Every finding on record at Goldwater Care Bloomington

Based on interviews and record reviews, the facility failed to ensure a required discharge assessment was completed for three (R1, R2, and R3) of three and failed to communicate the discharge summary in the resident's medical record for one (R2) of three residents reviewed for discharge documentation in a total sample list of six. Findings include:On 8/21/2026 at 6:15AM, V3 Licensed Practical Nurse (LPN) stated a discharge assessment is to be completed upon discharging a resident and must be documented under the assessment tab on resident's medical records.On 8/21/2026 at 8:34AM, V11 LPN stated nurses perform a thorough assessment before a resident is discharged from the facility. V11 stated this assessment is to be documented in the resident's medical record upon discharge. On 8/21/2026 at 8:49AM, V2 Director of Nursing (DON) stated the nurses are to document the completed resident discharge assessment in the resident's medical records.On 8/21/2026 at 8:49AM, V2 stated the facility's Social Services Director (SSD) communicates with the receiving facility's SSD and sends all documents needed including discharge referral packet and doctor's orders.On 8/22/2026 at 10:01AM, V1 Administrator stated nurses are expected to follow the facility's discharge/transfer policy.On 8/21/2026 at 8:49AM, V2 Director of Nursing (DON) confirmed R1, R2, and R3's discharge assessment was not completed.On 8/22/2026 at 11:44AM, V1 and V2 confirmed R2's discharge referral packet sent to the receiving facility could not be produced.R1's discharge instructions (discharge assessment) dated 5/29/26 at 3:47PM, documents Section B as completed and sections A, C, D, E, F, G not completed.R2's discharge instructions (discharge assessment) dated 8/11/2026 at 2:36PM show Sections A, B, C, D, E, F, and G not completed.R3's discharge instructions (discharge assessment) dated 7/1/2026 at 10:19AM, documents Section B as completed and sections A, C, D, E, F, G not completed.2. On 8/21/2026 at 8:49AM, V2 stated nurses are to document a progress note after a resident is discharged from the facility. On 8/21/2026 at 8:49AM, V2 confirmed no progress notes were documented about R2's discharge on [DATE].A facility policy titled Discharge/Transfer of Resident undated documents a Purpose: To provide safe departure from the facility; To provide for continuity of care and treatment. This policy further documents to 10. Thoroughly assess resident prior to discharge/transfer. and 11. Document discharge summary. Include notes on specific instructions given (medications, dressings, etc.) to resident and responsible parties in lay terminology.A facility policy titled Notice of Transfer and Discharge with effective date 3/17/2017 documents .the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to receiving health care institution or provider. The policy further states Documentation in the resident's medical record must include: The reason for the transfer, The specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).R1's medical record documents R1 admitted on [DATE] and discharged on 6/1/2026 with diagnosis including sepsis, malignant melanoma, secondary neoplasm of brain, and morbid obesity.R1's Minimum Data Set, dated [DATE] documents R1 has cognitive impairment.R2's medical record documents R2 admitted on [DATE] and discharged [DATE] with diagnosis including anxiety disorder, major depressive disorder, chronic obstructive pulmonary disease, and chest pain on breathing.R2's Minimum Data Set, dated [DATE] documents R2 has no cognitive impairment.R3's medical record documents R3 admitted on [DATE] and discharged on 7/1/2026 with diagnosis including right artificial hip joint, hypertension, atrial fibrillation, and coronary angioplasty implant and graft.R3's Minimum Data Set, dated [DATE] documents R3 has no cognitive impairment.

Based on interview and record review, the facility failed to report a fall with injury to the state agency for one (R4) of three residents reviewed for falls in a sample list of six. Findings include:R4's Care Plan with an initiation date of 6/17/26 documents diagnoses including Unspecified Dementia, Mild with Mood Disturbance, Unspecified Convulsions, Polymyalgia Rheumatica, Metabolic Encephalopathy, Alzheimer's Disease and History of Falling. R4's Minimum Data Set (MDS) dated [DATE] documents R4 was not cognitively intact, ambulated with staff assistance using a manual wheelchair, and required maximum assistance with daily care. R4's fall risk assessments dated 09/13/2025, 03/17/2026, 05/10/2026, 06/17/2026, 06/30/2026, and 07/02/2026 consistently documented R4 as at risk for falls. R4's care plan dated 6/25/2026 identified R4's fall risk related to a history of falls and knee pain. R4's Electronic Health Record (EHR) documented falls on 03/17/2026, 05/10/2026, 06/04/2026, 06/05/2026, 06/17/2026, 06/30/2026, and 07/02/2026.R4's progress notes document on 06/04/2026, R4 experienced a fall resulting in a head laceration requiring staples in the emergency department. On 06/17/2026, R4 sustained a fall with a hematoma and was again sent to the emergency department. On 07/02/2026 at 8:52 PM, R4 was found on the floor next to the bed in R4's room. V15, Licensed Practical Nurse (LPN), assessed R4 and documented no signs of pain or injury; however, because R4 could not make needs known, V15 sent R4 to the hospital. R4 did not return to the facility and was discharged on 07/02/2026.On 7/22/2026 at 12:40pm during interview, V15 Licensed Practical Nurse stated V15 was on duty on 07/02/2026 and had observed R4 earlier in the evening in bed, positioned in the low position with mats in place. V15 reported that V15 had never worked with R4 before and identified fall risk residents only by information received during report. V15 stated no interventions were implemented after R4's fall because R4 was sent to the hospital.On 7/22/2026 at 1:30pm V2, Director of Nursing, and V21, Assistant Director of Nursing, confirmed that no post fall interventions were completed for R4 following the 07/02/2026 fall. Both stated that R4's fall with injury was not reported to (the state agency) because R4 was in the hospital. Both acknowledged awareness that R4 sustained a hematoma.The Facility Incident and Accidents Policy dated 4/7/2019 documents the Director of Nursing, Assistant Director of Nursing or Nursing Supervisor must notify (the state agency), by phone, within 24 hours of the occurrence.

Based on observation, interview and record review the facility failed to provide care and services in accordance with physician orders for ordered daily weights, failed to implement and document ordered blood glucose monitoring and diabetic management, and failed to assess, monitor, and provide ordered wound care following hospitalization and/or fall-related injuries for four (R10, R12, R80, R88) of four residents reviewed for post-hospitalization on a sample list of 39 residents. Findings include: Record review revealed R10 had diagnoses that included Dementia, Chronic Kidney Disease, Congestive Heart Failure, Seizure Disorder, and recurrent falls. R10 sustained multiple falls on 05/10/2026, 06/04/2026, and 06/05/2026. Following a fall on 06/04/2026, R10 sustained a scalp laceration requiring emergency department evaluation and staple placement and returned to the facility on [DATE]. Review of physician orders and clinical documentation failed to demonstrate ongoing wound assessments, staple site monitoring, or completion of ordered wound care interventions following R10's return to the facility. R10's review of weight monitoring records from April 2026 through June 2026 also failed to demonstrate completion of ordered daily weights. On 06/09/2026 at 9:36 AM, V14 Certified Nursing Assistant (CNA) stated R10 and R12 were weighed monthly. During observation of care, V14 noted a staple site on R10 and stated they were unaware that R10 had a staple. On 06/09/2026 at 9:40 AM, V15 Certified Nursing Assistant (CNA) again stated they were unaware of the staples and searched through R10's hair before locating the staple site. On 06/08/2026 at 1:35 PM, V3 Assistant Director of Nursing (ADON) confirmed no wound assessments had been completed following R10's return from the emergency department on 6/5/26, no monitoring had been completed based on emergency department discharge instructions on 6/5/26. V3 stated V3 was unaware that R10 had a staple in place. Record review revealed R12 had diagnoses including Chronic Diastolic Heart Failure, Acute-on-Chronic Heart Failure, Chronic Kidney Disease, COPD, Epilepsy, Chronic Pain Syndrome, and Obesity. R12 returned from hospitalization with physician orders for daily weights. Review of records from 04/07/2026 through 06/03/2026 of nursing documentation and Medication Administration Records failed to demonstrate consistent completion of weight monitoring. Record review revealed R80 had physician orders on 5/9/26 that documents requiring ongoing blood glucose monitoring following hospitalization. R80's blood sugars obtained in the clinical documentation from 5/9/2026 to 5/15/2026 failed to demonstrate completion of ordered monitoring and there was no evidence of R80's refusal, physician notification, or follow-up blood sugar checks. On 06/09/2026 at 11:01 AM, V2 Director of Nursing (DON) confirmed there were no documented weights, blood glucose checks, or wound assessments completed as ordered for the R10, R12 and R80. V2 DON further confirmed documentation and reporting related to the fall injury had not been completed and reported to the state agency. On 06/07/2026 at 10:05 AM, R88 was observed sitting in a recliner with R88's feet elevated. R88 stated R88 was admitted to the facility after developing a sore on R88's buttocks while residing in an assisted living facility. R88 reported R88 had been using pillows for comfort while sitting and stated R88 slipped off the pillows and fell to the floor. R88's Electronic Health Record (EHR) documents diagnoses including an Unspecified Open Wound of the Right Lower Leg and a Stage 3 Pressure Ulcer of the Left Buttock. R88's Care Plan dated 6/2/26 documents a risk for impaired skin integrity related to poor mobility, with a goal to prevent further alteration in skin integrity. R88's wound physician visit note dated 6/4/26 documents recommendations for a Dietician consultation and initiation of Vitamin C 500 milligrams (mg) by mouth twice daily, a multivitamin by mouth daily, Zinc 220 mg by mouth daily for 14 days, and a protein supplement twice daily or as directed by the Dietician. R88's Medication Administration Record (MAR) dated June 2026 does not include the physician-recommended orders from the 6/4/26 wound physician visit. On 6/10/26 at 10:34 AM, V3 Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated R88 was seen by the wound physician on 6/4/26 and stated the recommendations were missed and not initiated as they should have been. V3 stated the Dietician is scheduled to be in the facility on 6/17/26 and will review the recommendation for protein supplementation at that time.

A. Based on observation, interview, and record review the facility failed to provide proper transport and privacy while transporting a resident to the shower room for one resident (R5) of four residents reviewed for quality of care in a sample of 16. B. Based on observation, interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for three residents (R7, R8, and R14) of four residents reviewed for quality of care in a sample of 16. Findings Include: A. On 04/06/26 at 09:50AM V3, Certified Nursing Assistant (CNA), was observed transporting R5 from the shower room to R5's room using a shower chair with R5 wrapped in a top sheet. During the transport R5 was heard exclaiming to V3 I am cold, slow down V3 responded by saying I am going slow, R5 then stated No you're not, you always go to fast. I am cold. R5's Care Plan dated 01/30/2023 with multiple revision dates documents an admission date of 1/24/2023. The Care Plan documents diagnoses of Thoracic, Thoracolumbar and Lumbosacral Intervertebral Disc Disorder, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus Without Complications, Anxiety Disorder, Depression, Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations. The same record documents under ADL (Activities of Daily Living) care for R5's Bathing: I require partial/moderate assistance with showers. Date Initiated: 08/12/2023 Revision on: 09/15/2025. R5's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R5 is cognitively intact. The same MDS Section GG subcategory E documents R5 requires partial to moderate assist with bathing. On 04/06/26 at 10:00AM V3, Certified Nursing Assistant (CNA), confirmed V3 took R5 to and from the shower room using the shower chair. On 04/06/26 at 10:05AM V4, License Practical Nurse (LPN), confirmed V3 transported R5 in the hallway to and from the shower room using the shower chair as the transport chair. V4 stated the shower chair should not be used as the chair to transport residents to the shower room from or to their room. V4 stated the resident should be clothed in their personal clothing not wrapped in a sheet. On 4/7/26 at 10:10am R5 stated V3, CNA, took R5 to and from his room to the shower room in the shower chair in the hallway wrapped in a thin white sheet. R5 stated this has caused him to feel embarrassment and some increased anxiety. R5 stated this is not the first time R5 has been transported in a sheet up and down the hallway and prefers to be dressed and transported to and from the shower room in his personal wheelchair not the shower chair. On 4/8/26 at 2:15pm V2, Director of Nursing, confirmed R5 was transported to the shower room and back to the resident room wrapped in a top sheet using the shower chair as the mode for transport by V3 on 4/6/26 at 10:00AM. V2 stated staff should not be using the shower chair as a transport chair. V2 stated the resident should be properly clothed not wrapped in a top sheet alone. The Bathing – Shower and Tub Bath policy dated 1-31-18 documents the Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. The document further states under subsection shower: Assist resident to undress and place in shower chair/transfer device. Assist resident when bathing is completed and make sure they are well dried. Assist to dress resident, as necessary. The Dignity policy dated 4-23-18 documents under section Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The same policy further documents Maintaining a resident's dignity should include but is not limited to the following: Encouraging and assisting residents to dress in their own clothes, rather than hospital- type gowns, and appropriate footwear for the time of day and individual preferences. B. R14's undated Care Plan documents an admission date to the facility of 3/10/2025 with the following diagnoses: Unspecified Protein-Calorie Malnutrition, Dysthymic Disorder, Anxiety Disorder, Epilepsy, Chronic Migraine Without Aura, Insomnia, Sleep Apnea, Spastic Hemiplegia Affecting Left Nondominant Side, Chronic Pain, Hypertension, Pain In Left Shoulder, Myalgia, Age-Related Osteoporosis, Overactive Bladder, Depression, Chronic Kidney Disease, Constipation. R14's undated Care Plan documents R14 has Activities of Daily Living self-care assistance needs related to epilepsy, chronic pain, and myalgia with an intervention of R14 requires substantial/maximal assistance for toilet transfer and is encouraged to use call light for assistance. R14's Minimum Data Set (MDS) section C dated 3/26/2026 documents R14 has moderate cognitive impairment. On 04/08/2026 at 9:20 AM, R14 stated she experiences prolonged wait times after activating the call light, which at times results in episodes of incontinence. R14 reported that these episodes cause her to feel embarrassed. R5's Minimum Data Set (MDS) Set dated March 16, 2026, documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R5 is cognitively intact. The same MDS Section GG subcategory E documents R5 requires partial to moderate assist with bathing. On 04/07/2026 at 10:10 AM, R5 activated the call light. The call light remained active until 10:25 AM, at which time the surveyor exited the resident's room. No staff response was observed during this time period. R7's undated Care Plan documents an admission date to this facility of 3/30/2023 with the following diagnoses: Chronic Obstructive Pulmonary Disease, Thrombocytopenia, Diastolic Heart Failure, Personal History Of Transient Ischemic Attack Hypertension, Gastro-Esophageal Reflux Disease Without Esophagitis, Peripheral Vascular Disease, Obstructive Sleep Apnea, Anxiety Disorder, Insomnia, Hyperlipidemia, Major Depressive Disorder, Hypokalemia, Presence Of Cardiac Pacemaker, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side. This Care Plan documents R7 having an Activities of Daily Living self care deficit related to history of Cerebral Vascular accident and diagnosis of left sided hemiparesis. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. On 3/7/2026 at 11:15 AM R7 stated it takes sometimes up to 30 minutes for her call light to be answered. R8's undated Care Plan documents an admission date to the facility of 6/09/2025 with the following diagnoses: Neuromuscular Dysfunction Of Bladder, Paraplegia, Hyperlipidemia, Major Depressive Disorder, Stiff-Man Syndrome. R8's Minimal Data Set section C dated 2/16/2026 documents R8 as cognitively intact. On 4/8/2026 at 11:00 AM R8 stated he pressed his call light last night and it took someone over thirty minutes to respond to R8's call light. The Resident Council Meeting Minutes dated 4/7/2026 document residents' concerns regarding call light response times taking too long. The facility's Call Light Policy dated 11/28/2012 documents: Resident's call lights will be answered in a timely manner. On 4/8/2026 at 10:42 AM V2 Director of Nursing (DON) stated it is her expectation for call lights to be answered within five to fifteen minutes.

Based on observation, interview, and record review the facility failed to ensure medications were administered and central line dressings were changed according to physician orders for two (R4 and R6) of three residents reviewed for quality of care, in a total sample of 16.Findings Include: 1.R4's Medical Record documents R4 discharged from the facility on 3/7/26. R4's Medication Administration Record dated 2/13/2026 printed on 4/7/2026 documents Vancomycin HCI-Sodium Chloride (antibiotic) 200 milliliters (ml) intravenously every 48 hours at 9:30 AM related to subacute osteomyelitis, left ankle and foot per physician's order.R4's Medication Administration Audit Report printed on 4/7/2026 documents R4 received the Vancomycin HCI-Sodium Chloride 200 milliliters (ml) on 2/13/2026 at 5:12 pm, 2/15/2026 at 6:37pm, 2/19/2026 at 12:20 pm, 2/25/2026 at 11:31 am, 3/3/2026 at 4:04 pm, and at 3/5/2026 at 5:40 pm instead of 9:30 am. R4's Electronic Medical Record does not document notification to the physician the medication was not administered on time. On 4/9/26 at 11:02 AM V2 DON confirmed this documentation.R4's Medication Administration Record 3/12/2026 (late entry) documents a physician order for a Peripherally Inserted Central Catheter (PICC) line site dressing change every week in the morning every Thursday for PICC care. R4's Electronic Medical Record does not document the PICC line dressing was changed since R4 was admitted to the facility on [DATE]. On 4/9/26 at 11:02 am V2 DON confirmed this documentation.On 4/6/2026 at 11:11 am, V9 R4's family member verbalized concern about the care provided to R4 during R4's stay at the facility including the care related to the PICC line, particularly the dressing not being changed.2.R6's Medication Administration Record dated 4/5/2026 printed on 4/6/2026 documents Daptomycin (antibiotic) 700 mg intravenously in the morning at 8:00 am and Ceftriaxone Sodium Injection Solution Reconstituted (antibiotic) 2 GM (Ceftriaxone Sodium) Use 2 gram intravenously in the evening for infection at 5:00 pm.R6's Medication Administration Audit Report Documents Daptomycin 700 mg was administered on 4/5/2026 at 2:06 pm and on 4/6/26 at 9:51 pm. The Audit documents Ceftriaxone Sodium 2 gram was administered on 4/5/2026 at 9:34 pm and on 4/6/2026 at 9:51 pm. There is no documentation the two IV medications were administered on 4/4/2026. R6's medical record does not document physician and resident's representative notification of the omitted medications or the late medications. On 4/9/26 at 11:02 am V2 DON confirmed this documentation.On 4/6/2026 at 10:16 am R6 was in his room seated in a wheelchair. An intravenous (IV) pole was behind R6 containing an empty IV bag labeled Ceftriaxone 2 gram (gm). R6 stated he had not received his IV medication this morning. R6 had a peripherally inserted central catheter (PICC) line in R6's right arm.On 4/6/2026 at 10:32 am V4 Licensed Practical Nurse stated R6 is on Daptomycin IV every morning and Ceftriaxone IV in the afternoon. V4 stated Daptomycin is scheduled for 8:00 am but not been administered at this time and V4 already notified V2 Director of Nursing (DON). V4 stated she is an LPN and not able to administer the IV medication. V4 stated she will just change the order to 7am-10am to give the RN more time.On 4/6/2026 at 2:54pm V17 Physician stated he did not receive any phone call regarding R6 at this time.On 4/6/2026 at 1:30 pm V11 R6's family member stated she visited R6 yesterday (4/5/2026) and noticed the two IV medications were administered late in the day and were given back-to-back. R6 stated they have not changed R6's IV dressing since he was admitted to the facility on [DATE]. R4's IV line observed to right arm covered with a dressing dated 5/4 (later determined wrong date).On 4/6/2026 at 10:37 am. V2 Director of Nursing (DON) stated nurses need to notify the physician and resident's representative for late medication administration and should have an order before changing the orders. V2 stated the information should be documented in resident's medical record.On 4/6/2026 at 1:30 p.m. V2 DON clarified R6's IV line dressing was from the hospital, and the date was wrong since R6 was admitted to the facility on [DATE]. V2 stated IV dressings are to be changed every three days.The Facility's Medication Administration General Guidelines (undated) document medications are to be administered in accordance with written orders of the physician. Medications are administered within one hour before and after scheduled time unless specified by the prescriber.

Based on observations, interviews and record reviews the facility failed to maintain the resident hallways and resident common seating area carpet, in a clean, sanitary, odor free condition. This failure affects all 76 residents that reside in the facility.Findings include: Resident Council Minutes dated [DATE] and [DATE] old business ([DATE]) and new business, documents residents' grievance of unclean carpet. Resident Council minute grievance notes documented a resolution to spot clean the carpets.On [DATE] at 10:20 am, V6 (R5's Family Member) stated the carpet throughout the facility is 'filthy and smells like urine.' V6 also stated Them spot cleaning the halls is not enough. On [DATE] at 10:35 am, V3, Maintenance Director/Housekeeping/Laundry Supervisor toured the facility with this surveyor. V3 stated I figured it was probably the carpet when I heard state was in the building for environmental issues. I 've been here four years. I have tried different ways over the years to tackle the problem. Resident council group continues to complain because it is still a big issue. Last Spring, I had a commercial, carpet cleaning extraction machine. It was old and died. I don't have a commercial extractor available. I have to use a residential carpet cleaner. Basically, it is used for spot cleaning. The carpets need deep cleaned. The residential carpet extractor is the same as the one you can rent for your home. On [DATE] at 10:40 am, V3 Maintenance Director/Housekeeper/ Laundry Supervisor began the tour of the facility. V4 Maintenance Assistant brought a small, residential, upright carpet cleaning extractor to the resident hallway, T- junction of the hallway. V4 stated the residential appliance is what the facility uses to clean the facility carpet. V4 confirmed the facility does not use a commercial extractor /cleaner in the facility. V4 then stated the strength of the cleaner is the same as what is used when cleaning carpets at home. R7's Minimum Data Set (MDS) dated [DATE] documents R7's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating no cognitive impairment. On [DATE] at 10:50 am, R7 stated he is blind in one eye and can barely see out of the other. He can't tell if the carpet is soiled. R7 stated I know something stinks in all the hallways. It may well be the carpet.On [DATE] at 11:00 am through 11:25 am, V3 Maintenance Director and this surveyor continued the tour of all common areas and resident lounges. All resident hallways and common areas, East Long Hall, East Short Hall, [NAME] Long Hall, [NAME] Short Hall, Center Hallway, in front of both East and [NAME] Dining rooms and around the nurses' stations all had light green, or light green with beige bordered carpet. All hallways had a faint urine odor. There were copious wide-spread black and brown stains Some of the stains measured approximately six to eight-foot size patches The stains extended the full length of 100 foot on East and [NAME] Long hallways. The stains also dominated the full forty-foot length of the East, West, and Center hallways of the facility. More of the carpet was stained than not, throughout the facility. There was also a foul feces-like odor on the [NAME] long hallway. Also on the [NAME] long hallway, there was an approximately five-foot section of black mold-like substance present that extended approximately six inches out from the baseboard. V3 stated the facility had a toilet overflow awhile back and had to have a plumber out to fix it. That caused this black stain. V3 also stated the facility has had a couple other toilets back up too. V3 stated I can't smell since I had Covid. I can't confirm the odor. Bottom line is the carpet is old and needs to be replaced. In my opinion, a tile surface would be much better and easier to keep clean. On [DATE] at 11:30 am, V8 Certified Nursing Assistant (CNA) stated No, the carpets are not clean comfortable or homelike. They haven't been, since I started working here three years ago. They are dirty and need cleaned. There are odors from the carpet. That is expected when you see all the stains. On [DATE] at 11:35 am, V9 CNA stated I don't smell anything, probably because I am busy and used to it. The condition of the carpet is not even close to being clean. I see housekeeping spot clean at times. That does not seem to make any difference. It needs to be replaced. The worst areas of the carpet are the areas at the nurse's station, (V9, points to the East Hall carpet around the nurse's station to confirm) where a couple of the residents eat. That is why the carpet is soiled with black stains. On [DATE], V10 Agency, Licensed Practical Nurse stated I work in a lot of facilities. I have worked here several times. What stands out to me is the horrible odors from the dirty carpet. I can give all the medication in the world to the residents, but the atmosphere is not conducive to healing. Absolutely, not clean, comfortable, or homelike. It is a shame. This is a very nice home. R2's MDS dated [DATE] documents R2's BIMS score as 15 out of a possible 15, indicating no cognitive impairment. On [DATE] at 11:50 am, R2 stated I have no problem with the care in the facility, they keep me clean and dry. They keep my room neat and tidy. The hallways are atrocious. The carpets are filthy, and they stink. The smell is not in my room, thank God. I am usually in my room or dining room. I don't have any issues with either of those places, where I spend my time in. R4's MDS dated [DATE] documents R4's BIMS score as 15 out of a possible 15, indicating no cognitive impairment. On [DATE] at 12:00pm, R4 stated I had my toilet overflow several weeks ago. Then, as you would expect, there was a strong odor of (feces). I think the carpet outside my room had some seepage, from that situation. I just kept my door closed a couple days. That smell is gone. The normal odor of urine is bad in some areas. I am sure that comes from the carpet. You can look and you will see, the carpet has never been cleaned. It has gotten worse over the past few months. The stains all connect. It is hard to tell the actual color of the carpet now. It is bad. R3's MDS dated [DATE] documents R3's BIMS score as 15 out of a possible 15, indicating no cognitive impairment. On [DATE] at 12:10 pm, R3 stated Occasionally there can be bad odors of urine. It was real bad in the hot weather. Some odor is expected in a nursing home. The carpet, they need to take a scrub brush to. The carpets are terrible. It is filthy, as I am sure you have already noticed.R1 MDS dated [DATE] documents R1's BIMS score as 15 out of a possible 15, indicating no cognitive impairment. On [DATE] at 12:20pm, R1 stated The carpet in the hall looks bad. The carpet is full of stains. I have not noticed any odors out there. My floor is fine. I am glad there isn't carpet in here. On [DATE] at 12:25 pm, V7 (R6's Family Member) stated I am in the facility four to five hours almost every day. I have not noticed any lingering odors from the carpet. I have certainly noticed the condition of the carpet. It is old and full of stains. It does not matter what hall you're on. The carpet is definitely dirty. I have seen them vacuum regularly, that is all. If this were my home, I would recognize it is time to change the carpet. I would have been replacing it a long time ago. On [DATE] at 12:30 pm, V5 Activity Director confirmed the resident council meeting minutes for [DATE] and [DATE] document the carpets in the facility are dirty and the resolution was to spot clean the carpets. V15 stated The residents had been complaining much longer than two months that the carpet is real dirty. They have not complained about an odor, that I recall. The resolution is always the same, to spot clean the carpet. That is not working, obviously. We have invited (V11, Regional Director of Operations) Corporate to attend council group and hear, firsthand from the residents. I believe she is coming next month.The facility CMS Matrix 802 dated [DATE] documents 76 residents reside in the facility.

