right femoral neck. On 02/21/25 at 10:16 AM, V5 (Licensed Practical Nurse) stated, R1 was weighed earlier in the morning on 1/19/25 and her weight was off so she was supposed to get a re-weight for R1. They had already put R1 to bed so they had to get her back up. R1 was in her wheelchair and had her legs crossed. When she pushed her up on the wheelchair platform her right leg/foot hit the vertical bar of the scale on R1's left side. R1 said ouch and she backed up and repositioned the wheelchair on the scale. R1 did not have foot pedals on her wheelchair. V5 stated she weighed R1 around 5:30 PM. V5 said she assessed R1 when they put her to bed and did not notice anything and then she left at 6:00 PM. V5 stated, R1 is a small lady, she did not propel herself in her wheelchair and she did not move around a lot or flail around. V5 stated R1 is confused, R1 will babble and her sentences usually do not make sense. On 02/20/25 at 1:36 PM, V7 (Certified Nurse Aide) stated, she worked at 6:00 AM on the Monday morning of 01/20/25. V7 stated R1 is not cognitive all the time but when she was transferring R1 she was saying ouch but she couldn't figure out where the pain was coming from. Then she saw R1's hip and it did not look right so she told the nurse and the nurse came down to evaluate R1. V7 stated she did not get R1 out of bed, the previous shift gets her up due to she gets up around 4:00 AM and moves to the recliner before breakfast, she was getting R1 ready for breakfast. On 02/20/25 at 1:50 PM, V4 (Licensed Practical Nurse/LPN) stated, V12 (CNA) came in at 10:00 PM on 1/19/25 and R1 was sleeping, they noticed on 1/20/25 at 4:00 AM when R1 gets up that she was uncomfortable and she starting assessing R1 then. On 02/20/25 at 8:52 PM, V6 (CNA) stated she assisted R1 the weekend of 01/19/25. On 01/18/25 R1 seemed weak so another girl helped her transfer her. On 01/19/25, V6 noticed R1 had not been reweighed yet and reweighed her. Over the weekend R1 seemed like she was in pain but not excruciating pain. V6 said that she did not notice her foot on 01/18/25 or 01/19/25 until the evening of 01/19 when her foot seemed like it was turned inward. V6 said she told V5 about it. On 02/20/25 at 12:05 PM, V8 (Therapy Director) stated she heard about the incident with R1 and her leg hitting the scale but she was not present. The injury R1 has can occur due to a fall, any impact with limb, depending on the person. R1 has declined after surgery, mainly due to her cognition level. R1 was evaluated for therapy but was declined due to cognition limitations. On 02/21/25 at 5:35 PM, V1 (Administrator) stated the injury with R1 they felt was a positioning concern therefore all the staff has been in-serviced on correct positioning and transferring after the injury with R1 occurred. The facility policy dated 09/08/23 titled, Safe Patient Handling Program documents: purpose: to identify, assess and develop strategies to control the risk of injury to resident, nurses and other health care workers associated with lifting, transferring, repositioning, or movement of a resident. This program applies to all staff-assisted resident lifts, transfers and ambulation performed by employees under normal conditions, during the performance of non-routine tasks and in the event of emergencies. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 01/23/25. In attendance - V1, V4 (LPN), V13 (Director of Nursing/facility nurse practitioner), V15 (Registered Nurse), V16 (Medical Records), and V17 (Director of Maintenance). 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V1, V4, V13 (Director of Nursing/facility nurse practitioner) and V14 (Regional Clinical Director) provided in-service to nursing staff regarding weight management policy and body alignments in chair and positioning. Completed on 1/23/25. 4. Plan to monitor performance to ensure solutions are sustained: V13/designee will audit transfer and repositioning 3 a week for 2 weeks, 2 times a week for 2 weeks and weekly for 1 month identifying transfer and repositioning.

Based on observation, interview, and record review the facility failed to place resident's call lights within reach for 3 of 11 residents (R2, R9, and R10) reviewed for call lights in a sample of 11. Findings include: 1. R2 Face Sheet documents an admitted [DATE] and a discharge date of [DATE] with diagnoses including: aftercare following joint replacement surgery, presence of unspecified artificial hip joint, anxiety disorder, peripheral vascular disease, and pain. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, indicating R2 has moderate cognitive impairment. R2's Care Plan documents: problem with a start date of 02/13/25: category: falls; (R2) is at risk for falls due to: recent hip surgery with an approach listed as: provide individualized toileting interventions based on needs/patterns dated 02/13/25. R2's Care Plan also documents a problem with a start date of 02/13/25 of (R2) is at risk for alteration in tissue perfusion due to: Dx (diagnosis) Hypertension with an approach listed of: call light within reach while in room and remind resident to call for assistance as needed dated 02/13/25. R2's Progress Note dated 02/13/25 at 7:53 AM documents in part: 5 day review complete. interview completed with (R2). (R2) is alert with adequate communication skills and is able to make needs known. R2 has some short/long term memory deficit with BIMS score of 12. (R2) is up daily with assist per staff with ADL's (Activities of Daily Living) Orientation: oriented, generally normal to person, place and time, Memory: intact (recent and past), thinking: clear and organized, speech clarity: clear speech ability to understand others: understands, current bowel continence level: always continent, current urinary continence level: always continent. R2's Progress Not dated 02/15/25 at 12:41 PM documents in part: (V3-Dietary Manager/Certified Nursing Assistant/CNA), was picking up lunch trays and resident needed to use the BR (bathroom), so she took her to the BR. (V3) states that she was telling her she didn't have her call light available last night and (V3) reported it to (V4-Licensed Practical Nurse/LPN). (V4) and (V3) went to speak with (R2) and (V10- family) who was in the room. (R2) states that at 2:00 AM she didn't have her call light and thought that they left it in recliner when putting her to bed. Stated that she needed to use the BR, but didn't know what to do. (R2) states that she called (V10). (V10) confirmed that (R2) called at 3:16 AM. (V10) stated that he tried to call the facility but no one answered, so he went back to bed. (R2) states that she could hear staff next door with resident. (R2) was asked did she yell out for help, or do anything to try and get help. (R2) stated no, she didn't want any one to think she was a bother by yelling out. (V4) and (V3) advised (R2) and (V10) to next time yell out or hit the wall or something if unable to find call light. (V4) and (V3) also programmed (facility) telephone number in her phone, so she had another option to also call the facility as well. (V10) also gave her a long stick thing to also be able to hit the wall with in case of happening again. (R2) states that she just needed to use the BR and was worried about getting a bed some for not getting up. (R2) transfers x1 assist and able to ambulate using w/w (wheeled walker) with stand by assistance. (R2) stated since her recent right hip surgery that she was worried to be ambulating by herself. (V4) stated that she would speak to staff as well in regards to issue at 2:00 AM. (V1-Administrator) made aware as well. The facility document titled, Grievance/Concern/Complaint Form with a date received of 02/15/25 and a date filed in log of 02/18/25 documents: R2 initiated and person reported to was V3. Resident (R2) states that she didn't have her call light within reach. States she didn't know where it was. States she didn't yell out for help or do anything. States she called her son at 3:16 AM. The area titled, Summary/findings documents: call light had fallen and was on the floor by the bed when staff entered room. The area titled, recommendation/action taken: documents: Secure call light on bed rail when in bed. Clips ordered. (Facility name) telephone entered into her cell phone. Educated on banging wall for help and yelling for help. On 02/21/25 at 1:25 PM, R2 was interviewed via telephone call and stated she woke up sometime around or just after 2:00 AM and needed to use the bathroom but did not have her call light. R2 said she did hear someone in a room close to hers and she yelled out to them but no one came. R2 said that just after 3:00 AM she called her son because she did not know what to do and she really needed to use the bathroom and her bed was up high and she was afraid to try to get up on her own because of her hip surgery. R2 said that the staff finally came in around 6:00 AM and changed her brief that was wet but did not even clean her off, just put a dry one on. R2 stated her call light was over in her recliner that she was sitting in before she went to bed. R2 stated she was wet by 3:15 AM because she could not wait and she does not remember anyone coming in and checking on her until 6:00 AM when she was still wet and they were getting her up for breakfast. On 02/21/25 at 1:22 PM, V10 stated R2 called him at 3:18 AM. V10 said he called the facility after that and no one answered the phone. He then came to the facility at 12:30 PM and R2 was wet again. V10 said he talked to the staff about R2 not having her call light the night before and she was told to hit the wall, yell out, and they put the facility number in her phone to call them. V10 stated R2 told him she did yell out and he tried to call the facility and no one answered. 2. On 02/20/25 at 12:28 PM, R9 was observed sitting in the recliner in her room with a mechanical lift pad under her, her call light was sitting on her bed, approximately 4 feet away. When R9 was asked if she could reach her call light, she stated yes and looked around and pointed over to her bed and said it's over there. R9's MDS dated [DATE] documents: a BIMS score of 06 indicating resident is severely cognitively impaired. R9's functional ability documents her toilet transfer ability as not applicable -not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury and her chair/bed - to - chair transfer ability listed as dependent - helper does all of the effort. R9's diagnoses include: dementia, weakness, disorientation, and pain. 3. On 02/20/25 at 1:09 PM, R10 was sleeping in her recliner and her call light was approximately four feet away laying over her bed rail. R10's MDS dated [DATE] documents a BIMS score of 15 indicating resident is cognitively intact. R10's functional abilities lists her toilet transfer and chair/bed - to - chair transfer as: supervision or touching assistance indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. R10's additional active diagnoses include: unspecified fracture of sacrum, fracture of unspecified parts of lumbosacral spine and pelvis, and major depressive disorder. On 02/21/25 at 10:16 AM, V5 (LPN) stated residents call light should always be placed in their reach, if they are in bed, it is best to wrap it around their rail or clip it to the sheet or pillow so they can find it. V5 stated, residents should be checked at least every two hours. The facility policy dated 07/2014 titled, Answering the Call Light documents in part: 5. when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to formulate a Care Plan to address a resident's pain and to provide as needed pain medication in a timely fashion for one resident of nine residents (R1) reviewed for quality of care in the sample of nine. This failure resulted in R1 experiencing unresolved excruciating pain from a femur fracture, with accompanying feelings of fear and anxiety. Findings include: R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Displaced Comminuted Fracture of Shaft of Left Femur, Fibromyalgia, Polyneuropathy, Depression, and Anxiety Disorder. R1's Care Plan dated 12/9/24 did not document any problem areas nor interventions addressing pain. R1's 12/8/24 Brief Interview for Mental Status Score documented a score of 14, indicating R1 has minimal deficits in cognition. R1's December Physicians Order Sheet documented orders for hydrocodone-acetaminophen 5-325 milligrams take one tablet every 4 hours as needed for pain, not to exceed 3 grams of acetaminophen every 24 hours, and methocarbamol 500 milligrams take one tablet every 4 hours as needed for muscle cramps/spasms. R1's December Medication Administration Record documented that R1 received the hydrocodone-acetaminophen and the methocarbamol on 12/13/24 at 4:39pm and not again until 12/14/24 at 7:34am, with V8, Registered Nurse (RN) administering the 12/14/24 dose. The same MAR documented R1's pain on 12/14/24 at the beginning of the day shift (6am) as zero on a scale of zero to ten. On 12/18/24 at 1:40pm, R1 was alert and oriented to person, place, and time. R1 stated she had fallen while living in the community and fractured her femur, needed nursing facility care for rehabilitation, and therefore was admitted to the facility on [DATE]. R1 stated she has experienced a significant amount of pain from the fracture, as well as anxiety. R1 stated when she asked for her as needed pain medication and muscle relaxer, it rarely came within 20 minutes, and it generally took at least an hour. R1 stated this made her pain more difficult to control. R1 stated on Saturday 12/14/24 at 3am, she was experiencing excruciating pain from the fracture and turned on her call light and told, One of the CNAs (Certified Nursing Assistants), she needed the pain medication and muscle relaxer. R1 stated after several minutes, nobody came back, so she turned her call light on several more times throughout the early morning hours, and CNA staff told her the nurse was busy on another hall, the nurse had a delivery of medications she needed to put away, and that she was busy with another resident. R1 stated she did not receive the medications until about 7:30am that morning, when V8 came in to give her morning medications. R1 stated she told V8 how upset she was about waiting all that time and being in pain, and V8 stated the night nurse (V9, Registered Nurse) was new and she was overwhelmed. R1 stated when she finally received the medications, She was in terrible pain and it took the medications a lot longer to be effective, and they didn't control the pain as well, and she was extremely upset. When R1 was told by the Surveyor that the beginning of shift documentation rated her pain at zero, R1 stated, It wasn't a zero, it was a ten. R1 stated, She called her husband and said, I want to go home, I'm not safe here, I'm scared, they aren't giving me my pain pills after I ask for them and they aren't answering my call light. R1 stated her husband came and got her and she left without signing any discharge paperwork. R1 stated since she left AMA (Against Medical Advice) and did not consult with staff, she did not have any discharge medications. R1 stated her pain got much worse as the day wore on, and she ended up going to the emergency room that evening. R1 stated she is still in the hospital and is being treated for Pneumonia. R1's Nursing Progress Note dated 12/3/24 documented the following: admitted a [AGE] year-old Caucasian female via ambulance from (local hospital). Brought into facility via stretcher and transferred to chair per 2 EMT's (Emergency Medical Technicians) with TTWB (Toe Touch Weight Bearing) status to LLE (Lower Left Extremity) (due to fractured left femur). This note further stated, Resident states she has chronic pain due to fibromyalgia and rates it normally at a chronic 4 (on a 0-10 scale). R1's Nursing Progress Note, authored by V8, dated 12/14/24 at 10:15am documented the following: This morning this nurse went to residents' room to give her morning meds, she asked for pain pill along with her meds. Resident took meds without any further complaints. Shortly after the stepson came in facility and said resident called him and wanted to go home. This nurse went to resident room to speak with resident. Resident stated I was supposed to go home soon anyways, I think I am good to go home now. I will feel better being at home with my husband and my family can care for me there. Spoke with resident and stepson about the need to stay further for therapy and to be monitored. Stepson stated he felt she should stay a few more days anyways because her husband would not be able to fully care for her. Resident stated, I do not care I am leaving this place this morning either way. Spoke with resident and stepson about being toe touch weight bearing, the risk, and dangers of leaving against medical advice, she stated she understood all of that and was still adamant of leaving and going home. The stepson said the husband was on his way, I told him I would be back in to speak with him further when he arrived. Shortly after the PTA (Physical Therapy Assistant) came to inform nurse that husband just came in, grabbed residents' things, and took her out via wheelchair and they was gone without signing the paperwork. (V1) Administrator, (V2) DON (Director of Nurses), MD (Medical Doctor) and (V3) ADON (Assistant Director of Nurses) all notified. On 12/18/24 at 11:30am, V8 stated when she came in to work at 6am on 12/14/24, nothing was said in report from the night shift about R1 being in pain or upset. V8 stated she went into R1's room about 8am to give R1 her morning medications. V8 stated R1 asked if her pain medication and muscle relaxer were being given and V8 stated no, do you need them, and R1 stated yes. V8 stated she did not recall what R1's pain level was at that time. V8 stated R1 said she had asked for them on night shift but did not receive them. V8 stated later during the morning, an extended family member of R1 came in and said R1 had called, was upset about not receiving her pain medications timely, and wanted to go home. V8 stated she went and talked to R1 and told her she was not ready for discharge and strongly discouraged her leaving. V8 stated R1 said her husband was coming to get her and she was leaving. V8 stated she told R1 she would need to sign some documents before she left, and R1 said OK. V8 stated when she re-entered the room shortly thereafter, R1 and her belongings were gone. On 12/18/24 at 2:30pm, V9, stated she worked 6pm to 6am on 12/13/24-12/14/24. V9 stated it was the first night she worked alone at the facility after having, Trained on a couple of night shifts. V9 stated she found herself, Working by herself with 2 CNAs and 40 something residents. V9 stated it was, A horrible night. V9 stated she had a newly admitted resident with a blood sugar of over 600 who had no medications or insulin, and had another resident sustain a fall. V9 stated she could not remember anything about R1 and did not recall R1 having asked for pain medication, but as chaotic as it was, it's possible she did. V9 stated after that night, she texted V2, Director of Nurses, to let her know she would not be returning, as she did not feel she could provide safe resident care under those circumstances. V9 stated the Surveyor calling her was the first she had heard anything about R1 not receiving pain medication that night. On 12/19/24 at 8:45am, V2 stated the role of the 6pm-6am nurse is to pass medications, supervise CNA staff, assist CNA staff as needed, and assess residents as needed. V2 stated she has heard no complaints from residents or families about not receiving as needed pain medications in a timely fashion. When asked about what happened with R1 as outlined above, V2 stated she had heard on 12/14/24 from staff that R1 left AMA because R1 was upset that she didn't get her pain medication timely. V2 stated she did not investigate R1's complaint, but V3, Assistant Director of Nurses, did. On 12/19/24 at 9:20am, V3 stated, She did not really do an investigation into (R1's) not getting pain medication because nobody would admit to her having asked for it. V3 stated she did ask V9 about it, and V9 stated, She had a really rough night, and she didn't remember (R1) asking for pain medication. The facility's Pain Prevention and Treatment Policy dated October 2017 documented, Policy: To assess for, reduce, the incidence of, and the severity of pain to help residents attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible. The facility will develop and implement a plan, using pharmacological and non-pharmacological interventions to manage pain and/or try to prevent the pain consistent with residents goals.