Based on observation, interview and record review the facility failed to assist one (R1) resident while eating causing R1 to spill hot coffee on her left hip and left thigh out of three residents reviewed for Accidents in a sample list of three residents. R1 obtained four separate blisters which required treatment from a Wound Physician. Findings include:R1's Electronic Medical Record (EMR) documents medical diagnoses as Hemiplegia and Hemiparesis following Cerebrovascular Disease affecting Right dominant side, Disorders of the Brain, Morbid Severe Obesity due to excess calories, Epilepsy, Traumatic Brain Injury, Colostomy, Chronic pain due to trauma and Legal Blindness. R1's care plan intervention dated 5/2/25 documents R1 is usually provided with one assist by staff to eat. R1's Visual Bedside Kardex Report dated 8/16/25 documents R1 is usually provided with one assist by staff to eat. This same Kardex documents R1's call light should be within reach. R1's Physician Order Set (POS) dated August 2025 documents a physician order starting 4/22/25 to provide a regular consistency diet with thin liquids. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 requires moderate assistance with eating and is dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. This same MDS defines moderate assistance as Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.R1's Nurse Progress Note dated 8/4/25 at 8:00 AM documents R1 called out and stated she spilled her coffee in bed. R1's Skin Condition Report dated 8/4/25 documents R1 called out after spilling coffee on her Left Lateral Hip and Thigh while in bed eating breakfast at 8:00 AM. This same report documents the hot coffee spill caused a large red, blanchable area measuring 15.0 centimeters (cm) long by 10.0 cm wide with no depth. This same report documents at 1:00 PM R1's Left Hip and Left lateral thigh were re-assessed and found to have four separate intact blisters measuring blister 1 as 4.0 cm long by 2.0 cm wide, blister 2 as 3.0 cm long by 1.0 cm wide, blister 3 as 3.0 cm long by 1.0 cm wide, and blister 4 as 3.5 cm long by 1.0 cm wide. This same report documents R1 complained of moderate pain to area and pain medication order was increased.R1's Wound Initial Evaluation and Management Summary dated 8/7/25 documents R1's Left Lateral Hip wound was from a hot liquid burn that resulted in a ruptured blister. This same report documents R1's Left Lateral Hip burn wound measures 1.0 centimeters (cm) wide by 2.0 cm long by 0.2 cm deep with moderate serous drainage, 100% thick adherent devitalized necrotic tissue with an estimated time to heal as one to two months. R1's Final Report to the State Agency dated 8/10/25 documents R1 stated she was laying in bed, drinking coffee in her personal tumbler and her cup slipped from her hand spilling coffee on her outer left hip/thigh. This same report documents R1 initially was assessed to have a blanchable red area to her Left outer Hip/Thigh which was left open to air. This report documents upon reassessment, R1 had four blisters that had formed on her outer Left Hip/Thigh requiring a medicated treatment with Silvadene cream. This same report documents V12 Wound Physician assessed R1 on 8/7/25 and changed R1's treatment order. This same report documents R1 is moderately cognitively impaired. R1's Wound Evaluation and Management Summary dated 8/14/25 documents R1's Left Lateral Hip burn wound measures 1.0 cm long by 3.5 cm wide by 0.1 cm deep with moderate serous drainage and 100% thick adherent devitalized necrotic tissue.On 8/16/25 at 8:55 AM V6 Licensed Practical Nurse (LPN) and V8 Certified Nurse Aide (CNA) completed a skin check for R1. R1's Left Hip showed three separate open areas. R1's upper Left Hip showed a dime sized open area with a pink wound bed and dark pink periwound, middle Left Hip was the largest of the three open areas, showed an irregular shaped open wound a few inches wide with attached yellow slough, dark red periwound and moderate yellow drainage and R1's medial Left Hip area showed a triangle shaped open area with a pink wound base and pink periwound. R1's dressing did not cover the medial nor the top open areas. On 8/16/25 at 9:10 AM V8 Certified Nurse Aide (CNA) set up R1's breakfast tray. The top of R1's meal ticket was highlighted in green. V8 CNA stated she did not know what the green highlighting meant. V9 CNA entered R1's room and stated she was not sure what the green highlighting meant but thought it may mean R1 was independent in eating. On 8/16/25 at 9:20 AM R1 was laying in her bed with head of bed up 60 degrees eating her breakfast. R1's call light was connected to the far side rail and laying under the fitted sheet. R1 stated she could not reach her call light and did not know where it was. There were no staff in R1's room. R1 stated This is just like the time when I couldn't get them (staff) to answer my call light when I spilled my coffee. On 8/16/25 at 9:25 AM V10 Certified Nurse Aide (CNA) entered R1's room. V10 CNA moved R1's bed away from the wall to be able to reach her call light. V10 CNA then stated R1 wouldn't be able to reach her call light due to it was under her fitted sheet and out of R1's reach. On 8/16/25 at 12:30 PM R1 was laying in her bed with the head of the bed up 60 degrees eating her lunch. R1's pink tumbler cup was on R1's bedside table within her reach. There were no staff present in R1's room. On 8/16/25 at 8:35 AM V6 Licensed Practical Nurse (LPN) stated R1 likes to have coffee in the morning. V6 LPN stated R1 likes to drink her coffee from her own personal tumbler. V6 LPN stated she was R1's nurse on 8/4/25 and heard R1 yelling out from her room. V6 LPN stated when she arrived, R1 had spilled hot coffee 'all over' her Left Hip and Left Lateral Thigh area causing the 'entire' area to be red. V6 LPN stated she removed the wet clothing, cleaned up the coffee and applied a cold washcloth to R1's Left Hip and lateral thigh area. V6 LPN stated later on that afternoon, R1 had developed several blisters from the hot coffee burn. On 8/16/25 at 9:00 AM R1 stated she likes to drink her coffee from her own cup (pointing to a tall pink tumbler with a slide lid and side handle). R1 stated someone set up her breakfast tray that morning (8/4/25) and then left R1 by herself to eat her breakfast. R1 stated she was trying to reach for her cup and couldn't reach it due to the handle was on the far side from her. R1 stated she activated her call light, but no one answered so she tried again to reach for her coffee and ended up spilling it 'all over' her. R1 stated it hurt a little bit when it first happened and hurt ‘a whole lot' later in the day. R1 stated it hurts when V12 Wound Physician ‘cuts on it'. R1 stated He (V15) slices and dices on my hip and boy does it hurt!. On 8/16/25 at 9:15 AM V9 Certified Nurse Aide (CNA) stated R1's Kardex and care plan documents R1 is usually one assist with eating. On 8/16/25 at 11:30 AM V3 Minimum Data Set (MDS) nurse stated R1's MDS section for eating, R1's care plan Activity of Daily Living (ADL) section for eating and R1's Kardex do not match. On 8/16/25 at 12:10 PM V4 Assistant Director of Nurses (ADON)/Wound Nurse stated R1 spilled hot coffee on herself the morning of 8/4/25. V4 stated the staff alerted V4 and she went to R1's room to assess R1. V4 Wound Nurse stated R1 had a large, reddened area on her outer Left Hip and Thigh which later blistered. V4 Wound Nurse stated R1 did not have any prior wounds that were being treated by the facility. On 8/16/25 at 1:50 PM V13 Certified Nurse Aide (CNA) stated staff have to get R1 set up just like R1 wants or R1 won't be able to manage eating by herself. On 8/16/25 at 2:45 PM V15 Certified Nurse Aide (CNA) stated V14 CNA served R1 her breakfast tray on 8/4/25. V15 CNA stated R1 ended up spilling her hot coffee on her Left Hip. V15 CNA stated he heard R1's call light sounding but not sure how long. V15 CNA stated the staff are all very busy at that time of morning trying to get everyone ready for breakfast. V15 CNA stated R1 needs set up assistance with her meals but 'the staff never stay in the room' with R1. On 8/16/25 at 3:00 PM V1 Administrator stated R1's Minimum Data Set (MDS) assessment does not match R1's care plan and R1's Kardex. V1 Administrator confirmed R1's Electronic Medical Record (EMR) does not include any documented refusals from R1 of staff being present for meals to assist R1 if necessary. V1 Administrator stated the facility does not have a policy on serving hot liquids to cognitively impaired residents. On 8/16/25 at 3:40 PM V2 Director of Nurses (DON) stated staff should follow the MDS and care plan. V2 DON confirmed R1's MDS, care plan and Kardex do not match which could be confusing for staff. V2 DON stated R1 should have been assisted with setting up her tray so that she could manage the drinks which would have prevented her from being burned. V2 DON stated the staff were in-serviced due to R1 being burned and will also in-service the staff on documenting refusals of care.

Based on observation, interview, and record review the facility failed to prevent a fall by failing to ensure fall precautions were in place and failed to minimize the risk of injury from a fall by failing to ensure interventions to reduce the risk of injury were in place. The facility also failed to ensure fall precautions and interventions were in place after a fall with injury for one (R1) of three residents reviewed for falls on the sample list of four. This immediate jeopardy began on [DATE] at 8:00 PM when this failure resulted in R1 having a high impact fall on [DATE] from an elevated bed onto the floor. This fall resulted in R1 sustaining a right leg fracture with shattered and displaced bone fragments. This fall contributed to R1's death five days later [DATE]. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 10:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's undated Care Plan documents diagnoses including cerebral infarction, cerebral aneurysm, thrombocytopenia, dysarthria and anarthria, rheumatoid arthritis, type II diabetes mellitus with diabetic neuropathy, and pain in right knee. This care plan documents R1 requires maximum assistance of two people for bed mobility and sitting up and R1 requires a mechanical lift for transfers. R1's Fall Care Plan dated 3/2024 documents R1 has a history of falls and contains an intervention dated [DATE] to have fall mats on the floor next to the bed and for the bed to be in the low position when R1 is in bed due to the history of R1 rolling out of the bed onto the floor. This care plan documents R1 has fallen out of bed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].On [DATE] at 10:08 AM, R1 was lying in bed on a low air loss mattress. R1's bed was elevated three feet from the floor. Fall mats were not lying on the floor beside the bed. At this time R1 was unresponsive. R1 was breathing with mouth open, and breaths were irregular and labored. On [DATE] at 9:25 AM V31, Maintenance Director measured the height of R1's bed frame from the floor in standard position at 22 inches, then measured the bedframe from the floor at the position R1's bed was observed to be (on [DATE]) when R1 was in bed. This bed position measured 32 inches from floor. V31 stated the air mattress was at minimum 4 inches in height which would put R1 36 inches from floor when observed lying in bed. V31 verified this is a high position for bed. The Progress Note by V8 Registered Nurse (RN) dated [DATE] documents on [DATE] at 8:00 PM R1 was found on the floor next to the bed on his back after V13, Certified Nursing Assistant (CNA) heard his screams from another resident room. V8, documents that R1 fell from the bed in the high position with the low air loss mattress on and inflated. R1 complained of right knee pain and required four staff assist including the mechanical lift to transfer R1 to the bed. V8 documents R1's POA (V30) and hospice physician (V25) were notified, and orders were received to keep R1 comfortable with morphine and to not send R1 to the hospital at that time.The Incident Statement dated [DATE] documents, V13 CNA stated she was in another resident room when she could hear R1 screaming. R1's Progress Note dated [DATE] at 8:15 PM documents V32, LPN, contacted hospice staff stating R1 was having continued uncontrolled right knee pain after pain medication was administered as ordered, and staff cannot reposition R1 without extreme pain.R1's Physician Orders dated [DATE] document a new order for a 2-view x-ray of R1's right knee related to pain in the right knee and a one-time administration of 20mg of Morphine to be given for uncontrolled pain. At 3:07 PM on [DATE] V30, R1's Family Member stated she came to see R1 on Monday [DATE]. V30 stated she was notified of the fall on [DATE] around 9:00 or 9:30 PM. V30 stated she had not been in to see R1 all weekend but had called for updates on [DATE] and [DATE] and was told that R1 was just a little sore and bruised. V30 stated when she entered R1's room on [DATE] R1 was receiving a sponge bath from a CNA (unnamed). V30 stated R1 was not being moved but screaming in pain just from touch alone. R1's Biotech X-Ray report dated [DATE] at 11:22 AM documents R1 has an acute comminuted fracture distal femur with 3cm dorsal lateral displacement distal fragments noted. R1's progress notes dated [DATE] document R1 was sent to the local emergency department per family request. R1's Hospital Records dated [DATE] document R1 reported significant pain to the right hip area upon arrival on [DATE] and R1 had obvious gross deformity to the right lower extremity with significant enlargement of the right thigh. Right leg x-ray was completed at 3:32pm on [DATE] with results of acute comminuted fracture distal femoral Meta diaphysis just above prothesis with distal fragment displaced laterally and posteriorly by 4cm and right hip fracture cannot be ruled out. Records document R1's family declined surgical intervention due to R1's bleeding disorder and complications associated with surgery and that R1 was placed in a knee immobilizer and returned to the facility.R1's Nurse Practitioner Visit Note dated [DATE] documents R1 fell out of bed ([DATE]) Friday night when trying to reach something at the request of his roommate. R1 had significant pain throughout the weekend. X-ray's obtained yesterday ([DATE]) confirmed R1 had an acute comminuted distal femur fracture of the right femur just above the prosthetic. R1 considered high risk for surgery and would have required transfer to different hospital. Family opted for conservative treatment. Added scheduled morphine due to R1's pain level in addition to current as needed ordered morphine. Family wishes to continue to focus on comfort. R1's progress note dated [DATE] at 10:50 AM documents R1 expired at facility. R1's death certificate dated [DATE] documents Immune Thrombocytopenic Purpura with contributing factors of ischemic heart disease and fracture of femur related to fall listed as cause of death. Manner of death listed as accident. On [DATE] at 1:51 PM, V34, Deputy Coroner, stated R1's cause of death was listed as Immune Thrombolytic Purpura (ITP) which is a low platelet count, this contributed to R1 being unable to have surgery to set his fracture. V34 stated this was an extensive traumatic fracture and that it contributed to R1's death with manner of death as an accident. V34 stated the significant pain R1 suffered caused stress to his heart and was also a significant factor attributing to his death. On [DATE] at 12:33 PM, V15 Certified Nurse Assistant (CNA) stated she was working the night R1 fell but was not R1's assigned CNA. V15, CNA stated she was in a resident's room when the fall occurred. V15, CNA stated when she entered R1's room after his fall, R1 was screaming out in pain stating his right knee hurt requesting staff to rub it. V15, CNA stated V13, CNA and V15 were performing care for R1 after his fall and R1 was verbalizing and exhibiting signs of excruciating pain. V15 stated two days later, [DATE], between 8:00 pm and 10:00 pm, V15 and an un-named agency CNA were providing incontinence care for R1 when she felt something move in R1's knee. V15 stated she heard a pop sound, and R1 continued to be in significant pain at this time and she reported both pain and the shifting pop in R1's right leg to V8, RN after care completion. On [DATE] at 2:20 PM, V8 stated R1 was on his back on the floor, no mat, when she was called into the room by R1's cries. V8 stated R1 stated a CNA was just in the room prior to the fall. V8 stated R1 asked staff to stretch his leg out after transferring R1 to bed and that is when R1 screamed out in pain several times. On [DATE] at 10:30 AM, V12 Nurse Practitioner (NP), stated she was not aware of R1's fall on Friday, [DATE]th but was notified the following Tuesday, [DATE]th. V12 stated she found out about the entire event on the morning of 7/15 during the scheduled IDT (Interdisciplinary Team) meeting. V12 stated prior to R1's fall he was stable with minimal intermittent confusion, a pleasant man who she enjoyed caring for. V12 stated that had R1 not fallen he would have lived longer. V12 stated she has never observed fall mats in R1's room. On [DATE] at 2:09 PM, V2 Director of Nursing (DON), confirmed that R1's Care Plan included an intervention to have fall mats on the floor next to the bed and at the time of the fall he did not have the mats. V2 stated the mat should have been in place to reduce the risk of R1's injury due to his history of rolling out of bed.The facility fall policy dated [DATE] document's the purpose is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions, and to provide necessary supervision, that assistive devices are utilized as necessary. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. On [DATE] V2 Director of Nursing (DON) conducted facility wide audits of all residents' fall care plans. Audits of observations that fall interventions were in place were conducted by Interdisciplinary Team Members (Maintenance Director, Social Services Director, Assistant Director of Nursing, Business Services, and floor RN's)2. On [DATE] V2 DON, V29 Quality Assurance Nurse, and the MDS Coordinator provided education on how to access fall interventions by accessing the resident's Kardex with ongoing education to be provided to staff members on FMLA (Family Medical Leave of Act), vacation, or agency staff.3. On [DATE] V37 [NAME] President of Operations provided education to V1 and V2 regarding the facility's Fall Prevention Program policy that included the DON's responsibilities related to monitoring of the fall prevention program.4. On [DATE] V1 and V2 provided education on the facility's Fall Prevention Program policy to all licensed and certified nursing staff. Ongoing education to be provided to staff members on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.5. On [DATE] V2 and V29 Quality Assurance (QA) Nurse educated Hospice Company staff on the facility's Fall Prevention Program policy.6. On [DATE] V2 and V29 QA Nurse educated all licensed and certified nursing staff on the facility's Incident Accident policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.7. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Pain Management policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.8. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Pain Assessment policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.9. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Physician-Family Notification - Change in Condition policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.10. On [DATE] V2 and V29 educated licensed and certified nursing staff on the facility's Basic Care Plan policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.11. On [DATE] V2 and V29 educated all Interdisciplinary team (IDT) members on the facility's Comprehensive Care Plan policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.12. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Resident Rounds guidelines. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.13. On [DATE] V2 and V29 educated all licensed and certified nursing staff on the facility's Hospice Service policy. Ongoing education to be provided to staff member on FMLA, vacation, and all agency staff prior to returning to the facility by V1, V2 or Designee.14. On [DATE] an impromptu QAPI (Quality Assurance Performance Improvement) meeting was held with the medical director and staff IDT members to discuss deficiency and facility action plan.15. Starting on [DATE] V2, V29 and designee began audits to ensure all new unwitnessed and witnessed falls and the interventions have been added to the resident's care plan. These audits will be ongoing seven days per week for six weeks. Quality Assurance oversight of these audits will be done by V37. The Audit tool dated week end [DATE] documents first audit completed [DATE].The facility presented an abatement plan to remove the immediacy on [DATE] at 1:28 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned [DATE] at 2:42 PM. The facility presented a revised abatement plan to remove the immediacy on [DATE] at 2:51 PM. The survey team reviewed the abatement plan and was able to accept the plan to remove the immediacy. The abatement plan was approved on [DATE] at 3:16 PM.

Based on interview and record review the facility failed to ensure timely medical treatment for one (R4) of three residents reviewed for change in condition on a sample list of 6. This failure resulted in R4 having an acute ischemic stroke resulting in receptive aphasia. The facility's Physician-Family Notification-Change in Condition Policy dated 11/13/2018 documents that the facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: B) a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). On 4/11/2025 the facility held a nurse's meeting, and the V2 (Director of Nursing (DON)) educated the nurses on Documentation Guidelines for Change in Condition. A power point handout dated 2/28/2023 was provided and documents that nurses should always include the resident's signs and symptoms specific to the change in condition including vital signs. This education material also documents that nurses are not to monitor a change in condition without notifying the physician or nurse practitioner first. On 7/21/25 at 9:01 AM, V27 (R4 Family Member) stated that she called R4 on 7/1/25 around 8:00 AM and V27 stated R4's speech was garbled, and she was confused and kept asking V27 if she was there. V27 stated she reported this to V11(Licensed Practical Nurse) the nurse caring for R4 that morning.On 7/22/25 at 10:13 AM, V26 (Certified Nurse Assistant (CNA)) stated that she took care of R4 on July 1, 2025, and R4 wasn't acting right and wasn't making eye contact. V26 stated that R4 was transferring slower than normal and R4 couldn't hold her cup at breakfast and wasn't making sense when she talked.On 7/23/25 at 10:25 AM, V11 (Licensed Practica Nurse-LPN) stated that R4 seemed confused around mid-morning on 7/1/25 when she went to group therapy and V24 (Occupational Therapist (OT)) reported to V11 that R4 was acting nervous and confused. V11 stated that after lunch R4 continued to decline and was kept at the nurses' station for monitoring. Review of R4's electronic medical record does not include evidence that R4's vital signs were measured on 7/1/25. On 7/21/25 at 1:40 PM, V24 (OT) stated that R4 participated in a group therapy session on the morning of 7/1/25 and was having difficulty following one step commands. V24 stated that R4 exhibited confusion off and on during previous therapy sessions, but V24 stated this time it seemed more concerning. Speech Therapy note dated 7/1/25 documents that R4 was unable to effectively participate due to altered mental status.Physical Therapy note dated 7/1/25 documents that R4 needed max cueing for visual, verbal and tactile due to increase in confusion.On 7/22/25 at 10:39 AM, V12 (Nurse Practitioner) stated that she saw R4 the morning of 7/1/25 and resident was confused and seemed out of it. V12 stated she thought it was due to the medications R4 had received that morning but told V11 to monitor and call with any changes. V12 stated that V11 did not contact her that afternoon when R4 declined, and she said V11 should have called to report R4's change in condition and may have resulted in a more positive outcome for R4.On 7/23/25 at 11:57 AM, V2 (DON) stated she assessed R4 around lunch on 7/1/25 and R4 was giving goofy answers to her questions and kept saying that her daughter was at the facility. V2 stated that V11 should have got a set of vital signs on V11 and should have notified V12 when R4's condition worsened.

Based on interview and record review the facility failed to conduct a comprehensive pain assessment after a fall with injury, failed to administer as needed pain medications as ordered by the physician when signs of symptoms of excruciating pain were present, and failed to notify the family and physician when a change in the level of pain was identified for one (R1) of three residents reviewed for pain on a sample size of four. This failure resulted in R1 suffering excruciating pain in which R1 was observed with facial grimacing, yelling and screaming for four days after sustaining a right leg fracture.R1's Progress Note dated [DATE] documents that on [DATE] at 8:00 p.m., R1 was found on floor next to bed on his back after V13, Certified Nursing Assistant (CNA) heard his screams while V13 was in another resident room. V8, Licensed Practical Nurse (LPN), documents that R1 fell from bed in high position with low air loss mattress on and inflated. R1 complained of right knee pain at 7/10 with no previous complaints of pain and required 4 staff assist including mechanical lift to place R1 back in bed. V8 documents V30, R1's family member, and hospice physician were notified, and facility was to keep R1 comfortable with morphine.R1's undated Care Plan documents diagnosis including cerebral infarction, cerebral aneurysm, thrombocytopenia, dysarthria and anarthria, rheumatoid arthritis, type 2 diabetes mellitus with diabetic neuropathy, and pain in right knee. This care plan also documents R1 has a potential for pain and is on pain medication therapy related to terminal diagnosis on hospice care with a start date of [DATE]; goals listed to have any complaint of pain controlled at acceptable level and to be free of discomfort. Interventions include to administer medications as ordered, assess for pain, and to notify physician if pain medication is non-effective.R1's Hospice Care Plan dated [DATE] documents R1 will be pain free or pain will be at tolerable level.R1's Medication Administration Record (MAR) dated [DATE] documents the following orders for Morphine Sulfate (Concentrate) Solution 20 milligrams(mg) per milliliter (ml) with a start date of [DATE]. -Give 0.25ml every 2 hours as needed (PRN) for pain rated 1-3 on a scale of 10.-Give 0.5 ml every 2 hours as needed (PRN) for pain rated 4-7 on a scale of 10.-Give 1.0 ml every 2 hours as needed (PRN) for pain rated 8-10 on a scale of 10.R1's MAR also documents scheduled order for 325mg of acetaminophen, 2 tabs three times a day, and every 4 hours as needed for pain, not to exceed 4000mg per day, with a start date of [DATE].V14, Hospice Registered Nurse (HRN), documented in R1's Hospice Progress Note dated [DATE] that V8, LPN called and stated R1 had fallen and was complaining of pain. V8, LPN stated R1 did not have any morphine in stock currently, and that she (V8) had no access to emergency box to pull bottle of morphine in facility stating, I'm new here. V8, LPN reported V30, R1's family member did not want R1 sent to hospital. Documents hospice attempted contact with V30 but was unable to verify V30's requests to not transport to local emergency department (ED). A new prescription for morphine was sent to the backup pharmacy and a hospice visit was scheduled for the next day, [DATE].V14, HRN, documented in R1's Hospice Progress Note dated [DATE] that V8, LPN called a second time stating R1 had now vomited three times. V14, HRN instructed V8, LPN to administer anti-emetic as ordered.R1's incident statement dated [DATE], documented V13 CNA stated she was in another resident's room when she could hear R1 screaming. V13 stated when she arrived to R1's room he was visualized in bed screaming in pain with several staff around.R1's Hospice Visit Notes dated [DATE], documented V14, HRN, stated R1 could be heard moaning in pain from down the hall. V14 documented having to wait for facility nurse V9, LPN to return from lunch break to get pain medications to relieve R1's acute pain. V14 stated she had to demand that R1 have medication for pain control as V9 stated no morphine had been retrieved from facility emergency backup supply box yet.R1's MAR dated [DATE] documented on [DATE] at 11:27 AM, Fifteen- and one-half hours post fall incident, 1st administration of PRN pain medication. R1 received ordered prn dose of 20mg/1ml Morphine indicated for pain score of 8-10 on pain scale with 10 being the worst pain. MAR documents sporadic administration of PRN morphine with continued high levels of reported pain until order for scheduled administration received on [DATE].R1's Progress Note dated [DATE], at 8:15 PM, documented V32, LPN, contacted R1's hospice stating R1 is having continued uncontrolled right knee pain after pain medication administered as ordered, and staff cannot reposition R1 without extreme pain.R1's Physician Orders dated [DATE] document new order for a 2-view x-ray of right knee related to pain in right knee and a one-time administration of 20mg of Morphine to be given for uncontrolled pain.R1's Hospital Records with print date of [DATE] documented R1 reported significant pain to right hip area upon arrival on [DATE]. R1 had obvious gross deformity to right lower extremity with significant enlargement of right thigh. Right leg x-ray was completed at 3:32pm on [DATE] with results of acute comminuted fracture distal femoral Meta diaphysis just above prothesis with distal fragment displaced laterally and posteriorly by 4cm and right hip fracture cannot be ruled out. Records document R1's family declined surgical intervention due to R1's bleeding disorder and complications associated with surgery and that R1 was placed in a knee immobilizer and returned to facility.R1's Progress Notes dated [DATE] at 9:54 PM documented R1 in extreme pain after return from hospital.R1's Progress Notes dated [DATE] at 8:30 AM documented R1 complains of severe pain in right leg with little positioning.R1's Nurse Practitioner Visit Note dated [DATE] documented R1 fell out of bed ([DATE]) Friday night when trying to reach something at the request of his roommate. R1 had significant pain throughout the weekend. Xray's obtained yesterday ([DATE]) confirmed R1 had an acute comminuted distal femur fracture of the right femur just above the prosthetic. R1 considered high risk for surgery and would have required transfer to different hospital. Family opted for conservative treatment. Added scheduled morphine due to R1's pain level in addition to current as needed ordered morphine. Family wishes to continue to focus on comfort.On [DATE] at 10:08 AM, R1 was lying in bed on a low air loss mattress. R1's bed was elevated three feet from the floor. Fall mats were not lying on the floor beside the bed. At this time R1 was unresponsive and appeared to be actively dying. R1 was breathing with mouth open, and breaths were irregular and labored.R1's Progress Note dated [DATE] at 10:50 a.m. documents R1 expired at facility.R1's Death Certificate dated [DATE] documents Immune Thrombocytopenic Purpura with contributing factors of ischemic heart disease and fracture of femur related to fall listed as cause of death. Manner of death listed as accident.On [DATE] at 1:51 PM, V34, Deputy Coroner, stated R1's cause of death was listed as Immune Thrombolytic Purpura (ITP) which is a low platelet count, this contributed to R1 being unable to have surgery to set his fracture. V34 stated this was an extensive traumatic fracture and the pain associated with this type of fracture is severe. V34 stated that the significant pain R1 suffered after his fall could have possibly caused stress to his heart becoming a significant factor attributing to his death. On [DATE] at 12:33 PM, V15 Certified Nurse Assistant (CNA) stated that she was working the night that R1 fell but was not R1's assigned to care for R1. V15, CNA stated she was in a resident's room when the fall occurred. V15, CNA stated when she entered R1's room after his fall, R1 was screaming out in pain stating his right knee hurt requesting staff to rub it. V15, CNA stated V13, CNA and herself were performing care for R1 after his fall and R1 was verbalizing and exhibiting signs of excruciating pain evidenced by facial grimacing and crying out in pain. V15 stated that 2 days later, [DATE], between 8 pm and 10 pm, herself and un-named agency CNA were providing incontinence care for R1, and she felt something move in R1's knee. V15 stated she heard a pop sound, and R1 continued to be in significant pain at this time which she reported both pain and shifting pop in right leg to V8, RN after care completion. At 3:07 PM on [DATE] V30, R1's family member stated she came to see R1 on Monday [DATE]. V30 stated she was notified of fall on [DATE] sometime around 9:00 or 9:30 PM. V30 stated she had not been in to see R1 all weekend but had called for updates on [DATE] and [DATE]. V30 stated both times she was told that R1 was just a little sore and bruised. V30 stated she entered R1's room on [DATE] and observed R1 receiving a sponge bath from a CNA (unnamed). V30 stated R1 was not being moved but screaming in pain just from touch alone.On [DATE] at 10:30 AM, V12 Nurse Practitioner (NP), stated that she wasn't aware of R1's fall that he had on Friday, [DATE]th but was notified the following Tuesday, [DATE]th. V12 stated that she found out about the entire event on the morning of [DATE] when they had their scheduled IDT meeting. V12 stated she was disappointed in how the staff managed the resident's care over the weekend after his fall. V12 stated they didn't do much for him. V12 stated that she met with R1's wife and son on Tuesday, [DATE]th to discuss the plan and at that point V12 recommended scheduled morphine as well as PRN and a Foley catheter. Facility policy titled Pain Management Program dated [DATE] documents the purpose to effectively manage pain to remove effects of unrelieved pain.On [DATE] at 11:40 AM, V2 DON stated that V8 did have access to the emergency medication box (E-box) to pull morphine, and that she had already educated V8 on E-box procedure for R1. V2 stated V8 should have pulled order morphine the night of the fall to provide R1 pain relief.