Based on observation, interview, and, record review the facility failed to treat residents with dignity by answering call lights in a timely manner for two residents of nine residents (R1,R6) reviewed for resident rights in the sample of nine. This failure resulted in R1 and R6 experiencing feelings of embarrassment and humiliation. Findings include: 1. R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Displaced Comminuted Fracture of Shaft of Left Femur, Fibromyalgia, Polyneuropathy, Depression, and Anxiety Disorder. R1's Brief Interview for Mental Status Score (BIMS) dated 12/8/24 documented a score of 14, indicating R1 has minimal deficits in cognition. R1's Nursing Progress Note dated 12/3/24 documented, admitted a [AGE] year-old Caucasian female via ambulance from (local hospital). Brought into facility via stretcher and transferred to chair per 2 EMT's (Emergency Medical Technicians) with TTWB (Toe Touch Weight Bearing) status to LLE (Lower Left Extremity) (due to fractured left femur). This note further stated, Resident. States she has chronic pain due to Fibromyalgia and rates it normally at a chronic 4 (on a 0-10 scale). On 12/18/24 at 1:40pm, R1 was alert and oriented to person, place, and time. R1 stated she had fallen while living in the community and fractured her femur and needed nursing facility care for rehabilitation. R1 stated she was admitted to the facility on [DATE]. R1 stated call lights routinely take over an hour to be answered. R1 stated she had experienced difficulty with loose stools and had been incontinent in bed while waiting long periods on her call light. R1 stated, That was very hard on my dignity. R1 stated when she had complained to one of the Certified Nursing Assistants (CNA) (identity unknown) about waiting so long, the CNA told her to, Just go ahead and go in the bed and we will clean you up later. On 12/19/24 at 10:50am, R1 was alert and oriented to person, place, and time. R1 stated, You can't imagine how embarrassing it is to turn on your call light and wait for over an hour and then lose control of your bowels because nobody came to check on you. Then you have to have somebody clean you up. It's pretty humiliating. 2. R6's Face Sheet documented an admitted [DATE] and documented Diagnoses including Fracture of Left Femur, Malignant Neoplasm of Colon and Low Back Pain. R6's BIMS dated 12/17/24 documented a score of 15, indicating R6 has no deficits in cognition. R6's Nursing Progress Note dated 12/10/24 documented, Resident arrived to facility at approx 1:45pm via facility transport van. Left hip surgery on 12/5/24, left hip dressing has moderate serosanguinous drainage with purple bruising to left hip. Maximum 2 assist pivot transfer with front wheeled walker from wheelchair to bedside commode. On 12/17/24 at 12:25pm, R6 was alert and oriented to person, place, and time. R6 stated call lights generally take about 45 minutes at minimum. R6 stated she fell at home and broke her left leg and is dependent on staff for transfers, and she cannot ambulate at this time. R6 stated she has been having loose stools since admission and has had several accidents while waiting for her call light to be answered. R6 stated she wears incontinence briefs but prefers to defecate on the commode rather than the incontinence brief. R6 stated when she has accidents, staff have to clean her up and it is very embarrassing. R6 stated, I've pretty much thrown my dignity out the door since I've been here. V11, R6's family member, who was also in the room with R6 stated he has been present during several of these instances and he corroborated her account. 3. On 12/17/24 at 9:35am, V10, Ombudsman, stated complaints about long call light wait times comes up at almost every monthly resident council meeting. Resident Council Meeting Minutes documented the following: 9/26/24: Call lights not being answered in a timely manner still an issue. Leaving residents on the toilet too long. Not having beds made and leaving beds dirty. 10/24/24: Still not having call lights answered in a timely manner. On 12/19/24 at 8:45am, V2, Director of Nurses, when asked what her expectation is as to how long residents should have to wait on call lights. V2 stated the State Agency does not specify in any regulations as to how long it should take for call lights to be answered, but ideally, they should be answered as soon as possible. V2 stated she did not feel the problem was that call lights are not answered timely, but that resident's perception is that it takes longer than it actually does. V2 further stated a former CNA staff member contractually employed via a staffing agency had a lot of complaints from residents about her being slow to answer call lights, and since she left their employment in October 2024, the problem seems to have resolved. V2 stated it is not acceptable for staff to tell residents to be purposely incontinent in bed if it takes too long to answer call lights. The facility's, Answering the Call Light Policy, dated July 2014 stated, The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 8. Answer the resident's call light as soon as possible. The facility's, Resident Rights, policy dated August 31st, 2023, stated, The resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility, including: A facility must treat each resident with respect and dignity and care for the resident manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview, and record review, the facility failed to provide timely ADL (Activities of Daily Living) assistance for residents who are dependent on staff for two of six residents (R1, R6) reviewed for ADL care in a sample of nine. Findings include: 1. R1's Face Sheet documented an admitted [DATE] and listed diagnoses including Displaced Comminuted Fracture of Shaft of Left Femur, Fibromyalgia, Polyneuropathy, Depression, and Anxiety Disorder. R1's Brief Interview for Mental Status Score (BIMS) dated 12/8/24 documented a score of 14, indicating R1 has minimal deficits in cognition. R1's Nursing Progress Note dated 12/3/24 documented, admitted a [AGE] year-old Caucasian female via ambulance from (local hospital). Brought into facility via stretcher and transferred to chair per 2 EMT's (Emergency Medical Technicians) with TTWB (Toe Touch Weight Bearing) status to LLE (Lower Left Extremity) (due to fractured left femur). This note further stated, Resident. States she has chronic pain due to fibromyalgia and rates it normally at a chronic 4 (on a 0-10 scale). On 12/18/24 at 1:40pm, R1 was alert and oriented to person, place, and time. R1 stated she had fell while living in the community and fractured her femur and needed nursing facility care for rehabilitation. R1 stated she was admitted to the facility on [DATE] and discharged on [DATE]. R1 stated she is unable to ambulate and was dependent on staff for almost all ADLs. R1 stated call lights routinely take over an hour to be answered. R1 stated she had experienced difficulty with loose stools and had been incontinent in bed while waiting long periods on her call light. R1 stated when she had complained to one of the Certified Nursing Assistants (CNA) (identity unknown) about waiting so long, the CNA told her to, Just go ahead and go in the bed and we will clean you up later. 2. R6's Face Sheet documented an admitted [DATE] and documented Diagnoses including Fracture of Left Femur, Malignant Neoplasm of Colon, and Low Back Pain. R6's BIMS dated 12/17/24 documented a score of 15, indicating R6 has no deficits in cognition. R6's Nursing Progress Note dated 12/10/24 documented, Resident arrived to facility at approx 1:45pm via facility transport van. Left hip surgery on 12/5/24, left hip dressing has moderate serosanguinous drainage with purple bruising to left hip. Maximum 2 assist pivot transfer with front wheeled walker from wheelchair to bedside commode. On 12/17/24 at 12:25pm, R6 was alert and oriented to person, place, and time. R6 stated call lights generally take about 45 minutes at minimum. R6 stated she fell at home and broke her left leg and is dependent on staff for transfers, and she cannot ambulate at this time. R6 stated she has been having loose stools since admission and has had several accidents while waiting for her call light to be answered. V11, R6's family member, who was in the room at that time stated he has been present during several of these instances and he corroborated her account. On 12/19/24 at 8:45am, V2, Director of Nurses, when asked what her expectation is as to how long residents should have to wait on call lights. V6 stated the State Agency does not specify in any regulations as to how long it should take for call lights to be answered, but ideally, they should be answered as soon as possible. V2 stated she did not feel the problem was that call lights are not answered timely, but that resident's perception is that it takes longer than it actually does. V2 further stated a former CNA staff member contractually employed via a staffing agency had a lot of complaints from residents about her being slow to answer call lights, and since she left their employment in October 2024, the problem seems to have resolved. The facility's, Answering the Call Light Policy, dated July 2014 stated, The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 8. Answer the resident's call light as soon as possible.

Based on observation, interview, and record review, the facility failed to maintain aseptic technique while performing a dressing change during wound treatment for 1 (R21) of 2 residents reviewed for infection control in the sample of 23. Findings include: R21's Face Sheet documented an admission to the facility on [DATE] and listed diagnoses including type 2 diabetes mellitus without complications, pressure ulcer of left heel stage 2, unspecified diastolic (congestive) heart failure and unspecified intellectual disabilities. R21's Physician Order Summary documented an order dated 10/11/2024, metronidazole 500mg. Cleanse area to left heel with NS (normal saline) or wound cleanser and apply betadine, crushed flagyl, calcium alginate and kerlix daily and as needed. R21's Minimum Data Set (MDS) dated [DATE] documents no Brief Interview for Mental Status (BIMS) score. Section C0700, under staff assessment for mental status documented memory problem, showing R21 had severe cognitive impairment. On 10/16/2024 at 2:50 PM, V4 (Licensed Practical Nurse/LPN) and V3 (Assistant Director of Nursing/ADON) provided dressing change to left heel for R21. V4 and V3 gathered supplies that included wound cleanser spray, betadine, metronidazole, calcium alginate, kerlix and tape. There were no extra gloves set up for care. V4 donned a gown, washed her hands with soap and water, then donned gloves prior to procedure. During observation of R21's dressing change, V4 removed the old dressing dated 10/15/2024. Once the old dressing had been removed, V4 started to clean the wound with the wound cleanser spray and applied betanidine 10% to the wound area with a cotton ball, without donning new gloves or washing her hands. V4 then applied crushed metronidazole 500 mg tablet with calcium alginate to the wound. V4 finished the dressing change by wrapping the calcium alginate with kerlix wrap and secured it in place with tape. No observation of hand hygiene or new gloves donned throughout the entire wound dressing change procedure. On 10/16/2024 at 3:02 PM, V4 (LPN) stated she did not change her gloves during R21's dressing change. V4 did confirm that she should have donned new gloves and washed her hands between removing the old dressing and cleaning the area per the facility policy and procedure. On 10/16/2024 at 3:03 PM V3 (ADON) stated, V4 did not change her gloves during R21's dressing change per the facility's policy and procedure. V3 stated, V4 should have changed her gloves. On 10/17/2024 at 9:17 AM, V1 (Administrator) stated, she would expect V4 to follow the facility's policy and procedure for dressing changes, including infection control practices. The facility policy titled Dressings, Dry/Clean (January 2018) documents under Procedure step 9 pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry hands thoroughly. 11. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface.