Based on interview and record review the facility failed to employ a registered nurse, eight hours a day, seven days a week. This failure has the potential to affect all 88 residents who reside in the facility. Findings include: The facility provided census dated 4/9/25 documents 88 residents reside in the facility. The facility provided staffing sheets dated February 3, 7, 17, 21, 27, 28, March 3, 21, 22, 23, 31, and April 4, 2025 document that there was not eight hours per day of registered nursing care provided on those dates. On 4/10/25 at 9:39AM, V5 Scheduler confirmed that on February 3, 7, 17, 21, 27, 28, March 3, 21, 22, 23, 31 and April 4, 2025 there was not eight hours per day of registered nursing care provided on those dates.

Based on observation, interview and record review the facility failed to assess, monitor, implement careplan interventions, obtain treatment orders and failed to prevent cross contamination during wound care for one (R63) resident's facility acquired Left Heel Pressure Ulcer. This failure resulted in R63's Left Heel Pressure Ulcer deteriorating leading to surgical debridement and infection requiring two antibiotic therapies. Findings include: R63's undated Face Sheet documents R63 admitted to the facility on [DATE] with medical diagnoses as Metabolic Encephalopathy, Severe Protein Calorie Malnutrition, Lack of Coordination and Cognitive Communication Deficit. R63's Minimum Data Set (MDS) dated [DATE] documents R63 as severely cognitively intact. This same MDS documents R63 requires maximum assistance for toileting, dressing, personal hygiene and bed mobility. R63's Careplan initiated 10/30/24 does not document R63's Left Heel Stage 4 Pressure Ulcer, Left Heel wound infection and antibiotic therapies prescribed for R63's Left Heel Stage 4 Pressure Ulcer. R63's careplan intervention dated 11/1/24 instructs staff to complete weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R63's Physician Order Sheet dated February 2025 documents a physician order starting 2/14/25 with no end date to Cleanse Left Heel with normal saline pat dry, apply Gentamicin Sulfate Ointment 0.1 % to wound bed, and then Calcium Alginate cover with non-adherent pad, and absorbent pad and then wrap foot with gauze, change daily and (PRN) as needed. This same POS documents a physician order starting 2/6/25 and ending 3/6/25 to administer Doxycycline Hydrochloride 100 milligrams (mg) twice daily for 28 days for Osteomyelitis. This same POS documents physician orders to apply pressure relieving boots and float heels starting 12/12/24. R63's Pressure Ulcer Risk assessment dated [DATE] documents R63 as not at risk for obtaining pressure ulcers. The facility was unable to provide Pressure Ulcer Risk Assessments for R63 from 10/28/24-12/3/24. R63's Medical Record does not show any assessment of R63's Left Heel Pressure Ulcer 11/1/24-12/12/24. R63's Skin Condition Report dated 10/31/24 documents R63 has no abnormal skin conditions. R63's Skin Observation Report dated 11/1/24 documents R63's bilateral heels as areas of concern. R63's Skin Condition Report dated 11/13/24 documents R63's Left Heel was pressure wound black, Right Heel non blanchable redness. Float heels when in bed. R63's Medical Record documents the first review by a Registered Dietician was 1/26/25. R63's Laboratory Results Report dated 2/11/25 documents R63's Left Heel wound culture was obtained on 2/6/25 with results of moderate growth of Methylicillin Susceptible Staphaureus (MSSA). R63's Wound Evaluation and Management Summary dated 2/12/25 documents R63's Left Lateral Heel Stage 4 Pressure Ulcer measured at 2.2 cm (centimeters) long by 1.8 cm wide by 0.4 cm deep. This same report documents V21 Wound Physician surgically debrided R63's Left Heel Pressure Ulcer to a Stage 4. This same report documents a wound culture was obtained from R63's Left Lateral Heel Stage 4 Pressure Ulcer. R63's Wound Evaluation and Management Summary dated 2/19/25 documents R63's Left Lateral Heel Stage 4 Pressure Ulcer's wound culture showed Methicillin Susceptible Staph Aureus (MSSA). This same report documents R63 is currently on Doxycycline antibiotic and will be started on Gentamycin Sulfate ointment. On 2/24/25 at 9:30 AM V4 Licensed Practical Nurse (LPN)/Wound Nurse completed the dressing changes for R63's Left Heel. V4 LPN/Wound Nurse placed R63's dressing supplies directly on R63's bedside table that had multiple areas of dried spilled liquids and unknown food debris. V4 LPN then used those same supplies to apply to R63's Left Heel. V4 LPN placed her scissors on R63's contaminated bedside table and then used the contaminated scissors to cut a piece of Calcium Alginate to apply to R63's open Stage 4 Left Heel Pressure Ulcer. On 2/25/25 at 2:00 PM V4 Licensed Practical Nurse (LPN)/Wound Nurse stated R63 admitted to the facility on [DATE] with no pressure ulcers. V4 stated R63 is very compliant with whatever the staff asks her to do. V4 LPN stated cross contaminating R63's Left Heel Stage 4 Pressure Ulcer could cause an infection or cause R63's current wound infection to become worse. On 2/26/25 at 1:00 PM V22 Nurse Practitioner (NP) stated the facility should have included R63's Pressure Ulcer in her careplan, assessed R63's Left Heel weekly and documented all necessary information. V22 NP stated V21 Wound Physician was asked to assess R63's Left Heel Pressure Ulcer after it had opened. V22 NP stated V21 Wound Physician doesn't normally look at closed wounds. V22 NP stated R63's Left Heel was soft prior to it opening. On 2/26/25 at 2:00 PM V2 Director of Nurses (DON) stated R63 admitted to the facility with no pressure ulcers. V2 Director of Nurses (DON) stated she reviewed R63's 11/1/24 shower sheet. V2 DON stated she assessed R63's heels on 11/1/24 and noted that they were 'soft and mushy'. V2 DON stated she should have implemented careplan interventions at that point but did not. V2 DON stated R63 was first noted to have 'boggy' heels on 11/13/24. V2 DON stated V10 Registered Nurse (RN) had noticed on 11/13/24 that R63's heels both had pressure ulcers but did not obtain any physician orders or update R63's careplan. V2 DON stated V21 Wound Physician first saw R63 on 12/12/24 and ordered the moon boots and to float her heels. V2 DON stated the staff should have been floating R63's heels prior to that. V2 DON stated the staff should have been completing weekly assessments of R63's Left Heel Pressure Ulcer from the first time it was noted. V2 DON stated the facility has provided all of the information available but there are Pressure Ulcer Risk Assessments and Skin Evaluations missing and R63's careplan should have been updated. V2 DON stated We (facility) should have caught (R63's) risk for obtaining pressure ulcers earlier. It's really all my fault from the beginning because I didn't do anything from her 11/1/24 shower sheet when we (staff) first noticed (R63) had problems with her heels. We will be inservicing all the nursing staff about pressure ulcers. The facility policy titled Pressure Injury and Skin Condition Assessment revised 1/17/18 documents a skin condition assessment and pressure ulcer risk assessment will be updated quarterly and as necessary. Residents identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending Physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. Conduct hand washing in accordance with facility standard/universal precautions. Pressure ulcers and other ulcers will be measured at least weekly and recorded in centimeters in the resdient's clinical record. A wound assessment for each identified open area will be competed and will include site location, size, stage of pressure ulcer, odor, drainage, description and date/initials of the individual performing the assessment.

Based on interview and record review the facility failed to provide timely call light response for six (R7, R11, R22, R26, R35, R226) of nine residents reviewed for call light response times in the sample list of 41. Findings include: 1. On 2/24/25 at 10:33 AM, a resident council meeting was held. During the meeting R22 stated it takes a long time for call lights to be answered, R22's room mate (R26) cries and calls out, so R22 turns the call light on for R26. R22 stated R22 has had to go looking for staff because no one responds to the call light. R22 stated R22's/R26's room gets overlooked because it is in the corner and not on the main part of the hallway. R35 stated R35 has waited for over an hour for R35's call light to be answered and especially during breakfast and when staff are giving showers. R7 stated R7 turns the call light on for R7's room mate, R11, since a lot of times R11 isn't able to find the call light. R7 stated R11 waits a long time for the call light to be answered and often ends up getting out of bed by herself, but R11 is suppose to have assistance from staff. R7 stated R11 can't wait and ends up taking herself to the bathroom. These residents stated call light wait times has been an ongoing issue brought up in the resident council meetings that hasn't been resolved. On 2/24/25 at 11:34 AM V11 Activity Director confirmed call lights has been an ongoing concern brought up in the resident council meetings. V11 stated call light audits have been conducted and the longest has been about 30 minutes. The Resident Council Minutes dated 10/1/24, 11/5/24, 12/4/24-12/6/24, 1/15/25, and 2/4/25 document concerns with call light response times taking too long. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. R11's MDS dated [DATE] documents R11 has moderate cognitive impairment and requires supervision/touching assistance from staff for toileting and transfers. R35's MDS dated [DATE] documents R35 as cognitively intact and R35 requires substantial/maximal assistance of staff for transfers, toileting, dressing and hygiene. R22's MDS dated [DATE] documents R22 as cognitively intact and requires setup/clean up to supervision/touch assistance from staff for Activities of Daily Living. R26 MDS dated [DATE] documents R26 as cognitively intact and is dependent on staff for toileting, transfers, hygiene, and dressing. 2. On 02/23/25 at 9:20 AM R226 stated on an unidentified date R226's call light was on for 45 minutes. R226's Admission MDS dated [DATE] documents R226 as cognitively intact and requires partial/moderate assistance from staff for hygiene, dressing and transfers and supervision/touch assistance for walking. The facility's Call Light policy dated 2/2/18 documents all staff should assist in answering call lights and to answer call lights promptly.

Based on observation, interview and record review the facility failed to ensure four residents (R19, R65, R24, R226) had physician orders for medications which were in residents rooms out of four residents reviewed for qualified persons in a sample of 41 residents. Findings include: 1. R65's undated Face Sheet documents medical diagnoses of Rhabdomyolosis, Metabolic Encephalopathy and Cognitive Communication Deficit. R65's Physician Order Sheet (POS) dated February 2025 does not document a physician order for Magnesium Oxide 500 milligrams (mg). This same POS does not document a physician order for R65 to have medications left at his bedside. On 2/23/25 at 10:40 AM R65 had a bottle of Magnesium Oxide 500 mg sitting on his bedside dresser. On 2/25/24 at 1:30 AM R65 had a bottle of Magnesium Oxide 500 mg sitting on his bedside dresser. On 2/23/25 at 10:45 AM R65 stated the bottle of Magnesium Oxide belongs to him. R65 stated he buys the Magnesium Oxide and keeps it in his room. On 2/25/25 at 1:40 PM V2 Director of Nurses (DON) stated R65 has been known to go to a store, buy over the counter medications and leave them in his room. V2 DON stated the facility was not aware that R65 had the bottle of Magnesium Oxide and will remove it promptly due to R65 is not supposed to have medications kept at his bedside. 2. R19's undated Face Sheet documents medical diagnoses of Bilateral Primary Osteoarthritis of Knee, Alzheimer's Disease, Morbid Obesity and Obstructive Sleep Apnea. R19's Physician Order Sheet (POS) dated February 2025 does not document a physician order for Zeasorb Antifungal powder nor another bottle of antifungal powder 1%. This same POS does not document a physician order for R19 to have medications left at her bedside. On 2/23/25 at 11:08 AM one bottle of Zeasorb antifungal powder was sitting on R19's bedside dresser. On 2/23/25 at 1:25 AM one bottle of Zeasorb antifungal powder and another bottle of antifungal powder 1% was sitting R19's bedside dresser. On 2/23/25 at 11:10 AM R19 stated she occasionally gets gaulded under her breasts and the staff will put the antifungal powder on. R19 stated They (staff) all know it is there. They use it and then leave it in here so they have it handy the next time. On 2/25/25 at 1:45 PM V2 Director of Nurses (DON) stated R19 does not have an order to self administer medications and should not have any medication left at her bedside. V2 DON stated all medications should have a physician order and only the residents with self administration assessments and have a physician order to keep their medication at the bedside should have them sitting in the resident room. V2 DON stated other residents could have access to medications left unattended. 40385 3.) On 2/23/25 at 9:11 AM there was a tube of menthol topical gel on R36's bed. R36 stated the staff apply the gel to R36's shoulders as needed and R36 always keeps this medication in R36's room. R36's medical record did not contain an active order for the menthol gel or that the medication may be stored at R36's bedside. R36's February 2025 Medication Administration Record does not document an order or administration of the topical menthol gel. On 2/23/25 at 11:22 AM V12 Licensed Practical Nurse stated R36 uses the topical menthol gel and it is applied by staff. V12 stated R36 used to have an order to keep that medication in R36's room. V12 confirmed R36 does not have an active order for this medication or that it may be kept at the bedside. On 2/25/25 at 1:07 PM V2 Director of Nursing confirmed all medications administered should have an active order. V2 stated medications should be stored in the medication cart/medication room unless there is an order to keep the medication in the resident's room. 38780 4. On 2/23/25 at 9:14am, R24 was sitting in a recliner in R24's room. An open bottle of Calcium Carbonate Ultra Strength 1000 milligrams (mg) was observed on a table next to R24's recliner. No licensed nursing staff were present in R24's room during this time. On 2/25/25 at 9:15am, R24 was sitting in a recliner in R24's room. An open bottle of Calcium Carbonate Ultra Strength 1000mg was observed on a table next to R24's recliner. No licensed nursing staff were present in R24's room during this time. On 2/25/25 at 9:16am, R24 stated R24 takes the Calcium Carbonate when needed for heartburn. R24's Physician Order Sheet (current) does not document an order for Calcium Carbonate 1000mg. The facility Medication Storage Policy dated 7/2/19 documents the facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for four (R66, R28, R33, R49) of four residents reviewed for infection control in the sample list of 41. Findings include: The facility's Enhanced Barrier Precautions policy dated 5/7/24 documents EBP is an intervention designed to reduce the transmission of multidrug-resistant organisms by using gowns and gloves during high contact resident care activities for residents with indwelling medical devices or chronic wounds. The Centers for Disease Control and Prevention Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021 documents Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE (Personal Protective Equipment) required and defining high risk resident care activities. Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room). 1. On 2/23/25 at 8:58 AM there was an EBP sign posted on R66's room door that indicated to wear gown and gloves for high contact resident care activities that included toileting, dressing, and transfers. There was no PPE cart containing gowns near R66's room. On 2/23/25 at 12:50 PM V16 Certified Nursing Assistant (CNA) entered R66's room and emptied R66's catheter. V16 was not wearing a gown while handling R66's urinary catheter bag. On 2/23/25 at 1:04 PM V16 and V15 CNAs dressed R66, handled R66's urinary catheter bag, and transferred R66 from the bed into a geriatric chair with a full mechanical lift. V15 and V16 were not wearing gowns during R66's care. On 2/23/25 at 1:21 PM V16 was asked about EBP and V16 stated V16 was unsure what that was. On 2/24/25 at 2:48 PM V13 and V14 CNAs provided R66's incontinence care and urinary catheter cleaning/care. V13 and V14 were not wearing gowns during R66's care. V13 confirmed EBP signage posted on R66's room door and that neither V13 or V14 wore gowns during R66's observed care. V13 stated a gown is suppose to be worn for the cares listed on the sign. V13 stated V13 did not know if the sign was posted for R66 or R66's room mate and was unsure the reason why EBP was needed. V13 stated it is confusing to know if the resident is on contact precautions or EBP. On 2/24/25 at 3:29 PM V14 CNA stated V14 has to ask the nurses about who is on transmission based precautions (TBP), because sometimes signs aren't posted. When asked about EBP, V14 stated that is used for influenza, COVID-19, and we wear gown, gloves and mask. When asked about EBP, stated that is used for influenza, COVID, and we wear mask, gown, gloves. Asked about difference between EBP and TBP and V14 was unsure. V14 stated the facility has not provided any training on EBP. R66's Physician Order dated 1/10/25 documents EBP due to urinary catheter. 20892 2. February 23, 2025 at 9:00 AM while doing the facility tour R28, R33 and R49 rooms door's had signage for Enhance Barrier Precaution (EBP) and there was no equipment carts outside the rooms for the staff to have access to gowns, gloves or masks to don before entering the rooms. R28's Electronic Medical Record (EMR) section titled Diagnosis documents R28 on 1/2/25 has the diagnosis of Urinary Tract Infection (UTI) and this is the reason for her EBP status. R33 EMR documents R33 receives hospice services and has incontinence of both bowel and bladder and has had skin breakdown, reason for his EBP status R49 EMR documents R49 has the need for enhanced barrier precautions related to presence of chronic wounds, nonpressure. V4, Infection Control Preventionist stated on 2/24/25 at 11:13 AM, The reason we did not have the equipment carts outside the rooms is because the residents would run right into the cart. The staff knows the gowns, gloves and masks are available to them in the Utility room on each unit.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for self-administration of medication. This failure affects two (R24 and R36) of two residents reviewed for self-administration of medication on the sample list of 41. Findings include: 1. The facility Self-Administration of Medications Policy dated August 2020 documents residents will have a self-administration of medication assessment, a physicians order to self-administer medication, and this will be care planned. On 2/23/25 at 9:14 am, a medicine cup containing R24's morning medications was observed on R24's bedside table. R24's last name was written on said medicine cup. This medicine cup contained the following medications: Glimepiride 2 milligrams (mg); Multivitamin; Omeprazole 20 mg; Plavix 75 mg; Potassium Chloride 20 milliequivalent (mEq); Tamsulosin 0.4 mg; Gabapentin 600 mg and Carbidopa-Levodopa 25-100 mg (two tabs). No licensed nursing staff were present in R24's room during this time. On 2/23/25 at 9:15am, R24 stated, those are my morning meds. I'll take them here shortly. R24's Comprehensive assessment dated [DATE] documents R24 is cognitively intact. R24's Physician Order Sheet (current) does not document an order for self-administration of medication. R24's Electronic Medical Record does not contain a self-administration of medication assessment. R24's Care Plan (current) does not document R24 is able to self-administer medication. 40385 2.) On 2/23/25 at 9:20 AM R226 was sitting in a recliner in R226's room and there was a medication cup containing two white pills on R226's overbed table. R226 stated R226 thought the pills were iron pills. R226 stated the nurses don't always wait for R226 to take R226's medications prior to leaving the room. On 2/23/25 at 9:32 AM V12 Licensed Practical Nurse stated the pills at R226's bedside were two probiotic pills that V12 administered this morning. V12 stated V12 probably should have waited to make sure R226 took all of R226's medications. V12 confirmed there would be a physician's order if R226 was able to self administer medications. R226's February 2025 Medication Administration Record documents Lactobacillus (probiotic) give two tablets daily at 8:00 AM. There are no orders, assessment, or care plan in R226's medical record that documents R226 has been assessed for the ability to self administer medications. On 2/25/25 at 1:07 PM V2 Director of Nursing stated there needs to be a physician's order for residents to self administer medications. V2 confirmed there is no order for R226 to self administer medications. V2 stated the nurses should not be leaving medications at the bedside for residents to take, the nurses should stay with the resident to observe the resident consume the medications.

Based on observation, interview, and record review the facility failed to ensure resident rooms were equipped with call lights and failed to provide an appropriate call light for three (R7, R11, R66) of three residents reviewed for accommodations of needs in the sample list of 41. Findings include: The facility's Call Light policy dated 2/2/18 documents the nurse call light system will be available at all times and within easy accessibility for residents who have the ability to use a call light. This policy documents to report call light system problems to to the maintenance department for servicing. 1. On 02/24/25 at 10:33 AM, during the resident council meeting, R7 stated R7 doesn't have a call light and hasn't had one since moving into the room that is shared with R11. R7 stated a lot of times R7 has to find R11's call light because R11 is unable to find it. R7 stated R11 needs staff assistance for transfers, but R11 self transfers because staff don't answer the call light timely. On 2/24/25 at 11:27 AM, R7's/R11's room contained only one call cord with one call light that was attached to R11's bed. There was a desk bell on R11's overbed table. R7's side of the room did not contain a call light or bell. R11 was asked about the call light and bell, R11 was confused and did not understand. At 11:28 AM V19 Certified Nursing Assistant (CNA) stated R7's/R11's call light box only allows for one cord and R7 uses a bell as a call light. V19 stated R7 and R11 shared the call light. On 2/24/25 at 11:32 AM, V19 Maintenance stated V19 was not aware that R7's/R11's room only has one call light. V19 stated the staff should have notified the maintenance department. V19 confirmed each resident should have their own call light. On 2/24/25 at 2:22 PM, V18 Maintenance Director stated V18 had been working on R7's/R11's call light and trying to find call light cords since both residents were moved into the room together. V18 confirmed that R7 and R11 began sharing the room in October 2024 and there has only been one call light in that room since then. On 2/25/25 at 9:13 AM V2 Director of Nursing and V4 Assistant Director of Nursing in January 2025 they became aware that R7 and R11 were sharing a call light and were told by maintenance staff that parts had been ordered. R7's Census and R11's Census document R7 and R11 have shared a room since 10/21/24. 2. On 2/23/25 at 8:58 AM R66 was lying in bed and R66's flat, touch pad style call light was on the floor mat beside R66's bed, out of R66's reach. On 2/23/25 at 12:16 PM R66 was in bed and R66's call light was on the floor. On 2/23/25 at 1:04 PM V15 and V16 CNA turned R66 in bed, dressed R66, and transferred R66 with a full mechanical lift into a geriatric chair. R66 had no functional movement of R66's arms and did not assist the staff during these cares. On 2/23/25 at 9:31 AM V16 CNA stated R66 isn't able to use the call light since R66 is unable to use R66's arms. V16 stated R66 isn't able to activate the call light with R66's chin or head. At 12:50 PM V16 confirmed R66's call light was on the floor, out of R66's reach. At 1:21 PM V16 stated R66 yells out to alert staff that R66 is in pain and when R66 wants pain medication. On 2/24/25 at 2:48 PM V14 stated R66 isn't able to use R66's call light, staff have tried positioning it near R66's head and feet, and no other style of call light has been used. R66 agreed with V14's statement. R66 stated R66 just yells out for staff or asks R66's room mate to turn on the call light. V13 and V14 CNAs used wedge cushions to position R66 onto R66's side at a 90 degree angle to the mattress and placed the call light next to R66's hand. R66 attempted to activate the touch pad call light and was inconsistently able to activate the call light by poking it with R66's finger. R66 stated R66 is only able to activate the call light when lying in this exact position due to R66's limited hand movement. On 2/24/25 at 3:18 PM V3 Licensed Practical Nurse stated staff tried using a bell as a call light for R66, but R66 wasn't able to use it. V3 stated R66 said R66 would use a mouth type call light that is activated by blowing into it, which is what R66 used at the hospital, but this facility does not have that style of call light. On 2/24/25 at 9:13 AM V2 Director of Nursing confirmed R66 has not had any other call lights attempted or trialed besides the flat touch pad style. V2 stated V2 was not aware that there are other styles of call lights that could be used. R66's MDS 1/13/25 documents R66 as cognitively intact, has impaired range of motion to both upper and lower extremities, is dependent on staff assistance for activities of daily living, and has frequent pain. R66's Care Plan dated 1/9/25 documents R66 has limited physical mobility related to quadriplegia and to ensure call light is within reach and encourage use. R66's Progress Note dated and recorded by V22 Nurse Practitioner 1/9/25 documents R66 is a new admission following a fall at home with cervical ligament injury and disc fracture of C4-C5 and associated cord compression of C3-C4. R66 underwent a laminectomy and developed cord compression and quadriplegia and was transferred to a hospital rehabilitation center prior to admitting to current facility.