Based on observation, record review, and interview, the facility failed to appropriately date and label refrigerated food items and store foods to maintain food quality in the freezer. This failure has the potential to affect all 35 residents. The Findings Include: On August 29th, 2023, from 9:00 AM-9:45 AM the initial tour of the kitchen was conducted, and the following items were found in the freezer: There were items that were opened for use and not labeled with date and time of opening and were not tied up to prevent freezer burn. Two bags of undetermined food products in clear plastic bags were loosely twisted at the top and not secured to prevent freezer burn. During this initial tour the reach in refrigerator was found to have a bowl of potato salad that was not labeled with food item/date/time, drinks that were poured in glasses ready for tray assembly that were not covered, a black container that had a lid on it was not labeled with food item/date or time, and a bag of lunch meat on the bottom was not labeled. V11 (Food Service Supervisor) stated that a resident's family member had brought that food in and that is why it was not labeled, and the bag of lunch meat was hers from yesterday that she brought for lunch. In the walk-in refrigerator several items were not dated/labeled, and these items included: ranch salad dressing, shredded cheese, sour cream, lunch meat, tortillas, and cheese slices. Luncheon meat was found to be dated 7/29 and was brown in color. V11 stated that she had not been here over the weekend and that must have been when all this occurred and that she would throw out the luncheon meat and discard the items that were not labeled with date and time of opening. A Food and Supply Storage policy with a revision date of January 2023 states: Food and supply storage shall be maintained in a clean, safe, and sanitary manner. The procedure lists: 4. prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date 6. All foods will be covered, labeled, and dated . The Resident Census and Conditions of Residents dated 8/29/23 documents 35 residents reside in the facility.

Based on interview and record review the facility failed to ensure staffing levels were sufficient to meet resident needs in a timely manner. This failure has the potential to affect all 35 residents residing in the facility. Findings Include: On 08/29/23 at 01:55 PM, R17, R7, R31, R30, R12, and R8 stated that their needs are not tended to in a timely manner by staff. All agree that the staff do the best they can with the amount of people they have working, but there just doesn't seem to be enough to tend to everyone when needed. R17 and R7 stated that staffing levels and response times seem to be worse on weekends. R12 stated that previously she has had to wait for 30 minutes for her call light to be answered, as evidence by watching the clock. R12 stated she finds that amount of time to be unsatisfactory because, when ya gotta go, ya gotta go, referring to using the restroom. R8 stated that he has had to wait 2 hours for his call light to be answered, which he too finds acceptable. R17, R7, R31, R30, R12, and R8 were all observed as being alert and oriented to person, place, and time during these interviews. No statements indicating a concern with dignity were made. On 8/29/23 at 10:00 AM, R31 who was alert to person, place and time stated that they do not have enough CNA's (Certified Nurse Assistant) especially after lunch and at night. R3 stated that she is dependent on staff to get her to the restroom and there have been times that she had an accident in the night waiting for them to get to her call light. R31 was unable to state the last time this had occurred and said that she is occasionally incontinent even with timely staff response. R31 stated that sometimes there is only one CNA that works the whole building, and that is not enough. On 8/29/23 at 11:20 AM, R26 who is alert to person place and time stated that they could use more CNA's. R26 stated that they ones who work do a good job, but they just don't have enough to get to everyone timely. On 8/29/23 at 10:20 AM, R22 who is alert to person place and time stated that they do not have enough CNAs after lunch through the rest of the day. R22 stated that they take too long to answer call lights. On 8/29/23 at 9:30 AM, R135 stated that they never answer his call light timely, and he waits forever for them to answer his call lights. On 8/30/23 at 10:03 AM, V6 (CNA) stated that while staff do their best to attempt to serve residents in a timely manner, they do not have enough staff to always do so. V6 stated she works 6 AM - 2 PM. V6 stated usually there is one aide assigned per hallway and then staff float from hall to hall to assist each other as needed, with residents who require assistance of more than one person, etc. V6 stated that she has had residents complain regarding the amount of time it takes staff to answer call lights. V6 stated one resident in particular that comes to mind that has complained regarding call light answer times is R31. V6 stated there are residents who have had incontinence episodes, waiting on their call lights to be answered. V6 stated she has expressed to V2 (Assistant Director of Nursing, ADON) that more staff are needed to care for residents in a timely manner. V6 stated it is her goal to have call lights answered within 5-10 min. On 8/30/23 at 10:15 AM, V7 (CNA) stated that she works as a facility employee from 6 AM - 2 PM. V7 stated she has had residents complain to her regarding the amount of time it takes staff to respond to their call lights. V7 stated there also have been residents who were waiting to use the restroom experience incontinence episodes while waiting for staff to tend to them. V7 stated it has been expressed to V1 (Administrator), this past Monday during a staff meeting that more staff are needed. V7 stated that V1 stated the facility is within their required amount for staffing. V7 stated that she isn't sure of the patient ratios that the facility is using, but the facility has to many residents now that require the assistance of two staff, or are very demanding, taking up much of staff's time. V7 stated while resident care tasks do get completed, V7 stated they are not always in a timely manner. On 08/29/23 at 9:15 AM, V1 stated the facility utilizes agency staff as well as having their own staff at the facility. V1 stated employees always want more staff, but based on their census, the facility is within the desired staffing levels to meet resident needs. On 08/30/23 at 2:23 PM, V1 stated there was a day over this past weekend on the 10 PM - 6 AM shift when there was 1 CNA working the building with 1 nurse. V1 stated there were 2 aides scheduled, but one was an agency staff and didn't show up. V1 stated there were no complaints made to her or ill outcomes from the 1 nurse and 1 CNA working the building that night. V1 stated usually there are 2 CNA's and a nurse scheduled during night shift. V1 stated that the nurse already working that night was their staff member on call. 08/31/23 8:25 AM V1 stated that the facility schedules the following number of staff for each shift: Day- 3 CNA & 2 nurses; Afternoon- 2 CNA & 1 nurse, although attempting to start scheduling 3 CNA recently due to a rise in census; Night- 2 CNA & 1 nurse. V1 stated this past Monday, 8/28/23, she did have a meeting with the staff. V1 stated the only concern expressed by staff were staffing levels. V1 stated staff expressed their need for more staff and that they were having trouble getting tasks completed. V1 stated staff expressed to her they wish she could come walk in their shoes, in which she stated she previously has as she worked as an agency nurse prior to starting this job. On 8/31/23 at 10:10 AM, V2 stated that there was a day recently in which she was working night shift as the nurse and only one aide was working with her. V2 stated that there were no complaints regarding staffing that night and herself and the aide were able to complete all duties needed. V2 stated that another CNA, which was agency, was also scheduled to work that night, but didn't show up. V2 stated that she makes the schedules and night shift staff now at the facility are mainly agency staff. V2 stated that she will send out messages to staff to see if they can come fill the vacant positions, but they do not always come in. V2 stated the night the agency CNA didn't show up, a day shift aide was supposed to come in at 4 AM but didn't show up. V1 provided a list of the following residents which utilize a mechanical lift in the facility: R8, R7, R135, R15, R12, R29, R31, R1. Review of the Daily Staffing Information Form dated 8/25/23 documents 1 Licensed Practical Nurse and I CNA worked night shift on this date. Review of the Resident Census and Conditions of Residents dated 8/29/23 documents a facility census of 35 residents. The same document notates the number of residents which need Assist of One or Two Staff for the following Activities of Daily Living: Bathing- 28, Dressing- 32, Transferring- 22, Toilet Use- 34, Eating- 33.

Based on interview and record review the facility failed to ensure 5 of 5 (R3, R5, R7, R21, and R26) residents reviewed for immunizations in the sample of 32, received the education addressing the benefits and risks and/or had the opportunity to receive the 20-valent pneumococcal conjugate vaccine (PCV20 or Prevnar 20). Findings Include: 1. Review of R3's Resident Face Sheet documents an admitted to the facility as 10/29/18 and documents a birthdate indicating R3 is [AGE] years of age. Diagnoses on this same document include, but are not limited to: Chronic Kidney Disease, stage 5; Diabetes Mellitus; Cerebral Infarction; Essential Hypertension. Review of R3's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 2. Review of R5's Resident Face Sheet documents a current admitted to the facility as 3/3/14 and birthdate indicating R5 is [AGE] years of age. Diagnoses on this same document include but are not limited to: Schizoaffective Disorder; Gastro-esophageal reflux without esophagitis; Arthropathy. Review of R5's Clinical Record did not indicate that R5 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 3. Review of R7's Resident Face Sheet documents a current admitted to the facility as 3/11/16 and birthdate indicating R7 is [AGE] years of age. Diagnoses on this same document include but are not limited to: Multiple sclerosis; Osteoporosis without current pathological fracture; Morbid (severe) obesity due to excess calories; Shortness of Breath. Review of R7's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 4. Review of R21's Resident Face Sheet documents a current admitted to the facility as 9/29/17 and birthdate indicating that R21 is [AGE] years of age. Diagnoses on this same document include but are not limited to: Type 2 Diabetes Mellitus Without Complications; Essential Hypertension; Weakness; Dependence on Supplemental Oxygen. Review of R21's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 5. Review of R26's Resident Face Sheet documents a current admitted to the facility as 10/5/19 and birthdate indicating R26 is [AGE] years of age. Diagnoses on this same document include but are not limited to: Acute Respiratory Failure With Hypoxia; Encounter For Prophylactic Immunotherapy For Respiratory Syncytial Virus; Chronic Obstructive Pulmonary Disease; Acute On Chronic Diastolic (Congestive) Heart Failure; Emphysema; Shortness Of Breath; Essential Hypertension. Review of R26's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. On 8/31/23 at 10:15 AM, V2 (Assistant Director of Nursing, ADON) stated that she started at the facility in July 2023. V2 stated that 2 weeks ago, she started an immunization audit and mailed out consents for Flu and Pneumonia Vaccines to be given. V2 stated that they have not received any consents back from families yet, so she has started calling families to follow up and get verbal consent. V2 stated that the facility uses (company name) pharmacy and have been notified that they do not have any of the 20-valent pneumococcal conjugate vaccine available to send them currently. On 08/31/23 at 02:07 PM, V8 (Regional Administrator) stated that the facility acknowledges that R21, R7, R5, R3, and R26 were all eligible to currently receive the 20-valent pneumococcal conjugate vaccine. V8 stated these residents were not provided education regarding the 20-valent pneumococcal conjugate vaccine or given the opportunity to accept or decline the vaccine. V8 concedes that the facility is now in the process of providing the education for this vaccine, obtaining consents, and administering the vaccination once available. Although V8 stated the facility has not offered 20-valent pneumococcal conjugate vaccine to any residents yet at this time, it is also acknowledged that not everyone in the facility will be eligible to receive the 20-valent pneumococcal conjugate vaccine, and a screening process will be conducted. R26, R21, R7, R5, and R3's Clinical Records were reviewed with V8 and revealed past administration of previous versions of the pneumonia vaccine had been given per resident wishes or education with documented refusal were noted. Review of the facility policy titled, Pneumococcal Vaccine with a revision date of December 2016 stated, It is the policy of (company) that all residents are protected from incident of pneumonia by obtaining pneumococcal vaccines, if desired, per CDC (Centers for Disease Control and Prevention) guidelines. Review of information found at https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html documents, Pneumococcal disease is common in young children, but older adults are at greatest risk of serious illness and death. In the United States, there are 2 kinds of vaccines that help prevent pneumococcal disease Pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20), Pneumococcal polysaccharide vaccine (PPSV23). Additional information found on the same site documents, For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for Adults [AGE] years or older. Adults 19 through [AGE] years old with certain medical conditions or other risk factors. Adults who received an earlier pneumococcal conjugate vaccine (PCV13 or PCV7) should talk with a vaccine provider to learn about available options to complete their pneumococcal vaccine series. Adults [AGE] years or older have the option to get PCV20 if they have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old. These adults can talk with their doctor and decide, together, whether to get PCV20.

Based on observation, interview and record review the facility failed to ensure residents with limited mobility were properly assessed for assistive devices for 1 of 1 (R135) resident reviewed for assistive devices in a sample of 32. The Findings Include: R135's resident face sheet documents an admitted [DATE]. This same document includes the following diagnosis: frontal lobe and executive function deficit following non traumatic intracerebral hemorrhage, alcohol dependence, bipolar disorder, major depressive disorder, generalized anxiety disorder, post traumatic disorder, epilepsy, and cerebral infarction due to cerebral venous thrombosis, and functional quadriplegia. R135 is alert to person, place, and time. R135's care plan documents that he has a BIMS (Brief Interview of Mental Status) of 15 indicating that R135 is fully cognitively intact. A problem area in R135's care plan with a start date of 8/31/23 documents that R135 is at risk for weakness or tiredness due to late effects of Cerebral Vascular Accident. The goal is for the resident to be out of bed daily and able to attend activities of choice daily as tolerated by next review date. The approaches for this problem area are as follows: call light within reach while in room and remind resident to call for assistance as needed, diet as ordered, encourage rest periods as needed, invite resident to daily activities of choice as tolerated, monitor appetite and weight, monitor lab work as available, observe resident for weakness and or tiredness, provide medication as ordered and observe effectiveness of medication, provide monthly activity calendar in room and to report excessive tiredness and weakness to the physician. A problem category in this same care plan with a start date of 8/31/23 documents: Activities of Daily Living status/rehabilitation potential. Goal for this problem area is discharge to community. I will have access to necessary services to promote adjustment to my new living environment and or post discharge from the facility. Approaches listed for this problem are as follows: Activities of Daily Living: I require assistance with oral care, grooming, eating, toileting, dressing and mobility (All dependent). I will need assistance to have my personal care needs met while supporting my strengths and personal goals. Safety: I will need to be monitored to prevent falling in my new environment. I will need assistance with bed/chair mobility, assistance with transfers, and assistance with locomotion. I use a mechanical lift and wheelchair and need safety reminders to use durable medical equipment safely. R135's current physician order sheet for August 2023 includes an order for: rehab physical therapy, occupational therapy, and speech therapy to evaluate and treat with a start date of 8/25/23. Restorative therapy program for active range of motion 6-7 times a week every shift and restorative therapy program for bed mobility 6-7 times a week every shift with a start date of 8/25/23. A Skilled occupational therapy 8 visits in a 30-day period to address therapeutic exercise, therapeutic activities, neuromuscular retraining, and self-care training with a start date of 8/26/23. Physical therapy evaluation and treatment for 6 visits in 4 weeks for therapy exercises, therapeutic activities, gait training, wheelchair management with a start date of 8/29/23. On August 29th, 2023, at 9:45AM, R135 was observed to be sitting in a standard wheelchair with a mechanical lift sling underneath him. The wheelchair had foot pedals and a cushion on the seat. R135 was positioned in front of the television and upon entering the room his head was found to be hanging back with no support. R135 attempted to lift his head up to speak but appeared to not have the strength to lift his head completely up. R135 at this time stated that he was put in this chair by therapy and left alone and has no idea how long it has been but feels like forever. When asked if he was comfortable in this chair R135 stated (explicit) no, this is the first time I have been out of bed since I got here and I am uncomfortable and want to get back in bed. After turning on R135's call light V6 (Certified Nurse Assistant) and V13 (Physical Therapist) came in to assist R135 at 9:53 AM back to his bed by the mechanical lift. When asked at this time why R135 was left in a wheelchair that allowed his head to hang back due to no support V13 instructed V10 (Director of Therapy) to go get R135 a different wheelchair. V10 came back with a high back wheelchair. V10 told R135 at this time that when he was ready to get out of bed, they would place him in the wheelchair and determine if it was a better fit for him. On 8/30/23 at 11:00 AM, R135 was up in the high back wheelchair that V10 had changed out for him on 8/29/23. When asked if this chair was better than yesterday's chair, R135 stated that it was much better and that he had better support for his back and head. At this time R135 was observed to be sitting straight up in this chair, and his head was not hanging back with no support. On 8/31/23 at 1:30 PM, V9 (Certified Occupational Therapy Assistant) stated that she was the therapist on call this weekend that did his evaluation. V9 stated when she was here on 8/26/23 she did a telehealth evaluation with an Occupational Therapist to complete the evaluation. V9 stated that she assessed his recliner as being adequate for him to safely sit in it and recline. However, she did not place R135 in the standard wheelchair that she brought in for the staff to use. V9 stated that she put foot pedals on the wheelchair and a cushion to use on the seat but did not actually place him in the chair to determine if it was appropriate. V9 stated that she did not fit R135 in a wheelchair on the assessment on 8/26/23, she just grabbed a wheelchair that was available and left it in the room for R135 to use. V9 stated her expectation would be for the nursing staff to let her know if the wheelchair didn't appear to be properly fitted for residents. V9 stated that she just wanted to have a chair for him to be able to get up out of bed, go to the dining room to eat and be included in activities because she knew he would not be starting therapy yet. V9 went on to state that after the evaluation occurred, he would start therapy and that is when he would be able to select a wheelchair and they would assess it. V9 stated that she was unaware that the wheelchair was not fitting R135's needs until V10 told her on Tuesday 8/29/23 when she got him a wheelchair with a higher back. Occupational Therapy Treatment Encounter note dated 8/26/23 document a completion of a telehealth evaluation with Certified Occupational Therapy Assistant (COTA) was completed and assessment of bed mobility, bilateral upper extremities, self-feeding tasks and sitting balance was assessed. This note documented under functional skills assessment that R135 was dependent for toilet transfers, eating, oral hygiene, toileting hygiene, shower/bathing, upper body dressing, lower body dressing and putting on/taking off footwear. On this same note it documents under the summary of skilled services that R135 required minimum/moderate assist to maintain posture on edge of bed. An occupational therapy evaluation and plan of care document dates 8/26/23 documents under the balance section that R135's sitting balance is poor and maintains balance with moderate assist and upper extremity support. This same document under functional skills assessment-mobility during activities of daily living regarding wheelchair mobility states detailed wheelchair mobility assessment= no. On 8/31/23 at 2:45 PM, V8 (Regional Administrator) stated that she would expect therapy to have evaluated R135 for a proper wheelchair. V8 stated that the CNA's (Certified Nurse Assistants) and licensed nursing staff use the equipment that therapy leaves in the room after the initial evaluation under the impression that is what is safest and most appropriate for the resident. V8 stated that occupational therapy is typically the therapy that evaluates/fits residents in wheelchairs. A facility policy titled Quality of Life-Accommodation of Needs with a revision date of February 2012 documents: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. The procedure of the policy includes: 1. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and on an ongoing basis. 3. In order to accommodate individual needs and preferences, adaptions may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples may include: providing a variety of types (for example, chairs with and without arms), sizes (height and depth), and firmness of furniture in rooms and common areas so that residents with varying degrees of strength and mobility can independently arise to a standing position .

Based on interview and record review the facility failed to refer 1 (R32) of 2 residents for a PASARR (Preadmission Screening and Resident Review) level II screening after receiving a new mental health diagnosis in a sample of 32 residents reviewed for assessments. The Findings include: R32 was admitted to this facility on 02/28/22 with primary diagnoses to include encephalopathy, vascular dementia, and depression according to his facility face sheet. R32's OBRA I (Omnibus Budget Reconciliation Act) dated 02/23/23 indicates he is appropriate for nursing services at this time. R32 was given a new diagnosis of major depressive disorder, recurrent severe without psychotic features on 11/08/22, and again on 07/10/23. R32's face sheet documents a diagnosis of major depressive disorder. R32's record does not contain a referral for a PASARR II screening after either of these diagnoses were added. On 09/01/23 at 10:58 AM, when asked for R32's PASARR II referral, V14 (Social Services) stated a referral for a level II screening had not been submitted because she did not see the new diagnosis when given to R32. V14 stated she would normally send the referral with each new mental health diagnosis given after a resident's initial admitted . A facility policy titled, Resident Assessment: Coordination with PASARR Program . Policy Explanation and Compliance Guidelines, dated October 2017 includes - . 6. Any resident who exhibits a newly evident or possible serious mental disorder . or a related condition will be referred promptly to the State mental health or intellectual authority for a level II resident review .

Based on observation, interview and record review, the facility failed to implement a plan to address a resident with contractures for 1 of 4 residents (R2) reviewed for contractures in a sample of 5. Findings: R2's medical record, Physician's Order Report dated 11/01/2022 - 1/10/2023 documents R2 being admitted on [DATE] with a diagnosis of Encephalopathy, unspecified (Primary Admission). R2's medical record, Minimum Data Set (MDS) dated [DATE], documents, Brief Interview for Mental Status (BIMS) score is 01, severe cognition, Functional Status documents, Extensive Assistance with physical assistance x 2 with bed mobility and total dependence with physical assistance times/x 2 people with transfers. On 1/09/2023, at 9:50 a.m., R2 observed lying in bed R2 was noted to have contractures to his upper and lower extremities. On 1/10/2023, at 1:30 p.m., V3 (Assistant Director of Nursing), stated that when R2 was admitted he had contractures noted to his upper and lower extremities. V3 stated that she forgot to input the restorative care plan for R2, so no documentation has been noted of R2 receiving restorative care. V3 stated that Certified Nursing Aide/CNAs usually perform passive range of motion while providing care to R2. On 1/10/2023, at 10:15 a.m., V11, (Certified Nurse Aide), stated that R2 has had contractures since his admission. V11 stated that R2 can move his upper extremities when he wants to, and she has performed passive range of motion to his lower extremities while providing care to him. V11 stated, I think there is a place in R2's medical chart that we check off, but I can't be certain. V11 stated she does not know how many repetitions of passive range of motion to perform on R2. V11 stated, I just do a few stretching exercises of his extremities when I can. On 1/10/2023, at 10:20 a.m., V12 (Certified Nurse Aide), stated that V12 stated that R2 has had contractures since she has provided care to him. V12 stated that when she provides care to R2, she tries to perform passive range of motion on his upper and lower extremities, but sometimes he refuses it. V12 stated that she does not really know how many repetitions of passive range of motion to perform on R2. V12 stated she was not sure if there was a place in R2's chart to check off for passive range of motion. On 1/10/2023, at 12:40 p.m., V10 (Primary Physician) stated that R2 has always had contractures to his upper and lower extremities since he has been admitted and she has only seen a slight decline in his contractures since he has been at the facility. No documentation could be found in R2's Medical Record that documented R2's had been receiving any restorative or range of motion care for R2's contractures. The facility could not provide any documentation of R2 receiving restorative care or range of motion care for R2's contractures at the facility since his admitted [DATE].

Based on interview and record review, the facility failed to provide care consistent with professional standards to prevent pressure ulcer development for 1 of 1 residents (R135) reviewed for pressure ulcers in the sample of 21. Findings included: On 9/26/2022 at 9:30am, V8 (Family) stated R135 was admitted to this facility on Tuesday 8/23/2022 for therapy after having left hip repair surgery resulting from falling and fracturing his hip. V8 stated R135 was discharged on [DATE]. V8 stated on 8/31/2022 after lunch, R135 had been discharged from this facility and admitted to a different facility and was waiting for the new facility to pick him up when he became very ill. V8 stated the family decided to have R135 sent to the local emergency room instead of going to the new facility. V8 stated R135 was admitted to the hospital due to septic shock caused by an infected bedsore that R135 had newly developed after being admitted to the nursing home on 8/23/2022. On 9/27/2022 at 1:00pm, V2 (Assistant Director of Nursing/ADON) stated R135 did not have a pressure wound to his bottom when he was admitted to this facility. After reviewing R135's medical records, V2 stated the nursing staff first documented R135 having an open area to his coccyx on 8/31/2022 just prior to him being discharged from this facility. V2 stated the reason R135 did not have any orders to treat the open area to his coccyx because there was not time to contact R135's doctor before R135 left the facility. V2 stated R135 was assessed as high risk for pressure ulcers when he was admitted to this facility on 8/23/2022. V2 stated interventions in place to prevent R135 from developing skin break down were pressure relieving mattress and a special cushion for R135's chair that's relieves pressure. A Nurses Note in R135's medical record dated 8/23/2022 at 3:00pm documented R135's admission skin assessment as both heels firm, 0 (zero) open areas to skin, 0 (zero) redness . On 9/26/2022 at 1:00pm, V12 (Physical Therapy Director) stated she worked with R135 everyday while he was admitted to this facility. V12 stated R135 was very weak and frail when he was admitted . V12 stated on 8/27/2022 about 10:30am, V12 was working with R135, and the nursing staff was assisting her. V12 stated at this time the nursing staff had first noticed R135 had an open area to his bottom. V12 said she made note of it in her treatment note that day. V12 stated she recommended R135 use a special chair cushion to relieve pressure on his bottom. V12, stated she obtained the cushion and she and the nursing staff placed it under R135 after getting R135 up in his chair that day. V12 stated R135 said the cushion helped a lot and he felt better sitting on the new cushion. A Physical Therapy Treatment note dated 8/27/2022 at 11:02am, documented the following: Worked on improving ability to assist with bed mobility, including rolling side to side. Nursing present and noted an open area to patient's bottom. Obtained cushion for patient's recliner. Assisted nursing staff with mechanical lift to place cushion in recliner chair. Patient appears to be comfortable and is positioned properly in recliner upon completion of treatment. Lotion applied to BLE (bilateral lower extremities), and pillow positioned under feet to allow for heals to float. On 9/27/2022 at 1:00pm, V2 (ADON) stated she would rather have her nursing staff down on the hallway providing care and not at the computer documenting care. V2 stated she reviews the nursing documentation on a daily basis and makes sure everything is taken care of and she or her designee sets up wound care services after a new open area has been noted or someone is admitted with wounds. V2 stated she is only human, and things get missed sometimes. V2 stated she was not aware that R135 had developed an open area until 8/31/2022 when R135 was being discharged from this facility. V2 stated because of her late notification, R135 had not been seen by the facility's wound care doctor. V2 stated the nursing staff did fail to measure R135's open area and had not documented it in accordance with professional standards or the facility's wound care policy. V2 stated she thought R135's buttocks only had some redness which was treated with preventative skin cream, however, V2 could not find any orders for the cream and could not find any documentation of the cream being applied. R135's Nurses Notes on 8/31/2022 at 3:08pm, R135 was discharged from this facility, transported to the local hospital through the emergency room after being evaluated. The local hospital emergency room admission paperwork for R135, dated 8/31/2022, documents R135 as having 2 open areas to his buttocks area. These areas were evaluated by a Wound Care Specialist Advanced Practice Nurse Practitioner and measure 3.0cm (Centimeters) by 2.0cm and 0.1cm deep and 2.0 cm by 1.0cm and 0.1cm deep and are classified as stage 2 pressure ulcers, one to the coccyx and one to the left buttocks. A facility policy titled Wound Management Program (with last revision date of 2/26/2021) documents The facility will assess residents weekly for current skin conditions The charge nurse will assess for clear skin, redness, open areas and pressure areas The nurse will measure the wound area, notify the patients doctor and obtain appropriate treatment orders.