Based on interview and record review the facility failed to complete a discharge summary for one resident (R75) out of one resident reviewed for discharge in a sample list of 41 residents. Findings include: The facility was not able to provide a policy in regards to documentation upon a resident being discharge to home or to another facility. V1 stated at 11:18 AM on 2/26/25 was We only have this policy about transferring or discharging a resident. No information about what needs to be documented in the discharge summary or recapitulation of stay. R75 Electronic Medical Record (EMR) documents R75 admitted to facility on 11/6/24 and discharged on [DATE]. R75's Electronic Medical Record does not include a discharge summary or recapitulation of stay while here at the facility. R75's Care Plan initiated 11/16/24 documents R75 wishes to return to her home in (Local CIty) and son whom she lives with. The careplan continues to document: to establish a pre-discharge plan with me/family/caregivers and evaluate progress and revise plan as needed. On 2/25/25 V2 at 11:30 AM V2, Director of Nursing, stated V2 finished documenting on R75, the nurse who discharges the resident should have documented the information in the Progress notes of EMR. V2 stated she did the part for the nurses but the other disciplines did not chart any information.

Based on observation, interview, and record review the facility failed to provide services to address a decline in walking and transfer ability for one (R42) of 24 residents in the sample of 41. Findings include: On 2/23/25 between 10:30 AM and 4:00 PM and on 2/24/25 between 8:32 AM and 4:00 PM intermittent random observations were conducted of R42 who was sitting in a wheelchair near the nurses' station on R42's unit. On 2/25/25 at 10:33 AM V14 Certified Nursing Assistant (CNA) and V3 Licensed Practical Nurse (LPN) transferred R42 out of bed into a wheelchair and propelled R42 out into the hallway. On 2/25/25 at 3:12 PM R42 walked approximately 50 feet with wheeled walker and extensive assistance from V13 and V14 CNAs and V3 LPN. V3 had hold of the front of R42's walker to apply resistance pressure while walking backwards. V13 used a gait belt and assisted R42 with walking while V14 followed with the wheelchair. R42's gait was unsteady and R42 leaned forward with feet outstretched trailing behind R42. V3 stated if V3 did not apply resistance on R42's walker, R42 would fly forward. V14 stated staff doesn't walk with R42 due to not having enough time. V13 stated staff only walk with R42 occasionally/as needed if R42 looks like R42 is getting restless. On 2/25/25 at 10:57 AM V10 Registered Nurse stated within the last two months R42 has declined, R42 no longer walks, R42 has been using the wheelchair and needs extensive assistance from staff for transfers. On 2/25/25 at 11:44 AM V3 stated R42's balance and physical ability has declined within the last three weeks. V3 confirmed the wheelchair is R42's primary mode of locomotion. R42's Minimum Data Set, dated dated dated [DATE] documents R42 has short and long term memory impairment, R42 used supervision/touch assistance from staff for transfers and walking up to 150 feet, and a walker was the only mobility device used during the look back period. R42's Care Plan (current) documents R42 has an activity of daily living self performance deficit related to disease process of Huntington's Disease. This care plan documents an intervention dated 3/31/24 that R42 is independent with supervision for transfers and ambulation and sometimes needs one assist. This care plan has not been updated with R42's current level of functioning. R42's Nursing Notes document R42 fell on [DATE], 1/14/25 and 2/15/25. There is no documentation that therapy or restorative nursing services were offered or implemented to address R42's decline in walking and transfers. On 2/25/25 at 9:13 AM V2 Director of Nursing and V4 Assistant Director of Nursing stated R42 has not had therapy offered or implemented recently after R42 started using the wheelchair. V2 stated the facility does not have restorative nursing programs implemented/documented. At 9:56 AM V2 stated R42 last received therapy services on 7/22/24. The facility's Restorative Nursing Program dated 1/4/19 documents the purpose of the program is to promote each resident's ability to maintain or regain the highest degree of independence as safely possible. This policy documents residents will be screened for restorative nursing needs upon admission, annually, quarterly and with significant changes in condition, and will be determined by the interdisciplinary team as needed and/or may be determined as a continuation of care following therapy services. This policy documents restorative programs will include individualized goals and measurable objectives that are documented on the resident's plan of care, implementation of interventions will be documented, and resident's progress will be periodically reviewed by the nurse.

Based on interview and record review the facility failed to provide showers as scheduled for one (R35) of two residents reviewed for showers in the sample list of 41. Findings include: On 2/24/25 at 10:33 AM during the resident council meeting, R35 stated R35 is suppose to have showers twice per week, but has only been getting showers five or six times per month. R35's MDS dated [DATE] documents R35 is cognitively intact and requires substantial/maximal assistance from staff for bathing. R35's shower task documents R35 is scheduled for showers on Mondays and Thursdays and does not document that R35 was offered a shower after 2/17/25. On 2/25/25 at 2:36 PM V27 Certified Nursing Assistant (CNA) stated We work with four CNAs on the [NAME] Hall, which is not enough because we don't always get showers done. It would be nice to have a shower aide. On 2/24/25 R35's February 2025 shower documentation was requested. V2 provided R35's shower sheets dated 2/2/25, 2/11/25 and 2/14/25. On 2/24/25 at 12:43 PM V2 confirmed all February 2025 shower documentation was provided for R35 and confirmed R35 should receive showers twice weekly as scheduled. The facility's Bathing- Shower and Tub Bath policy dated 1/31/18 documents the purpose of the policy is to ensure resident's cleanliness to maintain proper hygiene and dignity. This policy documents bathing will be offered according to resident's preferred frequency or twice per week and document bathing in the resident's electronic medical record.

Based on observation, interview, and record review, the facility failed to respond to a resident requesting to be put to bed in a timely manner. This failure affected one (R1) out of three residents reviewed for falls in a sample list of six residents, resulting in R1 falling and sustaining a left rib fracture. Findings include: 1. R1's Minimum Data Set (MDS), dated [DATE], documents R1 as mildly cognitively impaired. This same MDS documents R1 as requiring substantial/maximum assistance for toileting, upper and lower body dressing and chair/bed to chair transfer. R1's undated Face Sheet documents Medical diagnoses of Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Muscle Weakness (Generalized), Abnormalities Of Gait And Mobility, Symptoms And Signs Involving The Musculoskeletal System among others. R1's Careplan, dated 10/26/24, documents R1 is at risk for falls due to hemiplegia and weakness and lists an intervention to make sure call light is always within reach. R1's Fall Risk Assessment, dated 3/4/2024, documents R1 is at risk for falls. R1's Fall Investigation, dated 7/8/24, documents R1 had an unwitnessed fall at R1's bedside at 11:15 PM on 7/8/24. This same fall investigation documents R1 was oriented to person and place and called for help prior to the fall. This fall investigation documents R1 complained of left sided extremity pain. R1's fall investigation documents, (R1) stated 'I was leaning over in my chair and slipped out of my chair and hit the floor.' This same fall investigation documents first aid initiated to Left forearm by elbow; site cleansed with wound cleanser and 3 steri-strips applied and wrapped with gauze dressing. This fall investigation documents per (R1) request, narcotic pain medication administered. R1's X-Ray of the chest report, dated 07/09/2024 at 3:22 PM, documents, Clinical indication: Pain. Impression: Stable radiograph with no evidence of acute cardiopulmonary disease. R1's Computerized Tomography Scan of Chest, dated 7/10/24, documents, Impression: Left sixth rib fracture. R1's Nurse Progress Note, dated 07/08/2024 at 11:15 PM, documents, Resident had an un-witnessed fall 07/08/2024 11:15 PM Location of Fall: Resident's room. This nurse was summoned to the resident's room due to complaint of resident lying on his bedroom floor. Upon entering resident found on floor in a left side lying position. Resident complained of left sided extremity pain. Resident able to move upper and lower extremity equally on Right side of body. Resident strengths equal to baseline weakness prior to fall. Four centimeter curved skin tear noted to Left outer forearm proximal to elbow. Resident denies headache, dizziness, nausea at this time. On 7/16/24 at 10:50 AM R1 stated R1 fell from his wheelchair later in the night after R1 had requested to go to bed earlier in the evening. R1 stated he is in the hospital at this time due to pain from a fractured rib. On 7/16/24 at 10:50 AM V3 R1's Family Member stated V3 was notified that R1 fell from the wheelchair in his room and received skin tears to the arm. V3 stated the nurse told V3 that R1 was watching television and fell from his wheelchair. V3 stated that their son was visiting R1 on 7/8/24 and left the facility around 6:30 PM due to R1 requesting to go to bed. Hospital Records dated 7/10/24 at 11:25 AM state that R1 presented to the ER today after falling out of his wheelchair yesterday landing on his chest and sustaining what was found after evaluation to be a left sixth rib fracture. The Hospital Records document R1 had had a chest X-ray at the nursing home where he resides which did not reveal a fracture but the Computed Tomography in the Emergency Department did. The Hospital Records document R1 was admitted for pain control. On 7/18/24 at 1:41 PM V1 and V2 state that care plans are updated after a fall. V1 and V2 acknowledged at R1's care plan was updated on 7/8/24. R1 care plan now states On 7/8/24, I had a fall from my wheelchair. CNA staff will be educated on my bedtime preferences. On 7/18/24 at 1:57 PM V15 stated R1 was up in the wheelchair upon V15 arrival to shift at 7:30 PM. V15 stated R1 wanted to go to bed. V15 stated 30 min later, V15 checked on R1 and R1 was napping in the chair. V15 stated V15 next saw R1 laying on the floor, on his left side facing the door. V15 stated the nurse assessed R1. V15 stated R1's hemi-walker was in a different position, as if R1 attempted to transfer self to bed and fell .

Based on observation, interview, and record review the facility failed to ensure narcotic pain medication was obtained to be given as ordered resulting in R5 experiencing uncontrolled pain for 24 hours. The facility also failed to timely administer requested pain pain medication for one (R5) of five residents reviewed for medications in the sample list of 11. Findings include: On 7/2/24 at 12:06 PM R5 was sitting in a wheelchair in R5's room, and R5's left leg was in a cast. R5 stated R5 is waiting for requested pain medication that R5 had reported to V3 Certified Nursing Assistant (CNA) about 30 minutes ago. R5 stated R5 fractured R5's left ankle in two places prior to admitting to the facility. R5 stated at first the facility was not managing R5's pain, since the hospital hadn't sent prescriptions for pain medications R5 went an entire day without the ordered pain medication. R5 stated R5's leg hurt so bad that day that R5 was crying, and R5 rated the pain a 10 on a 0-10 scale. R5's ongoing Diagnoses List includes a diagnosis of displaced bimalleolar fracture of the left lower leg, subsequent encounter for closed fracture with routine healing. R5's Admission Minimum Data Set, dated dated dated [DATE] documents R5 is cognitively intact and during the last five days R5 had constant pain rated a 9 on a 0-10 scale that frequently affected sleep, therapy participation, and daily activities. R5's Care Plan dated 6/28/24 documents R6 has a fracture related to Osteoporosis and includes an intervention to administer pain medication as ordered. R5's Order Summary Report dated 6/18/24 includes orders for Norco (narcotic pain medication) 5-325 milligrams (mg) give one tablet by mouth every 6 hours as needed (PRN) for left ankle fracture, Acetaminophen Extra Strength Oral Tablet give 500 mg by mouth every 4 hours PRN for pain, and Tramadol Hydrochloride (narcotic pain medication) give 50 mg every 8 hours PRN for pain. R5's Pain assessment dated [DATE] at 11:24 PM documents R5 has left ankle pain related to recent fracture/surgery, rated as very severe almost constantly which almost constantly affects sleep and daily activities. R5's June 2024 Medication Administration Record (MAR) does not document between 6/18/24 and 6/19/24 R5 received any scheduled pain medication, or any PRN pain medication was administered other than Acetaminophen on 6/19/24 at 12:22 PM and Norco on 6/19/24 at 4:26 PM (almost 24 hours after R5's admission.) This MAR documents on 6/19/24 R5's pain was rated 6 at 12:00 AM, 7 at 6:00 AM, Not Applicable at 12:00 PM, 9 at 12:22 PM when PRN Acetaminophen was administered, 10 when PRN Norco was given at 4:26 PM, and 0 at 6:00 PM. This MAR documents Norco was given on 6/19/24 at 9:40 PM with pain rated 8; 6/20/24 at 3:40 AM for pain rated 6 and at 10:40 AM for pain rated 5. R5's July 2024 MAR documents PRN Tramadol 100 mg was given on 7/2/24 at 12:57 PM (over an hour after R5's request) for pain rated 5. R5's Nursing Notes document the following: On 6/18/24 at 4:48 PM R5 admitted to the facility with left ankle pain. On 6/18/24 at 11:12 PM R5 had left ankle pain and R5 receives scheduled pain medication which is effective in managing R5's pain. On 6/20/2024 at 1:01 PM documents the following: R5's family called to discuss R5's pain medications and that Norco is ineffective. R5 was sent with unsigned prescriptions for pain medication from the hospital that were forwarded yesterday to the Nurse Practitioner for review. On 6/20/24 the electronically signed prescriptions were located in the bin containing electronic facsimiles (fax) and Oxycodone (narcotic) and Tramadol were ordered from pharmacy. There is no documentation in R5's medical record that attempts were made to notify the physician and obtain R5's ordered narcotic pain medication prior to 6/19/24. On 7/2/24 at 12:38 PM V4 MDS Coordinator stated R5 admitted late afternoon from the hospital and R5's narcotic prescriptions were not signed by a physician. V4 stated there wasn't a practitioner in the building to sign the prescriptions. V4 stated the facility has a medical group on call to contact to request prescription signatures and V4 was the nurse manager on call the day R5 admitted , V4 would have instructed the nurse to contact the medical group to sign R5's prescriptions. V4 confirmed attempts were not made to obtain R5's Norco until 6/19/24, and Tramadol and Oxycodone on 6/2024. V4 stated (R5's) pain increased unfortunately since we couldn't back track (change what happened). On 7/2/24 at 12:47 PM (45 minutes after R5's interview) V5 LPN stated V3 CNA reported earlier that R5 requested pain medication. V5 stated V5 has been busy with a new admission and hospital transfer and V5 forgot to administer R5's pain medication. On 7/2/24 at 1:58 PM V6 CNA stated R5 was in a lot of pain the night R5 admitted to the facility. V6 stated R5 called to request pain medication, R5 was in a lot of pain, and the nurse didn't have the pain medication because it hadn't been delivered. V6 stated R5 did not get out of bed that evening, we tried ice packs, and R5 required assistance of two staff for bed mobility due to the amount of pain R5 was in. V6 stated R5 had facial expressions of pain and tears in R5's eyes. On 7/2/24 at 2:35 PM V2 Director of Nursing stated the hospital is suppose to send prescriptions electronically signed which are sent to pharmacy and then pharmacy will dispense the medication. V2 stated the nurses should look at the hospital discharge orders and enter the orders onto the order list that is sent to pharmacy, and then the pharmacy is suppose to reach out to the facility to notify us if they don't have a signed prescription. V2 stated the nurse is then responsible for notifying the physician to obtain the signed prescription, the facility has a Nurse Practitioner who rounds daily who is available to sign prescriptions, and that should not have happened (referring to R5's lack of pain medication). On 7/3/24 at 9:18 AM V2 stated V2 expects the nurses to administer pain medication as soon as possible when requested, and it should be a priority. On 7/2/24 at 2:45 PM V8 Pharmacist stated R5's Norco prescription was faxed to the pharmacy on 6/19/24 at 2:37 PM and two tablets were pulled from the backup medication supply. V8 stated R5's Norco was not previously obtained from the backup medication supply due to the pharmacy not having a valid signed prescription for the medication. V8 stated on 6/18/24 at 6:10 PM the facility faxed electronic prescriptions to the pharmacy for R5's narcotic pain medications that were not signed by a physician. V8 stated V8 notified R5's physician's office at 9:19 AM on 6/19/24 to request signed prescriptions for R5's Norco, Oxycodone, and Tramadol orders, and had not gotten a response by 12:26 PM so V8 contacted the office again and was informed the physician would be rounding at the facility that day. V8 stated the pharmacy received R5's Oxycodone and Tramadol signed prescriptions on 6/19/24 at 4:42 PM and the medications were dispensed on 6/20/24 since the fax was received after 4:00 PM. V8 stated the medications can be delivered the same day if the facility calls to request it and the facility can contact the after hours pharmacy to obtain medications. V8 stated neither Tramadol or Oxycodone were pulled from the backup medication supply. V8 confirmed there is no documentation that the facility contacted the after hours pharmacy to obtain R8's Oxycodone or Tramadol. On 7/3/24 at 9:39 AM V9 Nurse Practitioner was asked what are the potential consequences for R5 going without pain medication for 24 hours. V9 stated besides discomfort, it could cause increased heart rate and blood pressure. V9 stated it is more so unfortunate for (R5) to experience the pain when going 24 hours without pain medication, and the pharmacy doesn't always send medications quickly. V9 stated R5's pain is effectively managed now with Tramadol and scheduled Acetaminophen and the first few days R5 was using pain medication quite frequent, which was probably due to R5 trying to catch up on the pain. The facility's backup medication supply list includes Norco 5-325 mg and Tramadol 50 mg. The facility provided pharmacy policy titled Controlled Substance Prescriptions, dated 2018, documents a signed written prescription must be obtained in order to dispense controlled medications. The facility provided pharmacy policy titled Emergency Pharmacy & Emergency Kits, dated 2018, documents the emergency pharmacy is available 24 hours per day for emergency needs through the emergency medication supply or by special order from the pharmacy. Once orders are verified and prescriptions are verified for controlled medications, the nurse can remove the required medication from the emergency supply and if the medication is not available in this supply the nurse should contact the after hours emergency pharmacy if necessary. The facility's Pain Assessment policy dated 7/6/18 documents medications will be administered when requested, assess pain control effectiveness when PRN medication is administered and during medication administration, and notify the physician when there is inadequate pain control. This policy documents pain interventions will be balanced with adequate response in order to provide comfort, maintain functional status, and in accordance with the resident's wishes and plan of care.

Based on observation, interview, and record review, the facility failed to obtain and monitor weights, failed to complete nutritional assessments, and failed to monitor nutritional status for residents. This failure affects two (R10, R22) of three residents reviewed for body weight in a sample list of 32 residents. These failures resulted in R10 experiencing an unintended unmonitored significant weight loss of over 40 lbs.(pounds) in 3 months, placing R10 at risk for multiple clinical issues and hospitalization . Findings include: 1. R10's undated Face Sheet documents R10 admitted to facility on 9/22/23. This same Face Sheet documents R10's medical diagnoses of Diabetes Mellitus Type II, Pulmonary Edema, Dementia, Chronic Kidney Disease Stage 3, Heart Failure, Abnormalities of Gait and Mobility, Schizophrenia, and Anxiety. R10's Minimum Data Set (MDS), dated [DATE], documents R10 as severely cognitively impaired. This same MDS documents R10 required maximum assistance for eating, dressing, toileting, bed mobility and transfers. R10's Physician Order Sheet (POS), dated January 2024, documents a physician order, dated 1/22/24, to obtain weekly weights. This same POS does not document a routine weight order prior to 1/22/24. R10's Careplan does not include a focus area, goal, or interventions for Nutrition or weight monitoring. R10's Electronic Medical Record (EMR) documents R10's weight on 10/9/23 as 177.0 pounds (lbs), 10/17/23 as 176.0 pounds (lbs), 1/5/24 as 134.0 lbs and weight on 1/31/24 as 131.5 lbs. This same EMR does not document a completed nutritional assessment for R10's length of stay. On 2/1/24 at 2:30 PM, R10 was sitting in wheelchair in the resident community lounge area. R10 was attempting to adjust shirt due to R10's shirt being very loose fitting. R10's face was pale with both cheeks slightly sunk in. On 1/31/24 at 11:10 AM, V2, Director of Nurses (DON), stated, Weights are to be obtained for the first three days of a resident's stay and then weekly for four weeks. After that, if the resident's weight is stable, it can be reduced to monthly, assuming the Physician signs off on that. Every resident should be weighed at least monthly. If a resident refuses to be weighed, then the staff should re-attempt, and document the resident's refusals. The staff should communicate these things to the management team, so the Interdisciplinary Team (IDT) can review and possibly initiate new interventions. I don't know why (R10's) weight was not done for November and December. Once that was brought to our attention, we (facility) re-weighed her and she did actually lose that much weight. That is unhealthy to lose that much weight that fast. On 2/1/24 at 7:50 AM, V16, Licensed Dietician, stated, Every resident should be weighed by the facility policy. This facility's policy requires a new resident to be weighed daily for the first three days, then weekly for four weeks. I am not sure what happened with (R10's) weights. (R10) should have been weighed at least monthly. For some reason, (R10's) weight was obtained in October as 176 pounds (lbs) on 10/17/23, and 134 lbs on 1/5/24. (R10) does not have any weights documented in between those two dates. There does not seem to be any reasonable explanation for that dramatic weight loss. I do not know why the facility did not weigh (R10), but I do know her nutritional status affects her clinical status. If (R10) did lose 44.5 lbs in three months without purpose, then there is a clinical reason behind it. I would expect the facility to do a complete assessment on (R10) to determine the cause of her weight loss. That much weight loss is not healthy even when it is intended, which (R10's) is not. The facility caused harm by putting (R10) at high risk of multiple clinical issues from not monitoring her unintended dramatic weight loss. This could have resulted in a hospitalization or even death caused by a clinical status change brought on by weight loss that was not monitored. 2. R22's undated Face Sheet documents an admitted [DATE], and discharge date of [DATE]. This same Face Sheet documents R22's medical diagnoses as Wedge Compression Fracture of Lumbar Vertebrae, Protein Calorie Malnutrition, Diabetes Mellitus Type II, Atrial Fibrillation, Repeated Falls, Weakness, and Long term use of Anti-Coagulants. R22's Minimum Data Set (MDS), dated [DATE], documents R22 as moderately cognitively impaired. This same MDS documents R22 as dependent on staff for assistance with toileting, personal hygiene, bed mobility and supervision with eating. R22's Physician Order Sheet (POS), dated December 2023, documents a physician order to obtain R22's height and weight on 12/19/23. This same POS documents a physician order to obtain daily weights for three days starting 12/20/23-12/22/23 and then weekly weight x four weeks. R22's Physician Progress Note, dated 12/29/23, documents R22's weight as 109.6 lbs. R22's Electronic Medical Record (EMR) does not document any other weights obtained by facility during entire stay. On 1/31/24 at 11:15 AM, V2, Director of Nurses (DON), stated R22's Hospital records, dated 12/6/23, documents a weight of 149.0 pounds (lbs) and V7's progress note on 12/29/23 states her weight as 109.6 lbs. V2 stated R22's weight loss seems too dramatic, and does not believe it to be true weight loss. V2, DON, stated, We (facility) did not obtain any weights for (R22). I don't have a good answer as to why. Maybe the staff thought since (R22) was on hospice they don't need to get her weight. I really do not know. I will have to inservice my staff on these things. They are important pieces of information that involves the resident's care and well-being. On 1/31/24 at 4:00 PM, V15, Certified Dietary Manager (CDM), stated the Dietary department reviews the residents weight in weekly weight meetings. V15 stated, (R22's) weight was recorded on section K of the Minimum Data Set (MDS), so that is what I used. I didn't question it since that was on the MDS. That information should be accurate. I should have asked about the follow up weights but did not. I did let (V16) Licensed Dietician know that (R22) had admitted so that (V16) could review. (V16) Licensed Dietician did call me on 1/11/24 to ask the staff to obtain a height and weight because it was not listed in the Electronic Medical Record (EMR). On 1/31/24 at 4:15 PM, V11, Minimum Data Set (MDS) Coordinator, stated the staff attempted to get R22's weight on admission and R22 refused. V11 stated V11 used the hospital weight on 11/30/23 of 140 pounds (lbs) to enter on R22's MDS assessment as facility obtained weight. V11 stated no re-attempts were made to obtain R22's weight. V11, MDS, stated, I asked (R22) to be weighed and she refused. I did not go back and ask her again. I did not ask the staff to attempt to get her weight. I should have tried again or had the staff try. On 2/1/24 at 7:53 AM, V16, Licensed Dietician, stated, All new residents should be weighed seven times in the first five weeks. That weight gives me a good solid indicator of the nutritional status of that resident. If there is no weight or height obtained, as with (R22), I cannot complete the nutritional assessment. This is super important. I repeat, I cannot do any assessment without that information. We have no idea if (R22) gained or lost weight. (R22) admitted to the facility on hospice, so there is reason alone to think she might have lost weight. On 2/1/24 at 4:05 PM, V7, Medical Director, stated the weight documented in V7's progress note was incorrect. V7 stated R22 did not appear to have lost 40 lbs during her stay at facility. V7 stated R22's weight was unknown to V7. The facility policy titled 'Weights', revised 10/17/2019, documents, each resident shall be weighed on admission or at least monthly thereafter or in accordance with the Physician orders. Re-weight should be obtained if there is a difference of five pounds or greater (loss or gain) since previous recorded weight. Re-weight should be obtained as soon as possible after an unanticipated weight change is noted and prior to calling the physician within 72 hours. Efforts should be made to obtain all weights and re-weights by the 10th of each month. Undesired or unanticipated weight gain or loss of 5% in 30 days, 7.5 % in three months or 10% in six months shall be reported to the Physician, Dietician and/or Dietary Manager as appropriate. Weekly weights may be discontinued if the resident's weight has remained stable for four consecutive weeks or as determined by the Physician, Dietician or Interdisciplinary Team (IDT).

Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to assess a resident with previous medical history of Respiratory illness and hospitalization s who was in acute respiratory distress, and failed to notify the Physician timely of a change in respiratory condition for a resident. These failures resulted in R17 experiencing respiratory distress for a period of 15 hours, with a low oxygen level, and yelling out to staff of being unable to breathe before R17 was transferred to a local hospital in respiratory distress. This failure affects one (R17) of three residents reviewed for a change in condition. R17 experienced respiratory distress for a period of 15 hours, with a low oxygen level and yelling out to staff being unable to breathe. R17 was eventually transferred to a local hospital with respiratory distress. The Immediate Jeopardy began on 12/12/23 when staff failed to assess R17 and notify the physician of R17's complaints of respiratory distress for a period of 15 hours. V1, Administrator, was notified of the Immediate Jeopardy on 1/18/2024 at 9:24 AM. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 1/19/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training through ongoing Quality Assurance Performance Improvement (QAPI) review. Findings include: Facility Assessment, dated 7/30/23-1/30/24, documents residents who are experiencing acute care episodes or exacerbations of diseases are immediately given a full report to physician and follow their orders. R17's undated Face Sheet documents an admitted [DATE], with medical diagnoses of Chronic Obstructive Pulmonary Disorder (COPD) with Acute Exacerbation, Metabolic Encephalopathy, Diabetes Mellitus, Acute and Chronic Respiratory Failure with Hypoxia, Protein Calorie Malnutrition, Hepatic Failure, Heart Failure, Severe Sepsis with Septic Shock, and Anemia. R17's Minimum Data Set (MDS), dated [DATE], documents R17 as moderately cognitively impaired, and requires moderate assistance from staff for dressing, personal hygiene and mobility. This same MDS documents R17 does not have a medical diagnosis of Anxiety. R17's Care plan intervention, dated 10/17/23, instructs staff to monitor for difficulty breathing on exertion. This same care plan did not include a focus area, goal, nor interventions for Oxygen therapy. R17's current Electronic Medical Record (EMR) shows the last set of vital signs obtained for R17 was on 12/12/23 at 12:11 PM, and were within normal limits. This same EMR documents R17 had a previous hospitalization from [DATE] to 11/2/23, with diagnoses of Acute on Chronic Respiratory Failure and Sepsis. R17's Physician Progress Note, dated 12/11/23, documents R17 had a moderate cough productive of clear sputum. Lungs clear bilaterally with no rales, rhonchi or wheezes. This same note documents a physician order for Mucinex 600 milligrams (mg) twice daily. R17's Physician Order Sheet (POS), dated December 2023, does not document a physician order for Mucinex 600 mg twice daily. R17's Medication Administration Record (MAR), dated December 2023, documents R17 was administered one puff of scheduled Fluticasone-Salmeterol Inhaler 500-50 micrograms (mcg)/ACT on 12/12/23 at 4:00 PM, and 12/13/23 at 8:00 AM per physician order. This same MAR documents R17 was administered Ipratropium/Albuterol inhalation solution 0.5-2.5 milligrams (mg) per 3 milliliters (ml) on 12/12/23 at 8:00 PM and on 12/13/23 at 8:00 AM per physician order. This same MAR documents R17's Lisinopril 5 mg and Atenolol 50 mg were both held at 7:43 AM on 12/13/23 due to 'low blood pressure.' R17's Nurse Progress Notes document: -12/12/23 at 6:21 PM, documents At 5:35 PM (R17) complained of difficulty breathing during wound care. Care was paused and (V22, Licensed Practical Nurse/LPN) was notified of (R17's) complaint. At 6:00 PM, (R17) was reassessed due to pale color and increased work of breath noted upon exhalation. At 6:05 PM, a second notification via (V27, Certified Nurse Aide/CNA) was sent to (V22, LPN). At 6:08 PM (R17) was reassessed with oxygen saturation at 77%. Nasal canula in place and functioning properly. (V22, LPN) notified at shift change and at bedside. (V22, LPN) administering treatment at 6:11 PM. Will continue to monitor. -12/13/23 at 4:52 AM, documents Every hour (R17) hollers out very loudly for help. Does not use the call light. (R17) says he can not breathe. (V22) tried to educate (R17) that if he can holler that loud, he is breathing fine. (R17) was given breathing treatments whenever the time was appropriate. Despite (V22) trying to educate (R17), he continued to holler out. It is my estimation that (R17's) problem is much more anxiety related than physical. -12/13/23 at 7:43 AM, documents R17's Lisinopril 5 milligrams (mg) (blood pressure medication) and Atenolol 50 mg (blood pressure medication) was held due to low blood pressure. -12/13/24 at 9:14 AM, documents, Weekly wound rounds completed this shift. (R17) not well tolerated. (R17) complained of difficulty breathing. Oxygen saturation was 88% on 3 Liters per Nasal Canula with heart rate of 74. Pulse oximetry kept in place during wound assessment. Decreased oxygen saturation noted during care, while rolling in bed from Left to Right. Message sent to (V30, Nurse Practitioner) via voice to voice call, advising change of condition and request for breathing treatment to be administered as needed. Power of Attorney (POA) advised to call back via voice message. Will continue to monitor. -12/13/23 at 9:47 AM, documents, Received orders from (V30) Nurse Practitioner to send (R17) to emergency room for further evaluation and treatment. R17's hospital records, dated 12/13/23-12/15/23, document R17's admission diagnoses as Sepsis, Loculated Pleural Effusion, and Empyema. This same hospital record documents R17's Hospital emergency room note, dated 12/13/23, documents, (R17) presents to emergency room from facility complaining of worsening shortness of breath and cough. Alert and oriented, ill-appearing, in mild distress with wheezes, rhonchi and crackles noted bilaterally. (R17) was chronically on 3 Liters (L) of Oxygen and in the emergency department was placed on 6 L of Oxygen. (R17) had a blood pressure of 70/50 and was given a fluid bolus and Antibiotics. (R17) Chest X-Ray reveals bilateral infiltrates. (R17) was transferred to the Intensive Care Unit (ICU) for Septic Shock and Acute on Chronic Respiratory Failure. (R17's) CT (Computerized Tomography) of chest showed Left sided Empyema. (R17) was transferred to Critical Care Unit (CCU) in critical condition. These same hospital records documents, (R17's) Final diagnosis and diagnosis during hospitalization of Septic Shock from Left Sided Loculated Pleural Effusion, Bilateral Pneumonia, Acute on Chronic Hypoxic Respiratory Failure secondary to Left Sided Loculated Pleural Effusion, Concern for Bacterial Pneumonia, Concern for Acute Adrenal Insufficiency, Acute Kidney Injury from Septic Shock, Hyperkalemia, Chronic Normocytic Anemia with Iron and Folate Deficiency, Chronic Stage III-IV Sacral Wound with history of Osteomyelitis and 54 millimeter (mm) Abdominal Aortic Aneurysm. (R17) was made comfort care on 12/15/23 at 12:45 AM and passed away at 12:52 AM. These same hospital records document R17's cause of death as Septic Shock from Left Sided Empyema/Loculated Pleural Effusion. R17's Computerized Tomography (CT) of chest/pelvis and abdomen results, dated 12/13/23, documents, Impression: Findings suspicious for Empyema on the Left side, Emphysematous changes in lungs, Bilateral lower lung zone infiltrates, Right Pleural Effusion, 54 millimeter (mm) Infrarenal Abdominal Aortic Aneurysm. On 1/17/24 at 9:30 AM, V47, Minimum Data Set (MDS)/Careplan Coordinator, stated the designated department head would add in careplans for the resident need, and V47 reviews the entire careplan afterwards as a back up system. V47 stated any resident who receives Oxygen should have a separate Oxygen careplan. V47 stated the interventions should include keeping the head of bed raised, following the physician order for Oxygen use, obtaining Oxygen saturation levels every shift, and monitoring for signs and symptoms of low Oxygen levels. On 1/11/24 at 1:10 PM, V22, Licensed Practical Nurse (LPN), stated V22 was R17's nurse on the evening of 12/12/23 and early morning of 12/13/24. V22 stated, (R17) was always complaining he couldn't breathe. All the time. (R17) would not use his call light he would just bang on the table and yell out. That night (12/13/23), (R17) was at it again. (R17) was yelling loud enough you could hear it down the hall. I went into (R17's) room and told him he can't be in that much respiratory distress since he had enough lung power to yell that loud. (R17) had already had whatever medication was ordered to help him breathe. (R17) just needed to calm down. (R17) was short of breath from yelling out. We (staff) boosted (R17) up in bed. I personally believe that (R17) had anxiety issues. (R17) doesn't have that diagnosis but I know that is the problem. (R17) could breathe just fine. I know this since (R17) was yelling so loud. You can't yell that loud and be in respiratory distress at the same time. (R17) yelled out all the time. (R17) had just gotten out of the hospital from his respiratory problems. I am sure the Physician already knew (R17) had breathing problems, so there would be no need for me to call him. What am I supposed to do, call the doctor in the middle of the night and tell him (R17) couldn't breathe? I am sure the doctor would love that since he already knew that was a common complaint of (R17's). I don't remember getting any vital signs. I didn't listen to (R17's) lungs. There was no need to. (R17) was just having anxiety not breathing problems. The vital signs would be in (R17's) Electronic Medical Record (EMR). That is where the CNA's document them. If the vitals are not in (R17's) EMR then they were not done. On 1/11/24 at 1:30 PM, V19, Wound Nurse, stated V19 was providing wound care to (R17's) roommate on the evening of 12/12/23. V19 stated R17 was yelling out saying he couldn't breathe. V19 stated R17 would normally yell out in place of using his call light. V19 stated, That night was different. (R17) was very short of breath. (R17) skin was dusky looking, and he just didn't look right. There was something more than his normal yelling. You could tell (R17) really couldn't breathe. I had (V27, CNA) working with me so I stayed with (R17) and sent (V27) to go get (R17's) nurse. (V27) returned to (R17's) room a few minutes later, but (V22) (R17's) nurse never showed up. We (V19, V27) stayed with (R17) for ten more minutes or so. I sent (V27) again to get (V22), but that time neither (V27, CNA, V22, LPN) of them returned. So, I called out into the hall and asked another CNA to sit with (R17) and I went to get (V22) myself. (V22) was sitting at the nurses desk. When I explained to (V22) LPN what was going on with (R17), (V22) exclaimed 'If (R17) can yell, he can breathe. It is just behaviors.' I found a pulse oximeter and obtained (R17's) oxygen saturation. It was 77%. (R17's) skin was still dusky, and he still didn't look good. I told (V22) LPN (R17) was not stable, but he did not take it seriously. I even checked the Pulse Oximeter on my own finger to make sure it was working properly. It was. There was nothing wrong with the machine. There was something wrong with (R17). At that point, (V22, LPN) came in and assessed (R17), and I left the situation. The next morning, I went in to provide wound care to (R17) again, and the same situation happened again. I really thought (V22, LPN) would have sent (R17) out the night before because of his change in condition, but (R17) was still in his room. (R17) was still having trouble breathing so I called (V30, Nurse Practitioner) to ask to get (R17) sent in to the emergency room . (V30) called back and gave the order to send (R17) to the emergency room . On 1/17/24 at 12:10 PM, V30, Nurse Practitioner (NP), stated the expectation of the provider is for the facility to ensure all of the Physician orders are completed and non-pharmacological interventions are carried out before calling for new orders. V30, NP, stated after all of the existing orders and non-pharmacological interventions are completed, then the facility should call the provider to obtain new orders. V30 stated R17 did have an established medical history of co-morbidities with medications in place to maintain R17 as stable. V30 stated, Early intervention is the best way to prevent decline in health. When the facility delayed medical treatment, assessments/monitoring or notification to the provider then that would have caused harm (medical decline) to (R17). As it sounds, (R17) was having respiratory distress that was not addressed. The facility should have notified the provider of (R17's) worsening condition. V30 stated V30 would have sent R17 to the emergency room for further clinical support on the evening of 12/12/23 when staff initially noted R17's change in condition. V30 stated, It is standard for nurses to hold blood pressure medications if a resident's blood pressure is low, but you have to look at the bigger picture. (R17) had been in respiratory distress all night which could contribute to his low blood pressure. That should have been reported as well. On 1/23/24 at 10:10 AM, V6, Assistant Director of Nurses (ADON)/Licensed Practical Nurse (LPN), stated R17 was seen by V39, Medical Director/Physician, on 12/11/23. V6 stated V39's Physician Progress Note that documented a new order for Mucinex was 'overlooked'. V6 stated facility does not review the physician progress notes, only the written orders. The facility policy titled 'Physician-Family Notification-Change in Condition', revised 11/13/18, documents the facility will inform the resident, consult with the resident's physician or authorized designees such as Nurse Practitioner, and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental or psychosocial status and/or a need to alter treatment significantly and/or a decision to transfer or discharge the resident from the facility. The Immediate Jeopardy that began on 12/12/23 was removed on 1/19/24, when the facility took the following actions to remove the immediacy. 1. V2, DON, started inservicing staff on change of condition with proper physician notification, documentation, and proper respiratory assessment; initiated on 1/18/24 by V2, Director of Nursing, and V46, Regional Clinical Nurse. V2 stated this inservicing will be on-going until 100% of staff has been inserviced. V2 stated staff on vacation or Family Medical Leave Act (FMLA) will be inserviced before returning to work. 2. V2 confirmed new hire staff will have immediate training as it relates to accurate documentation, proper respiratory assessment, and change of condition with proper MD and Power of Attorney (POA) notification. V2 stated agency staff will be trained by nurse management as a 1:1 in service. V2, DON, stated all staff will be trained prior to working with residents. 3. V19 and V22 confirmed they have received one on one inservicing related to respiratory assessment, follow through interventions, proper documentation, and physician notification. Education was provided by V2, Director of Nursing, on 1/18/24 for V19, Wound Nurse/LPN and 1/19/24 for V22, LPN. 4. A facility wide audit was conducted for all residents to identify those residents at risk for respiratory conditions or complications. A list of those residents at risk have been identified and lists have been placed at the nurses stations in binders. On 1/23/24 at 9:40 AM, V2, DON, stated the first audit was completed 1/18/24 and will be ongoing. The facility provided documentation of audits being completed 1/18/24, 1/19/24, 1/22/24 and 1/23/24. 5. Nursing staff have been provided with appropriate assessment tools including change of condition assessment and interact pathways and assessments to conduct appropriate respiratory assessment. V9, LPN, and V3, RN, both confirmed they had been inserviced on 1/19/24 by V2, DON, and V47, MDS/CP Coordinator/LPN, on residents at risk for oxygen distress/complications, use of EMR assessments, and manually triggering 72 hour assessment. V9, LPN, showed the binder on west nurses station and V3 showed the binder on east nurses station. 6. Audits will be conducted five days per week to ensure residents with change of condition have been assessed with proper notification and reviewed during QAPI meetings for at least six months. On 1/23/24 at 9:45 AM, V2, DON, stated these audits began on 1/18/24 and will be ongoing. V2, DON, stated audit was completed by V2, DON, and V6, ADON. The facility provided documentation of audits being completed 1/18/24, 1/19/24, 1/22/24 and 1/23/24. 7. Emergency QAPI meeting was held with the medical director on 1/18/24. V2 stated the meeting was conducted by V46, Regional Clinical Nurse, and included all members of the QAPI team including V39, Medical Director. 8. On 1/19/24, V2, Director of Nursing, confirmed the IDT team was inserviced with all members present. V2 stated V46, Regional Clinical Nurse, provided the inservice to the IDT team on 1/18/24. 9. A facility wide audit was done to identify all residents with orders for oxygen and careplans updated on 1/18/24. The facility provided documentation of audits being completed 1/18/24, 1/19/24, 1/22/24 and 1/23/24. B. Based on observation, interview, and record review, the facility failed to monitor and follow physician orders for wound care for one of three residents (R3) reviewed for wounds in a sample list of 23 residents. Findings include: R3's undated Face Sheet documents an admitted [DATE]. This same Face Sheet documents R3's medical diagnoses of Spondylosis of Lumbar Region without Myelopathy or Radiculopathy, Syndrome of Inappropriate secretion of Antidiuretic Hormone, Anxiety, Depression, Disorders of the eyelids, Exposure Keratoconjunctivitis, Legal Blindness, Seizure Disorder, Waldenstrom Macroglobulinemia, Methicillin Resistant Staphylococcus Aureas MRSA), Pressure Ulcer of Sacrum Stage IV, Right Femur Fracture and Obstructive and Reflex Uropathy. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact. This same MDS documents R3 as legally blind and requiring maximum one person assist for toileting, upper and lower body dressing and moderate assistance for chair/bed to chair transfer. R3's Initial Wound Evaluation and Management Summary, dated 12/7/23, documents R3's Right Upper Lateral Leg partial thickness venous wound as a fluid filled blister cluster wound measuring 5.5 centimeters (cm) long by 9.0 cm wide by not measurable depth. This same summary documents Additional wound detail: increased bilateral lower extremity (BLE) edema with several fluid blisters to BLE. This cluster is tense and may rupture. If the blisters rupture then start Vaseline soaked gauze covered with absorbent pad and wrap with gauze daily and as needed. R3's Nurse Progress Note, dated 12/9/23 at 9:51 AM, documents, Blood filled blister noted on (R3's) Lateral side of Right Knee. Blister is 15.0 centimeters (cm) x 6.0 cm wide. Redness and warmth noted around the blister. (R3) reported pain 7/10. As needed Percocet offered, it was not effective. As needed Acetaminophen #3 offered. R3's Wound Evaluation and Management Summary, dated 12/13/23, documents V32, Wound Physician, did not assess R3's Right Upper Lateral Leg partial thickness venous wound due to a recent wound related hospitalization . R3's Weekly Skin Observation, dated 12/30/23, does not document R3's Right Upper Lateral Distal extremity vascular wound. R3's Wound Rounds report, dated 1/8/24, does not document R3's Right Upper Lateral Distal extremity open wound. R3's Careplan, dated 1/10/24, instructs staff to complete treatment as ordered by physician. This same careplan includes an intervention dated 1/10/24 that instructs staff to Monitor dressing to Right Distal leg vascular wound per order to ensure it is intact and adhering. Report loose dressing to treatment nurse. This same care plan does not include a focus area, goal nor interventions for R3's Right Distal Extremity vascular wound prior to 1/10/24. R3's Physician Order Sheet (POS), dated January 2024, documents a physician order starting 1/5/24 to monitor blisters to Right Lower Leg every shift. Cleanse with normal saline, apply border foam twice daily. This same POS documents a physician order to complete weekly skin observations. R3's Treatment Administration Record (TAR), dated January 2024, documents a physician ordered treatment starting 12/22/23 and discontinued 1/3/24 to cleanse Right Lower Extremity and apply bordered foam every three days. This physician ordered treatment was not signed off as completed. This same TAR documents a physician order starting 1/5/24 and discontinued 1/11/24 to monitor blisters to Right Lower Leg every shift, cleanse with normal saline, pat dry and apply bordered foam twice daily. This treatment was not signed out as completed on 1/5/24, 1/6/24, 1/7/24 and 1/8/24. On 1/10/24 at 10:45 AM, V19, Wound Nurse, completed wound care for R3's Right Upper Outer Distal vascular wound. R3's incontinence brief, Coccyx dressing, incontinence pads, mattress and sheet R3 was laying on were completely saturated with light yellow liquid. V19, Wound Nurse, used disinfectant wipes to attempt to clean R3's bed mattress due to linens being excessively saturated. R3's bed linens were completely saturated from R3's upper shoulders to below feet. V19, Wound Nurse, removed the foam to expose a large open area the shape and size of a hand held eraser. This area was very red with white edges, open and draining large amount of clear/yellow drainage. The dressing on R3's Right Upper Lateral Distal extremity was grossly saturated with yellow drainage and dated 1/8/24. V19, Wound Nurse, applied non-adhesive dressing to R3's Right Upper Lateral Distal extremity wound and wrapped with gauze. On 1/10/24 at 11:40 AM, V19, Wound Nurse, stated R3's legs should have been wrapped. V19 stated, I was not aware of the area on (R3's) Right Upper Lateral Distal extremity. It had been open before but healed. Since it is open again, apparently for a few days according to the dressing we found dated 1/8/24. That dressing should have been changed twice per shift. On 1/17/24 at 10:30 AM, V19, Wound Nurse, stated R3 has first appointment at an offsite wound clinic on 1/25/24. V19 stated R3 had first wound assessment for this Right Upper Lateral distal extremity wound on 12/7/23. V19 stated V32, Wound Physician, did not see R3 on 12/13/23 due to R3 being hospitalized from 12/11/23-12/22/23. V19, Wound Nurse, stated V32, Wound Physician, signed off on R3 on 1/3/24, due to R3 was going to start going to the wound clinic. V19 stated V32's last time assessing R3's wounds was 12/7/23. V19 stated, I did the assessments but did not measure (R3's) Right Upper Lateral Distal wound. I just leave the same measurements in the assessments every week because you have to put something in for the computer system to allow you to move on to the next date. I should have really assessed (R3's) wounds on the weeks that (V32) Wound Physician wasn't there to do it.