Based on interview and record review the facility failed to implement their abuse policy which includes the requirements for identifying and reporting circumstances of suspected abuse for 1 of 3 residents (R2) reviewed for abuse in a sample of 5. The findings include: A facility Long-Term Care Facility and IID (Individuals with Intellectual Disabilities) - Serious Injury Incident Final Report dated 08/22/22 at 4:00 PM by V1 (Administrator) was reviewed and describes in part in the detailed incident summary a resident's narcotic medication card of oxycod/apap ([MEDICATION(S)]-Acetaminophen) 5-325 mg (milligram) had pills missing that were replaced with Tylenol 500 mg tabs. A total of 15 pills were removed from resident card and replaced with Tylenol 500 mg. Each popped out area was taped back closed. This facility investigation included written statements given by nursing staff. One of these statements given by V9 (Licensed Practical Nurse - LPN) dated 08/16/22 at 8:30 (no AM or PM documented) was as follows - The only thing I recall that has been tampered with is (R2's) oxy 5 mg. There is tape all over the back of one of the rows of his narcotics. It should be noted that R2 was not the resident named in the facility's Long-Term Care Facility and IID (Individuals with Intellectual Disabilities) - Serious Injury Incident Final Report dated 08/22/22 at 4:00 PM. On 08/30/22 at 2:30 PM, when asked if V1 had seen V9's written statement referencing R2's narc med card within the 08/15/22 drug diversion internal investigation regarding another resident's oxy or had a separate investigation for R2, she stated she had not seen V9's statement and there was not an investigation on R2. This surveyor showed V1 the written statement V9 provided about observing R2's [MEDICATION(S)] card to have been tampered with and the back taped over. V1 confirmed V9 did not report this, nor did V1 or V3 catch this statement when doing the other resident's investigation regarding missing [MEDICATION(S)]. On 08/31/22 at 1:08 PM, V9 (LPN) stated she noticed R2's narc med card for what would be his midnight and 6:00 AM dose (2 tablets) had been torn and re-covered with clear tape, but the pills were there. V9 stated she checked for the same color, size, shape, and number, and was confident they were R2's prescribed [MEDICATION(S)]. When asked about the date she observed this, V9 did not know for sure, but commented it was around the time that the other [MEDICATION(S)] pills went missing for another resident. V9 stated she did not report R2's med card observation to anyone at the time. V9 stated she didn't know to report it and thought you only report if the meds are missing. V9 stated she noticed those particular pills because that would have been the times she would be passing meds during her 6:00 PM to 6:00 AM shift. V9 also added she was contacted by V1 yesterday afternoon and provided an amended statement for the record. V9's amended written statement dated Tuesday [DATE] documents, Approximately 1 month ago I had noticed (R2's) [MEDICATION(S)] 5 mg where 2 tablets were taped on the back of the card. No medications was missing at all. I only noticed the tape. Signed by V9. A facility policy titled, Abuse Prevention Program dated April of 2018 documents in part - Definitions: Abuse: Abuse is the willful infliction of injury .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 .Procedures for Prevention: 5. Internal Reporting Requirements and Identification of Allegations - Employees are required to report any incident, allegations, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator .

Based on interview and record review, the facility failed to ensure residents were safe from misappropriation of controlled substance medication for 1 of 3 (R3) residents reviewed for theft in a sample of 5. The findings include: A facility Long-Term Care Facility and IID (Individuals with Intellectual Disabilities) - Serious Injury Incident Initial Report dated 08/15/22 at 2:00 PM by V1 (Administrator) documents in part - Incident Category: Drug Diversion. Resident Involved: R3. Detailed Incident Summary: Nurse (V7 - Licensed Practical Nurse - LPN) notified ADON (V3 - Assistant Director of Nursing) during shift change that narcotic on resident card was replaced with Tylenol 500 .Final report to follow. A facility Long-Term Care Facility and IID (Individuals with Intellectual Disabilities) - Serious Injury Incident Final Report dated 08/22/22 at 4:00 PM by V1 describes the following detailed incident summary - On 08/15/22, V7 notified V3 during shift change that narcotic oxycod/apap ([MEDICATION(S)]-Acetaminophen) 5-325 mg (milligram) was missing and replaced with Tylenol 500 mg tabs. A total of 15 pills were removed from resident card and replaced with Tylenol 500 mg. Each popped out area was taped back closed. Police were notified immediately. All nursing staff was called to the building to complete drug testing. All facility nursing were tested and negative. Two agency staff were contacted. V6 (Agency Registered Nurse - RN) has not returned phone calls. V11 (Agency LPN) was slated to test and did not show up for testing. Both agency staff are a no return to building. All narcotic cards were visually inspected, and no other missing medications were noted. Nursing staff educated to visually inspect front and back of narcotic cards during shift/shift change. All notifications made to include local police department, Illinois State Police fraud unit, physician, and POA (power of attorney). On 08/30/22 at 11:45 AM, V3 stated there were three residents in the facility prescribed [MEDICATION(S)] - R1, R2, and R3. R3's [MEDICATION(S)] was discontinued on 08/15/22. R1 and R2 are now the only residents prescribed and receiving [MEDICATION(S)] at this time. The only staff that have not responded to V3's texts and phone calls for interview and drug testing during the facility investigation were V6 and V11, both agency nurses. R3's Face Sheet documents he was admitted to this facility on 08/09/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's hospital After Visit Summary dated 07/31/22 to 08/08/22 gives instruction in part to start taking [MEDICATION(S)]-Acetaminophen 5-325 mg (milligram) 1 tablet by mouth every 6 hours as needed for chronic pain. R3's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's August Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's progress note dated 08/11/22 documents he was sent to the local hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's progress note dated 08/26/22 documents admission back to the facility. R3's internal facility incident investigation included a photocopy of one medication card for 30 [MEDICATION(S)] pills, prescription number 92 dated 08/09/22 received from the facility pharmacy. The pill bubbles numbered #30 and #29 were empty correlating with R3's August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There were 28 pills remaining on the card with random numbered slots observed to be opened, tampered with, and taped back in place in the following slots - #3, #5, #7, #9, #12 - #14, #16, #18, #19, #24 - #28 for a total of 15 pills slots performed and taped back in place not document as being administered to R3. R3's facility incident investigation also included printed copies of V3's screen shots confirming attempts were made to contact V6 and V11 via text messages and phone calls asking them to return her call in an attempt to follow up as to whether either nurse had gotten their drug screen as instructed. Neither V6 nor V11 ever responded to V3's calls and texts. On 08/30/22 at 2:00 PM, V3 stated that when V7 (LPN) brought R3's med card of [MEDICATION(S)] to her and asked her to look at it, she did not realize at first what had happened because the pills were there, and they looked identical to the oxy. V3 stated, V7 told me that the card had been taped up and replaced with the same shape, color, size of pill as his oxy, but it was Tylenol 500. I couldn't believe it. It took me a minute to realize what I was looking at. We've never had anything like this happen before. On 08/30/22 at 11:47 AM, V1 (Administrator) stated she reviewed the dining room camera footage for the days around the time R3's [MEDICATION(S)] was discovered missing but was unable to get a clear view of the nurse or med cards being handled. V1 stated V6 worked 1 half-shift on 08/13/22 and has not been back. On 08/31/22 at 10:42 AM, V8 (LPN) stated she has gone over and over the day of 08/13/22 when she was the only other floor nurse working with V6. V8 stated V6 came in a few minutes late. When she got here, she was very upbeat and talkative. At one point, V6 reported her that her husband currently had Covid-19, so we did the Covid-19 test on V6. She stated she was waiting on her son's results, also. V8 stated she was not happy that V6 had come to the facility to work having positive family members at home. V8 stated, Then, all of a sudden V6 stated she did not feel well, was asking me questions, and told me she wanted to go home. She stated she would get the meds passed before she went home. It was about 9:30 AM. I went to lunch at 9:30 because she told me she was going to go home. Before I went, she told me she needed my keys. I gave her my keys and went to lunch. V8 continued, I came back from lunch at 10:30 AM. I told her we had to count meds. We counted narcs with no abnormalities. She told me her son was Covid-19 positive and she had to go home. I saw a roll of tape on her cart. I didn't think anything of it at that time and threw it in her top drawer. She left at 11:00 AM. The narcs did come out o.k. however, I did not look at the back of the cards. We had never had to do that before. The front looked normal. V8 stated she did work on 08/13 and 08/14 and didn't notice if there was tape on R3's card, but again had not checked the back of the card. On 08/31/22 at 1:08 PM, V9 (LPN) stated she worked on 08/13 and 08/14 but had no knowledge of tape on the back of R3's oxy card when they did count. On 09/01/22 at 11:22 AM, V7 (LPN) stated she worked on 08/15/22 from 6:00 AM to 6:00 PM. During that time, she did a narc count of the C-hall cart with V11 (Agency LPN) who also worked that day from 6:00 AM to 2:30 PM. V7 stated it was at that time she discovered the tape on the back of R3's [MEDICATION(S)]-Acetaminophen 5-325 mg card and the Tylenol 500 mg in some of the spots where oxy should have been. V7 stated she never had any reason to suspect any other nurse/agency nurse of stealing resident narcotics. V7 continued, we usually flipped through the resident narc med cards while in the drawer and confirmed the count on the card with the computer system count to make sure it was correct. On 08/15/22, V7 stated, I pulled the card up from the drawer some and noticed the foil on the back bottom left of R3's card was catching on the other cards in the narc drawer. I flipped it over and saw all the tape. I looked at the front of the card and the pills appeared to be the same, but the numbers were different. I googled the different number, and it was Tylenol 500 mg. When asked the last time she worked and did narc count, V7 stated she worked on 08/11/22 because she was the nurse who sent R3 out to the hospital that afternoon, and she did not see the tape on R3's med card on that date. On 08/12/22, V7 stated she counted narcs with V2 (DON) and did not notice the tears or tape. V7 stated, The DON pulled the cards out into a pile and would flip them over. R3 was the first card in the narc drawer, and it was intact with no tape. V7 confirmed she did not work on 08/13/22 or 08/14/22, so the last time she did count was on 08/12/22. V7 also confirmed, We start dispensing meds from the left side of the card (starting at #31 or #30 depending on the month), so R3 had a total of 30 oxy pills when I gave him his first pill from the #30 slot on 08/09/22. V7 stated V8 (LPN) worked on 08/10/22 and would have given pill #29 that day. V7 stated she believed R3 only received the 2 pills from that card because he went back out to the hospital on the 11th and the medication was discontinued and removed from the drawer on the 15th after she discovered it had been tampered with. On 09/01/22 at 11:55, V2 confirmed she did a narc count with V7 on 08/12/22 and R3's card for [MEDICATION(S)]-acetaminophen did not have tape on the back. V2 also stated she worked on Saturday, 08/13/22 from 11:00 AM to 4:00 PM due to the agency RN (V6) leaving mid shift around 11:00 AM that day. V2 stated she only counts narcotics when she takes over a med cart and on 08/13/22, she worked the floor and did other nursing duties without the opportunity to count meds that day. She did not work on 08/14/22. The last verifiable date that R3's medication card for [MEDICATION(S)]-acetaminophen did not have tape on the back was on 08/12/22 by V2 and V7, as stated above in their interviews. On 08/31/22 at 10:42 AM, V8 (LPN) stated she worked on 08/13/22 and 08/14/22 and did narc counts on both days with V9 (LPN). V8 stated she didn't notice tape on the back of R3's card but confirmed she didn't flip the card over and look at the back. In the facility investigation it is noted that all facility nursing staff returned to the facility after being called on 08/15/22, submitted to a drug test to include V2 (DON), V3 (ADON), V5 (LPN), V7 (LPN), V8 (LPN), V9 (LPN), and V10 (LPN). All facility nursing staff tested negative for drugs and R3's facility incident investigation contained copies of these negative drug screens. Agency staff working in the facility during this time were V6 (RN) and V11 (LPN). V6 and V11 have not submitted for testing. An attempt was made by this surveyor to contact V6 (Agency RN) on 08/30/22 at 12:03 PM. V6 did not answer, the voicemail box was full, and a message was not able to be left. An attempt was made by this surveyor to contact V11 (Agency LPN) on 08/30/22 at 12:06 PM. V11 did not answer the phone, however this surveyor left a message for her to return my phone call. By the end of the investigation V11 had not returned the call. A facility policy titled, Abuse Prevention Program dated April of 2018 documents in part - Definitions: Abuse: Abuse is the willful infliction of injury .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 . Misappropriation of resident property: misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .

Based on Interview and record review, the facility failed to assess a resident and send them for further evaluation for 1 of 3 (R2) residents reviewed for symptoms of Pneumonia in the sample of 3. This failure resulted in R2 being admitted to the Intensive Care Unit on 4/26/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The undated facility document titled, Face Sheet documents R2's Admittance date of 08/13/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS) Section C, dated 02/18/22 documents: a Brief Interview of Mental Status (BIMS) score as a 15 (Cognitively Intact). On 05/09/22 at 1:30 PM, R2 was observed returning back to the facility from a hospital stay via a stretcher and two paramedics. On 05/11/22 at 11:12 AM, R2 stated, she is feeling better now, she was really sick for a while she was in the Intensive Care Unit (ICU). R2 stated she was in the hospital for around 15 days. She was so sick; she had such a bad cough when she left the facility. R2 stated, she told them (the staff) she needed to go to the hospital. She was weak and felt miserable. R2's Hospital records document by V4 (Physician/Hospitalist): admitted : 04/26/2022, Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Chief complaint: productive cough. Review of Symptoms documents: Positive for cough and shortness of breath, positive for back pain, positive for weakness and appearance: she is ill-appearing. R2's Hospital records by V12 (Physician/Hospitalist) document, at 11:05 PM on 04/26/22, Impression: Mild to moderate bibasilar consolidation, increased from the prior exam. This could represent Atelectasis, Aspiration Pneumonia, and/or Pneumonia. R2's Hospital notes dated 04/26/22 at 19:33 (7:33 PM) by V13 (Physician/Hospitalist) document: Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: [CONDITION(S)]. Emergency Department (ED) course/Medical Decision making: Pulse Ox: SpO2: 94% on 3L (Liters) NC (nasal cannula). No current [CONDITION(S)]. ED Course: dated Differential is broad but based off the shortness of breath and cough suspect Pneumonia versus Upper Respiratory Infection versus Chronic Heart Failure We will also get [MEDICATION(S)] and blood cultures under the suspicion patient may have a Pneumonia. R2's Hospital notes by V13 (Physician/Hospitalist) at 04/27/22 at 0101 (1:01 AM) document Clinical Impression: Pneumonia (primary) Disposition: Admit. On 04/19/2022 at 10:52 AM R2's progress notes documents, V11's (Physician) office called and spoke with nurse about resident's increase in pain last night and O2 saturation of 90 % Nurse stated, 'I will let the doctor know and we will get back with you if she wants to change anything.' On 04/18/22 at 2:50 PM, V11 (Physician) stated, she does not remember if she was notified of that event, she probably was, she is notified by the nursing facility all the time about different events. She does not remember R2's cough, when she was in there on 04/17/22 she believes she was fine. On 04/26/2022 at 06:36 PM, R2's progress notes documents, (V5 (Licensed Practical Nurse)) has called the ambulance to transport resident (R2) to Emergency Department (ED) and has called ED to give report that resident will be coming with c/o (complaints of) neck pain from fall that happened approximately 2 months ago. On 04/28/2022 at 07:41 AM, R2's progress notes documents, According to hospital resident was admitted with Acute Respiratory Failure/Pneumonia. On 05/11/22 at 10:44 AM, V4 (Physician/Hospitalist) stated, upon presentation R2 had a bad wet cough. She had Pneumonia prior to coming into the hospital but could not state for how long prior. Upon X-ray review, he would say R2 had Pneumonia at least a few days prior. Upon entry to the hospital R2 was coughing quite a bit, a wet productive cough. R2 could have come to the hospital a few days earlier. They (the facility staff) may have not taken her symptoms as seriously as should have. R2 was admitted to the hospital, to the Intensive Care Unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/12/22 at 10:10 AM, V2 (Director of Nursing (DON)) stated, residents would be evaluated for X-rays to be ordered or to be sent out for further evaluation if their lungs were diminished, there was wheezing coughing up phlegm, or shortness of breath. V2 (Director of Nursing) stated, she does not remember if R2 had chest X-rays done. V2 (DON) stated, she does not remember R2 having a cough, she was sent to the hospital for neck pain and acquired pneumonia while she was at the hospital. As of 05/06/22 there was no documentation of an X-ray for R2 prior to going to the hospital. On 05/11/22 at 12:15 PM, V8 (Licensed Practical Nurse (LPN)) stated, R2 did have a cough, she thought she had an X-ray done. R2 did also have complaints of neck and shoulder pain since a previous fall. When Oxygen saturations are taken, the value is entered in the MAR (Medication Administration Record) along with whether the individual is on Oxygen or not and the amount of Oxygen the individual is on. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] < 92% apply Oxygen 2ml Via Nasal Cannula check during dayshift, (DX: unspecified Bacterial Pneumonia) once a day; 6:00 AM - 6:00 PM and 04/09/2022 - 04/29/2022 Oxygen special Instructions: < 92% apply Oxygen 2ml via nasal cannula check during dayshift and PRN (as needed) (DX: unspecified Bacterial Pneumonia) Once a day; 6:00 AM - 6:00 PM. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation on the POS of an order to increase R2's Oxygen to 3 liters. On 05/18/22 at 12:30 PM, V3 (Assistant Director of Nursing) stated, if a resident's Oxygen saturation is less than 92% and they are already receiving Oxygen, they will notify the physician and increase the rate of Oxygen given and recheck the Oxygen saturation again later. R2's Oxygen was increased to 3 liters on 04/24/22 due to her Oxygen saturation being below 92%. R2 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation of R2's Oxygen saturation prior to increasing the Oxygen to 3 liters on 4/24/22. On 05/12/22 at 2:00 PM, V1 (Administrator) stated, she is not a nurse, therefore she would advise a nurse to evaluate the resident for X-rays or being sent out for further evaluation. V1 (Administrator) stated, R2 was sent to the hospital for neck pain, she acquired Pneumonia at the hospital. On 05/20/22 at 2:15 PM, V10 (Licensed Practical Nurse) stated, she does not remember if R2 had a cough prior to going to the hospital because there were a lot of residents that had a cough during that time frame. On 05/11/22 at 11:15 AM, R1 stated, R2 did have a bad cough for a while then she went to the hospital. She could hear her coughing a lot at night and she was pretty sick. R1 stated she then started coughing pretty bad after R2 left for the hospital. She got an X-ray and had [CONDITION(S)]. She is glad she did not have Pneumonia. On 04/26/2022 at 02:53 PM, R1's progress notes document, Administrator spoke with resident and R1 is complaining about roommate keeping her up at night. Administrator asked R1 if she would like to be moved and R1 stated 'No'. On 05/11/22 at 12:40 PM, R1 stated, R2 was just keeping her up at night with her coughing. She did not want to change rooms; she was just having a hard time sleeping with R2's coughing. R1's Minimum Data Set (MDS) dated [DATE] documents her Brief Interview for Mental Status (BIMS) is documented as 15 (cognitively Intact). On 05/18/22 at 2:30 PM, V1 (Administrator) stated, the facility does not have a policy on assessments to send a resident out for further evaluation or to the hospital.