Based on observation, interview, and record review, the facility failed to protect the residents right to be free from mental, verbal, and physical abuse by other residents. This failure affects six of six residents (R8, R19, R20, R23, R18 and R19) reviewed for abuse in a sample list of 23 residents. Ths failure resulted in R18 verbally and mentally abusing R8, and R8 experiencing fear and tearfulness. Findings include: 1. R8's undated Face Sheet documents medical diagnoses of Cerebral Infarction, Dysarthria, Heart Failure, and Slurred Speech. R8's Minimum Data Set (MDS), dated [DATE], documents R8 as cognitively intact. R18's Minimum Data Set (MDS), dated [DATE], documents R18 as severely cognitively impaired. This same MDS documents R18 as independent in mobility. This same MDS documents R18 was assessed to have physical behavioral symptoms (such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred one to three days in the prior week of assessment. R8's Nurse Progress Notes do not document R8's report of mental and verbal abuse from R18 on 1/8/24. R8's Abuse Risk Assessment, dated 11/15/23, documents R8 is at risk for abuse. R8's Careplan does not include a focus area, goal, nor interventions for being at risk for abuse. On 1/9/24 at 12:05 PM, R8 was laying in bed in R8's room. R8 stated, I have a problem with my roommate (R18). (R18) has something very wrong with her. (R18) is not right. (R18's) husband comes to visit her every day. (R18) has accused me before of sleeping with her husband, and I have just laughed it off. Nothing came of those other times. But last night was something different. I felt bad for (R18) before last night, and now I am just scared of her. Last night, (R18) started screaming and yelling at me saying I was sleeping with her husband. Saying I wanted her husband's big d***. I just told (R18) to shut up. (R18) was all red faced and p***** off. (R18) was seeing red. (R18) accused me of sleeping with her husband and yelled 'You b****! You b****! You b****!' at me. (R18) just kept yelling 'You want to hook up with him! I will get you!'. I would never do such a thing. That would be horrible. I am a tough cookie, but that really scared me. I do not want (R18) back in my room after her threatening me like that. (R18) scares me. I told (V9) Licensed Practical Nurse (LPN) last night I wanted (R18) moved. (V9) told me she let (V2) Director of Nursing (DON) know what happened. (R18) slept in here last night. I did not get much sleep because I was afraid (R18) was going to start in again, and no one would be here to help me. R8 was making good eye contact, smiling, and conversational throughout initial portions of interview. R8 did not make good eye contact, became tearful when talking about (R18), and cried through remainder of interview. On 1/9/24 at 12:25 PM, V9, Licensed Practical Nurse (LPN), stated R8 informed V9 on the evening of 1/8/24 around 9:30 PM of R18 yelling at R8. V9, LPN, stated, (R8) reported to me that (R18) was yelling at her and accusing her of sleeping with and having sex with (R18's) husband. (R8) never told me (R18) was using foul language. I let (V2) Director of Nurses (DON) know right then since (V2) was working the floor on the other side. I just let (V2) know. (V2) said we would talk about a possible room change in the morning. I did not assess (R8) since she did not report being physically hurt in any way. I did not report this to the physician. I just reported it to (V2). On 1/9/24 at 12:30 PM, R8's allegation of mental and verbal abuse was reported to V1, Administrator. V1, Administrator, was also informed of R8's statement of not wanting R18 in R8's room, and that R8 claimed R8 was scared of R18. On 1/9/24 at 2:08 PM, R8 was laying in bed in R8's room. R18 was sitting in the wheelchair in R18 and R8's shared room with R8. No staff were present in or around R8 and R18's shared room. On 1/11/24 at 2:00 PM, V1, Administrator, stated the abuse investigation was started immediately after being made aware of the allegation on 1/9/24. V1, Administrator, stated R8 can be tearful at times because R8 is sensitive to situations. V1 stated, We (facility) thought it was a roommate issue until the abuse allegation was reported to me on 1/9/24. Then I knew it was more than that. (R18) does have behaviors with other residents. When (R18) has those behaviors towards her previous roommates, we (facility) move (R18) to another room. We are having a hard time finding the right fit for (R18) due to her behaviors. I do think (R18) yelled at and accused (R8), but (R8) did not cry about it when I spoke with her. 2. R19's undated Face Sheet documents medical diagnoses of Dementia, Depression, Spinal Stenosis, Osteoarthritis, Low Back Pain, Morbid Obesity, Chronic Heart Failure, and Chronic Kidney Disease Stage 4. R19's Minimum Data Set (MDS), dated [DATE], documents R19 as cognitively intact. This same MDS documents R19 as requiring maximum assistance for bathing, dressing, toileting and bed mobility. R18's Minimum Data Set (MDS), dated [DATE], documents R18 as severely cognitively impaired. This same MDS documents R18 as independent in mobility. This same MDS documents R18 was assessed to have physical behavioral symptoms (such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred one to three days in prior week of assessment. R19's undated Final Incident Report to State Agency documents R19 reported an altercation with roommate (R18). This same report documents, (R18) was moved. On 1/11/24 at 2:20 PM, R19 stated, I had an old roommate (R18) that accused me of trying to have relations with her husband. I think that was a week or so ago. (R18) got so mad one night because she really thought I was trying to take her husband that she threw a plastic cup at me. You know the ones they serve the coffee in. (R18) threw it right at me. It hit my bed and fell to the floor. (R18) then wheeled over and tried to grab my bedside table. (R18) was trying to throw my bedside table at me. (R18) was yelling all kinds of (expletive) words at me. Calling me all kinds of names. (R18) can't use her legs very well, but she is strong in her arms. I was scared of her after that. I made them (facility) move her. They (facility) just moved her across the hall and I guess she did the same thing to that lady over there. On 1/11/24 at 2:35 PM, V1, Administrator, was notified of R19's allegation of abuse by R18. V1 stated she would start an investigation. 40385 3. R20's MDS dated R20's MDS dated [DATE] documents R20 is cognitively intact. R9's Minimum Data Set (MDS), dated [DATE], documents R9 is cognitively intact and exhibited verbal and physical behaviors towards others one to three days during the seven day look back period. R9's undated diagnoses list documents R9 has a diagnosis of psychotic disorder with delusions as of 1/10/24. R9's Physician/Prescriber Order Sheet, dated 1/10/24, documents R9's diagnoses of Dementia with moderate behavioral disturbances. R9's Nursing Note, dated 12/10/23 at 12:36 AM, recorded by V42, Licensed Practical Nurse (LPN), documents R9 complained about R9's room mate (R20) not allowing R9 to turn on the room light during the night, and R9 requested for R9 or R20 to change rooms. There is no documentation that this request was followed up on. R9's and R20's undated census document R9 and R20 shared a room from 11/22/23 until 12/19/23, when R9 was hospitalized . R9's Nursing Note, dated 12/19/2023 at 3:11 AM, recorded by V40, LPN, documents at 2:15 AM, a Certified Nursing Assistant (CNA) reported R9 was hitting R20 with the call light and bed control. This note documents R9 was asked what was going on and R9 reported R9 wanted the tv on and room mate (R20) kept turning the tv off. R9 denied hitting R20 and called R20 a liar. V40 instructed the CNA to bring R9 out of the room to watch tv. This note documents when V40 turned around, R9 slapped R20 on the left forearm, R9 denied hitting R20, and R9 stated R20 hit R9. This note documents R9 was transferred into a wheelchair, and while the CNA brought R9 out of the room, R9 reached over and squeezed/pinched R20's foot causing pain. This note documents R9 was sent to the emergency room for a psychiatric evaluation, and the local police came to the facility and obtained statements. R20's Nursing Note, dated 12/19/2023 at 3:30 AM, documents at approximately 2:15 AM, R20 was hit several times by room mate R9 with the call light and bed controller. R20 had red marks on R20's left anterior forearm. R20 reported that R9 had turned the tv volume to 70 and refused to turn it down, so R20 turned the tv off. R9 and R20 fought over the tv for several minutes. When V42 LPN turned away, R9 loudly slapped R20's left forearm. The facility's Initial/Final Report to the Illinois Department of Public Health, dated 12/22/23, documents the following: On 12/19/23 at 3:30 AM, (R9) was physically and verbally aggressive towards room mate, (R20). (R9) was yelling at (R20) after (R20) asked (R9) to turn the television (tv) volume down causing (R9/R20) to argue. (R20) reported that (R9) hit (R20's) left forearm with the remote and call light. (R9) was witnessed to pinch (R20's) foot. (R20) had a red mark and complaints of stinging to the left forearm. The Nurse (V40 Licensed Practical Nurse(LPN)) intervened and (R9) was sent to the hospital. On 1/16/24 at 1:33 PM, R9 stated R9 used to reside with another resident who was a troublemaker. R9 stated, It's my tv, and R9 had the tv down low. R9 stated there wasn't any physical hitting, it was all verbal, and nurses and CNAs witnessed the incident. R9 stated anyone around could hear the commotion. R9 stated R9 isn't saying R9 is innocent, she mouthed off and I (R9) mouthed back. R9 stated the staff knew R9 wanted a different room mate. On 1/16/24 at 1:44 PM, R20 stated R20 had a room mate who physically attacked me. R20 stated R9 woke R20 up with the tv volume at 70, and R20 told R9 to turn the tv volume down. R20 stated R9 came over to R20's bed and hit R20's hand with the bed remote that caused bruising. R20 stated R20 called for staff and R9 continued to hit R20 as the staff removed R9 from the room. R20 stated the staff witnessed the incident. R20 stated R20 did not feel afraid of R9, but R20 felt like R20 could not defend herself. On 1/16/24 at 12:32 PM, V42, LPN, stated V42 recalls the night of 12/10/23, R9 had turned on R9's call light and was mad because R20 was upset with R9 for turning on the room light to go to the bathroom. V42 stated V42 explained to R20 that R9 needed the light on to be able to get to the bathroom, and R9 wanted R20 to be moved out of R20's room. V42 stated R9 does not like people in R9's room. V42 stated V42 was able to calm both R9 and R20 down, both R9/R2 went to bed, and V42 passed onto the dayshift nurse that R9 wanted R20's room moved. V42 stated V42 is not sure who takes care of resident room changes. V42 confirmed R20's room was not changed until after R9's/R20's incident on 12/19/23. On 1/16/24 at 12:46 PM, V40, LPN, stated V40 recalled R9's/R20's incident on 12/19/23. V40 stated V41, CNA, came running up the hall and told V40 to immediately go to R9's room, since R9 and R20 were arguing over the tv. V40 stated R9 was sitting in a recliner next to R20, and R20 reported R9 took R20's call light and started whipping R20 with it. V40 stated V40 turned V40's back to get the CNAs and V40 heard a smack. V40 stated R9 had smacked R20 on the arm, and there was a red mark on R20's arm. V40 stated R9 transferred into a wheelchair and while removing R9 from the room, R9 grabbed and squeezed R20's foot as hard as she could. V40 stated that was the first time V40 has observed R9 to be abusive to R9's room mates. On 1/16/24 at 1:06 PM, V41, CNA, stated R9 has had many conflicts with roommates, You have to run to her (R9's) room when you hear something. V41 stated V41 witnessed R9 with the bed control slapping R20's left arm and as R9 was removed from the room, R9 grabbed R20's leg and banged R9's fist on R20's leg. V41 confirmed R9's actions towards R20 were intentional and not an accident. On 1/16/24 at 3:21 PM, V1, Administrator, stated V1 did not feel like abuse occurred for R9's/R20's incident, because R9 did not have the wilful intent to cause harm since R9 has dementia. V1 stated R9 would not have done that if R9 didn't have dementia, and V1 is under the understanding when a resident has dementia they don't have the wilful intent to cause harm. 4. R23's MDS, dated [DATE], documents R23 has severe cognitive impairment. R23's Social Service Note, dated 8/17/2023 at 1:20 PM, documents R23's room was moved after staff determined the room was unsafe due to room mate's (R9) behavior. R23's and R9's undated census document R23 and R9 shared a room from 7/19/23 until 8/1/23. On 1/16/24 at 12:46 PM, V41, CNA, stated on an unidentified date, V41 heard screaming from R9's/R23's room, V41 went to the room, R9 was yelling at R23, and R9 picked up R9's walker and hit R23's leg with the walker. V41 stated V41 went to get V3, Registered Nurse, V41 returned to the room, and R9 hit R23's leg again with the walker. V41 stated R9's actions were intentional and not an accident. R41 stated R23 did not respond to R9's actions as R23 is generally a quiet person.

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent worsening of a residents (R3) pressure ulcer. The facility also failed to assess, monitor, and follow physician orders for resident's wounds. These failures affect two (R3, R14) out of four residents reviewed for Pressure Ulcers in a sample list of 23 residents. These failures resulted in a deterioration R3's Stage IV Sacral Pressure Ulcer with grey tissue, foul odor and substantial amount of drainage from the wound. Findings include: 1. R3's undated Face Sheet documents an admitted [DATE]. This same Face Sheet documents R3's medical diagnoses of Spondylosis of Lumbar Region without Myelopathy or Radiculopathy, Syndrome of Inappropriate secretion of Antidiuretic Hormone, Anxiety, Depression, Disorders of the eyelids, Exposure Keratoconjunctivitis, Legal Blindness, Seizure Disorder, Waldenstrom Macroglobulinemia, Methicillin Resistant Staphylococcus Aureas MRSA), Pressure Ulcer of Sacrum Stage IV, Right Femur Fracture and Obstructive and Reflex Uropathy. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. This same MDS documents R3 as legally blind and requiring maximum one person assist for toileting, upper and lower body dressing and moderate assistance for chair/bed to chair transfer. R3's Hospital Wound Assessment Summary, dated 11/13/23, (day before discharge) documents R3's Stage IV Coccyx Pressure Ulcer as having 76-100% red granulation tissue, 1-25% yellow slough, moderate amount of drainage and measuring 18.5 centimeters (cm) long by 10.5 cm by 4.2 cm including wound at Right lower edge of main Coccyx wound measuring 7.0 cm long by 3.8 cm wide by 0.1 cm deep. R3's Hospital Discharge Record, dated 11/14/23, documents a physician order to place a negative pressure wound vacuum (wound vac) set at 125 millimeters (mm) Hg (Mercury) continual negative pressure over R3's Coccyx wound every three days and as needed. R3's Admission Observation, completed 11/15/23, documents, Pressure wound present on Coccyx. See Wound Nurse Wound Assessment. This same assessment does not document wound description or measurements of R3's Coccyx Pressure Ulcer. R3's Pressure Ulcer Risk assessment dated [DATE] documents R3 is at risk for Pressure Ulcers. R3's Wound Assessment Details Reports, dated 11/14/23, 11/22/23, 11/29/23, 12/4/23, 12/7/23, 12/26/23, and 1/8/23, all document R3's Stage IV Coccyx Pressure Ulcer as 100% beefy red, having no drainage and measuring 14.0 centimeters (cm) long x 4.0 cm wide by 0.0 cm deep. R3's Careplan, dated 11/20/23, instructs staff to monitor pressure ulcer on Coccyx and follow physician orders for treatment. This same careplan does not include a focus area, goal nor interventions for R3's Stage IV Pressure Ulcer prior to 11/20/23. R3's Wound Evaluation and Management Summary documents the folllowing: - 11/16/23 documents an initial assessment of R3's Stage IV Coccyx Pressure Ulcer as having heavy serosanguinous drainage measuring 14.0 cm long x 15. 0 cm wide x 4.0 cm deep. This same evaluation documents physician orders to start Vitamin C 500 milligrams (mg) twice daily, Multivitamin daily, Zinc Sulphate 220 mg daily for 14 days, protein supplement three times per day, Registered Dietician (RD) consultation, upgrade offloading chair cushion, reposition per facility protocol and refer (R3) to plastic surgeon for flap closure. - 12/13/23 documents V32, Wound Physician, did not assess R3's Right Upper Lateral Leg partial thickness venous wound due to a recent wound related hospitalization (currently in the hospital). - 1/3/24 documents V32, Wound Physician, is signing off (case) due to R3 to see offsite wound clinic. R3's Electronic Medical Record (EMR) does not document R3 being seen by a wound clinic. R3's Medication Administration Record (MAR), dated November 2023, does not include physician orders for Vitamin C 500 milligrams (mg) twice daily, Multivitamin daily, Zinc Sulphate 220 mg daily for 14 days, protein supplement three times per day, Registered Dietician (RD) consultation, upgrade offloading chair cushion, reposition per facility protocol and refer (R3) to plastic surgeon for flap closure. R3's MAR, dated December 2023, documents a physician order starting 12/23/23 for a daily Multi Vitamin and Vitamin C 500 milligrams (mg) twice daily. The same MAR does not include physician orders for Zinc Sulfate 220 mg daily or protein supplement three times per day. R3's Treatment Administration Record (TAR), dated November 2023, a physician order starting 11/16/23 and ending on 11/18/23, to apply wound vacuum to (R3's) Coccyx wound. Apply oil emulsion over exposed bone medially prior to placing sponge for wound vac. Setting 125 mmHg continuous. Change every three days. This treatment was documented as not completed on 11/16/23 and 11/18/23, with a note referring to 'see nurse progress note'. This same TAR documents a physician order starting and ending on 11/17/23, and again starting 11/19/23 and ending on 11/30/23, documents apply saline moistened gauze covered with absorbent pad to (R3's) Sacral Stage IV Pressure Ulcer daily. This same TAR does not document R3's Sacral Pressure Ulcer dressing change as being completed on 11/19/23, 11/21/23, 11/22/23 and 11/24/23. This same TAR does not document treatment orders for R3's Stage IV Pressure Ulcer wound from 11/14/23-11/16/23. R3's Nurse Progress Notes do not document R3's physician ordered wound vac being applied or refused nor use of alternate saline dressing as ordered. On 1/10/24 at 10:45 AM, V19, Wound Nurse, completed wound care for R3's Stage Four Pressure Ulcer on Coccyx and R3's Right outer calf wound. V18, Certified Nurse Aide (CNA), assisted with positioning of R3 during wound care. R3's incontinence brief, Coccyx dressing, incontinence pads, mattress, and sheet R3 was laying on, were completely saturated with light yellow liquid. V19, Wound Nurse, used disinfectant wipes to attempt to clean R3's bed mattress due to linens being excessively saturated. R3's Coccyx bandage was grossly saturated with pieces of cotton on inside of bandage separated into ball shaped pieces. R3's Coccyx bandage was not dated or initialed. R3's bed linens were completely saturated from R3's upper shoulders to below feet. R3's Coccyx Stage Four Pressure Ulcer was a large open area with undermining at edges covered with grey slough, copious amount of brown/grey drainage and had very foul odor that permeated the room. On 1/10/24 at 11:00 AM, V19, Wound Nurse, stated, (R3) should never have been left in this mess. V19 also stated, We (facility) are trying to heal (R3's) wounds not make them worse. I just can't believe what condition (R3) has been left in. I can not tell you when (R3's) Coccyx dressing was changed last because it was not dated. Some of that drainage was from (R3's) Coccyx wound, but I believe most of it was from (R3's) Right outer calf and other weeping areas on (R3's) lower legs. (R3) has Methylicillin Resistant Staphylococcus Aureus (MRSA) in her Coccyx wound already. That is why (R3) is on contact isolation precautions. I am going to have to do some training with the staff. On 1/17/24 at 8:25 AM, V48, Receptionist, stated R3 had an appointment at the local wound clinic on 11/20/23, but did not attend that, and has her next appointment scheduled for 1/25/24. V48 stated R3 has not been to any other wound clinic. On 1/17/24 at 10:30 AM, V19, Wound Nurse, stated R3 has first appointment at an offsite wound clinic on 1/25/24. V19 stated R3 admitted to facility on 11/14/23, had first wound assessment on 11/14/24, and was seen by V32, Wound Physician, on 11/16/23, 11/30/23, and 12/7/23. V19 stated V32 did not see R3 on 12/13/23, due to R3 being hospitalized from 12/11/23-12/22/23 for R3's wound infection. V19 stated, (V32) signed off on (R3) on 1/3/24 due to (R3) was going to start going to the wound clinic. (V32's) last time assessing (R3's) wounds was 12/7/23. I have assessed (R3's) wound weekly since then when (R3) was not in the hospital. (R3) has been in the hospital most of that time so there are some assessments that are not done. I did the assessments, but did not measure (R3's) Coccyx wound. I just leave the same measurements in the assessments every week because you have to put something in for the computer system to allow you to move on to the next date. I should have really assessed (R3's) wounds on the weeks that (V32) Wound Physician wasn't there to do it. V19, Wound Nurse, stated R3's Coccyx wound was not 100% beefy granulation as documented. V19, Wound Nurse, stated R3's Coccyx wound 'appears larger' and no beefy granulation tissue was present. V19, Wound Nurse, stated, (R3's) Coccyx wound appears worse to me. There is no granulation tissue. All the tissue we can see is grey. It has a foul odor and there is a substantial amount of drainage. This is much worse than when (R3) came back from the hospital. 2. R14's undated Face Sheet documents an admitted [DATE], with medical diagnoses list includes Wedge Compression Fracture of Second Lumbar Vertebrae, Anxiety, Hypertension, Urinary Tract Infection (UTI). R14's Minimum Data Set (MDS), dated [DATE], documents R14 is cognitively intact. This same MDS documents R14 requires maximum assistance for bed mobility, transfers and bathing. R14's Pressure Ulcer Risk Assessment, dated 12/30/23, documents R14 is at moderate risk of obtaining a pressure ulcer. R14's Care plan documents R14 requires one assist for bed mobility. This same care plan does not include a focus area, goal, nor interventions for R14's Coccyx pressure ulcer. R14's Physician Order Sheet (POS), dated 9/30/23, to apply a Hydrocolloid dressing over R14's Coccyx area every three days and as needed. R14's Treatment Administration Record (TAR), dated January 2024, documents a physician order starting 9/30/23 to apply a Hydrocolloid dressing over R14's Coccyx area every three days and as needed. R14's Wound Assessment Details Report, dated 1/2/24, documents R14's Coccyx Pressure Ulcer as Stage II measuring 0.3 centimeters (cm) long by 0.3 cm wide by 0 depth. R14's Wound Assessment Details Report, dated 1/10/24, documents R14's Coccyx Pressure Ulcer as Stage II measuring 1.0 centimeters (cm) long by 2.0 cm wide by 0 depth. On 1/10/24 at 9:10 AM, V19, Wound Nurse, completed wound care for R14's Coccyx wound. R14 did not have a previous dressing in place to Coccyx. R14's Coccyx area showed three nickel sized open areas that were red with small amount of clear drainage. Several small tinted areas noted on inside of R14's incontinence brief located directly in line with where R14's open wounds would come in contact. V19 cleansed areas then applied Zinc cream and bordered foam over R14's open wounds. On 1/10/24 at 9:30 AM, V19, Wound Nurse, stated, (R14) had a Stage One Pressure Ulcer on her Coccyx. Now it looks like it has opened in a few small spots. So that would make it a Stage Two. I hate to see that (R14's) wound has gotten worse, but hopefully we can get it heading back the right direction. We (facility) have been out of the Hydrocolloid dressings so I have been putting on Zinc and foam until we get our supply truck in on Wednesday. I know I put on the wrong dressing, but that is only because we (facility) do not have the ones ordered by the Physician. We (facility) have standing orders but those are to be used if there is not an order in place. (R14) does have an order, we are just out of the supplies. The facility policy titled 'Pressure Injury and Skin Condition Assessment', revised 1/17/18, documents the resdient's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care.