Based on interview and record review, the facility failed to accurately report a decline in condition and seek timely medical treatment for 1 (R2) of 3 residents reviewed for decline in condition in the sample of 11. These failures resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to accurately report and seek timely medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] & pneumonia. This past noncompliance occurred from [DATE] to [DATE]. V20, Regional Director, and V1, Administrator were notified of the Immediate Jeopardy on [DATE] at 10:38 AM. The surveyor confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE]. Findings Include: R2's admission record with a print date of [DATE] documents that R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE], documents under section C, R2's Brief Interview for Mental Status (BIMS) summary score is 15 which indicates R2 is cognitively intact. R2's MDS documents under section GG, Functional Status that R2 is independent with eating, oral hygiene, upper body dressing, rolling left to right in bed, lying to sitting on side of bed and sitting to lying back in bed, set-up/clean up assistance with toileting hygiene, lower body dressing, putting on/off footwear, supervision with transfers, moderate assistance with showers/bathing. R2's same MDS documents under section L that R2 is assessed as having no teeth. R2's medical record document, titled, Hospital Admission Summary, dated [DATE], at 7:33 p.m., documents (R2) with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing home initially sent patient to the emergency department because she received her roommate's medications yesterday. These medications were 200 mg (milligram) [MEDICATION(S)], 6.25 mg [MEDICATION(S)], 10 mg Cetirizine, 100 mg [MEDICATION(S)], 20 mg [MEDICATION(S)], 50 mg [MEDICATION(S)], 5 mg [MEDICATION(S)], 40 mg [MEDICATION(S)]. According to the nursing home, the patient received the right medication today. The patient was hypotensive with EMS. They report a blood pressure of 70/palp (palpable). They gave her a 300 bolus of [MEDICATION(S)] (LR), and she seemed to improve. Her BP (blood pressure) on arrival was ,d+[DATE]. The patient appears altered on exam. She is responsive but unable to provide many answers. This same hospital admission summary documents R2 was admitted to the hospital on [DATE] with an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's hospital record dated [DATE], documents under portable Anterior Posterior (AP) view chest There are bilateral lower lung pulmonary opacities. This is suggestive of multifocal pneumonia. R2's hospital notes dated [DATE], documents It was also noted during this time, that there was mold growing on her (R2's) upper dentures. R2's hospital record dated [DATE], documents under Assessment/Plan: [CONDITION(S)] secondary to multifocal pneumonia and [CONDITION(S)] with multi-organ failure, initiated [MEDICATION(S)] and [MEDICATION(S)] for HAP (hospital acquired pneumonia) and [CONDITION(S)], added [MEDICATION(S)], as clinically rapidly deteriorating despite broad-spectrum antibiotic coverage and RN (Registered Nurse-V15) reports mold growing from oral mucosa and denture, s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Despite these measures, patient continues to deteriorate rapidly. Discussed goals of care with next of kin, (sister), who is the only remaining relative the patient has, sister is now ready for patient to transition to comfort care, given her advanced age, poor previous level of functioning, and overwhelming infection, which is unlikely to resolve despite broad-spectrum antibiotics. Under Hospital Course, R2's hospital discharge summary documents, [AGE] year-old female (R2) presented with [CONDITION(S)] secondary to multifocal pneumonia with [CONDITION(S)] and multi-organ failure. Despite broad-spectrum antibiotics and aggressive fluid resuscitation, the patient continues to deteriorate rapidly. Nursing staff noticed the patient's dentures were full of mold raising suspicion for fungal infection contributing to refractory [CONDITION(S)]. [MEDICATION(S)] was empirically initiated also without clinical response after 2 days. The patient's mental status continues to worsen to obtundation. Given advanced age, very poor previous functioning prior to admission, multiple comorbidities, and overwhelming infection with multi-organ failure, this patient carries a grave prognosis. Multiple discussions on goals of care held with family which is the patient's niece in-law and sister. Eventually the patient was made comfort care on [DATE], afternoon, and passed away peacefully on [DATE] at 12:35 a.m. This hospital record documents hospital associated pneumonia which would indicate R2 developed pneumonia after her admission to the hospital, however her chest x-ray documents R2 had multifocal pneumonia on [DATE], her day of admission to the hospital. On [DATE], at 9:00 a.m., V15 (local hospital Registered Nurse), stated that on [DATE], at 9:50 a.m., she was taking care of R2 and removed R2's dentures and she noticed the upper, inside area of the dentures that holds up against the roof of the mouth was completely covered with black spots of mold, the outside area of the teeth was covered with caked on food particles. V15 stated there were no visible signs of sores inside R2's mouth. V15 stated she notified V7, (Local Hospital Physician), immediately and voiced her findings to him that R2's dentures could possibly be a potential cause of R2's infection. V15 stated that R2 was having a decline in her condition and V15 stated she was getting ready to transfer R2 to the intensive care unit at that time. R2's Facility's document, titled, Event Report, dated [DATE], at 7:45 a.m. documents R2 was given her roommate (R4's) medications by V2 (Director of Nursing). The report documents under observation the following adverse drug reactions are present, Other-Diarrhea and nausea. This same report documents under interventions, doctor notified, resident notified, blood pressures measured thru out the day. The event report does not document what incorrect medications R2 received. On [DATE], at 1:00 p.m., V2, Director of Nursing, (DON), stated that she was training with V3, Assistant Director of Nursing, (ADON), and was administering medications on [DATE], during the morning medication pass. V2, stated that upon entering R2's room, she asked R2 if she was R4. V2 stated that R2 stated yes and V2 gave R2 the medications. V2 stated after going back to the medication cart to administer R4's medications, she realized she had given R2, R4's medications. V2 stated that at that time, V3 called R2's primary care physician and reported the medication error. V2 stated that she has only been working at the facility for about 8 weeks. On [DATE], at 1:15 p.m., V3, Assistant Director of Nursing, (ADON), stated that she was training V2, (DON), on [DATE], at 7:45 a.m., with administering medications during the morning medication pass. V3 stated that V2 told her that she had given the wrong medications to R2. V3 stated that she then called V14, (Primary Care Physician) of R2 and notified V14 of the medication error. V3 stated V14 ordered to monitor blood pressure every two hours and increase fluids. R2's progress notes document the following: [DATE], 10:23 a.m. Notified doctor in regard to nausea and diarrhea. New order given to take blood pressure every two hours and increase fluids. Notified doctor that blood pressure was ,d+[DATE] and doctor stated, That is not a bad blood pressure, increase water intake. [DATE], 12:30 p.m. Blood pressure ,d+[DATE]. [DATE], 2:30 p.m., Blood pressure ,d+[DATE]. [DATE], 3:12 p.m., Resident has had 3 episodes of diarrhea today. She is complaining of nausea and abdominal pains. Offering clear, liquid diet for supper. Will continue to monitor. [DATE], 4:00 p.m., Blood pressure ,d+[DATE]. Resident answered questions appropriately. Drank some water and orange juice and had a couple of sips of chicken and beef broth. She stated, I am feeling somewhat better, but my belly is still cramping. Will continue to monitor. [DATE], 5:36 p.m., res (resident) refused her broth for pm (evening) meal, she agreed to drink water, res stated she was feeling better, bp (blood pressure) ,d+[DATE], p (pulse) 66, res denies nausea or upset stomach, 0 loose stools, res instructed to use call light for help to get up, res denies dizziness, will continue to monitor. [DATE], 6:18 p.m., Upon coming on to shift, reported to this nurse by day nurse that orders received to monitor res bp every 2 hours. Res bp checked by this nurse using a manual cuff and stethoscope, BP ,d+[DATE] at 6:15 p.m. Res A&O (alert and oriented) x 3, c/o (complains of) upset stomach and loose stools. Will continue to monitor. [DATE], 8:26 p.m., This nurse checked res bp at 8:10 p.m. with a manual cuff to LUE (left upper extremity), BP ,d+[DATE]. Res A&O x 3, c/o upset stomach but denies loose stools in last 2 hrs. (hours) Will continue to monitor. [DATE], 10:08 p.m., Res BP checked via manual cuff by this nurse at 10:00 p.m. BP ,d+[DATE]. Res A&O x 3, sitting up on edge of bed, Res continue to c/o upset stomach and asked this nurse to get one of her cans of ginger ale out of her drawer. This nurse assisted res put legs up in bed, elevated HOB (head of bed) and gave res a sip of ginger ale. Will continue to monitor. [DATE], 12:13 a.m., Res BP checked by this nurse via manual cuff; BP ,d+[DATE]. Res laying and sleeping in bed. Res woke easily when this nurse told res she was going to check BP again, res c/o cuff being kind of tight. This nurse assisted res to take a couple of sips of water and readjusted O2 (oxygen) nasal canula in nose. Will continue to monitor. [DATE], 2:21 a.m., Res BP checked by this nurse via manual cuff; BP ,d+[DATE]. Res noted sitting on edge of bed, with O2 nasal canula sitting across lap. This nurse assisted res with putting nasal canula back in nose and lay res back in bed. Res thanked nurse and closed eyes. Will continue to monitor. [DATE], 3:54 a.m., Res had gotten up to use toilet, without O2, while trying to get back to bed, Res became very weak and confused, asking where we are and if we are in Australia. This nurse and CNA (certified nursing assistant) assisted res back to bed. Upon assessment, O2 Saturation (O2 Sat) 69%, titrated O2 up to 5L (liters) over a period of 20 minutes to get O2 Sat up to 92% on NC (nasal canula), and on big O2 tank and off the O2 concentrator, BP was initially ,d+[DATE], P 116, at 3:25 a.m., currently BP ,d+[DATE], P 88, res is becoming more lucid, able to tell nurse where she is and room number. Will continue to monitor. [DATE], 5:20 a.m., Res condition continues to improve, Res O2 Sat (oxygen saturation) remains at 92% on 5L per NC (nasal cannula), BP currently ,d+[DATE], P 94. Will continue to monitor. [DATE], 12:20 p.m., res not wanting to eat lunch, continues to say she doesn't feel well, O2 Sat 92% on 3L/NC, increased to 4 able to get O2 up to 95%. Kept saying just doesn't feel well. [DATE], at 4:27 p.m., res sleeping this nurse not able to get res to wake well, CNA able to get res awake and up to sitting position, res not wanting to eat, res not answering questions. Vitals WNL (within normal limits), pulse at 92, O2 back to 92% on 4L, increased to 5L, able to get O2 Sat back to 95%, pale res cont. (continues) to say doesn't feel well. [DATE], 7:25 p.m., res color gray, not able to get a good BP, res not answering questions, holding chest, best BP 118/in the 50's faint, pulse irregular and at 99 - 110, O2 Sat 95% on 5L/NC, lethargic, area around mouth has blue tint, res looking gray. [DATE], 7:29 p.m., res full code, sent to ER (emergency room ) for eval (evaluation), notified ambulance, left with res. [DATE], 7:36 p.m., called family, notified admin (Administrator), DON, ADON, attending bed hold policy sent with res, called hospital, gave report. R2's facility medical record does not document R2's blood pressure was monitored every two hours after 5:20 AM on [DATE]. R2's progress notes document blood pressures on [DATE] at 5:20 AM, 4:27 PM (documented as within normal limits with no figure documented), and at 7:25 PM. On [DATE] at 10:45 AM, V10, (Licensed Practical Nurse), stated she provided care to R2 the night before R2 was transferred to the hospital on [DATE]. V10 stated R2 appeared less confused than she had been when she first came on to her shift. V10 stated R2 did complain of stomach pain. V10 stated this was something R2 would do from time to time and R2 would ask for Modicum at times. V10 stated on the night before R2 was sent to the emergency room she was in R2's room assisting her roommate when R2 got up and went to the bathroom. V10 stated when R2 exited the bathroom her incontinence brief was around her knees and R2 was confused. V10 stated she assisted R2 to bed and checked her vital signs. V10 stated R2's blood pressure was better than it had been all night. V10 stated she checked R2's oxygen saturation because R2 didn't wear her oxygen to the bathroom. V10 stated R2's oxygen saturation was only 69%. V10 stated she administered oxygen via a concentrator and started titrating the oxygen up. V10 stated that did not seem to be helping so she had the Certified Nursing Assistant, (V18), get her a pure oxygen tank and titrated it up to 5 liters. V10 stated R2's oxygen saturation went up to 92% at that time. V10 stated she stayed with R2 about 15 minutes to ensure it stayed about 90%. V10 stated she checked R2's oxygen saturation about every 15 minutes after that. When asked if she notified R2's physician she stated she thought she remembered only one other time R2's oxygen saturation had dropped like that. V10 stated it was over a year ago when R2 had pneumonia. V10 stated R2's oxygen saturation did not drop like that routinely. When asked again if V10 had notified R2's physician. V10 stated she had not heard the question correctly and stated, No, I passed it on to the AM nurse. V10 stated it was approximately 4:15 AM when she left R2's room and she was catching up on everything else she had to do. V10 stated R2's oxygen saturations were back up where they needed to be and getting a hold of R2's doctor at that time of night is nearly impossible. When asked if R2's physician was the facility medical director V10 stated they were not. When asked if she could notify the facility medical director if she wasn't able to reach a resident's primary care physician V10 stated she could. When asked if she would typically call a physician or send a resident to the hospital with an oxygen saturation of 69% V10 stated, Yes, if I couldn't get the oxygen levels up myself. V10 stated she thought it was odd R2's oxygen saturation was that low because that never happens with R2. V10 stated if it hadn't come back up, she would have sent R2 to the hospital. V10 stated R2 wears oxygen continuously but would sometimes go the bathroom or the dining room without it. When asked if she had checked R2's temperature at that time because it wasn't documented V10 stated she had, and it was 97 something. V10 stated she was aware of the previous medication administration error and had been manually checking R2's blood pressure every two hours. V10 stated R2 was independent with denture care. V10 stated R2 would sleep with them in her mouth and with her mouth open and her dentures would dangle down. V10 stated she would try to get R2 to take them out and instead R2 would just push them back in place. V10 stated this had been common behavior for R2 for months. V10 stated she would see R2 brushing her dentures when she would pass medications in the morning. When asked how R2 brushed her dentures V10 stated she could remember R2 rinsing them off but couldn't remember seeing R2 brush them. When asked if she did routine oral assessments on residents with dentures V10 stated she would look in residents' mouths when she did a Medicare part A assessment on them and if they were a new admit or if a resident had a complaint. On [DATE], at 3:40 p.m., V18, (Certified Nurse Assistant) (CNA), stated that she was working at the facility on [DATE] (6pm-6am) and on [DATE] (6pm-6am). V18 stated that she was aware that R2 had received the wrong medications and that she was checking her blood pressure every 2 hours as ordered and all the blood pressures she obtained were within normal limits. V18 stated that early in the morning around 4:00 a.m., she went to get an O2 tank for the nurse. V18 stated that the nurse at that time was checking R2's pulse ox and was trying to get it up. V18 stated that at that time, R2 seemed a little lethargic, slightly confused. V18 stated that when she came back in the next evening on [DATE], she went to check in on R2 and noticed that R2 was not acting right. V18 stated R2 couldn't talk or breathe right and R2 did not have much skin color. V18 stated that she went to get the nurse right away to come down and check on her. V18 stated that R2 refused dental care and she would try to encourage R2 to have her clean them. V18 stated that R2 slept with her dentures in and stated that R2's dentures looked like they were going to fall out of her mouth a lot of the time. On [DATE], at 1:30 p.m., V4, (Licensed Practical Nurse), stated that she worked on [DATE], from 8:00 am. to 7:30 p.m. V4 stated that she took care of R2 that day. V4 stated that R2 did not eat any breakfast that morning and complained of not feeling well. V4 stated R2 did take her medications that morning and she encouraged R2 to try to eat and drink that morning. V4 stated that she checked R2's blood pressure that morning and it was in a normal range. V4 stated that at lunch, R2 continued to say she did not feel well and did not feel like eating. V4 stated she encouraged R2 to try to eat and drink fluids. V4 stated that around 4:30 p.m. that day she checked on R2 and R2 was having difficulty arousing to wake. V4 stated that V13, (Certified Nurse Aide/CNA), was able to get R2 awake and sit her up on the side of her bed. V4 stated that R2 did take her medications and ate a few bites of her supper meal. V4 stated she checked on R2 around 5:00 p.m. and she was resting. V4 stated that at around 6:45 p.m., she went to assess R2, and her skin color looked gray and the area around the outside of R2's mouth had a blue tint color, R2 was holding her chest, not answering questions, appeared lethargic, she could not get a good blood pressure and R2's pulse was irregular. V4 stated she notified V14, (Physician), and R2 was sent out to the emergency room . On [DATE], at 2:11 p.m., V13, (CNA), stated he provided care to R2 on the evening she was transferred to the hospital. V13 stated the main thing he remember that day was that he took R2 her dinner tray. V13 stated R2 was sleeping. V13 stated R2 was slow but still coherent enough to sit on the side of the bed and eat. V13 stated R2 was able to verbalize to him to a point. When asked if that was R2's normal. V13 stated R2 would normally be sitting on the side of the bed when he went into her room. V13 stated R2 was definitely tired. When asked if R2 complained of anything or looked different. V13 stated R2 looked exhausted. When asked if he was the CNA who got the nurse to assess R2 prior to her being transferred to the emergency room , V13 stated he believed he was. When asked why he got the nurse V13 stated R2 just wasn't acting like herself. V13 stated the nurse responded quickly when she was notified of R2's condition. When asked if he was aware R2 had received the wrong medication on [DATE] V13 stated he was told about it after notifying the nurse of the change in R2. When asked if he had been notified of any extra monitoring when he came on shift. V13 stated, No, I was told she (R2) was acting normal. When asked if he monitored R2's blood pressure every two hours throughout his shift V13 stated he had not. V13 stated he came on shift at 2:00 PM and passed the dinner tray around 4:30 PM. V13 stated once he reported R2's condition to the nurse she had him get a blood pressure and he is not sure if the other CNA, V18, got one before that. When asked if he ever cleaned R2's dentures V13 stated he had not and that R2 was very protective of her dentures. V13 stated she would hide them in a Kleenex box when she took them out so the facility staff wouldn't clean them. V13 stated as far as he knew R2 cleaned them every night, but she wouldn't let him clean them at all. On [DATE] 2:52 PM, V5, (CNA), stated she provided care to R2 on the day she went to the hospital and left her shift around 1:30 PM or 2:00 PM that day so she wasn't at the facility when R2 was sent to the hospital. V5 stated R2 was sitting on the edge of her bed that day, complained of her stomach hurting, but other than that there were no issues. V5 stated she was checking R2's blood pressure every two hours throughout her shift but could not remember what R2's blood pressure readings were. V5 stated the CNA's check the vital signs but the nurses chart them. V5 stated R2 always had stomach pain and diarrhea so that was not new for her. When asked if she ever provided denture care for R2 V5 stated, She (R2) wouldn't let me. V5 stated R2 took care of them herself and never took them out of her mouth. On [DATE], at 11:04 a.m., V3 (ADON) stated R2 did not have an oral assessment done by the facility staff after the initial assessment was done on [DATE]. When asked if R2 had seen a dentist after that V3 stated she had checked with their dentist yesterday and they told her R2 had not been seen because they refused. When asked who refused, V3 stated she guessed the family. V3 stated she sends the dental service the resident face sheet and they contact the family to see if they want their services. When asked what happens if a resident doesn't want their services V3 stated then we ask them who their dentist is and/or try to find them one in the community. V3 stated it is very hard to find a dentist who accepts R2's insurance. When asked how often oral assessments are done by the facility staff V3 stated on admission. When asked if the facility did routine oral assessments on residents V3 stated they do them on admission and if there is a problem. On [DATE], at 11:25 a.m., V3, (Assistant Director of Nursing/ADON), stated that R2 had an order to wear oxygen at night and was known to take the oxygen off and if her O2 Saturation was low (69%), oxygen would be reapplied on her and if after 20 minutes or so, R2's oxygen level would not have come up above 90%, the physician would be notified at that time. V3 stated she would expect the nursing staff to continue BP every 2 hours unless the BP had leveled out. I asked V3 since R2 complained of not feeling well on [DATE], Should the staff have continued BP every 2 hours? V3 stated that R2 was pretty much fine except when her O2 Sat dropped in the morning of [DATE] and she was fine until she was sent out to the hospital in the evening. On [DATE], at 4:20 p.m., V16, (Family member), stated that she visited R2 almost every day at the nursing home. V16 stated that she never witnessed R2 clean her dentures, have any foul odors coming from her mouth, and R2 did not complain of any mouth pain. V16 stated that R2's dentures looked like they were a little loose and she could not recall when she last saw a dentist. V16 stated that R2 was alert and took care of herself and was dressed and looked appropriate when she went to visit her. On [DATE], at 1:00 p.m., V14, (Physician), stated that she was notified on [DATE], in regards, to R2 receiving her roommate's medications. V14 stated she ordered R2's blood pressure to be checked every two hours, increase R2's water intake, and notify her if R2 had a decline in her condition or blood pressure readings. V14 stated she was not notified again about R2's condition until [DATE], around 7:00 p.m. V14 states she sees residents once a month and was not aware R2's dentures were moldy. On [DATE], at 10:00 a.m., spoke with V17, (Medical Director) and asked him, If a resident has a decline in condition where they become lethargic, confused and their O2 Saturation drops to 69% and it takes the nurse after applying oxygen ,d+[DATE] minutes to get the O2 Saturation above 90%, is that a time when a physician should be notified about this change in condition? and V17 stated, Yes. V17 stated that he was at the facility on Friday, [DATE], doing his rounds and was not aware of R2 having mold found on her dentures. V17 stated, Are there any pictures of that? I told him, I am not aware or have seen any pictures at this time. I asked V17, How often should staff assess residents' mouth and dentures? V17 stated the staff usually checks on them nightly and to follow the professional standards of practice. V17 stated that he does not cover V14's, (Primary Care Physician), residents, but that the facility staff knows they can contact him at any time regarding concerns with any of the residents at the facility. On [DATE], at 2:00 p.m., V7, (Hospital Physician) stated that R2 was transferred from the nursing home to the emergency roiagnom on [DATE], at 7:30 p.m., with a change in mental status and low blood pressure. V7 stated that R2 was given her roommate's medications on [DATE] and had received her own medications on [DATE]. V7 stated that R2 was responsive but not able to answer any questions appropriately on [DATE]. V7 stated that R2 received intravenous fluids and laboratory bloodwork was obtained that showed R2 had an infection. V7 stated that R2 was given intravenous antibiotics at that time. V7 stated that on [DATE], 9:50 a.m., V9, (Registered Nurse), notified him that she had found mold on R2's upper, inside dentures. V7 stated upon those findings, he ordered intravenous anti-fungal treatment which R2 received for a couple of days with no improvement noted. V7 stated that R2's condition started to rapidly decline, and the family was notified and R2 was put on comfort care and passed away on [DATE]. V7 stated that with R2 receiving the wrong medications, her increased lethargy and delay in seeking further medical treatment, along with the mold findings on her dentures were contributing factors for the rapid decline in her condition that resulted in her death. R2's Death Certificate documents R2's expired on [DATE] and lists the causes of death and appropriate interval between on set and death as a) [CONDITION(S)], 3 min; b) [CONDITION(S)] with mulit organ failure, 3 days; and c) pneumonia, 5 days. R2's care plan, revised date - [DATE], start date- [DATE], documents ADL Functional/Rehabilitation Potential, Resident is independent with grooming and hygiene. She does her own denture care. She refuses to let staff take out dentures. Short term goal date- [DATE], Resident will maintain current status. Approach start date - [DATE], Independent. No other interventions documented. CMS's (Center for Medicare and Medicaid Services) Version 3.0 Manual documents under Oral /Dental Status, Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions, such as aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes. Under steps for assessment it documents, 6. Oral examination of residents who are uncooperative and do not allow for a thorough oral exam may result in medical conditions being missed. Referral for dental evaluation should be considered for these residents and any resident who exhibits dental or oral issues. According to https://www.prosthodontics.org/assets/[DATE]._JOP_Denture_Care_Guidelines_Supplement1.pdf, under section, Guidelines for the care and maintenance of dentures, 15. Patients who wear dentures should be checked annually by the dentist, prosthodontist, or dental professional for maintenance of optimum denture fit and function, for evaluation for oral [CONDITION(S)] and bone loss, and for assessment of oral health status. The Facility Policy, [CONDITION(S)], dated ,d+[DATE], under Assessment and Recognition, 1. A nurse will assess a resident with a suspected infection and document related findings. Assessment date will include k) Description of any new or worsening decline in functional status, including confusion, incontinence, falling, decreased mobility, reduced food intake and lack of cooperation with staff. 2. The nurse will report findings to the physician or provider. An Immediate Jeopardy was identified to have begun on [DATE]. V1 (Administrator) and V20 (Regional Director) were notified of the Immediate Jeopardy on [DATE] at 10:38 AM. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy as confirmed through observation, interview, and record review: Identified Incident of Immediate Jeopardy: Resident (R2) received other residents' medications [DATE] at approx. (approximately) 7:30 am, MD (physician) was notified, and orders received to monitor residents blood pressure and increase fluids. Monitoring continued until 5:20 am on [DATE] due to blood pressure stabilized. Resident oxygen desaturated at 3:54 am to 69% when up going to bathroom without wearing ordered oxygen, nurse applied oxygen as ordered and oxygen saturation recovered to 92%. On [DATE] at 7:25 pm resident was sent to emergency room for evaluation and admitted for [CONDITION(S)], pneumonia, and altered mental status. Proposed Removal Plan: Other Residents with Potential to be affected by the Immediate Jeopardy Incident: All residents have the potential to be affected by alleged deficient practice. Staff Identified: All nursing staff in facility is identified as responsible for resident's safety. Notification of the Allegation of Immediate Jeopardy: V17 (Medical Director) Immediate Changes to Facility Systems: The two nurses identified in alleged deficient practice in-serviced by V20, BSN (Bachelor of Science in Nursing), RN, LNHA (Licensed Nursing Home Administrator), Regional Director/V1 LNHA (Administrator), on med (medication) pass policy/procedures. Started [DATE] and Completed [DATE]. All licensed nursing staff in-serviced on medications pass policy/procedures by V2 (RN, DON)/V3 (ADON)/V1 LNHA (Administrator). Started [DATE] and Completed [DATE]. All licensed nursing staff in-serviced by V2 (RN/DON)/V3 (ADON)/V1 LNHA (Administrator) on change of condition notification policy. Started [DATE] and Completed [DATE]. Policies were reviewed and meet current standards. Training The two nurses identified in alleged deficient practice in-serviced by V20 (BSN, RN, LNHA, Regional Director)/V1 LNHA (Administrator) on med pass policy/procedures. Started [DATE] and Completed [DATE]. All licensed nursing staff in-serviced on medication pass policy/procedures by V2 (DON)/V3 (ADON)/V1 (Administrator). Started [DATE] and Completed [DATE]. All licensed nursing staff in-serviced by V2 (DON)/V3 (ADON)/V1 (Administrator) on change of condition notification policy. Started [DATE] and Completed [DATE]. All staff nurses were able to be trained by coming in on their off day. Ongoing Monitoring All licensed nursing staff will be trained during orientation and quarterly for 1 year regarding medication pass policy and procedures. A [TRUNCATED]