Based on observation, interview, and record review, the facility failed to respond to a residents call light in a timely manner; failed to thoroughly investigate and provide increased supervision to prevent a residents fall; failed to complete fall risk assessments and implement fall interventions; failed to timely report a fall with head injury to the physician; failed to complete post fall assessments; and failed to complete post fall neurological assessments for a resident. These failures affects three (R3, R7, R21) out of four residents reviewed for falls in a sample list of 23 residents, resulting in R3 falling and sustaining a femur fracture. Findings include: 1. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact. This same MDS documents R3 as legally blind and requiring maximum one person assist for toileting, upper and lower body dressing and moderate assistance for chair/bed to chair transfer. R3's undated Face Sheet documents Medical diagnoses of Spondylosis of Lumbar Region without Myelopathy or Radiculopathy, Syndrome of Inappropriate secretion of Antidiuretic Hormone, Anxiety, Depression, Disorders of the eyelids, Exposure Keratoconjunctivitis, Legal Blindness, Seizure Disorder, Waldenstrom Macroglobulinemia, Methicillin Resistant Staphylococcus Aureas MRSA), Pressure Ulcer of Sacrum Stage IV, Right Femur Fracture, and Obstructive and Reflex Uropathy. R3's Careplan intervention, dated 11/18/23, documents R3 requires prompt response to all requests, follow facility fall protocol. R3's Fall Risk Assessment, dated 12/22/23, documents R3 is at risk for falls. R3's Fall Investigation, dated 1/1/24, documents R3 had an unwitnessed fall in R3's bathroom at 2:20 AM on 1/1/24. This same fall investigation documents R3 was cognitively intact and call light had been activated prior to fall. This fall investigation documents R3 complained of pain in Right Shoulder and Groin area. R3's fall investigation documents, (R3) stated she had to use the restroom and did not want to wait for help. This same fall investigation documents per (R3) request, (R3) sent out to emergency room for evaluation due to pain that could not be controlled with current pain medication orders. R3's X-Ray of Right Hip report, dated 1/1/24, documents, Clinical indication: Right Hip pain after fall, possible fracture. Impression: Remote fractures of the Left Superior and Inferior Pubic Rami. There is small question of small Lateral Cortical step-off with the lateral aspect of the Right Femoral Neck and [NAME] nondisplaced fracture is not excluded. Recommendation is for Computerized Tomography (CT) of the Right Hip for further characterization. R3's Magnetic Resonance Imaging (MRI) of Pelvis without contrast, dated 1/4/24, documents, Impression: Nondisplaced, mildly impacted subcapital fracture of the Right Femur with mild surrounding marrow edema. Partial-thickness tearing at the origin of the bilateral Hamstring tendons. R3's Nurse Progress Note, dated 1/1/24 at 2:20 AM, documents, Notified by (V38) Certified Nurse Aide (CNA) after returning from supply room downstairs that (R3) was sitting on her bottom in her room in restroom. (R3) stated she had to go to the restroom and could not wait. Call light was on. (V38) was in another resident's room during time of incident. (R3) stated she could not remember how she ended up on the floor. No new injuries noted. Vital signs stable. (R3) transferred safely back into bed. (R3) stated her pain medication was not controlling her pain and expressed she did not want me to leave her side. I explained to (R3) that I could not give her anymore pain medication due to her orders but would give it as soon as her orders allowed. (R3) expressed she wanted to go to the emergency room to get looked at because she was now feeling increased pain in her Right Shoulder and groin area with movement. 911 notified to transport (R3) to emergency room . On 1/16/24 at 8:05 AM, R3 stated R3 fell on the early morning of 1/1/24. R3 stated, I had to use the bathroom. They (staff) have told me I will get septic if I let urine or bowel movement get into my wound on my bottom. I had to go really bad. I put on my call light and waited 35 minutes. I know I am blind, but I know it was 35 minutes because I keep the television on to help me keep track of time. An entire sitcom show played while I was waiting for someone to help me to the bathroom. Finally, because they (staff) just kept telling me I would get an infection in my wound, I just got up with the wheelchair and made it to the bathroom. That was no small feat. I used the bathroom and tried to lock my brakes on my wheelchair, but apparently I didn't get my brakes locked. I ended up on the floor of the bathroom. My call light was still sounding. It took another 15-20 minutes before anyone came to answer my call light. Then (V38) Certified Nurse Aide (CNA) came in and saw me on the floor. (V38) told me she would be back. So, (V38) CNA and (V24) Licensed Practical Nurse (LPN) came back in around 15 minutes later. They (V24, V38) helped me get back into my wheelchair. (V24) did not do any kind of assessment to see if I was hurt. (V24) asked me if I was having pain and I told her 'I always have pain'. After I got in bed, (V24) told me I 'should be ok' and would get me pain medication when it was due. I told (V24) right then that I think I needed to be sent to the emergency room . So, (V24) complied. On 1/16/24 at 11:15 AM, V24, Licensed Practical Nurse (LPN), stated V24 was the nurse for R3 on the night/early morning of 1/1/24 when R3 fell . V24 stated, We (facility) have been short staffed a lot lately. The residents have had to wait longer on call lights than what they should have to. We (staff) just do the best we can. V24 also stated, We (staff) have to prioritize who needs the help the most. I am sure (R3) had to wait if she said she did. (R3) is absolutely alert and oriented. I had been in (R3's) room a couple times earlier in the night helping her to the bathroom. I think (R3) was being checked for a Urinary Tract Infection (UTI) the day before she fell . On 1/11/24 at 10:00 AM, V2 Director of Nurses (DON), stated R3 fell on [DATE] at 2:20 AM while taking herself to the bathroom. V2 stated, (R3) told me that she had already been to the bathroom and was transferring herself back to the wheelchair when she fell . V2 stated R3 was sent to the emergency room and was admitted to the hospital. V2 stated R3 was in hospital for several days due to a hip fracture from the fall. V2, DON, stated R3's call light was on at the time of her fall. V2 stated R3's X-Ray was not clear whether she had a fracture or not. V2 stated the hospital records did show that it could not determine if the fracture was caused by the fall or by other disease process. So the question is did (R3) fall and obtain the fracture or did the fracture cause her to fall. The hospital record said it was undetermined. Either way (R3) should not have been up by herself. The staff should have answered (R3's) call light more timely so that (R3) did not get up independently. The facility call light tracking record for R3's room and bathroom, dated 12/31/23 at 11:00 PM through 1/1/24 at 11:59 PM, documents R3's call light was activated at 12:04 AM for a total of 12 minutes, and again at 2:51 AM for a total of 13 minutes. This same report does not document R3's call light being activated at time of fall (2:20 AM) on 1/1/24. This same report also documents R3's call light was activated at 2:59 AM for five minutes, 3:39 AM for two minutes, 4:03 AM for two minutes, and 4:16 AM for 16 seconds. On 1/18/24 at 12:45 PM, V43, Maintenance Director, stated the facility has a computerized program to track call lights. V43 stated by the report, you can see what time the call light was activated, de-activated, what room/bed the call light was used for, etc. V43 stated R3's call light report does not show when R3's call light was activated. V43 stated sometimes the system misses activations and he will look into that. V43 stated unsure why R3's call light report documents R3's call light was activated after R3 was sent to the hospital (2:51 AM, 2:59 AM, 3:39 AM, 4:03 am and 4:16 am). V43 stated, I will have to assess my systems to see what happened. I don't really know. 40385 2. R7's undated diagnoses list documents R7's diagnoses include Parkinson's Disease and Dementia. R7's Minimum Data Set (MDS), dated [DATE], documents R7 has severe cognitive impairment, requires substantial/maximal assistance of staff for toileting and dressing, requires supervision/touching assistance for sit to standing movement, transfers, and walking, and R7 is frequently incontinent of urine. R7's Care Plan, dated as 1/9/24, documents R7 is at risk for acute pain related to recent surgical three screw fixation of left femoral neck fracture. R7's Care Plan, revised 1/10/24, documents R7 is at risk for falls and includes, but is not limited to, the following interventions: -1/4/24 R7's name will be placed on the get up list to be out of bed prior to shift change. -1/4/24. Offer to assist R7 to the bathroom while conducting rounds during the night. -1/3/24 R7 returned from the hospital and therapy will work with R7 on strengthening and gait. R7 is to have increased supervision and attempt to keep R7 visually in the common areas. -11/30/23 R7 fell while not using R7's walker. R7 did not sleep well the night before which affected R7's safety awareness. Monitor R7's sleeping habits at night and continue frequent checks. -11/11/23 Remind R7 to sit back and upright in the chair, or encourage R7 to lie down if R7 appears tired. -11/10/23 physical and occupational therapy to evaluate and treat. Continue to remind R7 to use walker when ambulating. -9/3/23 Attempted to ambulate without walker. Encourage R7 to use walker when ambulating. R7's fall investigation, dated 11/17/23 at 7:00 AM, documents R7 had an unwitnessed fall, and R7 slipped out of the chair in the lounge. R7's Fall IDT (Interdisciplinary Team) Note, dated 11/07/2023 at 11:53 AM, documents the root cause of the fall as R7 has diagnoses of Parkinson's Disease and Dementia, has severe cognitive impairment, has a lack of safety awareness, often ambulates without assistance, and R7 slipped out of the chair. The post fall intervention is documented as Resident (R7) is in the safest environment possible, continue current interventions. R7's fall investigation, dated 11/10/23 at 9:10 AM, documents R7 had a witnessed fall while attempting to independently ambulate without R7's walker. R7's Fall IDT Note, dated 11/10/23 at 11:33 AM, documents the root cause as R7's poor safety awareness, attempt to ambulate without assistance and R7's legs were weak and gave out. The new intervention is for physical and occupational therapy to evaluate and to continue to remind R7 to use R7's walker. R7's fall investigation, dated 11/11/23 at 7:00 AM, documents R7 had a witnessed fall when R7 fell forward out of R7's chair. R7's Fall IDT Note, dated 11/13/23 at 11:28 AM, documents root cause as R7 has Dementia and Parkinson's Disease and frequently rests in the alcove when tired. The interventions already in place in included reminders to use the walker and recommending frequent rest periods. The new intervention was to remind R7 to sit back and upright when in a chair, and encourage to lie down when R7 looks tired. R7's fall investigation, dated 11/30/23 at 11:10 AM, documents R7 was walking out of R7's room and housekeeping and room mate report R7 had fallen. This report documents the room mate did not see the fall, but heard the crash. R7 reported falling and self transferring after the fall. R7's Fall IDT Note, dated 11/30/23 at 11:30 AM, R7's room mate witnessed R7 fall in R7's room, R7 was not using R7's walker, R7 lost balance and fell . R7 had self transferred post fall and was observed again without R7's walker. The root cause of the fall is R7's diagnosis of Parkinson's disease, severe cognitive impairment, lack of safety awareness, and R7 forgets to use R7's walker. R7 did not sleep well the night prior and seemed restless prior to the fall. New intervention is documented as monitor R7's sleep habits, encourage to lie down at night and continue frequent checks. There are no documented staff interviews for the investigations of falls on 11/7/23, 11/10/23, 11/11/23, and 11/30/23, and there is no documentation when R7 was last observed prior to the falls, R7's activity at that time, or when R7 was last toileted or provided incontinence cares. R7's Nursing Note, dated 1/1/2024 at 3:34 PM, documents R7 was more confused than usual and not easily redirected, R7 seems more unbalanced and was repeatedly not using R7's walker. This note documents the physician was contacted and orders received for urinalysis and to start antibiotic on 1/2/24. There is no documentation that an increase in supervision or frequency of monitoring R7 was implemented after this note. R7's Nursing Note, dated 1/2/2024 at 11:00 PM, documents R7 stated R7 fell in R7's room earlier this evening and there was no witnesses to this. R7 complained of left groin discomfort and left hip pain. R7's Nursing Note, dated 1/2/2024 at 11:15 PM, documents R7's family spoke to R7 on the phone and R7 requested to go to the emergency room for evaluation. The facility's Report to IDPH (Illinois Department of Public Health) Regional Office, dated 1/10/24, documents R7 stated R7 was self transferring to the chair when R7 fell , R7 was able to get off of the floor and into the recliner after falling. This report documents R7 returned from the hospital on 1/2/24 with no new orders, and on the morning of 1/4/24, the hospital contacted the facility to report that after further review of R7's imaging, R7 has a fracture and requested R7 return to the hospital. This report documents R7 has a history of repeated falls, shuffled gait, and likes to ambulate independently. This report documents R7 to have increased supervision and attempt to keep R7 visually in common areas. The fall investigation, dated 1/2/24 at 11:00 PM, includes interviews with V9 Licensed Practical Nurse (LPN) and V41 Certified Nursing Assistant (CNA), but does not document when R7 was last observed/check on, R7's activity at that time, and when R7 was last toileted or provided incontinence cares. V41's witness statement dated 1/3/24 documents V41 was completing rounds and heard R7's room mate calling for help. This note documents the room mate reported hearing R7 fall, but did not witness it since the curtain was pulled. V41 asked R7 if R7 fell , and R7 reported yes. R7 was asked how R7 got into the recliner, and R7 stated R7 stood on R7's own to transfer into the recliner. R7's Hip and Pelvis X-ray dated 1/3/24 at 12:51 AM documents History: Per ordering provider: Unwitnessed fall, left hip pain. Acute impacted subcaptial femoral neck fracture on the left (let hip fracture). R7's Response History Report, dated 12/19/23-1/17/24, documents to check R7's location every hour and the last completed check on 1/2/24 was at 2:22 PM. R7's fall investigation, dated 1/4/24 at 3:25 AM, documents V50, CNA, witnessed R7 standing near R7's dresser, removing R7's wet incontinence brief, and R7 fell to the floor onto R7's left side. R7's fall investigation, dated 1/4/24 at 7:00 AM, documents R7 had an unwitnessed fall and was found asleep on the floor mat beside R7's bed. There is no documentation when R7 was last checked on or assisted with toileting/incontinence cares prior to these falls. On 1/17/24 at 12:23 PM, V9, LPN, stated that night (1/2/24), R7 had been walking without R7's walker, which is usual for R7. V9 stated V9 did not think R7 had 15 minute checks in place that night, but that is an intervention that can be used if the resident is confused. V9 stated 15 minute checks are documented on a paper flowsheet. V9 stated we just watched him (R7) closely that night. V9 stated R7's fall was not witnessed, R7 told R7's family that R7 fell , so V9 went to check on R7. V9 stated R7 reported that R7 self transferred off of the floor as R7 was physically able to do that. V9 stated prior to the fall R7 was in R7's room in R7's recliner, but did not recall when R7 was last observed prior to the fall. V9 stated the nurses document information such as when last checked on and last toileted on a form. On 1/17/24 at 12:43 PM, V2, Director of Nursing (DON), stated the facility is in the process of transitioning from paper fall investigations to computerized forms. V2 stated, What you have for R7's falls, is the entire investigation. V2 confirmed there is no documentation to identify the last time R7 was checked on and R7's activity at that time, or when R7 was last toileted/provided incontinence cares prior to the falls. V2 stated staff should keep frequent eyes on R7 when R7 is up and about and obtain R7's walker. V2 stated 15 minute checks are implemented post fall and at the nurse's discretion if the resident is more confused or has gait changes. V6, Assistant DON, stated 15 minute checks are documented in the task section of the resident's electronic medical record. At 1:05 PM, V2 stated therapy and increased supervision were the post fall interventions for R7's fall on 1/2/24. V2 stated the root cause and post fall interventions are documented in the IDT notes. V2 confirmed the 1/4/24 post fall intervention is to offer toileting during the night while conducting rounds. At 1:11 PM, V6, ADON, stated R7 is incontinent and also uses the toilet, R7's room mate is checked and changed every two hours during the night, and staff should be checking and offering toileting to R7 when checking R7's room mate during the night. V6 stated staff should also be offering R7 toileting routinely during the day as well. On 1/17/24 at 4:16 PM, V30, Nurse Practitioner, stated usually when there are changes in a resident's condition such as increased confusion, the nursing staff will increase supervision and monitoring. V30 stated if frequent checks or increased monitoring were implemented for R7 it would have lowered R7's risk for falling. 3.) R21's Minimum Data Set, dated dated [DATE], documents R21 has severe cognitive impairment, is dependent on staff when moving from sitting to standing position, requires substantial/maximal assistance of staff for toileting, and is frequently incontinent of bowel and bladder. The only documented Fall Risk Assessment in R21's electronic medical record is dated 12/11/23. R21's Nursing Note, dated 12/11/2023 at 2:08 AM, documents R21 was found lying on the floor beside R21's bed with R21's head against the night stand. R21 was unsure how R21 fell out of bed and reported pain to the back of R21's head. This note documents R21 had a red area to the left forehead and denied pain to the area. R21's Post Fall Investigation, dated 12/11/23, documents R21 had an unwitnessed fall at 1:45 AM. R21 was found on the floor of R21's room with R21's head positioned near the night stand. This investigation documents conflicting information, recorded by V51, CNA, that R21 was sleeping prior to the fall when last checked at 12:00 AM, R21 was toileted at 12:00 AM, and R21 was repositioned last at 11:00 PM bed check. R21's undated Fall/Incident Investigation Documentation documents R21 was found on the floor at 1:45 AM on 12/11/23, and was last observed by the CNA sleeping at 12:00 AM. R21's current interventions include low bed, nonskid footwear, call light within reach, and staff to supervise toileting. Fall mats were placed beside the bed as the new intervention. The root cause is identified as R21 has diagnoses of Dementia, polyneuropathy, and insomnia, has severe cognitive impairment, and R21 was unable to state the cause of the fall. Attempts were made to contact V51, but were unsuccessful. On 1/16/24 at 10:21 AM, V2, DON, stated fall risk assessments are completed upon admission, quarterly, and post fall, and V2 confirmed these assessments are documented in the assessment section of the resident's electronic medical record. V2 stated V2 completes the typed summary of the fall investigation, and the nurses and CNAs fill out the other fall forms. V2 reviewed R21's fall investigation and confirmed documented information is conflicted as to when R21 was last toileted/changed prior to the fall. V2 stated R21 either attempted to get up or rolled from the bed, and R21 wasn't able to say what the cause was. V6, ADON, stated R21 was incontinent and also required toileting assistance, during the night R21 should have been on a check and change program. V2, DON, stated the expectation is for staff to check for incontinence/change R21 at least every two hours. At 10:55 AM, V2 provided R7's Fall Risk Assessment, dated 12/21/22, and V2 stated that was the last assessment V2 could locate prior to 12/11/23. At 11:04 AM, V2 confirmed R21's entire fall investigation was provided. The facility's Fall Policy and Procedure, revised 12/6/23, documents fall risk assessments are completed upon admission, quarterly and with changes in condition, and interventions are based on the identification of high fall risk. This policy documents to assess for injury, initiate neurological protocol, assess root cause, and initiate a timeline of events. This policy documents nursing staff are responsible for ensuring safety precautions are consistently implemented and maintained. 4.) R21's Minimum Data Set ,dated 12/11/23, documents R21 has severe cognitive impairment. R21's Nursing Note, dated 12/11/2023 at 2:08 AM, documents R21 was found lying on the floor beside R21's bed with R21's head against the night stand. R21 was unsure how R21 fell out of bed and reported pain to the back of R21's head. This note documents R21 had a red area to the left forehead and denied pain to the area. This note documents neurological assessments were initiated and the Nurse Practitioner was notified by fax (electronic facsimile). There are no documented post fall assessments in R21's medical record after 12/12/23 at 6:57 PM. The last documented post fall neurological assessment in R21's medical record is dated 12/11/23 at 4:30 PM. On 1/16/24 at 10:21 AM, V2, Director of Nursing, stated post fall assessments are documented as part of the neurological assessments or in a progress note, and the facility has both paper and electronic forms. V2 stated the neurological assessments have time frames that start every 15 minutes four times, then every 30 minutes four times, then hourly four times, then every four hours. V2 confirmed post fall assessments continue for 72 hours after the fall. V2 stated the nurses notify the resident's power of attorney, physician and nurse manager on call. V2 stated if there is no injury from the fall, then the physician/provider can be notified by sending an electronic facsimile. V2 stated if there is an injury, then V2 would expect the staff to call the provider. V2 stated V2 would not consider complaints of head pain and reddened forehead post fall as an injury, and the facility's policy is to monitor if the resident does not take an anticoagulant. At 10:55 AM, V2 stated V2 was unable to locate any additional post fall and neurological assessments. On 1/17/24 at 12:20 PM, V30, Nurse Practitioner (NP), stated the provider should be notified with every resident fall. V30 stated there are notifications that can be made by fax for an uncomplicated witnessed fall with no injuries and no need for clinical support or emergency medicine, and other notifications should require a telephone call to the provider. V30 stated when a resident has an unwitnessed fall, a complete neurological exam should be completed and the provider should be called, not faxed, regardless of whether or not they are on an anti-coagulant. V30 stated, There are neurological processes that may be affected that may only show up with further diagnostic testing such as a Computerized Tomography (CT) exam. The facility can not always tell if there is an internal bleed or some other internal injury and would need to notify the physician by phone to receive prompt instructions for further care of the resident. In those cases, a fax is not an acceptable form of notification. The facility's Physician-Family Notification- Change in Condition policy, revised 11/13/18, documents the facility will consult with the resident's physician or Nurse Practitioner when there is an accident involving the resident that results in injury and has the potential for requiring physician intervention. The facility's undated Neurological Assessment policy documents: Unless otherwise ordered by the physician, neuro (neurological) checks will be completed along the following schedule: Q (every) 15 minutes times 1 hour, Q 30 minutes x 2 hours, Q 4 hours x 24 hours and then Q shift X 48 hours. Notify physician immediately regarding any changes in the neurological assessment or other signs of possible increased intracranial pressure i.e.(for example), headache, change in mentation, vomiting or irregular breathing.

Based on observation, interview, and record review, the facility failed to implement IDT (Inter-Disciplinary Team) and fall care planned fall interventions, failed to update the fall care plan after a fall, and failed to ensure a call light and personal belongings were within reach for one of three residents (R1) reviewed for falls with injury in the sample of three. These findings resulted in R1 falling face forward out of her wheelchair, resulting in R1 experiencing increased pain and fracturing her left femur which required surgical intervention. Findings include: The facility's Fall Prevention Program policy, dated 11-21-17, documents, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The fall prevention program includes the following components: Methods to identify risk factors. Care plan incorporates identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, (and) preventative measures. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team (IDT) to ensure appropriate care and services were provided and determine possible safety interventions. The Director of Nursing, or designee, is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. Fall/safety interventions may include by are not limited to: The nurse call light device will be placed within the resident's reach at all times. The resident's personal possessions will be maintained within reach when possible. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. The frequency of safety monitoring will be determined by the resident's risk factors and plan of care. In the event safety monitoring is initiated for 15-30-minute periods, a documentation record will be used to validate observations. R1's Order Summary Report, dated 9-22-23, documents R1 is an [AGE] year-old with the diagnoses of Chronic Instability of the Knee, Mild Intellectual Disabilities, History of Falling, Syncope and Collapse, Morbid Severe Obesity, Cognitive Communication Deficit, Chronic Pain, Abnormal Posture, Fracture of the Left Femur with subsequent encounter for Closes Fracture, and Hypertension. R1's Fall Plan of Care, dated 9-20-23, documents the following fall interventions: Be sure my call light is within easy reach for me and encourage me to use it for assistance as needed. Ensure all my personal items are in easy reach and not on the floor. R1's MDS (Minimum Data Set) Assessment, dated 8-13-23, documents R1 is cognitively intact, requires extensive assistance with transfers, bed mobility, and toileting. This same MDS documents R1 has had no falls between 5-13-23 and 8-13-23. R1's Witnesses Fall Report, dated 8-18-23 at 9:30 PM, and signed by V6, (LPN/Licensed Practical Nurse) documents, Resident in spa room with CNA (Certified Nursing Assistant) assisting (R1) being re-positioned in wheelchair and (R1) fell forward and hit face on toilet seat. Immediate Action Taken: Re-positioned in wheelchair and taken back to her room and placed in bed. Injury Location: Bruise to face. R1's IDT (Inter-Disciplinary Team) Health Status Note, dated 8-21-23 at 11:28 AM, documents, 8-18-23 resident fall was witnessed by staff in restroom. (R1) reached for sink and slid out of wheelchair, hitting her face on the sink. (R1) did have a bloody nose and bruising to the right side of her face. (V4/R1's Physician) notified. Care plan updated. CS (Central Supply) to work on ordering (R1) a seatbelt or chest harness for additional support for resident to not slide out of wheelchair. Assessment will be performed on (R1) and new belt to make sure (R1) can release herself prior to initiating assistive device. R1's Comprehensive Care Plan, dated 9-20-23, does not include any documentation regarding R1's fall on 8-18-23, or a revision to update or revise R1's fall interventions following R1's fall on 8-18-23. R1's Progress Notes, dated 8-27-23 at 11:00 AM, document, (R1) found in floor in her room. (R1) states she was reaching for her book and fell forward from her wheelchair. Found face forward with left leg bent under her. (R1) Hoyer (mechanical lift) back to bed. (R1) complains of pain in left knee on little movement. R1's Progress Notes, dated 8-27-23 at 11:20 AM, document R1 was sent to the hospital for increased complaints of pain to the left knee. R1's Hospital Emergency Department Notes, dated 8-27-23, document, (R1) arrived at the emergency department for left leg pain after falling out of her wheelchair this morning, and R1 was complaining of left anterior lower jaw pain and left leg pain. These same notes document R1 had a fall a week prior resulting in a facial injury. ` R1's X-Ray Left Femur, dated 8-27-23, documents, Findings: Displaced and mildly angulated distal left femoral (left thigh) fracture. Left hip osteoarthritis. R1's Operative Procedure Note, dated 8-31-23, documents R1 had an open reduction and internal fixation of the femur shaft fracture with intramedullary (inner tissue) implant. R1's Final Report to Public Health Department, dated 9-5-23 and signed by V1 (Administrator) and V2 (Director of Nursing) documents, On 8-27-23 (R1) was observed on the floor in resident's room. Upon assessment (R1) stated that she was reaching for her book and fell forward in her wheelchair. (R1) was mechanically lifted back to bed with assist of two clinical staff members, offered pain medication, leg immobilizer, and ice applied. (R1) assessed further and complaints of pain to left knee. (V4/R1's Primary Physician) was called and order obtained to send (R1) to emergency department for evaluation. (R1) was admitted to hospital and was not returned to facility at this time. Conclusion: Surgery to repair (R1's) left hip was postponed due to diagnosis of sepsis due to aspiration pneumonia. (R1) had a recent decline prior to the fall and diet was changed to pureed after speech therapy evaluation on 8-1-23. Postoperative Diagnosis: Open reduction internal fixation of left distal femur peri-prosthetic fracture. On 9-22-23 at 9:10 AM, R1 was sitting in a high back padded chair with the foot of the chair elevated and R1's legs elevated. R1 had a bedside table across the front of her and was eating breakfast. R1 had non-skid socks on and a non-skid pad under her buttocks. R1 stated, The day I fell (8-27-23), I was brushing my teeth and fell forward out of my chair. I am top heavy and have fell (sic) out of my chair several times. I broke my knee when I fell . The staff was just in my room right before I fell . I am in no pain right now. On 9-22-23 from 11:25 AM to 11:52 AM, R1 was sitting in her room in a high back padded chair with the foot of the chair elevated and R1's legs elevated. R1 was not in reach of her call light or belongings, and was approximately four feet away from her bed, call light, and bedside table. R1 was fidgety and moving her feet. On 9-22-23 at 10:00 AM, V5 (CNA/Certified Nursing Assistant) stated, I was taking care of (R1) on the day she fell (8-27-23). I had just taken (R1) to the toilet and left her in her room in her wheelchair. I came out of another resident's room and saw (R1) laying on the floor in front of her wheelchair. (R1) had fell (sic) forward out of her wheelchair and her legs were crossed under her. I immediately yelled at staff to get the nurse. The nurse (V6/Licensed Practical Nurse/LPN) came in the room and assessed (R1) and we noticed (R1's) left knee looked out of place. (V6) called 911 while I stayed with (R1) and then the ambulance came and took (R1) to the hospital. I did not notice (R1) to have any other injuries. On 9-22-23 at 11:52 AM, V5 (CNA) stated, I took (R1) to her room today and left her in her chair while I went to find help and get the (mechanical lift). I guess I must have left her in there without her call light. I really did not think about it. On 9-22-23 at 11:05 AM, V2 (Director of Nursing) stated, The IDT team did not meet about (R1's) fall on 8-18-23 (Friday) until 8-21-23 (Monday). The IDT team does not meet about falls over the weekend until Mondays. There were no fall interventions put into place after (R1's) fall on 8-18-23 from the nurse that I am aware of. I did not realize nurses could update the care plans with new fall interventions. The IDT team met on 8-21-23, and decided to order a self-releasing harness for (R1) to keep her from falling out of her wheelchair. I do not believe we (the facility) ever received the harness before (R1) fell out of her wheelchair again on 8-27-23. I know (R1) has had multiple falls from slipping out or falling forward out of her wheelchair. The IDT did not re-evaluate (R1's) fall interventions or put anything else into place while we were waiting on the harness. (R1's) fall care plan does not include documentation or interventions addressing (R1's) fall on 8-17-23. On 9-22-23 at 11:55 AM, V6 (LPN) stated, I was (R1's) nurse both times (R1) fell (8-17-23 and 8-27-23). I do not recall doing any fall interventions following (R1's) fall on 8-17-23. (R1) fell face first out of her wheelchair and had a bloody nose. I did not know I could implement fall interventions or document on the care plan. The only thing different we (the facility) did was do neurological checks for 72 hours after her fall on 8-17-23. (R1) fell face first out of her chair on 8-27-23 and I sent her to the emergency room immediately. (R1) broke her leg. (R1) did not have any kind of harness or seat belt on when she fell on [DATE]. On 9-22-23 at 12:00 PM, V2 stated, (R1) should not have been left in her room without her call light or other belongings in reach. On 9-22-23 at 12:00 PM, V1 (Administrator) stated, (V5) should not have left (R1) in her room without her call light within reach. (V5) will need to be disciplined.