Based on interview and record review, the facility failed to notify the primary care physician when a decline in condition occurred for 1 (R2) of 3 residents reviewed for notification in the sample of 11. This failure resulted in R2's physician not being notified of R2 having an oxygen saturation of 69%, complaints of not feeling well, and increased fatigue which resulted in R2 being admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: R2's admission record with a print date of [DATE] documents that R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS), dated [DATE], documents under section C, R2's Brief Interview for Mental Status (BIMS) summary score is 15 which indicates R2 is cognitively intact. R2's progress notes document the following: [DATE], 3:54 a.m. documents, Resident had gotten up to use toilet, without O2 (Oxygen), while trying to get back to bed, resident became very weak and confused, asking where we are and if we are in Australia. This nurse and CNA (Certified Nursing Assistant) assisted resident back to bed. Upon assessment, O2 Saturation 69%, titrated O2 up to 5L (liters) over a period of 20 minutes to get O2 Sat (Saturation) up to 92% on NC (nasal cannula) and on big O2 tank and off the O2 concentrator, BP (Plood Pressure) was initially ,d+[DATE], P (pulse) 116, at 3:25 a.m., currently BP ,d+[DATE], P88, resident is becoming more lucid, able to tell nurse where she is and room number. Will continue to monitor. [DATE], 5:20 a.m., Resident condition continues to improve, Resident O2 Sat (Oxygen Saturation) remains at 92% on 5L per NC (nasal cannula), BP currently ,d+[DATE], P94. Will continue to monitor. [DATE], 12:20 p.m., resident not wanting to eat lunch, continues to say she doesn't feel well, O2 Sat 92% on 3L/NC, increased to 4L able to get O2 up to 95%. Resident kept saying just doesn't feel well. [DATE], at 4:27 p.m., resident sleeping this nurse not able to get resident to wake well, CNA able to get resident awake and up to sitting position, resident not wanting to eat, resident not answering questions. Vitals WNL (within normal limits), pulse at 92, O2 back to 92% on 4L, increased to 5L, able to get O2 Sat back to 95%, color pale, resident continues to say doesn't feel well. [DATE], 7:25 p.m. documents, resident color gray, not able to get a good BP, resident not answering questions, holding chest, best BP 118/in the 50's faint, pulse irregular and at ,d+[DATE], O2 Sat 95% on 5L/NC, lethargic, area around mouth has blue tint, resident looking gray. R2's progress notes, [DATE], 7:29 p.m., resident full code, sent to ER (emergency room ) for evaluation, notified ambulance, left with resident. R2's progress notes do not document R2's physician was notified of the changes in R2's condition. On [DATE] at 10:45 AM, V10, (Licensed Practical Nurse), stated she went into the room to help R2's roommate to the bathroom and while she was in the room, R2 got up by herself and went to the bathroom. V10 stated when R2 came out of the bathroom her incontinence brief was still down around her knees and she was confused. V10 stated she assisted R2 back to bed and checked her vital signs. V10 stated R2's Blood Pressure was better than it had been all night. V10 stated she checked R2's oxygen saturation because R2 didn't wear her oxygen to the bathroom. V10 stated R2's oxygen saturation was only 69% and she put oxygen on via a concentrator and started titrating the oxygen up. V10 stated it wasn't cutting it, so she had the CNA, (V18), go get a pure oxygen tank and titrated it to 5 liters and R2's oxygen saturation went up to 92%. V10 stated she stayed with R2 about 15 minutes to ensure her oxygen saturation stayed about 90%. V10 stated she checked R2's oxygen saturation about every 15 minutes after that. When asked if she notified R2's physician, V10 stated she thought she remembered only one other time R2's oxygen saturation had dropped like that, and it was over a year ago when R2 had pneumonia. V10 stated R2's oxygen saturation did not drop like that routinely. When asked again if she had notified R2's physician of this occurrence, V10 stated, No, I passed it on to the AM (morning shift) nurse. On [DATE], at 11:25 a.m., V3, (Assistant Director of Nursing), (ADON), stated that R2 had an order to wear oxygen at night and was known to take the oxygen off and if she assessed her and her oxygen saturation was low (69%), she would have reapplied the oxygen on her and if after 20 minutes or so, R2's oxygen level would not have come up above 90%, she would have notified the physician at that time, but only if she couldn't get her oxygen level back up. On [DATE], at 1:00 p.m., V14, (Physician), stated that she was notified on [DATE], in regards, to R2 receiving her roommate's medications. V14 stated she ordered R2's Blood Pressure be monitored every two hours, increased water intake, and to notify her if R2 had a decline in her condition or Blood Pressure readings. V14 stated she was not notified again about R2's condition until [DATE], around 7:00 p.m. On [DATE], at 10:00 a.m., spoke with V17, (Medical Director), and asked him, If a resident has a decline in condition where they become lethargic, confused and their O2 Saturation drops to 69% and it takes the nurse after applying oxygen ,d+[DATE] minutes to get the O2 Saturation above 90%, is that a time when a physician should be notified about this change in condition? and V17 stated, Yes. R2's medical record document, titled, Hospital Admission Summary, dated [DATE], at 7:33 p.m., documents in part (R2) with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] .The patient appears altered on exam. She is responsive but unable to provide many answers. This same hospital admission summary documents R2 was admitted to the hospital on [DATE] with admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's hospital record dated [DATE], documents under Assessment/Plan: [CONDITION(S)] secondary to Multifocal Pneumonia and [CONDITION(S)] with Multi-Organ Failure, initiated [MEDICATION(S)] and [MEDICATION(S)] for HAP (Hospital Acquired Pneumonia) and [CONDITION(S)], added [MEDICATION(S)], as clinically rapidly deteriorating despite broad-spectrum antibiotic coverage and RN (Registered Nurse-V15) reports mold growing from oral mucosa and denture, s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Despite these measures, patient continues to deteriorate rapidly. Discussed goals of care with next of kin, (sister), who is the only remaining relative the patient has, sister is now ready for patient to transition to comfort care, given her advanced age, poor previous level of functioning, and overwhelming infection, which is unlikely to resolve despite broad-spectrum antibiotics. Under Hospital Course, R2's hospital discharge summary documents, [AGE] year-old female (R2) presented with [CONDITION(S)] secondary to Multifocal Pneumonia with [CONDITION(S)] and Multi-Organ Failure. Despite broad-spectrum antibiotics and aggressive fluid resuscitation, the patient continues to deteriorate rapidly. Nursing staff noticed the patient's dentures were full of mold raising suspicion for fungal infection contributing to Refractory [CONDITION(S)]. [MEDICATION(S)] was empirically initiated also without clinical response after 2 days. The patient's mental status continues to worsen to obtundation. Given advanced age, very poor previous functioning prior to admission, multiple comorbidities, and overwhelming infection with Multi-Organ Failure, this patient carries a grave prognosis. Multiple discussions on goals of care held with family which is the patient's niece in-law and sister. Eventually the patient was made comfort care on [DATE], afternoon, and passed away peacefully on [DATE] at 12:35 a.m. This hospital record documents Hospital associated Pneumonia which would indicate R2 developed Pneumonia after her admission to the hospital, however her chest x-ray documents R2 had Multifocal Pneumonia on [DATE], her day of admission to the hospital. R2's Death Certificate documents R2's expired on [DATE] and lists the causes of death and appropriate interval between on set and death as a) [CONDITION(S)], 3 min; b) [CONDITION(S)] with Multi-Organ failure, 3 days; and c) Pneumonia, 5 days. Facility Policy, [CONDITION(S)], dated ,d+[DATE], under Assessment and Recognition, 1. A nurse will assess a resident with a suspected infection and document related findings. Assessment date will include k) Description of any new or worsening decline in functional status, including confusion, incontinence, falling, decreased mobility, reduced food intake and lack of cooperation with staff. 2. The nurse will report findings to the physician or provider.

Based on interview and record review the facility failed to monitor the [MEDICATION NAME]/International Normalized Ratio by obtaining physician ordered blood work, for 1 of 3 residents (R2) reviewed for the monitoring of anticoagulation therapy in the sample of 3. This failure resulted in R2 being admitted to the Intensive Care Unit with an elevated INR (International Normalized Ration) of greater than 11 and required Packed Red Blood Cells, Vitamin K, and Fresh Frozen Plasma. R2 was in the hospital for a total of 4 days. Findings Include: R2 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. R2's Computerized Physician order [REDACTED].\INR on 2/3/17. The results of the 2-3-17 PT was 23.9 and the INR was 2.1. R2's physician order [REDACTED]. There is no further PT/INR results after 2/3/17. The Medication Administration History documents that the [MEDICATION NAME] 5 mg was given as ordered from 1/31/17 to 2/21/17. E3 ADON (Assistant Director of Nurses), on 3/14/17 at 10:00AM, stated that the facility orders the PT/INR for residents taking [MEDICATION NAME] as ordered by the physician. E3 stated R2 started taking [MEDICATION NAME] 5 mg on 1/31/17 and the PT/INR was drawn on 2/3/17. The physician was notified on 2/3/17 and an order was received to continue the same dose and repeat the PT/INR in one week. E3 stated there is no further orders regarding the [MEDICATION NAME] or INR. She stated R2 did not get the PT/INR drawn as ordered one week after the previous PT/INR (2-3-17), which would have been due on 2/10/17. E3 stated R2 continued to received the [MEDICATION NAME] 5mg starting on 1/31/17 and continued until she was hosptalized on [DATE]. She went on to say [MEDICATION NAME] was given related to the Left Hip Surgery. R2's hospital Emergency Department (ED) record dated 2/22/17, documents that R2 was diagnosed with [REDACTED]. The ED records state that R2's Hemoglobin was 6.9, INR was greater than 11, CT (Computerized Tomography) of Abdomen and Pelvis documents [MEDICAL CONDITION], and she takes [MEDICATION NAME] for [MEDICAL CONDITIONS] [MEDICATION NAME]. While in the ED R2 received 6 units of FFP (Fresh Frozen Plasma), 2 units of RBC (Red Blood Cells) and 10 mg (Milligrams) of Vitamin K. The next day, (2/23/17), R2's Hospital Record documents that the INR was 1.9 and Hemoglobin was 7.5, another 2 units of FFP and 1 unit of RBC was given. On 2/24/17 the Hospital Record documents that the INR was 1.7 and the hemoglobin was 8.9. The Hospitalist Progress Note, dated 2/24/17, documents to start Occupational and Physical Therapy, remove the foley, and give a full liquid diet. R2's Discharge Summary, dated 2/26/17, documents the patient went home on 2/26/17 with Home Health Services. On 3/14/17 at 2:00PM Z1 (Physician) stated the elevated INR caused by the [MEDICATION NAME] necessitated the need for the RBC, FFP, and Vitamin K. On 3/15/17 at 10:00AM Z1 stated she does not consider this a life threatening event and considered treating R2 as an outpatient.