Based on record review and interview, the facility failed to initiate new fall prevention interventions in response to falls, and failed to implement existing interventions to prevent falls. These failures affect two residents (R2 and R3) out of three reviewed for falls on the sample of seven. These failures resulted in R2 experiencing an intraparenchymal hemorrhage (brain bleed) which required an 8-day hospital stay to resolve, and R3 experiencing a fractured right clavicle and 9 sutures in the forehead. Findings include: 1. R2's Electronic Medical Record documents R2 was admitted to the facility 11/12/21, with Medical Diagnoses including Cerebral Infarction (Stroke), Muscle Weakness, Lack of Coordination, Difficulty Walking, Muscle Wasting and Atrophy, Loss of Vision of Left Eye, Non-Ruptured Cerebral Aneurysm, Non-Traumatic Cerebral Hemorrhage (Resolved), and Monoplegia (weakness) of Right Upper Limb. R2's Census Detail (undated) documents R2 was in the hospital from 12/12/21 through 12/20/21, and readmitted to the facility 12/20/21. R2's Nurses Notes, dated 12/9/21, document R2 experienced a fall from a wheelchair on 12/9/21 at 9:30 am. This same Nurses Note documents R2 was complaining of right shoulder pain after this fall and received an x-ray of the right shoulder. R2's Care Plan for fall prevention documents a simple narrative statement, dated 12/9/21, I had a fall from my wheelchair this morning, I was leaning forward (due to) abdominal discomfort, I overextended my lean and fell forward. This Care Plan did not include a new intervention in response to this fall to prevent further falls nor to ensure R2's safety in the event of further falls. R2's Nurses Notes, dated 12/12/21, document R2 experienced another fall from the recliner on 12/12/21 around 11:30 (am) when R2 was observed by facility staff lying on the floor on (R2's) face. This same Nurses Note documents R2 was sent to the emergency room after a neurological check at the facility. R2's Emergency Department Notes, dated 12/12/21, document R2 experienced acute bruising (ecchymosis) around the right temple, and an acute Right Side Traumatic Intraparenchymal Hemorrhage (brain bleed). These same Emergency Department Notes document R2 admitted to the hospital for treatment of this new brain bleed. On 12/23/21 at 11:30 am, V1 Administrator, V2, Director of Nursing, and V17, Regional Clinical Director, all declined to answer if they thought the simple narrative statement documented in R2's Care Plan for the fall on 12/9/21 constituted an intervention, without first reviewing R2's record. At 2:18 pm, V2, Director of Nursing, stated, We knew (R2) was leaning forward to relieve (R2's) pain so we increased (R2's) pain medication (Tylenol) and it seemed effective. I can't say why it doesn't make it onto the Care Plan. R2's Medication Administration Record (MAR) for December 2021 documents prior to the fall on 12/9/21, R2 received 3 doses of Acetaminophen (Tylenol) 650 milligrams, one dose on 12/4/21 at 12:33 pm, one dose on 12/8/21 at 4:37 pm, and one dose on 12/9/21 at 1:00 am. This same MAR documents after R2's fall on 12/9/21, R2 received 3 doses of Acetaminophen 650 milligrams, one dose on 12/9/21 at 12:20 pm, one dose on 12/11/21 at 4:27 pm, and one dose on 12/12/21 at 5:33 am. On 12/23/21 at 3:31 pm, V2, Director of Nursing, acknowledged R2 did have a sore right shoulder after the fall on 12/9/21, prompting R2's Advanced Practice Nurse (V15) to order an x-ray. 2. R3's Electronic Medical Record documents R3 was admitted to the facility 9/15/21, with medical diagnoses including Muscle Weakness, Unsteadiness on Feet, Muscle Wasting and Atrophy, [CONDITION(S)] and Collapse, and [CONDITION(S)]. This same Medical Record documents a medical diagnosis of Fracture of Left Clavicle, dated 12/14/21. R3's Nurses Notes, dated 12/3/21, documents R3 experienced a fall on 12/3/21 at 9:50 pm while ambulating to the bathroom. R3's Care Plan for fall prevention documents a simple statement, dated 12/3/21, I am in the safest environment possible. This Care Plan did not include a new intervention in response to this fall to prevent further falls, nor to ensure R3's safety in the event of further falls. R3's Nurses Notes, dated 12/13/21 documents R3 experienced another fall while ambulating to the bathroom with a staff member, landing prone on the floor and hitting (R3's) forehead on the floor. This same Nurses Note documents R3 was sent to the emergency room for evaluation. R3's Care Plan for fall prevention, dated 12/13/21, documents R3 had fallen because R3 tripped over the phone cord. This same Care Plan documents an existing fall prevention intervention, dated 9/16/21, to Keep a clear pathway to my bathroom. R3's emergency room Report documents an x-ray of the left shoulder determined R3 had fractured the left clavicle. This emergency room Report also documented R3 experienced a right forehead laceration, and bruise of the right knee. The hospital discharge instructions document R3 is to have the sutures removed from the right forehead in approximately 7 days, and to remain non-weight Bearing on the left upper extremity. On 12/23/21 at 11:30 am, V1, Administrator, V2, Director of Nursing, and V17, Regional Clinical Director, all declined to answer if they thought the simple narrative statement documented in R3's Care Plan for the fall on 12/3/21 constituted an intervention, without a review of R3's record. On 12/23/21 at 2:18 pm, V2, Director of Nursing, stated, I talked to the CNA (Certified Nursing Assistant, unnamed) who walked (R3) to the bathroom and she said the phone was on the overbed table and she moved it to the bedside bureau but there must have been a little bit of the cord left sticking out.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to follow their infection control policy to prevent the spread of a highly contagious disease COVID-19 (Human Coronavirus) to residents and staff. The facility allowed symptomatic staff to work with residents affecting two (R4, R5) of 15 residents sampled for COVID-19. These failures have the potential to affect seven additional residents (R2, R8-R12, R16) and multiple staff. Subsequently R4 and R5 tested positive for COVID-19 after being unnecessarily exposed to COVID-19 in the facility resulting in the potential for serious complications, hospitalization , and/or death. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/17/21, onsite record review and interview verified that the facility is in the process of staff re-education on the facility infection control policies and protocols. The facility remains out of compliance at a severity level two. B. Based on observation, interview, and record review, the facility failed to ensure a resident's physician was notified of symptoms of COVID-19 and a COVID-19 positive rapid test result. The facility failed to initiate contact/droplet precautions for symptomatic residents and residents upon admission to the facility. The facility also failed to ensure a resident was transferred to the COVID-19 positive unit after testing positive for COVID-19. These failures affect three of 23 residents (R1, R3, R17) reviewed for COVID in the sample of 23. C. Based on interview and record review, the facility failed to restrict a symptomatic employee from working at the facility. This failure affects six of 23 residents (R8, R19, R20, R21, R22 and R23) reviewed for COVID-19 on the sample list of 23 residents. Findings include: A.1. The facility's COVID-19 Testing and Response Plan dated 11/29/21 documents the facility recognizes that residents living in a congregate setting are at high risk of being infected by COVID-19. The protocol is for the purpose of protecting the well-being of any individual including residents. This protocol enables the facility to prevent and/or decrease the risk of COVID-19 transmission by following this testing plan and response strategy. Testing will be completed per guidance and evaluated on an individual basis. COVID-19 symptoms include runny nose, cough, fever, shortness of breath, chills, muscle pain, headache, fatigue, nausea, vomiting and diarrhea. Symptoms may appear two to 14 days after exposure. COVID-19 is thought to spread mainly by close contact (within about 6 feet) from person-to-person in respiratory droplets from an infected person. These droplets can land in the mouths of people nearby and possibly be inhaled into the lungs. Core Principals of COVID-19 Infection Prevention include universal screening of all staff, visitors and other persons who enter the facility for COVID-19. All are required to answer the questions on the screening form provided at the facility. The health and well-being of the residents of the facility is dependent upon accurate and truthful reporting. Inform visitors if they are experiencing symptoms of COVID or have had close contact with someone with COVID-19, they are not allowed to enter the facility. Healthcare personnel, even if fully vaccinated, should report any symptoms and should be restricted from work until they have been evaluated. The screening must check for each of the following exclusion criteria including a body temperature of 100 degrees Fahrenheit (F) or more; Symptoms of COVID-19; diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Completing resident and staff testing as required by current guidance. For symptomatic residents, test per protocol and inform staff to stay home when sick insuring non-punitive practices during this period. Follow the respiratory protection program. Any resident identified with symptoms of fever and/or lower respiratory illness including cough should immediately be placed in both contact/droplet isolation. The Facility Infection Control person is to be notified immediately. Rapid [MEDICATION(S)] testing is to be performed and if negative a PCR test. If staff have been tested due to mass testing with negative results and is asymptomatic, they may continue to work. Fully vaccinated staff with higher risk exposures who are asymptomatic do not need to be restricted from work following their exposure. All staff should promptly notify a supervisor of any symptoms of illness in themselves or individuals in their care. Staff who are ill are to exclude themselves from work environments and are to seek the advice of their healthcare provider. All staff should be pre-screened prior to their shift. If symptoms or temperature are present, the staff member should be sent home. Staff symptomatic for COVID-19 should be considered possible cases and excluded from work. The facility's universal screening is a check list based protocol and completed on all staff, visitors and other persons. The health and well-being of the residents the facility cares for is dependent on accurate and truthful reporting. Symptomatic healthcare personnel should be restricted from work until they have been evaluated per guidelines. The facility and State Survey Agency do not support staff working while ill. On 12/6/21 at 10:05am, V5 (Licensed Practical Nurse/LPN) stated on 11/24/21, V5 came in to work and felt terrible. V5 stated V5 was the nurse taking care of R2, R4, R5, R8, R9, R10 and R12 on 11/24/21. V5 stated V5 had respiratory symptoms that started on 11/24/21 including nasal and [MEDICATION(S)] congestion and a runny nose. V5 stated it got progressively worse throughout the day while working. V5 performed a rapid COVID test which was negative at the end of V5's shift on 11/24/21. V5 stated V5 continued to get worse and had a rough night with sweating and chills in addition to the respiratory symptoms. V5 stated V5 felt awful on 11/25/21 and had additional symptoms including emesis. V5 went to bed early and woke up on 11/25/21 with a fever of over 100 degrees Fahrenheit (F). V5 stated V5 had hot and cold sweats on 11/25/21. V5 stated V5 called in to V14 (Minimum Data Set/MDS Coordinator) and notified V14 of V5's symptoms and that V5 would not be coming into work V5's scheduled shift on 11/26/21 due to still feeling bad and having a fever, emesis and [MEDICATION(S)] congestion on 11/26/21. V5 stated V5 was not instructed to have any further testing or evaluation completed during the call with V14 on 11/26/21 or any other facility staff. V5 was scheduled to work on 11/29/21 and thought it would be okay since V5 was feeling good. V5 stated V5 decided to perform a rapid test on V5 for COVID on 11/29/21 after V5 had been working for 2.5 hours because V5 wanted to make sure V5 was negative for COVID, but the test resulted that V5 was positive for COVID. V5 stated V5's respiratory symptoms for COVID began on 11/24/21 and peaked on 11/26/21. V5 stated V5 had close contact to R5 and R9 on 11/29/21. V5 stated V5 also had contact with R10 while administering medications and R12. R16's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 and R11's MAR's dated November 2021 document V5 administered medications to R2 and R11 on 11/29/21. On 12/2/21 at 9:00am, V1 (Administrator) stated the facility identified close contacts of V5 (LPN) on 11/24/21 as R4 and R5. V1 confirmed V5 had contact with R5, R9, R10 and R12 on 11/29/21. On 12/2/21 at 12:45pm, V11 (Infection Preventionist/IP) stated V5 (LPN) was not feeling well/feeling sick on 11/24/21 while at work, but V5 tested at the end of V5's shift and was negative for COVID. The facility's New List of COVID positive starting 11/18/21 sheets document V5 (LPN) had a COVID test performed on 11/29/21 resulting in a positive result for COVID. This sheet documents V5's last day worked as 11/29/21. This sheet documents on 11/25/21, V5 had emesis with chills and fever and 11/26/21 V5 had emesis and fever with [MEDICATION(S)]/productive cough and as a precaution V5 tested on [DATE] and tested positive. V5 worked in the facility on 11/29/21 from 6:00am - 8:30am and had contact with four residents that were not identified on this sheet. There is no documentation of the additional residents V5 had contact with on 11/29/21 on this sheet. There is no documentation V5 (LPN) completed the facility screening questions on 11/24/21 or 11/29/21 prior to working at the facility. On 12/7/21 at 2:15pm, V11 (IP) stated V5 (LPN) should not have continued to work on 11/24/21 with COVID symptoms. R4, last having contact with V5 on 11/24/21 and R5, last having contact with V5 on 11/24/21 and 11/29/21 tested positive for COVID on 12/2/21 per the facility's COVID testing log. The facility's Employee Screening Prior to Clocking in to Work sheet documents the definition of a temperature is when your temperature is 2 degrees above what is normal for you or greater that (than) 100.0 degrees with a screening dated 12/4/21 at 6:00am V5's temperature was 99.7 degrees Fahrenheit (F). This sheet documents on 12/5/21 at 6:00am a temperature of 97.9 degrees F and 12/6/21 at 6:00am at 96.8 degrees F. On 12/16/21 at 10:15am, V2 (Director of Nursing/DON) stated V5's (LPN) first day back to work after V5 being placed on isolation due to testing positive for COVID-19 infection was on 12/4/21. At the time of this interview, V2 (DON) and V9 (IP) stated they were unaware of V5's temperature of 99.7 degrees F when screening on 12/4/21 and that V2 and V9 were unaware of V5 contacting staff at that time regarding V5's temperature. An Immediate Jeopardy situation was identified on 12/9/21. The Immediate Jeopardy was identified to have begun on 11/24/21 when the facility allowed V5 (Licensed Practical Nurse/LPN) to work in the facility with symptoms of COVID-19 infection thereby exposing multiple residents residing in the facility to COVID-19 infection. V5 also reported to work following increased signs and symptoms of COVID on 11/25/21 and 11/26/21 prior to being tested /evaluated for COVID. On 12/9/21 at 3:33pm V1 (Administrator) was notified of the Immediate Jeopardy situation. The Employee Screening Prior to Clocking In to Work logs document: On 12/15/21 at 1:47 PM V28 (Activity Aide) had New Symptoms of COVID-19. The December 12 - December 18, 2021 schedule documents V28 worked on 12/15/21 from 1:30 PM to 5:00 PM. On 12/16/21 at 6:06 AM V27 (Registered Nurse/RN) had New Symptoms of COVID-19. The 12/16/21 Daily Staffing Assignment documents V27 was assigned to work 6:00 AM - 2:30 PM on the COVID-19 positive red zone. V27's timecard documents V27 worked on 12/16/21 from 6:06 AM-2:00 PM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1. On 12/15/21 at 10:00 AM V2 (Director of Nursing/DON) confirmed education on COVID-19 symptom screening, testing and response plan, including reporting exposure, illness and self-screening was conducted on 12/6/21, 12/8/21, and 12/9/21 with all facility staff. The education was provided by V1 (Administrator), V2 (DON), V9 (Infection Preventionist), V31 (Corporate Infection Control Nurse), V14 (Minimum Data Set/MDS Coordinator), V11 (Infection Preventionist), and V3 (MDS Coordinator). Staff completed a post-training quiz. On 12/16/21 at 8:57 AM V2 stated V2 provided education on COVID-19 symptom screening, testing, and response plan to agency staff on 12/15/21. 2. On 12/15/21 at 11:52 AM V2 (DON) stated V2 reviews the employee screening logs daily to review employee screening was completed prior to working and reviews if employees answered yes to any of the screening questions. 3. The Employee Screening Prior to Clocking in to Work audit tool documents on 12/13/21 V24 (Certified Nursing Assistant/CNA) was noncompliant with screening and received a written warning. On 12/15/21 at 11:30 AM V9 (Infection Preventionist) stated V24 (CNA) had not completed COVID-19 screening prior to working on 12/13/21, and V24 received disciplinary action. V9 confirmed V24 had not received education on screening prior to V9 providing education on 12/13/21. 4. On 12/15/21 at 10:00 AM V1 (Administrator) stated audits are completed daily by V1 (Administrator), V2 (DON), V3 (MDS Coordinator) or V9 (Infection Preventionist) to ensure staff completed screening prior to work and symptoms are reported. The employee schedules are compared to the employee screening logs as part of the audit. If there are any employees who worked without screening, they receive disciplinary action. Daily audits began on 12/9/21. Results of the audit will be reviewed at the next scheduled quarterly Quality Assurance meeting in January 2022. 5. On 12/20/21 at 1:20 PM V2 (DON) confirmed employee call offs are reviewed by the management team during the Quality Assurance daily meetings. 6. The Employee Screening Prior to Clocking in to Work audit tool documents on 12/15/21 V25 (Agency CNA) and V26 (Agency Licensed Practical Nurse) were noncompliant with screening prior to work. On 12/15/21 at 1:00 PM V1 confirmed V25 and V26 worked night shift on 12/14/21 and did not screen prior to working. 7. On 12/20/21 at 9:50 AM V2 (DON) confirmed all staff had completed screening prior to work and no staff were identified to have worked with COVID-19 symptoms as of 12/17/21. On 12/17/21 100% of facility staff screened prior to work. B. The facility's COVID-19 Testing and Response Plan revised 11/29/21 documents: In most cases, COVID-19 causes mild symptoms including a runny nose, sore throat, cough or worsening cough & fever. Other symptoms may be shortness of breath, chills or shaking with chills, muscle pain, headache (new or unusual onset, not related to dietary reasons such as hunger, or history of migraines, cluster, or tension headaches, or headaches typical for the person), loss of smell or taste, fatigue, nausea, vomiting or diarrhea. This protocol enables facility to prevent &/or decrease the risk of COVID-19 transmission by following this testing plan & response strategy. Staff symptomatic for COVID-19 should be considered possible cases and excluded from work. Any resident identified with symptoms of fever and/or lower respiratory illness (cough, shortness of breath, sore throat) should be immediately placed in both contact/droplet transmission-based precautions in a private room if possible. The isolation should be implemented by the healthcare member who discovers the symptoms. Staff will wear full Personal Protective Equipment including N95 mask, gown, gloves, and eye protection for the care of residents who are suspected to have COVID-19. Residents who are new admissions or readmissions that are unvaccinated for COVID-19 must quarantine for 14 days. B.1. R1's Progress Notes dated 10/10/21 at 9:24pm document R1 was sleeping most of evening with an occasional nonproductive cough noted. There is no documentation in R1's progress notes from 10/8/21-10/10/21 that R1 had been lethargic, sleepy or that R1 had been having a cough. There is no documentation R1 received a rapid COVID-19 test at this time. The facility's COVID-19 rapid testing log documents R1's result for R1's rapid COVID-19 test on 10/10/21 at 11:30pm was positive. There are no additional COVID-19 tests documented for R1 on 10/10/21. R1's Progress Notes dated 10/10/21-10/11/21 and medical records do not document R1 tested positive for COVID-19 on 10/10/21 at 11:30pm. R1's Progress Notes dated as below document: 10/10/21 at 9:24pm document R1 sleeping most of shift with non-productive cough noted. Temperature 97.5. 10/11/21 at 12:28am document R1's temperature remains elevated at 100.5 with no documentation of when R1's temperature began for October 2021. 10/11/21 at 12:10pm document R1 noted pale and short of breath this am. Oxygen saturation 83% on 3Liters/nasal cannula (NC.) Oxygen saturations (SaO2) increased to 4Liters/NC. SaO2-84%-88%. R1 still S.O.B (short of breath) and not coherent. Order received to send R1 to the hospital for evaluation. R1 left facility with paperwork at 10:02am and was transferred to the hospital. There is no documentation in R1's medical record that V29 (Nurse Practitioner) or V30 (R1's Physician) were notified of R1's change in condition including non-productive cough on 10/10/21 at 9:24pm or that R1's rapid COVID test resulted positive on 10/10/21 at 11:30pm. R1's Census List and Progress Notes do not document R1 was transferred to the COVID-19 positive unit after testing positive for COVID-19 on 10/10/21 or 10/11/21. On 12/8/21 at 5:01pm, V9 (Infection Preventionist) stated V9 did not recall being notified after hours of R1 testing positive on 10/10/21 at 11:30pm for COVID-19 or that R1 was moved to the COVID-19 positive unit at that time. V9 stated resident room moves should be documented in the resident's medical record and V9 was unsure if R1 had been transferred to the unit where COVID-19 positive residents resided. R1's medical records document R1 was sent to the hospital on 10/11/21 at 10:02am, several hours after R1's medical records document R1's symptoms including continuing fever with decline. R1's hospital records document diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . B.2. The facility's Floor Plan dated December 2021 documents the facility's designated red zone (COVID-19 positive) and green zone (asymptomatic/COVID-19 negative.) This floor plan does not identify a dedicated yellow zone for resident's on quarantine/isolation for new admissions/readmissions, COVID-19 exposure or symptomatic residents who have not tested positive. R3's Census dated 12/16/21 documents R3 has resided in the same room since 10/21/21. R3's Order Summary Report dated 12/1/21-12/31/21 documents an order dated 12/16/21 for contact/droplet precautions for 14 days due to respiratory symptoms. R3's Progress Notes document the following: On 12/9/21 5:38 AM R3 had a dry, nonproductive cough, that R3 stated has had for a while. V26 (Licensed Practical Nurse) administered an [MEDICATION(S)] nebulizer treatment. On 12/15/21: At 8:00 AM R3 sat up and began coughing. R3 coughed up clear phlegm. R3's lung sounds were diminished and clear. At 11:58 AM orders were given for a rapid COVID-19 test, influenza A and B test, Complete Blood Count, Basic Metabolic Panel, and Brain Natriuretic Peptide. R3's COVID-19 Focused Daily Assessments from 12/2/21-12/16/21 document R3 was not placed in contact/droplet precautions and does not document R3 had any respiratory symptoms prior to 12/9/21. There is no documentation in R3's medical record that R3 has a chronic cough, or that R3 was placed on contact/droplet precautions prior to 12/16/21. R17's Census dated 12/16/21 documents R17 (R3's roommate) has resided in the same room since 10/21/21. R17 was transferred to the hospital on 12/13/21 and returned on 12/15/21 to the same room. R17's Order Summary Report dated 12/1/21-12/31/21 documents an order dated 12/16/21 for contact/droplet precautions for 14 days for protocol for new admissions/readmissions. There is no documentation that R17 was placed on contact/droplet precautions prior to 12/16/21. R17's Progress Notes document on 12/15/21 at 4:30 PM R17 returned from the hospital and was readmitted to R17's prior room. R17's COVID-19 Focused Daily assessment dated [DATE] at 10:17 AM documents R17 was not placed on contact/droplet precautions. On 12/15/21 at 3:15 PM a list of residents unvaccinated for COVID-19 was requested from V1 (Administrator). The electronic mail dated 12/15/21 at 3:42 PM from V1 (Administrator) documents R3 and R17 are unvaccinated. On 12/15/21 at 2:46 PM R3 was lying in bed. There was no isolation signage posted on or near the entrance to R3's room. R3's room did not contain receptacles for isolation waste or linens. R3's room was located in the green zone of the facility where COVID-19 asymptomatic/negative residents reside. On 12/16/21 at 9:35 AM R3 and R17 were observed sharing the same room. There was no isolation signage posted on or near the entrance to R3's/R17's room. R3's/R17's room did not contain receptacles for isolation waste or linens. R3's/R17's room was located in the facility's green zone. On 12/16/21 at 9:37 AM V33 (LPN) stated R3 is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's lung sounds were diminished. R3 had no further symptoms the remainder of the day. V33 received orders for Complete Blood Count, Basic Metabolic Panel, Brain Natriuretic Peptide, Influenza swab, and rapid COVID-19 test. V33 performed R3's rapid COVID-19 test and it was negative. R17 returned to the facility from the hospital on 12/15/21 at 4:30 PM, after R3's testing was completed. V33 confirmed R3 and R17 share a room. On 12/16/21 at 9:54 AM V9 (Infection Preventionist) stated V9 would expect staff to follow the facility's COVID-19 Response Plan and conduct a respiratory evaluation if a resident is experiencing symptoms of COVID-19. The symptomatic resident should be placed on isolation and conduct a COVID-19 rapid test. V9 had followed up with V33 (LPN) regarding R3's symptoms. R3's cough and phlegm is normal for R3 in the morning. V9 was not aware that R3 had documented symptoms of a cough on 12/9/21. Residents who return from the hospital and are unvaccinated should be placed in the facility's yellow zone on quarantine for 14 days, in a private room. V9 confirmed R3 and R17 share a room and are unvaccinated for COVID-19. On 12/16/21 at 10:16 AM V9 stated the facility does not currently have a yellow zone, and there are no residents currently on quarantine/isolation. There are two residents on the red zone (COVID-19 positive). C. The facility's COVID-19 Testing and Response Plan dated 11/29/21 documents the facility recognizes that residents living in a congregate setting are at high risk of being infected by COVID-19. The protocol is for the purpose of protecting the well-being of any individual including residents. This protocol enables the facility to prevent and/or decrease the risk of COVID-19 transmission by following this testing plan and response strategy. Testing will be completed per guidance and evaluated on an individual basis. COVID-19 symptoms include runny nose, cough, fever, shortness of breath, chills, muscle pain, headache, fatigue, nausea, vomiting and diarrhea. Symptoms may appear two to 14 days after exposure. COVID-19 is thought to spread mainly by close contact (within about 6 feet) from person-to-person in respiratory droplets from an infected person. These droplets can land in the mouths of people nearby and possibly be inhaled into the lungs. Core Principals of COVID-19 Infection Prevention include universal screening of all staff, visitors and other persons who enter the facility for COVID-19. All are required to answer the questions on the screening form provided at the facility. The health and well-being of the residents of the facility is dependent upon accurate and truthful reporting. Inform visitors if they are experiencing symptoms of COVID-19 or have had close contact with someone with COVID-19, they are not allowed to enter the facility. The screening must check for each of the following exclusion criteria including a body temperature of 100 degrees Fahrenheit (F) or more; Symptoms of COVID-19; diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . C.1. The Employee Screening Prior to Clocking In to Work logs document: On 12/15/21 at 1:47 PM V28 (Activity Aide) had New Symptoms of COVID-19. The December 12 - December 18, 2021 schedule documents V28 worked on 12/15/21 from 1:30 PM to 5:00 PM. On 12/16/21 at 11:51 AM V28 (Activity Aide) stated V28 reported to work on 12/15/21 at approximately 1:48 PM and worked for about 4.5 hours. V28 had symptoms of hoarse voice and a cough that started on 12/14/21. V28 reported V28's symptoms to V28's supervisor (V10 Activity Director). V10 reported V28's symptoms to V2 (Director of Nursing) and V9 (Infection Preventionist). V14 (Minimum Data Set Coordinator) conducted a COVID-19 rapid test and V28 was negative. V2 was aware of V28's test results. V2 and V14 allowed V28 to work and instructed V28 to wear Personal Protective Equipment. On 12/15/21 V28 worked on the East wing of the facility and conducted BINGO in the West dining room with R8, R19, R20, R21, R22, and R23. V28 was audibly hoarse and had a cough during V28's phone interview. R8's and R23's Progress Notes document V28 provided one to one visits with R8 and R23 on 12/15/21.

Based on record review and interview the facility failed to ensure that one (R1) of four residents reviewed for falls in a sample of 15 was properly supervised during toileting. This failure resulted in R1 falling from the commode and sustaining a head laceration and subdural hematoma. Findings include: The Physician order [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] under Brief Interview for Mental Status assesses R1 as having severe cognitive impairment. The MDS documents under Functional Status that R1 is not steady, only able to stabilize with staff when moving on and off the toilet and that there is impairment to one side, upper (shoulder, elbow, wrist and hand) and lower extremities (hip, knee ankle and foot). The MDS documents a previous fall with injury. On 2/8/13 at 12:40 pm E4 (Minimum Data Set Coordinator and Registered Nurse) stated that she had assessed R1's functional ability through direct observation and information received from other staff. The information was then entered into the Minimum (MDS) data set [DATE]. E4 stated R1 required assistance of one for all transfers during this time of resident assessment (4/8/12). The facility document titled Fall Assessment and dated 3/30/12 for R1 reflects a previous fall and per the facility document automatically makes a resident high risk for falls. The facility's fall occurrence reports dated 2/4/12, 4/21/12 and 4/27/12 document the following falls for R1: On 2/4/12 R1slid from her wheelchair sustaining a laceration to her left forearm. On 4/21/12 R1 stood up from her wheelchair and fell . On 4/27/12 R1 was toileted by E3 (Certified Nursing Assistant) and was left alone while on the toilet. R1 was found on the floor and was noted to have a gash to the left forehead area and blood was noted on the floor. E2 (Director of Nursing) documents "Resident fell off of toilet while reaching for something. Resident has poor safety awareness and is impulsive....resident needs one assist for transfers....staff momentarily left resident on toilet to tend to another resident." R1 was transferred to the hospital for evaluation and treatment of [REDACTED]. The hospital emergency room notes dated 4/27/12 documents the following: Computerized Tomography of R1's head reflects "a small left temporoparietal subacute subdural hematoma and a right sylvan fissure subarachnoid hemorrhage is seen. Encephalomalacia is present in the the right Middle Cerebral Artery (MCA) territory as described." emergency room discharge [DIAGNOSES REDACTED]. R1 was transported back to the facility on [DATE] per emergency room notes. A hospital document titled History and Physical Exam - Neurosurgeon and dated 6/5/12 documents R1 having sleepiness and increased subdural hygroma. A Computerized Tomography of R1's head and dated 6/5/12 states "Demonstrates chronic hygromatous fluid increasing in thickness, measuring 1.7 centimeters in greatest diameter. Ventricles appear stable in size. Continued appearance of right-sided MCA infarct. Very mild midline shift. Assessment: Left Subdural hematoma --worsening Plan: Admit with Burr hole evacuation tomorrow." The reports are signed by Z1 (Neurosurgeon). Hospital records document R1's admit on 6/5/12 and discharge back to the facility on [DATE] after a Burr hole evacuation of a hematoma sustained on 4/27/12. On 2/7/13 at 9:45 am E2 stated that E3 should not have left R1 on the toilet by herself on 4/27/12 due to her cognitive status and E3 had used bad judgement. E2 stated that E3 had been disciplined and stated "I can not control everything my staff does." At 1:20 pm on 2/7/13 E2 described the interventions put in R1's plan of care concerning falls. She stated that after the fall on 4/21/12 she had updated R1's Plan of Care and instructed the staff to inform R1's visitors to notify the staff when leaving so staff could attend to R1. E2 stated "I did not want (R1) to be left alone because she would try to transfer herself."